Case studies in infrahyoid neck
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Case Studies in Infrahyoid Neck. Nicholas A. Koontz, M.D. Neuroradiology Fellow, University of Utah. Financial Disclosures. But first…. Please direct your smart phone, tablet, or laptop’s browser to:. Objectives. Review Infrahyoid Neck Anatomy Deep Spaces Nodal Stations

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Case Studies in Infrahyoid Neck

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Case studies in infrahyoid neck

Case Studies in Infrahyoid Neck

Nicholas A. Koontz, M.D.

Neuroradiology Fellow, University of Utah


Financial disclosures

Financial Disclosures


But first

But first…

  • Please direct your smart phone, tablet, or laptop’s browser to:


Objectives

Objectives

  • Review Infrahyoid Neck Anatomy

    • Deep Spaces

    • Nodal Stations

  • Cases, Cases, Cases

    • Tackle challenging cases

    • Develop an appropriate differential diagnosis

    • Identify useful discriminators

  • Multiple choice questions


Anatomy

Anatomy


Anatomic spaces of infrahyoid neck

Anatomic Spaces of Infrahyoid Neck

Visceral Space

Carotid

Space

Retropharyngeal

Space

Perivertebral

Space

Posterior

Cervical Space


Infrahyoid lymph node stations

Infrahyoid Lymph Node Stations


Cases

Cases


Case 1

Case 1

  • 65 year-old woman with neck pain, palpable lump


Differential diagnosis

Differential Diagnosis

Differentiated Thyroid Ca

Medullary Thyroid Ca

Anaplastic Thyroid Ca

Thyroid NHL

Multinodular Goiter


Most likely diagnosis

Most Likely Diagnosis

Differentiated Thyroid Ca (DTCa)

Age & Sex

Ill-defined

Infiltrating, invasive

Mixed solid/cystic

Intra-thyroidal

Calcs

Intra-thyroidal

Intra-nodal

Adenopathy

Some solid

Some cystic

Punctate calcs


Question 1

Question 1

  • Which of the following is a TRUE statement?

    • A. Follicular is the most common subtype of DTCa

    • B. Hematogenous spread is more commonly associated with Papillary carcinoma

    • C. The peak incidence of DTCa is seen in women in the third or fourth decade

    • D. Rising free T4 is a clinical marker for disease recurrence


Question 11

Question 1

  • Which of the following is a TRUE statement?

    • A. Follicular is the most common subtype of DTCa

    • B. Hematogenous spread is more commonly associated with Papillary carcinoma

    • C. The peak incidence of DTCa is seen in women in the third or fourth decade

    • D. Rising free T4 is a clinical marker for disease recurrence


Dtca companion cases

DTCa Companion Cases


1 75 year old woman neck lump

1) 75 year-old-woman, neck lump


2 48 year old woman enlarging mass

2) 48 year-old-woman, enlarging mass


3 nodal manifestations of dtca

3) Nodal Manifestations of DTCa


4 30 year old woman adenoma

4) 30 year-old-woman, adenoma

Magnified Cor CECT of LN


Case 2

Case 2

  • 55 year-old-woman with right neck mass, cough


Differential diagnosis1

Differential Diagnosis

H&N SCCa Metastatic Nodes

Systemic Nodal Metastases

Thyroid Ca Metastatic Nodes

HL or NHL Nodes

Granulomatous Lymph Nodes

Reactive Adenopathy


Most likely diagnosis1

Most LikelyDiagnosis

Systemic Nodal Mets

Infrahyoid (level IV) location

H&N primary SCCa more commonly levels II & III

Non-calcified

Sarcoid, DTCa often Ca++

Central low-density/necrosis

HL, NHL, & reactive nodes usually solid, but can be low-density


Use everything at your disposal

Use Everything at Your Disposal

“I’ll tell you right now – that ain’t normal.”

-- Rick Wiggins


Question 2

Question 2

  • Which of the following is MOST suggestive of systemic nodal metastases in the neck?

    • A. Enlarged suprahyoid (level I or II) node

    • B. Enlarged left supraclavicular lymph node

    • C. Centrally necrotic lymph node

    • D. Calcification within an enlarged cervical node


Question 21

Question 2

  • Which of the following is MOST suggestive of systemic nodal metastases in the neck?

    • A. Enlarged suprahyoid (level I or II) node

    • B. Enlarged left supraclavicular lymph node

    • C. Centrally necrotic lymph node

    • D. Calcification within an enlarged cervical node


Companion case

Companion Case


25 year old man with neck mass

25-year-old man with neck mass


Hl with signal node

HL with“Signal” Node

AKA Virchow node

Isolated left supraclavicular adenopathy look to the chest & abdomen for primary

Most HL patients present with neck nodes

Concurrent mediastinal nodes common

Rarely extranodal H&N disease

M > F

Peak incidence in mid-20s


Question 3

Question 3

  • Which of the following is a TRUE statement?

    • A. HL is more common than NHL

    • B. Extranodal disease favors HL over NHL

    • C. Imaging can reliably differentiate NHL from HL

    • D. HL has an earlier peak incidence than NHL


Question 31

Question 3

  • Which of the following is a TRUE statement?

    • A. HL is more common than NHL

    • B. Extranodal disease favors HL over NHL

    • C. Imaging can reliably differentiate NHL from HL

    • D. HL has an earlier peak incidence than NHL


Case 4

Case 4

  • 55-year-old woman with known thyroid nodules, reportedly benign – surveillance US


Case studies in infrahyoid neck

Longitudinal

Transverse

Power Doppler


Case studies in infrahyoid neck

Prior biopsy reported benign


Differential diagnosis2

Differential Diagnosis

Congenital lesion

Lymphatic malformation

Venolymphatic malformation

Venous malformation

3rdBranchial cleft cyst

Neurofibroma

Schwannoma

Malignant Lymph node

Carotid artery Pseudoaneurysm


Most likely diagnosis2

Most LikelyDiagnosis

Congenital lesion

Lymphatic malformation

Benign, circumscribed

No flow on US

Demonstrably separate from IJV and CCA

Venolymphatic malformation

Possible, but would have essentially no venous component

Why not a NST?


Carotid space nerve sheath tumor

Carotid Space Nerve Sheath Tumor

Pros

Cons

Echogenicity

Lack of vascularity

  • Location

  • Size

  • Morphology

  • Low Density

Image c/o Lauren Ladd, M.D.


Question 4

Question 4

  • Which of the following is a FALSE statement?

    • A. Most lymphatic malformations are diagnosed before age 2

    • B. Lymphatic malformations can be acquired

    • C. Lymphatic malformations have no malignant potential

    • D. Microcystic lymphatic malformations are less likely to recur than macrocysticmalformations


Question 41

Question 4

  • Which of the following is a FALSE statement?

    • A. Most lymphatic malformations are diagnosed before age 2

    • B. Lymphatic malformations can be acquired

    • C. Lymphatic malformations have no malignant potential

    • D. Microcystic lymphatic malformations are less likely to recur than macrocysticmalformations


Case 5

Case 5

  • 25-year-old man with enlarging neck mass, recent URI


Same patient 3 days prior

Same patient, 3 days prior


Differential diagnosis3

Differential Diagnosis

Thyroglossal Duct Cyst

Lymphatic Malformation

Mixed Laryngocele

Necrotic Lymph Node

Abscess

Thyroid Ca


Most likely diagnosis3

Most Likely Diagnosis

Infected Thyroglossal Duct Cystwith associated FOM Abscess

Classic history

Midline/paramidline infrahyoid

Wall enhancement  infected

Round or ovoid

Cyst

No calcs or solid component


Thyroglossal duct cyst key points

Thyroglossal Duct CystKey Points

Cystic remnant of TGD

Lesion of the young

Location

20-25% = Suprahyoid

50% = Hyoid

25% = Infrahyoid

Infrahyoid typically embedded in strap muscles  “claw” sign

Wall enhancement if infected

< 1% will develop Thyroid Ca


Question 5

Question 5

  • Which of the following is a TRUE statement?

    • A. Thyroglossal duct cyst is the most common congenital neck mass

    • B. Thyroglossal duct cysts are always midline structures

    • C. The most common malignancy to develop in a thyroglossal duct cyst is medullary thyroid Ca

    • D. Treatment of thyroglossal duct cyst is typically needle aspiration


Question 51

Question 5

  • Which of the following is a TRUE statement?

    • A. Thyroglossal duct cyst is the most common congenital neck mass

    • B. Thyroglossal duct cysts are always midline structures

    • C. The most common malignancy to develop in a thyroglossal duct cyst is medullary thyroid Ca

    • D. Treatment of thyroglossal duct cyst is typically needle aspiration


Tgd cyst companion cases

TGD Cyst Companion Cases


1 50 year old man with neck mass

1) 50-year-old man with neck mass

TGD Cyst. High density = heme, protein.


2 young girl dysphagia

2) Young girl, dysphagia

TGD Cyst. Suprahyoid/BOT.


3 enlarging neck mass

3) Enlarging neck mass

TGD Cyst Thyroid Ca. Enhancing nodule. Coarse calc. Nodal Met.


4 ectopic thyroid

4) Ectopic Thyroid


Case 6

Case 6

  • 31-year-old woman with difficult intubation during elective surgery


Case studies in infrahyoid neck

“I’ll tell you right now – that ain’t normal.”

-- Rick Wiggins


Case studies in infrahyoid neck

Ax T1WI +C FS

Ax T1WI +C FS

Cor T1WI +C FS

Ax T2WI FS

Ax T2WI FS


Differential diagnosis4

Differential Diagnosis

NF1

NF2

Schwannomatosis

Laryngeal SCCa with Mets

Chondrosarcoma with Mets


Case studies in infrahyoid neck

Ax T2WI FS

Ax T1WI +C FS


Most likely diagnosis4

Most Likely Diagnosis

Schwannomatosis

Morphology & Margins

SCCa infiltrative/invasive

Distribution

CS + Brachial plexus  NST

NORMAL IACs

NF2 less likely

Age

NF1 = 1st decade

NF2 = 2nd decade

Schwannomatosis = 3-4th decades

No matrix calcification

MR signal  NST


Question 6

Question 6

  • Which of the following is a TRUE statement?

    • A. Schwannomas grow centrally within an involved nerve

    • B. Schwannomatosis patients demonstrate a normal life expectancy

    • C. Schwannomasarise from pericytes in the nerve sheath

    • D. Schwannomatosis is more common than NF1


Question 61

Question 6

  • Which of the following is a TRUE statement?

    • A. Schwannomas grow centrally within an involved nerve

    • B. Schwannomatosis patients demonstrate a normal life expectancy

    • C. Schwannomasarise from pericytes in the nerve sheath

    • D. Schwannomatosis is more common than NF1


Schwannomatosis key points

Schwannomatosis Key Points

  • Multiple nonintradermalschwannomas WITHOUT vestibular nerve involvement

  • Separate disease entity from NF2

    • Different gene mutation

      • SMARCB1 vs. NF2

    • Later onset

      • 4th decade vs. 2nd decade

    • Normal life expectancy (unlike NF2)

    • Pain >> neurologic deficits (unlike NF2)

  • Similar incidence to NF2 (~ 1/40,000)


Infrahyoid neck conclusion

Infrahyoid Neck Conclusion

  • Several deep spaces & nodal stations

    • Wide variety of pathology

  • Look for useful discriminators:

    • Age

    • History

    • Deep space of origin


Thanks

Thanks

[email protected]


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