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Neck Masses in Children
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Neck Masses in Children
, Neck Mass in the Child, Pediatric Neck Mass
See Also
Lymphadenopathy of the Head and Neck
Lymphadenopathy
Neck Masses in Adults
Epidemiology
Neck Masses in Children are benign in 90% cases
History
Onset: Neonatal period
Congenital
Neck Mass
(see below)
Onset of congenital
Neck Mass
is variable
Vascular Malformation
s
Typically present at birth and grow as the child grows
Subcutaneous
Hemangioma
Develop weeks after birth and may grow rapidly
May be delayed for years or until adulthood (until local inflammation or infection)
Example:
Thyroglossal Duct Cyst
Exposures
Upper Respiratory Infection
s
Animal exposure
See Pet-Borne Disease
See
Cat Scratch Disease
Rural farm animal exposures (e.g. atypical
Tuberculosis
)
Tick Bite
s
See
Vector Borne Disease
Tuberculosis
exposure
Travel
See
Fever in the Returning Traveler
Ionizing radiation exposure
See
Cancer Risk due to Diagnostic Radiology
Medications
See
Medication Causes of Lymphadenopathy
Lymphadenopathy
Presentations
Fever
with rapid enlargment, focal tenderness and overlying erythema
Acute
Lymphadenitis
(inflammatory)
Fever
with weight loss and
Night Sweats
Consider malignancy
Fever
with
Conjunctivitis
and strawberry
Tongue
Kawasaki Disease
Exam
Define specific region of involvement
See
Lymphadenopathy of the Head and Neck
See below
Causes
Congenital
Neck Mass
(55%)
Thyroglossal Duct Cyst
(common, midline mass)
Dermoid cyst
Sebaceous Cyst
Branchial Cleft Cyst
(lateral, posterior to sternocleidomastoid
Muscle
)
Cystic Hygroma
(
Lymphangioma
)
Hemangioma
Teratoma
Thymic
Cyst
Bronchogenic
Cyst
Laryngocele
Torticollis
Causes
Inflammatory
Neck Mass
(27%)
See
Lymphadenopathy of the Head and Neck
Reactive
Lymphadenopathy
or
Lymphadenitis
Present in 40% infants
Present in 55% all healthy children
Cervical node size <3 mm is normal
Cervical node size <=1 cm normal under age 12 years
Viral Infection
Viral
Upper Respiratory Infection
s (most common)
Epstein Barr Virus
(EBV,
Mononucleosis
)
Cytomegalovirus
(CMV)
HIV Infection
or
AIDS
Bacteria
l
Causes
Staphylococcus aureus
Beta hemolytic
Streptococcus
Viral
Lymphadenitis of the Head and Neck
Nodes Tender and fluctuant
Unilateral tender and fluctuant adenopathy
Head and neck abscess (e.g.
Retropharyngeal Abscess
)
Granuloma
tous Disease
Mycobacterium Avium Intracellulare
(MAI)
Cat Scratch Disease
(
Bartonella
henslae)
Toxoplasmosis
Sarcoidosis
Histoplasmosis
Actinomycosis
Fungal Infection
Tuberculosis
Other causes
Kawasaki Disease
Sialadenitis
Tick-Borne Illness
Causes
Neoplastic
Neck Mass
(11%)
Malignant
Thyroid Cancer
Fibrosarcoma
Lymphoma
(most common pediatric neck cancer, esp. boys)
Hodgkin's Disease
Lymphoma
Non-Hodgkin's Lymphoma
Rhabdomyosarcoma
Second most common pediatric head and neck cancer
Highly aggressive tumor
Neuroblastoma
Most common pediatric head and neck cancer in age <5 years (esp. age <1-2 months)
Nasopharygeal malignancy
Uncommon in general, but more common in children of african or asian descent
May be associated with prior
Epstein Barr Virus
(EBV,
Mononucleosis
) Infection
May present with
Epistaxis
Benign
Lipoma
(rare in children)
Fibroma/Neurofibroma
Lipoblastoma
Paraganglioma
Goiter
Salivary Gland Tumor
Teratoma
(common and rarely malignant)
Pilomatrixoma (composed of
Hair Follicle
matrix cells)
Causes
Location - Anterior Triangle
See
Lymphadenopathy of the Head and Neck
Submandibular
Cystic Hygroma
Sialadenitis
Atypical
Mycobacteria
l Infection
Cat-Scratch Disease
Carotid
Branchial Cleft Cyst
Cystic Hygroma
Submental
Thyroglossal Duct Cyst
Dermoid cyst
Cystic Hygroma
Midline
Thyroglossal Duct Cyst
Dermoid cyst
Anterior Sternocleidomastoid
Branchial Cleft Cyst
Causes
Location - Pre-auricular
See
Lymphadenopathy of the Head and Neck
Cystic Hygroma
Parotitis
Atypical
Mycobacteria
l Infection
Cat Scratch Disease
Causes
Location - Posterior Triangle
See
Lymphadenopathy of the Head and Neck
Occipital
Lymphoma
Metastatic Disease
Cystic Hygroma
Supraclavicular
Lymphoma
Cystic Hygroma
Metastatic Disease
Mediastinal disease
Tuberculosis
Histoplasmosis
Sarcoidosis
Labs
First-line tests
Complete Blood Count
with differential
Monospot
Second-line tests (if indicated)
Bartonella
hensalae titer
Consider for suspected
Cat Scratch Disease
HIV Infection
Screening
Epstein-Barr Virus
titer
Cytomegalovirus
titer
Toxoplasmosis
Tuberculosis Screening
(e.g. PPD,
Quantiferon-TB
)
Imaging
Soft Tissue Neck
Ultrasound
Preferred first-line study
No radiation
Differentiates solid from cystic
Defines lesion vascularity
Defines lesion size and location
Limited by depth and overlying structures that shadow underlying structures
Can be used to direct fine-needle aspiration
Indications
Afebrile child with
Neck Mass
Febrile child with palpable
Neck Mass
Suspected
Thyroglossal Duct Cyst
Thyroid
mass
Neck CT with
Intravenous Contrast
Precautions
See
Cancer Risk due to Diagnostic Radiology
Do not use IV contrast when evaluating
Thyroid
mass
IV contrast interferes with thyroid
Radioactive Iodine
uptake
Indications
Neck malignancy suspected
Retropharyngeal Abscess
(or other deep neck abscess) suspected
Neck MRI
Precautions
MRI typically requires sedation in younger children
Indications
High definition of soft tissue anatomy is required
Vascular Malformation
suspected
Diagnostics
Neck Mass
Biopsy
Indications
Palpable node present in newborn
Node has increased in size after two weeks
Indications: Signs of serious disease indicating early biopsy
Progressively enlarging firm-hard node >2 cm diameter
Supraclavicular adenopathy (with pulmonary infection)
Persistent
Lymphadenopathy
(despite specific treatment or empiric
Antibiotic
management as below)
Node has not decreased in size after 4-6 weeks
Node has not regressed to normal size within 8-12 weeks
Persistent fever (or weight loss,
Night Sweats
)
Fixation of node to adjacent tissue
Thyroid
mass
Lymph Node
in atypical site
Posterior triangle
Deep to Sternocleidomastoid
Technique
Fine Needle aspiration (with or without
Ultrasound
guidance)
Gene
ral
Anesthesia
is needed in >76% of children (especially young children)
FNA interpretation should be by cytopathologist experienced with Pediatric Neck Mass pathology
Efficacy
Test Sensitivity
: >90%
Test Specificity
: 85%
Management
Step 0: Exclude obvious cause (e.g.
Otitis Media
,
Streptococcal Pharyngitis
)
Consider lab testing as above
Step 1a: Treat Reactive
Lymphadenitis
(if indicated)
Indications
Fever
or Chills
Focal tender adenopathy
Overlying erythema
Empiric
Antibiotic
s for 10 day course (to cover
Group A Streptococcus
or
Staphylococcus aureus
)
Cephalexin
(
Keflex
)
Amoxicillin
-Clavulanate (
Augmentin
)
Clindamycin
(
Cleocin
)
Step 1b: Evaluate
Antibiotic
effect on
Lymphadenopathy
(if treated)
Improves in 2-3 days
Complete
Antibiotic
course
Consider extending for up to 30 days if does not resolve after 10 day course
No further management if resolves
Does not improve on
Antibiotic
s
Obtain imaging as above (typically starting with
Ultrasound
)
Consult for drainage if abscess is identified on
Ultrasound
Consider
Consultation
with infectious disease or otolaryngology
Step 2: Consider Malignancy causes
Indications
See
Neck Mass
Biopsy indications above
Hard, firm or immobile
Neck Mass
Lymphadenopathy
with
Fever
,
Night Sweats
, weight loss
Approach
Refer to head and neck surgery (urgent)
See Imaging above
See
Neck Mass
biopsy (as above)
Step 3: Consider developmental
Neck Mass
Indications
See congenital
Neck Mass
lesions as above
Approach
Refer to head and neck surgery
See Imaging above
Step 4: Observation
Observe for 4-6 weeks
Indications to refer to head and neck surgery
Neck Mass
continues to enlarge
Neck Mass
>2 cm following 4-6 weeks of observation
References
Hanback and Kosoko (2023) Crit Dec Emerg Med 37(4): 14-5
Townsend (2001) Sabiston Surgery p. 1498-500
Meier (2014) Am Fam Physician 89(5): 353-8 [PubMed]
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