Neck masses

Published on 21/03/2015 by admin

Filed under Pediatrics

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1171 times

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.

Key Physical Findings

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