Pediatric Neck Masses: Congenital Lesions, Evaluation & Treatment

Most important patient factor when evaluating a neck mass

Patient age.

Most common categories of pediatric neck masses

Inflammatory and congenital.

Neck mass in a patient older than 40

Consider neoplastic until proven otherwise, especially with tobacco or alcohol use.

Important history questions for a neck mass

Duration, growth pattern, pain, voice changes, swallowing difficulty, ear pain, fever, night sweats, weight loss, tobacco, alcohol, and travel.

Important physical examination characteristics of a neck mass

Location, mobility, consistency, and tenderness; examine mucosal and submucosal areas of the head and neck.

Lateral congenital neck mass in a child

Suggests a branchial cleft cyst; laryngocele is another possibility.

Midline congenital anterior neck mass

Suggests a thyroglossal duct cyst.

Supraclavicular neck mass in an older adult

Concerning for metastasis from a primary tumor elsewhere.

Primary imaging modality for most adult neck masses in the lecture

CT.

Role of CT and MRI in evaluating neck masses

Distinguish solid, cystic, and vascular masses; define relationships to vital structures; help identify the primary source.

Role of ultrasound in evaluating neck masses

Distinguishes solid from cystic lesions; especially useful for thyroid lesions and avoiding radiation.

Role of chest X-ray in evaluating neck masses

Evaluates suspected tuberculosis, sarcoidosis, lung malignancy, or pulmonary metastases.

Role of PET in head and neck cancer

Detects increased metabolic activity for staging and surveillance; generally not the initial neck mass study.

Fine-needle aspiration (FNA) of a neck mass

Obtains cells to help distinguish benign, malignant, inflammatory, infectious, and congenital cystic processes.

When might an incisional or excisional biopsy be needed?

When lymphoma requires definitive diagnosis and histopathologic classification.

Branchial cleft cyst: embryologic cause

Incomplete closure or disappearance of a branchial cleft during embryonic development.

Branchial cleft cyst: typical location

Lateral neck, usually along the anterior border of the sternocleidomastoid muscle or below the jaw.

Branchial cleft cyst: typical presentation

Painless lateral neck mass that may become tender and inflamed after an upper respiratory infection.

Branchial cleft cyst: additional examination clues

Skin pits, tags, or a draining sinus or fistula near the neck or collarbone.

Branchial cleft cyst: usual age at presentation

Late childhood or early adulthood, often when it becomes infected.

Branchial cleft cyst: treatment

Control infection first if present, then surgically excise the cyst and tract.

Thyroglossal duct cyst: embryologic cause

Incomplete obliteration of the thyroglossal duct during fetal development.

Most frequently seen congenital head and neck lesion in children in the lecture

Thyroglossal duct cyst.

Thyroglossal duct cyst: classic presentation

Painless midline anterior neck mass that moves with swallowing and tongue protrusion.

Neck mass that moves with tongue protrusion

Thyroglossal duct cyst.

Thyroglossal duct cyst: effect of infection

May enlarge or become symptomatic after an upper respiratory infection.

Thyroglossal duct cyst: diagnosis

History and physical examination.

Thyroglossal duct cyst: definitive treatment

Sistrunk procedure; treat infection with antibiotics when present and refer to otolaryngology.

Branchial cleft cyst versus thyroglossal duct cyst

Branchial cleft cyst is lateral along the anterior sternocleidomastoid border; thyroglossal duct cyst is midline and moves with tongue protrusion.

Cystic hygroma: underlying abnormality

Congenital lymphatic malformation caused by abnormal development or connection of lymphatic channels.

Cystic hygroma: typical location

Side or back of an infant's head or neck.

Cystic hygroma: timing of detection

May be detected prenatally by ultrasound or during infancy.

Cystic hygroma: genetic associations

Turner syndrome, Down syndrome, trisomy 13, trisomy 18, and Noonan syndrome.

Cystic hygroma: complications

Respiratory distress, feeding or swallowing difficulty, infection, and bleeding.

Cystic hygroma: treatment described in the lecture

Surgical excision; complete removal may be difficult when the lesion surrounds vital neck structures.

Dermoid cyst: underlying cause

Entrapment of skin or specialized embryonic cells beneath the surface during fetal development.

Dermoid cyst: possible contents

Hair follicles, sebaceous glands, and sweat glands.

Dermoid cyst: classic presentation

Firm, painless, mobile mass, often in the midline or floor of the mouth.

Dermoid cyst: usual age of recognition

Often noticed by age 5.

Dermoid cyst: treatment

Complete surgical removal.

Lymphangioma: underlying cause

Congenital malformation of lymphatic channels caused by failure of lymphatic spaces to connect properly.

Lymphangioma: examination findings

Soft, doughy, smooth, nontender, compressible mass that may transilluminate.

Lymphangioma: useful imaging

CT or MRI to define the extent and relationship to surrounding structures.

Lymphangioma: treatments described in the lecture

Surgical excision; sclerotherapy may stabilize or decrease the size in some cases.

Hemangioma: classic appearance

Reddish-purple, compressible vascular mass that enlarges with crying or straining.

Hemangioma: auscultation finding

A bruit may be heard.

Hemangioma: typical course

Appears in the first few months of life, grows rapidly early, and later involutes.

Hemangioma: indications for intervention

Airway compromise, skin ulceration, or dysphagia.

Medication used to promote hemangioma involution

Propranolol.

Lymphangioma versus hemangioma

Lymphangioma is a lymphatic lesion that may transilluminate; hemangioma is a reddish-purple vascular lesion that may have a bruit.

Teratoma: tissue origin

Pluripotential cells containing elements from all three germ layers.

Teratoma: typical neck presentation

Firm neck mass recognized at birth or within the first year of life.

Teratoma: major compressive complications

Tracheal compression causes respiratory compromise; esophageal compression causes dysphagia.

Teratoma: treatment

Surgical excision.

Thymus: embryologic origin

Third pharyngeal pouch, called the third branchial pouch in the lecture.

Thymic cyst: underlying cause

Thymic tissue remaining along the pathway of descent into the mediastinum.

Thymic cyst: typical presentation

Slow-growing, asymptomatic neck mass that may become painful if infected.

Thymic cyst: possible compressive symptoms

Dyspnea and dysphagia.

Thymic cyst: diagnostic histologic finding

Hassall corpuscles.

Thymic cyst: treatment

Surgical excision.

Most common cause of cervical adenopathy in children

Reactive viral lymphadenopathy.

Reactive viral lymphadenopathy: common associated viruses

Adenovirus, rhinovirus, and enterovirus.

Reactive viral lymphadenopathy: typical course

Usually regresses within 1-2 weeks.

Reactive viral lymphadenopathy: initial management

Observation.

Reactive cervical lymphadenopathy: lecture criteria for further investigation

A mass greater than 1 cm that enlarges or does not resolve within 4-6 weeks.

EBV-associated lymphadenopathy: accompanying symptoms

Fever and throat pain.

Bacterial suppurative lymphadenopathy: common organisms

Staphylococcus aureus and group A Streptococcus.

Bacterial suppurative lymphadenopathy: typical location and associated symptoms

Submandibular nodes with sore throat, skin lesions, or upper respiratory symptoms.

Bacterial suppurative lymphadenopathy: initial treatment

Empiric antibiotics.

Bacterial suppurative lymphadenopathy: next step if antibiotics fail

Fine-needle aspiration or incision and drainage.

Toxoplasmosis: causative organism

Toxoplasma gondii.

Toxoplasmosis: transmission

Undercooked meat or ingestion of oocysts from cat feces.

Toxoplasmosis: symptoms

Fever, malaise, sore throat, and myalgias with lymphadenopathy.

Toxoplasmosis: diagnosis

Serologic testing.

Tularemia: causative organism

Francisella tularensis.

Tularemia: exposure clues

Rabbits, ticks, or contaminated water.

Tularemia: presentation

Tonsillitis and painful adenopathy with fever, chills, headache, and fatigue.

Tularemia: diagnostic testing

Serology and culture.

Tularemia: antibiotic emphasized in the lecture

Streptomycin.

Brucellosis: causative organism

Brucella species.

Brucellosis: classic exposure

Ingestion of unpasteurized milk.

Brucellosis: presentation

Generalized lymphadenopathy, fever, fatigue, and malaise.

Brucellosis: diagnostic testing

Serology and culture.

Cat-scratch disease: causative organism

Bartonella henselae.

Cat-scratch disease: typical patient and exposure

Patient younger than 20 with a history of cat contact.

Cat-scratch disease: presentation

Tender regional lymphadenopathy, fever, and malaise.

Cat-scratch disease: lymph node locations

Preauricular, submandibular, or axillary nodes.

Cat-scratch disease: diagnostic test

Serology using indirect fluorescent antibodies.

Cat-scratch disease: antibiotic emphasized in the lecture

Azithromycin.

Cat-associated lymphadenopathy: Bartonella versus Toxoplasma

Bartonella follows cat contact or scratches; Toxoplasma follows ingestion of oocysts from cat feces or undercooked meat.

Neoplastic neck mass: concerning characteristics

Slow-growing, firm mass with dysphagia, odynophagia, dysphonia, otalgia, or weight loss.

Most common metastatic malignancy presenting in the neck

Squamous cell carcinoma.

Preferred initial tissue sampling for suspected metastatic neck malignancy

Fine-needle aspiration rather than initial open excision.

Squamous cell carcinoma of the head and neck: possible primary sites

Mouth, throat, larynx, or skin.

Squamous cell carcinoma: major risk factors

Tobacco use, alcohol use, and HPV infection.

Squamous cell carcinoma: possible symptoms

Neck lump, nonhealing sore, sore throat, ear pain, and hoarseness.

Can a metastatic neck mass appear before its primary tumor is identified?

Yes.

Squamous cell carcinoma: treatment modalities

Surgery, radiation, and chemotherapy, depending on the case.

Primary thyroid tumor: typical location

Anterior compartment of the neck.

Thyroid mass: concerning historical features

Hoarseness and a history of neck radiation.