Neck Masses in Children

Aka: Neck Masses in Children, Neck Mass in the Child, Pediatric Neck Mass

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II. Epidemiology

  1. Neck Masses in Children are benign in 90% cases

III. History

  1. Onset: Neonatal period
    1. Congenital Neck Mass (see below)
    2. Onset of congenital Neck Mass is variable
      1. Vascular Malformations
        1. Typically present at birth and grow as the child grows
      2. Subcutaneous Hemangioma
        1. Develop weeks after birth and may grow rapidly
      3. May be delayed for years or until adulthood (until local inflammation or infection)
        1. Example: Thyroglossal Duct Cyst
  2. Exposures
    1. Upper Respiratory Infections
    2. Animal exposure
      1. See Pet-Borne Disease
      2. See Cat Scratch Disease
      3. Rural farm animal exposures (e.g. atypical Tuberculosis)
    3. Tick Bites
      1. See Vector Borne Disease
    4. Tuberculosis exposure
    5. Travel
      1. See Fever in the Returning Traveler
    6. Ionizing radiation exposure
      1. See Cancer Risk due to Diagnostic Radiology
    7. Medications
      1. See Medication Causes of Lymphadenopathy
  3. Lymphadenopathy Presentations
    1. Fever with rapid enlargment, focal tenderness and overlying erythema
      1. Acute Lymphadenitis (inflammatory)
    2. Fever with weight loss and Night Sweats
      1. Consider malignancy
    3. Fever with Conjunctivitis and strawberry Tongue
      1. Kawasaki Disease

IV. Exam

  1. Define specific region of involvement
    1. See Lymphadenopathy of the Head and Neck
    2. See below

V. Causes: Congenital Neck Mass (55%)

  1. Thyroglossal Duct Cyst (common, midline mass)
  2. Dermoid Cyst
  3. Sebaceous Cyst
  4. Branchial Cleft Cyst (lateral, posterior to sternocleidomastoid Muscle)
  5. Cystic Hygroma (Lymphangioma)
  6. Hemangioma
  7. Teratoma
  8. Thymic Cyst
  9. Bronchogenic Cyst
  10. Laryngocele
  11. Torticollis

VI. Causes: Inflammatory Neck Mass (27%)

  1. See Lymphadenopathy of the Head and Neck
  2. Reactive Lymphadenopathy or Lymphadenitis
    1. Present in 40% infants
    2. Present in 55% all healthy children
    3. Cervical node size <3 mm is normal
    4. Cervical node size <=1 cm normal under age 12 years
  3. Viral Infection
    1. Viral Upper Respiratory Infections (most common)
    2. Epstein Barr Virus (EBV, Mononucleosis)
    3. Cytomegalovirus (CMV)
    4. HIV Infection or AIDS
  4. Bacterial
    1. Causes
      1. Staphylococcus aureus
      2. Beta hemolytic Streptococcus
      3. Viral Lymphadenitis of the Head and Neck
    2. Nodes Tender and fluctuant
    3. Unilateral tender and fluctuant adenopathy
    4. Head and neck abscess (e.g. Retropharyngeal Abscess)
  5. Granulomatous Disease
    1. Mycobacterium Avium Intracellulare (MAI)
    2. Cat Scratch Disease (Bartonella henslae)
    3. Toxoplasmosis
    4. Sarcoidosis
    5. Histoplasmosis
    6. Actinomycosis
    7. Fungal Infection
    8. Tuberculosis
  6. Other causes
    1. Kawasaki Disease
    2. Sialadenitis
    3. Tick-Borne Illness

VII. Causes: Neoplastic Neck Mass (11%)

  1. Malignant
    1. Thyroid Cancer
    2. Fibrosarcoma
    3. Lymphoma (most common pediatric neck cancer, esp. boys)
      1. Hodgkin's DiseaseLymphoma
      2. Non-Hodgkin's Lymphoma
    4. Rhabdomyosarcoma
      1. Second most common pediatric head and neck cancer
      2. Highly aggressive tumor
    5. Neuroblastoma
      1. Most common pediatric head and neck cancer in age <5 years (esp. age <1-2 months)
    6. Nasopharygeal malignancy
      1. Uncommon in general, but more common in children of african or asian descent
      2. May be associated with prior Epstein Barr Virus (EBV, Mononucleosis) Infection
      3. May present with Epistaxis
  2. Benign
    1. Lipoma (rare in children)
    2. Fibroma/Neurofibroma
    3. Lipoblastoma
    4. Paraganglioma
    5. Goiter
    6. Salivary Gland Tumor
    7. Teratoma (common and rarely malignant)
    8. Pilomatrixoma (composed of Hair Follicle matrix cells)

VIII. Causes: Location - Anterior Triangle

  1. See Lymphadenopathy of the Head and Neck
  2. Submandibular
    1. Cystic Hygroma
    2. Sialadenitis
    3. Atypical Mycobacterial Infection
    4. Cat-Scratch Disease
  3. Carotid
    1. Branchial Cleft Cyst
    2. Cystic Hygroma
  4. Submental
    1. Thyroglossal Duct Cyst
    2. Dermoid Cyst
    3. Cystic Hygroma
  5. Midline
    1. Thyroglossal Duct Cyst
    2. Dermoid Cyst
  6. Anterior Sternocleidomastoid
    1. Branchial Cleft Cyst

IX. Causes: Location - Pre-auricular

  1. See Lymphadenopathy of the Head and Neck
  2. Cystic Hygroma
  3. Parotitis
  4. Atypical Mycobacterial Infection
  5. Cat Scratch Disease

X. Causes: Location - Posterior Triangle

  1. See Lymphadenopathy of the Head and Neck
  2. Occipital
    1. Lymphoma
    2. Metastatic Disease
    3. Cystic Hygroma
  3. Supraclavicular
    1. Lymphoma
    2. Cystic Hygroma
    3. Metastatic Disease
    4. Mediastinal disease
      1. Tuberculosis
      2. Histoplasmosis
      3. Sarcoidosis

XI. Labs

  1. First-line tests
    1. Complete Blood Count with differential
    2. Monospot
  2. Second-line tests (if indicated)
    1. Bartonella hensalae titer
      1. Consider for suspected Cat Scratch Disease
    2. HIV Infection Screening
    3. Epstein-Barr Virus titer
    4. Cytomegalovirus titer
    5. Toxoplasmosis
    6. Tuberculosis Screening (e.g. PPD, Quantiferon-TB)

XII. Imaging

  1. Soft Tissue Neck Ultrasound
    1. Preferred first-line study
      1. No radiation
      2. Differentiates solid from cystic
      3. Defines lesion vascularity
      4. Defines lesion size and location
        1. Limited by depth and overlying structures that shadow underlying structures
        2. Can be used to direct fine-needle aspiration
    2. Indications
      1. Afebrile child with Neck Mass
      2. Febrile child with palpable Neck Mass
      3. Suspected Thyroglossal Duct Cyst
      4. Thyroid mass
  2. Neck CT with Intravenous Contrast
    1. Precautions
      1. See Cancer Risk due to Diagnostic Radiology
      2. Do not use IV contrast when evaluating Thyroid mass
        1. IV contrast interferes with thyroid Radioactive Iodine uptake
    2. Indications
      1. Neck malignancy suspected
      2. Retropharyngeal Abscess (or other deep neck abscess) suspected
  3. Neck MRI
    1. Precautions
      1. MRI typically requires sedation in younger children
    2. Indications
      1. High definition of soft tissue anatomy is required
      2. Vascular Malformation suspected

XIII. Diagnostics: Neck Mass Biopsy

  1. Indications
    1. Palpable node present in newborn
    2. Node has increased in size after two weeks
  2. Indications: Signs of serious disease indicating early biopsy
    1. Progressively enlarging firm-hard node >2 cm diameter
    2. Supraclavicular adenopathy (with pulmonary infection)
    3. Persistent Lymphadenopathy (despite specific treatment or empiric Antibiotic management as below)
      1. Node has not decreased in size after 4-6 weeks
      2. Node has not regressed to normal size within 8-12 weeks
    4. Persistent fever (or weight loss, Night Sweats)
    5. Fixation of node to adjacent tissue
    6. Thyroid mass
    7. Lymph Node in atypical site
      1. Posterior triangle
      2. Deep to Sternocleidomastoid
  3. Technique
    1. Fine Needle aspiration (with or without Ultrasound guidance)
    2. General Anesthesia is needed in >76% of children (especially young children)
    3. FNA interpretation should be by cytopathologist experienced with Pediatric Neck Mass pathology
  4. Efficacy
    1. Test Sensitivity: >90%
    2. Test Specificity: 85%

XIV. Management

  1. Step 0: Exclude obvious cause (e.g. Otitis Media, Streptococcal Pharyngitis)
    1. Consider lab testing as above
  2. Step 1a: Treat Reactive Lymphadenitis (if indicated)
    1. Indications
      1. Fever or Chills
      2. Focal tender adenopathy
      3. Overlying erythema
    2. Empiric Antibiotics for 10 day course (to cover Group A Streptococcus or Staphylococcus aureus)
      1. Cephalexin (Keflex)
      2. Amoxicillin-Clavulanate (Augmentin)
      3. Clindamycin (Cleocin)
  3. Step 1b: Evaluate Antibiotic effect on Lymphadenopathy (if treated)
    1. Improves in 2-3 days
      1. Complete Antibiotic course
        1. Consider extending for up to 30 days if does not resolve after 10 day course
      2. No further management if resolves
    2. Does not improve on Antibiotics
      1. Obtain imaging as above (typically starting with Ultrasound)
      2. Consult for drainage if abscess is identified on Ultrasound
      3. Consider Consultation with infectious disease or otolaryngology
  4. Step 2: Consider Malignancy causes
    1. Indications
      1. See Neck Mass Biopsy indications above
      2. Hard, firm or immobile Neck Mass
      3. Lymphadenopathy with Fever, Night Sweats, weight loss
    2. Approach
      1. Refer to head and neck surgery (urgent)
      2. See Imaging above
      3. See Neck Mass biopsy (as above)
  5. Step 3: Consider developmental Neck Mass
    1. Indications
      1. See congenital Neck Mass lesions as above
    2. Approach
      1. Refer to head and neck surgery
      2. See Imaging above
  6. Step 4: Observation
    1. Observe for 4-6 weeks
    2. Indications to refer to head and neck surgery
      1. Neck Mass continues to enlarge
      2. Neck Mass >2 cm following 4-6 weeks of observation

XV. References

  1. Hanback and Kosoko (2023) Crit Dec Emerg Med 37(4): 14-5
  2. Townsend (2001) Sabiston Surgery p. 1498-500
  3. Meier (2014) Am Fam Physician 89(5): 353-8 [PubMed]

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