Neck masses: When ultrasound is enough? - espr.org · Fibromatosis colli 15 d old child, 4 d ago...
Transcript of Neck masses: When ultrasound is enough? - espr.org · Fibromatosis colli 15 d old child, 4 d ago...
Neck masses: When
ultrasound is enough?
Marja Perhomaa
MD, Chief paediatric radiologist
Oulu University Hospital, Finland
ESPR 2019 Helsinki
Evaluation on paediatric neck masses – The
Referral• Clinical history
– How long the mass has been there?
– Has it changed?
– Has it increased/ decreased in size?
– Has the child symptoms of infection? General symptoms?
– Has the child been travelling lately?
• Physical examination– Palpation: Is the mass movable, soft/ hard?
– Other masses, bilateral masses?
– Ear, nose, throat, teeth
– LOCATION
Ultrasound in assessing neck masses in children
• Size
• Shape
• Borders
• Vascularity
• Internal content
• Relationship to nearby
structures
HOW
• High-frequency linear
transducer
• color doppler
WHAT
Aetiology of neck masses
• Inflammatory
• Congenital
• Neoplastic
80 – 90 % of paediatric neck masses are benign
Inflammatory neck masses
• Reactive enlarged lymph nodes– no imaging needed
• Uncomplicated cervical lymphadenitis
• Suppurative adenitis: US
• Abscess:– Superficial abscess: US
– Deep neck masses require MRI (or CT)
Lymphadenitis related to special pathogens
• Tuberculous mycobacteria
• Non-tuberculous mycobacteria– Mycobacterium avium intracellulare
– In young children , 1-5 yo
– Submandibular or preauricular area
– No fewer, painless
– Fluctuating mass, possible sinus tractlater
– Discoloration of the skin
– Hypoechoic lymph nodes withliquefaction, necrosis
– Often single enlarged node surroundedby smaller satellite nodes
– Adjacent soft tissue oedema
• Toxoplasma gondii
• Francisella tularensis
Inflammatory neck masses
• Infection of congenital neck mass
• Inflammation/infection of – Thyroid gland
– Salivary gland
– Subcutaneous tissue
• Lymphadenopathy related to Kawasaki disease, HIV, autoimmune diseases
Congenital neck masses
• Thyroglossal duct cyst
or ectopic thyroid
• Branchial apparatus cysts
• Cervical thymus/thymic cyst
• Lymphatic malformations(vascular malformations)
Thyroglossal duct cysts
• 70-90 % of all congenital neck masses
• Midline/paramidline soft mass
• Most common location at the level of thehyoid bone or just below
• Painless if not infected
• Moves vertically with swallowing
• US: hypo/anechoic cyst, thin wall– May contain debris, septa
– Associated soft tissue -ectopic thyroid
– Is the thyroid gland normal?
• DD dermoid/epidermoid cyst, ectopic thyroid, goiter, lymphadenopathy
Foramen caecum
Hyoid bone
Thyroidgland
Graphics: Pitkäranta A, Lauhio A. Duodecim 2007;123:2009-13
TGDC
Dermoid cyst
5 y. o. suffered from cough. 3 d earlier a lump was detected above thyroid gland. CRP < 5.
Branchial apparatus cysts
• Lateral neck mass
• 95 % 2nd apparatus cyst– From the lower border of
sternocleidomastoidmuscle to the palatine tonsils
– Stable/slowly growing
– Simple or complicted cyst• Proteinaceous fluid, hemorrage, infection
– Sinus/fistula• Open along the anterior border of the
sternocleidomastoid muscle
– DD lymphatic malformation, cervicalthymic cyst, infrahyoid thyroglossal ductcyst, necrotic adenopathy, abcess
Graphics: Pitkäranta A, Lauhio A. Duodecim 2007;123:2009-13
Tonsil
External auditorycanal
1st branchialapparatus fistula
2nd branchialApparatus fistula
4 y.o. boy. Parents noticed a mobile resistence in the right neck. No symptoms of infection.
Followed for 5 m, operated. PAD Branchial cyst
Branchial cleft fistula
3 y o girl. From birth a secreting fistula has been active in the medial borderof sternocleidomastoid muscle. At operation a fistula to the tonsil was found.
Aberrant cervival thymus or thymic cyst
• Remnants of 3rd branchial pouch
• Mass in the path of thymopharyngeal duct– Failure to descent
– Sequestrated thymic tissue
– Persistence of remnant tissue
• Characteristic appearance on ultrasound– Multiple linear hyperechoic septa and
homogenously distributed hyperechoic foci
– Unechoic/ intralesional debris in cysts
• Up to 50% of cervical thymic cystscontinuous with mediastinal thymus
• Intimate relationship to the carotid sheat
KL Moore. The developing human, 4th ed. Saunders 1988
Thymopharyngeal duct cyst
9 y o boy, otherwise healthy. 4 wk ago a left sided mass appeared,was growing. Mild symptoms of infection.
Lymphatic malformations
• Posterior cervical triangle most common
• Most present before age of 2 years, 50 % at/before birth
• Multilocular, soft cystic mass
• May increase in size rapidly with upper respiratory tract
infection or hemorrhage
• Do not spontaneously involute
• US may be sufficient with focal lesions
• Most require MR (or CT) to assess the extent of the mass
Lymphatic malformations
• Focal, well-defined
• Unilocular/multilocular
• Infiltrative
• Infection and hemorrhage may change thecharacteristics of LM
• Frequently part of combined vascular malformation
• DD teratoma, venous malformation
Lymphatic malformation with beeding
2.5 y old boy with respiratory infection.Convulsions, lifeless. Head MRI done,
A suprasternal/retrosternal expansion was detected.
Infantile hemangioma
• Most common neoplasms in the head and neck during infancy
• Absent / small at birth, progressive enlargement during 1 st year of life – stationary- involuting
• Masseter, parotid gland
• DD: RMS
Fibromatosis colli
• Neonates/young infants
• Often related to traumatic birth
• Firm, growing neck mass, typically detected at age of two weeks
• Torticollis to the affected side
• US– Fusiform enlargement of the sternocleidomastoid muscle, usually lower two-
thirds
– Well–defined borders, no extension beyond the muscle planes, no relatedlymphadenopathy
– Uncommonly calcifications may be detected
• DD:adenopathy, ectopic thymus, teratoma, hemangioma, lipoma, malignancy
Fibromatosis colli
15 d old child, 4 d ago left sided neck mass was observed. No infection, not painfull. A fuciformenlargement of the left side sternocleidomastoid muscle was observed.
Some other neck masses diagnosed with US
• Ranula– A fluid filled cyst originating from sublingual salivary gland
– In the floor of the mouth, or as a submental orsubmandibular mass
• Pilomatrixoma– Epithelial inclusion cyst
– Mobile, painless, firm oval tumor
– Hyperechoic, sometimes calcifications
• Congenital goiter
Neck masses: When ultrasound is enough?
• With superficial neck masses
• Can be completely evaluated
with US
• No suspicion of neoplastic
mass
NO
• Too large, too deep or
hyperechoic to be fully
evaluated with US
• Suspicion of high flow
vascular lesion
• Suspicion of malignancy
YES