Head and Neck 10 -- Cystic Lesions
Terms
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- What is the classification of cystic head and neck masses?
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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?
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Branchial cleft cysts
Thyrogolssal duct cyst
Lymphangioma/cystic hygroma
Epidermoid/dermoid
Thymic cyst
Tornwaldt cyst - What are the branchial cleft custs?
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First
Second
Third - What is the location of the first branchial cleft cyst?
- Periparotid
- 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?
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Brancial cleft cysts
Thyroglossal duct cyst
Cystic hygroma
Dermoid/epidermoid - What are possible cystic lesions of the parotid space?
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First branchial cleft cyst
Cystic hygroma
Abscess
Obstructed parotid duct/sialocele
Warthin tumo
Cystic neural sheath tumor
Malignant tumor - Which malignant tumor of the parotid is particularly likely to be cystic?
- Mucoepidermoid
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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
Dermoid
External laryngocele
Submandibular gland mucocele
Abscess or suppurative node
Diving ranula
Malignant adenopathy - What is DDx of sublingual space cystic lesion?
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Epidermoid
Simple ranula
Obstructed submandibular duct (sialocele) - Carotid space?
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Juular vein thrombosis
Carotid artery aneurysm
Abscess
Malignant nodes - Visceral space?
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Thyroglossal duct cyst
Internal laryngocele
Cystic benign thyroid or parathyroid tumor
Cystic malignant thyroid tumor
Malignant laryngeal SCCa - Posterior cervical space?
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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?
- Otorrhea
- Why?
- It will recurr otherwise
- Where?
- 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?
- RARE
- 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?
- 20%
- What percent are at or just below hyoid?
- 80%
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What does the cyst look like on imaging?
Position? - Midline
- 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
- Removal
- What is the surgery like?
- Meticulous
- What are the most common sites for cystic hygroma, in order?
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Posterior cervical space
Submandibular
Parotid
Sublingual - 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?
- Pharyngitis
- What precedes most cases of peritonsillar abscess?
- Pharyngitis
- 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?
- Ranula
- What is retention cyst of the submandibular gland called?
- Mucocele
- 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?
- Infection
- What is this called?
- Pyolaryngocele
- 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?
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Degenerated goiter
Necrotic tumor
Abscess - What is characteristic displacement pattern of thyroid lesions?
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Trachea displaced contralaterally
Carotid space displaced to ipsilateral side - What else can have cyst in this region as well, further confusing issue?
- Parathyroid
- How common are thymic cysts?
- Very rare
- When do they occur?
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2/3 in 1st decade
1/3 in 10s-20s