ULTRASONOGRAPHIC ASSESSMENT OF NECK MASSES by Gretchen A.W. Gooding, MD; Karen A . Herzog, MD; Faye C. Laing, MD and Eugene J. McDonald, Jr., MD
ABSTRACT Fourteen patients are presented to illustrate the usefulness of ultrasonography in assessing masses of the neck. Included are five patients with primary tumors, two with metastasis to a cervical node, three with cervical adenitis, two with simple cysts, and two with hematoma related to endarterectomy for occlusive disease of the carotid artery.
Indexing Words Neck Ultrasonography Cat-Scratch Fever
Neck Carcinoma Postendarterectomy Hematoma Neck Neoplasms cysts
Ultrasonography has gained acceptance as an accurate diagnostic technique in the assessment of cystic, solid, and complex masses. Goldberg (1) evaluated its use in diagnosing superficial masses. We wish to detail the applications and usefulness of ultrasonography in evaluation of masses in the neck, excluding the thyroid gland which has already been examined in depth (2-5). MATERIAL AND METHODS
Fourteen patients with neck masses ranging in diameter from 1t o 10 cm were scanned using a commercially available ultrasonographic unit. * Twelve of the patients had clinically palpable masses, while in two patients (Cases 1 3 and 14) the mass was situated at the site of a recent endarterectomy for occlusive disease of the carotid artery. The patients were positioned such that the mass was in as superficial a position as possible. Anterior lesions were usually best delineated with the patient lying supine and with the neck hyperextended. Posterior or laterally situated neck masses were best evaluated with the patient prone or in a lateral decubitus position, respectively. Mineral oil was applied to the neck, then transverse and longitudinal contact B scans were obtained over the area of interest using a highfrequency (MHz) transducer. A mode analysis From the Department of Radiology, University o f California School of Medicine. San Francisco, California. Received December 3. 1 9 7 5 ; revision accepted October 25. 1976. For reprints contact: Gretchen A . W . Gooding, M D , Department o f Radiology, 380-M, University of California School of Medicine, San Francisco, CA 9 4 1 4 3 . 248
was also done over specific areas to corroborate the cystic or solid characteristics of the lesion in question. Permanent recordings of the image were made on Polaroid film. RESULTS
The masses were categorized on the basis of their ultrasonographic appearance as being either cystic, solid, or complex. Not surprisingly, a rather broad spectrum of pathologic entities was encountered (Table I). Surgical confirmation was available in 1 0 of the patients. Three of the masses were due t o inflammation of cervical lymph nodes(Cases 1, 2, and 3). Interestingly, the ultrasonographic appearance of these three masses differed markedly. In one patient, the mass was cystic, as confirmed by A mode analysis (Fig. 1A); in another, the mass appeared solid (Fig. 1B); while in the third patient, a complex mass was apparent (Fig. 1C). Two other patients had benign cysts, clearly demonstrated at ultrasonography. One had a 1 cm sebaceous cyst (Case 4), while the other had a branchial cleft cyst (Case 5) (Fig. 2). Neoplasms accounted for the masses in seven patients; these included two patients with metastatic disease to the supraclavicular area (Cases 11 and 12). Five of the neoplastic neck masses appeared solid ultrasonographically (Cases 6, 7, 8, 9, and 12); two masses were complex (Cases 10 and 11)(Fig. 3A and B). The final two patients had recently undergone carotid endarterectomy for vascular occlusive *Picker EDC Ultrasonoscope. JOURNAL O F CLINICAL ULTRASOUND
TABLE I
Case
Size and Location of Cervical Mass
Ultrasonographic Character
Category
Pathological Diagnosis
1
4 x 2 cm, l e f t posterior triangle mass
cystic
inflammation
cervical adenitis (abscess secondary to cat-scratch fever)
2
2 'h x 2 cm, left jugulo-
solid
inflammation
cervical adenitis (granulomas of cervical node consistent with cat-scratch fever)
complex
inflammation
cervical adenitis
digastric node
3
5 x 6 cm mass in left mandibular angle
4
1 cm mass a t nape of neck
cystic
benign cyst
sebaceous cyst
5
2 x 3 mass in left lateral
cystic
benign cyst
branchial cleft cyst
solid
neoplasm
thymoma
solid
neoplasm
lipoma
solid
neoplasm
mixed tumor of the parotid
solid
neoplasm
squamous cell carcinoma of the right right pyriform sinus
complex
neoplasm
malignant schwannoma with hemorrhagic necrosis
complex
neoplasm
metastatic neuroblastoma
solid
neoplasm
metastatic medullary carcinoma of the thyoid
aspect of neck
6
3 x 2 cm mass just t o the right of sternal notch
7
5 x 6 cm mass in right supraclavicular area
8
3 x 5 cm tumor of the left parotid gland
9
3 x 5 cm mass, right anterior cervical area
10 9 x 10 cm mass of right side of neck
11
7 x 4 cm mass, left supraclavicular area
12
3 x 6 cm, left supraclavicular mass
13
mass a t site of carotid endarterectomy
complex
hematoma
hematoma
14
mass a t site of carotid endarterectomy
complex
hematoma
hematoma
disease. Postoperatively, hematomas developed at the operative site. Ultrasonographically, these herhatomas appeared as complex masses (Fig. 4). DISCUSSION
Ultrasonography is an ideal modality for delineating masses in the neck because they are usually palpable and relatively superficial. Ultrasonographic techniques can define the margins and depth of the lesion; discriminate between cystic, solid, and complex characteristics; and readily determine changes in size and sonic character. VOLUME 5 . NUMBER 4
Depending on the stage of development when scanned, adenitis may exhibit various sonographic patterns. In one of our three patients with adenitis (Case l), a sterile abscess in the form of a cyst had developed within an involved lymph node. In the second, the solid node had not progressed to frank abscess formation; in the third patient, a complex pattern emerged as the inflamed node progressed toward fluctuation. Thus adenitis may present a cystic, solid, or complex pattern. Both benign cysts, i.e., the sebaceous cyst and the branchial cleft cyst were cystic ultra249
I
F I G U R E 1A. Case 1 A cystic mass, an abscess, i n the neck of a patient w i t h cat-scratch fever. (The d o t - t o - d o t distance on this and subsequent sonograms I S 1 c m )
c
FIGURE 1C. Case 3 . A large transsonic mass w i t h a strong back wall containing a f e w internal echoes, a complex configuration of cervical adenitis. (A-scan shown below.)
h
refJreF I G U R E 1B. Case 2. A Poorly marginated solid senting cervical adenitis, consistent w i t h cat-scratch fever.
250
F I G U R E 2. Case 5. A cystic mass in the l e f t lateral aspect of the neck, representing a branchial cleft cyst. J O U R N A L O F CLINICAL U L T R A S O U N D
F I G U R E 3A. Case 10 A well circumscribed solid mass, medullary carcinoma of the thyroid metastatic to a left supraclavicular node.
F I G U R E 36. Case 11. A complex mass with strong posterior wall echoes, found to be metastatic ganglioneuroblastoma in a left supraclavicular node with hemorrhage.
sonographically. Perrin and Vermelin report two cases of branchial cleft cyst, both determined to be cystic by ultrasonography (6). Goldberg (1), however, described a sebaceous cyst that was found t o be a complex mass. The five primary tumors of the neck that we saw were all solid except for the malignant schwannoma, which also had a complex compartment of hemorrhage and necrosis. This latter presentation was similar to the case of metastatic neuroblastoma where hemorrhage had developed within the involved node. These observations should be helpful to the clinician in assessing whether the tumor observations should be helpful to the clinician in assessing whether the tumor itself is rapidly enlarging, or whether a secondary phenomenon such F I G U R E 4. A complex mass, a hematoma, compressing the right as hemorrhage or necrosis of tumor has oc- common carotid artery a t the endarterectomy s i t e curred. Wiley e t a1 (7) have also found ultrasoWhile ultrasonography can be used to characnography useful in evaluating neoplastic nodes terize a mass as to its cystic or solid nature, it in the neck and report their ability to delineate cannot predict the histologic appearance. For the node boundaries, proximity to major ves- example, it cannot differentiate an infectious sels, and response to chemotherapy. process from a neoplastic one, although fluid In Case 6, ultrasonography was valuable in in a mass can be detected, nor can it distinguish assessing what was clinically thought to be a malignant process from a benign one. Desaneurysmal dilatation of an innominate artery, pite these deficiencies, ultrasonography adds but which proved to be a solid tumor ultraso- a new and valuable dimension t o the assessment nographically; it was a thymoma, transmitting of neck masses. a pulsation. Because the technique can distinguish a transsonic vascular structure from a REFERENCES solid mass, we believe it is also of value in 1. Goldberg BB: Ultrasonic evaluation of superficial defining the extent of hematoma resulting masses. J Clin Ultrasound 3:91, 1975. from carotid endarterectomy and may be 2. Blum M, Goldman AB, Herskovic A, and Hernberg J: helpful in observing the evolution of an infecClinical applications of thyroid echography. N Engl tion at the operative site. B mode ultrasonogJ Med 287:1164,1972. raphy has also been suggested as a screening 3. Miskin M, Rosen IB, and Walfish PG: B mode ultraprocedure for asymptomatic carotid bruits sonography in assessment of thyroid gland lesions. Ann Intern Med 79:505.1973. (8).
m
VOLUME 5, NUMBER 4
251
4. Thijs LG: Diagnostic ultrasound in clinical thyroid investigation. J Clin Endocrinol Metab 32:709, 1971. 5. Rasmussen SN, Christiansen NJB, Jorgensen JS, and Holm HH: Differentiation between cystic and solid thyroid nodules by ultrasonic examination: An estimation of the value of ultrasonic examination as a supplement to isotopic scanning: A preliminary communication. Acta Chir Scand 137:331, 1971. 6 . Perrin C and Vermelin M: Kystes branchiaux de decouverte tardive interet de I’echographie. J Fr
2 52
Otorhinolaryngol 22:839,1973. 7. Wiley AL, Zagzebski JA, Tolbert DD, and Banjavic RA: Ultrasound B scans for clinical evaluation of neoplastic neck nodes. Arch Otolaryngol 101:509, 1975. 8. Anderson RD, Powell DF, and Vitek JJ: B mode sonography as a screening procedure for asymptomatic carotid bruits. Am J Roentgen01 124:292, 1975.
J O U R N A L O F CLINICAL U L T R A S O U N D
ABSTRACT Fourteen patients are presented to illustrate the usefulness of ultrasonography in assessing masses of the neck. Included are five patients with primary tumors, two with metastasis to a cervical node, three with cervical adenitis, two with simple cysts, and two with hematoma related to endarterectomy for occlusive disease of the carotid artery.
Indexing Words Neck Ultrasonography Cat-Scratch Fever
Neck Carcinoma Postendarterectomy Hematoma Neck Neoplasms cysts
Ultrasonography has gained acceptance as an accurate diagnostic technique in the assessment of cystic, solid, and complex masses. Goldberg (1) evaluated its use in diagnosing superficial masses. We wish to detail the applications and usefulness of ultrasonography in evaluation of masses in the neck, excluding the thyroid gland which has already been examined in depth (2-5). MATERIAL AND METHODS
Fourteen patients with neck masses ranging in diameter from 1t o 10 cm were scanned using a commercially available ultrasonographic unit. * Twelve of the patients had clinically palpable masses, while in two patients (Cases 1 3 and 14) the mass was situated at the site of a recent endarterectomy for occlusive disease of the carotid artery. The patients were positioned such that the mass was in as superficial a position as possible. Anterior lesions were usually best delineated with the patient lying supine and with the neck hyperextended. Posterior or laterally situated neck masses were best evaluated with the patient prone or in a lateral decubitus position, respectively. Mineral oil was applied to the neck, then transverse and longitudinal contact B scans were obtained over the area of interest using a highfrequency (MHz) transducer. A mode analysis From the Department of Radiology, University o f California School of Medicine. San Francisco, California. Received December 3. 1 9 7 5 ; revision accepted October 25. 1976. For reprints contact: Gretchen A . W . Gooding, M D , Department o f Radiology, 380-M, University of California School of Medicine, San Francisco, CA 9 4 1 4 3 . 248
was also done over specific areas to corroborate the cystic or solid characteristics of the lesion in question. Permanent recordings of the image were made on Polaroid film. RESULTS
The masses were categorized on the basis of their ultrasonographic appearance as being either cystic, solid, or complex. Not surprisingly, a rather broad spectrum of pathologic entities was encountered (Table I). Surgical confirmation was available in 1 0 of the patients. Three of the masses were due t o inflammation of cervical lymph nodes(Cases 1, 2, and 3). Interestingly, the ultrasonographic appearance of these three masses differed markedly. In one patient, the mass was cystic, as confirmed by A mode analysis (Fig. 1A); in another, the mass appeared solid (Fig. 1B); while in the third patient, a complex mass was apparent (Fig. 1C). Two other patients had benign cysts, clearly demonstrated at ultrasonography. One had a 1 cm sebaceous cyst (Case 4), while the other had a branchial cleft cyst (Case 5) (Fig. 2). Neoplasms accounted for the masses in seven patients; these included two patients with metastatic disease to the supraclavicular area (Cases 11 and 12). Five of the neoplastic neck masses appeared solid ultrasonographically (Cases 6, 7, 8, 9, and 12); two masses were complex (Cases 10 and 11)(Fig. 3A and B). The final two patients had recently undergone carotid endarterectomy for vascular occlusive *Picker EDC Ultrasonoscope. JOURNAL O F CLINICAL ULTRASOUND
TABLE I
Case
Size and Location of Cervical Mass
Ultrasonographic Character
Category
Pathological Diagnosis
1
4 x 2 cm, l e f t posterior triangle mass
cystic
inflammation
cervical adenitis (abscess secondary to cat-scratch fever)
2
2 'h x 2 cm, left jugulo-
solid
inflammation
cervical adenitis (granulomas of cervical node consistent with cat-scratch fever)
complex
inflammation
cervical adenitis
digastric node
3
5 x 6 cm mass in left mandibular angle
4
1 cm mass a t nape of neck
cystic
benign cyst
sebaceous cyst
5
2 x 3 mass in left lateral
cystic
benign cyst
branchial cleft cyst
solid
neoplasm
thymoma
solid
neoplasm
lipoma
solid
neoplasm
mixed tumor of the parotid
solid
neoplasm
squamous cell carcinoma of the right right pyriform sinus
complex
neoplasm
malignant schwannoma with hemorrhagic necrosis
complex
neoplasm
metastatic neuroblastoma
solid
neoplasm
metastatic medullary carcinoma of the thyoid
aspect of neck
6
3 x 2 cm mass just t o the right of sternal notch
7
5 x 6 cm mass in right supraclavicular area
8
3 x 5 cm tumor of the left parotid gland
9
3 x 5 cm mass, right anterior cervical area
10 9 x 10 cm mass of right side of neck
11
7 x 4 cm mass, left supraclavicular area
12
3 x 6 cm, left supraclavicular mass
13
mass a t site of carotid endarterectomy
complex
hematoma
hematoma
14
mass a t site of carotid endarterectomy
complex
hematoma
hematoma
disease. Postoperatively, hematomas developed at the operative site. Ultrasonographically, these herhatomas appeared as complex masses (Fig. 4). DISCUSSION
Ultrasonography is an ideal modality for delineating masses in the neck because they are usually palpable and relatively superficial. Ultrasonographic techniques can define the margins and depth of the lesion; discriminate between cystic, solid, and complex characteristics; and readily determine changes in size and sonic character. VOLUME 5 . NUMBER 4
Depending on the stage of development when scanned, adenitis may exhibit various sonographic patterns. In one of our three patients with adenitis (Case l), a sterile abscess in the form of a cyst had developed within an involved lymph node. In the second, the solid node had not progressed to frank abscess formation; in the third patient, a complex pattern emerged as the inflamed node progressed toward fluctuation. Thus adenitis may present a cystic, solid, or complex pattern. Both benign cysts, i.e., the sebaceous cyst and the branchial cleft cyst were cystic ultra249
I
F I G U R E 1A. Case 1 A cystic mass, an abscess, i n the neck of a patient w i t h cat-scratch fever. (The d o t - t o - d o t distance on this and subsequent sonograms I S 1 c m )
c
FIGURE 1C. Case 3 . A large transsonic mass w i t h a strong back wall containing a f e w internal echoes, a complex configuration of cervical adenitis. (A-scan shown below.)
h
refJreF I G U R E 1B. Case 2. A Poorly marginated solid senting cervical adenitis, consistent w i t h cat-scratch fever.
250
F I G U R E 2. Case 5. A cystic mass in the l e f t lateral aspect of the neck, representing a branchial cleft cyst. J O U R N A L O F CLINICAL U L T R A S O U N D
F I G U R E 3A. Case 10 A well circumscribed solid mass, medullary carcinoma of the thyroid metastatic to a left supraclavicular node.
F I G U R E 36. Case 11. A complex mass with strong posterior wall echoes, found to be metastatic ganglioneuroblastoma in a left supraclavicular node with hemorrhage.
sonographically. Perrin and Vermelin report two cases of branchial cleft cyst, both determined to be cystic by ultrasonography (6). Goldberg (1), however, described a sebaceous cyst that was found t o be a complex mass. The five primary tumors of the neck that we saw were all solid except for the malignant schwannoma, which also had a complex compartment of hemorrhage and necrosis. This latter presentation was similar to the case of metastatic neuroblastoma where hemorrhage had developed within the involved node. These observations should be helpful to the clinician in assessing whether the tumor observations should be helpful to the clinician in assessing whether the tumor itself is rapidly enlarging, or whether a secondary phenomenon such F I G U R E 4. A complex mass, a hematoma, compressing the right as hemorrhage or necrosis of tumor has oc- common carotid artery a t the endarterectomy s i t e curred. Wiley e t a1 (7) have also found ultrasoWhile ultrasonography can be used to characnography useful in evaluating neoplastic nodes terize a mass as to its cystic or solid nature, it in the neck and report their ability to delineate cannot predict the histologic appearance. For the node boundaries, proximity to major ves- example, it cannot differentiate an infectious sels, and response to chemotherapy. process from a neoplastic one, although fluid In Case 6, ultrasonography was valuable in in a mass can be detected, nor can it distinguish assessing what was clinically thought to be a malignant process from a benign one. Desaneurysmal dilatation of an innominate artery, pite these deficiencies, ultrasonography adds but which proved to be a solid tumor ultraso- a new and valuable dimension t o the assessment nographically; it was a thymoma, transmitting of neck masses. a pulsation. Because the technique can distinguish a transsonic vascular structure from a REFERENCES solid mass, we believe it is also of value in 1. Goldberg BB: Ultrasonic evaluation of superficial defining the extent of hematoma resulting masses. J Clin Ultrasound 3:91, 1975. from carotid endarterectomy and may be 2. Blum M, Goldman AB, Herskovic A, and Hernberg J: helpful in observing the evolution of an infecClinical applications of thyroid echography. N Engl tion at the operative site. B mode ultrasonogJ Med 287:1164,1972. raphy has also been suggested as a screening 3. Miskin M, Rosen IB, and Walfish PG: B mode ultraprocedure for asymptomatic carotid bruits sonography in assessment of thyroid gland lesions. Ann Intern Med 79:505.1973. (8).
m
VOLUME 5, NUMBER 4
251
4. Thijs LG: Diagnostic ultrasound in clinical thyroid investigation. J Clin Endocrinol Metab 32:709, 1971. 5. Rasmussen SN, Christiansen NJB, Jorgensen JS, and Holm HH: Differentiation between cystic and solid thyroid nodules by ultrasonic examination: An estimation of the value of ultrasonic examination as a supplement to isotopic scanning: A preliminary communication. Acta Chir Scand 137:331, 1971. 6 . Perrin C and Vermelin M: Kystes branchiaux de decouverte tardive interet de I’echographie. J Fr
2 52
Otorhinolaryngol 22:839,1973. 7. Wiley AL, Zagzebski JA, Tolbert DD, and Banjavic RA: Ultrasound B scans for clinical evaluation of neoplastic neck nodes. Arch Otolaryngol 101:509, 1975. 8. Anderson RD, Powell DF, and Vitek JJ: B mode sonography as a screening procedure for asymptomatic carotid bruits. Am J Roentgen01 124:292, 1975.
J O U R N A L O F CLINICAL U L T R A S O U N D
