Neck Cases 11-20

Thyroglossal Duct Cyst

Case 11: What is the most likely diagnosis?

Some TGDC will present as a cystic mass embedded within the tongue at the junction of the anterior 2/3 rds and posterior 1/3rd (red arrows). TGDC may occasionally be so large that they can cause respiratory distress. A suprahyoid location of TGDC is seen in about 20% of cases. Suprahyoid cysts are usually midline while infrahyoid cysts are slightly off midline.

DDx: TGDC 1. Ranula 2. Lymphatic Malformation 3. Dermoid-Epidermoid Cyst

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DDx

DDx: Ectopic Lingual Thyroid Gland 1.

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Case 12: What is the most likely diagnosis?

SCCA of the Base of Tongue Lymphoma Lingual Hyperplasia Ectopic Thyroid Adenoma/Goiter/Hyperplasia/Thyroiditis/Carcinoma Metastasis

Ectopic Thyroid Gland (Lingual Thyroid Gland) Ectopic thyroid tissue is an uncommon entity, resulting from an aberrant migration of the gland. Thyroid ectopia can be found anywhere along the path of descent (thyroglossal duct tract) near the midline of the neck. An ectopic gland is 4x more likely in females. Lingual thyroid tissue appears on CT and MRI as a mass extending from the mucosal surface of the tongue base near the foramen cecum. The mass appears hyperdense on precontrast CT and demonstrates homogeneous enhancement (red arrow). Radionuclide imaging can confirm the presence of functioning ectopic thyroid tissue. An ectopic gland may be the only functioning thyroid tissue as in this case (blue arrows).

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DDx

Dermoid Cyst of the Floor of the Mouth

Case 13: What is the most likely diagnosis?

A dermoid cyst is a hamartomatous tumor of developmental origin. They may be intra- or extracranial. The periphery of the tumor is usually well-defined and is often covered by a thick, dermis-like cyst wall (blue arrow).

The cyst is usually of fat density but may contain sebaceous glands and/or skin adnexa. MRI or CT is useful in diagnosing dermoid cysts by their characteristic fatty content or fat droplets. Fat globules are occasionally be seen in larger lesions on T1-weighted images as well-defined hyperintense rounded lesions (red arrow) that fatsuppress. The floor of the mouth is a common location for extracranial cysts.

DDx: Dermoid Cyst 1.

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Epidermoid Cyst Lipoma Liposarcoma Sebaceous Cyst Pilomatrixoma Steatocystoma

DDx

Case 14: What is the most likely diagnosis?

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DDx: Simple Ranula

Case 14: What is the most likely diagnosis?

1. Dermoid Cyst 2. Epidermoid Cyst 3. Lymphangioma - Cystic Hygroma

Simple Ranula A simple ranula is a post-obstructive retention cyst of sublingual gland drainage that occurs as a result of trauma or inflammation leading to dilatation of the sublingual ducts (Rivini, Bartholin). Simple ranulas are located superior to the mylohyoid muscle and in the sublingual space (red arrows). Simple ranulas are usually true cysts with the lining formed by the sublingual gland capsule. Rarely the ducts can also rupture with spillage of mucin or fluid into the surrounding soft tissues. When the ranula is quite large it may extend posterior and inferior to the mylohyoid muscle and is termed a “plunging” ranula. Typical CT findings include smooth, well-delineated cystic lesions with a uniformly thin, non-enhancing wall. Ranulas have a high signal intensity on T2-weighted images but varies with protein content. Infected ranulas may have thickened enhancing walls and cannot be easily distinguished from an abscess.

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DDx

External Laryngocele

Case 15: What is the most likely diagnosis?

External laryngocele presents as a mass usually situated laterally between the superior border of the thyroid cartilage and the hyoid bone in the area of the thyrohyoid membrane. External laryngocele arise as a dilatation of the laryngeal ventricle and may contain either air (red arrows) or mucous. A internal laryngocele is located within the paraglottic space while an external laryngocele extends through the thyrohyoid membrane outside the larynx. They are probably caused by prolonged increased intralaryngeal pressure and a lack of normal thyroarytenoid muscle sphincteric action. This results in prolonged elevation of intralaryngeal pressure that is transmitted to the saccule of the ventricle, which may dilate into a laryngocele. When infected, they are termed a laryngopyocele

DDx: External Laryngocele 1.

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Laryngeal Neoplasm Submucosal Cysts Laryngopyocele Thyroplasty

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Case 16: What is the most likely diagnosis?

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Case 16: What is the most likely diagnosis?

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DDx: Zenker’s Diverticulum 1.

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Case 16: What is the most likely diagnosis?

Achalasia Neurenteric Duplication Cyst Killian-Jamison Diverticulum Esophageal Motility Disorder

Zenker’s Diverticulum Zenker’s Diverticulum is the most common form of esophageal diverticulum. Arising from increased pressure in the oropharynx during swallow against a closed esophageal sphincter. Intradiverticular filling defects usually represent food.

These diverticulum usually present in people older than 50 and especially in the 7th and 8th decades of life. The optimal method of diagnosis is a barium swallow esophogram. Patients usually have a posterior midline pouch greater than 2 cm in diameter arising just above the cricopharyngeus muscle (red arrows). Patients often present with dysphagia, regurgitation of undigested food, aspiration, noisy deglutition, halitosis, and changes in their voice. The diverticulum is rarely palpable. A Killian-Jamieson diverticulum occurs just below the upper esophageal sphincter. These are seldom larger than 1.5 cm, are less frequent than Zenker's diverticulum, and are usually asymptomatic.

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Lymphatic Malformation Below Floor of Mouth

Case 17: What is the most likely diagnosis?

Lymphatic malformations (LM) are dilated collections of abnormal vascular channels and spaces that contain lymphatic fluid. They result from failure of normal embryogenesis of lymphatic vessels during fetal development. LM of the floor of the tongue and floor of the mouth can be associated with chronic airway problems, recurrent infection, and speech abnormalities. They are usually low in CT attenuation, poorly marginated ,and are typically multi-spatial (red arrows). They may also contain subacute blood products, which is easily seen as blood-fluid levels on CT or MR. Pure LM are non-enhancing, which differentiates them from venous malformations.

DDx: Lymphatic Malformation 1.

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Ranula Lipoma Resolving Hematoma

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DDx: Cystic Hygroma 1.

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Case 18: What is the most likely diagnosis?

Teratoma Hemangioma Hemorrhagic Neoplasm Abscess

Macrocystic Cystic Hygroma (Lymphangioma) Cystic hygromas may be microcystic or macrocystic in nature. Macrocystic lymphangioma are defined as containing spaces that are < 2 cm in size (red arrows). In 80% of instances, cystic hygromas are located in the cervico-facial region.

More than 60% are clearly visible at birth and up to 90% become overt before the age of two. CT and MR scans demonstrate multicompartmental, multicystic, homogeneous, non-invasive cystic appearing lesions. They are of low CT attenuation. Blood products or sedimentation levels are often seen within the lesion. (blue arrow}. Lymphangiomas are more common in patients with Turner syndrome, Trisomy 21, Noonan’s and Klinefelter’s syndromes.

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DDx

DDx: Cystic Hygroma

nd Case Case of Macrocystic Cystic Hygroma Teratoma 18a: 2

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Hemangioma Hemorrhagic Neoplasm Abscess

Macrocystic Cystic Hygroma (Lymphangioma) Cystic hygromas may be microcystic or macrocystic in nature. Macrocystic lymphangioma are defined as containing spaces that are < 2 cm in size (red arrows). In 80% of instances, cystic hygromas are located in the cervico-facial region. More than 60% are clearly visible at birth and up to 90% become overt before the age of two. CT and MR scans demonstrate multicompartmental, multicystic, homogeneous, non-invasive cystic appearing lesions. They are of low CT attenuation. Blood products or sedimentation levels are often seen within the lesion. (blue arrow}. Lymphangiomas are more common in patients with Turner syndrome, Trisomy 21, Noonan’s and Klinefelter’s syndromes. .

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DDx

Case 19: What is the most likely diagnosis?

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Carotid Body Tumor

Case 19: What is the most likely diagnosis?

Carotid Body Tumors (CBT) arise from the nonchromaffin paraganglioma cells primarily located in the adventitial layer of blood vessels. Initially, CBT are asymptomatic and slow growing. These tumors tend to surround the external and internal carotid arteries without any significant compression. Patients often present with pain, hoarseness, dysphagia, Horner’s syndrome, tongue paresis and vertigo. Non-contrast T1-weighted MR images demonstrate a heterogeneous mass with isointense signal intensity that splays the carotid artery bifurcation vessels. There may be multiple serpentine areas of low signal intensity representing flow voids throughout the mass giving it a “salt-and-pepper appearance”. Arteriography or MRA usually shows the pathognomonic tumor blush between the internal and external carotid arteries (red arrows).

DDx: Carotid Body Tumor 1.

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Glomus Vagale Schwannoma Thyroid Ca with Nodal Mets Vascular Mets

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Case 20: What is the most likely diagnosis?

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Glomus Vagale

Case 20: What is the most likely diagnosis?

A glomus vagale is a tumor that arises from paraganglia in and around the vagus nerve. Glomus bodies are found within the vagus nerve and its ganglia. Most glomus vagale tumors manifest as a painless neck mass (red arrows) near the angle of the mandible. There may be lower cranial neuropathies; dysphagia, palatal weakness, and tongue hemiatrophy. Large tumors may contain necrotic, calcified, or hemorrhagic foci with varying degrees of heterogeneous enhancement. A characteristic salt-and-pepper appearance may be seen on T1- and T2-weighted images. These lesions demonstrate intense contrast enhancement. Glomus vagale tumors usually displace the internal carotid artery anteriorly and the internal jugular vein posteriorly.

DDx: Glomus Vagale 1.

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Glomus Jugulare Tumor Carotid Body Tumor Schwannoma Vascular Metastases

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