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  • Reactive cervical lymphadenopathy and lymphadenitis are the most common causes of neck masses in children.
  • Laboratory testing is often not necessary in the evaluation of cervical lymphadenopathy as the cause can usually be determined by the history and physical examination.
  • An enlarged cervical mass that does not improve after 4 to 6 weeks needs to be referred to a subspecialist for further work-up.
  • Congenital neck lesions can present even after the first decade of life often with an infection or obstruction.
  • Supraclavicular lymphadenopathy in any age group is worrisome and should be investigated.

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The emergency physician is often called upon to evaluate an infant or child with a neck mass. Most of these neck masses are benign and result from reactive lymph nodes caused by viral infections. On occasion, a patient can present with a significant neck mass of unknown etiology. The challenge is to distinguish between the pathologic lesions that need expeditious management versus those neck conditions that are benign but still cause a lot of parental anxiety. This chapter will discuss an approach to the pediatric patient presenting with a neck mass. Important elements of the history and physical examination will be highlighted and a discussion of the differential diagnoses and management options will be presented (see Fig. 17–1).

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Figure 17-1.
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Algorithm on the management of a child with a neck mass.

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An understanding of the anatomy of the neck is important in generating a working differential diagnoses in a pediatric patient presenting with a neck mass. There are several anatomic classifications used in describing the location of neck lesions. A simple method is to divide the neck into two compartments or triangles with the sternocleidomastoid muscle as the common boundary (Fig. 17–1). The anterior compartment is defined by the anterior border of the sternocleidomastoid muscle, the lower border of the mandible, the sternum inferiorly, and a line extending from the submandibular symphysis to the sternal notch.1 Vital structures located in this compartment include the larynx, trachea, esophagus, the thyroid and parathyroid glands, the carotid sheath, and the suprahyoid and infrahyoid muscles. Several lymph node chains are found in this area, including the jugulodigastric chain that lies anterior to the sternocleidomastoid muscle. The posterior compartment is defined inferiorly by the clavicle, laterally by the trapezius, and medially by the sternocleidomastoid muscle. Structures that are found in this area include the subclavian vessels, cervical roots of the brachial plexus, spinal accessory nerve, and also several lymph node chains.

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Knowledge of the anatomy of the neck and the specific regions drained by the lymph node group will help the clinician in locating the primary infection. The posterior part of the tongue, tonsils, sinuses, nasopharynx, larynx, and pharyngeal regions drain into the superficial and deep anterior cervical lymph nodes. The anterior scalp, ear canal, pinna, and the conjunctiva drain ...

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