and Cystic Neck Masses - Lieberman`s eRadiology Learning Sites

Anna Calabro’
Gillian Lieberman, MD
April 2014
Thyroglossal duct
cyst (TDC) and
cystic neck masses
Anna Calabrò, University of Trieste
School of Medicine
Gillian Lieberman, MD
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Anna Calabro’
Gillian Lieberman, MD
Agenda
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Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
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Anna Calabro’
Gillian Lieberman, MD
Our patient’s history
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19 year old male
Patient presented with a 3 weeks history of
palpable mass in the region of the right
lateral thyroid cartilage
Otherwise healthy and asymptomatic
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Anna Calabro’
Gillian Lieberman, MD
Menu of tests
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Ultrasound
Doppler ultrasound
MR neck with and without gadolinium
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Anna Calabro’
Gillian Lieberman, MD
Our patient: neck mass on US
Elongated cystic anechoic structure
PACS, MTAH
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Anna Calabro’
Gillian Lieberman, MD
Our patient: neck mass on doppler US
PACS, MTAH
Anechoic fluid collection without internal vascularity
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Anna Calabro’
Gillian Lieberman, MD
Our patient: neck mass on MR
*
*
PACS, MTAH
Axial MRI neck,T2, fat saturation
PACS, MTAH
Coronal MRI neck, T2, fat saturation
 HYPERINTENSE lobulated cystic structure
 hyoid bone level
 insinuates in the right strap musculature
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Anna Calabro’
Gillian Lieberman, MD
Our patient: neck mass on contrast MR
*
*
PACS, MTAH
Axial MRI neck, T1, fat saturation
PACS, MTAH
Coronal MRI neck, T1, fat saturation
 HYPOINTENSE lobulated cystic structure
 hyoid bone insinuating in the strap muscles
 Rim enhancement!
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Anna Calabro’
Gillian Lieberman, MD
Agenda
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Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
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Anna Calabro’
Gillian Lieberman, MD
Neck anatomy
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Drake:Gray’s Anatomy for students,2nd Edition
The neck can be divided into
2 regions:
- The posterior triangle,
bordered by the SCM muscle,
trapezius muscle and the
clavicle.
- The anterior triangle,
bordered by the SCM muscle
and the mandible.
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Anna Calabro’
Gillian Lieberman, MD
Neck anatomy
Hyoid bone
www.radiologyassistant.nl
The anterior triangle is divided into the
 SUPRAHYOID region
 INFRAHYOID region
by the HYOID bone
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Anna Calabro’
Gillian Lieberman, MD
Let’s review our patient’s lesion imaging
findings
 Midline/para midline location
 Hyoid bone level or below it
 Insinuates strap muscles
 Anechoic cystic structure on US
 No internal vasculature on Doppler US
 Hypointense on T1 sequence
 Hyperintense on T2 sequence
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Anna Calabro’
Gillian Lieberman, MD
What is the diagnosis?
 Thyroglossal
duct cyst !
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Anna Calabro’
Gillian Lieberman, MD
Agenda
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Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
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Anna Calabro’
Gillian Lieberman, MD
Thyroglossal duct anatomy and embryology
 The thyroglossal duct runs from
the base of tongue at the foramen
caecum to the thyroid gland.
 The embryonic thyroid gland
travels through the duct to reach its
final normal position.
 Normally, at 5-6 gestational
https://my.statdx.com/
weeks, the thyroglossal duct then
involutes, but when the duct
persists, a thyroglossal duct cyst
can develop anywhere along this
tract.
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Anna Calabro’
Gillian Lieberman, MD
Thyroglossal duct anatomy and embryology
TDC LOCATION:
The location is in the midline or
paramedian.
 65% infrahyoidal,
 20% suprahyoidal,
 15% at the level of the hyoid
bone
http://www.radiologyassistant.nl/ml
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Anna Calabro’
Gillian Lieberman, MD
TDC Epidemiology

They typically present during childhood (90%
before the age of 10), or remain asymptomatic
until they become infected, in which case they can
present at any time.

Thyroglossal duct cysts account for 70% of all
congenital neck anomalies, and are the second
most common benign neck mass, after
lymphadenopathy.
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Anna Calabro’
Gillian Lieberman, MD
Agenda
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Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
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Anna Calabro’
Gillian Lieberman, MD
TDC radiographics features
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Best diagnostic clue: Midline/paramidline
infrahyoid or hyoid level cystic neck mass
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Embedded in strap muscles
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Wall may enhance if infected
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Anna Calabro’
Gillian Lieberman, MD
TDC radiographics features: US
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Ultrasound: Unless infected, they are painless,
fluctuant masses which spread the strap
muscles. The fluid is usually anechoic and the
walls are thin, without internal vascularity.
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However, in some cases, the internal fluid may
contain debris.
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If there is associated infection, there may be
surrounding inflammatory change.
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Anna Calabro’
Gillian Lieberman, MD
TDC radiographic features: MR
§
T1 - typically low signal (in uncomplicated non
infected cases)
§
T2 - typically high signal
§
T1 C+ (Gd) - no enhancement in uncomplicated
cysts, thin peripheral enhancement may be seen
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Anna Calabro’
Gillian Lieberman, MD
TDC radiographics features on CT:
companion patient #1
*
www.radiologyassistant.nl
Axial CT head, post contrast
 cystic lesion
 embedded in the strap musculature
 compression of thyroid cartilage confirms lesion to be benign
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Anna Calabro’
Gillian Lieberman, MD
TDC radiographics features on CT:
companion patient #2
Sagittal CT head and neck, post contrast
 thin band of tissue (white arrow)
connecting the TDC with the
native thyroid gland inferiorly.
 note location of TDC in relation
*
*
to the hyoid bone
*
http://emedicine.medscape.com
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Anna Calabro’
Gillian Lieberman, MD
Agenda
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Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnoses of TDC
Other cystic neck masses
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Anna Calabro’
Gillian Lieberman, MD
Differential Diagnoses of TDC
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Lymphatic malformation
Dermoid or epidermoid cysts in oral cavity
Lingual thyroid
Submandibular or sublingual space
abscess
Mixed laryngocele
Delphian chain necrotic node
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Lymphatic malformations
 A lymphatic malformation is a cystic mass in the head or neck that results
from an abnormal formation of embryonic lymphatic vessels;
 There are two main types of lymphatic malformations:
lymphangioma - a group of lymphatic vessels that form a mass or lump.
cystic hygroma - a large cyst or pocket of lymphatic fluid that results from
blocked lymphatic vessels.
 Unilocular or multilocular (sponge-like)
 Focal or trans-spatial (diffuse/infiltrative)
 Posterior to the SCM
 Association with neurofibromatosis
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Lymphatic malformations
on CT and MR
*
*
www.medscape.com
Axial CT neck, post contrast
www.wiki.uiowa.edu
Axial MR neck, T2
on CT: Low attenuation non-enhancing left neck mass that extends to
the posterior paraspinal soft tissues of the upper back.
on MR: T2 hyperintense lesion
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Oral cavity dermoid and
epidermoid cysts
Oral dermoid cysts
 may be congenital or acquired
 most commonly involve the floor of the mouth, submandibular space,
sublingual space, or root of tongue
 CONTENT: fatty, fluid, or mixed components
Epidermoid cysts
 benign developmental anomalies
 they present as a slow-growing asymptomatic mass and are usually
diagnosed only after they have reached a considerable size. They may
obstruct the upper airway and gastrointestinal tract and potentially can
be fatal
 CONTENT: only fluid-filled
 Neither directly involves hyoid bone
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Oral cavity dermoid and
epidermoid cysts on MR
https://wiki.uiowa.edu
Axial MR neck, T1
https://wiki.uiowa.edu
Axial MR neck, T2
On MR: On T1 fatty elements appear bright, fluid dark
On T2 fat is dark and fluid is bright
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Oral cavity dermoid and
epidermoid cysts on CT
*
http://www.ncbi.nlm.nih.gov
Sagittal CT head
On CT: Low density lesion, a variety of internal appearances depending
on composition, wall may enhance with contrast
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Lingual thyroid
 A lingual thyroid is a specific type of ectopic thyroid, and results from
lack of normal caudal migration of the thyroid gland from foramen
caecum down to its normal location anterior to the larynx and upper
trachea.
 Most common location is at the base of tongue
 Many patients are asymptomatic .In symptomatic patients the lingual
mass may result in dysphagia, bleeding from mucosal ulceration, or
even air-way obstruction (more common in infants).
 On CT without contrast: hyperdense soft tissue mass, of the same

attenuation as normal thyroid tissue. It is hyperdense on account of
the accumulation of iodine within the gland.
On CT with contrast: the entire gland demonstrates prominent
homogenous enhancement just like the normal thyroid gland.
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Anna Calabro’
Gillian Lieberman, MD
TDC
DDx:
Lingual
thyroid
on
CT
TDC DDx: Lingual thyroid on CT
*
*
http://www.mypacs.net
http://www.mypacs.net
Axial CT neck, post contrast
Sagittal Head and neck
 CT without contrast: hyperdense soft tissue mass
 CT with contrast: prominent homogenous enhancement
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Lingual thyroid on CT
TDC
DDx:
Lingual
thyroid
on
MR
and MRI
*
*
http://www.mypacs.net
Sagittal MR head and neck, T1
http://www.mypacs.net
Sagittal MR head and neck, T2
MRI: T1 - iso to hyperintense to muscle mass
T2 - can vary from hypo to iso to hyperintense to muscle
T1 C+ (Gd) - homogeneous contrast enhancement
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Submandibular or
sublingual space abscess
 Location:
- the submandibular space is superior the hyoid bone, lateral or
superficial to the mylohyoid muscle sling, and deep to the platysma
muscle.
- the sublingual space is deep and medial to the mylohyoid muscle and
lateral to the genihyoid/genioglossus muscles. It communicates with the
posterior superior submandibular space and inferior pararpharyngeal
space.
 Origin: Odontogenic or salivary gland infection due to a duct calculus.
 Not embedded within strap muscles
 Thick enhancing wall around collections of pus.
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Submandibular space
abscess on CT
*
http://radiologypics.com
Axial CT neck, post contrast
http://radiologypics.com
Coronal CT head, bone window
 On post contrast CT: hypodense area representing fluid collection in the
submandibular space, due to and abscess
 On bone window CT: lucency in the rigth side of the mandible, which
explains the odontogenic origin of the abscess
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Sublingual space
abscess on CT
*
http://www.medscape.com
Axial CT head, post contrast
Axial CT head, bone window
 On contrast CT: hypodense lesion representing an abscess in the
sublingual space
 On bone window CT: lucency on the mandible explains the odontogenic
origin of the abscess
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Mixed laryngocele
 Traces back to laryngeal origin
 Not embedded within strap muscles
 Extends both internally into the airway and externally
through the thyrohyoid membrane
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Mixed laryngocele on CT
* *
http://www.ncbi.nlm.nih.gov
Axial neck CT
Mixed internal and external laryngocele that shows air density.
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Delphian chain necrotic
node (prelaryngeal)
 May be difficult to differentiate from infected TGDC
 Rare in children
 At level of sternum
 Involvement of this node can be as a result as diffuse
nodal involvement in SCC (H&N), or in isolation from
direct lymphatic spread of laryngeal cancer through the
anterior commissure. Thyroid carcinomas may also
involve this node.
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Anna Calabro’
Gillian Lieberman, MD
TDC DDx: Delphian chain necrotic
node on CT
Axial CT neck, post contrast
*
Hypodense round lesion,
with peripheral rim
enhancement
http://www.mypacs.net
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Anna Calabro’
Gillian Lieberman, MD
Agenda







Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnoses of TDC
Other cystic neck masses
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Anna Calabro’
Gillian Lieberman, MD
Other cystic neck masses
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Necrotic lymphadenopathy (papillary thyroid
and squamous cell ca nodal mets, HPV
lymphadenitis)
Cystic Hygroma (posterior neck)
Branchial cleft cysts (type 2)
Laryngocele
Abscess
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Anna Calabro’
Gillian Lieberman, MD
Cystic Hygroma – Key facts
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

Most common form of Lymphangioma
Congenital benign non-capsulated lesion
arising from expanding embryonic lymph
'lakes' that do not develop normal lymphatic
drainage.
90% in children 10% in young adults.
May occur anywhere in the head and neck.
Mostly located in posterior cervical space.
10% extend into the mediastinum.
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Anna Calabro’
Gillian Lieberman, MD
Cystic Hygroma on MRI
Axial MRI neck, T2, fatsat
Coronal MRI neck, T1
www.radiologyassistant.nl
 Multiloculated lesion in the posterior cervical space
 On T2 weighted image, the lesion has a fluid intensity
 There is no enhancement on the T1 weighted image
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Anna Calabro’
Gillian Lieberman, MD
Second branchial cleft cyst – Key facts

It’s a cystic dilation of remnant of
the 2nd branchial apparatus

95% of all branchial cleft
anomalies arise from the second
branchial cleft.

Most common presentation: cyst,
sometimes in combination with a
sinus or fistula.
www.surgicalcore.org
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Anna Calabro’
Gillian Lieberman, MD
Second branchial cleft cyst
■ Most common location: posterior to the
submandibular gland and anterior
margin of the SCM muscle
web.uni-plovdiv.bg
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Anna Calabro’
Gillian Lieberman, MD
Second branchial cleft cyst on US
www.radiologyassistant.nl
 Usually sharply demarcated
 Echogenicity is variable:
- anechoic - 41%
- homogeneously hypoechoic with internal debris - 24%
- pseudosolid - 12%
- heterogeneous - 23%
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Anna Calabro’
Gillian Lieberman, MD
Second branchial cleft cyst on CT
Axial CT neck, post contrast
 Rounded, sharply circumscribed
**
**
structure, with central fluid
density
 Fairly thick wall with subtle
peripheral enhancement
 Location: posterior to
submandibular gland and
anterior/deep to SCM
 Infection: fat stranding of the
adjacent fat planes
 Anterior displacement and mass
effect with extrinsic compression of
the left internal jugular vein
www.radiopaedia.org
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Anna Calabro’
Gillian Lieberman, MD
Second branchial cleft cyst on MR
T1 - variable signal
*
dependant on protein
content.
- high protein content : high
signal
- low protein content : low
signal (as in image)
*
www.radiologyassistant.nl
Axial MRI neck, T1
Axial MRI neck, T1 C+ (Gd)
T2 - usually high signal
T1 C+ (Gd) - no
enhancement in
uncomplicated lesions.
The lesion shows edge
enhancement postGadolinium.
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Anna Calabro’
Gillian Lieberman, MD
Laryngocele: anatomy
 Laryngocele: abnormal
dilation of the laryngeal
saccule.
 The laryngeal ventricle is a
slit-like opening between the
false and true vocal cords.
It is the anatomic landmark
between supraglottis and
glottis.
The ventricle extends laterally
and then cranially into the
paraglottic space.
http://web.uni-plovdiv.bg
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Anna Calabro’
Gillian Lieberman, MD
Laryngocele: mechanism


http://www.hxbenefit.com
When the opening of the
laryngeal ventricle is
completely obstructed by a
tumor, the mucosa in the
paraglottic space continues
to produce fluid.
This results in a fluid-filled
internal laryngocele (does
not cross the thyrohyoid
membrane)
When the opening of the
laryngeal ventricle is
partially obstructed, a
pressure-valve mechanism
may result in an aircontaining internal
laryngocele.
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Anna Calabro’
Gillian Lieberman, MD
Laryngocele on CT
http://www.hxbenefit.com
http://home.earthlink.net
Neck anatomy is difficult to learn. Try to recognize as many anatomic
and pathologic structures as you can, in the coronal CT images on the
right, using the left image as a guide, then continue.
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Anna Calabro’
Gillian Lieberman, MD
Laryngocele on CT
Coronal CT head
jvjvf
 Anatomic structures from
*
*
*
*
*
*
*
** *
the top:
-hyoid bone
-epiglottis
-thyrohyoid membrane
-thyroid cartilage
-cricoid cartilage
 Pathology structures:
http://home.earthlink.net
-tumor/mass
-INTERNAL laryngocele
-EXTERNAL laryngocele
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Anna Calabro’
Gillian Lieberman, MD
Laryngocele on CT
* *
*
www.radiologyassistant.nl
Axial CT neck , lower cut
Axial CT neck, higher cut
 Well defined, air, fluid or pus filled lesion related to the paraglottic
space, which has continuity with the laryngeal ventricle.
 Secondary internal and external laryngocele caused by a tumor at the
level of the laryngeal ventricle.
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Anna Calabro’
Gillian Lieberman, MD
Laryngocele Types

INTERNAL - the dilated ventricular saccule is confined
to the paralaryngeal space

EXTERNAL - the saccule herniates through the
thyrohyoid membrane (anteriorly)

MIXED - has components both inside and outside the
larynx

The lesion can be air-filled (laryngocele)
fluid filled (laryngeal mucocele)
pus filled (laryngopyocele)


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Anna Calabro’
Gillian Lieberman, MD
References

Branstetter, BF and Weissman JL. Normal Anatomy of the Neck with CT and MR Imaging Correlation. Radiologic Clinics of North
America; Sept 2000 38:925-940.

Emerick, Kevin, and Derrick Lin. Differential diagnosis of a neck mass; May 2010.

Ahuja AT, King AD, King W et-al. Thyroglossal duct cysts: sonographic appearances in adults. AJNR Am J Neuroradiol. 1999;20 (4): 57982. AJNR Am J

Meuwly JY, Lepori D, Theumann N et-al. Multimodality imaging evaluation of the pediatric neck: techniques and spectrum of findings.
Radiographics. 25 (4): 931-48

http://pediatric-ent.com/2011/09/lump-or-mass-in-the-neck/#bca

http://radiopaedia.org/articles

http://www.radiologyassistant.nl/en/p49c603213caff/infrahyoid-neck.html#i4aedf5ff2169a

https://my.statdx.com/

http://emedicine.medscape.com/article/1346365-overview#a20

http://www.surgicalcore.org/popup/55306


http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
http://radiopaedia.org/articles/second-branchial-cleft-cyst

http://www.medscape.com/viewarticle/510370_3

https://wiki.uiowa.edu/display/protocols/Lymphatic+Malformation+Rads

http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2005_%20Larynx.htm

http://www.hxbenefit.com/laryngocele.html

http://home.earthlink.net/~radiologist/tf/030705.htm
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Anna Calabro’
Gillian Lieberman, MD
References

Curtin, HD. "Larynx." In Head and Neck Imaging, Som and Curtin, eds. St. Louis: Mosby-Yearbook. pp 665-671.

http://www.brown.edu/Departments/Diagnostic_Imaging/cases/hn.html

https://wiki.uiowa.edu/display/protocols/Dermoid+Cysts+Rads

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781235/

http://www.mypacs.net/cases/LINGUAL-THYROID-57329773.html

http://radiologypics.com/2013/02/14/submandibular-space-abscess/

http://www.medscape.com/viewarticle/729323_3

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640037/#B12

http://www.mypacs.net/mpv4/hss/casemanager
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Anna Calabro’
Gillian Lieberman, MD
Acknowledgements





Gillian Lieberman, MD
Jayant Boolchand, MD
Alejandro Heffess, MD
Pierre Sasson, MD
Mount Auburn Radiology Department
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