II. Epidemiology
- Neck Masses in Children are benign in 90% cases
III. History
- Onset: Neonatal period
- Congenital Neck Mass (see below)
- Onset of congenital Neck Mass is variable
- Vascular Malformations
- Typically present at birth and grow as the child grows
- Subcutaneous Hemangioma
- Develop weeks after birth and may grow rapidly
- May be delayed for years or until adulthood (until local inflammation or infection)
- Example: Thyroglossal Duct Cyst
- Vascular Malformations
- Exposures
- Upper Respiratory Infections
- Animal exposure
- See Pet-Borne Disease
- See Cat Scratch Disease
- Rural farm animal exposures (e.g. atypical Tuberculosis)
- Tick Bites
- Tuberculosis exposure
- Travel
- Ionizing radiation exposure
- Medications
-
Lymphadenopathy Presentations
- Fever with rapid enlargment, focal tenderness and overlying erythema
- Acute Lymphadenitis (inflammatory)
- Fever with weight loss and Night Sweats
- Consider malignancy
- Fever with Conjunctivitis and strawberry Tongue
- Fever with rapid enlargment, focal tenderness and overlying erythema
IV. Exam
- Define specific region of involvement
- See Lymphadenopathy of the Head and Neck
- See below
V. Causes: Congenital Neck Mass (55%)
- Thyroglossal Duct Cyst (common, midline mass)
- Dermoid cyst
- Sebaceous Cyst
- Branchial Cleft Cyst (lateral, posterior to sternocleidomastoid Muscle)
- Cystic Hygroma (Lymphangioma)
- Hemangioma
- Teratoma
- Thymic Cyst
- Bronchogenic Cyst
- Laryngocele
- Torticollis
VI. Causes: Inflammatory Neck Mass (27%)
- See Lymphadenopathy of the Head and Neck
- Reactive Lymphadenopathy or Lymphadenitis
- Present in 40% infants
- Present in 55% all healthy children
- Cervical node size <3 mm is normal
- Cervical node size <=1 cm normal under age 12 years
-
Viral Infection
- Viral Upper Respiratory Infections (most common)
- Epstein Barr Virus (EBV, Mononucleosis)
- Cytomegalovirus (CMV)
- HIV Infection or AIDS
-
Bacterial
- Causes
- Staphylococcus aureus
- Beta hemolytic Streptococcus
- Viral Lymphadenitis of the Head and Neck
- Nodes Tender and fluctuant
- Unilateral tender and fluctuant adenopathy
- Head and neck abscess (e.g. Retropharyngeal Abscess)
- Causes
-
Granulomatous Disease
- Mycobacterium Avium Intracellulare (MAI)
- Cat Scratch Disease (Bartonella henslae)
- Toxoplasmosis
- Sarcoidosis
- Histoplasmosis
- Actinomycosis
- Fungal Infection
- Tuberculosis
- Other causes
- Kawasaki Disease
- Sialadenitis
- Tick-Borne Illness
VII. Causes: Neoplastic Neck Mass (11%)
- Malignant
- Thyroid Cancer
- Fibrosarcoma
- Lymphoma (most common pediatric neck cancer, esp. boys)
- Rhabdomyosarcoma
- Second most common pediatric head and neck cancer
- Highly aggressive tumor
- Neuroblastoma
- Most common pediatric head and neck cancer in age <5 years (esp. age <1-2 months)
- Nasopharygeal malignancy
- Uncommon in general, but more common in children of african or asian descent
- May be associated with prior Epstein Barr Virus (EBV, Mononucleosis) Infection
- May present with Epistaxis
- Benign
- Lipoma (rare in children)
- Fibroma/Neurofibroma
- Lipoblastoma
- Paraganglioma
- Goiter
- Salivary Gland Tumor
- Teratoma (common and rarely malignant)
- Pilomatrixoma (composed of Hair Follicle matrix cells)
VIII. Causes: Location - Anterior Triangle
- See Lymphadenopathy of the Head and Neck
- Submandibular
- Cystic Hygroma
- Sialadenitis
- Atypical Mycobacterial Infection
- Cat-Scratch Disease
- Carotid
- Submental
- Thyroglossal Duct Cyst
- Dermoid cyst
- Cystic Hygroma
- Midline
- Thyroglossal Duct Cyst
- Dermoid cyst
- Anterior Sternocleidomastoid
IX. Causes: Location - Pre-auricular
- See Lymphadenopathy of the Head and Neck
- Cystic Hygroma
- Parotitis
- Atypical Mycobacterial Infection
- Cat Scratch Disease
X. Causes: Location - Posterior Triangle
- See Lymphadenopathy of the Head and Neck
- Occipital
- Lymphoma
- Metastatic Disease
- Cystic Hygroma
- Supraclavicular
- Lymphoma
- Cystic Hygroma
- Metastatic Disease
- Mediastinal disease
XI. Labs
- First-line tests
- Complete Blood Count with differential
- Monospot
- Second-line tests (if indicated)
- Bartonella hensalae titer
- Consider for suspected Cat Scratch Disease
- HIV Infection Screening
- Epstein-Barr Virus titer
- Cytomegalovirus titer
- Toxoplasmosis
- Tuberculosis Screening (e.g. PPD, Quantiferon-TB)
- Bartonella hensalae titer
XII. Imaging
- Soft Tissue Neck Ultrasound
- Preferred first-line study
- No radiation
- Differentiates solid from cystic
- Defines lesion vascularity
- Defines lesion size and location
- Limited by depth and overlying structures that shadow underlying structures
- Can be used to direct fine-needle aspiration
- Indications
- Afebrile child with Neck Mass
- Febrile child with palpable Neck Mass
- Suspected Thyroglossal Duct Cyst
- Thyroid mass
- Preferred first-line study
- Neck CT with Intravenous Contrast
- Precautions
- See Cancer Risk due to Diagnostic Radiology
- Do not use IV contrast when evaluating Thyroid mass
- IV contrast interferes with thyroid Radioactive Iodine uptake
- Indications
- Neck malignancy suspected
- Retropharyngeal Abscess (or other deep neck abscess) suspected
- Precautions
- Neck MRI
- Precautions
- MRI typically requires sedation in younger children
- Indications
- High definition of soft tissue anatomy is required
- Vascular Malformation suspected
- Precautions
XIII. Diagnostics: Neck Mass Biopsy
- Indications
- Palpable node present in newborn
- Node has increased in size after two weeks
- Indications: Signs of serious disease indicating early biopsy
- Progressively enlarging firm-hard node >2 cm diameter
- Supraclavicular adenopathy (with pulmonary infection)
- Persistent Lymphadenopathy (despite specific treatment or empiric Antibiotic management as below)
- Node has not decreased in size after 4-6 weeks
- Node has not regressed to normal size within 8-12 weeks
- Persistent fever (or weight loss, Night Sweats)
- Fixation of node to adjacent tissue
- Thyroid mass
- Lymph Node in atypical site
- Posterior triangle
- Deep to Sternocleidomastoid
- Technique
- Fine Needle aspiration (with or without Ultrasound guidance)
- General Anesthesia is needed in >76% of children (especially young children)
- FNA interpretation should be by cytopathologist experienced with Pediatric Neck Mass pathology
- Efficacy
- Test Sensitivity: >90%
- Test Specificity: 85%
XIV. Management
- Step 0: Exclude obvious cause (e.g. Otitis Media, Streptococcal Pharyngitis)
- Consider lab testing as above
- Step 1a: Treat Reactive Lymphadenitis (if indicated)
- Indications
- Fever or Chills
- Focal tender adenopathy
- Overlying erythema
- Empiric Antibiotics for 10 day course (to cover Group A Streptococcus or Staphylococcus aureus)
- Cephalexin (Keflex)
- Amoxicillin-Clavulanate (Augmentin)
- Clindamycin (Cleocin)
- Indications
- Step 1b: Evaluate Antibiotic effect on Lymphadenopathy (if treated)
- Improves in 2-3 days
- Complete Antibiotic course
- Consider extending for up to 30 days if does not resolve after 10 day course
- No further management if resolves
- Complete Antibiotic course
- Does not improve on Antibiotics
- Obtain imaging as above (typically starting with Ultrasound)
- Consult for drainage if abscess is identified on Ultrasound
- Consider Consultation with infectious disease or otolaryngology
- Improves in 2-3 days
- Step 2: Consider Malignancy causes
- Indications
- See Neck Mass Biopsy indications above
- Hard, firm or immobile Neck Mass
- Lymphadenopathy with Fever, Night Sweats, weight loss
- Approach
- Refer to head and neck surgery (urgent)
- See Imaging above
- See Neck Mass biopsy (as above)
- Indications
- Step 3: Consider developmental Neck Mass
- Indications
- See congenital Neck Mass lesions as above
- Approach
- Refer to head and neck surgery
- See Imaging above
- Indications
- Step 4: Observation
XV. References
- Hanback and Kosoko (2023) Crit Dec Emerg Med 37(4): 14-5
- Townsend (2001) Sabiston Surgery p. 1498-500
- Meier (2014) Am Fam Physician 89(5): 353-8 [PubMed]