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.
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
Neck anatomy and cervical triangles.
Table 118-1 Neck Masses
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Table 118-1 Neck Masses
|Inflammatory Neck Masses||Cystic Neck Masses||Solid Neck Masses|
|Cervical lymphadenopathy||Congenital malformations||Benign lesions|
|Suppurative lymph nodes||Thyroglossal duct cysts||Inflammatory adenopathy|
|Granulomatous disease||Branchial apparatus cyst||Lipoma/lipoblastoma|
|Fistulas||Salivary gland masses|
|Cat scratch disease||Dermoid cysts||Epidermal inclusion cysts|
|Actinomycosis||Lymphangioma (cystic hygroma)||Drugs|
and General Approach
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.
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.