Cystic Neck Mass in A Child
Bernadette L. Koch, MD
DIFFERENTIAL DIAGNOSIS
Common
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Suppurative Lymph Nodes
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Abscess
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Thyroglossal Duct Cyst
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Lymphatic Malformation
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Ranula
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2nd Branchial Cleft Cyst
Less Common
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1st Branchial Cleft Cyst
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Thymic Cyst
Rare but Important
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Dermoid and Epidermoid
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Teratoma
ESSENTIAL INFORMATION
Helpful Clues for Common Diagnoses
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Suppurative Lymph Nodes
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Key facts
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Pus in lymph node = intranodal abscess
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Imaging
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Thick enhancing nodal walls with central hypodensity
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Edema in surrounding fat (cellulitis)
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± thickening of muscles (myositis)
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Associated nonsuppurative adenopathy
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Nontuberculous mycobacterial adenitis lacks surrounding inflammatory changes
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Abscess
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Key facts
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Superficial abscesses: Anterior or posterior cervical or submandibular space
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If anterior to left thyroid lobe, think 4th branchial apparatus anomaly
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Exclude dental infection and salivary gland calculus as cause of H&N infection
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Imaging
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Wide prevertebral soft tissue = cellulitis and edema ± frank abscess
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False-positive in children if neck not in extended position
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Rim-enhancing mass with low-attenuation center; majority drainable pus, up to 25% may be phlegmon without drainable pus
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Edema in surrounding fat (cellulitis), ± thickening of muscles (myositis), occasionally air in abscess cavity
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Thyroglossal Duct Cyst
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Key facts
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Remnant of thyroglossal duct, anywhere from foramen cecum at base of tongue to thyroid bed in infrahyoid neck
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Treatment = resect cyst, tract, and midline hyoid bone (Sistrunk procedure)
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Imaging
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Cyst with minimal rim enhancement
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At hyoid > suprahyoid = infrahyoid
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Most in suprahyoid neck are midline; may be paramidline in infrahyoid neck
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Infrahyoid embedded in strap muscles
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May contain hyperechoic debris without hemorrhage or infection
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Increased enhancement and surrounding inflammatory change when infected
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± nodularity or calcifications if associated thyroid carcinoma (adults)
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Lymphatic Malformation
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Key facts
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Congenital vascular malformation
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Variably sized lymphatic channels
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Present at birth
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Grows with child
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Imaging
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Unilocular or multilocular; macrocystic or microcystic
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1 space or trans-spatial
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Only septations enhance, unless associated with venous malformation
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Lack high-flow vessels on flow sensitive MR sequences and angiography
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Fluid-fluid levels
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Ranula
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2nd Branchial Cleft Cyst
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Key facts
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Characteristic location = at or inferior to angle of mandible, posterolateral to submandibular gland, lateral to carotid space, and anteromedial to sternocleidomastoid muscle (SCM)
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Uncommon locations = parapharyngeal space, beaking in between internal and external carotid artery, anterior surface of infrahyoid carotid space
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Imaging
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Well-defined unilocular cyst in typical location
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No significant contrast enhancement unless infected
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Helpful Clues for Less Common Diagnoses
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1st Branchial Cleft Cyst
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Key facts
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Remnant of 1st branchial apparatus
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In or superficial to parotid gland, around pinna or external auditory canal
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May extend to angle of mandible
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Proximity to facial nerve important for surgical planning
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Imaging
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Well-defined nonenhancing cyst; contrast-enhancing wall with surrounding inflammation if infected
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Thymic Cyst
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Key facts
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Remnant of thymopharyngeal duct
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3rd branchial pouch remnant
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Wall contains Hassall corpuscles
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Imaging
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Cystic neck mass along course of thymopharyngeal duct
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± solid enhancing thymic tissue
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Closely associated with carotid sheath
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May be connected to mediastinal thymus
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Rarely ruptures into parapharyngeal space
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Helpful Clues for Rare Diagnoses

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