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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5770_Библиотеки_им_академика_М_И_Перельмана.pdf
6 Sonography ofOther Neck Masses
107
6.3.5 Hemangiomas andVascular
Malformations
In contrast to hemangiomas, vascular malformation does not
describe proliferative vascular disease. Vascular malformations are congenital and can be arterial, venous, or lymphatic.
Many of these tumors occur in the head and neck region, and
Fig. 6.22 Hemangioma (HE)
of the face. Using color-coded
sonography, only a few blood
vessels can be detected even
with a low pulse repetition
frequency.NBnasal bone
ultrasound imaging should be the rst step in diagnosis,
especially because these tumors are often seen in children.
Therefore, head and neck surgeons should be familiar with
their typical sonographic features.
Hemangioma [4] is commonly characterized by a regular
border and a heterogenous echo inside (Figs.6.22 and 6.23).
The detection of blood vessels may be difcult; color-coded
Fig. 6.23 Hemangioma (HE)
next to the jaw (J)
108
P. J e ck er
sonography detects only the blood ow, not the extent of vascularity. Nevertheless, duplex sonography is an essential part
of the examination, and the examiner should try to detect as
many intratumoral vessels as possible. Therefore, the pulse
repetition frequency (PRF) should be reduced to a minimum.
Vascular malformations are located subcutaneously.
Often it is difcult to detect surrounding structures (Figs.6.24
and 6.25). The echo resembles multicystic disease, so the
Fig. 6.24 Vascular
malformation. (a) B-scan
shows the vascular
malformation (VM) next to
the mandible. (b) Duplex
sonography indicates high
vascularization
a
depiction of blood vessels entering the tumor is mandatory.
Using pulsed-wave (pw) Doppler, high systolic velocities
can be detected as a result of intratumoral shunts. In venous
malformations, an increasing tumor volume can be detected
when the Valsalva maneuver is performed (Fig.6.25).
Lymphatic malformations also look like a multicystic
tumor (Fig.6.26). They are localized in the head and neck
region in 70–80% of cases [5].
b
a
6 Sonography ofOther Neck Masses
109
b
Fig. 6.25 Supraclavicular vascular malformation (VM). (a) B-scan. (b) Duplex scan. (c) Increasing thickness is seen with performance of the
Valsalva maneuver (right)
110
P. J e ck er
Fig. 6.25 (continued)
Fig. 6.26 Lymphangioma
(LA) of the left neck
c
6.4 Branchial Cysts andThyroglossal
Cysts
Branchial cysts result from a failure of the obliteration of the
branchial clefts during embryological development. They
can occur anywhere in the lateral neck. Thyroglossal cysts
are remnants of the thyroglossal duct, which describes the
descensus of the thyroid gland from the tongue base via the
hyoid to the area in front of the cricoid cartilage. The size of
these cysts may differ signicantly.
6.4.1 Branchial Cysts
Branchial cysts commonly grow within a few days. They can
be detected under the anterior portion of the sternocleido-
6 Sonography ofOther Neck Masses
Fig. 6.27 Typical branchial
cyst (CY) of the right neck.
No structures can be detected
within the cyst. The relative
enhancement of the echo
behind the cyst can be seen.
SCM sternocleidomastoid
muscle
111
Fig. 6.28 Often, branchial
cysts are lled with thickened
secretion. The cyst then
appears brighter, but the
relative enhancement of the
echo behind the cyst can still
be detected. ECA external
carotid artery, ICA internal
carotid artery
mastoid muscle and next to the internal and external carotid
artery [3]. Branchial cysts are lled with uid, which results
in a hypoechoic pattern with an acoustic enhancement
(Fig. 6.27). A regular capsule can be seen. Sometimes the
cystic uid contains epithelia. Then the pattern is more
hyperechoic, but the acoustic enhancement behind the cyst
still exists (Fig.6.28). In case of location next to the mandible, the dorsal part of the submandibular gland can be seen
next to the cyst (Fig.6.29).
Painless cysts can be compressed (Video 6.5). This compression maneuver can be observed while sonography is performed (Fig. 6.30). This nding should be documented,
112
Fig. 6.29 Lateral branchial
cysts (RF) can occur in every
neck level. This cyst is located
directly lateral to the
submandibular gland (SM).
ECA external carotid artery,
ICA internal carotid artery
P. J e ck er
Fig. 6.30 Sonocompression
is a typical feature of
branchial cysts (CY). Note the
difference between the normal
cyst (left) and the shape of the
cyst during compression
(right). The arrow indicates
the direction of the
compression
because it is a typical feature of branchial cysts (as well as of
other cystic tumors).
Commonly, very few blood vessels are detectable in
the area of the capsule with the use of color-coded sonography (Fig. 6.31). Some authors additionally describe
intratumoral “vessels,” which must be interpreted as arti-
facts. In case of an inammation of the cyst, the number
of blood vessels increases (Fig. 6.32). Furthermore, the
echo of the infected cyst is often more heterogenous
(Fig.6.33). Due to the inammation, the surrounding tissue looks more hyperechoic, as a result of local edema. To
relief the cyst in case of acute infection, puncture is a
6 Sonography ofOther Neck Masses
Fig. 6.31 Duplex scan of a
lateral branchial cyst (CY).
Blood vessels can be detected
only in the area of the
capsule. ECA external carotid
artery, ICA internal carotid
artery
113
Fig. 6.32 B-scan (right) and
duplex scan (left) of an
infected lateral branchial cyst
(CY). Note the heterogenous
pattern within the cyst and the
high number of blood vessels
around the cyst. ECA external
carotid artery, ICA internal
carotid artery
therapeutic option. It can be performed under ultrasound
control (Fig.6.34).
It is important to consider the sonographic characteristics of branchial cysts to avoid overlooking other diseases,
especially malignant lymph nodes. If the node’s tissue is
necrotic, its sonographic appearance may resemble that of
a branchial cyst (Fig.6.35). Therefore, knowledge of the
clinical examination of the head and neck region and the
patient’s history is essential for correct sonographic diagnosis of a branchial cyst.
114
Fig. 6.33 B-scan sonography
of an infected lateral
branchial cyst (CY). The cyst
itself shows a heterogenous
pattern, and the surrounding
tissue, including the
sternocleidomastoid muscle
(SCM), is edematous and
thickened. ECA external
carotid artery
P. J e ck er
Fig. 6.34 In case of an
infection, ultrasound-guided
puncture is a therapeutic
option. The needle (arrows)
can be seen easily within the
cyst (CY). SM submandibular
gland
6.4.2 Thyroglossal Cysts
The most important sonographic characteristic of thyroglossal cysts is their contact with the hyoid bone [6]. The cyst can
be located anywhere around the hyoid—under it (Fig.6.36)
or above it (Fig.6.37). Similar to branchial cysts, the pattern
of the cyst is more or less hypoechoic, but an acoustic
enhancement can always be seen. Because these cysts usu-
ally are much smaller than branchial cysts, a sonographic
compression maneuver is difcult to perform. The shape of
the cyst may be lobulated (Figs.6.37 and 6.38), and sometimes intracystic septation can be seen (Fig. 6.39). Blood
vessels can be detected only in the area of the smooth capsule and, if present, in the area of the septation. If a cystic
duct is present, it also can be seen (Fig.6.40). In cases of
acute inammation, the surrounding tissue also appears
edematous and hyperechoic (Fig.6.41).
a
6 Sonography ofOther Neck Masses
Fig. 6.35 Many tumors (TU)
can imitate a branchial cyst.
The differential diagnosis
always includes a necrotic
metastatic lymph node. (a): A
metastasis of a cancer of
unknown origin. (b): A
metastatic node in a patient
with endometrial cancer. CCA
common carotid artery, SD
thyroid gland, IJV internal
jugular vein
115
b
Fig. 6.36 A thyroglossal cyst
(CY) always has contact with
the hyoid (HY). The cyst has
a poor echo as well as (more
or less) relative acoustic
enhancement of the echo.
TOtongue
a
116
Fig. 6.37 This thyroglossal
cyst (CY) is located above the
hyoid (HY). The cyst has a
poor echo, with some acoustic
enhancement. (a): Sagittal
section. (b): Transverse
section. SM suprahyoidal
muscles, TO tongue
P. J e ck er
b
Particular attention should be paid to the tongue base [2].
Often parts of the cyst or even the whole cyst is located in
this deep central neck area, where it cannot be palpated
(Fig.6.42). The sonographic appearance of these deep thyroglossal cysts is the same as the appearance of supercial
cysts (Video 6.6). These deep cysts are difcult to detect
because they are commonly smaller than the thyroglossal
cysts located directly under the skin (Fig. 6.43). But even
such small and deeply located cysts can be seen with the use
of ultrasound, and appropriate surgery can be planned.
Because the thyroglossal duct marks the descensus of the
thyroid gland, thyroid tissue often can be found within the
cyst [7]. Then the sonographic appearance of the supposed
cyst is comparable to the pattern of thyroid gland; this is true