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Cervicothoracic Lesions in Infants and Children¹

¹ From the Department of Radiology, Institut de Diagnostic per la Imatge, Hospital Materno-Infantil Vall d'Hebron, Paseo Vall d'Hebron 119–129, E-08035 Barcelona, Spain (A.C., E.V., J.V., J.P., J.L., P.G.P.); and the Department of Radiology, Hospital Germans Trias i Pujol, Badalona, Spain (J.A.J.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1997 RSNA scientific assembly. Received April 17, 1998; revision requested May 14 and received July 8; accepted July 9. Address reprint requests to A.C.

View larger version (66K): [in a new window]   Figure 1. Figures 1, 2. (1) Axial drawing of the fasciae and spaces of the infrahyoid neck. The superficial layer of the DCF (red line) encircles the neck deep to the superficial fascia. The middle layer of the DCF (blue line) encircles the visceral space and contains the thyroid gland, trachea, and esophagus. The deep layer of the DCF (green line) forms the posterior wall of the retropharyngeal space and danger space and delineates the prevertebral space. Note that the three layers of the DCF form the carotid sheath. (Adapted and reprinted, with permission, from reference 2.) (2) Sagittal drawing of the layers of the DCF and the spaces of the neck with extension to the thorax. Red line = superficial layer of the DCF, blue line = middle layer of the DCF, green line = deep layer of the DCF. The visceral space is contained between the two blue lines and is continuous from the cervical area to the superior mediastinum. The posterior margin of the visceral space serves as the anterior wall of the retropharyngeal space. This compartment continues caudally into the thorax to the posterior mediastinum (P) (T3). A = anterior mediastinum, Ao = aorta, E = esophagus, M = middle mediastinum, PA = pulmonary artery, T = trachea. (Adapted and reprinted, with permission, from reference 2.)

View larger version (50K): [in a new window]   Figure 2. Figures 1, 2. (1) Axial drawing of the fasciae and spaces of the infrahyoid neck. The superficial layer of the DCF (red line) encircles the neck deep to the superficial fascia. The middle layer of the DCF (blue line) encircles the visceral space and contains the thyroid gland, trachea, and esophagus. The deep layer of the DCF (green line) forms the posterior wall of the retropharyngeal space and danger space and delineates the prevertebral space. Note that the three layers of the DCF form the carotid sheath. (Adapted and reprinted, with permission, from reference 2.) (2) Sagittal drawing of the layers of the DCF and the spaces of the neck with extension to the thorax. Red line = superficial layer of the DCF, blue line = middle layer of the DCF, green line = deep layer of the DCF. The visceral space is contained between the two blue lines and is continuous from the cervical area to the superior mediastinum. The posterior margin of the visceral space serves as the anterior wall of the retropharyngeal space. This compartment continues caudally into the thorax to the posterior mediastinum (P) (T3). A = anterior mediastinum, Ao = aorta, E = esophagus, M = middle mediastinum, PA = pulmonary artery, T = trachea. (Adapted and reprinted, with permission, from reference 2.)

View larger version (156K): [in a new window]   Figure 3.  Lymphangioma in a 10-year-old girl with a cervicothoracic mass, which was partially resected previously. Coronal T1-weighted electrocardiographically gated MR image (796/15 [repetition time msec/echo time msec]) shows a heterogeneous cervicomediastinal mass with hyperintense hemorrhagic areas (arrowheads) and jugular ectasia (arrow).

View larger version (143K): [in a new window]   Figure 4a.  Massive lymphatic malformation in a newborn girl who was in respiratory distress and had an obvious calvarial, cervical, and thoracic mass. Coronal T2-weighted MR image (2,200/20) (a) and axial T1-weighted MR image (570/15) (b) show a huge, multiseptated, cystic mass with hemorrhagic areas (arrows in a) and fluid-fluid levels (arrowheads in b). The mass extends to the cervical, mediastinal, axillary, and pulmonary compartments. The karyotype was normal.

View larger version (135K): [in a new window]   Figure 4b.  Massive lymphatic malformation in a newborn girl who was in respiratory distress and had an obvious calvarial, cervical, and thoracic mass. Coronal T2-weighted MR image (2,200/20) (a) and axial T1-weighted MR image (570/15) (b) show a huge, multiseptated, cystic mass with hemorrhagic areas (arrows in a) and fluid-fluid levels (arrowheads in b). The mass extends to the cervical, mediastinal, axillary, and pulmonary compartments. The karyotype was normal.

View larger version (136K): [in a new window]   Figure 5a.  Hemangioma in a 1-year-old girl with a cervical mass. Contrast-enhanced coronal T1-weighted electrocardiographically gated MR images (546/30) (a obtained anterior to b) show a heterogeneous, enhancing cervicothoracic mass with multiple flow voids (arrow in a). The mass reaches the mediastinum and displaces the enlarged internal jugular vein (arrow in b). Note the enlarged external jugular vein draining the mass (arrowhead in b).

View larger version (145K): [in a new window]   Figure 5b.  Hemangioma in a 1-year-old girl with a cervical mass. Contrast-enhanced coronal T1-weighted electrocardiographically gated MR images (546/30) (a obtained anterior to b) show a heterogeneous, enhancing cervicothoracic mass with multiple flow voids (arrow in a). The mass reaches the mediastinum and displaces the enlarged internal jugular vein (arrow in b). Note the enlarged external jugular vein draining the mass (arrowhead in b).

View larger version (145K): [in a new window]   Figure 6.  Cervical thymus in an 8-month-old girl who was examined to rule out a vascular anomaly. Oblique sagittal T1-weighted electrocardiographically gated MR image (512/30) shows extension of the thymus from the anterior mediastinum to the lower neck (arrows).

View larger version (110K): [in a new window]   Figure 7a.  Thymic cyst in an 18-year-old woman with stridor, hoarseness, and dyspnea. (a) Contrast-enhanced axial CT scan shows a hypoattenuating mediastinal mass (arrow) that displaces the trachea and supraaortic vessels anteriorly. (b) US scan shows an anechoic mass (M) extending up through the thoracic inlet behind the thyroid (TH). (c) Photomicrograph (hematoxylin-eosin stain) shows Hassall corpuscles.

View larger version (105K): [in a new window]   Figure 7b.  Thymic cyst in an 18-year-old woman with stridor, hoarseness, and dyspnea. (a) Contrast-enhanced axial CT scan shows a hypoattenuating mediastinal mass (arrow) that displaces the trachea and supraaortic vessels anteriorly. (b) US scan shows an anechoic mass (M) extending up through the thoracic inlet behind the thyroid (TH). (c) Photomicrograph (hematoxylin-eosin stain) shows Hassall corpuscles.

View larger version (143K): [in a new window]   Figure 7c.  Thymic cyst in an 18-year-old woman with stridor, hoarseness, and dyspnea. (a) Contrast-enhanced axial CT scan shows a hypoattenuating mediastinal mass (arrow) that displaces the trachea and supraaortic vessels anteriorly. (b) US scan shows an anechoic mass (M) extending up through the thoracic inlet behind the thyroid (TH). (c) Photomicrograph (hematoxylin-eosin stain) shows Hassall corpuscles.

View larger version (131K): [in a new window]   Figure 8.  Cervical right aortic arch in a 10-year-old boy with ventricular septal defect. A posterior tracheal indentation was found on plain radiographs. Oblique sagittal T1-weighted electrocardiographically gated MR image (905/25) shows a high position of the aortic arch, which passes through the thoracic inlet (arrow).

View larger version (113K): [in a new window]   Figure 9a.  Tuberculous spondylitis with abscess formation in an 18-month-old girl who had two supraclavicular fistulas on the left side. (a) Axial CT scan at the thoracic level shows fragmented destruction of the vertebral body with an associated large paraspinal mass (arrow), which is probably surrounded by the prevertebral fascia. Note the small bone fragment indenting the thecal sac anteriorly (black arrowhead). Calcification of a right carinal lymph node is seen (white arrowhead). (b) Contrast-enhanced axial CT scan of the lower neck shows prevertebral extension of the tuberculous abscess, which demonstrates hypoattenuating central areas (arrowheads). (Figs 9a and 9b courtesy of U. V. Willi, MD, University Children's Hospital, Zurich, Switzerland.)

View larger version (144K): [in a new window]   Figure 9b.  Tuberculous spondylitis with abscess formation in an 18-month-old girl who had two supraclavicular fistulas on the left side. (a) Axial CT scan at the thoracic level shows fragmented destruction of the vertebral body with an associated large paraspinal mass (arrow), which is probably surrounded by the prevertebral fascia. Note the small bone fragment indenting the thecal sac anteriorly (black arrowhead). Calcification of a right carinal lymph node is seen (white arrowhead). (b) Contrast-enhanced axial CT scan of the lower neck shows prevertebral extension of the tuberculous abscess, which demonstrates hypoattenuating central areas (arrowheads). (Figs 9a and 9b courtesy of U. V. Willi, MD, University Children's Hospital, Zurich, Switzerland.)

View larger version (114K): [in a new window]   Figure 10a.  Retropharyngeal abscess with mediastinal extension in a 3-year-old boy with pharyngeal perforation caused by a pen. (a) Lateral radiograph of the neck shows widening of the prevertebral space with air in the retropharynx (arrow). (b) Anteroposterior plain radiograph of the cervicothoracic region shows bilateral widening of the upper mediastinum. Note the air in the soft tissue on the left side of the neck (arrow).

View larger version (146K): [in a new window]   Figure 10b.  Retropharyngeal abscess with mediastinal extension in a 3-year-old boy with pharyngeal perforation caused by a pen. (a) Lateral radiograph of the neck shows widening of the prevertebral space with air in the retropharynx (arrow). (b) Anteroposterior plain radiograph of the cervicothoracic region shows bilateral widening of the upper mediastinum. Note the air in the soft tissue on the left side of the neck (arrow).

View larger version (126K): [in a new window]   Figure 11a.  Retropharyngeal abscess with mediastinal extension in a 2-year-old girl with pharyngeal perforation caused by a pen. (a) Axial CT scan shows extraluminal air and oral contrast material in the retropharyngeal space (arrow). (b) Axial CT scan obtained at a lower level than a shows mediastinal extension (arrows). (Figs 11a and 11b reprinted, with permission, from reference 10.)

View larger version (124K): [in a new window]   Figure 11b.  Retropharyngeal abscess with mediastinal extension in a 2-year-old girl with pharyngeal perforation caused by a pen. (a) Axial CT scan shows extraluminal air and oral contrast material in the retropharyngeal space (arrow). (b) Axial CT scan obtained at a lower level than a shows mediastinal extension (arrows). (Figs 11a and 11b reprinted, with permission, from reference 10.)

View larger version (129K): [in a new window]   Figure 12a.  Lipoma in a 3-year-old girl with an upper respiratory infection. (a) Posteroanterior chest radiograph shows a mediastinal mass displacing the trachea (arrowhead). (b) Contrast-enhanced axial CT scan shows a mediastinal mass of fat attenuation that extends through the thoracic inlet.

View larger version (104K): [in a new window]   Figure 12b.  Lipoma in a 3-year-old girl with an upper respiratory infection. (a) Posteroanterior chest radiograph shows a mediastinal mass displacing the trachea (arrowhead). (b) Contrast-enhanced axial CT scan shows a mediastinal mass of fat attenuation that extends through the thoracic inlet.

View larger version (128K): [in a new window]   Figure 13.  Cervicothoracic lipoblastoma in an 8-year-old girl with a left-sided cervical mass that was partially resected at another institution. Axial CT scan shows a fatty mass (M) with thick septa that lies deep behind the left sternocleidomastoid muscle (scm) and displaces the trachea.

View larger version (125K): [in a new window]   Figure 14a.  Multiple neurofibromas in a 9-year-old girl with neurofibromatosis. Contrast-enhanced axial CT scans at the thoracic inlet (a) and supraaortic level (b) show a well-defined mediastinal mass with bilateral, isoattenuating, nonenhancing masses displacing the supraaortic vessels anteriorly and extending along the borders of the lower ribs (arrows).

View larger version (109K): [in a new window]   Figure 14b.  Multiple neurofibromas in a 9-year-old girl with neurofibromatosis. Contrast-enhanced axial CT scans at the thoracic inlet (a) and supraaortic level (b) show a well-defined mediastinal mass with bilateral, isoattenuating, nonenhancing masses displacing the supraaortic vessels anteriorly and extending along the borders of the lower ribs (arrows).

View larger version (142K): [in a new window]   Figure 15.  Plexiform neurofibromatosis in an 18-month-old boy with chronic myeloid leukemia. He had multiple café au lait spots, and a posterior mediastinal mass was incidentally discovered on a chest radiograph. Coronal T1-weighted MR image (560/30) shows a well-defined paraspinal mass (arrowhead). Extensive plexiform neurofibromatosis affecting the right brachial plexus is also evident (arrows).

View larger version (169K): [in a new window]   Figure 16a.  Aggressive fibromatosis in a 12-year-old girl with a previously diagnosed cervical mass that extended to the mediastinum. Coronal T1-weighted (900/15) (a) and T2-weighted (2,280/20) (b) MR images show a predominantly hypointense lesion that involves the left sternocleidomastoid muscle, surrounds the great vessels, and extends into the mediastinum (arrows). (Figs 16a and 16b reprinted, with permission, from reference 10.)

View larger version (156K): [in a new window]   Figure 16b.  Aggressive fibromatosis in a 12-year-old girl with a previously diagnosed cervical mass that extended to the mediastinum. Coronal T1-weighted (900/15) (a) and T2-weighted (2,280/20) (b) MR images show a predominantly hypointense lesion that involves the left sternocleidomastoid muscle, surrounds the great vessels, and extends into the mediastinum (arrows). (Figs 16a and 16b reprinted, with permission, from reference 10.)

View larger version (153K): [in a new window]   Figure 17.  Lymphoma in a 17-year-old girl with intermittent fever. Coronal T1-weighted MR image (500/20) shows masses of intermediate signal intensity that correspond mainly to right jugular and supraclavicular chain lymph nodes (arrows).

View larger version (108K): [in a new window]   Figure 18a.  Thyroid carcinoma in a 12-year-old girl with anterior cervical swelling. Coronal (a) and axial (b) T2-weighted electrocardiographically gated MR images (2,340/80) show a multinodular, hyperintense thyroid mass (M) with involvement of left laterocervical and supraclavicular lymph nodes (arrows).

View larger version (92K): [in a new window]   Figure 18b.  Thyroid carcinoma in a 12-year-old girl with anterior cervical swelling. Coronal (a) and axial (b) T2-weighted electrocardiographically gated MR images (2,340/80) show a multinodular, hyperintense thyroid mass (M) with involvement of left laterocervical and supraclavicular lymph nodes (arrows).

View larger version (163K): [in a new window]   Figure 19.  Neuroblastoma in a 2-month-old girl with stridor. Coronal T2-weighted MR image (2,500/15) shows a slightly hyperintense mass that involves the lower cervical and mediastinal regions (arrow) and displaces the trachea (arrowhead).

View larger version (134K): [in a new window]   Figure 20a.  Chest wall rhabdomyosarcoma in a 2-year-old boy with dysphonia and Horner syndrome. (a) Coronal T2-weighted MR image (5,000/90) shows a cervicothoracic mass with supraclavicular extension and displacement of the trachea (arrowhead). (b) Contrast-enhanced axial CT scan shows chest wall involvement. Note that the first rib is partially destroyed (arrow).

View larger version (129K): [in a new window]   Figure 20b.  Chest wall rhabdomyosarcoma in a 2-year-old boy with dysphonia and Horner syndrome. (a) Coronal T2-weighted MR image (5,000/90) shows a cervicothoracic mass with supraclavicular extension and displacement of the trachea (arrowhead). (b) Contrast-enhanced axial CT scan shows chest wall involvement. Note that the first rib is partially destroyed (arrow).

View larger version (166K): [in a new window]   Figure 21a.  Pneumomediastinum in a 5-year-old boy with a history of trauma who developed swelling of the neck, face, and thorax. Posteroanterior chest radiograph (a) and lateral radiograph of the neck (b) show pneumomediastinum and air in the neck and soft tissues. Note the air in the carotid space (arrows in a) and retropharyngeal space (arrowhead in b).

View larger version (126K): [in a new window]   Figure 21b.  Pneumomediastinum in a 5-year-old boy with a history of trauma who developed swelling of the neck, face, and thorax. Posteroanterior chest radiograph (a) and lateral radiograph of the neck (b) show pneumomediastinum and air in the neck and soft tissues. Note the air in the carotid space (arrows in a) and retropharyngeal space (arrowhead in b).

View larger version (138K): [in a new window]   Figure 22a.  Traumatic pharyngeal pseudodiverticulum in a 3-month-old boy who underwent repair of bilateral inguinal hernias at a rural hospital. Endotracheal intubation was reported to have been difficult, and shortly after surgery the patient developed respiratory difficulty. (a) Chest radiograph shows a large cervicothoracic air collection (arrowheads). (b) Esophagogram shows a large, contrast material–filled cavity (arrow) that compresses the esophagus and displaces it anteriorly.

View larger version (119K): [in a new window]   Figure 22b.  Traumatic pharyngeal pseudodiverticulum in a 3-month-old boy who underwent repair of bilateral inguinal hernias at a rural hospital. Endotracheal intubation was reported to have been difficult, and shortly after surgery the patient developed respiratory difficulty. (a) Chest radiograph shows a large cervicothoracic air collection (arrowheads). (b) Esophagogram shows a large, contrast material–filled cavity (arrow) that compresses the esophagus and displaces it anteriorly.

View larger version (147K): [in a new window]   Figure 23a.  Esophageal foreign-body granuloma in a 3-year-old boy with cough, stridor, and dysphagia who was admitted in respiratory distress. He had had a choking episode while eating paella with clams 1 month earlier. (a) Posteroanterior chest radiograph shows a foreign body (a clamshell) at the thoracic inlet (arrow). (b, c) Axial CT scan (b) and three-dimensional reconstruction image (c) show the hyperattenuating foreign body (arrow) with a hypoattenuating pseudomass that causes tracheal stenosis.

View larger version (115K): [in a new window]   Figure 23b.  Esophageal foreign-body granuloma in a 3-year-old boy with cough, stridor, and dysphagia who was admitted in respiratory distress. He had had a choking episode while eating paella with clams 1 month earlier. (a) Posteroanterior chest radiograph shows a foreign body (a clamshell) at the thoracic inlet (arrow). (b, c) Axial CT scan (b) and three-dimensional reconstruction image (c) show the hyperattenuating foreign body (arrow) with a hypoattenuating pseudomass that causes tracheal stenosis.

View larger version (133K): [in a new window]   Figure 23c.  Esophageal foreign-body granuloma in a 3-year-old boy with cough, stridor, and dysphagia who was admitted in respiratory distress. He had had a choking episode while eating paella with clams 1 month earlier. (a) Posteroanterior chest radiograph shows a foreign body (a clamshell) at the thoracic inlet (arrow). (b, c) Axial CT scan (b) and three-dimensional reconstruction image (c) show the hyperattenuating foreign body (arrow) with a hypoattenuating pseudomass that causes tracheal stenosis.

View larger version (18K): [in a new window]   Figure 24.  Diagram illustrates a diagnostic approach to cervicothoracic lesions.