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Head and Neck 10 -- Cystic Lesions


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What is the classification of cystic head and neck masses?
1) Congenital

2) Inflammatory

3) Vascular

4) Visceral saccular cysts

5) Parenchymal cysts

6) Benign tumors

7) Malignant tumors
What are the congenital cystic masses?
Branchial cleft cysts

Thyrogolssal duct cyst

Lymphangioma/cystic hygroma


Thymic cyst

Tornwaldt cyst
What are the branchial cleft custs?


What is the location of the first branchial cleft cyst?
What is the location of the second branchial cleft cyst?
Posterior submandibular space
What is the location of the third branchial cleft cyst?
Posterior cervical space
What are the most common congenital cystic head/neck masses?
Brancial cleft cysts

Thyroglossal duct cyst

Cystic hygroma

What are possible cystic lesions of the parotid space?
First branchial cleft cyst

Cystic hygroma


Obstructed parotid duct/sialocele

Warthin tumo

Cystic neural sheath tumor

Malignant tumor
Which malignant tumor of the parotid is particularly likely to be cystic?
What is the differential diagnosis of posterior submandibular space cystic lesions

(i.e. angle of mandible lesions)
Second branchial cleft cyst

Cystic hygroma

Lateral thyroglossal duct cyst


External laryngocele

Submandibular gland mucocele

Abscess or suppurative node

Diving ranula

Malignant adenopathy
What is DDx of sublingual space cystic lesion?

Simple ranula

Obstructed submandibular duct (sialocele)
Carotid space?
Juular vein thrombosis

Carotid artery aneurysm


Malignant nodes
Visceral space?
Thyroglossal duct cyst

Internal laryngocele

Cystic benign thyroid or parathyroid tumor

Cystic malignant thyroid tumor

Malignant laryngeal SCCa
Posterior cervical space?
Cystic hygroma

Abscess/suppurative node

Cystic neural sheath tumor

Malignant adenopathy
What is typical history of patient with a first branchial cleft cyst?
Multiple parotid abscesses unresponsive to treatment
What sometimes occurs clinically?
It will recurr otherwise
Angle of mandible
What else can be seen clinically?
Cutaneous opening.
What is imaging appearance?
Cystic mass in parotid space
Where exactly is cyst?
May be superficial to, within, or deep to parotid
Where can it extend?
Parapharyngeal space if deep part of gland involved
How common is the lesion?
Second branchial cleft cyst--Where can it protrude to?
Posterior cervical space
What can this then be confused with?
Third branchial cleft cyst
How common is third branchial cleft cyst?
RARE cyst located in posterior cervical space
Where can thyroglossal duct cyst present?
Anywhere from foramen cecum to pyramidal lobe of thyroid
Where does is present, in most cases?
Between hyoid and pyramidal lobe of thyroid
What is it called when thyroglossal duct cyst dissects from hyoid region back up through tongue base towards foramen cecum?
Suprahyoid thyroglossal duct cyst
What percentage of thyroglossal duct cysts are suprahyoid?
What percent are at or just below hyoid?
What does the cyst look like on imaging?

In what structures is the TDC nestled?
Strap muscles
What is its appearance in relationship to them?
Seems to "beak" over the edges of the cyst
What is true of the TDC as it gets closer to the thyroid?
Can be off midline, as it approaches the thyroid lobes
What is important in imaging?
Must image the whole course of the cyst, which will be above the cyst.
What modality is best?
MRI, T2W (fat sat)
What is treatment
What is the surgery like?
What are the most common sites for cystic hygroma, in order?
Posterior cervical space



What is true of spatial localization of cystic hygromas?
They are transspatial
Where is epidermoid most commonly located?
Under the tongue
What is the source of 1/3 of all neck infections?
What precedes most cases of peritonsillar abscess?
How does multispatial infection occur sometimes?
Rupture of suppurative lymph node
What is evidence of Tb adenitis?
Multiple mixed high and low density nodes
What is a retention cyst?
Blocked secretion
What is retention cyst of the sublingual gland called?
What is retention cyst of the submandibular gland called?
What is retention cyst of the tonsil (faucial or adenoidal) called?
Retention cyst
What is retention cyst of lingual tonsil (tongue base)?
Vallecular cyst
Paranasal sinus?
Retention cyst
What is a laryngocele?
Obstruction of the laryngeal ventricle or its sacculus (appendix) is functionally obstructed, and presses into the submucosal space.
What types of things functionally obstruct?
Increased intraglottic pressure, such as excessive coughing, playing instrument, blowing glass
What is other cause of laryngocele?
Obstruction of the proximal aspect (i.e. stump) of the saccule by tumor, trauma, or postinflammatory stenosis
What is a simple laryngocele?
Laryngocele in submucosal location within the paralaryngeal (paraglottic) space of the supraglottis.
What clinches the diagnosis of simple laryngocele?
Can follow the lesion back to the supraglottis
What is an external laryngocele?
The laryngocele continues to dissect through the submucosal space, and pops out of the larynx.
How does it pop out?
Thyrohyoid membrane
Where is it when it pops out?
Lower submandibular space
What is the other name for external laryngocele?
Mixed larnyngocele
What is a secondary laryngocele?
Those forming secondary to tumor obstruction at the opening to the laryngeal ventricle
In which patients should laryngocele be cause for alarm?
Any adult smoker.
What should be done?
Search of the lower supraglottis radiographically AND clinically for tumor.
What is a complication of laryngocele?
What is this called?
What is the appearance
Wall thicking of laryngocele
What is Zenker's diverticulum?
Outpouching of the posterior wall of the upper esophagus
What is CT appearance?
Oval mass in posterior visceral space
What does it contain?
"foamy" material
What is the name of typical thyroid cyst?
Colloid cyst
What is presentation of colloid cyst?
Rapidly enlarging tense lower neck mass
What may make it painful?
Hemmorhage into lesion
How easy is the diagnosis to make?
Easy if very small, but if large may be unsure where lesion arises. Also, cannot always differentiate from other lesions in DDx.
What is in DDx of unilocular thyroid cyst?
Degenerated goiter

Necrotic tumor

What is characteristic displacement pattern of thyroid lesions?
Trachea displaced contralaterally

Carotid space displaced to ipsilateral side
What else can have cyst in this region as well, further confusing issue?
How common are thymic cysts?
Very rare
When do they occur?
2/3 in 1st decade

1/3 in 10s-20s

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