Neck masses: When ultrasound is enough? - espr.org · Fibromatosis colli 15 d old child, 4 d ago left sided neck mass was observed. No infection, not painfull. A fuciform enlargement

Neck masses: When

ultrasound is enough?

Marja Perhomaa

MD, Chief paediatric radiologist

Oulu University Hospital, Finland

ESPR 2019 Helsinki

Evaluation on paediatric neck masses – The

Referral• Clinical history

– How long the mass has been there?

– Has it changed?

– Has it increased/ decreased in size?

– Has the child symptoms of infection? General symptoms?

– Has the child been travelling lately?

• Physical examination– Palpation: Is the mass movable, soft/ hard?

– Other masses, bilateral masses?

– Ear, nose, throat, teeth

– LOCATION

Ultrasound in assessing neck masses in children

• Size

• Shape

• Borders

• Vascularity

• Internal content

• Relationship to nearby

structures

HOW

• High-frequency linear

transducer

• color doppler

WHAT

Aetiology of neck masses

• Inflammatory

• Congenital

• Neoplastic

80 – 90 % of paediatric neck masses are benign

Inflammatory neck masses

• Reactive enlarged lymph nodes– no imaging needed

• Uncomplicated cervical lymphadenitis

• Suppurative adenitis: US

• Abscess:– Superficial abscess: US

– Deep neck masses require MRI (or CT)

Lymphadenitis related to special pathogens

• Tuberculous mycobacteria

• Non-tuberculous mycobacteria– Mycobacterium avium intracellulare

– In young children , 1-5 yo

– Submandibular or preauricular area

– No fewer, painless

– Fluctuating mass, possible sinus tractlater

– Discoloration of the skin

– Hypoechoic lymph nodes withliquefaction, necrosis

– Often single enlarged node surroundedby smaller satellite nodes

– Adjacent soft tissue oedema

• Toxoplasma gondii

• Francisella tularensis

Inflammatory neck masses

• Infection of congenital neck mass

• Inflammation/infection of – Thyroid gland

– Salivary gland

– Subcutaneous tissue

• Lymphadenopathy related to Kawasaki disease, HIV, autoimmune diseases

Congenital neck masses

• Thyroglossal duct cyst

or ectopic thyroid

• Branchial apparatus cysts

• Cervical thymus/thymic cyst

• Lymphatic malformations(vascular malformations)

Thyroglossal duct cysts

• 70-90 % of all congenital neck masses

• Midline/paramidline soft mass

• Most common location at the level of thehyoid bone or just below

• Painless if not infected

• Moves vertically with swallowing

• US: hypo/anechoic cyst, thin wall– May contain debris, septa

– Associated soft tissue -ectopic thyroid

– Is the thyroid gland normal?

• DD dermoid/epidermoid cyst, ectopic thyroid, goiter, lymphadenopathy

Foramen caecum

Hyoid bone

Thyroidgland

Graphics: Pitkäranta A, Lauhio A. Duodecim 2007;123:2009-13

TGDC

Dermoid cyst

5 y. o. suffered from cough. 3 d earlier a lump was detected above thyroid gland. CRP < 5.

Branchial apparatus cysts

• Lateral neck mass

• 95 % 2nd apparatus cyst– From the lower border of

sternocleidomastoidmuscle to the palatine tonsils

– Stable/slowly growing

– Simple or complicted cyst• Proteinaceous fluid, hemorrage, infection

– Sinus/fistula• Open along the anterior border of the

sternocleidomastoid muscle

– DD lymphatic malformation, cervicalthymic cyst, infrahyoid thyroglossal ductcyst, necrotic adenopathy, abcess

Graphics: Pitkäranta A, Lauhio A. Duodecim 2007;123:2009-13

Tonsil

External auditorycanal

1st branchialapparatus fistula

2nd branchialApparatus fistula

4 y.o. boy. Parents noticed a mobile resistence in the right neck. No symptoms of infection.

Followed for 5 m, operated. PAD Branchial cyst

Branchial cleft fistula

3 y o girl. From birth a secreting fistula has been active in the medial borderof sternocleidomastoid muscle. At operation a fistula to the tonsil was found.

Aberrant cervival thymus or thymic cyst

• Remnants of 3rd branchial pouch

• Mass in the path of thymopharyngeal duct– Failure to descent

– Sequestrated thymic tissue

– Persistence of remnant tissue

• Characteristic appearance on ultrasound– Multiple linear hyperechoic septa and

homogenously distributed hyperechoic foci

– Unechoic/ intralesional debris in cysts

• Up to 50% of cervical thymic cystscontinuous with mediastinal thymus

• Intimate relationship to the carotid sheat

KL Moore. The developing human, 4th ed. Saunders 1988

Thymopharyngeal duct cyst

9 y o boy, otherwise healthy. 4 wk ago a left sided mass appeared,was growing. Mild symptoms of infection.

Lymphatic malformations

• Posterior cervical triangle most common

• Most present before age of 2 years, 50 % at/before birth

• Multilocular, soft cystic mass

• May increase in size rapidly with upper respiratory tract

infection or hemorrhage

• Do not spontaneously involute

• US may be sufficient with focal lesions

• Most require MR (or CT) to assess the extent of the mass

Lymphatic malformations

• Focal, well-defined

• Unilocular/multilocular

• Infiltrative

• Infection and hemorrhage may change thecharacteristics of LM

• Frequently part of combined vascular malformation

• DD teratoma, venous malformation

1 y o boy. Suddenly a 6 cm fluctuating massoccurred in the right neck

Lymphatic malformation with beeding

2.5 y old boy with respiratory infection.Convulsions, lifeless. Head MRI done,

A suprasternal/retrosternal expansion was detected.

Infantile hemangioma

• Most common neoplasms in the head and neck during infancy

• Absent / small at birth, progressive enlargement during 1 st year of life – stationary- involuting

• Masseter, parotid gland

• DD: RMS

Fibromatosis colli

• Neonates/young infants

• Often related to traumatic birth

• Firm, growing neck mass, typically detected at age of two weeks

• Torticollis to the affected side

• US– Fusiform enlargement of the sternocleidomastoid muscle, usually lower two-

thirds

– Well–defined borders, no extension beyond the muscle planes, no relatedlymphadenopathy

– Uncommonly calcifications may be detected

• DD:adenopathy, ectopic thymus, teratoma, hemangioma, lipoma, malignancy

Fibromatosis colli

15 d old child, 4 d ago left sided neck mass was observed. No infection, not painfull. A fuciformenlargement of the left side sternocleidomastoid muscle was observed.

Fibromatosis colli

Some other neck masses diagnosed with US

• Ranula– A fluid filled cyst originating from sublingual salivary gland

– In the floor of the mouth, or as a submental orsubmandibular mass

• Pilomatrixoma– Epithelial inclusion cyst

– Mobile, painless, firm oval tumor

– Hyperechoic, sometimes calcifications

• Congenital goiter

Neck masses: When ultrasound is enough?

• With superficial neck masses

• Can be completely evaluated

with US

• No suspicion of neoplastic

mass

NO

• Too large, too deep or

hyperechoic to be fully

evaluated with US

• Suspicion of high flow

vascular lesion

• Suspicion of malignancy

YES

Thank You !

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