Cervical Thymic Cyst in Childhood: A Case Report
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Abstract:
Cervical thymic cysts are rare cervical masses which usually present in the first decade of life accounting for 0.3% - 1% of all congenital neck masses. Due to its rarity thymic cysts are seldom included in the differential diagnosis of cystic cervical mass and are often mistaken for more common conditions such as branchial cleft cyst or cystic hygroma. Herein we present a case of a 6-year-old girl with a right lateral cervical cystic mass with multiple septae extended from mandibular angle along the neurovascular bundle of the neck which revealed to be a thymic cyst at histopathology.Keywords:
Cystic hygroma
Neurovascular bundle
Histopathology
Neck mass
Cystic hygroma is one of the congenital benign tumors of the lymphatic system, which commonly occurs on the neck and axial area. Despite its benign nature, cystic hygroma of the neck is potentially a life-threatening condition. The massive mass on the neck may block the neonatal airway. Here we report a newborn baby presented with cystic hygroma on the neck, which impairs the neonatal airway and breathing. Complete excision was carried out. The patient had an uneventful postoperative recovery.
Cystic hygroma
Neck mass
Lymphangioma
Airway obstruction
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Identical twins were noted to have a soft asymptomatic neck mass, each on the opposite side, at 1 week of age. The mass took a dramatic course 1 week later to present as a neck abscess, yet without systemic symptoms. Ultrasonography was highly suggestive of an infected lymphatic malformation (cystic hygroma). Intravenous antibiotics and drainage (aspiration/incision and drainage) resulted in resolution of the mass and no recurrence at 18 months follow-up. The concept of spontaneous involution of lymphatic malformation (cystic hygroma) is discussed as well as the management of neck abscesses in infancy.
Cystic hygroma
Neck mass
Presentation (obstetrics)
Incision and drainage
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OBJECTIVE: To investigate the characteristic of non-thyroid-related neck cyst for the purpose of im proving the accuracy of diagnosis of neck cyst preoperatively.
METHOD: Retrospectively analyzed 122 cases of non thyroid related neck cyst during 1999 2005 in our department.
RESULT: Congenital mass (n=84) constitute the main part of total cases (n 122), among which thyroglossal cyst is the most common reason. Infective cyst is the second cause of neck cyst (n=30), among which the number of submaxillary gland cyst is 25. Tumor is the most rare cause of neck cyst (n=8). Timing and position of cysts, auxiliary examination of physical sign and puncture cytological analysis lead to more accurate diagnosis preoperatively.
CONCLUSION: Accurate diagnosis of neck cyst reduce the blindness and minimize the risk preoperatively.
Neck mass
Thyroglossal cyst
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Background: Accurate diagnosis is important for planning of management of the congenital cystic neck mass. Clinical history, physical examination and appropriate knowledge of embryology and anatomy of the cervical region frequently allow the differential diagnosis to be narrowed and ultrasound especially high frequency ultrasound help to further confirmation. USG has been used as the initial imaging procedure in the evaluation of them. Ultrasound not only confirms the cystic nature of the lesion but also evaluates exact location, size, extent, relation to the surrounding structures and internal characteristic of mass. Objectives: To establish the usefulness of ultrasound in the evaluation of congenital cystic neck masses. Methods: From January 2014 to March 2018 a total 50 patients with clinically suspected congenital cystic mass in the neck region were selected who under want operative treatment and histopathological examination. A through history taking and physical examination were done then patient were scanned with gray scale ultrasound and colour Doppler in necessary case. Histopathological report collected from the patient and compare with USG diagnosis. Results: In USG 37 patient diagnosed as congenital lesions and 13 patient diagnosed as non-congenital lesion. Among the congenital lesions thyroglossal duct cyst-19, branchial cleft cyst-12, cystic hygroma-4, hemangioma-1 and epidermoid cyst-1. In histopathology 32 patient diagnosed as congenital lesion and 18 diagnosed as non-congenital lesion. Among the congenital lesions thyroglossal duct cyst-18, branchial cleft cyst-8, cystic hygroma-4, hemangioma-1 and epidermoid cyst-1. Among the 19 USG diagnosed thyroglossal duct cyst 17 is confirmed by histopathology and 2 is differ. Among the 12 USG diagnosed branchial cleft cyst 7 is confirmed by histopathology and 5 is differ. Over all sensitivity of USG-93.7% and specificity-64% and accuracy-74%. Conclusion: USG is a useful modality for the diagnosis of congenital cystic mass in the cervical region. Bangladesh J Otorhinolaryngol; April 2018; 24(1): 68-78
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Neck mass
Histopathology
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The cystic neck mass is easily found by physical examination, but different diagnosis of each is not easily. We have performed a clinical study on 96 cases of cystic neck mass which were diagnosed and treated surgically in the Department of Otolaryngology-Head and neck surgery, Chonbug National University Hospital from 1985 to 1995. Of 96cases, thyroglossal duct cyst was most common (42.7%), ranula (22.9%) was second, and the third is branchial cleft cyst (13.5%). Most of the cystic neck mass were found before the 3th decade (70%). There was no significant sexual difference (male 47.9%, female 52.1%). Average duration of symptom prior to hospital entry was predilection under 1 year (62.5 O. The lesion were found on the midline of the neck in thyroglossal duct cyst and dermoid cyst, but on the lateral side of the neck, branchial cleft cyst and cystic hygroma were common.
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Dermoid cyst
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Thyroglossal duct cysts (TGDC) are the most common form of congenital cysts in the head and neck and usually presents as a midline neck mass at the level of the thyrohyoid membrane. We report a case of an atypical presentation of a thyroglossal duct cyst with cutaneous extrusion. To our knowledge, this is the first case to be reported in the English literature. A 92-year-old female presented with a 5-year history of an ulcerated midline neck mass with anterior cutaneous extrusion. A computer tomography (CT) scan of the neck showed a cystic mass posteroinferior to the hyoid bone highly suggestive of a thyroglossal duct cyst. Written informed consent from the patient's family was obtained for this case report. The patient underwent a modified Sistrunk procedure and final histopathology confirmed it to be a thyroglossal duct cyst measuring 10cm in its largest dimension. The patient tolerated the procedure well. Cutaneous extrusion of a thyroglossal duct cyst is extremely rare. Although skin ulceration usually suggests underlying malignancy, benign entities may also result in such aggressive presentations. A differential diagnosis of a carcinoma should be considered in an ulcerative midline mass with close relations to the hyoid bone.
Hyoid bone
Neck mass
Thyroglossal cyst
Histopathology
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Histopathology
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Teratomas arise from primordial germ cells which arrest during its migration from the hindgut allantois the gonads during the first weeks of gestational life, they may occur in both gonadal and extra-gonadal locations. They occur in 1/40,000 live births. The most common anatomical locations are the sacro-coccygeal region and the ovary, neck teratomas constituted about 1.5%. Malignant transformation has been reported. A 2-year-old boy presented with a gradually enlarging mass in the left side of the neck causing stridor and difficulties in respiration especially during sleep, the parents noticed difficulties during swallowing. The mass was misdiagnosed as cystic hygroma and the patient underwent 2 sessions of sclerotherapy with no improvement. Clinical examination showed a large mass in the left side of the neck which was multilobulated causing tracheal shift to the opposite side. There were no signs of inflammations over the mass. CT-scan showed evidence of enhancing multi-cystic lesion with multiple flecks of calcification. Complete surgical resection was done successfully and the histopathological study of the mass showed mature elements of ectodermal, mesodermal, and ectodermal germinal layers which was consistent with mature cystic teratoma. The follow up showed no postoperative complications. Mature cystic teratoma of the neck is very rare and may be difficult to be differentiated both clinically and radiologically from other neck masses. The accurate diagnosis must be made before any kind of treatment is started. Complete surgical resection is the main management option and required to decrease the recurrence.
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A cystic hygroma generally begins to develop between the 6th and 9th weeks of gestation due to failure of the jugular lymphatic sacs to drain into the internal jugular vein, which probably results in the dilatation of the lymphatic sacs into cystic spaces and may lead to the jugular lymphatic obstruction sequence and hydrops fetalis1, 2. Prognosis of affected cases is poor. It occurs in the neck in approximately 75% of cases and typically involves the posterior and lateral rather than anterior portions of the neck, often occurring bilaterally in an asymmetric fashion3, 4. We report the course and outcome of a case in which ultrasound imaging was used to identify a huge, extensively invasive cystic hygroma in the anterior aspect of the neck, in a fetus at 29 weeks' gestation. A 30-year-old primigravid woman was referred to our hospital because of a fetal anterior neck mass detected during an ultrasound examination at 29 weeks' gestation. A further ultrasound examination was performed, which revealed a single viable male fetus with a huge anterior neck mass, measuring 10.1 × 6.9 × 6.0 cm. The mass was asymmetrical, thin-walled and multiseptate, with solid components interspersed with the multicystic areas (Figure 1). It occupied the whole area of the fetal neck, extending from the fetal chin to the anterior portion of the neck (Figure 2). No other abnormalities were detected. Fetal karyotyping was performed, which revealed a normal 46,XY karyotype. Serial scans of the fetal neck revealed continuing growth of the mass causing hyperextension of the fetal neck with development of mild polyhydramnios. The mass increased in size over the next 7 weeks to 14.0 × 8.8 × 9.0 cm without development of hydrops fetalis. Fetal growth was otherwise normal. A Cesarean section was planned in cooperation with the neonatologist, otolaryngologist, pediatric surgeon and anesthesiologist. This was performed at 37 weeks' gestation and a 3650-g male neonate with a huge anterior neck mass (Figure 3) was delivered; the mass did not impair spontaneous respiration and the neonate had Apgar scores of 8 and 10 at 1 and 5 min, respectively. However, the neonate was then intubated to maintain the airway. A computed tomography scan of the neck showed a large mass extending from ears to sternum. It was multiseptate, with fluid density with no enhancement, compatible with a cystic hygroma. Excision of the fetal neck mass was performed on the 4th day after birth, but the fetal neck structures had been extensively invaded, making complete excision impossible. The mass was pathologically confirmed as a cystic hygroma. The postoperative period was complicated by rapid accumulation of fluid at the surgical site, infection, pneumonia and eventually respiratory failure, and the infant died at the age of 81 days. Transverse ultrasound image of the fetal neck mass showing the large, asymmetrical, thin-walled, multiseptate, cystic mass with solid components interspersed with the multicystic areas. Coronal ultrasound image of the fetal face showing the multiseptate, cystic mass extending from the chin to the anterior portion of the neck. Photograph of the fetus at birth after intubation showing the huge anterior neck mass extending from both ears to the anterior portion of the neck and the sternum. While it is quite uncommon, recognition of a cystic hygroma in the anterior part of the neck is important, because it can be a life-threatening complication, as an acute airway obstruction can occur. Prenatal diagnosis allows evaluation and preparation for establishing an airway at delivery and planning of a surgical approach. Its differential diagnosis includes: 1) a branchial cleft cyst, which could be cystic or multicystic, 2) a cervical teratoma, which would be a large, complex, unilateral, cystic solid tumor of the anterolateral portion of the neck, 3) a goitrous thyroid, which typically is symmetrically enlarged bilaterally, or 4) a rare sarcoma5, 6. The sonographic findings of the cystic hygroma colli typically show asymmetric, thin-walled, multiseptate, cystic masses. In our case, sonography also showed a more complex echotexture with solid components interspersed with the multicystic areas. These findings could be explained by obstructed lymphatics occurring among muscle and fibrous tissue or portions of abnormal lymphatics remaining clumped together and non-dilated7. The frequency of chromosomal abnormalities associated with cystic hygroma colli may be as high as 62%8; Turner's syndrome is the most common. The risk of recurrence for aneuploidy is low, but cystic hygroma colli with normal karyotype may be inherited as an autosomal recessive trait with 25% recurrence9. Complete surgical removal of a cystic hygroma is the ideal treatment. However, a cystic hygroma can often invade other neck structures, making complete excision impossible. Multiple operations may be necessary to remove a large, complex lesion, particularly those with extension into the mediastinum10. In our case, complete excision of the tumor was impossible due to extensive invasion into other neck structures and the sternum as demonstrated by the preoperative computed tomography scan. The recurrence rate depends on the complexity of the lesion and the degree of excision; recurrence is 50–100% in incompletely excised lesions10. In summary, with the diagnosis of a fetal neck mass, an in-depth evaluation must be performed by a specialized multidisciplinary team. It is important to identify the type of neck mass and its relationship to adjacent structures. The parents should be counseled about the need to determine the fetal karyotype in all cases, and amniocentesis or chorionic villus sampling should be offered. Prenatal diagnosis of a fetal neck mass, particularly a huge mass, allows for a carefully planned delivery that maintains an open airway and potentially improves the perinatal outcome. C. Suwanrath-Kengpol*, T. Suntharasaj*, S. Patrapinyokul , P. Chanvitan , * Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110, Thailand, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110, Thailand, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110, Thailand
Cystic hygroma
Neck mass
Internal jugular vein
Jugular vein
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Thyroglossal duct cyst is the most common congenital neck mass. About 50% of cases present before the age of 10. A second group present in young adulthood.We present a case of an 85 years old male patient who presented to us with a huge swelling occupying the whole front of the neck, matching the characters of a thyroglossal cyst by history and clinical examination. The swelling first appeared in early adulthood. He received faulty advice that led him to believe that the operation was too risky. He lived without treatment or complications except for very slow progressive enlargement of the swelling over the years until it became cosmetically very bad and interfering with his daily activities. The swelling was cystic, non-tender with surrounding healthy skin except small area showing minimal signs of inflammation. Neck US and (CT) confirmed the diagnosis of thyroglossal cyst, 92*76 mm in size.We performed surgical excision of the cyst, tract and central part of hyoid bone (Sistrunk operation) and sent the specimen for histopathological evaluation, which confirmed pre-operative diagnosis.Diagnosis of TGDC shouldn't be excluded even in extremes of age, or extreme size, and can be managed according to standard lines of management.
Hyoid bone
Thyroglossal cyst
Neck mass
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