Radiology of Cervical Masses

Dr.Bushra Hussein Ahmed Abdelmalik

Radiologist

introduction• Imaging the neck is unlike imaging any region of thetorso or brain since maximal contrast resolution isnecessary to differentiate lesions in cross-sectionalexams of those solid organs. Because of the various organ systems, the neck has very good native contrast resolution between lesions and adjacent normalstructures and at the interface with the skull baseand thoracic inlet

Cont…Intravenous contrast is necessary,however, to differentiate veins (and arteries) fromadenopathy and masses . The baseline scan has to be obtained by using . Intravenous contrast also helps characterize internal lymph nodearchitecture for necrosis.

Neck masses could be

Ct image of the neck showing different contrast of its structure

Enhanced axial CT image through the oropharynx. (1)Partially necrotic pathologic lymph node (level II). (2) Normal submandibularnode (level I-b) with fatty hilum

Cervical Triangles

Cystic Hygroma

• Cystic hygromas are fluid-filled sacs that result from a blockage in the lymphatic system. The lymphatic system is a network of vessels that maintains fluids in the blood, as well as transports fats and immune system cells. Cystic hygromas are single or multiple cysts found mostly in the neck region. A cystic hygroma can be present as a birth defect (congenital) or develop at any time during a person’s life. A cystic hygroma in a developing baby can progress to hydrops (an excess amount of fluid in the body) and eventually fetal death. Some cases of congenital cystic hygromas resolve

• leading to webbed neck, edema (swelling), and a lymphangioma (a benign yellowish-tan tumor on

• the skin composed of swollen lymph vessels). In other instances the hygroma can progress in sizeto become larger than the fetus.

• Cystic hygromas occur in approximately 1% of fetuses during the ninth to sixteenth week of pregnancy.

• In childhood, tumors and tumor-like lesions of the neck are rare and tend to be benign. Very common are congenital cystic lesions (thyroglossal duct cysts, branchial cysts, dermoid cysts, lymphangiomas, cystic hygromas). Common neoplastic lesions are hemangiomas and papillomas. The most common malignant tumors in the head and neck region are lymphomas and rhabdomyosarcomas. Lymph node enlargements, reactive or/and infectious, account also for a significant amount of cervical masses.

Congenital cystic Hygroma

U/S of A cystic Hygroma

Salivary glands are:-

1. Parotid glands

2. Submandibular glands

3. Sublingual glands

4. Accessory salivary glands

Common Diseases of Salivary Glands

1-Stones.

2-Inflamation.

3-Tumors.

Submandibular Gland Stones & Ludwig's Angina

1. Stone formation is common in the submandibular salivary gland and its duct

2. This is made up of calcium phosphate and carbonate

3. They are radio-opaque

a) Salivary Calculi1. Stone formation is common in the submandibular salivary gland and

its duct2. This is made up of calcium phosphate and carbonate3. They are radio-opaque Stones are :-1. Painful recurrent swelling of the affected gland at the time of meals 2. Purulent discharge from the duct into the mouth3. The affected gland is swollen, tender and on pressure gland may

produce purulent discharge from the orifice of the duct 4. The orifice is swollen and red5. The stone is palpable on bi-manual examination6. They are radio-opaque

b) Inflammation of The Salivary GlandsAcute Parotitis

Causes:

1. Infective

a) Viral (mumps)

b) Bacterial

c) Tuberculous

d) Fungal

2. In post operative period to poor oral hygiene

3. During chronic and debilitating illness (Typhoid fever , Cholera etc.)

4. Following radiotherapy

5. Sjogren's syndrome

They may show repeated attacks of pain and swelling due to infection and obstruction of the duct secondary to stricture

Parotid Swelling

Tumors of the Salivary Glands :-

If the swelling in connection with the muscle may be due to fibroma, lipoma, rhabdomyoma or idiopathic hypertrophy of the muscle

Incidence of salivary tumorsParotid gland – 75%

80% Benign (and 80% of the benign tumors are pleomorphic adenoma) 20% Malignant Submandibular gland --15% 60% Bengin(95%of the benign tumors are pleomorphic adenoma) 40% Malignant Minor salivary gland 10% 40% Benign (all most al pleomorphic adenoma) 60% Malignant

.

Differential diagnosis of a Parotid Swelling

1. Parotditis

2. Pleomorphic adenoma

3. Carcinoma

4. Pre auricular lymphadenitis 5 Sebaceous cyst or swelling in relation to skin

6. Neuroma of the facial nerve

7. Adamantinoma of the mandible

8. Neurofibroma

Diagnostic features of the malignant swellings

1. The swelling is hard , rapidly growing with irregular surface

2. It is painful

3. Facial nerve involvement is the characteristic feature of parotid malignancy

4. Regional lymph nodes may be involved 5. More common in parotid gland

6. Patient is usually above 50 years

7. Carcinoma of the Submandibular gland is less common

8. The overlying skin becomes fixed to the swelling and reddish blue in color and hot. The veins over the swelling are prominent.

Mikulicz’s disease

1. Symmetrical enlargement of the salivary glands

2. Swelling of the lacrimal glands with narrowing of the palpebral fissures

3. Dryness of the mouth

It may occur in following conditions1. Leukemia 2. Tuberculosis

3. Sarcoidosis 4. Sjogren’s syndrome

Differential Diagnosis of Swelling Of The Neck

1. Midline swelling (from above downwards)

a) Submental triangle 1. Ludwig’s angina 2. Sbmental lymph adenitis 3. Sublingual dermoid and lipoma 4. Cold abscess 5. Secondaries from the tip of the tongue and lip

In connection with hyoid bone and thyroid cartilage

1.Thyroglossal cyst

2. Subhyoid bursitis

3. Goiter of the thyroid isthmus or cyst

4. Extrinsic carcinoma of the larynx

Suprasternal notch

1. Retrosternal goiter

2. Thymus (if enlarged)

3. Cold abscess

Lateral swelling

a) Submandibular triangle 1. Submandibular lymph adenitis, secondaries or lymphoma 2. Submandibular salivary gland tumour 3. Deep runula 4. Extension of the swelling of the jaw 5. Lymphangioma 6. Schwanoma

Squamous cell carinoma

SQUAMOUS CELL CARCINOMA OF THE TONSIL

• About 90% of tonsillar cancers are squamous cell carcinomas.• These tumors are relatively frequent• , occurring mostly between the ages of 50 and 70. • They are three to four times more common in males than females and• are often associated with a history • of smoking and drinking alcohol. • Sixty percent of patients present with cervical metastases that is bilateral in • 15% of the cases. Distant metastases are found in about 7%.

LYMPHOMA OF THE TONSIL

Lymphoma is the second most common type of tonsillar malignancy. Lymphoma of the tonsil usually presents with a submucosal mass

in an asymmetrical enlargement of one tonsil. When lymphadenopathy is present, multiple enlarged lymph nodes

commonly are observed on the same side of the neck. Lymphomas are difficult to distinguish from undifferentiated

carcinomas and lymphoma

Axial CT scan, showing enlarged left tonsilLymphoma of the right tonsil with parotid and neck

metastasis

Epidermoid cyst

Carotid triangle

1. Aneurysm of the carotid artery

2. Carotid body tumour

3. Branchial cyst

4. Goiter

5. Stemomastoid tumour

Posterior or Supraclavicular triangle

1. Cystic hygroma2. Lipoma 3. Pharyngeal pouch4. Cervical rib5. Aneurysm of the subclavian artery6. Supraclavicular lymph adenitis, secondaries and lymphoma 7. Abscess.8. Epidermoid cyst

Cervical Abscess

Swelling Arising From Different Anatomical Structures

Skin and superficial fascia 1. Boils and furuncles

2. Sebaceous cyst

3. Lipoma

4. Dermoid cyst

5. Ludwig’s angina or cellulitis

* Branchial arch remnant Branchial cyst

* Salivary glands

1.Submandibular salivary gland tumour (mixed tumour or carcinoma),

2. Tumours of the parotid gland

* Pharynx

pharyngeal pouch

* Bone

Cervical rib

* Larynx

Carcinoma

Lymph node masses

1. Infective, e.g; pyogenic, tuberculosis

2. Secondaries

3. Lymphoma

4. Lymphangioma, cystic hygroma

Blood vessels 1. Aneurysm of carotid or subclavian artery

2. Carotid body tumour

Complications

1. Infection-branchial sinus

2. Branchiogenic carcinoma (rare)

Diffrential diagnosis1. Tuberculous lymph node (cold abscess)

2. Acute lymph adenitis

Cystic Hygroma

1. It is a congential discorder of lymphatic system. It is a varierty of limphangioma in wich lymph is collected in lymphatic sac.

2. It is a multilocular swelling with larger cysts at the periphery and smaller cysts at the center. Many of the cysts are inter-communicating with each other, due to this reason swelling is soft cystic and compressible

3. It is commonly placed at the root of the neck and posterior triangle. Second most common site is axilla. Other sites are groin, mediastinum, tongue and buccal mucosa.

Pharyngeal Pouch

It is protrusion or herniation of the mucosa of the pharynx through the Killian’s dehiscence, which is weakness between upper oblique fibers of the thyropharngeus and lower horizontal fibers of the cricopharngeus.

Clinical featuresIt is common in middle and old age, more commonly seen in men.

There are three stage of the pharyngeal diverticulum 1. Stage one is an initial bulging. Usually it is symptomless.2. Stage two is a well formed diverticulum the mouth of the diverticulum is vertical which gives

rise to regurgitation of food when patient-turns from side to side.

3 Stage three of large diverticulum-the mouth of the diverticulum becomes horizontal and fundus of the sac becomes dependent.It presses the oesophagus when it is full.There may be gurgling sounds in the neck.A visible swelling in the neck behind the sternoclidomastoid muscle is soft in consistency and indentable. This leads to increasing dysphagia

* Cervical Adenitis

Inflamation of the lymph nodes of the neck is a common feature. There are about 800 lymph nodes in the body ; out of which 300 are in the neck.

Acute Cervical Lymph Adentis

1.The lymph nodes are enlarged, soft and tender with marked pain

2. Pyrexia

3. Abscess formation

4. Leucocytosis .

Tuberculosis Adenitis

In majority of instances children and young adults are affected but the condition can occur at any age

Source of infection :

1. Tonsil, adenoids and dental caries

2. Apex of lung

3. Air-borne infection

4. Haematogenous-Pulmonary Tuberculosis.

5. The human tuberculosis bacillus is the causative organism and in 54 per cent of cases upper jugular group of lymph nodes are affected

Clinical Features

1. Matted mass of lymph nodes.

2. Fluctuant swelling (cold abscess)

3. Multiple sinuses with caseating tuberculous pus discharge

4. Multiple scars (if sinuses healed)

Differential diagnosis

1. Chronic non-tuberculous adenitis

2. Hodgkin’s disease

3. Secondaries

4. Branchial cyst

5. Actinomycosis

Lipoma of Neck

Axial CT scan of a patient with a large Lipoma

Hodgkin's Lymphoma of the Neck and MediastinumCT scan shows Hodgkin's lymphoma surrounding the trachea and

narrowing its lumen

The axial CT scan photograph below shows a soft tissue mass resembling adenoids, arising from the vault of the

nasopharynx. This mass protrudes into both nasal cavities, completely obstructing the airway

X-Ray of Tracheal Imaging of Tracheal Leiomyoma

CT with a tracheal filling defect

Tracheal Leiomyoma

MRI of the same lesion

Axial CT scan of the neck showing the epiglottic cyst in the pictures above.

Appearance of a Scrofula

Pictures of Scrofula, CT Imaging and Acid-Fast Bacilli

Secondary Carcinoma Of The Neck

The secondary carcinomatous involovement of the cervical lymph nodes is commonly encountered.

Cervical Lymphatic Sec. Masses.

1. Tip of tongue, central part of floor of mouth and lower lip

Submental triangle (mental)

2.Anterior t-thirds of tongue, floor of mouth, cheek and alveolus

Submandibular triangle (sub-mandibular)

3. Posterior one-third of tongue, tonsil larynx, oropharynx and pyriform fossa

Carotid triangle (jugulo-digastric)

4. Nasopharynx, retro-pharygeal region and external lear

Posterior triangle (upper part)

5. Thyroid, post-cricoid region, oesophagus, breast, lungs, tastes and abdominal organs

Supraclavicular triangle(Supraclavicular)

• The thyroid gland develops from the median bud of the pharynx which passes from the base of the tongue to the isthmus (thyroglossal duct). Paratllicular cells are derived from the fourth branchial arch.

• The weight of the normal gland is 20-25g. There are 20-40 follicles in a loobule which is functional unit.

• Arterial supply

i. Superior thyroid artery-branch of external carotid.

ii. Inferior thyroid artery-branch of thyrocervical trunk.• Venous drainage

I. Superior thyroid vein.

II. Middle thyroid vein

III. Interior thyroid vein-Brachiocepalic vein

Anatomy of the thyroid gland

Thyroid blood supply

Thyroid Anatomy

Thyroid scanning

• Indication:I. To see the which parts the thyroid gland are functioning or

functionless (hot or cold).

II. To see the areas of hyperfunctioning in toxic nodular goitre.

III. In evaluation of solitary toxic multi nodular goitre.

IV. To know the metastasis in thyroid malignancy.

V. To know about the ectopic thyroid.

Other tests:

Serum cholesterol, BMR, ECG and tendon reflexes etc. are value to day.

GIOTERS

• Enlargement of the thyroid gland.• Classification:

1. Euthyroid goiters (simple)

1. Diffuse hyperplasic giotre

2. Nodular giotere1. Multiple

2. Solitary

2. Toxic gioters1. Diffuse toxic giotre (Gravo’s disease)

2. Toxic nodular goitre (Pummer’s disease)

3. Toxic nodule

3. Neoplastic giotre1. Benign

2. Malignant

Nodular Goitre1. Due to persistent fluctuating T.S.H stimulation.

2. Common in female

3. Patient is usually euthroid

• ure 9. Transverse thyroid ultrasound demonstrating a hypoechoic mass replacing the right lobe of the gland with early extracapsular spread(arrow). These appearances are non-specific and may be seen in anaplastic carcinoma (as in this case) and primary thyroid lymphoma.

4. Thyroiditis 1. Granulomatous thyroiditis

2. Auto-immune thyroiditis1. Focal

2. Diffuse

3. Riedel’s thyroiditis1. Goitrogens

2. Non-giotrogens.

4. Rare goitres1. Pyogenic thyroiditis

2. Tuberculous thyroiditis.

3. Amyloid goitre.

COMPLICATIONs

I. Tracheal obstruction

II. Dysphagia

III. Secondary thyrotoxicosis in 30% of the patients.

IV. Risk of carcinoma is 5-8 %

s

3. Solitary Nodule

• A goitre which, on clinical examination appears to appears to be a single nodule in an otherwise normal gland is termed as solitary nodule:

1. 50% of solitary nodules are simple multinodular goiters on exploration.

2. 25% of true solitary nodules are malignant.

INVESTIGATION

ultrasound may demonstrate the multiple nodules in clinically solitary goitre.

Selection scan to differentiate between a benign and a malignant cold nodule.

4. Retrosternal Goitre

causes:1. In males with short neck and strong pretracheal muscles (because of

negative intrathoracic pressure)

2. Ectopic thyroid.

Types:

1. Substernal- always palpable

2. Plunging-occasionally palpable.

3. Intrathoracic- not palpable.

Diagnosis of Retrosternal goiter

X-ray of the neck shows soft tissue density in the superior mediastinum.

Thyroid scan to confirm the diagnosis.

TOXIC GOITRE

• Clinical types:1. Diffuse toxic goitre (Graves’ disease)

2. Toxic nodular goitre (Plmmer’s disease)

3. Toxic nodule

Clinical feature thyorotoxicosis

it is more common in female than males.

Wayene’s clinical diagnostic index gives all the important symptoms and signs of thyrotoxicosis.

NEOPLASMS OF THE THYROID

1. Benign

Adenomas

2. Malignant

1. Primary1. Carcinoma

1. Differentiated-papillary or follicular

2. Undifferentiated-anaplastic.

2. Malignant Lymphoma

3. Medullary carcinoma

2. Secondary1. Local infiltation

2. Metastasis

BENIGN TUMOURS

• Adenomas

1. Follicular adenoma

2. Papillary adenoma (doubtful entity)

Adenomas are usually present as solitary nodules and clinically it is difficult to differentiate them from solitary goiter. There is no invasion of the capsule. Distinction between a follicular carcinoma and an follicular adenoma can only be made by histological examination. All papillary tumors should be considered as malignant even it capsulated.

MALIGNANT TUMORS

• Papillary Carcinoma (60%)– Mostly mixture of papillary and colloid follicles.

1. Occult-Only one focus (less than 1.5cm)

2. Intrathyroidal-Multiple foci in same or both lobes.

3. Extrathyroidal-spread to lymph nodes is common.

Spread:

Lymphatic spread to cervical to lymph nodes is common. Multiple Intragladular seedlings may occur in the same lobe. Blood-brone metastates are most unusual.

U/S of the Thyroid

Nuclear Medicine Imaging

Papillary carcinoma is the more common well-differentiated cancer of the thyroid. Papillary/follicular carcinoma must be considered a variant of the papillary thyroid carcinoma (mixed form). Despite its well-differentiated characteristics, papillary carcinoma may be overtly or minimally invasive. In fact, these tumors may spread easily to other organs.

Papillary carcinoma appears as an irregular solid or cystic mass in a normal thyroid parenchyma. As with most tumors, the cause of thyroid cancers is unknown; however, that thyroid cancers are more often found in patients with a history of low- or high-dose external irradiation (40-50 Gy) is well known. The life expectancy of patients with this cancer is related to their age. The prognosis is better for younger patients than for patients who are older than 45 years. Of patients with papillary cancers, 10-15% present with lymph node or lung metastases. Some years ago, lymph node metastases were thought to be aberrant (supernumerary) thyroids because of their well-differentiated aspect.

• Mortality \ Morbidity• In contrast to other cancers, thyroid cancer is almost always curable. Most

thyroid cancers grow slowly and are associated with a very favorable prognosis. The mean survival rate after 10 years is higher than 90% and is 100% in very young patients with minimal nonmetastatic disease.

• Metastases are still frequent and are due to invasion of the lymphatics and spread to the lymph nodes. Vascular involvement is even more rare, occurring in fewer than 10% of cases. In most patients (35-50%), metastases are found at diagnosis. Distant spread (ie, to lungs or bones) is very uncommon. Worldwide, autopsy reviews show a high incidence of microscopic foci of thyroid carcinoma.

• Differing from medullary thyroid carcinoma, papillary thyroid cancer is not a part of multiple endocrine neoplasia syndromes.

• The mean mortality rate is 1.5% for females and 1.4% for males

RaceThis cancer occurs more frequently in whites than in blacks.

SexThe female-to-male ratio is near 3:1 and is related to the patient's age.

In patients younger than 19 years, the female-to-male ratio is 3.2:1.In patients aged 20-45 years, the female-to-male ratio is 3.6:1.

In patients older than 45 years, the female-to-male ratio is 2.8:1.Age with a peak in patients aged 30-50 years.

Follicular carcinoma (17%)

1. Noninvasive-minimal invasion of the capsulate and vascular tissue.

2. Invasive-marked invasion.

Spread:

1. Haematogenous spread to bones lungs is common mainly from invasive variety.

2. Lymphatic spread is rare.

Characteristics features of secondaries of follicular carcinoma-

1. Extremely painful

2. Very vascular and pulsatile

3. Osteolytic

4. Produce thyroid hormone

5. Affinity to iodine like thyroid gland

6. Blood borne.

ANAPLASTIC CARCINOMA (13%)

– Local infiltration is an early fealure. It has an extremely lethal tumors. It is usually hard and irregular.

– Spread

Lymph and haematogenous.

Treatment-Palliative. Resection of tumor only when there is no invasion through thyroid capsules and no evidence of metastasis.

Radiotherapy and multiple chemotherapy.

ANAPLASTIC CARCINOMA T1 weighted axial MRI of the lower neck with contrast

T1 weighted axial MRI of the lower neck with contrast enhancement at the level of the thyroid gland showing a complex thyroid mass with extensive soft tissue invasion (anaplastic carcinoma

The role of ultrasound in the management of nodular thyroid disease

• . Transverse thyroid ultrasound demonstrating a hypoechoic mass replacing the right lobe of the gland with early extracapsular spread(arrow). These appearances are non-specific and may be seen in anaplastic carcinoma (as in this case) and primary thyroid lymphoma

MEDULLARY CARCINOMA (6%)

1. Tumors from parafollicular cells (C-cells)

2. High levels of calicitonion in the blood. The level falls after resection a tumor and will rise again if the tumor recurs.

3. Often associated with other endocrine tumers (M.E.N 2A)

4. May be associated with neuromas of the skin, tongue and mucosa of the lip etc. (M.E.N 2B)

5. Lymphatic and blood metastasses are common.

6. Sometimes it may be associated with diarrhoea due to high 5HT.

DIAGNOSIS OF MALIGNANT TUMOURS

1. Typical symptoms and signs:1. Goiter of recent origin

2. Pressure symptoms

3. Recurrent laryngeal nerve palsy

4. Mobility of thyroid, side and with deglutition is restricted

5. Firm to hard and irregular thyroid.

Metastases-lymph nodes, bones or lungs .

.

DEVELOPMENTAL ANOMAILIES

• Ectopic thyroid1. Lingual thyroid

2. Median ectopic thyroid

3. Lateral aberrant thyroid

4. Struma overii (in ovarian teratoma).

Scan is a must to know the position of the normal thyroid gland if present.

CT Lingual thyroid with and without contrast

ANOMALIES OF THE THYROGLOSSAL TRACT

• Thyroglossal Cyst- any where in the region of the thyroglossal tract. Common sites are:

1. Subhyoid

2. In relation to thyroid cartilage

3. Suprahoid

Diagnosis– usually it is in the mid line and moves with deglutition as well as with protrusion of the tongue (Tract is attached to foramen caecum)

Branchial Fistula

It represents the persistent second branchial cleft.1. It appears as a small discharging at the anterior border of the lower one third

of the sternomastoid muscle2. The fistulous tract is lined by ciliated columnar epithelium3. The discharge is either mucus or mucopurulent

4. Drainage of the infected branchial cyst may also develop branchial fistula5. Usually tract ends blindly at the lateral pharyngeal wall (Branchial sinus is

more appropriate term)6. It may be unilateral or bilateral

Branchial Cyst

Clinical features1. Arises from the remnants of the second branchial cleft

2. It is situated beneath the upper one third of the stemomastoid muscle at its anterior border

3. It is lined by squamous epithelium and contains clear fluid which contains envelop shaped cholestrol crystals

4. It is a fluctuant and trans illuminating cystic swelling

5. Though congenital, it presents in young adults are congenital cysts, that arise in the lateral aspect of the neck when the second branchial cleft fails to close during embryonic development. At about the fourth week of embryonic life, 4 branchial (or pharyngeal) clefts develop between 5 ridges known as the branchial (or pharyngeal) arches.

BRANCHIAL CLEFT CYSTS

• These arches and clefts contribute to the formation of various structures of the head and neck The second arch grows downwards and ultimately covers the third and fourth arches. The buried clefts normally disappear around the seventh week of development. If a portion of the cleft remains entrapped and fails to disappear, its remnants form a cyst . . Branchial cleft cysts are the most common of congenital neck masses. They are bilateral in about 2-3% of the cases. Usually, they do not appear at birth, but become noticeable much later in life. If they get infected, they may form a deep neck abscess or a draining fistula. The treatment of branchial cleft cysts is surgical excision.

U/S of the branchial cyst

•

CT of Thyroglossal cyst

MRI SectionsT1&T2 of the Branchial cyst

THYRGLOSSAL FISTULA

1. Never congenital. Occurs because of inflamed cyst.

2. Recurrent attacks of inflammation.

Treatment

sistrunk’s operation-Removal of the cyst or fistula along with whole of the thyroglossal tract, upto foramencaecum.

Fistulography

Fistulography

• These films were taken after injecting a radio-opaque dye into the skin openings (pits). They demonstrate bilateral branchial cleft tracts extending from the skin of the neck to the oropharynx.

• Swelling which moves with deglutition:1. Thyroglossal cyst

2. Cyst in relation of the isthmus

3. Thyroid swelling

4. Sub hyoid bursal cyst

5. Enlarged pretracheal gland

6. Ectopic thyroid

Swelling which moves with protrusion of the tongue thyroglossal cyst.

Hypoparathyroidism(Primary)

Causes

1. Single adenoma 70%

2. Multiple adenoma 6%

3. Hyperplasia 20%

4. Carcinoma 1%(rare)

Clinical Features

1.Common in females 2. Generalised decalcification of the bones leads to pathological fractures and

pseudo tumours of any bone.3. Bilateral renal stones or nephroclacinosis4. Psychiatric symptoms-tiredness, listlessness (wrongly labelled as neurotic) 5.

Dyspeptic symptoms -neusea, vomiting, anorexia

Investigations

X-ray changes first appear in phalanges and skull-loss of density and subperiosteal erosions.

Differential diagnosis

1. Secondary (causes of hypercalcaemia) carcinoma in bones2. Multiple myeloma 3. Milk alkali syndrome4. Vitamin D intoxication5. Hodgkin’s disease 6. Sarcoidosis7. Thyrotoxicosis

Carotid Body Tumour

Carotid body is a flattened brownish nodule of a few millimeter in diameter, Situated with in the adventitious coat on posterior aspect of the common carotid artery at or just below the bifurcation. Slowly growing, locally invasive unilateral tumour

Arises from the carotid body (chemo-receptor) at the bifurcation of the carotid artery, and closely adherent to it. It moves side to side but not vertically

Remains localized for years, regional metastasis occurs in about 20 per cent of cases

Distant-metastasis are rare

. Carotid angiography is diagnostic

. Attempt for biopsy may lead torrential hemorrhage

carotid

Carotid

Cervical Rib

A rib arises from the seventh cervical vertebra

An incomplete rib, with the free end which may expanded into a large bony mass

Cervical Ribs may be unilateral or bilateral with local symptoms .

The rib-lump is hard, and fixed palpable mass in the neck

Cervical Rib

U/S B-Scan of the CR

Cervical Rib Doppler

Supraclavicular Lump: ??? Brachial Plexus Neurogenic Tumour

• The diagnosis of a brachial plexus neurogenic tumour should be considered in patients presenting with a supraclavicular lump. Pre-operative diagnosis assists in optimal management. Five cases of neurogenic tumours of the brachial plexus presenting as a supraclavicular lump are reviewed. Excision or enucleation was performed.Only one case developed a permanent neurological deficit. (??Differenciate between neurofibroma and schwannoma ) .

• The majority present as a slow growing mass diagnosis may be suggested by pain or paraesthesia in the arm or shoulder particularly on

palpation . . • CT has been superseded by MRI because of its better differentiation of

soft tissues

CT and MRI in diff.diag.

T1-weighted images show the tumour to be of intermediate signal and T2-weighted images show a high signal with some heterogeneity. These appearances are not specific to peripheral nerve tumours, although the diagnosis may be suggested if the lesion arises from a major nerve trunk. MRI may also assist in pre-operative differentiation between schwannoma and neurofibroma. The nerve is shown to lie peripheral to the tumour in schwannomas while it is central or obliterated in neurofibromas. In addition, schwannomas often show cystic change where neurofibromas do not

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