Neck Cases - Cases 1-10

Case 1: What is the most likely diagnosis?

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Case 1: What is the most likely diagnosis?

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Fluid Filled Laryngocele

Case 1a: What is the most likely diagnosis?

A laryngocele is caused by dilatation of the laryngeal ventricle, which may be congenital or acquired. Acquired causes are usually due to increased supraglottic pressure (brasswind instrument players, chronic coughers). The laryngocele displays well-defined margins on CT (red arrows) with homogeneous fluid or air CT attenuation. The fluid component on T1- and T2-weighted MR images may be variable depending on the protein contents. Coronal reconstructed images are useful in localizing the laryngocele to the region of the laryngeal ventricle. Laryngoceles may also arise from obstruction of the ventricle by coexistent malignant tumors, inflammatory lesions, or other mass lesions. Patients commonly present with voice hoarseness, dyspnea, and reflex cough. They may become infected causing a laryngopyocele.

DDx: Laryngocele 1.

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Laryngeal Neoplasm Submucosal Cyst Laryngeal Abscess Laryngopyocele Pharyngocele

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DDx: Pharyngocele

Case 2: What 1.is Laryngocele the most likely diagnosis?

2. Normal Pyriform Sinus

Pharyngocele A pharyngocele is a lateral bulging of the pharyngeal wall (red arrows). They are usually caused by frequent prolonged high intrapharyngeal pressure with gradual loss of muscular resilience. Pharyngoceles arise from the lateral wall of the pyriform sinus or tonsillar fossa. Congenital types result from branchial cleft remnants and are usually unilateral. Acquired pharyngocele typically arise in one of two weak areas: (1) junction of the superior and middle pharyngeal constrictor muscles at the inferior pole of the tonsil and lateral vallecula, (2) between the middle and inferior pharyngeal constrictor muscles and the thyrohyoid membrane at the base of the pyriform fossa. Symptoms may include neck or throat pain, otalgia, dysphagia, regurgitation, dysphonia, and cough.

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DDx

Case 3: What is the most likely diagnosis?

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DDx: Submucosal Cyst

Case 3a: What is the most likely diagnosis?

1. Nasopharyngeal Angiofibroma 2. Nasopharyngeal Tumor 3. Thornwaldt's Cyst

Submucosal Cyst in Fossa of Rosenmuller Most submucosal cysts are usually less than 1 cm in size and are asymptomatic; often being found incidentally. They usually show very bright signal on T2-weighted images (red arrows) and can be either bright or dark on T1-weighted images depending on the protein content. When the cysts are hyperintense on T1-weighted images, they are usually slightly hypointense on T2-weighted scans. Mild peripheral enhancement is usually seen.

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DDx

DDx: Vallecular Submucosal Cyst

Epidermoid Case 4: 1.What isCystthe most likely diagnosis?

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Thyroglossal Duct Cyst Enteric Duplication Cyst Papillomatosis

Vallecular Submucosal Cyst Vallecular cyst and pre-epiglottic cysts are rare but recognized causes of respiratory distress shortly after birth and in early infancy. They are benign lesions but may occasionally cause serious airway obstruction. In adults, they develop due to obstruction of a mucous secreting gland at the base of the tongue. The lesion gradually increases in size with accumulation of fluid or mucoid secretions. These cysts are submucosal in location and, therefore, may be missed at endoscopy when small. They are best seen on CT or MR imaging studies. On CT, vallecular cysts are seen as nonenhancing, fluid density lesions centered on the mucosa of the vallecula (red arrows). When infected, vallecular cysts may demonstrate increased density and enhance heterogeneously, making them indistinguishable from an abscess.

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DDx

DDx: Thornwaldt (Tornwaldt) Cyst

Case 5: 1.What is the Submucosal Cyst most likely diagnosis?

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Rathke Cleft Cyst Adenoidal Retention Cyst Encephalocele Meningocele

Thornwaldt (Tornwaldt) Cyst The pharyngeal bursa (Thornwaldt bursa) represents a persistent communication between the roof of the nasopharynx and the notochord. Thornwaldt cysts are often detected as incidental findings on cross-sectional imaging and autopsy studies. MRI is the exam of choice to delineate and characterize this entity. The presence of protein within the cyst leads to high signal intensity on both T1- and T2-weighted images (red arrows). High T1-W MR signal intensity will usually exclude a neoplasm. Thornwaldt cyst are midline, usually unilocular, lesions situated between the longus capitus muscles. They are homogeneous and fluid-like in texture with no evidence of an adjacent mass lesion. Fat-saturated T1W post-contrast enhanced images usually show minimal peripheral enhancement.

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Case 6: What is the most likely diagnosis?

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Case 6: What is the most likely diagnosis?

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1st Branchial Cleft Cyst (Type I)

Case 6: What is the most likely diagnosis?

Branchial cleft cysts are benign lesions that arise from embryologic precursor that develops into the tissue of the neck.

The branchial clefts that are important in the neck are the 1st-4th ones. Lesions from branchial cleft remnants may arise anywhere along the course of their internal opening, tract of descent, or external openings. When a branchial cleft does not completely involute, a branchial cleft cyst may form along the tract of descent. The 1st branchial cleft forms the EAC. Type I cysts are located near the external auditory canal, parotid gland, or angle of the mandible. MRI is superior to CT for imaging 1st branchial cleft cysts as they be imbedded within the parotid gland and better characterized by MRI. Branchial cleft cysts have a variable appearance on T1- and T2-weighted scans depending on their protein content (red arrows). Uninfected branchial cleft cyst should not enhance on MRI.

DDx: 1st Branchial Cleft Cyst 1.

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Lymphangioma Metastatic Squamous Cell Carcinoma Cystic Hygroma Dermoid Cyst Lipomas

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Case 6a: 2nd Case of 1st Branchial Cleft Cyst

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Branchial Cleft Cyst

1. Lymphangioma Case 6a: 2nd Case of 1st Branchial Cleft Cyst 2.

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Metastatic Squamous Cell CA Cystic Hygroma Dermoid Cyst Lipoma

1st Branchial Cleft Cyst (Type I) The 1st branchial cleft forms a portion of the EAC. Therefore a 1 st branchial cyst may extend along a tract to drain into the EAC (red arrows).

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Case 7: What is the most likely diagnosis?

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Case 7: What is the most likely diagnosis?

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2nd Branchial Cleft Cyst

Case 7: What is the most likely diagnosis?

95% of branchial anomalies arise from the 2 nd branchial cleft. They most frequently present an asymptomatic swelling along the anterior border of the upper third of the sternocleidomastoid and just under the angle of the mandible. Branchial cleft tracts are linear rounded tracts that present somewhere along the decent of a branchial tract (red arrows). They may begin along a mucosal surface and extend all the way to a cutaneous opening. The exact pathway varies depending on the cleft of origin. Contrast enhanced CT reveals a welldefined, unilocular, non-enhancing, water attenuating masses or tracts. Cysts are typically filled with mucoid material. . Branchial cleft cysts tend to be rounded and well defined whereas lymphangiomas are more infiltrative. Cysts can be distinguished from hemangiomas as the latter will show homogeneous rather than peripheral enhancement.

DDx: 2nd Branchial Cleft Cyst 1.

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Lymphangioma Dermoid Cysts Hemangiomas Paragangliomas Metastatic Adenopathy

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Case 7a: 2nd Case of 2nd Branchial Cleft Cyst

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Case 7a: 2nd Case of 2nd Branchial Cleft Cyst

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Case 8: What is the most likely diagnosis?

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Tonsil Squamous Cell Carcinoma (SCCA)

Case 8: What is the most likely diagnosis?

Tonsillar SCCA are more strongly associated with human papillomavirus infection than are cancers of other regions of the neck. Presentation usually includes neck mass, enlarged tonsils, sore throat, ear pain, and bleeding from the mouth and is found 3-4 times more commonly in men. Tonsillar SCCA is also highly correlated with a history of alcohol abuse and smoking. SCCA of the oropharynx often has nodal spread with characteristic “watery” nodes (red arrow) that are often misdiagnosed as brachial cleft cysts. Most brachial cleft cyst present in the first decades of life where SCCA is more common after the 3 rd decade. One should exercise extreme caution in making the diagnosis of a branchial cleft cyst after the 3 rd decade, if there is a multilocular appearance, or nodular enhancement.

DDx: SCCA with Nodal Metastasis 1.

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Suppurative Adenopathy Benign Branchial Cleft Cyst Scrofula Diffuse Large B-Cell Lymphoma

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Case 9: What is the most likely diagnosis?

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2nd Branchial Cleft Cyst

Case 9: What is the most likely diagnosis?

This case demonstrates a cyst filled with material that is high in signal intensity on T1-weighted scans. This usually indicated a benign process, especially if it is homogeneous in signal intensity. The high T1 signal is due to T1 shortening of water by adjacent mucoproteinaceous material. The T2-weighted signal is usually low in these cases as well (red arrows). High T1-weighted signal intensity is unusual in tumors except for low grade papillary thyroid carcinoma that are mature enough to produce colloid. High T1 signal can also be seen in lymphangiomas that have chylous fat-containing secretions.

DDx: 2nd Branchial Cleft Cyst 1. Lymphangioma 2. Dermoid Cyst 3. Hemangioma 4. Hemorrhagic Neoplasm

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Thyroglossal Duct Cyst (TGDC)

Case 10: What is the most likely diagnosis?

Thyroglossal duct cysts are the most common congenital neck cyst. They are usually located near midline when above the hyoid bone and slightly off-midline when below the hyoid bone. A TGDC develop from persistence of an epithelial tract along the descent of the thyroid gland. This tract extends from the foramen cecum of the tongue to its final position in the anterior neck. The tract loops inferior and posterior to the hyoid bone. Normally this duct obliterates early in fetal life. TGDC usually present in the first two decade of life with intermittent midline or para-midline upper neck swelling. They are rarely so far lateral as to be confused with a branchial cleft cyst. TGDC usually present as a well-defined “cystic” mass with peripheral enhancement due to the epithelial lining (red arrows). When infected, there may be more ill-defined margins due to adjacent cellulitis. Sometimes islands of thyroid tissue may line the walls of the cyst. Presentation often includes dysphagia, dysphonia, draining sinus, fever, and an enlarging neck mass.

DDx: TGDC 1. Lymphatic Malformation 2. Dermoid Cyst 3. Ranula 4. Vallecular Cyst 5. Lymphadenopathy

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