Neck MASSES in KIDS 

divided into the broad categories of congenital, inflammatory/infective and neoplastic

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 mass Rare 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 cellsMost cases are sporadic, though an association with neurofibromatosis and Li Fraumeni syndrome exists	Incidence peaks at age 2–5 years and 15–19 yearsMost common soft tissue malignancy in children Up to 89% of cases present in the nec	Management may involve a combination of surgery, radiotherapy and chemotharpy

• Timeline
  • Neonatal and early infancy are usually congenital
    • Include teratomas, sternocleidomastoid tumors, vascular or lymphatic malformations
    • Vascular and lymphatic malformation present at birth and grow with the child
    • Reactive lymphadenopathy common infancy and early childhood
    • Congenital masses may present later because of continued grow or superimposed infection
    • Likelihood of malignancy increases with later childhood/ adolescence
• Time course
  • Rapid – usually inflammatory/ infectious, including secondary infection of an underlying mass
  • Inflammation usually resolves in 6 weeks
  • Cervical mass > 6 weeks – further evaluate
  • If potentially effecting airway or contain abscess – refer

• Associated symptoms
  • Viral prodrome, fevers, tenderness – reactive lymphadenopathy, consider suppurative lymphadenitis or infection underlying mass
  • Malignant neck masses typically asymptomatic – consider B symptoms, anemia, thrombocytopenia

• 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

• Risk factors
  • URTis, cat scratch, mycobacterial infection – animals, overseas, tick bites
  • Hx of radiation, family history of malignancy

• Location
  • Midline – more likely congenital
    • Thyroglossal duct cyst – anywhere along embryological pathway from base of tongue to thyroid gland. Often at hyoid bone. Will elevate with tongue protrusion or swallowing
    • Dermoid cysts tethered to overlying skin
  • Thyroid masses – need further evaluation
• Palpation
  • Reactive lymphadenitis – collection small, tender mobile lumps
  • Consider suppurative – warmth, fluctuance, induration, severe tenderness 
  • Malignancy – firm, irregular, immobile or fixed
  • Size
    • Cervical node < 1cm can be normal in children
    • Examine ENT and for stigmata hematological malignancy

• Investigations
  • FBC, blood film
  • Targeted serolgical investigation for atypical infection
  • USS, consider referral for FNA (often need anaesthetic)
  • do CT or MRI if strong suspicion Ca
  • Investigations for atypical infection in lymphadenopathy
    • TB testing
    • Epstein-Barr virus titre
    • Cytomegalovirus titre
    • Human immunodeficiency virus titre
    • Toxoplasmosis titre

• Management
  • Watchful waiting 6 weeks for suspected lymphadenitis – bilateral, no red flag features
  • 10 days Augmetnin/cephalexin/clindamycin for suspected suppurative lymphadenitis – if not improving 4 weeks – investigate/refer sooner if deteriorating
  • All neck masses suspicious for non-haematological malignancy (Red Flags above) 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