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188
M. Riccabona
10.3 Pathologic Findings
10.3.1 Lymph Nodes
US Findings
Enlargement, changed echotexture (inhomogenicity, missing hilus, increased or
decreased echogenicity), focal structural alterations (inltration, abscess formation), irregular or spherical shape, diameter >1 cm and length-to-diameter ratio
>0.8. Conglomeration, large bulk of nodes, focal large spherical anechoic node,
changed architecture, potentially inhomogenous stiffness on US-elastography
(Fig.10.7).
Potential dorsal enhancement, particularly after anechoic or necrotic parts.
Note In enlarged nodes always assess adjacent soft tissue structures and glands in
search for complications or origin (e.g. tumour, secondary abscess formations in
paratonsillar/pharyngeal region). Furthermore, there may be stula tracts (e.g. in
MOTT/mycobacteria infection other than tuberculosis, or with dental origin)
(Fig.10.8).
a
c
b
d
Fig. 10.7 US in lymph node pathology. (a) Split image, sagittal lateral neck—grouped spherical
enlarged lymph nodes (LK). (b) Extended eld of view, similar region: a large node (dotted line)
with multiple smaller adjacent conglomerated lymph nodes; (c–e) US-elastography of an enlarged
lymph node: grey scale image showing a focal lesion in an enlarged inammatory node (c), with
aCDS showing no vessels in the entire node (d). US-elastography colour map shows reduced stiffness of the necrotic parts (green) and even lower stiffness of the liquid parts (blue); regional shear
wave velocity measurements taken in the respective regions conrm the colour encoded ndings (e)
e
10 Ultrasound oftheNeck inChildhood
Fig. 10.8 Fistula tact in necrotising node inammation/abscess. (a) Large suppurated lymph node
with stula tract to skin in infection with atypical mycobacteria. (b) Fistula tract deriving from
mandibula—from dental infection
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CDS
For potential disruption of vascular architecture, focal non-perfused areas in granulomatous or tumourous inltration/abscess formation (see Fig.10.2).
• In inammation hypervascularity and hyperaemia (increased diastolic velocity
with reduced RI). As modern US devices perfect in demonstrating vasculature
using (a)CDS and other new ow imaging techniques, role of ce-US restricted
(only for conrmation in doubtful cases if with therapeutic consequence).
• 3DUS may be particularly useful for demonstrating disrupted vascular architecture.
Note Though various criteria indicate suspicion of malignancy, US cannot reliably
dene entity; some inammatory nodes look similar to malignant nodes (e.g. granulomatous disease), whereas some malignant nodes (e.g. hypervascular lymphoma)
may resemble hyperaeremic inammatory changes.
10.3.2 Pathology ofCervical Soft Tissue
10.3.2.1 Malformations
Cervical Cyst
Congenital malformation and positioned medially (median cyst—remnant of thyroglossal duct) or lateral (remnant of embryological branchial arches/clefts).
US Findings
Complicated or simple cyst may contain echogenic debris. May get infected and
then resemble abscess with complicated uid, perifocal oedematous changes of
adjacent soft tissue and dorsal sound amplication—but cyst wall is thinner, more
regular and sharper than abscess (Fig.10.9).
Dermoid Cyst
Subcutaneous cyst, may contain echogenic material, but no specic US criteria.
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M. Riccabona
a
Fig. 10.9 Cervical cysts. (a) Lateral branchial cleft cyst. (b) Median cervical (ductus thyreo-
glossus) cyst adjacent to larynx, with clinical signs of secondary infection; dorsal through
transmission causes increased echogenicity behind the complex cyst with sedimentations conrming its liquid nature. Note: US alone cannot always differentiate between an old or inamed
cyst/abscess
b
Duplication Cysts
Arise from trachea or oesophagus (usually lower neck) and may get infected.
US Finding
• Cyst-like appearance and may cause compression of adjacent structures.
• Some wall structure (with respective gut/bronchial signature) depictable, often
with complex contents, air within if connection to structure of origin.
Thymic Cyst
Positioned (para-)median, inferior to thyroid gland, on entire pathway down to
mediastinum.
Vary in size, otherwise undistinguishable from any other uncomplicated cyst.
Cervical Ectopic Thymus
Either isolated or connected to thymus, resembling typical thymal echotexture (see
chapter chest US) (Fig.10.10). Intermittent cervical herniation of thoracic thymus
may occur with crying or valsalva.
10.3.2.2 Tumours
Haemangioma
Cavernous or capillary haemangioma, positioned supercially and show typical
skin discolouration.
US Findings
• Depending on anatomy and entity, more or less homogeneous, echogenic,
tumour-like lesions, potentially with hazy margins and some inltrating aspects
and tubular anechoic structures (representing dilated vessels).
• Central thrombosis may be present (Fig.10.11, also see respective chapter).
10 Ultrasound oftheNeck inChildhood
Fig. 10.10 Cervical thymus. (a) Cervical ectopic thymus adjacent to thyroid gland. No connec-
tion to mediastinum. (b) Large neonatal thymus that reaches up into lower median cervical space
191
ab
Fig. 10.11 Cervical masses—haemangioma. (a) Grey scale image shows nonspecic echogenic,
well-demarked mass below an area with only minor skin discolouration, as the tumour is mainly
positioned subcutaneously. (b) CDS shows hypervascularisation—consistent with a haemangioma
CDS
• Hyperaemia and hypervascularisation.
• Often some major feeding vessels can be depicted.
Spectral Analysis
• Differentiates lesions into high- and low-ow vascular or arterial/venous malformations; arteriovenous shunts can be identied.
Note Same phenomena and classication/imaging appearance as anywhere else in body.
Lymphatic Malformation
US Findings
• Mass of septated cysts, potentially with some nodular tissue.
• Tend to bleed—then show mixed echogenicity, sometimes with uid–uid levels
(see also respective chapter) (Fig.10.12).
aCDS
• Potentially some high-resistance vessels within septae.
Note Often mixed tumours (containing haemangiomatous and lymphangiomatous
as well as other mesenchymal tissue) can be encountered; denite differentiation
only by histology. Look similar everywhere in the body.
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M. Riccabona
ab
Fig. 10.12 Cervical cystic lymphatic malformation. (a) Grey scale image of a cystic “lymphan-
gioma” (lymphatic vascular malformation) with central complex cyst that exhibits echoes with
uid levels and sedimentation after haemorrhage. (b) aCDS demonstrates vascularised septae
without any ow in cystic and haemorrhagic parts
Other Mesenchymal Tumours
Various tumours: lipoma, broma, brolipoma and sarcomatous variants.
US Findings
• No specic US features.
• Aggressive bromatosis more invasive, inltration with destruction of borders
and may exhibit inhomogenous echogenicity.
Note Same appearance as everywhere else.
Neuroblastoma, (Ganglio-)Neuroma, Neurofibroma andOther Nerve
(Sheath) Tumours
See respective chapters, denitive diagnosis of entity often requires histology.
Note Neuroblastoma tends to invade spinal canal, particularly in the neck, and may
have calcications.
Teratoma
US Findings
• US appearance varies with its components. May be purely cystic or may have
fatty or calcied compartments, with more or less large solid components.
• Same appearance as everywhere else.
• Details discussed with genital tumours (see respective chapter).
Other Malignant Tumours
Commonly rhabdomyosarcoma, but also liposarcoma, metastases and lymphoma.
10 Ultrasound oftheNeck inChildhood
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US Findings
• Usually tumour depictable.
• Sometimes origin and affected space can be dened.
Diagnosis usually by histology.
Note Imaging appearance varies—specic diagnosis of underlying entity often
impossible. Do not confuse the benign neonatal bromatosis coli (sternocleidomastoid muscle “haematoma”) with a malignant tumour!
Role ofUS
Shows lesion, denes relation to surrounding structures, potentially guides biopsy
and serves for follow-up.
10.3.2.3 Abscess Formations
All inammatory changes may also manifest in neck, resembling ndings in other
body compartments (cellulitis/phlegmon, abscess).
US Findings
Originates from phlegmonous soft tissue (increased echogenicity of swollen tissue
with more or less uid collections, particularly along septae, hypervascularisation—may also be seen around abscess) or other inammatory conditions.
Abscess formation—central complex uid with oating echoes and dorsal
through transmission, surrounding membrane-like abscess wall with perifocal
inammatory changes (Fig.10.13).
CDS
• Hypervascular wall (no vessels in central necrotic part).
• Potentially secondary vascular involvement—particularly of jugular vein—
always includes assessment of ipsilateral, particularly venous, structures.
US insufcient for deeply located abscesses, cannot exactly dene anatomy
Note
and extension (e.g. mediastinal or skull-base extension)—additional cross-sectional
imaging advisable especially preoperatively. Differentiation of primary abscess
ab c
Fig. 10.13 Cervical abscess. (a) Grey scale image of a complex cystic mass with uid levels and
debris (++)—together with the clinical ndings consistent with an abscess. (b) CDS: vascularised
capsule, no central vessels and compression of adjacent vein in a supercial lymph node abscess.
(c) CDS, axial section: abscess (++) of the deeper parapharyngeal space
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M. Riccabona
from infected pre-existing cystic formation (cervical cyst, lymphatic malformation)
sometimes impossible/difcult.
All abscesses, e.g. from lymph nodes, tonsils and other soft tissues, exhibit no
other imaging criteria than mentioned above and have same appearance everywhere
else in the body.
10.3.2.4 Traumatic Changes
Haematoma (Including Sternocleidomastoid Muscle “Haematoma”)
US Findings
• Initially echogenic, later hypoechoic, potentially inhomogenous.
• May eventually develop into cyst-like appearance (seroma).
• Typically seen in muscles as well as subcutaneously, rarely in larynx.
• May be difcult to differentiate perifocal (reactive) changes/swelling from
haematoma.
Note Sternocleidomastoid muscle “haematoma” in newborns with resulting torticol-
lis—usually after birth trauma, also called/consistent with benign bromatosis colli of
unclear origin resulting from contracture of muscle—can be identied as fusiform
sternocleidomastoid muscle enlargement in continuity within fascial and muscle borders. Echogenicity may vary depending on age and insonation angle (from hypoechoic
to slightly hyperechoic) (Fig.10.14). Sometimes typical muscular septae preserved.
Small calcications occur, hypervascularisation may be present on CDS.
Fig. 10.14 US images of a bromatosis colli. (a) Oblique section, preserved muscle structure and
septae (++). (b) Large tumour-like appearance—the entire length only depictable by extended
view US (++) may sometimes be huge and frightening; however, other imaging has no higher
specicity, biopsy not indicated. (c) Typical conguration aligning along the fascia of the sternocleidomastoid muscle
10 Ultrasound oftheNeck inChildhood
195
Note Does not need (additional) imaging; do not mistake for rhabdomyoma,
aggressive bromatosis and other (malignant) tumours.
10.3.3 Thyroid Gland
10.3.3.1 Cystic Changes
Cysts may be normal and may be congenital, posttraumatic or regressive cysts—the
latter after/in thyroid disease. Many focal, partially cystic lesions exist—for a DDx
list, see Table10.1.
US Findings
• Anechoic spaces with thin membrane and sharp borders.
• If proteinaceous component, secondary haemorrhage or infection—oating echoes.
• Can be differentiated from nodular solid lesions by typical dorsal through transmission and no vessels on aCDS.
10.3.3.2 Malformations
Typical query in newborn: is there (ectopic) thyroid tissue?
• Gland may be hypoplastic or hypertrophic, asymmetric, etc.—numerous form
and shape variations. (Fig.10.15).
• Size does not necessarily correspond with function.
10.3.3.3 Inflammation
Either focal or diffuse. Typically thyroid gland enlarged with slightly altered
echotexture; echogenicity can be increased, sometimes (also focally) decreased—
inhomogenous appearance possible.
US Findings (Fig.10.16)
• Subacute thyroiditis: typically anechoic patchy changes.
• Lymphocytic thyroiditis (Hashimoto): more globally patchy anechoic disruption
of echotexture.
• Morbus Basedow/Graves’ disease (hyperthyroidism)/immune processes, pronounced swelling of isthmus, diffusely swollen and more or less homogeneous gland:
– CDS: signicant hypervascularisation (“thyroid inferno”).
• Sclerosing thyroiditis: gland eventually gets smaller, rather inhomogenously
hypoechoic, sharp contours with regional bumpy alterations of surface.
CDS
Hypervascularisation—unspecic, in late phases (atrophy) reduced vascularity.
• Corresponds more with function/treatment than underlying entity.
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M. Riccabona
abc
Fig. 10.15 Thyroid shape and position variations. (a) Thyroid agenesis—no thyroid tissue depict-
able. (b) Ectopic thyroid situated at base of tongue (++). (c) Only one single, but hypertrophic
thyroid lobe—the left lobe is absent
Fig. 10.16 Thyroiditis—Basedow/Graves’ disease. (a) Inhomogenously enlarged gland. (b) CDS
demonstrates massive hypervascularisation (“thyroid inferno”). (c) Improved delineation of parathyroid gland by CDS in these conditions
abc
Fig. 10.17 Hypothyreosis. (a) Axial view: hyperechoic enlarged neonatal thyroid gland in neona-
tal hypothyreosis, callipers for standard measurements of lobe (2, 3) and isthmus (1). (b) CDS of
the same glands as in (a) impressive hypervascularity. (c) Goitre with focal nodule (arrow),
T Trachea
10.3.3.4 Other Conditions
Hypothyroidism/Struma Diffusa/Colloides (Fig.10.17)
Slightly enlarged gland with patchy structure, potentially increased echogenicity.
The neonatal goitre with maternal hypothyroidism usually is slightly enlarged and
with only slight hypervascularity; huge goitres and hypervascularity hint towards
(genegtic) thyroid hormone synthesis defects.
Nodular Goitre
Usually enlarged gland.
• Dened by formation of nodules, commonly surrounded by anechoic structures
(increased regional vascularisation—use CDS).
10 Ultrasound oftheNeck inChildhood
Fig. 10.18 US in different forms of goitre. (a) Huge thyroid tumour-like enlargement (++) with
focal regressive changes (arrow) in familiar Mediterranean fever, dual image technique display.
(b) Extended view US: huge thyroid adenoma, also focal regressive/degenerative nodule
197
• Central regressive changes make nodular ndings inhomogenous.
• Potentially cysts with uid–uid level and even calcications, often irregularly
distributed throughout both lobes.
Amyloid Goitre
Usually signicant enlargement with multiple nodular pseudotumours (amyloid
tumours) throughout gland, associated with regressive changes (e.g. familiar
Mediterranean fever) (Fig.10.18a).
Adenoma/Carcinoma
Focal tumours—adenomas usually produce hormone and lead to hyperthyroidism.
• Single or multiple nodes with varying echotexture and usually sharp margins.
• Varying echotexture—depends on extent of central regressive changes
(Fig.10.18b).
• Clear diagnosis cannot be achieved by US.
• Signs of malignancy/carcinoma: inltrative behaviour, unclear margins, vascular
disruption and regional nodes. Rare in childhood.
Note US mostly nonspecic, diagnosis usually made by combining US ndings,
history, laboratory data and potentially scintigraphy and/or biopsy results—hormone status and scintigraphy irreplaceable, sometimes US-guided ne needle
biopsy (though less frequently in children than in adults). Although US-elastography
may hint at malignancy by indicating stiffer tissue, it cannot be clearly diagnostic or
replace histology.
10.3.4 Salivary Glands (Parotid, Sublingual, Submandibular Gland)
10.3.4.1 Inflammation
US: Inhomogenous altered echogenicity and enlargement, nonspecic:
• Often from viral infection (mumps, Epstein Barr, CMV) (Fig.10.19). Multiple
intraparotid lymph nodes may be present. Hypervascularisation on CDS.