Paediatric neck mass

Red flags and associations

• Fever/chills/night sweats/weight loss – Infection/lymphoma
• Easy bruising/bleeding – Leukaemia
• Neck skin lesion – Infection/neoplasm
• Jaundice
• Arthritis – Lupus/rheumatoid
• Generalised lymphadenopathy in 2 or more anatomical regions correlated with serious systemic disease
• Bilateral, mobile, non-tender associated with viral infection
• Painful/tender lymphadenopathy often associated with infection
• Exposure to cats/radiation/tuberculosis
• Supraclavicular nodes pathological
• Splenomegaly

Neck mass by location

• Anterior midline
  • Thyroglossal cyst
  • Acute cervical lymphadenitis
  • Dermoid and epidermoid cysts
  • Goitre
  • Ludwig angina
  • Lymphoma
  • Thyroid tumour
  • Thyroiditis
  • Fractured larynx

• Anterior triangle
  • Acute cervical lymphadenitis
  • Brachial cleft lesion
  • Cat scratch disease
  • Haemangioma
  • Haematoma
  • Laryngocoele
  • Lymphoma
  • Salivary gland tumour
  • Sialedinitis
  • Mumps
  • Atypical mycobacteria

• Sternomastoid
  • Torticollis
• Posterior triangle
  • Acute cervical lymphadenitis
  • Cystic hygroma
  • Lymphoma
  • Neuroblastoma
  • Rhabdomyosarcoma
  • Haematoma

Neck mass by type

• Inflammatory
  • Acute cervical lymphadenitis
  • Facial and deep neck infections
  • TB
  • Ludwig angina
  • Mumps
  • EBV
  • Atypical mycobacteria
  • Cat scratch disease
  • HIV/AIDS
  • Toxoplasmosis
  • Kawsaki disease

• Fungal
  • Coccidiomycosis
  • Blastomycosis
  • Histoplasmosis
• Congenital
  • Branchial cleft lesion
  • Thyroglossal cyst
  • Dermoid/epidermoid cyst
  • Teratoma
  • Lipoma
  • Cystic hygroma
  • Mucous retention cyst
  • Laryngocoele
  • Thymic cyst

• Thyroid
  • Thyroid tumour
  • Thyrotoxicosis
  • Hashimotos
• Tumors
  • Leukaemia
  • Lymphoma
  • Neuroblastoma
  • Rhabdomyosarcoma
  • Hodgkin disease

• Salivary gland mass
  • Parotitis
  • Sialedinitis
• Trauma
  • Haematoma
  • Pseudoaneurysm
  • Fractured larynx
  • Torticollis

Diagnosis

• X-ray:
  • Lateral neck film calcification may suggest teratoma or neuroblastoma
  • CXR if respiratory distress, suspicious for TB
  • Thyroid scan if TFT’s abnormal
• USS
  • Initial scan of choice
• CT
  • If deep structures considered likely to be involved
  • Careful lying flat if mediastinal mass considered/airway compromise/sedation required
• Biopsy

Management of acute adenitis (RCH)

• Fluctuant node – I&D *unless TB suspected as sinus formation occurs
• Well
  • Oral flucloxacillin for 10 days with review in 48 hours
• Neonates, unwell or failed oral Rx
  • IV flucloxacillin and admission
• Investigations for persistent adenitis
  • FBC/film – Infectious or leukaemia/lymphoma
  • Serology – EBV, CMV, HIV, Toxoplasmosis, Bartonella henselae
  • Mantoux
  • CXR
  • CT pre-operatively possibly
  • Excision biopsy

Persistent enlargement of nodes >2 weeks (RCH)

• Atopic eczema
  • Often more prominent on posterior of neck and usually bilateral
• Infections
  • EBV/CMV – Generalised lymphadenopathy and hepatosplenomegaly
  • MAC
  • TB
  • Cat scratch
  • Toxoplasma gondii – Generalised lymphadenopathy, fatigue, myalgia
  • HIV
• Malignancy
  • Lymphoma/leukaemia
• Rheumatological
  • Juvenile RA
  • SLE

When to biopsy?

• Palpable node in newborn
• Persistent enlargement >1cm after 2 weeks of antibiotics for presumed bacterial lymphadenitis
• Progressively enlarging non-tender rubbery node over 2cm
• Persistent B symptoms
• Fixed, non-mobile, matted nodes
• Unexplained or rising ESR
• Suspicious FBC/CXR
• Generalised lymphadenopathy without cause
• Node in atypical site i.e. posterior triangle deep to SCM or supraclavicular

Specific diagnoses

Neoplastic neck masses

• 90% of neck masses in children are benign
• Malignancy more likely in posterior triangle and supraclavicular region
• Hard, painless, immobile
• Lymphoma is most common
• Rhabdomyosarcoma second
• When to biopsy (See below)

Atypical mycobacteria

• MAC
• Common cause of chronic neck mass in developed nations
• Ubiquitous in the environment
• Seen in children aged 1-5 in rural areas mostly (rare over 12 yo)
• Human to human transmission does not occur
• Present with subacute gradual enlargement of unilateral, firm and non-tender mass
• 50% become fluctuant and 10% drain spontaneously
• May disseminate in immunocompromised
• May require biopsy for diagnosis
• Treatment: Complete surgical excision
  • Incision and drainge leads to sinus formation
  • Some may resolve spontaneously over 3-12 months
  • Most respond poorly to antibiotics but liaise with ID

Cervical tuberculosis

• Aka scrofula
• May be lympho-haematogenous spread from paratracheal nodes or direct spread from apical pleura to supraclavicular nodes
• Matted, firm nodes +- tender, erythematous, indurated
• Chronic, slow-growing and mostly unilateral
• Generalised lymphadenopathy in 10-20%
• Abnormal CXR in 15-20%
• Often suppurates and forms sinus
• Diagnosis may require Mantoux and biopsy
• Treat as for pulmonary TB

Neck dermoid cyst

• Cystic teratoma containing all types of mature epidermal tissue
• Due to developmental inclusion of epidermis
• Almost always benign and slow growing
• Mobile, painless, soft and superficial. Can become very large
• No elevation with tongue protrusion (vs. thyroglossal cyst)
• May have punctum
• Usually paramedian or in midline
• May become inflamed/infected
• Complete surgical excision is definitive treatment (recurs if incised)

Cystic hygroma

• Aka lymphangioma
• Congenital multiloculated lymphatic malformation
• 65-75% present at birth; 80-90% by 2^nd year of life
• 75% in the neck
• 2:1 left sided
• Strongly associated with Turner syndrome
• Discrete, soft, motile, non-tender, compressible lobulated mass
• Transilluminates
• Grows in proportion to child
• No clear treatment better than another but has airway risks

Thyroglossal duct cyst

• Soft, smooth, round, non-tender midline mass that rises with tongue protrusion
  • Although absence of elevation does not rule this out
• Rarely discharges
• Sudden increase in size can occur with viral URTI
• Usually age 2-10yo when appears
• Requires surgical excision
  • Recurrence rate of 5%
• Thyroid cancer in <1% (papillary adenocarcinoma)
• Ectopic thyroid tissue in 1/3

Thyroid tumours

• Papillary cancer accounts for 60-80% of malignant thyroid tumours in children
• There is a 25-30% chance that a thyroid nodule found in a child will be malignant
  • Much more likely than in adults
• Radiation therapy increases risk 50-fold
• Presents as solitary, hard, painless nodule in a euthyroid patient with otherwise normal thyroid gland
• FNA is simplest method of diagnosis
• Thyroid scan
  • Cold nodule increases suspicion of malignancy
  • Hot nodule is almost invariably benign
• Usually indolent course with excellent prognosis

Last Updated on November 22, 2021 by Andrew Crofton