Neck swelling in children is a finding that elicits immediate parental concern and often prompts a visit to the physician. The finding of a neck mass invokes a response because it can be associated with malignancy. Malignancy, though part of the differential diagnosis, is a relatively uncommon cause of neck swelling by far. More common causes include inflammatory conditions, such as reactive lymphadenopathy from viral upper respiratory tract infections, bacterial adenitis, and congenital anomalies with or without bacterial superinfection. Because children often have palpable normal lymph nodes, a significant neck mass is typically defined as swelling that exceeds 2 cm in diameter. In rare cases, smaller nodes may have characteristics that prompt evaluation. Congenital anomalies, although present at birth, may not become clinically apparent until the child is school age or older.
Hospitalization is required if neck masses are present in conjunction with systemic symptoms such as fever, fatigue, or pallor; if the neck masses are large enough to comprise the airway; or if the neck masses have not responded to outpatient therapy.
A differential diagnosis list for neck masses is presented in Table 13-1. Neck masses that require immediate evaluation include those that follow trauma and those that cause airway compromise (Table 13-2). The most common causes of neck swelling include benign reactive lymphadenopathy, bacterial lymphadenitis (including that caused by Bartonella henselae), hematoma, congenital causes (e.g., thyroglossal duct cyst, branchial cleft cyst, cystic hygroma), and benign tumors (e.g., lipoma, keloid). Table 13-3 indicates the type of mass by location.
Table 13-1. Differential Diagnosis of Neck Mass by Etiology. |Favorite Table|Download (.pdf)
Table 13-1. Differential Diagnosis of Neck Mass by Etiology.
Thyroglossal duct cyst
Branchial cleft cyst
Cystic hygroma (lymphangioma)
Squamous epithelial cyst (congenital or posttraumatic)
Pilomatrixoma (Malherbe calcifying epithelioma)
Lymphadenopathy—secondary to local head and neck infection
Lymphadenopathy—secondary to systemic infection—infectious mononucleosis, cytomegalovirus, HIV, toxoplasmosis, others
Lymphadenitis—streptococcal, staphylococcal, fungal, mycobacterial, cat-scratch disease, tularemia
Focal myositis—inflammatory muscular pseudotumor
Local hypersensitivity reaction (sting/bite)
Serum sickness, autoimmune disease
Pseudolymphoma (secondary to phenytoin)
Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy)
Caffey-Silverman syndrome (infantile hyperostosis)
Sternocleidomastoid tumor of infancy (fibromatosis colli)
Cervical spine fracture
Lipoma, fibroma, neurofibroma
Goiter (with or without thyroid hormone disturbance)
Teratoma (may be malignant)
”Normal” anatomy or variant
Lymphoma—Hodgkin disease or non-Hodgkin lymphoma
Nasopharyngeal squamous cell carcinoma
Thyroid or salivary gland tumor
Table 13-2. Life-Threatening Causes of Neck Mass. |Favorite Table|Download (.pdf)
Table 13-2. Life-Threatening Causes of Neck Mass.
Hematoma secondary to trauma
Cervical spine injury
Vascular compromise or acute bleeding
Late arteriovenous fistula