Neck masses

Paediatric cervical masses according to anatomical location
Location	Aetiology
	Congenital	Inflammatory/infective	Neoplastic
Submental	Thyroglossal cyst Dermoid cyst	Sialadenitis Lymphadenitis Reactive lymphadenopathy	Malignant lymphadenopathy Benign connective tissue tumour
Submandibular	Vascular or lymphatic malformation Branchial cleft cyst	Sialadenitis Lymphadenitis Reactive lymphadenopathy	Malignant lymphadenopathy Salivary gland tumour Benign connective tissue tumour
Carotid triangle	Vascular or lymphatic malformation Branchial cleft cyst	Lymphadenitis Reactive lymphadenopathy Sternocleidomastoid tumour of infancy	Malignant lymphadenopathy Benign connective tissue tumour
Muscular triangle	Thyroglossal duct cyst Dermoid cyst	Goitre	Thyroid tumour Benign connective tissue tumour
Posterior triangle	Vascular or lymphatic malformation	Lymphadenitis Reactive lymphadenopathy	Malignant lymphadenopathy Benign connective tissue tumour

Comparison of common benign and red flag conditions
Condition	Pathophysiology	Clinical features	Management
Thyroglossal duct cysts	Congenital abnormality that may present at any age, though typically diagnosed prior to adulthood Occurs as a result of failure of the thyroglossal duct to involute	Most common midline congenital neck mass Arises anywhere along the midline path of the thyroglossal duct Suspect if ongoing midline mass following resolution of infection	If asymptomatic, can be managed conservatively Treatment involves surgical excision (Sistrunk’s procedure)
Branchial cleft abnormality	Congenital abnormality that may present at any age, though typically diagnosed prior to adulthood Occurs as a result of failure of the pharyngeal clefts to involute	Most common lateral congenital neck mass May present as a cyst, sinus or fistula that can become infected Can arise in numerous positions in the head and neck, most typically in the anterolateral neck	If asymptomatic, can be managed conservatively Treatment involves surgical excision
Reactive lymphadenopathy	Occurs secondary to a local infective or inflammatory process May be complicated by secondary infection	Most common cause for paediatric neck mass Presents with transiently enlarged, tender lymph nodes May occur at any age, though most commonly seen in infancy	Expectant management appropriate for up to six weeks Empiric antibiotics may be used if bacterial infection is suspected
Lymphoma	Diffuse group of malignant tumours of lymphoid tissue Hodgkin’s lymphoma is differentiated by the presence of Reed-Sternberg cells	Most common cause for malignant paediatric neck massRare in children younger than five years Hodgkin’s lymphoma presents with cervical adenopathy more commonly than non-Hodgkin’s lymphoma	Depending on the cell subtype, treatment involves chemotherapy or radiotherapy
Rhabdomyosarcoma	Thought to arise from primitive striated muscle cells Most cases are sporadic, though an association with neurofibromatosis and Li Fraumeni syndrome exists	Incidence peaks at age 2–5 years and 15–19 years Most common soft tissue malignancy in children Up to 89% of cases present in the neck	Management may involve a combination of surgery, radiotherapy and chemotherapy

• History
  • Cervical masses in the neonatal period and early infancy
    • predominantly congenital and may include
      • teratomas
      • sternocleidomastoid tumours of infancy
      • vascular or lymphatic malformations.
        • typically grow commensurately with the growth of the child
  • infancy and early childhood
    • Reactive lymphadenopathy is most common with 40–55% of young children found to have palpable cervical lymph nodes
  • later childhood/adolescence
    • Congenital masses may present in because of continuous growth or superimposed infection, while the likelihood of malignancy also rises in this age group.

• Time course
  • Rapidly developed masses are typically inflammatory and may include
    • reactive lymphadenopathy
    • lymphadenitis
    • secondary infection of underlying congenital or neoplastic masses. 
    • Inflammatory pathology typically resolves within four weeks. 
  • Cervical masses that persist past six weeks warrant further evaluation.
  • Rapidly growing masses should be immediately referred if they are thought to potentially affect the airway or have features suggestive of abscess formation. 
  • Masses that grow at a slower rate, for months to years, are suggestive of benign neoplasms or a slowly enlarging congenital malformation.

• Associated symptoms
  • reactive lymphadenopathy
    • Viral prodrome
    • Fevers
    • cervical tenderness 
  • underlying congenital or neoplastic mass
    • ca develop suppurative lymphadenitis or infection and may present similarly. 
  • Malignant neck masses
    • typically asymptomatic
    • they can become infected secondarily
    • Constitutional symptoms
      • Weight
      • night sweats 
  • Symptoms suggestive of anaemia or thrombocytopaenia or symptoms that may immunocompromise the patient are concerning for haematological malignancy.
• Red flag features of presentation

Red flag features of presentation

Weight loss

Sustained fevers/night sweats

Generalised lymphadenopathy

Signs and symptoms of pancytopenia

Mass persisting >6 weeks

Lymph node >3 cm

Thyroid mass

Supraclavicular mass

Hard, irregular mass

Fixed mass

• Examination
  • Location
    • Midline masses
      • likely congenital and are typically
        • thyroglossal duct cysts
        • dermoid cysts
      • Thyroglossal duct cysts
        • most common midline congenital abnormality and may arise anywhere along the embryological pathway of the thyroid from the base of the tongue to the final position of the thyroid gland
        • however, they are most commonly found at the level of the hyoid bone. 
        • will elevate with tongue protrusion or swallowing while dermoid cysts are tethered to the overlying skin.
      • Thyroid masses
        • potentially malignant and need further evaluation
    • Lateral
      • Lymphadenopathy
        • may present an inflammatory or neoplastic process. Lymphadenopathy in the posterior triangle has a higher risk of malignancy
        • supraclavicular lymphadenopathy is considered a red flag
• Palpation
  • Reactive lymphadenitis is typified by a local collection of small, tender, mobile lumps. 
  • The possibility of suppurative lymphadenitis should be considered if there is palpable warmth, fluctulence, induration or severe tenderness. Red flags concerning for malignancy include firm, irregular masses that are immobile or fixed

• Size
  • Review of the lump size is a simple measure that can help determine level of clinical concern. 
  • Palpable cervical lymph nodes less than 1 cm in size can be considered normal in children, while increasing node size is associated with a significantly increased risk of malignancy
  • Lymph nodes greater than 1 cm in size that persist for longer than six weeks or despite antibiotic therapy should be evaluated with medical imaging and a possible tissue biopsy.

• General examination
  • An ear, nose and throat examination should be performed to identify any local sources of infection. 
  • An examination for peripheral stigmata of haematological malignancy, such as signs of pancytopaenia or generalised lymphadenopathy, should also be conducted.

• Investigations
  • FBC and blood film may help identify pancytopenia and atypical cells suggestive of haematological malignancy, 
  • Purified protein derivative for tuberculosis
  • Bartonella henselae titre
  • (cat-scratch disease)
  • Epstein-Barr virus titre
  • Cytomegalovirus titre
  • Human immunodeficiency virus titre
  • Toxoplasmosis titre
  • Ultrasonography +/- FNA

• Management
  • Watchful waiting for up to 6weeks is recommended for patients with suspected reactive lymphadenitis (bilateral lymphadenopathy with no red flag features for malignancy or deep cervical abscess). 
  • The use of empirical antibiotics is controversial, although widely accepted, in patients thought to have suppurative lymphadenitis (eg lymphadenopathy with marked erythema and tenderness, asymmetric lymphadenopathy and systemic symptoms)
  • A 10-day course of amoxycillin/clavulanate, cephalexin or clindamycin is recognised as appropriate coverage for the most commonly involved organisms.
  • All neck masses suspicious for non-haematological malignancy are best referred urgently to a head and neck surgeon for further evaluation including possible biopsy. Medical imaging, including USS, CT or MRI, may be considered as part of the referral.