Neck Masses

Published on 26/03/2015 by admin

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Last modified 22/04/2025

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CHAPTER 20 Neck Masses

Magdy W. Attia, MD, Eileen C. Quintana, MD, MPH

1 What are the important components of the medical history in a child with a neck mass?

The history should include:

image Onset

image Duration of symptoms

image Rapidity of growth with changes in size or position

image Pain

image History of recent infection or trauma

image Generalized symptoms, such as fever, weight loss, poor appetite, night sweats, or fatigue

image History of exposure to communicable diseases

image Travel history

2 What are the important components of the physical examination of a child with a neck mass?

Observe the general appearance of the child. Screen rapidly for true emergencies. Inspect the patient in the neutral position to discern subtle swellings. Palpate the neck from behind with the patient seated or with the child on the mother’s lap. Examine all masses to determine location, size, multiplicity, consistency, mobility, color, and temperature. Note other characteristics, such as tenderness, compressibility, and mobility with swallowing and with tongue protrusion. Pay special attention to associated systems, such as the chest, abdomen, and the lymphatic system, to ensure a complete examination.

Davenport M: ABCs of general surgery in children. Lumps and swellings of the head and neck. BMJ 312:368–371, 1996.

3 Which true emergencies are associated with neck masses?

True emergencies involving a neck mass include respiratory distress, vascular compromise, and cervical spinal cord compression.

4 Describe an initial focused evaluation of a child with a neck mass.

Address the airway, breathing, and circulation (ABCs) appropriately. Immediately note the child’s level of consciousness and work of breathing. Obtain a focused and pertinent history. Evaluate for stridor, hoarseness, dysphagia, and drooling. Perform a neurologic examination.

5 List the etiologic classifications of neck lesions/masses.

See Table 20-1.

TABLE 20-1 ETIOLOGIC CLASSIFICATIONS OF NECK LESIONS AND MASSES

image

6 List the anatomic classifications of a neck mass, with the most common masses in each category.

See Table 20-2.

TABLE 20-2 THE ANATOMIC CLASSIFICATIONS OF A NECK MASS, WITH THE MOST COMMON MASSES IN EACH CATEGORY

Midline Lateral
Thyroglossal duct cyst Lymphadenopathy
Lymphadenopathy Cystic hygroma
Dermoid cyst Branchial cleft cyst
Epidermoid cyst Sternocleidomastoid mass
Sialadenitis Parotitis
Ectopic thyroid tissue Thyroid gland tumors

7 How is the workup of a child with a neck mass conducted?

Generally, a thorough history and physical examination lead to a provisional diagnosis and initiation of either therapy or watchful waiting. The lack of rapid resolution or the presence of worrisome clinical findings should trigger the workup. The choice of the best study depends on the type of mass (solid versus cystic, benign versus malignant) and the location and extent of the lesion. Initially, ultrasonography is a good screening study; if further anatomic details are needed, contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) is then indicated. If signs of malignancy are present (i.e., a painless, firm, slow-growing mass in the upper third of the neck, or lymph nodes fixed to underlying tissue) or the lesion does not resolve, then surgical referral and biopsy are warranted. Consider a complete blood count, erythrocyte sedimentation rate (ESR), chest radiography, and purified protein derivative test in the early workup.

Gross E, Sichel JY: Congenital neck lesions. Surg Clin North Am 86:383–392, 2006.

Turkington JR, Paterson A, Sweeney LE, Thornbury GD: Neck masses in children. Br J Radiol 78:75–85, 2005.

8 What are cystic hygromas? When do they usually appear?

Cystic lymphatic malformations are believed to be formed from congenital failure of the lymphatic primordial buds to establish drainage into the venous system. This leads to the accumulation of lymphatic fluid and cyst formation, and a large neck mass. They are discrete, soft, mobile, and nontender masses most commonly found in the posterior triangle of the neck. They may be transilluminated, and usually grow in proportion to the child.

Cystic hygromas usually appear by the end of the second year of life (80–90% of cases) during the period of active lymphatic growth; they appear less commonly at birth (10–20% of cases).

9 What are the most common locations of cystic hygromas?

They develop in close proximity to large veins and lymphatic ducts:

image Lateral neck (75%)

image Axilla (20%)

image Mediastinum (5%)

image Retroperitoneum (5%)

image Pelvis (5%)

image Groin (5%)

10 What is the most serious complication of cystic hygroma? What are the treatments for this condition?

Respiratory compromise, which is seen when a large mass extrinsically compresses the airway. The treatment is usually surgical excision of the lesion; however, sclerotherapy, repeated aspiration, incision and drainage, radiation therapy, and intralesional injections are other treatment modalities that have been recently recommended.

Koch BL: Cystic malformations of the neck in children. Pediatr Radiol 35:463–477, 2005.

11 What is the most common head and neck congenital lesion identified in infancy?

Hemangioma. These are most noticeable after the first month of life. Females are affected three times more commonly than males.

12 How do hemangiomas appear on physical examination?

These masses are soft, mobile, and nontender and have a bluish or fiery red hue. Regressing hemangiomas are gray. The most common locations of hemangiomas are:

image Face: Lips, nose, eyelids, and ears

image Scalp

13 Describe some of the complications of hemangiomas.

image Hemorrhage

image Ulceration

image Infection

image Necrosis

image Thrombocytopenia and coagulopathies: Due to platelet trapping; Kasabach-Merritt syndrome

image Airway compromise—the child may have stridor

image Congestive heart failure

image Visual impairment in some periorbital hemangiomas

14 What are the treatments for hemangiomas?

The treatment of hemangiomas is observation; most hemangiomas resolve spontaneously. Other treatment modalities include compression garments, steroids, chemotherapy, radiation therapy, and laser therapy. Surgical excision is reserved for rapidly growing lesions compromising vision, hearing, or the airway.

Connor SE, Flis C, Langdon JD: Vascular masses of the head and neck. Clin Radiol 60:856–868, 2005.

15 What is the origin of branchial cleft cysts?

These develop from malformations of the branchial arches (first through fourth). Most of them arise from the second branchial cleft.

16 How does a child with a branchial cleft sinus or cyst present?

Generally, the child presents with a single, painless, cystic lesion deep to the anterior, upper one third of the sternocleidomastoid. The lesion is movable, smooth, tense, and nontranslucent, and occasionally has clear mucoid drainage from a small opening along the anterior border of the sternocleidomastoid muscle. Sometimes the tract is palpable.

17 What is the most common complication of branchial cysts?

Infection is the most common complication, and usually responds well to antibiotics and warm soaks. The definitive treatment is complete excision of the cyst and tract.

KEY POINTS: BRANCHIAL CLEFT CYSTS

Usually a single painless cystic lesion

May become infected, thus red and tender

Found on the lateral neck, at the anterior upper third of sternocleidomastoid

Treat infection with antibiotics and surgical excision

18 Compare dermoid and epidermoid cysts.

See Table 20-3.

TABLE 20-3 COMPARISON BETWEEN DERMOID AND EPIDERMOID CYSTS

Features Dermoid Cyst Epidermoid Cyst
Origins Congenital Traumatic or inflammatory
  Inclusion of embryonic epidermis within embryonal fusion planes Follicular infundibulum of the hair shaft
Location Head and neck: lateral to the supraorbital palpebral ridge, midline face, especially nasal bridge or neck Head and neck: lateral to the supraorbital palpebral ridge, midline face, especially nasal bridge or neck
Contents Lined by epithelium and contain sebaceous glands, hair follicles, connective tissues, and papillae Lined by epithelium, does not contain cutaneous appendages but rather keratinized cellular debris
Treatment Surgical excision Surgical excision

19 How is radiologic imaging helpful in management of a dermoid cyst?

Either MRI or CT may be used to evaluate a dermoid cyst prior to complete excision because dermoid cysts occasionally have intracranial extension.

20 What is a thyroglossal duct cyst?

This common congenital neck mass is due to a ductal ectodermal remnant that never obliterated. Remember, a thyroglossal duct cyst has no external opening because the tract does not reach the skin surface.

21 How does a thyroglossal duct cyst present clinically?

This is commonly noted in a child 2–10 years old, as a midline cystic structure, immediately adjacent to the hyoid bone, at or about the level of the thyroid cartilage. Some may be sublingual (3%) or suprasternal (7%). A thyroglossal duct cyst is a soft, smooth, nontender (unless infected) mass that can be noted when the child swallows or with tongue protrusion.

22 Describe the workup of a child with a thyroglossal duct cyst.

The diagnosis is often made on clinical grounds alone. Ultrasonography, CT, or MRI may be indicated in unusual clinical presentations. CT provides better visualization of lesions adjacent to the hyoid bone. Radioisotope scanning is used for detecting ectopic thyroid tissue within thyroglossal ducts. Postoperative thyroid function tests may be indicated to determine whether thyroid replacement therapy is needed.

KEY POINTS: THYROGLOSSAL DUCT CYSTS

Midline swelling, usually near the thyroid cartilage

Moves when the child swallows or protrudes the tongue

Diagnosis is made clinically

23 Is cervical lymphadenopathy common in childhood?

Yes, cervical lymphadenopathy is common during the middle years of childhood but is seldom pathologic. Children usually present with an indolent, nontender, dominant node in the jugular chain that persists over several months. Systemic symptoms are rare. Although laboratory studies are not usually indicated, most children have a normal blood count and normal chest radiograph, and if the node is biopsied it shows reactive hyperplasia.

24 Is a supraclavicular lymph node more concerning?

Supraclavicular adenopathy in any age group should be considered pathologic until proven otherwise. Swelling of these nodes may be the first sign of occult thoracic or abdominal pathology, such as malignancy (lymphoma). Initiate a workup including a chest x-ray and consultation with a surgeon immediately.

25 What is the most common cause of acute cervical lymph node enlargement?

Infection:

image Viral: Severe viral pharyngitis can cause cervical lymph nodes to enlarge acutely, usually bilaterally. Infections of the upper respiratory tract can lead to lymph node enlargement. Agents include influenza A and B viruses, Epstein-Barr virus, rhinovirus, enterovirus, and adenovirus.

image Bacterial: Acute suppurative cervical lymphadenitis secondary to bacterial infection is another cause for cervical lymph node enlargement. Common bacterial pathogens include Staphylococcus aureus, group A β-hemolytic streptococci, Streptococcus pneumoniae (rarely), anaerobes from mouth flora, and Bartonella henselae (cat scratch disease).

26 How does a child with acute suppurative cervical lymphadenitis present?

Acute suppurative cervical lymphadenitis often presents after upper respiratory tract infection, pharyngitis, or tonsillitis, with rapid, unilateral enlargement of multiple adjacent lymph nodes. Marked tenderness, warmth, and erythema are often seen. Fever, irritability, and toxic appearance are more common in the younger child. Spontaneous purulent drainage may occur if the infection is untreated.

27 How is acute suppurative cervical lymphadenitis best treated?

The initial treatment consists of oral antibiotics and warm soaks to the neck. If the child is young and toxic, admission is warranted for IV antibiotic therapy and close observation. If fluctuance is identified, drainage by surgical incision or ultrasonography-guided needle aspiration is recommended for both therapeutic and diagnostic purposes.

28 What is the differential diagnosis of subacute or chronic cervical lymphadenitis?

This condition refers to a child with a large, minimally tender, mildly inflamed, and nonfluctuant cervical lymph node that appears slowly over several weeks with no associated prodrome or systemic illness. Elements of the differential diagnosis are the following:

image Reactive response to a nonspecific infection (bacterial or viral)

image Cat scratch disease

image Infectious mononucleosis

image Mycobacterium tuberculosis: typical or atypical

image Toxoplasmosis

image Cytomegalovirus

image HIV infection

image Sarcoidosis

image Histoplasmosis

image Actinomycosis

image Malignancy

29 What is the workup for a child with subacute or chronic cervical lymphadenitis?

image Perform a complete history and physical examination.

image Note the child’s overall general appearance.

image Assess the number, size, and location of lymph nodes.

image Palpate for any organomegaly.

image Consider laboratory studies, including complete blood count with differential, ESR, chest x-ray, and a purified protein derivative test.

image Begin antibiotics to cover staphylococcus and streptococcus.

image Arrange for the patient to be followed closely by his or her primary care physician.

30 When should a child with chronic lymphadenopathy be referred for biopsy?

Referral is warranted if the condition does not respond to treatment or a lymph node persists or enlarges despite adequate antibiotic therapy (of a few weeks duration).

31 Describe the clinical picture of cat scratch disease.

Children with cat scratch disease may give a history of a scratch by a kitten or only exposure to a kitten. Cat scratch disease is a common infectious disease in all ages groups. Kittens, in particular, are the reservoir for this disease. Although most children do not recall the scratch, a papule at the primary inoculation “scratch site” and regional lymphadenopathy usually develop in 1–2 weeks. A positive result on a cat scratch disease antigen skin test (not recommended) or demonstration of micro-organism (B. henselae) by silver stain from an aspirated node is confirmatory. If cat scratch disease is suspected, the best initial test is the B. henselae IgM enzyme immunoassay. If the test result is negative, consider polymerase chain reaction for Bartonella by using the biopsy tissue.

32 What is the treatment for cat scratch disease?

Cat scratch disease is self-limited; resolution is expected in 6–8 weeks. Initial treatment may consist of warm compresses and analgesics. Treatment should be reserved for those with systemic symptoms or severe local reaction. However, many physicians start antibiotics, such as trimethoprim-sulfamethoxazole or azithromycin, upon clinical suspicion.

KEY POINTS: CAT SCRATCH DISEASE

1 Most patients do not recall a cat scratch.

2 Kittens are usually the reservoir.

3 Lymphadenopathy develops 1–2 weeks after the scratch.

4 B. henselae IgM enzyme immunoassay is the best test.

5 Treat with observation or trimethoprim-sulfamethoxazole or azithromycin.

33 Describe the most common neoplasm of the neck based on age.

Approximately 5% of all neoplastic lesions occur in the head and neck region.

image In preschool-age children: neuroblastoma, non-Hodgkin’s lymphoma, rhabdomyosarcoma, and Hodgkin’s lymphoma are most common.

image In school-age children: lymphomas, either non-Hodgkin’s or Hodgkin’s, thyroid carcinoma, and rhabdomyosarcoma are more likely.

image In adolescents: Hodgkin’s lymphoma predominates.

34 When should a neoplastic lesion in the neck be suspected? What evaluation is necessary?

A neoplastic lesion presents as a painless, firm, fixed cervical mass. Other presenting signs and symptoms are unilateral ptosis, nasal obstruction, or otorrhea. A detailed history and physical examination, complete blood count with differential, renal and liver profiles, chest x-ray, or CT/MRI are sometimes obtained in the emergency department. An urgent referral to a surgeon or oncologist is recommended for further studies, such as a bone marrow examination.

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