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Clinical radiology quiz
Quix Am J Otolaryngol 10:291-293,
1989
Clinical Radiology
Quiz
PETER M. SOM, EDITOR
A 47-year-old man presented with a painless right parotid fullness of several months’ duration. He was otherwise in good health and provided no other significant medical history. Physical examination revealed a solitary, firm, non-
tender right parotid mass. A post-contrast computed tomography (CT) scan of the neck was performed. Based on these CT scans and the above information, what is the most likely diagnosis?
Figure 1. Axial contrast-enhanced CT scans at the level of the nasopharynx (A), at the level of the parotid glands (B), and aIt the lev ,el of the hyoid bone (C). (Panels B and C appear on following page.)
291
CLINICAL RADIOLOGY
DISCUSSION
American Journal of Otolaryngology 292
A diagnosis can be achieved in this case based on the three representative CT scans, as follows: In Fig lA, there is a large, bulky mass filling the nasopharynx. The retropharyngeal soft tissues and the fat planes of the parapharyngeal space are normal. The mass is evidently noninvasive, and in a patient of this age, a lymphoma might be a good diagnosis. However, hyperplastic adenoidal tissue, both normal and abnormal, can also be seen in patients of this age. However, if this was normal adenoidal tissue it would be extraordinarily large: when normal adenoids are seen in patients in the third through fifth decades of life, the lymph tissue is usually either very small or of moderate size. Such a degree of hyperplasia would be very uncommon. Logically, one should suspect that this patient has either hyperplastic lymph tissue with some other underlying pathologic condition or a lymphoma. Figure 1B reveals multiple, bilateral parotid cysts and some enlarged lymph nodes in the upper right posterior triangle of the neck, extending just to the parotid gland. The most likely cause of multiple unilateral or bilateral parotid cystic lesions is War-thin’s tumors. Although these tumors may be solid, they are the most common parotid neoplasms to undergo cystic change, and there is usually at least one portion of the wall of a cystic Warthin’s tumor that has an identifiable
QUIZ
tumor nodule. Multiple congenital cysts have been reported, although they are rare. However, neither these congenital cysts nor War-thin’s tumors would explain the enlarged adenoids or cervical lymph nodes. The differential diagnosis of multiple parotid masses also includes lymphoma, granulomatous disease, and metastases. Lymphoma involving the parotid glands, whether as a rare primary parotid lymphoma or as the more common secondary involvement from a generalized lymphoma, has not been reported to undergo cystic degeneration. Such lymphomas usually appear on imaging as multiple, solid parotid masses. Similarly, granulomatous disease does not commonly become cystic in appearance, and metastases are unlikely to cause a nasopharyngeal mass and cystic parotid masses without either an appropriate history or some signs or symptoms not found in this patient. Figure 1C reveals multiple enlarged lymph nodes in the posterior triangles of the neck, the internal jugular chains, the submandibular chains, and the submental group. These nodes are not necrotic and are sharply delineated. The most likely diagnosis would be hyperplastic adenopathy, lymphoma, or metastases from a head and neck primary. If the nasopharyngeal mass was a carcinoma, it would almost certainly be invasive and have extended beyond the pharyngobasilar fascia to infiltrate the retropharyngeal
CLINICAL RADIOLOGY QUIZ
and parapharyngeal spaces. Also, it is likely that at least some of the lymph nodes would be necrotic, since this is common with squamous cell carcinoma. Lymphoma could cause similar lymph nodes, but not the cystic parotid masses. Hyperplastic nodes from a common infection are unlikely since these nodes were non-tender and painless, and there was no recent history of infection. However, hyperplastic nodes can be seen in patients who are (HIV] human immunodeficiency virus-positive and otherwise asymptomatic. In fact, the constellation of multiple parotid cysts, hyperplastic lymph nodes, and hyperplastic adenoidal tissue is pathognomonic for an HIVpositive patient. These patients need not have AIDS or AIDSrelated complex, and usually present with a painless parotid mass. It is on imaging that the cystic, multiple, and often bilateral nature of the disease is seen in conjunction with hyperplastic cervical nodes and, possibly, enlarged adenoids. The parotid cysts are lymphoepithelial cysts that either develop as an obstructive cyst from the
interstitial lymphocystic infiltration of the gland or as cysts within parotid lymph nodes in a fashion similar to that suggested for Warthin’s tumors. When the radiologist has made this diagnosis, the clinician should be alerted so that proper patient handling can be ensured. Even if the results of a blood test for HIV are negative, these imaging findings are definitive-in two clinical series, such patients eventually did test HIVpositive. SUGGESTED READING Shugar JMA, Som PM, Jacobson AL, et al: Multicentric parotid cysts and cervical adenopathy in AIDS patients. A newly recognized entity: CT and MR manifestations. Laryngoscope 1988; 98:772-775 Holliday RA, Cohen WA, Schinella RA, et al: Benign lymphoepithelial parotid cysts and hyperplastic cervical adenopathy in AIDS-risk patients: A new CT appearance. Radiology 1988; 168:439-441 Ryan JR, Iaochim HL, Marmer J, et al: Acquired immune deficiency syndrome related lymphadenopathies presenting in the salivary gland lymph nodes. Arch Otolaryngol 1985; 111:554-556
Volume
10
Number
4
July 1989 293
1989
Clinical Radiology
Quiz
PETER M. SOM, EDITOR
A 47-year-old man presented with a painless right parotid fullness of several months’ duration. He was otherwise in good health and provided no other significant medical history. Physical examination revealed a solitary, firm, non-
tender right parotid mass. A post-contrast computed tomography (CT) scan of the neck was performed. Based on these CT scans and the above information, what is the most likely diagnosis?
Figure 1. Axial contrast-enhanced CT scans at the level of the nasopharynx (A), at the level of the parotid glands (B), and aIt the lev ,el of the hyoid bone (C). (Panels B and C appear on following page.)
291
CLINICAL RADIOLOGY
DISCUSSION
American Journal of Otolaryngology 292
A diagnosis can be achieved in this case based on the three representative CT scans, as follows: In Fig lA, there is a large, bulky mass filling the nasopharynx. The retropharyngeal soft tissues and the fat planes of the parapharyngeal space are normal. The mass is evidently noninvasive, and in a patient of this age, a lymphoma might be a good diagnosis. However, hyperplastic adenoidal tissue, both normal and abnormal, can also be seen in patients of this age. However, if this was normal adenoidal tissue it would be extraordinarily large: when normal adenoids are seen in patients in the third through fifth decades of life, the lymph tissue is usually either very small or of moderate size. Such a degree of hyperplasia would be very uncommon. Logically, one should suspect that this patient has either hyperplastic lymph tissue with some other underlying pathologic condition or a lymphoma. Figure 1B reveals multiple, bilateral parotid cysts and some enlarged lymph nodes in the upper right posterior triangle of the neck, extending just to the parotid gland. The most likely cause of multiple unilateral or bilateral parotid cystic lesions is War-thin’s tumors. Although these tumors may be solid, they are the most common parotid neoplasms to undergo cystic change, and there is usually at least one portion of the wall of a cystic Warthin’s tumor that has an identifiable
QUIZ
tumor nodule. Multiple congenital cysts have been reported, although they are rare. However, neither these congenital cysts nor War-thin’s tumors would explain the enlarged adenoids or cervical lymph nodes. The differential diagnosis of multiple parotid masses also includes lymphoma, granulomatous disease, and metastases. Lymphoma involving the parotid glands, whether as a rare primary parotid lymphoma or as the more common secondary involvement from a generalized lymphoma, has not been reported to undergo cystic degeneration. Such lymphomas usually appear on imaging as multiple, solid parotid masses. Similarly, granulomatous disease does not commonly become cystic in appearance, and metastases are unlikely to cause a nasopharyngeal mass and cystic parotid masses without either an appropriate history or some signs or symptoms not found in this patient. Figure 1C reveals multiple enlarged lymph nodes in the posterior triangles of the neck, the internal jugular chains, the submandibular chains, and the submental group. These nodes are not necrotic and are sharply delineated. The most likely diagnosis would be hyperplastic adenopathy, lymphoma, or metastases from a head and neck primary. If the nasopharyngeal mass was a carcinoma, it would almost certainly be invasive and have extended beyond the pharyngobasilar fascia to infiltrate the retropharyngeal
CLINICAL RADIOLOGY QUIZ
and parapharyngeal spaces. Also, it is likely that at least some of the lymph nodes would be necrotic, since this is common with squamous cell carcinoma. Lymphoma could cause similar lymph nodes, but not the cystic parotid masses. Hyperplastic nodes from a common infection are unlikely since these nodes were non-tender and painless, and there was no recent history of infection. However, hyperplastic nodes can be seen in patients who are (HIV] human immunodeficiency virus-positive and otherwise asymptomatic. In fact, the constellation of multiple parotid cysts, hyperplastic lymph nodes, and hyperplastic adenoidal tissue is pathognomonic for an HIVpositive patient. These patients need not have AIDS or AIDSrelated complex, and usually present with a painless parotid mass. It is on imaging that the cystic, multiple, and often bilateral nature of the disease is seen in conjunction with hyperplastic cervical nodes and, possibly, enlarged adenoids. The parotid cysts are lymphoepithelial cysts that either develop as an obstructive cyst from the
interstitial lymphocystic infiltration of the gland or as cysts within parotid lymph nodes in a fashion similar to that suggested for Warthin’s tumors. When the radiologist has made this diagnosis, the clinician should be alerted so that proper patient handling can be ensured. Even if the results of a blood test for HIV are negative, these imaging findings are definitive-in two clinical series, such patients eventually did test HIVpositive. SUGGESTED READING Shugar JMA, Som PM, Jacobson AL, et al: Multicentric parotid cysts and cervical adenopathy in AIDS patients. A newly recognized entity: CT and MR manifestations. Laryngoscope 1988; 98:772-775 Holliday RA, Cohen WA, Schinella RA, et al: Benign lymphoepithelial parotid cysts and hyperplastic cervical adenopathy in AIDS-risk patients: A new CT appearance. Radiology 1988; 168:439-441 Ryan JR, Iaochim HL, Marmer J, et al: Acquired immune deficiency syndrome related lymphadenopathies presenting in the salivary gland lymph nodes. Arch Otolaryngol 1985; 111:554-556
Volume
10
Number
4
July 1989 293