 Well, thanks again for the invitation. This has been a lot of fun yesterday. I really enjoyed and I hope it went over well for you And so we'll start the day-to-day and as you said our neck is on the line So we'll start with the pediatric neck masses The objectives of this particular lecture first of all to describe the ultrasound scanning technique then look at the imaging findings in common neck masses and Of course to understand the differential and provide some clues to the diagnosis So the scanning technique it's pretty straightforward You put the patient in the supine position you hyper extend the neck some by either putting a sponge pillow some object under the upper back You want to use a high-frequency linear array or curved array transducer because a lot of your structures are in the near field You want transverse and longitudinal scans and of course color Doppler General facts about neck masses in children most of them are benign in contrast to adults We're going to see a lot more cancers in children most are benign and we can group them into three categories congenital masses Vascular lesions and then of course lymph adenopathy Malignant neck masses do occur But they're rare and you'll sort of know when you see one as I go through the lecture I'll show you what they look like and they'll have a different appearance from most of these other lesions But if we start with the congenital or developmental masses will divide them into those that have a cystic appearance and those that have a mixed or solid appearance So starting off with the cystic lesions will begin with the thyroglossal duct cyst Which is the most common congenital neck lesion Congenital lesion it's not the most common lesion overall because that would probably be lymph adenopathy But if you talk about congenital lesions, it's thyroglossal duct cysts and it counts for about 70% of those congenital lesions Half of the patients will present in the first decade of life. You can see it though throughout life the thyroglossal duct is cyst is a remnant of the thyroglossal duct and The duck extends from the base of the tongue to the thyroid So you can see this lesion anywhere along the course of descent of the duck 15% of cysts will be at the level of the high bone 20% above and most of them below the higher bone So the ultrasound appearance is quite classic You're looking for a midline lesion or slightly slightly off midline The more inferior the cyst is in the neck the more likely it is to be off midline It has discrete margins. It may be hypo anechoic It can have a few echoes if the contents contain some protein or if they're infected and it's a vascular So this is the higher bone. This is the midline cystic mass. That's the thyroglossal duct cyst Lower down we're about the level of the thyroid Here's a cyst that's slightly off midline, but you can see the midline. It's extending from the midline Again, thyroglossal duct cyst You can see echoes within it. Here's another midline one higher bone The lesion with echoes it doesn't necessarily mean it's infected This can just be a lot of protonaceous material and in this case it was just protonaceous material And here's the CT this midline cystic lesion. That's classic for thyroglossal duct cyst Second brachial cleft cyst the next most common of the congenital lesions And the second brachial cleft cyst is the most common of the brachial cleft cyst This results from incomplete closure of the brachial apparatus which is present in the fetus and it gives rise to the critical neck structures and There six in the and the brachial apparatus there are five clefts and six arches The brachial cleft cyst arises from the second arch. That's the most common of the brachial cleft cyst It's anterior to the sternocleidomastoid muscle Anterolateral to the vessels it is in the lateral neck. That's going to be your clue About eight percent of the brachial cleft cyst arise from the first arch or cleft And two percent arise lower down. They're really rare more common in adults This is a patient with a lateral neck mass. It's cystic There may be a few echoes because of protein within it. The classic location is lateral neck Anter to the sternocleidomastoid muscle lateral neck cystic mass second brachial cleft cyst Here's another one lateral neck. This is in the left neck Cystic with a few echoes. It was not infected when it was taken out. That was just protein in it It's anterior to the sternocleidomastoid muscle and it is lateral to vessels and you can see on the ct Lateral to vessel same thing we see on the ultrasound and anterior To the muscle lateral neck second brachial cleft cyst Another malformation that cystic is cystic hygroma Also known as lymphatic malformation And it simply represents large dilated lymphatic spaces. Here's your clue It's in the posterior triangle of the neck. The legions we were just looking at are more anterior This is classically posterior triangle of the neck and this is the common site for cystic hygroma 90 percent are detected by age two years Most of these are president birth and it's a large Painless soft tissue mass. It may enlarge or become painful over time If it gets infected or if it bleeds It has a typical appearance again posterior neck. Okay, your sternocleidomastoid is behind the muscle It is multi-locular It is fluid filled. It has septations The fluid is a vascular the septations can show vascularity It is in the posterior neck Here's another one sternocleidomastoid muscle posterior neck multi-locular Legion it just extends down. This does require some additional imaging and we usually do MR to show the full extent. It's a large lesion. It's multi-locular It also encases vessels and nerves. So it's a very difficult surgical process It's challenging and the MR really gives information about the full extent and the relationship to vessels and nerves fourth cystic lesion The dermoid cyst and this is really the most uncommon of the congenital lesions but you can recognize that if you see one because They arise in the sublingual under the tongue and submandibular locations Cystic and they have these very bright internal echoes. Okay, due to fat And if you're familiar with the appearance on CT or MR, it's a so-called sac of marbles Looks like a sac with these in this case on the MR. You see these low density Intensity structures due to fat So dermoid cyst There are a couple of more congenital masses and they're going to look complex cystic and solid or solid And those will be the teratoma and the cervical thymus The teratoma contains all three germ layers and it is typically found in when it's in the neck It's typically found in newborns. It is in the anterior neck midline off midline, but it's huge It can involve the entire neck It is heterogeneous with cystic and solid components It contains fat soft tissue calcification This is a newborn with an in utero Mast you can see how large it was on the fetal MR And on the ultrasound postnatal. It is a huge mass filling the neck It has calcifications if you see calcification Heterogeneous mass it's a teratoma. That's your clue color doesn't have much color It's got cystic components solid components calcification And here is the MR. It fills the entire neck and that's that's sort of classic also for teratomas They're really really large. They present their birth Midline, but they extend to both sides of the midline Cervical thymus last of the congenital lesions. We'll look at again It presents in infants as a rule It's an anterior, but it's a lower neck mass your clue looking at clues on each lesion So it can be a lateral or midline. Here's another clue Follow it down. It's contiguous with the mediastinal thymus Eventually it regresses. It's your leave alone lesion We got to look at normal thymus because you have to understand what normal thymus looks like to understand the ectopic thymus This is thymus. Okay, I'm the chest and if you do ultrasound This is thymus. It's sort of soft tissue Zecogenic and you see a speckled appearance with these hypercoic foci Okay thymus Now this patient is a five-year-old boy. He's a little older than something, but he has a lower neck mass So here's the transverse view. This is thymus Okay, you got this mass in the midline and it's hypoechoic and you have these multiple linear foci sort of speckled appearance in this case when I do the sagittal or longitudinal view Here's the neck component and this goes into the anterior mediastinum That's a cervical thymus. It's just extending into the neck Here's another one It's got thymic characteristics. It's solid with speckled echoes Cervical thymus sometimes it can be ectopic and not be connected, but most of the time it's connected congenital lesions second category vascular lesions We're going to look at high flow lesions homangioma and arterial venous malformations and one slow flow lesion venous malformation This is the characteristic classification of vascular lesions no matter where they are Infantile homangioma is really the most common the vascular lesions and simply Contains lots of vascular channels Okay, and it occurs in the subcutaneous tissues. So it's a little bit more superficial It is the really one of the most common vascular tumors of infancy It's the infantile form is absent at birth and it appears in the first few months of life There is another form called congenital which is present at birth But more commonly it appears a little bit later It has this characteristic pattern where it initially increases in size It has a proliferative phase and then it completely invalids You can see some bluish discoloration in the skin So this is an infant who has a palpable mass with some bluish discoloration And you can see that here's the skin. It's very superficial in the soft tissues It's well defined. It's slightly hypocholic a little heterogeneous And use Doppler. Okay, you see there's a lot of color. It's a vascular mass If you do pulse or duplex Doppler, you'll see characteristic Isostolic and diastolic flow Well-defined mass Flow homangioma Here's another one. It's superficial. It's in the soft tissues. Here's the skin Color flow highly vascular. It's got to be a vascular lesion systolic diastolic flow homangioma discrete mass vascular mass There is another high flow malformation the arterial venous malformation Where you have multiple vessels Interposed between the arteries and the veins. So it's a collection of vessels. There's not much soft tissue It's diffuse and infiltrative. It is present at birth. It will not regress. It will grow with the child What you're seeing now is just a group of vessels. It's really not a discrete mass It just extends through the neck. It's simply a collection of vessels not well defined If you do your Doppler, you're going to get the same pattern a high velocity low resistance arterial flow Sometimes it is difficult to distinguish the homangioma and the arterial venous Malformation but this one is just a tangle of vessels without much soft tissue And there's one more and there's this is the Slow flow low flow venous malformation Now you have dilated venous spaces. So what you see is this infiltrative mass in the soft tissues With hypocoic spaces again put your color on it's vascular and it's all venous It's all venous slow flow It's uh Not pulsatile typical of venous flow So this one can increase some over time depends on how large it is whether they'll need to embolize it