DIFFERENTIAL DIAGNOSIS OF HEAD & NECK LESIONS

DIFFERENTIAL DIAGNOSIS OF HEAD & NECK LESIONS IS VERY INTERESTING TOPIC TO DISCUSS.

Temporal Bone

  • Approach:

  • Soft tissue mass in the middle ear:

ü Cholesteatoma ü Chronic otitis media
ü Granulation tissue ü Cholesterol granuloma
ü Glomus tympanicum tumor ü Aberrant ICA
ü High or dehiscent jugular bulb ü
  • Vascular mass in middle ear:

·        Glomus tympanicum ·        Aberrant carotid artery
·        Carotid artery aneurysm ·        Persistent stapedial artery
·        Exposed jugular bulb ·        Exposed carotid artery
·        Hemangioma ·        Extensive glomus jugulare
  • Intra-canalicular IAC masses:

Exclusively intra-canalicular lesions: §  Acoustic neuroma (CN VIII), common

§  Facial neuroma (CN VII), rare

§  Hemangioma

§  Lipoma

Not primarily intra-canalicular: §  Meningioma

§  Epidermoid

 

  • Jugular fossa mass:

o   Glomus jugular tumor is the  most common

o   Neurofibroma is the  2nd most common

o   Schwannoma

o   Chondrosarcoma

o   Metastases

  • Mastoid bone defect:

ü Neoplastic bone destruction

ü Cholesteatoma

ü Post-operative simple / radical mastoidectomy

ü Post-traumatic deformity

  • Petrous apex lesions:

§  Cholesterol granuloma which appears T1 hyper-intense

§  Mucocele

   –  T1 hypo-intense

     – but may be T1 hyper-intense if à proteinaceous, then                           indistinguishable from cholesterol granuloma

§  Epidermoid àrestricted diffusion

§  Chondrosarcoma

§  Chordoma à if central extending to petrous

§  Endolymphatic sac tumor:  rare, more posterior; L > R; if bilateral, you think of VHL

ORBIT

  • Approach to orbital masses:

 

  • Orbital masses by Etiology:

Tumors: o   Hemangioma:  in adults: cavernous, in children: capillary.

o   Lymphoma

o   Metastases

o   Lymphangioma

o   Less common:

     ü Rhabdomyosarcoma

    ü Hemangiopericytoma

    ü Neurofibroma

Inflammatory: o   Pseudotumor is common

o   Thyroid ophthalmopathy is common

o   Cellulitis, abscess

o   Granulomatous is Wegener disease

Vascular: o   Carotid-cavernous fistula

o   Venous varix

o   Thrombosis of superior ophthalmic vein

Trauma: o   Hematoma

o   Foreign body

  • Extra-conal & Intra-conal Disease:

Extraconal disease Intraconal disease
Nasal disease:

·        Infection

·        Neoplasm

Orbital bone disease:

·        Subperiosteal abscess

·        Osteomyelitis

·        Fibrous dysplasia

·        Tumors

·        Trauma

Sinus disease:

·        Mucocele

·        Invasive infections

·        Neoplasm

Lacrimal gland disease:

·        Adenitis

·        Lymphoma

·        Pseudotumor

·        Tumor

Well-defined margins:

·        Hemangioma

·        Schwannoma

·        Orbital varix

·        Meningioma

Ill-defined margins:

·        Pseudotumor

·        Infection

·        Lymphoma

·        Metastases

Muscle enlargement:

·        Pseudotumor

·        Graves disease (thyroid ophthalmopathy)

·        Myositis

·        Carotid cavernous fistula

  • Vascular orbital lesions:

Tumor: ü Hemangioma, hemangioendothelioma, hemangiopericytoma

ü Lymphangioma

ü Meningioma

Vascular:

(with enlarged superior ophthalmic vein):

ü Carotid cavernous fistula

ü Cavernous thrombosis

ü Orbital varix

ü Ophthalmic artery aneurysm

  • Optic nerve sheath enlargement

Tumor o   Optic nerve glioma

o   Meningioma

o   Meningeal carcinomatosis

o   Metastases, lymphoma, leukemia

Inflammatory o   Optic neuritis

o   Pseudotumor

o   Sarcoid

increase intracranial pressure  
Trauma: o   hematoma
  • Tramtrack enhancement of orbital nerve:

§  Optic nerve meningioma

§  Optic neuritis

§  Idiopathic

§  Pseudotumor

§  Sarcoidosis

§  Leukemia, lymphoma

§  Peri-optic hemorrhage

§  Metastases

§  Normal variant

  • Third nerve palsy:

• Compression: ·        Intracranial aneurysm (do not miss)

·        Uncal herniation

·        Tumors  : neurofibroma, metastases, primary

·        Granuloma :Tolosa-Hunt, sarcoid

• Infection: ·        Encephalitis

·        Meningitis

·        Herpes zoster

• Vasculitis, dural cavernous sinus fistula
• Demyelination
• Trauma
• Infiltration (leptomeningeal carcinomatosis)
  • Ocular muscle enlargement:

o   Thyroid ophthalmopathy (most common cause); painless

o   Infection from adjacent sinus

o  Pseudotumor; painful

o   Granulomatous: TB, sarcoid, cysticercosis

o   Rare causes:

High flow: ü Dural AVM,

ü Carotid cavernous sinus fistula (CCF)

ü Lymphangioma

Hemorrhage  
Tumor: ü Lymphoma

ü Rhabdomyosarcoma

ü Leukemia

ü Metastases

Trauma  
Acromegaly  
Apical mass  
  • Overview of Orbital Masses:

Mass Children Adults
Tumor: ·        Retinoblastoma

·        Rhabdomyosarcoma

·        Optic nerve glioma

·        Lymphoma

·        Hemangioma

·        Hemangioma

·        Schwannoma

·        Melanoma

·        Meningioma

·        Lymphoma

Other: ·        Dermoid cyst ·        Pseudotumor

·        Trauma

  • Mnemonic for childhood orbital masses: “LO VISON:”

o   Leukemia

o   Optic nerve glioma

o   Vascular malformation (hemangioma, lymphangioma)

o   Inflammation

o   Sarcoma, rhabdomyosarcoma

o   Ophthalmopathy, orbital pseudotumor

o   Neuroblastoma

  • Cystic orbital lesions:

·        Dermoid

·        Epidermoid

·        Teratoma

·        Aneurysmal bone cyst

·        Cholesterol granuloma

·        Colobomatous cyst

  • T1W hyperintense orbital masses:

Tumor: §  Melanotic melanoma

§  Retinoblastoma

§  Choroidal metastases

§  Hemangioma

Detachment: §  Coats disease

§  Persistent hyperplastic primary vitreous (PHPV)

§  Trauma

Other: §  Hemorrhage

§  Phthisis bulbi

§  Intra-vitreal oil treatment for detachment

  • Globe calcifications:

Tumor: ü Retinoblastoma à 95% are calcified, 35% are bilateral.

ü Astrocytic hamartoma àassociated with TS, NF.

ü Choroidal osteoma

Infection: (chorioretinitis) ü Toxoplasmosis

ü Herpes

ü CMV

ü Rubella

Other: Phthisis bulbi:

ü Calcification à in end-stage disease

ü Shrunken bulb

Optic nerve drusen:

ü Most common cause of calcifications in à adults

ü Bilateral

  • Sudden onset of proptosis:

·        Orbital varix à worsened by Valsalva maneuver.

·        Hemorrhage into cavernous hemangioma

·        CCF

·        Hemorrhage into lymphangioma

·        Thrombosis of superior orbital vein

  • Lacrimal gland enlargement:

Lymphoid lesions, 50%:  

o   Benign lymphoid hyperplasia

o   Mikulicz disease

o   Lymphoma

o   Pseudotumor

o   Sjögren syndrome

Epithelial neoplasm: o   Pleomorphic adenoma, 75%

o   Adenoid cystic carcinoma

 

  • Diffuse bone abnormality:

Signs:

·        bony enlargement (fibrous dysplasia), expansion, sclerosis

ü Fibrous dysplasia

ü Paget disease

ü Thalassemia

ü Congenital (rare):

o   osteopetrosis, craniometaphyseal and diaphyseal dysplasia

                                            

Sinuses

  • Radio-opaque sinus:

Normal variant: ü Hypoplasia

ü Unilateral thick bone

Sinusitis:
Acute à Air-Fluid Level (AFL)

Chronic à mucosal thickening, retention cysts

ü Allergic

ü Fungal à aspergillosis, mucormycosis

ü Granulomatous à sarcoid, Wegener disease

Solid masses: ü SCC

ü Polyp, inverted papilloma

ü Lymphoma

ü Juvenile angiofibroma:

o   Most common tumor in children.

ü Mucocele:

o   Expansile, associated with cystic fibrosis in children.

Post-surgical: ü Caldwell-Luc operation

 

Naso-oropharynx

  • Mucosal space mass:

Tumors: ·        SCC

·        Lymphoma

·        Rhabdomyosarcoma

·        Melanoma

Benign masses: ·        Adenoids

·        Juvenile angiofibroma

·        Thornwaldt cyst

  • Parapharyngeal & carotid space masses:

Tumors:

·   Salivary gland tumors:

       – 80% are à benign,

       – 20% are à malignant

·      Neurogenic tumor àschwannomas, glomus vagale)

·        Nasopharyngeal carcinoma

·        Lymphadenopathy à benign, malignant

Abscess, cellulitis  
  • Pre-vertebral mass:

ü Metastases

ü Chordoma

ü Osteomyelitis, abscess

ü Hematoma

 

Neck

  • Cystic Extra-thyroid / Thyroid lesions:

Cystic extra-thyroid lesions Cystic thyroid lesions
Neck:

ü Branchial cleft cyst: Lateral to carotid artery.

ü Thyroglossal duct cyst: Midline mass.

ü Ranula:  Retention cyst of sublingual glands.

ü Retention cysts of mucous glands (parotid)

ü Cystic hygroma (lymphangioma):   most common <2 years of age

ü uncommon lesions:

o   Teratoma.

o   Dermoid.

o   Cervical thymic cysts.

o   Hemangioma.

Naso-oropharynx:

ü Thornwaldt cyst

ü Mucus retention cyst (obstructed glands)

ü Necrotic SCC (thick wall)

Larynx, paralaryngeal space:

ü Laryngocele

ü Mucus retention cyst

ü Colloid cysts

ü Cystic degeneration

ü Cystic tumor:

     – Papillary cancer

     – Cystic metastases (papillary cancer)

 

  • Solid neck mass:

Tumors: ü SCC of the larynx or Naso-oropharynx  is common.

ü Lymphadenopathy:

  • Reactive hyperplasia
  • Malignant

ü Parotid tumors

ü Neural tumors:

  • Neurilemoma
  • Neurofibroma
  • Glomus tumors

ü Other rare tumors:

  • Mesenchymal, dermoid, teratoma
Inflammatory: ü Infection à abscess, fungal, TB

ü Granulomatous inflammation sarcoid, TB lymphadenitis = scrofula.

Congenital: ü Ectopic thyroid
  • Vascular head & neck masses:

Glomus tumor: ü Glomus vagale

ü Glomus jugulare

ü Carotid body tumor

ü Glomus tympanicum

Hemangioma:  
AVM:  
Aneurysm:

 

Often ICA:

ü Pseudo-aneurysm

ü Post-traumatic

 

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