Neck Masses

Published on 26/03/2015 by admin

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Last modified 26/03/2015

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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?

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