Uncommon ultrasound findings in the cervical region

Transcription

1 Uncommon ultrasound findings in the cervical region Poster No.: C-1132 Congress: ECR 2014 Type: Educational Exhibit Authors: V. Donciu, S. M. Petrescu, E. NEGUT, C. ZAHARIA ; Bucharest/RO, BUCHAREST, ro/ro Keywords: Ear / Nose / Throat, Head and neck, Lymph nodes, Echocardiography, Observer performance, Puncture, Genetic defects, Metastases DOI: /ecr2014/C-1132 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 51

2 Learning objectives To review the anatomy of the cervical region and the most common pathologies related to. To understand the importance of sonographic examination of the cervical region as a valuable diagnostic tool in different pathologies, especially uncommon ones, involving lymph nodes, lumps and bumps. To learn what a radiologist should take into consideration as a differential diagnosis when in front of a cervical pathology. To understand the advantages and the limitations of this technique compared with others imaging modalities. Background Anatomy of the cervical region is very complex and for a more efficient ultrasound examination it is important to identify the normal anatomical structures of the neck region, considering its division in several spaces or triangles. There are many versions of division of the neck region: relative to hyoid bone: suprahyoid and infrahyoid space. relative to SCM: anterior and posterior triangle. The borders of the anterior triangle, where we can find the major structure of the neck, are the inferior border of the mandible, the SCM and the midline. Anterior triangle is subdivided further in submental and submandibular triangles by the anterior belly of the digastric muscle; muscular and carotid triangles by the superior belly of the omohyoid muscle. [2] The borders of the posterior triangle are the SCM, the trapezius muscle and the clavicle. Omohyoid muscle divide the posterior triangle in occipital and supraclavicular triangle.[2] This format is useful to avoid anarchic sliding of the ultrasound probe among the neck and helps us to presuppose what kind of pathology we expect to find towards each region. Table 1 on page 3 Even though CT and MRI are considered to be the best imaging method for evaluation of salivary glands, ultrasound, in experienced hand, can, sometimes, substitute both CT and MRI, and provide us some important differential diagnostic data.[3] However, there are situation in which ultrasound examination is limited by location of the lesions or infiltration Page 2 of 51

3 of adjacent structures (bone, parapharyngeal space, deep lymph nodes). In this cases, we can't ignore the performance of CT and MRI. [3] Salivary glands (parotid, submandibular, sublingual gland) have, in generally, homogeneous echogenicity and varies from very bright and remarkably hyperechoic to only slightly hyperechoic in comparison to adjacent muscles. If the salivary glands are prone to fatty infiltration, then, their echogenicity is diffuse increased, generating artifacts. [1,3] Unlike the submandibular gland, parotid gland contains lymph nodes, localized mainly in the upper and lower poles of the gland. Normal intraparotid lymph nodes are hypoechoic, oval with a hyperechoic hilum (important criteria for the normality).[3] We should also mentioned the main excretory ducts Stenon and Wharton, which, if nondilated, aren't visible during US examination. As we can see in the above table, lymph nodes, are omnipresent in every region, therefore, identification of cervical lymphadenopathy is critical, not only for diagnosis and staging of malignant diseases, but also, for therapy management. On ultrasound, normal nodes tend to be hypoechoic, compared with adjacent muscles, oval, with a fairly uniform thick cortex, and an echogenic hilus. On color Doppler, normal cervical nodes show hilar vascularity, branching radially toward periphery of lymph node.[4] As part of the jugulodigastric region, the IJV (internal jugular vein), carotid artery and the vagus nerve, are important structures to identify as many pathologies are related to (IJV thrombosis, paragangliomas, nerve sheath tumors). IJV is best examined with patient lying down, because, if patient is examined sitting up, then IJV will commonly be collapsed. Its patency may be checked with the Valsalva manoeuvre.[1] Between the great vessels, lies deeply the vagus nerve, whose transverse diameter should not exceed 2-3 mm.[1] As far as the musculature of the neck, SCM, digastric and omohyoid muscles, are important landmarks that we should recognize.[2] For the purpose of this article, I will focus on pathology less frequent, considering that the detailed anatomy of the cervical region and diseases of the thyroid gland are topics that deserve addressed separately. Images for this section: Page 3 of 51

4 Table 1: The key structure for each region and afferent pathologies Page 4 of 51

5 Findings and procedure details Having many advantages, including high resolution and the possibility of using Doppler, cervical ultrasound is a common routine clinical practice. For this reason, and because cervical structures can be approached in an easy way, any abnormality can be detected. Most echographic findings are related to the ear, nose and throat (ENT) and hematologic pathologies from the hospital that I practice in. By far, the most common pathology is related to lymph nodes. There are many criteria by which a lymph node is benign or malignant: size, shape, echogenic hilus, echogenicity, necrosis, extracapsular spread, color flow, number and calcification.[2] I will detail these criteria during the presentation of the cases. Case nr.1 (Fig. 1 on page 30, Fig. 2 on page 31) Lymph node tuberculosis Page 5 of 51

6 Fig. 1 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 6 of 51

7 Fig. 2 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 42-year-old women, with a right laterocervical mass. On ultrasound: laterocervical, on the right side, we can observe a large polinodular group, with multiple calcifications inside. It appears that the lesion infiltrates de SCM muscle. Adjacent, a lymphadenopathy (2,5 cm), also with multiple calcifications inside. Both lesions have direct contact with submandibular gland. Discussions: The normal lymph node has a smooth margin, if the normal sharp smooth outline is lost, we should suspect an extracapsular spread, and the presence of the microcalcification inside suggest a high possibility of metastases from a papillary carcinoma of the thyroid. [2] Page 7 of 51

8 In this case, even though all the criteria indicates metastatic lymph nodes with extracapsular spreading, histopathology confirmed lymph nodes tuberculosis. Regarding the SCM muscle, was described several areas of chronic inflammation. Thyroid gland was within normal limits. Case nr.2 ( Fig. 3 on page 32, Fig. 4 on page 33) Lymph node tuberculosis Fig. 3 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 8 of 51

9 Fig. 4 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 53-year-old male with laterocervical mass on left side. On ultrasound: a 3 cm hypoechogenic nodule with sharp smooth borders, adjacent to jugular space. On color Doppler, there is no vasculature inside, just in the periphery. Discussions: The images above are suggestive of cystic necrosis, which is often identified in tuberculous nodes, but we should be careful as necrosis is a criteria for malignancy (see case nr.3).[2] In this condition, cytology is a must. As in the previous case, histopathology is the one that established the final diagnosis, which was lymph node tuberculosis. Case nr.3 ( Fig. 5 on page 34, Fig. 6 on page 35) Page 9 of 51

10 Necrotic lymph nodes Fig. 5 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 10 of 51

11 Fig. 6 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 67-year-old male with pharyngeal cancer. On ultrasound: lymph nodes with irregular thickened cortex with cyst like transformations, no hyperechogenyc hilus; poor peripheral vascularization. Discussions: When a patient is known with a cancer, necrosis in a node is a strong sign of malignancy. There are two types of necrosis: cystic necrosis and coagulation necrosis that may coexist in the same lymph node, with a central "geographic appearance".[2] Also, focal absence of perfusion sustain the diagnosis of malignancy.[2] Case nr.4 ( Fig. 7 on page 36, Fig. 8 on page 37) Page 11 of 51

12 Extracapsular spread Fig. 7 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 12 of 51

13 Fig. 8 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 72-year-old male with pharyngeal cancer. On ultrasound: lymphadenopathies invading IJV, which is compressed, involving also ECA (completely) and ICA ¾ of its circumference. Discussions: This is a typical case of extracapsular spread, implying a grave prognosis for the patient. [2] Advanced extracapsular spread is suggested by the invasion of adjacent structures, in our case IJV, ECA. Histopathology confirmed that it was a metastatic node. Case nr. 5 ( Fig. 9 on page 38, Fig. 10 on page 39) Page 13 of 51

14 Sialolithiasis submandibular gland Fig. 9 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 14 of 51

15 Fig. 10 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 35-year-old female with painful neck mass. On ultrasound: enlarged left submandibular gland, with pronounced vascularization, mostly along the ducts surrounded by moderate edema. Main duct dilated, with an inclavated calculus. Discussions: Salivary stones are more often located in the submandibular gland than parotid, because the submandibular saliva has a greater mucous content.[1,3] It is important to make a distinction, for the benefit of treatment, between a calculus in the glandular parenchyma and an intraductal one.[3] Case nr.6 ( Fig. 11 on page 40, Fig. 12 on page 41) Page 15 of 51

16 Warthin tumor parotid gland Fig. 11 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 16 of 51

17 Fig. 12 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 54-year-old man with Non Hodgkin Lymphoma. On ultrasound: hypoechoic nodular mass in the parotid gland, intense heterogeneous, with well defined borders and poor vascularization. Discussions: Warthin tumors are one of the most common benign lesions. The lesion described above has typical characteristics for a Warthin tumor, exception is made, in our case, by poor vascularization (this kind of tumors are in generally hypervascularized). There are described Warthin tumors that appear in the form of a simple cyst at US, so, again, differential diagnoses is needed with cystic carcinomas. [3] Page 17 of 51

18 Case nr.7 ( Fig. 13 on page 42, Fig. 14 on page 43) Metastatic lesions in the submandibular gland Fig. 13 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 18 of 51

19 Fig. 14 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 70-year-old male with hypopharynx cancer. On ultrasound: voluminous mass located in the left submandibular gland, that has an echogenicity lower than the surrounding glandular parenchyma, blurred margins and pronounced vascularization. Discussions: Submandibular glands are very rare sites of metastases.[3] Usually, primary tumors metastasizing to salivary glands are located in head and neck region, similar to our case. Even though in our patient, the mass has obvious malignant criteria, there are situation in which metastases are well defined and oval, making a more difficult differential.[3] Case nr. 8 ( Fig. 15 on page 44, Fig. 16 on page 45, Fig. 17 on page 46) Page 19 of 51

20 Malignant tumor in the submandibular gland Fig. 15 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 20 of 51

21 Fig. 16 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 21 of 51

22 Fig. 17 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 42-year-old female diagnosed with submandibular malignant cancer, operated in 2009, with segmental resection of left mandibular ramus. On ultrasound: right IJV nonobstructive thrombosis; hypoechoic tumoral mass in the submandibular gland area, irregular, blurred borders, that seems to invade the superficial musculature. Interrupted mandibular cotex. Discussion: It is an interesting case of local tumor recurrence diagnosed on histopathology. This patient has a spectrum of lesions on ultrasound, that were confirmed by CT imaging: IJV thrombosis, necrotic recurrent carcinoma (necrotic because of lack of vascularization on US) and bone destructions. Regarding bone lesions, it was difficult to establish its nature, based only on imaging: whether is postoperative (unknown medical history) or Page 22 of 51

23 direct invasion of the tumor. Accurate diagnosis is made by histopathological examination (in this case, it was a postoperative lesion). Case nr.9 ( Fig. 18 on page 47, Fig. 19 on page 48) Ectopic thyroid gland Fig. 18 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 23 of 51

24 Fig. 19 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 30-year-old female, with no significant medical history. On ultrasound: a 2,5 cm nodular mass, located at the base of the tongue, with echogenicity similar to tongue musculature, smooth borders and detectable vascularization inside. In thyroid area, there are some cystic lesions, one on the left, and three on the right side, with no viewable thyroid tissue. Discussions: The lingual thyroid is four times common in females than in males. During embryological development, thyroid gland migrates down from the foramen caecum (posterior aspect of the tongue) to its permanent location. If the embryonic gland does not descent normally, ectopic or residual thyroid tissue may be found between the foramen caecum and the epiglottis. The ultrasound appearances are of a well-defined, uniformly echogenic, solid, Page 24 of 51

25 vascular mass in the sublingual region.[1] Particularity of this case is the presence of cystic lesions in the thyroid area. Case nr. 10 ( Fig. 20 on page 49) Infected second branchial cysts Fig. 20 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 41-year-old man, with history of chronic smoking, presents with a right laterocervical painful, erythematous mass. On ultrasound: laterocervical on the right side, posterior to SCM muscle, is seen a hypoechoic nodule, sharp borders, slightly inhomogeneous, with no vascularization on color Doppler. Page 25 of 51

26 Discussions: Branchial clef cysts are congenital epithelial cysts which arise from a failure of obliteration of the second branchial clef cyst (the vast majority) in embryonic development. Sonographic appearances may vary, from anechoic, thin-walled and compressible mass, to hypoechoic with internal debris and posterior acoustic enhancement.[1] We should be aware that a branchial cleft cyst mimics metastases from a head and neck cancer and from papillary carcinoma of the thyroid, therefore is indicated a thorough search for a possible tongue, tonsil and thyroid primary, especially if the patient is older then 40 years.this case draws attention by its non- characteristics findings: patient older than 40 year, smoker (risk factor for cancers), with normal thyroid gland (exclude thyroid follicular carcinoma), and erythematous mass (infected branchial cyst). Case nr. 11 Miscellaneous lesions Page 26 of 51

27 Fig. 21 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Phlegmon in massteric muscle in a 37-year old man Page 27 of 51

28 Fig. 22 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Page 28 of 51

29 Fig. 23 References: Radiology, Coltea Clinical Hospital - Bucharest/RO Dissecting aneurysm of the CCA (common carotid artery) in a 68-year old female with cutaneous nasal cancer Page 29 of 51

30 Fig. 24 References: Radiology, Coltea Clinical Hospital - Bucharest/RO A 29-year old man with adenophlegmon post-ingestion of a fishbone with SCM muscle edema Images for this section: Page 30 of 51

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51 Conclusion It is essential for the radiologist to be master of the anatomic structures in order to recognize different masses in the cervical region. If the lesions are small and have a superficial location, spatial resolution, using a linear ultrasound probe (10 MHz), is considered much better than CT or MRI, nevertheless, if ultrasound examination is limited by various factors, the use of other imaging techniques can and should be implemented. And last but not least, we should be aware that histopathology is the final exam that define the accurate diagnostic. Personal information References Paul L. Allan. Clinical Ultrasound. Chapter 45, Ultrasound of the neck. UK. Elsevier Anil Ahuja. Practical Head and Neck Ultrasound. London. GMM Ewa J. Bialek, MD, PhD, Wieslaw Jakubowski, MD, PhD, Piotr Zajkowski, MD, PhD. US of the major Salivary Glands: Anatomy and Spatial Relationships, Pathologic Conditions, and Pitfalls. RadioGraphics. Volume 26. May-June : Anil T. Ahuja. Michael Ying. Sonographic Evaluation of Cervical Lymph Nodes. AJR:184, May : Page 51 of 51