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Case Studies in Infrahyoid Neck
Nicholas A. Koontz, M.D.Neuroradiology Fellow, University of Utah
Financial Disclosures
But first…
• Please direct your smart phone, tablet, or laptop’s browser to:
Objectives
• Review Infrahyoid Neck Anatomy– Deep Spaces– Nodal Stations
• Cases, Cases, Cases– Tackle challenging cases– Develop an appropriate differential diagnosis– Identify useful discriminators
• Multiple choice questions
Anatomy
Anatomic Spaces of Infrahyoid Neck
Posterior Cervical Space
Visceral Space
Retropharyngeal Space
PerivertebralSpace
CarotidSpace
Infrahyoid Lymph Node Stations
Cases
Case 1
• 65 year-old woman with neck pain, palpable lump
Differential Diagnosis
• Differentiated Thyroid Ca
• Medullary Thyroid Ca
• Anaplastic Thyroid Ca
• Thyroid NHL
• Multinodular Goiter
Most Likely Diagnosis
• Differentiated Thyroid Ca (DTCa)• Age & Sex• Ill-defined• Infiltrating, invasive• Mixed solid/cystic• Intra-thyroidal• Calcs
• Intra-thyroidal• Intra-nodal
• Adenopathy• Some solid• Some cystic• Punctate calcs
Question 1
• Which of the following is a TRUE statement?– A. Follicular is the most common subtype of DTCa– B. Hematogenous spread is more commonly
associated with Papillary carcinoma– C. The peak incidence of DTCa is seen in women
in the third or fourth decade– D. Rising free T4 is a clinical marker for disease
recurrence
Question 1
• Which of the following is a TRUE statement?– A. Follicular is the most common subtype of DTCa– B. Hematogenous spread is more commonly
associated with Papillary carcinoma– C. The peak incidence of DTCa is seen in women
in the third or fourth decade– D. Rising free T4 is a clinical marker for disease
recurrence
DTCa Companion Cases
1) 75 year-old-woman, neck lump
2) 48 year-old-woman, enlarging mass
3) Nodal Manifestations of DTCa
4) 30 year-old-woman, adenoma
Magnified Cor CECT of LN
Case 2
• 55 year-old-woman with right neck mass, cough
Differential Diagnosis
• H&N SCCa Metastatic Nodes
• Systemic Nodal Metastases
• Thyroid Ca Metastatic Nodes
• HL or NHL Nodes
• Granulomatous Lymph Nodes
• Reactive Adenopathy
Most LikelyDiagnosis
• Systemic Nodal Mets• Infrahyoid (level IV) location
• H&N primary SCCa more commonly levels II & III
• Non-calcified• Sarcoid, DTCa often Ca++
• Central low-density/necrosis• HL, NHL, & reactive nodes usually
solid, but can be low-density
Use Everything at Your Disposal“I’ll tell you right now – that ain’t normal.”
-- Rick Wiggins
Question 2
• Which of the following is MOST suggestive of systemic nodal metastases in the neck?– A. Enlarged suprahyoid (level I or II) node– B. Enlarged left supraclavicular lymph node– C. Centrally necrotic lymph node– D. Calcification within an enlarged cervical node
Question 2
• Which of the following is MOST suggestive of systemic nodal metastases in the neck?– A. Enlarged suprahyoid (level I or II) node– B. Enlarged left supraclavicular lymph node– C. Centrally necrotic lymph node– D. Calcification within an enlarged cervical node
Companion Case
25-year-old man with neck mass
HL with“Signal” Node
• AKA Virchow node
• Isolated left supraclavicular adenopathy look to the chest & abdomen for primary
• Most HL patients present with neck nodes• Concurrent mediastinal nodes common• Rarely extranodal H&N disease
• M > F
• Peak incidence in mid-20s
Question 3
• Which of the following is a TRUE statement?– A. HL is more common than NHL– B. Extranodal disease favors HL over NHL– C. Imaging can reliably differentiate NHL from HL– D. HL has an earlier peak incidence than NHL
Question 3
• Which of the following is a TRUE statement?– A. HL is more common than NHL– B. Extranodal disease favors HL over NHL– C. Imaging can reliably differentiate NHL from HL– D. HL has an earlier peak incidence than NHL
Case 4
• 55-year-old woman with known thyroid nodules, reportedly benign – surveillance US
Longitudinal Transverse
Power Doppler
Prior biopsy reported benign
Differential Diagnosis
• Congenital lesion• Lymphatic malformation• Venolymphatic malformation• Venous malformation• 3rd Branchial cleft cyst
• Neurofibroma
• Schwannoma
• Malignant Lymph node
• Carotid artery Pseudoaneurysm
Most LikelyDiagnosis
• Congenital lesion• Lymphatic malformation
• Benign, circumscribed• No flow on US• Demonstrably separate
from IJV and CCA• Venolymphatic
malformation• Possible, but would have
essentially no venous component
• Why not a NST?
Carotid Space Nerve Sheath Tumor
Pros• Location• Size• Morphology• Low Density
Cons• Echogenicity• Lack of vascularity
Image c/o Lauren Ladd, M.D.
CS Nerve Sheath Tumor Comparison
CS Schwannoma CS Neurofibroma
Shape Fusiform Ovoid or fusiform (***unless plexiform)
Margins Circumscribed Circumscribed (***unless plexiform)
Size 2 - 8 cm 2 - 5 cm
M:F Male predominance Female Predominance
NECT Isodense to muscle Hypodense
CECT Uniform enhancement, rare low density Poorly enhancing
T1WI -C Variable, no flow voids Isointense to muscle
T1WI +C Marked uniform enhancement Homogeneous or patchy enhancement
T2WI Hyperintense to muscle, +/- intratumoral cysts Very hyperintense, "target sign"
Question 4
• Which of the following is a FALSE statement?– A. Most lymphatic malformations are diagnosed
before age 2– B. Lymphatic malformations can be acquired– C. Lymphatic malformations have no malignant
potential– D. Microcystic lymphatic malformations are less
likely to recur than macrocystic malformations
Question 4
• Which of the following is a FALSE statement?– A. Most lymphatic malformations are diagnosed
before age 2– B. Lymphatic malformations can be acquired– C. Lymphatic malformations have no malignant
potential– D. Microcystic lymphatic malformations are less
likely to recur than macrocystic malformations
Case 5
• 25-year-old man with enlarging neck mass, recent URI
Same patient, 3 days prior
Differential Diagnosis
• Thyroglossal Duct Cyst
• Lymphatic Malformation
• Mixed Laryngocele
• Necrotic Lymph Node
• Abscess
• Thyroid Ca
Most Likely Diagnosis
• Infected Thyroglossal Duct Cyst with associated FOM Abscess
• Classic history
• Midline/paramidline infrahyoid
• Wall enhancement infected
• Round or ovoid
• Cyst
• No calcs or solid component
Thyroglossal Duct CystKey Points
• Cystic remnant of TGD• Lesion of the young• Location
• 20-25% = Suprahyoid• 50% = Hyoid• 25% = Infrahyoid
• Infrahyoid typically embedded in strap muscles “claw” sign
• Wall enhancement if infected
• < 1% will develop Thyroid Ca
Question 5
• Which of the following is a TRUE statement?– A. Thyroglossal duct cyst is the most common
congenital neck mass– B. Thyroglossal duct cysts are always midline
structures– C. The most common malignancy to develop in a
thyroglossal duct cyst is medullary thyroid Ca– D. Treatment of thyroglossal duct cyst is typically
needle aspiration
Question 5
• Which of the following is a TRUE statement?– A. Thyroglossal duct cyst is the most common
congenital neck mass– B. Thyroglossal duct cysts are always midline
structures– C. The most common malignancy to develop in a
thyroglossal duct cyst is medullary thyroid Ca– D. Treatment of thyroglossal duct cyst is typically
needle aspiration
TGD Cyst Companion Cases
1) 50-year-old man with neck mass
TGD Cyst. High density = heme, protein.
2) Young girl, dysphagia
TGD Cyst. Suprahyoid/BOT.
3) Enlarging neck mass
TGD Cyst Thyroid Ca. Enhancing nodule. Coarse calc. Nodal Met.
4) Ectopic Thyroid
Case 6
• 31-year-old woman with difficult intubation during elective surgery
“I’ll tell you right now – that ain’t normal.”
-- Rick Wiggins
Ax T1WI +C FS Ax T1WI +C FS
Cor T1WI +C FS
Ax T2WI FS Ax T2WI FS
Differential Diagnosis
• NF1
• NF2
• Schwannomatosis
• Laryngeal SCCa with Mets
• Chondrosarcoma with Mets
Ax T1WI +C FSAx T2WI FS
Most Likely Diagnosis
• Schwannomatosis• Morphology & Margins
• SCCa infiltrative/invasive
• Distribution• CS + Brachial plexus NST• NORMAL IACs
• NF2 less likely• Age
• NF1 = 1st decade• NF2 = 2nd decade• Schwannomatosis = 3-4th decades
• No matrix calcification• MR signal NST
Question 6
• Which of the following is a TRUE statement?– A. Schwannomas grow centrally within an
involved nerve– B. Schwannomatosis patients demonstrate a
normal life expectancy– C. Schwannomas arise from pericytes in the nerve
sheath– D. Schwannomatosis is more common than NF1
Question 6
• Which of the following is a TRUE statement?– A. Schwannomas grow centrally within an
involved nerve– B. Schwannomatosis patients demonstrate a
normal life expectancy– C. Schwannomas arise from pericytes in the nerve
sheath– D. Schwannomatosis is more common than NF1
Schwannomatosis Key Points
• Multiple nonintradermal schwannomas WITHOUT vestibular nerve involvement
• Separate disease entity from NF2– Different gene mutation
• SMARCB1 vs. NF2
– Later onset• 4th decade vs. 2nd decade
– Normal life expectancy (unlike NF2)– Pain >> neurologic deficits (unlike NF2)
• Similar incidence to NF2 (~ 1/40,000)
Infrahyoid Neck Conclusion
• Several deep spaces & nodal stations– Wide variety of pathology
• Look for useful discriminators:– Age– History– Deep space of origin
Thanks