Neck lumps in Children
2 is good review and in Papers.
Lymph Nodes 1
SCM covers the majority of nodes thus not felt.
- Therefore Level V are frequently referred even when normal as superficial.
Level IIB nodes are most likely to be enlarged due to the drainage of throat.
- Peaks of presentation in pre-school/early school and then in Teens.
Defines 'Reactive' as normal morpho but with high flow, normal pattern.
1. Lymphadenitis
Rad : "Inflammatory fat wrap" = Echogenic thickening around nodes. Et al.
DD: Cat Scratch fever, fungi, Mononucleosis, AIDS, Sarcoid, Histiocytosis et al 2
Mycobacterial = Well child with large, round nodes which are less hot / vascular than expected and often with extension to skin.
2. Lymphoma
CF: Feel hard, round, non-mobile but painless.
Radiology:
-- Round, hypoechoic, clustered nodes.
-- Hypervascular (vascular index might help in future)
3. Papillary Thyroid Ca.
The only other commonish malignancy in nodes in kids.
Rad: Microcalcification +/- cystic change.
NB = Look at thyroid as well.
Congenital Lesions
= Mostly Cysts and diagnosable by Location, Location, Location.1
1. Thyroglossal Cysts.
Anatomy:
Thyroglossal Duct= Back of Tongue -> Over Hyoid -> lower neck.
Pathology: Persistence of part of duct =
1) Ectopic Thyroid and/or
2) Thyroglossal duct cyst
So, always check the thyroid to ensure it is there.
Hyoid Bone is key =
-20% Suprahyoid
-30% @ Hyoid
-50% Infrahyoid
Radiology:
-Avascular, mid/off mid cyst. ( infra hyoid often embed in strap muscles )
-Often pseudosolid.
-Look for Track as the diffs don't have this but will be small and subtle.
Rx:
Small risk of malignant degeneration into Pap Thryoid which can be tricky to diff from normal tissue. Also risks of infection etc
--SISTRUNK Procedure: En-block removal of thyroglossal cyst & duct remnant with central part of hyoid bone.
DD: Epidermoid / Dermoid
Does not have track. US is best at diff
2. Branchial Cleft Cysts
| Type | Freq | Anatomy | Presentation |
|---|---|---|---|
| 1st | 8% | EAC => Angle of Mandible | Cyst on top of Parotid |
| 2nd | 90-95% | Faucial Tonsil => Low ant. Neck | Cyst anterior to SCM, anterolateral to Carotid space |
| 3rd | <1% | Upper Post Triangle => Ant lower neck | Cyst medial to SCM, posterior to Carotid space |
| 4th | 1% | Pyriform fossa => Thru Thyrohyoid membrane => Mediastinum | Cyst / Collection in/around the upper thyroid |
Also 2nd cleft can rarely fistulate and be open all / most of the way with saliva coming out.
3. Vascular Malformations
Generally divided into LOW & HIGH flow lesions. In H&N
Lymphatic
75% of all are in H&N.
CF: <2yr old, Soft cyst in posterior triangle.
Radiology: Lobulated, thin-walled, micro (<2mm) vs macro cyst.
-- High T2, often Fluid-Fluid levels (= slow flow).
-- Transpatial (as lymph channels)
Venous
45% of all are in H&N
CF: Teen/YP, ^^Exercise/Valsalva, compressible.
Radiology: Septated, High T2.
-- PHLEBOLITHS
Infantile Haemangioma
60% of all are in H&N.
Rarely seen at birth but 90% become visible in first month.
Epid: 1% of newborn but 12% at 1y age.
NH: Grow in 1st yr, tend to regress 1-3ys.
RAD: US = Discrete masses.
-- High-velocity arterial and low-resistance venous waveforms.