Pediatric Head and Neck Masses

Overview & Initial Approach - Mass Mysteries

Systematic evaluation: history, exam, imaging. Goal: differentiate congenital, inflammatory, neoplastic.

• Key Clues:
  • Age, location, duration
  • Symptoms: pain, fever, red flags (B symptoms)
• Diagnostic Flow:

• Main Types:
  • Congenital: Thyroglossal duct cyst, branchial cleft cyst
  • Inflammatory: Reactive lymphadenopathy, abscess
  • Neoplastic: Lymphoma, rhabdomyosarcoma

⭐ Most pediatric neck masses are benign. Persistent masses (>4-6 weeks) or red flags warrant urgent, thorough investigation.

Congenital Neck Lumps - Born This Way

Inflammatory Invaders - Swelling Showdown

• Lymphadenitis: Most frequent inflammatory mass.
  • Viral: Common (EBV, CMV). Often bilateral, tender, self-limiting.
  • Bacterial: S. aureus, Strep. pyogenes. Acute, very tender, unilateral. Rx: Antibiotics.
  • TB (Scrofula): Chronic, matted, non-tender "cold abscess". Positive PPD/IGRA.
• Abscesses: E.g., peritonsillar, retropharyngeal. Fluctuant, fever, pain. Rx: I&D + antibiotics.

⭐ Scrofula (TB cervical lymphadenitis): most common extrapulmonary TB in children.

Neoplastic Newcomers - Growth Gone Wild

• Malignant (Rapid, concerning):
  • Rhabdomyosarcoma (RMS): Most common peds soft tissue sarcoma. Rapid, firm. Sites: orbit, parameningeal (e.g., nasopharynx). Biopsy: Desmin+.

    ⭐ Parameningeal RMS carries worst prognosis due to high risk of CNS invasion.

  • Lymphoma (NHL > HL): NHL (Burkitt's): very rapid, rubbery nodes, B-symptoms. HL: slower, cervical/supraclavicular, Reed-Sternberg cells.
  • Neuroblastoma: Often metastatic. Horner's syndrome. ↑Urine VMA/HVA.
  • Thyroid Ca: Papillary type common. H/o neck radiation. Cold nodule.
• Benign (Usually slow): Pilomatricoma (firm, calcified), Dermoid cyst (midline, doughy).

Diagnosis & Management - Cracking the Case

Diagnosis: Meticulous History (onset, red flags), full Examination (📌 7 S's e.g., site, size, consistency, mobility), and targeted investigations.

• Investigations:
  • USG: Initial choice; differentiates cystic vs. solid.
  • CT/MRI: For deep extension, bony involvement, vascularity.
  • FNAC: Key for palpable masses; guides further steps.
  • Biopsy (Excisional preferred if benign, Incisional if malignancy suspected): Gold standard for histology.
• Management Strategy:
  • Conservative: Observation for likely benign/reactive (e.g., reactive lymph node).
  • Medical: Antibiotics for infections (e.g., lymphadenitis), steroids for inflammation.
  • Surgical: Excision for symptomatic benign lesions or confirmed/suspected malignancy.
  • Adjuvant therapy (chemo/radio) for specific malignancies.
  • Always involve Multidisciplinary Team (MDT).

⭐ Most common pediatric neck mass is inflammatory lymphadenopathy.

High‑Yield Points - ⚡ Biggest Takeaways

• Inflammatory lymphadenopathy: Most common pediatric neck mass.
• Thyroglossal duct cysts: Midline, move with tongue protrusion; treat with Sistrunk procedure.
• Branchial cleft cysts: Lateral, anterior to SCM. Lymphatic malformations (cystic hygroma) transilluminate.
• Ultrasound: Initial imaging of choice. CT/MRI for complex lesions.
• Suspect malignancy with: Rapid growth, firm/fixed mass, B symptoms, supraclavicular location.
• Common pediatric head/neck malignancies: Lymphoma, rhabdomyosarcoma, neuroblastoma.