Radiological approach to neck mass Neck Imaging

1. By:-
Jwan Ali Ahmed AlSofi
Neck imaging

5. • Plain radiography:
• Conventional films can only be used for a preliminary evaluation especially of the
retropharyngeal space when there is a question of retropharyngeal phlegmon or abscess.
• ULTRASOUND: Ultrasound is useful in
1. differentiating solid from cystic neck lesions,
2. in recording the size of nodes (at least in upper neck)
3. in discriminating high-flow from low-flow vascular malformations
• Computed tomography (CT)
• gives a greatly improved soft tissue detail and air space delineation.
• The vascularity of the lesion as well as its relation to vascular structures can be determined.
• Entire extent of large masses can be assesed.
• CT angiography provides non invasive evaluation of vascular structures of the neck.
• CT/MRI are best indicated for deep or extensive lesions, where para and retropharyngeal spaces are
best suspected to be involved, and when ultrasonography is inconclusive.
• MPT
• MRI is good to excellent in detection of the lesion and extent of involvement of adjoining
structures.
• PET Scan or Combined PET-CT :
1. is excellent for staging and follow up of a malignant Neck mass and in Lymphoma
2. Is the investigation of choice for cases with malignant Lymph node of unknown primary (It
Can Easily detect Hidden Primary in the neck or elsewhere)
3. Differentiate between between benign and malignant masses in a patient with known
Cancer
• US-Guided FNA or Biopsy:
This is commonly used for evaluation of suspicious thyroid nodule , suspicious cervical LYMPH
NODES and for solid neck masses when malignancy is suspected based on CT or MRI.

7. How to approach a Patient
with Neck Mass
radiologically?
(What Radiological Test to
be Ordered and When??)

8. 1. For Pediatric Age Group:

10. Diagnostic approach
• In a neck lesion in a child, ultrasound can usually determine whether a lesion is
cystic or solid.
 Cyst
In cystic lesions the diagnosis can frequently be made based on the location of
the lesion.
 Lymph node
If the lesion is solid the next step is to assess whether it is a lymph node or
something else.
Often more than one lymph node is enlarged.
Try to differentiate between reactive nodes, lymphadenitis due to TB or cat-
scratch disease and malignant lymphoma.
 Solid - not a lymph node
If a solid lesion is not a lymph node look for a possible site of origin, like the
salivary gland, the thyroid gland or the sternocleidomastoid muscle.

11. Lymph Node
• reactive nodes
• lymphadenitis
• Malignant
Others

13. Posterior
acoustic
enhancement,
also known as
increased
through
transmission:-
tissue behind the
lesion appears more
hyperechoic
Indicates cyst

14. Posterior acoustic shadowing refers to a darkening of the ultrasound
image beneath a structure
Indicates Solid lesion

16. 2.For Adult Age group:

17. • The initial diagnostic test of choice in an adult with a persistent
neck mass is contrast-enhanced CT(CECT) which provides
valuable initial information regarding the size, extent, location,
and content or consistency of the mass.
• Additionally, contrast media may help identify malignant lymph nodes
that are not enlarged and distinguish vessels from lymph nodes.
• Iodine-based contrast media should be avoided in patients with a
history of thyroid disease or when metastatic thyroid cancer is a
concern.
• Although positron emission tomography (PET) with CT can be used
to distinguish between malignant and unaffected tissues, its use in
the preliminary diagnosis is not as effective and should be limited to
definitive management of a malignancy.
• But remember US can still be used as an initial study for adult patient
patient specially if the primary aim is
• to know whether the lesion is cystic or Solid,
• to detect nodal size,
• differentiate high-flow from low-flow vascular lesion.
• Ultrasonography, It may also be preferred to avoid contrast media–
induced nephropathy in patients with underlying renal disease.

19. • Contrast enhanced MRI imaging
• defines soft tissues more clearly than CT ,
• permitting assessment of margins and perineural spread.
• This can aid assessment of operability or radiotherapy
planning of the primary site.
• MRI does not expose patients to ionising radiation, is less
affected by dental amalgam, but can be subject to
movement artefact in the larynx and tongue.
• MRI is a useful adjunct to computed tomography in
detecting and, more importantly, staging the primary tumour.
• Disadvantages MRI : It has NO advantage over US or CT for
assessing nodal disease . Contrast material should be
administered with caution in patients with severe renal
impairment. Claustrophobia, difficulty lying flat, and the long
scan time makes MRI impossible for some patients. The
presence of non-MRI compatible metalwork and pacemakers is
an absolute contraindication.

22. After a neck mass is observed , the 1st thing we have
to know is whether the lesion is benign or malignant ,
if the lesion is cyst then it is very unlikely to be
malignant ,
while if the lesion is solid then it is mostly malignant is
adult specially those above above 40yr of age, while
most of the solid neck masses in children are still
benign .
As stated previously , US is very useful for making the
diagnosis of cystic vs. Solid masses.
After a lesion is proved cystic , then the differential
diagnosis would be according to the location.

23. Location of cysticlesions
• Once you have decided that the lesion is cystic its location will
often point to its nature .
Midline lesions
o Midline lesions are either thyroglossal duct cysts, dermoid
cysts or ranulas.
o Older children can be asked to protrude their tongue.
 A thyroglossal duct cyst will move upward with the hyoid
bone.
 Ranulas have a typical location in the floor of the mouth.
Off-midline lesions
o Off-midline lesions can be branchial cleft cysts or
lymphangiomas.
o Branchial cleft cysts often contain debris.
o Anteriorly located lymphangiomas are often multicystic.
o In the posterior neck they are often single.

25. Location US appearance
Thyroglossal
duct cyst
Midline of neck - hypo-echoic and may
contain internal echoes
- In fornt of the trachea
Branchial cyst - Anterior to SCM
- Superficial to bifurcation
of ICA
- Anechoic / sometimes
internal echoes
- Post acoustic enhancement
Dermoid cyst Suprasternal notch oval lesion With
homogeneous hyper-echoic
contents
Post acoustic enhancement
Ranula • Floor of the mouth
• It can also extend through
or over mylohyoid muscle
and is then called
"plunging ranula" and
present as a submental
submandibular mass
- Anechoic
- Post acoustic enhancement
- continuous with the
sublingual salivary

26. Lymphanagioma
• Remember that Lymphnagioma could be multicompartmental and
multispaceous ,then US will not be able to determine the exact
extension of the lesion specially to the chest which is an important
consideration for surgical resection, then CT or MRI would be of help to
know the extension of a large lesion.
• Below is an eg. of a child with a large neck mass, US features suggested
Lymphangioma but the extent was not possible to be assumed on US,
MRI was helpful to delineate the extent.
Look how MRI
proved the
mediastinal and
intrathoracic
extension of the
Cystic Hygroma
and its relation
to the vessels .

27. Thyroglossal duct cyst
• Thyroglossal duct cysts are common lesions in children.
• The thyroglossal duct runs from the base of tongue at the foramen
caecum to the thyroid gland.
• The embryonic thyroid gland travels through the duct to reach its final
normal position.
• Normally, the thyroglossal duct then involutes, but when the duct
persists, a thyroglossal duct cyst can develop anywhere along this tract .
• Thyroglossal duct cysts move upward if the tongue is protruded or
during swallowing
• Ultrasound is usually sufficient to make the diagnosis.
• Always look for the presence of a normal thyroid gland and make
an image of it.

29. • Thyroglossal duct cysts can be anechoic orhypo-
echoic with internal echoes, due to infection,
hemorrhage, or proteinaceouscontent.
• The majority of thyroglossal duct cysts is located
within 2 cm of the midline.
• Here a tranverse image of a hypoechoicthyroglossal duct
cyst with some internal echoes located in the midline.

30. Here a tranverse image of an anechoic
thyroglossal duct cyst just left of the midline.

33. Dermoid cyst
• Dermoid cysts are inclusion cysts, that contain
epithelium and skin adnexa like hair follicles, sebaceous
glands and sweatglands.
• 7% of dermoid cysts occur in the head and neck region,
especially around the orbit and in the midline of the neck
with a predilection for the suprasternal notch.
• The content of
 Thyroglossal duct cysts is usually hypo-echoic and
may contain internal echoes,
 while dermoid cysts generally have a more
homogeneous hyper-echoic content.

35. • Here a typical homogeneous hyper-echoic ovallesion,
representing a dermoid cyst, which was located in its
favorite location, the suprasternalnotch.

36. Branchial cleft cyst
• Most branchial cysts are remnants of the second brancial cleft.
• Cysts at the level of the thyroid gland can be remnants of the third
or fourth branchial cleft.
• Incomplete obliteration results in either a cyst (75%), a sinus or a
fistula (25%).
• Cysts present as painless masses, sometimes appearing suddenly after
internal hemorrhage.
• They are located along the anterior border of the
sternocleidomastoid muscle, lateral to the common carotid
artery, and if more cranially between the internal and external
carotid artery.
• Sometimes a beak sign may be seen as a curved rim of the lesion
pointing medially between the internal and external carotid.

39. On ultrasound
• they often contains internal echoes caused by debris,
which consists of cholesterol crystals.
• The cyst is usually compressible, which results in
movement of the content.  This may not be the case
in a cyst with a fresh internal hemorrhage.
• They can inflame and present with an empyema.

40. Here another
branchial cyst
with atypical
location
superficial to
the carotid
artery
bifurcation.

42. Ranula
• A ranula is a fluid filled
cyst originating from the
sublingualsalivary
• It can extend into the
floor of the mouth and be
visible on inspection of
the oral cavity.
• It can also extend through
or over mylohyoid
muscle and is then called
"plunging ranula" and
present as asubmental
submandibular mass.
• Here an image of a sixteen-
year-old with a firm
swelling under the tongue
the left side.
• Ultrasound showed an
anechoic continuous with
the sublingual salivary

44. Solid Neck Masses
Once a neck mass is turned to be not cystic
(i.e SOLID) , then the next step is to know
whether this SOLID MASS is LYMPH NODES or
NOT
if it is LYMPH NODES whether it is BENIGN or
MALIGNANT.
US is again very helpful to decide whether such
solid lesion is lymph nodes or not and whether it
has benign or malignant features.

45. Solid lesions - Lymphnodes

46. This image shows a commonly used
classification for the location of lymph
nodes.
1.Level 1
Submental and submandibular
nodes
2.Level 2
Nodes along the internal jugular
vein, above the level of the hyoid
bone
3.Level 3
Nodes along the internal jugular
vein, between the hyoid bone and
cricoid cartilage
4.Level 4
Nodes along the internal jugular
vein, below the cricoid cartilage
5.Level 5
Posterior to the sternocleidomastoid
muscle, above the clavicles
6.Level 6
Anterior to the thyroid gland

47. LN appearance on US:-
Normal lymph nodes are always visible
with ultrasound in children.
A normal lymph node:
1. Is sharply delineated
2. Is oval
3. Has an echogenic center
4. Has a short axis < 10 mm.
The normal jugulodigastric node which is
located below the mandibular angle can
have a short axis of 15 mm.

50. • Enlarged lymph nodes in the neck are very common in children.
• In most cases these are reactive nodes as a reaction to a nearby infection.
• Less commonly it is due to a primary infection of the lymph nodes itself, which is
called lymphadenitis.
• Usually the terms reactive lymphadenopathy and lymphadenitis are used
synonymously.
• Although ultrasound cannot always reliably distinguish lymphadenitis from a
malignant lymphoma, the following table can be helpful to decide whether an
excision biopsy should be done or that a "wait and scan" policy can be adopted.
• Supraclavicular lymph nodes should always be considered to be malignant
until proven otherwise.

51. • Vascular Pattern:
 Normal and reactive lymph
nodes tend to have central
hilar vascular pattern.
 club- or Y-shaped and extended
from the extra-nodal area into
deep portion of the node.
 May be appear as apparently a-
vascular lesion.
 Metastatic and lympho-
matous nodes usually show
peripheral or mixed vascularity.
 The presence of peripheral
vascularity strongly suggesting
of a pathologic process.

54. • After a solid neck mass turned to be lymph
nodes with suspicious malignant features, the next
step is to confirm its malignant nature by either US or
sometimes CT guided FNA/Biopsy.
• If the malignant nature of the lymph nodes is
confirmed by Histopathology , the next step will be :
1. If the Lymph nodes turned to be lymphoma, then staging has to
be done with either CT scan or PET scan (PET is preferred over CT
both for staging and follow up, once it is available and the pt can
pay for it), US has limited role for staging and follow up .
2. If the lymph nodes turned to be cancerous (Metastatic ) , the next
step is to know its primary source by either CT scan, MRI or PET
scan. Most of the malignant cervical lymph nodes has a hidden
primary in the pharynx , but supraclavicular lymph nodes can be
from primary of Breast, Intra-abdominal (mainly pancreas and
stomach) and Chest (bronchogenic and esophagus ) .

55. Below is a case with malignant neck
lymph node, after investigation it
revealed to has a primary from
Tonsil .

56. - In many cases the imaging findings in a solid lesion will be non-specific
and a diagnosis can only be made through biopsy or excision.
- the solid neck is not lymph nodes , then it should be further
characterized for :
- possible site of origin (is it arising from vessels, nerve course ,muscles, bone ,
salivary glands... etc.) ,
- content (fat, hemorrhage, calcium, necrosis..etc ) ,
- vascularity ,
- extension ,
- invasion to any nearby structures ,
- mass effect on vital structure and compression on air way and food passage
as well as for complication .
- According to the analysis of the above features , a possible diagnosis
(provisional diagnosis ) or a narrow list of differential diagnosis can be
achieved .
- These questions could usually be answered by Contrast Enhanced CT
Scan +/- CT Angiography or by Contrast Enhanced MRI .
- If still the result was not conclusive , the next step would be FNA/Biopsy
of the lesion under US or CT guidance after excluding the vascular
nature of the lesion based on Imaging features .

57. Solid lesions - not lymph nodes

58. Thyroid nodules
• Thyroid nodules are common.
• They can be single or multiple.
• Some are purely cystic but most are solid.
• On ultrasound they are isoechoic with the normal
gland.
• In a goiter a multitude of solid nodules are seen.
• If there is concern about a possible malignancy fine
needle aspiration can bedone.

60. • This is an
ultrasound
image of a
six-year-old
girl with a
small cyst
with a septum
in the right
thyroid lobe.
It remained
unchanged
over a year.

61. Thyroiditis
• The most common forms of thyroiditis are Hashimoto's thyroiditis and
Graves disease.
• Both Hashimoto's thyreoiditis and Graves disease can present as an enlarged
and hyperemic thyroid.
• Hashimoto's thyroiditis or chronic lymphocytic thyroiditis:
 is an auto-immune disease.
 It presents with hypothyroidism.
 Although primarily a disease of the middle-aged it can present in
children.
 On ultrasound the gland is diffusely enlarged and inhomogeneous.
 In a later stage the gland shrinks.
 On color doppler the blood flow is often normal but can be increased
like in Graves' disease.

62. • In Graves disease the thyroid gland is also enlarged and
shows an increased perfusion.
• On color Doppler it has been described as an inferno in red
and blue.
• Here an image of a 16-year-old girl with hyperthreoidism.
A diffusely enlarged thyroid gland is seen with hyperemia.
The final diagnosis was Graves disease.
She was treated with I-131.

63. Venous malformation
Venous malformation
• A six-month-old boy presented
with a swelling in the left neck at
birth.
• Several ultrasound examinations
could not differentiate between a
hemangioma or a venous
malformation.
At six months of age, the
ultrasound showed a lesion,
which was mostly composed of
vessels which increased in size
on straining.
• On color Doppler the lesion
showed increased flow while
crying.
The final diagnosis on imaging
and on clinical examination was
a venous malformation.

64. Salivary glands
Enlargement of the salivary
glands can be diffuse or focal.
Diffuse swelling mostly affects
the parotid glands.
If it is bilateral it can be caused
by autoimmune diseases (like
Sjögren's disease) or infections(
HIV).
On ultrasound many small
hypoechoic lesions are present.
Unilateral swelling can be
caused by a bacterial parotitis.
Hemangioma is the most
common parotid gland tumor of
childhood, which involute inthe
course of a fewmonths.
Salivary glands
• Enlargement of the salivary
glands can be diffuse or focal.
• Diffuse swelling mostly affects
the parotid glands.
• If it is bilateral it can be caused
by autoimmune diseases (like
Sjögren's disease) or
infections (HIV).
• On ultrasound many small
hypoechoic lesions are present.
• Unilateral swelling can be
caused by a bacterial parotitis.
• Hemangioma is the most
common parotid gland tumor
of childhood, which involute in
the course of a few months.

68. • 90% OF ADULT NECK MASSESARE MALIGNANT.
• 90% OF PEDIATRIC NECK MASSES ARE
INFECTIOUS IN NATURE.
Some Pearls

69. Spaces of the infrahyoid neck
1.Visceral space
• Central compartment containing several viscera like the larynx,
thyroid, hypopharynx and cervical esophagus
2.Carotid space
• Paired space just lateral to the visceral compartment which contains the
internal carotid artery, internal jugular vein and several neural structures.
3.Retropharyngeal space
• A small virtual space containing only fat continuous with the suprahyoid
space and the middle mediastinum.
4.Posterior Cervical Space
• Paired space posterolateral to the carotid
space. It contains fat, lymph nodes and
neural elements.
5.Perivertebral space
• This large space completely encircles the vertebral body including the
pre- and paravertebral muscles.

70. Spaces of the infrahyoid neck

72. THANK YOUALL

73. • A 5 year old boy presents with a 2cm size oval shape mobile lump at the
midline of his neck above the level of the hyoid bone . Which initial
imaging modality is best to make the diagnosis ?
1. Plain Xray of Neck AP and Lateral
2. Ultrasound (US) of neck
3. Contrast Enhanced CT Neck
4. MRI NECK
• Contrast Enhanced CT scan is the primary investigation of Choices for
differentiating cystic from Solid Neck mass .
• True False
• Group 3 or Level 3 lymph nodes of the neck is the lymph nodes located
at:
1. Submandibular region
2. Submental region
3. Between Hyoid and Cricoid posterior to Sternocleidomastoid muscle
4. Between Hyoid and cricoid along the sternocleidomastoid muscle and
Internal Jugular vein(IJV)