Neck masses in children

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.

Intermuscular Fibrolipoma of the Neck: A Rare Case Report

Lipomas are slow growing tumors rarely found in children. We report a very rare case of an intermuscular fibrolipoma found deep within the posterior triangle of the neck. A 3 year old child was brought with the complaints of right sided neck mass and an inability to fully turn his head for two months. Ultrasound and computed tomography of the neck suggested a diagnosis of intermuscular lipoma. The patient was successfully managed by complete surgical resection of the mass. Histopathological examination confirmed the diagnosis as intermuscular fibrolipoma. Due to the rarity of the case, we are prompted to report it.

Imaging of parotid anomalies in infants and children

A wide spectrum of disorders involves the parotid glands, in infancy and childhood. Acute or chronic inflammatory/infectious diseases are predominant. The first branchial cleft anomalies are congenital lesions that typically manifest during childhood. Tumor lesions are more likely to be benign, with infantile hemangioma the most common in infancy and pleomorphic adenoma the most frequent in childhood. Malignant tumors are uncommon, with mucoepidermoid carcinoma the least rare. Infiltrative parotid diseases are rare and have some pediatric clinical specificities. These common and uncommon disorders of parotid glands during childhood and their imaging characteristics are reviewed.

Neck masses in children: a 10-year single-centre experience in Northwest China

Neck masses in children are a common clinical concern but there is a paucity of published information about them. We organised this retrospective study to analyse their prevalence and treatment in Northwest China. The records of 207 children who presented with neck masses between 2008 and 2017 were retrieved from the Department of Oral and Maxillofacial Surgery, Lanzhou University Second Hospital, and age, sex, clinical presentation, preoperative investigation, surgical procedure, histopathological diagnosis, and complications were recorded. Their mean (range) age was 10 years (6 months to 21 years), and the male:female ratio was 1.23:1. In total 128 patients (62%) had congenital lesions, 35 (17%) had inflammatory lesions, and 44 (21%) had neoplastic lesions. The most common mass was a thyroglossal cyst (31%), followed by plunging ranula (17%) and lymphangioma (16%). Temporary injury to the facial nerve and wound infection were the major complications of surgical treatment. The types of neck masses in Northwest China differ from those previously reported, which may be attributed to genetic alterations in people of this race. The present report adds to the knowledge of diagnosis and treatment of neck masses in children in Northwest China, and brings out the demographic differences between races.

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.

Pleomorphic Lipoma of the Neck in an Infant: A Rare Clinical Entity

Lipomas are rare in the pediatric age group. A 10-month-old male child presented with an asymptomatic neck mass which was evaluated and excised completely. Histopathology was consistent with pleomorphic lipoma, not previously reported in children.

Pediatric Mass Lesions of the Head and Neck Region and Fine-Needle Aspiration Biopsy Results

Objective

1. To provide a classification of pediatric mass of the head and neck region and evaluate their frequency. 2. To examine the findings of fine-needle aspiration biopsy (FNAB) in pediatric patients along with its contribution to diagnosis.

Methods

Totally, 233 pediatric patients (125 boys and 108 girls) operated at Başkent University for head and neck mass were included. Clinical, radiological, and histopathological data were retrieved from medical records.

Results

The mean age was 119±65 months, and the mean duration of follow-up was 75±49 months. Localization of the masses was as follows: 208 (89%) in the neck, 21 (9%) in the oral cavity, 2 (1%) in the neck and nasopharynx, and two (1%) in the larynx. The most common surgical procedure was open excisional biopsy (n=105, 45%) followed by cystic mass excision (n=72, 31%) and salivary gland excision (n=33, 14%). Based on histopathological findings, benign cystic lesions were the most common disease group (n=77, 33.1%), whereas reactive lymphadenopathy was the most common condition (n=36, 15%) when a single disease was considered. Infectious/inflammatory diseases, malignancies, and benign salivary gland diseases were present in 49 (21%), 24 (10.3%), and 22 (9.4%) patients, respectively. FNAB was performed in 29.8% of the patients with an accuracy of 90.3% (95% CI, 80.1-96.4).

Conclusion

The differential diagnosis of head and neck masses during childhood includes a wide spectrum with the different conditions being benign cystic diseases of congenital origin and reactive lymphadenopathies. Owing to its high predictive value, FNAB represents a rapid and reliable method that can be commonly used in both adult and pediatric patients.

Internal jugular vein thrombosis due to heterozygote methylene tetrahydrofolate reductase (MTHFR) 1298C and Factor V G1691A mutations after a minor trauma

Internal jugular vein thrombosis usually appears in central venous catheterization, distant malignancies, hypercoagulation, infections, or secondary to ovarian hyperstimulation syndrome. A 44-year-old female patient presented to us with sore throat, and pain and swelling on the right side of her neck. She had a history of simple neck trauma 10 days ago. Ultrasonography and computed tomography showed bilateral multiple lymphadenopathies and right internal jugular vein thrombosis. Patient was put on parenteral antibiotherapy and oral anticoagulant treatment. Genomic DNA tests for hypercoagulation revealed methylene tetrahydrofolate reductase 1298C heterozygote mutation and Factor V G1691A (Leiden) mutation. Patient has been under clinical control for 1 year and does not have any complaints. In this article, diagnosis, treatment, and the etiology of internal jugular vein thrombosis, which is a rare and potentially fatal condition, have been discussed through this case.

Neck masses in paediatric population: An experience with children attended the Central Teaching Hospital of Pediatrics in Baghdad 2008-2009

BACKGROUND

Pediatric neck mass is a frequent cause for surgical consultation. Neck masses can be simply classified into congenital, inflammatory, and neoplastic. Although most of the cases are due to benign processes, malignant causes must not be overlooked. The aim of this study is to assess the paediatric neck masses in Iraqi patients highlighting the distribution of cases according to their demographic characteristics and etiology.

PATIENTS AND METHODS

A cross-sectional observed study is conducted in the Department of Pediatric Surgery, at the Central Teaching Hospital of Pediatrics in Baghdad from April 2008 to March 2009. Sixty four patients with neck masses aged 14 years and below were examined and managed. The underlying causes of the neck masses were addressed and categorized.

RESULTS

Among the 64 patients, 42 (65.6%) were male. The inflammatory group represents 57% of the cases, while the malignant neoplasm accounts for approximately 10% of the conditions mainly due to lymphoma 5 (7.8%). Sixteen patients (25%) fall in the congenital group, in which the thyroglossal duct cyst was the commonest type. Wound infection developed in two patients, while one patient with cystic hygroma showed recurrence.

CONCLUSION

Pediatrics neck masses are distributed in categories that similar in pattern and distribution in the world except the infectious/inflammatory category that shows variation in distribution in respect to the socioeconomic status. The surgical intervention and procedures are related to the facility as well as to the experience.

Paediatric neck masses at a University teaching hospital in northwestern Tanzania: a prospective analysis of 148 cases

Background

Pediatric neck masses are one of the common surgical conditions presenting to the pediatric surgical wards and clinics in many centers worldwide. There is paucity of published information regarding pediatric neck masses in Tanzania and the study area in particular. This study determines the etiology, clinico-histopathological patterns and treatment outcome of pediatric neck masses and to identify predictors of outcome in our local setting.

Methods

This was a prospective cross-sectional hospital based study done in children aged ten years and below with neck masses for a five months period. Statistical data analysis was done using SPSS version 17.0.

Results

A total of 148 patients were studied. Their ages ranged from 2 months to 10 years (median 3 years). The male to female ratio was 2.5:1. Inflammatory lesions were the most frequent cause of neck masses accounting for 43.9% of cases. The median duration of illness was 2 years. Except for the neck mass, 72 (48.6%) of the children had clinically stable health condition on presentation. The posterior triangle was commonly involved in 118 (79.7%) patients. eight (5.4%) were HIV positive. The majority of patients (95.9%) were treated surgically. Postoperative complication rate was 30.4% and surgical site infection was the most frequent complication in 37.5% of cases. The median length of hospital stay was 10 days and was significantly longer in patients with malignant masses and those with surgical site infection (p <0.001). The overall mortality rate in this study was 8.1% and it was significantly associated with malignant masses, associated pre-existing illness, late presentation, HIV positivity, low CD 4 count, high ASA class and presence of surgical site infections (p <0.001). The outcome of patients on discharge was excellent as more than 90% of patients were successfully treated and discharged well.

Conclusion

Pediatric neck masses are among the most common causes of paediatric surgical admissions and pose a diagnostic and therapeutic challenge in our setting. We advocate early surgical consultation and thorough and timely histopathological examination of neck masses in children.

Pediatric neck masses

The majority of neck masses in the pediatric population are congenital or inflammatory in origin requiring a thorough understanding of embryology and anatomy of the cervical region. However, malignancy must always be ruled out as they represent 11%-15% of all neck masses in the pediatric population. The initial history and physical are of utmost important to correctly work-up and eventually diagnose the lesion. This article addresses many aspects of the workup, diagnosis and eventual proper surgical or medical management of pediatric neck masses.

Unusual presentation of angiomyomatous hamartoma in an eight-month-old infant: case report and literature review

BACKGROUND

Evaluation of palpable neck masses may be a diagnostic problem in pediatric patients, with differential diagnosis including congenital, inflammatory, tumoral and traumatic lesions. Ultrasonography is usually a satisfactory method to make a correct pre-operative evaluation of neck masses, although diagnosis is often challenging for the surgeon and the radiologist and sometimes only possible after a histopathological examination of the resected lesion.

CASE PRESENTATION

We report an 8-month-old patient with a cervical, anterior midline mass. Ultrasonographic images showed features suggesting a partly cystic lesion, with a preoperative suspect of thyroglossal duct cyst. Histological examination, performed after surgical removal of the mass, led to a diagnosis of lymph node angiomyomatous hamartoma (AH).

CONCLUSIONS

AH, a rarely occurring benign lymph node lesion, has been reported in the neck lateral region only twice. This case, presenting as a palpable neck midline mass, is the first reported case occurring in infancy. Although rare, AH should be included in the differential diagnosis of head and neck masses.

Function of blood monocytes among patients with orofacial infections

Few data are available on the significance of the integrity of the innate immune system among patients with orofacial infections. This was assessed in the present study. Peripheral blood mononuclear cells (PBMCs) were isolated from 23 patients with orofacial infections before surgical debridement and from 12 healthy volunteers. PBMCs were stimulated with bacterial endotoxin (LPS) and with Pam3Cys. Concentrations of interleukin (IL)-1β, IL-6 and tumor necrosis factor-alpha (TNFα) were estimated in supernatants by an enzyme immunoassay. Concentrations of estimated cytokines released from PBMCs of healthy volunteers and of patients did not differ. Intensity of cytokine release after stimulation was related with the time until complete resolution of the infection (p: 0.046). It is concluded that adequate functions of blood monocytes are associated with favorable outcome after surgery for orofacial abscesses. It seems, however, that impairment of monocyte function predisposes to infection persistence.

The reliability of high resolution ultrasound in the identification of pus collections in head and neck swellings

Head and neck swellings often present to oral and maxillofacial surgeons. It is often unclear whether a collection of pus is present. This information is essential for decisions regarding surgical intervention. Although ultrasound scanning (USS) is widely used to investigate the presence of a collection, the reliability and validity of this investigation in this context is uncertain. A retrospective review of 4000 consecutive head and neck USS reports over a 4 year period in the Cardiff University Health Board produced 43 cases in which ultrasound had been used to look for evidence of pus collection. The management and treatment outcome of these patients were reviewed and the data analysed. 36 of 43 patients had their swelling incised in theatre, and in 92% of these cases USS and clinical findings corresponded. Of the seven not taken to theatre, four were USS negative and three USS positive; in all seven cases the swelling resolved with antimicrobial therapy. Sensitivity and specificity of USS imaging to identify pus collection were very high, 96% and 82%, respectively. The evidence in this study indicates that USS is a very reliable diagnostic tool in the diagnosis of a collection as well as providing evidence that small collections of pus can resolve without surgical drainage.

An evaluation of efficacy of ultrasonography in the diagnosis of head and neck swellings

OBJECTIVE

The aim of this study was to evaluate the efficacy of ultrasonography in the diagnosis of swellings in the head and neck regions.

METHODS

For this study, 70 cases with clinically obvious swellings in head and neck regions were selected randomly. The ultrasonographic features considered were shape, boundary, echo intensity, ultrasound architecture of lesion, posterior echoes and ultrasound characteristic of tissues. Intergroup comparisons were made between four different types of swellings: inflammatory; cystic; benign; and malignant.

RESULTS

A comparison was made between benign and malignant neoplasms, and the criteria of boundary, echo intensity and ultrasound architecture of lesions are statistically significant as the P-value is <0.05. The comparison of inflammatory swellings and malignant neoplasms shows that criteria of boundary and ultrasound architecture of lesions are statistically significant. The comparison of cystic swellings and benign neoplasms concluded that only the criterion of ultrasound characteristics of tissues is statistically significant. The comparison of inflammatory swellings and benign neoplasms shows that the criteria of boundary and echo intensity are statistically significant. The comparison of inflammatory swellings and cystic swellings concluded that the criteria of boundary, shape, echo intensity, posterior echoes and ultrasound characteristics of tissues are statistically significant. The comparison of cystic swellings and malignant neoplasms concluded that the criteria of ultrasonography, boundary, shape, echo intensity, ultrasound architecture of lesion, posterior echoes and ultrasound characteristics of tissues are statistically significant as the P-value is <0.05.

CONCLUSION

It can be concluded that clinical diagnosis had a sensitivity and accuracy of 85.7% and ultrasonographic diagnosis had a sensitivity and accuracy of 98.5%.

The presentation and management of fibromatosis colli

We conducted a systematic chart review to identify all infants with fibromatosis colli who had been seen at Children's Hospital in Boston from January 1999 through December 2004. We found 7 such cases, which involved 4 boys and 3 girls, aged 1 to 3.5 weeks at presentation. We compiled information on each patient's birth history, presenting signs and symptoms, significant medical history, imaging findings, management, follow-up, and outcome. Six of the 7 patients presented with a neck mass, and the remaining patient presented with neck "fullness." Five patients developed torticollis at some point. All patients were treated conservatively with physiotherapy. Five patients experienced a complete resolution of signs and symptoms, and the other 2 experienced improvement. Based on our findings, we recommend that early management of fibromatosis colli include observation and physiotherapy to prevent or reverse torticollis and the craniofacial asymmetry that can result. Similarly attractive is the opportunity that physiotherapy provides for parents to involve themselves in the care of their newborn. It is important, therefore, to quickly identify fibromatosis colli as such in order to avoid unnecessary expenditures of resources and to promptly begin conservative treatment.

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.

Posttraumatic internal jugular vein thrombosis presenting as a painful neck mass in a child

An uncommon case of a pediatric traumatic internal jugular vein thrombosis is presented. A 7-year-old boy developed severe neck pain after falling from a bunk bed. Initially, the child was diagnosed and treated for a lymphadenitis with a possible abscess formation. Contrast-enhanced computed tomography and Doppler ultrasound imaging of the neck revealed the presence of an occlusive thrombosis of the left internal jugular vein. The patient was treated with intravenous antibiotics and followed closely over the next year. He had full resolution of his symptoms without the development of complications associated with this injury process. Internal jugular vein thrombosis is an uncommon and potentially life-threatening disorder caused by various conditions. This case illustrates the need for a systematic approach when evaluating neck masses, and internal jugular venous thrombosis should be included in the differential of anterior neck swelling.

Imaging manifestations of neck masses in the immunocompromised host

Human immunodeficiency virus (HIV) infection, haematological malignancy, and immunosuppression for transplantation and autoimmune disorders have led to a large increase in immunocompromised patients. Neck masses are relatively common in this patient group and include both opportunistic and severe manifestations of common infections, benign hyperplasia, and primary or secondary malignancies. Although biopsy may be necessary for definitive diagnosis, features on cross-sectional imaging may suggest a specific diagnosis or limit the differential diagnosis and facilitate optimal patient management. This article will review critical aspects of neck anatomy, illustrate the spectrum of imaging features, and discuss the interpretative pearls and pitfalls when evaluating neck masses in immunocompromised patients.

Malignant neoplasms of the head and neck

Head and neck masses represent a common clinical entity in children. In general, these masses are classified as developmental, inflammatory, or neoplastic. Having a working knowledge of lesions within this region and conducting a thorough history and physical examination generally enables the clinician to facilitate an appropriate workup and establish a diagnosis. The differential diagnosis is broad, and expeditiously distinguishing benign from malignant masses is critical for instituting a timely multidisciplinary approach to the management of malignant lesions. Neoplasms of the head and neck account for approximately 5% of all childhood malignancies. A diagnosis of malignancy may represent a primary tumor or metastatic foci to cervical nodes. In this review, we discuss the general approach to evaluating suspicious masses and adenopathy in the head and neck region and summarize the most common malignant neoplasms of the head and neck with regard to their incidence, clinical presentation, diagnostic evaluation, staging, and management. Thyroid, parathyroid, and salivary gland tumors are discussed elsewhere in this issue of Seminars in Pediatric Surgery.