A Practical Approach to differential diagnosis. This presentation offers a practical approach in differential diagnosis in head and neck masses in children and it is based on the article by Dr. Bernadette L. Koch published on Statdx.com . Neck Masses need to be divided in Cystic and Solid and according the location.

1. A Practical Guide to the
Differential Diagnosis
felice.d’arco@gosh.nhs.uk

2. Summary
o Essential Anatomy of The Neck
 Superficial Fascia (subcutaneous Tissue)
 Neck Spaces (3 layers of the deep cervical
fascia)
o Features of the Lesion: Where? Cystic?
Solid?

3. Anatomy of the Neck
 Superficial Cervical Fascia: thin layer of
subcutaneous connective tissue that lies between
the dermis of the skin and the deep cervical fascia
 Contents: platysma, nerves, blood / lymphatic
vessels, fat.
 Pathology (related to the content!!):
Teratoma, Vasc. Malformations/neoplasm, Cellulitis,
Plexiform Neurofibromas (NF1), Subcutaneous Fat
Fibrosis (neonates)
NB: It is considered by some to be a part of the Panniculus adiposus, and
not true fascia. Bailey, B.J. Ed: Head and Neck Surgery-Otolaryngology 2006.

4. Superficial Cervical Fascia (yellow)
From internet
Subcutaneous fat
tissue between
the skin and the
superficial layer of
the deep cervical
fascia (green)
Superficial layer DCF
Skin

5. Anatomy of the Neck
 Deep Cervical Fascia (DCF): 3 layers 
superficial (SL), middle (ML) and deep (DL)
 The layers divide neck in compartments (on
the axial plane).
 Neck is also divided in Suprahyoid neck
(SHN) Infrahyoid neck (IHN) (on the coronal
and sagittal plane)

6. Hyoid Bone

7. Superficial Layer DCF
SHN: Around Masticatory Sp. & Parotid Sp; part of
carotid space
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Superficial layer
DCF

8. Superficial Layer DCF
IHN: surrounds strap, sternocleidomastoid
& trapezius muscles
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Superficial layer
DCF

9. Middle Layer DCF
SHN: defines Pharyngeal Mucosal Space
deep margin; contributes to carotid space
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ML - DCF

10. Middle Layer DCF
IHN: Surrounds Visceral Sp.; contributes of
carotid space
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ML - DCF

11. Deep Layer DCF
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SHN & IHN: Surrounds perivertebral space (paraspinal and pre-vertebral
components), Contributes to carotid space.
DL - DCF

12. Deep Layer DCF: Alar Fascia
Part of the DL-DCF which forms the lateral and posterior walls of the
Retropharyngeal space and separates this space from the Danger Space (virutal
space)
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DS: from the skull base to the mediastinum;
Boundaries ANT: Retropharyngeal Sp. POST: pre-
vertebral component of periveterbal space

13. Neck Masses in Children: Solid
 Reactive/metastatic Lymph nodes
 Lymphoma
 Infantile Hemangioma
 Rhabdomyosarcoma
 Lipoma
 Matastatic Neuroblastoma (mostly osseous);
Primary Neck Neuroblastoma (posterior
carotid space)
 Fibromatosis Colli (neonate)

14. Neck Masses in Children: Cystic
 Thyreoglossal Duct Cyst
 Laryngocele
 Abscess
 Branchial Cleft Cyst
 Lymphatic Malformation
 Dermoid/Epidermoid
 Teratoma (mixed solid and cystic)

15. Space or Anatomic
region Differential Diagnosis
Superficial Fascia Teratoma, Vascular Malformations, lipoma, plexiform
Neurofibroma, fibromatosis colli of SCM (in neonates)
Danger Sp. Cellulitis/Abscess
Masticator Sp. Venous/lymphatic Malf., rhabdomyosarcoma, cellulitis/abscess
Parotid Sp. Infection, Lymphatic malf., RMV thrombosis
Carotid Sp. IJV thrombosis, lymphadenopathy, abscess, neuroblastoma
Retropharyngeal Sp. Cellulitis/Abscess, extension of tumours or goiter
Perivertebral Sp. Neuroenteric cyst, Cellulitis/Abscess, Spondylodiskitis
Posterior Cervical Sp. Lymphatic malf., lymphadenopathy, lymphoma
Submandibular/Subling
ual Sp.
Thyroglossal cyst, venous/lymphatic Malf, dermoid cyst, ranula,
sublingual gland disease
Pharyngeal and
Parapharyngeal Sp.
Lymphangioma, paraganglioma, rhabdomyosarcoma, abscess,
Lymphoma
Infantile Hemangioma : can occur in any space!

16. Solid Neck Masses

17. Reactive Lymph Nodes
 Most frequent solid “masses” in children
 Benign, reversible enlargement of nodes in
response to antigen stimulus
 Acute/Chronic; Localized/Generalized
 IMAGING:
 Multiple well-defined, oval-shaped nodes that can be
enlarged (> 2 cm in children), typically oval-shaped
rather than round, mild homogeneous enhancement

18. CECT appearance Do not forget the levels of the Neck !
Drawing by F. Gaillard
Tonsils
LevelIIA
LevelIIA
Level V a

19. Differential Diagnosis
1) METASTATIC NODES
Rare in children
Bigger size (but in children this criterion
does not work as in adult!)
Round node shape rather than oval
Clustered nodes
Focal nodal defect/necrosis
Extracapsular spread
Primary Tumor! NB: DD between Meta Nodes and Suppurative Nodes is
often obvious clinically (Hot, tender, febrile patient)
Christine M. Glastonbury

20. Differential Diagnosis
2) Lymphoma (NHL and HL)
- SIZE ! BILATERAL non-symmetric!
-Posterior Cervical Space often involved
-Homogeneous lobulated nodal masses
-Single or multiple nodal chain
-Variable contrast enhancement
-Necrotic center may be present

21. Lymphoma Neck
Internal jugular chain
Spinal Accessory Chain
4 yo HL
Bilateral Internal jugular chain

22. Infantile Hemangioma
 Can be in different locations in the neck
(subcutaneous tissue)
 Is a benign neoplasm (not malformation)
 Proliferative phase: few weeks after birth to 1-2
years
 Involuting phase: gradual regression over next
several years (90% resolve by 9 years)
 Often single lesion.

23.  IMAGING Key Features:
 Well-defined enhancing mass, mildly hyper T2 to muscle
 Internal Vessels (Serpiginous Flow Voids)
 No Calcifications! (DD Venous Malformation)
 US: mean venous peaks not elevated (DD AVM)
 Involuting Phase: fatty replacement
Infantile Hemangioma

24. First
Diagnosi
s
After
Treatment
with
Propanolol

26. Differential Diagnosis
1) Venous Malformation
Large venous lakes
- T2 signal more hyperintense
- Variable enhancement (patchy,
heterogeneous)
- Phleboliths: Calcium within the
lesion
- No Flow voids

27. Differential Diagnosis
2) AVM
- High flow and tortuous feeding
arteries
- Large draining veins
- Nidus/AV shunting
- Ill defined mass
- US: elevated venous peaks
- Worsening overtime
- Clinical: arterial feeding is
evident

28. Differential Diagnosis
3) Rhabdomyosarcoma
- Different age : 2- 5 y; 15-19 y
- Aggressive behavior: bony erosion,
invasions surrounding tissues
- Non-Homogeneous appearance
(necrosis, hemorrhage) and contrast
- Diffusion restriction (Lope 2012)

29. Rhabdomyosarcoma Neck

30. Rhabdomyosarcoma Neck
T2 signal, hyper but not too much
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31.  Fat signal/ density in all sequences, if associated
c.e. suspect liposcarcoma
Lipoma
CT: Low Density ( −100 to −50 HU)
Hyper in T1 Suppressed in Fat-Sat

32.  Metastatic : Typical Osseous Meta in Calvarium, Skull base, Orbits,
Temporal bones  DWI restriction, c.e.
 Radiologist need to suggest abdominal US
 MIGB uptake
 Rare Nodal Metastasis
Neuroblastoma

35.  Primary Neck NB : Posterior Carotid
Space
 1-5 % of NB
 Moderately enhancing mass
 Associated Lymphoadenopathy
 DD with Reactive Nodes and
Lymphoma very difficult (biopsy)
 Presence of Ca++ (extremely rare in
Lymphoma)
Neuroblastoma

36.  Sternocleidomastoid Enlargement of Infancy
 Appears within 2 weeks of delivery; regresses by 8 months
 Nontender (DD with myositis) , monolateral
 Enlargement of the muscle which enhances diffusely
 Surrounding tissues are normal (DD with
Rhabdomyosarcoma together with age)
 Diagnosis: Clinical + US
Fibromatosis Colli

37. Normal Fibromatosis Colli
Smiti et al.2010
Dr. B. Koch

38. Cystic Neck Masses

39.  Remnant of the TGD (Between foramen
cecum at tongue base → thyroid bed in
infrahyoid neck)
 Most common congenital neck
lesions
 Median cyst (could be also
paramedian in the infrahyoid neck)
 Thin rim of c.e. is possible (often
associated with infection)
 Embedded by strap muscles when
infrahyoid (“claw sign”)
Thyroglossal Duct Cyst
Harnsberger 2004

41. Differential Diagnosis
1) Lingual Thyroid
- Solid, enhancing mass
- Ectopic Thyroid Tissue in
the base of the tongue or
floor of the mouth

42. Differential Diagnosis
2) Laryngocele
- Traces back to the
Larynx
- Air and fluid

43. Differential Diagnosis
3) Median Sub-Lingual
Abscess
- Clinical: associated
Odontogenic or salivary
gland infection
- Thick enhancing wall, DWI
restriction in MRI
Harnsberger 2004

44. NB: most frequent location of an abscess in neck
is retropharyngeal space

45.  Congenital malformations during development of the
branchial apparatus
 4 types of branchial cleft anomalies: cysts, sinuses,
fistulas from the 1st , 2nd, 3rd and 4th branchial arches
 2nd branchial cleft anomaly is the most common:
95%
Branchial Cleft Anomalies
Head and neck region
at 4 weeks gestation
(Meuwly et al 2005)

46.  Unilocular cysts with thin wall
 Fluid content: CT hypodense, T1 hypohintense, T2
hyperintense
 No enhancement or subtle wall enhancement
 If infected: wall thickening/enhancement, increase
density of the fluid
 Neoplastic degeneration: enhancing nodules along
the wall
Branchial Cleft Anomalies

47. 1st Branchial Cleft
Anomaly
 Benign, congenital cyst in or adjacent to parotid
gland, EAC, or pinna
 Several classifications related to embryology or
location
Postero-inferior to auricle Adjacent to parotid gl./mandible angle
B. Koch 2015

49. 2nd Branchial Cleft
Anomaly
 Typical location: Antero-medially to the SCM
(superior 1/3), posteriorly to the submandibular
gland, laterally to the carotid space
B. Koch 2015

51. 3rd Branchial Cleft Anomaly
-Medially to the middle 1/3 of the SCM
-Lower than 2nd BCC
-In the posterior cervical space
Carotid sp
3BCC
SCM
Post Cerv
Sp
4th Branchial Cleft Anomaly
It is a tract from the pyriform sinus to
the
Superior aspect of the thyroid
Thyroid
B. Koch 2015

52.  Uni- or multiloculated, non-enhancing, cystic neck
mass.
 Micro- and macro cystic
 Often trans-spatial, with fluid-fluid levels
(hemorrhage and high proteinaceous components)
 Venolymphatic Malf. : Combined elements of venous
malformation & lymphatic malformation (contrast
enhancement of the venous elements)
Lymphatic Malformation

54.  2nd BCC: unilocular cyst, typical location, no fluid-
fluid levels
 Abscess/suppurative nodes: clinical signs of
infection, peripheral enhancement and cellulitis
 Thyroglossal duct cyst: typical (midline) location,
single cyst
Differential Diagnosis

55. Dermoid/Epidermoid Cyst
 Definition: Cystic mass resulting from congenital
epithelial inclusion or rest
 Epidermoid: Epithelial elements only, fluid content
 Dermoid: Epithelial elements plus dermal
substructure, fluid, fatty or mixed content
 Location: oral cavity (DD with Ranula and TGDC),
midline anterior neck (DD with TGDC), orbit (DD
with abscess and lymphatic malf.), nasal with
associated nasal dermal sinus ± intracranial
extension

56. Imaging
Epidermoid: homogeneous T1
hypo and T2 hyper. Increase T1
signal if high protein fluid
Dermoid: heterogeneous
signal. Fatty elements are T1
hyper and low in fat sat T2.
Possible Ca++
Both can have DWI restriction
and thin rim enhancement
T1 T2 fat-sat
T1

57. Dermoid: tyipical “sac of marbles” appearance
due to area of fatty attentuation
Malik et al. 2012

58. Differential Diagnosis
 Ranula: salivary gland retention cyst in sublingual
space.
 Can be indistinguishable from epidermoid cyst
which doesn’t show restriction.
 Often is ruptured into the submandibular space
(diving ranula) which shows typical “comet shape”
(body in the SMS and tail in the SLS)
 No fat, no Ca++ and no DWI restriction

59. Malik et al. 2012
Tail
Body

60. Teratoma
 Anterior neck, midline mass containing all 3 germ
layers
 Mixed (cystic and solid) with fat and calcium
 DD: Lymphatic Malf (fluid with no fat, calcium or
solid components), Goiter (homogeneous, respects
limits of the thyroid gland)

61. Mixed solido-cystic mass with fat content

64.  Neck masses are common findings in children and
can be a diagnostic challenge
 Often trans-spatial
 No space-specificity
 Distinction in Solid or Cystic (or mixed) can help in
the differential diagnosis
Conclusion

65. Thank you