What should you do when you noticed a lump in your child’s neck?
The first thing to do is don’t panic. We know the first thought in a parent’s mind is their child could have cancer. Rest assured, this is very rare. Normally lesions in the neck are not tumors can be dealt with and treated appropriately. Typical lesions in the neck are either large or infected lymph nodes, developmental or congenital cysts, vascular lesions consisting of blood vessels, or rarely tumors or cancer.
Inflammatory Neck Mass
When a lump is noticed in the neck, we look for clues as to the urgency of treatment. Is the lump painful and red and look infected (Figure 1) or does it not seem to bother your child (Figure 2)? If the lump looks infected, it will need to be treated, and treatments vary based on the severity of the infection and what bacteria your doctors presumed to be present.
The most common infections of the neck are caused by Staphylococcus or Streptococcus species, so empiric antibiotic therapy is directed at those pathogens. Antibiotics that treat these bacteria are readily available and are routinely prescribed for many different infections throughout the body. They are often from the penicillin and cephalosporin family of medications. These include Amoxicillin, Augmentin, Cefdinir and Cephalexin. Other less commonly used antibiotics like clindamycin have good coverage for these bacteria and may be used as first-line therapy or if the other antibiotics fail. The choice of antibiotic by your pediatrician may be influenced by the severity of the neck infection as well.
If your child does not respond to oral antibiotics or if your child seems really sick with fever, lethargy and a swollen red neck lesion (Figure 3) your pediatrician may send you to the emergency room or admit you to the hospital to monitor your child and treat them intravenous antibiotics, which will penetrate into the bloodstream faster to expedite treatment.
Often a form of radiographic imaging of the lesion will occur, frequently with either an ultrasound or computed tomography to define where and how extensive the infection is (Figure 4). Sometimes the infections will resolve with the intravenous antibiotics alone, and sometimes the infection will need surgical drainage. The lab tests and radiographic tests your doctors obtain in the hospital, as well as how your child is responding to treatment, will guide those decisions from your doctors.
Infections in the neck can occur in a child’s lymph nodes, salivary glands, existing cysts in the neck or the skin itself. Most infections in the neck occur in the lymph nodes. Lymph nodes are part of the body’s defense system against infection and illness. These nodes contain lymphocytes, which produce antibodies that destroy or immobilize infecting bacteria by binding to them and allowing the body to recognize and destroy them. When lymph nodes become enlarged or swollen, it usually means that the lymphocytes have increased in number in response to the infection, producing an army of specific antibodies to that bacteria.
There are 200 to 300 lymph nodes in the back of the nose and head and neck that can become infected. These lymph nodes drain the different areas of the head and neck and help fight infection in those areas (Figure 5).
In certain types of unusual neck infections, your child does not necessarily seem that sick, but the infected lesion seems to worsen, with associated changes to the constancy and color of the overlying skin (Figure 5). The most common type of an atypical lymph node infection is a non-tuberculosis mycobacterium. This can often be discerned by its clinical course or by performing a fine needle aspiration of the lesion for culture, which could also rule out an infected tumor or cancer. Often a tuberculosis test is placed since a weakly positive test will help rule in this type of infected while excluding tuberculosis itself, since a vigorous response would be seen in the presence of tuberculosis. Different classifications of antibiotics are used to treat these particular infections and the treatment course is often weeks to months. Non-tuberculosis mycobacterial infections are often removed surgically as well.
Neck Masses
Many lesions in the neck causing lumps, however, are not infected when they are found. These lesions can be large lymph nodes, developmental or congenital cysts, vascular lesions consisting of blood vessels, or rarely tumors or cancer. Location, consistency, and color of the lesion or skin can give us clues as to what the lesion may be.
Lesions in the anterior neck (Figure 7) are often enlarged lymph nodes, dermoid cysts or thyroglossal duct cysts. Thyroglossal duct cysts are congenital cysts, meaning they were present when the child was born, being formed when the thyroid gland in the fetus was being developed in-utero. Sometimes these cysts do not present until the infant or toddler stage when they fill with fluid. Dermoid cysts can also be present at birth and undetectable. They are slow-growing and can go unnoticed until they enlarge enough to be seen or felt. Both of these lesions do not go away and need to be removed. They both can become infected as well.
Other congenital lesions can present as lumps in the neck formed by abnormal development of the brachial system, which is a series of sections of the face and neck that form the facial and neck features in embryonic development. If these sections of the face and neck do not seal up completely, then neck and facial cysts, sinus tracts and fistulas (or holes) can form. These often occur laterally in the neck.
Vascular Neck Masses
Lesions of the blood vessels and lymph vessels can occur anywhere in the neck and can discolor the skin. Bluish lesions are often vascular malformations (Figure 8, 9) and reddish bulky lesions are often hemangiomas (Figure 10).
Lymph vessel lesions or lymphatic malformations are more cystic and do not discolor the skin, occurring as small to very large lesions (Figure 11). Vascular and lymphatic malformations can occur in any age group and can be observed, resected or injected with agents that will scar or sclerosis them, depending on the problems they are causing. Hemangiomas are more solid, cellular lesions of small capillary blood vessels that are present at birth, often grow for the first two years of life, then regress and can resolve by the school-age years. They as well maybe treated or observed, depending on the size, location, and problems they are causing. A breakthrough in treatment over the last decade or so has revolutionized the management of hemangiomas. Propranolol, a heart medication, was found serendipitously to dramatically slow the growth of the lesions, and now is often used as first-line therapy if treatment is needed.
Diagnosing Pediatric Neck Masses
Your doctor may have important questions concerning the lump to provide clues as to the nature of the lump, need for testing and treatment options. These include the length of time the lump has been present, the change in size, if any, of the lump, whether the lump has been infected and has if there has been any injury to the area. Your doctor may be concerned about what pets you may have as a source of infection if you have and traveled outside the country, contracting an unusual infection. An ultrasound may help determine the nature of a neck lump and is often the first test obtained. Your doctor may order a CT scan or MRI, Which can better delineate the relationship of the lesion to the surrounding structures as well as potentially give some idea of what the lesion may be.
A needle biopsy may need to be obtained, or the lump may need to be removed completely to exam the cells under the microscope. Proper identification of the causes of the lump will help your doctor make the best decision about treatment. Your first step is always to contact your pediatrician, who can begin diagnosis and treatment as well as guide you to a pediatric ear nose and throat specialist if necessary.