Neck masses in kids

QUICK FACTS!

  • 90% of pediatric head and neck masses are benign, which is in stark contrast from adults (80% are neoplastic if age >45 years)
  • 40% of healthy children (without symptoms) have palpable cervical LAD
  • DDx mainly includes infectious, neoplastic, and congenital causes
    • Infectious: reactive LAD secondary to viral infection (most common cause), bacterial lymphadenitis (second most common cause), and then subacute/chronic infectious processes (EBV, CMV, HIV, Bartonella, Mycobacterial infections, Nocardia, Toxoplasmosis)
    • Neoplastic: <6 years-old think rhabdomyosarcoma or non-Hodgkin’s lymphoma; >6 years-old think Hodgkin’s lymphoma
    • Congenital: midline neck masses (thyroglossal duct cyst, dermoid cyst), lateral (branchial cleft cysts)
  • Don’t use steroids!!! This can delay diagnosis of leukemia, lymphoma, or histiocytic disease

WORRISOME FEATURES?! 

  • Systemic symptoms (fever >1 week, night sweats, weight loss [>10% of body weight])
  • Supraclavicular (lower cervical) nodes
  • Generalized LAD
  • Fixed nontender nodes in the absence of other symptoms
  • Nontender lymph nodes >1 cm with onset in the neonatal period
  • Nontender lymph nodes ≥2 cm that increase in size from baseline or do not respond to 2 weeks of antibiotics
  • Abnormal CXR (particularly mediastinal mass or hilar adenopathy)
  • Abnormal CBC (eg, lymphoblasts, cytopenias in more than 1 cell line)
  • Absence of symptoms in the ear, nose, and throat regions
  • Persistently elevated ESR/CRP or rising ESR/CRP despite antibiotic therapy

WHEN TO BIOPSY? 

  • Suspicion of malignancy
  • No resolution of LAD over 4-6 weeks
  • LAD that steadily increases in size over 2-3 weeks
  • LAD >2 cm
  • Multiple lymph nodes that have concerning features on US or CT

KEY REFERENCES!