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Neck masses are a common complaint seen in children presenting to the ED. Ninety percent are benign in nature.1 Congenital, inflammatory, and malignant lesions make up most of the masses in the pediatric head and neck region.2,3 This chapter provides an overview of pediatric neck masses and outlines a simplified approach to their clinical diagnoses and management.

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Neck masses can be classified by anatomic site of presentation (Figure 118-1) or by pathology. Table 118-1 presents a combined approach that is practical for the ED.

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Figure 118-1.
Graphic Jump Location

Neck anatomy and cervical triangles.

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Table Graphic Jump Location
Table 118-1 Neck Masses in Children 
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Presentation and General Approach

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Neck swelling, even when asymptomatic and incidentally discovered, is often of great concern to the caretaker. Some inflammatory masses are insidious, and others may progress rapidly. Infectious causes must be distinguished from noninfectious causes. Associated symptoms of fever, chills, pain, recent upper respiratory or GI infections help to identify infection. A family history of illnesses and sick contacts, exposure to domestic animals (particularly cats), and diet (exposure to undercooked meat) also suggest infection. Determine immunization status. Note the size, location, and feel of the mass, the color of overlying skin, its relationship to underlying structures, its mobility, and whether the mass is tender or warm, firm, rubbery, or fluctuant. Benign reactive lymph nodes are usually mobile, firm, not attached to undersurfaces, and mildly tender; cystic masses are usually soft, ballotable and mobile masses; malignant lesions are more frequently hard, nontender, and may be fixed to underlying structures and therefore immobile.

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Further diagnostic studies are directed by the clinical presentation. Localized, uncomplicated cervical lymphadenitis, for instance, usually does not require further investigation and may be empirically treated with antibiotics. If the mass does not regress with antibiotics, blood testing (complete blood count, erythrocyte sedimentation rate, cultures, serologies) or imaging with CT, MRI, or US may be needed. Some masses may require tissue diagnosis with fine needle aspiration or biopsy, and others may require incision and drainage with staining and culture of purulent material. Subacute and chronic cases may be evaluated with special testing for Bartonella henselae, mycobacteria, or fungi. Skin testing for tuberculosis may be indicated.

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