Neck masses in children
Block 12 – Head and Neck 2012
Dr EW Müller
• Infections with acute or chronic lymphadenitis
• Tumors
• Congenital
Thyroglossal cyst
Epidermoid cyst
Branchial cyst or fistula
Haemangioma and arterio-venous malformations
Infection: Acute lymphadenitis
• Most common cause: Bacterial infection of the
oropharynx, face or scalp: Tonsillitis, Pharyngitis,
impetigo of the scalp
• Organisms: Staph aureus, Streptococcus
• Clinic: Multiple tender lymph nodes in the submandibular
or anterior cervical region. The lymph nodes are smooth,
soft, not matted, mobile. Fever, systemic illness.
• Initial treatment with antibiotics (Cloxacillin, Ampicillin)
often results in resolution without suppuration.
• Without (and with) treatment, the lymph node may
become enlarged and fluctuant, leading to abscess
• An abscess needs surgical drainage.
Drainage pathways
• Face, anterior scalp,
forehead drain into facial,
preauricular, submental
• Tonsills, posterior
pharynx drain into
jugulodigastric, deep
cervical LNs
• Posterior scalp, back of
ear, external ear drain
into posterior superficial
cervical, posterior
auricular, occipital LNs
Infection: Chronic lymphadenitis
• Clinic: Chronically enlarged, non-tender lymph
• Differential diagnosis: Tb, atypical mycobacterial
infection, cat scratch disease; malignancy
• A single, dominant lymph node (>2cm big)
present longer than 6 – 8 wks, which has not
responded to antibiotic therapy, should be
excised, cultured, and submitted for histological
• HIV – often associated with Tb, lymphoma. Look
for abnormally large lymphnodes
• Lymphoma: By far the most common
childhood neoplasm presenting with
enlarged lymph nodes in the neck.
• Lymph nodes are usually rubbery, non
tender and fixed. They may enlarge
• Diagnosis: By biopsy of enlarged lymph
Congenital neck masses
Branchial Cysts and Sinuses
Thyroglossal duct cyst
Dermoid and epidermoid cyst
Branchial Cysts and Sinuses
• These are remnants of the branchial
apparatus which develops between the 4th
and 8th week of pregnancy.
• The apparatus consists of 4 branchial
arches separated by branchial clefts. If the
clefts fail to regress, a sinus or cyst will
Embryonic branchial apparatus
Mandibula and Maxillary process of the upper jaw
Inferior parathyroid and thymus
Superior parathyroid and parafollicular
Branchial remnants
• Present as fistulas or cysts anywhere on the
anterior border of the sternocleidomastoideus
• Cyst presents with nontender enlarging swelling
• Fistula presents with drainage of saliva from the
• Treatment: Early excision
• Complication: Cysts and fistulas can become
infected if not resected early in childhood
Thyroglossal cyst - Embryology
The foramen caecum is the
site of the development of
the thyroid at the base of
the prospective tongue.
As the tongue develops,
the thryroid diverticulum
descends in the neck,
maintaining its connection
to the foramen caecum. A
cyst can be located
anywhere along the
migratory tract if it fails to
become obliterated.
Thyroglossal cyst - Clinic
• Thyroglossal cysts are located in the
midline at or just below the hyoid bone.
• Due to communication with the mouth via
the foramen caecum the cyst can become
• The cyst is smooth, soft and non-tender.
• Owing to its attachment to the foramen
caecum, the cyst does move upwards
when the tongue protrudes.
Thyroglossal cyst
Thyroglossal cyst - Treatment
• Early surgical excision to avoid the
complications of infection
• Surgery entails complete excision of the
cyst and its tract upward to the base of the
tongue (Sistrunk Operation)
Epidermoid cysts
• Represent ectodermal elements, which where
trapped beneath the skin
• Epidermoid cysts contain sebaceous material
within the cyst cavity.
• Most common location is at the lateral corner of
the eyebrow. Presents with a characteristic
• Midline epidermoid cysts develop due to
entrapment of epithelium of branchial arch origin
at the time of embryologic midline fusion. They
might be confused with midline thyroglossal duct
• Lymphangiomas are congenital malformations of
lymph tissue that result from the failure of lymph
spaces to connect to the rest of the lymphatic
• Lymphangiomas present as a soft, smooth,
nontender mass that is compressible and can be
• Depending on the size and location, there might
be respiratory compromise and difficulty in
Lymphangioma: Treatment
• Goals: Improvement of cosmetic appearance,
relieve of impaired breathing and eating.
• Big lesions causing respiratory embarrassment
might need urgent intubation at birth.
• Surgery is difficult because of the infiltrative
nature of these lesions.
• Preferred treatment is infiltration with Bleomycin,
alcohol or other scerosing agents.
• Haemangiomas are benign tumors of the
capillary vessels of the skin
• They can occur anywhere, but are
common in the face and neck
• Typical growth, stationary and
involutionary phase
• Treatment : conservative (wait and see);
excision or sclerosation
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