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

Causes of Neck Masses

Congenital Causes

• Branchial cleft cyst

• Bronchogenic cyst

• Dermoid cyst

• Laryngocele

• Lymphangioma

• Thymic cyst

• Thyroglosal duct cyst

Inflammatory and Infectious Causes

• Actinomycosis

• Cat-scratch disease

• Histoplasmosis

• Ludwig angina

• Mycobacterium tuberculosis

• Nontuberculosis mycobacterial infections

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