Chapter 10: Neck Masses

High-Yield Facts

• Most common neck masses in children are benign reactive lymphadenopathy and lymphadenitis.

• Congenital neck lesions can present even after the first decade of life often with an infection or obstruction.

• Occasionally, a neck mass may be related to a systemic illness or sign of a neoplastic condition and further investigation is warranted particularly if there is supraclavicular lymphadenopathy.

• Neck masses that affect the airway require immediate intervention.

• 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 evaluation.

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.¹ Forty-one percent of infants will have a palpable cervical node in the first year of life.² Occasionally, 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. Presence or absence of respiratory involvement as well as location of the lesion can help direct the clinician's evaluation (Fig. 10-1).

Inflammatory lymphadenopathy is the most common neck mass in children with a reported prevalence of 28% to 55% in otherwise normal infants and children.³ Congenital neck lesions include hemangiomas which are the most common; thyroglossal duct cysts which account for 70% of midline neck masses;^4,5 and branchial cleft sinuses or cysts which occur in the anterior triangle of the lateral neck.^6,7

Anatomy

The neck can be divided into two compartments or triangles (Fig. 10-2). The anterior triangle is formed by the mandible, sternocleidomastoid muscle, clavicle, and the line running from the mental symphysis to suprasternal notch. 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.⁸ The posterior triangle 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.