Evaluation and management of neck masses in children

Neck masses in children usually fall into one of three categories: developmental, inflammatory/reactive, or neoplastic. Common congenital developmental masses in the neck include thyroglossal duct cysts, branchial cleft cysts, dermoid cysts, vascular malformations, and hemangiomas. Inflammatory neck masses can be the result of reactive lymphadenopathy, infectious lymphadenitis (viral, staphylococcal, and mycobacterial infections; cat-scratch disease), or Kawasaki disease. Common benign neoplastic lesions include pilomatrixomas, lipomas, fibromas, neurofibromas, and salivary gland tumors. Although rare in children, malignant lesions occurring in the neck include lymphoma, rhabdomyosarcoma, thyroid carcinoma, and metastatic nasopharyngeal carcinoma. Workup for a neck mass may include a complete blood count; purified protein derivative test for tuberculosis; and measurement of titers for Epstein-Barr virus, cat-scratch disease, cytomegalovirus, human immunodeficiency virus, and toxoplasmosis if the history raises suspicion for any of these conditions. Ultrasonography is the preferred imaging study for a developmental or palpable mass. Computed tomography with intravenous contrast media is recommended for evaluating a malignancy or a suspected retropharyngeal or deep neck abscess. Congenital neck masses are excised to prevent potential growth and secondary infection of the lesion. Antibiotic therapy for suspected bacterial lymphadenitis should target Staphylococcus aureus and group A streptococcus. Lack of response to initial antibiotics should prompt consideration of intravenous antibiotic therapy, referral for possible incision and drainage, or further workup. If malignancy is suspected (accompanying type B symptoms; hard, firm, or rubbery consistency; fixed mass; supraclavicular mass; lymph node larger than 2 cm in diameter; persistent enlargement for more than two weeks; no decrease in size after four to six weeks; absence of inflammation; ulceration; failure to respond to antibiotic therapy; or a thyroid mass), the patient should be referred to a head and neck surgeon for urgent evaluation and possible biopsy.