Epidermoid Lipoma, fibroma, neurofibroma Keloid Goiter (with or without thyroid hormone disturbance) Osteochondroma Teratoma (may be malignant) Malignant Lymphoma—Hodgkin disease, non-Hodgkin lymphoma Leukemia Other—rhabdomyosarcoma, neuroblastoma, histiocytosis X, nasopharyngeal squamous cell carcinoma, thyroid, or salivary gland tumor “Normal” anatomy or variant FIGURE 48.1 Evaluation of the child with a neck mass a Malignancy: nontender, >3 cm diameter (and firm), enlarging mass of several weeks’ duration, ulceration, location deep to superficial fascia or fixed to tissue, supraclavicular mass, systemic lymphadenopathy and bruising, superior vena cava syndrome After obtaining a thorough account of the mass itself, it is critical to assess the involvement of other organ systems Constitutional symptoms of fever, fatigue, weight loss, night sweats, or adenopathy elsewhere are revealing ENT and respiratory symptoms such as noisy breathing (e.g., wheezing or stridor), dyspnea, sore throat, and neck pain are likewise significant Eliciting an exposure history will further inform the differential Temporal exposure to known sick contacts, or recent trauma from animal scratches and bites can contribute to the differential diagnosis Antibiotic or antiepileptic drug exposure may cause symptoms like serum sickness (e.g., fever, malaise, rash, arthralgias, nephritis) or pseudolymphoma, respectively (see Fig 48.1 ) Physical Examination The child presenting with a neck mass should have a thorough head-to-toe examination, beginning with assessment for critical illness A meticulous neck evaluation may be deferred until after completion of the remaining examination Inspection of the oral cavity should describe structures such as oral mucosa, dentition, Stensen duct (i.e., the parotid duct), and other glands Movement of the mass with swallowing or tongue protrusion is important to note Further inspection should include assessment of the scalp, ears, sinuses, and nasopharynx Evaluate remaining structures to determine if additional lesions are present The neck examination describes the location of the mass, including visual inspection and palpation while in flexion and extension Figure 48.2 diagrams common locations of neck mass Those in the supraclavicular area or the posterior triangle (superior to the clavicle, and posterior or lateral to the sternocleidomastoid), have a higher incidence of being neoplastic than those in the anterior triangle (anterior or medial to the sternocleidomastoid) Palpation provides critical characteristics of the mass including size, shape, consistency, mobility, existence, and severity of tenderness Presence of crepitation, thrill, bruit, fluctuance, or overlying skin changes should also be noted Characteristics that may be associated with malignancy include masses that are firm, larger than cm in diameter, nonpainful, progressively enlarging, ulcerating, deep to fascia or fixed to tissue, longer duration (i.e., weeks), or discovered in a newborn These criteria are sensitive but not specific for cancer FIGURE 48.2 Differential diagnosis of neck mass by location Area Parotid: cystic hygroma, hemangioma, lymphadenitis, parotitis, Sjögren and Caffey–Silverman syndrome, lymphoma Area Postauricular: lymphadenitis, branchial cleft cyst (1st), squamous epithelial cyst Area Submental: lymphadenitis, cystic hygroma, sialadenitis, tumor, cystic fibrosis Area Submandibular: lymphadenitis, cystic hygroma, sialadenitis, tumor, cystic fibrosis Area Jugulodigastric: lymphadenitis, squamous epithelial cyst, branchial cleft cyst (1st), parotid tumor, normal—transverse process C2, styloid process Area Midline neck: lymphadenitis, thyroglossal duct cyst, dermoid, laryngocele, normal—hyoid, thyroid Area Sternocleidomastoid (anterior): lymphadenitis, branchial cleft cyst (2nd, 3rd), pilomatrixoma, rare tumors Area Spinal accessory: lymphadenitis, lymphoma, metastasis (from nasopharynx) Area Paratracheal: thyroid, parathyroid, esophageal diverticulum Area 10 Supraclavicular: cystic hygroma, lipoma, lymphoma, metastasis, normal—fat pad, pneumatocele of upper lobe Area 11 Suprasternal: thyroid, lipoma, dermoid, thymus, mediastinal mass (From May M Neck masses in children: diagnosis and treatment Pediatr Ann 1976;5(8):517–535 Reprinted by permission.) Thoracoabdominal examination should pay special attention to auscultation and consideration for other signs of systemic illness Extrathoracic compression of the upper airway may manifest only as faint inspiratory stridor A goiter may be coupled with signs of thyroid hormone excess (e.g., tachycardia, bounding