Congenital cystic masses of the neck: radiologic-pathologic correlation

Imaging manifestations of head and neck lymphatic malformations: A single-center experience of 170 surgical cases

OBJECTIVES

To discuss the imaging manifestations and the utility of preoperative ultrasonography (US), contrast-enhanced computed tomography (CE-CT) and contrast enhanced magnetic resonance imaging (CE-MRI) in diagnosing the pediatric head and neck lymphatic malformations (HNLMs).

METHODS

We performed a retrospective review of 170 children who were referred to our hospital in the past 9 years for the treatment of HNLMs.

RESULTS

The diagnostic rates of US, CE-CT and CE-MRI were 93.0% (146/157), 94.7% (143/151) and 100% (45/45), respectively. As in multilocular cases, intracystic septa detection rate was 91.5% (130/142), 50.4% (68/135) and 88.1% (37/42), and which had a statistical difference (χ2 = 25.8131, p < 0.05). US showed capsule contents anechoic in 51.0% (80/157) cases, hypoechoic or mixed echoic in 49.0% (77/157) cases, and flocculent or dotted echo floating in 36.9% (58/157) cases. CT showed low density of the capsule contents without enhancement in 69.5% (105/151) cases and mixed density with enhancement in 30.4% (46/151) cases. Liquid-liquid levers were seen in 8.6% (13/151) cases. MRI showed T1WI high signal and T2WI low signal of the capsule contents without enhancement in 28.9% (13/45) cases and mixed density in 71.1% (32/45) cases. Liquid-liquid levers were seen in 46.7% (21/45) cases. There were statistically significant differences between pure HNLMs and intracystic hemorrhage in capsule content (echo, density, signal), enhancement, and liquid-liquid lever (all p < 0.05). Among US, CE-CT and CE-MRI, intracystic hemorrhage diagnostic accuracy had a statistical difference (χ2 = 25.4152, p < 0.05).

CONCLUSIONS

For clinical diagnosis and evaluation of HNLMs, we suggest that US combined with CE-CT for acute cases, and for stable cases, US combined with CE-MRI.

Checklist: Neck computed tomography in non-traumatic emergencies

Patients attending the emergency department (ED) with cervical inflammatory/infectious symptoms or presenting masses that may involve the aerodigestive tract or vascular structures require a contrast-enhanced computed tomography (CT) scan of the neck. Its radiological interpretation is hampered by the anatomical complexity and pathophysiological interrelationship between the different component systems in a relatively small area. Recent studies propose a systematic evaluation of the cervical structures, using a 7-item checklist, to correctly identify the pathology and detect incidental findings that may interfere with patient management. As a conclusion, the aim of this paper is to review CT findings in non-traumatic pathology of the neck in the ED, highlighting the importance of a systematic approach in its interpretation and synthesis of a structured, complete, and concise radiological report.

Perplexing First Branchialcleft Anomalies-A Case Series with Review of Literature

Incomplete obliteration of the branchial apparatus results in the formation of branchial cleft anomalies. First branchial cleft anomalies may persist anywhere in the first branchial arch, from the external auditory canal at the level of the bony cartilaginous junction to the submandibular triangle. The majority of cases present in childhood as an opening in the skin though they may present as cysts or neck masses, mostly mistaken for neck abscesses which leads to inadequate treatment and complications. Here different cases of first branchial cleft anomalies with variable presentation and treatment are illustrated. The need for proper diagnosis and adequate treatment cannot be overemphasized to avoid mismanagement and complications.

Cystic lesions in the salivary gland. Pitfalls to be avoided on cytology

Cystic lesions of the salivary glands are very uncommon entities. However, on occasion, some neoplasms of the salivary glands show a cystic component, which may be predominant or only partially cystic. Basal cell adenoma, canalicular adenoma, oncocytoma, sebaceous adenoma, intraductal papilloma, epithelial-myoepithelial carcinoma, intraductal carcinoma, and secretory carcinoma are such cystic entities. Cystic degeneration and necrosis, which can develop within solid tumours, represent another possibility. The ability to recognise this type of lesion is a challenge in diagnostic cytology because hypocellular fluid is frequently recovered. Furthermore, evaluating all of the differential diagnoses for cystic lesions of the salivary glands is helpful in obtaining the correct diagnosis. Herein, we evaluate the various types of cystic lesions within the salivary glands.

Oropharyngeal Teratoma: Five-Month-Old Presenting With Failure to Thrive and Severe Obstructive Sleep Apnea

Oropharyngeal teratomas are an extremely rare congenital tumor. They are often diagnosed prenatally and can cause significant airway obstruction and feeding difficulties at birth. We present a five-month-old female that was diagnosed with a palatal teratoma that presented with failure to thrive, difficulty feeding, and eventually with severe obstructive sleep apnea. We present a five-month-old term, otherwise healthy female who became stridulous after an episode of the respiratory syncytial virus at one month old. At three months old, an otolaryngologist diagnosed mild laryngomalacia with no mass identified, and no surgical intervention was recommended. Due to continued poor weight gain, at four months old, a nasogastric tube was placed. She was subsequently admitted for further workup. She had severe stridor, a failure to thrive, and was in the 0.07th percentile for weight. Workup revealed severe obstructive sleep apnea and a palatal mass obstructing her left oropharynx. A biopsy and debulking of the mass was performed in the operating room. Pathology resulted as a mature teratoma with evidence of glial and intestinal tissue. There are no pathognomonic characteristics found on imaging to diagnose teratomas, and diagnosis is made with pathologic identification of two of the three germ cell layers. Although most teratomas are benign, there is potential for malignant transformation involving any of the represented germ cell layers. Many teratomas are diagnosed prenatally and can be quite large, often requiring Ex Utero Intrapartum Treatment (EXIT) procedure at birth to establish a safe airway. Overall, this case highlights the importance of a thorough head and neck exam, including a bilateral flexible laryngoscopy, when evaluating an infant with airway obstruction. Providers evaluating these patients should consider oropharyngeal masses, such as teratoma, as part of the differential to ensure accurate and timely diagnosis.

Transoral robotic surgery for adult parapharyngeal lymphangioma: A case report

BACKGROUND

Lymphangiomas are a group of benign swellings which are commonly seen in children. The most common sites of presentation is the head and neck region, less commonly seen in axilla, chest, liver, spleen, etc. The ideal modality of treatment has always been surgical excision irrespective of the site and age group. But with the advent of minimally invasive surgical techniques, it is now possible to perform excision of parapharyngeal space lesions with minimal morbidity and good clearance.

CASE SUMMARY

A 42-year-old male patient who presented with difficulty in swallowing and had undergone surgery twice outside, where Transcervical approach was attempted to remove the parapharyngeal mass, but failed. Magnetic resonance imaging scan demonstrated a 6 cm x 5 cm x 4 cm left parapharyngeal mass. He underwent transoral robotic surgery for the excision of the parapharyngeal lesion and had an uneventful post-operative recovery.

CONCLUSION

Lymphangiomas are hamartomatous swellings which are benign in nature. The symptoms of the patient with large parapharyngeal mass include dysphagia, dyspnoea and neck swelling. Clinicoradiological evaluation is of utmost importance to determine the adjacent vital structures and the approach to the tumor. With the advent of robotics in oncology, transoral robotic excision is one of the best approaches to perform such a surgery.

An Atypical Case of Intracranial Dermoid Cyst in an Adult Female: A Case Report and Literature Review

Intracranial dermoid cysts are unusual cystic tumors that are often benign, develop slowly, and are present from birth. They are made up of mature squamous epithelium and may house ectodermal features such as glands (apocrine, eccrine, and sebaceous). Dermoid cysts may be asymptomatic and can be detected incidentally during brain imaging for unrelated causes. Dermoid cysts tend to grow gradually and may eventually exert pressure on the brain and surrounding areas. Unfortunately, they can seldom burst, resulting in an unfavorable prognosis for the patient depending on the size, location, and clinical presentation. Headache, convulsions, cerebral ischemia, and aseptic meningitis are the most frequent symptoms. Magnetic resonance imaging (MRI) and computed tomography (CT) of the brain aid in accurate diagnosis and therapy planning. In some cases, the treatment consists of surgical monitoring with regular surveillance imaging. In other cases, surgery is needed, depending on the symptoms and the location of the cyst in the brain.

Excision of massive left branchial cleft cyst with secondary hypertension

Branchial anomalies are heterogeneous congenital malformations that form secondary to incomplete closure of pharyngeal clefts and pouches. There have been no reports of branchial cleft cysts causing carotid artery compression and hypertension. We report a large branchial cleft cyst causing suspected secondary hypertension from carotid artery compression.

Incidentalomas in the head & neck

Incidental findings (IFs) in the head & neck are a frequent challenge to the reporting radiologist. A combination of complex anatomy, widely varied imaging techniques and the high prevalence of benign pathology, makes safe and appropriate management of head & neck IFs problematic. The non-head & neck radiologist is unlikely to have prior personal experience of the relevant specialties or current involvement with the pertinent multidisciplinary teams, creating unfamiliarity with both the clinical aspects of head & neck disease and the value of examination techniques. This triumvirate of complex anatomy, pathology and imaging creates the perfect environment for excessive investigation and overdiagnosis. In this article, the most frequently encountered and clinically relevant head & neck IFs are summarised. To reflect daily clinical practice, we will firstly consider anatomic abnormalities identified on cross-sectional imaging and ultrasound, followed by a review of PET-CT incidental findings.

Evaluation of Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Mean Platelet Volume in Patients with Branchial Cleft Cyst

Branchial cleft cysts are benign masses of the head and neck. Etiopathogenesis is unclear and many factors such as inflammatory mechanisms can play a role. The aim of our study is to investigate the predictive value of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and mean platelet volume (MPV), which are hematologic inflammatory markers, in branchial cleft cyst (BCC). The records of 27 patients who were operated with the diagnosis of BCC in the ENT clinic between January 2011 and March 2020 and 27 healty subjects were retrospectively reviewed. The control group consisted age and sex-matched subjects scheduled for rhinoplasty. Neutrophil, lymphocyte, platelet and MPV values were recorded from the complete blood count samples for all participants. The statistical relationship for NLR, PLR and MPV values between the patient and the control groups was investigated. The NLR values of the patients were significantly lower than the healthy controls (p:0.007). But no statistically significant correlation was found for PLR (p:0.586) and MPV(p:0.676) values between the groups. This is the first study to evaluate the significance of NLR, PLR and MPV in branchial cleft cyst. Decreased NLR may be used as a predictive marker for BCC. But PLR ande MPV should not be used to predict branchial cleft cyst.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02789-1.

Diagnosis difficulty of histiocytosis in the thyroid region of a child: a rare case report with literature review of differential diagnoses

Background

Isolated histiocytosis of thyroid region is very rare; clinical history, exam, and radiological aspects are non-specific, and etiological reasoning is quite difficult considering the tremendous number of differential diagnoses.

Case presentation

This is the case of a 6-year-old girl who came to the emergency room with an acute presentation bulging of the anterior and left lateral regions of the neck. The palpation of the mass showed tenderness; there was no sign of inflammation, nor was there any fistula to the anterior border of the sternocleidomastoid muscle.

The patient was stable. She did not have any signs of compression. The initial blood showed anemia and inflammatory syndrome. She underwent cervical ultrasound exam that showed a mass at the expense of the left thyroid lobe; the mass extends through the sub-hyoid muscles to the lateral cervical region.

A CT scan with and without contrast injection was performed. It showed a heterogenous mass, which seemed centered in the anterior compartment, and from which it extended to the left lateral compartment, as well as the posterior compartment, invading the prevertebral muscles and englobing the carotid and the internal jugular vein.

The patient underwent surgical biopsy. A basal cervical incision was made, dissection with the myo-cutaneous plane. Per-operative observation established that the mass breeched the infrahyoid muscles, as well as the sternocleidomastoid muscle. A biopsy was performed without opening the middle line.

The pathological exam showed an eosinophilic granulomatosis, associated with Stembergoid cells. The immune-histochemical exam concluded that the lesion is histiocytosis. The patient underwent a cervicothoracic and pelvic CT scan to rule out systemic forms. The diagnosis of isolated histiocytosis of thyroid region was confirmed.

The patient underwent hemithyroidectomy, associated with careful dissection of extension of the mass to lateral compartment of the neck. Postoperative exam showed no abnormalities. No dysphonia and no hypocalcemia were observed.

The 8-month follow-up showed satisfactory results, no cervical swelling, and no signs of inflammation or compression. Postoperative naso-fibroscopy was normal.

Conclusions

The most important takeaway message of this work is that methodical approach of neck masses allows to rule out the most aggressive lesions frequently encountered, which allows clinicians to establish thorough diagnosis and management without further delay.

Diagnostic and Operative Challenges in a Type I First Branchial Cleft Cyst: A Case Report

First branchial cleft cyst (FBCC) is a rare entity of congenital anomalies in the head and neck area. Dealing with FBCC is a clinical challenge as the condition is frequently forgotten in the differential diagnosis of lateral neck swelling. We report a rare case of unilateral type I FBCC in an 11-year-old boy who presented with a painless and slow-growing preauricular mass masquerading as a benign cystic lesion of the parotid. The lesion was completely removed via surgical excision. Histopathology report confirmed the findings of squamous epithelium‑lined cyst wall, which was a characteristic of a branchial cleft cyst. The combination of good clinical acumen, with the help of radiological correlation, along with a strong degree of suspicion for the condition, facilitates the diagnosis of this condition and hence proper management.

Fourth Branchial Pouch Sinus: A Rare, Often Misdiagnosed Congenital Anomaly

Pathologies of the branchial apparatus originate from abnormal embryological development and frequently affects the second branchial cleft. Fourth branchial cleft lesions are exceptionally few and existing literature on it is scarce. We present a case of a fourth branchial pouch sinus, masquerading as a recurrent neck abscess.

Type III Second Branchial Cleft Cyst: A Rare Presentation

The second branchial cleft cyst (BCC) is the most common type of BCC. Bailey proposed a classification of the second BCC into four types, among which a Bailey type II cyst is the most common presenting lateral to the carotid space. A Bailey type III cyst, which extends between internal and external carotid arteries is an extremely rare occurrence. Complete surgical excision is the treatment modality of choice for branchial cysts and this warrants thorough imaging to see the detailed extent of the cyst. Contrast-enhanced computed tomography and Magnetic resonance imaging, both aid in diagnosis. Here we report a rare case of Type III second BCC, which presented with dysphagia, along with an elaboration of findings on imaging and treatment details.

Clinical Results Evaluation of Patients With Submental Mass Through Endoscopy-Assisted Transoral Surgery

BACKGROUND

Surgical resection through extraoral approach is the first choice for submental mass but leaves a visible scar. This study introduces an endoscopy-assisted transoral approach to resect submental mass and evaluates the clinical results.

PATIENTS AND METHODS

From September 2018 to December 2019, 5 patients with submental mass underwent surgical resection through endoscopy-assisted transoral approach. The swallowing, speech, and appearance domains of the University of Washington Quality of Life questionnaire were assessed preoperatively and at 3 months postoperatively.

RESULTS

Each mass was completely removed without rupture. No patient developed any permanent postoperative complications. The function and aesthetic outcomes were excellent without recurrence.

CONCLUSIONS

Endoscopy-assisted transoral approach for resection of submental mass is a reliable technique that achieves excellent postoperative aesthetics and functional results.

Manifestations of radiation toxicity in the head, neck, and spine: An image-based review

BACKGROUND AND PURPOSE

Radiation therapy is an important component of treatment in patients with malignancies of the head, neck, and spine. However, radiation to these regions has well-known potential side effects, many of which can be encountered on imaging. In this manuscript, we review selected radiographic manifestations of therapeutic radiation to the head, neck, and spine that may be encountered in the practice of radiology.

METHODS

We conducted an extensive literature review of known complications of radiation therapy in the head, neck, and spine. We excluded intracranial and pulmonary radiation effects from our search. We selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications.

RESULTS

Based on our initial literature search and imaging database review, we selected cases of radiation-induced tumors, radiation tissue necrosis (osteoradionecrosis and soft tissue necrosis), carotid stenosis and blowout secondary to radiation, enlarging thyroglossal duct cysts, radiation myelopathy, and radiation-induced vertebral compression fractures.

CONCLUSIONS

We describe the clinical and imaging features of selected sequelae of radiation therapy to the head, neck, and spine, with a focus on those with characteristic imaging findings that can be instrumental in helping to make the diagnosis. Knowledge of these entities and their imaging findings is crucial for accurate diagnosis. Not only do radiologists play a key role in early detection of these entities, but many of these entities can be misinterpreted if one is not familiar with them.

Symptomatic Thyroglossal Duct Cyst Presenting With Synchronous and Localized Tongue Base Extranodal Mantle Cell Lymphoma. A Unique Case Report Demonstrating Lymphoma Colonization of Cyst Wall, Potentially Relating to a Persistent Embryological Foramen Cecum Remnant

A 77-year-old male presented with a progressively enlarging midline neck mass. On further investigation he was found to have synchronous thyroglossal duct cyst and extranodal mantle cell lymphoma (MCL) localized to the base of tongue. Both pathologies were managed simultaneously with a surgical approach and the patient remained in clinical remission at the time of publication without indication for systemic oncological treatment. Histology revealed primary extranodal nonblastoid MCL forming a base of tongue mass, with colonization of the thyroglossal duct cyst. Lymphoma was also found in the epithelium of a crypt-like tract traversing one of the tongue base tumor sections. This tract was anatomically and histologically consistent with documented descriptions of the foramen cecum. This case report illustrates a previously undescribed temporal, clinical, and histological association between a base of tongue MCL and symptomatic thyroglossal duct cyst. We provide evidence for a potential causal relationship for the presentation of the thyroglossal duct cyst as a result of oropharyngeal MCL, in the absence of clinical and histological evidence of disseminated disease, directly infiltrating from its tongue base origin to the infrahyoid neck region, potentially via an embryologic foramen cecum remnant. We also highlight the crucial role of the histopathologist in multidisciplinary clinicopathological discussion in demonstrating how fundamental embryological and microanatomical relationships can unite apparently separate diseases.

Pediatric chest wall masses: spectrum of benign findings on ultrasound

A palpable finding along the chest wall is a frequent indication for pediatric US. Accurate identification of benign lesions can reassure families and appropriately triage children who need follow-up, cross-sectional imaging, or biopsy. In this pictorial essay, we review chest wall anatomy, illustrate US techniques and discuss key US imaging features of common benign lesions and normal variants.

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.

Ectopic thymic tissue in subglottis of children: evaluation and management

OBJECTIVES

Ectopic thymic tissue in the subglottis is an extremely rare disease that causes airway obstruction. Few cases reported were accurately diagnosed before surgery.

METHODS

A case of a 2-year-old boy with airway obstruction caused by a left subglottic mass was reported. The presentation of radiological imaging, direct laryngoscopy and bronchoscopy, pathology, and surgical management were reviewed. An extensive search in PubMed, EMBASE, Web of Science, Google Scholar, and EBSCO of English literature was performed without a limit of time.

RESULTS

Besides our case, only six cases were reported since 1987. The definitive diagnosis on these patients were made with the findings of pathology, of which, five were ectopic thymus and two were ectopic thymic cysts. Our case was the only one with a correct suspicion preoperatively. Four cases underwent open surgical resection, and two cases underwent microlaryngeal surgery, while one deceased after emergency tracheostomy. No recurrences were found by six patients during the follow-up after successful treatments.

CONCLUSION

Ectopic thymus is a rare condition, infrequently considered in the differential diagnosis of subglottic masses. Modified laryngofissure may be an effective approach to removing the subglottic ectopic thymus and reconstructing the intact subglottic mucosa.

Prenatal Diagnosis of Third and Fourth Branchial Apparatus Anomalies: Case Series and Comparison with Lymphatic Malformation

BACKGROUND AND PURPOSE

Third and fourth branchial apparatus anomalies are rare congenital anomalies. The purpose of this study was to investigate imaging features of these lesions on fetal MR imaging in comparison with lymphatic malformations, the major competing differential diagnosis in these cases.

MATERIALS AND METHODS

A retrospective review of our institutional fetal MR imaging database between 1997 and 2019 resulted in 4 patients with confirmed third and fourth branchial apparatus anomalies and 14 patients with confirmed lymphatic malformations. The imaging features were reviewed by consensus, and the Fisher exact test was used to evaluate statistically significant differences between these 2 populations.

RESULTS

Four cases of third and fourth branchial apparatus anomalies were imaged at 29 weeks 1 day (range, 23 weeks 1 day to 33 weeks 4 days). All 4 cases demonstrated unilateral, unilocular cysts without reduced diffusion or hemorrhage and a medially directed beaked contour that tapered between the spine and airway at the level of the piriform sinus. Compared with 14 cases of fetal lymphatic malformations imaged at 27 weeks 6 days (range, 21 weeks 3 days to 34 weeks 6 days), third and fourth branchial apparatus cysts were significantly more likely to be unilocular (P < .005) and to have a medially beaked contour (P < .005). The combination of features of unilateral, unilocular, and medially beaked contour was observed only in the fetuses with third and fourth branchial apparatus cysts (P < .001).

CONCLUSIONS

The presence of a left-sided unilocular cyst with a medially beaked contour tapering at the level of the piriform sinus suggests the diagnosis of third and fourth branchial apparatus anomaly. Accurate diagnosis in the prenatal period allows proper counseling, genetic work-up, and treatment, potentially sparing patients from recurrent infections and associated morbidity.

A new transoral modality for the treatment of lingual thyroglossal duct cyst with suspension laryngoscopy by plasma coblation

INTRODUCTION

Lingual thyroglossal duct cysts (LTGDC) are a rare kind of thyroglossal duct cyst. However, Sistrunk surgery is not very suitable for this type of cyst. This study aimed to explore the efficacy of transoral excision of LTGDC by plasma coblation.

METHODS

The present study reviewed 11 patients, comprising seven males and four females, who had been diagnosed with LTGDC preoperatively by computed tomography (CT) and fibre-optic electronic laryngoscopy. Of those patients, two had recurrence after surgery of epiglottic cysts. All these patients underwent transoral excision by plasma coblation. Then, we collected preoperative data of the patients, observed the effect of surgery, and analysed factors relevant to LTGDC, including the estimated bleeding amount, postoperative hospitalisation, complications and recurrence rates.

RESULTS

The connection between LTGDC and hyoid was tapered on sagittal images of CT, which was vital evidence for the diagnosis of LTGDC. Surgery was performed successfully for all 11 patients, and all recovered without complication. There was no evidence of recurrence after surgery, during follow up for 3-43 months.

CONCLUSIONS

Transoral surgery for LTGDC can be performed successfully by plasma coblation, which is an effective and safe surgical treatment. Fibre-optic electronic laryngoscopy and CT are essential to the diagnosis of LTGDC in order to avoid missing detection and misdiagnosis.

Unusual location of a second branchial cleft cyst presenting in the suprasternal notch

BACKGROUND

Second branchial cleft cysts (SBCCs) are congenital benign tumors that comprise up to 90% of all branchial cleft anomalies. SBCCs typically present in the lateral neck along the anterior border of the upper third of the sternocleidomastoid muscle. We describe a case of a SBCC presenting in an unusual location in the lower neck close to midline.

METHODS

An 18-year-old male presented with a 2-year history of a neck mass in the suprasternal notch. Imaging findings were reviewed with a head and neck radiologist who felt that the findings were highly suggestive of a fourth branchial cleft cyst.

RESULTS

The patient underwent surgical excision of the mass. Final pathologic evaluation confirmed the diagnosis of a second branchial cleft cyst.

CONCLUSIONS

Though extremely uncommon, second branchial cleft cysts can extend to the suprasternal notch and should not be excluded from the differential diagnoses of lower neck masses.

Diagnosis and management of congenital floor of mouth masses: A systematic review

OBJECTIVES

Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants.

METHODS

A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined.

RESULTS

85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%.

CONCLUSION

Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.

Comparison of sonographic findings between neonates with pyriform sinus fistulas and lymphangiomas

PURPOSE

In neonates, pyriform sinus fistulas and lymphangiomas require different early treatment, such as surgical resection or sclerosing therapy, respectively. We aimed to evaluate the use of sonographic findings for differentiating between pyriform sinus fistulas and lymphangiomas in neonates with a lateral cervical cystic mass.

METHODS

Sixteen cases diagnosed with pyriform sinus fistulas (n = 7) or lymphangiomas (n = 9) were included. Sonographic findings, including fistulas from the pyriform sinus, air-containing cysts, abnormal thyroid parenchyma echogenicity, internal septae within the cyst and spread to the opposite cervical site, were compared between neonates with pyriform sinus fistulas and those with lymphangiomas. Fisher's exact was used for statistical comparisons.

RESULTS

A significant difference was observed between cases with and without air-containing cysts (present/absent in neonate with pyriform sinus fistula vs lymphangioma: 5/2 vs. 0/9; p = 0.005), abnormal thyroid parenchyma echogenicity (present/absent: 4/3 vs. 0/9; p = 0.019), and internal septae within the cysts (present/absent: 2/7 vs. 9/9; p = 0.005). No significant differences were observed between cases with or without a fistula from the pyriform sinus (present/absent: 2/5 vs. 9/0; p = 0.175) and spread to the opposite cervical site (present/absent: 4/3 vs. 4/5; p = 0.500).

CONCLUSIONS

Ultrasound can differentiate pyriform sinus fistulas from lymphangiomas in neonates. In our small cohort, if they exhibited the respective sonographic findings; fistula from pyriform sinus, air-containing cysts or abnormal thyroid parenchyma echogenicity, patients were diagnosed as cases of pyriform sinus fistula. These diagnoses are critical for pediatric surgeons or otolaryngologists in surgical planning.

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.

Unusual Isolated Parapharyngeal Second Branchial Cleft Cyst: A Case Report and Literature Review

Second branchial cleft cysts (BCCs) are common congenital causes of neck swellings; however, isolated parapharyngeal space presentation is extremely rare, with only sporadic cases reported. Our objectives in this report are to describe a case and review different diagnostic and management strategies adopted in the current world literature. The case presented is a 26-year-old female with a large isolated parapharyngeal BCC extending to skull base in which first presenting symptoms were referred otalgia and painful side-to-side head rotation for months followed by odynophagia. A previously ordered computed tomography (CT) scan suspected a parapharyngeal abscess. Correct diagnosis was preoperatively achieved using magnetic resonance imaging (MRI) showing a 3.1 × 3.4 × 5.4 cm parapharyngeal BCC. Cyst was completely surgically excised transoral without complications. No evidence of recurrence has been noted after 24-month follow-up. A comprehensive world literature search for all reported cases in the last 30-years revealed thirty cases in 23 separate case reports with different diagnostic and surgical modalities adopted. Presentation and management strategies in such rare cases are discussed in detail. Our study shows that although rare, BCC diagnosis should be kept in mind while dealing with isolated parapharyngeal space swellings with MRI being key for successful preoperative diagnosis. If encountered, the transoral route can be a safe, aesthetically pleasing and effective way for complete surgical excision in contrast to most other parapharyngeal swellings, which are usually better excised via a transcervical approach.

Feasibility of same day surgery for pediatric second branchial cleft anomalies

OBJECTIVE

The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation.

METHODS

A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement.

RESULTS

There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst > 3.0 cm (p = 0.046), operative time > 90 min (p < 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay.

CONCLUSION

Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.

Computed Tomography Findings of Complete Branchial Cleft Fistula

Branchial cleft anomalies are embryonic remnants of the branchial arches and are described as the second most common congenital neck mass. Depending on their extent, these anomalies are classified as a cyst, sinus, or fistula with branchial cysts being the most common. Branchial cysts deriving from the second branchial arch are by far the most common, accounting for approximately 95% of all cases. Complete second branch arch fistulas with both an internal and external opening are a rare variant of this anomaly, and even less have been well-documented on computed tomography (CT) imaging in the literature. We present here a case of a 20-year-old female with CT findings consistent with a complete second branchial arch fistula extending from the tonsillar fossa to the external lateral neck.

A familial PLCB4 mutation causing auriculocondylar syndrome 2 with variable severity

Auriculocondylar syndrome (ARCND, MIM #614669, #602483, and #615706); also known as ''question-mark ear syndrome'' or ''dysgnathia complex'', is a rare craniofacial malformation of first and second branchial arches with a prevalence of <1/1,000,000. It is characterized by a distinctive auricular malformation (question mark ear (QME)) and highly variable mandibular anomalies. Variants found in PLCB4, GNAI3, and in EDN1 genes are responsible for >90% of tested ARCND patients. Whole exome sequencing in a multigenerational Egyptian kindred with high intrafamilial variability revealed a known heterozygous missense variant in PLCB4 (NM_000933.3:c.1862G>A:p.(Arg621His)). This report increases the number of molecularly characterized ARCND patients to 29 and emphasizes the highly variable clinical presentation within families.

Robotic Surgery in Head and Neck in Pediatric Population: Our Experience

Robot assisted surgery of the head and neck is a relatively novel approach in the management of head and neck tumors. There are very few reported cases of robot-assisted surgery of the head and neck in pediatric population in the world literature and no report of such procedures in the Indian subcontinent. In this article we present three such cases we performed for the first time in the country. The first case is that of second branchial cleft cyst, the second is a 4-year-old boy with a tongue base cyst and the third patient is a 12-year-old girl with left parotid gland tumor. All the patients underwent successful Robotic surgeries. Case 1 underwent robotic excision of the cyst through a retroauricular hairline incision. Case 2 underwent transoral robotic excision of the tongue base cyst. Case 3 underwent robotic excision of the tumor through a modified facelift incision. The mean docking time for the robot was 12.33 min and approximate blood loss was less than 10 ml in all cases. The patient and their parents were extremely satisfied with the cosmetic outcomes of the scarless surgery. Robot assisted surgery has the advantage of performing minimally invasive procedures within constrained spaces especially in children. The multiarticulated endowrist movements of the robotic arms combined with higher magnification and three-dimensional depth perception allows a precise surgery with better visualization in otherwise inaccessible areas resulting in better surgical outcome. With exceptional advantages of scarless surgery, minimal blood loss and postoperative pain and better surgeon ergonomics, robotic technique is an effective and feasible option in Pediatric Head and neck Surgery.

Papillary thyroid carcinoma metastasis to a branchial cleft cyst: a case report and review of imaging

Branchial cleft cysts are the most common lesions in the lateral neck with ectopic thyroid tissue found only rarely within these cysts. Over the years, multiple cases of papillary thyroid carcinoma arising from these ectopic thyroid tissues have been described in the literature with these cases sharing a normal thyroid gland on surgical and histological evaluation. Recently, however, there are three cases of papillary thyroid carcinoma in a branchial cleft cyst reported to be the result of metastasis from a thyroid primary. We present a 49-year-old female with a rare case of papillary thyroid carcinoma metastasis to a branchial cleft cyst with imaging characteristics that may prospectively suggest metastatic involvement.

Thyroglossal duct cysts and site-specific differential diagnoses: imaging findings with emphasis on ultrasound assessment

Thyroglossal duct cysts (TGDCs) are the most common congenital abnormality of the neck, accounting for approximately 70% of congenital neck lesions. Two-thirds of thyroglossal duct anomalies are diagnosed within the first three decades of life, with more than half being identified before 10 years of age. The age of presentation, clinical examination and imaging are essential for an accurate diagnosis. This review aims to summarize the imaging findings of TGDCs and their main differential diagnoses with emphasis on ultrasound assessment. A focus on site-specific key differentiating between them is also addressed.

Prevalence and Features of Thyroglossal Duct Cyst on Ultrasonography, According to Radioactive Iodine Therapy: A Single-Center Study

Objective: The relationship between radioactive iodine therapy (RIT) and prevalence of thyroglossal duct cysts (TGDC) on ultrasonography (US) has not been reported. We assessed the prevalence and US features of TGDC according to RIT. Methods: From July 2017 to June 2018, 3,146 subjects underwent thyroid or neck US at our center. The presence or absence of TGDCs was prospectively investigated based on real-time US examination. Among the 3,146 subjects, 261 subjects were excluded because of <18 years of age, unclear information of RIT, or the presence of a radiation therapy history to the neck. Eventually, 2,885 subjects were included in this study. Results: Of the 2,885 subjects finally included, 126 (4.4%) showed a TGDC on US. Those with RIT history showed a higher prevalence of TGDCs than those without (no statistical difference, p = 0.062). In 697 male subjects, there were statistical differences in type of surgery, RIT history, and session number of RIT between those with or without TGDCs (p < 0.0001). In 126 subjects with TGDCs, only sex showed a significant difference between those with or without RIT history (p = 0.015). However, there were no significant differences in the location, size, and shape of TGDCs (p > 0.05). The common US features of TGDC were suprahyoid location, ~1 centimeter, and flat-to-ovoid or round shape. Conclusions: RIT may increase the prevalence of TGDCs, particularly in men.

CT of the Neck: Image Analysis and Reporting in the Emergency Setting

Interpreting findings seen at CT of the neck is challenging owing to the complex and nuanced anatomy of the neck, which contains multiple organ systems in a relatively small area. In the emergency department setting, CT is performed to investigate acute infectious or inflammatory symptoms and chronic processes. With few exceptions, neck CT should be performed with intravenous contrast material, which accentuates abnormally enhancing phlegmonous and neoplastic tissues and can be used to delineate any abscesses or necrotic areas. As part of the evaluation, the vascular structures and aerodigestive tract must be scrutinized, particularly for patency. Furthermore, although the patient may present because of symptoms that suggest non-life-threatening conditions involving structures such as the teeth or salivary glands, there may be serious implications for other areas, such as the orbits, brain, and spinal cord, that also may be revealed at the examination. With a focus on the emergency setting, the authors propose using an approach to interpreting neck CT findings whereby 12 areas are systematically evaluated and reported on: the cutaneous and subcutaneous soft tissues, aerodigestive tract and adjacent soft tissues, teeth and periodontal tissues, thyroid gland, salivary glands, lymph nodes, vascular structures, bony airspaces, cervical spine, orbits and imaged brain, lung apices, and superior mediastinum. The use of a systematic approach to interpreting neck CT findings is essential for identifying all salient findings, recognizing and synthesizing the implications of these findings to formulate the correct diagnosis, and reporting the findings and impressions in a complete, clear, and logical manner.Online supplemental material is available for this article.^©RSNA, 2019.

CT and MR imaging findings of non-neoplastic cystic lesions of the parotid gland

A variety of neoplastic and non-neoplastic lesions of the parotid gland can present with a predominantly cystic architecture, and although radiologists frequently encounter cystic parotid tumors, other non-neoplastic lesions should also be included in the differential diagnoses of cystic parotid lesions. Non-neoplastic cystic lesions are usually classified as either congenital/acquired cystic lesions or inflammatory/infectious lesions. Adequate knowledge about these rare conditions is essential for appropriate diagnosis and optimal treatment strategy. This review article describes CT and MR imaging features of non-neoplastic cystic lesions of the parotid gland and provides helpful suggestions on the differential diagnoses for cystic parotid lesions.

Cystic form of cervical lymphadenopathy. Guidelines of the French Society of Otorhinolaryngology - Head and Neck Surgery (SFORL). Part 1: Diagnostic procedures for lymphadenopathy in case of cervical mass with cystic aspect

OBJECTIVES

The authors present the guidelines of the French Society of Otorhinolaryngology - Head and Neck Surgery Society on diagnostic procedures for lymphadenopathy in case of a cervical mass with cystic aspect.

METHODS

A multidisciplinary work-group was entrusted with a review of the scientific literature on the topic. Guidelines were drawn up, then read over by an editorial group independent of the work-group, and the final version was drawn up. Guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence.

RESULTS

In adults presenting a cystic cervical mass, it is recommended to suspect cervical lymphadenopathy: in order of decreasing frequency, cystic metastasis of head and neck squamous cell carcinoma, of undifferentiated nasopharyngeal carcinoma, and of thyroid papillary carcinoma (Grade C). On discovery of a cystic cervical mass on ultrasound, architectural elements indicating a lymph node and a thyroid nodule with signs of malignancy should be screened for, especially if the mass is located in levels III, IV or VI (Grade A). Malignant lymphadenopathy should be suspected in case of cervical mass with cystic component on CT (Grade B), but benign or malignant status cannot be diagnosed only on radiological data (CT or MRI) (Grade A), and 18-FDG PET-CT should be performed, particularly in case of inconclusive ultrasound-guided fine needle aspiration biopsy (Grade C).

Infected Lingual Thyroglossal Duct Cyst Mimicking Supraglottitis

A thyroglossal duct cyst (TGDC) is a common embryological remnant that typically presents as an anterior neck mass; however, this malformation can occur in any adjacent area, including the tongue base (lingual type), along the migration path of the thyroid during embryonic development. Lingual TGDC is often quiescent until infection occurs. Supraglottitis or inflammation of the supraglottis, is a potentially life-threatening disease. Because of the anatomical proximity of lingual TGDC to the supraglottis, lingual TGDC infection might be related to a presentation of supraglottitis. A 49-year-old male initially presented with clinical symptoms of acute supraglottitis. After intensive medical treatment resulting in no improvement, a computed tomography scan was performed. The result raised the suspicion of an infected lingual TGDC. Transoral marsupialization using a rigid laryngoscope was performed to drain the abscess inside the cyst. A diagnosis of lingual TGDC was made based on the characteristic histological pattern of the lesion. After treatment, a follow-up computed tomography scan showed no evidence of recurrence. To the authors' knowledge, only a few reports have pointed out similarities in the clinical and radiological findings between acute supraglottitis and an infected lingual TGDC. Clinicians should consider lingual TGDC during the differential diagnosis of supraglottitis, especially in patients with poor response to medical treatment.

Thyroglossal duct pathology and mimics

Congenital anterior neck masses comprise a rare group of lesions typically diagnosed in childhood. Most commonly, lesions are anomalies of the thyroglossal duct, namely the thyroglossal duct cyst, along with ectopic thyroid tissue. Although usually suspected based on clinical examination, imaging can confirm the diagnosis, assess the extent, and evaluate for associated complications. Imaging characteristics on ultrasound, CT, and MRI may at times be equivocal; differential considerations include branchial cleft cyst, dermoid/epidermoid, laryngocele, thymic cyst, lymphatic malformation, and metastatic disease. Thus, understanding of the embryologic course of thyroid development is crucial with recognition of critical landmarks such as the foramen cecum, hyoid bone, thyroid cartilage, and strap musculature to aid in the diagnosis of an anterior neck mass.

Clinical Study of Second Branchial Cleft Anomalies

OBJECTIVE

The objective of this study was to review the clinical characteristics and surgical treatment outcomes of second branchial cleft anomalies, and to evaluate the usefulness and accuracy of preoperative fine-needle aspiration cytology (FNAC) in the diagnosis of branchial cleft cysts.

METHODS

A retrospective chart review was performed at Chonnam National University Hwasun Hospital from January 2010 to December 2016.

RESULTS

Among 25 patients with second branchial cleft anomalies, in 23 patients (92.0%), these anomalies presented as cysts, and in the remaining 2 patients (8.0%), these anomalies presented as fistulas. Fine-needle aspiration cytology had a diagnostic sensitivity of 100%, a positive-predictive value of 100%, and accuracy of 100% for diagnosing second branchial cleft cyst. All patients of second branchial cleft anomalies were treated surgically under general anesthesia. No recurrence of second branchial cleft anomalies was observed.

CONCLUSION

Branchial cleft cysts were the most common type of second branchial cleft anomalies. Preoperative FNAC is a useful and accurate method for preoperative evaluation of branchial cleft cysts. Surgical excision of second branchial cleft anomalies is the treatment of choice without any complications and with no recurrence.

CT and MR imaging findings of infection-free and benign second branchial cleft cysts

PURPOSE

The present study aimed to assess CT and MR imaging findings of infection-free and benign second branchial cleft cysts (SBCCs).

METHODS

Eleven patients with histopathologically confirmed infection-free and benign SBCCs underwent preoperative contrast-enhanced CT (CECT) and/or MR imaging. We assessed qualitative (presence and extent of wall thickening, degree of contrast enhancement of the thickened wall on CECT images, and signal intensity of the thickened wall on T2-weighted images) and quantitative (maximum thickness of the thickened wall) imaging findings.

RESULTS

Eccentric and smooth wall thickening was observed in 11/11 (100%) patients. The wall thickening extent (percentage of the thickened wall to the circumference of the wall) was small (1%-25%) in 4/11 (36%), moderate (26%-50%) in 6/11 (54%), extensive (51%-75%) in 1/11 (9%), and diffuse (76%-100%) in 0/11 (0%) patients. Mild homogeneous enhancement of the thickened wall on CECT images was observed in 7/7 (100%) patients. The signal intensity of the thickened wall on T2-weighted images was isointense relative to that of normal lymph nodes in 7/8 (88%) and mildly hyperintense in 1/8 (12%) patient. The maximum thickness of the thickened walls ranged from 2 to 4 (mean 3.4) mm.

CONCLUSIONS

Infection-free and benign SBCCs are identifiable as cysts with eccentric and smooth wall thickening on CECT and MR images. The wall thickness was almost always less than half of the wall circumference, isointense relative to normal lymph nodes, and showed mild homogeneous enhancement.

Sonographic diagnosis of coexisting ectopic thyroid and fourth branchial cleft cyst

Ectopic thyroid and fourth branchial cleft anomaly are rare congenital anomalies of the neck. This is a case report of the coexistence of these two rare congenital anomalies in a 1-year-old girl. She had ectopic lingual thyroid and asymptomatic abscess in the fourth branchial cleft cyst, which was found in ultrasonography carried out to evaluate congenital hypothyroidism. To the best of our knowledge, this is the first reported case of ectopic thyroid coexisting with fourth branchial cleft anomaly in the same patient.