neck mass. life-threatening causes of neck mass hematoma secondary to trauma ▫cervical spine...

Neck Mass

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 epiglotitis, tonsillar abscess, Ludwig’s angina or retropharyngeal abscess

Life-Threatening Causes Of Neck Mass

• Bacteremia/Sepsis associated with a local neck infection of a cyst

• Non-Hodkin’s lymphoma with mediastinal mass and airway compromise

• Thyroid storm• Kawasaki disease with coronary vasculitis• Tumor : Leukemia, Lymphoma,

Rhabdomyosarcoma• Lemierre’s Syndrome

Differential Diagnosis by Etiology

•Congenital•Inflammatory•Trauma•Neoplasm

Congenital Masses

• Thyroglossal duct cyst• Cystic hygromas• Branchial cleft cyst• Hemangiomas• Neonatal Torticollis = Fibromatosis colli• Dermoid cyst

Congenital Masses

Thyroglossal Duct Cysts• Most common congenital cyst of the neck• Develop anywhere from the base of the tongue to

sternal notch of the anterior angle• Fails to obliterate before formation of the hyoid

bone• Usually midline, adjacent to hyoid bone• Dx Before than 10 years of age• Soft, non tender, smooth and they move cranially

when child swallows or protrude their tongue• If infected: warm, erythematous, drainage

Thyroglossal Duct Cysts

• Antibiotics• Warm Compress• Incision and Drainage• Complete excision – treatment of choice after

complete resolution of infection

Cystic Hygromas

• Cystic lymphatic malformation in the posterior triangle of the neck

• Most diagnosed at birth • Hx of trauma or URI• 90% present before 2 years of age• Discrete, soft , mobile, non tender and vary

greatly in size• Extension to mediastinum – Chylothorax or

chylomediastinum, rarely airway compromise• Infection is uncommon

Cystic Hygromas

•CXR•US•CT or MRI to determine extent and

involvement of surrounding structures•Treatment: Complete excision

Branchial cleft anomalies

• Defect in the development of the second branchial arch

• Firm masses along the anterior border of the sternocleidomastoid muscle

• Branchial clefts sinuses: Painless, drainage• Cysts: fluctuant, mobile , nontender if the sinus

tract becomes block• Cysts may become infected – painful and warm• Incision and drainage of a branchial lesion

should be avoided because it may result in fistula formation

Branchial cleft anomalies

• US : thin walled , anechoic, fluid filled cyst• Treatment

Antibiotics if infectedExcision of entire tract and cyst to prevent recurrence

Hemangiomas

• Capillary hemangiomas, strawberry hemangiomas, capillary-cavernous hemangiomas noticed in infancy

• Soft, mobile , nontender, bluish or reddish• Larger in the first year and involute over next

several years• When located in the beard distribution associated

with glottic and subglottic hemangiomas, increasing the risk for airway compromise

• Tx: Conservative and nonoperative• Corticosteroids, laser tx, resection

Neonatal Torticollis

• Sternocleidomastoid fibrosis and shortening of the muscle

• Occur in the first 3 weeks of life• Infant holding chin and face away from affected

side• Head tilted toward fibrous mass• Mass is firm , attached to muscle• Tx: Physical therapy- massage , ROM exercises,

stretching exercises and positional changes• Complications: Facial and cranial asymmetry w/o

intervention

Inflammatory Neck Masses

• Cervical Lymphadenophaty• Cervical Lymphadenitis• Cat-Scratch disease• Mycobacterial infection• Lemierre’s Syndrome• Retropharyngeal abscess• Kawasaki disease

Cervical Lymphadenopathy

• Most common reason for neck masses in children• 90% between 4 -8 years can have cervical

adenopathy without obvious infection or systemic illness

• Newborns and infants warrants investigation• Anterior cervical LN: URI, oral or pharyngeal

infections• Posterior cervical LN: drains scalp and nasopharynx• Supraclavicular LN: pathologic and needs biopsy• Etiology: bacterial or viral infections• Treat underlying infection

Cervical Lymphadenitis

• Acute infection within the lymph node• MRSA, GAS, H. Influenza, Anaerobic and virus• Hx of previous URI• One or more cervical LN becomes enlarged,

tender, warm and erythematous• Systemic symptoms• Antibiotics (B-lactamase resistant) & warm

compresses• If failure: Serology, US, I&D• If Toxic : Admit for IV antibiotics • Complications: cellulitis and Abscess formation

Cat-scratch disease

• Another common cause of LN enlargement in children

• Regional LN enlarge 2-4 weeks after scratch• Fever and malaise (30%)• Single node involvement• Warm, tender, indurated and erythema• Serology testing : IFA, PCR• Symptomatic treatment• Surgical excision can lead to formation of a

draining sinus• Antibiotics : systemic illness, immunocompromised• Oral zithromax, Rifampin, TMT-SMZ, Ciprofloxacin

Mycobacterial infection of the cervical LN• Atypical strains: MAI and M. Scrofulaceum• Submandibular, red, rubbery and minimally

tender to palpation• If systemic complications are present consider

immunodeficiency• Clinical systemic signs of M. Tuberculosis:

cervical and supraclavicular LN are commonly involved

• PPD and CXR• PPD may be negative in atypical mycobacterium • Excisional biopsy: need to be performed to

differentiate between tuberculous and non- Tb

Mycobacterial infection of the cervical LN• Tx for Atypical mycobacterium

▫ Complete Surgical Excision

• Incision and drainage result in a draining sinus

• Tx for M. tuberculosis lymphadenitis▫ 6-9 month of antituberculosis chemotherapy

Lemierre’s Syndrome

• Infection of the parapharyngeal space • Septic thrombophlebitis of the internal jugular

vein• Septic embolization to lungs/CNS• Adolescents• Sore throat, fever, fullness to one side of the

neck, trismus, neck pain, dysphagia, dyspnea, toxic appearing

• Microbiology: G (-) Fusobacterium necrophorum• Antibiotics for 6 weeks

Neoplasms• Fortunately 80-90% of neck masses in children

are benign

• Usually painless, firm, fixed cervical mass

• Systemic symptoms may not be present

Neoplasm• Findings that prompt work up include:

▫ Supraclavicular lymphadenopathy▫ LN larger than 2 cm in diameter▫ Enlarged LN > 2 weeks▫ No decreased in size of a LN after 4-6 weeks▫ Lack of inflammation▫ Firm, rubbery consistency▫ Ulceration▫ Failure to respond to antibiotics▫ Systemic symptoms

Neoplasm• Hodgkin and non- Hodgkin Lymphoma• Rhabdomyosarcoma, Neuroblastoma, Thyroid• Nasopharyngeal carcinomas and Teratomas• CBC• CXR• Selective CT• MRI

Laboratory Testing

• CBC• PT, PTT• Thyroid studies• Throat cultures• EBV Serology• C-spine Xray• CXR• Ultrasound• Neck CT

Therapy• No therapy• PO Antibiotics• Follow up in several days to monitor clinical

response and need for aspiration and drainage• Surgical consultation for suspected tumor or

congenital cysts• Hospitalization

▫ Systemic toxicity▫ Airway compromise▫ Severe local disease