(tdc) and cystic neck masses
TRANSCRIPT
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Thyroglossal duct cyst (TDC) and
cystic neck masses Anna Calabrò, University of Trieste
School of Medicine
Gillian Lieberman, MD
April 2014 Anna Calabro’
Gillian Lieberman, MD
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Agenda
Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
Anna Calabro’
Gillian Lieberman, MD
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Our patient’s history
19 year old male
Patient presented with a 3 weeks history of
palpable mass in the region of the right
lateral thyroid cartilage
Otherwise healthy and asymptomatic
Anna Calabro’
Gillian Lieberman, MD
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Menu of tests
Ultrasound
Doppler ultrasound
MR neck with and without gadolinium
Anna Calabro’
Gillian Lieberman, MD
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Our patient: neck mass on US
Elongated cystic anechoic structure PACS, MTAH
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Gillian Lieberman, MD
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Our patient: neck mass on doppler US
Anechoic fluid collection without internal vascularity
PACS, MTAH
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Gillian Lieberman, MD
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Our patient: neck mass on MR
Axial MRI neck,T2, fat saturation Coronal MRI neck, T2, fat saturation
PACS, MTAH
HYPERINTENSE lobulated cystic structure
hyoid bone level
insinuates in the right strap musculature
Anna Calabro’
Gillian Lieberman, MD
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PACS, MTAH
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Our patient: neck mass on contrast MR
PACS, MTAH
Axial MRI neck, T1, fat saturation Coronal MRI neck, T1, fat saturation
HYPOINTENSE lobulated cystic structure
hyoid bone insinuating in the strap muscles
Rim enhancement!
Anna Calabro’
Gillian Lieberman, MD
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PACS, MTAH
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Agenda
Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
Anna Calabro’
Gillian Lieberman, MD
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Neck anatomy
The neck can be divided into 2 regions:
- The posterior triangle, bordered by the SCM muscle, trapezius muscle and the clavicle.
- The anterior triangle, bordered by the SCM muscle and the mandible.
Drake:Gray’s Anatomy for students,2nd Edition
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Gillian Lieberman, MD
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Neck anatomy
The anterior triangle is divided into the
SUPRAHYOID region
INFRAHYOID region
by the HYOID bone
Hyoid bone
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Gillian Lieberman, MD
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www.radiologyassistant.nl
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Let’s review our patient’s lesion imaging
findings
Midline/para midline location
Hyoid bone level or below it
Insinuates strap muscles
Anechoic cystic structure on US
No internal vasculature on Doppler US
Hypointense on T1 sequence
Hyperintense on T2 sequence
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Gillian Lieberman, MD
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Thyroglossal duct cyst !
Anna Calabro’
Gillian Lieberman, MD
What is the diagnosis?
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Agenda
Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
Anna Calabro’
Gillian Lieberman, MD
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Thyroglossal duct anatomy and embryology
https://my.statdx.com/
The thyroglossal duct runs from
the base of tongue at the foramen
caecum to the thyroid gland.
The embryonic thyroid gland
travels through the duct to reach its
final normal position.
Normally, at 5-6 gestational
weeks, the thyroglossal duct then
involutes, but when the duct
persists, a thyroglossal duct cyst
can develop anywhere along this
tract.
Anna Calabro’
Gillian Lieberman, MD
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Thyroglossal duct anatomy and embryology
TDC LOCATION:
The location is in the midline or
paramedian.
65% infrahyoidal,
20% suprahyoidal,
15% at the level of the hyoid
bone
http://www.radiologyassistant.nl/ml
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Gillian Lieberman, MD
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They typically present during childhood (90%
before the age of 10), or remain asymptomatic
until they become infected, in which case they can
present at any time.
Thyroglossal duct cysts account for 70% of all
congenital neck anomalies, and are the second
most common benign neck mass, after
lymphadenopathy.
Anna Calabro’
Gillian Lieberman, MD
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TDC Epidemiology
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Agenda
Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnosis of TDC
Other cystic neck masses
Anna Calabro’
Gillian Lieberman, MD
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TDC radiographics features
Best diagnostic clue: Midline/paramidline infrahyoid or hyoid level cystic neck mass
Embedded in strap muscles
Wall may enhance if infected
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Gillian Lieberman, MD
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TDC radiographics features: US
Ultrasound: Unless infected, they are painless, fluctuant masses which spread the strap muscles. The fluid is usually anechoic and the walls are thin, without internal vascularity.
However, in some cases, the internal fluid may contain debris.
If there is associated infection, there may be surrounding inflammatory change.
Anna Calabro’
Gillian Lieberman, MD
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TDC radiographic features: MR
§ T1 - typically low signal (in uncomplicated non infected cases)
§ T2 - typically high signal
§ T1 C+ (Gd) - no enhancement in uncomplicated cysts, thin peripheral enhancement may be seen
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Gillian Lieberman, MD
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TDC radiographics features on CT: companion patient #1
Axial CT head, post contrast
cystic lesion
embedded in the strap musculature
compression of thyroid cartilage confirms lesion to be benign
www.radiologyassistant.nl
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Gillian Lieberman, MD
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TDC radiographics features on CT: companion patient #2
http://emedicine.medscape.com
Sagittal CT head and neck, post contrast
thin band of tissue (white arrow)
connecting the TDC with the
native thyroid gland inferiorly.
note location of TDC in relation
to the hyoid bone
Anna Calabro’
Gillian Lieberman, MD
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Agenda
Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnoses of TDC
Other cystic neck masses
Anna Calabro’
Gillian Lieberman, MD
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Differential Diagnoses of TDC
Lymphatic malformation
Dermoid or epidermoid cysts in oral cavity
Lingual thyroid
Submandibular or sublingual space
abscess
Mixed laryngocele
Delphian chain necrotic node
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Gillian Lieberman, MD
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TDC DDx: Lymphatic malformations
A lymphatic malformation is a cystic mass in the head or neck that results
from an abnormal formation of embryonic lymphatic vessels;
There are two main types of lymphatic malformations:
lymphangioma - a group of lymphatic vessels that form a mass or lump.
cystic hygroma - a large cyst or pocket of lymphatic fluid that results from
blocked lymphatic vessels.
Unilocular or multilocular (sponge-like)
Focal or trans-spatial (diffuse/infiltrative)
Posterior to the SCM
Association with neurofibromatosis
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Gillian Lieberman, MD
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TDC DDx: Lymphatic malformations on CT and MR
Anna Calabro’
Gillian Lieberman, MD
www.medscape.com www.wiki.uiowa.edu
Axial CT neck, post contrast Axial MR neck, T2
on CT: Low attenuation non-enhancing left neck mass that extends to
the posterior paraspinal soft tissues of the upper back.
on MR: T2 hyperintense lesion
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TDC DDx: Oral cavity dermoid and epidermoid cysts
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Gillian Lieberman, MD
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Oral dermoid cysts
may be congenital or acquired
most commonly involve the floor of the mouth, submandibular space,
sublingual space, or root of tongue
CONTENT: fatty, fluid, or mixed components
Epidermoid cysts
benign developmental anomalies
they present as a slow-growing asymptomatic mass and are usually
diagnosed only after they have reached a considerable size. They may
obstruct the upper airway and gastrointestinal tract and potentially can
be fatal
CONTENT: only fluid-filled
Neither directly involves hyoid bone
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Gillian Lieberman, MD
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https://wiki.uiowa.edu
On MR: On T1 fatty elements appear bright, fluid dark
On T2 fat is dark and fluid is bright
Axial MR neck, T1 Axial MR neck, T2
https://wiki.uiowa.edu
TDC DDx: Oral cavity dermoid and epidermoid cysts on MR
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TDC DDx: Oral cavity dermoid and epidermoid cysts on CT
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Gillian Lieberman, MD
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http://www.ncbi.nlm.nih.gov
Sagittal CT head
On CT: Low density lesion, a variety of internal appearances depending
on composition, wall may enhance with contrast
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TDC DDx: Lingual thyroid
A lingual thyroid is a specific type of ectopic thyroid, and results from
lack of normal caudal migration of the thyroid gland from foramen
caecum down to its normal location anterior to the larynx and upper
trachea.
Most common location is at the base of tongue
Many patients are asymptomatic .In symptomatic patients the lingual
mass may result in dysphagia, bleeding from mucosal ulceration, or
even air-way obstruction (more common in infants).
On CT without contrast: hyperdense soft tissue mass, of the same
attenuation as normal thyroid tissue. It is hyperdense on account of
the accumulation of iodine within the gland.
On CT with contrast: the entire gland demonstrates prominent
homogenous enhancement just like the normal thyroid gland.
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Gillian Lieberman, MD
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TDC DDx: Lingual thyroid on CT
Anna Calabro’
Gillian Lieberman, MD
http://www.mypacs.net
CT without contrast: hyperdense soft tissue mass
CT with contrast: prominent homogenous enhancement
TDC DDx: Lingual thyroid on CT
Axial CT neck, post contrast Sagittal Head and neck
http://www.mypacs.net
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TDC DDx: Lingual thyroid on CT and MRI
Anna Calabro’
Gillian Lieberman, MD
http://www.mypacs.net
TDC DDx: Lingual thyroid on MR
Sagittal MR head and neck, T2 Sagittal MR head and neck, T1
MRI: T1 - iso to hyperintense to muscle mass
T2 - can vary from hypo to iso to hyperintense to muscle
T1 C+ (Gd) - homogeneous contrast enhancement
http://www.mypacs.net
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TDC DDx: Submandibular or sublingual space abscess
Location:
- the submandibular space is superior the hyoid bone, lateral or
superficial to the mylohyoid muscle sling, and deep to the platysma
muscle.
- the sublingual space is deep and medial to the mylohyoid muscle and
lateral to the genihyoid/genioglossus muscles. It communicates with the
posterior superior submandibular space and inferior pararpharyngeal
space.
Origin: Odontogenic or salivary gland infection due to a duct calculus.
Not embedded within strap muscles
Thick enhancing wall around collections of pus.
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Gillian Lieberman, MD
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TDC DDx: Submandibular space abscess on CT
Anna Calabro’
Gillian Lieberman, MD
Axial CT neck, post contrast Coronal CT head, bone window
http://radiologypics.com
On post contrast CT: hypodense area representing fluid collection in the
submandibular space, due to and abscess
On bone window CT: lucency in the rigth side of the mandible, which
explains the odontogenic origin of the abscess
http://radiologypics.com
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TDC DDx: Sublingual space abscess on CT
Anna Calabro’
Gillian Lieberman, MD
http://www.medscape.com
Axial CT head, post contrast Axial CT head, bone window
On contrast CT: hypodense lesion representing an abscess in the
sublingual space
On bone window CT: lucency on the mandible explains the odontogenic
origin of the abscess
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TDC DDx: Mixed laryngocele
Traces back to laryngeal origin
Not embedded within strap muscles
Extends both internally into the airway and externally
through the thyrohyoid membrane
Anna Calabro’
Gillian Lieberman, MD
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TDC DDx: Mixed laryngocele on CT
Anna Calabro’
Gillian Lieberman, MD
Mixed internal and external laryngocele that shows air density.
http://www.ncbi.nlm.nih.gov
Axial neck CT
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TDC DDx: Delphian chain necrotic node (prelaryngeal)
May be difficult to differentiate from infected TGDC
Rare in children
At level of sternum
Involvement of this node can be as a result as diffuse
nodal involvement in SCC (H&N), or in isolation from
direct lymphatic spread of laryngeal cancer through the
anterior commissure. Thyroid carcinomas may also
involve this node.
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Gillian Lieberman, MD
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TDC DDx: Delphian chain necrotic node on CT
Anna Calabro’
Gillian Lieberman, MD
http://www.mypacs.net
Axial CT neck, post contrast
Hypodense round lesion,
with peripheral rim
enhancement *
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Agenda
Our patient’s history
Our patient’s imaging work up and findings
Neck anatomy
TDC Anatomy-Embryology-Epidemiology
TDC Radiographics features
Differential diagnoses of TDC
Other cystic neck masses
Anna Calabro’
Gillian Lieberman, MD
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Other cystic neck masses
Necrotic lymphadenopathy (papillary thyroid
and squamous cell ca nodal mets, HPV
lymphadenitis)
Cystic Hygroma (posterior neck)
Branchial cleft cysts (type 2)
Laryngocele
Abscess
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Gillian Lieberman, MD
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Cystic Hygroma – Key facts
Most common form of Lymphangioma
Congenital benign non-capsulated lesion arising from expanding embryonic lymph 'lakes' that do not develop normal lymphatic drainage.
90% in children 10% in young adults. May occur anywhere in the head and neck. Mostly located in posterior cervical space. 10% extend into the mediastinum.
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Gillian Lieberman, MD
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Cystic Hygroma on MRI
Multiloculated lesion in the posterior cervical space
On T2 weighted image, the lesion has a fluid intensity
There is no enhancement on the T1 weighted image
Axial MRI neck, T2, fatsat Coronal MRI neck, T1 www.radiologyassistant.nl
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Gillian Lieberman, MD
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Second branchial cleft cyst – Key facts
It’s a cystic dilation of remnant of
the 2nd branchial apparatus
95% of all branchial cleft
anomalies arise from the second
branchial cleft.
Most common presentation: cyst,
sometimes in combination with a
sinus or fistula.
www.surgicalcore.org
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Gillian Lieberman, MD
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Second branchial cleft cyst
■ Most common location: posterior to the
submandibular gland and anterior
margin of the SCM muscle
web.uni-plovdiv.bg
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Gillian Lieberman, MD
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Second branchial cleft cyst on US
Usually sharply demarcated
Echogenicity is variable:
- anechoic - 41%
- homogeneously hypoechoic with internal debris - 24%
- pseudosolid - 12%
- heterogeneous - 23%
www.radiologyassistant.nl
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Gillian Lieberman, MD
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Second branchial cleft cyst on CT Axial CT neck, post contrast
Rounded, sharply circumscribed
structure, with central fluid
density
Fairly thick wall with subtle
peripheral enhancement
Location: posterior to
submandibular gland and
anterior/deep to SCM
Infection: fat stranding of the
adjacent fat planes
Anterior displacement and mass
effect with extrinsic compression of
the left internal jugular vein www.radiopaedia.org
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Gillian Lieberman, MD
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Second branchial cleft cyst on MR
www.radiologyassistant.nl
T1 - variable signal
dependant on protein
content.
- high protein content : high
signal
- low protein content : low
signal (as in image)
T2 - usually high signal
T1 C+ (Gd) - no
enhancement in
uncomplicated lesions.
The lesion shows edge
enhancement post-
Gadolinium.
Axial MRI neck, T1 Axial MRI neck, T1 C+ (Gd)
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Gillian Lieberman, MD
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Laryngocele: anatomy
Laryngocele: abnormal
dilation of the laryngeal
saccule.
The laryngeal ventricle is a
slit-like opening between the
false and true vocal cords.
It is the anatomic landmark
between supraglottis and
glottis.
The ventricle extends laterally
and then cranially into the
paraglottic space.
Anna Calabro’
Gillian Lieberman, MD
http://web.uni-plovdiv.bg
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Laryngocele: mechanism When the opening of the
laryngeal ventricle is completely obstructed by a tumor, the mucosa in the paraglottic space continues to produce fluid. This results in a fluid-filled internal laryngocele (does not cross the thyrohyoid membrane)
When the opening of the laryngeal ventricle is partially obstructed, a pressure-valve mechanism may result in an air-containing internal laryngocele.
Anna Calabro’
Gillian Lieberman, MD
http://www.hxbenefit.com
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Laryngocele on CT
Anna Calabro’
Gillian Lieberman, MD
Neck anatomy is difficult to learn. Try to recognize as many anatomic
and pathologic structures as you can, in the coronal CT images on the
right, using the left image as a guide, then continue.
http://www.hxbenefit.com http://home.earthlink.net
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Laryngocele on CT
Anna Calabro’
Gillian Lieberman, MD
jvjvf Coronal CT head
Anatomic structures from
the top:
-hyoid bone
-epiglottis
-thyrohyoid membrane
-thyroid cartilage
-cricoid cartilage
Pathology structures:
-tumor/mass
-INTERNAL laryngocele
-EXTERNAL laryngocele
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Laryngocele on CT
Axial CT neck , lower cut Axial CT neck, higher cut
Well defined, air, fluid or pus filled lesion related to the paraglottic
space, which has continuity with the laryngeal ventricle.
Secondary internal and external laryngocele caused by a tumor at the
level of the laryngeal ventricle.
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Gillian Lieberman, MD
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www.radiologyassistant.nl
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Laryngocele Types
INTERNAL - the dilated ventricular saccule is confined to the paralaryngeal space
EXTERNAL - the saccule herniates through the thyrohyoid membrane (anteriorly)
MIXED - has components both inside and outside the larynx
The lesion can be air-filled (laryngocele)
fluid filled (laryngeal mucocele)
pus filled (laryngopyocele)
Anna Calabro’
Gillian Lieberman, MD
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References Branstetter, BF and Weissman JL. Normal Anatomy of the Neck with CT and MR Imaging Correlation. Radiologic Clinics of North
America; Sept 2000 38:925-940.
Emerick, Kevin, and Derrick Lin. Differential diagnosis of a neck mass; May 2010.
Ahuja AT, King AD, King W et-al. Thyroglossal duct cysts: sonographic appearances in adults. AJNR Am J Neuroradiol. 1999;20 (4): 579-82. AJNR Am J
Meuwly JY, Lepori D, Theumann N et-al. Multimodality imaging evaluation of the pediatric neck: techniques and spectrum of findings. Radiographics. 25 (4): 931-48
http://pediatric-ent.com/2011/09/lump-or-mass-in-the-neck/#bca
http://radiopaedia.org/articles
http://www.radiologyassistant.nl/en/p49c603213caff/infrahyoid-neck.html#i4aedf5ff2169a
https://my.statdx.com/
http://emedicine.medscape.com/article/1346365-overview#a20
http://www.surgicalcore.org/popup/55306
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
http://radiopaedia.org/articles/second-branchial-cleft-cyst
http://www.medscape.com/viewarticle/510370_3
https://wiki.uiowa.edu/display/protocols/Lymphatic+Malformation+Rads
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2005_%20Larynx.htm
http://www.hxbenefit.com/laryngocele.html
http://home.earthlink.net/~radiologist/tf/030705.htm
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Gillian Lieberman, MD
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References
Anna Calabro’
Gillian Lieberman, MD
Curtin, HD. "Larynx." In Head and Neck Imaging, Som and Curtin, eds. St. Louis: Mosby-Yearbook. pp 665-671.
http://www.brown.edu/Departments/Diagnostic_Imaging/cases/hn.html
https://wiki.uiowa.edu/display/protocols/Dermoid+Cysts+Rads
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781235/
http://www.mypacs.net/cases/LINGUAL-THYROID-57329773.html
http://radiologypics.com/2013/02/14/submandibular-space-abscess/
http://www.medscape.com/viewarticle/729323_3
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640037/#B12
http://www.mypacs.net/mpv4/hss/casemanager
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Acknowledgements
Gillian Lieberman, MD
Jayant Boolchand, MD
Alejandro Heffess, MD
Pierre Sasson, MD
Mount Auburn Radiology Department
Anna Calabro’
Gillian Lieberman, MD