Sonography of Pediatric Neck Masses

What is this bump in my neck? Ultrasonographic evaluation of pediatric neck masses

Neck masses are common in pediatric patients, with benign etiologies such as congenital or inflammatory lesions accounting most of these masses. Anatomic location (most important), clinical history, and the appearance in ultrasonography (US) are helpful clues to narrow down differential diagnosis. Because of widespread availability, lack of ionizing radiation, and no need for sedation or contrast administration, US is the preferred initial modality for the evaluation. Further evaluation with cross-sectional imagings is needed for more extensive lesions with trans-spatial extension or suspicion of intrathoracic or retropharyngeal extension. This review will focus on US appearance and clinical presentation of masses of the neck in children, to enable radiologist to arrive at a reasonable differential diagnosis. We also briefly discuss more complex pathologies that need to be evaluated with cross-sectional modalities such as CT scan and magnetic resonance imaging.

Heterotopic squamous epithelial inclusion cyst in a cervical lymph node in a child: a case report and literature review

BACKGROUND

A squamous epithelial inclusion cyst in a lymph node is a rare heterotopic phenomenon. Heterotopic squamous inclusion cysts in cervical lymph nodes are even rarer, and to date, only 3 such cases have been reported in the literature, none of which have described the ultrasound features. Here, we report a pediatric case, focusing on the ultrasonographic manifestations of the disease and the differential diagnosis of cervical space-occupying lesions in children.

CASE DESCRIPTION

We report the case of a 6-year-old boy in good health, who presented with a non-tender mass on the right side of the neck 1 month earlier. Some 7 days before admission, the mass gradually increased in size and became tender. Laboratory tests showed an increase in C-reactive protein of 17 mg/L (normal range: 0-8 mg/L). The physical examination revealed a palpable 3.0 cm × 2.0 cm mass with tenderness and poor mobility in the right submandibular region. Doppler ultrasonography showed an oval, ill-defined mass in the right submandibular area, consisting of a peripheral homogeneous hypoechoic component with hilar-like vascularity and an internal heterogeneous very hypoechoic component with patchy hyperechoic areas. The computed tomography (CT) scan showed a heterogeneously hypodense mass with irregular annular enhancement in the right submandibular region. Lymph node tuberculosis or space-occupying lesions were suspected based on the clinical and imaging findings. The mass was completely excised by surgery. The pathological diagnosis was a secondary infection of squamous epithelial inclusion cysts in the right cervical lymph node. The peripheral homogeneous hypoechoic component was normal lymph node tissue, and the internal heterogeneous very hypoechoic component was a squamous inclusion cyst with keratin debris. The patient was followed up for a total of 3 times after surgery, and no recurrence of the tumor was found.

CONCLUSIONS

Ultrasonography can help in the early diagnosis of heterotopic squamous inclusion cysts in children's cervical lymph nodes, and can be used to differentiate other cervical lesions. We reviewed the literature and found that this heterotopic phenomenon was more likely to occur in the submandibular region of the neck in younger patients. Surgery may be an effective treatment for this disease.

Pediatric Neck Masses: Imaging Guidelines and Recommendations

Neck masses commonly present in children and several potential diagnostic and management pathways exist, though with a paucity of evidence-based recommendations. The purpose of this article is to evaluate the current literature and utilization of various diagnostic imaging modalities , with a review of imaging features and management pearls for pediatric neck masses. A comprehensive understanding and practical imaging workflow will guide optimal patient workup and management.

Ultrasound Evaluation of Pediatric Slow-Flow Vascular Malformations: Practical Diagnostic Reporting to Guide Interventional Management

OBJECTIVE. This article reviews the ultrasound characteristics of pediatric slow-flow vascular malformations and underscores findings that significantly impact diagnosis and treatment. Key imaging features are discussed including lesion size, malformation location, morphology, and mimics. CONCLUSION. Ultrasound findings affect the management of slow-flow vascular malformations and should be emphasized in lesion diagnosis. Superficial, focal lesions with well-defined margins are ideal for ultrasound evaluation.

Size of the Tonsil on Ultrasound in Children Without Tonsil-Associated Symptoms

This study was performed to establish the reference for tonsil size in children, including neonates, without tonsil-associated symptoms, in relation to anthropometric indices (sex/age/height/weight/body mass index).We evaluated the size of both tonsils in 362 children by ultrasonography. Tonsil size was calculated as 0.523abc (a, transverse diameter on the transverse image; b, longitudinal diameter on the transverse image; c, longitudinal diameter on the longitudinal image) and compared between each age year using the Wilcoxon signed rank sum test with Bonferroni correction. We evaluated the relationships between tonsil size and anthropometric indices.Among these children, tonsil size was significantly increased by the age of 3 years (0-1 vs 1-2 [volume (right) = 210.15 ± 205.27 vs 737.83 ± 335.72 mm, P (right) < 0.0001 and volume (left) = 218.26 ± 207.23 vs 645.33 ± 240.31 mm, P (left) < 0.0001]; 1-2 vs 2-3 [volume (right) = 737.83 ± 335.72 vs 1073.86 ± 468.21 mm, P (right) = 0.004 and volume (left) = 645.33 ± 240.31 vs 1109.73 ± 563.20 mm, P (left) < 0.0001]). Although there was a tendency for the tonsil size to increase in years 3-12, there was no significant difference. Using single linear regression analysis, we found a correlation between tonsil size and age (r right/left = 0.67/0.65), height (r right/left = 0.72/0.70), and weight (r right/left = 0.66/0.64), with height having the strongest correlation.In conclusion, tonsil size significantly increased by 3 years of age. Tonsil size was correlated with anthropometric indices, with height showing the strongest correlation.

The use of point of care ultrasound in the evaluation of pediatric soft tissue neck masses

OBJECTIVE

Most soft tissue neck masses represent benign inflammatory or infectious processes; however, in some cases the diagnosis is not clear and a broader differential must be considered. The aim of this study was to compare point-of-care ultrasound (POCUS) to radiology department imaging (RDI) in the diagnosis of soft tissue neck masses.

METHODS

This prospective pilot study involved a convenience sample of patients ranging in age from 1 month to 18 years of age presenting to the Pediatric Emergency Department (PED) with a soft tissue neck mass. All children who presented to the PED with soft tissue neck mass at times when an investigator was in the department, and who were candidates for enrollment, underwent a POCUS. The managing pediatric emergency medicine (PEM) provider determined whether RDI was indicated. The results of the POCUS sonologist and radiologist were compared. The kappa statistic was used to analyze agreement with p < 0.05 denoting statistical significance.

RESULTS

Twenty-seven patients were enrolled into the study. Twenty-two received radiology ultrasound (RUS), 3 patients received CT, and 2 patients received both RUS and CT. There was agreement between POCUS and RDI diagnoses in 21/27 cases (78%). Accordingly, overall concordance between POCUS and RDI diagnoses was good: the kappa statistic comparing diagnoses obtained by POCUS versus RDI was 0.69 (p < 0.001).

CONCLUSION

This prospective pilot study describes the reliability of POCUS as an imaging modality in the management of patients with undifferentiated soft tissue neck masses. POCUS demonstrated good agreement with RDI as a bedside imaging tool in the evaluation of pediatric soft tissue neck masses.

Clinical approach to pediatric neck masses: Retrospective analysis of 98 cases

OBJECTIVE:

Pediatric neck masses (PNMs) are a frequently encountered problem in otorhinolaryngology practice. The clinical approach to cervical masses in childhood varies from that of adults. Due to differences among clinicians in the assessment of a PNM, studies investigating this subject are significant contributions to the literature. For this reason, a review was conducted of pediatric PNM cases with an open biopsy (incisional/excisional) and a histopathological diagnosis.

METHODS:

The hospital records of 98 (34 girls, 64 boys) pediatric patients aged between 8.5 months and 16 years were reviewed. The history, physical examination findings, blood tests, medical treatments, imaging reports, and the pathology and/or microbiology results of the patients were recorded and evaluated. The cervical masses were categorized according to the etiology, imaging features, size, and location.

RESULTS:

Surgical biopsy was planned due to the suspicion of malignancy, typical clinical presentation or location, or size greater than 20 mm despite antibiotherapy for 2 to 6 weeks. Excisional biopsy (91.8%) was the first choice for histopathological sampling. Infectious masses were observed most commonly, followed by congenital and neoplastic masses, at a rate of 49%, 27.6%, and 23.4%, respectively. Hodgkin lymphoma was the most frequent type of malignancy (39.1%). Thyroglossal and branchial cysts constituted 74.1% of congenital masses. Sixty-seven percent of all masses were solid, and the lateral levels of the neck were the most affected locations (44.9%).

CONCLUSION:

In most cases, the diagnosis can be made with a detailed history and physical examination. In the presence of nonspecific findings, blood tests, imaging, and histopathological sampling are required. Ultrasound should be the first preference for imaging, and excisional biopsy is suggested rather than fine needle aspiration biopsy for histopathological sampling in pediatric neck masses.

Sonography of pediatric superficial lumps and bumps: illustrative examples from head to toe

Superficial lumps and bumps are extremely common in children, and the vast majority ultimately prove to be benign. Duplex/color Doppler ultrasound (US) has emerged as the first-line imaging modality for the evaluation of these superficial pediatric masses because it provides a means for rapid acquisition of information including size, shape, location, internal content and vascularity. More important, it does so without utilizing radiation, iodinated contrast material or sedation/anesthesia. In this review, we present the sonographic findings of a variety of cases ranging from head to toe that are either uncommonly seen or were diagnosed in an atypical fashion (i.e. ultrasound). In situations where the lesion is too deep, hyperechoic or large to be fully assessed within the field of view or if malignancy is suspected, then additional cross-sectional imaging is warranted for further evaluation.

Incidental radiographic findings of thyroglossal duct cysts: Prevalence and management

OBJECTIVES/HYPOTHESIS

To determine the epidemiology of incidental thyroglossal duct cysts (TGDC) discovered on imaging studies obtained in the head and neck area in children and to discuss subsequent management.

METHODS

A retrospective chart review was performed at Texas Children's Hospital of all computed tomography (CT) and magnetic resonance (MR) imaging studies obtained in the head and neck region between July 2011 and July 2014. Images obtained for the purpose of evaluating a neck or lingual mass were excluded from the study, as were patients with previously known TGDCs. Data including age, sex, location of TGDC, size, presence of symptoms, referral to Otolaryngology, and intervention were recorded.

RESULTS

A total of 60,663 CT and MR studies of the head, brain, sinus, neck, and C-spine during this time period were reviewed; of these 69 (0.1%) cases contained incidental discovery of probable TGDCs with more males (40) than females (29). Ages ranged from 3 days to 17 years old, with the mean age at 5 years. Locations varied, with majority at base of tongue (83%) followed by hyoid (13%) then infrahyoid straps (4%). Sizes ranged from 2 to 28 mm with average size at 8 mm. 11 of these patients were referred to an Otolaryngologist; 9 were asymptomatic and decision was made to observe, the other two subsequently underwent surgical excision secondary to mass effect and dysphagia with histologic confirmation of diagnosis.

CONCLUSION

TGDCs commonly present as an anterior neck mass, however the majority of incidentally discovered TGDCs on imaging are located at the base of tongue. Management of these findings should include referral to an Otolaryngologist for further evaluation with the decision to intervene surgically based on development of clinical symptoms.

Thyroid Imaging in Infants

Congenital hypothyroidism is the most common preventable cause of mental retardation. It is important to know the cause of each patient's thyroid dysfunction to foresee the course of therapy and outcomes. Imaging methods, such as ultrasound and thyroid scan, help determine the anatomy and function of the thyroid gland. Although thyroid scan is considered superior in detecting ectopic thyroid tissue, ultrasound is able to detect the presence of thyroid tissue not otherwise visualized in 15% of patients.

Pediatric Mass Lesions of the Head and Neck Region and Fine-Needle Aspiration Biopsy Results

Objective

1. To provide a classification of pediatric mass of the head and neck region and evaluate their frequency. 2. To examine the findings of fine-needle aspiration biopsy (FNAB) in pediatric patients along with its contribution to diagnosis.

Methods

Totally, 233 pediatric patients (125 boys and 108 girls) operated at Başkent University for head and neck mass were included. Clinical, radiological, and histopathological data were retrieved from medical records.

Results

The mean age was 119±65 months, and the mean duration of follow-up was 75±49 months. Localization of the masses was as follows: 208 (89%) in the neck, 21 (9%) in the oral cavity, 2 (1%) in the neck and nasopharynx, and two (1%) in the larynx. The most common surgical procedure was open excisional biopsy (n=105, 45%) followed by cystic mass excision (n=72, 31%) and salivary gland excision (n=33, 14%). Based on histopathological findings, benign cystic lesions were the most common disease group (n=77, 33.1%), whereas reactive lymphadenopathy was the most common condition (n=36, 15%) when a single disease was considered. Infectious/inflammatory diseases, malignancies, and benign salivary gland diseases were present in 49 (21%), 24 (10.3%), and 22 (9.4%) patients, respectively. FNAB was performed in 29.8% of the patients with an accuracy of 90.3% (95% CI, 80.1-96.4).

Conclusion

The differential diagnosis of head and neck masses during childhood includes a wide spectrum with the different conditions being benign cystic diseases of congenital origin and reactive lymphadenopathies. Owing to its high predictive value, FNAB represents a rapid and reliable method that can be commonly used in both adult and pediatric patients.

The management of pediatric neck masses

Neck masses are a common clinical concern both in adults and children. The differential diagnosis is quite broad, from congenital lesions to malignant tumors. Based on the different pathologic diagnosis, the treatments are varied. To the best of our knowledge, limited reports, which specifically discuss the incidence and distribution of neck diseases in early childhood, have been published. Because of the great population in China, a thorough review of the previous clinical data for pediatric neck masses might be potentially valuable for oral and maxillofacial surgeons, which might provide a deeper understanding and better the accuracy of our clinical diagnosis and management. In this article, a 10-year retrospective review was completed; the whole cases were diagnosed and treated in the same major clinical institute in east China, which might represent as a typical cohort for the patient population and serve as a reference for future clinical management.

Correlation between pre-operative diagnosis and post-operative pathology reading in pediatric neck masses--a review of 281 cases

OBJECTIVE

Describe the pre-operative diagnosis correlation of pediatric neck masses with the final post-operative pathology reading. Evaluate if added imaging studies were associated with higher frequency of correct diagnosis.

STUDY DESIGN

Retrospective case series review.

SETTING

Tertiary Academic Medical Center.

SUBJECTS AND METHODS

Data was collected from 281 pediatric patients with an undiagnosed neck mass that underwent open biopsy from January 1986 to December 2011. Data collection included pre-operative accuracy and relative contributions of clinical clues and imaging studies.

RESULTS

Pre-operative and post-operative diagnoses match varied for each category of diagnoses. The difference in distribution of correct pre-operative diagnoses between 6 categories of neck masses was statistically significant. The highest number of cases with correct pre-op diagnosis was seen with congenital masses which were correctly diagnosed with 75% of cases (n=109), followed by benign tumors which were diagnosed with 73.7% of cases (n=19). When CT scans were included in the pre-op work up, it was associated with a non-significant trend toward a less frequent correlation between pre and post-operative diagnosis in congenital, nodal inflammatory and miscellaneous masses. However, with regards to the diagnosis of benign tumors, CT scan was associated with a trend toward higher proportion of correct pre-op diagnosis. In cases where US was included in the evaluation, we found a trend toward less frequent correlation with post op diagnosis in benign tumors, nodal inflammatory, non-nodal inflammatory and miscellaneous diagnoses and an increase in accuracy for congenital masses.

CONCLUSION

Certain types of pediatric neck masses are easy to diagnose likely due to their classic presentation. Failure to diagnose masses often occurs when the clinical picture is vague or non-specific. Ancillary imaging studies do not always correlate with increased accuracy of diagnosis, particularly when the clinical clues are typical.

Ultrasound to differentiate thyroglossal duct cysts and dermoid cysts in children

OBJECTIVES/HYPOTHESIS

To determine if ultrasound could differentiate between thyroglossal duct cysts (TGDC) and midline dermoid cysts (DC).

STUDY DESIGN

Cohort study.

METHODS

A search of pathology reports yielded 91 patients with TGDC or midline DC. Ultrasound images were presented to a radiologist blinded to pathology who evaluated the following: 1) depth of lesion from skin, 2) maximum diameter, 3) dimensions, 4) midline location, 5) distance from base of tongue, 6) tract, 7) wall regularity, 8) wall thickness, 9) margin definition, 10) heterogeneity, 11) internal septae, 12) solid components, 13) intralesional Doppler flow, and 14) posterior enhancement. The predictive power of these variables was evaluated in a multiple logistic regression model.

RESULTS

There were 53 TGDC and 38 DC. TGDC were significantly more likely than DC to have the following features: 1) smaller distance from base of tongue, 2) tract, 3) irregular wall, 4) ill-defined margin, 5) internal septae, 6) solid components, and 7) intralesional Doppler flow. Three clinically reliable ultrasound variables were independently able to discriminate between TGDC and DC. A predictive model was fashioned whereby each variable was scored as 0 or 1, with a total score calculated (septae + irregular wall + solid components = TGDC [or SIST] score). We propose a scoring system whereby 0 = suggestive of DC; 1 = suggestive of TGDC; and ≥2 = highly suggestive of TGDC.

CONCLUSIONS

It may be possible to differentiate between TGDC and midline DC preoperatively using ultrasound.