1. The child with a neck mass
Bernadette L. Koch, MD
E
valuation of neck masses is a com-
mon indication for imaging chil-
dren. Fortunately, most lesions are
either congenital or inflammatory in ori-
gin, and only 5% of all childhood neo-
plasms occur in the head and neck. The
primary goal of imaging is to determine
the extent of the disease and suggest a dif-
ferential diagnosis based on the location
and imaging characteristics.
A reasonable differential diagnosis
can usually be made based on location
(midline or lateral), clinical history (con-
genital or acquired, presence or absence
of fever and tenderness), and imaging
characteristics (cystic versus solid). The In addition, it is the imaging modality CT is ideal for evaluating osseous erosion
remainder of this manuscript will focus of choice in children with suspected thy- in children with suspected rhabdomyosar-
on the more common cystic and solid roglossal duct cyst, not only to prove the coma, with MRI frequently performed as
masses that occur in the pediatric neck. cystic nature of the midline neck mass but an adjunct in patients with suspected
also to confirm the presence of a normal- intracranial or intraspinal extension. MRI
Imaging modalities appearing bi-lobed thyroid gland in the is the preferred method of imaging in chil-
Potential imaging modalities include lower neck.1 Ultrasound is also ideal for dren with suspected hemangioma of
conventional radiographs, ultrasound evaluating patients with suspected fibro- infancy, congenital vascular malforma-
(US), computed tomography (CT), mag- matosis colli.2,3 Ultrasound, CT, or MRI tions, cervical neuroblastoma, and neu-
netic resonance imaging (MRI) and can be used for evaluating jugular vein rofibroma. Nuclear medicine imaging is
nuclear medicine. Conventional radio- patency in patients with suspected frequently used in combination with CT
graphs are used for evaluation of patients Lemierre syndrome (internal jugular vein and/or MRI for evaluation of children
with stridor, suspected retropharyngeal thrombophlebitis and septic emboli sec- with neuroblastoma (I-123), lymphoma
abscess or adenoid hypertrophy. Ultra- ondary to pharyngotonsillitis).4,5 CT and/ (gallium-67 citrate or fluorodeoxyglucose
sound is ideal for optimally determining or MRI are frequently used to evaluate the positron emission tomography [FDG-
whether a mass is cystic or solid, as well total extent of more diffuse diseases, PET]), osteomyelitis (technetium [Tc]-
as for assessing whether a node is suppu- including inflammatory, congenital, and 99m-methylene diphosphonate [MDP],
rative and for guiding abscess drainage. neoplastic processes. Since imaging with gallium-67 citrate) and other neoplasms.
MRI frequently requires sedation in chil-
Dr. Koch is a Staff Radiologist, Neurora- dren less than 6 or 7 years of age, CT of Cystic neck masses
diologist, Associate Professor of Radiol- the neck is more frequently performed on The majority of cystic neck masses in
ogy, and Assistant Professor of Pediatrics, these children. CT of the neck is also fre- children are congenital malformations
Department of Radiology, Cincinnati
Children’s Hospital Medical Center, quently performed in combination with and include thyroglossal duct cysts, bran-
Cincinnati, OH. CT of the chest/abdomen/pelvis in chil- chial apparatus cysts, dermoid cysts, and
dren with neoplasms such as lymphoma. lymphatic malformations.
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2. CHILD WITH A NECK MASS
A B
FIGURE 1. Thyroglossal duct cyst. (A) Transverse sonographic image shows a hypoechoic well-defined paramidline neck mass with a thin
imperceptible wall and increased through-transmission. (B) Transverse sonographic image in the lower neck shows a normal-appearing bi-
lobed thyroid gland.
FIGURE 3. Diagram of the face shows distribution of first branchial apparatus anom-
alies (Figure reprinted with permission from Olsen KD, Maragos NE, Weiland LH. First
FIGURE 2. Thyroglossal duct cyst. Axial CT image branchial cleft anomalies. Laryngoscope. 1980;90:423-43611; and from Benson MT,
shows a low-attenuation nonenhancing midline Dalen K, Mancuso AA. Congenital anomalies of the branchial apparatus: Embryology
mass at the base of the tongue. and pathologic anatomy. RadioGraphics. 1992;12:943.12)
Thyroglossal duct cysts 59% are at the hyoid bone, and 25% evaluate for a normal-appearing bi-lobed
The thyroglossal duct (TGD) is a nor- to 65% are in the infrahyoid neck.7,8 thyroid gland in the lower neck and to
mal fetal structure that extends from the Patients typically present with a midline confirm the cystic nature of the midline
foramen cecum at the posterior aspect of neck mass that elevates with swallowing neck mass.1 Uncomplicated thyroglossal
the tongue to the lower neck in the region or protrusion of the tongue. If infected, duct cysts may be anechoic, hyperechoic,
of the thyroid bed. The TGD normally they might present with warmth, ery- or heterogeneous on US. The presence of
involutes during the 5th or 6th week of thema, and fever. In the past, nuclear med- intralesional echoes does not imply super-
fetal life. If any portion of the duct does icine imaging with Tc-99m-pertechnetate imposed infection or hemorrhage (Figure
not involute, remnant secretory epithe- was used to assess for the presence of a bi- 1).9 On CT and MRI, thyroglossal duct
lium may form a cyst.6,7 Most TGD cysts lobed thyroid gland in the lower neck and cysts will appear as fluid-filled cysts of
occur in the midline. Twenty percent rule out ectopic thyroid in the midline variable attenuation and signal intensity,
to 25% are in the suprahyoid neck, 15% to mass. More recently, US has been used to depending on the protein content of the
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3. CHILD WITH A NECK MASS
A B
FIGURE 4. First branchial apparatus anomaly. Axial fast spin-echo images (A) at the level of the parotid gland and (B) at the level of the lower aspect
of the external auditory canal show two hyperintense cystic masses that were connected by a small fluid-filled tract (images of the tract not included).
FIGURE 6. Diagram shows the course of the thymopharyngeal duct. (Figure
FIGURE 5. Second branchial apparatus cyst. Axial postcon- reprinted with permission from Benson MT, Dalen K, Mancuso AA. Congenital
trast CT image shows a well-defined, low-attenuation, nonen- anomalies of the branchial apparatus: Embryology and pathologic anatomy.
hancing left neck mass anterior to the sternocleidomastoid RadioGraphics. 1992;12:94312; and from Zarbo RJ, McClatchey KD, Areen
muscle, lateral to the carotid sheath, and posterior to the sub- RG, et al. Thymopharyngeal duct cyst: A form of cervical thymus. Ann Otol
mandibular gland. Rhinol Laryngol. 1983;92(3 Pt 1):284-289.15)
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4. CHILD WITH A NECK MASS
A B
FIGURE 7. Third branchial apparatus anomaly—thymic cyst. (A) Axial post-
contrast CT image at the level of the hyoid bone shows a well-defined, low-
attenuation, nonenhancing mass in the region of the carotid sheath
deviating the internal carotid artery anteriorly (arrow) and the jugular vein lat-
erally (arrowhead). (B) Axial postcontrast CT image at the level of the upper
mediastinum shows extension of the low-attenuation mass to the expected
level of the thymus.
FIGURE 8. Dermoid cyst. Axial postcontrast CT image shows a FIGURE 9. Lipoma. Axial postcontrast CT of the lower neck shows a lobu-
low-attenuation, nonenhancing right paramidline anterior neck lated fat-attenuation mass at the cervicothoracic junction.
mass deep to the strap muscles. Differential diagnosis includes
a thyroglossal duct cyst.
cyst (Figure 2). If there is superimposed of gestation and consist of 6 pairs of meso- Patients typically present with masses or
infection, there may be edema in the adja- dermal branchial arches separated by sinus tracts, with or without recurrent
cent soft tissues and peripheral contrast 5 paired endodermal pharyngeal pouches infection. The cysts may be imaged with
enhancement. Treatment of thyroglossal internally and 5 paired ectodermal bran- CT, US, or MRI. MR imaging is ideal in
duct cysts is surgical excision (Sistrunk chial clefts externally. Anomalies of the evaluating the fluid-filled tract, which
procedure) that includes excision of the branchial apparatus may be in the form of may extend from the more superficial cyst
cyst, the entire remnant tract, and a central cysts, sinus tracts, or fistulae. Branchial to the external auditory canal (Figure 4).
portion of the hyoid bone.10 apparatus cysts are the most common Second branchial apparatus cysts are
branchial apparatus anomalies that re- the most common and account for up to
Branchial apparatus anomalies quire imaging. 95% of all branchial apparatus anomalies.
Normal branchial apparatus embryol- First branchial anomalies account for Most are located anterior to the sternoclei-
ogy is quite complex and beyond the only 8% of all branchial anomalies and domastoid muscle, posterior to the sub-
scope of this manuscript. However, in are usually cysts or sinuses near the ex- mandibular gland and lateral to the carotid
general, the branchial apparatus structures ternal auditory canal, the pinnae, or the sheath (Figure 5). Occasionally, cysts may
develop between the 4th and 6th week region of the parotid gland (Figure 3).11-13 protrude between the internal and external
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5. CHILD WITH A NECK MASS
FIGURE 11. Lymphatic malformation. Axial fast spin-echo
image of the neck shows a multilocular right neck mass deep
FIGURE 10. Lymphatic malformation. Axial postcontrast CT image shows a low- to the sternocleidomastoid muscle with several fluid-fluid lev-
attenuation nonenhancing left supraclavicular neck mass that extends to the els consistent with blood products secondary to prior intra-
posterior paraspinal soft tissues of the upper back. lesional hemorrhage.
FIGURE 12. Mixed lymphatic and venous malformation. FIGURE 13. Fibromatosis colli. Longitudinal sonographic image of the right neck
Postcontrast axial CT images show an enlarged right shows diffuse enlargement of the right sternocleidomastoid muscle with fairly
palatine tonsil without significant contrast enhancement, homogeneous echoes.
with multiple intralesional small round calcifications con-
sistent with phleboliths.
carotid arteries; rarely, they are deep to the imaging characteristics on all modalities. fuses in the anterior mediastinum along the
platysma muscle and anterior to the sterno- The key to making this diagnosis is the course of the thymopharyngeal duct. Simi-
cleidomastoid muscle or located directly location of the lesion. lar to the thyroglossal duct cysts, when the
adjacent to the pharyngeal wall.14 As with The most common third branchial duct fails to involute, a cyst may occur
other cysts, these lesions will be hyper- apparatus anomaly is the thymic cyst. anywhere along the thymopharyngeal duct
echoic or anechoic on US, low in attenua- These are rare remnants of the third from the angle of the mandible to the upper
tion on CT, and fluid in signal intensity on branchial pouch. In normal embryologic mediastinum (Figure 6).12,15 There may be
MRI unless there is associated superim- development, the thymic primordia intralesional echoes on US with or without
posed infection, which will change the migrates from the pharynx caudally and superimposed hemorrhage or infection.
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6. CHILD WITH A NECK MASS
FIGURE 15. Cat-scratch disease. Axial post-
contrast CT of the neck shows right greater
than left enlarged anterior and posterior cer-
vical chain lymph nodes in a toddler without
fever, erythema, or pain. The boy had a
recent history of a cat bite to the tongue.
tory tract infection or intralesional hem-
orrhage. Although they may be seen in
genetic syndromes such as Turner’s syn-
drome, Noonan’s syndrome, and trisomy
FIGURE 14. Mycobacterium avium intracellulare adenopathy. Axial postcontrast CT images 21 syndrome, most LMs occur in chil-
reveal multiple intraparotid and periparotid left neck nodes with low-attenuation centers with- dren with normal karyotype.
out significant edema in the subcutaneous fat.
Lymphatic malformations can be
Up to 50% of cervical thymic cysts will as midline neck masses with variable divided into microcystic, macrocystic,
be continuous with the mediastinal thy- attenuation, echogenicity, and signal or mixed lesions. They may be unilocu-
mus (Figure 7).16 Cervical thymic cysts intensity, depending on internal con- lar, multilocular, focal, or diffuse/infil-
are intimately associated with the tents (Figure 8). If fat globules are trative. The fluid-filled spaces are
carotid sheath; they frequently splay the identifiable on CT or MRI, then a der- usually anechoic or hypoechoic on US
carotid artery and jugular vein, particu- moid cyst is the most likely diagnosis. and usually have low attenuation on CT
larly when they involve the suprahyoid If there are associated calcifications, and fluid signal intensity on MRI. There
neck. As with other branchial apparatus then the lesion is more likely a ter- may be minimal enhancement of inter-
anomalies, the location is the key to atoma or venous malformation. If the nal septations.17-20 They are the primary
suggesting the diagnosis. In a child, any lesion is entirely composed of fat, then cystic malformation to present with
cystic mass that involves the neck and simple lipoma is the most likely diag- transspatial involvement (Figure 10). Of
also extends to the anterior mediastinum nosis (Figure 9). all cystic lesions in the neck, LMs are
should certainly suggest a cervical the most likely to hemorrhage, fre-
thymic cyst. Lymphatic malformations quently resulting in intralesional fluid-
Lymphatic malformations (LMs) are fluid levels (Figure 11). As with other
Dermoid cysts and epidermoid cysts vascular malformations composed of cystic lesions, if there is superimposed
Dermoid cysts may contain squa- primative embryonic lymph sacs of infection, the imaging characteristics
mous epithelium and skin appendages varying sizes. Lymphatic malformations will change accordingly.
such as hair follicles and sebaceous typically increase in size as the child Lymphatic malformations are fre-
glands. Epidermoid cysts contain only grows, and they may show rapid increase quently part of mixed vascular mal-
squamous epithelium. Both may present in size in association with upper respira- formations, with the most common
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7. CHILD WITH A NECK MASS
A B
FIGURE 16. Mononucleosis. (A) Lateral scout film obtained from a CT shows marked enlargement of the adenoids and near complete obstruc-
tion of the nasopharyngeal airway. (B) Axial postcontrast CT image at the level of the palatine tonsils shows bilateral enlargement of the palatine
tonsils as well as bilateral anterior and posterior cervical chain lymphadenopathy in this 16-year-old with mononucleosis.
additional component being a venous including fibromatosis colli, inflamma- Inflammatory adenopathy
malformation. The venous malforma- tory adenopathy, hemangioma, neurofi- Nonsuppurative adenitis is the most
tion component may appear as a cystic broma, teratoma, lymphoma, rhabdomyo- common non-neoplastic solid neck mass
malformation on precontrast images but sarcoma, neuroblastoma, and metastatic in children. The majority of children with
will show postcontrast enhancement and adenopathy. uncomplicated cervical adenitis are
may contain phleboliths (Figure 12). treated medically and do not require imag-
When LMs are complex and transspatial Fibromatosis colli ing. If they are toxic-appearing or have
or when they involve multiple structures Fibromatosis colli or sternocleido- symptoms that increase despite adminis-
of the neck (eg, airway, tongue, floor of mastoid tumor of infancy occurs in tration of antibiotic therapy, postcontrast
mouth) or the parotid gland, and in neonates. The etiology is uncertain but CT imaging is frequently performed to
patients with combined vascular malfor- may be related to intramuscular hemor- assess the extent of the inflammatory
mations, MR imaging is the preferred rhage or fibrosis. There is an increased process and rule out a focal abscess. When
modality.18-20 risk in neonates with a history of breech imaging children with cervical adenitis,
The preferred treatment of LMs is sur- presentation and/or difficult delivery. the key questions to be answered are loca-
gical excision. However, complete surgi- Patients typically present at 2 to 4 weeks tion of abscess, extent of cellulitis and
cal excision may be difficult when the of age with a unilateral neck mass, myositis, and evaluation of the vascular
lesions are microcystic and infiltrative. with or without torticollis. Ultrasound structures of the neck to exclude jugular
Macrocystic lesions may also be treated is the imaging modality of choice, vein compression or thrombosis as well as
with percutaneous sclerotherapy, includ- showing focal or diffuse enlargement narrowing of the internal carotid artery.25
ing alcohol solution, cyclophosphamide, of the ster-nocleidomastoid muscle Lymphadenitis may be secondary to viral
bleomycin and doxycycline.21-23 (SCM), which may be homogeneous disease, bacterial disease, mycobacterial
or heterogeneous in echotexture (Fig- disease, or fungal disease. Nonsuppura-
Solid neck masses ure 13). There may be a rim of de- tive inflammatory adenitis has a typical
The remainder of this manuscript will creased echoes thought to represent appearance on all imaging modalities
focus on benign and malignant extra thy- compressed normal adjacent stern- showing multiple (sometimes conglomer-
roid solid neck masses in children, ocleidomastoid muscle.2,3,24 ate) nodes. Hilar flow is demonstrated on
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8. CHILD WITH A NECK MASS
FIGURE 17. Abscess. Axial postcontrast CT image of the neck FIGURE 18. Hemangioma. Axial postcontrast CT image shows diffuse
shows a low-attenuation left submandibular collection with a enhancement of a large neck mass that replaces the deep and superficial
very irregular, mildly enhancing wall and associated edema of portions of the right parotid gland in an infant.
the adjacent subcutaneous fat and several small lymph nodes
at the periphery.
FIGURE 19. Hemangioma. Axial postcontrast T1- FIGURE 20. Neurofibroma. Axial fast spin- FIGURE 21. Teratoma. Axial postcontrast
weighted image shows diffuse homogenous contrast echo image at the level of the epiglottis CT image of the upper neck shows a large
enhancement of a left parotid gland mass with multi- shows large bilateral symmetric carotid heterogeneous neck mass in this neonate.
ple intralesional high-flow vessels. sheath masses and elongated serpiginous There are multiple areas of fat attenuation
suboccipital masses. The right suboccipital as well as multifocal areas of calcification.
lesions show focal central areas of
hypointensity typical of a target sign, which
is consistent with neurofibroma.
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9. CHILD WITH A NECK MASS
A B
FIGURE 22. Lymphoma. (A) Axial postcontrast CT image of the neck shows
bulky left anterior and posterior cervical chain lymph nodes, as well as conglom-
erate nodes posterior to the trachea deviating the trachea and thyroid anteriorly
and to the right. (B) Gallium-67 citrate scintigraphy shows uptake in the left
supraclavicular region and anterior neck in this child with Hodgkin’s disease.
A B
FIGURE 23. Lymphoma. (A) Axial postcontrast CT image shows conglomerate lymph nodes compressing the jugular vein in the left lower neck.
(B) Corresponding fluorodeoxyglucose positron emission tomographic image shows abnormal uptake in the left supraclavicular region, as well
as in the left mediastinum.
US. Nontuberculous mycobacterial dis- tis presents with significant cervical Hemangioma of infancy
ease may lack evidence of surrounding adenopathy and associated enlargement Hemangioma of infancy is a benign
cellulitis and myositis and may contain of the palatine and adenoid tonsils, mono- neoplasm resulting from endothelial pro-
small calcifications or low-attenuation nucleosis should be considered (Figure liferation, which usually presents in chil-
centers (Figure 14).26-28 Cat-scratch disease 16). A well-defined or irregularly shaped dren less than 6 months of age, gradually
is not uncommon in children and may also fluid collection with an enhancing rim is increases over the next 2 years, and spon-
present with cervical adenopathy, without certainly suggestive of an abscess (Fig- taneously involutes over the next 5 to
significant associated cellulitis (Figure ure 17). However, these imaging charac- 7 years. In the proliferative phase, they
15). This diagnosis should be considered teristics are not 100% specific, and the demonstrate diffuse intense contrast
in any child with a history of exposure to appearance of phlegmon without true enhancement (Figure 18). High-flow
cats. If a child without evidence of celluli- drainable pus can be similar.29 intralesional flow voids will be demon-
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10. CHILD WITH A NECK MASS
FIGURE 24. Rhabdomyosarcoma. Axial postcontrast FIGURE 25. Neuroblastoma. Axial proton-density–weighted image of the neck shows a
CT image of the neck shows a large heterogeneous well-defined right neck mass in the carotid sheath deviating the carotid artery and jugular
right neck mass. This mass surrounds the carotid vein anteriorly and mildly deviating the trachea to the left.
artery and deviates it anteriorly and medially. The jugu-
lar vein is not identified.
strated on MRI (Figure 19). During the may be very well defined; plexiform
involutional phase, they show evidence lesions are ill defined and infiltrative. Fre-
of fatty infiltration and decrease in quently, neurofibromas will show vari-
size.30,31 Attention to the age of the patient able contrast enhancement, with or
with a significantly enhancing neck mass without a “target sign” composed of a
is extremely important. In an older child central area of decreased T2 signal inten-
without a prior history of a neck mass in sity and decreased contrast enhancement
infancy, similar imaging characteristics (Figure 20).32
should raise the question of sarcoma
rather than of benign hemangioma. Teratomas
Treatment of hemangioma occurring in Teratomas are neoplasms composed
an infant is usually expectant waiting. of multiple tissues that are foreign to the
Steroids, interferon, and, rarely, surgery part of the body in which the lesion
are reserved for lesions that compromise arises.33 Teratomas in children are most
the airway or are associated with signifi- commonly sacrococcygeal, and 5% to
cant loss of skin integrity. 14% occur in the head and neck region;
most of these children are less than
Neurofibromas 1 year of age at the time of diagnosis.
FIGURE 26. Neuroblastoma. Posterior I- Neurofibromas are unencapsulated These lesions contain all 3 germ layers,
123-metaiodobenzylguanidine image of the benign nerve sheath tumors of Schwann originate from pleuripotential cells, and
chest reveals focal areas of abnormal
cell origin. They may be single or multi- may be composed of mature or immature
increased radiopharmaceutical uptake in
the left shoulder and midthoracic spine in ple; when multiple or plexiform, they elements. In the neonate, the presence of
this patient with known neuroblastoma. Note almost always occur in children with neu- immature elements does not correlate
normal uptake in the salivary glands. rofibromatosis Type 1. Solitary lesions with malignant potential, and most ter-
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11. CHILD WITH A NECK MASS
atomas are benign. Most are very large and complex
A lesions containing solid and cystic components, fre-
quently with fat and calcification (Figure 21). Treatment
is surgical excision.
Malignant solid masses
Lymphoma
Malignant lymphoma accounts for approximately 50%
of head and neck malignancies in children. Approximately
50% of cervical involvement with lymphoma is due to
Hodgkin’s disease and 50% due to non-Hodgkin’s lym-
phoma. Imaging characteristics cannot distinguish
between the two. Patients may present with unilateral or
bilateral disease in both Hodgkin’s and non-Hodgkin’s
lymphoma. Lymphomatous nodes have a similar appear-
ance to inflammatory and metastatic nodes from other pri-
B mary malignancies. However, lymphomatous nodes are
frequently larger and more extensive than inflammatory
adenopathy. The differential diagnosis in children with
bulky cervical adenopathy includes mononucleosis (partic-
ularly if there is associated enlargement of the adenoids
and palatine tonsil), metastatic disease (rarely, from pri-
mary malignancy such as nasopharyngeal carcinoma,
rhabdomyosarcoma, or neuroblastoma), and lymphopro-
liferative disease (particularly in the posttransplant
patients). Imaging of patients with head and neck lym-
phoma should include CT of the involved area and adja-
cent lymph nodes as well as the chest, abdomen, and
pelvis. In addition, gallium-67 citrate scintigraphy is fre-
quently used for initial staging and follow-up (Figure 22).
Increasingly, FDG-PET is being used in evaluation of
these patients (Figure 23).
C Rhabdomyosarcoma
Rhabdomyosarcoma is the most common childhood
soft-tissue sarcoma and involves the head and neck in up
to 40% of patients.34,35 Rhabdomyosarcoma is divided by
sites of origin into orbit, parameningeal (middle ear,
paranasal sinus, nasopharynx), and all other sites. Up to
55% of parameningeal rhabdomyosarcomas have intra-
cranial extension. In these patients, CT is helpful to assess
bony destruction and MRI is complimentary to evaluate
for intracranial extension. Rhabdomyosarcoma is typi-
cally heterogeneous on all imaging modalities (Figure
24), with or without osseous erosion.34
Neuroblastoma
FIGURE 27. Metastatic adenopathy. (A) Axial postcontrast CT of the neck Neuroblastoma is the most common malignant tumor in
shows a heterogeneous left supraclavicular mass deviating the trachea to the children <1 year of age; primary lesions are usually located
right in a patient with metastatic hepatoblastoma. (B) Axial postcontrast CT in the adrenal gland and retroperitoneum. Cervical lym-
image of the neck shows large heterogeneous left neck mass deviating and
phadenopathy from neuroblastoma is most often metasta-
compressing the jugular vein in a teenager with metastatic testicular carci-
noma. (C) Axial postcontrast CT image of the neck shows a heterogeneous tic disease. Less than 5% of primary lesions are located in
low-attenuation left lower neck mass with an irregular enhancing wall in a the neck. In addition to presenting with a palpable neck
teenager with metastatic nasopharyngeal carcinoma. mass, patients may present with feeding difficulties,
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12. CHILD WITH A NECK MASS
airway symptoms, or opsomyoclonus gland excludes ectopic thyroid in patients with thy- 24. Yamaguchi M, Takeuchi S, Matsuo S. Ultrasonic
roglossal duct cyst. AJR Am J Roentgenol. 1995;164: evaluation of pediatric superficial masses. J Clin Ultra-
(opsoclonus, myoclonus, and cerebellar 1489-1491. sound. 1987;15:107-113.
ataxia), which is thought to be a paraneo- 2. Youkilis RA, Koch B, Myer CMI. Ultrasonographic 25. Hudgins PA, Dorey JH, Jacobs IN. Internal carotid
plastic syndrome. Most patients with cervi- imaging of sternocleidomastoid tumor of infancy. Ann artery narrowing in children with retropharyngeal lym-
Otol Rhinol Laryngol. 1995;104:323-325. phadenitis and abscess. AJNR Am J Neuroradiol.
cal primary lesions present with a well- 3. Chan YL, Cheng JC, Metreweli C. Ultrasonography 1998;19:1841-1843.
defined mass posterior to the carotid sheath of congenital muscular torticollis. Pediatr Radiology. 26. Nadel DM, Bilaniuk L, Handler SD. Imaging of gran-
vessels with or without intraspinal exten- 1992;22:356-360. ulomatous neck masses in children. Int J Pediatr
4. Screaton NJ, Ravenel JG, Lehner PJ, et al. Lemierre Otorhinolaryngol. 1996;37:151-62.
sion and with or without calcification.36-38 syndrome: Forgotten but not extinct––report of four 27. Hazra R, Robson CD, Perez-Atayde AR, Husson
CT and MRI nicely show the primary mass cases. Radiology. 1999;213:369-374. RN. Lymphadenitis due to nontuberculous mycobac-
(Figure 25), occasionally with intraspinal 5. Ramirez S, Hild TG, Rudolph CN, et al. Increased teria in children: Presentation and response to ther-
diagnosis of Lemierre syndrome and other Fusobac- apy. Clin Infect Dis. 1999;28:123-129.
extension. In addition to CT or MRI, I-123- terium necrophorum infections at a Children’s Hospital. 28. Robson CD, Hazra R, Barnes PD, et al. Nontu-
metaiodobenzylguanidine (MIBG) is in- Pediatrics. 2003;112:e380. berculous mycobacterial infection of the head
dicated in the workup of these children to 6. Thomas JR. Thyroglossal-duct cysts. Ear Nose and neck in immunocompetent children: CT and
Throat J. 1979;58:510-514. MR findings. AJNR Am J Neuroradiol. 1999;20:
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atr Clin North Am. 1981;28:841-844. 29. Stone ME, Walner DL, Koch BL, et al. Correlation
Metastatic adenopathy 8. Solomon JR, Rangecroft L. Thyroglossal-duct between computed tomography and surgical find-
lesions in childhood. J Pediatr Surg. 1984;19: ings in retropharyngeal inflammatory processes in
Metastatic cervical adenopathy un- 555-561. children. Int J Pediatr Otorhinolaryngol. 1999;49:
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1994;163:1475-1477. lar malformations in infants and children: A classifica-
neuroblastoma, rhabdomyosarcoma, naso- 10. Sistrunk WE. The surgical treatment of cysts of the tion based on endothelial characteristics. Plast
pharyngeal carcinoma, and thyroid carci- thyroglossal tract. Ann Surg. 1920;71:121-123. Reconstr Surg. 1982;69:412-422.
noma (Figure 27). 11. Olsen KD, Maragos NE, Weiland LH. First branch- 31. Burrows PE, Mulliken JB, Fellows KE, et al. Child-
ial cleft anomalies. Laryngoscope. 1980;90:423-436. hood hemangiomas and vascular malformation: Angio-
12. Benson MT, Dalen K, Mancuso AA, et al. Congen- graphic differentiation. AJR Am J Roentgenol. 1983;
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