surrounding bone and cartilage, nonemergent surgical excision is the treatment of choice Encephaloceles consist of neural tissue that has herniated through a congenital defect in the midline of the calvarium Unlike gliomas, encephaloceles have an intracranial communication Lesions appear as soft, at times pulsatile, compressible masses that enlarge with crying or straining Compression of the jugular veins (Furstenberg test) may also cause the mass to expand in size Some infants with nasal encephaloceles are born with overt craniofacial deformities and a rounded swelling at the base of the nose, whereas in others, the mass is confined to the nasopharynx, and external facial features are normal The latter may present with signs of persistent nasal obstruction In these patients, a grapelike mass is found on nasopharyngoscopy MRI is the modality of choice for differentiating encephaloceles from other midline nasal masses and for determining their size and extent Because of the risk of hydrocephalus or herniation of brain tissue into the lesion, rapid evaluation by a neurosurgeon is needed for these lesions Preauricular Lesions Preauricular lesions, located just anterior to the tragus, are common congenital anomalies noted in approximately 1% of children They may be the result of imperfect fusion of the first two branchial arches (sinus tract, pit) or may consist of first arch remnants (cutaneous tag) They can be unilateral or bilateral, single or multiple Usually, they are seen as isolated minor anomalies, but in 3% to 10% of cases they can be found in association with other developmental anomalies involving the first branchial arch or in infants with chromosomal disorders (including brachio-oto-renal syndrome) Most lesions are evident shortly after birth Some individuals simply have a surface pit or dimple, whereas in others, the overlying dimple represents the entrance to a sinus tract or blind pouch with a small cyst at its base ( Fig 120.6 ) The latter may contain hair and other epidermal elements Sinuses are prone to infection and abscess formation, and may present with sudden enlargement of a painful preauricular mass with overlying erythema When this occurs, the patient should be treated with appropriate antimicrobial therapy before elective excision of the cyst and fistula tract Cutaneous tags, also called accessory auricles, are flesh-colored pedunculated lesions that may or may not have a cartilaginous component ( Fig 120.7 ) Some with narrow bases may simply be tied off with silk sutures Those with wider bases and those containing cartilage can be referred for elective excision for cosmetic reasons FIGURE 120.7 Multiple preauricular skin tags (Courtesy of David Tunkel, MD.) NECK LESIONS CLINICAL PEARLS AND PITFALLS Parotitis is most commonly viral, and treatment involves supportive care including citric or sour food to facilitate salivary flow Avoid incision and drainage of facial abscesses near the ramus of the mandible, as they may represent an infected first branchial cleft remnant When torticollis is associated with a neck mass in infants, sternocleidomastoid tumor (fibromatosis colli) should be considered Posterior triangle and supraclavicular masses carry a much higher risk for neoplasm than anterior triangle masses Consider treatment for MRSA in acute lymphadenitis if the infection is not improving after treatment or in regions of high prevalence Consider an evaluation for pyriform sinus fistulas in children with acute suppurative thyroiditis Neck lesions in children may be of congenital origin or may be acquired as the result of an inflammatory process ( Fig 120.8 ) Although malignancy is a rare cause of neck masses in children, it must always be considered in the differential diagnosis Neck masses or lesions are most conveniently divided into those occurring in the midline and those located in the lateral aspects of the neck (see Chapters 48 Neck Mass and 118 ENT Emergencies ) Midline Neck Lesions Submental lymphadenitis or lymphadenopathy occurs in the midline just beneath the chin Nodal enlargement stems from drainage of a primary infection of the lower lip, buccal floor, or anterior tongue Management should be directed at treating the primary infection and if antibiotics are indicated should cover for oral anaerobes Dermoid cysts (see “Face and Scalp Lesions” section) can occur throughout the midline of the neck but are usually found above the area of the hyoid They may also be found more laterally along the anterior border of the sternocleidomastoid FIGURE 120.8 Head and neck congenital lesions seen in children in frontal and lateral views The shaded areas denote the distribution in which a given lesion may be found (A ), dermoid cyst; (B ), thyroglossal duct cyst; (C ), second branchial cleft appendage; (D ), second branchial cleft sinus; (E ), second branchial cleft cyst; (F ), first branchial pouch defect; (G ), preauricular sinus or appendage