Pedi Neck Mass Slides 071031

8/14/2019 Pedi Neck Mass Slides 071031

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Pediatric Neck MassesPediatric Neck Masses

MarkMarkDomanskiDomanski, M.D., M.D.

MichaelMichael UnderbrinkUnderbrink, M.D., M.D.

Dept. of OtolaryngologyDept. of Otolaryngology

University of Texas MedicalUniversity of Texas MedicalBranch, GalvestonBranch, Galveston

October 31October 31stst, 2007, 20071


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Total % oftotal

Congeital lesions 244 55%Branchial cleft cyst 78 18%

Thyroglossal duct cyst 73 16%Dermoid cyst 43 10%Lymphangioma 34 8%Hemangioma 10 2%Teratoma 2Bronchogenic cyst 2

Thymic cyst 1Myelomeningocele 1

Inflammatory lesions 118 27%

Reactive lympadenopathy 71 16%Undetermined etiology 66 15%

Sinus histiocytosis 5 1%Granulomatous disease 32 7%

Atypical mycobacteria 20 4%Cat scratch disease 6 1%Toxoplasmosis 2Sarcoid 2

Suppurative lympadenitis 10 2%Sialadenitis 5 1%

Non-infammatory benignlesions

23 5%

Inclusion cyst 13 3%Fibromatosis 9 2%Keliod 1

Benign neoplasms 12 3%

Neurofibroma 3 1%

Lipoma 3 1%Lipoblastoma 2Paraganglioma 1Goiter 1Benign mixed tumor 1Osteoblastoma 1

Malignant neoplasms 48 11%

Lymphoma 34 8%Hodgkin's 23 5%Non-Hodkin's 11 2%

Thyroid Carcinoma 6 1%

Rhabdomyosarcoma 2Neuroblastoma 2Fibrous histiocytoma 1Acinic cell carcinoma 1Histiocytosis X 1Chloroma 1

Total 445TorsiglieriTorsiglieri et al., 1988et al., 198822


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TorsiglieriTorsiglieri et al., 1988et al., 198822

Inflammatory

lesions

27%

Malignant

neoplasms, 11%Benign neoplasms

3%

Non-infammatory

benign lesions

5%

Congenital lesions

54%

N= 445


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Initial EvaluationInitial Evaluation

H&PH&P AgeAge

OnsetOnset

Rapidity of growthRapidity of growth Fluctuation in sizeFluctuation in size

PainPain

InfectionInfection TraumaTrauma

TravelTravel

ExposureExposure

PEPE SizeSize

MultiplicityMultiplicity

LateralityLaterality ConsistencyConsistency

ColorColor

MobilityMobility TendernessTenderness

FluctuationFluctuation

Congenital

Inflammatory

Benign

Malignant


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Location, Location, Location!Location, Location, Location!

Moir. 20048


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Likely Etiology Determines DirectionLikely Etiology Determines Direction

of Testingof Testing

XX--rayray

U/SU/S

CTCT

MRIMRI

FNAFNA

Surgical BiopsySurgical Biopsy

Tissue CultureTissue Culture

CXRCXR

LabsLabs

PPDPPD Gram stainGram stain

CultureCulture


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1. Congenital lesions1. Congenital lesions 2. Inflammatory lesions2. Inflammatory lesions

3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions 4. Benign4. Benign neoplasmsneoplasms

5. Malignant5. Malignant neoplasmsneoplasms


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1. Congenital lesions1. Congenital lesions 2. Inflammatory lesions2. Inflammatory lesions

3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions 4. Benign4. Benign neoplasmsneoplasms



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1. Congenital Lesions1. Congenital Lesions

Branchial cleft cyst 78 18%Thyroglossal duct cyst 73 16%Dermoid cyst 43 10%Lymphangioma 34 8%

Hemangioma 10 2%Teratoma 2Bronchogenic cyst 2

Thymic cyst 1Myelomeningocele 1


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EmbryologyEmbryology Ectoderm,Ectoderm,

mesoderm,mesoderm,

endodermendoderm

Incomplete closureIncomplete closure

may result inmay result inbranchial cleftbranchial cleft

anomaliesanomalies

Moir. 20048


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Development of First Four Arches

Nicollas. 20003

Each arch layer gives rise to:

nerve (ectoderm)

artery, muscle and cartilage (mesoderm)

glands (endoderm).


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Cyst Sinus Fistula

Schroeder. 20074

Branchial CleftBranchial Cleft AnomaliesAnomalies


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Distribution of neck malformations

as cysts, fistulas, or sinusesper Nicollas et. al. (n=191)

Nicollas. 20003

(Sinus)

Total 139 5 47 191


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Imagining in Branchial Cleft CystsImagining in Branchial Cleft Cysts

MRIMRI

More reliably confirmsMore reliably confirmscystic naturecystic nature

More precisely definesMore precisely defines

lesionlesion Better to delineateBetter to delineate

glandular tissueglandular tissue

ieie fat planesfat planes

CTCT

Adequate for mostAdequate for mostlesionslesions

Cost, availabilityCost, availability

U/SU/S

cysticcystic vsvs noncysticnoncystic

does not evaluatedoes not evaluateextentextent

Both MRI and CT have difficulty distinguishing branchial

cleft cyst from lymphangioma in children.

BranstetterBranstetter, 20069


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11stst

Branchial Cleft Cyst, Type IIBranchial Cleft Cyst, Type II Type IType I

EctodermalEctodermal duplication ofduplication ofEACEAC

Near external auditoryNear external auditory

canalcanal Usually inferior andUsually inferior and

posterior to tragusposterior to tragus

Type IIType II Associated withAssociated with

submandibularsubmandibular glandgland



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Type 1 First Branchial Cleft CystType 1 First Branchial Cleft Cyst

Both MRI and CT havedifficulty distinguishingbranchial cleft cyst from

lymphangioma inchildren.


LymphangiomaLymphangioma

mass

auricle

parotid


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Branchial CystBranchial Cyst

NoncalcifiedNoncalcified

massmass

CT shows lesionCT shows lesion

under SCMunder SCM

Malik et al 20026


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22ndnd Brachial Cleft CystBrachial Cleft Cyst

T2 MRIT2 MRI

Posterior to RPosterior to Rsubmandibularsubmandibularglandgland

Thickened wallsThickened walls

suggest priorsuggest priorhemorrhage orhemorrhage orinfectioninfection

Gujar and Mukherji 20045


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Anterior to carotid bifurcationAnterior to carotid bifurcation

Schroeder et al, 20074


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Under the anterior SCMUnder the anterior SCM



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Exiting skin medial to lateral border of SCMExiting skin medial to lateral border of SCM



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Left 2Left 2ndnd

BA FistulaBA Fistula

Anterior to carotid bifurcationAnterior to carotid bifurcation

Under the anterior SCMUnder the anterior SCM

Exiting skin medial to lateral border of SCMExiting skin medial to lateral border of SCM



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22ndnd

BA cyst with sinusBA cyst with sinustract extending intotract extending into

the pharynx above thethe pharynx above the

carotid bifurcationcarotid bifurcation


Watch the hypoglossal!


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PreauricularPreauricular SinusSinus

Not related to 1Not related to 1stst

branchial cleftbranchial cleft

anomaliesanomalies

Active infectionActive infectionduring excisionduring excision

increases chance ofincreases chance ofrecurrancerecurrance

Moir. 20048


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ThyroglossalThyroglossal Duct CystDuct Cyst persistent tract from thepersistent tract from the

descent of the thyroiddescent of the thyroidfrom the foramenfrom the foramencecumcecum

epithelial liningepithelial lining

composed of eithercomposed of eithersquamoussquamous or respiratoryor respiratoryepitheliumepithelium

confirm normal thyroidconfirm normal thyroidtissuetissue

Learning Radiology.com200711


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ThyroglossalThyroglossal Duct CystDuct Cyst CT w/ ContrastCT w/ Contrast

Embedded in theEmbedded in the

strap musclesstrap muscles

Extends deep toExtends deep to

involve the preinvolve the pre--epiglotticepiglottic spacespace



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Moir. 20048


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DermoidDermoid CystsCysts

Ectoderm and mesodermEctoderm and mesoderm 7% of7% ofdermoiddermoid cysts occur in head andcysts occur in head and

neckneck

Thought to be of congenital inclusionThought to be of congenital inclusion

typetype

mean diameter = 1.2 cm (0.6mean diameter = 1.2 cm (0.6--3.3)3.3)

Treatment: complete excisionTreatment: complete excision

Pryor et al 200512


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DermoidDermoid CystsCysts Cranial TheoryCranial Theory

GrunwaldGrunwald in 1910in 1910AsAs neuroectodermalneuroectodermal tract recedes,tract recedes, demaldemal

attachementsattachements follow its course and canfollow its course and can

form a sinus or cystform a sinus or cyst

Beware of possible intracranialBeware of possible intracranial

involvementinvolvement

Pryor et al 200512


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Orbit is the most common site for dermoids in the head and neck(61%)

Direct excision is sufficient for neck dermoids, more extensiveapproaches (craniotomy, mastoidectomy) are needed for othersites

DiffDiffdxdx: in midline of neck:: in midline of neck: thyroglossalthyroglossal duct cystduct cyst

in head & neck, n = 59

Pryor et al 200512


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DermoidDermoid CystsCysts

H & E

CT of dermoid cyst

Pryor et al 200512


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TeratomaTeratoma H&N account for ~2% ofH&N account for ~2% of

teratomasteratomas

NewbornNewborn 2.5 yr at2.5 yr at

presentationpresentation All 3 germinal layers presentAll 3 germinal layers present

Mostly benign lesionsMostly benign lesions

amenable to curativeamenable to curative

excisionexcision

WakhluWakhluA et alA et al 200013


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TeratomaTeratoma

Prognosis good if noPrognosis good if no

respiratory compromiserespiratory compromise

Usually wellUsually well

differentiated anddifferentiated andrecurrence is uncommonrecurrence is uncommon

Antenatal diagnosis isAntenatal diagnosis isroutine in developedroutine in developed

worldworld



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TeratomaTeratoma

Proximity to vitalProximity to vital

structures makes surgerystructures makes surgery

technically demanding.technically demanding.

Evaluate post op thyroidEvaluate post op thyroidand parathyroid function.and parathyroid function.



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TeratomaTeratoma 3 germ layers3 germ layers

Arise fromArise from

pluripotentpluripotent

cells andcells and

ectopicectopicembryogenicembryogenic

nonnon--germgermcellscells



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HypopharyngealHypopharyngeal TeratomaTeratoma

calcified calcification and fat

Malik et al 20026

T tT t


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TeratomaTeratomaT1 MRIT1 MRI

Fatty

Calcified



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LymphangiomaLymphangioma Benign,Benign, multiloculatedmultiloculated, soft, soft

Posterior neck triangle predominancePosterior neck triangle predominance

MultiMulti--septatedseptated, insinuating lesions, insinuating lesions

Infiltrate and cross tissue planesInfiltrate and cross tissue planes

Most occur by 2 yrs of ageMost occur by 2 yrs of age

Incidence: 1 in 6,000 to 16,000 birthsIncidence: 1 in 6,000 to 16,000 births

BurezqBurezq 200614Head and and Neck Surgery,Head and and Neck Surgery, 200615


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Lymphatic Vascular malformationLymphatic Vascular malformation

T1 MRIT1 MRI

High signalHigh signal

representsrepresentsproteinaceousproteinaceousfluidfluid

Crosses tissueCrosses tissueplanesplanes



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CentrifugalCentrifugal vsvs CentripetalCentripetalCentrifugal theoryCentrifugal theory

the lymphatic system develops asthe lymphatic system develops as mesenchymalmesenchymalspaces that later coalesce into a system ofspaces that later coalesce into a system ofvessels that eventually join the venous system.vessels that eventually join the venous system.

Centripetal theoryCentripetal theory

jugular and posteriorjugular and posterior lymphaticslymphatics form asform asoutgrowths of endothelium from veins into theoutgrowths of endothelium from veins into thesurroundingsurrounding mesenchymemesenchyme..

BurezqBurezq 200614


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ClassificationClassificationSize:Size:

MicrocysticMicrocystic: capillary: capillary lymphangiomaslymphangiomas lesions are less than 1 cm in diameterlesions are less than 1 cm in diameter

MacrocysticMacrocystic: cystic: cystic hygromashygromas cysts are larger than 1 cmcysts are larger than 1 cm

CysticCystic hygromashygromas #1 type of#1 type oflymphangiomalymphangioma

Gross et al, 200616


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CysticCystic HygromaHygroma

NoncalcifiedNoncalcified

SeptatedSeptated onon

U/SU/S

Malik et al 20026


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Cystic CompositionCystic Composition 55--yearyear--old boy withold boy with

lymphangiomalymphangioma

L parotid &L parotid &

parapharyngealparapharyngeal spacespace mixed macromixed macro--

andmicrocysticandmicrocystic typetype

Treated by surgicalTreated by surgicalresectionresection

Gross et al, 200616

Type 1 First Branchial Cleft CystType 1 First Branchial Cleft CystLymphangiomaLymphangioma


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Type 1 First Branchial Cleft CystType 1 First Branchial Cleft Cyst

Both MRI and CT havedifficulty distinguishingbranchial cleft cyst from

lymphangioma inchildren.


LymphangiomaLymphangioma

mass

auricle

parotid

BurezqBurezq et al 2006et al 2006


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BurezqBurezq et al, 2006et al, 2006(expert opinion)(expert opinion)

1. Error in establishing a communication1. Error in establishing a communication

between the lymphatic and venous systembetween the lymphatic and venous system CysticCystic hygromahygroma

2. Error in morphogenesis of lymphatic system:2. Error in morphogenesis of lymphatic system:

this includes other types of lymphaticthis includes other types of lymphatic

malformationsmalformations microcysticmicrocystic,, macrocysticmacrocystic and mixed lymphatic lesionsand mixed lymphatic lesions

BurezqBurezq 200614


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ManagementManagement -- ControversialControversial Spontaneous resolution?Spontaneous resolution?

Formation of new lymphatic channels?Formation of new lymphatic channels?

Serial aspiration?Serial aspiration?

SclerosantSclerosantAgents?Agents? OKOK--432 (432 (lyophiliziedlyophilizied mixture of lowmixture of low--virulence group Avirulence group ASterpSterp

pyogenspyogens

Surgical Excision?Surgical Excision? Is the surgical risk out weigh the benefit in a benign lesionIs the surgical risk out weigh the benefit in a benign lesion

BurezqBurezq 200614


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Success with Serial AspirationsSuccess with Serial Aspirations

BurezqBurezq 200614


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Success with OKSuccess with OK--432432

Supraclavicular macrocysticlymphangioma

Gross et al, 200616


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HemangiomaHemangioma Less than 1/3 present at birthLess than 1/3 present at birth

Usually seen in 1Usually seen in 1stst few months of life andfew months of life and

enlarge progressivelyenlarge progressively

90% cases involutes spontaneously90% cases involutes spontaneously

SclerosingSclerosing agents controversialagents controversial


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GlutGlut--11

erythrocyteerythrocyte--type glucose transportertype glucose transporter

found only infound only in microvascularmicrovascular endothelia of bloodendothelia of bloodtissuetissuebarriers such as in the central nervous system, retina,barriers such as in the central nervous system, retina,placenta,placenta, ciliaryciliary muscle, andmuscle, and endoneuriumendoneurium of peripheralof peripheralnervesnerves

HemangiomasHemangiomas stain consistently for Glutstain consistently for Glut--1, in all stages1, in all stagesof development and involution whereas vascularof development and involution whereas vascularmalformations did notmalformations did not

Mo et al, 200617

MacArther, 200618


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Pediatric Neck MassesPediatric Neck Masses 1. Congenital lesions1. Congenital lesions

2. Inflammatory lesions2. Inflammatory lesions

3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions

4. Benign4. Benign neoplasmsneoplasms



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Pediatric Neck MassesPediatric Neck Masses 1. Congenital lesions1. Congenital lesions






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2. Inflammatory Lesions2. Inflammatory LesionsReactive lympadenopathy 71 16%

Undetermined etiology 66 15%Sinus histiocytosis 5 1%

Granulomatous disease 32 7%Atypical mycobacteria 20 4%

Cat scratch disease 6 1%Toxoplasmosis 2Sarcoid 2

Suppurative lympadenitis 10 2%Sialadenitis 5 1%

When does cervicalWhen does cervical


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lymphadenopathylymphadenopathy require FNA?require FNA?

Benign reactive lymph node may persistBenign reactive lymph node may persist

for weeks to monthsfor weeks to months

Lymphoma can present the same wayLymphoma can present the same way

Rapkiewicz et al 200721


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To FNA or not to FNA?To FNA or not to FNA? ReactiveReactive lymphadenopathylymphadenopathy the most likelythe most likely

etiology of pediatric neck massesetiology of pediatric neck masses

DiagnosticDiagnostic dilemadilema: a mass that does not: a mass that does notresolve after initial treatmentresolve after initial treatment



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FNA ancillary studiesFNA ancillary studies Gram stain, cultureGram stain, culture

Acid fast stainAcid fast stain

ImunocytochemistryImunocytochemistry

CytogeneticsCytogenetics


Limitations to FNA


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Limitations to FNALimitations to FNA

A lesion may not be homogenousA lesion may not be homogenous

FNA samples only part of the massFNA samples only part of the mass

May miss the true lesionMay miss the true lesion

Unable to appreciate histologicalUnable to appreciate histological

architecturearchitecture


Time to contemplate open biopsyTime to contemplate open biopsy


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Enlarging massEnlarging mass

Poor response to medical treatmentPoor response to medical treatment

Suspicious clinical courseSuspicious clinical course

Unusual image findingsUnusual image findings

Systemic symptomsSystemic symptoms


Case F R


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CaseCase

F.R.F.R.

88 y/oy/o female,female, hxhx + PPD several yrs prior+ PPD several yrs prior

Presents with R cervicalPresents with R cervical adenopathyadenopathy

FNA suggestsFNA suggests granulomagranuloma

Repeat FNARepeat FNA--> same result> same result

AFB stain and cultures negativeAFB stain and cultures negative

ClarithromycinClarithromycin andand ethambutolethambutol startedstarted


Case F R


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CaseCase

F.R.F.R.

AdenopathyAdenopathy and pain increasedand pain increased

Third FNA nonThird FNA non--diagnosticdiagnostic

CT shows bulky homogenousCT shows bulky homogenous

lymphadenopathylymphadenopathy of R upper spinalof R upper spinalaccessory and upper jugular chains.accessory and upper jugular chains.

Open biopsy displayedOpen biopsy displayed Hodgkin'sHodgkin'slymphoma.lymphoma.


Reactive Lymphadenopathy


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ReactiveReactive

LymphadenopathyLymphadenopathy

33--yearyear--old childold child

MultipleMultiple hypoechoichypoechoiclesionslesions

variable shape andvariable shape andsizessizes

consistent withconsistent withreactive lymphreactive lymphnodesnodes

Malik et al 20026

Enlarged Lymph Node


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Enlarged Lymph NodeEnlarged Lymph Node

NonspecificNonspecific

Cause:Cause:

cryptococcalcryptococcal

adenitisadenitis

YeastlikeYeastlikefungusfungus


AtypicalAtypical mycobacteriamycobacteria: ex:: ex:


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cryptococcuscryptococcus

Saprobe inSaprobe in

naturenature

worldwideworldwide

distributiondistribution Found in soilFound in soil

Portal of entryPortal of entryis lungis lung

AtypicalAtypical mycobacteriamycobacteria: ex:: ex:


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cryptococcuscryptococcus Associated w/Associated w/

AIDSAIDS organorgan

transplantationtransplantation

LymphoreticularLymphoreticulardiseasesdiseases

pts lackpts lack

apprarentapprarentpredisposingpredisposingfactorsfactors

BartonellaBartonella henselaehenselae


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HypoechoicHypoechoic massesmasses

with irregular rim ofwith irregular rim ofisoechoicisoechoic tissuetissue

Biopsy: Cat ScratchBiopsy: Cat Scratch

DiseaseDisease

Malik et al 20026



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GramGram coccobacilluscoccobacillus

22-- 14 day incubation14 day incubation

DxDx: requires prolonged: requires prolonged

incubation (2 + weeks)incubation (2 + weeks) Rx: erythromycin 1Rx: erythromycin 1--4 m4 m

(unclear efficacy)(unclear efficacy)

Normally benign courseNormally benign course

Malik et al 20026

In heart valve

PeritonsillarPeritonsillar AbcessAbcess


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PeritonsillarPeritonsillarAbcessAbcess

Soft tissue density inSoft tissue density in

submentalsubmental spacespace

Malik et al 20026

RetropharyngealRetropharyngeal


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AbscessAbscess Widening ofWidening of

prevertebralprevertebral spacespace

Malik et al 20026

Retropharyngeal Space AbscessRetropharyngeal Space Abscess


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et op a y gea Space bscessp y g p



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RetropharyngealPeritonsillar

Malik et al 20026

SppurativeSppurative Cervical AdenitisCervical Adenitis


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pppp

hypoechoic

Malik et al 20026

Thyroid AbscessThyroid Abscess


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yy

Malik et al 20026



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1. Congenital lesions1. Congenital lesions







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3. Non3. Non--inflammatory Benigninflammatory Benign


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LesionsLesionsInclusion cyst 13 3%

Fibromatosis 9 2%Keloid 1

Inclusion CystInclusion Cyst


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AcquiredAcquired dermoiddermoid cystscysts

result from a part of the skin being traumaticallyresult from a part of the skin being traumaticallyimplanted in the deeper layers afterimplanted in the deeper layers after ectopicectopic formationformationof aof a dermal cyst l ined w ithdermal cyst l ined w ith squamoussquamousepitheliumepithelium ..

Congenital inclusionCongenital inclusion dermoiddermoid cysts form alongcysts form alongthe lines of embryologic fusion and contain boththe lines of embryologic fusion and contain both

dermal and epidermal derivatives.dermal and epidermal derivatives. DermoidDermoid cysts of the head and neck are thought to becysts of the head and neck are thought to be

the congenital inclusion type.the congenital inclusion type.

Pryor et al 200512

Inclusion CystInclusion Cyst


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many cysts originate from themany cysts originate from the infundibularinfundibular

portion of the hair follicle, and the moreportion of the hair follicle, and the moregeneral term,general term, epidermoidepidermoid cystcyst, is favored, is favored

Becker et a, 200519

Epidermal Inclusion CystEpidermal Inclusion Cyst


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Cyst containing keratinous material true epidermis with a granular layerand adjacent laminated keratinousmaterial

Becker et al, 200519

TorticollisTorticollis


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FibromatosisFibromatosis ColliColli


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SCMSCM

IsoechoicIsoechoic massmass

CT showsCT shows isodenseisodense

mass R sidemass R side

Note normal SCM onNote normal SCM on

L sideL side

Malik et al 20026

FibromatosisFibromatosis ColliColli -- FNAFNA


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PaucicellularPaucicellular

specimenspecimen

Bland spindleBland spindlecell cytologycell cytology

r/or/o nodularnodular fascitisfascitis andand fibrosarcomafibrosarcoma


FibromatosisFibromatosis ColliColli


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r/or/o nodularnodular fascitisfascitis andand fibrosarcomafibrosarcoma

Ro 200720


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Moir. 20042



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4. Benign Neoplasms4. Benign Neoplasms


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Neurofibroma 3 1%

Lipoma 3 1%Lipoblastoma 2Paraganglioma 1Goiter 1Benign mixed tumor 1Osteoblastoma 1

NeurofibromaNeurofibroma


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solitary lesionsolitary lesion

vsvs part of the generalized syndrome ofpart of the generalized syndrome of

neurofibromatosisneurofibromatosis NFNF--1, aka von Recklinghausen disease1, aka von Recklinghausen disease

NFNF--22

Believed to arise from Schwann cell butBelieved to arise from Schwann cell butorigin uncertainorigin uncertain



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solitary lesionsolitary lesion

vsvs part of the generalized syndrome ofpart of the generalized syndrome of

neurofibromatosisneurofibromatosis NFNF--1, aka von Recklinghausen disease1, aka von Recklinghausen disease

NFNF--22

Believed to arise from Schwann cell butBelieved to arise from Schwann cell butorigin uncertainorigin uncertain



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T2 MRIT2 MRI

Central low T2Central low T2

signal issignal ischaracteristic ofcharacteristic of

neurofibromasneurofibromas


LipomaLipoma


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LipoblastomaLipoblastoma
http://www.microscopyu.com/galleries/pathology/lipomalarge.html


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Rare benignRare benign mesynchymalmesynchymal

tumor oftumor ofembryonalembryonal fatfat

May clinically andMay clinically and radiologicallyradiologicallymimic amimic a hemangiomahemangioma

Collections ofCollections oflipoblastslipoblastsmultivuolatedmultivuolated w/ round nucleiw/ round nuclei

FNA

LipoblastomaLipoblastoma


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ResemblesResembles

embryological adiposeembryological adiposetissuetissue

Surgical specimen

LipomaLipoma LipoblastomaLipoblastoma


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NeonatalNeonatal

GoiterGoiter


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GoiterGoiter

CT shows large peripheral rimCT shows large peripheral rimenhancing, low attenuationenhancing, low attenuationmassmass

1: 4000 live births1: 4000 live births

Female 2x = MaleFemale 2x = Malepredominancepredominance

Delayed ossification at boneDelayed ossification at boneendsends

Malik et al, 20026Rovet et al, 200310


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5. Malignant Neoplasms5. Malignant Neoplasms


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Lymphoma 34 8%Hodgkin's 23 5%

Non-Hodkin's 11 2%Thyroid Carcinoma 6 1%Rhabdomyosarcoma 2

Neuroblastoma 2Fibrous histiocytoma 1Acinic cell carcinoma 1Histiocytosis X 1Chloroma 1

LymphomaLymphoma


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Third most common pediatric cancerThird most common pediatric cancer

Incidence: 11Incidence: 11--20 per million children20 per million children

Geographical varianceGeographical variance 50 % of50 % of

childhood cancers in equatorial Africachildhood cancers in equatorial Africa Due to high incidence ofDue to high incidence ofBurkittBurkittss lymphomalymphoma

Male predominance 2.5:1Male predominance 2.5:1

Beware theBeware the supraclavicularsupraclavicular mass!mass!


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35% of patients35% of patients

with H&Nwith H&Nlymphomalymphomapresent with apresent with asupraclavicularsupraclavicular

massmass

35% of pts with35% of pts with

suprclavicularsuprclavicularmasses hadmasses hadlymphomalymphoma

Turkington et al 200522 TorsiglieriTorsiglieri et al., 1988et al., 198822

NeuroblastomaNeuroblastoma


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NoncontrastNoncontrast T1T1

MRIMRI

Mass (arrow)Mass (arrow)lateral to carotidlateral to carotid

arteryartery(arrowhead).(arrowhead).


RhabdomyosarcomaRhabdomyosarcoma -- CTCT


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Ill definedIll defined

enhancing softenhancing soft

tissue densitytissue density

areas of necrosisareas of necrosis

Malik et al 20026

RhabdomyosarcomaRhabdomyosarcoma

of the Masticator Spaceof the Masticator Space


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pp

NonNon--contrast T1contrast T1 intermediateintermediatesignalsignal

T2T2 increased signalincreased signal


TorsiglieriTorsiglieri et al., 1988et al., 198822


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Inflammatory

lesions

27%

Malignant

neoplasms, 11%

Benign neoplasms

3%

Non-infammatory

benign lesions

5%

Congenital lesions

54%

N= 445

Total % oftotal

Congeital lesions 244 55%Branchial cleft cyst 78 18%Thyroglossal duct cyst 73 16%Dermoid cyst 43 10%Lymphangioma 34 8%Hemangioma 10 2%

Non-infammatory benignlesions

23 5%

Inclusion cyst 13 3%Fibromatosis 9 2%

Keliod 1


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gTeratoma 2Bronchogenic cyst 2Thymic cyst 1

Myelomeningocele 1Inflammatory lesions 118 27%

Reactive lympadenopathy 71 16%Undetermined etiology 66 15%Sinus histiocytosis 5 1%

Granulomatous disease 32 7%Atypical mycobacteria 20 4%Cat scratch disease 6 1%Toxoplasmosis 2Sarcoid 2

Suppurative lympadenitis 10 2%

Sialadenitis 5 1%

Benign neoplasms 12 3%Neurofibroma 3 1%Lipoma 3 1%Lipoblastoma 2Paraganglioma 1Goiter 1Benign mixed tumor 1Osteoblastoma 1

Malignant neoplasms 48 11%Lymphoma 34 8%Hodgkin's 23 5%Non-Hodkin's 11 2%

Thyroid Carcinoma 6 1%Rhabdomyosarcoma 2

Neuroblastoma 2Fibrous histiocytoma 1Acinic cell carcinoma 1Histiocytosis X 1Chloroma 1

Total 445TorsiglieriTorsiglieri et al., 1988et al., 198822

ConclusionsConclusions


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Initial evaluation (H&P)Initial evaluation (H&P)

Congenital, infectious, benign, malignantCongenital, infectious, benign, malignant Beware of tuberculosis, cat scratchBeware of tuberculosis, cat scratch

disease, atypical infectionsdisease, atypical infections

Beware of systemic symptomsBeware of systemic symptoms

Beware theBeware the supraclavicularsupraclavicular massmass

Consider FNA or biopsy in the mass thatConsider FNA or biopsy in the mass thatdoes not resolve with treatment.does not resolve with treatment.

BibliographyBibliography


114/116

1.1. NeoReviews.orgNeoReviews.org,,http://neoreviews.aappublications.org/case27/case.shtmlhttp://neoreviews.aappublications.org/case27/case.shtml, 10/18/07., 10/18/07.

2.2.

TorsiglieriTorsiglieri

AJAJ

JrJr

, Tom LW, Ross AJ 3rd, Wetmore RF, Handler SD,, Tom LW, Ross AJ 3rd, Wetmore RF, Handler SD,

PotsicPotsic

WP. Pediatric neck masses: guidelines for evaluation.WP. Pediatric neck masses: guidelines for evaluation. IntInt JJ PediatrPediatrOtorhinolaryngolOtorhinolaryngol.. 1988 Dec;16(3):1991988 Dec;16(3):199--210.210.

3.3. Nicollas R, Guelfucci B, Roman S, Triglia JM.Nicollas R, Guelfucci B, Roman S, Triglia JM. Congenital cysts andCongenital cysts andfistulas of the neck.fistulas of the neck. IntInt JJ PediatrPediatrOtorhinolaryngolOtorhinolaryngol. 2000 Sep. 2000 Sep29;55(2):11729;55(2):117--24.24.

4.4. Schroeder JWSchroeder JW JrJr,, MohyuddinMohyuddin N,N, MaddalozzoMaddalozzo J. Branchial anomalies inJ. Branchial anomalies inthe pediatric population.the pediatric population. OtolaryngolOtolaryngol Head NeckHead Neck SurgSurg. 2007. 2007Aug;137(2):289Aug;137(2):289--95.95.

5.5. GujarGujarS, Gandhi D,S, Gandhi D, MukherjiMukherji SK. Pediatric head and neck masses. TopSK. Pediatric head and neck masses. TopMagnMagn ResonReson Imaging. 2004 Apr;15(2):95Imaging. 2004 Apr;15(2):95--101.101.

6.6. MalikMalikA,A, OditaOdita J, Rodriguez J,J, Rodriguez J, HardjasudarmaHardjasudarma M. Pediatric neck masses:M. Pediatric neck masses:a pictorial review for practicing radiologists.a pictorial review for practicing radiologists. CurrCurrProblProbl DiagnDiagn RadiolRadiol..2002 Jul2002 Jul--Aug;31(4):146Aug;31(4):146--57.57.

Bibliography (cont)Bibliography (cont)
http://neoreviews.aappublications.org/case27/case.shtmlhttp://neoreviews.aappublications.org/case27/case.shtmlhttp://neoreviews.aappublications.org/case27/case.shtmlhttp://neoreviews.aappublications.org/case27/case.shtmlhttp://neoreviews.aappublications.org/case27/case.shtmlhttp://neoreviews.aappublications.org/case27/case.shtmlhttp://neoreviews.aappublications.org/case27/case.shtml


115/116

7.7. ROH,ROH, JL.JL.LymphomasLymphomas of the head and neck in the pediatricof the head and neck in the pediatricpopulation, International journal of pediatricpopulation, International journal of pediatric otorhinolaryngologyotorhinolaryngology,,

Volume 71, Issue 9, September 2007, Pages 1471Volume 71, Issue 9, September 2007, Pages 1471--1477.1477.8.8. MoirMoirCR. Neck Cysts, Sinuses,CR. Neck Cysts, Sinuses, ThyroglossalThyroglossal DuctDuct CytsCyts, and, and

Branchial Cleft Anomalies, Operative Tech in GenBranchial Cleft Anomalies, Operative Tech in Gen SurgSurg, v 6, n 4, v 6, n 4(Dec), 2004: 281(Dec), 2004: 281--295.295.

9.9. BranstetterBranstetterBF, Branchial Cleft Cysts,BF, Branchial Cleft Cysts, EmedicineEmedicine,,

http://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htm Oct 24, 2006.Oct 24, 2006.10.10. RovetRovet JF. Congenital hypothyroidism: an analysis of persistingJF. Congenital hypothyroidism: an analysis of persisting

deficits and associated factors. Childdeficits and associated factors. Child NeuropsycholNeuropsychol. 2002. 2002Sep;8(3):150Sep;8(3):150--62.62.

11.11. ThyroglossalThyroglossal Duct Cyst, LearningDuct Cyst, Learning Radiology.comRadiology.com,,http://www.learningradiology.com/archives06/COW%20231http://www.learningradiology.com/archives06/COW%20231--Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlThyroglossal%20Duct%20Cyst/tgdccorrect.html, accessed, accessed10/30/2007.10/30/2007.
http://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htmhttp://www.emedicine.com/radio/topic107.htmhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.htmlhttp://www.emedicine.com/radio/topic107.htm


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http://www.histopathology-india.net/FC.htmhttp://www.emedicine.com/derm/topic860.htm

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