Differential Diagnosis and radiological imaging of the Cervical x

1. Radiology of Cervical Masses
Dr.Bushra Hussein Ahmed Abdelmalik
Radiologist

2. introduction
• Imaging the neck is unlike imaging any region of the
torso or brain since maximal contrast resolution is
necessary to differentiate lesions in cross-sectional
exams of those solid organs.
Because of the various organ systems, the neck has very
good native contrast resolution between lesions and adjacent normal
structures and at the interface with the skull base
and thoracic inlet

3. Cont…
Intravenous contrast is necessary,
however, to differentiate veins (and arteries) from
adenopathy and masses .
The baseline scan has to be obtained by using . Intravenous
contrast also helps characterize internal lymph node
architecture for necrosis.

4. Neck masses could be

5. Ct image of the neck showing
different contrast of its structure

6. Enhanced axial CT image through the oropharynx. (1)
Partially necrotic pathologic lymph node (level II). (2) Normal
submandibular
node (level I-b) with fatty hilum

7. Cervical Triangles

8. Cystic Hygroma
• Cystic hygromas are fluid-filled sacs that result from a
blockage in the lymphatic system. The lymphatic system is a
network of vessels that maintains fluids in the blood, as well as
transports fats and immune system cells. Cystic hygromas are
single or multiple cysts found mostly in the neck region. A
cystic hygroma can be present as a birth defect (congenital) or
develop at any time during a person’s life. A cystic hygroma in a
developing baby can progress to hydrops (an excess amount of fluid
in the body) and eventually fetal death. Some cases of congenital
cystic hygromas resolve
• leading to webbed neck, edema (swelling), and a lymphangioma (a
benign yellowish-tan tumor on
• the skin composed of swollen lymph vessels). In other instances the
hygroma can progress in sizeto become larger than the fetus.
• Cystic hygromas occur in approximately 1% of fetuses during
the ninth to sixteenth week of pregnancy.

9. • In childhood, tumors and tumor-like lesions of the neck
are rare and tend to be benign. Very common are
congenital cystic lesions (thyroglossal duct cysts,
branchial cysts, dermoid cysts, lymphangiomas, cystic
hygromas). Common neoplastic lesions are
hemangiomas and papillomas. The most common
malignant tumors in the head and neck region are
lymphomas and rhabdomyosarcomas. Lymph node
enlargements, reactive or/and infectious, account also
for a significant amount of cervical masses.

10. Congenital cystic Hygroma

11. U/S of A cystic Hygroma

12. Salivary glands are:-
1.Parotid glands
2.Submandibular glands
3.Sublingual glands
4.Accessory salivary glands

13. Common Diseases of Salivary Glands
1-Stones.
2-Inflamation.
3-Tumors.

14. Submandibular Gland Stones & Ludwig's Angina

15. 1. Stone formation is common in the submandibular salivary gland and its
duct
2. This is made up of calcium phosphate and carbonate
3. They are radio-opaque

16. a) Salivary Calculi
1. Stone formation is common in the submandibular salivary gland and
its duct
2. This is made up of calcium phosphate and carbonate
3. They are radio-opaque
Stones are :-
1. Painful recurrent swelling of the affected gland at the time of meals
2. Purulent discharge from the duct into the mouth
3. The affected gland is swollen, tender and on pressure gland may
produce purulent discharge from the orifice of the duct
4. The orifice is swollen and red
5. The stone is palpable on bi-manual examination
6. They are radio-opaque

17. b) Inflammation of The Salivary Glands
Acute Parotitis
Causes:
1. Infective
a) Viral (mumps)
b) Bacterial
c) Tuberculous
d) Fungal
2. In post operative period to poor oral hygiene
3. During chronic and debilitating illness (Typhoid fever , Cholera etc.)
4. Following radiotherapy
5. Sjogren's syndrome
They may show repeated attacks of pain and swelling due to infection and
obstruction of the duct secondary to stricture

18. Parotid Swelling

19. Tumors of the Salivary Glands :-
If the swelling in connection with the muscle may be due to fibroma, lipoma,
rhabdomyoma or idiopathic hypertrophy of the muscle
Incidence of salivary tumors
Parotid gland – 75%
80% Benign (and 80% of the benign tumors are pleomorphic adenoma)
20% Malignant
Submandibular gland --15%
60% Bengin(95%of the benign tumors are pleomorphic adenoma)
40% Malignant
Minor salivary gland 10%
40% Benign (all most al pleomorphic adenoma)
60% Malignant
.

20. Differential diagnosis of
a Parotid Swelling
1. Parotditis
2. Pleomorphic adenoma
3. Carcinoma
4. Pre auricular lymphadenitis
5 Sebaceous cyst or swelling in relation to skin
6. Neuroma of the facial nerve
7. Adamantinoma of the mandible
8. Neurofibroma

21. Diagnostic features of the malignant swellings
1.The swelling is hard , rapidly growing with irregular surface
2.It is painful
3.Facial nerve involvement is the characteristic feature of parotid malignancy
4.Regional lymph nodes may be involved 5. More common in parotid gland
6. Patient is usually above 50 years
7. Carcinoma of the Submandibular gland is less common
8. The overlying skin becomes fixed to the swelling and reddish blue in color
and hot. The veins over the swelling are prominent.

22. Mikulicz’s disease
1. Symmetrical enlargement of the salivary glands
2. Swelling of the lacrimal glands with narrowing of the palpebral fissures
3. Dryness of the mouth
It may occur in following conditions
1. Leukemia 2. Tuberculosis
3. Sarcoidosis 4. Sjogren’s syndrome

23. Differential Diagnosis of Swelling
Of The Neck
1. Midline swelling (from above downwards)
a) Submental triangle
1. Ludwig’s angina
2. Sbmental lymph adenitis
3. Sublingual dermoid and lipoma
4. Cold abscess
5. Secondaries from the tip of the tongue and lip

24. In connection with hyoid bone
and thyroid cartilage
1.Thyroglossal cyst
2. Subhyoid bursitis
3. Goiter of the thyroid isthmus or cyst
4. Extrinsic carcinoma of the larynx

25. Suprasternal notch
1. Retrosternal goiter
2. Thymus (if enlarged)
3. Cold abscess

26. Lateral swelling
a) Submandibular triangle
1. Submandibular lymph adenitis, secondaries or lymphoma
2. Submandibular salivary gland tumour
3. Deep runula
4. Extension of the swelling of the jaw
5. Lymphangioma
6. Schwanoma

27. Squamous cell carinoma
SQUAMOUS CELL CARCINOMA OF THE TONSIL
• About 90% of tonsillar cancers are squamous cell carcinomas.
• These tumors are relatively frequent
• , occurring mostly between the ages of 50 and 70.
• They are three to four times more common in males than females and
• are often associated with a history
• of smoking and drinking alcohol.
• Sixty percent of patients present with cervical metastases that is bilateral in
• 15% of the cases. Distant metastases are found in about 7%.

28. LYMPHOMA OF THE TONSIL
Lymphoma is the second most common type of tonsillar malignancy.
Lymphoma of the tonsil usually presents with a submucosal mass
in an asymmetrical enlargement of one tonsil. When
lymphadenopathy is present, multiple enlarged lymph nodes
commonly are observed on the same side of the neck.
Lymphomas are difficult to distinguish from undifferentiated
carcinomas and lymphoma

29. Axial CT scan, showing enlarged left tonsil
Lymphoma of the right tonsil with parotid and neck
metastasis

30. Epidermoid cyst

31. Carotid triangle
1. Aneurysm of the carotid artery
2. Carotid body tumour
3. Branchial cyst
4. Goiter
5. Stemomastoid tumour

32. Posterior or Supraclavicular triangle
1. Cystic hygroma
2. Lipoma
3. Pharyngeal pouch
4. Cervical rib
5. Aneurysm of the subclavian artery
6. Supraclavicular lymph adenitis, secondaries and lymphoma
7. Abscess.
8. Epidermoid cyst

33. Cervical Abscess

34. Swelling Arising From Different
Anatomical Structures
Skin and superficial fascia
1. Boils and furuncles
2. Sebaceous cyst
3. Lipoma
4. Dermoid cyst
5. Ludwig’s angina or cellulitis

35. * Branchial arch remnant Branchial cyst
* Salivary glands
1.Submandibular salivary gland tumour (mixed tumour or carcinoma),
2. Tumours of the parotid gland
* Pharynx
pharyngeal pouch
* Bone
Cervical rib
* Larynx
Carcinoma

36. Lymph node masses
1. Infective, e.g; pyogenic, tuberculosis
2. Secondaries
3. Lymphoma
4. Lymphangioma, cystic hygroma
Blood vessels
1. Aneurysm of carotid or subclavian artery
2. Carotid body tumour

37. Complications
1. Infection-branchial sinus
2. Branchiogenic carcinoma (rare)
Diffrential diagnosis
1. Tuberculous lymph node (cold abscess)
2. Acute lymph adenitis

38. Cystic Hygroma
1. It is a congential discorder of lymphatic system. It is a varierty of
limphangioma in wich lymph is collected in lymphatic sac.
2. It is a multilocular swelling with larger cysts at the periphery and smaller
cysts at the center. Many of the cysts are inter-communicating with each
other, due to this reason swelling is soft cystic and compressible
3. It is commonly placed at the root of the neck and posterior triangle. Second
most common site is axilla. Other sites are groin, mediastinum, tongue
and buccal mucosa.

39. Pharyngeal Pouch
It is protrusion or herniation of the mucosa of the pharynx through the Killian’s dehiscence,
which is weakness between upper oblique fibers of the thyropharngeus and lower horizontal
fibers of the cricopharngeus.
Clinical features
It is common in middle and old age, more commonly seen in men.
There are three stage of the pharyngeal diverticulum
1. Stage one is an initial bulging. Usually it is symptomless.
2. Stage two is a well formed diverticulum the mouth of the diverticulum is vertical which gives
rise to regurgitation of food when patient-turns from side to side.
3 Stage three of large diverticulum-the mouth of the diverticulum becomes
horizontal and fundus of the sac becomes dependent.It presses the oesophagus
when it is full.There may be gurgling sounds in the neck.A visible swelling in the
neck behind the sternoclidomastoid muscle is soft in consistency and indentable.
This leads to increasing dysphagia

40. * Cervical Adenitis
Inflamation of the lymph nodes of the neck is a common feature. There
are about 800 lymph nodes in the body ; out of which 300 are in the
neck.

41. Acute Cervical Lymph Adentis
1.The lymph nodes are enlarged, soft and tender with marked pain
2. Pyrexia
3. Abscess formation
4. Leucocytosis .

42. Tuberculosis Adenitis
In majority of instances children and young adults are affected but the
condition can occur at any age
Source of infection :
1. Tonsil, adenoids and dental caries
2. Apex of lung
3. Air-borne infection
4. Haematogenous-Pulmonary Tuberculosis.
5. The human tuberculosis bacillus is the causative organism and in 54 per
cent of cases upper jugular group of lymph nodes are affected

43. Clinical Features
1. Matted mass of lymph nodes.
2. Fluctuant swelling (cold abscess)
3. Multiple sinuses with caseating tuberculous pus discharge
4. Multiple scars (if sinuses healed)

44. Differential diagnosis
1. Chronic non-tuberculous adenitis
2. Hodgkin’s disease
3. Secondaries
4. Branchial cyst
5. Actinomycosis

45. Lipoma of Neck
Axial CT scan of a patient with a large Lipoma

46. Hodgkin's Lymphoma of the Neck and Mediastinum
CT scan shows Hodgkin's lymphoma surrounding the trachea and
narrowing its lumen

47. The axial CT scan photograph below shows a soft tissue
mass resembling adenoids, arising from the vault of the
nasopharynx. This mass protrudes into both nasal cavities,
completely obstructing the airway

48. X-Ray of Tracheal Imaging of Tracheal Leiomyoma

49. CT with a tracheal filling defect
Tracheal Leiomyoma

50. MRI of the same lesion

51. Axial CT scan of the neck showing the epiglottic cyst in the
pictures above.

52. Appearance of a Scrofula

53. Pictures of Scrofula, CT Imaging and Acid-Fast Bacilli

54. Secondary Carcinoma Of The Neck
The secondary carcinomatous involovement of the cervical lymph nodes is
commonly encountered.

56. Cervical Lymphatic Sec. Masses.
1. Tip of tongue, central part of floor of
mouth and lower lip
Submental triangle (mental)
2.Anterior t-thirds of tongue, floor of
mouth, cheek and alveolus
Submandibular triangle
(sub-mandibular)
3. Posterior one-third of tongue,
tonsil larynx, oropharynx and pyriform
fossa
Carotid triangle
(jugulo-digastric)
4. Nasopharynx, retro-pharygeal
region and external lear
Posterior triangle
(upper part)
5. Thyroid, post-cricoid region,
oesophagus, breast, lungs, tastes
and abdominal organs
Supraclavicular triangle
(Supraclavicular)

57. • The thyroid gland develops from the median bud of the pharynx which
passes from the base of the tongue to the isthmus (thyroglossal duct).
Paratllicular cells are derived from the fourth branchial arch.
• The weight of the normal gland is 20-25g. There are 20-40 follicles in a
loobule which is functional unit.
• Arterial supply
i. Superior thyroid artery-branch of external carotid.
ii. Inferior thyroid artery-branch of thyrocervical trunk.
• Venous drainage
I. Superior thyroid vein.
II. Middle thyroid vein
III. Interior thyroid vein-Brachiocepalic vein
Anatomy of the thyroid gland

58. Thyroid blood supply

59. Thyroid Anatomy

60. Thyroid scanning
• Indication:
I. To see the which parts the thyroid gland are functioning or
functionless (hot or cold).
II. To see the areas of hyperfunctioning in toxic nodular goitre.
III. In evaluation of solitary toxic multi nodular goitre.
IV. To know the metastasis in thyroid malignancy.
V. To know about the ectopic thyroid.
Other tests:
Serum cholesterol, BMR, ECG and tendon reflexes etc. are value to
day.

61. GIOTERS
• Enlargement of the thyroid gland.
• Classification:
1. Euthyroid goiters (simple)
1. Diffuse hyperplasic giotre
2. Nodular giotere
1. Multiple
2. Solitary
2. Toxic gioters
1. Diffuse toxic giotre (Gravo’s disease)
2. Toxic nodular goitre (Pummer’s disease)
3. Toxic nodule
3. Neoplastic giotre
1. Benign
2. Malignant

62. Nodular Goitre
1. Due to persistent fluctuating T.S.H stimulation.
2. Common in female
3. Patient is usually euthroid

63. • ure 9. Transverse thyroid ultrasound
demonstrating a hypoechoic mass
replacing the right lobe of the gland with
early extracapsular spread(arrow). These
appearances are non-specific and may be
seen in anaplastic carcinoma (as in this
case) and primary thyroid lymphoma.

64. 4. Thyroiditis
1. Granulomatous thyroiditis
2. Auto-immune thyroiditis
1. Focal
2. Diffuse
3. Riedel’s thyroiditis
1. Goitrogens
2. Non-giotrogens.
4. Rare goitres
1. Pyogenic thyroiditis
2. Tuberculous thyroiditis.
3. Amyloid goitre.

65. COMPLICATIONs
I. Tracheal obstruction
II. Dysphagia
III. Secondary thyrotoxicosis in 30% of the patients.
IV. Risk of carcinoma is 5-8 %
s

66. 3. Solitary Nodule
• A goitre which, on clinical examination appears to appears to be a single
nodule in an otherwise normal gland is termed as solitary nodule:
1. 50% of solitary nodules are simple multinodular goiters on exploration.
2. 25% of true solitary nodules are malignant.

67. INVESTIGATION
ultrasound may demonstrate the multiple nodules in clinically solitary
goitre.
Selection scan to differentiate between a benign and a malignant cold
nodule.

68. 4. Retrosternal Goitre
causes:
1. In males with short neck and strong pretracheal muscles (because of
negative intrathoracic pressure)
2. Ectopic thyroid.
Types:
1. Substernal- always palpable
2. Plunging-occasionally palpable.
3. Intrathoracic- not palpable.

69. Diagnosis of Retrosternal goiter
X-ray of the neck shows soft tissue density in the superior mediastinum.
Thyroid scan to confirm the diagnosis.

70. TOXIC GOITRE
• Clinical types:
1. Diffuse toxic goitre (Graves’ disease)
2. Toxic nodular goitre (Plmmer’s disease)
3. Toxic nodule
Clinical feature thyorotoxicosis
it is more common in female than males.
Wayene’s clinical diagnostic index gives all the important symptoms and
signs of thyrotoxicosis.

71. NEOPLASMS OF THE THYROID
1. Benign
Adenomas
2. Malignant
1. Primary
1. Carcinoma
1. Differentiated-papillary or follicular
2. Undifferentiated-anaplastic.
2. Malignant Lymphoma
3. Medullary carcinoma
2. Secondary
1. Local infiltation
2. Metastasis

72. BENIGN TUMOURS
• Adenomas
1. Follicular adenoma
2. Papillary adenoma (doubtful entity)
Adenomas are usually present as solitary nodules and clinically it is
difficult to differentiate them from solitary goiter. There is no
invasion of the capsule. Distinction between a follicular carcinoma
and an follicular adenoma can only be made by histological
examination. All papillary tumors should be considered as
malignant even it capsulated.

73. MALIGNANT TUMORS
• Papillary Carcinoma (60%)
– Mostly mixture of papillary and colloid follicles.
1. Occult-Only one focus (less than 1.5cm)
2. Intrathyroidal-Multiple foci in same or both lobes.
3. Extrathyroidal-spread to lymph nodes is common.
Spread:
Lymphatic spread to cervical to lymph nodes is common. Multiple
Intragladular seedlings may occur in the same lobe. Blood-brone
metastates are most unusual.

74. U/S of the Thyroid

75. Nuclear Medicine Imaging

76. Papillary carcinoma is the more common well-differentiated cancer of the
thyroid. Papillary/follicular carcinoma must be considered a variant of the
papillary thyroid carcinoma (mixed form). Despite its well-differentiated
characteristics, papillary carcinoma may be overtly or minimally invasive. In
fact, these tumors may spread easily to other organs.
Papillary carcinoma appears as an irregular solid or cystic mass in a
normal thyroid parenchyma. As with most tumors, the cause of thyroid
cancers is unknown; however, that thyroid cancers are more often found in
patients with a history of low- or high-dose external irradiation (40-50 Gy) is
well known. The life expectancy of patients with this cancer is related to their
age. The prognosis is better for younger patients than for patients who are
older than 45 years. Of patients with papillary cancers, 10-15% present
with lymph node or lung metastases. Some years ago, lymph node
metastases were thought to be aberrant (supernumerary) thyroids because
of their well-differentiated aspect.

77. • Mortality Morbidity
• In contrast to other cancers, thyroid cancer is almost always curable. Most
thyroid cancers grow slowly and are associated with a very favorable
prognosis. The mean survival rate after 10 years is higher than 90% and is
100% in very young patients with minimal nonmetastatic disease.
• Metastases are still frequent and are due to invasion of the lymphatics and
spread to the lymph nodes. Vascular involvement is even more rare,
occurring in fewer than 10% of cases. In most patients (35-50%),
metastases are found at diagnosis. Distant spread (ie, to lungs or bones) is
very uncommon. Worldwide, autopsy reviews show a high incidence of
microscopic foci of thyroid carcinoma.
• Differing from medullary thyroid carcinoma, papillary thyroid cancer is not a
part of multiple endocrine neoplasia syndromes.
• The mean mortality rate is 1.5% for females and 1.4% for males

78. Race
This cancer occurs more frequently in whites than in blacks.
Sex
The female-to-male ratio is near 3:1 and is related to the patient's age.
In patients younger than 19 years, the female-to-male ratio is 3.2:1.
In patients aged 20-45 years, the female-to-male ratio is 3.6:1.
In patients older than 45 years, the female-to-male ratio is 2.8:1.
Age with a peak in patients aged 30-50 years.

79. Follicular carcinoma (17%)
1. Noninvasive-minimal invasion of the capsulate and vascular tissue.
2. Invasive-marked invasion.
Spread:
1. Haematogenous spread to bones lungs is common mainly from invasive
variety.
2. Lymphatic spread is rare.
Characteristics features of secondaries of follicular carcinoma-
1. Extremely painful
2. Very vascular and pulsatile
3. Osteolytic
4. Produce thyroid hormone
5. Affinity to iodine like thyroid gland
6. Blood borne.

80. ANAPLASTIC CARCINOMA (13%)
– Local infiltration is an early fealure. It has an extremely lethal
tumors. It is usually hard and irregular.
– Spread
Lymph and haematogenous.
Treatment-Palliative. Resection of tumor only when there is no
invasion through thyroid capsules and no evidence of
metastasis.
Radiotherapy and multiple chemotherapy.

81. ANAPLASTIC CARCINOMA
T1 weighted axial MRI of the lower neck with contrast
T1 weighted axial MRI of the lower neck with contrast enhancement at the level
of the thyroid gland showing a complex thyroid mass with extensive soft
tissue invasion (anaplastic carcinoma

82. The role of ultrasound in the management of nodular
thyroid disease
• . Transverse thyroid ultrasound demonstrating a hypoechoic mass replacing
the right lobe of the gland with early extracapsular spread(arrow). These
appearances are non-specific and may be seen in anaplastic carcinoma
(as in this case) and primary thyroid lymphoma

83. MEDULLARY CARCINOMA (6%)
1. Tumors from parafollicular cells (C-cells)
2. High levels of calicitonion in the blood. The level falls after resection a
tumor and will rise again if the tumor recurs.
3. Often associated with other endocrine tumers (M.E.N 2A)
4. May be associated with neuromas of the skin, tongue and mucosa of
the lip etc. (M.E.N 2B)
5. Lymphatic and blood metastasses are common.
6. Sometimes it may be associated with diarrhoea due to high 5HT.

84. DIAGNOSIS OF MALIGNANT TUMOURS
1. Typical symptoms and signs:
1. Goiter of recent origin
2. Pressure symptoms
3. Recurrent laryngeal nerve palsy
4. Mobility of thyroid, side and with deglutition is restricted
5. Firm to hard and irregular thyroid.
Metastases-lymph nodes, bones or lungs .
.

85. DEVELOPMENTAL ANOMAILIES
• Ectopic thyroid
1. Lingual thyroid
2. Median ectopic thyroid
3. Lateral aberrant thyroid
4. Struma overii (in ovarian teratoma).
Scan is a must to know the position of the normal thyroid gland if present.

86. CT Lingual thyroid with and without contrast

87. ANOMALIES OF THE THYROGLOSSAL TRACT
• Thyroglossal Cyst- any where in the region of the thyroglossal
tract. Common sites are:
1. Subhyoid
2. In relation to thyroid cartilage
3. Suprahoid
Diagnosis– usually it is in the mid line and moves with deglutition as well as
with protrusion of the tongue (Tract is attached to foramen caecum)

88. Branchial Fistula
It represents the persistent second branchial cleft.
1. It appears as a small discharging at the anterior border of the lower one third
of the sternomastoid muscle
2. The fistulous tract is lined by ciliated columnar epithelium
3. The discharge is either mucus or mucopurulent
4. Drainage of the infected branchial cyst may also develop branchial fistula
5. Usually tract ends blindly at the lateral pharyngeal wall (Branchial sinus is
more appropriate term)
6. It may be unilateral or bilateral

89. Branchial Cyst
Clinical features
1. Arises from the remnants of the second branchial cleft
2. It is situated beneath the upper one third of the stemomastoid muscle at
its anterior border
3. It is lined by squamous epithelium and contains clear fluid which contains
envelop shaped cholestrol crystals
4. It is a fluctuant and trans illuminating cystic swelling
5. Though congenital, it presents in young adults are congenital cysts, that
arise in the lateral aspect of the neck when the second branchial cleft
fails to close during embryonic development. At about the fourth week of
embryonic life, 4 branchial (or pharyngeal) clefts develop between 5
ridges known as the branchial (or pharyngeal) arches.

90. BRANCHIAL CLEFT CYSTS
• These arches and clefts contribute to the formation of various structures of
the head and neck The second arch grows downwards and ultimately
covers the third and fourth arches. The buried clefts normally disappear
around the seventh week of development. If a portion of the cleft remains
entrapped and fails to disappear, its remnants form a cyst . . Branchial cleft
cysts are the most common of congenital neck masses. They are bilateral
in about 2-3% of the cases. Usually, they do not appear at birth, but
become noticeable much later in life. If they get infected, they may form a
deep neck abscess or a draining fistula. The treatment of branchial cleft
cysts is surgical excision.

92. U/S of the branchial cyst
•

93. CT of Thyroglossal cyst

94. MRI SectionsT1&T2 of the Branchial cyst

95. THYRGLOSSAL FISTULA
1. Never congenital. Occurs because of inflamed cyst.
2. Recurrent attacks of inflammation.
Treatment
sistrunk’s operation-Removal of the cyst or fistula along with whole of
the thyroglossal tract, upto foramencaecum.

96. Fistulography

97. Fistulography
• These films were taken after injecting a radio-opaque dye into the skin
openings (pits). They demonstrate bilateral branchial cleft tracts extending
from the skin of the neck to the oropharynx.

98. • Swelling which moves with deglutition:
1. Thyroglossal cyst
2. Cyst in relation of the isthmus
3. Thyroid swelling
4. Sub hyoid bursal cyst
5. Enlarged pretracheal gland
6. Ectopic thyroid
Swelling which moves with protrusion of the tongue thyroglossal cyst.

99. Hypoparathyroidism
(Primary)
Causes
1. Single adenoma 70%
2. Multiple adenoma 6%
3. Hyperplasia 20%
4. Carcinoma 1%(rare)

100. Clinical Features
1.Common in females
2. Generalised decalcification of the bones leads to pathological fractures and
pseudo tumours of any bone.
3. Bilateral renal stones or nephroclacinosis
4. Psychiatric symptoms-tiredness, listlessness (wrongly labelled as neurotic) 5.
Dyspeptic symptoms -neusea, vomiting, anorexia

101. Investigations
X-ray changes first appear in phalanges and skull-loss of density and
subperiosteal erosions.

102. Differential diagnosis
1. Secondary (causes of hypercalcaemia) carcinoma in bones
2. Multiple myeloma
3. Milk alkali syndrome
4. Vitamin D intoxication
5. Hodgkin’s disease
6. Sarcoidosis
7. Thyrotoxicosis

103. Carotid Body Tumour
Carotid body is a flattened brownish nodule of a few millimeter in
diameter, Situated with in the adventitious coat on posterior aspect of the
common carotid artery at or just below the bifurcation. Slowly growing,
locally invasive unilateral tumour
Arises from the carotid body (chemo-receptor) at the bifurcation of the
carotid artery, and closely adherent to it. It moves side to side but not
vertically
Remains localized for years, regional metastasis occurs in about 20 per
cent of cases
Distant-metastasis are rare
. Carotid angiography is diagnostic
. Attempt for biopsy may lead torrential hemorrhage

104. carotid

105. Carotid

106. Cervical Rib
A rib arises from the seventh cervical vertebra
An incomplete rib, with the free end which may expanded into a large bony mass
Cervical Ribs may be unilateral or bilateral with local symptoms .
The rib-lump is hard, and fixed palpable mass in the neck

107. Cervical Rib

108. U/S B-Scan of the CR

109. Cervical Rib Doppler

110. Supraclavicular Lump:
??? Brachial Plexus Neurogenic Tumour
• The diagnosis of a brachial plexus neurogenic tumour should be
considered in patients presenting with a supraclavicular lump. Pre-
operative diagnosis assists in optimal management. Five cases of
neurogenic tumours of the brachial plexus presenting as a supraclavicular
lump are reviewed. Excision or enucleation was performed.Only one case
developed a permanent neurological deficit. (??Differenciate between
neurofibroma and schwannoma ) .
• The majority present as a slow growing mass diagnosis may be
suggested by pain or paraesthesia in the arm or shoulder particularly on
palpation . .
• CT has been superseded by MRI because of its better differentiation of
soft tissues

111. CT and MRI in diff.diag.
T1-weighted images show the tumour to be of intermediate signal and
T2-weighted images
show a high signal with some heterogeneity. These appearances are
not specific to peripheral nerve tumours, although the diagnosis may
be suggested if the lesion arises from a major nerve trunk.
MRI may also assist in pre-operative differentiation between
schwannoma and neurofibroma. The nerve is shown to lie peripheral
to the tumour in schwannomas while it is central or obliterated in
neurofibromas. In addition, schwannomas often show cystic change
where neurofibromas do not

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