Neck masses

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Chapter 32 NECK MASSES

Kevin Haggerty

General Discussion

Pediatric neck lesions may be divided into three categories: congenital, inflammatory or infectious, and neoplastic. Although most adult neck masses are malignant, 90% of pediatric neck lesions are benign. Given the diverse nature and etiologies of these lesions, no definitive or algorithmic approaches to neck masses have been established. Physicians must recognize that most of these lesions are benign and use a careful history and physical examination to guide their approach. The rapidity of onset, associated symptoms, family and social history, age of the patient, and physical findings are essential in the formulation of a differential diagnosis.

Palpable cervical nodes are present in 40% of infants. When all age groups are considered, about 55% of children have palpable nodes that are not associated with infection or systemic illness. Lymphoid tissue proliferates until puberty, at which time lymphoid mass is double that of adult values. Lymph nodes smaller than 3 mm in diameter are normal. Cervical nodes up to 1 cm in diameter are normal in children younger than 12 years of age. Small nodes in the anterior cervical triangle are usually benign.

The presence of a painless mass present at birth or identified shortly after birth is consistent with a lesion of congenital origin. Rapid enlargement often occurs with malignant lesions, inflammatory masses, and congenital masses such as thyroglossal duct cysts, branchial cleft cysts, and lymphangiomas. Acute or subacute enlargement, tenderness, and overlying erythema or fluctuance of the cervical lymph nodes, especially if temporally related to a recent upper respiratory tract infection, suggest an inflammatory origin. Cystic lesions are usually pharyngeal cleft remnants and vascular malformations, whereas solid lesions are generally inflammatory or neoplastic. Systemic symptoms may suggest a malignant or infectious process. Malignant lesions tend to be painless, solid, and associated with other systemic manifestations. Malignancy should be considered in any patient with a solitary posterior cervical mass. Supraclavicular masses are most likely to represent lymphoma.

Inflammatory or Infectious Lesions

Most pediatric cervical lymphadenopathy is not associated with systemic illness or infection. Viral upper respiratory tract infection is the most common cause of bilateral lymphadenopathy. Suppurative lymph nodes are unilateral, tender, warm nodes caused by pyogenic infection of the tonsils and pharynx.

Mycobacterial lymphadenitis is seen in children 1 to 5 years of age and is usually accompanied by symptoms consistent with a disseminated mycobacterial infection.

Bartonella henselae infection, or cat-scratch fever, most commonly presents as tender regional (usually axillary, preauricular, or cervical) lymphadenopathy 5 to 60 days after contact with affected cats. It is usually accompanied by fever, malaise, and fatigue.

Congenital Masses

Congenital masses may be present from birth or become more prominent with growth and development. Thyroglossal duct cysts are the most common congenital masses, developing between 2 and 10 years of age. They arise from the remnants of embryonic thyroid tissue and are usually located midline to left of midline, inferior to the hyoid bone. Cystic hygromas or lymphangiomas are present from birth or arise in early infancy. These lesions are soft and mobile and are usually located in the posterior triangle of the neck. Cystic hygromas arise from lymphatic tissue that did not connect to the venous system. These lesions may enlarge rapidly and cause respiratory compromise.

Neoplastic Lesions

About 5% of pediatric malignancies occur in the head and neck. Most of these lesions are lymphomas (non-Hodgkin and Hodgkin). Non-Hodgkin lymphoma most commonly is found in children under the age of 6 years, whereas Hodgkin lymphoma is more common in adolescents and teens. Both these malignancies may present as a firm, painless, unilateral, supraclavicular mass. Neuroblastoma, while the most common solid tumor in children, is not commonly found in the head and neck. Primary neuroblastoma of the neck may arise from the cervical sympathetic chain.

The head and neck are common sites for rhabdomyosarcoma. This tumor arises most commonly in children 7 to 13 years of age and often presents as a painless, firm, nonmobile enlarging neck mass.

Medications Associated with Lymph Node Enlargement

• Allopurinol

• Hydralazine

• Phenytoin

Causes of Neck Masses

Congenital Causes

• Branchial cleft cyst

• Thyroglosal duct cyst

Inflammatory and Infectious Causes

Neoplastic Causes

Key Physical Findings

Vital signs

Quantification of the size of the lesion

Location or anatomical site of the lesion (posterior triangle, supraclavicular)

Mobility or fixation to internal structures

Consistency of the lesion

Tenderness

Surrounding skin findings and color

Regional lymphadenopathy

General physical examination

Table 32-1 characterizes key examination findings of common lesions.

Table 32-1 Key Examination Findings of Common Lesions

Diagnosis	Location	Physical Findings
Branchial cleft cyst	Anterior to middle third of sternocleidomastoid muscle	Mass that may retract with swallowing. Fistula may or may not be present.
Cat-scratch disease	Anterior triangle, submandibular, or preauricular	Tender lymphadenopathy
Cystic hygroma (lymphangioma)	Anterior triangle, submandibular, or preauricular	Soft spongy mass, nontender. May increase in size with Valsalva maneuver. Can be differentiated from hemangioma in that it transilluminates.
Dermoid cyst	Midline lesions	Mobile, painless, firm mass. Does not move with tongue protrusion.
Hemangioma	May occur at various locations on neck and face	Soft mobile mass that increases in size with Valsalva maneuver. Red/bluish. Does not transilluminate.
Lymphadenitis	Multiple inflamed masses in the anterior and posterior triangle	Painful, erythematous, fluctuant nodes. Patient may have fever; may drain purulent fluid.
Lymphoma	Occipital and supraclavicular	Large, firm, usually painless mass
Mycobacterial and granulomatous infections	Cervical, submandibular, supraclavicular	Painful, may be erythematous, may have draining sinus tract
Rhabdomyosarcoma	Parameningeal sites (posterior aspect of neck), multiple locations	Painless, rapidly enlarging mass
Thyroglossal duct cyst	Anterior neck, submental and midline	Firm mass that retracts with tongue protrusion

Suggested Work-up

The history and physical examination may provide adequate information to assess the risk of serious disease. Children with presumed bacterial lymphadenitis or a low-risk mass of undetermined causation without significant findings may be placed on a trial of antibiotics and observation. This trial should not exceed 2 weeks.

Complete blood count (CBC)	If an infection or malignant process is suspected
Purified protein derivative (PPD) tuberculin test	If mycobacterial infection is suspected. The test will be negative in 50% of cases of atypical mycobacterial infection.
Erythrocyte sedimentation rate (ESR), C-reactive protein	May be useful in characterizing the neck mass as part of a systemic illness
Chest radiograph	If malignancy or mycobacterial infection is suspected
Ultrasonography	To distinguish between a cystic lesion and a solid mass. Helpful in differentiating congenital cystic masses from solid lymph nodes and neoplasms.
Fine needle aspiration or open biopsy	May be required to establish the diagnosis, especially when other diagnostic tests are unrevealing and the mass persists or increases in size. See Table 32-2.

Table 32-2 Criteria for Cervical Lymph Node Biopsy ^*

* When other diagnostic tests are unrevealing, biopsy may be required to rule out malignancy and establish the diagnosis.

Additional Work-up

Serologic studies	If toxoplasmosis, histoplasmosis, cytomegalovirus infection, or Epstein-Barr virus infection is suspected
Bartonella henselae antibody	If cat-scratch disease is suspected
Wound cultures	Useful in cases of suppurative lymphadenitis to identify a pathogen and choose an appropriate antibiotic
Rheumatoid factor and antinuclear antibodies	If a rheumatologic process is suspected
Computed tomography (CT) scan	More effective than ultrasonography in identifying deeper, less well-defined lesions
Magnetic resonance imaging (MRI) of neck masses	Becoming more widely used early in the evaluation
Thyroid scan and/or thyroid function tests	If thyroglossal duct cyst is suspected
Sialography	If sialadenitis is suspected
Arteriography	May be helpful in evaluating hemangioma