Imaging of granulomatous lesions of the neck in children

Offense and Defense in Granulomatous Inflammation Disease

Granulomatous inflammation (GI) diseases are a group of chronic inflammation disorders characterized by focal collections of multinucleated giant cells, epithelioid cells and macrophages, with or without necrosis. GI diseases are closely related to microbes, especially virulent intracellular bacterial infections are important factors in the progression of these diseases. They employ a range of strategies to survive the stresses imposed upon them and persist in host cells, becoming the initiator of the fighting. Microbe-host communication is essential to maintain functions of a healthy host, so defense capacity of hosts is another influence factor, which is thought to combine to determine the result of the fighting. With the development of gene research technology, many human genetic loci were identified to be involved in GI diseases susceptibility, providing more insights into and knowledge about GI diseases. The current review aims to provide an update on the most recent progress in the identification and characterization of bacteria in GI diseases in a variety of organ systems and clinical conditions, and examine the invasion and escape mechanisms of pathogens that have been demonstrated in previous studies, we also review the existing data on the predictive factors of the host, mainly on genetic findings. These strategies may improve our understanding of the mechanisms underlying GI diseases, and open new avenues for the study of the associated conditions in the future.

Radiomics and machine learning for the diagnosis of pediatric cervical non-tuberculous mycobacterial lymphadenitis

Non-tuberculous mycobacterial (NTM) infection is an emerging infectious entity that often presents as lymphadenitis in the pediatric age group. Current practice involves invasive testing and excisional biopsy to diagnose NTM lymphadenitis. In this study, we performed a retrospective analysis of 249 lymph nodes selected from 143 CT scans of pediatric patients presenting with lymphadenopathy at the Montreal Children’s Hospital between 2005 and 2018. A Random Forest classifier was trained on the ten most discriminative features from a set of 1231 radiomic features. The model classifying nodes as pyogenic, NTM, reactive, or proliferative lymphadenopathy achieved an accuracy of 72%, a precision of 68%, and a recall of 70%. Between NTM and all other causes of lymphadenopathy, the model achieved an area under the curve (AUC) of 89%. Between NTM and pyogenic lymphadenitis, the model achieved an AUC of 90%. Between NTM and the reactive and proliferative lymphadenopathy groups, the model achieved an AUC of 93%. These results indicate that radiomics can achieve a high accuracy for classification of NTM lymphadenitis. Such a non-invasive highly accurate diagnostic approach has the potential to reduce the need for invasive procedures in the pediatric population.

Tuberculosis of the parotid lymph nodes: clinical and imaging features

Objectives

To characterize clinical, computed tomography (CT) and magnetic resonance imaging (MRI) features of tuberculosis (TB) of the parotid nodes.

Materials and methods

CT (n=21) and MR (n=7) images, and clinical data from 25 patients with TB of the parotid nodes were retrospectively analyzed by two experienced radiologists who reached consensus.

Results

Younger patients (aged <50 years) accounted for 72%. Eighty percent of patients were asymptomatic, and had no history of TB exposure. According to clinical and imaging findings, 64% and 60% patients were misdiagnosed as having tumors, respectively. A total of 43 lesions were identified. Thirty-eight (88.4%) lesions involved the superficial lobe. Fourteen (56%) cases had multiple lesions. There were four types of changes in the parotid fascia: local thickening (40%, n=10); local rupture with thickened adjacent skin (28%, n=7); focal bulge (20%, n=5); and no changes (12%, n=3). Cervical lymphadenopathy was seen in 14 out of 25 cases (56%). The lesions were contrast-enhanced in four patterns on CT images: homogeneous enhancement (37.1%, n=13), irregular cyst-like enhancement (37.1%, n=13), thick-walled ring enhancement (14.2%, n=5), and garland-like enhancement (11.4%, n=4). On MRI, the signal intensity of lesions was isointense on T1-weighted image, hyperintense on T2-weighted image, markedly hyperintense on diffusion-weighted imaging, and low on the apparent diffusion coefficient map. The surrounding parotid parenchymal edema was identified clearly on coronal MR images.

Conclusion

TB of the parotid nodes tend to simulate tumors clinically and radiologically. Their preferential sites are the superficial lobe. In young patients with positive purified protein derivative skin test and lesions accompanied by cervical lymphadenopathy, changes in the parotid fascia and parotid parenchymal edema adjacent to the lesions on CT and MRI may be helpful in the diagnosis and to facilitate differential diagnosis.

Imaging of Submandibular and Sublingual Salivary Glands

The submandibular and sublingual salivary glands are major salivary glands with a wide spectrum of pathologic conditions. The corresponding spaces along the floor of mouth have complex anatomy, best evaluated with cross-sectional imaging. The spectrum of diseases in these regions varies from simple infection to advanced malignancy, not just from the gland itself but also from the surrounding structures. The most common abnormalities in these spaces are inflammatory and infectious, and computed tomography is currently the most common imaging modality used. The anatomy of these spaces is much better depicted with MR; however, all the modalities have their unique roles.

Imaging Findings of Ulceroglandular Tularemia

Francisella tularensis, the causative organism in Tularemia, is a relatively rare disease. There are a few radiological clues to elucidate its presence when suspicion arises. There should be strong consideration for Tularemia in the differential of any patient with its classic symptoms, diffuse cervical lymphadenopathy with evidence of necrosis, and enlarged adenoids. Ultrasound may demonstrate suppurative lymphadenopathy suggestive of infection, as in the case presented. CT often will demonstrate the extent of lymphadenopathy. On chest radiography, tularemia pneumonia is often the presenting finding, which may demonstrate bilateral or lobar infiltrates. Additionally, hilar lymphadenopathy and pleural effusions are often associated findings. Cavitary lesions may be present, which are better delineated on CT scan. We present a case of a 7-year-old male who presented with a painful right-sided palpable neck mass for 9 days, who was diagnosed with Tularemia after numerous admissions.

CT features and analysis for misdiagnosis of parotid tuberculosis

PURPOSE

To analyze the computed tomography (CT) features and the reasons for misdiagnosis of parotid tuberculosis (TB).

METHODS

CT features of 13 cases of parotid TB identified more than a 10-year period (2005-2015) were retrospectively analyzed. The CT features were analyzed for nature, range, and extent of the various pathological patterns.

RESULTS

Because of the nonspecific CT features, 10 of 13 cases were misdiagnosed as benign and malignant tumors of parotid gland and received surgery. Ten cases of lymph nodal TB, one case of parenchymal TB, and two cases of mixed (concurrence of lymph nodal and parenchymal types) TB were found in the parotid gland. On contrast-enhanced CT scan, two cases showed homogeneous enhancement and eight cases showed ring enhancement (including five cases with thin-walled ring enhancement, two cases with flower-ring enhancement, and one case with thick-walled and eccentric ring enhancement); diffuse enhancement was seen in the one case of parenchymal type; the two cases of mixed type showed diffuse enhancement of parotid gland and ring enhancement of lymph node. Thickened skin around the parotid gland was seen in eight cases, including sinus tract between the lesion and skin in two cases. Ipsilateral cervical lymphadenopathy was found in 10 patients and bilateral was found in 3 patients.

CONCLUSIONS

Nonspecific CT features of parotid TB closely relate with pathological changes. Recognition and understanding the spectrum of CT features of parotid TB is helpful for differential diagnosis, but the definitive diagnosis still depends on laboratory and pathological examination.

Imaging of Pediatric Neck Masses

Pediatric neck masses comprise a wide spectrum of entities, benign and malignant. The role of imaging is to characterize these lesions, in order to better determine which can be expectantly managed and which require immediate intervention. An important consideration in the pediatric population is ionizing radiation; while X-ray and CT can be useful, radiation can have harmful effects, particularly in children. In this article, we review imaging feature of common pediatric neck masses, with emphasis on radiation sparing modalities (ultrasound and MRI) when possible.

How to cite this article

Sajedi P, Shet N. Imaging of Pediatric Neck Masses. Int J Head Neck Surg 2016;7(2):89-96.

Granulomatous cervicofacial lymphadenitis in children: a nine-year study in Singapore

INTRODUCTION

Granulomatous cervicofacial lymphadenitis (GCL) is not uncommon in children. Nontuberculous mycobacteria (NTM) seem to be the predominant cause. We sought to study the clinical and microbiological profile of patients with GCL, and identify features that may impact outcome.

METHODS

Children aged < 16 years who presented to KK Women's and Children's Hospital, Singapore, between January 1998 and December 2006, and who had GCL were identified from laboratory records. Clinical and laboratory data was collected and analysed for risk factors for patients with positive lymph node cultures, and for patients with and without recurrence after treatment.

RESULTS

In all, 60 children were identified, with a median age of 56 (interquartile range [IQR] 34-101) months. Median duration of symptoms before presentation was 5 (IQR 4-8) weeks. The majority presented with single (73.3%) or unilateral (96.7%) lymphadenopathy, located in the submandibular, preauricular/parotid or infra-/post-auricular region (76.7%). Out of 51 patients, 26 (51.0%) had a tuberculin skin test reading of ≥ 10 mm. Out of 52 patients, 10 (19.2%) had positive mycobacterial cultures, which included seven isolates of NTM. Out of 34 cases, tuberculous polymerase chain reaction was positive in 11 (32.4%). With regard to recurrence after initial treatment, age < 5 years at presentation was found to be a predictor for recurrence (p = 0.008), while initial complete excision of affected nodes predicted no recurrence (p = 0.003).

CONCLUSION

In our study, younger age was noted to be associated with a higher chance of recurrence, while complete excision of the involved node at initial presentation predicted non-recurrence.

Granulomatous disease in the head and neck: developing a differential diagnosis

Granulomatous diseases have a varied etiology that includes autoimmune, infectious, idiopathic, and hereditary causes. The unifying factor in these diseases is the formation of granulomas, which histologically are mononuclear inflammatory cells or macrophages surrounded by lymphocytes. Granulomatous diseases often have systemic manifestations that affect organs throughout the body. Granulomatous diseases with head and neck manifestations include granulomatosis with polyangiitis, Churg-Strauss syndrome, Behçet disease, chronic granulomatous disease, and sarcoidosis. Infectious causes include tuberculosis, cat-scratch disease, syphilis, leprosy, actinomycosis, rhinoscleroma, and fungal infections. In the head and neck, granulomatous disease may affect the orbits, sinonasal cavities, salivary glands, aerodigestive tract, temporal bone, or skull base. Imaging findings include sinonasal opacification, ocular and other soft-tissue masses, osseous erosion, airway narrowing, lymphadenopathy, and salivary gland infiltration. Vascular involvement may also be evident, with displacement, narrowing, or occlusion of arteries and veins. Some radiologic findings of granulomatous processes have a considerable overlap with findings of malignancy, and a radiologic differential diagnosis inclusive of both is critical to avoid incorrect clinical treatment. Without the benefit of a prior clinical diagnosis, laboratory findings, or suggestive clinical signs and symptoms, granulomatous diseases may be difficult to differentiate radiologically. Although individual granulomatous diseases may have overlapping findings at imaging, certain radiologic findings should prompt the inclusion of granulomatous diseases in the differential diagnosis, thus facilitating appropriate clinical management.

Evaluation of clinical and sonographic features in 55 children with tularemia

AIM

The aim of this study was to determine the clinical characteristics and sonographic features of lymphadenopathy (LAP) and to evaluate the treatment modalities and treatment outcomes in children with tularemia.

MATERIALS AND METHODS

Demographic characteristics, ultrasonographic and physical examination findings, and treatment outcomes in 55 tularemia patients (24 male and 31 female) with a mean age of 10.8 ± 4.0 years were analyzed retrospectively. Lymph node necrosis was classified in three stages based on ultrasound findings-stage 1, cortical microabscesses; stage 2, cortical and medullar abscesses; stage 3, total necrosis of the lymph node.

RESULTS

In total, 50 (90%) of the patients had oropharyngeal, four (8%) had glandular, and one (2%) had oculoglandular tularemia. The most common symptoms were sore throat (67%) and fever (64%). LAP was the most frequently (100%) observed sign. Abscess formation was noted in 36 (65%) patients, of which seven (19%) were sonographically classified as stage 1, 20 (55%) as stage 2, and nine (26%) as stage 3. There was a statistically significant correlation between delayed treatment and stage of abscess formation in lymph nodes (p<0.05). Treatment failure was observed in 24 (44%) patients. There was no significant correlation between treatment regimen and treatment failure (p>0.05). In all, nine (16%) of the patients did not respond to medical treatment, and surgical intervention was required.

CONCLUSION

Tularemia should be considered in the differential diagnosis of children presenting with unexplained fever, sore throat, and cervical LAP in endemic areas. Sonographic findings may be useful in the evaluation and staging of this infection.

Tularaemia presenting as parapharyngeal abscess: case presentation

Objective:

We report an extremely rare case of the oropharyngeal form of tularaemia, causing a parapharyngeal abscess.

Case report:

A 48-year-old woman presented with fever, sore throat, breathing difficulty and a right-sided neck swelling. This mass had previously been treated with penicillin without response, and had already been surgically drained once in another hospital. On physical examination, the tonsils were exudative and hypertrophic and the pharynx was hyperaemic. A fluctuant, 4 × 4 cm mass was seen on endoscopic examination, originating from the left parapharyngeal area and protruding towards the pyriform sinus, and partly obstructing the airway. Microagglutination test antibody titres for Francisella tularensis were positive (1/1280). The patient healed completely after definitive drainage of the abscess and antimicrobial therapy for 14 days (streptomycin, 2 × 1 g intramuscularly).

Conclusion:

Tularaemia should be considered in the differential diagnosis of patients presenting with tonsillopharyngitis, cervical lymphadenitis and parapharyngeal abscess who do not respond to treatment with penicillin, even if they do not live in an endemic region.

Imaging of pediatric neck masses

Palpable neck masses are a common indication for pediatric imaging. Such lesions may be caused by infectious, inflammatory, tumoral, traumatic, lymphovascular, immunologic, or congenital etiologies. Radiological assessment of neck masses in young children should be tailored based on patient presentation and physical examination, as well as clinical suspicion. The goal of imaging should be to help arrive at a diagnosis or limited differential in an efficient manner while minimizing radiation exposure.

Imaging appearance of granulomatous lesions of head and neck

We aim to review the imaging appearance of granulomatous lesions of the head and neck. Granulomatous lesions are seen in different regions of the head and neck and a difficult diagnostic challenge for the radiologist. Infective granulomas may be due to bacterial or fungal agents. Non-infective granulomas are Wegener's granulomatosis, sarcoidosis, amyloidosis, chemical granuloma and reparative giant cell granuloma. Familiarity with the clinical presentation and imaging features of these lesions can suggest diagnosis in some cases. CT and MR imaging demonstrate the exact location, extension and effect on surrounding structures. A thorough knowledge of age, gender, common location, clinical features and imaging appearance of granulomatous lesions are important for diagnosis.

Evaluation of cervical computed tomography findings in oropharyngeal tularaemia

Cervical contrast-enhanced computed tomography (CECT) was performed in 16 cases (5M, 11F) of oropharyngeal tularaemia, diagnosed at Zonguldak Karaelmas University, Turkey, between January 2004 and March 2006. All patients showed lymphadenopathy with contrast enhancement, 12 of them with peripheral contrast enhancement. Lymph node necrosis was found in 13 of the patients, abscess formation in 9 and cyst formation in 13. This appears to be the largest series of cervical CECT in oropharyngeal tularaemia reported to date. Tularaemia is a differential diagnosis of massive adenotonsillar enlargement and extensive necrotic cervical lymphadenopathy.

Mycobacterium fortuitum-induced persistent parotitis: successful therapy with clarithromycin and ciprofloxacin

BACKGROUND

Parotitis caused by nontuberculous mycobacteria, a very rare disease entity, has never been reported to be caused by Mycobacterium fortuitum (M. fortuitum) in the literature.

METHODS AND RESULTS

An 8-year-old girl was seen with painful swelling of the right parotid gland despite antibiotic treatment of more than 1 month. Elevated serum amylase activity and diffuse contrast-enhanced CT of the parotid gland confirmed the diagnosis of parotitis. Histopathological study of specimens taken from the right parotid tail mass showed granulomatous inflammation with acid-fast positive bacilli; culture later confirmed M. fortuitum. After administration of clarithromycin and ciprofloxacin for 9 consecutive months, the parotitis and parotid tail mass were completely resolved at follow-up examination.

CONCLUSION

To our knowledge, this is the first case report of parotitis caused by M. fortuitum and its successful medical treatment.

Mediastinal Histoplasmosis: F-18 FDG PET and CT Findings Simulating Malignant Disease

We describe the computed tomography and F-18 FDG PET findings of a patient with extensive mediastinal nodal enlargement resulting from histoplasmosis. This patient with known metastatic melanoma presenting for restaging was initially considered to have widespread mediastinal and cervical metastases on the basis of the imaging findings. Bronchoalveolar lavage fluid and transbronchial lymph node biopsy were consistent with histoplasmosis. The imaging findings improved after treatment with antifungal medication. A relatively small area of pulmonary involvement proved to be the clue in the imaging studies that the disease was inflammatory rather than neoplastic.

Management of isolated extrapulmonary tuberculosis in a pregnant patient

The worldwide incidence of tuberculosis is increasing, largely as a consequence of both the increasing prevalence of human immunodeficiency virus and the emergence of drug-resistant strains. The pulmonary system is typically the primary site of involvement by this infectious disease; however, extrapulmonary disease does occasionally occur. Although uncommon, neck involvement can occur. The usual presentation is bilateral adenopathy from pulmonary dissemination. Tuberculous cervical adenitis in the absence of pulmonary findings is rare. A concurrent diagnosis of pregnancy complicates the treatment of the infected patient. We present a case of isolated, unilateral tuberculous cervical adenitis in a pregnant patient and discuss the multidisciplinary approach necessary for the appropriate management of this unique situation.

Tularemia presenting as tonsillopharyngitis and cervical lymphadenitis: a case report and review of the literature

In this report, we describe a 57-year-old woman with oropharyngeal tularemia who presented with tonsillopharyngitis and cervical lymphadenitis. Clinical and radiological manifestations and histopathological characteristics of this disease are discussed with a review of the world literature. The oropharyngeal form of tularemia should be considered in the differential diagnosis of cases involving tonsillopharyngitis and cervical lymphadenitis, particularly in those not responding to penicillin treatment.

Nontuberculous mycobacterial lymphadenitis of the head and neck: radiologic observations and clinical context

OBJECTIVE

To summarize the radiologic findings in our series of immunocompetent children with NTMA and to review the clinical and laboratory findings, as well as the treatment and clinical courses, in these patients.

MATERIALS AND METHODS

We reviewed the computed tomographic (CT) studies, as well as the clinical courses of eleven patients with laboratory-confirmed diagnosis of NTMA, and recorded the anatomic locations of the affected lymph nodes.

RESULTS

In 10 of 11 patients, there were peripherally enhancing, centrally cystic nodes. In 7 of the patients, there was (usually mild) inflammation of the regional fat and overlying skin thickening. Adenopathy in the parotid and submandibular regions was most common. In 4 of the patients, there was more than one nodal group involved.

CONCLUSION

In a child who presents with enlarging neck masses and with radiologically demonstrated centrally cystic nodal masses exhibiting relatively little mass effect or inflammatory change in the surrounding fat, the diagnosis of NTMA should be entertained.