Neck lumps are a common presenting complaint to the paediatric emergency department with many aetiologies, sometimes resulting in a diagnostic conundrum. Thorough history taking and detailed examination can aid in diagnosis. Causes of paediatric neck lumps can be broadly divided into three categories – congenital, inflammatory and neoplastic. Clinicians dread missing that last one, and with increasing age becomes increasingly more common. However, it is important to acknowledge that 80-90% of paediatric neck lumps are benign in origin. This article aims to provide background and natural histories of different aetiologies to allow a systematic approach to the child with a neck lump to narrow the differential diagnosis, target investigations and facilitate management.
Inflammatory masses account for around 75% of paediatric neck lumps. Reactive lymphadenopathy is the commonest inflammatory cause, usually resulting from a concurrent upper respiratory tract infection. They will gradually shrink over a number of weeks. They may grow again with subsequent upper respiratory tract infections. This waxing and waning course is normal, and families should be reassured and given red flag features that necessitate further assessment. Document the size, consistency and location in the notes to compare if they represent.
Lymphadenitis can result from bacterial or viral infections resulting in enlarged, firm nodes that are tender to touch. A viral prodrome often accompanies viral lymphadenitis. The lumps can be bilateral, and they may morph into bacterial lymphadenitis. Children with acute bacterial lymphadenitis often have a short history of unilateral neck swelling, commonly in the anterior triangle. It is often associated with systemic symptoms such as fever. Occasionally you may be able to identify the source of infection, like a dental abscess. It is important to consider deep-seated neck infections such as retropharyngeal abscesses in such cases. Difficulty swallowing, stridor or altered voice should prompt urgent ENT assessment. Simple lymphadenitis can progress into fluctuant masses, suggesting abscess formation. These may require surgical drainage following confirmation on ultrasound scan. Local guidelines should be consulted around antibiotic choice.
Many other inflammatory conditions cause enlarged lymph nodes, some necessitating specific investigations and treatment.
Key Points on Inflammatory Masses
- Very common, mostly reactive to intercurrent infection
- Firm, tender lumps +/- fever are often lymphadenitis and require antibiotics
- Stridor/difficulty swallowing/change in voice could indicate deep seated infection and require ENT review
- Consider other signs/symptoms to indicate other inflammatory causes
Around 12% of paediatric neck masses are caused by congenital lesions. Although not common, understanding their origins and pathognomonic clinical findings can make diagnosis much easier. Congenital lesions include thyroglossal cysts, branchial cleft defects, lymphatic malformations and dermoid cysts.
Thyroglossal cysts are the commonest, accounting for 53% of congenital neck lumps and 70% of congenital midline neck lumps. The thyroglossal duct fails to atrophy and remains attached to the base of the pharynx. This results in a smooth, rounded midline neck lesion that rises when the patient pokes out their tongue due to the persistent attachment.
Branchial cleft defects
Disruption in branchial arch development results in branchial cleft defects. The 5th and 6th arches become rudimentary, so cysts may form from the 1st to 4th branchial clefts. The position of the lump depends on which cleft is affected. Pre-auricular lumps result from disruption of the 1st branchial arch, parotid in the 2nd and the anterior cervical triangle of the neck in the 3rd/4th arch. These can be uni- or bilateral and affect either side, although the left appears more commonly affected in 3rd/4th cleft defects. 2nd branchial cleft defects are the most, accounting for up to 95% of cases.
Vascular malformations and haemangiomas also fall into the congenital category of paediatric neck lumps. Vascular malformations are present from birth, whereas haemangiomas are often absent at birth but rapidly increase in size within the first few weeks of life. These may be visible on the surface, but airway haemangiomas may present with an infant with worsening stridor. Haemangiomas and vascular malformations may differ in size and can affect vital surrounding structures.
Although the name is misleading, sternocleidomastoid tumours are benign masses occurring in infancy, resulting in torticollis. In-utero contraction of the sternocleidomastoid muscle results in fibrous tissue deposition. The infant turns their head to the unaffected side, which can cause positional plagiocephaly if untreated. Physiotherapy and reassurance are the mainstay of treatment. Intervention is rarely required.
Key Points on Congenital Masses
- Most commonly, thyroglossal cysts causing a midline neck lump which moves on tongue protrusion and swallowing
- Branchial cleft defects commonly arise from the 2nd arch, therefore submandibular in location.
- Haemangiomas rapidly increase in size over 1st weeks of life
- Vascular malformations are present at birth
- Sternocleidomastoid tumours cause torticollis in infants but are benign masses treated with physiotherapy.
Although rare, many predictive features can lead to suspicion of malignant neck masses. Of all biopsied lymph nodes, around 27% are found to be malignant. This can be either primary malignancy (lymphoma) or metastasis. Neoplastic neck lumps can arise from lymphoma, leukaemia, thyroid neoplasm or as metastases from primary malignancy elsewhere.
Multiple physical features can assist in the timely diagnosis of malignancy. The bigger the mass, and if there are masses in multiple locations, the higher the risk of malignancy. Supraclavicular neck masses are highly predictive of malignant masses, and non-mobile nodes, tethered to underlying structures, are also more likely to be neoplastic. Additionally, those nodes that are present for > six weeks are more likely to be neoplastic.
Although evidence suggests systemic symptoms do not correlate strongly to malignancy, ask about symptoms such as fever, weight loss and night sweats. Since metastatic cancer can present with neck lumps, it is also helpful to keep an open mind when considering other symptoms that may potentially point to a primary malignancy. A thorough history and full systems exam can aid in patient management.
Key Points on Neoplastic Neck Masses
- Supraclavicular masses are more likely to be malignant
- Non-mobile, larger, multiple location masses are more likely to be malignant
- Persistent neck lumps (> six weeks) are more likely to be malignant
Summary of Approach to Neck Lumps
Red flag features
- Septic or unwell looking child
- Difficulty swallowing
- Stridor or airway compromise
- Change in voice
- Rapidly progressing
- Tethered/persistent/supraclavicular nodes
Neck lumps are a very common presenting complaint.
Most paediatric neck lumps are benign, although they may require specific investigations and management.
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