Evaluation and Management of Pediatric Neck Masses: An Otolaryngology Perspective

Cervical bronchogenic cyst in a toddler

Bronchogenic cyst is a congenital abnormality arising from the tracheobronchial system. Localisation of such cysts in the head and neck region is rare. We report a girl in her early childhood with a painless enlarging right lateral neck mass diagnosed with a branchial cleft cyst based on clinical and radiological MRI findings. An incidental finding of a cervical bronchogenic cyst was made on the final histopathological specimen. Although rare, bronchogenic cysts should be considered as differential diagnoses for paediatric patients' lateral and midline cervical masses.

A Rare Presentation of a Branchial Cleft Cyst: Can It Cause Syncope in a Pediatric Patient?

Branchial cleft cysts (BCCs) are a congenital malformation most commonly seen in children and adolescents. BCCs are usually incidental findings and are benign in nature. In this report, we present a case of a 13-year-old female with syncope as a rare complication of a fluid-filled second BCC. The patient initially presented with a unilateral non-tender swelling on the right side of the neck and submandibular region, which was suspicious of an inflammatory process. After initial lab investigations came back negative, imaging studies of the neck with computed tomography (CT) with intravenous contrast revealed a hypodense lesion with a uniform density, which lay beneath the sternocleidomastoid muscle and abutted the carotid sheath. The cyst was surgically excised, and histopathological studies of the cyst wall and the analysis of the fluid contained within the cyst confirmed that it was indeed a branchial cleft cyst. We propose that the syncopal episodes she experienced most likely occurred due to the proximity of the cyst wall to the carotid sheath, which caused a mass effect leading to carotid sinus syndrome (CSS). This is the first case of CSS due to a BCC to be reported in the pediatric population.

Congenital Neck Masses

There are many possible causes of congenital neck masses, with the most common ones being thyroglossal duct cysts, branchial cleft anomalies, and vascular malformations. Most congenital neck masses are asymptomatic in the neonatal period, but depending on the location and the size, they can cause airway obstruction and serious complications at birth. Proper diagnosis is important for optimal treatment planning, and if the airway is compromised, multidisciplinary teamwork is critical for proper airway management. This review summarizes the clinical features, etiology, diagnosis, management, and prognosis of different types of congenital neck masses.

Diagnosis difficulty of histiocytosis in the thyroid region of a child: a rare case report with literature review of differential diagnoses

Background

Isolated histiocytosis of thyroid region is very rare; clinical history, exam, and radiological aspects are non-specific, and etiological reasoning is quite difficult considering the tremendous number of differential diagnoses.

Case presentation

This is the case of a 6-year-old girl who came to the emergency room with an acute presentation bulging of the anterior and left lateral regions of the neck. The palpation of the mass showed tenderness; there was no sign of inflammation, nor was there any fistula to the anterior border of the sternocleidomastoid muscle.

The patient was stable. She did not have any signs of compression. The initial blood showed anemia and inflammatory syndrome. She underwent cervical ultrasound exam that showed a mass at the expense of the left thyroid lobe; the mass extends through the sub-hyoid muscles to the lateral cervical region.

A CT scan with and without contrast injection was performed. It showed a heterogenous mass, which seemed centered in the anterior compartment, and from which it extended to the left lateral compartment, as well as the posterior compartment, invading the prevertebral muscles and englobing the carotid and the internal jugular vein.

The patient underwent surgical biopsy. A basal cervical incision was made, dissection with the myo-cutaneous plane. Per-operative observation established that the mass breeched the infrahyoid muscles, as well as the sternocleidomastoid muscle. A biopsy was performed without opening the middle line.

The pathological exam showed an eosinophilic granulomatosis, associated with Stembergoid cells. The immune-histochemical exam concluded that the lesion is histiocytosis. The patient underwent a cervicothoracic and pelvic CT scan to rule out systemic forms. The diagnosis of isolated histiocytosis of thyroid region was confirmed.

The patient underwent hemithyroidectomy, associated with careful dissection of extension of the mass to lateral compartment of the neck. Postoperative exam showed no abnormalities. No dysphonia and no hypocalcemia were observed.

The 8-month follow-up showed satisfactory results, no cervical swelling, and no signs of inflammation or compression. Postoperative naso-fibroscopy was normal.

Conclusions

The most important takeaway message of this work is that methodical approach of neck masses allows to rule out the most aggressive lesions frequently encountered, which allows clinicians to establish thorough diagnosis and management without further delay.

Presentation and evaluation of an atypical, supraclavicular mass in a pediatric patient

Although the vast majority of pediatric neck masses are benign, pediatric malignancies commonly present in the supraclavicular region. We present the case of a 4-year-old male who presented with a mass in the trapezius muscle with accompanying lymphadenopathy. An extensive work-up was performed to exclude malignancy, and the patient was ultimately diagnosed with a benign monocytic mass, which surgically excised. He has been doing well since surgery with no evidence of recurrence. A review of the literature revealed this case to be the first of its kind to be reported.

Isolated lesions of the suprasternal notch in pediatric patients

BACKGROUND

Palpable masses of the head and neck are a common indication for imaging in the pediatric population. Midline lesions of the infrahyoid neck, particularly lesions isolated to the suprasternal notch, are not well studied.

OBJECTIVE

To delineate the histopathological and imaging spectrum of masses that occur within and isolated to the suprasternal notch.

MATERIALS AND METHODS

A retrospective study was performed to identify patients with an isolated lesion of the suprasternal notch that had available pathological diagnoses. Available imaging was reviewed and characterized by fellowship-trained pediatric radiologists and compared by descriptive statistics to the final pathological diagnoses.

RESULTS

Eighteen masses isolated to the suprasternal notch with available pathological diagnoses were identified. Of these, congenital epithelial inclusion cysts were diagnosed in 14 patients (77.8%) with dermoid cysts comprising 11 of those (61.1%) and epidermoid cysts accounting for 3 (16.7%). The most common imaging appearance was a cystic or pseudosolid appearance without vascularity.

CONCLUSIONS

Isolated resected lesions of the suprasternal notch in pediatric patients are most frequently dermoid/epidermoid cysts, with a differential diagnosis including other less common entities.

Ether Day Revisited: The Surgical Records of Edward Gilbert Abbott

Background

The details of the public demonstration of the effects of ether that initiated the modern era of surgery and anesthesia are often misreported. Existing published transcripts of the clinical records are incomplete or inaccurate.

Methods

The patient notes of Gilbert Abbott were photographed, transcribed, and reviewed.

Results

The records are handwritten in "Surgical Records for 1846; Volume 30," of the Massachusetts General Hospital. The patient was admitted on September 25. The presenting condition was a congenital, mobile, compressible, multilobed, small lesion at the angle of the left mandible, and base of tongue. The operation on October 16 was an attempted ligation of the blood supply to the lesion. The postoperative diagnosis was a vascular lesion ("erectile tumor"). Postoperative management included application of sclerosants. The mass was unchanged in size on discharge on December 7. There is no documentation of the anesthetic administration in the progress note but a retrospective report of the anesthetic is pasted into the Records book. This account reported that the patient did not respond to the initial incision. He moved and cried out during the latter part of the procedure. Although he was aware of the operation taking place, he later said he had not experienced pain. The commentary concluded that the demonstration of the analgesic effectiveness of ether was inconclusive but that subsequently ether was shown to be effective.

Conclusions

The surgery on October 16, an unsuccessful ligation of a congenital lymphovascular malformation, was performed under incomplete general anesthesia. Examination of the primary documents may allow for more accurate accounts of circumstances surrounding the discovery of anesthesia.

Pediatric Neck Masses: Imaging Guidelines and Recommendations

Neck masses commonly present in children and several potential diagnostic and management pathways exist, though with a paucity of evidence-based recommendations. The purpose of this article is to evaluate the current literature and utilization of various diagnostic imaging modalities , with a review of imaging features and management pearls for pediatric neck masses. A comprehensive understanding and practical imaging workflow will guide optimal patient workup and management.

Needle aspiration of lateral neck abscess in children: A simple and effective treatment

BACKGROUND

Cervical abscesses frequently occurred in pediatric patients. Surgical drainage is currently recommended in the cases not responding to medical therapy. Needle aspiration may represent a simple, effective and minimally invasive treatment for acute neck suppuration in selected cases.

OBJECTIVE

To evaluate the effectiveness of needle aspiration in the treatment of cervical abscesses in pediatric age as an alternative to surgical drainage.

METHODS

From November 2013 to November 2019, at the ENT Department of the "Bambino Gesù" Pediatric Hospital, Rome, we treated 47 children with cervical abscess by performing aspiration with a 19 G needle in wakefulness after applying local anesthetic. Parenteral antibiotic treatment was associated with all patients both before and after treatment.

RESULTS

Complete regression of the abscess occurred in 46 children with no evidence of recurrence in the follow-up period. Surgical drainage was required in only one patient due to the lack of resolution of the abscess episode. No complications such as hematomas or hypertrophic scars were found in any patient.

CONCLUSIONS

Our results confirm the effectiveness of needle aspiration in the treatment of cervical abscesses in children as an alternative to surgical drainage.

Chronic Lateral Neck Mass in an Adolescent Female

Neck masses are a common finding in the pediatric population, with a broad differential diagnosis resulting in real diagnostic challenges. They are most frequently caused by reactive lymphadenopathy, infectious lymphadenitis, or congenital anomalies of the neck. This case report describes a 16-year-old female presenting to the pediatric emergency department with 5 weeks of right-sided neck mass. Based on her history, physical examination, and prolonged clinical course, the differential diagnosis included infectious, congenital, and neoplastic causes. The patient was ultimately diagnosed with a branchial cleft cyst and referred to a pediatric head and neck surgeon.

A case report of a spontaneous sternocleidomastoid hematoma: a challenging diagnosis in infantile neck swellings

Background

Pediatric neck masses are a common complaint in children. The most common etiologies include congenital lesions, lymphadenopathy, vascular malformations, inflammatory, and malignant lesions. Spontaneous sternocleidomastoid hematoma is exceptional in infant.

Case presentation

We describe a case of spontaneous cervical hematoma diagnosed in a 4-month-old child. Past history did not reveal a neck trauma, a history of difficult labor, a bleeding disorder or a pertinent family history. The diagnosis was suspected based on the imaging features and confirmed after surgical removal.

Conclusions

Sternocleidomastoid swelling is commonly encountered in infancy.

Ultrasound still remains the initial modality of choice. The management modalities are controversial.

Appraisal of clinical practice guidelines for the evaluation and management of neck masses in children

AIM

The purpose of this systematic review was to use the Appraisal of Guidelines for Research and Evaluation tool to assess the methodological quality of clinical practice guidelines (CPGs) for the workup and management of paediatric neck masses.

METHODS

MEDLINE, Embase, Cochrane and grey literature were searched to identify CPG incorporating paediatric neck masses. Four authors with previous training of the Appraisal of Guidelines for Research and Evaluation tool evaluated the included studies.

RESULTS

Nine studies met inclusion criteria. The highest scoring domains were 'Scope and Purpose' (74.0 ± 4.5) and 'Clarity of Presentation' (72.9 ± 6.3). The lowest scoring domains were 'Rigour and Development' (18.8 ± 7.5) and 'Applicability' (23.7 ± 6.1). One study was 'High' quality, three received scores of 'Average' and five were found to be 'Low' quality.

CONCLUSION

The majority of paediatric neck mass CPGs were low to average quality. The domains in need of greatest improvement were 'Rigour and Development' and 'Applicability', suggesting significant concerns in current CPGs focused on paediatric neck masses.

Diagnosis and management of congenital floor of mouth masses: A systematic review

OBJECTIVES

Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants.

METHODS

A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined.

RESULTS

85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%.

CONCLUSION

Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.