Neck Masses in Children

Felice D’ArcoDiagnostic Imaging

Great Ormond Street Hospital For Children

A Practical Guide to the Differential Diagnosis

felice.d’arco@gosh.nhs.uk

Summary

o Essential Anatomy of The Neck Superficial Fascia (subcutaneous Tissue) Neck Spaces (3 layers of the deep

cervical fascia)o Features of the Lesion: Where? Cystic?

Solid?

Anatomy of the Neck Superficial Cervical Fascia: thin layer

of subcutaneous connective tissue that lies between the dermis of the skin and the deep cervical fascia

Contents: platysma, nerves, blood /

lymphatic vessels, fat. Pathology (related to the

content!!): Teratoma, Vasc. Malformations/neoplasm, Cellulitis, Plexiform Neurofibromas (NF1), Subcutaneous Fat Fibrosis (neonates)

NB: It is considered by some to be a part of the Panniculus adiposus, and not true fascia. Bailey, B.J. Ed: Head and Neck Surgery-Otolaryngology 2006.

Superficial Cervical Fascia (yellow)

From internet

Subcutaneous fat tissue between the skin and the superficial layer of the deep cervical fascia (green)

Superficial layer DCF

Skin

Anatomy of the Neck Deep Cervical Fascia (DCF): 3 layers

superficial (SL), middle (ML) and deep (DL)

The layers divide neck in compartments (on the axial plane).

Neck is also divided in Suprahyoid neck (SHN) Infrahyoid neck (IHN) (on the coronal and sagittal plane)

Hyoid Bone

Superficial Layer DCFSHN: Around Masticatory Sp. & Parotid Sp;

part of carotid space

www.statdx.com

Superficial layer DCF

Superficial Layer DCFIHN: surrounds strap,

sternocleidomastoid & trapezius muscles

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Superficial layer DCF

Middle Layer DCFSHN: defines Pharyngeal Mucosal Space deep margin; contributes to

carotid space

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ML - DCF

Middle Layer DCFIHN: Surrounds Visceral Sp.; contributes of carotid space

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ML - DCF

Deep Layer DCF

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SHN & IHN: Surrounds perivertebral space (paraspinal and pre-vertebral components), Contributes to carotid space.

DL - DCF

Deep Layer DCF: Alar FasciaPart of the DL-DCF which forms the lateral and posterior walls of the

Retropharyngeal space and separates this space from the Danger Space (virutal space)

www.statdx.com

DS: from the skull base to the mediastinum; Boundaries ANT:

Retropharyngeal Sp. POST: pre-vertebral component of periveterbal space

Neck Masses in Children: Solid

Reactive/metastatic Lymph nodes Lymphoma Infantile Hemangioma Rhabdomyosarcoma Lipoma Matastatic Neuroblastoma (mostly

osseous); Primary Neck Neuroblastoma (posterior carotid space)

Fibromatosis Colli (neonate)

Neck Masses in Children: Cystic

Thyreoglossal Duct Cyst Laryngocele Abscess Branchial Cleft Cyst Lymphatic Malformation Dermoid/Epidermoid Teratoma (mixed solid and cystic)

Space or Anatomic region Differential DiagnosisSuperficial Fascia Teratoma, Vascular Malformations, lipoma, plexiform

Neurofibroma, fibromatosis colli of SCM (in neonates)Danger Sp. Cellulitis/Abscess

Masticator Sp. Venous/lymphatic Malf., rhabdomyosarcoma, cellulitis/abscess

Parotid Sp. Infection, Lymphatic malf., RMV thrombosisCarotid Sp. IJV thrombosis, lymphadenopathy, abscess,

neuroblastomaRetropharyngeal Sp. Cellulitis/Abscess, extension of tumours or goiter

Perivertebral Sp. Neuroenteric cyst, Cellulitis/Abscess, Spondylodiskitis

Posterior Cervical Sp.

Lymphatic malf., lymphadenopathy, lymphoma

Submandibular/Sublingual Sp.

Thyroglossal cyst, venous/lymphatic Malf, dermoid cyst, ranula, sublingual gland disease

Pharyngeal and Parapharyngeal Sp.

Lymphangioma, paraganglioma, rhabdomyosarcoma, abscess, Lymphoma

Infantile Hemangioma : can occur in any space!

Solid Neck Masses

Reactive Lymph Nodes

Most frequent solid “masses” in children Benign, reversible enlargement of nodes in

response to antigen stimulus Acute/Chronic; Localized/Generalized IMAGING: Multiple well-defined, oval-shaped nodes that

can be enlarged (> 2 cm in children), typically oval-shaped rather than round, mild homogeneous enhancement

CECT appearance Do not forget the levels of the Neck !

Drawing by F. Gaillard

Tonsils

Leve

l II

A

Level II A

Level V a

Differential Diagnosis1) METASTATIC NODES

Rare in children

Bigger size (but in children this criterion does not work as in adult!)

Round node shape rather than oval

Clustered nodes

Focal nodal defect/necrosis

Extracapsular spread

Primary Tumor! NB: DD between Meta Nodes and Suppurative Nodes is often obvious clinically (Hot, tender, febrile patient)

Christine M. Glastonbury

Differential Diagnosis2) Lymphoma (NHL and HL) - SIZE ! BILATERAL non-symmetric!

-Posterior Cervical Space often involved

-Homogeneous lobulated nodal masses

-Single or multiple nodal chain

-Variable contrast enhancement

-Necrotic center may be present

Lymphoma Neck

Internal jugular chainSpinal Accessory Chain

4 yo HL

Bilateral Internal jugular chain

Infantile Hemangioma

Can be in different locations in the neck (subcutaneous tissue)

Is a benign neoplasm (not malformation) Proliferative phase: few weeks after birth to 1-2

years Involuting phase: gradual regression over next

several years (90% resolve by 9 years) Often single lesion.

IMAGING Key Features: Well-defined enhancing mass, mildly hyper T2 to

muscle Internal Vessels (Serpiginous Flow Voids) No Calcifications! (DD Venous Malformation) US: mean venous peaks not elevated (DD AVM) Involuting Phase: fatty replacement

Infantile Hemangioma

First Diagnosis

After Treatment with Propanolol

Differential Diagnosis

1) Venous Malformation

Large venous lakes - T2 signal more hyperintense

- Variable enhancement (patchy, heterogeneous)

- Phleboliths: Calcium within the lesion

- No Flow voids

Differential Diagnosis2) AVM- High flow and tortuous

feeding arteries

- Large draining veins

- Nidus/AV shunting

- Ill defined mass

- US: elevated venous peaks

- Worsening overtime

- Clinical: arterial feeding is evident

Differential Diagnosis3) Rhabdomyosarcoma- Different age : 2- 5 y; 15-19 y

- Aggressive behavior: bony erosion, invasions surrounding tissues

- Non-Homogeneous appearance (necrosis, hemorrhage) and contrast

- Diffusion restriction (Lope 2012)

Rhabdomyosarcoma Neck

Rhabdomyosarcoma Neck

T2 signal, hyper but not too much

statdx.com

Fat signal/ density in all sequences, if associated c.e. suspect liposcarcoma

Lipoma

CT: Low Density ( −100 to −50 HU)

Hyper in T1 Suppressed in Fat-Sat

Metastatic : Typical Osseous Meta in Calvarium, Skull base, Orbits, Temporal bones DWI restriction, c.e.

Radiologist need to suggest abdominal US MIGB uptake Rare Nodal Metastasis

Neuroblastoma

Primary Neck NB : Posterior Carotid Space

1-5 % of NB Moderately enhancing mass Associated Lymphoadenopathy DD with Reactive Nodes and

Lymphoma very difficult (biopsy) Presence of Ca++ (extremely rare

in Lymphoma)

Neuroblastoma

Sternocleidomastoid Enlargement of Infancy Appears within 2 weeks of delivery; regresses by 8

months Nontender (DD with myositis) , monolateral Enlargement of the muscle which enhances diffusely Surrounding tissues are normal (DD with

Rhabdomyosarcoma together with age) Diagnosis: Clinical + US

Fibromatosis Colli

Normal Fibromatosis Colli

Smiti et al.2010

Dr. B. Koch

Cystic Neck Masses

Remnant of the TGD (Between foramen cecum at tongue base → thyroid bed in infrahyoid neck)

Most common congenital neck lesions

Median cyst (could be also paramedian in the infrahyoid neck)

Thin rim of c.e. is possible (often associated with infection)

Embedded by strap muscles when infrahyoid (“claw sign”)

Thyroglossal Duct Cyst

Harnsberger 2004

Differential Diagnosis

1)Lingual Thyroid- Solid, enhancing

mass

- Ectopic Thyroid Tissue in the base of the tongue or floor of the mouth

Differential Diagnosis

2) Laryngocele - Traces back to the

Larynx

- Air and fluid

Differential Diagnosis3) Median Sub-

Lingual Abscess - Clinical: associated

Odontogenic or salivary gland infection

- Thick enhancing wall, DWI restriction in MRI

Harnsberger 2004

NB: most frequent location of an abscess in neck is retropharyngeal space

Congenital malformations during development of the branchial apparatus

4 types of branchial cleft anomalies: cysts, sinuses, fistulas from the 1st , 2nd, 3rd and 4th branchial arches

2nd branchial cleft anomaly is the most common: 95%

Branchial Cleft Anomalies

Head and neck region at 4 weeks gestation (Meuwly et al 2005)

Unilocular cysts with thin wall Fluid content: CT hypodense, T1

hypohintense, T2 hyperintense No enhancement or subtle wall enhancement If infected: wall thickening/enhancement,

increase density of the fluid Neoplastic degeneration: enhancing nodules

along the wall

Branchial Cleft Anomalies

1st Branchial Cleft Anomaly

Benign, congenital cyst in or adjacent to parotid gland, EAC, or pinna

Several classifications related to embryology or location

Postero-inferior to auricle Adjacent to parotid gl./mandible angleB. Koch 2015

2nd Branchial Cleft Anomaly

Typical location: Antero-medially to the SCM (superior 1/3), posteriorly to the submandibular gland, laterally to the carotid space

B. Koch 2015

3rd Branchial Cleft Anomaly- Medially to the middle 1/3 of the

SCM- Lower than 2nd BCC

- In the posterior cervical space

Carotid sp

3BCC

SCM

Post Cerv Sp

4th Branchial Cleft AnomalyIt is a tract from the pyriform sinus to the

Superior aspect of the thyroid

Thyroid

B. Koch 2015

Uni- or multiloculated, non-enhancing, cystic neck mass.

Micro- and macro cystic Often trans-spatial, with fluid-fluid levels

(hemorrhage and high proteinaceous components)

Venolymphatic Malf. : Combined elements of venous malformation & lymphatic malformation (contrast enhancement of the venous elements)

Lymphatic Malformation

2nd BCC: unilocular cyst, typical location, no fluid-fluid levels

Abscess/suppurative nodes: clinical signs of infection, peripheral enhancement and cellulitis

Thyroglossal duct cyst: typical (midline) location, single cyst

Differential Diagnosis

Dermoid/Epidermoid Cyst

Definition: Cystic mass resulting from congenital epithelial inclusion or rest

Epidermoid: Epithelial elements only, fluid content Dermoid: Epithelial elements plus dermal

substructure, fluid, fatty or mixed content Location: oral cavity (DD with Ranula and TGDC),

midline anterior neck (DD with TGDC), orbit (DD with abscess and lymphatic malf.), nasal with associated nasal dermal sinus ± intracranial extension

Imaging

Epidermoid: homogeneous T1 hypo and T2 hyper. Increase T1 signal if high protein fluidDermoid: heterogeneous signal. Fatty elements are T1 hyper and low in fat sat T2. Possible Ca++Both can have DWI restriction and thin rim enhancement

T1 T2 fat-sat

T1

Dermoid: tyipical “sac of marbles” appearance due to area of fatty

attentuation

Malik et al. 2012

Differential Diagnosis Ranula: salivary gland retention cyst in

sublingual space. Can be indistinguishable from epidermoid

cyst which doesn’t show restriction. Often is ruptured into the submandibular

space (diving ranula) which shows typical “comet shape” (body in the SMS and tail in the SLS)

No fat, no Ca++ and no DWI restriction

Malik et al. 2012

Tail

Body

Teratoma Anterior neck, midline mass containing all 3

germ layers Mixed (cystic and solid) with fat and

calcium DD: Lymphatic Malf (fluid with no fat, calcium

or solid components), Goiter (homogeneous, respects limits of the thyroid gland)

Mixed solido-cystic mass with fat content

Neck masses are common findings in children and can be a diagnostic challenge

Often trans-spatial No space-specificity Distinction in Solid or Cystic (or mixed) can

help in the differential diagnosis

Conclusion

Thank you