Suggested Readings and Key References General References Herzog LW Prevalence of lymphadenopathy of the head and neck in infants in children Clin Pediatr 1983;22(7):485–487 Kimia AA, Rudloe TF, Aprahamian N, et al Predictors of a drainable suppurative adenitis among children presenting with cervical adenopathy Am J Emerge Med 2019;37(1):109–113 Nield LS, Kamat D Lymphadenopathy in children: when and how to evaluate Clin Pediatr 2004;43:25–33 Sahai S Lymphadenopathy Pediatr Rev 2013;34(5):216–227 Twist CJ, Link MP Assessment of lymphadenopathy in children Pediatr Clin North Am 2002;49:1009–1025 Bartonella Henselae Infection English R Cat-scratch disease Pediatr Rev 2006;24(4):123–128 Floren TA, Zaoutis TE, Zaoutis LB Beyond cat scratch disease: widening spectrum of Bartonella henselae infection Pediatrics 2008;121(5):e1413–e1425 Massei F, Gori L, Macchia P, et al The expanded spectrum of bartonellosis in children Infect Dis Clin North Am 2005;19(3):691–711 Cervical Adenopathy Gosche JR, Vick L Acute, subacute, and chronic cervical lymphadenitis in children Semin Pediatr Surg 2006;15(2):99–106 Rajasekaran K, Krakovitz P Enlarged neck lymph nodes in children Pediatr Clin North Am 2013;60:923–936 Imaging Gorliz F, Bisset GS 3rd, D’Amico B, et al A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses Pediatr Radiol 2017;47(4):422–428 Ludwig BJ, Wang J, Nadgir RN, et al Imaging of cervical lymphadenopathy in children and young adults AJR Am J Roentgenol 2012;199:1105–1113 Restrepo R, Oneta J, Lopez K, et al Head and neck lymph nodes in children: the spectrum from normal to abnormal Pediatr Radiol 2009;39:836–846 Mycobacterial Infections Albright JT, Pranski SM Nontuberculous mycobacterial infections of the head and neck Pediatr Clin North Am 2003;50(2):503–514 Cruz AT, Geltemeyer AM, Starke JR, et al Comparing the tuberculin skin test and TSPOT.TB blood test in children Pediatrics 2011;127(1):e31–e38 Marais BJ, Gie RP, Schaaf HS, et al Childhood pulmonary tuberculosis: old wisdom and new challenges Am J Respir Crit Care Med 2006;173(10):1078–1090 Starke JR Management of nontuberculous mycobacterial cervical adenitis Pediatr Infect Dis J 2000;19(7):674–675 Epstein–Barr Viral Infections Luzuriaga K, Sullivan JL Infectious mononucleosis N Engl J Med 2010;362(21):1993– 2000 Kawasaki Disease Bayers S, Shulman ST, Paller AS Kawasaki disease: part I Diagnosis, clinical features, and pathogenesis J Am Acad Dermatol 2013;69(4):501.e1–e11; quiz 511–512 Bayers S, Shulman ST, Paller AS Kawasaki disease: part II Complications and treatment J Am Acad Dermatol 2013;69(4):513.e1–e8 Scuccimarri R Kawasaki disease Pediatr Clin North Am 2012;59:425–445 Son MB, Newburger JW Kawasaki disease Pediatr Rev 2013;34(4):151–162 Histiocytosis Bhasin A, Tolan RW Jr Hemophagocytic lymphohistiocytosis—a diagnostic dilemma: two cases and review Clin Pediatr (Phila) 2013;52(4):297–301 Drutz JE Histiocytosis Pediatr Rev 2011;32(5):218–219 Risma K, Jordan MB Hemophagocytic lymphohistiocytosis: updates and evolving concepts Curr Opin Pediatr 2012;24(1):9–15 Weitzman S, Jaffe R Uncommon histiocytic disorders: the non-Langerhans cell histiocytoses Pediatr Blood Cancer 2005;45(3):256–264 Windebank K, Nanduri V Langerhans cell histiocytosis Arch Dis Child 2009;94(11):904–908 Other Carroll MC, Yueng-Yue KA, Esterly NB, et al Drug-induced hypersensitivity syndrome in pediatric patients Pediatrics 2001;108(2):485–492 Shetty AK, Beaty MW, McGuirt WF Jr Kimura’s disease: a diagnostic challenge Pediatrics 2002;110(3):e39 Vigo G, Zulian F Periodic fevers with aphthous stomatitis, pharyngitis, and adenitis (PFAPA) Autoimmun Rev 2012;12:52–55 Yoo IH, Na H, Bae EY Recurrent lymphadenopathy in children with Kikuchi-Fujimoto disease Eur J Pediatr 2014;173(9):1193–1199 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 If clinical presentation suggests impending airway obstruction, lab work does little to inform immediate decision making, and the increased stress may convert a partial obstruction into a critical airway Oxygenation may be determined noninvasively by pulse oximetry Suspicion for traumatic injury warrants cervical spine immobilization Definitive airway control prior to full evaluation may be necessary Child With Neck Mass and Respiratory Distress or Systemic Toxicity The mechanism and duration of symptoms are crucial elements in the evaluation of a neck mass Trauma from vehicular collisions, falls from heights, or sports injuries may cause formation of a hematoma near vital structures such as the carotid artery or trachea (see Chapter 112 Neck Trauma ) Allergic reactions ranging from local bee stings to anaphylaxis may precipitate an acute emergency if there is enough tissue edema to obstruct the larynx or trachea (see Chapter 85 Allergic Emergencies ) Local and regional infections may present with cervical lymphadenopathy, but can have more significant life-threatening aspects Acute airway obstruction may result from viral or bacterial infections with associated tonsillar hypertrophy or laryngocele enlargement Bacterial pharyngitis occasionally progresses to deep space neck infections including retropharyngeal abscess, lateral pharyngeal abscess (LPA), and peritonsillar abscess (PTA) Lemierre syndrome, an uncommon parapharyngeal infection involving thrombophlebitis of the internal jugular vein with septic emboli including metastatic pulmonary abscesses, may manifest as respiratory distress and systemic toxicity in the adolescent with a history of pharyngitis Dental infection that spreads to the floor of the mouth (i.e., Ludwig angina) and neck may cause cervical swelling and airway compression Rarely, epiglottitis may present with associated cervical adenitis or the appearance of a submandibular mass from ballooning of the hypopharynx Concomitant dysphagia, drooling, or stridor would raise suspicion for these complications Occasionally, branchial cleft cysts or cystic hygromas can become infected and progress to abscess formation or rarely to mediastinitis Children with human immunodeficiency virus (HIV) infection (see Chapter 94 Infectious Disease Emergencies ) may present with parotitis or generalized lymphadenopathy (e.g., axillary, cervical, occipital), particularly visible in the neck Children may have hyperthyroid symptoms when a neck mass represents thyromegaly Similarly, patients with the mucocutaneous lymph node syndrome ... Drug-induced hypersensitivity syndrome in pediatric patients Pediatrics 2001;108(2):485–492 Shetty AK, Beaty MW, McGuirt WF Jr Kimura’s disease: a diagnostic challenge Pediatrics 2002;110(3):e39 Vigo G,... 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... 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