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DOI: 10.1148/rg.261055050
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RadioGraphics 2006;26:157-171
© RSNA, 2006

EDUCATION EXHIBIT

Causes of Facial Swelling in Pediatric Patients: Correlation of Clinical and Radiologic Findings1

Geetika Khanna, MD, Yutaka Sato, MD, Richard J. H. Smith, MD, Nancy M. Bauman, MD and Jeffrey Nerad, MD

1 From the Departments of Radiology (G.K., Y.S.), Otolaryngology (R.J.H.S., N.M.B.), and Ophthalmology (J.N.), University of Iowa College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242. Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Annual Meeting. Received March 15, 2005; revision requested April 4 and received May 25; accepted June 6. All authors have no financial relationships to disclose. Address correspondence to G.K. (e-mail: geetika-khanna{at}uiowa.edu).


   Abstract
Top
 Abstract
LEARNING OBJECTIVES
 Introduction
 Acute Swelling with Inflammation
 Nonprogressive Swelling
 Slowly Progressive Swelling
 Rapidly Progressive Swelling
 Summary
 References
 
Facial swelling is a common clinical problem in pediatric patients. The causes of swelling are diverse, and knowledge of the typical clinical and imaging manifestations and the most common sites of occurrence of these conditions is needed to formulate a differential diagnosis. The general clinical manifestations may be classified into the following four groups: (a) acute swelling with inflammation, (b) nonprogressive swelling, (c) slowly progressive swelling, and (d) rapidly progressive swelling. Conditions that may account for acute swelling accompanied by inflammation include lymphadenitis, sinusitis, odontogenic infection, and abscess. Contrast-enhanced computed tomography is the modality of choice for detection of abscesses requiring surgical drainage. Nonprogressive midfacial swelling is suggestive of a congenital anomaly (eg, a cephalocele, nasal glioma, or nasal dermoid or epidermoid cyst). Slowly progressive swelling may indicate the presence of a neurofibroma, hemangioma, lymphangioma, vascular malformation, or pseudocyst, or of fibrous dysplasia. The differential diagnosis for rapidly progressive facial swelling in association with cranial nerve deficits should include rhabdomyosarcoma, Langerhans cell histiocytosis, Ewing sarcoma, osteogenic sarcoma, and metastatic neuroblastoma.

© RSNA, 2006


   LEARNING OBJECTIVES
Top
 Abstract
 LEARNING OBJECTIVES
Introduction
 Acute Swelling with Inflammation
 Nonprogressive Swelling
 Slowly Progressive Swelling
 Rapidly Progressive Swelling
 Summary
 References
 
After reading this article and taking the test, the reader will be able to:


   Introduction
Top
 Abstract
 LEARNING OBJECTIVES
 Introduction
Acute Swelling with Inflammation
 Nonprogressive Swelling
 Slowly Progressive Swelling
 Rapidly Progressive Swelling
 Summary
 References
 
Facial swelling is a common clinical problem in the pediatric population. The origins of a facial mass or swelling can vary from congenital causes to acquired conditions such as infection and benign or malignant conditions in soft tissue and/or bone. The clinical history and physical manifestations are the most important factors in the evaluation of facial swelling and in deciding whether imaging is indicated (Fig 1). Recent advances in imaging and therapeutic techniques have led to the increasing use of computed tomography (CT) and magnetic resonance (MR) imaging for determining the presence and extent of disease and for treatment planning.



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  		Figure 1.  Differential diagnosis of facial swelling according to the location of the lesion.

 
In this article, the causes of pediatric facial swelling are classified according to their typical clinical manifestations and correlated with findings at CT and MR imaging, the modalities most useful for evaluation of these pathologic conditions.


   Acute Swelling with Inflammation
Top
 Abstract
 LEARNING OBJECTIVES
 Introduction
 Acute Swelling with Inflammation
Nonprogressive Swelling
 Slowly Progressive Swelling
 Rapidly Progressive Swelling
 Summary
 References
 
Inflammatory swelling is the most common type of facial swelling in children, and lymphadenitis is its most common cause, followed by sinusitis and odontogenic infection. Lymphadenitis most commonly manifests as swelling and erythema in the upper neck and submandibular and/or parotid region. Although upper-airway viral infections are the most common cause of cervical and facial adenitis, most such infections are self-limited and do not require diagnostic imaging (1). Staphylococcus aureus and group A Streptococci are the most common causes of bacterial lymphadenitis (Fig 2). Children with systemic symptoms, marked lymphadenopathy, or overlying cellulitis may require early parenteral antibiotic treatment. While most children with lymphadenitis do not require imaging, contrast-enhanced CT is the modality of choice to detect an abscess that may require surgical drainage. In the absence of significant surrounding inflammatory changes, an infection by an atypical mycobacterium should be considered.



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  		Figure 2a.  Cervical bacterial lymphadenitis and abscess in a 1-year-old boy with fever. (a) Photograph shows erythematous swelling of the upper neck, which was tender at palpation. Swelling was refractory to antibiotics. (b) Contrast material–enhanced CT scan shows lymphadenitis of the left-sided level 1 nodes (arrow) and associated necrosis (arrowhead) suggestive of early abscess formation.

 


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  		Figure 2b.  Cervical bacterial lymphadenitis and abscess in a 1-year-old boy with fever. (a) Photograph shows erythematous swelling of the upper neck, which was tender at palpation. Swelling was refractory to antibiotics. (b) Contrast material–enhanced CT scan shows lymphadenitis of the left-sided level 1 nodes (arrow) and associated necrosis (arrowhead) suggestive of early abscess formation.

 
Swelling caused by sinusitis typically is centered around the malar and brow regions. Periorbital and orbital inflammation may occur by extension of inflammation from the ethmoidal sinuses through the lamina papyracea, the thin orbital plate of the ethmoid bone (Fig 3a) (2). In adolescents, the frontal sinus may be the original site of infection. Maxillary sinusitis is less commonly complicated by orbital cellulitis (3). Orbital inflammation limited to the soft tissues anterior to the orbital septum (preorbital or preseptal cellulitis) manifests with cellulitis of the eyelids, without visual loss or ophthalmoplegia. The orbital septum separates the periorbital from the intraorbital space and can usually be seen on CT images as a thin band that parallels the superior orbital rim deep to the facial musculature. If the inflammation extends through the orbital septum, it is classified as orbital or postseptal cellulitis, which is associated with a higher risk of complications such as superior ophthalmic vein thrombosis, cavernous sinus thrombosis, and loss of vision (4). A subperiosteal abscess is most commonly seen along the medial wall of the orbit, forming a spindle-shaped fluid collection between the lamina papyracea and the medial rectus muscle (Fig 3b). A subperiosteal abscess may extend into the intraconal space and form an orbital abscess (5).



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  		Figure 3a.  Orbital cellulitis and subperiosteal abscess in an 11-year-old girl with painful swelling. (a) Photograph shows periorbital swelling, proptosis, and chemosis of the right eye. (b) Contrast-enhanced CT scan shows soft-tissue edema and infiltration of the fat plane in the preseptal (*) and extraconal (arrowhead) spaces, as well as a fluid collection under the periorbita (straight arrow) and associated inflammation of the right ethmoidal sinus (curved arrow). The abscess was surgically drained.

 


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  		Figure 3b.  Orbital cellulitis and subperiosteal abscess in an 11-year-old girl with painful swelling. (a) Photograph shows periorbital swelling, proptosis, and chemosis of the right eye. (b) Contrast-enhanced CT scan shows soft-tissue edema and infiltration of the fat plane in the preseptal (*) and extraconal (arrowhead) spaces, as well as a fluid collection under the periorbita (straight arrow) and associated inflammation of the right ethmoidal sinus (curved arrow). The abscess was surgically drained.

 
With the widespread use of antibiotic therapy, the Pott puffy tumor has become a rare complication of frontal sinusitis. It is caused by frontal osteomyelitis and abscess formation under the galea aponeurotica because of underlying frontal sinusitis (6). The typical manifestation is a broad swollen bump with a doughy consistency, which may occur anywhere in the region over the brow (Fig 4a). CT scans show frontal sinusitis, frontal osteomyelitis, and subgaleal abscess (Fig 4b, 4c). The abscess may extend intracranially and lead to complications such as epidural abscess, meningitis, or cerebral abscess (7).



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  		Figure 4a.  Pott puffy tumor in a 14-year-old boy. (a) Photograph shows bilateral periorbital swelling and, in the brow region, a large swollen bump that had a doughy consistency at palpation. (b, c) Contrast-enhanced CT scans show a subgaleal abscess (arrow in b) and frontal sinusitis (c). (Air in the abscess and the sinus was introduced during diagnostic aspiration.)

 


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  		Figure 4b.  Pott puffy tumor in a 14-year-old boy. (a) Photograph shows bilateral periorbital swelling and, in the brow region, a large swollen bump that had a doughy consistency at palpation. (b, c) Contrast-enhanced CT scans show a subgaleal abscess (arrow in b) and frontal sinusitis (c). (Air in the abscess and the sinus was introduced during diagnostic aspiration.)

 


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  		Figure 4c.  Pott puffy tumor in a 14-year-old boy. (a) Photograph shows bilateral periorbital swelling and, in the brow region, a large swollen bump that had a doughy consistency at palpation. (b, c) Contrast-enhanced CT scans show a subgaleal abscess (arrow in b) and frontal sinusitis (c). (Air in the abscess and the sinus was introduced during diagnostic aspiration.)

 
Jaw swelling and trismus after a dental procedure are the typical clinical manifestations of a masticator space phlegmon or abscess (Fig 5a) and may be accompanied by mandibular osteomyelitis. Because the masticator space extends above the zygoma, imaging should always include the suprazygomatic masticator space and the cephalad attachment of the temporalis muscle. If the abscess extends above the zygoma, additional drainage of the suprazygomatic component may be required (Fig 5b).



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  		Figure 5a.  Odontogenic masticator phlegmon and abscess in a 15-year-old girl. (a) Contrast-enhanced CT scan shows a right masticator space phlegmon with swelling of the masseter (curved arrow) and pterygoid muscles (straight arrow), as well as a small abscess (arrowhead). (b) CT scan shows phlegmonous changes that extend along the temporalis muscle and into the suprazygomatic masticator space (arrow).

 


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  		Figure 5b.  Odontogenic masticator phlegmon and abscess in a 15-year-old girl. (a) Contrast-enhanced CT scan shows a right masticator space phlegmon with swelling of the masseter (curved arrow) and pterygoid muscles (straight arrow), as well as a small abscess (arrowhead). (b) CT scan shows phlegmonous changes that extend along the temporalis muscle and into the suprazygomatic masticator space (arrow).

 

   Nonprogressive Swelling
Top
 Abstract
 LEARNING OBJECTIVES
 Introduction
 Acute Swelling with Inflammation
 Nonprogressive Swelling
Slowly Progressive Swelling
 Rapidly Progressive Swelling
 Summary
 References
 
Nonprogressive swelling is typical of congenital midfacial masses, including frontoethmoidal cephaloceles, nasal gliomas, and nasal dermoid and/or epidermoid cysts (8). A cephalocele results from the herniation of intracranial tissue through a faulty closure of the calvarial suture when the cutaneous ectoderm and the neuroectoderm near the anterior neuropore fail to detach at approximately the 3rd week of fetal development (9). Frontoethmoidal cephaloceles, which account for only 10% of cephaloceles, are differentiated according to the sutures involved: The nasofrontal cephalocele occurs between the nasal and frontal bones (Fig 6 ); the nasoethmoidal cephalocele, between the nasal bone and the nasal cartilage; and the naso-orbital cephalocele, between the maxilla and the lacrimal bones (Fig 7). Cephaloceles occur as nonprogressive masses around the nasal dorsum, orbits, and forehead. The mass may be pulsatile and may become enlarged during jugular vein compression (Furstenberg sign). A nasal glioma represents the distal part of a cephalocele that remains in the extracranial location after the disruption of a central connection. Gliomas are extranasal in 60% of patients, intranasal in 30%, and both extranasal and intranasal in 10%. An extranasal glioma is a smooth, firm, noncompressible mass that occurs near the root of the nose. Nasal dermoid and epidermoid cysts result from dermal inclusion in the cranium through a patent suture (Fig 8). The nasal skin dimple (pit) may be located anywhere between the glabella and the columella of the nose, and it continues as a dermal sinus into the cranium through a bone defect (10). A dermoid or epidermoid cyst may develop along the course of the dermal sinus (11).



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  		Figure 6a.  Nasofrontal cephalocele in a 6-month-old girl. (a) Photograph shows a midfacial mass at the glabella, with hypertelorism. At palpation, the mass was soft and compressible. (b, c) Plain radiograph (b) and three-dimensional reformatted CT image (c) of the skull base show a bone defect between the nasal and frontal bones (arrows).

 


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  		Figure 6b.  Nasofrontal cephalocele in a 6-month-old girl. (a) Photograph shows a midfacial mass at the glabella, with hypertelorism. At palpation, the mass was soft and compressible. (b, c) Plain radiograph (b) and three-dimensional reformatted CT image (c) of the skull base show a bone defect between the nasal and frontal bones (arrows).

 


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  		Figure 6c.  Nasofrontal cephalocele in a 6-month-old girl. (a) Photograph shows a midfacial mass at the glabella, with hypertelorism. At palpation, the mass was soft and compressible. (b, c) Plain radiograph (b) and three-dimensional reformatted CT image (c) of the skull base show a bone defect between the nasal and frontal bones (arrows).

 


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  		Figure 7.  Naso-orbital cephalocele in a 2-month-old boy with midfacial and orbital swelling. Axial unenhanced CT scan of the orbits shows bilateral naso-orbital bone defects (arrows) and a cephalocele (*), which protrudes into both orbits.

 


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  		Figure 8a.  Nasal dermoid cyst in a 1-year-old boy. (a) Photograph shows a midfacial mass at the bridge of the nose. (b, c) Axial contrast-enhanced CT scans show a fatty mass at the nasal bridge (arrowhead in b) and intracranial extension of the mass through a bone defect at the foramen cecum (arrow in c). (d) Photograph shows the resected dermal sinus and dermoid cyst.

 


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  		Figure 8b.  Nasal dermoid cyst in a 1-year-old boy. (a) Photograph shows a midfacial mass at the bridge of the nose. (b, c) Axial contrast-enhanced CT scans show a fatty mass at the nasal bridge (arrowhead in b) and intracranial extension of the mass through a bone defect at the foramen cecum (arrow in c). (d) Photograph shows the resected dermal sinus and dermoid cyst.

 


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  		Figure 8c.  Nasal dermoid cyst in a 1-year-old boy. (a) Photograph shows a midfacial mass at the bridge of the nose. (b, c) Axial contrast-enhanced CT scans show a fatty mass at the nasal bridge (arrowhead in b) and intracranial extension of the mass through a bone defect at the foramen cecum (arrow in c). (d) Photograph shows the resected dermal sinus and dermoid cyst.

 


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  		Figure 8d.  Nasal dermoid cyst in a 1-year-old boy. (a) Photograph shows a midfacial mass at the bridge of the nose. (b, c) Axial contrast-enhanced CT scans show a fatty mass at the nasal bridge (arrowhead in b) and intracranial extension of the mass through a bone defect at the foramen cecum (arrow in c). (d) Photograph shows the resected dermal sinus and dermoid cyst.

 
Frontoethmoidal cephaloceles, nasal gliomas, and nasal dermoids and epidermoids have similar clinical manifestations, including a broad nasal bridge, glabellar swelling, and hypertelorism (12). The characteristics of CT and MR imaging are complementary for depiction of these lesions. CT scans can show bony defects of the craniofacial junction, and MR images can show the relationship of a midfacial mass to the brain (13). With both modalities, thin-section resolution is necessary (CT sections must be no more than 1.5 mm thick; MR sections, no more than 3 mm).

Dacryocystoceles are tense blue-gray masses that may appear at the inferomedial canthus in neonates (Fig 9a). They are caused by congenital obstruction of the nasolacrimal duct. CT and MR images depict a cystic mass that extends from the inferomedial canthus into the nasal cavity, along the course of the nasolacrimal duct (Fig 9b, 9c) (14). Dacryocystoceles should be treated promptly to prevent secondary infection. Possible treatments include manual pressure, probing with irrigation, and, in severe cases, which are rare, endoscopic resection and marsupialization.



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  		Figure 9a.  Dacryocystocele in a 2-month-old girl. (a) Photograph shows a bluish inferomedial canthus mass. (b, c) T2-weighted MR images show a cystic mass that extends from the medial canthus (arrow in b) into the nasal cavity (* in c), along the nasolacrimal duct.

 


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  		Figure 9b.  Dacryocystocele in a 2-month-old girl. (a) Photograph shows a bluish inferomedial canthus mass. (b, c) T2-weighted MR images show a cystic mass that extends from the medial canthus (arrow in b) into the nasal cavity (* in c), along the nasolacrimal duct.

 


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  		Figure 9c.  Dacryocystocele in a 2-month-old girl. (a) Photograph shows a bluish inferomedial canthus mass. (b, c) T2-weighted MR images show a cystic mass that extends from the medial canthus (arrow in b) into the nasal cavity (* in c), along the nasolacrimal duct.

 
Orbital dermoids are the most common developmental lesion of the orbit and account for 5% of all orbital masses. They appear most frequently in the upper outer quadrant of the orbit and in close relation to the frontozygomatic suture (Fig 10a). Unlike dacryocystoceles, which often are observed in neonates, orbital dermoids are usually seen in older children. At imaging, dermoids may appear with fat density, and, as they progress, they may be associated with gradual erosive changes in the adjacent bone (fossa formation) (Fig 10b) (15). Progression is typically slow.



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  		Figure 10a.  Orbital dermoid cyst in a 7-year-old boy. (a) Photograph shows a mass in the upper outer orbital quadrant. (b) Contrast-enhanced CT scan shows a fatty mass lesion (*) in the lateral aspect of the right orbit, adjacent to the frontozygomatic suture, with osseous scalloping that produces the appearance of a fossa (arrow). The cyst was surgically removed.

 


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  		Figure 10b.  Orbital dermoid cyst in a 7-year-old boy. (a) Photograph shows a mass in the upper outer orbital quadrant. (b) Contrast-enhanced CT scan shows a fatty mass lesion (*) in the lateral aspect of the right orbit, adjacent to the frontozygomatic suture, with osseous scalloping that produces the appearance of a fossa (arrow). The cyst was surgically removed.

 
A first branchial cleft cyst is a remnant of the first branchial apparatus; such remnants account for only 5% of branchial cleft cysts. A second branchial cleft cyst is the most common variant. A first branchial cleft cyst may occur as a cystic lesion or a sinus in the postauricular region (type 1) or in the parotid gland (type 2) (16). In a type 2 first branchial cleft cyst, the parotid cyst may communicate with the external auditory canal, which may cause otorrhea without otitis media. On images, a cystic mass is depicted in the parotid gland as well as at the osseocartilaginous junction in the external auditory canal (Fig 11).



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  		Figure 11.  First branchial cleft cyst. Coronal CT scan shows a cystic mass in the parotid gland (arrow) that is connected with a smaller cyst in the external auditory canal at the osseocartilaginous junction (arrowhead).

 

   Slowly Progressive Swelling
Top
 Abstract
 LEARNING OBJECTIVES
 Introduction
 Acute Swelling with Inflammation
 Nonprogressive Swelling
 Slowly Progressive Swelling
Rapidly Progressive Swelling
 Summary
 References
 
Slowly progressive swelling may be secondary to an underlying mass such as neurofibroma, lymphatic or vascular malformation, or hemangioma, or may be due to an osseous disease such as fibrous dysplasia. Plexiform neurofibromas are virtually pathognomonic of type I neurofibromatosis (Fig 12). Histologically, this benign tumor consists of a heterogeneous mixture of Schwann cells, perineural cells, and fibroblasts. The tumor demonstrates an infiltrative growth pattern with transspatial involvement (ie, extension from one space to another, regardless of fascial boundaries). Although plexiform neurofibromas can occur anywhere in the body, the first division of the trigeminal nerve, in the region of the orbital apex, is most often involved. When the orbit is involved in neurofibroma, the lesion gradually enlarges until it involves nearly all orbital structures, both internal and external (17). The affected orbit and its neural foramina are enlarged, and there is erosion of the skull base, particularly the sphenoid bone (Fig 12). Investigators in recent studies have shown that deficiency of the sphenoid bone is likely multifactorial and may be due to interaction between the neurofibroma and the sphenoid bone during development (18,19). A sphenoid bone defect may allow herniation of the temporal lobe into the orbit, a condition that may be associated with pulsatile exophthalmos. At palpation, the multiple cords and nodules of such a tumor give it a "bag of worms" appearance. On CT scans, the affected orbit appears enlarged, and its walls are eroded (20). MR images demonstrate an infiltrative mass with T1 and T2 prolongation and diffuse and intense contrast enhancement.



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  		Figure 12a.  Plexiform neurofibroma in a 7-year-old girl with type 1 neurofibromatosis. (a) Photograph shows protrusion of the right side of the face and exophthalmos. Swelling and protrusion were slowly progressive, and the exophthalmos was pulsatile at palpation. (b) Contrast-enhanced T1-weighted fat-saturated axial MR image shows a poorly demarcated enhancing mass lesion that extends from the subcutaneous soft tissue into the orbit (arrow), middle cranial fossa (*), and cavernous sinus (arrowhead). (c) Three-dimensional reformatted CT image shows an enlarged right orbit, with marked widening of the superior orbital fissure (arrow).

 


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  		Figure 12b.  Plexiform neurofibroma in a 7-year-old girl with type 1 neurofibromatosis. (a) Photograph shows protrusion of the right side of the face and exophthalmos. Swelling and protrusion were slowly progressive, and the exophthalmos was pulsatile at palpation. (b) Contrast-enhanced T1-weighted fat-saturated axial MR image shows a poorly demarcated enhancing mass lesion that extends from the subcutaneous soft tissue into the orbit (arrow), middle cranial fossa (*), and cavernous sinus (arrowhead). (c) Three-dimensional reformatted CT image shows an enlarged right orbit, with marked widening of the superior orbital fissure (arrow).

 


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  		Figure 12c.  Plexiform neurofibroma in a 7-year-old girl with type 1 neurofibromatosis. (a) Photograph shows protrusion of the right side of the face and exophthalmos. Swelling and protrusion were slowly progressive, and the exophthalmos was pulsatile at palpation. (b) Contrast-enhanced T1-weighted fat-saturated axial MR image shows a poorly demarcated enhancing mass lesion that extends from the subcutaneous soft tissue into the orbit (arrow), middle cranial fossa (*), and cavernous sinus (arrowhead). (c) Three-dimensional reformatted CT image shows an enlarged right orbit, with marked widening of the superior orbital fissure (arrow).

 
Hemangiomas and lymphangiomas also may demonstrate a transspatial growth pattern due to the intrinsic nature of blood vessels and lymphatics (21). Capillary hemangiomas of infancy are bright red, protuberant, and compressible lesions that are sometimes described as "strawberry marks" and that most often are located on the face, scalp, back, and anterior chest wall (Fig 13a). They are five times more common in females than in males, but they are apparent at birth in only 20% of those affected. At histopathologic analysis, they show neoplastic features of endothelial proliferation. Rapid enlargement is noted in the first 2 to 10 months (the proliferative phase), followed by spontaneous regression (involuting phase). Treatment in most cases consists of expectant observation and repeated reassurance of the parents. During the proliferative phase, local complications, such as necrosis of the overlying skin, and systemic complications, such as high-output cardiac failure and consumptive coagulopathy (Kasabach-Merritt syndrome), constitute indications for more active therapy with steroids and, in selected cases, transcatheter embolization. MR images show a well-demarcated lesion with T1 and T2 prolongation and with intense contrast enhancement (Fig 13b). The presence of flow voids helps to differentiate these lesions from soft-tissue masses such as rhabdomyosarcoma. Fatty replacement of the nidus is manifested by T1 shortening at MR imaging during the involuting phase (22,23).



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  		Figure 13a.  Infantile capillary hemangioma in a 1-month-old girl. (a) Photograph shows a strawberry-colored lesion and swelling of the left cheek. (b) T2-weighted MR image shows a hyperintense left parotid mass with multiple flow voids.

 


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  		Figure 13b.  Infantile capillary hemangioma in a 1-month-old girl. (a) Photograph shows a strawberry-colored lesion and swelling of the left cheek. (b) T2-weighted MR image shows a hyperintense left parotid mass with multiple flow voids.

 
Vascular malformations are developmental anomalies of vascular remodeling that do not show neoplastic endothelial proliferation (24). They occur equally in males and females, and 90% are present at birth. They grow in proportion with the somatic growth of the infant; they neither regress spontaneously nor respond to steroid therapy. The malformations are further classified as either low-flow lesions (lymphatic, capillary, and venous malformations) or high-flow lesions (arteriovenous malformations). On images, vascular malformations are characterized as a conglomeration of abnormal vascular channels without interposed stroma. Venous malformations are sometimes referred to as port-wine stains (Fig 14). At imaging, venous malformations appear as well-defined masses with avid contrast enhancement, and phleboliths may be observed (Fig 15). Lymphangiomas are typically soft nontender neck masses that are evident at birth. In lymphatic malformations, enlarged lymphatic channels are separated by contrast-enhanced septa, and fluid-fluid levels are often seen because of associated hemorrhage (25,26).



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  		Figure 14.  Venous malformations. Photograph shows a port-wine stain on the left cheek of a 5-year-old boy.

 


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  		Figure 15a.  Venous malformations. T1-weighted MR images obtained without (a) and with (b) the use of contrast material and fat saturation in a 4-year-old boy show a T1-hypointense focal mass in the right buccal space (arrow) that appears intensely enhanced in b.

 


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  		Figure 15b.  Venous malformations. T1-weighted MR images obtained without (a) and with (b) the use of contrast material and fat saturation in a 4-year-old boy show a T1-hypointense focal mass in the right buccal space (arrow) that appears intensely enhanced in b.

 
Fibrous dysplasia of the facial skeleton produces characteristic deformities. Extensive maxillary involvement results in a slowly progressive protrusion of the malar surface and loss of the nasomaxillary angle, which produces a feline facial appearance that is referred to as leontiasis ossea (Fig 16). The radiographic appearance of fibrous dysplasia may be osteolytic and/or sclerotic. The diploic space is expanded and is bordered by a thin rim of cortical bone. Unenhanced MR images show a low to intermediate signal in the affected region, and contrast-enhanced images show intense enhancement (27).



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  		Figure 16a.  Leontiasis ossea caused by fibrous dysplasia in a 5-year-old boy. (a) Photograph shows swelling of the right malar region, protrusion of the right cheek, and loss of the nasomaxillary angle, which cause a feline facial appearance. (b) Axial CT scan shows a fibro-osseous lesion that involves the right maxillary bone. (c) Three-dimensional reformatted CT image shows protuberance of the right maxilla and loss of the nasomaxillary angle (arrowhead).

 


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  		Figure 16b.  Leontiasis ossea caused by fibrous dysplasia in a 5-year-old boy. (a) Photograph shows swelling of the right malar region, protrusion of the right cheek, and loss of the nasomaxillary angle, which cause a feline facial appearance. (b) Axial CT scan shows a fibro-osseous lesion that involves the right maxillary bone. (c) Three-dimensional reformatted CT image shows protuberance of the right maxilla and loss of the nasomaxillary angle (arrowhead).

 


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  		Figure 16c.  Leontiasis ossea caused by fibrous dysplasia in a 5-year-old boy. (a) Photograph shows swelling of the right malar region, protrusion of the right cheek, and loss of the nasomaxillary angle, which cause a feline facial appearance. (b) Axial CT scan shows a fibro-osseous lesion that involves the right maxillary bone. (c) Three-dimensional reformatted CT image shows protuberance of the right maxilla and loss of the nasomaxillary angle (arrowhead).

 
Cherubism, or hereditary fibrous dysplasia, is characterized by extensive mandibular swelling that affects both sides of the face (28). Maxillary involvement causes the orbital floor to bulge upward. The latter finding, and the downward retraction of the facial skin because of the swelling of the jaw, exposes the lower sclera and causes the eyes to appear as though they are directed heavenward, a characteristic sign of cherubism. The disease often progresses rapidly until the age of 7 years and then gradually regresses.

Plunging ranula is a pseudocyst in the submandibular space that is caused by a ruptured sublingual gland retention cyst. The lesion generally is manifested as a gradually enlarging and painless mass in the submental or submandibular triangle (Fig 17a ), although a rapid increase in swelling also has been described. At imaging, the sublingual and submandibular components of the lesion are continuous, with constriction at the myohyoid muscle, an appearance that led some to describe the shape of the lesion as that of a "comet tail"; the head of the comet is the part in the submandibular space, and the tail points toward the sublingual space (Fig 17b, 17c) (29).



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  		Figure 17a.  Plunging ranula in a 16-year-old girl with slowly progressive but painless swelling beneath the chin. (a) Photograph shows swelling of the left submental region. (b, c) T2-weighted MR images show a large submandibular cystic mass (* in b) with a diameter that progressively narrows toward the sublingual space (arrow in c), in a comet-tail configuration.

 


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  		Figure 17b.  Plunging ranula in a 16-year-old girl with slowly progressive but painless swelling beneath the chin. (a) Photograph shows swelling of the left submental region. (b, c) T2-weighted MR images show a large submandibular cystic mass (* in b) with a diameter that progressively narrows toward the sublingual space (arrow in c), in a comet-tail configuration.

 


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  		Figure 17c.  Plunging ranula in a 16-year-old girl with slowly progressive but painless swelling beneath the chin. (a) Photograph shows swelling of the left submental region. (b, c) T2-weighted MR images show a large submandibular cystic mass (* in b) with a diameter that progressively narrows toward the sublingual space (arrow in c), in a comet-tail configuration.

 

   Rapidly Progressive Swelling
Top
 Abstract
 LEARNING OBJECTIVES
 Introduction
 Acute Swelling with Inflammation
 Nonprogressive Swelling
 Slowly Progressive Swelling
 Rapidly Progressive Swelling
Summary
 References
 
Differential diagnoses of rapidly progressive swelling caused by facial masses in pediatric patients should include rhabdomyosarcoma, Langerhans cell histiocytosis, Ewing sarcoma, osteogenic sarcoma, and metastatic neuroblastoma (30). Malignancy should be strongly considered when cranial nerve deficits are present, as in facial numbness or paralysis, which are caused by involvement of the fifth and seventh cranial nerves, respectively. Hematoma also may occur as a rapidly progressive mass, and the possibility of non-accidental trauma should be considered in the appropriate clinical setting.

Rhabdomyosarcomas are the most common solid head-and-neck malignancies. The lesions may be classified into three groups, according to the site of origin: orbital; parameningeal (middle ear, paranasal sinus, and nasopharyngeal); and other. Orbital rhabdomyosarcoma is manifested with rapidly progressive unilateral proptosis during the 1st decade of life (Fig 18a). The most common site is the superonasal quadrant of the orbit. On images, orbital rhabdomyosarcoma is located in the conal or the extraconal space and shows moderate contrast enhancement (Fig 18b) (31,32). In parameningeal rhabdomyosarcoma, MR imaging is essential to determine whether intracranial extension, which is known to occur in up to 55% of cases, is present.



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  		Figure 18a.  Orbital rhabdomyosarcoma in a 4-year-old girl with progressive ptosis and decrease in visual acuity. (a) Photograph shows ptosis of the left eye. (b) Contrast-enhanced CT scan shows a homogeneously enhancing orbital mass (*), in the inner superior quadrant, that displaces and deforms the globe.

 


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  		Figure 18b.  Orbital rhabdomyosarcoma in a 4-year-old girl with progressive ptosis and decrease in visual acuity. (a) Photograph shows ptosis of the left eye. (b) Contrast-enhanced CT scan shows a homogeneously enhancing orbital mass (*), in the inner superior quadrant, that displaces and deforms the globe.

 
The ramus of the mandible is the most common site of Ewing sarcoma of the head and neck (Fig 19). The typical manifestations are a rapidly growing mass with associated pain and local paresthesias. Mandibular involvement may cause additional associated symptoms, such as loosening of teeth and otitis media. Images of Ewing sarcoma and osteogenic sarcoma show large soft-tissue masses that originate in the marrow, permeate and destroy the cortical bone, and extend into the masticator space. The extent of bone marrow involvement is best evaluated with T1-weighted imaging, whereas T2-weighted imaging is of value for defining the margins of the tumor and its relation to neurovascular bundles and adjacent muscle (Fig 20).



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  		Figure 19a.  Rhabdomyosarcoma in a 7-year-old boy with rapidly progressive swelling of the jaw. (a) Photograph shows swelling of the left side of the jaw. (b) Contrast-enhanced T1-weighted MR image shows a large and enhancing masticator space mass (*) that displaces the parotid gland posterolaterally (black arrow) and the parapharyngeal fat posteromedially (white arrow).

 


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  		Figure 19b.  Rhabdomyosarcoma in a 7-year-old boy with rapidly progressive swelling of the jaw. (a) Photograph shows swelling of the left side of the jaw. (b) Contrast-enhanced T1-weighted MR image shows a large and enhancing masticator space mass (*) that displaces the parotid gland posterolaterally (black arrow) and the parapharyngeal fat posteromedially (white arrow).

 


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  		Figure 20a.  Mandibular Ewing sarcoma in an 8-year-old boy with rapidly progressive swelling and paresthesias of the right cheek. (a) Photograph shows severe swelling of the right side of the face. At palpation, a solid nonmobile mass was found. (b) CT scan shows a mass in the masticator space (arrows), with associated destruction of the mandibular bone and with a sunburst-shaped periosteal reaction (arrowhead).

 


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  		Figure 20b.  Mandibular Ewing sarcoma in an 8-year-old boy with rapidly progressive swelling and paresthesias of the right cheek. (a) Photograph shows severe swelling of the right side of the face. At palpation, a solid nonmobile mass was found. (b) CT scan shows a mass in the masticator space (arrows), with associated destruction of the mandibular bone and with a sunburst-shaped periosteal reaction (arrowhead).

 
Both Langerhans cell histiocytosis (Fig 21a) and metastatic neuroblastoma (Fig 22) characteristically involve the posterolateral part of the orbit, where the frontal bone and greater wing of the sphenoid meet (33). A rapidly progressive periorbital mass or proptosis may be observed. Associated findings, such as periorbital edema or ecchymosis (so-called raccoon eyes), may evoke concern about possible nonaccidental trauma. Children with lesions of the temporal bone often have mastoid involvement, which may be manifested by otalgia and/or drainage of fluid from the ear (Fig 21b). CT of Langerhans cell histiocytosis depicts a sharply circumscribed osteolytic lesion with differential involvement of the inner and outer tables of the skull (34). On MR images, the soft-tissue mass has signal intensity similar to that of skeletal muscle and enhances avidly. Orbital involvement is seen in up to 8% of patients with neuroblastoma. CT and MR images demonstrate a soft-tissue mass that originates in the diploic space and extends beyond the inner and outer tables and that is isointense to muscle on both T1- and T2-weighted images, with avid contrast enhancement (Fig 22).



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  		Figure 21a.  Langerhans cell histiocytosis in a 1-year-old girl with left-sided proptosis. (a) CT scan shows a lytic lesion of the frontal and sphenoid bones (arrows) and an associated soft-tissue mass that extends into the orbit. (b) CT scan shows destruction of the temporal bone (arrowhead).

 


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  		Figure 21b.  Langerhans cell histiocytosis in a 1-year-old girl with left-sided proptosis. (a) CT scan shows a lytic lesion of the frontal and sphenoid bones (arrows) and an associated soft-tissue mass that extends into the orbit. (b) CT scan shows destruction of the temporal bone (arrowhead).

 


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  		Figure 22a.  Metastatic neuroblastoma in a 1-year-old boy. (a) Photograph shows periorbital ecchymosis and swelling suggestive of traumatic head injury. (b, c) Coronal MR images obtained before (b) and after (c) the administration of a gadolinium-based contrast agent demonstrate bilateral soft-tissue masses with extensive skull-base infiltration (arrows in b) and orbital encroachment. (d) Contrast-enhanced CT scan of the abdomen demonstrates a left adrenal mass (arrow), which was subsequently proved to be a neuroblastoma.

 


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  		Figure 22b.  Metastatic neuroblastoma in a 1-year-old boy. (a) Photograph shows periorbital ecchymosis and swelling suggestive of traumatic head injury. (b, c) Coronal MR images obtained before (b) and after (c) the administration of a gadolinium-based contrast agent demonstrate bilateral soft-tissue masses with extensive skull-base infiltration (arrows in b) and orbital encroachment. (d) Contrast-enhanced CT scan of the abdomen demonstrates a left adrenal mass (arrow), which was subsequently proved to be a neuroblastoma.

 


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  		Figure 22c.  Metastatic neuroblastoma in a 1-year-old boy. (a) Photograph shows periorbital ecchymosis and swelling suggestive of traumatic head injury. (b, c) Coronal MR images obtained before (b) and after (c) the administration of a gadolinium-based contrast agent demonstrate bilateral soft-tissue masses with extensive skull-base infiltration (arrows in b) and orbital encroachment. (d) Contrast-enhanced CT scan of the abdomen demonstrates a left adrenal mass (arrow), which was subsequently proved to be a neuroblastoma.

 


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  		Figure 22d.  Metastatic neuroblastoma in a 1-year-old boy. (a) Photograph shows periorbital ecchymosis and swelling suggestive of traumatic head injury. (b, c) Coronal MR images obtained before (b) and after (c) the administration of a gadolinium-based contrast agent demonstrate bilateral soft-tissue masses with extensive skull-base infiltration (arrows in b) and orbital encroachment. (d) Contrast-enhanced CT scan of the abdomen demonstrates a left adrenal mass (arrow), which was subsequently proved to be a neuroblastoma.

 

   Summary
Top
 Abstract
 LEARNING OBJECTIVES
 Introduction
 Acute Swelling with Inflammation
 Nonprogressive Swelling
 Slowly Progressive Swelling
 Rapidly Progressive Swelling
 Summary
References
 
Facial swelling in the pediatric patient may have a wide variety of causes. Knowledge of the location and clinical characteristics of a lesion helps to formulate a differential diagnosis. Infection is the most common cause of facial swelling, and imaging is indicated if there is concern about an underlying abscess that might require drainage. Midfacial and nonprogressive masses require consideration of a congenital or developmental cause. Rapidly progressive lesions with associated cranial nerve deficits are suggestive of malignancy. Contrast-enhanced CT is useful for evaluation of both the soft-tissue component and any associated osseous findings. MR imaging is useful to evaluate the intracranial extension of the lesions.


   Acknowledgments
 
We sincerely thank our patients and their families for permission to publish the clinical photographs included in this article.


   References
Top
 Abstract
 LEARNING OBJECTIVES
 Introduction
 Acute Swelling with Inflammation
 Nonprogressive Swelling
 Slowly Progressive Swelling
 Rapidly Progressive Swelling
 Summary
 References
 

  1. Leung AK, Robson WL. Childhood cervical lymphadenopathy. J Pediatr Health Care 2004; 18(1):3–7.[Medline]
  2. Weber AL, Mikulis DK. Inflammatory disorders of the paraorbital sinuses and their complications. Radiol Clin North Am 1987;25:615–630.[Medline]
  3. Bilaniuk LT, Zimmerman RA. Computer-assisted tomography: sinus lesions with orbital involvement. Head Neck Surg 1980;2:293–301.[Medline]
  4. Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg 1991;104(6):789–795.[Medline]
  5. Eustis HS, Mafee MF, Walton C, Mondonca J. MR imaging and CT of orbital infections and complications in acute rhinosinusitis. Radiol Clin North Am 1998;36:1165–1183.[CrossRef][Medline]
  6. Babu RP, Todor R, Kasoff SS. Pott’s puffy tumor: the forgotten entity—case report. J Neurosurg 1996;84:110–112.[Medline]
  7. Remmler D, Boles R. Intracranial complications of frontal sinusitis. Laryngoscope 1980;90(11 pt 1): 1814–1824.[Medline]
  8. Castillo M. Congenital abnormalities of the nose: CT and MR findings. AJR Am J Roentgenol 1994; 162:1211–1217.[Abstract/Free Full Text]
  9. Naidich TP, Blaser SI, Bauer BS, Armstrong DC, McLone DG, Zimmerman RA. Embryology and congenital lesions of the midface. In: Som PM, Curtin HD, eds. Head and neck imaging. Vol 2. 4th ed. St Louis, Mo: Mosby, 2003;183:3–86.
  10. Bradley PJ. Nasal dermoids in children. Int J Pediatr Otorhinolaryngol 1981;3:63–70.[CrossRef][Medline]
  11. Lowe LH, Booth TN, Joglar JM, Rollins NK. Midface anomalies in children. RadioGraphics 2000;20:907–922.[Abstract/Free Full Text]
  12. Harley EH. Pediatric congenital nasal masses. Ear Nose Throat J 1991;70:28–32.[Medline]
  13. Barkovich AJ, Vandermarck P, Edwards MS, et al. Congenital nasal masses: CT and MR imaging features in 16 cases. AJNR Am J Neuroradiol 1991;12:105–116.[Abstract]
  14. Kaufman LM, Villablanca JP, Mafee MR. Diagnostic imaging of cystic lesions in the child’s orbit. Radiol Clin North Am 1998;36:1149–1163.[CrossRef][Medline]
  15. Grove AS. Giant dermoid cysts of the orbit. Ophthalmology 1979;86:1513–1520.[Medline]
  16. Benson MT, Dalen K, Mancuso AA, Kerr HH, Cacciarelli AA, Mafee MF. Congenital anomalies of the branchial apparatus: embryology and pathologic anatomy. RadioGraphics 1992;12:943–960.[Abstract]
  17. Linder B, Campos M, Schafer M. CT and MRI of orbital abnormalities in neurofibromatosis and selected craniofacial anomalies. Radiol Clin North Am 1987;25:787–802.[Medline]
  18. Jacquemin C, Bosley T, Liu D, Svedberg H, Buhaliqa A. Reassessment of sphenoid dysplasia associated with neurofibromatosis type 1. AJNR Am J Neuroradiol 2002;23:644–648.[Abstract/Free Full Text]
  19. Jacquemin C, Bosley T, Svedberg H. Orbit deformities in craniofacial neurofibromatosis type 1. AJNR Am J Neuroradiol 2003;24:1678–1682.[Abstract/Free Full Text]
  20. Zimmerman RA, Bilaniuk LT, Mezger RA, et al. Computed tomography of orbitofacial neurofibromatosis. Radiology 1983;146:113–116.[Free Full Text]
  21. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982;69:412–420.[Medline]
  22. Baker LL, Dillon WP, Hieshima GB, Dowd CF, Frieden IJ. Hemangiomas and vascular malformations of the head and neck: MR characterization. AJNR Am J Neuroradiol 1993;14:307–314.[Abstract]
  23. Meyer JS, Hoffer FA, Barnes PD, Mulliken JB. Biological classification of soft-tissue vascular anomalies: MR correlation. AJR Am J Roentgenol 1991;157:559–564.[Free Full Text]
  24. Mulliken J. Classification of vascular birthmarks. In: Mulliken J, ed. Vascular birthmarks, hemangiomas and malformations. Philadelphia, Pa: Saunders, 1988; 24–37.
  25. Siegel MJ, Glazer HS, St Amour TE, Rosenthal DD. Lymphangiomas in children: MR imaging. Radiology 1989;170:467–470.[Abstract/Free Full Text]
  26. Yuh WT, Buehner LS, Kao SC, Robinson RA, Dolan KD, Phillips JJ. Magnetic resonance imaging of pediatric head and neck cystic hygromas. Ann Otol Rhinol Laryngol 1991;100(9 pt 1):737–742.[Medline]
  27. Casselman JW, De Jonge I, Neyt L, De Clercq C, D’Hont G. MRI in craniofacial fibrous dysplasia. Neuroradiology 1993;35:234–237.[CrossRef][Medline]
  28. Yamaguchi T, Dorfman HD, Eisig S. Cherubism: clinicopathologic features. Skeletal Radiol 1999; 28:350–353.[CrossRef][Medline]
  29. Rabinov K, Weber A. Radiology of the salivary glands. Boston, Mass: Hall, 1985; 265–291.
  30. Cunningham MJ, Myers EN, Bluestone CD. Malignant tumors of the head and neck in children: a twenty-year review. Int J Pediatr Otorhinolaryngol 1987;13(3):279–292.[CrossRef][Medline]
  31. Vade A, Armstrong D. Orbital rhabdomyosarcoma in children. Radiol Clin North Am 1987;25: 701–714.[Medline]
  32. Mafee MF, Pai E, Philip B. Rhabdomyosarcoma of the orbit: evaluation with MR imaging and CT. Radiol Clin North Am 1998;36:1215–1227.[CrossRef][Medline]
  33. Hidayat AA, Mafee MF, Laver NV, Noujaim S. Langerhans’ cell histocytosis and juvenile xanthogranuloma of the orbit: clinicopathologic, CT, and MR imaging features. Radiol Clin North Am 1998;36:1229–1240.[CrossRef][Medline]
  34. Hermans R, De Foer B, Smet MH, et al. Eosinophilic granuloma of the head and neck: CT and MRI features in three cases. Pediatr Radiol 1994; 24:33–36.[CrossRef][Medline]



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N. D'Ambrosio, S. Soohoo, C. Warshall, A. Johnson, and S. Karimi
Craniofacial and Intracranial Manifestations of Langerhans Cell Histiocytosis: Report of Findings in 100 Patients
Am. J. Roentgenol., August 1, 2008; 191(2): 589 - 597.
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