Prenatal, Congenital, and Neonatal Abnormalities

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Chapter 14

Prenatal, Congenital, and Neonatal Abnormalities

Congenital lesions of the neck consist of a variety of entities, some of which become apparent at birth or shortly thereafter, whereas others present clinically later in life. This chapter will focus on congenital lesions that can be recognized in the fetus or the newborn. Currently, many congenital cervical lesions may be diagnosed prenatally, making it essential for pediatric radiologists to be familiar with general patterns of these lesions in fetal imaging.

Other congenital lesions that cause symptoms only when enlarged or infected will be discussed elsewhere in the relevant chapters.

Presence of mass lesions in the fetal neck may considerably influence other fetal organs and organ systems because of the complex anatomy of the neck and the proximity of the lesion to vascular, upper gastrointestinal, and, especially, airway structures.

Conditions that may result in tracheolaryngeal obstruction and, thus, could be life threatening include extrinsic causes such as cervical teratomas, venolymphatic malformations, and vascular rings, and intrinsic causes such as congenital high airway obstruction syndrome and upper airway hemangiomas. Giant fetal neck masses may grow to obstruct the esophagus, thereby leading to an accumulation of amniotic fluid and polyhydramnios and increasing the risk of preterm labor.

Accurate depiction and distinction of these conditions with imaging facilitate prenatal counseling and delivery planning. In addition, some congenital cervical lesions may be associated with other serious anomalies and may be the first manifestation of a systemic disease or syndrome, potentially requiring further investigation.

Fetal neck lesions occasionally present a diagnostic challenge. Giant fetal neck masses may resemble each other, sharing many imaging features including cystic and solid components, increased vascularity, and foci of mineralization. The exact origin of a midline cervical cyst may be difficult to establish. For accurate diagnosis, it may be necessary to utilize complementary imaging modalities.

Imaging Modalities

Imaging of the fetal neck is performed by ultrasonography and magnetic resonance imaging (MRI). Evaluation of the neonatal neck may be performed by ultrasonography, computed tomography (CT) with contrast, and MRI with and without contrast. Some indeterminate hypervascular lesions may rarely require evaluation with conventional angiography. Lateral radiography of the neck may still be used in emergent initial evaluation of upper airway pathology but is rarely of value in the workup of congenital lesions.

Ultrasonography

Ultrasonography is a noninvasive, real-time, high-resolution imaging modality that provides anatomic images supplemented by Doppler evaluation of blood flow. It is equally useful for primary obstetric imaging and for portable bedside evaluation of a neck mass in the restless child.

Prenatal ultrasonography includes routine evaluation of normal anatomic structures of the head, face, and neck, as well as upper airway patency and pattern of swallowing. Airway patency may be difficult to confirm with ultrasonography, hence ancillary signs of airway and upper gastrointestinal tract compromise, such as a small stomach or polyhydramnios, should be routinely searched for. Ultrasonography demonstrates morphologic characteristics of cervical pathology, specifically the cystic or solid nature of any lesion and the presence or absence of fat and calcifications.

Color Doppler provides valuable characterization of a lesion’s vascularity and blood supply, detects possible arteriovenous shunting, and depicts the major neck vessels. Three-dimensional reconstruction clearly depicts the relationship of cervical lesions with adjacent facial and skull base structures (e-Fig. 14-1). Potential shortcomings of ultrasonography involve cases with poor acoustic windows because of an anterior position of the placenta, maternal obesity or polyhydramnios, and abnormal fetal position with unusual flexion and extension of the fetal neck.

Ultrasonography imaging of congenital neck lesions in young children is performed with high-resolution (3 or 5, up to 12 megahertz [MHz]) transducers. The examination is fast and usually requires no sedation. Reliable distinction of the cystic or solid nature of the lesion may be sufficient for diagnosis in some instances; however, assessment of surrounding tissue invasion may be suboptimal.

Magnetic Resonance Imaging

MRI is a superb imaging modality for the evaluation of fetal or neonatal neck lesions and may help further clarify the lesion’s relationship with surrounding structures. Fetal MRI is considered safe to perform in the second and third trimesters for further assessment of a cervical mass detected by routine obstetric ultrasonography. Fetal MRI is approved by the U.S. Food and Drug Agency for magnet field strengths up to 3.0 Tesla.

Fetal imaging prior to 18 weeks of gestational age is typically of little value because of the unknown safety profile of exposure to magnetic fields during organogenesis, as well as the relatively poor image quality in a small fetus. For fast and effective performance of fetal MRI, familiarity and optimal use of imaging sequences is crucial.

Useful MRI sequences for fetal neck imaging include the following:

MRI sequences for imaging of neonatal neck lesions include the following:

Prenatal neck imaging sometimes may be more useful in the evaluation of lesion extension and, particularly, airway and upper gastrointestinal tract patency, rather than the establishment of a precise diagnosis. Knowledge of airway status may help facilitate prenatal counseling and management, including the decision to utilize the ex utero intrapartum treatment procedure. This procedure may be required for fetuses diagnosed with a giant neck mass to gain time to secure an airway while the neonate is still attached to the umbilical cord.

The postnatal appearance of prenatally diagnosed cervical lesions may be of additional diagnostic value, as certain lesions may have a predictable developmental pattern. For example, congenital hemangiomas may remain stable in size or become smaller, whereas teratomas are likely to increase in size; lymphatic malformations may develop blood-fluid levels caused by intralesional hemorrhage. For this reason, it is important to evaluate a cervical lesion throughout its phases of development.

Vascular Neck Lesions

The nomenclature of vascular anomalies had been a controversial topic until Mulliken and Glowacki proposed a classification that divides pediatric vascular lesions into two major categories: (1) vascular tumors and (2) vascular malformations. This classification, based on pathologic differences as well as the clinical and cellular behavior of vascular lesions, was widely accepted and adopted by the International Society for the Study of Vascular Anomalies in 1996.

Vascular tumors in young children are almost solely hemangiomas, which are true endothelial tumors with increased mitotic activity during the proliferative phase and eventual involution. Vascular malformations are congenital nonneoplastic lesions, which are further classified according to the type of abnormal vessel comprising the lesion. Vascular malformations, therefore, may consist of abnormal capillaries, veins, lymphatic vessels, or arteries, or of a combination of different types of vessels (i.e., arteriovenous malformation).

Additionally, vascular lesions are classified on the basis of hemodynamics as high-flow and low-flow types. Low-flow lesions consist of any combination of capillary, venous, and lymphatic components, whereas high-flow lesions contain arterial components. Vascular malformations grow in proportion to the patient’s growth but may exhibit rapid growth or expansion following infection, trauma, or hormonal changes such as during puberty or pregnancy. Vascular malformations do not involute spontaneously.

The current classification of vascular lesions serves to distinguish neoplastic from nonneoplastic entities, as they have different treatments and prognoses. However, this classification should not be perceived as a final arrangement. A better understanding of the molecular biology and genetics of vascular anomalies may lead to further refinement of the existing system.

Vascular Tumors

Infantile Hemangioma

Infantile hemangiomas are benign vascular neoplasms, with an increased incidence in premature children with low birth weight. These lesions have a predictable clinical course notable for early proliferation, which is often followed by spontaneous involution. Growth and involution continue with the following stages. The nascent phase may be observed in the first 2 to 4 weeks of life. A precursor lesion such as macula, multiple telangiectasias, or discoloration in a beard distribution may be seen at birth. The proliferative phase is remarkable for rapid growth of the tumor in the first year of life. At the proliferative stage, the hemangioma appears as a bulky compressible lesion of strawberry-red color and may have cutaneous as well as deep components.

On cross-sectional imaging, it appears as a lobulated mass with intense uniform enhancement, which usually demonstrates intralesional flow voids on MRI (Fig. 14-2, A). Proliferation may be biphasic. Careful assessment of upper airway status is important because the deep portions of a cervical hemangioma may enlarge sufficiently at this stage to impinge on the airway and cause obstruction. During the final involution phase, which may continue for up to 12 years, the rate of regression is variable. Involution is never complete, although the residual lesion may not be grossly visible; in the neck, it leaves persistent fibrofatty tissue. Infantile hemangiomas are positive for the glucose transporter 1 (GLUT-1) marker at all stages of lesion development.

Most infantile hemangiomas do not cause any morbidity or mortality but may create cosmetic inconvenience. Nonetheless, a hemangioma of the neck is considered an alarming lesion if it assumes a beard distribution (involvement of the lower face, anterior neck, and submandibular and parotid regions) because of an increased incidence of subglottic hemangioma, high risk of airway compromise, and known association with PHACES syndrome (Posterior fossa malformations, Hemangiomas, Arterial, Cardiac anomalies, Eye anomalies, Sternal cleft). The arteriopathy of PHACES syndrome commonly comprises a spectrum of congenital and progressive large arterial lesions ipsilateral to the cutaneous hemangioma. It entails careful searching (and monitoring) with imaging for potential vascular anomalies once a diagnosis of cervicofacial segmental hemangioma is established.

Upper airway hemangiomas (see Fig. 14-2, B and C) become symptomatic in the proliferative phase, causing biphasic stridor, respiratory distress, and potentially even life-threatening airway obstruction, which may require emergent intubation. These hemangiomas are often multifocal and occur above and below the vocal cords. Close monitoring with cross-sectional imaging may be indicated because laryngoscopy may not accurately depict the degree of invasion. MRI is preferred in the setting of intubation or tracheostomy.

In rare cases, cervicofacial infantile hemangioma may be associated with central nervous system hemangiomas in intracranial (see Fig. 14-2, D) or intraspinal locations. The reported cases of central nervous system hemangiomas indicate a specific pattern of distribution, with a predilection for the basal cisterns, ventricular system, and extradural spinal involvement.

In the past, infantile hemangiomas have been confused with other vascular neoplasms, particularly kaposiform hemangioendotheliomas (KHEs) and tufted angiomas, especially in the setting of consumptive coagulopathy, referred to as the Kasabach-Merrit phenomenon; it is now generally accepted that infantile hemangiomas are rarely, if ever, responsible for this phenomenon.

Congenital Hemangioma

Congenital hemangiomas are uncommon lesions that are fully developed at birth and do not go through the proliferative stage in postnatal life. These lesions may be diagnosed in utero, as early as at 12 weeks of gestational age. Two types of congenital hemangiomas are described: (1) rapidly involuting congenital hemangioma (RICH) and (2) noninvoluting lesions congenital hemangioma (NICH).

RICH has a predilection for scalp and neck locations. On prenatal imaging, it may appear as a large heterogeneous mass, emanating from the posterior neck (Fig. 14-3, A) with increased vascularity, best demonstrated on obstetric Doppler ultrasonography. Postnatal imaging features of RICH include large irregular flow voids and arterial aneurysms, direct arteriovenous shunts (seen on angiography), and calcifications. Their imaging appearance may occasionally resemble congenital infantile fibrosarcoma.

RICH may have a dramatic presentation at birth with high-output congestive heart failure, which may occur in the setting of a large hemangioma (see Fig. 14-3, B). Rapid involution is usually completed by 14 months of age. Usually, RICH is managed conservatively. Presence of complications may prompt surgical removal.

NICH, on the contrary, never involutes and may even grow with the child. It usually has an imaging appearance similar to infantile hemangioma, being more homogeneous with uniform parenchymal enhancement.

Most hemangiomas resolve spontaneously, however, approximately 10% to 20% require treatment, which includes pharmacologic, surgical, or laser intervention. Treatment is indicated when functional or cosmetic complications that are worse than the side effects of intervention arise. Lesion size and location, patient age, and phase of the lesion (proliferative, involuting, and mature) also influence the method and timing of intervention.

Kaposiform Hemangioendothelioma

KHE is a rare, aggressive vascular tumor of infancy of intermediate malignancy and differs from hemangioma by histopathology and clinical appearance. The head and neck are uncommon locations. KHE presents as an ill-defined vascular mass with stranding in the subcutaneous fat, intralesional calcifications, and prominent feeding and draining vessels (e-Fig. 14-4). It tends to cause bony destruction and may be associated with the Kasabach-Merritt phenomenon. It should be noted that thrombocytopenia occurs with the rarer KHE and not with the more commonly seen infantile hemangioma.

Venolymphatic Malformations Spectrum

Cervical venolymphatic malformations, similar to venolymphatic malformations located elsewhere in the body, represent a spectrum of entities consisting of a combination of anomalous lymphatic and venous channels. When the lymphatic vascular component is prevalent, lesions are called lymphatic malformations, whereas those with dominant venous components are called venous malformations.

Lymphatic malformations of the neck may be diagnosed prenatally or may present clinically at birth or shortly thereafter. The most pure lymphatic malformation, which seemingly consists of lymphatic channels only, is represented by a fetal posterior neck cystic hygroma. A focal nuchal translucency, perceived as a hypoechoic subcutaneous region in the posterior neck, may be identified on obstetric ultrasonography at 11 to 14 weeks’ gestational age; it is considered a normal finding if it measures below a defined threshold, and eventually involutes by term.

A pathologic cystic hygroma develops in cases of failure of appropriate connections between the lymphatic jugular sac and jugular vein. Such a lesion becomes apparent as nuchal thickening at 18 to 20 weeks’ gestational age. Approximately 60% of nuchal cystic hygromas result from chromosome abnormalities and are associated with aneuploidy syndromes such as Turner syndrome, trisomy 18, trisomy 21, and multiple other syndromes and conditions, including congenital diaphragmatic hernia (Fryns syndrome). Accumulation of lymph may cause lymphedema and nonimmune hydrops, a condition with a high mortality rate.

Ultrasonography demonstrates translucent nuchal thickening, with no identifiable arterial or venous flow by Doppler. MRI reveals focal edema of the posterior fetal neck (e-Fig. 14-5) and, in severe cases, depicts associated lymphedema, pleural effusions, ascites, and anasarca.

Lymphatic or venolymphatic malformations of the fetal or neonatal neck represent congenital lesions that may be apparent at birth or may “silently” grow with a child in the first few years before suddenly becoming symptomatic following spontaneous hemorrhage or infection. They usually present as large, transspatial, multicystic masses with intervening septations and fluid–fluid levels (Fig. 14-6, A and B). Ultrasonography demonstrates septated hypoechoic cystic lesions (see Fig. 14-6, C) without internal vascularity, although some vascular flow may be seen within the intralesional septae.

Lymphatic malformations may have a very complex appearance because of their multi-compartmental nature and internal hemorrhages. Relatively thick intralesional septations or foci of chronic hemorrhage may show enhancement and mimic solid portions of a cystic teratoma. Absence of calcifications and a relatively mild mass effect on surrounding structures despite the large size of the lesion lead to the correct diagnosis. Absence or presence of calcifications is easier to establish on fetal ultrasonography; blood products and calcifications may be occasionally confused on fetal MRI.

Systemic lymphatic malformations include rare conditions known as lymphangiomatosis and Gorham disease (vanishing bone disease). These entities are poorly understood and likely represent a spectrum of congenital disorders of lymphatic development. They manifest by numerous foci of vascular and lymphatic proliferation, involving multiple organs, including bones and lungs (Fig. 14-7 and e-Fig. 14-8), and often cause serious consequences.

The current approach to treatment of venolymphatic malformations is navigation-assisted interventional sclerotherapy with doxycycline or other sclerosants, which provides excellent results for large macrocystic head and neck lesions. Therapy for microcystic and mixed lesions continues to be a challenge.

Venous Vascular Malformations

Venous malformations represent slow-growing lesions that consist of dysplastic venous channels that may have a minor lymphatic component. They are present at birth but usually manifest clinically later in life.

On imaging, they appear as well-defined, ovoid, heterogeneous lesions with strong enhancement and occasional intralesional phleboliths (Fig. 14-9). A calcified phlebolith may occasionally simulate a flow void on MRI, leading to an erroneous identification of the lesion as a hemangioma. Many lesions may be successfully treated with sclerotherapy, although larger and infiltrative lesions may be more challenging to treat.

Teratoma

Even though teratoma is one of the most common tumors of the fetal neck, neck teratomas account for only 5% to 10% of all fetal and neonatal teratomas. Most cervical teratomas are benign, yet it is the most common mass in the fetal neck that has potential to cause fetal demise from airway obstruction. On rare occasions, large vascular teratomas may result in nonimmune fetal hydrops and subsequent fetal death. Teratomas usually originate in the anterolateral neck and may involve the face and cranial base, sometimes extending to the thorax. Interval lesion enlargement in late gestation often causes hyperextension of the neck, which is characteristic of cervical teratoma. The lesion may be intimately associated with the thyroid gland and, in addition to tracheal compression, may cause esophageal compression.

Teratomas are composed of all three germ layers with tissue differentiation that infrequently results in the presence of identifiable organs within these lesions. For instance, an oropharyngeal teratoma (epignathus) often contains identifiable fetal parts; this lesion is usually more aggressive and may grow more rapidly during gestation.

Teratomas are subdivided into mature, immature, and malignant types, each of which differs by histology and hence imaging appearance. Benign mature lesions are mostly cystic, whereas immature lesions tend to be more solid. Malignant teratoma types are uncommonly found in the neck and are less aggressive compared with other locations. Most teratomas demonstrate a combination of cystic and solid components (Fig. 14-10, A to C). Intratumoral foci of hemorrhage and necrosis are suggestive of malignancy. Intralesional fat and calcifications are nearly pathognomonic findings for teratoma but may not always be discernible on fetal MRI and are better seen on ultrasonography. Cervical teratoma and congenital hemangioma share many MRI and ultrasonography features, including interval growth in utero, and establishing the correct diagnosis may be quite challenging. Both imaging modalities are often necessary for optimal assessment.

Postnatal imaging of teratomas may include CT, which is helpful for demonstration of osseous involvement. MRI, with or without contrast, is superb for precise depiction of lesion morphology and extension (Fig. 14-11, A). Magnetic resonance angiography may provide crucial information about the vascular supply for surgical planning (see Fig. 14-11, B). Surgical treatment of teratomas may be curative, although the mortality rate remains high. Persistent disfiguration of facial structure, voice issues, and hypothyroidism are among the common complications.

Cervical Cystic Lesions

A variety of unilocular cystic neck lesions may be diagnosed on prenatal imaging or may present in neonates. These lesions are uncommon; they originate from different embryonic structures, and their precise diagnosis may be challenging, especially in fetuses. Perinatal cystic neck lesions include dermoid and epidermoid cysts, laryngoceles, foregut duplication cysts, and thymic cysts.

Dermoid and Epidermoid Cysts

Dermoid cysts are congenital benign lesions that contain ectodermal elements, including hair follicles and sweat and sebaceous glands. Cervical dermoids are most commonly seen at floor of the mouth, in the submandibular or sublingual spaces, or at the suprasternal notch. They often demonstrate fatty content with imaging.

Epidermoid cysts are rare congenital unilocular lesions, which may closely resemble a thyroglossal duct cyst; however, a characteristic pattern of restricted diffusion typical for epidermoids helps distinguish these entities. Epidermoid cysts appear earlier, compared with dermoid cysts, with most lesions being evident during infancy (Fig. 14-12, A and B) or diagnosed prenatally (see Fig. 14-12, C). Dermoids and epidermoids have different histologies, but it is not always possible to differentiate them on imaging. It is more important to define the lesion position in relation to the oral floor muscles, as it may guide a surgical approach.

Laryngocele

Most laryngoceles are acquired lesions, seen in middle-aged persons who are involved in activities that cause increased supraglottic pressure. Congenital laryngoceles are rare and likely reflect congenital enlargement of the laryngeal saccule. The three types of laryngoceles are internal, external, and combined laryngoceles. The internal laryngocele is found entirely within the larynx, whereas the external or mixed types protrude through the thyrohyoid membrane and may extend into the lateral neck.

Clinically, laryngoceles may manifest as fluctuating soft tissue masses causing airway obstruction in young infants, or the masses may be diagnosed prenatally (e-Fig. 14-13). Evaluation of a laryngocele with high-resolution cross-sectional imaging depicts the anatomic boundaries of the lesion and the contents of the cyst, which may be filled with air, fluid, or proteinaceous material.

Foregut Duplication Cyst

Foregut duplication cysts in the neck may be incidental findings, may present in the neonate with frank respiratory distress secondary to obstruction, or may be diagnosed prenatally as unilocular cystic masses in the anterior compartment of the fetal neck and mediastinum (e-Fig. 14-14). The cyst may or may not communicate with the esophagus; however, thorough search for this communication should be performed. Identification of abnormal canalization of the gastrointestinal tract confirms the diagnosis of foregut duplication cyst.

Preoperative imaging is recommended to differentiate these lesions from other congenital head and neck masses. Surgical excision with complete removal of the mucosal lining is curative.

Cervical Soft Tissue Masses

Ectopic Thymus

Ectopic thymus is usually discovered incidentally on neck imaging performed for unrelated indications. It may be seen anywhere along the course of the primordial thymopharyngeal duct, from the mandibular angle to the thoracic inlet. It is located most often along the carotid sheath but may extend to the midline (Fig. 14-16, A) or may be bilateral. It may be recognized by its imaging characteristics, identical to orthotopic thymus (see Fig. 14-16, B). Ectopic thymus usually resolves with involution of the intrathoracic orthotopic thymus.

Fetal or Neonatal Goiter

Goiter is a rare cause of fetal neck mass. It may occur in the setting of maternal thyroid disorders such as Graves disease or Hashimoto thyroiditis, or as a manifestation of primary fetal hypothyroidism or hyperthyroidism. Fetal thyroid function may be assessed by ultrasound-guided umbilical cord blood sampling (cordocentesis). The fetal thyroid may be markedly enlarged, causing neck hyperextension, airway obstruction, or compression of the esophagus.

Fetal goiter may be diagnosed on ultrasonography as a bilobed echogenic mass in the anterior neck, with increased vascularity; fetal MRI demonstrates a midline symmetric cervical mass with high signal on T1-weighted imaging (Fig. 14-17). Treatment of fetal goiter includes intra-amniotic thyroxin injection, the main goal being reduction in the size of the goiter and prevention of tracheal obstruction. It may be associated with congenital deafness in the setting of Pendred syndrome (e-Fig. 14-18).

Infantile Fibromatoses

Infantile fibromatosis represents a spectrum of rare congenital disorder that involves skeletal and smooth muscles in very young children. It may manifest as a solitary form or as a multicentric form with visceral involvement. Aggressive infantile fibromatosis occurs in the first 2 years of life and may present as a nodular soft tissue mass in the head and neck, with an imaging appearance mimicking infantile fibrosarcoma or hemangioma. A desmoid type of fibromatosis may present as a nodular tumor, which often grows along the nerve sheath or vascular bundle and has a tendency to frequent hemorrhage or necrosis in the central portion, producing a target appearance on imaging (Fig. 14-19). The prognosis is good for solitary neck lesion. These lesions usually stop growing or spontaneously regress.

Fibromatosis colli is a benign condition that involves the sternocleidomastoid muscle only. It usually affects neonates and manifests as a hard unilateral soft tissue mass associated with ipsilateral torticollis caused by the muscular contraction and rotation of the chin to the opposite side. Imaging, with ultrasonography or MRI, may be performed if the clinical presentation is unusual. Both modalities reveal diffuse or focal enlargement of sternocleidomastoid muscle (Fig. 14-20) and no discrete mass or lymphadenopathy. Congenital torticollis usually spontaneously resolves in a few months. A child with cervical lymphadenitis and retropharyngeal abscess may present with a postinflammatory torticollis known as Grisel syndrome; this condition is caused by increased ligamentous laxity.

Neonatal Malignancy

Neuroblastoma

Neuroblastoma is a common malignant tumor of childhood. Less than 5% occur within the neck as a primary site, arising in the sympathetic ganglia. Cervical location of neuroblastoma is more common in young infants. This tumor has known association with Horner syndrome.

The imaging of cervical neuroblastoma may be performed with CT or MRI (Fig. 14-21). Both modalities may depict tumor extension, presence of mineralization, and bony or spinal canal invasion. Restricted diffusion pattern on diffusion-weighted MRI confirms the hypercellular, malignant nature of the tumor. Intratumoral dystrophic calcifications are not uncommon and are observed in 50% of cervical neuroblastomas.

Congenital Infantile Fibrosarcoma

Congenital infantile fibrosarcoma, a rare tumor of infancy, has a markedly different clinical course and a more favorable prognosis compared with adult fibrosarcoma. It may present at birth or soon after or may be diagnosed in utero. Infantile fibrosarcoma has unique cytogenetic findings, which help distinguish this tumor from other infantile tumors such as embryonal rhabdomyosarcoma or from infantile fibromatosis. The tumor appears as a large solid soft tissue mass of the neck (e-Fig. 14-22), which may be rather homogeneous or have central necrosis and hemorrhage.

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