44. Pediatric Neck Masses

Question 1

zygomatic bone, helix, antihelix, tragus, antitragus, mandibular angle, mandible inferior border, trapezius, omohyroid inferior belly, frontal bone, supraorbital margin, infraorbital margin, philtrum, commisure of the lips, mental protuberance, submandibular gland, thyroid cartilage, clavicle, jugular notch, sternal head, clavicular head, sternocleidomastoid

Answer 1

landmarks

Question 2

posterior auriciular, occipital, superifical cervical, deep cervical, posterior cervical, preauricular, parotid, tonsillar, submental, submandibular

Answer 2

lymph nodes of the head and neck

Question 3

1st pharyngeal groove and mesenchyme of the first pharyngeal arch form the ear canal, second and third pharyngeal arches meet up together to form the cervical sinus, third and fourth pharyngeal pouches meet up

Answer 3

embryology

Question 4

thyroglossal duct embryology

Question 5

when was it noticed, has it changed in size, does it wax and wane, prior treatment and response, exposures, exposures to travel or animals, other symptoms include fevers, weight loss, night sweats, bruising, fatigue, upper respiratory, and fatigue

Answer 5

neck mass history

Question 6

location like anterior to sternocleidomastoid muscle, posterior to the sternocleidomastoid, midline, number of lesions which can be bilateral, palpable nodules in other areas too, pores/sinuses, redness or skin changes, texture, tenderness, mobility

Answer 6

neck mass exam

Question 7

thyroglossal duct cysts, cervical branchial cleft cysts, lymphatic malformations like cystic hygroma or other vascular malformations, teratomas

Answer 7

congenital neck masses

Question 8

found inferior to the thyroid, midline usually adjacent to the hyoid bone, but can occur elsewhere along the tract, gradually increases in size, CT is used to confirm and very anatomic relationships, treatment is surgical, make sure there is functional thyroid tissue

Answer 8

thyroglossal duct cyst

Question 9

dermoid cysts, lipomas, thyroid nodules, most lymph nodes are more lateral unless right under the chin, branchial cleft anomalies are more lateral

Answer 9

midline neck mass differentials

Question 10

can be cystic, sinus, or fistula, all made of stratified squamous epithelium, 20% of pediatric neck masses, first cleft makes up 1-4%, second cleft makes up >80%, third cleft is rare, connects skin to the pyriform sinus, opening lower than the second cleft

Answer 10

branchial remnants

Question 11

associated with the external auditory canal, openining high in the neck, adjacent to the angle of the mandible

Answer 11

first cleft sinus cyst

Question 12

opening at the anterior border of the SCM in the upper neck, path is from the skin to the tonsillar fossa, opening anterior edge of SCM lower in the neck than with first cleft anomalies

Answer 12

second cleft cyst

Question 13

draining sinus, gradually increases mass at the squamous debris accumulates, infection, little nubbins of tissue

Answer 13

clinical findings for brachial remnant cysts

Question 14

imaging to assess anatomy usually by CT, treat infection if present, surgical rese tion for large cosmetic or functional issues, recurrent infections

Answer 14

brachial cleft remnant managment

Question 15

50% are associatedwith syndromes such as down syndrome or noonan syndrome, usually face or neck but can be axillary, size can change over time and wax and wane, clinically causes cosmetic issues, functional impairment affecting the airway, infections in the mass, bleeding, diagnosis confirmed with ultrasound or MRI, can be diagnosed prenatally, managed with surgey, sclerotherapy, medications like sildafenil or sirolimus

Answer 15

cystic hygroma/lymphatic malformation

Question 16

palpable mass in the sternocleidomastoid in a newborn, pseudotumor, causes head position with tild forward affected side and chin toward opposite side, resolves with time, stretching, and physical therapy

Answer 16

fibromatosis coli

Question 17

acute or subacute onset, local signs of inflammation, systemic signs of illlness, bilateral lymphadenopathy can be due to viral upper respiratory infection, strep throat, mononucleosis or epstein barr virus, cytomegalo virus, tinea capitis, unilateral lymphadenopathy can be due to bacterial lymphadenitis, mycobacterial lmyphadenitis, cat scratch disease, ifnected branchial cleft remnants, and parapharyngeal abscesses

Answer 17

inflammatory neck masses

Question 18

drain scalp and skin, can be due to scalp infections or myobacterial infections, or malignnacies like skin neoplasms, lymphomas, head and neck squamous cell carcinomas

Answer 18

preauricular nodes

Question 19

drain the scalp, neck, and upper thoracic skin, differential diagnosis inlcudes scalp infections, mycobacterial infection, skin neoplasms, lymphomas, head and neck squamous cell carcinomas

Answer 19

posterior cervical nodes

Question 20

drain gastrointestinal tract, genitourinary tract, pulmonary, differential diagnosis includes thyroid/laryngeal disease, mycobacterial/fungal infections, malignancies like abdominal/thoracic

Answer 20

supraclavicular nodes

Question 21

drain the oral cavity, differential diagnosis includes mononucleosis, upper respiratory infection, mycobacterial infection, toxoplasma, cytomegalovirus, dental disease, rubella, and malignancies like squamous cell carcinoma of the head and neck, lymphomas, and leukemias

Answer 21

submandibular nodes

Question 22

drain the larynx, tongue, oropharynx, and anterior neck, differential diagnosis includes mononucleosis, upper respiratory infection, mycobacterial infection, toxoplasma, cytomegalovirus, dental disease, rubella, and malignancies including squamous cell carcinoma of the head and neck, lymphomas, and leukemias

Answer 22

anterior cervical nodes

Question 23

associated with posterior cervical adenopathy in children

Answer 23

tinea capitis

Question 24

symmetric bilateral lymphadenopathy, presents with tonsillopharyngitis, fever, other signs of illness, diagnosis with serology of epstein barr virus, monospot heterophil antibodies are less accurate in younger patients

Answer 24

mononucleosis

Question 25

massive red area of cervical lymph nodes, unilateral, tender, red, malaise, most commonly due to staphylococcus aureus and group A strep, usually treat with antibiotics, often oral, may need IV if more ill or not tolerating per oral, ocassioinaly need drainage, ultrasound is usually first choice for drainage

Answer 25

cervical lymphadenitis

Question 26

slow progresison, often not tender, mostly under age 5, treatment is excision or observation, don’t aspirate, not systemically ill, tuberculosis skin test may be weak, IGRA negative

Answer 26

atypical mycobacterial lymphadenitis

Question 27

ill appearing with fever, sore throat, tender, decreased neck range of motion, usually benign with medical management, IV antibiotic to cover staph and strep, support hydration, may need surgical management if inadequate response to medical management, airway concern

Answer 27

parapharyngeal abscess

Question 28

slowly enlarging node with warmth and some tenderness, papule at site of inoculation, affects regional nodes based on site of inoculation, systemic symptoms mild if at all, history of contact with cats especially young ones, causative agents bartonella henselae, treatment with azithromycin may hasten

Answer 28

cat scratch disease

Question 29

vascular with hemangioma most common, soft tissue neoplasms like lipomas

Answer 29

benign neck masses

Question 30

lymphoma most common, sarcomas, thyroid cancer, metatstatic head and neck cancer

Answer 30

malignant neck masses

Question 31

inflammatory and congenital are the most frequent, then benign neoplastic, then malignant neoplastic, most pediatric neck masses are not cancer, inflammatory and congenital causes are more common, even among neoplastic masses, malignancy is uncommon

Answer 31

frequency of neoplastic neck masses

Question 32

not common in children, present as persistent adenopathy, generally large and enlarging without signs of suppuration, immobile nodes, rubbery matted notes, may have systemic symptoms like fever, weight loss, night sweats, and adenopathy in less common locations like supraclavicular are worrisome, very uncommon in younger kids but as kids get older lymphoma becomes the most malignant neck mass, benigns is still more common

Answer 32

lymphoma

Question 33

little ones are common and benign, <1cm in an infant or <2-3 cm in a child, other factors to consider are can you tell why they have the node, hard texture is worrisome, mobile ones are reassuring, mattered or adhered to skin is more worrisome, supraclavicular needs workup regardless of size, symptoms include fever, malaise, weight loss

Answer 33

general guidance on lymph nodes

Question 34

bilaterally enlarged posterior cervical lymph nodes

Answer 34

rosai dorfman disease