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PEDIATRIC NECK MASSBackground

Cervical palpation very often identifies one or more neck mass in the pediatric patient. The

differential diagnosis is extensive, but diagnosis is made often with history and physical alone.

An understanding of surface anatomy, lymphatic drainage patterns in the neck, and head and

neck embryology are extremely useful in diagnosis. Typically three primary categories of neck

masses are described:

Inflammatory

Congenital

Neoplastic

Other causes include traumatic, metabolic, autoimmune, and idiopathic conditions, not

discussed here.

Most pediatric masses are the result of a self-limited bacterial or viral infection. It is important

to be able to distinguish inflammatory masses or normal neck structures from masses that

require intervention or referral.

Historical investigations

Patient age and duration of symptoms are the most important points in historical evaluation.

Abnormal historical features:

Demographic characteristics

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palpable nodes or masses in neonates/newborns irrespective of its size

palpable nodes or masses >1cm in children aged 6-12mo

persistent palpable nodes/masses >3cm in children aged >12y/o

Mass size over time increase in size at initial 2 week follow-up

no change in size after 6 weeks for any child

failure of lesion to decrease to size considered within normal limits by 6-8 weeks

Head and Neck symptoms Absence of URTI history or findings

Chronic unilateral nasal discharge or bleeding

Referred ear pain (otalgia)

Hearing loss (unilateral)

Difficulty handling secretions

Voice changes (hoarse, muffled)

Odynophagia, dysphagia, globus sensation

Systemic symptoms or other body systems Hemoptysis

Cough

Anorexia and/or weight loss

Persistent fatigue, fevers, chills, night sweats

Risk factors for infection or malignancy Infectious contact, travel, pets,

Irradiation, family history of malignancy

Physical Examination

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An accurate description of the location and palpable characteristics of the mass or masses is the

most important aspect of the physical exam. A full Head and Neck examination should also be

done to identify any primary sites of malignancy or infection, including tympanic membranes,

nasal mucosa, and oropharynx.

Mass characteristics indicate much about the underlying pathology (Adapted from (2))

Characteristic Normal Abnorma

Size 1.5cm

Mobility Mobile or fixed

Consistency Soft, fleshy Firm, rubb

Parotid or thyroid gland mass No Yes

Hoarseness, stridor No Yes

Otalgia with normal ear exam No Yes

Neck muscle weakness or altered sensation No Yes

Though mass tenderness is important to note and may be indicative of inflammation, it

may not be especially useful as infectious, congenital, and neoplastic masses can all be

tender or nontender at different times.

Otitis media is common in children so unilateral serous effusion is less worrisome than in

adults, particularly if there is was diagnosis of acute otitis media in recent weeks (or

chronic/recurrent otitis media)

Supraclavicular or posterior triangle masses are more suspicious than anterior chain

adenitis

Differential Diagnosis

Many neck masses tend to occur in consistent locations:

Midline Thyroglossal duct cyst, ectopic thyroid tissue

Associated with sternocleidomastoid (SCM) Branchial cleft anomalies

Associated with thyroid gland Diffuse enlargement or nodule of thyroid (be

Associated with major salivary glands Sialoadenitis, salivary neoplasm

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Lymph node routes clusters Inflammatory/neoplastic adenopathy

Malignancy

Malignant masses are uncommon in children, but when do occur are most often lymphomas or

soft-tissue sarcomas. Rhabdomyosarcoma is the most common soft tissue malignancy. In

contrast, in adults over 40 years of age, a malignant neoplasm causes 80% of solitary neckmasses.(2)

Click here to see lymph nodes associated with metastasis

Selected congenital masses

The thyroglossal duct cyst is usually found close to midline superior to the thyroid gland

and may elevate on swallowing or tongue protrusion. It is a thyroid tissue remnant left

during embryological descent of the thyroid anlage from the foramen cecum of the

tongue to its final position anterior to the trachea. Removal by a head and neck surgeon

is often recommended due to risk of future inflammation/infection.

Fig. 2: Path of descent and sites of ectopic thyroid remnants during embryonic development.

(From (4))

Branchial cleft cysts will often present as a mass under the sternocleidomastoid muscle.

A sinus/fistula tract opening may be visible on the skin anterior to the junction of the

middle and lower thirds of the sternocleidomastoid muscle, and it may enlarge rapidly

after an URTI. Saliva or mucoid/mucopurulent material may be seen to drain from it and

there may be communication with the aerodigestive tract. Several variants exist.

Branchial cleft cysts, sinuses, and fistulae are remnants of pharyngeal embryological

development, description of which being too complex for this discussion. Careful note

should be made of external ear malformations or pits, facial nerve palsies, and hearing

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deficits. If suspected, referral to an otolaryngologist should be made for assessment and

possible excision.

Hemangiomas are the most common of all congenital anomalies. They often present as a

soft, painless, and compressible mass on any skin or mucosal surface or within bone,

muscle, or glands. Hemangiomas near the skin are usually red to violaceous. Manydifferent types exist, from a port wine stain, for example, which is a pink or red mark that

does not blanch with pressure, to a cavernous hemangioma, which is a red or purple bag

of worms that increases in size on valsalva. They result from inappropriate development

of vascular endothelium and channels and associated nervous components. Spontaneous

involution is most common. Observation is initally recommended, but referral may be

made to a dermatologist, plastic surgeon, or head and neck surgeon, as required for

persistent lesions.

Lymphangioma or cystic hygromas are uncommon benign cystic masses that are soft,

slow growing, painless masses with a doughy consistency. Often they can be

transilluminated. They rarely present at birth but develop during the first several months

of infancy. Most present before 2 years of age. Surgical excision is the treatment of

choice but recurrence rates are high.

Summary

Most often, pediatric neck masses are inflammatory cervical lymphadenitis that can be observed

for 2 weeks with or without antibiotic therapy dependent on suspected etiology. However, there

should be a strong index of suspicion for potentially malignant masses and immediate referral

should be made to a head and neck surgeon for further evaluation.

REFERENCES

(1) Eric Schwetschenau, Daniel J Kelly. The Adult Neck Mass. American Family Physician66[5], 831-838. 2002.

Ref Type: Journal (Full)

(2) William B Armstrong, Mark F Giglio. Is this lump in the neck anything to worry about?

How to recognize warning signs of an abnormal mass. Postgraduate Medicine 104[3], 63-76.

1998.

Ref Type: Journal (Full)

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(3) Kyle Kennedy, Norman Friedman. Pediatric Head and Neck Tumors. Francis Quinn Jr,

editor. Grand Rounds Presentation, Department of Otolaryngology, University of Texas

Medical Branch . 1999.

Ref Type: Report

(4) Keith L Moore, T.V.N.Persaud. The Pharyngeal (Branchial) Apparatus. In: Keith LMoore, T.V.N.Persaud, editors. Before We Are Born: Essentials of Embryology and Birth

Defects. Philadelphia, Pennsylvania: W.B. Saunders Company, 2005: 197-239.

Acknowledgments

Written by: Stephen Kennedy

Edited by Jeff Bishop

Last updated on February 9, 2011 @4:56 pm

I. EpidemiologyA.Neck masses in children are benign in 90% cases

II. Etiologies: Congenital Neck Mass (55%). Thyroglossal Duct Cyst

A.Dermoid cyst

B.Sebaceous Cyst

C.Branchial Cleft Cyst

D.Lymphangioma orCystic Hygroma

E.Hemangioma

F.Teratoma

G.Thymic CystH.BronchogenicCystI.Laryngocele

III. Etiologies: Inflammatory Neck Mass (27%). Reactive Lymphadenopathy

1.Present in 40% infants

2.Present in 55% all healthy children

3.Cervical node size

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4.Cervical node size

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2.Cystic Hygroma3.Sialadenitis

4.AtypicalMycobacterial Infection

5.Cat-Scratch Disease

A.Carotid

1.Lymphadenitis

2.Branchial Cleft Cyst3.Cystic HygromaB.Submental

1.Lymphadenitis

2.Thyroglossal Duct Cyst

3.Dermoid cyst

4.Cystic Hygroma

C.Midline

1.Thyroglossal Duct Cyst2.Dermoid cyst3.Lymphadenitis

D.Anterior Sternocleidomastoid

1.Lymphadenitis

2.Branchial Cleft Cyst

VI. Etiologies by Location: Pre-auricular. Lymphadenitis

A.Cystic HygromaB.Parotitis

C.AtypicalMycobacterial Infection

D.Cat Scratch DiseaseVII. Etiologies by Location: Posterior Triangle. Occipital

1.Lymphadenitis

2.Lymphoma

3.Metastatic Disease4.Cystic Hygroma

A.Supraclavicular

1.Lymphoma

2.Cystic Hygroma

3.Metastatic Disease

4.Mediastinal disease. Tuberculosis

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a.Histoplasmosisb.Sarcoidosis

VIII. Criteria for Cervical Node Biopsy. Palpable node present in newborn

A.Node has increased in size after two weeks

B.Node has not decreased in size after 4-6 weeks

C.Node has not regressed to normal size within 8-12 weeksD.Signs of serious disease indicate early biopsy

1.Progressively enlarging firm-hard node >2 cm

diameter

2.Supraclavicular adenopathy (no pulmonary infection)

3.Persistent fever or weight loss

4.Fixation of node to adjacent tissue

5.Node in atypical site

. Posterior trianglea.Deep to Sternocleidomastoid

IX. References. Townsend (2001) Sabiston Surgery p. 1498-500

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