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results if performed suboptimally (e.g., obtained during expiratory phase, crying,
or with the neck flexed).
Duplex US is considered the first-line imaging modality to differentiate
between cystic and solid lesions in superficial locations. US informs the location,
size, shape, internal content, and vascularity of the mass, and lesions like cystic
hygroma, lymphadenopathy, thyroglossal duct, cysts, and fibromatosis colli have
fairly definitive patterns. Calcification within a mass may suggest a teratoma or
neuroblastoma, but is not specific. Limitations of US include the lack of universal
availability and the technician-dependent results.
Deep, vascular, or indeterminate lesions necessitate cross-sectional imaging to
further elucidate the composition and anatomic extent. The high-contrast
resolution and absence of ionizing radiation make MRI the preferred modality for
vascular and neoplastic lesions. Limitations include universal availability, length
of studies, and patient ability to cooperate with examination. Contrast-enhanced
CT is considered by many to be the diagnostic modality of choice when rapid
imaging is indicated, or to evaluate deep space neck infections and abscesses with
high fever and severe tenderness on examination.

DISPOSITION
Patients presenting with systemic toxicity, airway compromise, or severe local
disease require hospitalization and initiation of definitive therapy. Patients
presenting with fever and reactive lymphadenopathy or lymphadenitis may
undergo a trial of oral antibiotics with follow-up at 36 to 48 hours for clinical
response and possible need for aspiration or drainage. Masses suggestive of a
lymph node, but absent generalized lymphadenopathy or fever may be
reevaluated over 4 weeks, with careful documentation of lesion characteristics.
When the mass is suspicious for tumor or congenital cyst, surgical consultation
for biopsy or excision is indicated.
Suggested Readings and Key References
Aulino JM, Kirsch CFE, Burns J, et al. ACR Appropriateness Criteria® neck
mass/adenopathy. Am Coll Radiol Rev 2018. Available online at

. Accessed April 4, 2020.
Badawy MK. Pediatric neck masses. Clin Pediatr Emerg Med 2010;11:73–80.
Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis,
antimicrobial therapy, and management of complications: a statement for
healthcare professionals from the Committee on Rheumatic Fever,
Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the