Pediatric head and neck masses

The effect of point-of-care ultrasound on length of stay in the emergency department in children with neck swelling

BACKGROUND

Ultrasound is the imaging modality of choice in children presenting to the emergency department (ED) with soft tissue neck swelling. Point of care ultrasound (POCUS) has good accuracy when compared to comprehensive radiology department ultrasound (RADUS). POCUS could potentially improve ED length of stay (LOS) by improving efficiency. We aimed to evaluate the LOS of pediatric patients seen in ED with soft tissue neck swelling who received POCUS compared to RADUS. We determined unscheduled 30-day return visit rates in both groups as a balancing measure.

METHODS

We performed a retrospective review of the electronic medical record for our cross-sectional study of discharged patients ≤21 years of age who had a neck ultrasound performed by a credentialed POCUS physician or by the radiology department between July 2014 and January 2020. We included patients who had both POCUS and RADUS in the POCUS group. We compared median ED LOS in both groups using the Mann Whitney U test and proportion of unscheduled return visits to the ED in both groups using odds ratio and 95% CI.

RESULTS

There were 925 patients: 76 with only POCUS, 6 with POCUS and RADUS, and 843 with only RADUS performed. Median LOS in the POCUS group was 68.5 min (IQR 38.3120.3) versus 154.0 min (IQR 111.0, 211.0) in the RADUS group (p < 0.001). Return visit overall was 7.6%: 13.2% in the POCUS group versus 7.1% in the RADUS group (p = 0.07).

CONCLUSION

Pediatric patients evaluated in the ED for soft tissue neck swelling had a shorter LOS with POCUS than with RADUS without a statistically significant increase in 30-day return visits. We suggest a "POCUS First" approach to the care of these patients.

The use of point of care ultrasound in the evaluation of pediatric soft tissue neck masses

OBJECTIVE

Most soft tissue neck masses represent benign inflammatory or infectious processes; however, in some cases the diagnosis is not clear and a broader differential must be considered. The aim of this study was to compare point-of-care ultrasound (POCUS) to radiology department imaging (RDI) in the diagnosis of soft tissue neck masses.

METHODS

This prospective pilot study involved a convenience sample of patients ranging in age from 1 month to 18 years of age presenting to the Pediatric Emergency Department (PED) with a soft tissue neck mass. All children who presented to the PED with soft tissue neck mass at times when an investigator was in the department, and who were candidates for enrollment, underwent a POCUS. The managing pediatric emergency medicine (PEM) provider determined whether RDI was indicated. The results of the POCUS sonologist and radiologist were compared. The kappa statistic was used to analyze agreement with p < 0.05 denoting statistical significance.

RESULTS

Twenty-seven patients were enrolled into the study. Twenty-two received radiology ultrasound (RUS), 3 patients received CT, and 2 patients received both RUS and CT. There was agreement between POCUS and RDI diagnoses in 21/27 cases (78%). Accordingly, overall concordance between POCUS and RDI diagnoses was good: the kappa statistic comparing diagnoses obtained by POCUS versus RDI was 0.69 (p < 0.001).

CONCLUSION

This prospective pilot study describes the reliability of POCUS as an imaging modality in the management of patients with undifferentiated soft tissue neck masses. POCUS demonstrated good agreement with RDI as a bedside imaging tool in the evaluation of pediatric soft tissue neck masses.

Pattern of acquired neck masses in a Kenyan paediatric population

Acquired paediatric neck masses constitute a diagnostic challenge. Their pattern is important in formulating management protocol. Reports from developing countries including Kenya are scarce. This study describes the causes, location, clinical features and gender distribution of these masses in a Kenyan paediatric population. This prospective cross-sectional study was carried out in a regional Eastern and Central African referral centre in Kenya. Children aged 16 years and below with neck masses, who presented to various clinics and wards in a 5 month period were examined. One hundred and eighty four of 235 masses (78%) were acquired. Inflammatory cases were the most common (64%), followed by malignant neoplasm (32%). The most common inflammatory cases were abscesses, reactive lymphadenopathy and tuberculous adenitis. They mainly involved upper cervical and submandibular lymph nodes and were more prevalent in those aged less than 4 years. Lymphomas were the most common malignant masses (42%). Malignant masses were widespread in location; non-tender, and most frequent in those aged 4-8 years. In conclusion, inflammatory conditions consistent with upper airway infection cause most acquired paediatric neck masses, but malignant neoplasms constitute a significant proportion. Prudent management of infection and early confirmation of diagnosis are recommended.

Head and neck lymph nodes in children: the spectrum from normal to abnormal

Lymphadenopathy of the head and neck region is a common finding in children and a very common reason to image the craniocervical region. Enlarged lymph nodes are commonly palpated by the pediatrician in the office and commonly imaged by the pediatric radiologist. The difficult task of the clinician is to determine whether the adenopathy is acute (<3 weeks) or chronic (>6 weeks) and when imaging is indicated. In children, radiation is always a consideration when choosing an imaging modality; thus, US is usually the first imaging study at our institution, and CT the second option, usually reserved for the very ill child or for when there is a high index of suspicion for malignancy. We present the normal anatomy of head and neck lymph nodes and the US, CT, and MRI appearances in normal and pathologic states to help clinicians generate a reasonable differential diagnosis and prevent unnecessary procedures.

Characterization of pediatric head and neck masses with diffusion-weighted MR imaging

We aimed to assess the clinical usefulness of the ADCs calculated from diffusion-weighted echo-planar MR images in the characterization of pediatric head and neck masses. This study included 78 pediatric patients (46 boys and 32 girls aged 3 months-15 years, mean 6 years) with head and neck mass. Routine MR imaging and diffusion-weighted MR imaging were done on a 1.5-T MR unit using a single-shot echo-planar imaging (EPI) with a b factor of 0.500 and 1,000 s mm(-2). The ADC value was calculated. The mean ADC values of the malignant tumours, benign solid masses and cystic lesions were (0.93 +/- 0.18) x 10(-3), (1.57 +/- 0.26) x 10(-3) and (2.01 +/- 0.21 ) x 10(-3) mm(2) s(-1), respectively. The difference in ADC value between the malignant tumours and benign lesions was statistically significant (p < 0.001). When an apparent diffusion coefficient value of 1.25 x 10(-3) mm(2) s(-1) was used as a threshold value for differentiating malignant from benign head and neck mass, the best results were obtained with an accuracy of 92.8%, sensitivity of 94.4%, specificity of 91.2%, positive predictive value of 91% and negative predictive value of 94.2%. Diffusion-weighted MR imaging is a new promising imaging approach that can be used for characterization of pediatric head and neck mass.

CT versus MR: still a tough decision

CT and MRI are the two most widely used imaging modalities for evaluating head and neck pathology. There is continued controversy in the literature about which modality is superior for imaging different areas of the head and neck. This article summarizes the literature supporting the use of CT, MRI, or both for specific clinical scenarios in otolaryngology. Familiarity with the benefits and potential pitfalls of each modality allows referring physicians and radiologists to tailor imaging regimens to the needs of individual patients.

Congenital neck masses: a descriptive retrospective study of 252 cases

PURPOSE

This retrospective study was conducted to analyze congenital neck masses in Jordanians compared with international findings.

PATIENTS AND METHODS

The records of patients with congenital neck masses between 1991 and 2002 were retrieved from the Department of Pathology, Jordan University of Science and Technology, and analyzed for age, gender, location, clinical features, and treatment.

RESULTS

Within the 12-year period of the study, a total of 2,063 neck mass lesions were found; of these, 252 (12%) were congenital masses. These cases were distributed into 166 (66%) midline, 55 (22%) lateral, and 31 (12%) entire neck masses. The most frequent mass was thyroglossal duct cyst (fistulas) (53%), followed by cysts (fistulas) of the branchial apparatus (22%), dermoid cysts (11%), hemangiomas (7%), and 1ymphangiomas (6%). The majority of branchial arch anomalies (85%) were of the second arch. The mean age of patients was 16 years, with the greatest number of cases (38%) in the first decade. The male-to-female ratio was 1:1.2, with most lesions affecting females. The majority of lesions presented with painless neck swelling, and all lesions were surgically excised.

CONCLUSIONS

The overall frequency and age distribution of congenital neck masses in northern Jordanians are similar to international findings. However, the gender distribution and relative frequency of individual types of neck masses are somewhat different from those in other countries. These differences may be attributed to genetic and geographic differences.

Role of diffusion weighted MR in the discrimination diagnosis of the cystic and/or necrotic head and neck lesions

PURPOSE

The purpose was to determine whether the diffusion weighted imaging (DWI) was able to differentiate necrotic tumor or metastatic lesions from infected necrotic lesions such as abscesses and necrotic lymphadenitis in the neck.

MATERIALS AND METHODS

DWI was performed on 37 consecutive patients with 85 head and neck necrotic and cystic lesions. The lesions were classified into four categories: metastatic lymph node involvement including lymphoma, necrotic tumor, abscesses and necrotic lymphadenitis. Each lesion was histopathologically studied and proved.

RESULTS

In 12 patients, there were 35 necrotic lymphadenitis (necrotic tuberculosis lymphadenitis, n=18; necrotic nonspecific suppurative lymphadenitis, n=17). Of the 15 necrotic metastatic nodes, 11 lesions were lymphomatous involvement and 4 lesions were other tumor involvement. Other 11 patients have abscesses. Thirteen primary tumoral necrotic lesions arose in the neck of nine patients. All of the abscesses and necrotic lymphadenitis showed hyperintensity on DWI, in contrast to necrotic tumor and necrotic nodal metastasis that showed hypointensity on DWI. DWI successfully differentiated metastatic nodes and necrotic tumors from necrotic lymphadenitis and abscesses.

CONCLUSION

DWI may be supportive for differentiating necrotic tumor lesions such as necrotic tumor and metastatic necrotic nodes from the infective necrotic lesions such as necrotic lymphadenitis and abscesses in the head and neck.