Neck Cases 31-40

Burnt-Out Masticator Space Infantile Hemangioma

Case 31: What is the most likely diagnosis?

The infantile type of capillary hemangioma are common lesion in the parotid space in the first 6 years of life but may also may involve the masticator space. They usually regress by age 6 and may only be recognizable by the presence of phleboliths (red arrows) within the nearly completely involuted lesion.

DDx: Burnt-Out Hemangioma 1.

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Metastasis With Dystrophic Calcification Old Masticator Space Abscess AVM Venolymphatic Malformation

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Case 32: What is the most likely diagnosis?

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Parotid Space Lymph-Hemangioma

Case 32: What is the most likely diagnosis?

Lymphangiomas are less common than hemangiomas in the parotid region. They are very subtle on CT scans because they are often isodense on both pre- and post-contrast studies, even though they are readily palpable.

This is one of the reasons that MRI is the study of choice for evaluation of parotid masses. Lymphangiomas do not enhance with contrast since the sinusoidal spaces fill very slowly, if at all, following contrast administration.

They are usually very hyperintense on T2-W MR and may have blood-fluid levels. Some lesions may have adjacent hemangiomatous or venolymphatic portions. This lesion has a tiny phlebolith (red arrow) that is in the hemangiomatous portion of the lesion.

DDx: Lymph-Hemangioma 1. Primary Parotid Malignancy 2. Parotid Abscess 3. 1st Branchial Cleft Cyst 4. Metastatic Adenopathy

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Case 33: What is the most likely diagnosis?

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Carotid Body Tumor

Case 33: What is the most likely diagnosis?

Carotid Body Tumors present as slow-growing, lateral cervical masses of the carotid bifurcation that are pulsatile. The majority of these lesions are painless, but may cause dysphagia, syncope with or without diaphoresis, nausea, trembling and blurred vision. The angiographic picture is characterized by spreading of the external and internal carotid arteries by the tumor (red arrows). It contains a vast net of tortuous, essentially regular vessels and large vascular lakes. The tumor vessels arise from the external carotid artery, which usually is displaced anteromedially or anterolaterally as the internal carotid is shifted laterally and backward.

DDx: Carotid Body Tumor 1.

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Vascular Metastasis Glomus Vagale AVM Hemangioma Schwannoma

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Case 34: What is the most likely diagnosis?

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DDx: Retropharyngeal Abscess and Suppurative Adenopathy

Case 34: What is the most likely diagnosis?

1. Retropharyngeal Cellulitis 2. Retropharyngeal Hematoma 3. Prevertebral Abscess

4. Retropharyngeal Effusion secondary to Acute Calcific Prevertebral Tendinitis 5. Retropharyngeal Tumor

Retropharyngeal Abscess and Suppurative Adenopathy Suppurative adenopathy (SA) and retropharyngeal abscess (RA) are most common in pediatrics, patients. Patients often will present with fever, toxicity, dysphagia, respiratory distress, drooling, and stridor. SA usually results as a complication of pharyngeal infection when infected lymph drains into the retropharyngeal group of lymph nodes. SA represents the development of an abscess within the lymph node itself. Initially, the affected node will enlarge but maintains its normal oval shape since the capsule remains intact. With continued enlargement, however, the intranodal abscess will rupture (red arrow) and spread throughout the potential retropharyngeal space. A RA (blue arrow) is a potentially life threatening condition since the infection can spread unimpeded from the skull base to the upper mediastinum. RA often spread downward to the T4 level but if there is involvement of the adjacent “danger” space (black arrow) they may go as low as the diaphragm .

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DDx

Case 35: What is the most likely diagnosis?

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Case 35: What is the most likely diagnosis?

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2nd Branchial Cleft Cyst

Case 35: What is the most likely diagnosis?

Branchial cleft cysts are benign lesions that are thought to develop from failure of regression of embryologic precursor that form the gills in fish (branchia = gills {Greek}). Second branchial cleft cysts (SBCC) accounts for 95% of branchial anomalies. SBBC are usually located along the anteromedial border of the upper third of the sternocleidomastoid and just under the angle of the mandible. Branchial cleft cysts (red arrows) usually have high signal intensity on T1-W scans due to their high mucoid content. They are variable on T2-W images depending on the viscosity of the mucoproteinaceous fluid. Uninfected branchial cleft cysts do not significantly enhance on MRI. Branchial cleft cysts are more well-defined as compared to lymphangiomas.

DDx: 2nd Branchial Cleft Cyst 1.

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Lymphangioma Dermoid-Epidermoid Cysts Hemangiomas Paraganglioma

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Case 36: What is the most likely diagnosis?

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Necrotizing Fasciitis

Case 36: What is the most likely diagnosis?

Necrotizing fasciitis (NF) is a rare, but severe form of cellulitis usually caused by group A streptococci. There is a very high mortality rate with NF. It typically progresses quite rapidly leading to necrosis of skin, fascia, and underlying tissues. Asymmetrical facial edema, skin thickening, and presence of gas in the tissues (red arrows) is commonly found. The cellulitis tends to track along the myofascial planes of the neck. Involvement of surrounding muscle and vessels usually occurs a bit later. NF typically tracts into the carotid space since this space is surrounded by portions of all three layers of the deep cervical fascia, Carotid space involvement may, in turn, cause IJV thrombophlebitis and carotid occlusion. Once in the carotid sheath, NF can then spread along these vessels into the mediastinum. CT scanning is useful in identifying the extent of cellulitis, development of associated abscess, presence of air, and development of septic vascular thrombosis.

DDx: Necrotizing Fasciitis 1.

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Anasarca Superior Vena Cava Obstruction Toxic Shock Syndrome Anaphylactic Edema

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DDx: Periapical and Buccal Space Abscess

Case 37: What is the most likely diagnosis?

1. Buccal Space SCCA 2. Lymphoma 3. Minor Salivary Gland Neoplasm

Periapical Abscess of Tooth #5Subperiosteal Abscess Buccal Space Abscess Periapical abscess (PA) begin as an infection in the pulp chamber of a carious tooth. The infection spreads to the aperture of the tooth root where it gradually demineralizes and erodes the adjacent bone resulting in a localized abscess. The maxillary or mandibular teeth can be involved. Over time PA can break out through the inner or outer cortex of the maxilla or mandible extend into the surrounding subperiosteal space. Pus from these foci can track in various directions, including toward the buccal mucosa. CT will show a radiolucent area when an apical abscess has been preset for 2 or 3 weeks (red arrows). Caries may also be seen between two adjacent teeth, and the affected tooth may be impacted.

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DDx: Nodal Metastasis - SCCA 1.

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Case 38: What is the most likely diagnosis?

Branchial Cleft Cyst Papillary Thyroid CA Tuberculous Lymphadenitis Suppurative Lymphadenitis

DDx: Nodal Metastasis - SCCA Nodal metastasis from SCCA of the head and neck may occasionally present with “watery-appearing” neck nodes (red arrows) that must be distinguished from branchial cleft cysts. Often the primary tumor may not be readily apparent. The differential diagnosis of low attenuation “nodes” must include non-neoplastic (suppurative node, TB lymphadenitis, branchial cleft cyst) as well as neoplastic (H&N SCCA, papillary thyroid CA) causes. Watery-appearing nodes are especially common with oropharyngeal H&N SCCA. Great care should be made in diagnosing branchial cleft cysts in adult patients; especially if there are septations, mural nodules, or non-uniformity of the cyst wall.

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Case 39: What is the most likely diagnosis?

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Spontaneous Retropharyngeal Hematoma

Case 39: What is the most likely diagnosis?

Spontaneous retropharyngeal hematoma (RH) is a rare cause of acute noninflammatory neck swelling that may rapidly evolve to cause upper airway obstruction. Most documented causes have been: coagulopathic states, trauma, carotid artery rupture, metastasis, angiographic procedures, and foreign body ingestion. Classical presentation is “Capp’s triad” of tracheal/esophageal compression, anterior displacement of trachea, and subcutaneous bruising over neck and anterior chest. Precontrast T1-MRI shows a peripherally hyperintense mass (red arrows) that extends from the upper nasopharynx into the hypopharyngeal region displacing the trachea, larynx, and esophagus anteriorly . T2-weighted gradient-echo images show the mass to be hypointense due to deoxyhemoglobin (blue arrows). Postcontrast T1-W image shows minimal peripheral enhancement (green arrow).

DDx: Retropharyngeal Hematoma 1.

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Retropharyngeal Abscess Pharyngeal Neoplasm With Retrovertebral Spread Prevertebral Extension of Vertebral Neoplasm Liposarcoma

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Carotid Body Tumor

Case 40: What is the most likely diagnosis?

Carotid Body Tumors (CBT) arise from the nonchromaffin paraganglion cells primarily located in the adventitial layer of blood vessels at the carotid bifurcation. There is a higher incidence of CBTs in individuals living at high altitudes. Initially, CBTs are asymptomatic and slow growing. These tumors tend to splay the external and internal carotid arteries without any significant compression. Patients often present with pain, hoarseness, dysphagia, Horner’s syndrome, tongue paresis and vertigo. Contrast-enhanced CT images demonstrate a markedly enhancing soft-tissue mass (red arrows) centered at the carotid bifurcation with splaying of the internal and external carotid arteries.

DDx: Carotid Body Tumor 1.

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Schwannoma Vascular Metastasis Aneurysm Hemangioma Venolymphatic Malformation

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