Clinical Radiology (2008) 63, 613e622

REVIEW

Imaging of cystic or cyst-like neck masses

K.T. Wong, Y.Y.P. Lee, A.D. King, A.T. Ahuja*
Department of Diagnostic Radiology & Organ Imaging, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
Received 18 October 2007; received in revised form 10 December 2007; accepted 14 December 2007

Cystic or cyst-like neck masses form a unique category within head and neck radiology with unique differential diagnoses. The precise anatomical location and imaging appearances are important for accurate diagnosis and formulating the differential diagnoses of cystic lesions in the neck. In vast majority of cases ultrasound, sometimes supplemented by ne-needle aspiration cytology (FNAC), is adequate for pre-treatment assessment. For large, deep-seated lesions assessment using magnetic resonance imaging (MRI) or computed tomography (CT) often provides useful supplementary information. Radiologists should be aware of imaging ndings of common cystic neck masses to help in their appropriate management. 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction
A palpable neck mass is a commonly encountered clinical problem. Meticulous clinical history and physical examination may suggest the clinical diagnosis. Imaging is increasingly performed to conrm the clinical diagnosis and assess the anatomical extent of involvement before any form of treatment. Apart from its location, the distinction between solid and cystic or cyst-like neck masses helps in the denitive diagnosis or to narrow the differential diagnoses.1 Cystic masses of the neck include a wide range of congenital and acquired lesions. The vast majority of cystic lesions in infants and children are congenital or developmental in origin, whereas inammatory and neoplastic diseases constitute the majority of cystic or cyst-like neck masses in adults. Although there are overlapping features, differentiation between the lesions can usually be made based

* Guarantor and correspondent: A.T. Ahuja, Department of Diagnostic Radiology & Organ Imaging, Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin N.T., Hong Kong. Tel.: 852 2632 1180; fax: 852 2648 7269. E-mail address: aniltahuja@cuhk.edu.hk (A.T. Ahuja).

on specic imaging ndings and relevant clinical information. High-resolution ultrasound is an ideal initial imaging investigation for neck tumours.2 It is readily available, relatively inexpensive, and does not involve ionizing radiation. Modern ultrasound machines equipped with high-resolution transducers provide excellent spatial and contrast resolution. Development of three-dimensional (3D) technology, extended eld-of-view or panoramic imaging, and colour and power Doppler applications have led to great improvements in diagnostic utility and accuracy of ultrasound.3 Ultrasound also has the unique advantage over other imaging techniques in providing reliable, real-time guidance for ne-needle aspiration cytology (FNAC) or core biopsy. Cross-sectional imaging techniques, such as magnetic resonance imaging (MRI) and computed tomography (CT), serve a supplementary role in work-up of cystic neck masses. The multiplanar capability of MRI and multidetector CT allows precise preoperative anatomical localization, particularly for more deep-seated and locally extensive lesions and T2-weighted MRI particularly helps to distinguish cystic from solid components.

0009-9260/$ - see front matter 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2007.12.007

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Site-specic differential diagnoses

The differential diagnoses of a cystic neck mass depend on the patients age and anatomical location of the lesion. Site-specic differential diagnoses of common cystic neck masses are summarized in Table 1.

Submental region
Epidermoid/dermoid cyst
A dermoid cyst is the most common of the teratomatous lesions in the head and neck region, approximately 7% occur of all dermoids occurring in this region.4 Histologically it contains two germ cell layers and skin appendages (e.g., hair follicles and sebaceous glands). An epidermoid cyst is less common in the neck than a dermoid cyst and is comprised solely of ectoderm. Dermoid/epidermoid cysts are frequently midline in location, typically arising either in the oor of mouth deep to the mylohyoid muscles or in the suprasternal notch. They may also occur in the
Table 1 location Common cystic neck masses based on anatomical Dermoid/epidermoid Ranula Thyroglossal duct cyst Acute suppurative thyroiditis Colloid and haemorrhagic thyroid cystic nodule Thymic cyst Second branchial cleft cyst Abscess Diving ranula Cystic metastatic lymph node Extraglandular mass - First branchial cleft cyst Intraglandular mass - Warthins tumour - Acquired cysts of parotid gland - Rare vascular lesions (pseudoaneurysm, arteriovenous stula/ malformation, venous vascular malformation) Cystic metastatic lymph node Venous vascular malformation Second branchial cleft cyst Abscess Distended internal jugular vein Lymphangioma Venous vascular malformation Cystic metastatic lymph node Tuberculous lymphadenitis

orbit, nasal, and oral cavities. The sebaceous secretions result in slow enlargement of these lesions. On ultrasound, the cyst is usually well-dened and anechoic with posterior acoustic enhancement in a midline position of the neck.2 Due to the presence of cellular material within the cyst, it may exhibit a pseudosolid appearance on ultrasound with uniform homogeneous internal echoes. Dermoid cysts may have mixed internal echoes because of its fat content and may show the presence of osseo-dental structures within, seen as echogenic foci with dense posterior acoustic shadowing. On CT or MRI, globules of fat oating within the lesion may produce a characteristic sack of marbles appearance, and fat and/or uid levels may be present (Fig. 1). Both CT and MRI clearly dene their anatomical location, extent, and internal appearance.5

Ranula
A ranula is a mucous retention cyst resulting from obstruction of the sublingual gland or its duct, or rarely the minor salivary glands in the sublingual space.6,7 There are two forms: (1) simple ranula, which is the most common form and invariably involves the sublingual gland. It is a true cyst with an epithelial lining. Anatomically it is conned within the oor of mouth deep to the level of mylohyoid muscle. (2) Diving ranula, which forms from enlargement of a simple ranula with subsequent

Submental region Midline/thyroid region

Submandibular region

Parotid region

Along cervical chain

Posterior triangle

Figure 1 Axial, fat-suppressed, T2-weighted MRI image shows the characteristic appearances of a midline dermoid cyst in the oor of mouth with a sack of marbles appearance (arrow) due to presence of fat globules (arrowheads) within the dermoid cyst.

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rupture that extends posteriorly around the posterior free margin of mylohyoid muscle, through its bres or defect of the mylohyoid muscle (i.e., boutonniere anomaly, which is present in 77% of normal individuals undergoing CT8) into the submandibular space. Therefore, anatomically it extends supercially to the level of mylohyoid muscle. It is a pseudocyst and is not lined by epithelium. On ultrasound, a ranula appears as a unilocular, well-dened, cystic lesion in the submental region related to the sublingual gland (Fig. 2). It may contain ne internal echoes, usually due to presence of debris from previous episodes of inammation. For a diving ranula, the bulk of the cystic collection is in the submandibular region, but a small beak may be seen within the sublingual space.2 On CT, a simple ranula usually appears as an ovoid-shaped cyst with an homogeneous central attenuation region of 10e20 HU, which lies lateral to the genioglossal muscles and deep to the mylohyoid muscle. A diving ranula often inltrates adjacent tissue planes, extending inferiorly and dorsally to the submandibular space. On MRI, a ranula usually shows low signal intensity on the T1weighted sequence and high signal on T2-weighted sequence. Occasionally when the protein content of the cystic uid is high, the lesion will appear hyperintense on the T1-weighted sequence.9

Midline/thyroid region
Thyroglossal duct cyst
In the third to fourth week of fetal development the paired thyroid primordia descend into the neck along the thyroglossal duct that runs from the foramen caecum at the base of the tongue to the lower anterior neck, passing the hyoid bone. The duct normally involutes by the eighth week.10 Persistence of the duct or a portion of the duct can lead to congenital anomalies, such as ectopic thyroid tissue or thyroglossal duct cysts (TDC). The majority of TDCs are infrahyoid (25e65%), 15e50% occur at the level of the hyoid, and 20e25% are suprahyoid in location.11 Patients usually present with a painless midline mass and there is often a history of previous incision and drainage at the site.12 About 50% present before the age of 10 years, the second group of patients presenting in young adulthood. On ultrasound, TDCs may appear (1) frankly cystic with homogeneous anechoic internal appearance and posterior acoustic enhancement; (2) hypoechoic echopattern with internal debris; (3) heterogeneous echopattern, probably due to repeated infections or haemorrhage; or (4) uniformly echogenic pseudosolid appearance (Fig. 3) due to the proteinaceous content of the cyst secreted by the epithelial lining.13,14

Figure 2 Transverse grey-scale ultrasound image shows a well-dened, lobulate cystic lesion (arrows) in the left submental region deep to the mylohyoid muscle (arrowheads) and closely related to the left sublingual gland (not shown) compatible with a ranula.

Figure 3 Longitudinal grey-scale ultrasound of anterior neck in the midline shows an infrahyoid thyroglossal duct cyst (arrow) with a pseudosolid appearance. Note the posterior enhancement. Arrowhead marks the hyoid bone.

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On MRI, TDCs are invariably hyperintense on T2-weighted sequences. The signal intensity on T1weighted images is highly variable due to difference in cystic content, with T1-hyperintensity seen in lesions with high proteinaceous cystic content.15 On preoperative imaging work-up of a patient with thyroglossal duct cyst, the following aspects need to be considered16: (1) thyroid carcinoma can develop in a TDC, with an incidence of 1% in adults: 95% papillary adenocarcinoma, 5% squamous cell carcinoma.17,18 Therefore, any solid component within a cyst requires FNAC if the cyst is not going to be excised. (2) Normal thyroid tissue has to be identied by ultrasound in the anterior neck before surgery to prevent postoperative hypothyroidism. (3) The relationship of the TDC with the hyoid bone must be determined as it helps the surgeon to completely excise the lesion so reducing the chance of a postoperative recurrence.

the presence of the abscess and the stula tract from the piriform fossa.20,21

Colloid and haemorrhagic thyroid cystic nodule

True epithelial thyroid cysts are rare.22 Most cystic thyroid lesions are due to haemorrhage or degeneration within a hyperplastic nodule, which is usually part of a multinodular goitre. On ultrasound, these appear as well-dened, heterogeneous nodules with a cystic component and internal septa. The comet tail sign, suggesting the presence of colloid within, is occasionally seen.23 The presence of multiple cystic nodules is diagnostic of multinodular thyroid. It should be noted that about 20e30% of papillary carcinomas have a cystic component that may mimic benign cystic thyroid nodules. The presence of characteristic punctuate calcications and chaotic intranodular vascularity on power Doppler examination raises the suspicion of a malignant lesion, which would necessitate further assessment using FNAC.

Acute suppurative thyroiditis

Acute suppurative thyroiditis is more common in children. It has a left-sided predominance and is frequently associated with a fourth branchial cleft anomaly. The child typically presents acutely with pain, thyroid swelling, fever, and odynophagia. There is usually a history of previous similar episodes or evidence of multiple incision and drainage. The infection usually begins in the perithyroidal soft tissues. The thyroid gland is relatively resistant to infection due to its inherently high iodine content and the presence of a thick brous capsule, so it tends to be involved only in the later stage of infection.2 On ultrasound, both intra- and extra-thyroid abscesses are seen as ill-dened, hypoechoic, heterogeneous areas with internal debris. Occasionally small echogenic foci with reverberation artefacts due to the presence of gas bubbles are demonstrated. The fascial planes between the thyroid gland and perithyroidal soft tissue are obliterated.2 Adjacent reactive lymph nodes are frequently present. Apart from diagnosis, ultrasound enables real-time guidance for needle aspiration, if necessary, and to monitor the response to antibiotic treatment. In complicated cases or if there is suboptimal response to medical treatment, CT is useful for more exact anatomical delineation of the suppurative process before surgical drainage. After the infection has settled, a barium study is indicated to identify any associated piriform fossa sinus.19 CT and MRI have also been used to demonstrate

Thymic cyst
The thymus gland forms when the paired thymic primordia complete their inferior migration along the thymopharyngeal ducts and fuse. Obliteration of the lumen of the thymopharyngeal tract occurs during the seventh and eighth week of gestation.10 Persistence or sequestered remnants of the thymopharyngeal duct lead to the development of thymic cyst. Thymic cyst is uncommon, with most lesions detected as an incidental imaging nding. It may be present anywhere from the angle of the mandible to the superior mediastinum adjacent to the carotid sheath. A connection with mediastinal thymic tissue may be present.24 On ultrasound it appears as a well-dened, anechoic cystic lesion below the level of the thyroid gland and related to the carotid sheath. On CT, the cyst wall is thin and uniformly smooth, and the cyst content is of mucoid attenuation (10e25 HU). On MRI, the cystic content usually has low to intermediate T1-weighted and high T2-weighted signal intensity.4

Submandibular region
Abscess
An abscess in the submandibular area usually originates from suppurative adenopthy, salivary

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gland infection, dental abscess, or mandibular osteomyelitis. On ultrasound, an abscess appears as an ill-dened, irregular collection with thick walls and internal debris. It may be unilocular or multilocular. The adjacent soft tissues are oedematous with loss of fascial planes. Enlarged reactive regional lymph nodes are commonly seen. The rim of the abscess may demonstrate hypervascularity on power Doppler imaging.2 On CT, an abscess usually appears as a single or multi-loculated low density area with rim enhancement (Fig. 4). Internal gas collections may be present. The adjacent subcutaneous and fascial fat planes are often obliterated. On MRI, an abscess typically has low T1-weighted and high T2-weighted signal intensities. Rim or thick peripheral enhancement is commonly seen in a mature neck abscess.7 Ultrasound helps to conrm the clinical diagnosis of abscess, delineate its anatomical location before surgery or aspiration, identify complications such as venous thrombosis or carotid involvement, and provide real-time imaging guidance for aspiration.

Second branchial cleft cyst (BCC)

Of all the branchial cleft anomalies, 95% arise from the remnants of the second branchial apparatus,

the most common form is second BCC.6 This typically presents as a cystic mass at the angle of the mandible and is more common in children and young adults. The site of second BCC is embryologically dened, typically located supercial to the common carotid artery and internal jugular vein, posterior to the submandibular gland and along the medial and anterior margin of the sternocleidomastoid muscle.2 On ultrasound, most uninfected second BCCs demonstrate the typical appearances of a cyst in that they are well-dened and anechoic with no internal debris and show posterior acoustic enhancement (Fig. 5); however, some cysts may exhibit a pseudosolid appearance with uniform internal echoes. This is due to proteinaceous content, such as mucus, debris, lymphocytes, epithelial cells, and cholesterol crystals, within the cyst.25 BCCs complicated by previous infection/ inammation are usually ill-dened, heterogeneous, and thick-walled, containing internal debris and septa. Such cysts mimic metastatic nodes from papillary carcinoma of thyroid or squamous cell carcinoma.26 In these cases FNAC of any solid mural component is recommended to exclude a metastatic lymph node. CT or MRI may be indicated if a sinus or stula is suspected. If a beak is identied on ultrasound pointing medially, then it is prudent to obtain further imaging in order to exclude a sinus or stula. On CT, second BCC appears as a homogeneous mass with low attenuation and a thin,

Figure 4 Contrast-enhanced CT image shows an illdened uid collection with peripheral enhancement (arrow) posterior to the left submandibular gland (arrowhead) compatible with an abscess. Note the extension of the suppurative process to adjacent retropharyngeal space (open arrow) and paralaryngeal area (curved arrow).

Figure 5 Transverse grey-scale ultrasound image of right upper neck shows a well-circumscribed anechoic cystic lesion (arrow) posterior to the submandibular gland (arrowhead) and supercial to internal carotid artery (open arrow). The anatomical location and appearances are compatible with a second BCC.

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well-dened wall in the typical location, i.e., posterior to submandibular gland, anterior to major vessels and medial to the anterior margin of sternocleidomastoid muscle. Conversely, infected cysts can be hyperattenuated with an ill-dened, irregular rim, mimicking a metastatic node.1 On MRI, the T2-weighted signal intensity is invariably high due to presence of intracystic uid. The proteinaceous content of the cyst may some times cause it to appear hyperintense rather than isointense or hypointense on T1-weighted series.27

Cystic metastatic lymph node and diving ranula

Cystic metastatic lymph node and diving ranula are also found in this region and are referred to elsewhere in the text.

Parotid region
Extra-glandular lesions
First BCC. A rst BCC arises from abnormal embryogenesis of the rst branchial apparatus and accounts for 8% of all branchial cleft abnormalities.1 It may be associated with changes in the temporal bone in the form of a tract through the external auditory canal and temporal bone. Anatomically rst BCC occurs in and around the parotid gland, external auditory canal and the angle of the mandible. The typical history is a middle-age female with history of recurrent parotid abscesses. On ultrasound, a rst BCC may appear as truly cystic with anechoic content, homogeneous hyperechoic with a pseudosolid appearance or heterogeneous hypoechoic with internal debris in infected cysts.2 The key to the correct diagnosis is the close anatomical location with the parotid gland. On CT, a rst BCC appears as well-dened, thin-walled lesion of mucoid attenuation (10e25 HU), whereas on MRI, it is usually of low to intermediate T1-weighted and high T2-weighted signal intensity.4

Intra-glandular lesions
Warthins tumour. Warthins tumour is a benign salivary gland tumour that accounts for 6e10% of parotid tumours.9 About 15% of patients have bilateral involvement. On ultrasound, Warthins tumour is typically a well-circumscribed, hypoechoic mass in the

parotid tail with internal heterogeneity (solid and cystic components) and posterior acoustic enhancement.28 The classical appearances of a welldened, multiseptate, cystic internal architecture has a high specicity for the diagnosis of Warthins tumour.29 Power Doppler ultrasound may show vessels in a hilar distribution with branches in the septa of the structure. On MRI, Warthins tumour usually appears as well-circumscribed, heterogeneous lesion with mixed cystic and enhancing solid components.9 Acquired cysts of parotid gland. Congenital epithelial cysts of the parotid gland are rare. The acquired cystic lesions in parotid gland consist mainly of (1) ductal cysts/sialocysts that develop as a result of ductal obstruction, which may be caused by a post-inammatory stricture, calculus, trauma or post-surgery. (2) Lymphoepithelial cysts, which are more commonly seen in children and patients with human immunodeciency virus (HIV) infection. Rare vascular lesions.30 Vascular lesions within the parotid gland are rare. Three vascular lesions may occasionally be encountered and present clinically as a parotid mass. These include: (1) pseudoaneurysm (from branches of external carotid artery), which on ultrasound appears as a wellcircumscribed, hypoechoic mass with an internal cystic component. On power Doppler imaging, the cystic component demonstrates chaotic arterial ow with adjacent supplying artery. On MRI, pseudoaneurysm shows isointense T1 and hyperintense T2 signal intensity with avid homogeneous enhancement after intravenous gadolinium. An angiogram helps to conrm the diagnosis, identify the artery of origin, and plan surgical or endovascular treatment; (2) arteriovenous stula/malformation, which on ultrasound appears as an area of multiple serpinginous anechoic structures with blood ow on grey-scale and power Doppler ultrasound. Engorged draining veins are seen in its vicinity. MRI helps to depict the lesion with numerous serpinginous signal voids. The supplying arteries and engorged draining veins are well demonstrated using MRA and digital subtraction angiography; (3) venous vascular malformation, which on ultrasound it appears as a well-dened heterogeneous lesion with multiple anechoic sinusoidal spaces with slow ow on grey-scale imaging and presence of phleboliths. The lesion is typically hypovascular on power Doppler examination. On MRI, venous vascular malformation of parotid is hypo/isointense on T1-weighted sequence, markedly hyperintense on T2-weighted sequence with avid enhancement after intravenous gadolinium.

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Cystic mass along cervical chain

Cystic metastatic lymph node
Metastatic cervical lymph nodes from squamous cell carcinoma of the head and neck and papillary carcinoma of thyroid gland are the most common types of nodal metastases with intranodal cystic necrosis.31,32 On ultrasound cystic necrosis may manifest itself as a truly cystic area or as a central, ill-dened area of relative hypoechogenicity accompanied by eccentric solid component within an enlarged lymph node.33,34 The solid areas usually demonstrate increased peripheral and chaotic vascularity on Doppler (Fig. 6).35,36 The presence of characteristic punctuate calcications within the solid component of the cystic node should alert the radiologist towards a careful search for primary papillary carcinoma in the thyroid gland. Occasionally cystic necrosis within a metastatic lymph node may be very orid, mimicking a congenital cyst, such as a second BCC.26 On CT, cystic nodal necrosis appears as focal area of low attenuation with or without a surrounding rim of soft-tissue enhancement. On MRI, the presence of a focal area of high signal intensity on T2-weighted images or low signal intensity on T1weighted images with or without a surrounding rim of enhancement suggest the presence of nodal necrosis.37 The sensitivity of MRI and CT is shown

to be better ultrasound.37

than

that

of

high-resolution

Venous vascular malformation

Approximately 15% of venous vascular malformations occur in the head and neck, the masseter muscle being the most common site. Although primarily a vascular malformation with large cavernous spaces, there may also be lymphatic elements present. The role of imaging is to identify the exact anatomical location and the extent of the lesion before therapy. The diagnosis is readily made by ultrasound, particularly when the presence of phlebolith is demonstrated. MRI is the best imaging technique to depict the exact anatomical location and extent, especially for large and deepseated lesions.38 The ultrasound appearances are fairly characteristic and show a lesion with a hypoechoic, heterogeneous echopattern with multiple sinusoidal spaces. Phleboliths are seen in 22% of cases (Fig. 7),38,39 although with the newer highresolution transducers they are more commonly detected in head and neck venous vascular malformation, especially in adults. Although power Doppler may depict the slow owing nature of venous vascular malformation, the ow phenomenon is usually better demonstrated on real-time grey-scale ultrasound. On MRI, venous vascular malformation shows a characteristic high signal on T2-weighted fatsaturated sequences ensuring its conspicuity.38 Although MRI may not be as sensitive as ultrasound in the identication of phleboliths, it is excellent (better than CT and ultrasound) at depicting the

Figure 6 Transverse grey-scale ultrasound image of right upper cervical level shows an enlarged lymph node (arrow) with cystic intranodal necrosis (arrowhead). At histology a metastatic squamous cell carcinoma was diagnosed. Note the presence of chaotic peripheral vascularity (open arrows) within the solid component of the metastatic node on power Doppler ultrasound.

Figure 7 Transverse grey-scale ultrasound at right lower cervical level shows a heterogeneous lesion (arrows) with multiple anechoic sinusoidal spaces, septa, and phlebolith (arrowhead) compatible with a venous vascular malformation.

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full extent of large venous vascular malformations, which may be trans-spatial.

Second BCC and abscesses

Second BCC and abscesses are discussed above.

offers superb contrast resolution for delineation of the extent of cystic hygromas, which invariably appear as high signal intensity masses with multiple internal septae (Fig. 8).27,42 In patients treated by sclerotherapy with OK-432 (Pacibanil) injection, serial MRI helps to assess treatment response and the necessity for repeated injection.44,45

Distended internal jugular vein

Phlebectasia is dilatation of an isolated vein, and the internal jugular vein is the most commonly affected. It may present with cervical swelling that expands with increased intrathoracic pressure.40 Ultrasound supplemented by Doppler ultrasound examination accurately identies the dilated internal jugular vein and venous blood ow on the Valsalva manoeuvre.40,41

Venous vascular malformation and cystic metastatic lymph node

Venous vascular malformation and cystic metastatic lymph node are referred to above.

Tuberculous lymphadenitis
Tuberculous lymphadenitis has a predilection for the posterior triangle of the neck. On imaging, it may appear almost entirely cystic or necrotic and mimic a cystic metastatic lymph node. The presence of nodal matting, surrounding soft-tissue oedema, avascularity, or displaced hilar vessels on power Doppler ultrasound examination are clues that may suggest a tuberculous rather than

Posterior triangle
Lymphangioma
Lymphatic malformations are congenital abnormalities that arise when developing lymphatics fail to establish communication with developing veins.42,43 They can be divided into three types: (1) cystic hygroma, which has large lymphatic spaces; (2) cavernous lymphangioma, which has smaller spaces and develops from buds that would have formed terminal lymphatics; (3) capillary lymphangioma, which contains the smallest cystic spaces. The cystic hygroma is the most commonly encountered type and typically presents in children, of which 50e60% present at birth or perinatally, and 30% present by age of 2 years.4 They usually present clinically as painless compressible neck mass, more commonly in the posterior triangle. Following haemorrhage they can enlarge rapidly and become tense.4 Large lesions can involve more than one anatomical space and so the primary role of imaging is to demonstrate the anatomical extent before surgery or sclerotherapy. On ultrasound, cystic hygroma appears as a compressible multiloculate cystic lesion with intervening thin septa. Vascularity may be seen within the septa. Large lesions tend to be transpatial and follow no obvious anatomical boundaries. If there is a previous episode of haemorrhage or infection, they may contain internal low-level echoes debris and show irregular walls.1,2,27 Although the diagnosis can easily be obtained by ultrasound, MRI or CT is often required to demonstrate the extension to other compartments of the neck that it can involve. T2-weighted sequence

Figure 8 Coronal, T2-weighted, MRI image shows a large cystic lesion (arrow) with internal septa (arrowheads) in right lower posterior triangle compatible with a cystic hygroma/macrocystic lymphangioma.

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a metastatic cause.34,46,47 However, there is overlap of appearance in these two entities and FNA for microbiological culture and cytology is usually required.

Summary
The precise anatomical location and imaging appearances are important for the accurate diagnosis and formulating the differential diagnoses of cystic lesions in the neck. In the vast majority of cases ultrasound, sometimes supplemented by FNAC, is adequate for pre-treatment assessment. For large deep-seated lesions assessment with MRI or CT provides useful supplementary information. Radiologists should be aware of the imaging ndings of common cystic neck masses to help in their appropriate management.

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