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Pediatric Facial Masses: A Guide to Radiologic Diagnosis
eEdE-130 Pediatric Facial Masses: A Guide to Radiologic Diagnosis Matthew Neimark Judah Burns Jacqueline Bello Keivan Shifteh Albert Einstein College of Medicine Montefiore Medical Center
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Disclosures None
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Purpose To guide the differentiation of facial masses in children based on clinical characteristics and anatomical location To describe the use of imaging modalities most useful in differentiating facial masses: computed tomography (CT) and magnetic resonance (MR) To provide pictorial review of the differential diagnosis of facial masses in children.
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Approach Useful Clinical Differential of Pediatric Facial Masses
Acute, with inflammation and/or infection Nonprogressive Slowly Progressive Rapidly Progressive/Malignant From Khanna et al.
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Findings Acute, with inflammation and/or infection Lymphadenitis
Sinusitis with Sub periosteal Abscess Masticator Space Abscess Osteomyelitis of the Mandible Sialadenitis
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Lymphadenitis Usually secondary to upper respiratory viral illnesses
Can occur wherever there are normal lymph nodes Submental Submandibular Parotid Obtain CT if there is concern for Abscess Lymphadenitis secondary to upper respiratory infection
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Lymphadenitis Lymphadenitis secondary to odontogenic infection
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Sinusitis with Sub periosteal Abscess
Frontal Sinus – Pott’s Puffy Tumor Ethmoid Sinus – Orbital Cellulitis, Abscess Risk for Superior orbital vein thrombosis Cavernous sinus thrombosis Intracranial abscess/meningitis Maxillary Sinus – Orbital Cellulitis, Abscess (rare) CT Usually Sufficient Pott’s Puffy Tumor
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Masticator Space Abscess
Masticator Space Includes: Muscles of mastication Ramus and body of mandible Inferior alveolar artery, vein, and nerve Mandibular Nerve Abscess is associated with Dental Procedures Mandibular Osteomyelitis CT usually sufficient
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Masticator Space Abscess
Abscess involving temporalis muscle (MR) – Patient with chronic osteitis of the mandible
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Masticator Space Abscess
Infection spreading to skull base (CT) – Patient with chronic osteitis of the mandible
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Osteomyelitis of the Mandible
Associated with Dental Procedures Injury CT for visualization of osseous changes MR for bone marrow replacement Differential Diagnosis SAPHO Syndrome Synovitis Acne Pustulosis Hyperostosis Osteitis
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Sialadenitis Locations Look for associated abscess
Submandibular Gland Associated with stone obstructing duct Parotid Gland Sublingual Gland Look for associated abscess CT usually sufficient for acute disease can assess for possible obstructing stone MR may be able to help assess for chronic cases Fibrous vs. Fatty gland Chronic forms often associated with granulomatous infection Mycobacterium Avium
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Findings Nonprogressive Mucocele Nasal Dermoid/Epidermoid
Dacrocystocele First Branchial Cleft Cyst
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Mucocele Most Common in Frontal and Ethmoid Sinuses
Can cause bony expansion and thinning of bony sinus wall CT can assess for bony changes MR for assessment of contents, differential, etiology Elevated protein content associated with increased T1 Fungal sinusitis associated with decreased T2 Evaluate intracranial involvement Rule out obstructing mass
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Nasal Dermoid/Epidermoid
Congenital cystic midline lesions overlying the nose or nasal bridge In addition to glabellar swelling, patients can present with hypertelorism CT can assess for bone defects MR assess for association with intracranial contents demonstrate sinus tract with greater sensitivity differentiate epidermoid from dermoid DWI+ implies epidermoid
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Dacrocystocele Congenital cystic lesions near the inferomedial canthus, bluish color Secondary to obstruction of lacrimal duct CT usually sufficient May be diagnosed in utero by ultrasound Often resolve during infancy May become infected
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First Branchial Cleft Cyst
Type 1 – Periauricular Type 2 - Intraparotid May become infected CT or MR may be performed MR preferable for small cysts and for possible sinus tract
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Findings Slowly Progressive Plexiform Neurofibroma
Infantile Hemangioma Lymphangioma Plunging Ranula Fibrous Dysplasia Aneurysmal Bone Cyst
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Plexiform Neurofibroma
Associated with neurofibromatosis type I Most common in first division of trigeminal nerve Associated with sphenoid wing dysplasia widening of skull base foramina CT demonstrates infiltrative mass demonstration of bony changes MR necessary for full characterization of lesion Plexiform Neurofibroma With Sphenoid Wing Dysplasia See widening of pterygopalatine fossa
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Infantile Hemangioma Low flow vascular malformation
Five times more common in girls Characterized by rapid growth during infancy, and then spontaneous regression Locations Parotid Facial/Malar Soft Tissues Orbit MR generally preferable to CT Association with PHACES syndrome P - Posterior Fossa H - Hemangioma A - Arterial abnormalities of head and neck C - Cardiac abnormalities and coarctation of aorta E - Eye abnormalities S - Sternal Defects MR Tricks
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Infantile Hemangioma Low flow vascular malformation
Five times more common in girls Characterized by rapid growth during infancy, and then spontaneous regression Locations Parotid Facial/Malar Soft Tissues Orbit MR generally preferable to CT Association with PHACES syndrome P - Posterior Fossa H - Hemangioma A - Arterial abnormalities of head and neck C - Cardiac abnormalities and coarctation of aorta E - Eye abnormalities S - Sternal Defects
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InfantileHemangioma
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Lymphangioma Can occur in virtually and space in head and neck
Most commonly seen in Masticator space Submandibular space Parotid space Multiloculated mass, fluid/fluid levels Characterized by spontaneous hemorrhage Best evaluated with MR Fluid-Fluid levels Hemorrhagic products
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Plunging Ranula Ranula Plunging ranula
pseudocyst secondary to ruptured sublingual gland retention cyst Plunging ranula pseudocyst ruptures into submandibular space Can extend into parapharyngeal space in ~10% May become infected Ultrasound usually initial imaging modality MR used to evaluate extent of large lesions
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Fibrous Dysplasia Expansion of medullary bone with preservation of cortex Can affect calvarium and facial bones Associated with hereditary syndromes Cherubism McCune-Albright Syndrome Characteristic Ground-glass appearance
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Fibrous Dysplasia (cont)
MR Low signal on T1 and T2 Post contrast enhancement Facial Appearances Leontiasis Ossea – Characteristic expansion of malar bone with feline appearance Cherubism – Hereditary fibrous dysplasia of the mandible
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Aneurysmal Bone Cyst Expansile, multiloculated lesion of bone
Characterized by fluid-fluid levels Most common in ramus of mandible CT for demonstration of bone features of lesion MR for characterization of cyst contents, fluid-fluid levels
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Findings Rapidly Progressive/Malignant Rhabdomyosarcoma
Langerhans Cell Histiocytosis Osteosarcoma Lymphoma Neuroblastoma Metastasis Juvenile Cemento-ossifying Fibroma
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Rhabdomysarcoma Tumor of striated muscle
Most common soft tissue sarcoma in pediatric group Most common solid head/neck malignancy Rarely can be congenital Locations Orbital Parameningeal (middle ear, paranasal sinus, nasopharyngeal, masticator space, parapharyngeal space, pterygopalatine fossa) Other locations in head and neck
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Rhabdomysarcoma CT for evaluation of bony involvement
MR for evaluation of soft tissue extent 55% of parameningeal rhabdomyosarcomas have intracranial extent
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Langerhans Cell Histiocytosis
Syndrome of histiocytic proliferation Soft tissue lesion, most commonly arising from the medulla of bone in the calvarium and head Common in the orbit Mandible and Maxillary lesions may also occur CT for bony extent of lesion (will show sharp “beveled” margins) MR for soft tissue extent and intraorbital, intracranial evaluation
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Osteosarcoma Bone based tumor with Locations
Soft tissue component Osteoid matrix Periosteal reaction Locations Mandible Maxilla Skull Base Can be seen in patients treated by radiation therapy for retinoblastoma CT Determine bony extent of tumor Determine soft tissue extent of tumor, structures involved
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Lymphoma Nodal Tissues Non-nodal CT MR Submandibular Submental Parotid
Virtually any area in the face including Orbit Muscles of mastication Parotid gland Lacrimal Gland CT Enlarged lymph nodes for nodal disease Infiltrative mass for non-nodal disease MR Determine extent of disease including perineural spread
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Neuroblastoma Metastasis
Location Calvarium Facial Bones Tendency to deposit in skeletal sutures Aggressive periosteal reaction Indium-111 MIBG most specific imaging test CT to demonstrate bony destruction and periosteal reaction MR to evaluate extend of disease in head and neck, possible nodal involvement
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Cemento-Ossifying Fibroma
Occurs in the mandible Juvenile form differs from adult in that it is locally aggressive with high potential of recurrence Imaging appearance similar to fibrous dysplasia
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Summary Acute, with inflammation and/or infection Nonprogressive
Lymphadenitis Sinusitis with Sub periosteal Abscess Masticator Space Abscess Osteomyelitis of the Mandible Sialadenitis Nonprogressive Mucocele Nasal Dermoid/Epidermoid Dacrocystocele First Branchial Cleft Cyst Slowly Progressive Plexiform Neurofibroma Infantile Hemangioma Lymphangioma Plunging Ranula Fibrous Dysplasia Aneurysmal Bone Cyst Rapidly Progressive/Malignant Rhabdomyosarcoma Langerhans Cell Histiocytosis Osteosarcoma Lymphoma Neuroblastoma Metastasis Juvenile Cemento-ossifying Fibroma
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References Hunter DW, L'Heureux PR, Latchaw RE. Malignant facial tumors in children: radiologic evaluation. Stressing value of conventional and computerized tomography. Pediatr Radiol 1980;10:2-8 Orvidas LJ, Kasperbauer JL, Lewis JE, et al. Pediatric parotid masses. Arch Otolaryngol Head Neck Surg 2000;126: Khanna G, Sato Y, Smith RJ, et al. Causes of facial swelling in pediatric patients: correlation of clinical and radiologic findings. Radiographics 2006;26: du Toit J, Wieselthaler N. Let's face it - 13 unusual causes of facial masses in children. Insights Imaging 2015;6:
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