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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

Case Studies in Infrahyoid Neck

Nicholas A. Koontz, M.D.

Neuroradiology Fellow, University of Utah



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



Anatomic spaces of infrahyoid neck
Anatomic Spaces of Infrahyoid Neck

Visceral Space

Carotid

Space

Retropharyngeal

Space

Perivertebral

Space

Posterior

Cervical Space




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






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




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


Longitudinal

Transverse

Power Doppler



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



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



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.



Case 6
Case 6

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


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

-- Rick Wiggins


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


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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