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Unlocking the mysteries of pediatric neck masses.


SAN DIEGO -- Be thorough in your history taking when infants or children present with a neck mass, Dr. Seth M. Pransky advised.

"We want to know how long it's been there and what the associated symptoms are," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "Was there an antecedent respiratory infection or antecedent trauma? Has it become bigger or smaller, or has it remained the same size? What have the child's exposures been in terms of ill contacts, animals, and food?"

Such questions can guide you in determining what the correct diagnosis might be, said Dr. Pransky, director of pediatric otolaryngology at Children's Specialists Medical Group, San Diego.

An estimated 55% of pediatric neck masses are congenital, followed by acquired forms that include infectious, neoplastic, and inflammatory processes.

Branchial cleft anomalies are some of the most common types of congenital neck masses. These typically present as sinus tracts or fistulas detected at birth, with an opening in the skin with subsequent discharge that can be mucoid or mucopurulent. They may also present as cysts that enlarge gradually and present in the second or third decade of life.

A common type of branchial cleft anomaly is a preauricular anomaly that "begins as a pit in the preauricular region and often extends via a sinus tract down to a cystic dilatation almost always at the root of the helix," Dr. Pransky said. "You can milk out the secretions. If you get that kind of discharge, we generally recommend surgical excision, and ultimately recurrent acute infection occurs. If there's no discharge we'll leave it alone."

Incising and draining preauricular anomalies make the ultimate surgical excision more difficult, he added. "These need to be treated conservatively with antibiotics and warm compresses ... until the ultimate surgical excision can be carried out."

First branchial arch anomalies can extend deeply into the neck. They present either as parallel to the external auditory canal or in the upper neck, below the angle of the mandible. "These are a lot more challenging to manage surgically,'" Dr. Pransky said. "Fortunately they are rare."

Second branchial anomalies occur in the mid to lower portion of the neck along the anterior sternocleidomastoid muscle. Fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. "If you milk it you'll see strandy secretions, which are probably mucus," he said. "I'm not comfortable with just taking out the neck portion of these lesions. I also take out the tonsil in conjunction with the entire fistulous tract."

Second branchial cysts are "soft and fluctuate and frequently present as a soft swelling, not as an infectious problem," he said. Other assorted second branchial anomalies include skin tags, punctums, or cartilaginous remnants.

Third/fourth branchial cleft anomalies are rare and may present as an infectious swelling low in the floor of the neck laterally or in the anterior neck adjacent to the thyroid gland. "When you aspirate the lesion, you're going to get a mixed polymicrobial infection," Dr. Pransky said. "That's because you're getting organisms from the hypopharynx."

These anomalies may also present as acute thyroiditis. "That tract goes from the pyriform fossa in the hypopharynx through the thyroid gland into the neck," he said. "When a 5- or 6-year-old presents with a thyroiditis, my first thought is that they have a branchial three or branchial four anomaly."

Midline neck masses are also common. The three most common diagnoses are thyroglossal duct cyst, dermold cyst, and lymphadenitis. Location and the clinical picture at presentation of the swelling are helpful in determining the correct diagnosis.

Lymphadenitis tends to be submental and associated with infection of either the chin region (often from acne) or the teeth.

Dermoids can occur anywhere from the submental region to the suprasternal notch and are usually small, quite mobile, and located in the subcutaneous tissue.

Thyroglossal duct cysts are very common and generally are located at the level of or just below the hyoid. These are anatomically beneath the strap muscles of the neck and therefore are less mobile, often present after an upper respiratory infection, and tend to be larger than dermoids.

Another congenital neck mass Dr. Pransky discussed is pilomatixoma, which is a tumor of the hair cell shaft that grows slowly, is painless, and appears in different regions on the neck and face. These tumors feel firm and gritty, are bluish in color, and contain deposits of calcium.

"These are more bothersome than worrisome, but they need to come out as they tend to continue to enlarge," Dr. Pransky said. "Malignancy in these lesions is very rare. These are unencapsulated, so when you take out the lesion, you have to take out the tissue around it as well to make sure that you don't come back."

Dr. Pransky disclosed no conflicts of interest.
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Title Annotation:CLINICAL ROUNDS
Author:Brunk, Doug
Publication:Pediatric News
Date:Aug 1, 2009
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