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Neck Mass

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

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Neck Mass

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  1. Neck Mass

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

  3. 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

  4. Differential Diagnosis by Etiology • Congenital • Inflammatory • Trauma • Neoplasm

  5. Congenital Masses • Thyroglossal duct cyst • Cystic hygromas • Branchial cleft cyst • Hemangiomas • Neonatal Torticollis = Fibromatosiscolli • Dermoid cyst

  6. 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

  7. Thyroglossal Duct Cysts • Antibiotics • Warm Compress • Incision and Drainage • Complete excision – treatment of choice after complete resolution of infection

  8. 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

  9. Cystic Hygromas • CXR • US • CT or MRI to determine extent and involvement of surrounding structures • Treatment: Complete excision

  10. 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

  11. Branchial cleft anomalies • US : thin walled , anechoic, fluid filled cyst • Treatment Antibiotics if infected Excision of entire tract and cyst to prevent recurrence

  12. 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 subglottichemangiomas, increasing the risk for airway compromise • Tx: Conservative and nonoperative • Corticosteroids, laser tx, resection

  13. 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

  14. Inflammatory Neck Masses • Cervical Lymphadenophaty • Cervical Lymphadenitis • Cat-Scratch disease • Mycobacterial infection • Lemierre’s Syndrome • Retropharyngeal abscess • Kawasaki disease

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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 (-) Fusobacteriumnecrophorum • Antibiotics for 6 weeks

  21. Neoplasms • Fortunately 80-90% of neck masses in children are benign • Usually painless, firm, fixed cervical mass • Systemic symptoms may not be present

  22. Neoplasm • Findings that prompt work up include: • Supraclavicularlymphadenopathy • 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

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

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

  25. 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

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