Neck spaces: Cases Dr Frans Naude

Lesotho patient presented with neck swelling for the last 26 years

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Iodine deficient regions Decrease thyroid hormone Increased TSH Goiter Risk of low iodine: increased breast cancer ( Japanese 6/ , USA 22/ ) Japanese iodine uptake x25 higher

Iodine deficiency is also associated with increased risk for thyroid carcinoma in animal models and humans. Iodine replacement increase risk ratio from papillary to follicular cancer (Altern Med Rev 2008;13(2): ) Ulla Feldt-Rasmussen. Thyroid. May 2001, 11(5):

Child with neck mass UM year old Presented with mass in the neck

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Another child with neck mass

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Cystic neck masses in child DIA H&N 5-13 Expert DDX 5-12

Lymphangioma Def: Uni/Multiloculated,non-enhancing cystic neck masses with imperceptible wall that insinuates between vessel and the normal neck structures Contiguous neck space involvement(trans- spatial) Synonyms = cystic hygroma/lymphatic malformation

Region Supra hyoid – submandibular and masticator spaces Infrahyoid – posterior cervical space Invaginates into normal structures with minimal mass effect/ multi or uni septated

CT Findings NECT: Low density, poorly circumscribed cystic neck mass Fluid –Fluid lesions in multiloculated lesions CECT No significant enhancement in mass or wall (complex lesions, veins may cause enhancement)

MRI T1 w: Primarily hypointense, may be hyperintense due to hemorrhage or protein rich fluid. Fluid –fluid levels often seen. T2-w: hyperintense throughout ( best sequence to map lesion) Trans-spatial extension/poorly marginated. T1+C: most often no enhancement. If enhancement present,most likely due to mixed vascular structures

U/S Confirm diagnosis Classify type ( macrocysitic/microcytic and mixed) ( microcytic with cyst <1cm ) Biom Imag Interv J 2011;7(3): e 18

Take home point Unilocular cervical lesion : thyroglossal cyst, branchial cleft cysts, thymic cyst ( lymphangioma = multilocular) Lymphangioma = trans spatial

Treatment Surgical Bleomycin sclerotherapy Biom Imag Interv J 2011;7(3): e 18

Expert DDX H&N 5-14

Cystic neck masses in adult DIA H&N 5-16

Adult with neck mass 53 yr Right neck mass

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Carotid body tumor Location : Mass in the center of the carotid bifurcation, splaying the ECA and ICA Avid enhancing mass DI H&N III 8 :21

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Patient with: Neuropathy of left cranial nerve 7-12 Tinnitus

pt w tinnitis

Glomus jugulare paraganglioma Clinical: Pulsatile tinnitus with vascular retrotympanic mass Neuropathy : Cranial nerve 9-12 (sometimes 7&8) Arises from margin of jugular foramen (neural crest cells surrounding the jugular foramen) Projects supero-laterally into middle ear cavity Permeative destructive bony changes on CT Vertical part of the posterior wall of ICA often involved

DDX: Jugular foramen schwanoma, meningioma, pseudolesion, metatases

Patient 5 Stridor, hoarseness, dyspnea Smoking history Right neck mass

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Squamous cancer Hypopharangeal SSCa Prognosis better :pyriforme sinus>posterior wall> post cricoid Moderately enhancing mass. Central- Necrotic lymphnode metastases

Suppurative lymph nodes

Patient 6 Smoker Right neck mass FNA ? Primary tumour

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Styloidogenic jugular venous compression syndrome Cause intracranial venous hypertension

Symptoms caused by an elongated styloid are rare but, when present, usually manifest as Eagle syndrome. classic form of Eagle syndrome is caused by various degrees of impingement on cranial nerves V, VII, IX, or X by the styloid process. second type of Eagle syndrome is related to carotid compression by an elongated styloid process

In this fast growing world there is not a lot of open spaces….so I better stop typing before this space turns into something

References Diagnostic imaging anatomy: head and neck Diagnostic imaging head and neck (Harnsberger) Ulla Feldt-Rasmussen. Thyroid. May 2001, 11(5): Expert DDX