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Congenital Overview
Summary Thoughts: Congenital Lesions of Head and Neck
Neck masses are a common indication for imaging the pediatric H&N. The majority of neck masses in children are either congenital or inflammatory in origin, with only 5% of childhood neoplasms occurring in the H&N. The most common extrathyroid, nonneoplastic solid neck masses in children are related to inflammatory disease and do not require imaging unless there is concern for deep neck infection or abscess. The most common cystic masses in the pediatric H&N are congenital lesions secondary to abnormal embryogenesis involving the thyroglossal duct (TGD), branchial apparatus, or vascular endothelium. Thyroglossal duct cysts (TGDCs) account for 70-90% of all congenital neck abnormalities in children. The most common branchial apparatus lesion is the 2nd branchial cleft cyst (BCC), and lymphatic malformations are the most common vascular malformations in the H&N.
Whenever a cystic neck mass in a child is encountered on an imaging study, a very reasonable differential diagnosis can be made based on location (midline, paramidline, or lateral, as well as location relative to carotid sheath), imaging appearance (simple cyst, complicated cyst, enhancement, ± solid component), and clinical presentation (present since birth or acute onset, ± clinical evidence of infection).
Terminology
TGDC or tract is an anomalous remnant of the TGD, which, during normal development, completely involutes. Cysts are located anywhere from the midline posterior tongue at the foramen cecum to the thyroid bed in the lower neck.
Branchial apparatus anomalies may be in the form of cysts, sinus tracts, or fistulae. Cysts are fluid-filled with well-defined walls secondary to the failure of obliteration of a branchial cleft or pouch. Sinus tracts are congenital tracts with 1 opening , either externally to the skin surface (or external auditory canal) or internally to the pharynx or tonsillar fossa (2nd branchial cleft), superolateral hypopharynx (3rd branchial cleft), or pyriform sinus (4th or 3rd branchial pouch). Fistulae are congenital tracts with 2 openings , 1 internally and 1 externally, secondary to failure of obliteration of the branchial cleft and pouch.
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