Deepak M. Sampathu MD, PhD Assistant Professor of Clinical Radiology University of Pennsylvania
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1 Deepak M. Sampathu MD, PhD Assistant Professor of Clinical Radiology University of Pennsylvania
2 Objectives Recognize benign masses and masslike lesions of the neck and skull base Understand the imaging characteristics of benign masses and mass-like lesions of the neck and skull base on CT and MRI
3 Neck Masses By location: Midline/paramidline anterior neck Floor of mouth Submandibular space at angle of jaw Along lateral cervical nodal chain Posterior neck
4 Midline/paramidline anterior neck Thyroglossal duct cyst Laryngocele Dermoid/epidermoid cyst Venolymphatic malformation
5 Thyroglossal duct cyst Most common congenital neck mass Child / young adult Location Suprahyoid 20% At level of hyoid or infrahyoid 80% Painless fluctuant mass Risk of thyroid carcinoma Sistrunk procedure (Harnsberger, Handbook of Head and Neck Imaging, 1995)
6 Thyroglossal duct cyst
7 Thyroglossal duct cyst
8 Papillary carcinoma in TGDC
9 Epidermoid
10 Laryngocele Adulthood Enlarged laryngeal saccule Laryngeal saccule blind pouch arising from laryngeal ventricle Types: Internal External Mixed Laryngoscopy is critical (Harnsberger, Handbook of Head and Neck Imaging, 1995)
11 Laryngocele
12 Laryngocele
13 Floor of Mouth Ranula/Sialocele Abscess, Ludwig s angina Dermoid/ Epidermoid cyst Lymphatic malformation
14 Floor of Mouth Lesions (Vogl et al, AJR 1993)
15 Ranula Peak prevalance age years Pseudocyst in floor of mouth Submandibular duct obstruction Types Simple Plunging/Diving DDx: Sialocele - Ruptured SMD extravasates saliva into sublingual space
16 Simple ranula
17 Plunging Ranula
18 Plunging Ranula
19 Floor of Mouth Infection Clinical findings get history! Imaging findings dirty fat Thickening of platysma/skin Abscess: peripherally-enhancing collection Most common etiology: odontogenic Ludwig s angina: 5% fatality rate Mixed bacterial infection: aerobes/anaerobes Potential airway compromise
20 Infection - Ludwig angina
21 Dermoid
22 Dermoid/Epidermoid cyst Usually present at age Terminology Epidermoid: squamous epithelial lining Dermoid: squamous epithelial lining + skin appendages (sebaceous glands, hair follicles) [Teratoma: true neoplasm with tissue of one or more germ layers] Etiology: Trapped pouches of ectoderm or failure of ectoderm to separate from neural tube Dermoid: 5% malignant degeneration to SCCa
23 Dermoid/Epidermoid cyst Imaging characteristics Epidermoid CT: fluid attenuation MRI: hyper on T2, hypo on T1 Restricted diffusion Dermoid More variable on CT/MR Restricted diffusion
24 Dermoid/epidermoid
25 Presumed epidermoid
26 Lymphatic malformation lymphangioma, cystic hygroma ~50% present at birth or before age 5, do not spontaneously regress Slow-flow vascular malformation containing embryonic lymphatic sacs Can occur in any H&N space transspatial mass with fluid-fluid levels Venolymphatic malformation: venous and lymphatic elements in same mass
27 Lymphatic malformation
28 Lymphatic malformation
29 Submandibular space at angle of jaw 2 nd Branchial cleft cyst (DDx - Cystic/necrotic level IIA lymphadenopathy ) Plunging ranula/sialocele Abscess/Ludwig s angina Lymphatic malformation
30 Cystic/necrotic lymphadenopathy Infectious etiologies Mycobacterial Bacterial Neoplastic etiologies Squamous cell carcinoma Papillary thyroid carcinoma (lymphoma rarely cystic-appearing)
31 2 nd branchial cleft cyst Most common branchial apparatus anomaly Typically present at age subtypes based on location Classic is type 2: Posterior to submandibular gland Anteromedial to sternocleidomastoid muscle Lateral to carotid sheath
32 Branchial Apparatus (Ibrahim et al. Neurimag Clin N Amer 2012)
33 2 nd branchial cleft cyst
34 2 nd branchial cleft cyst
35 Lymphadenopathy R tonsillar SCCa
36 Metastatic lymphadenopathy from oropharyngeal SCCa
37 2 nd branchial cleft cyst
38 Cystic lesion at level 2A in adult Consider cancer until proven otherwise Increasing incidence of HPV-related squamous cell cancer in adults < age 40 Male>female, nonsmokers Occur in oropharynx Propensity for cystic adenopathy Primary tumor may be small FNA for workup (avoid open biopsy) If FNA inconclusive, some advocate for blind oropharyngeal biopsies/pet in workup
39 Along cervical nodal chain Suppurative or cystic/necrotic lymphadenopathy 2 nd /3 rd Branchial cleft cyst Paraganglioma Schwannoma
40 Suppurative Lymphadenitis
41 Carotid body paraganglioma Benign neuroendocrine neoplasm arising in paraganglionic tissue Slowly growing, painless, pulsatile mass Vascular mass splaying ICA and ECA salt and pepper appearance in larger tumors on T1WI: Salt = areas of high signal intensity Pepper = flow voids Intense rapid enhancement
42 Paragangliomas
43 Carotid body paraganglioma
44 Multiple paragangliomas Multiple gene mutations identified in familial and sporadic types SDH: succinate dehydrogenase gene RET protoongogene: multiple endocrine neoplasia (MEN) syndromes VHL gene: von Hippel-Lindau syndrome
45 Carotid space schwannoma Benign tumor of Schwann cells that wrap around a nerve Clinical presentation: Typical: asymptomatic palpable mass if large, may cause dysphagia or occlusion of IJV Horner syndrome Hoarseness (vocal cord paralysis Imaging: lack of flow voids Dense uniform enhancement +/- intratumoral cysts
46 Schwannoma
47 Parotid space 1 st Branchial cleft cyst Parotid lymphoepithelial cyst/sialocele/sialectasis Lymphoepithelial lesions (bilateral and multiple, HIV or Sjogren) Warthin s tumor (bilateral parotid tails)
48 1 st branchial cleft cyst 1 st branchial arch extends from EAC, through parotid gland, to submandibular space Locations Adjacent to external auditory canal Intraparotid/periparotid CT/MR cannot differentiate from cystic parotid mass
49 1 st Branchial Cleft Cyst
50 Infected 1 st BCC
51 Benign Lymphoepithelial lesions in HIV Intraparotid May be: Cystic Mixed cystic/solid Solid (lymphadenopathy) DDx: Sjogren s Warthin s tumors
52 Lymphoepithelial Lesions
53 Posterior cervical space Cystic hygroma (very large lymphatic malformation presents at < 2-year-old) Lymphatic malformation (smaller lymphatic malformation presents at any age) Level 5 Cystic/necrotic lymphadenopathy 3 rd Branchial cleft cyst (posterior to the carotid, rare)
54 Lymphatic malformation
55 Lymphatic malformation
56 Infectious lymphadenopathy - bacterial
57 Skull Base Benign masses Anterior skull base Central skull base Posterior skull base (jugular foramen)
58 Anterior Skull Base Fibrous Dysplasia Cephalocele Meningioma
59 Fibrous Dysplasia Benign fibro-osseous lesion in which normal bone is replaced by weak osseous & fibrous tissue Classic appearance groundglass density on CT Variable enhancment of fibrous component
60 Fibrous Dysplasia
61 Fibrous Dysplasia
62 Cephalocele Cephalocele: general term for protrusion of intracranial contents through defect in calvarium or skull base Meningoencephalocele/encephalocele: Brain tissue, meninges, and CSF Meningocele: Meninges and CSF only CT: delineation of osseous defect MR: heterogeneous appearance reflecting brain tissue and CSF contents
63 Ethmoid meningoencephalocele
64 Meningioma Most common extra-axial intracranial neoplasm Typical meningioma WHO grade 1 (~70%) Atypical meningioma WHO grade 2 (~30%) Malignant meningioma WHO grade 3 (~1%) Well-circumscribed extra-axial mass with dural attachment Majority enhance homogeneously and intensely Necrosis, cysts, hemorrhage (8-23%) Calcifications (20-25%)
65 Meningioma
66 Central Skull Base Meningioma Pituitary Macroadenoma Chordoma Benign Fibrofatty lesion (arrested pneumatization) Cholesterol granuloma
67 Meningioma
68 Meningioma
69 Pituitary Macroadenoma Sellar mass without separate identifiable pituitary gland Most common suprasellar mass in adults superior extension of macroadenoma +/- mass effect on optic chiasm +/- cavernous sinus invasion Usually isointense with gray matter Most enhance heterogeneously
70 Pituitary Macroadenoma
71 Pituitary Macroadenoma
72 Chordoma Arises primitive notochord remnant Rare, locally aggressive Considered low-grade malignancy Local recurrence is common despite combined surgical and radiation therapy Imaging: destructive midline mass which is hyperintense on T2WI
73 Clival Chordoma
74 Clival chordoma
75 Cholesterol Granuloma Expansile lesion in petrous apex consisting of fibrosis and vascular proliferation Giant cell reaction to deposition of cholesterol crystals in air cells CT: sharply marginated, expansile lesion MR: high signal intensity on T1WI, no internal enhancement
76 Cholesterol Granuloma
77 Benign fibro-fatty lesion of sphenoid Synonym: arrested pneumatization of sphenoid Common incidental finding on imaging leave me alone lesion Nonexpansile lesion in sphenoid bone with sclerotic margins Internal fat attenuation is invariably present
78 Benign fibro-fatty lesion of sphenoid
79 Encephalocele in sphenoid siunus
80 Posterior Skull Base Lesions of jugular foramen: Paraganglioma Schwannoma Meningioma
81 Glomus jugulare paraganglioma Benign tumor arising from neural crest cells in/around jugular foramen CT: permeative bone destruction around jugular foramen MR: vascular mass
82 Glomus jugulare paraganglioma In-111 Octreoscan
83 Glomus jugulare paraganglioma
84 Jugular foramen schwannoma Benign neoplasm of differentiated Schwann cells around cranial nerve 9, 10, or 11 in jugular foramen CT: well marginated, expanded jugular foramen without permeative destruction MR: tubular or dumbell-shaped mass; no flow-voids Homogeneously enhancing except for cystic areas in larger lesions
85 Jugular foramen schwannoma
86 Jugular foramen schwannoma
87 Jugular foramen meningioma Mass arising from arachnoid meningothelial cap cells along cranial nerves 9-11 in jugular foramen CT: permeative/sclerotic margins MR: enhancing mass with dural tail(s), no flow voids
88 Jugular foramen menngioma
89 Objectives Recognize benign masses and masslike lesions of the neck and skull base Understand the imaging characteristics of benign masses and mass-like lesions of the neck and skull base on CT and MRI
90 Thanks
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