Neck Mass



Neck Mass


Paula J. Woodward, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Cystic Hygroma


  • Nuchal Cord, Mimic


  • Occipital Encephalocele


Less Common



  • Cervical Teratoma


  • Goiter


  • Truncal Lymphangioma


Rare but Important



  • Iniencephaly


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Is the mass predominately cystic or solid?



    • Cystic favors cystic hygroma


    • Solid favors teratoma, goiter or encephalocele


  • Where is it located?



    • Posterior masses favor cystic hygroma and cephaloceles


    • Anterior masses favor teratoma or goiter


  • Always check the calvarium and spine



    • If intact, encephalocele and spinal defect excluded


  • Always use color Doppler



    • Rule out nuchal cord


    • Look for flow within mass


Helpful Clues for Common Diagnoses



  • Cystic Hygroma



    • Result of failed/delayed jugular venous-lymphatic connection



      • Creates a multiseptated nuchal fluid collection


    • Located in posterior subcutaneous tissues, frequently wrapping around laterally



      • May involve only one side of neck causing postural abnormality


    • May be massive and mimic amniotic fluid



      • Concern for airway obstruction at birth


    • Internal septations



      • Multiple, fine linear septations


      • Thick, midline septation is nuchal ligament


    • Nonimmune hydrops common with large hygromas


    • Small cystic hygromas can evolve into thick nuchal fold


    • Aneuploidy in 2/3 of fetuses with 2nd trimester cystic hygroma



      • Turner syndrome most common, especially for larger septated hygromas


      • Trisomy 21 next most common; smaller less complicated hygromas and nuchal skin thickening


    • Cardiovascular anomalies often present



      • Aortic arch defects most frequent, especially in Turner syndrome


  • Nuchal Cord, Mimic



    • Nuchal cord can be confused with cystic hygroma on grayscale images


    • Obvious flow with color Doppler


    • Cords with less vascular coiling are more pliable and more likely to wrap around neck


    • Longer cords also have increased incidence of nuchal wrapping


  • Occipital Encephalocele



    • Osseous defect should be demonstrated



      • Usually midline: Occipital


      • Lateral: Parietal, inferior temporal


      • May be difficult to see with small defect


    • Cephalocele



      • More generic term for herniation of intracranial contents


    • Encephalocele



      • Meninges & brain


      • Most common


    • Cranial meningocele



      • Meninges only


    • Chiari III



      • Hindbrain malformation


      • Cerebellum herniated into cephalocele


    • Diverse appearance of herniated neural tissue



      • Gyral pattern may be identified


      • Mixed cystic/solid mass


      • “Cyst within a cyst” or “target” sign suggests prolapsed 4th ventricle


      • In first trimester head may look small or irregular


    • Microcephaly in 25%


    • Other central nervous system anomalies common


    • Large occipital cephaloceles may also involve cervical spine


Helpful Clues for Less Common Diagnoses



  • Cervical Teratoma




    • Mixed cystic and solid mass involving anterior aspect of neck



      • Frequently extends to involve surrounding structures


    • Calcifications are virtually pathognomonic of teratoma


    • Head is often held in hyperextension or deviated to one side


    • Polyhydramnios from upper esophageal obstruction


    • Solid portions of mass often very vascular



      • Arteriovenous shunting may be present


      • Vascular shunting may result in hydrops


  • Goiter

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Aug 10, 2016 | Posted by in OBSTETRICS | Comments Off on Neck Mass

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