CASE CONFERENCE
Ashmita Monga, M.D.
19 day/o female with swelling on neck.
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HPI
 Swelling on the R ant neck for 5 days
 Not increasing in size
 No history of trauma
 No history of fever
 No history of redness
 No difficulty in breathing
 No history of keeping neck to one particular side
 Has good po intake
 No excessive crying, no abnormal behavior
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BIRTH HISTORY
 FT, NSVD with no complications with normal nursery
course
 Maternal labs – RPR neg, HIV neg, Hepatitis B neg,
GBS neg, PPD neg
 Neonatal labs – RPR neg, no ABO incompatibility
 No history of forceps delivery or vacuum assisted
delivery
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SOCIAL HISTORY
 Baby lives with mother, grand-mother, uncle.
 No smokers.
 Has two dogs and two birds.
 Father recently travelled to DR.
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PHYSICAL EXAMINATION
 VS – T 98.6 F, P 120, R 38, O2 Sat 99 %
 Alert, active, in NAD
 Neck – firm, irregular mass ~ 2 cm in diameter
on distal part of right sternocleidomastoid
muscle. Non-erythematous, Non-tender,
movable, not fixed.
Rest of PE - WNL
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DIFFERENTIAL DIAGNOSIS OF NECK MASSES
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 CONGENITAL MASSES
 VASCULAR AND LYMPHATIC
MALFORMATIONS
 INFECTIOUS AND INFLAMMATORY LESIONS
 OTHER BENIGN LESIONS
 CONGENITAL MASSES
 VASCULAR AND LYMPHATIC
MALFORMATIONS
 INFECTIOUS AND INFLAMMATORY LESIONS
 OTHER BENIGN LESIONS
BRACHIAL CLEFT CYST
 Formed along course of 1st, 2nd, 3rd or 4th brachial clefts
as a result of improper closure during embryonic life.
 2nd Brachial cleft cysts are most common.
 May be inherited as autosomal dominant trait.
 May be unilateral or bilateral.
 May open into the cutaneous surface or drain into
pharynx.
 Secondary infection– treat with antibiotics.
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THYROGLOSSAL DUCT CYST
 Most common midline mass.
 Failure of involution of any portion of thyroglossal
duct can cause this cyst.
 Presents as asymptomatic midline mass or below the
hyoid bone which elevates with tongue protrusion.
 Can be associated with ectopic thyroid tissue.
 Preoperative workup- TFT’s vs ultrasound.
 Thyroid scan - In hypothyroid individuals or if
abnormal result on US.
 Management- Excision ( Sistrunk Procedure).
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THYROGLOSSAL DUCT CYST
THYMUS GLAND ANOMALIES
 Failure of involution of thymopharyngeal ducts may
persist as cervical thymic cysts.
 Firm, mobile masses found in lower aspect of the neck.
 Presents during first decade of life.
 Work up- CXR and CT.
 Management- surgical excision.
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DERMOID AND TERATOID CYSTS
 Developmental anomalies composed of different cell layers.
 Dermoid cysts are composed of mesoderm and ectoderm and
may contain hair follicles, sebaceous glands and sweat glands.
 Often midline or paramedian, do not elevate with tongue
protrusion.
 Treatment- Simple excision.
 Teratoid cysts- Contain all 3 cell layers.
 Present within first year of life.
 Larger midline or paramedian masses than Dermoid cysts.
 Distinguished by cellular differentiation enough to have
recognizable organs or structures.
 Large size could cause aerodigestive compressive symptoms.
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DERMOID CYST
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LARYNGOCELES
 Lateral neck mass
 form congenitally as a result of enlargement of the laryngeal saccule with distension and
entrapment of air.
 Laryngoceles are classified as either internal, external, or combined.
 Internal laryngocele is -confined solely to the larynx and is caused from distension of the
saccule, typically to the false vocal cord and aryepiglottic fold.
 Presents as hoarseness and respiratory distress.
 External laryngoceles will protrude through the thyrohyoid ligament at the entrance of the
superior laryngeal nerve.
 Presents as a soft, compressible, lateral neck mass that may distend with increases in
intralaryngeal pressures.
 If infected—larynopyoceles
 Combined type has features of both internal and external laryngoceles.
 Work up- CT scan.
 Treatment- If asymptomatic, no treatment needed.
 Symptomatic ones and larynopyoceles should be excised.
 CONGENITAL MASSES
 VASCULAR AND LYMPHATIC
MALFORMATIONS
 INFECTIOUS AND INFLAMMATORY LESIONS
 OTHER BENIGN LESIONS
HEMANGIOMAS
 The most common tumor of infancy.
 Typically present within the first few months of life.
 Demonstrate a rapid growth and then a period a quiescence followed by a period
of involution.
 Work up- CT with contrast or MRI with gadolinium.
 Treatment- Parental reassurance and periodic photo documentation.
 Cavernous hemangiomas
– Larger and are associated with deeper tissue involvement.
– Less likely to spontaneously resolve.
 Subglottic hemangiomas may be associated with cutaneous hemangiomas.
 Perform airway evaluation if cutaneous vascular lesions associated with stridor.
 Hemangiomas causing complications-- high dose steroids can be used.
 Surgical excision if unresponsive – Subtotal or staged excision.
HEMANGIOMAS
LYMPHANGIOMAS
 Lymphatic cysts that are isolated from their normal route of
drainage into the venous system.
 Classified into capillary, cavernous, and cystic types based on the
size of the lymphatic spaces.
 Cystic hygromas
– Large, soft, painless, and compressible masses,
– Usually present by the age of 3.
– Most commonly present in the posterior triangle.
– When they present in the anterior triangles, airway obstruction is
more of a concern.
 Work up - CT.
 Spontaneous regression is rare.
 Treatment of choice for obstructing lesions - Surgical excision.
 Recurrence rates are generally high because of the poor
encapsulation and dissection planes.
CYSTIC HYGROMA
VASCULAR MALFORMATIONS
Present during birth and grow proportionately with the
child.
Progressive dilation of the venous structures.
Vascular malformations can cause significant bony
distortion and destruction.
Port wine stain (capillary type vascular malformation) is
the most common vascular malformation.
Arteriovenous malformations are clinically distinguishable
from other head and neck masses as they are pulsatile on
palpation and may be associated with an audible bruit.
PORT WINE STAIN
 CONGENITAL MASSES
 VASCULAR AND LYMPHATIC
MALFORMATIONS
 INFECTIOUS AND INFLAMMATORY LESIONS
 OTHER BENIGN LESIONS
CERVICAL ADENITIS
Infection and inflammation of the cervical lymph nodes is
the most common cause of pediatric neck masses.
Palpable cervical lymph nodes are present in 40% of
infants.
Cervical nodes that are asymptomatic and < 1 cm in
diameter may be considered normal in children under 12.
Most common site of cervical adenitis is the
submandibular or deep cervical nodes.
Lymphadenitis may be of viral, bacterial, fungal, parasitic,
or noninfectious etiology.
CERVICAL ADENITIS
Most common bacterial cause of cervical adenitis is
Staphylococcus aureus and Group A Streptococci.
The cervical lymphadenopathy is usually tender .
Associated with malaise and fever.
Majority of the cases respond within 4-6 weeks to a ten
day course of a beta-lactamase resistant antibiotic.
If there is failure to respond, a fine needle aspiration is
warranted to exclude other diagnoses.
Node suppuration may occur, and needle aspiration or I
and D of the necrotic lymph node may be required.
RETROPHARYNGEAL ABSCESS
 The parapharyngeal and retropharyngeal spaces are the most common neck
spaces to be involved in pediatric neck abscesses.
 Occurs in around 3-4 years of age.
 Usually polymicrobial --aerobic organisms (Staphylococcus, Streptococcus,
Niesseria)
anaerobes (Fusobacterium, Peptostreptococcus, and Bacteroides).
 Clinical manifestations- fever, decreased po, drooling, difficulty to move the neck.
 Muffled voice, stridor or respiratory distress.
 Work up– CT scan with contrast It allows for precise anatomical localization and
relation to such structures as the major cervical vessels can be assessed .
 Treatment—IV antibiotics with/without surgical drainage (either intraoral or
external).
 Abscesses that are confined within a capsule and that do not extend posterior or
lateral to the great vessels may be safely drained via a transoral approach.
RETROPHARYNGEAL ABSCESS
LEMIERRE’S SYNDROME
 Septic thrombophlebitis of the internal jugular vein and metastatic
abscesses in lungs.
 Causative organism- Fusobacterium necrophorum.
 Was classically seen as a complication of inadequately treated
tonsillitis, but may also be seen with neck abscesses.
 Presentation with spiking fevers and fullness to one side of the
neck.
 CXR- Multiple cavitary nodules, often B/L associated with pleural
effusion.
 Treatment is with prolonged course of intravenous penicillin or
cefoxitin.
 Recurrent septic emboli occurrence may require surgical ligation or
excision of the internal jugular vein.
TUBERCULOUS AND NON TUBERCULOUS MYCOBACTERIA
 NTB More common than TB in children.
 Mycobacterial infection - Single large cervical lymph node. Later, the overlying
skin may turn a characteristic violaceous color.
 For tuberculous adenitis, a CXR is needed to rule out active pulmonary disease.
 A PPD is usually strongly reactive.
 Treatment with combinations of isoniazid, ethambutol, streptomycin, and
rifampin.
 NTM –
 Rarely exhibit fever or systemic symptoms.
 CXR is usually normal.
 PPD reactions - normal or only intermediate in reactivity.
 The treatment is less definitive with high resistance to traditional anti-tuberculous
agents alone and requires a combination of typical and atypical agents.
 Unless total surgical excision can be obtained, chronic draining sinuses often
develop and persist until spontaneous resolution occurs.
VIRAL ADENITIS
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Viral adenitis is likely the most common infectious process in the neck.
Common pathogens include rhinovirus, adenovirus, and enterovirus.
Usually self-limited and are associated with upper respiratory symptoms.
Infectious Mononucleosis
– is caused by Ebstein Barr Virus (EBV).
– Exudative, almost necrotic tonsillitis, impressive cervical lymphadenopathy and
occassional hepatosplenomegaly.
Work up
– Heterophile antibodies (monospot) test may remain negative early in the disease,
otherwise confirmatory.
– IgM and IgG titers are most specific.
Treatment is usually supportive.
If adenotonsillitis is so severe that airway symptoms emerge, steroid and antibiotic therapy
may be necessary.
Ampicillin and Amoxicillin have been associated with a rash in 90% of EBV patients and
should be avoided.
CMV and HIV cervical lymphadenitis present with similar symptoms to EBV. Treatments
for the cervical lymphadenopathy are supportive as well.
CAT SCRATCH DISEASE
 Caused by Bartonella henselae.
 Can be transmitted to humans by a Cat scratch.
 Presents as self limited, unilateral, regional lymphadenopathy.
 May have low grade fevers and malaise.
 Work up
–Warthin-Starry stain-shows small pleomorphic gram-negative
rods.
–Cultures may take several weeks.
–Serologic testing of IgM and PCR of Bartonella DNA.
 Symptoms usually resolve over several weeks to months, but in
10% of the patients, the nodes may progress to suppuration and
require incision and drainage.
 Antibiotic therapy not helpful but some anecdotal evidence has
suggested benefit from macrolides and aminoglycosides.
 CONGENITAL MASSES
 VASCULAR AND LYMPHATIC
MALFORMATIONS
 INFECTIOUS AND INFLAMMATORY LESIONS
 OTHER BENIGN LESIONS
PLUNGING RANULA
 Mucus retention cyst or a mucus extravasation pseudocyst arising
from an obstructed sublingual gland.
 Simple ranula is confined to the oral cavity- cystic unilateral mass of
the floor of the mouth.
 Plunging ranula may pierce the mylohyoid and present as a
paramedian or lateral neck mass with or without an obvious oral
cavity ranula.
 Work up
– Cyst aspiration - fluid with high levels of protein and salivary
amylase.
– CT or MRI - uniloculated cystic mass arising from the sublingual
space with extension into the submental, submandibular, or
parapharyngeal space.
 Surgical treatment - excision in continuity with the sublingual gland
of origin.
PLUNGING RANULA
STERNOMASTOID TUMOR OF INFANCY
 Fibrotic lesion of the distal sternocleidomastoid.
 Present within the first 7 to 28 days of birth as a firm mass within
the SCM.
 Head tuck to the ipsilateral side and chin pointed away from the
lesion may be present.
 Possible association with breach delivery and forceps delivery.
 Work up
–Clinical
–Ultrasound - solid mass that is intrinsic to the SCM.
 Treatment - aggressive physical therapy and range of motion
exercises (80-100% regress by the first birthday).
 Rarely an untreated case can lead to long term torticollis and
resultant dysmorphosis.
 Surgical division of the SCM is only recommended if physical
therapy fails.
CONGENITAL MUSCULAR TORTICOLLIS
BACK TO OUR PATIENT
 Physiotherapy and massage.
 At 1 month of age with improving range of motion.
 At 5 months, swelling totally disappeared.
THANK YOU !!
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