Twelve-year-old with dysphagia.

Our appreciation is extended to Dr. Dana Bonaminio, Indiana University Department of Radiology, for contributing this case.

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Twelve-year-old with dysphagia.

One week history of an enlarging left neck mass, with neck pain and discomfort as well as dysphagia. Patient was placed on outpatient amoxicillin without relief of his symptoms. There is no history of hoarseness or stridor. There is no past medical history suggestive of acute or recurrent tonsillitis or sinusitis.

Here are some CT images of the same patient. Click to enlarge.

Twelve-year-old with dysphagia.

Findings:

Radiograph: Nonspecific diffuse thickening of the pre-cervical soft tissues as well as the aryepiglottic folds with protrusion into the tracheal air column.  Relatively normal appearing epiglottis and tongue base.  Increased prominence to the anterior neck soft tissues.  There is no radio dense foreign body.

CT: Large peripherally enhancing multiloculated deep left neck collection measuring approximately 3.2 (AP) x 3.4 cm (TRV) x 5.0 cm (CC), with significant mass effect and medial displacement of the airway.  The airway at the levels of the aryepiglottic folds (narrowest portion) is moderately stenotic.

Differential diagnosis:

• Suppurative lymph nodes
• Infected (type 4) brachial cleft cyst
• Nontuberculous mycobacterial adenitis (NTM)
• Necrotic metastatic nodes (in adult population)

Twelve-year-old with dysphagia.

Key points:

• Suppurative lymph nodes
  • General features:
    • Best diagnostic clue: Enlarged node with intranodal fluid and surrounding inflammation
    • Location: Any of nodal groups of H&N; unilateral or bilateral
    • Size: Typically enlarged nodes or confluence of nodes to intranodal abscess in 1-4 cm range
  • Morphology: Ovoid to round enlarged cystic-appearing node, frequently with poorly defined margins
• Infected 4th branchial cleft cyst
  • Location:
    • May occur anywhere from LEFT pyriform sinus apex to thyroid lobe
    • Commonly against or within superior aspect of the left lobe of thyroid gland or attached to thyroid cartilage
    • Upper end may communicate with or be adherent to pyriform sinus
  • Epidemiology:
    • Rarest of all forms of branchial cleft anomalies (1-2%)
  • Associated abnormalities:
    • 4th branchial sinus connection with apex of pyriform sinus is maintained, infection is likely
    • Thyroiditis ± thyroid abscess possible in such circumstances
  • Presentation:
    • Throat pain w dysphagia; typically in pediatric patient.
    • Fluctuant mass in lower third of neck anteromedial to sternocleidomastoid muscle; tender if infected
    • Recurrent neck abscesses or recurrent suppurative thyroiditis
  • Treatment
    • Complete resection of cyst & any associated branchial sinus (likely recurrence if not resected)
    • Surgery completed after antibiotic therapy if infected, thyroid lobectomy is required for lesions in thyroid lobe to prevent recurrence
    • Pyriform sinus opening must be obliterate
  • Pearls
    • Imaging diagnosis of left thyroid lobe abscess in pediatric patient should strongly suggest diagnosis.
• Nontuberculous mycobacterial adenitis (NTM)
  • Dominant peripherally enhancing, centrally hypo dense mass associated with relatively little fat stranding (given size and extent of lesion) and skin thickening.
  • PPD skin test weakly reactive in ˜ 55%
  • Pediatric age group; usually = 5 years of age

References:

1. StatDx. 09/11/2011
2. Koch BL. Cystic malformations of the neck in children. Pediatr Radiol. May 2005;35(5):463-77.
3. Benson MT, Dalen K, Mancuso AA. Congenital anomalies of the branchial apparatus: embryology and pathologic anatomy. Radiographics. Sep 1992;12(5):943-60.

Twelve-year-old with dysphagia.

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