Cystic Head and Neck Lesions

Transcription

1 Cystic Head and Neck Lesions Disclosures None Brad Wright, MD 19 March 2018 Key points Huge variety of cystic lesions in H&N May be cystic, necrotic, or solid but cystic-appearing Patient age, clinical history, lesion location can narrow DDx Always consider infection and malignancy! Case 1 25 yo M with URI, enlarging neck mass What is the best treatment? A. Antibiotics B. Incision and drainage C. Resection of the mass and part of hyoid What is the best treatment? A. Antibiotics B. Incision and drainage C. Resection of the mass and part of hyoid 1

2 Thyroglossal duct cyst No DDx Classic findings for thyroglossal duct cyst Midline or paramedian, at hyoid (50%), cystic Enhancing wall if infected Treat with Sistrunk procedure Case 2 35 yo M with enlarging neck mass Thyroglossal duct cyst carcinoma 2% of thyroglossal duct cysts Almost always (95%) papillary thyroid carcinoma Case 3 24 yo F with floor of mouth mass seen by dentist A. Abscess B. Dermoid C. Lymphatic malformation D. Ranula 2

3 A. Abscess B. Dermoid C. Lymphatic malformation D. Ranula Ranula Retention cyst related to trauma or inflammation of sublingual gland Simple: confined to sublingual space; horseshoe-shaped if bilateral Diving: dives into submandibular space, +/- tail of residual sublingual fluid DDx: lymphatic malformation, dermoid (fat), epidermoid (DWI+), abscess Case 4 23 yo M with gradual onset jaw/neck swelling on the right; h/o prior episodes Infected diving ranula Tail of residual fluid in sublingual space Thick enhancing wall Treat with antibiotics, then excision of sublingual gland or sclerotherapy (among other options) Case 5 62 yo M with floor of mouth swelling for 2 weeks; started with URI Tongue abscess Treat with I&D and antibiotics Specific location of an infected cystic lesion matters for treatment 3

4 Case 6 19 yo F with slowly growing non-painful submandibular mass Recommendation? A. Antibiotics B. Aspiration C. Biopsy D. MRI Recommendation? A. Antibiotics B. Aspiration C. Biopsy D. MRI T2 T1 T1 C+ FS Lymphatic malformation Congenital slow-flow vascular malformation; most present < 2 yo Transspatial, multilocular, +/- fluid-fluid levels, solidappearing components Treat with sclerotherapy and/or surgery 4

5 Case 7 2 yo M with left neck swelling Infected 2 nd branchial cleft cyst (type II) Most common location (type II): anterior to SCM, posterolateral to submandibular gland, lateral to carotid space Most present < 5 yo; DDx in >30 yo: metastatic node Case 8 23 yo M with enlarging neck mass x 8 days 2 nd branchial cleft cyst Surgical pathology: irritated branchial cleft cyst Case 9 51 yo F with neck mass x 2-3 months 2 nd branchial cleft cyst No malignant cells on FNA, no other lesions on CT or laryngoscopy Even so, caution is advised in any patient >30 yo 5

6 Case yo F with neck mass and type 1 DM What is it? A. Infection B. Malignancy How can we decide? At supraclavicular level At level of cricoid History is key! Type 1 DM Accidental needle stick with old needle 2 wks ago Mass is red and tender Case yo M with slowly growing neck mass Look for septic pulmonary emboli Necrotic metastatic node Case yo M with left lateral tongue SCCa Patient has RCC Metastatic left supraclavicular node also know as sentinel node or Virchow's node; associated with abdominal and pelvic malignancy 6

7 Necrotic metastatic node History helps Case yo M with R neck pain/swelling x 2 wks A. Infection B. Lymphoma C. SCCa D. Thyroid cancer A. Infection B. Lymphoma C. SCCa D. Thyroid cancer 7

8 Metastatic differentiated thyroid carcinoma (DTCa) Papillary or follicular carcinoma Suspect DTCa if: Nodal mass(es) in young female Bilateral low neck (level IV, V, VI) nodes Cystic or mixed cystic/solid nodes +/- calcs T1 hyperintense nodes Case yo F with lump in neck for 1 year T2 T2 STIR A. Carotid body tumor B. Infection C. Malignancy D. Schwannoma T1 T1 C+ FS 8

9 A. Carotid body tumor B. Infection C. Malignancy D. Schwannoma Schwannoma Circumscribed, ovoid/fusiform, T2 bright, no flow voids Intratumoral cysts if large In neck, most commonly from sympathetic chain or CN X DDx: Carotid body paraganglioma: splays carotid bifurcation, flow voids Neurofibroma: low density on CT, a/w NF1 Metastatic lymph node: history is key Case yo M with an incidental finding Laryngocele Internal laryngocele: dilated laryngeal saccule in paraglottic region of supraglottis; contains air or fluid Mixed (external) laryngocele: extends laterally through thyrohyoid membrane Usually related to chronic coughing, etc, but look for infiltrating mass Internal vs external laryngocele Case yo M with an incidental finding 9

10 Zenker diverticulum Extends posterior to esophagus, with opening into pouch at level of C5-C6 (just above cricopharyngeus muscle) Associated with esophageal dysmotility, regurgitation, aspiration DDx: Killian-Jamieson diverticulum is lower and protrudes laterally Case yo F with an incidental finding Tracheal diverticulum Typically right paratracheal above thoracic inlet; may see connection to trachea Congenital or acquired; a/w COPD Usually asymptomatic but can become infected Summary: a few pearls Distinction between an abscess and infected TGDC, ranula, or BCC matters If Dx is TGDC, BCC in >30 yo, or laryngocele, look for malignancy Low neck masses in young woman, esp cystic or calcified suspect DTCa Patient age, clinical history, and lesion location can narrow DDx References 1. Adams A, Mankad K, et al. (2016). Branchial cleft anomalies: a pictorial review of embryological development and spectrum of findings. Insights Imaging 7: Anil G and Tan TY (2010). Imaging characteristics of schwannoma of the cervical sympathetic chain: a review of 12 cases. AJNR 31: Eisenmenger LB and Wiggins RH (2015). Imaging of head and neck lymph nodes. Radiol Clin N Am 53: Ibrahim M, Hammoud K, et al. (2011). Congenital cystic lesions of the head and neck. Neuroimag Clin N Am 21: Koeller KK, Alamo L, et al. (1999). Congenital cystic masses of the neck: radiologic-pathologic correlation. RadioGraphics 19: References 6. Lee JY, Lee HY, et al. (2016). Plunging ranulas revisited: a CT study with emphasis on a defect of the mylohyoid muscle as the primary route of lesion propagation. Korean J Radiol 17: Ludwig BJ, Wang J, et al. (2012). Imaging of cervical lymphadenopathy in children and young adults. AJR 199: Mittal KM, Malik A, et al. (2012). Cystic masses of neck: a pictorial review. Indian J Radiol Imaging 22: Wassaf M, Blei F, et al. (2015). Vascular anomalies classification: recommendations from the international society for the study of vascular anomalies. Pediatrics 136:e Zander DA and Smoker WA (2014). Imaging of ectopic thyroid tissue and thyroglossal duct cysts. RadioGraphics 34: