Pediatric emergency medicine trisk 0939 0939

CHAPTER 48 ■ NECK MASS
CARLA PRUDEN, CONSTANCE M. McANENEY

INTRODUCTION
Neck masses are a common concern in the pediatric population. By definition,
these include any visible or palpable swelling that disturbs the normal contour of
the neck between the shoulder and the angle of the jaw. Other than trauma, the
three basic classifications of neck lesions are inflammatory, congenital, and
neoplastic. Inflammatory masses representing infectious changes in otherwise
normal structures, such as lymphadenopathy and lymphadenitis, are the most
common. Congenital anatomic defects of the neck including cystic hygromas,
branchial cleft cysts, hemangiomas, thyroglossal duct cysts, and dermoids, may
be minimally apparent at birth, with progressive cyst formation over time.
Neoplastic lesions of the head and neck often involve the lymphatic system.
These are fairly uncommon, but must be ruled out. With multiple potential
etiologies, an organized approach to the history and physical examination of the
head and neck, including a working understanding of the embryology, is
important to facilitate proper diagnosis and treatment.
Many factors, ranging from aesthetics to concern for malignancy, may
precipitate the initial emergency department (ED) visit. Direct compression of
vital structures (e.g., airway, cardiovascular structures, or cervical spinal cord)
can cause a principal threat to life. Rarely, systemic toxicity from progression of
local infection or thyroid storm can cause uncompensated shock. In this chapter,
recognition of masses that represent true emergencies will be addressed first (
Table 48.1 ), followed by the approach to common, nonemergent lesions ( Table
48.2 ). Table 48.3 lists causes of neck masses in children by location.

INITIAL EVALUATION AND DECISION MAKING
Initial history and physical examination should rapidly assess immediate threats
to airway, breathing, circulation, and neurologic status. The resultant clinical
impression should guide immediate interventions and work up. Children’s

airways are small, and compression of vital structures may lead to significant
distress. Stridor, hoarseness, dysphagia, and drooling are ominous indications of
airway compromise. Respiratory or cardiovascular compromise may manifest as
mental status changes.