Adults who have an asymptomatic neck mass should be considered to have a malignancy until proven otherwise.11 In contrast, majority of neck masses in children are benign in nature.8,10,12 These neck masses can be classified into four general categories that include inflammatory, congenital, neoplastic, and traumatic conditions (Table 17–2).
The vast majority of pediatric neck masses fall under this category. Viral upper respiratory tract infection is the most common cause of bilateral cervical lymph node enlargement. Other viral infections such as pharyngitis, conjunctivitis, and stomatitis are causes easily identified on physical examination. It is not unusual for viral infections to cause nodal enlargement in two or more noncontiguous sites. Most cases of cervical lymphadenopathy are reactive in nature, self-limited, and require no treatment.
Bacterial infections of the head and neck often cause unilateral lymph node enlargement. Cervical adenitis results when this enlargement is accompanied by local tenderness, redness, and warmth (Fig. 17–3). This is usually accompanied by systemic symptoms such as fever and irritability. Because 80% of all cases of acute adenitis are caused by Streptococcus and Staphylococcus, the antimicrobial therapy of choice is a first-generation cephalosporin, oxacillin, or clindamycin.9 Anaerobic organisms should be considered when the cause of the adenitis is from an odontogenic infection. Failure to respond to oral antibiotics, abscess formation, concomitant cellulitis, or systemic toxicity necessitates hospitalization for intravenous antibiotics (Fig. 17–4). Computed tomography (CT) of the neck with contrast or ultrasonography is helpful in distinguishing a lesion that has progressed into an abscess that may require incision and drainage.
Lateral neck of a child with a retropharyngeal abscess showing widening of the retrophayngeal space.
Right submandibular neck abscess.
Occasionally, the emergency physician may encounter a patient with a neck mass that is minimally tender, nonfluctuant, slowly enlarging over a few days or weeks with no obvious source or systemic symptoms. The differential diagnoses of such a mass is wide and consideration should be given to atypical mycobacterium as well as mycobacterium tuberculosis infection, infectious mononucleosis, cat scratch disease, HIV infection, sarcoidosis, actinomycosis, and toxoplasmosis. If a patient has not been treated, a course of an appropriate oral antibiotic is indicated with close follow-up to assess response to treatment. Ancillary testing may be initiated depending on the history and physical examination. This may include a complete blood count and a chest radiograph to detect pulmonary infiltrates or mediastinal adenopathy. Persistence of the mass despite antibiotics, suspicion of malignancy, or other esoteric etiology necessitates a referral to an infectious disease specialist or to an otolaryngologist for a biopsy.
Atypical mycobacteria also known as nontubercular mycobacteria (NTM) and in particular, mycobacterium avium complex (MAC), presents as a chronic cervical adenitis. This is usually seen in children between 1 and 5 years of age. The bacteria gain entry from a breakdown in the mucous membranes of the oropharynx and tonsils and then invade the regional lymph nodes. The usual presentation is that of an enlarged lymph node in the submandibular region that has a rubbery consistency, minimal tenderness, and a dull reddish color (Fig. 17–5). Occasionally, a draining sinus is present (Fig. 17–6). The treatment of choice is complete surgical resection or curettage of the node as most atypical mycobacteria respond poorly to antibiotics.13
Atypical mycobacterial infection of the neck. (Courtesy of Glenn Issacson, MD, Temple University School of Medicine.)
Draining sinus in atypical mycobacteria. (Courtesy of Christopher Russo, MD, St. Christopher's Hospital for Children.)
Bartonella henselae, the organism responsible for cat scratch disease, is a common cause of regional lymphadenopathy. The enlarged node usually involves the axillary area but occasionally can affect the cervical, epitrochlear, or inguinal nodes as well. Recent contact with a cat or kitten can be obtained in the majority of patients. A papule at the site of the inoculation is frequently noted, followed in 1 to 2 weeks by the development of tender, indurated, erythematous skin overlying the enlarged node in the lymphatic chain that drains the site of infection. Systemic symptoms such as fever and malaise are seen in about a third of the patients. Management consists of symptomatic relief, as the disease is usually self-limited, resolving spontaneously in 2 to 4 months. In patients with systemic involvement or painful adenitis, antibiotics such as trimethoprim-sulfamethoxazole, rifampin, azithromycin, ciprofloxacin, or parenteral gentamicin may be effective in ameliorating symptoms.14
Other inflammatory conditions to consider are infections of the salivary glands or sialadenitis. This can present as a tender and swollen mass in the area of the submandibular or parotid glands. Occasionally, the condition can be bilateral as in parotitis caused by the mumps virus. Majority can be treated with conservative measures such as hydration, pain relief, application of moist heat, and sialogogues. In those with bacterial superinfection, broad-spectrum antibiotics effective against staphylococcus, streptococcus, and anaerobic flora should be initiated.
Minor trauma to the neck and a variety of other conditions can cause spasm of the cervical muscles, primarily the sternocleidomastoid. Underlying etiologies of torticollis include upper respiratory infection, cervical adenitis, retropharyngeal abscess, atlantoaxial rotatory subluxation and rarely, dystonic reactions or intracranial and spinal cord tumors.15,16 Major traumatic injuries to the neck are covered in Chapter 30.
Congenital torticollis is suspected when an infant, usually at 2 to 8 weeks of age, presents with an ipsilateral neck mass with the head tilted toward it and the chin in the opposite direction. The cause of congenital torticollis is still not clear, although it may be related to bleeding into the sternocleidomastoid muscle from a difficult delivery.17 The onset of marked facial hypoplasia or asymmetry is an indication for surgical transection of the middle third of the affected sternocleidomastoid muscle.18
Hemangiomas are the most common congenital lesions of the head and neck. These lesions are red or purplish in color, flat or raised, and blanch with pressure. They grow rapidly in the first few months of life, slowly regress afterwards, and may even disappear with time. Close observation is the rule unless the lesions cause airway obstruction, high-output cardiac failure, thrombocytopenia or hemorrhage, and coagulopathy (Kasabach–Merritt syndrome).
Thyroglossal duct cysts arise from the vestiges of the thyroglossal duct that runs in the middle of the neck from the base of the tongue to the thyroid gland (Fig. 17–7). These cysts enlarge after bouts of upper respiratory infections. One clue that points toward a thyroglossal cyst aside from its midline location is that protusion of the tongue will retract the lesion. Majority of these cysts manifests between the age of 2 and 10 years, although a third do not become apparent until after the second decade of life.8,19 Infection is common because of the persistent communication with the base of the tongue and the oral flora. Once the infection has been treated, surgical excision to remove the cyst and its entire tract can follow.
Patient with thyroglossal duct cyst.
When primordial lymphatic ducts fail to establish drainage into the venous system, multiloculated cystic masses or cystic hygromas are formed. These lesions are found in areas where lymphatic ducts drain into large veins such as the neck, axilla, and mediastinum. The left side of the neck is frequently involved because it is where the thoracic duct enters the subclavian vein.7 Majority of the lesions are identified at birth, although some may not be diagnosed until the second decade of life or unless they become infected. There is a strong association between congenital cystic hygromas of the neck and Turner syndrome.20,21
Anomalous development of the branchial arches and cleft produces brachial cysts, sinuses, fistulae, or skin tags in the neck. Most branchial cleft anomalies originate from the second cleft. These painless cysts or sinuses are usually seen at the anterior border of the middle to lower third of the sternocleidomastoid muscle. They can become secondarily infected (Fig. 17–8). Brachial cysts are more commonly diagnosed after the first decade of life while fistulas are usually diagnosed shortly after birth.7,8
CT scan of an infected brachial cleft cyst. (Courtesy of William Collins, MD, University of Florida, Gainsville.)
Malignant neoplasms of the head and neck account for approximately 5% of all malignancies in childhood.22 Ninety percent of neck cancers in children are mesenchymal in origin in contrast to adults where the squamous cell line is involved.23 The most common malignancies of the neck are lymphomas (Hodgkin and non-Hodgkin lymphomas) and soft tissue sarcomas, primarily rhabdomyosarcoma. The neck is second to the orbit as a common site of rhabdomyosarcoma. The tumor presents as a rapidly enlarging, painless neck mass that is hard and immobile. Other tumors include neuroblastoma and lymph node metastasis from malignancies of the skin and thyroid. These masses tend to be hard and fixed to the underlying structures.