Neck Cases 21-30

DDx: Lymphatic Malformation

Case 21: What is the most likely diagnosis?

1. Hemangioma 2. Plexiform Neurofibroma 3. Myofascitis

Facial Lymphatic Malformation 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. 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.

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Plexiform Neurofibroma Along Cranial Nerves 9-11

Case 22: What is the most likely diagnosis?

Plexiform neurofibromas are elongated, multi-nodular lesions involving multiple fascicles of a large nerve or multiple trunks of a nerve plexus. With few exceptions, plexiform neurofibromas are pathognomonic of NF1. The neurogenic origin of lesions can often be suspected by bony expansion of neural foramina (red arrows). Aggressive neoplasms of the neck can extend into the neural foramina but do not usually enlarge the foramina. Cranial nerves with a sensory components (V, IX, X) are involved more frequently than pure motor nerves (XI, XII). Large neurofibromas of major nerves and plexiform variants should be carefully screened for the presence of anaplastic features. CT or MRI usually shows a prominently enhancing mass that extends along the expected course of a cranial nerve.

DDx: Plexiform Neurofibroma 1.

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Multiple Hemangiomas Metastasis Venolymphatic Malformations Sarcoma

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Lipoma

Case 23: What is the most likely diagnosis?

Lipomas are the most common benign mesenchymal tumor, arising in any location where fat is normally present. They are present in approximately 1% of the general population but are most common in the fifth and sixth decades of life, Imaging is usually diagnostic with little in the differential. On CT scans, a lipoma is isodense with normal subcutaneous fat. Composed almost entirely of mature fat, lipomas appear as relatively well-circumscribed, homogeneous masses (red arrows) with a thin capsule. As compared to a liposarcoma, lipomas do not contain tissue of soft tissue attenuation and do no enhance with contrast. Treatment is usually unnecessary unless the tumor becomes painful , exhibits growth, or restricts movement.

DDx: Lipoma 1. Dermoid Cyst 2. Madelung Disease Case 1 3. HIV Lipodystrophy Syndrome 4. Liposarcoma

Case 2

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Peritonsillar Abscess and Suppurative Retropharyngeal Nodes

Case 24: What is the most likely diagnosis?

Peritonsillar tonsillar abscesses (PTA) are most common in the first 3 decades of life. Patients present with fever, toxicity, dysphagia, respiratory distress, drooling, and stridor. PTA (red arrows) occur between the tonsil and the capsule of the tonsil and often displace the tonsil anteromedially. Spread of infection to the draining retropharyngeal nodes may lead to development of a suppurative node (blue arrows) which represents an intranodal abscess. Rupture of this node will spill infection into the surrounding potential space leading to a retropharyngeal abscess (RPA). RPA is a potentially life threatening condition since there is little resistance to craniocaudal spread toward the mediastinum.

DDx: Peritonsillar Abscess and Suppurative Retropharyngeal Node 1.

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Retropharyngeal Cellulitis Prevertebral Abscess Retropharyngeal Hematoma Retropharyngeal Effusion secondary to Acute Calcific Prevertebral Tendinitis

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Case 25: What is the most likely diagnosis?

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Infantile Parotid Capillary Hemangioma

Case 25: What is the most likely diagnosis?

Hemangioma is characterized by a benign proliferation of vessels lined by endothelial cells. Hemangiomas account for approximately 0.4% of salivary gland tumors and occur almost exclusively in the parotid gland.

They are most common in the first 6 years of life. The vast majority of these are of the “infantile” type meaning they have an initial proliferative phase and often involute by 6 years of age. Clinically, salivary hemangiomas present as asymptomatic swellings that may have a bluish hue to the overlying skin. MRI usually shows a slightly lobulated soft tissue mass with relatively homogeneous contrast enhancement. Intralesional flow-voids (red arrows) confirm the high vascularity of these lesion. Primary parotid malignancies and sarcomas tend to have a more heterogeneous appearance and variable contrast enhancement.

DDx: Parotid Hemangioma 1. Primary Parotid Malignancy 2. Rhabdomyosarcoma 3. Fibrosarcoma

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Internal Jugular Venous Thrombophlebitis - Deep Cervical Fasciitis

Case 26: What is the most likely diagnosis?

Thrombosis of the internal jugular vein may occur as a complication of head and neck infections, surgery, central venous access, and intravenous drug abuse. Central venous catheters now are the most common underlying cause. Potentially life threatening complications include cervical abscess, systemic sepsis and septic pulmonary embolism. The classic causes of thrombosis includes blood vessel trauma, stasis of blood flow, and a hypercoagulable state. CT findings include low-density intraluminal thrombus and a sharply defined enhancing vessel wall (due to contrast uptake by the vasa vasorum) (red arrows). Soft tissue edema and swelling around the IJ vein, adjacent musculature, and cervical fascia indicate deep cervical myofascitis.

DDx: Venous Thrombophlebitis - Cervical Fasciitis 1. Malignant Neoplasm with Extracapsular Nodal Spread 2. IJV Thrombosis and Perivascular Hematoma 3. Traumatic Vascular Thrombosis and Perivascular Hematoma

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DDx: Lymphangioma 1.

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Case 27: What is the most likely diagnosis?

Seroma Cervical Cellulitis Lipoma Liposarcoma

Lymphangioma of Lower Neck Lymphangioma is a benign hamartomatous malformation of lymphatic vessels; the majority occurring in the head and neck region. Thought to be a developmental malformation of vessels that have poor communication with the normal lymph system. Very large cystic spaces (red arrows) may be see in lesions proliferating in loose connective tissues and fascial spaces. Lymphangioma appears as multiple, intertwining lymph vessels in a loose fibrovascular stroma, sometimes with scattered aggregates of lymphoid tissue. There is no real encapsulation of the lesion, even when they appear well circumscribed clinically. These lesions can show intermittent enlargement with upper respiratory infections.

They are of variable CT density, often approaching 0 Hounsfield units.

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Case 28: What is the most likely diagnosis?

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Periapical Abscess Subperiosteal Abscess Submandibular - Masticator Space Abscess

Case 28: What is the most likely diagnosis?

Periapical abscesses (purple arrows) of the 2nd or 3rd molar teeth may spread into the submandibular space because the long roots of these teeth are located inferior and posterior to the attachment of the mylohyoid muscle (red arrows) to the mandible. This subperiosteal abscess wraps around the inferior aspect of the mandible laterally into the region of the masseter muscle (blue arrows) (i.e. masticator space. Additionally, there is extension of infection along the submandibular duct into the submandibular gland.

DDx: Periapical Abscess Subperiosteal Abscess Submandibular - Masticator Space Abscess 1. Malignant Submandibular Gland Neoplasm 2. Floor of Mouth Squamous Cell Carcinoma

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DDx: Mandibular Osteomyelitis

Case 28a: Another Case; Diagnosis?

1. Osteosarcoma 2. Dental Granuloma 3. Radicular Cyst

Failed Dental Implant  Mandibular Osteomyelitis Subperiosteal Abscess Mandibular Osteomyelitis (MO) is usually a consequence and extension of dental or periodontal infection. MO is rarely hematogenous or iatrogenic. In later stages it presents as pain and fever with swelling and redness of surrounding soft tissue. MO is often accompanied by acute suppurative inflammation with resorptive scalloping of margins of nonvital bone within large portions of the mandible. Upon radiologic examination, lesions appear as irregular, ill-defined, and predominantly radiolucent zones of bone destruction (red arrows). There may be accompanying subperiosteal abscess (blue arrows) or suppurative lymphadenopathy.

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Retropharyngeal Fluid-Edema (Likely Traumatic)

Case 29: What is the most likely diagnosis?

Edema fluid or lymph spilling into the retropharyngeal space is often secondary to venous or lymphatic obstruction or surrounding infection. Edema uniformly fills the retropharyngeal space from side to side. Secondly, edema has a smooth ovoid, rectangular, or “bow-tie” configuration on axial imaging and a diffuse craniocaudal distribution on sagittal images with tapered inferior and superior margins (red arrows). Edema will not cause wall thickening, nor will it enhance. Most cases resolve as cause of edema is treated. Ancillary findings include IJV thrombosis, adjacent neck infection, and, if secondary to acute calcific prevertebral tendinitis, there may be focal calcification anterior to C1-C2 in the longus colli tendons. The retropharyngeal space may extend into the mediastinum, often to the T4 level,

DDx: Retropharyngeal Fluid-Edema 1.

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Retropharyngeal Space Abscess Retropharyngeal Edema Other Etiology (IJV thrombosis, XRT, hypoproteinemia, anasarca, etc) Acute Calcific Prevertebral Tendinitis Infectious Spondylodiscitis

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Sjögren's Syndrome

Case 30: What is the most likely diagnosis?

Sjögren's Syndrome (SS) is one of the most prevalent autoimmune disorders. Nine out of 10 patients are women. The hallmark symptoms is dryness of the mouth and eyes (sicca symptoms).In addition, SS may cause skin, nose, and vaginal dryness, and may affect other organs of the body, including the kidneys, blood vessels, lungs, liver, pancreas, peripheral nervous system (distal axonal sensorimotor neuropathy) and brain. About half of the time SS occurs alone (Primary Sjögren’s) and the other half it occurs in the presence of another autoimmune connective tissue disease such as rheumatoid arthritis, lupus, or scleroderma (Secondary Sjögren’s). In the later stages of the disease multiple punctate calcifications (red arrows) may be seen in the parotid glands. Patients with SS have a higher rate of non-Hodgkin lymphoma compared to both patients with other autoimmune diseases and healthy people. About 5% of patients with Sjögren's syndrome will develop some form of lymphoid malignancy.

DDx: Sjögren's Syndrome 1. Parotid Sialolithiasis 2. Burnt-out Parotid Hemangioma 3. Prior Bilateral Parotitis

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