Neck Mass

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

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

Differential Diagnosis by Etiology Congenital Inflammatory Trauma Neoplasm

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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