Cystic Neck Research Articles

Abnormal Fetal Cystic Left Neck Mass.

An abnormal fetal cystic left neck mass was found on ultrasonography at 18 weeks gestation in a young woman. Fetal magnetic resonance imaging (MRI) demonstrated a large cystic anterior neck mass (Figure, A, sagittal view, and Figure, B, axial view, on T2-weighted half-Fourier acquired single turbo spin-echo [HASTE] MRI). The tracheoesophageal displacement index (TEDI) was found to be 24 mm. The neonate did well at the cesarean delivery (scheduled owing to the mother’s previous cesarean delivery) and had initial Apgar scores of 7 (1 minute) and 9 (5 minutes). Subsequently, the infant was intubated owing to increased difficulty with milky oral secretions and respiratory distress. Examination of the infant revealed a 5-cm, soft, fluctuant, and mobile neck mass that caused the head to deviate to the right with no cutaneous involvement. On day 2 of life, the mass had an air-fluid level and was markedly hyperintense on axial T2-weighted MRI with fat saturation (Figure, C). It appeared to be predominantly in the retropharyngeal space, anterior to the left carotid artery, and extended to abut themedial aspect of the right carotid sheath.Onday8of life, direct laryngoscopydemonstratedbulging in the left lateralpharyngealand retropharyngealwalls.Whentheneckmasswascompressed,air and fluid escaped froma communicating sinus lateral to the arytenoids in the left pyriform sinus (Figure, D). The mass was excised. A tract was isolated and ligated at the pyriform sinus, deep to the left thyroid lobe. The thyroid lobe was uninvolved. The patient was extubated on day 9 of life and had no problems breathing. What is your diagnosis? 80 mm 80 mm A B

Topical application of lipophilic anhydrous gel rich in vitamin E in the management of scars in patients surgically treated for neck cysts

Topical application of lipophilic anhydrous gel rich in vitamin E in the management of scars in patients surgically treated for neck cysts

Measurement of fine‐needle aspiration thyroglobulin levels increases the detection of metastatic papillary thyroid carcinoma in cystic neck lesions

Patients with previously resected papillary thyroid carcinoma (PTC) are monitored for disease recurrence/metastasis by ultrasound surveillance and fine-needle aspiration (FNA) cytology. However, accurate diagnosis in lesions with cystic degeneration may be difficult due to scant cellularity. In the current study, the authors evaluated thyroglobulin in FNA (Tg-FNA) for detecting metastatic and/or recurrent PTC in patients with cystic neck lesions after thyroidectomy. The pathology records were retrospectively searched for patients with previously resected PTC and subsequent Tg-FNA on a cystic neck mass. Tg-FNA was measured in needle rinses using a Tg assay. The ultrasound findings, Tg-FNA concentrations, and cytological and follow-up histological diagnoses were correlated. A total of 21 FNA specimens of cystic lesions from 19 patients were identified. Of 7 cases with cytologic and subsequent histologic diagnoses of metastatic PTC, the median Tg-FNA level was 100,982 ng/mL. Of 8 cytologically benign cases, 7 cases had Tg-FNA levels < 0.2 ng/mL, and 1 aberrant case demonstrated elevated Tg-FNA of > 1000 ng/mL. For 6 cytologically equivocal cases, including 3 classified as atypical/suspicious for carcinoma, 2 classified as insufficient/acellular debris, and 1 classified as spindle cell neoplasm, 4 patients demonstrated markedly elevated Tg-FNA levels (> 150 ng/mL) with subsequent surgical confirmation of metastatic PTC, whereas 2 patients had Tg-FNA levels of < 0.2 ng/mL with negative follow-up. Using a cutoff value of 0.2 ng/mL, Tg-FNA demonstrated a sensitivity of 100% and specificity of 87.5%. Tg-FNA is a useful ancillary test that improves the detection of cystic PTC metastases. Particularly in cytologically nondiagnostic cases, the measurement of Tg-FNA helps to distinguish benign from malignant cystic lesions.

Ultrasound-guided sclerotherapy for benign non-thyroid cystic mass in the neck.

Surgical excision has traditionally been the treatment of choice for benign non-thyroid cystic neck masses, including lymphatic malformation, ranula, branchial cleft cyst, thyroglossal duct cyst, and parathyroid cyst. However, there is a tendency toward recurrence after surgery, and surgery may be accompanied by complications, including nerve injuries, vascular injuries, and scar formation. Ultrasound-guided sclerotherapy using various agents has been challenged and successfully applied as an alternative treatment for benign non-thyroid cystic neck masses. This report reviews the available sclerosing agents and describes the applications of sclerotherapy to the treatment of benign cystic masses in the neck.

A Case of Lateral Neck Cyst with Ectopic Thyroid Papillary Carcinoma

Thyroid develops from median rudiment which is a surface elevation dorsal to the tuberculam impar and forms by proliferation of endodermal cells. Lateral thyroid element of the fourth pouch contributes in the development of thyroid gland. Failure of the lateral thyroid element to fuse with the median element may result in a lateral ectopic thyroid gland. In the present case, patient initially presented with lateral neck cyst. There were two possibilities in the patient: a) a cystic degeneration of lymph node metastasis from an occult thyroid papillary carcinoma and b) thyroid papillary carcinoma arising from ectopic thyroid tissue within a branchial cleft cyst. Histological examination demonstrated foci of normal thyroid glands along with evidence of papillary thyroid carcinoma. These finding favours the possibility of malignant transformation of follicular epithelial cells of ectopic thyroid tissue within a branchial cleft cyst. There was a focus of papillary thyroid carcinoma in the resected total thyroidectomy specimen. So differentiation between two possibilities becomes difficult in this patient. A papillary thyroid carcinoma found with a cyst of the lateral neck represents a diagnostic and therapeutic dilemma.

Cervical thymic cyst in an adult.

Cervical thymic cysts (CTCs) are unusual lesions, representing only 1% of cystic cervical masses. Diagnosis of this condition in adults is even rarer. We report a 34-year-old female who presented with asymptomatic progressively growing left-sided neck swelling. Neck ultrasound (US) showed a large cystic lesion with septation, compressing the ipsilateral vessels. Magnetic resonance imaging (MRI) confirmed the US findings. Surgical excision was performed which subsequently showed findings consistent with CTC. CTC in adult is extremely rare, with few reported cases identified in the literature. Thymic gland anomalies in the neck are the consequences of an arrest in the descent of the gland, sequestration of the thymic tissue, or failure of involution. The diagnosis of this condition is rarely done prior to surgical excision. The clinical presentation, radiologic imaging, surgical findings, and histologic appearance are all essential components to make the correct diagnosis of this very rare differential diagnosis of cystic lateral neck swelling.

Giant Thoracocervical Lymphangioma with Multivisceral Involvement: A Different Concept

ABSTRACT Background Lymphangiomas are benign lymphatic malformations frequently seen in head and neck region. Most reported cases are cervical lesions with mediastinal extension.1,2 Most are conceived as due to failure of fetal lymph sacs. Synchronous or metachronus lymphangiomatosis with cystic hygroma of the neck is also reported.3 Case details Massive multicompartmental mediastinal lymphangioma with cervical extension and concomitant visceral involvement is presented. It is proposed as a hamartomatous tumor rather than malunion of fetal jugular lymphatic sacs.2 Solid intrathoracic component with cystic neck extension supports mediastinal origin. Cell culture lines at 4 months were positive for endothelial cell lines positive for factor VIII antigen. Conclusion Giant thoracocervical lymphangioma is more likely to be a tumor rather than simple fetal failure of lymphatic sac fusion. Surgical excision is curative. How to cite this article Prasad GR, Nori M, Naseeruddin MD Rao JVS, Quadri SS. Giant Thoracocervical Lymphangioma with Multivisceral Involvement: A Different Concept. Int J Phonosurg Laryngol 2014;4(2):63-66.

Thyroglossal duct cyst and sinuses: A 20-year Los Angeles experience and lessons learned

BackgroundFirst described in 1920 and later modified in 1928, the Sistrunk procedure substantially reduced the incidence of recurrence of midline neck cysts compared with a local excision or cystectomy. The purpose of this study was to determine if the rate of recurrence was influenced by performing either a ‘classic’ or a ‘modified’ Sistrunk procedure, if the recurrence rate was influenced by the physician's training, how successful we have been in managing patients with a recurrence? Finally, is outpatient surgery safe for Sistrunk procedures? MethodsWe performed a retrospective review of all patients with a thyroglossal duct remnant (TGDR) who were seen at the Children's Hospital Los Angeles (CHLA) from 1990 to 2010. The following data were collected: patient age, gender, presence or absence of a pre-operative infection, imaging studies, type of procedure performed, the attending surgeon's training background, inpatient or outpatient status, and complications. ResultsA total of 128 patients (61% male, 39% female) met the inclusion criteria. The age ranged from 2 months to 14 years (mean of 5.1 years). A total of 137 procedures were performed; 114 (83.2%) for primary and 23 (16.8%) for secondary disease. Complications included post-operative infection (10.9%), recurrence of disease (6.6%), undesirable scar (5.8%), and fistula (2.9%). Surgeons with fellowship-training in pediatric otolaryngology had a recurrence rate of 4.0% and surgeons with fellowship-training in pediatric surgery or pediatric plastic surgery had a recurrence rate of 30.1%. Twenty patients had a ‘classic’ Sistrunk (14.6%) and 117 (85%) had a ‘modified’ procedure. Patients were admitted after surgery in 78 cases (56.9%) and 59 patients (43.1%) had an outpatient (OPD) procedure. ConclusionsThere is no place for cystectomy in the treatment of TGDR. A ‘modified’ Sistrunk procedure is the procedure of choice in both primary and revision cases. Wide local excision of recurrences is required and a ‘classic’ Sistrunk should be considered. Specific training to gain an intimate knowledge of the anatomy in and around the larynx and experience with multiple cases reduces the incidence of recurrence. Outpatient surgery is safe and effective for selected patients who undergo a Sistrunk procedure.

English

Cystic masses of neck consist of a variety of pathologic entities. The precise anatomical location and imaging appearances are important for accurate diagnosis and formulating the differential diagnoses. The age of presentation and clinical examination narrow down the differential diagnosis. US is useful in differentiating solid from cystic neck lesions. Ultrasound is often used for pre-treatment assessment. AIM&OBJECTIVE: To use readily available, relatively inexpensive, and non-ionizing radiological imaging technique for pre-treatment assessment of cystic lesions of neck. MATERIAL & METHODS: This study is conducted in department of Radio-diagnosis of TMMC &RC, TMU, Moradabad, in which we included patients of all age groups and both sexes. Imaging of neck lesions was done by Ultrasound using Scanners with 7-10 MHz transducers on MEDISON Diagnostic ultrasound system installed in department of Radio-diagnosis, TMMC&RC, Moradabad. Analytical Test: “t”-test. RESULT: 7.5% of cases were diagnosed of having cystic lesions of the neck, having approximately same occurrence in both male and females (p>.005). CONCLUSION: Cystic lesions of the neck are commonly seen as palpable neck masses. Clinical presentation along with imaging features, anatomical location, extent, internal composition,as assessed by US(Ultrasound) help in pre-treatment assessment.

Primary Multilocular Hydatid Cyst of Neck with Unique Presentation: A Rare Case Report and Literature Review

Hydatid cyst (HC) is a parasitic infection caused by larva form of Echinococcus. It occurs frequently in liver and lungs. Primary HC of neck is extremely rare occurrence and here we report it with unusual presentation. A 35-year-old male presented with slowly growing painless swelling in right side of neck for 6-7years. The swelling measured 11×6cm and cough impulse elicited on local examination. MRI scan revealed a multiloculated cystic lesion in neck. Fine needle aspiration cytology yielded fluid aspirate and smear showed fragment of laminated membrane, suggestive of HC. The intact cyst was removed surgically and histopathologic examination confirmed the diagnosis of HC. Both clinicians and radiologists should consider HC in differential diagnosis of head and neck swelling for proper management.

US imaging of benign cystic neck masses

Neck cysts are sporadic findings in neck ultrasonography, sometimes manifest with swelling and sometimes as incidental findings.

Human papillomavirus‐related head and neck squamous cell carcinoma

Human papillomavirus‐related head and neck squamous cell carcinoma

Thyroglobulin Measurement in Fine Needle Aspirates (Tg-FNA) of Cystic Neck Masses for Detection of Papillary Thyroid Carcinoma (PTC)

Introduction: Nuclear pseudoinclusions are one of the most specific pathologic features in diagnosing papillary thyroid carcinoma (PTC). However, the biologic nature of these pseudo-inclusions is largely unknown. Beta-catenin is an oncoprotein involved in Wnt signaling pathway which is activated in several malignancies including PTC. Using immunohistochemistry, we studied the expression of beta-catenin in PTC and hyalinizing trabecular adenoma (HTA), with particular focus on its expression in pseudoinclusions, both on histologic sections and on cytologic specimens. Materials and Methods: A cohort of 13 cases, including 8 cases of PTC and 5 cases of HTA, was applied in this study. Beta-catenin immunohistochemitry was performed on histology block recuts and cytology slides of each case. The beta-catenin labeling index of pseudoinclusions was counted in 15 high power fields and calculated in comparison with those counted on immediate next H&E stained histologic slides. Cytology slides were digitally scanned before destaining and restaining with beta-catenin. The number of beta-catenin-labeled pseudo-inclusions was compared with those digitally scanned slides. Results: On histologic sections, neoplastic cells from both PTC and HTA show much stronger membranous staining pattern of beta-catenin, compared to adjacent normal follicles or colloid nodules. However, labeling index of beta-catenin for nuclear pseudo-inclusions is significantly different between PTC and HTA. Strong intranuclear staining of beta-catenin was seen in 93.5% (range of 72-100%) of the pseudoinclusions in PTC, while only 6.4% (range of 0-13%) of pseudo-inclusions in HTA showed positive staining pattern (p<0.001). For cytologic slides, although it demonstrated similarly strong membranous staining pattern for beta-catenin in PTC cells, none of the nuclear pseudo-inclusions in both PTC and HTA was labeled with beta-catenin antibody on cytologic smears. Conclusions: Overexpression of the beta-catenin oncoprotein was seen in majority of the nuclear pseudo-inclusions in PTC, but only rarely seen in HTA. This differential expression suggests that activation of the betacatenin is likely involved in the formation of “malignant peudoinclusions” in PTC, but not in “benign peudoinclusions” in HTA. The failure of betacatenin labeling of pseudoinclusions on cytologic slides may be in part attributed to inability of the antibody to penetrate into nucleus through the intact cell membranes in cytologic preparations.

A Case of Pancreatic Retention Cyst Mimicking a Cystic Mucinous Neoplasm

Context An increased number of pancreatic cysts are being diagnosed due to the increased use of cross-sectional imaging and new technologies. Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) cytology and molecular analysis of the cystic fluid have led to a better characterization the pancreatic cysts, but some diagnosis still remain an enigma until surgery. Case report We present the case of a 63-year-old female, with no history of pancreatitis, who came to our attention with a pancreatic cyst. An abdominal ultrasound was performed because of abdominal discomfort and a cyst of the pancreatic neck was detected. The patient underwent a CT that confirmed a 4 cm cyst, with thin wall. She underwent a first EUS that revealed a 4 cm cyst with thin septa and thin wall, not communicating with the pancreatic duct. The fluid aspirated under EUS guidance was clear, mildly viscous, and the CEA in the fluid was 1,200 ng/mL. Since the cyst had no clear signs of malignancy, the patient underwent a clinical and radiological follow up and the cyst was stable after one year. During the second year follow up the cyst was minimally increased. At EUS the wall and the septa were still thin, with no mural nodules. A small calcification was observed on the wall. The pancreatic duct run very close to the cyst, but a communication was not clearly visible and the duct was not dilated. An EUS-FNA was performed and the CEA level was 8,813 ng/mL. The viscosity of the fluid was low, but on the basis of the high level of the CEA a mucinous cystic neoplasm was suspected and the patient underwent a distal pancreatectomy. Surprisingly the final diagnosis was that of a pancreatic retention cyst (PRC). Conclusion PRCs typically present as a well-defined, round-shape cystic lesions. They can be associated to different pathologic conditions including pancreatic inflame­mation and neoplasms. Smooth dilation of upstream pancreatic duct with uncommon communication to the cyst may be helpful for the differentiation. Combination of multiple imaging modalities should contribute to improve the diagnosis, but not always. To our knowledge, there are no cases in literature of PRC with such an high level of CEA.

Papillary carcinoma arising in thyroglossal duct cyst in the lateral neck

The patient presented here, a 74-year-old female, had a 3-year history of a gradually enlarging painless nodule in the right submental lateral region of the neck. A neck CT scan showed a well-demarcated cystic lesion, measuring 25mm in diameter, but without any definite evidence of neoplastic foci in the lymph nodes, thyroid gland, or lung. Clinicians first interpreted it as branchial cleft cyst, and a cystectomy was performed. Gross examination revealed a unilocular cystic lesion filled with yellowish clear fluids, containing a markedly thinned fibrous wall with smooth inner surface, partly coexisting with tiny solid and papillary-like components. On microscopic examination, the cystic tumor was lined by mono-layered ciliated columnar or metaplastic stratified squamous epithelium with underlying ectopic thyroid follicles or lymphocytic infiltrate, reminiscent of thyroglossal duct cyst (TDC), partly adjacent to the compressed lymph node tissue. Its solid parts were composed of a proliferation of atypical cuboidal to columnar epithelial cells with occasional nuclear grooves or intranuclear inclusions, arranged in a papillary growth pattern with supporting delicate fibrovascular cores. Immunohistochemically, these atypical cells were positive for thyroid transcription factor 1, thyroglobulin, and cytokeratin 19. Therefore, we finally made a diagnosis of papillary carcinoma (PC) arising in TDC in the lateral neck. Although metastatic thyroid PC of cervical lymph node was an important differential diagnosis owing to various overlapping clinicopathological features, coexistent benign lining epithelium or thyroid follicles, a histological hallmark of TDC, were present in the current case.

Wrong Egg in the Usual Nest: Thyroid Papillary Carcinoma within a Branchial Cleft Cyst

Branchial cleft cysts are the most common lesions to arise laterally in the neck. Ectopic thyroid tissue within a branchial cleft cyst is rare, and a papillary carcinoma arising from this tissue is extremely rare. We present a case of a lateral neck cyst representing a primary papillary carcinoma that arose in ectopic thyroid tissue within a branchial cleft cyst in a 41-year-old woman. After the mass was surgically excised, thyroid ultrasonography, thyroid scintigraphy, and whole-body F18-fluorodeoxyglucose-positron emission tomography/computed tomography detected no abnormality. The negative findings notwithstanding, surgery on the thyroid gland was planned, but the patient refused it. Therefore, she was followed up with ultrasonography and scintigraphy for 5 years, during which time she exhibited no evidence of recurrence. Total thyroidectomy is still the primary option in such cases, but when it cannot be performed for any reason, vigilant follow-up is essential.

Papillary thyroid carcinoma in a lateral neck cyst: primary of ectopic thyroid tissue versus cystic metastasis

To review the diagnosis of primary papillary carcinoma of ectopic thyroid tissue within branchial cleft cysts, and to discuss the diagnostic challenge of differentiating this condition from metastatic disease when an occult microcarcinoma is found in the thyroid gland. These comprise a case report and a literature review. We present the case of a 75-year-old woman with papillary thyroid carcinoma within the wall of a recurrent, 15 cm, lateral neck cyst. Histological examination of the patient's thyroid gland found a 0.5 mm papillary thyroid microcarcinoma. Our differential diagnosis was primary papillary carcinoma arising from ectopic thyroid tissue, or metastatic cystic degeneration of a lateral lymph node. We make an argument for the former.

Occult Papillary Thyroid Carcinoma Initially Presenting as Cervical Cystic Lymph Node Metastasis: Report of Two Cases

Cervical cystic lymph node metastasis as the first and sole manifestation of occult papillary thyroid carcinoma (PTC) is uncommon, and can be mistaken for branchial cleft cyst. The present study reports two cases of PTC initially presenting as upper lateral neck cysts. Ultrasound examination confirmed the presence of occult papillary carcinoma with neck metastasis. The critical importance of ultrasound examination of the soft tissue of the neck for the identification of the clinical manifestations and the imaging features of occult PTC are discussed, with an emphasis on factors that may contribute to misdiagnosis.

Cervical cystic vagal schwannoma mimicking a type 3 second branchial cleft cyst: a case report

In this article, we report a rare case of a cervical cystic vagal schwannoma mimicking a type 3 second branchial cleft cyst clinically, radiologically and cytologically. Although schwannoma is rare, it should be considered in the differential diagnosis of cystic neck masses. This article suggests that Doppler ultrasonography, computed tomography and fine needle aspiration biopsy findings may not be sufficient to provide the correct preoperative diagnosis of cystic lateral neck masses and further imaging techniques may be required.

Branchial cleft cyst carcinoma

With the recent changes in the cause of head and neck cancer and the association of cystic metastatic neck squamous cell carcinoma with human papilloma virus (HPV), patients who are diagnosed with a cystic lesion in their upper neck need thorough investigation before commencing any treatment. The differential diagnosis of a cystic mass in the upper neck of an adult over the age of 40 years is a branchial cleft cyst, cystic metastatic squamous cell carcinoma or a branchial cleft cyst carcinoma (BCCC). Investigation must include diagnostic imaging, biopsy or excision biopsy of likely primary sites, such as oropharyngeal sub-sites, and testing for HPV, Epstein-Barr virus immunological status. The existence of BCCC is an exceptional diagnosis, with less than 40 cases considered proven. Consensus agreement has been proposed on making such a diagnosis. The diagnosis of a BCCC should be one of exclusion rather than presumption, after all other possible diagnoses have been considered and excluded.