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Pediatric Neck Masses

Pediatric Neck Masses

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Pediatric Neck Masses

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    1. Pediatric Neck Masses Jaime J. Rueda July 24-29, 2006 Med-Peds Clinic conference

    2. Background In adults, 80% of neck masses are neoplastic and 80% of these are malignant Versus in kids, 90% of neck masses are benign Most common= lymphadenitis

    3. Miss A.S. Case: Miss A.S. is a 3 year old female who presents with a 1 week h/o a palpable neck mass. Pertinent history and physical? Types of neck masses? Indications for referral?

    4. History and Physical Age, location, physical characteristics, growth Associated sx: fever, wt. loss, night sweats, fatigue, sore throat Travel hx, exposure to people at risk for Tb, immunocompromised, cat scratches/bites PE: size, tender, erythematous, moves with swallowing/tongue protrusion, unilateral/bilateral, drainage

    6. Types of masses Inflammatory Cervical lymphadenopathy Suppurative lymph nodes (lymphadenitis) Granulomatous disease Congenital Thyroglossal duct cysts Branchial apparatus cysts Lymphangiomas (cystic hygromas) Hemangiomas Neoplasms (Benign and malignant) Lymphoma

    7. Inflammatory masses Cervical lymphadenopathy Palpable cervical nodes in 40% of infants Nodes <3mm and cervical nodes =1cm in diameter in <12 year olds are normal. Suppurative lymph nodes (lymphadenitis) Caused by -hemolytic strep and S. aureus Usually tender, fluctuant, erythematous, swollen If unilat, pyogenic infection in pharynx and tonsils but if bilateral, viral EBV(Mono) vs. CMV

    8. Granulomatous disease Atypical mycobacterium TB Chronic lymph node infections in kids(1-5 yo) Enters body through breaks in mucous membranes, e.g. teeth eruption Chronic, unilateral, firm masses in the submandibular or preauricular regions Dx: FNA, surgical excision, PPD? Tx: Azithromycin Cat Scratch Disease Etiology: Bartonella Henselae H/o exposure to cat, tender regional LAD, 1 inoculation site Dx: Hx, Bartonella titers Tx: Azithromycin, Bactrim, Rifampin

    9. Congenital Masses Thyroglossal duct cysts Vestigial remnants of embryonic thyroglossal duct Located subhyoid, midline or just lateral to it Retreats with tongue protrusion/swallowing Dx: CT, u/s, thyroid scan Tx: Sistrunk procedure

    10. Congenital masses continued Branchial apparatus(BA) cyst, fistula, sinus Remnants of fetal BA 90% from 2nd BA Cyst: Slowly enlarging, lateral cervical mass near ant. to middle 1/3 of SCM Round, smooth, mobile, nontender Dx & Tx: CT and abx if inflamed and surgery

    11. Congenital masses continued Lymphangioma (Cystic hygroma) Lateral cervical region along jugular chain of lymphatics 65% soft, painless, compressible at birth ? size with valsalva, transilluminates May impinge airway, thus requiring surgery Hemangioma 30% at birth? ? size in 1st yr Soft, mobile, bluish hue, no transillumination, ? size with valsalva ~90% resolve spont by 7 yo.

    12. Neoplasms Lymphoma Neck mass is presenting sign in 80% children with Hodgkins disease and 40% with non-Hodgkins(NHL) NHL: extranodal, more widespread, more common in <5 yo Charac: large, firm, mobile masses in posterior cervical triangle or supraclavicular area. Assoc. with B sx: fever>38 C, wt. loss of 10%, and night sweats

    13. Indications for referral Mass does not resolve with 2 wk course of abx Malignant tumor suspected Rapidly enlarging mass without inflammation Mass in thyroid/ parotid gland Fixed mass Matted cervical lymph nodes

    14. Conclusions Pediatric neck masses are common reasons for primary care visits that are mostly benign. Some have characteristic features on history and physical exam that aid in diagnosis Can be separated into 3 categories: inflammatory, congenital and Neoplastic Referral is indicated when antibiotics do not decrease the size of the mass or one suspects malignancy Follow up: A.S. had positive Bartonella IgG titer. She was treated with Azythromycin*3 days, and the size of the nodules have since decreased.

    15. Bibliography Davenport, M. ABC of general surgery in children: lumps and swellings of the head and neck. BMJ 1996; 312: 368-371. Drumm, AJ and Chow, JM. Congenital Neck Masses. American Family Physician 1989; 39(1): 159-163 Guarisco, JL. Congenital head and neck masses in infants and children:Part I and II. Ear, Nose and Throat Journal 1991; 70(1&2): 40-7, 75-82. Huebner, RE, et al. Usefulness of skin testing with mycobacterial antigens in children with cervical lymphadenopathy. The Pediatric Infectious Disease Journal 1992; 11(6): 450-456. May, M. Neck masses in children: diagnosis and treatment. Pediatric Annals 1976; 518: 89-116. Park, Y. Evaluation of neck masses in children. American Family Physician 1995; 51(8): 1904-1912.