Symptom-Based Diagnosis in Pediatrics (CHOP Morning Report) 1st Ed.

CHAPTER 13. NECK SWELLING

STEPHEN LUDWIG

BRANDON C. KU

DEFINITION

Neck swelling in children is a finding that elicits immediate parental concern and often prompts a visit to the physician. The finding of a neck mass invokes a response because it can be associated with malignancy. Malignancy, though part of the differential diagnosis, is a relatively uncommon cause of neck swelling by far. More common causes include inflammatory conditions, such as reactive lymphadenopathy from viral upper respiratory tract infections, bacterial adenitis, and congenital anomalies with or without bacterial superinfection. Because children often have palpable normal lymph nodes, a significant neck mass is typically defined as swelling that exceeds 2 cm in diameter. In rare cases, smaller nodes may have characteristics that prompt evaluation. Congenital anomalies, although present at birth, may not become clinically apparent until the child is school age or older.

Hospitalization is required if neck masses are present in conjunction with systemic symptoms such as fever, fatigue, or pallor; if the neck masses are large enough to comprise the airway; or if the neck masses have not responded to outpatient therapy.

CAUSE AND FREQUENCY

A differential diagnosis list for neck masses is presented in Table 13-1. Neck masses that require immediate evaluation include those that follow trauma and those that cause airway compromise (Table 13-2). The most common causes of neck swelling include benign reactive lymphadenopathy, bacterial lymphadenitis (including that caused by Bartonella henselae), hematoma, congenital causes (e.g., thyroglossal duct cyst, branchial cleft cyst, cystic hygroma), and benign tumors (e.g., lipoma, keloid). Table 13-3 indicates the type of mass by location.

TABLE 13-1. Differential diagnosis of neck mass by etiology.

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TABLE 13-2. Life-threatening causes of neck mass.

Hematoma secondary to trauma

Cervical spine injury

Vascular compromise or acute bleeding

Late arteriovenous fistula

Subcutaneous emphysema with associated airway or pulmonary injury

Local hypersensitivity reaction (sting/bite) with airway edema

Airway compromise with epiglottitis, tonsillar abscess, or infection of floor of mouth or retropharyngeal space

Bacteremia/sepsis associated with local infection of cyst (cystic hygroma, thyroglossal, or branchial cleft)

Lymphoma with mediastinal mass and airway compromise

Tumor-leukemia, rhabdomyosarcoma, histiocytosis

Thyroid storm from thyroid mass

Mucocutaneous lymph node syndrome with coronary vasculitis

TABLE 13-3. Differential diagnosis of neck mass by location.

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QUESTIONS TO ASK AND WHY

• Is the airway compromised?

—The first and most important question to ask relates to the presence of airway compromise, since it demands immediate attention if present. Airway compromise may result from intrinsic occlusion or extrinsic compression of the airway. Airway edema may result from swelling caused by trauma or allergic reaction. Neck masses may also be associated with intra-thoracic masses that can cause respiratory distress.

• Are there systemic signs of illness?

—Other questions that help with the differential diagnosis process are the presence or absence of systemic signs, such as fever, weight loss, anorexia, night sweats, lethargy, or fatigue. Some elements of the differential diagnosis are associated with these systemic findings, such as malignancy, and others are clearly more localized.

• Is there history of or clinical concern for trauma?

—This question will help identify acute causes of neck swelling that may require surgical intervention, such as rapidly expanding hematoma. Acute bleeding prompts immediate identification of the source of bleeding and subsequent hemostasis. In addition, any trauma to the cervical spine requires stabilization of the cervical spine and evaluation.

• Is the swelling due to lymphadenitis or lymphadenopathy?

—This question will help elucidate whether there are signs of active infection (i.e., lymphadenitis) as opposed to enlargement without infection (i.e., lymphadenopathy). Signs of lymphadenitis include swelling, redness, warmth, and tenderness. Signs of lymphadenopathy may include swelling and no or mild tenderness, but the absence of significant overlying erythema, warmth, or tenderness.

• Is the swelling acute, subacute, or chronic?

—This question provides insight into possible causes of the neck swelling. Bacterial infections are usually acute and progressive. Other infections are more subacute, including Epstein-Barr virus (EBV) infection, cat-scratch disease, or tuberculosis. Congenital defects may be more chronic, with perhaps an acute superinfection that brings them to medical attention. A tumor may progressively increase in size over a variable time course depending on its histologic characteristic.

SUGGESTED READINGS

1. Pruden CM, McAneney CM. Neck mass. In: Fleisher GR, Ludwig S, Bachur RG, Gorelick MH, Ruddy RM, Shaw KN, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2010:385-391.

2. Friedman AM. Evaluation and management of lymphadenopathy in children. Pediatr Rev. 2008;29:53-59.

3. Leung AK, Davies HD. Cervical lymphadenitis: etiology, diagnosis and management. Curr Inf Dis Rep. 2009;11:183-189.

4. Nield LS, Kamat D. Lymphadenopathy in children: when and how to evaluate. Clin Pediatr. 2004;43:25-33.

5. Kandom N, Lee EY: Neck masses in children: current imaging guidelines and imaging findings. Semin Roentgenol. 2012;47:7-20.