US of Pediatric Superficial Masses of The Head and Neck

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1239
Pediatric Imaging
US of Pediatric Superficial Masses
of the Head and Neck
Anmol Gupta Bansal, MD
Rebecca Oudsema, MD Superficial palpable masses of the head and neck are common
Joy A. Masseaux, MD in the pediatric population, with the vast majority of the lesions
Henrietta Kotlus Rosenberg, MD ultimately proven to be benign. Duplex ultrasonography (US)
has emerged as the first-line imaging modality for the evaluation
Abbreviations: BCC = branchial cleft cyst, of superficial pediatric masses. Without utilizing radiation, iodin-
TDC = thyroglossal duct cyst ated contrast material, or sedation and/or anesthesia, US provides
RadioGraphics 2018; 38:1239–1263 a means for quick and cost-effective acquisition of information,
https://doi.org/10.1148/rg.2018170165
including the location, size, shape, internal content, and vascular-
ity of the mass. In this review, the US findings are described for a
Content Codes:
variety of common and uncommon pediatric head and neck masses
From the Department of Radiology, Kravis diagnosed in our practice. Specifically, the entities covered include
Children’s Hospital at the Mount Sinai Hospi-
tal, One Gustave L. Levy Place, New York, NY neonatal scalp hematoma, craniosynostosis, dermoid and epider-
10029. Recipient of a Certificate of Merit award moid cysts, Langerhans cell histiocytosis, lymph nodes and their
for an education exhibit at the 2016 RSNA An-
nual Meeting. Received June 23, 2017; revision
complications, fibromatosis colli, thyroglossal duct cyst, branchial
requested September 21 and received October cleft cyst, cervical thymus, congenital goiter, thyroid papillary carci-
28; accepted November 6. For this journal-based noma, parathyroid adenoma, hemangioma, lymphangioma, jugular
SA-CME activity, the authors, editor, and re-
viewers have disclosed no relevant relationships. vein phlebectasia, Lemierre syndrome, acute parotitis and parotid
Address correspondence to A.G.B. (e-mail: abscess, leukemia and/or lymphoma, neurogenic tumor, and rhab-
anmolguptabansal@gmail.com).
domyosarcoma. Ultimately, in situations in which the head or neck
©
RSNA, 2018 • radiographics.rsna.org mass is too large, deep, or hyperechoic to be fully assessed within
the US field of view, or if malignancy or a high-flow vascular lesion
SA-CME Learning Objectives is suspected, then further evaluation with cross-sectional imaging is
After completing this journal-based SA-CME warranted.
activity, participants will be able to:
■■Describe the characteristic US findings
Online supplemental material is available for this article.
of various common and uncommon pe- ©
RSNA, 2018 • radiographics.rsna.org
diatric head and neck masses.
■■Recognize when further evaluation with
cross-sectional imaging is warranted.
■■Discuss the next best step if the find-
ings from a thorough US evaluation do
Introduction
not help confirm the presence of a super- Superficial palpable masses of the head and neck are common in
ficial mass. the pediatric population, with the vast majority of these lesions
See rsna.org/learning-center-rg. ultimately proven to be benign (1–3). These masses may originate
in the skin, subcutaneous fat, muscle, or bone. The most commonly
encountered masses include lymph nodes, lipomas, cysts, hemato-
mas, abscesses, and vascular malformations, to name a few. Although
some of these masses are discovered incidentally, others come to at-
tention because of fever, pain, or cosmetic deformity. In this review,
the ultrasonographic (US) findings of a variety of common and
uncommon head and neck lumps and bumps encountered in our
practice are described. There are too many head and neck masses to
cover in a single review; therefore, a variety of benign and malignant
1240 July-August 2018 radiographics.rsna.org
cal history and the physical examination. The

Teaching Points workup includes gathering relevant information,
■■ Duplex US is the first-line modality of choice for the evalua- such as whether the lesion was present at birth, if
tion of superficial head and neck masses. Without use of ion-
izing radiation, iodinated contrast material, or sedation and/
there is associated pain or fever, and whether the
or anesthesia, US is able to provide quick and cost-effective size of the lesion has changed with time. Like-
acquisition of information, including the location, size, shape, wise, at physical examination, it is important to
internal contents (solid or cystic), and vascularity of the mass, note the location, mobility, compressibility, and
as well as its relationship to nearby vessels. surface texture (smooth or irregular) of the mass,
■■ The goal of US is often to determine the next best step, with as well as whether it is tender, erythematous, or
options including clinical observation, follow-up US, radiogra-
warm to the touch (4–7).
phy, computed tomography (CT), magnetic resonance (MR)
imaging, tissue sampling, surgical resection, embolization, Duplex US is the first-line modality of choice
and sclerosis. Further investigation with cross-sectional imag- for the evaluation of superficial head and neck
ing is warranted if the mass is too large, deep, or hyperechoic masses. Without use of ionizing radiation, iodin-
to be completely imaged within the US field of view, or if ated contrast material, or sedation and/or an-
there are features of malignancy such as vascularity, invasion
esthesia, US is able to provide quick and cost-
of adjacent structures, or spiculated and/or irregular borders.
Risk factors for malignancy include onset during the neonatal effective acquisition of information, including
period, a firm mass, size greater than 3 cm, progressive or rap- the location, size, shape, internal contents (solid
id growth, location underneath the fascia, and skin ulceration. or cystic), and vascularity of the mass, as well as
■■ If the findings from a thorough investigation with US do not its relationship to nearby vessels. Moreover, if
demonstrate anything corresponding to the superficial palp indicated, US can also be used for guidance dur-
able mass of the head or neck, we do not recommend any ing interventional procedures for the purpose of
further imaging.
diagnosis (ie, tissue sampling and biopsy) and/or
■■ Although dermoid cysts and epidermoid cysts cannot be dis-
treatment (ie, drainage).
tinguished from each other with US alone, in our experience
we have seen that if a cyst is not covered by periosteum, it is Correlation of US and clinical findings often
more likely to represent a soft-tissue dermoid cyst, whereas helps to narrow the differential diagnosis and, in
if a cyst demonstrates periosteal draping, it is more likely to many cases, is diagnostic of the most likely cause.
represent an epidermoid cyst arising from the skull. The goal of US is often to determine the next
■■ Reactive lymph nodes will maintain their normal architecture, best step, with options including clinical obser-
which helps to differentiate them from lymphadenopathy. vation, follow-up US, radiography, computed
Uncomplicated cervical adenitis appears as a conglomerate
matted mass but will demonstrate normal homogeneous hy-
tomography (CT), magnetic resonance (MR) im-
poechoic parenchyma, with preservation of the hyperechoic aging, tissue sampling, surgical resection, embo-
hilum and oval shape. lization, and sclerosis. Further investigation with
cross-sectional imaging is warranted if the mass is
too large, deep, or hyperechoic to be completely
imaged within the US field of view, or if there
entities have been specifically chosen for discus- are features of malignancy such as vascularity,
sion: neonatal scalp hematoma, craniosynostosis, invasion of adjacent structures, or spiculated and/
dermoid and epidermoid cysts, Langerhans cell or irregular borders (4). Risk factors for malig-
histiocytosis, lymph nodes and their complica- nancy include onset during the neonatal period,
tions, fibromatosis colli, thyroglossal duct cyst a firm mass, size greater than 3 cm, progressive
(TDC), branchial cleft cyst (BCC), cervical or rapid growth, location underneath the fascia,
thymus, congenital goiter, thyroid papillary and skin ulceration (3). If the full extent of the
carcinoma, parathyroid adenoma, hemangioma, lesion can be established with US and if there
lymphangioma, internal jugular vein phlebectasia, are no suspicious features or risk factors, then no
Lemierre syndrome, acute parotitis and parotid further imaging is required. If the findings from
abscess, leukemia and/or lymphoma, neurogenic a thorough investigation with US do not demon-
tumors, and rhabdomyosarcoma. The aim is to strate anything corresponding to the superficial
help the reader determine when US may be used palpable mass of the head or neck, we do not
to evaluate superficial masses, to describe the recommend any further imaging.
characteristic US findings of the various entities,
and to recognize when additional cross-sectional US Scanning Technique
imaging, biopsy (at times US guided), an inter- The scanning technique typically uses a high-
ventional drainage procedure, or surgical excision frequency (9–3 MHz, 12–5 MHz, or 17–5 MHz)
is necessary. linear transducer to maximize resolution. For
In the workup of a superficial head or neck larger lesions, using a curvilinear transducer
mass in a pediatric patient, the first important and/or an extended field of view may be help-
step is to construct a differential diagnosis de- ful. Conversely, for small lesions, the “hockey
rived from the relevant findings from the clini- stick” (17–5io MHz) linear probe is used in our
RG • Volume 38 Number 4 Bansal et al 1241
to cranial sutures, cephalohematomas cannot

cross sutures unless there is craniosynostosis,
which would allow the periosteum to continue
uninterrupted across the affected suture. These
hematomas can occur from injury to the fetal head
in cases of forceps delivery or vacuum extractor
delivery or even spontaneously in cases of pro-
longed labor. By the end of the first 2–3 weeks,
peripheral calcification is produced by the elevated
periosteum; and by 2–3 months, the hematoma
Figure 1. Scalp anatomy and neonatal scalp hema-
tomas. Cephalohematomas accumulate between the typically has resolved (8). At US, the subperiosteal
pericranium (periosteum) and the skull. Because of the hemorrhage demonstrates moderate echogenicity
firm adherence of the pericranium to cranial sutures, and is bound by the periosteum (Fig 2). Most
cephalohematomas cannot cross sutures. Subgaleal he- often, the underlying brain is normal. At times, the
matomas, however, accumulate in the potential space
between the pericranium and the galea aponeurotica examination is limited by thick scalp hair, but use
and therefore can cross suture lines and spread across of a copious amount of gel is helpful.
the entire calvaria. Subgaleal hematomas are often as- Subgaleal hematoma is a rare but potentially
sociated with underlying skull fractures. lethal emergency. The term subgaleal hematoma
refers to bleeding in the potential space between
the pericranium and the galea aponeurotica
practice. Cine clips are useful for demonstrat- owing to rupture of the emissary veins, which
ing compressibility, for assessing the extent of a connect the scalp veins with the dural sinuses (9).
lesion that exceeds the US field of view, and for Unlike cephalohematomas, subgaleal hematomas
comparing the tissue characteristics of a lesion can be associated with an underlying fracture
with those of the surrounding soft tissues. Creat- and are located superficial to the periosteum, and
ing a gel mound over a superficial lesion allows they can cross suture lines and spread across the
for depiction of the most superficial aspects of a entire calvaria. This subaponeurotic space may
mass and most often obviates the need for a gel hold as much as 260 mL of blood (10), resulting
standoff pad. Comparison views of the opposite in severe hypovolemia. Moderate to severe sub-
side with dual-phase imaging are helpful in high- galeal hemorrhages occur in approximately 1.5 of
lighting asymmetry. Finally, to elicit cooperation 10 000 births (9), most commonly after vacuum-
from pediatric patients, you should have distrac- assisted delivery and forceps delivery, but may
tion techniques readily available, including a baby also occur spontaneously (11,12). Early signs
bottle, pacifier, musical toys, electronic gaming include a fluctuant boggy mass under the scalp,
devices, and/or video players. increasing head circumference, pallor, hypotonia,
and tachycardia (13).
Head Masses At US, the acute subgaleal hemorrhage shows
moderate echogenicity and will not be bound
Neonatal Scalp Hematoma by the pericranium (Fig 3). The echogenicity
At our institution, US is used to evaluate for becomes progressively less as the hematoma
superficial hematomas when there is clinical resolves. The information provided by the US
concern regarding the differential diagnosis, as image allows a description of the size of a le-
well as to determine if higher-tech imaging is sion, the content of the fluid collection, and
required. Precise knowledge of the relevant scalp the presence of an underlying fracture or other
anatomy is essential in the evaluation of neona- abnormality. CT may be necessary to fully char-
tal scalp collections (Fig 1). The scalp is divided acterize the extent of the hemorrhage and the
into skin, connective tissue, the aponeurosis, also underlying fracture.
known as the galea aponeurotica, and the peri-
cranium (periosteum), which covers the skull. Craniosynostosis
Although many types of neonatal scalp hemato- Craniosynostosis refers to the premature closure
mas exist, this review focuses on utilization of US of one or more cranial sutures, often occurring in
for assessment of suspected cephalohematomas utero. Usually, the metopic suture closes between
and subgaleal hematomas. 3 and 9 months of age (14); and the sagittal,
The term cephalohematoma refers to the accu- coronal, and lambdoid sutures typically fuse in
mulation of blood products between the pericra- the 2nd and 3rd decades of life (15,16). In the
nium and the cranial bone, and cephalohema- presence of synostosis, restriction of normal skull
tomas occur in about 1%–2% of newborns (8). growth perpendicular to the affected suture re-
Because of the firm adherence of the pericranium sults in an abnormal head shape, and intracranial
Figure 2. Cephalohematoma in a 1-week-old male neonate presenting with a firm fluctuant left pa-
rietal soft-tissue mass who had a history of a traumatic delivery. (a) Lateral cranial radiograph shows
soft-tissue swelling confined by the coronal and lambdoid sutures (arrows) and also by the sagittal su-
ture (not shown). (b) Sagittal gray-scale US image of the left parietal region shows marked separation
of the scalp from the underlying skull by subperiosteal bleeding that is bound by the pericranium and
therefore cannot cross sutures. The offset of the underlying skull bones is due to molding of the skull
during labor and delivery (partial overlap of frontal and parietal bones) (arrow). The underlying brain
was normal (not shown).
Figure 3. Subgaleal hematoma in a 2-day-old female newborn presenting with a large diffuse fluctuat-
ing mass who had a history of a vacuum-assisted delivery. (a) Lateral cranial radiograph shows almost
universal marked soft-tissue swelling (arrows) surrounding the cranial vault. (b) Sagittal gray-scale US
image of the left parietal region shows bleeding in the potential space between the periosteum and galea
aponeurotica, with an underlying fracture (arrow).
pressure may lead to neurocognitive impairment trigonocephaly. Less common is unilateral prema-
(17). The incidence of craniosynostosis overall ture fusion of the coronal suture or the lambdoid
is one in 2000–2500 children (18–20), with 8% suture. Unilateral premature fusion of the coronal
of the cases familial or syndromic (21). Nonsyn- suture, known as anterior plagiocephaly, often re-
dromic craniosynostosis can be either isolated sults in a harlequin eye deformity of the ipsilateral
(single suture) or complex (multiple sutures). orbit. Unilateral premature fusion of the lambdoid
Each type of craniosynostosis results in a suture results in posterior plagiocephaly. Surgical
characteristic dysmorphic head shape. The sagittal treatment may be indicated for correction of cos-
suture is most often involved, occurring in one in metic deformities and for avoidance of increased
2000 births, with a male-to-female ratio of 3.5:1 intracranial pressure, because brain growth is
(22,23). Craniosynostosis of the sagittal suture restricted in the presence of synostosis.
results in a long and narrow head shape called Although the diagnosis of craniosynostosis
scaphocephaly or dolichocephaly. Premature can often be made on the basis of the findings at
closure of the metopic suture is the second most physical examination because of the cosmetic and/
common type of craniosynostosis (18,24) and or calvarial deformity, US can be helpful in more
results in a triangular-shaped forehead termed subtle cases. At US, there is loss of the normal
Figure 4. Craniosynostosis in a 2-day-old female neonate presenting with a misshapen head, a possible
midline bone ridge, and increased intracranial pressure. (a) Gray-scale US image of the coronal suture
shows normal suture patency (arrow), as evidenced by the lack of connection of the adjacent skull bones.
(b) Gray-scale US image of the sagittal suture shows bone ridging in the midline (arrow) that is due to
fusion (premature closure) of the adjacent parietal bones.
Figure 5. Dermoid cyst and epidermoid cyst in two different patients. (a) Dermoid cyst in a 7-week-old
female infant presenting with a nontender compressible mass in the region of the anterior fontanelle that
was noted 1 week before presentation: Transverse gray-scale US image shows a well-defined subcutane-
ous avascular compressible anechoic cystic mass superficial to the periosteum (arrows). The underlying
skull was unremarkable. (b) Epidermoid cyst in a 9-month-old female infant presenting with a small hard
immobile right frontal mass: Transverse gray-scale US image shows a hypoechoic avascular well-defined
complex cystic mass containing debris, which arises from the right frontal bone. The periosteum (arrows)
is draped over the mass.
hypoechoic appearance of a segment of normal dermoid and epidermoid cysts are most often
skull suture secondary to fusion of the suture (Fig seen in the midline and in the frontotemporal
4). It may be quite challenging, in the presence of region and less frequently in the parietal regions
patient motion and/or excess scalp hair, to follow (26). Correlation with the physical findings is
the entire course of the sutures to confirm their most helpful in differentiating a soft-tissue cyst
patency. Both a lack of suture patency and ridging from a cranial cyst, because the soft-tissue cyst
of the sutures are characteristic of craniosynosto- is mobile and rubbery at palpation, and a lesion
sis. Although US is a good screening modality for arising from the skull will be immobile and hard.
craniosynostosis, definitive diagnosis and surgical At US, dermoid and epidermoid cysts are
planning require advanced imaging (CT) with generally well circumscribed, avascular, and hy-
three-dimensional reconstruction. poechoic, compared with subcutaneous fat, and
occasionally contain hyperechoic foci because of
Dermoid and Epidermoid Cysts the presence of calcification, fat, mucoid, and/
Dermoid and epidermoid cysts are benign or purulent material or soft tissue (Fig 5). To
ectoderm-lined inclusion cysts that are thought confirm the origin of the cyst, it is imperative
to occur because of the persistence of ectoder- to demonstrate whether the cyst is covered by
mal elements at suture closure and neural tube periosteum or is superficial to the periosteum.
closure sites (25). These cysts are closely related Although dermoid cysts and epidermoid cysts
in morphologic structure; dermoid cysts con- cannot be distinguished from each other with US
tain both ectoderm and skin elements (hair, alone, in our experience we have seen that if a
sebaceous glands, and squamous epithelium), cyst is not covered by periosteum, it is more likely
whereas epidermoid cysts contain only ectoderm. to represent a soft-tissue dermoid cyst, whereas if
Cranial lesions can arise in the soft tissues of the a cyst demonstrates periosteal draping, it is more
scalp, in the diploic space of the calvaria, or be- likely to represent an epidermoid cyst arising
tween the bone and the underlying dura. Cranial from the skull. Radiography can help to confirm
Figure 6. Langerhans cell histiocytosis in a 7-year-old boy presenting with a painful occipital mass.
Transverse gray-scale (a) and color Doppler (b) US images of the left occiput show a 1.5-cm minimally
vascular solid mass (marked by calipers on a) that extends from the diploic surface through the inner and
outer tables of the skull, with local subperiosteal spread (arrows on a).
the origin of the mass from the skull, the cystic Information about the aforementioned super-
nature of the mass, and its slender sclerotic mar- ficial pediatric head masses is summarized in the
gins. MR imaging is not indicated unless there Table.
is a suspicion of a sinus track with intracranial
extension, a suggestion of a solid mass with or Neck Masses
without bone invasion, or evidence of vascularity
within the mass, because other causes are possi- Normal Cervical Lymph Nodes
ble, including, but not limited to, Ewing sarcoma, Normal cervical lymph nodes are classified on
leukemia, and lymphoma. the basis of their anatomic locations: level 1, sub-
mental and/or submandibular; level 2, along the
Langerhans Cell Histiocytosis internal jugular vein above the level of the hyoid;
Langerhans cell histiocytosis, also known as level 3, along the internal jugular vein between
eosinophilic granuloma, represents an abnormal the hyoid and the cricoid cartilage; level 4, along
proliferation of Langerhans cells and has a va- the internal jugular vein below the cricoid carti-
riety of clinical manifestations. Peak occurrence lage; level 5, posterior to the sternocleidomastoid
of Langerhans cell histiocytosis is between 1 and muscle above the clavicles; and level 6, anterior
4 years of age, with a slight propensity for males to the thyroid gland (31).
(27). Langerhans cell histiocytosis may affect At gray-scale US, normal lymph nodes will
any organ and can be classified on the basis of be well defined and appear hypoechoic when
how many sites and organs are involved (unifo- compared with the adjacent musculature (Fig
cal single system, multifocal single system, or 7a, 7b). A flattened or oval configuration is typi-
multifocal multisystem) (28). Osseous Langer- cally depicted, with distinct borders and a short
hans cell histiocytosis most commonly involves axis–to–long axis ratio of less than 0.5 (32,33).
the calvaria (29). Pain and swelling are the usual By the end of the 1st decade of life, normal
presenting symptoms. cervical lymph nodes will measure up to 10 mm
On radiographs, the bone lesions of Langer- in size when measured in the short axis, with
hans cell histiocytosis are typically described as nodes larger than 10 mm considered enlarged.
“punched-out” lytic lesions without periosteal re- During the 1st decade of life, the short axis of
action or reactive sclerosis (30). In patients with normal lymph nodes generally measures 5 mm
Langerhans cell histiocytosis, asymmetric de- or less. A hyperechoic linear fatty hilum should
struction of the inner and outer tables of the skull be able to be identified in a normal lymph node.
results in a beveled appearance. At US, Langer- The vasculature courses through the hilum
hans cell histiocytosis manifests as a solid mass before radially branching from the central lymph
with minimal vascularity, extending from the node. This pattern of central vascular flow may
diploic surface (Fig 6). Because the differential be demonstrated at color Doppler US. The
diagnosis includes leukemia and/or lymphoma as perinodal soft tissues will be distinct, with well-
well as other neoplastic processes that cannot be defined planes separating the dermis, subcuta-
excluded with US alone, cross-sectional imaging neous fat, and muscle.
is required for more precise tissue characteriza-
tion and to assess the extent of the lesion, espe- Cervical Adenitis and Its Complications
cially with regard to invasion of the bone, dura, Cervical adenitis is the most common cause of
meninges, and/or cerebral cortex. a pediatric neck mass seen in response to non-
Superficial Pediatric Head Masses
Relative Fre- Typical US Differential Pertinent Cross-sectional How Entity Is

Entity quency Appearance Diagnosis Imaging Appearance Diagnosed
Cephalo 1%–2% of Hemorrhage is Caput suc- Crescent-shaped subperios- PE, US
hematoma newborns moderately cedaneum, teal collection confined by
echogenic and subgaleal the cranial suture
bound by the hematoma
periosteum
Subgaleal 1.5 of 10 000 Moderately echo- Cephalohema- Large extracranial collection PE, US, CT
hematoma births genic hemorrhage toma not confined by cranial recommended
not bound by the sutures to evaluate
periosteum full extent of
hemorrhage and
any underlying
fracture
Craniosynos- 1 in 2000– Suture not depicted Positional Abnormal fusion of the Primarily PE;
tosis 2500 along its expect- molding suture, with a dysmorphic US can help
children ed location, often head shape in subtle cases;
with associated CT with 3D
ridging reconstruction
helps surgical
planning
Dermoid and Relatively Well circumscribed, Sebaceous CT: epidermoid cysts have PE, US; occasion-
epidermoid common avascular, cyst, TDC fluid attenuation; dermoid ally, CT and/or
cysts hypoechoic to cysts have a more complex MR imaging is
subcutaneous fat appearance, typically fat needed for fur-
unless filled with attenuation ther evaluation
thick mucoid, MR imaging: epidermoid
purulent, and/ cysts are T1 hypointense
or hemorrhagic and T2 hyperintense; der-
material moid cysts are T1 hyperin-
tense and T2 hypointense
Langerhans cell 5–9 per 1 mil- Solid mass with Leukemia and/ CT: enhancing soft-tissue Clinical and radio-
histiocytosis lion patients minimal vascu- or lym- masses with surrounding logic findings
<15 y; 1 per larity, extending phoma osseous erosion in combination
1 million from the diploic MR imaging: T1 hypo- to with histopatho-
patients surface isointense, T2 hyperin- logic findings
≥15 y tense, diffuse enhancement
Note.—PE = physical examination, 3D = three-dimensional.
specific infectious and/or inflammatory triggers, conglomerate matted mass but will demonstrate
most commonly from a viral infection (such as normal homogeneous hypoechoic parenchyma,
adenovirus, rhinovirus, and enterovirus) causing with preservation of the hyperechoic hilum and
bilateral cervical nodal enlargement. Unilateral oval shape (Fig 7c, 7d) (6,32,36).
cervical adenitis is often due to bacterial infection Complications of cervical adenitis include sup-
of oropharyngeal origin (6,34,35). A child will puration (pus formation) and abscess formation,
present with a painful cervical mass that will of- for which US is an excellent modality to help
ten resolve with conservative medical treatment, differentiate simple from complicated cervical
without the need for further imaging workup. At adenitis (Fig 8). As the enlarged and inflamed
US evaluation, reactive lymph nodes—particu- lymph node undergoes suppuration, the center
larly submandibular, parotid, and upper internal of the node will demonstrate heterogeneously de-
jugular chain lymph nodes—may be enlarged creased echogenicity with progressive necrosis, as
and show increased vascularity at color Dop- well as reduction or loss of the hyperechoic fatty
pler US, with decreased values for the resistive stripe and decreased vascularity at color Doppler
index secondary to inflammatory vasodilation US. Central nodal complexity with debris, septa,
(32,35). However, these reactive lymph nodes or foci of air may also be seen. Adjacent reactive
will maintain their normal architecture, which edema of the surrounding perinodal soft tissues is
helps to differentiate them from lymphadenopa- commonly found, with effacement of the normal
thy. Uncomplicated cervical adenitis appears as a fat planes. Abscess formation will appear as a
Figure 7. Comparison of normal lymph nodes and cervical adenitis. (a, b) Normal lymph node: Gray-
scale (a) and color Doppler (b) US images show that a normal lymph node (marked by calipers on a) is
flat or oval, usually measures less than 5 mm in the short-axis diameter in young children, and appears
hypoechoic with a hyperechoic linear hilum (a), within which blood flow is depicted (colored areas on b).
(c, d) Cervical adenitis in a 4-year-old boy presenting with bilateral neck masses that had been enlarging
for the previous 2 weeks: Sagittal Doppler US images of the right (c) and left (d) parts of the neck show
enlarged lymph nodes with thickened cortices, as well as marked hypervascularity, findings consistent
with acute inflammation and infection. No evidence of suppuration or abscess formation was depicted.
Figure 8. Suppuration and early abscess formation in a 17-month-old boy with a left neck mass and fever.
Sagittal gray-scale (a) and color Doppler (b) US images of the left side of the neck show multiple enlarged
lymph nodes that were tender at palpation. The more superiorly positioned node (dashed arrow on a) shows
loss of the expected hyperechoic fatty hilum, a finding compatible with a suppurative node. The more inferiorly
positioned node (solid arrows on a) shows cavitation and increased vascularity in the periphery of the node,
findings consistent with abscess formation.
heterogeneously hypoechoic or anechoic mass able motion of the infected fluid during real-time
with a thick and irregular rim that demonstrates US observation.
increased peripheral blood flow at color Doppler When the behavior of inflamed lymph nodes
US (Fig 8) (6,34). Frank pus within the abscess differs from that associated with the usual viral
may initially appear isoechoic or hyperechoic and bacterial causes, other less-common causes
compared with the surrounding lymph node, should be considered, such as tuberculosis, cat-
most often becoming hypoechoic or anechoic scratch disease, mononucleosis, fungal disease,
during a course of antibiotic therapy, with detect- acquired immunodeficiency syndrome (AIDS),
Figure 9. Fibromatosis colli in a 3-week-old female newborn presenting with a right neck mass. Sagit-
tal gray-scale US images of the right (a) and left (b) sternocleidomastoid muscles show an enlarged
right sternocleidomastoid muscle (arrows on a), compared with the uninvolved corresponding left
muscle (arrows on b).
sarcoidosis, and histiocytosis. Cervical adenitis Fibromatosis colli is more commonly found on
secondary to mycobacterial infections such as tu- the right side (approximately 73% of the time)
berculosis is uncommon in Western countries but and may continue to grow weeks after birth
may be seen in immunocompromised individuals. (39,40). The differential diagnosis for a solid neck
In regions in which tuberculosis is endemic, it is a mass in a pediatric patient includes adenopathy,
much more common cause of lymphadenopathy ectopic thymus, teratoma, hemangioma, lipoma,
in the pediatric population. Enlarged and often and malignancy; however, the findings at physi-
matted lymph nodes—primarily in the internal cal examination in conjunction with the imaging
jugular chain, the posterior triangle, and the findings will often lead to the proper diagnosis of
supraclavicular fossa—will eventually caseate and fibromatosis colli (41).
undergo suppuration and central necrosis, with US imaging is the first step in the workup to
adjacent reactive cellulitis or myositis (6,32,34,37). evaluate for fibromatosis colli and will demonstrate
Malignant lymphadenopathy is also a con- either focal (most commonly in the lower two-
sideration in a child presenting with cervical thirds of the muscle) or diffuse enlargement of the
lymphadenopathy. Malignant lymphadenopathy sternocleidomastoid muscle (Fig 9) (34,39,40).
in the setting of metastatic disease or primary The affected fibrotic regions may have a variable
lymphoma and/or leukemia will often manifest appearance, often demonstrating an ellipsoid re-
differently, with nodal enlargement being pain- gion of thickening that is uniformly hyperechoic or
less, hard, and nonmobile (33,38). If lymphad hypoechoic compared with the adjacent unaffected
enopathy persists after a trial of antibiotic muscle (6,42). The swollen belly of the sternoclei-
therapy, tissue sampling is often the next step in domastoid muscle will smoothly blend with the
the workup, to look for malignancy. Please refer unaffected muscle fibers without evidence of a
to the “Leukemia and/or Lymphoma” section focal well-defined primary mass (6). At real-time
for further discussion of the US appearance of US, the mass will move synchronously with the
lymphomatous and leukemic nodes. remaining sternocleidomastoid muscle, confirm-
ing the location of the mass and its relationship
Fibromatosis Colli to the muscle (42). Uncommonly, hyperechoic
Fibromatosis colli is a condition of benign fibrous foci with acoustic shadowing may be depicted,
proliferation manifesting as fusiform enlargement owing to calcification, a finding that is likely the
of the sternocleidomastoid muscle, most marked sequela of prior hemorrhage. Pertinent associ-
at the belly of the muscle. Neonates and young ated findings, such as adjacent lymphadenopathy,
infants usually present with a hard, growing neck extension of the mass beyond the muscle planes,
mass approximately 2 weeks after birth, as well as or irregular mass margins, should be reported to
torticollis, and they often have a history of birth prompt further workup, because these suspicious
trauma, such as forceps delivery or breech pre- characteristics would not be expected in fibroma-
sentation (6,39). The baby’s head generally tilts tosis colli (42). With conservative management
toward the side with the mass, and the chin tilts and physical therapy, fibromatosis colli will resolve
to the opposite uninvolved side. It is hypothesized within 4–8 months of life (6,42). The need for
that birth trauma leads to hemorrhage and even- surgery is extremely rare, and surgery is reserved
tually fibrosis of the sternocleidomastoid muscle, for infants whose condition does not improve with
leading to muscle shortening and torticollis (6). stretching exercises. When the appearance of the
Figure 10. TDCs in three different patients. (a) Transverse gray-scale US image of the midline anterior
part of the neck at the level of the hyoid bone in a 12-year-old girl shows a 3.9-cm avascular cystic lesion
with internal debris, findings compatible with a minimally complex TDC. (b, c) Sagittal gray-scale (b)
and color Doppler (c) US images of the anterosuperior part of the neck slightly to the right of midline
in a 21-year-old woman show a small hypervascular hyperechoic intramural nodule (marked by calipers
on b) within the inferior wall of the thyroglossal duct, a finding compatible with a TDC. The findings at
histopathologic examination disclosed chronic infection of the TDC. (d) Transverse gray-scale US image
of the anterior part of the neck slightly to the left of the midline in a 17-month-old boy shows a TDC
as a 1.3-cm anechoic structure (marked by calipers) containing a 1.2-cm mobile avascular hyperechoic
conglomeration of contained mucus, findings that mimic a dermoid cyst.
swollen muscle meets the criteria for fibromatosis a fluctuant or gradually enlarging painless median
colli, it is important to offer the parents strong or paramedian cervical mass. Rarely, if a cystic
reassurance of the benign nature and behavior of structure is arising from the foramen cecum,
the condition. the structure will demonstrate a changing posi-
tion with swallowing or extension of the tongue
Thyroglossal Duct Cyst (6,34,43). If not incidentally discovered, TDCs
TDC is the most common congenital pediatric may undergo superimposed infection and manifest
neck mass. TDC is due to a failure of involution as a painful neck mass.
of this embryologic structure and can be found At US evaluation, TDCs will be a well-cir-
anywhere along the course of the thyroglossal cumscribed hypo- or anechoic cystic structure
duct, from the foramen cecum at the base of the with posterior acoustic enhancement (Fig 10).
tongue to the pyramidal lobe of the thyroid gland Imaging features of internal complexity, such as
(6,43). The most common location of a TDC is at septa and debris or internal echoes from protein-
the level of the hyoid bone. TDCs at the suprahy- aceous material, may be depicted in the absence
oid and hyoid levels manifest as midline masses in of infection. In the setting of an infected TDC,
the anterior part of the neck, whereas infrahyoid additional US findings such as a thickened and
TDCs may have a median or paramedian loca- irregular cyst wall with increased peripheral vas-
tion and may be embedded in the strap muscles cularity may be present. A soft-tissue mass associ-
of the neck. The differential diagnosis includes ated with a TDC may represent ectopic thyroid
adenopathy, a dermoid cyst, an ectopic thyroid, rests or, rarely, a carcinoma—with papillary thy-
and goiter (44). Examination during swallowing is roid carcinoma diagnosed in most cases (>80%)
helpful in demonstrating synchronous movement at histopathologic examination (43). Given this
of the TDC and tongue, a finding that confirms small potential for malignant transformation, as
the relationship of these two structures. Approxi- well as the potential for infection and the chal-
mately half of the patients with TDCs will present lenge of differentiating infection from tumor in
in the 1st decade of life, with a clinical history of the presence of hypervascular wall nodules and
Figure 11. BCC in an 8-year-old boy presenting with a right neck mass. Transverse (a) and sagittal (b)
color Doppler US images of the anterior right part of the neck show a long (6.5-cm) somewhat compress-
ible anechoic cystic structure (arrows) anteromedial to the sternocleidomastoid muscle and anterior to
the internal carotid artery (ICA). The location of the structure is characteristic of a BCC.
calcifications, elective resection is recommended. of the neck, usually in childhood or late adoles-
Before surgical removal, the presence of a prop- cence. Unlike a branchial cleft fistula or branchial
erly positioned thyroid gland must be confirmed, sinus, BCCs will be self-contained, without com-
because the ectopic thyroid rests may potentially munication with the skin or internal structures
be the only functional thyroid tissue in the body. such as the pharynx. If a BCC is superinfected, it
may manifest as a painful mass.
Branchial Cleft Cyst At US evaluation, BCCs are well-circumscribed
By the 4th week of gestation, the visible bran- round or oval hypo- or anechoic cystic structures
chial apparatus consists of four mesodermal with posterior acoustic enhancement (Fig 11). A
arches lined on either side by four ectodermal common location for BCCs is the anterior triangle
clefts externally and four endodermal pouches of the neck, located anterior to the sternocleido-
internally. The fifth and sixth arches are too mastoid muscles. These cysts lie anterolateral to
small to be visualized by this time. The second the great vessels of the neck and may be adherent
arch will progress to enlarge and surround to the internal jugular vein or possibly protrude
the second through fourth branchial clefts as between the internal and external carotid arteries
it grows caudally to meet the fifth arch, with (6,34,45). A variable complex cystic appearance
nearly complete enclosure of these clefts in an and peripheral hypervascularity may be seen in the
ectodermally lined cavity (45). A small sinus setting of superimposed infection. When imaging
opening remains, which is called the cervical a BCC, it is important to look for a concurrent
sinus of His. The first branchial cleft will persist branchial cleft sinus or branchial fistulas, because
into adulthood, and the remaining branchial resection of these tracts is necessary to prevent
clefts will obliterate along with the cervical sinus recurrence of the cyst (47,48). Those patients with
during development (43,45). a branchial cleft sinus or branchial fistulas will
BCCs are part of a spectrum of branchial often present earlier and have more symptoms
cleft anomalies, including branchial fistulas and than those with a BCC, owing to external and/or
branchial sinus tracts, that are thought to be from internal mucosal drainage and an increased risk of
the embryologic remnant of the cervical sinus or superinfection (48). Often, the entire tract will be
the branchial clefts that have failed to obliterate difficult to delineate but will be proven to be pres-
(43,45). Branchial sinuses are incomplete tracts ent at surgical resection (47,48).
that usually open up externally; branchial fistulas Fourth BCCs are very rare, only accounting
will communicate both externally and inter- for only 1%–4% of all branchial cleft anomalies
nally, because they represent failure of both the (49,50). The fourth branchial sinus tract arises
branchial cleft and branchial pouch to involute. from the piriform sinus and courses through the
Of the branchial cleft anomalies, a second BCC thyrohyoid membrane to dive into the mediasti-
is the most common, for which the differential num along the tracheoesophageal groove (49–52).
diagnosis includes lymphatic malformation, Therefore, a fourth BCC may occur anywhere
cervical thymic cyst, infrahyoid TDC, cystic- along this course but is most commonly positioned
necrotic adenopathy, abscess, and carotid space along the superolateral aspect of the left part of
schwannoma (6,34,45,46). Unlike the median or the thyroid gland (49,52). Patients will commonly
paramedian location of TDCs, BCCs manifest as present at a young age with a lateral neck mass,
a fluctuant painless mass found in the lateral part recurrent deep neck infection and abscesses, or
recurrent suppurative thyroiditis resistant to anti-

biotic therapy (49,50,52–54). Definitive treatment
is resection of the cyst and associated sinus tract
(50,52,54). A sinus tract connecting the thyroid
to the piriform sinus may be delineated with
cross-sectional imaging or a fluoroscopic barium
swallow study, to make the diagnosis (49,50,53).
If there is clinical suspicion of a fourth BCC or
branchial sinus, direct pharyngoscopy should be
performed to depict the sinus tract opening and to Figure 12. Cervical thymus in a 19-year-old
plan for surgical resection (49,50,53). man presenting with a left anterior neck mass
that had been unchanged for the previous 3
years. Sagittal gray-scale US image of the neck
Cervical Thymus left of midline shows a painless well-defined hy-
At approximately the 4th to 5th week of gesta- poechoic heterogeneous compressible avascular
tion, the thymus begins its development from structure containing a myriad of tiny bright hy-
both sides of the third branchial pouch. By perechoic foci with comet tail artifacts. The su-
perior margin of the structure is adjacent to the
the end of the 6th week of gestation, the thy-
undersurface of the body of the hyoid bone, and
mus descends caudally and medially into the the inferior margin overlies the upper third of the
anterior mediastinum before fusing at midline thyroid anteriorly.
(45,46,55,56). Ectopic thymic tissue may arise
anywhere along this path secondary to a failure
of descent or incomplete descent, implantation of even a history of polyhydramnios in utero owing
thymic tissue owing to sequestration, or persis- to impaired swallowing (57–59). Signs of thyroid
tence of remnant tissue and failure of involution gland dysfunction are limited in the neonate with
within the thymopharyngeal duct; any of these delayed clinical manifestations and are usually rec-
embryologic events can result in a cervically posi- ognized by abnormal results of screening thyroid
tioned thymus (45,46,55,56). A cervical thymus function studies (58,60). Congenital goiters may
is often diagnosed in infants and adolescents as be hereditary, such as those resulting from inborn
a painless unilateral midline or lateral neck mass, errors in fetal hormone production, or more com-
found above the level of the brachiocephalic vein. monly may be due to nonhereditary causes such as
Although the differential diagnosis for a cervical thyroid dysgenesis, transplacental passage of ma-
thymus can include adenopathy, branchial cleft ternal antibodies in the setting of Graves disease,
anomaly, teratoma, hemangioma, and lipoma, maternal ingestion of antithyroid medications, or
other diagnoses are considered extremely unlikely rare mutations of thyrotropin (thyroid-stimulating
when the characteristic normal thymic echo pat- hormone) receptors (McCune-Albright syndrome)
tern is demonstrated (41,56). No intervention is (57–59). Thyroid dysgenesis—a sporadic aplasia,
required because this benign “pseudomass” will hypoplasia, or ectopia of the thyroid gland—is the
eventually involute like normal thymic tissue, most common cause of newborn thyroid dysfunc-
although residual focal thymic tissue may persist tion, accounting for approximately 80% of con-
uneventfully throughout life in some patients. genital hypothyroidism (57–59).
At US, a cervical thymus will demonstrate Early identification of fetal hypothyroidism
the same characteristics as normally positioned plays a role in treatment to ensure proper neu-
thymic tissue, thereby helping to confirm the rologic and motor development (59). Amniotic
diagnosis (Fig 12). Multiple linear hyperechoic thyroid hormone assays do not correlate with
septa and discrete homogeneously distributed fetal thyroid status, thereby leaving fetal blood
hyperechoic foci give the thymus a speckled ap- sampling as the only reliable method for deter-
pearance (6,46,55). Continuity with the domi- mining fetal thyroid function (58,61).
nant thymic mass may be seen by way of the Antenatal US evaluation is difficult, but inves-
thymopharyngeal duct, a finding that may also tigators have attempted to use US findings to help
aid in diagnosis. correlate whether a fetal goiter is associated with
thyroid dysfunction. Fetal goiter is determined
Congenital Goiter by identifying a diffusely and homogeneously
Congenital goiter is an uncommon cause of neck enlarged thyroid gland with a circumference or
swelling in infants and is characterized as diffuse diameter that is greater than the 95th percentile
or nodular enlargement of the thyroid gland (57– for gestational age on the basis of normative values
59). Infants may be asymptomatic or may present (58,62). Once a goiter is identified, color Dop-
with a diffusely enlarged thyroid gland with stridor pler US may be used in conjunction with other
and respiratory distress in the newborn period or findings, such as bone maturation and fetal heart
Figure 13. Congenital goiter in a 4-day-old male

neonate presenting with a large anterior neck mass
and hyperthyroidism, whose mother has Graves dis-
ease. (a) Transverse gray-scale US image of the thy-
roid shows a diffusely and markedly enlarged thyroid
gland. (b, c) Transverse color Doppler images of the
right (b) and left (c) parts of the thyroid gland show
that the gland is diffusely hyperemic. The major ves-
sels of the neck are displaced laterally.
rate, to help determine the cause of the fetal goiter. Abnormal cervical lymph nodes may be enlarged
Peripheral vascularity is thought to be suggestive and heterogeneous in echotexture, may have as-
of an enlarged but inactive thyroid gland, whereas sociated calcifications and loss of the normal hilar
central vascularity is suggestive of an overactive stripe, and may demonstrate a bizarre vascular
thyroid gland, although these findings are not pattern that is often peripheral (68–70). Despite
exclusive to their diagnoses (58,61). Postnatal US the advanced stage at diagnosis, pediatric thyroid
evaluation will also demonstrate a diffusely and carcinomas are most commonly well differenti-
homogeneously enlarged thyroid gland that may ated at histopathologic examination and have a
show mass effect and narrowing of the adjacent better prognosis than those in adults (6,64,67).
airway (Fig 13). The findings at physical examina- At US evaluation, malignant thyroid nod-
tion may include neck hyperextension, and the ules are predominantly solid and hypoechoic,
birth history may include a difficult vaginal deliv- compared with the adjacent normal thyroid
ery owing to cervical dystocia. parenchyma, with prominent perinodular and/or
intranodular vascular flow (Fig 14). The borders
Thyroid Papillary Carcinoma of malignant thyroid nodules may be irregular
Thyroid cancer represents 1%–1.5% of the or microlobulated, but the presence of smooth
malignant tumors in the pediatric population, well-defined borders does not preclude the diag-
with approximately 60%–70% of pediatric thy- nosis. In addition to suspicious-appearing thyroid
roid cancers diagnosed as papillary carcinomas nodules, a diffusely enlarged thyroid gland with
(63,64). An increased risk of thyroid cancer is multiple microcalcifications should be managed
associated with a history of prior irradiation, as similarly, and cases should be followed up with
shown by the spike in incidence after the Cher- fine needle aspiration (63,67).
nobyl accident (63–65). There is a slight female
predilection (6,36,66). Unlike thyroid carcinomas Parathyroid Adenoma
in the adult population, pediatric thyroid carcino- Primary hyperparathyroidism is an uncommon en-
mas are often advanced at the time of diagnosis, tity in the pediatric population, with an incidence
manifesting with a palpable thyroid nodule, cervi- of approximately two to five in every 100 000
cal adenopathy, and distant metastases (most children (71). Children present with nonspecific
commonly pulmonary and osseous metastases) symptoms such as fatigue, lethargy, abdominal
(6,63,64,67). Therefore, when evaluating the pain, nausea, vomiting, and headache, which may
thyroid, a careful search for enlarged or abnor- lead to clinical confusion and a delay in diagnosis
mal-appearing cervical lymph nodes is essential. (72). Hyperparathyroidism may be secondary to
Figure 14. Thyroid papillary carcinoma in a 13-year-old female adolescent presenting with a painless
hard anterior neck mass. Transverse gray-scale (a) and color Doppler (b) US images of the thyroid show
a markedly hypervascular lobulated heterogeneously hypoechoic solid mass (arrows on a) within the
right side of the thyroid gland and extending into and enlarging the isthmus. The mass contains multiple
punctate microcalcifications.
Figure 15. Parathyroid adenoma in a 14-year-old female adolescent presenting with hy-
perparathyroidism. Sagittal gray-scale (a) and color Doppler (b) US images of the inferior
aspect of the right thyroid lobe show a well-circumscribed hypoechoic mass (arrows on a)
with minimal vascularity.
nonhereditary parathyroid adenomas (the most glands, each located posterior to the upper and
common cause) or may be associated with heredi- lower poles of the thyroid gland. The inferior
tary diseases such as multiple endocrine neoplasia glands are more variable in location, compared
types I and II (73). Surgical resection is the defini- with the superiorly positioned glands (36,73).
tive treatment for any form of parathyroid dys- Ectopic locations, including intrathyroid or upper
function in children, including primary, secondary, cervical locations in the setting of nondescent,
or tertiary causes of hyperparathyroidism (71). may be difficult to identify. In the presence of a
Parathyroid US has a growing role for pre- parathyroid adenoma, one or more parathyroid
surgical planning to aid surgeons in targeted glands will enlarge and appear as round solid
resection of parathyroid adenomas. Although masses that are hypoechoic compared with the
total gland exploration had proven to be success- adjacent thyroid parenchyma (Fig 15). This
ful when performed by experienced surgeons, decreased echogenicity is thought to correlate
unilateral focused resection is found to be just with the dense cellularity of the adenoma seen at
as effective as a bilateral explorative approach histopathologic examination (73). As the ade-
(73). In more emergent situations in which severe noma enlarges, it will adopt an oval and flattened
hypercalcemia may be life threatening, prompt shape as it grows between the tissue planes (74).
removal is the ultimate goal, and localization with At color Doppler US, there will be prominent
the aid of US guidance may help expedite surgi- peripheral hypervascularity with a feeding artery,
cal resection of the culprit gland (36,73,74). which may or may not be identified (75).
In healthy subjects, the parathyroid glands A few pitfalls exist with US evaluation of para-
cannot be depicted with US. Although variabil- thyroid adenomas. Parathyroid nodules are sepa-
ity exists in the population, the most common rated from the thyroid gland by a hyperechoic
configuration is the presence of four parathyroid capsule (36). The rare intracapsular parathyroid
Figure 16. Hemangiomas in two different patients. (a, b) Hemangioma in a 6-month-old female in-
fant presenting with a compressible bluish mass on her upper lip that had appeared at 3 months of
age: Transverse gray-scale (a) and color Doppler (b) US images of the mid upper lip show a 1.2-cm
hypoechoic hypervascular well-defined compressible mass (marked by calipers on a). (c, d) Heman-
gioma in a 2-month-old male infant presenting with a right cheek mass: Sagittal gray-scale (c) and color
Doppler (d) US images obtained in the region of the right parotid gland show a 4.7-cm heterogeneous
slightly lobulated hypervascular compressible mass (marked by calipers on c) that appears to be replacing
the entire right parotid gland.
adenoma is indistinguishable from a thyroid nod- Infantile hemangiomas are rarely seen at birth;
ule with US alone (36,73). In the setting of mul- however, 90% of them become visible during the
tinodular thyroid disease, posteriorly positioned 1st month of life. Hemangiomas are seen more
thyroid nodules may be mistaken for parathyroid often in girls, Caucasians, and premature babies
adenomas (73). However, the peripheral vascu- (78). Infantile hemangiomas usually grow rapidly
larity commonly seen in parathyroid adenomas is during the 1st year of life and gradually regress
less common in thyroid nodules, which may aid during the next 1–3 years (34,77).
in diagnosis (73). Centrally positioned cervical Cutaneous hemangiomas may manifest clini-
lymph nodes may also be mistaken for parathy- cally as flat erythematous lesions, flat blanching
roid adenomas; however, the presence of a fatty lesions, or localized areas of telangiectasia (78).
hilum and a central vascular pedicle often can When cutaneous hemangiomas extend deeper,
help differentiate such lymph nodes from true they may have a more bluish hue. During prolifer-
parathyroid adenomas (6,36,73). ation, hemangiomas may feel rubbery and warm,
Preoperative localization of parathyroid adeno- with a possible bruit (34). At US, hemangiomas
mas may be accomplished in some cases with the appear as discrete cutaneous or subcutaneous
use of radionuclide scanning with technetium Tc soft-tissue masses with prominent internal vascu-
99m sestamibi. However, complementary imag- larity (Fig 16). Both arterial and venous flow can
ing with other modalities, such as intraoperative be demonstrated within the masses, with high-
US, may be necessary (76). velocity arterial waveforms and low-resistance
venous waveforms (79). Most hemangiomas do
Hemangioma not require therapy; however, complications such
Hemangiomas are congenital neoplasms that as Kasabach-Merritt syndrome (consumptive
consist of vascular channels lined by endothe- coagulopathy), compression of adjacent structures,
lial cells (34). Infantile hemangiomas are the including the airway or orbits, formation of fis-
most common neoplasm in the head and neck sures, bleeding, and ulceration may require treat-
during infancy, with a prevalence of 1%–2% in ment of the underlying hemangioma (78). Some
newborns and up to 12% by 1 year of age (77). of the treatment methods include administration
of corticosteroids, chemotherapy, α-interferon which may also demonstrate internal vascularity

therapy, and propranolol therapy, each of which (79). Plexiform neurofibroma may appear as mul-
has its own set of side effects (78,80). tiple masses or enlarged peripheral nerves, giving
In contrast, according to the classification a “bag-of-worms” appearance similar to a heman-
system described by Mulliken and Glowacki (81) gioma or vascular malformation (34). MR imag-
in 1982, vascular malformations are congenital ing may be necessary for further characterization
anomalies that are present at birth and enlarge as of hemangiomas, which are isointense compared
the child grows. They do not involute and are pres- with muscle on T1-weighted MR images and are
ent throughout life. These lesions are categorized hyperintense on T2-weighted MR images (78).
according to the primary cell makeup—lymphatic, High-flow central and peripheral vessels demon-
capillary, arteriovenous, venous, or mixed—and strate diffuse contrast enhancement (78).
are divided into low-flow and high-flow lesions
(78). Low-flow lesions consist of venous mal- Lymphangioma
formations, lymphatic malformations, or mixed Lymphatic malformations, or lymphangiomas,
venolymphatic lesions; high-flow lesions include are congenital abnormalities of the lymphatic
arteriovenous malformations and arteriovenous system (82). They most often affect the head and
fistulas (78). Low-flow venous malformations and neck regions and consist of variably sized cystic
lymphatic malformations are common in the neck spaces (79). Lymphangiomas have been classi-
(79). Venous malformations consist of dysplastic fied into three types according to the size of the
venous channels and may appear as blue or purple lymphatic cavities involved: microcystic or capil-
skin discoloration or a compressible mass that lary lymphangiomas, macrocystic or cavernous
enlarges with a Valsalva maneuver (34). At US, lymphangiomas, and cystic lymphangiomas (83).
venous malformations may appear as a collection The incidence of lymphangiomas internation-
of vascular channels that may be compressed and ally is approximately one in 6,000–16,000 live
demonstrate low-velocity venous blood flow in births, with males and females equally affected
addition to phleboliths in 20%–80% of cases (79). (84). About 50% of the lesions are detected at
Lymphatic malformations may be macrocystic, birth, and 80%–90% are detected before the age
manifesting as multilocular cystic masses, or may of 2 years (84). Approximately 75% of lymphan-
be microcystic, composed of numerous small cysts giomas occur in the neck (6,84). Most lymph-
(34). At US, the microcystic type may appear angiomas are sporadic, but they can also occur
hyperechoic owing to numerous interfaces of the in syndromes such as Noonan syndrome, Turner
cyst walls (34). Low-flow vascular malformations syndrome, and trisomies 13, 18, and 21 (34).
can be treated with compressive garments, sclero- Clinically, lymphangiomas manifest as soft
therapy, or surgery (78). nontender masses with a doughy consistency
Arteriovenous malformations are high-flow (34). At US, lymphangiomas generally appear
lesions that consist of direct connections be- as multilocular cystic masses containing internal
tween arteries and veins (78). They are often septa of varying thickness (Fig 17); however,
initially detected in infancy and are indolent in multiple US imaging appearances have been de-
childhood, but it is common for arteriovenous scribed (79). For example, one group of investi-
malformations to grow at puberty and during gators demonstrated four different appearances
pregnancy, with hormonal treatment, or after of lymphangiomas at US: (a) cystic with thin
trauma (77). At US, arteriovenous malformations septa, (b) cystic with thick septa, (c) cystic with
appear as collections of multiple tortuous ves- thick septa as well as solid areas, and (d) mostly
sels without an associated soft-tissue mass (79). solid with scattered cystic foci (82). The cyst
In this way, arteriovenous malformations may be contents may be anechoic or at times hyper-
distinguished from hemangiomas, which dem- echoic if there is internal hemorrhage, infection,
onstrate the presence of associated parenchymal or an elevated lipid content (79). At Doppler
tissue (77). Color Doppler US of arteriovenous US imaging, arterial or venous flow may be seen
malformations demonstrates direct connections in the septa (34). Large lymphangiomas tend
between the arterial and venous systems, with to occupy more than one space in the neck and
high-velocity low-resistance arterial flow (78). Ar- insinuate between normal structures (34,79).
teriovenous malformations are generally treated CT and MR imaging are useful for evaluation
with transarterial embolization (78). of deeper extension into the neck or chest. On
In addition to other vascular malformations, CT images, lymphangiomas are hypoattenuat-
hemangiomas must also be differentiated from ing compared with adjacent muscle; and on MR
other types of soft-tissue tumors, both benign and images, they are usually T1 hypointense and
malignant. Differential diagnostic considerations markedly T2 hyperintense, unless complicated
include rhabdomyosarcoma and neuroblastoma, by hemorrhage (34). Enhancement is demon-
Figure 17. Lymphangioma in a 2-day-old female neonate presenting with a large right
neck mass. (a) Photograph shows the neck mass. (b, c) Sagittal gray-scale (b) and color
Doppler (c) US images of the right side of the neck show a large multiseptate cystic mass
(marked by calipers in b) with small solid components and occasional vascularity. (d) Cor-
responding coronal T2-weighted MR image (6067/105.072 [repetition time msec/echo time
msec]) helps confirm the US findings.
strated in cyst walls and septa but not in central more than 100 cases were reported in the literature
fluid components (34). until 2001, but awareness of this entity has in-
When large, lymphangiomas may compress creased since duplex US has become more widely
and infiltrate adjacent structures, resulting in used for evaluation of neck masses. Jugular vein
respiratory difficulty or dysphagia (85). These phlebectasia is thought to result from structural de-
lesions may enlarge owing to complications such fects in the vein walls and is considered a congeni-
as hemorrhage or infection (34). When compli- tal venous anomaly (88). The condition is found
cations arise, surgery is the preferred method more commonly in boys and on the right side, but
of treatment, although it may not be possible to jugular vein phlebectasia can be bilateral (89).
achieve complete excision (85). Other possible Internal jugular phlebectasia often manifests as
treatment methods include sclerotherapy (with unilateral neck swelling, which is not pulsatile or
OK-432, interferon, or bleomycin), aspiration, tender and enlarges with increased intrathoracic
steroid therapy, laser treatment, radiofrequency pressure from a Valsalva maneuver, coughing,
ablation, or cautery (82). sneezing, crying, or bending over (86). Dynamic
Lymphangiomas should be distinguished from US of the neck with and without a Valsalva maneu-
other cystic neck masses, including teratomas, ver can help confirm the diagnosis of phlebectasia
which usually demonstrate fat or calcification, and when the affected vein dilates during a Valsalva
venous malformations, which demonstrate internal maneuver to a diameter approximately twice the
blood flow and central enhancement (34). diameter at rest (Fig 18) (88,89). Color Doppler
US is useful to demonstrate the presence of blood
Jugular Vein Phlebectasia flow and to exclude thrombus and is the reference
Jugular vein phlebectasia is a rare congenital ab- standard for the diagnosis of jugular vein phleb
normality of the internal jugular veins that appears ectasia (89). Treatment is generally conservative,
as cystic dilatation in the neck during a Valsalva but if the patient has symptoms, surgery may be
maneuver (86). This entity was best characterized performed and may include ligation of the affected
by Gerwig (87) in 1952, who defined phlebectasia vein, venoplasty, or resection (90). Although there
as fusiform dilatation of a vein segment. Slightly may be many causes of pediatric neck masses, only
Figure 18. Right internal jugular vein phlebectasia in an 8-year-old girl presenting
with a painless compressible right neck mass. Sagittal dual-screen gray-scale (a) and
color Doppler (b) US images of the right lateral part of the neck show a relatively
normal-sized right internal jugular vein (0.6 cm) at rest (left image on a), which sub-
stantially increased in overall size (1.4 cm) during a Valsalva maneuver (right image on
a). Without a Valsalva maneuver, the right internal jugular vein demonstrates a dumb-
bell shape, with relative prominence of the proximal and distal portions and with the
midportion relatively slender. The vein was fully compressible (not shown).
three of these masses will enlarge during a Valsalva

maneuver: jugular vein phlebectasia, superior
mediastinal cysts or tumors, and laryngocele (most
common) (86).
Lemierre Syndrome
Lemierre syndrome, also known as necrobacil-
losis or postanginal syndrome, is caused by an
infection of the oropharynx complicated by septic
internal jugular vein thrombophlebitis, leading to
septic emboli to the lungs and other organs (91).
The disease is named for Dr Andre Lemierre, a
French bacteriologist who in 1936 described a 19). Spectral Doppler US of a patent internal
series of patients who developed septic thrombo- jugular vein may demonstrate loss of respiratory
phlebitis of the tonsillar and peritonsillar veins, phasicity and cardiac pulsatility, which indicates a
with subsequent septic embolization to the lungs more proximal thrombus in a vein that is not ac-
and other organs, ultimately leading to incurable cessible with US (91). Septic pulmonary emboli
sepsis and death in the preantibiotic era (92). may appear as nonspecific peripheral infiltrates
Since the widespread use of antibiotics for oro- on chest radiographs and are better evaluated
pharyngeal infections, the incidence of Lemierre with CT, if there is clinical suspicion for this dis-
syndrome has decreased markedly, now occurring ease. Early diagnosis and treatment are essential
in 0.6–2.3 per million people. There is a male to avoid substantial morbidity and mortality from
predominance, and more than 70% of cases af- this disease. The differential diagnosis is broad for
fect patients between 16 and 25 years of age (93). the widespread findings in Lemierre syndrome
Lemierre syndrome is most frequently caused and includes isolated oropharyngeal infection,
by the anaerobic bacterium Fusobacterium necro isolated jugular vein thrombosis, cervical lymph-
phorum, which is found in approximately 80% of adenitis, pneumonia or metastatic disease in
cases (91). Patients present with a sore throat and the lungs, and infectious or neoplastic processes
tonsillar exudates initially, followed as much as involving other organ systems (91). A high degree
a week later by unilateral neck swelling and pain of suspicion is needed to diagnose this disease,
indicating internal jugular thrombophlebitis (93). and contrast material–enhanced CT examina-
Subsequently, symptoms related to septic emboli tions of the neck and chest are the studies of
develop, including pulmonary infiltrates with choice to evaluate for jugular vein thrombosis, as
cavitation, septic arthritis, osteomyelitis, and, well as septic pulmonary emboli (93,94).
rarely, hepatic or splenic abscesses (94).
At US, the most common finding in patients Parotitis
with Lemierre syndrome is a hyperechoic throm- Acute parotitis is caused by infection of the
bus depicted within the affected internal jugular parotid gland with a virus such as mumps or,
vein, with decreased or absent blood flow (Fig more rarely, with a bacterial pathogen. Acute
Figure 19. Lemierre syndrome in a 16-year-old female adolescent presenting with fever, chills, sore
throat, and right neck pain and swelling that had been present for the previous week. Sagittal gray-
scale (a) and color Doppler (b) US images of the right side of the neck show a nonocclusive thrombus
(marked by calipers on a) within the right internal jugular vein. Subsequently performed CT of the chest
demonstrated scattered bilateral pulmonary nodules (not shown).
Figure 20. Parotitis in a 5-year-old girl presenting with a painful left cheek mass and lymphadenopathy.
Sagittal gray-scale (a) and color Doppler (b) US images of the left parotid gland show that the gland is
enlarged, nodular, and hyperemic, containing numerous hypoechoic nodules.
Figure 21. Parotid abscess in an

18-year-old man presenting with a
left cheek lump and a high fever.
(a) Sagittal gray-scale US image
of the left parotid gland shows a
complicated localized fluid col-
lection. (b) Corresponding axial
contrast-enhanced CT image helps
confirm an enlarged parotid gland
containing a rim-enhancing mass,
a finding compatible with an ab-
scess. (Reprinted, with permission,
from reference 98.)
suppurative parotitis is most commonly seen At US, the parotid gland appears enlarged
in children younger than 1 year old and often and heterogeneous in both viral and bacterial
occurs in newborns or in children with systemic parotitis, with increased vascularity at color
disease, with a rate of occurrence of 3.8 in 10 000 Doppler US (Fig 20). In the bacterial form
neonatal admissions (95,96). Bacterial parotitis of parotitis, the parotid gland demonstrates
is most often caused by Staphylococcus aureus and hypoechoic nodular areas that represent intra-
is commonly unilateral, resulting from (a) the parotid lymph nodes. In severe cases, avascular
spread of infection from adjacent structures such hypoechoic areas of suppuration or discrete
as the teeth or ears, (b) parotid calculi, or (c) im- abscesses may develop (Fig 21) (98,99). US
munosuppressive processes (97). may also reveal dilated tubular areas compatible
Figure 22. Lymphoma and/or leukemia in two different patients. (a, b) T-cell lymphoblastic leukemia
and/or lymphoma in a 14-year-old male adolescent presenting with a hard painless lump in the lower
right anterior portion of the neck: Sagittal gray-scale (a) and color Doppler (b) US images of the right
side of the neck show markedly enlarged, well-circumscribed, diffusely hypervascular hypoechoic masses
with a reticulated echotexture along the right neck jugular chain. Although these masses in themselves
have a nonspecific appearance, the lack of a fatty hilum and the blood flow emanating from the hilum, as
well as the presence of a mediastinal mass on a subsequent chest radiograph (not shown), were sugges-
tive of a neoplastic cause. (c) Hodgkin lymphoma in a 4-year-old girl presenting with swollen glands that
had been present for the previous 2 months: Sagittal Doppler US image of the left lateral part of the neck
shows multiple large hyperemic architecturally abnormal lymph nodes with a reticulated hypoechoic ap-
pearance, which lack the expected fatty hilum.
with dilated obstructed salivary ducts that may

contain hyperechoic calculi (100).
Recurrent acute parotitis manifests with periodic
attacks of parotid gland swelling, fever, and pain
(95). This condition usually manifests between the
ages of 2 and 5 years and resolves around puberty
(95,99). US demonstrates unilateral or bilateral
parotid enlargement with multiple 2–4-mm hy-
poechoic foci within the parotid glands, findings
that likely represent lymphocytic infiltration or
sialectasis (95,99). Acute parotitis and chronic tend to be round with absent hila and increased
parotitis have a similar imaging appearance to that central and peripheral vascularity (32). Lympho-
of mumps infection; Sjögren syndrome; granuloma- matous nodes have been shown to have internal
tous diseases such as cat-scratch disease, tubercu- reticulation—a micronodular appearance—as well
losis, and sarcoidosis; and HIV-associated parotitis, as elevated values for the resistive index and the
which has two appearances, including (a) gland pulsatility index at spectral Doppler US (32,35).
enlargement with multiple hypoechoic foci The nodes can become confluent, matted, and
related to lymphocytic infiltration and (b) large masslike. In leukemia, cervical nodes are clustered
anechoic areas nearly replacing the gland, which and appear slightly enlarged (Fig 22). The nodes
represent lymphoepithelial cysts (95,99,101). can maintain their borders or may become more
confluent, mimicking lymphoma (102).
Leukemia and/or Lymphoma Cross-sectional body imaging is necessary to
Leukemia is the most common cancer in chil- evaluate the extent of disease, including mediasti-
dren younger than the age of 15 years, account- nal masses and distant areas of lymphadenopathy.
ing for 35%–40% of cancers in this age group. At CT, lymphomatous nodes are enlarged and
Lymphoma is the third most common malignant isoattenuating to muscle and may demonstrate
tumor in childhood and accounts for 50% of all the loss of normal fatty hila (102). At MR imag-
head and neck cancers in children (6). Cervical ing, lymphomatous nodes are usually isointense
lymphadenopathy is a common initial finding in on T1-weighted MR images and hyperintense to
both lymphoma and leukemia. Head and neck muscle on T2-weighted MR images, often with
adenopathy is present in most cases of Hodgkin mild homogeneous enhancement (34). Confir-
lymphoma and is an initial finding in many cases mation of the diagnosis and exclusion of other
of acute lymphocytic leukemia (102). possible primary neck masses (including but
Considerable overlap exists between the US not limited to lymphadenitis, metastatic disease,
appearance of benign and malignant lymph nodes. teratoma, neurogenic tumors [neuroblastoma
In lymphoma, US generally demonstrates enlarged spectrum], and rhabdomyosarcoma) can only be
nodes that appear hypoechoic (Fig 22). The nodes accomplished with biopsy or excision.
Figure 23. Schwannoma in a patient presenting with a solid posterior neck mass.
Sagittal gray-scale (a) and color Doppler (b) US images of this solid mass in the poste-
rior part of the neck show that the mass arises from a nerve (arrows on a) and is solid,
heterogeneous, and mildly vascular. (Reprinted, with permission, from reference 98.)
Neurogenic Tumors mass (105). On CT and MR images, plexiform

Schwannomas and neurofibromas are the most neurofibromas appear as multilobulated masses
common neurogenic tumors, and in the neck, along the expected course of a nerve trunk, with
most are found in the posterior triangle (100). extension along nerve branches, creating the ap-
In children, tumors of the sympathetic nerves pearance of a bag of worms (108). A split fat sign
account for 7.4% of all neoplasms, with nine new may be seen, with a rim of fat around the lesion;
cases per year for every 1 million U.S. children and a target sign can be seen on MR images, with
(103). Most patients present with an isolated central T2 hypointensity against a background of
superficial soft-tissue mass of uncertain duration. T2 hyperintensity (108).
Schwannomas arise eccentrically from the outer Malignant peripheral nerve sheath tumor
nerve sheath, and neurofibromas develop in the (MPNST) is a high-grade sarcoma that can arise
endoneurium (104). At US, both schwannomas from a plexiform neurofibroma or from prior
and neurofibromas generally appear well circum- irradiation or can arise spontaneously. MPNST
scribed, homogeneous, and hypoechoic, with pos- affects approximately 5% of patients with neuro-
terior acoustic enhancement (Fig 23) (98,105). fibromatosis type 1 (109). MPNST is difficult to
Some schwannomas may demonstrate prominent distinguish from neurofibroma at US, although
internal vascularity, which can be easily com- some MPNSTs may demonstrate hyperemia
pressed with gentle pressure on the transducer. (105). Radionuclide imaging with gallium 67
It can be difficult to differentiate schwannomas citrate can show increased radiotracer uptake in
from reactive lymph nodes, which may have a MPNST, compared with that in neurofibroma;
similar appearance; however, identification of an and MR imaging may demonstrate altered MR
associated nerve can be used to reliably distin- signal intensity in MPNST, compared with that
guish schwannomas from nodes (106). in benign lesions (109).
Neurofibromatosis type 1, or von Recklinghau- Neuroblastoma is the third most common
sen disease, is an autosomal dominant phakoma- malignant neoplasm in children, with a rate of
tosis that affects one in 3500 individuals and is occurrence of one in 10 000 live births (103). Of
characterized by the development of widespread these cases, 25% appear to be congenital, usu-
neurofibromas, which may be cutaneous, sub- ally occurring in children nearing 18 months of
cutaneous, deep, or plexiform (107). Plexiform age (106). Cervical neuroblastoma accounts for
neurofibromas arise from multiple nerves and less than 5% of all neuroblastoma cases (110).
tend to grow along the nerves, extending into It presents as a nontender lateral neck mass,
adjacent structures, including skin, muscle, bone, usually with symptoms related to compression
and internal organs (107). At US, neurofibromas of adjacent structures, such as cranial nerves
appear well circumscribed and are hypoechoic, (Horner syndrome), the esophagus (swallowing
with posterior acoustic enhancement, and may difficulty), and the airway (stridor), as well as
demonstrate a target appearance—peripherally heterochromia iridis (difference in right and left
hypoechoic and centrally hyperechoic (108). eye colors) (6,110,111). At US, neuroblastoma
Plexiform neurofibromas demonstrate diffuse appears as a solid complex or hypoechoic mass,
peripheral nerve involvement rather than a focal sometimes with shadowing calcifications, arising
posterior to the carotid sheath, with displace- cytoma, angiosarcoma, and neurofibrosarcoma
ment or encasement of the carotid artery and (6). Cross-sectional imaging with MR imaging is
internal jugular vein (110). required, because the assessment of disease extent
US findings in neuroblastoma are nonspecific; and staging is limited with US alone, and tissue
therefore, CT, MR imaging, and/or radionuclide sampling is required for a final diagnosis (114). At
imaging with m-iodobenzylguanidine (MIBG) is MR imaging, rhabdomyosarcoma is usually isoin-
usually used to help confirm the diagnosis (79). tense to slightly hyperintense on T1-weighted MR
At CT, calcification, hemorrhage, or necrosis may images and T2 hyperintense, with marked contrast
be seen within the tumor, and MR imaging may enhancement, and possible intralesional hemor-
demonstrate mild T2 hyperintensity and intense rhage or necrosis (34). Treatment is based on the
enhancement (34). The differential diagnosis for extent of the disease as well as primary tumor
cervical neuroblastoma includes vascular tumor, localization, with orbital and nonparameningeal
lymphangioma, teratoma, sarcoma, and rhabdoid head and neck locations associated with a better
tumor (111). Surgical excision is the treatment of prognosis (6,112,115). Chemotherapy is the first
choice after precise preoperative US, CT, or MR line of treatment for rhabdomyosarcomas, with
imaging assessment to evaluate for encasement radiation therapy and surgery being the mainstay
and/or displacement of the major neck vessels for local tumor control (112).
and MR imaging for evaluation of intraspinal A summary of the aforementioned pediatric
involvement (103). neck masses is presented in Table E1.
Rhabdomyosarcoma Conclusion
Rhabdomyosarcomas are the most common Superficial palpable masses of the head and neck
soft-tissue sarcomas arising from the head and are extremely common in the pediatric popula-
neck, commonly originating from the orbital, tion, with most of these lesions ultimately proven
facial, and cervical musculature (112,113). The to be benign (1–3). Duplex US has emerged as
embryonal subtype is the most common variant, the first-line imaging modality for the evaluation
accounting for up to 60% of cases, and has the of superficial pediatric masses. Without the use
most favorable prognosis (6,112). Histologically, of ionizing radiation, iodinated contrast material,
rhabdomyosarcomas are low-grade small round or sedation and/or anesthesia, this safe, quick,
blue cell tumors that are similar to other pediat- and cost-effective imaging modality allows rapid
ric malignancies such as neuroblastoma, Ewing evaluation and characterization of masses. In this
sarcoma, and lymphoma (112), a similarity that review, we sought to present the US findings of a
makes histopathologic diagnosis of rhabdomyo- variety of common and uncommon, benign and
sarcoma difficult. The location of the soft-tissue malignant lumps and bumps of the head and neck
mass may help narrow the differential diagnosis. that have been diagnosed in our practice. In most
The differential diagnosis for deeper paramenin- cases, sufficient information can be obtained with
geal locations includes hemangioendothelioma, US. Therefore, CT or MR imaging is reserved
nasopharyngeal carcinoma, osteosarcoma, for lesions that are (a) too large, (b) too dense to
and primitive neuroectodermal tumor; and adequately penetrate with US, or (c) too deep to
the differential diagnosis for more superficial be completely imaged with US; or for use before
nonparameningeal locations includes fibrosar- resection when malignancy is suspected. On the
coma, chondrosarcoma, and synovial sarcoma other hand, if the findings from a thorough inves-
(113–115). Ultimately, the goal of the radiolo- tigation with US do not help confirm the presence
gist is to describe in detail the location and the of a superficial palpable mass of the head or neck,
involvement of adjacent compartments, as well no further imaging is recommended.
as perineural, vascular, and osseous involvement
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TM
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US of Pediatric Superficial Masses of The Head and Neck

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cal history and the physical examination. The

to cranial sutures, cephalohematomas cannot

Superficial Pediatric Head Masses

Relative Fre- Typical US Differential Pertinent Cross-sectional How Entity Is

Note.—PE = physical examination, 3D = three-dimensional.

recurrent suppurative thyroiditis resistant to anti-

Figure 13. Congenital goiter in a 4-day-old male

of corticosteroids, chemotherapy, α-interferon which may also demonstrate internal vascularity

three of these masses will enlarge during a Valsalva

Figure 21. Parotid abscess in an

with dilated obstructed salivary ducts that may

Neurogenic Tumors mass (105). On CT and MR images, plexiform

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