Neck masses and lesions

in pediatrics
i
Types
 congenital:
◦ Thyroglossal cyst.
◦ Branchial sinus, fistula or cyst.
◦ Dermoid cyst.
 vascular
◦ Hemangioma.
◦ Cystic hygroma
 lymph node:
◦ Infection: viral, fungal, bacterial (acute) or T.B (chronic).
◦ Tumor: primary (lymphoma), secondary e.g. neuroblastoma.
 tumors:
◦ Benign: lipoma, neurofibroma.
◦ Malignant: neuroblastoma, teratoma, rhabdomyosarcoma.
 miscellaneous
◦ Sternomastoid tumor.
◦ Thyroid (goiter, nodule).
◦ Salivary gland tumor, infection and sialectasis.
 Case 1
 6 years child present with mucus discharge
which is small in amount from a tiny opening
in lower anterior neck?
 Case 2
 5 years old child presents with a swelling in
the upper anterior neck for more than a year?
 What are differential diagnosis?
Branchial sinus, fistula or cyst

 Etiology: remnant of branchial clefts (usually the 2nd cleft)

 Types: may manifest as fistula, sinus or cyst.
 Anatomy:

 CF:
1. Fistula or sinus

2. Cyst

 10% bilateral.
 Dx.
1. clinical.
2. fisulogram : generally unnecessary.
3. US : for branchial cyst.
 Cx.
1. infection.
2. squamaous cell CA.
3. recurrence : due to incomplete excision.
4. injury to hypoglossal nerve and carotid artery.
 treatment:
1. surgical exicion.
2. for infected lesion: antibiotic, aspiration and some time
drainage.
 Case 3
 9 years old child presents with midline neck
mass for 2 years duration , the mass became
infected three times and get tender and
swollen with throat infection.
 What are the differential diagnosis?
 What is the most probable diagosis?
Thyroglossal duct cyst
 Most common midline neck mass.

 Etiology: remnant of thyroglossal duct.

 Site: usually at or just below hyoid bone.

 CF: midline neck mass, smooth, non tender

and move with the protrusion of tongue.
 The cyst connects to foramen cecum by
single or multiple tracts which pass through
the hyoid bone.
 Dx.

1. Clinical.
2. US of the neck to confirm the presence of
normal thyroid gland.
3. Thyroid function test and thyroid scan
indicated in those with feature of
hypothyrodism
4. Thyroid scan
 Rx:

Cx:
1. infection.
2. Malignancy.
3. recurrence.
4. fistula.
 Case 4
 Mass in the external angular area?
 Dermoid cyst
 Definition: congenital cyst lined by skin with fully
mature pilosebaceous structure containing buttery
substance formed from sebum, sweat,
desquamated epithelium and hair.
 Etiology:
ectodermal element that were trapped
beneath the skin at the lines of fusion.
 Sites:
1. head : external angular dermoid, internal
angular dermoid, midline scalp, intracranial.
2. neck : midline suprahyoid.
3. body : in the midline sites including sacral,
perineal and presternal
 CF: round, firm, painless, fixed to deep
tissue, not attached to skin.
In the scalp there may be intracranial
extension.
 Rx: excision.

 Cx:
1. infection.
2. recurrence.
3. malignant degeneration (rare).
 Note: dermoid cyst of ovaries is in fact cystic
teratoma and not dermoid cyst.
 Case 5
 Newborn presents with large cystic mass
involving the neck?
Cystic hygroma
 Definition: multiple cystic lymphatic
malformations.
 Etiology: morphogenic errors in the

development of lymphatic vessels or due to

failure of connection of jugular lymph trunk
with their draining channels.
 Site: neck 75%, axillae 20%, mediastinum,
retroperitonium, pelvis & groin.
 Neck lesions may extend in to mediastinum or
axilla.
 CF:
1. May be diagnosed antenatally.
2. Usually visible soft cystic mass at birth.
3. the lesion may develop complications: infection,
intralesional bleeding and airway obstruction.
 Ix:

1. US: differentiate macrocystic from microcystic

lesions.
2. MRI: extent and relation with vital structures.
 Rx:
1. Sclerotherapy: for predominantly macrocystic lesions.
e.g.OK432.
2. Excision: if no airway obstruction, resection scheduled at 3-6
months of age.
 Cx of surgery:
1. prolonged drainage.
2. infection.
3. bleeding.
4. recurrence.
4. injury to thyroid and parathyroid glands.
5. neurovascular injury e.g vagus N.,phrenic
N., recurrent laryngeal N., accessory N
 Case 6
 Sublingual & submental swelling?
 Ranula
 Definition: cystic mass develop below the tongue in the
floor of the mouth arise from sublingual gland.

 Types & etiology:

1. Simple ranula:
2. Plunging ranula:

 Rx: either
1. Drainage & marsuplization.
2. Complete resection of the cyst.
3. Excision of sublingual gland.
 Case 7
 Multiple neck masses associated with fever?
Cervical lymphadenopathy
 The most common neck masses in childhood.

1. Non specific reactive hyperplasia

2. lymphadenitis:
◦ acute :

◦ Chronic: due to TB or atypical mycobacteria. Not tender,

hard, fixed
4. tumors :
◦ Primary: lymphoma.
◦ Secondary: neuroblastoma, CA thyroid.
5. AIDS.
6. Sarcoidosis
7. Autoimmune disease.
 Mx:
1. Thorough head, neck and ENT
examination.
 Chest examination if supraclavicular L.N
involved.
 Abdominal examination if Lt.
Supraclavicular L.N involved.
2. Lab.: CBC, ESR, skin test.
3. Imaging: CXR, US abdomen.
4. Excisional biopsy
 Case 8
 Infant with tilting of the head?
Torticollis
Types:
1. congenital :
◦ srernomastoid tumor.
◦ Muscular torticollis (sternomastoid fibrosis
without tumor)
◦ Postural : due to moulding inside the uterus,
needs no treatment & resolved spontaneously.
2. acquired :
◦ Cervical hemivertebrae.
◦ Imbalance of ocular muscle.
◦ Otolaryngologic infection.
- Neurological
 Etiology of congenital type : it may be associated
with breech presentation or other abnormal
obstetric position.
 Pathology: fibrosis with muscle atrophy.
 CF:
1. 2/3 had a tumor, 1/3 had a fibrosis
without tumor.
2. usually found at 6 weeks after birth

3. Face rotated away from the affected side

and head tilted toward affected side.
4. With time, facial & cranial asymmetry with
flattening of facial structure on the affected
side.
 Ix: US to asses the extent of fibrosis.
US or x-ray of pelvis (ass. DDH)
 Mx:
1. Physiotherapy
2. Operation
3. Botox injection in to the muscle.
4. Exclude associated DDH and acquired
causes.
 Goiter
1. Autoimmune: Hashimoto
Graves
simple colloid goiter?
2. Compensatory :
hormone or receptor defect
iodine deficiency
goitrogens
3. Inflammatory :
acute suppurative thyroiditis
subacute thyroiditis
4. Neoplastic
Could be diffused or nodular
Could be toxic, hypothyroid or euthyroid
Most are euthyroid and surgery rarely indicated.
Case 9
 Hypothyrodism
 In infant, 90% is congenital due to dysgenesis of
the gland.
 In older children, the most common cause is
Hashimoto thyroidits.
1. No goiter: dysgenesis
TSH or TRH deficiency
2. With goiter : inborn defect in hormone synthesis
goitrogen
severe iodide deficiency
Hashimoto thyroiditis
 CF: large tongue, coarse facies, abdominal
distension, umbilical hernia, dry skin,
hoarse cry, short stature and delay
intellectual development.
 Ix :

1. TFT
2. US of neck
3. thyroid scan
 Rx: thyroxine
 Thyroid nodule
 Uncommon in children.
 High risk of malignancy 20%
 Ix: TFT, US, Scan
 All should be removed surgically.
Case 10
Ectopic thyroid
 Etiology: failure of migration of thyroid gland.
 Site: 90% lies at the base of tongue, rarely in the
midline of the neck.
 Dx:
1. Thyroid function test.
2. US of the neck.
3. Thyroid scan.
 Rx: controversial
1. Excision & replacement therapy.
2. Excision & reimplantation.
3. Trial of medical suppression to decrease the size
Q1/ neck mass gradually increase in
size since infancy
 What are the
differential
diagnosis?
 What important

clinical test that

should be taken?
Lymph nodes enlargement cervical
 Is the commonest cause of neck mass.
 Reactive hyperplasia usually follows viral

URTI.
 Reactive hyperplastic lymph nodes usually

unilateral and tender.

 CXR could be of value.
 Lymph node biopsy indicated if it fail to

regress 2 weeks after treatment.

 Key answers: TTFTF