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Pediatric Neck Masses






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Pediatric Neck Masses

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1. Pediatric Neck Masses Mark Domanski, M.D. Michael Underbrink, M.D. Dept. of Otolaryngology University of Texas Medical Branch, Galveston October 31st, 2007

2. From surgical biopsies of neck massesFrom surgical biopsies of neck masses

3. Torsiglieri et al., 19882 From surgical biopsies of neck masses. There are four basic groups, congenital, inflammatory, benign, and malignant.From surgical biopsies of neck masses. There are four basic groups, congenital, inflammatory, benign, and malignant.

4. Initial Evaluation H&P Age Onset Rapidity of growth Fluctuation in size Pain Infection Trauma Travel Exposure PE Size Multiplicity Laterality Consistency Color Mobility Tenderness Fluctuation Initial evaluation to suggest on category, not a specific diagnosis ex: at birth -> congenital, rapid enlargement -> inflammatory; supraclavicular 35% were lymphoma, also, 35% of lymphoma patients present with a supraclavicular mass (but lymphoma can present with an mass anywhere); midline vs lateral masses have different diff dxInitial evaluation to suggest on category, not a specific diagnosis ex: at birth -> congenital, rapid enlargement -> inflammatory; supraclavicular 35% were lymphoma, also, 35% of lymphoma patients present with a supraclavicular mass (but lymphoma can present with an mass anywhere); midline vs lateral masses have different diff dx

5. Location, Location, Location! Location helps narrow down one?s differential diagnosis. Moir CR. Neck Cysts, Sinuses, Thyroglossal Duct Cyts, and Branchial Cleft Anomalies, Operative Tech in Gen Surg, v 6, n 4 (Dec), 2004: 281-295. Location helps narrow down one?s differential diagnosis. Moir CR. Neck Cysts, Sinuses, Thyroglossal Duct Cyts, and Branchial Cleft Anomalies, Operative Tech in Gen Surg, v 6, n 4 (Dec), 2004: 281-295.

6. Age of Distrubtion

7. Likely Etiology Determines Direction of Testing X-ray U/S CT MRI FNA Surgical Biopsy Tissue Culture CXR Labs PPD Gram stain Culture Imaging may provide clues as to etiology, show extent of the lesion, nearby structures, and aid in surgical planning. FNA may provide pathology. Know the limitations of FNA ? does not show structure, and you may miss the structure of interest.Imaging may provide clues as to etiology, show extent of the lesion, nearby structures, and aid in surgical planning. FNA may provide pathology. Know the limitations of FNA ? does not show structure, and you may miss the structure of interest.

8. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

9. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

10. 1. Congenital Lesions

11. Embryology Ectoderm, mesoderm, endoderm Incomplete closure may result in branchial cleft anomalies 1???The first four branchial arches have clinical significance. During development, the second arch predominates (A). Indentationsbetween each arch form clefts on the external surface of the embryo (B) and pharyngealpouches internally. Incomplete fusion may lead to fistulae or sinus tracts. 1???The first four branchial arches have clinical significance. During development, the second arch predominates (A). Indentationsbetween each arch form clefts on the external surface of the embryo (B) and pharyngealpouches internally. Incomplete fusion may lead to fistulae or sinus tracts.

12. Development of First Four Arches Each ectoderm, mesoderm, and endodermal component develop into a corresponding structure for each arch. Branchial cleft anomalies are located between these structures. Each The definitions of several structures should be clarified. The term ?cleft? refers to the ectoblastic furrow in each arch. The term ?pouch? refers to the entoblastic depression that is found on each arch. The term ?cyst? refers to a component completely detached from the ectoblastic or entoblastic zones. Unlike malformations of the laterocervical region, malformations of the midline are unrelated to development of the branchial apparatus [1]. These anomalies result either from defective closure of the midline or persistence of remnants after thyroid migration. Dermoid cysts and mentosternal fistulas (none in this series) are examples of closure defects while thyroglossal tract cysts are examples of a migration remnant. Nicollas. 20003Each ectoderm, mesoderm, and endodermal component develop into a corresponding structure for each arch. Branchial cleft anomalies are located between these structures. Each The definitions of several structures should be clarified. The term ?cleft? refers to the ectoblastic furrow in each arch. The term ?pouch? refers to the entoblastic depression that is found on each arch. The term ?cyst? refers to a component completely detached from the ectoblastic or entoblastic zones. Unlike malformations of the laterocervical region, malformations of the midline are unrelated to development of the branchial apparatus [1]. These anomalies result either from defective closure of the midline or persistence of remnants after thyroid migration. Dermoid cysts and mentosternal fistulas (none in this series) are examples of closure defects while thyroglossal tract cysts are examples of a migration remnant. Nicollas. 20003

13. Branchial Cleft Anomalies Not all branchial cleft cysts are cysts! The definitions of several structures should be clarified. The term ?cleft? refers to the ectoblastic furrow in each arch. The term ?pouch? refers to the entoblastic depression that is found on each arch. The term ?cyst? refers to a component completely detached from the ectoblastic or entoblastic zones. Unlike malformations of the laterocervical region, malformations of the midline are unrelated to development of the branchial apparatus [1]. These anomalies result either from defective closure of the midline or persistence of remnants after thyroid migration. Dermoid cysts and mentosternal fistulas (none in this series) are examples of closure defects while thyroglossal tract cysts are examples of a migration remnant. Nicollas. 2003 Not all branchial cleft cysts are cysts! The definitions of several structures should be clarified. The term ?cleft? refers to the ectoblastic furrow in each arch. The term ?pouch? refers to the entoblastic depression that is found on each arch. The term ?cyst? refers to a component completely detached from the ectoblastic or entoblastic zones. Unlike malformations of the laterocervical region, malformations of the midline are unrelated to development of the branchial apparatus [1]. These anomalies result either from defective closure of the midline or persistence of remnants after thyroid migration. Dermoid cysts and mentosternal fistulas (none in this series) are examples of closure defects while thyroglossal tract cysts are examples of a migration remnant. Nicollas. 2003

14. Distribution of neck malformations as cysts, fistulas, or sinuses per Nicollas et. al. (n=191) Most malformations in Nicollas?s series presented as cysts. Sinuses were second most common, and fistulas relatively rare. However, if thyroglossal duct cysts are excluded, then sinuses are the most common presentation of a neck mass malformation.Most malformations in Nicollas?s series presented as cysts. Sinuses were second most common, and fistulas relatively rare. However, if thyroglossal duct cysts are excluded, then sinuses are the most common presentation of a neck mass malformation.

15. First branchail anomalies originate from the external auditory canal, second sinuses and fistulas are found at the tonsillar fossa, and the third openings are through the pyriform sinus. 1st branchial cleft anomalies may come close to branches of the facial nerve and may require facial nerve disection. Surgery on the second branch must avoid the hypoglossal and glossopharyngeal nerves. Dissection of the third fisutlas may injur the vagus or hypoglossal nerve. 2nd and 3rd branchail cleft cysts are found in the lower third of the neck, but their tracts differ in relationship to the carotid artery and thyroid cartilage. 2???Branchial cleft fistula.The uncommon first anomaly originates in the auditory canal, traverses the parotidgland and exits near the mandible. The typical second cleft has an external openingon the lower one-third of the neck near the anterior border of the sternomastoidmuscle. The tract bisects the carotid near its origin at the tonsillar fossa. Therare third anomaly opens near the second but traverses between the thyroid and carotid,passing posteriorly to its origin at the pyriform sinus. First branchail anomalies originate from the external auditory canal, second sinuses and fistulas are found at the tonsillar fossa, and the third openings are through the pyriform sinus. 1st branchial cleft anomalies may come close to branches of the facial nerve and may require facial nerve disection. Surgery on the second branch must avoid the hypoglossal and glossopharyngeal nerves. Dissection of the third fisutlas may injur the vagus or hypoglossal nerve. 2nd and 3rd branchail cleft cysts are found in the lower third of the neck, but their tracts differ in relationship to the carotid artery and thyroid cartilage. 2???Branchial cleft fistula.The uncommon first anomaly originates in the auditory canal, traverses the parotidgland and exits near the mandible. The typical second cleft has an external openingon the lower one-third of the neck near the anterior border of the sternomastoidmuscle. The tract bisects the carotid near its origin at the tonsillar fossa. Therare third anomaly opens near the second but traverses between the thyroid and carotid,passing posteriorly to its origin at the pyriform sinus.

16. Imagining in Branchial Cleft Cysts MRI More reliably confirms cystic nature More precisely defines lesion Better to delineate glandular tissue ie fat planes CT Adequate for most lesions Cost, availability U/S cystic vs noncystic does not evaluate extent Preferred Examination: Both computed tomography (CT) scanning and magnetic resonance imaging (MRI) are useful in the evaluation of branchial cleft cysts. The choice of preferred modality depends heavily on regional preferences, with some institutions favoring MRI and others favoring CT scanning. Advocates of MRI believe that this modality more reliably confirms the cystic nature of the mass and more precisely defines the extent of the lesion and its relationship to the surrounding structures. Advocates of CT scanning believe that for most lesions, all the clinically relevant information is available as clearly on CT scan as on MRI, but with preferable cost, availability, and ease of imaging. MRI is most advantageous for type I first branchial cleft cysts and for parapharyngeal masses that may be second branchial cleft cysts. The relationship of glandular tissue to the mass (eg, fat planes between the parotid gland and a parapharyngeal mass) is important for differential diagnosis and for surgical planning. Ultrasound is useful in situations where CT scanning and MRI are unavailable. Although ultrasound can confirm the cystic nature of a mass, it does not adequately evaluate the extent and depth of neck lesions. Limitations of Techniques: Both CT scanning and MRI may be unable to distinguish a branchial cleft cyst from a lymphangioma in children. In adults, metastatic squamous cell carcinoma to cervical nodes may mimic a branchial cleft cyst. - EmedicinePreferred Examination: Both computed tomography (CT) scanning and magnetic resonance imaging (MRI) are useful in the evaluation of branchial cleft cysts. The choice of preferred modality depends heavily on regional preferences, with some institutions favoring MRI and others favoring CT scanning. Advocates of MRI believe that this modality more reliably confirms the cystic nature of the mass and more precisely defines the extent of the lesion and its relationship to the surrounding structures. Advocates of CT scanning believe that for most lesions, all the clinically relevant information is available as clearly on CT scan as on MRI, but with preferable cost, availability, and ease of imaging. MRI is most advantageous for type I first branchial cleft cysts and for parapharyngeal masses that may be second branchial cleft cysts. The relationship of glandular tissue to the mass (eg, fat planes between the parotid gland and a parapharyngeal mass) is important for differential diagnosis and for surgical planning. Ultrasound is useful in situations where CT scanning and MRI are unavailable. Although ultrasound can confirm the cystic nature of a mass, it does not adequately evaluate the extent and depth of neck lesions. Limitations of Techniques: Both CT scanning and MRI may be unable to distinguish a branchial cleft cyst from a lymphangioma in children. In adults, metastatic squamous cell carcinoma to cervical nodes may mimic a branchial cleft cyst. - Emedicine

17. 1st Branchial Cleft Cyst, Type II Type I Ectodermal duplication of EAC Near external auditory canal Usually inferior and posterior to tragus Type II Associated with submandibular gland First branchial cleft cysts are divided into type I and type II. Type I cysts are located near the external auditory canal. Most commonly, they are inferior and posterior to the tragus (base of the ear), but they may also be in the parotid gland or at the angle of the mandible. Type I cysts may be difficult to distinguish from a solid parotid mass on clinical examination. Type II cysts are associated with the submandibular gland or found in the anterior triangle of the neck (see Image 2). Branstetter, 20069 First branchial cleft cyst, type II. Contrast-enhanced axial computed tomography scan at the level of the hyoid bone reveals an ill-defined, nonenhancing, water attenuation mass (m) posterior to the right submandibular gland (g). Branstetter, 20069 First branchial cleft cysts are divided into type I and type II. Type I cysts are located near the external auditory canal. Most commonly, they are inferior and posterior to the tragus (base of the ear), but they may also be in the parotid gland or at the angle of the mandible. Type I cysts may be difficult to distinguish from a solid parotid mass on clinical examination. Type II cysts are associated with the submandibular gland or found in the anterior triangle of the neck (see Image 2). Branstetter, 20069 First branchial cleft cyst, type II. Contrast-enhanced axial computed tomography scan at the level of the hyoid bone reveals an ill-defined, nonenhancing, water attenuation mass (m) posterior to the right submandibular gland (g). Branstetter, 20069

18. Type 1 First Branchial Cleft Cyst Both MRI and CT have difficulty distinguishing branchial cleft cyst from lymphangioma in children. Picture 5. Lymphangioma mimicking a type I first branchial cleft cyst. Nonenhanced axial computed tomography scan at the level of the parotid glands reveals an ill-defined water attenuation mass (m) immediately anterior to the left parotid gland (p). Picture 5. Lymphangioma mimicking a type I first branchial cleft cyst. Nonenhanced axial computed tomography scan at the level of the parotid glands reveals an ill-defined water attenuation mass (m) immediately anterior to the left parotid gland (p).

19. Branchial Cyst Noncalcified mass CT shows lesion under SCM Branchial cyst. Lateral neck radiograph (A) in an 11-year-old boy shows a noncalcified mass (arrow) indenting the airway in its anterior aspect. CT image (B) shows noncalcified, cystic lesion (arrow) under the sternocleidomastoid muscle, consistent with a branchial cyst. Branchial cyst. Lateral neck radiograph (A) in an 11-year-old boy shows a noncalcified mass (arrow) indenting the airway in its anterior aspect. CT image (B) shows noncalcified, cystic lesion (arrow) under the sternocleidomastoid muscle, consistent with a branchial cyst.

20. 2nd Brachial Cleft Cyst T2 MRI Posterior to R submandibular gland Thickened walls suggest prior hemorrhage or infection Second branchial cleft cyst. Axial FSE T2 weighted image in another patient showing the cystic lesion in a characteristic location, posterior to the right submandibular gland. Note the thickened walls, a result of prior hemorrhage or infection. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Second branchial cleft cyst. Axial FSE T2 weighted image in another patient showing the cystic lesion in a characteristic location, posterior to the right submandibular gland. Note the thickened walls, a result of prior hemorrhage or infection. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

24. Left 2nd BA Fistula Anterior to carotid bifurcation Under the anterior SCM Exiting skin medial to lateral border of SCM Figure 1.?(A) CT scan with contrast of the neck showing left second BA fistula anterior to carotid bifurcation. (B) CT scan with contrast of the neck showing left second BA fistula coursing under the anterior border of the sternocleidomastoid muscle. (C) CT scan with contrast of the neck showing left second BA fistula exiting the skin just medial to the anterior border of the sternocleidomastoid muscle. Figure 1.?(A) CT scan with contrast of the neck showing left second BA fistula anterior to carotid bifurcation. (B) CT scan with contrast of the neck showing left second BA fistula coursing under the anterior border of the sternocleidomastoid muscle. (C) CT scan with contrast of the neck showing left second BA fistula exiting the skin just medial to the anterior border of the sternocleidomastoid muscle.

25. 6???The external opening of the branchial cleft anomaly is almost always located in the lower third of the neck. It is excised using a transverse ellipticalincision in line with a previously marked skin crease. Depending on the age and sizeof the child, a single incision is sufficient for complete removal of the tract.The younger the child, the better to achieve to the most cosmetic and reliable excision. If the child is older and the neck longer, a second incision is planned further up the neck directly over the carotid bifurcation. The site is marked before extensionand turning of the head. 6???The external opening of the branchial cleft anomaly is almost always located in the lower third of the neck. It is excised using a transverse ellipticalincision in line with a previously marked skin crease. Depending on the age and sizeof the child, a single incision is sufficient for complete removal of the tract.The younger the child, the better to achieve to the most cosmetic and reliable excision. If the child is older and the neck longer, a second incision is planned further up the neck directly over the carotid bifurcation. The site is marked before extensionand turning of the head.

26. 7???A small probe or suture may be advanced through the tract to help with palpation and visualization of the tract. Injection of methyleneblue is messy and spillage obscures operative detail. Dissection of the tract beginsinferiorly and laterally, gradually mobilizing the fistula from its subcutaneousattachments and the platysma. Once the tract has been well identified, the divisioncontinues anteriorly and superiorly. Some tracts appear lined with circular musclewhich aids in full visualization and allows for firm traction to take place. Generally with traction and counter-traction, the investments of the tract into the surrounding tissue are well visualized and divided sharply or with electrocautery. 7???A small probe or suture may be advanced through the tract to help with palpation and visualization of the tract. Injection of methyleneblue is messy and spillage obscures operative detail. Dissection of the tract beginsinferiorly and laterally, gradually mobilizing the fistula from its subcutaneousattachments and the platysma. Once the tract has been well identified, the divisioncontinues anteriorly and superiorly. Some tracts appear lined with circular musclewhich aids in full visualization and allows for firm traction to take place. Generally with traction and counter-traction, the investments of the tract into the surrounding tissue are well visualized and divided sharply or with electrocautery.

27. 8???Cephalad retraction on the skinincision may allow for visualization of the carotid bifurcation and subsequent tractligation. This maneuver is aided by digit pressure from the anesthesiologist on theappropriate tonsillar fossa. If dissection continues directly on the tract, all nerves are avoided. Inflammation or prior infection increases the chance of risk to thehypoglossal nerve that lies anteriorly. Care must be taken during retraction to veryc arefully elevate the tissues around the nerve to avoid damage. Dissection stays below the posterior belly of digastric as the bifurcation is reached. The base ofthe tract is suture-ligated with Vicryl. Wound closure is simple with re-approximationof the platysma, subcutaneous tissues and skin using absorbable suture. Drainageis usually not required unless there has been extensive dissection or prior infection. 8???Cephalad retraction on the skinincision may allow for visualization of the carotid bifurcation and subsequent tractligation. This maneuver is aided by digit pressure from the anesthesiologist on theappropriate tonsillar fossa. If dissection continues directly on the tract, all nerves are avoided. Inflammation or prior infection increases the chance of risk to thehypoglossal nerve that lies anteriorly. Care must be taken during retraction to veryc arefully elevate the tissues around the nerve to avoid damage. Dissection stays below the posterior belly of digastric as the bifurcation is reached. The base ofthe tract is suture-ligated with Vicryl. Wound closure is simple with re-approximationof the platysma, subcutaneous tissues and skin using absorbable suture. Drainageis usually not required unless there has been extensive dissection or prior infection.

28. 2nd BA cyst with sinus tract extending into the pharynx above the carotid bifurcation Dissection stays below the posterior belly of the digastrics. Avoid the hypoglossal. Figure 2.?(A) Artist rendition of excision of second BA cyst with sinus tract extending into the pharynx above the carotid bifurcation. (B) Artist rendition of excision of second BA fistula with tract extending into the pharynx above the carotid bifurcation. Dissection stays below the posterior belly of the digastrics. Avoid the hypoglossal. Figure 2.?(A) Artist rendition of excision of second BA cyst with sinus tract extending into the pharynx above the carotid bifurcation. (B) Artist rendition of excision of second BA fistula with tract extending into the pharynx above the carotid bifurcation.

29. Preauricular Sinus Not related to 1st branchial cleft anomalies Active infection during excision increases chance of recurrance 9???This condition is not related to first branchial cleft anomalies.The area is often infected with Staphylococcus aureus thatrequires treatment before surgical excision. If resected during a time of active inflammation or infection, recurrence rates are high. An elliptical skin incisionor a skin flap are the best approaches for identification of sometimes multiple glandsin the subcutaneous tissue over the zygomatic arch. Full visualization and excisionof the glands is necessary to prevent recurrence. Although the opening may be small,the incision is sometimes out of proportion to the expected removal. Care must betaken to explain to the family the surgical procedure involved for these small masses. 9???This condition is not related to first branchial cleft anomalies.The area is often infected with Staphylococcus aureus thatrequires treatment before surgical excision. If resected during a time of active inflammation or infection, recurrence rates are high. An elliptical skin incisionor a skin flap are the best approaches for identification of sometimes multiple glandsin the subcutaneous tissue over the zygomatic arch. Full visualization and excisionof the glands is necessary to prevent recurrence. Although the opening may be small,the incision is sometimes out of proportion to the expected removal. Care must betaken to explain to the family the surgical procedure involved for these small masses.

30. Thyroglossal Duct Cyst persistent tract from the descent of the thyroid from the foramen cecum epithelial lining composed of either squamous or respiratory epithelium confirm normal thyroid tissue

31. Thyroglossal Duct Cyst CT w/ Contrast Embedded in the strap muscles Extends deep to involve the pre-epiglottic space Contrast-enhanced CT shows a thyroglossal duct cyst (arrow) embedded in the strap muscles and extending deeply to involve the pre-epiglottic space. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Contrast-enhanced CT shows a thyroglossal duct cyst (arrow) embedded in the strap muscles and extending deeply to involve the pre-epiglottic space. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

32. Sistrunk Procedure! If the mass is near the hyoid bone, use the sistrunk procedure to decrease recurrance. 4???Dissection continues directly onto the cyst where itis gently freed from surrounding tissue. The cyst may initially be located eccentrically but always narrows down to the midpoint of the hyoid bone. The lateral horns of the hyoid are identified as they fuse in the midline. The lateral musculature is freed just medial to the site of fusion on each site. The midpoint of the hyoid is grasped on either side of the suspected tracts with strong clamps. The bone is excised with Mayo scissors or light bone cutters. Sistrunk Procedure! If the mass is near the hyoid bone, use the sistrunk procedure to decrease recurrance. 4???Dissection continues directly onto the cyst where itis gently freed from surrounding tissue. The cyst may initially be located eccentrically but always narrows down to the midpoint of the hyoid bone. The lateral horns of the hyoid are identified as they fuse in the midline. The lateral musculature is freed just medial to the site of fusion on each site. The midpoint of the hyoid is grasped on either side of the suspected tracts with strong clamps. The bone is excised with Mayo scissors or light bone cutters.

33. 5???The mass is mobilized inferiorly along the suprathyroidfascia, leaving any suspected tracts with the midpoint of the bone. Once clear inferiorly,the anterior and superior muscles are gradually divided. As the last remnants ofmuscle are divided, care is taken to suture-ligate all possible accessory tractsleading to the base of the tongue. At this point, the anesthesiologist may help elevatethe foramen cecum further into the incision. The tract is then suture-ligated withabsorbable suture (inset). The muscles are re-approximated transversely in severallayers using interrupted stitches. The bone is not re-sutured. The remainder of thewound is closed in layers with absorbable suture. Generally no drains are placedunless there has been previous infection or a large amount of dissection has createdsignificant dead space. 5???The mass is mobilized inferiorly along the suprathyroidfascia, leaving any suspected tracts with the midpoint of the bone. Once clear inferiorly,the anterior and superior muscles are gradually divided. As the last remnants ofmuscle are divided, care is taken to suture-ligate all possible accessory tractsleading to the base of the tongue. At this point, the anesthesiologist may help elevatethe foramen cecum further into the incision. The tract is then suture-ligated withabsorbable suture (inset). The muscles are re-approximated transversely in severallayers using interrupted stitches. The bone is not re-sutured. The remainder of thewound is closed in layers with absorbable suture. Generally no drains are placedunless there has been previous infection or a large amount of dissection has createdsignificant dead space.

34. Dermoid Cysts Ectoderm and mesoderm 7% of dermoid cysts occur in head and neck Thought to be of congenital inclusion type mean diameter = 1.2 cm (0.6-3.3) Treatment: complete excision

35. Dermoid Cysts ? Cranial Theory Grunwald in 1910 As neuroectodermal tract recedes, demal attachements follow its course and can form a sinus or cyst Beware of possible intracranial involvement

37. Dermoid Cysts Histologic features of a dermoid cyst (hematoxylin-eosin; original magnification, ?40). Histologic features of a dermoid cyst (hematoxylin-eosin; original magnification, ?40).

38. Teratoma H&N account for ~2% of teratomas Newborn ? 2.5 yr at presentation All 3 germinal layers present Mostly benign lesions amenable to curative excision Remember airway!!! Tracheotomy may be necessary.Remember airway!!! Tracheotomy may be necessary.

39. Teratoma Prognosis good if no respiratory compromise Usually well differentiated and recurrence is uncommon Antenatal diagnosis is routine in developed world Remember airway!!! Tracheotomy may be necessary.Remember airway!!! Tracheotomy may be necessary.

40. Teratoma Proximity to vital structures makes surgery technically demanding. Evaluate post op thyroid and parathyroid function. Remember airway!!! Tracheotomy may be necessary.Remember airway!!! Tracheotomy may be necessary.

41. Teratoma ? 3 germ layers Arise from pluripotent cells and ectopic embryogenic non-germ cells

42. Teratoma ? 3 germ layers

43. Teratoma ? 3 germ layers

44. Hypopharyngeal Teratoma Calcification is virtually diagnostic. ? seen on plain flim Fig. 12. Hypopharyngeal teratoma. Lateral radiograph of the neck (A) in a newborn shows a calcified mass in the hypopharynx. CT image (B) demonstrates complex character, soft tissue mass with areas of calcification and fat. Magnetic resonance image in the sagittal plane (C) further characterizes the mass as a teratoma. Calcification is virtually diagnostic. ? seen on plain flim Fig. 12. Hypopharyngeal teratoma. Lateral radiograph of the neck (A) in a newborn shows a calcified mass in the hypopharynx. CT image (B) demonstrates complex character, soft tissue mass with areas of calcification and fat. Magnetic resonance image in the sagittal plane (C) further characterizes the mass as a teratoma.

45. Teratoma T1 MRI Sagittal noncontrast T1-weighted image of a patient with a large oral teratoma shows the fatty (arrowhead) and calcified (signal loss, large arrow) components of the lesion. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Sagittal noncontrast T1-weighted image of a patient with a large oral teratoma shows the fatty (arrowhead) and calcified (signal loss, large arrow) components of the lesion. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

46. Lymphangioma Benign, multiloculated, soft Posterior neck triangle predominance Multi-septated, insinuating lesions Infiltrate and cross tissue planes Most occur by 2 yrs of age Incidence: 1 in 6,000 to 16,000 births

47. Lymphatic Vascular malformation T1 MRI High signal represents proteinaceous fluid Crosses tissue planes Axial contrast T1-weighted images shows well-defined lymphatic malformation involving the posterior triangle of the neck (arrow). The high signal in the mass is due to proteinaceous fluid in the lesion. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Axial contrast T1-weighted images shows well-defined lymphatic malformation involving the posterior triangle of the neck (arrow). The high signal in the mass is due to proteinaceous fluid in the lesion. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

48. Centrifugal vs Centripetal Centrifugal theory the lymphatic system develops as mesenchymal spaces that later coalesce into a system of vessels that eventually join the venous system. Centripetal theory jugular and posterior lymphatics form as outgrowths of endothelium from veins into the surrounding mesenchyme. I feel like I am back in physicsI feel like I am back in physics

49. Classification Size: Microcystic: capillary lymphangiomas lesions are less than 1 cm in diameter Macrocystic: cystic hygromas cysts are larger than 1 cm Cystic hygromas #1 type of lymphangioma Several other classification schemes exist. Gross et al, 2006Several other classification schemes exist. Gross et al, 2006

50. Cystic Hygroma Noncalcified Septated on U/S Cystic hygroma. The anteroposterior and lateral radiographs of the neck (A, B) in a newborn show a large, noncalcified, soft tissue density mass in the left posterior triangle of the neck (arrows). Sonographic image (C) shows a multiseptated cystic lesion (arrow) consistent with a cystic hygroma. Cystic hygroma. The anteroposterior and lateral radiographs of the neck (A, B) in a newborn show a large, noncalcified, soft tissue density mass in the left posterior triangle of the neck (arrows). Sonographic image (C) shows a multiseptated cystic lesion (arrow) consistent with a cystic hygroma.

51. Cystic Composition 5-year-old boy with lymphangioma L parotid & parapharyngeal space mixed macro- andmicrocystic type Treated by surgical resection of the left parotid area and parapharyngeal space. of the left parotid area and parapharyngeal space.

52. Type 1 First Branchial Cleft Cyst Both MRI and CT have difficulty distinguishing branchial cleft cyst from lymphangioma in children. Picture 5. Lymphangioma mimicking a type I first branchial cleft cyst. Nonenhanced axial computed tomography scan at the level of the parotid glands reveals an ill-defined water attenuation mass (m) immediately anterior to the left parotid gland (p). Picture 5. Lymphangioma mimicking a type I first branchial cleft cyst. Nonenhanced axial computed tomography scan at the level of the parotid glands reveals an ill-defined water attenuation mass (m) immediately anterior to the left parotid gland (p).

53. Burezq et al, 2006 (expert opinion) 1. Error in establishing a communication between the lymphatic and venous system Cystic hygroma 2. Error in morphogenesis of lymphatic system: this includes other types of lymphatic malformations microcystic, macrocystic and mixed lymphatic lesions Burezeq believe there is a difference in the development of macrocystic and microcystic 1. Error in establishing a communication between the lymphatic and venous system: this is a true cystic hygroma, which we consider as a separate entity. 2. Error in morphogenesis of lymphatic system: this includes other types of lymphatic malformations (i.e., microcystic, macrocystic and mixed lymphatic lesions).Burezeq believe there is a difference in the development of macrocystic and microcystic 1. Error in establishing a communication between the lymphatic and venous system: this is a true cystic hygroma, which we consider as a separate entity. 2. Error in morphogenesis of lymphatic system: this includes other types of lymphatic malformations (i.e., microcystic, macrocystic and mixed lymphatic lesions).

54. Management - Controversial Spontaneous resolution? Formation of new lymphatic channels? Serial aspiration? Sclerosant Agents? OK-432 (lyophilizied mixture of low-virulence group A Sterp pyogens Surgical Excision? Is the surgical risk out weigh the benefit in a benign lesion

55. Success with Serial Aspirations Fig 1 HV was a 4-week-old boy who presented with left large neck mass and dysphagia. Computed tomography scan showed a 4.8 ? 3.6 cm multinucleated cyst extending into mediastinum as far down as level of carina and displacing trachea significantly to left and carotid sheath anteriorly. Internal jugular vein was minimally collapsed but patent. Aspiration was performed as therapeutic and diagnostic measure and revealed grossly bloody fluid. He needed a second aspiration at age of 11 years for mild recurrence. No further treatment was necessary. Fig 2 PC was a 7-year-old boy. He had large left neck mass with positional stridor when lying flat. Ultrasound examination showed large cystic mass extending from left parotid area down to right clavicle. There was mild retrosternal extension with partial compression of right subclavian vein. Laryngoscopic examination revealed normal mobile vocal cords with adequate glottic inlet. There was large posterolateral supraglottic swelling pushing entire larynx to left. Aspiration was performed with complete resolution of cyst and relief of symptoms. The child did very well and was followed for 2 years with no recurrence. From: ? Burezq: J Craniofac Surg, Volume 17(4).July 2006.815-818 Fig 1 HV was a 4-week-old boy who presented with left large neck mass and dysphagia. Computed tomography scan showed a 4.8 ? 3.6 cm multinucleated cyst extending into mediastinum as far down as level of carina and displacing trachea significantly to left and carotid sheath anteriorly. Internal jugular vein was minimally collapsed but patent. Aspiration was performed as therapeutic and diagnostic measure and revealed grossly bloody fluid. He needed a second aspiration at age of 11 years for mild recurrence. No further treatment was necessary. Fig 2 PC was a 7-year-old boy. He had large left neck mass with positional stridor when lying flat. Ultrasound examination showed large cystic mass extending from left parotid area down to right clavicle. There was mild retrosternal extension with partial compression of right subclavian vein. Laryngoscopic examination revealed normal mobile vocal cords with adequate glottic inlet. There was large posterolateral supraglottic swelling pushing entire larynx to left. Aspiration was performed with complete resolution of cyst and relief of symptoms. The child did very well and was followed for 2 years with no recurrence. From: ? Burezq: J Craniofac Surg, Volume 17(4).July 2006.815-818

56. Success with OK-432 Supraclavicular macrocystic lymphangiomain a 3-year-old boy. (A) Before injection of OK-432. (B)The same patient 6 months after sclerotherapy with OK-432. Supraclavicular macrocystic lymphangiomain a 3-year-old boy. (A) Before injection of OK-432. (B)The same patient 6 months after sclerotherapy with OK-432.

57. Hemangioma Less than 1/3 present at birth Usually seen in 1st few months of life and enlarge progressively 90% cases involutes spontaneously Sclerosing agents controversial

58. Glut-1 erythrocyte-type glucose transporter found only in microvascular endothelia of blood?tissue barriers such as in the central nervous system, retina, placenta, ciliary muscle, and endoneurium of peripheral nerves Hemangiomas stain consistently for Glut-1, in all stages of development and involution whereas vascular malformations did not Mo JQ, Dimashkieh HH, Bove KE, GLUT1 endothelial reactivity distinguishes hepatic infantile hemangioma from congenital hepatic vascular malformation with associated capillary proliferation. Hum Pathol. 2004 Feb;35(2):200-9. MacArthur 2006.Mo JQ, Dimashkieh HH, Bove KE, GLUT1 endothelial reactivity distinguishes hepatic infantile hemangioma from congenital hepatic vascular malformation with associated capillary proliferation. Hum Pathol. 2004 Feb;35(2):200-9. MacArthur 2006.

59. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

60. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

61. 2. Inflammatory Lesions

62. When does cervical lymphadenopathy require FNA? Benign reactive lymph node may persist for weeks to months Lymphoma can present the same way A difficult question. Rapkiewicz et al 2007.A difficult question. Rapkiewicz et al 2007.

63. To FNA or not to FNA? Reactive lymphadenopathy the most likely etiology of pediatric neck masses Diagnostic dilema: a mass that does not resolve after initial treatment FNA has been widely used in the adulp population and has recently evolved into a more acceptable diagnostic modality in the pediatric population.FNA has been widely used in the adulp population and has recently evolved into a more acceptable diagnostic modality in the pediatric population.

64. FNA ancillary studies Gram stain, culture Acid fast stain Imunocytochemistry Cytogenetics

65. Limitations to FNA A lesion may not be homogenous FNA samples only part of the mass May miss the true lesion Unable to appreciate histological architecture FNA is only as accurate as what is actually biopsied by the needle.FNA is only as accurate as what is actually biopsied by the needle.

66. Time to contemplate open biopsy Enlarging mass Poor response to medical treatment Suspicious clinical course Unusual image findings Systemic symptoms

67. Case ? F.R. 8 y/o female, hx + PPD several yrs prior Presents with R cervical adenopathy FNA suggests granuloma Repeat FNA -> same result AFB stain and cultures negative Clarithromycin and ethambutol started

68. Case ? F.R. Adenopathy and pain increased Third FNA non-diagnostic CT shows bulky homogenous lymphadenopathy of R upper spinal accessory and upper jugular chains. Open biopsy displayed Hodgkin's lymphoma.

69. Reactive Lymphadenopathy 3-year-old child Multiple hypoechoic lesions variable shape and sizes consistent with reactive lymph nodes Reactive lymphadenopathy. Sonographic images (A, B) in a 3-year-old child shows multiple hypoechoic lesions of variable shape and sizes in the neck consistent with reactive lymph nodes. Reactive lymphadenopathy. Sonographic images (A, B) in a 3-year-old child shows multiple hypoechoic lesions of variable shape and sizes in the neck consistent with reactive lymph nodes.

70. Enlarged Lymph Node Nonspecific Cause: cryptococcal adenitis Yeastlike fungus Axial contrast-enhanced CT shows enlargement of the level I lymph nodes on the left (arrow). These findings are nonspecific. The enlargement was due to cryptococcal adenitis. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Axial contrast-enhanced CT shows enlargement of the level I lymph nodes on the left (arrow). These findings are nonspecific. The enlargement was due to cryptococcal adenitis. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

71. Atypical mycobacteria: ex: cryptococcus Saprobe in nature worldwide distribution Found in soil Portal of entry is lung A saprobe is an organism that derives its nutrition from the dead remains of other organisms A saprobe is an organism that derives its nutrition from the dead remains of other organisms

72. Atypical mycobacteria: ex: cryptococcus Associated w/ AIDS organ transplantation Lymphoreticular diseases ? pts lack apprarent predisposing factors A saprobe is an organism that derives its nutrition from the dead remains of other organisms A saprobe is an organism that derives its nutrition from the dead remains of other organisms

73. Bartonella henselae Hypoechoic masses with irregular rim of isoechoic tissue Biopsy: Cat Scratch Disease Cat scratch disease. Sonographic images (A, B) in a 3-year-old child show large, predominantly hypoechoic mass (arrows) with irregular rim of isoechoic tissue in the neck, suggestive of enlarged lymph nodes. Biopsy of the lesion showed evidence of cat scratch disease. Cat scratch disease. Sonographic images (A, B) in a 3-year-old child show large, predominantly hypoechoic mass (arrows) with irregular rim of isoechoic tissue in the neck, suggestive of enlarged lymph nodes. Biopsy of the lesion showed evidence of cat scratch disease.

74. Bartonella henselae Gram ? coccobacillus 2- 14 day incubation Dx: requires prolonged incubation (2 + weeks) Rx: erythromycin 1-4 m (unclear efficacy) Normally benign course Cat scratch disease. Sonographic images (A, B) in a 3-year-old child show large, predominantly hypoechoic mass (arrows) with irregular rim of isoechoic tissue in the neck, suggestive of enlarged lymph nodes. Biopsy of the lesion showed evidence of cat scratch disease. Cat scratch disease. Sonographic images (A, B) in a 3-year-old child show large, predominantly hypoechoic mass (arrows) with irregular rim of isoechoic tissue in the neck, suggestive of enlarged lymph nodes. Biopsy of the lesion showed evidence of cat scratch disease.

75. Peritonsillar Abcess Soft tissue density in submental space

76. Retropharyngeal Abscess Widening of prevertebral space Retropharyngeal abscess. Lateral radiograph of the neck (A) in a 6-year-old boy shows widening of the prevertebral space (arrow). CT image (B) demonstrates irregular rim enhancing lesion (arrow) in the left retropharyngeal space consistent with an abscess. Retropharyngeal abscess. Lateral radiograph of the neck (A) in a 6-year-old boy shows widening of the prevertebral space (arrow). CT image (B) demonstrates irregular rim enhancing lesion (arrow) in the left retropharyngeal space consistent with an abscess.

77. Retropharyngeal Space Abscess Axial contrast-enhanced CT performed in a child who was running with a toothbrush in his mouth and fell. The toothbrush perforated his pharynx resulting in a retropharyngeal space abscess (arrow). From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Axial contrast-enhanced CT performed in a child who was running with a toothbrush in his mouth and fell. The toothbrush perforated his pharynx resulting in a retropharyngeal space abscess (arrow). From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

79. Sppurative Cervical Adenitis Cervical adenitis. Anteroposterior and lateral views of the neck (A, B) in a 5-month-old child demonstrate soft tissue mass in the left posterior triangle of the neck. Sonographic image (C) shows predominantly hypoechoic lesion. CT image (D) shows irregular enhancing wall of a fluid-filled lesion consistent with an abscess. Cervical adenitis. Anteroposterior and lateral views of the neck (A, B) in a 5-month-old child demonstrate soft tissue mass in the left posterior triangle of the neck. Sonographic image (C) shows predominantly hypoechoic lesion. CT image (D) shows irregular enhancing wall of a fluid-filled lesion consistent with an abscess.

80. Thyroid Abscess Thyroid abscess. Sonographic images (A, B) in an 8-year-old boy demonstrate hypoechoic mass in the region of the left thyroid gland. CT images (C) show peripheral rim enhancing, predominantly hypodense mass in the left thyroid gland, suggestive of an abscess. Thyroid abscess. Sonographic images (A, B) in an 8-year-old boy demonstrate hypoechoic mass in the region of the left thyroid gland. CT images (C) show peripheral rim enhancing, predominantly hypodense mass in the left thyroid gland, suggestive of an abscess.

81. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

82. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

83. 3. Non-inflammatory Benign Lesions

84. Inclusion Cyst Acquired dermoid cysts result from a part of the skin being traumatically implanted in the deeper layers after ectopic formation of a dermal cyst lined with squamous epithelium. Congenital inclusion dermoid cysts form along the lines of embryologic fusion and contain both dermal and epidermal derivatives. Dermoid cysts of the head and neck are thought to be the congenital inclusion type. Simulair to demoid cysts, but not of congenital typeSimulair to demoid cysts, but not of congenital type

85. Inclusion Cyst many cysts originate from the infundibular portion of the hair follicle, and the more general term, epidermoid cyst, is favored Simulair to demoid cysts, but not of congenital typeSimulair to demoid cysts, but not of congenital type

86. Inclusion Cyst Discharge of a foul-smelling cheeselike material is a common complaint. Less frequently, the cysts can become inflamed or infected, resulting in pain and tenderness. In the uncommon event of malignancy, rapid growth, friability, and bleeding have been reported Injuries, especially of the crushing type, such as the slamming of a car door on a finger, are frequently reported in association with subungual or terminal phalanx epidermoid cysts. Theoretically, any surgical procedure may result in epidermoid cysts, and it is surprising that they are not a more common occurrence

87. Epidermal Inclusion Cyst Cyst containing keratinous material (hematoxylin and eosin, original magnification X1.6). Picture 4. Higher-magnification view of the cyst wall of the cyst in Image 3 demonstrates a true epidermis with a granular layer and adjacent laminated keratinous material (hematoxylin and eosin, original magnification X20). Cyst containing keratinous material (hematoxylin and eosin, original magnification X1.6). Picture 4. Higher-magnification view of the cyst wall of the cyst in Image 3 demonstrates a true epidermis with a granular layer and adjacent laminated keratinous material (hematoxylin and eosin, original magnification X20).

88. Torticollis Also known as fibromatosis colliAlso known as fibromatosis colli

89. Fibromatosis Colli SCM Isoechoic mass CT shows isodense mass R side Note normal SCM on L side Fibromatosis colli. Sonographic image (A) in an 11-month-old child shows a large isoechoic mass in the region of the sternocleidomastoid muscle. CT image (B) shows isodense, oval mass in the right sternocleidomastoid muscle. Note the normal muscle on the left side. Fibromatosis colli. Sonographic image (A) in an 11-month-old child shows a large isoechoic mass in the region of the sternocleidomastoid muscle. CT image (B) shows isodense, oval mass in the right sternocleidomastoid muscle. Note the normal muscle on the left side.

90. Fibromatosis Colli - FNA Paucicellular specimen Bland spindle cell cytology Spindle cell neoplasm (fibromatosis). The smears demonstrate loosely cohesive bland spindle cells with eccentric wisps of cytoplasm. Bare nuclei are observed (Diff-Quik, ?20). Spindle cell neoplasm (fibromatosis). The smears demonstrate loosely cohesive bland spindle cells with eccentric wisps of cytoplasm. Bare nuclei are observed (Diff-Quik, ?20).

91. Fibromatosis Colli r/o nodular fascitis and fibrosarcoma

92. Most patients managed by physical therapy. 10???Patients are positioned as for branchial cleft excision. A shorttransverse incision is marked in a skin crease before full patient positioning. Dissectioncontinues through subcutaneous tissue to identify the lower third of the sternomastoidmuscle just above its sternal and clavicular heads. With gentle dissection, the tendinoustissue is dissected free from the underlying carotid sheath and divided with cautery.The deep cervical fascia is similarly divided to achieve full and complete separationof the muscle. If the incision is placed slightly lower, care must be taken to divideboth the sternal and clavicular heads. The cut ends of muscle are left free as theplatysma, subcutaneous tissue and skin are closed in layers with absorbable suture.Generally no drains are placed. Physical therapy begins immediately after operation. Most patients managed by physical therapy. 10???Patients are positioned as for branchial cleft excision. A shorttransverse incision is marked in a skin crease before full patient positioning. Dissectioncontinues through subcutaneous tissue to identify the lower third of the sternomastoidmuscle just above its sternal and clavicular heads. With gentle dissection, the tendinoustissue is dissected free from the underlying carotid sheath and divided with cautery.The deep cervical fascia is similarly divided to achieve full and complete separationof the muscle. If the incision is placed slightly lower, care must be taken to divideboth the sternal and clavicular heads. The cut ends of muscle are left free as theplatysma, subcutaneous tissue and skin are closed in layers with absorbable suture.Generally no drains are placed. Physical therapy begins immediately after operation.

93. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

94. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

95. 4. Benign Neoplasms

96. Neurofibroma solitary lesion vs part of the generalized syndrome of neurofibromatosis NF-1, aka von Recklinghausen disease NF-2 Believed to arise from Schwann cell but origin uncertain

97. Neurofibroma solitary lesion vs part of the generalized syndrome of neurofibromatosis NF-1, aka von Recklinghausen disease NF-2 Believed to arise from Schwann cell but origin uncertain

98. Neurofibroma T2 MRI Central low T2 signal is characteristic of neurofibromas Axial FSE T2 through the suprahyoid neck showing a tubular mass in the masticator space. Note the central low T2 signal, characteristic of neurofibromas. This mass extended to the foramen ovale superiorly and enhanced on contrast administration (not shown). From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Axial FSE T2 through the suprahyoid neck showing a tubular mass in the masticator space. Note the central low T2 signal, characteristic of neurofibromas. This mass extended to the foramen ovale superiorly and enhanced on contrast administration (not shown). From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

99. Lipoma

100. Lipoblastoma Rare benign mesynchymal tumor of embryonal fat May clinically and radiologically mimic a hemangioma Collections of lipoblasts ? multivuolated w/ round nuclei Lipoblastoma is a rare benign mesenchymal tumour of embryonal fat that occurs almost exclusively in infants and children Lipoblastoma is a rare benign mesenchymal tumour of embryonal fat that occurs almost exclusively in infants and children

101. Lipoblastoma Resembles embryological adipose tissue

102. Lipoma Lipoblastoma

103. Neonatal Goiter CT shows large peripheral rim enhancing, low attenuation mass 1: 4000 live births Female 2x = Male predominance Delayed ossification at bone ends Neonatal goiter. Lateral neck radiograph (A) shows a large, lobulated, soft tissue mass (arrow) in the neck. CT scan axial images (B, C) show a large, peripheral rim enhancing, low-attenuation mass in the region of thyroid gland. Knee radiograph (D) shows delayed ossification at the bone ends. Iodine redialy crosses the placenta and chronic excessive material iodine exposure may cause neonatal hypothyroidism and neonatal goiter. Rovet et al, 2003 In many centers, a knee radiograph is also performed to evaluate skeletal maturity at time of diagnosis.[19] Since this serves to indicate timing of disease onset, it may have some prognostic value,[1,2] at least as to psychologic outcome. As we observed, delayed skeletal maturation, as indicated by complete absence of ossification, at time of confirmatory evaluation occurs in a significant proportion of children with congenital hypothyroidism, suggesting that hypothyroidism begins during the seventh or eighth month of pregnancy in many cases. Rovet et al, 200310 2.3.2 Skeletal Maturity Skeletal maturity at the time of diagnosis can be used as a marker of the onset and period of prenatal hypothyroidism.[19] We found that children who show significantly delayed skeletal maturation, which is suggestive of hypothyroidism during the seventh to eighth months of pregnancy, obtain significantly lower IQ levels than do those children who have somewhat more mature or normal skeletal maturity at time of diagnosis.[20] Rovet et al, 2003Neonatal goiter. Lateral neck radiograph (A) shows a large, lobulated, soft tissue mass (arrow) in the neck. CT scan axial images (B, C) show a large, peripheral rim enhancing, low-attenuation mass in the region of thyroid gland. Knee radiograph (D) shows delayed ossification at the bone ends. Iodine redialy crosses the placenta and chronic excessive material iodine exposure may cause neonatal hypothyroidism and neonatal goiter. Rovet et al, 2003 In many centers, a knee radiograph is also performed to evaluate skeletal maturity at time of diagnosis.[19] Since this serves to indicate timing of disease onset, it may have some prognostic value,[1,2] at least as to psychologic outcome. As we observed, delayed skeletal maturation, as indicated by complete absence of ossification, at time of confirmatory evaluation occurs in a significant proportion of children with congenital hypothyroidism, suggesting that hypothyroidism begins during the seventh or eighth month of pregnancy in many cases. Rovet et al, 200310 2.3.2 Skeletal Maturity Skeletal maturity at the time of diagnosis can be used as a marker of the onset and period of prenatal hypothyroidism.[19] We found that children who show significantly delayed skeletal maturation, which is suggestive of hypothyroidism during the seventh to eighth months of pregnancy, obtain significantly lower IQ levels than do those children who have somewhat more mature or normal skeletal maturity at time of diagnosis.[20] Rovet et al, 2003

104. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

105. Pediatric Neck Masses 1. Congenital lesions 2. Inflammatory lesions 3. Non-inflammatory benign lesions 4. Benign neoplasms 5. Malignant neoplasms

106. 5. Malignant Neoplasms

107. Lymphoma Third most common pediatric cancer Incidence: 11-20 per million children Geographical variance ? 50 % of childhood cancers in equatorial Africa Due to high incidence of Burkitt?s lymphoma Male predominance 2.5:1

108. Beware the supraclavicular mass! 35% of patients with H&N lymphoma present with a supraclavicular mass 35% of pts with suprclavicular masses had lymphoma Turkington et al 2005.Turkington et al 2005.

109. 3.?Actuarial disease-free survival curve using (a) univariate and (b) multivariate analyses. Stage category and response to initial chemotherapy were independent determinants of patient survival. 3.?Actuarial disease-free survival curve using (a) univariate and (b) multivariate analyses. Stage category and response to initial chemotherapy were independent determinants of patient survival.

110. Neuroblastoma Noncontrast T1 MRI Mass (arrow) lateral to carotid artery (arrowhead). Noncontrast axial T1-weighted image shows an intermediate signal mass in the left neck (arrow) just lateral to the carotid artery (arrowhead). Pathology revealed neuroblastoma. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Noncontrast axial T1-weighted image shows an intermediate signal mass in the left neck (arrow) just lateral to the carotid artery (arrowhead). Pathology revealed neuroblastoma. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

111. Rhabdomyosarcoma - CT Ill defined enhancing soft tissue density areas of necrosis Rhabdomyosarcoma. CT axial image in a 10-year-old boy shows a large, ill-defined, soft tissue density, enhancing mass, delineated by arrows, in the right parapharyngeal space with areas of necrosis. Rhabdomyosarcoma. CT axial image in a 10-year-old boy shows a large, ill-defined, soft tissue density, enhancing mass, delineated by arrows, in the right parapharyngeal space with areas of necrosis.

112. Rhabdomyosarcoma of the Masticator Space Non-contrast T1 ? intermediate signal T2 ? increased signal Rhabdomyosarcoma of the masticator space. A: Axial non?contrast-enhanced T1-weighted image shows an intermediate signal mass arising from the right masticator space (arrow). B: The mass densely enhanced following contrast (not shown). The mass demonstrates increased signal on the T2-weighted images. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101 Rhabdomyosarcoma of the masticator space. A: Axial non?contrast-enhanced T1-weighted image shows an intermediate signal mass arising from the right masticator space (arrow). B: The mass densely enhanced following contrast (not shown). The mass demonstrates increased signal on the T2-weighted images. From: ? Gujar: Top Magn Reson Imaging, Volume 15(2).April 2004.95-101

113. Torsiglieri et al., 19882 From surgical biopsies of neck masses. There are four basic groups, congenital, inflammatory, benign, and malignant.From surgical biopsies of neck masses. There are four basic groups, congenital, inflammatory, benign, and malignant.

114. From surgical biopsies of neck massesFrom surgical biopsies of neck masses

115. Conclusions Initial evaluation (H&P) Congenital, infectious, benign, malignant Beware of tuberculosis, cat scratch disease, atypical infections Beware of systemic symptoms Beware the supraclavicular mass Consider FNA or biopsy in the mass that does not resolve with treatment.

116. Bibliography NeoReviews.org, http://neoreviews.aappublications.org/case27/case.shtml, 10/18/07. Torsiglieri AJ Jr, Tom LW, Ross AJ 3rd, Wetmore RF, Handler SD, Potsic WP. Pediatric neck masses: guidelines for evaluation. Int J Pediatr Otorhinolaryngol. 1988 Dec;16(3):199-210. Nicollas R, Guelfucci B, Roman S, Triglia JM. Congenital cysts and fistulas of the neck. Int J Pediatr Otorhinolaryngol. 2000 Sep 29;55(2):117-24. Schroeder JW Jr, Mohyuddin N, Maddalozzo J. Branchial anomalies in the pediatric population. Otolaryngol Head Neck Surg. 2007 Aug;137(2):289-95. Gujar S, Gandhi D, Mukherji SK. Pediatric head and neck masses. Top Magn Reson Imaging. 2004 Apr;15(2):95-101. Malik A, Odita J, Rodriguez J, Hardjasudarma M. Pediatric neck masses: a pictorial review for practicing radiologists. Curr Probl Diagn Radiol. 2002 Jul-Aug;31(4):146-57.

117. Bibliography (cont) ROH, JL.Lymphomas of the head and neck in the pediatric population, International journal of pediatric otorhinolaryngology, Volume 71, Issue 9, September 2007, Pages 1471-1477. Moir CR. Neck Cysts, Sinuses, Thyroglossal Duct Cyts, and Branchial Cleft Anomalies, Operative Tech in Gen Surg, v 6, n 4 (Dec), 2004: 281-295. Branstetter BF, Branchial Cleft Cysts, Emedicine, http://www.emedicine.com/radio/topic107.htm Oct 24, 2006. Rovet JF. Congenital hypothyroidism: an analysis of persisting deficits and associated factors. Child Neuropsychol. 2002 Sep;8(3):150-62. Thyroglossal Duct Cyst, Learning Radiology.com, http://www.learningradiology.com/archives06/COW%20231-Thyroglossal%20Duct%20Cyst/tgdccorrect.html, accessed 10/30/2007.

118. Bibliography (cont) Pryor SG, Lewis JE, Weaver AL, Orvidas LJ. Pediatric dermoid cysts of the head and neck. Otolaryngol Head Neck Surg. 2005 Jun;132(6):938-42. Wakhlu A, Wakhlu AK. Head and neck teratomas in children. Pediatr Surg Int. 2000;16(5-6):333-7. Burezq: J Craniofac Surg, Management of Cystic Hygromas: 30 Year Experience Volume 17(4).July 2006.815-818. Head and Neck Surgery?Otolaryngology, Bailey,Calhoun, 2006, p.1213-1215 Gross E, Sichel JY. Congenital neck lesions. Surg Clin North Am. 2006 Apr;86(2):383-92, ix. Mo JQ, Dimashkieh HH, Bove KE, GLUT1 endothelial reactivity distinguishes hepatic infantile hemangioma from congenital hepatic vascular malformation with associated capillary proliferation. Hum Pathol. 2004 Feb;35(2):200-9. MacArthur CJ , Head and neck hemangiomas of infancy. Current opinion in otolaryngology & head and neck surgery, 12/2006, Vol: 14, Issue: 6 Page: 397. Becker KA, Thomas I. Epidermal Inclusion Cyst. Emedicine.com 5/10/2006. www.emedicine.com/derm/topic860.htm Roy S, Fibromatosis Colli, Histopathology India.net www.histopathology-india.net/FC.htm Rapkiewicz A, Le BT, Simsir A, Cangiarella J, Levine P. Spectrum of head and neck lesions diagnosed by fine-needle aspiration cytology in the pediatric population. Cancer Cytopathology. Vol 111, Issue 4, Pages 242-251, 6 Jun 2007. J R A Turkington, A Paterson, L E Sweeney, G D Thornbury. Neck Masses in Childres. BR J of Radiology, 78 (2005), 75-85.


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