SM_11b: Pediatric Head and Neck Masses Flashcards
Describe the cervical triangles
Cervical triangles
- Clinically useful when evaluating a neck mass
Cervical levels are particularly useful to describe ____
Cervical levels are particularly useful to describe adenopathy
- Level I: submental, submandibular
- Level II-IV: jugulodigastric superior to inferior
- Level V: posterior triangle
- Level VI: anterior midline below hyoid bone
Cervical level I is ____
Cervical level I is submental / submandibular
Cervical levels II-IV are ____
Cervical levels II-IV are jugulodigastric superior to inferior
Cervical level V is ____
Cervical level V is posterior triangle
Cervical level VI is ____
Cervical level VI is anterior midline below hyoid bone
Midline lesions occur ____, while lateral lesions occur ____
Midline lesions occur along the anterior midline, while lateral lesions occur unilaterally or bilaterally off the anterior midline
Describe causes of midline neck lesions
Causes of midline neck lesions
- Thyroglossal duct cyst
- Dermoid cyst
- Lymph node
- Ectopic thyroid gland
- Other thyroid lesions sometimes
- Other rare possibilities
Describe causes of lateral neck lesions
Causes of lateral neck lesions
- Branchial cleft anomalies
- Vascular anomalies: lymphatic and venolymphatic malformations
- Inflammatory: atypical mycobacteria or other adenopathy/adenitis/abscess conditions
- Salivary gland lesions: parotid, submandibular
- Thyroid masses: usually in a lobe
- Neoplasia
- Teratoma
Congenital neck lessions are often ___
Congenital neck lessions are often cysts rather than solid masses
Infectious neck lesions are often associated with ____, except for ____
Infectious neck lesions are often associated with signs of infection, except for atypical mycobacteria
Neoplastic neck lesions are often ____
Neoplastic neck lesions are often masses rather than cysts
____ is most common imaging study when working up a pediatric neck mass
Ultrasound is most common imaging study when working up a pediatric neck mass
- Ultrasound: no radiation or sedation
- CT: good bone detail, radiation exposure
- MRI: good soft tissue detail
____ is the most common congenital neck lesion that presents as a mass and involves ____
Thyroglossal duct cyst is the most common congenital neck lesion that presents as a mass and involves persistence of the thyroglossal duct
- Tract often intimately associated with hyoid bone
- Specimen often has thyroid elements
Describe development of the thyroglossal duct
Development of the thyroglossal duct
- Follows path of thyroid gland decent during embryologic development
- 4th week gestation: epithelium in floor of pharynx that later forms the foramen cecum of the tongue evaginates to form the thyroglossal duct
- Distal end becomes bilobed and differentiates into thyroid gland
- Thyroid gland development completed at 8th week of gestation
- Duct normally involutes etween 8th and 10th week
Thyroglossal duct cyst is a ____ neck mass often in proximity to the ____ and has a propensity to get ____
Thyroglossal duct cyst is a midline neck mass often in proximity to the hyoid bone and has a propensity to get infected
Workup for thyroid mass involves ____ and ____
Workup for thyroid mass involves neck ultrasound and thyroid function tests
- Ultrasound determines cyst vs solid and if normal thyroid gland
- Ectopic gland can be hypothyroid
Definitive treatment for thyroglossal duct cyst is ____, which is called the ____ procedure
Definitive treatment for thyroglossal duct cyst is excision of cyst along with portion of hyoid bone, which is called the Sistrunk procedure
(far lower recurrence rate than removing the cyst alone)
Cervical dermoid cyst involves ____, is lined by ____, and can contain ____
Cervical dermoid cyst involves trapped epithelial elements (ectoderm and endoderm along embryologic lines of fusion), is lined by epithelium, and can contain skin elements such as hair and sebaceous glands
Cervical dermoid cyst presents similarly to ____ except ____
Cervical dermoid cyst presents similarly to thyroglossal duct cyst except without consistent relationship to hyoid bone
(commonly midline or paramedian mass, often benign appearing and non-tender lump)
Definitive treatment for a cervical dermoid cyst is ____
Definitive treatment for a cervical dermoid cyst is excision of the cyst
- Cysts are typically superficial to the trachea
- Subcutaneous or deep to the investing fascia so less risk of airway injury than with thyroglossal duct cyst surgery
- Between strap muscles
- Well encapsulated
- Characteristic thick yellowish appearance
Bilateral neck pits. Most likely diagnosis is ____
Bilateral neck pits. Most likely diagnosis is branchial cleft anomalies
Bilateral branchial anomalies should prompt closer inspection of the ___ and ___
Bilateral branchial anomalies should prompt closer inspection of the ears and kidneys
(branchio-oto-renal syndrome)
____ is the second most common congenital lesion that can present as a mass after thyroglossal duct cyst
Branchial cleft anomalies is the second most common congenital lesion that can present as a mass after thyroglossal duct cyst
Branchial cleft anomalies result from ____
Branchial cleft anomalies result from failure of clefts and pouches to obliterate during embryogenesis
Describe the embryology of the branchial apparatus
Embryology of the branchial apparatus
- Branchial arches are visible at 4-5th week of gestation: 4 dominant, 2 smaller
- Each arch is mesoderm associated with a primary blood vessel, nerve, and cartilage bar
- Aches are separated by external cleft (ectoderm) and internal pouch (endoderm)
- Forms many of the head and neck structures
Branchial cyst is ___
Branchial cyst is retained epidermal lined space without communication to mucosa or skin
Branchial sinus is ____
Branchial sinus is epidermal lined duct with external or internal communication
Branchial fistula is ____
Branchial fistula is epidermal lined tract communicating pharynx to skin
Describe workup and management of branchial cleft anomalies
Workup and management of branchial cleft anomalies
- Typically present as a mass, draining fistula, or abscess in neck or face
- Typical imaging includes ultrasound, CT, or MRI
- Acute treatment involves management of infection or abscess - antibiotics, rarely incision or drainage
- Definitive treatment is complete surgical excision
Most common branchial anomaly is ___
Most common branchial anomaly is second branchial anomaly
Describe second branchial cleft anomalies
Second branchial cleft anomalies
- 70-90% of all branchial cleft anomalies
- Arch: superior part of hyoid bone, stylohyoid ligament, styloid process, stapes, and the muscles innervated by the facial nerve (CN VII)
- Pouch: palatine tonsils
- Cleft: obliterates
Second branchial cleft anomaly presents as ____ or ____
Second branchial cleft anomaly presents as pit anterior to sternocleidomastoid muscle or solitary cyst
- Pit anterior to sternocleidomastoid: diagnosed as infant, often complete fistula to pharynx (tonsil fossa)
- Solitary cyst: often diagnosed at older age, recurrent neck abscess
