1. Neck Mass

2. Life-Threatening Causes Of Neck Mass
Hematoma secondary to trauma
Cervical spine injury
Vascular compromise or acute bleeding
Late Arteriovenous fistula
Subcutaneous emphysema with associated airway or pulmonary injury
Local hypersensitivity reaction (sting/bite) with airway edema
Airway compromise with epiglotitis, tonsillar abscess, Ludwig’s angina or retropharyngeal abscess

3. Life-Threatening Causes Of Neck Mass
Bacteremia/Sepsis associated with a local neck infection of a cyst
Non-Hodkin’s lymphoma with mediastinal mass and airway compromise
Thyroid storm
Kawasaki disease with coronary vasculitis
Tumor : Leukemia, Lymphoma, Rhabdomyosarcoma
Lemierre’s Syndrome

4. Differential Diagnosis by Etiology
Congenital
Inflammatory
Trauma
Neoplasm

5. Congenital Masses Thyroglossal duct cyst Cystic hygromas
Branchial cleft cyst
Hemangiomas
Neonatal Torticollis = Fibromatosis colli
Dermoid cyst

6. Thyroglossal Duct Cysts
Congenital Masses
Thyroglossal Duct Cysts
Most common congenital cyst of the neck
Develop anywhere from the base of the tongue to sternal notch of the anterior angle
Fails to obliterate before formation of the hyoid bone
Usually midline, adjacent to hyoid bone
Dx Before than 10 years of age
Soft, non tender, smooth and they move cranially when child swallows or protrude their tongue
If infected: warm, erythematous, drainage

7. Thyroglossal Duct Cysts
Antibiotics
Warm Compress
Incision and Drainage
Complete excision – treatment of choice after complete resolution of infection

8. Cystic Hygromas
Cystic lymphatic malformation in the posterior triangle of the neck
Most diagnosed at birth
Hx of trauma or URI
90% present before 2 years of age
Discrete, soft , mobile, non tender and vary greatly in size
Extension to mediastinum – Chylothorax or chylomediastinum, rarely airway compromise
Infection is uncommon

9. Cystic Hygromas
CXR US
CT or MRI to determine extent and involvement of surrounding structures
Treatment: Complete excision

10. Branchial cleft anomalies
Defect in the development of the second branchial arch
Firm masses along the anterior border of the sternocleidomastoid muscle
Branchial clefts sinuses: Painless, drainage
Cysts: fluctuant, mobile , nontender if the sinus tract becomes block
Cysts may become infected – painful and warm
Incision and drainage of a branchial lesion should be avoided because it may result in fistula formation

11. Branchial cleft anomalies
US : thin walled , anechoic, fluid filled cyst
Treatment
Antibiotics if infected
Excision of entire tract and cyst to prevent recurrence

12. Hemangiomas
Capillary hemangiomas, strawberry hemangiomas, capillary-cavernous hemangiomas noticed in infancy
Soft, mobile , nontender, bluish or reddish
Larger in the first year and involute over next several years
When located in the beard distribution associated with glottic and subglottic hemangiomas, increasing the risk for airway compromise
Tx: Conservative and nonoperative
Corticosteroids, laser tx, resection

13. Neonatal Torticollis
Sternocleidomastoid fibrosis and shortening of the muscle
Occur in the first 3 weeks of life
Infant holding chin and face away from affected side
Head tilted toward fibrous mass
Mass is firm , attached to muscle
Tx: Physical therapy- massage , ROM exercises, stretching exercises and positional changes
Complications: Facial and cranial asymmetry w/o intervention

14. Inflammatory Neck Masses
Cervical Lymphadenophaty
Cervical Lymphadenitis
Cat-Scratch disease
Mycobacterial infection
Lemierre’s Syndrome
Retropharyngeal abscess
Kawasaki disease

15. Cervical Lymphadenopathy
Most common reason for neck masses in children
90% between 4 -8 years can have cervical adenopathy without obvious infection or systemic illness
Newborns and infants warrants investigation
Anterior cervical LN: URI, oral or pharyngeal infections
Posterior cervical LN: drains scalp and nasopharynx
Supraclavicular LN: pathologic and needs biopsy
Etiology: bacterial or viral infections
Treat underlying infection

16. Cervical Lymphadenitis
Acute infection within the lymph node
MRSA, GAS, H. Influenza, Anaerobic and virus
Hx of previous URI
One or more cervical LN becomes enlarged, tender, warm and erythematous
Systemic symptoms
Antibiotics (B-lactamase resistant) & warm compresses
If failure: Serology, US, I&D
If Toxic : Admit for IV antibiotics
Complications: cellulitis and Abscess formation

17. Cat-scratch disease Another common cause of LN enlargement in children
Regional LN enlarge 2-4 weeks after scratch
Fever and malaise (30%)
Single node involvement
Warm, tender, indurated and erythema
Serology testing : IFA, PCR
Symptomatic treatment
Surgical excision can lead to formation of a draining sinus
Antibiotics : systemic illness, immunocompromised
Oral zithromax, Rifampin, TMT-SMZ, Ciprofloxacin

18. Mycobacterial infection of the cervical LN
Atypical strains: MAI and M. Scrofulaceum
Submandibular, red, rubbery and minimally tender to palpation
If systemic complications are present consider immunodeficiency
Clinical systemic signs of M. Tuberculosis: cervical and supraclavicular LN are commonly involved
PPD and CXR
PPD may be negative in atypical mycobacterium
Excisional biopsy: need to be performed to differentiate between tuberculous and non- Tb

19. Mycobacterial infection of the cervical LN
Tx for Atypical mycobacterium
Complete Surgical Excision
Incision and drainage result in a draining sinus
Tx for M. tuberculosis lymphadenitis
6-9 month of antituberculosis chemotherapy

20. Lemierre’s Syndrome Infection of the parapharyngeal space
Septic thrombophlebitis of the internal jugular vein
Septic embolization to lungs/CNS
Adolescents
Sore throat, fever, fullness to one side of the neck, trismus, neck pain, dysphagia, dyspnea, toxic appearing
Microbiology: G (-) Fusobacterium necrophorum
Antibiotics for 6 weeks

21. Neoplasms Fortunately 80-90% of neck masses in children are benign
Usually painless, firm, fixed cervical mass
Systemic symptoms may not be present

22. Neoplasm Findings that prompt work up include:
Supraclavicular lymphadenopathy
LN larger than 2 cm in diameter
Enlarged LN > 2 weeks
No decreased in size of a LN after 4-6 weeks
Lack of inflammation
Firm, rubbery consistency
Ulceration
Failure to respond to antibiotics
Systemic symptoms

23. Neoplasm Hodgkin and non- Hodgkin Lymphoma
Rhabdomyosarcoma, Neuroblastoma, Thyroid
Nasopharyngeal carcinomas and Teratomas
CBC
CXR
Selective CT
MRI

24. Laboratory Testing CBC PT, PTT Thyroid studies Throat cultures
EBV Serology
C-spine Xray
CXR
Ultrasound
Neck CT

25. Therapy No therapy PO Antibiotics
Follow up in several days to monitor clinical response and need for aspiration and drainage
Surgical consultation for suspected tumor or congenital cysts
Hospitalization
Systemic toxicity
Airway compromise
Severe local disease