Key points
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Most pediatric neck masses are infectious and resolve without intervention.
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Isolated masses less than 2 cm can be observed for 4 to 6 weeks.
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Pediatric histories should address sick contacts and other vectors.
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Atypical mycobacterium, Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus, and toxoplasmosis should be considered for a suspected infectious process not responding to antibiotic therapy.
Introduction
Neck masses in the pediatric population are a common occurrence. Fortunately, 80% to 90% of pediatric neck masses are benign in nature, with the majority stemming from infectious sources. Infectious processes are usually self-limiting or respond to a short course of oral antibiotics. Other less common sources of pediatric neck masses include congenital malformations, benign neoplasms, and rarely malignancies. Although rare, a malignancy should always be considered in the pediatric patient with a neck mass, and at times biopsy may be indicated.
Introduction
Neck masses in the pediatric population are a common occurrence. Fortunately, 80% to 90% of pediatric neck masses are benign in nature, with the majority stemming from infectious sources. Infectious processes are usually self-limiting or respond to a short course of oral antibiotics. Other less common sources of pediatric neck masses include congenital malformations, benign neoplasms, and rarely malignancies. Although rare, a malignancy should always be considered in the pediatric patient with a neck mass, and at times biopsy may be indicated.
History and physical examination
A thorough history and physical examination are of utmost importance when dealing with pediatric neck masses. Unfortunately symptoms may be difficult to elicit from children, and much of the history must be obtained through parents or caregivers. This requires the clinician to maintain a high index of suspicion and a low threshold for ordering diagnostic studies. Patient cooperation may also limit physical examination, further lending to the need for additional studies. Vital points in a pediatric neck mass history and physical examination along with possible implications include
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Duration
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Present since birth typically indicates a benign or congenital process; malignant processes are almost never congenital
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Vascular malformations generally are present at birth and grow with the child
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Hemangiomas develop shortly after birth with a rapid growth phase
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New rapidly growing masses are typically infectious
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Constitutional symptoms
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Fevers and tenderness are typically infectious signs
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Recent upper respiratory tract infection suggests reactive lymphadenopathy
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Symptoms such as fever, malaise, and weight loss may suggest malignancy
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Contact with pets or other vectors
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Cats or cat feces
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Wild animals
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Tick bites
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Contact with sick children or family members
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Foreign travel
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Location of mass
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Midline cystic lesions are typically dermoid or thyroglossal duct cysts (TGDC)
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Lateral neck masses are most commonly reactive lymphadenitis or brachial cleft cysts
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Consistency and relationship to surrounding structures
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Shotty lymphadenopathy (multiple small lymph nodes that feel like buckshot) typically indicates reactive lymphadenopathy
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Hard irregular masses, fixed to deep or surrounding structures may indicate malignancy
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Size
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Cervical lymph nodes up to 1 cm in size are normal in children younger than 12
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A thorough history and physical examination should assist the clinician in placing the mass in one of 3 categories: congenital, infectious, or neoplastic. The most common etiologies of each category are summarized in Table 1 .
| Location | Diagnosis | ||
|---|---|---|---|
| Developmental | Inflammatory/Reactive | Neoplastic | |
| Anterior sternocleidomastoid | Branchial cleft cyst, a vascular malformation | Reactive lymphadenopathy, a lymphadenitis (viral, bacterial), a sternocleidomastoid tumor of infancy | Lymphoma |
| Midline | Thyroglossal duct cyst, a dermoid cyst a | — | Thyroid tumor |
| Occipital | Vascular malformation | Reactive lymphadenopathy, a lymphadenitis a | Metastatic lesion |
| Preauricular | Hemangioma, vascular malformation, type 1 branchial cleft cyst | Reactive lymphadenopathy, a lymphadenitis, a parotitis, a atypical mycobacterium | Pilomatrixoma, salivary gland tumor |
| Submandibular | Branchial cleft cyst, a vascular malformation | Reactive lymphadenopathy, a lymphadenitis, a atypical mycobacterium | Salivary gland tumor |
| Submental | Thyroglossal duct cyst, a dermoid cyst a | Reactive lymphadenopathy, a lymphadenitis (viral, bacterial) a | — |
| Supraclavicular | Vascular malformation | — | Lymphoma, a metastatic lesion |
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