Neck masses in children Block 12 – Head and Neck 2012 - PowerPoint Presentation

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Neck masses in children

Block 12 – Head and Neck 2012

Dr EW MüllerSlide2

Aetiology

Infections with acute or chronic lymphadenitis

Tumors

Congenital

Thyroglossal cyst

Epidermoid cyst

Branchial cyst or fistula

Lymphangioma

Haemangioma and arterio-venous malformationsSlide3

Infection: Acute lymphadenitis

Most common cause: Bacterial infection of the oropharynx, face or scalp: Tonsillitis, Pharyngitis, impetigo of the scalp

Organisms: Staph aureus, Streptococcus

Clinic: Multiple tender lymph nodes in the submandibular or anterior cervical region. The lymph nodes are smooth, soft, not matted, mobile. Fever, systemic illness.

Initial treatment with antibiotics (Cloxacillin, Ampicillin) often results in resolution without suppuration.

Without (and with) treatment, the lymph node may become enlarged and fluctuant, leading to abscess formation.

An abscess needs surgical drainage.Slide4

Drainage pathways

Face, anterior scalp, forehead drain into facial, preauricular, submental LNs

Tonsills, posterior pharynx drain into jugulodigastric, deep cervical LNs

Posterior scalp, back of ear, external ear drain into posterior superficial cervical, posterior auricular, occipital LNsSlide5

Infection: Chronic lymphadenitis

Clinic: Chronically enlarged, non-tender lymph nodes.

Differential diagnosis: Tb, atypical mycobacterial infection, cat scratch disease; malignancy

A single, dominant lymph node (>2cm big) present longer than 6 – 8 wks, which has not responded to antibiotic therapy, should be excised, cultured, and submitted for histological examination.

HIV – often associated with Tb, lymphoma. Look for abnormally large lymphnodesSlide6

Neoplasms

Lymphoma: By far the most common childhood neoplasm presenting with enlarged lymph nodes in the neck.

Lymph nodes are usually rubbery, non tender and fixed. They may enlarge quickly.

Diagnosis: By biopsy of enlarged lymph node. Slide7
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Congenital neck masses

Branchial Cysts and Sinuses

Thyroglossal duct cyst

Dermoid and epidermoid cyst

LymphangiomaSlide9

Branchial Cysts and Sinuses

These are remnants of the branchial apparatus which develops between the 4

th

and 8

th

week of pregnancy.

The apparatus consists of 4 branchial arches separated by branchial clefts. If the clefts fail to regress, a sinus or cyst will form.Slide10

Embryonic branchial apparatus

Inferior parathyroid and thymus

Superior parathyroid and parafollicular cells

Mandibula and Maxillary process of the upper jaw

HyoidSlide11

Branchial remnants

Present as fistulas or cysts anywhere on the anterior border of the sternocleidomastoideus muscle

Cyst presents with nontender enlarging swelling

Fistula presents with drainage of saliva from the ostium

Treatment: Early excision

Complication: Cysts and fistulas can become infected if not resected early in childhoodSlide12

Thyroglossal cyst - Embryology

The foramen caecum is the site of the development of the thyroid at the base of the prospective tongue. As the tongue develops, the thryroid diverticulum descends in the neck, maintaining its connection to the foramen caecum. A cyst can be located anywhere along the migratory tract if it fails to become obliterated.Slide13

Thyroglossal cyst - Clinic

Thyroglossal cysts are located in the midline at or just below the hyoid bone.

Due to communication with the mouth via the foramen caecum the cyst can become infected.

The cyst is smooth, soft and non-tender.

Owing to its attachment to the foramen caecum, the cyst does move upwards when the tongue protrudes.Slide14

Thyroglossal cystSlide15
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Thyroglossal cyst - Treatment

Early surgical excision to avoid the complications of infection

Surgery entails complete excision of the cyst and its tract upward to the base of the tongue (Sistrunk Operation)Slide17

Epidermoid cysts

Represent ectodermal elements, which where trapped beneath the skin

Epidermoid cysts contain sebaceous material within the cyst cavity.

Most common location is at the lateral corner of the eyebrow. Presents with a characteristic swelling.

Midline epidermoid cysts develop due to entrapment of epithelium of branchial arch origin at the time of embryologic midline fusion. They might be confused with midline thyroglossal duct cysts.Slide18

Lymphangioma

Lymphangiomas are congenital malformations of lymph tissue that result from the failure of lymph spaces to connect to the rest of the lymphatic system.

Lymphangiomas present as a soft, smooth, nontender mass that is compressible and can be transilluminated.

Depending on the size and location, there might be respiratory compromise and difficulty in feeding.Slide19

Lymphangioma: Treatment

Goals: Improvement of cosmetic appearance, relieve of impaired breathing and eating.

Big lesions causing respiratory embarrassment might need urgent intubation at birth.

Surgery is difficult because of the infiltrative nature of these lesions.

Preferred treatment is infiltration with Bleomycin, alcohol or other scerosing agents.Slide20

Haemangiomas

Haemangiomas are benign tumors of the capillary vessels of the skin

They can occur anywhere, but are common in the face and neck

Typical growth, stationary and involutionary phase

Treatment : conservative (wait and see); excision or sclerosation