Basics
Description
A mass in the tissues of the neck; cervical adenopathy is defined as a neck node >1 cm. ‚
Etiology
Varies depending on underlying condition. ‚
Diagnosis
To diagnose and appropriately manage neck masses, one must combine the history with a careful examination of the mass. The major task of the differential diagnosis is to distinguish infections from congenital and malignant causes. ‚
History
- Fever: infection, Kawasaki disease, malignancy, "PFAPA " ¯ (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome
- Intercurrent infection: reactive hyperplasia, mononucleosis, abscess, congenital cyst
- Subacute or chronic cervical lymphadenitis: cat-scratch disease, toxoplasmosis, Epstein-Barr virus (EBV), and mycobacterial infection
- Increasing size: infection, newly infected congenital lesion, malignancy (less common)
- Sore throat: mononucleosis, peritonsillar or retropharyngeal abscess
- Swallowing problems: retropharyngeal or peritonsillar abscess, thyroglossal duct cyst
- Cat contact: cat-scratch disease, toxoplasmosis
- Recurrently infected mass: infected congenital cyst (thyroglossal duct, branchial cleft)
- Mass noticed neonatally: cystic hygroma, hemangioma, sternocleidomastoid tumor of infancy
- Weight loss, cough, chronic constitutional symptoms: malignancy, tuberculosis
- Hypothyroid or hyperthyroid symptoms: thyroglossal duct cyst, thyroidal diseases
Physical Exam
- Tender, erythematous, indurated mass may indicate cervical adenitis, infected congenital lesion, or cat-scratch disease
- Nontender, enlarged lymph nodes(s) suggest reactive hyperplasia or malignancy.
- Fluctuant mass may indicate adenitis with abscess or cystic hygroma.
- Drainage suggests adenitis with abscess, atypical mycobacterial disease, infected thyroglossal duct, or branchial cleft cyst.
- Regional adenopathy: reactive hyperplasia, cat-scratch disease, or malignancy
- Exudative pharyngitis: mononucleosis
- Asymmetric soft palate with uvular deviation suggests peritonsillar abscess.
- Pulmonary findings: tuberculosis, malignancy
- Midline mass suggests thyroglossal duct or dermoid cyst or thyroidal disease.
- If mass moves with tongue protrusion, thyroglossal duct cyst may be present.
- Sinus opening may indicate thyroglossal duct, branchial cleft, or dermoid cyst.
- Multiloculated mass that transilluminates suggests cystic hygroma.
- Matted-down mass may indicate malignancy.
- Mass posterior to sternocleidomastoid muscle may be malignancy or infection.
- Inferior deep cervical nodes (scalene and supraclavicular) suggest malignancy.
- Generalized adenopathy suggests malignancy.
- Hepatosplenomegaly may indicate malignancy or infectious mononucleosis.
- Skin discoloration suggests trauma, abscess, or atypical mycobacterial disease.
- A skin papule is a clue to cat-scratch disease.
- Conjunctivitis, oral involvement, extremity changes, rash, and adenopathy, in the context of fever: Suspect Kawasaki disease.
- Torticollis in a neonate suggests sternocleidomastoid (pseudo) tumor of infancy.
Diagnostic Tests & Interpretation
- CBC
- Infections: leukocytosis
- Mononucleosis: atypical lymphocytosis
- Kawasaki: thrombocytosis after 1st week
- Neck malignancies: usually normal initially
- Complete metabolic panel with lactate dehydrogenase (LDH) and uric acid when malignancy is suspected
- "Mono spot " ¯ (mononucleosis) test: less reliable in children <4 years old; EBV titers more useful
- Indirect fluorescent antibody titers for Bartonella: confirms cat-scratch disease
- Purified protein derivative: negative or weakly positive in atypical mycobacterial infections
- Chest radiograph: important in all evaluations when malignancy is a possibility; adenopathy seen in malignancies and tuberculosis; cavitary lesions and infiltrates in tuberculosis
- Lateral neck radiograph: prevertebral soft tissue space at C2 " “C3 abnormally wide (>1/2 adjacent vertebral body diameter) in cases of retropharyngeal abscess
- Ultrasound
- 1st-line imaging modality in neck masses
- provides immediate, noninvasive information on location, size, and composition of mass (cystic vs. solid)
- Doppler adds information about vascularity.
- CT or MRI scan: useful in evaluating deep neck infections and complex neck masses
- CT advantages: more readily available; shorter study; less need for sedation
- MRI advantages: no ionizing radiation; better soft tissue resolution
- Thyroid scintigraphy: useful when malignancy is a concern
- Gram stain and culture of specimen after needle aspiration or incision and drainage: diagnostic and therapeutic with infections
- Histologic evaluation after fine-needle aspiration or biopsy: diagnostic for malignant versus congenital versus infectious causes
Differential Diagnosis
- Infectious
- Reactive hyperplasia: self-limited, enlargement of bilateral minimally tender nodes; usually viral
- Bacterial lymphadenitis
- Usually staphylococcal or streptococcal infection of unilateral, tender, swollen, warm, erythematous node
- Cellulitis " “adenitis syndrome in neonates caused by group B Streptococcus
- Cat-scratch disease
- A usually self-limited, although sometimes protracted, illness (2 " “4 months)
- Caused by the gram-negative bacillus Bartonella henselae
- Starts as a papule at a cat-scratch site; progresses to regional adenopathy, 5 " “50 days later (median, 12 days)
- Axillary adenopathy is most common; cervical nodes 2nd most common.
- Adenopathy for weeks to months
- Tuberculosis: acute or insidious onset of fever and firm, nontender adenopathy in children exposed to adult infected with acid-fast bacillus Mycobacterium tuberculosis
- Atypical mycobacterial disease
- Infection usually caused by Mycobacterium avium complex or Mycobacterium scrofulaceum (ubiquitous agents found in the soil)
- Rapidly enlarging mass of firm, nontender nodes in young children with no known exposure to tuberculosis
- Nodes often occur with overlying skin discoloration and thinning; some spontaneously drain.
- Infectious mononucleosis: EBV infection most commonly seen in older children who present with fever, exudative pharyngitis, adenopathy, and hepatosplenomegaly.
- Toxoplasmosis
- Parasitic disease caused by Toxoplasma gondii which presents with cervical adenopathy, rash, fever, malaise, and hepatosplenomegaly
- Acquired from contact with cat feces or inadequately cooked meat
- Retropharyngeal abscess
- Suppurative adenitis of the retropharyngeal nodes that presents in children <5 years of age
- These children often have fever, neck stiffness, dysphagia, respiratory distress, drooling, and stridor.
- Peritonsillar abscess: suppurative sequela of a severe tonsillopharyngitis, usually caused by group A ˇ ²-hemolytic Streptococcus (GABHS); commonly presents in older children and adolescents with trismus, "hot potato " ¯ voice, and uvular deviation from a bulging palatal abscess
- Ludwig angina
- Rapidly expanding, diffuse inflammation of the submandibular/sublingual spaces
- May compromise the airway
- Often occurs with dental infections
- Congenital
- Branchial cleft cyst: common congenital neck lesion (usually a remnant of the 2nd branchial cleft) which presents as a nontender (unless infected) cyst at the anterior border of the sternocleidomastoid
- Thyroglossal duct cyst: common congenital neck mass which is a remnant of the embryonic thyroglossal sinus and presents as a nontender (unless infected), mobile, anterior midline mass near the hyoid bone
- Cystic hygroma (lymphangioma): complex, multiloculated mass of lymphatic tissue, which presents in the 1st year of life as a large, soft, compressible mass in the posterior triangle of the neck; may cause airway obstruction
- Dermoid cyst: small, firm, nontender mass, usually high in the midline
- Hemangioma: bluish purple, blanching mass characterized by rapid growth in the 1st year of life, then slow regression
- Sternocleidomastoid (pseudo) tumor of infancy (congenital muscular torticollis): benign perinatal fibromatosis, often associated with difficult deliveries or abnormal uterine positioning, that results in a hard, immobile, fusiform mass in the sternocleidomastoid
- Laryngocele: cystic dilation of the laryngeal saccule; presents as an air-filled cyst or as a foreign body sensation with coughing
- Cervical wattle: benign pedunculated congenital anomaly on lateral neck with a core of elastic cartilage
- Cervical bronchogenic cyst: cervical neck mass in the anteromedial neck (superior to the sternal notch), resulting from abnormal development of the tracheobronchial tree
- Thymic cyst: ectopic thymic mass resulting from abnormal development of pharyngeal pouches and branchial clefts
- Teratoma: malformation of all three germ layers that can cause significant airway obstruction as well as feeding dysfunction
- Ranula: a mucocele created by obstruction of the sublingual salivary glands; usually a painless, slowly accumulating mass
- Malignant
- Hodgkin lymphoma: slowly enlarging, unilateral, firm, nontender neck malignancy; usually presents in previously well adolescents
- Non-Hodgkin lymphoma: presents in young adolescents as a painless, rapidly growing, firm collection of lymph nodes
- Leukemia: most common tumor associated with cervical adenitis in first 6 years of life
- Neuroblastoma: commonly presents in infants/young children as a large, nontender abdominal mass; associated with a myriad of signs and symptoms due to its propensity for metastasis
- Rhabdomyosarcoma: head and neck malignancy that usually presents as a rapidly enlarging mass
- Melanoma: an increasingly identified cause of neck malignancy in pediatrics
- Thyroid
- Chronic lymphocytic thyroiditis (Hashimoto thyroiditis): autoimmune childhood goiter that may be eu-, hypo-, or hyperthyroid
- Thyrotoxicosis (Graves disease): clinically hyperfunctioning thyroid caused by circulating thyroid cell " “stimulating antibodies
- Thyroiditis: painful bacterial infection of the thyroid caused by Staphylococcus or Streptococcus
- Miscellaneous
- Kawasaki disease
- Idiopathic vasculitis distinguished by prolonged fever, conjunctivitis, oral involvement, extremity changes, rash, and unilateral cervical node >1.5 cm
- Cervical node: least common feature
- PFAPA syndrome
- Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis
- Idiopathic, periodic, febrile syndrome most commonly seen in young children
- Sinus histiocytosis with massive lymphadenopathy (Rosai " “Dorfman disease); benign form of histiocytosis that presents as massive, painless enlargement of cervical nodes
- Hematoma: secondary to trauma
- Hypersensitivity reaction: secondary to bites, stings, or other allergens
- Drugs: Notably, phenytoin and isoniazid may be associated with lymphadenopathy.
- Immunization: Adenopathy may follow DPT or polio immunization.
Treatment
General Measures
- Infectious
- Antibiotics
- Incision and drainage (I&D) of abscesses
- Congenital
- Antibiotics if infected
- ENT referral for surgical excision
- Malignancy: oncology referral for chemotherapy/radiation/excision
- Thyroidal: endocrine referral for pharmacotherapy
- Miscellaneous
- Kawasaki disease: IVIG and aspirin therapy to prevent coronary artery aneurysms; cardiology referral for echocardiography
- PFAPA syndrome: Steroids (a single dose) are efficacious in aborting fever attacks.
- Sternocleidomastoid tumor of infancy: massage, range of motion, and stretching
Alert
Corticosteroids should not be given to neck mass patients until malignancy has been excluded, except in dire conditions of airway compromise. ‚
Ongoing Care
Close follow-up is essential for all neck masses; consider referral for biopsy in the following cases: ‚
- Nodes not responding to antibiotics
- Toxic illness/systemic symptoms
- Clinical signs of malignancy (weight loss, peripheral adenopathy, hepatosplenomegaly)
- Firm, nontender nodes fixed to deep tissues
- Nodes posterior to the sternocleidomastoid or in the lower cervical/supraclavicular regions
- Bilateral nodes >2 cm
Additional Reading
- Al-Dajani ‚ N, Wootton ‚ SH. Cervical lymphadenitis, suppurative parotitis, thyroiditis, and infected cysts. Infect Dis Clin North Am. 2007;21(2):523 " “541, viii. ‚ [View Abstract]
- Dulin ‚ MF, Kennard ‚ TP, Leach ‚ L, et al. Management of cervical lymphadenitis in children. Am Fam Physician. 2008;78(9):1097 " “1098. ‚ [View Abstract]
- Friedman ‚ ER, John ‚ SD. Imaging of pediatric neck masses. Radiol Clin North Am. 2011;49(4):617 " “632. ‚ [View Abstract]
- Geddes ‚ G, Butterly ‚ MM, Patel ‚ SM, et al. Pediatric neck masses. Pediatr Rev. 2013;34(3):115 " “124. ‚ [View Abstract]
Codes
ICD09
- 784.2 Swelling, mass, or lump in head and neck
- 785.6 Enlargement of lymph nodes
- 682.1 Cellulitis and abscess of neck
- 075 Infectious mononucleosis
- 759.2 Anomalies of other endocrine glands
ICD10
- R22.1 Localized swelling, mass and lump, neck
- R59.0 Localized enlarged lymph nodes
- L02.11 Cutaneous abscess of neck
- B27.90 Infectious mononucleosis, unspecified without complication
- Q89.2 Congenital malformations of other endocrine glands
SNOMED
- 274751001 Mass in head or neck (finding)
- 127086001 cervical lymphadenopathy (disorder)
- 6284004 abscess of neck (disorder)
- 271558008 Infectious mononucleosis (disorder)
- 39462005 Thyroglossal duct cyst
FAQ
- Q: How should nodes respond to therapy?
- A: Consider referral for biopsy if increasing size after 2 weeks, no decrease in size >2 " “4 weeks, or not back to normal >8 " “12 weeks.
- Q: Do all external neck abscesses need antibiotic therapy after drainage?
- A: Many experts believe that antibiotics are not always necessary if I&D is done appropriately.
- Q: Is antibiotic coverage for community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) necessary?
- A: As CA-MRSA is increasingly common, an antibiotic agent with MRSA coverage is indicated; clindamycin is a common choice.