FIGURE 120.9 Thyroglossal duct cyst (Reprinted with permission from Snell RS Clinical Anatomy 7th ed Baltimore, MD: Lippincott Williams & Wilkins; 2005:CD418.) Thyroglossal duct cysts are among the more common midline neck masses in children and are the most common congenital mass of the neck in this age group Approximately 40% present before 10 years of age They are composed of an ectodermal ductal remnant that fails to regress after fetal descent of the thyroid gland They may occur anywhere along the path of descent of the thyroid, from the base of the tongue to the sternal notch, although they most commonly occur near the level of the hyoid bone Presentation is usually that of a painless, smooth, mobile, cystic mass that is located in the midline or just slightly off-center ( Fig 120.9 ) Because of its intimate association with the hyoid, the mass moves with protrusion of the tongue or swallowing On occasion, an overlying pore is present Cysts may go unnoticed until infection occurs, causing acute swelling, pain, and erythema of the overlying skin Patients with asymptomatic thyroglossal duct cysts should be referred for elective surgical excision If the thyroglossal duct cyst is infected on presentation, excision is deferred until appropriate antimicrobial therapy is completed and inflammation has subsided If incision and drainage are required during treatment, the patient should be referred to a surgeon comfortable with thyroid anatomy Elective excision involves removal of the cyst, the entire duct to the level of the foramen cecum, and often the midportion of the hyoid bone On rare occasions, ectopic thyroid tissue in a thyroglossal duct cyst is the patient’s only functioning thyroid Therefore, ultrasound, radioisotope scanning, or CT scan is recommended to confirm the presence of a normal thyroid gland before surgery Goiter , or diffuse enlargement of the thyroid gland, may be congenital or the result of infiltration, inflammation, or overstimulation of the gland Congenital goiter is usually apparent at birth and may be due to transplacental exposure to maternal antithyroid antibodies, antithyroid medications, as well as congenital errors in thyroid hormone synthesis or the thyroid-stimulating hormone (TSH) receptor By far, the most common acquired cause of pediatric thyroid enlargement is chronic lymphocytic thyroiditis (also called Hashimoto thyroiditis or autoimmune thyroiditis ) Other acquired causes of goiter in children include acute suppurative thyroiditis , iodine-deficiency (rare in children in the United States), colloid goiter, goiter secondary to hyperthyroidism (e.g., Graves disease ), infiltrative diseases of the thyroid and thyroid nodules (including malignancy) See Chapter 89 Endocrine Emergencies Lymphocytic thyroiditis is characterized by a defect in cell-mediated immunity that results in lymphocytic infiltration of the thyroid gland Females are more commonly affected, and peak occurrence is during adolescence The disorder has been associated with other autoimmune diseases including chronic urticaria and diabetes Usual presentation is one of a slow-growing, painless midline neck mass Occasionally, a patient may complain of sore throat Examination reveals a firm, nontender, diffusely enlarged gland in most affected children, but approximately one-third will have some lobular or nodular enlargement Evaluation includes assessment of thyroid function and the detection of thyroid autoantibodies in the serum Most patients with lymphocytic thyroiditis are euthyroid When thyroid dysfunction is present, it usually takes the form of hypothyroidism Any degree of nodularity of the gland warrants further investigation to rule out malignancy Inflammation of the thyroid gland secondary to infection, acute suppurative thyroiditis , is a rare cause of thyroid enlargement in children that can be associated with an underlying pyriform sinus fistula Presentation usually follows an upper respiratory tract infection or otitis media and is characterized by the abrupt appearance of a painful, tender, swollen mass in the region of the thyroid Systemic illness in the form of fever and chills and severe dysphagia are often present Flexion of the neck may alleviate pain, whereas extension worsens it Etiologic agents include S aureus and oropharyngeal flora Appropriate broadspectrum parenteral antimicrobial therapy is usually sufficient to eradicate the infection Abscess formation necessitates incision and drainage by a surgeon comfortable with thyroid anatomy Evaluation with a CT or esophagography should be performed to improve identification of a pyriform sinus fistula If present, the fistula will often require excision after resolution of the acute infection in order to prevent recurrences Acute immune stimulation of the thyroid gland may also produce diffuse thyroid enlargement In Graves disease , autoantibody attachment to the thyrotropin receptor stimulates an increase in thyroid hormone synthesis and release Patients may initially have a history of changes of behavior, decrease in school performance, and/or increase in linear growth On presentation, patients will have a symmetrically enlarged smooth nontender goiter and may have signs of thyrotoxicosis, including tachycardia, nervousness, tremor, hypertension, exophthalmos, and increased appetite A thyroid bruit may be auscultated in 50% of patients An elevated free T4 in the context of a low TSH level and presence of TSH receptor antibodies confirms the diagnosis Consultation with a pediatric endocrinologist is indicated with initial focus on managing the symptoms of hyperthyroidism or thyrotoxicosis, if present Thyroid nodules are present in up to 2% of children, and deserve careful attention Although most are secondary to chronic lymphocytic thyroiditis or consist of a benign adenoma, the incidence of malignant neoplasms is actually higher in children with thyroid nodules than in adults Hence, every thyroid nodule found in a child merits a complete evaluation In the ED, this evaluation should include thyroid function tests and neck ultrasound Urgent outpatient follow-up with a specialist with expertise in the evaluation of thyroid nodules is required to facilitate additional testing including ultrasound-guided fine-needle aspiration and genetic testing Lateral Neck Lesions Enlarged cervical lymph nodes constitute the most common lateral neck masses in children Knowledge of the anatomy of the cervical lymphatics is of fundamental importance to understanding processes that cause enlargement of cervical lymph nodes This section focuses mainly on local processes that cause nodal enlargement, but it is important to note that many systemic infections, inflammatory disorders, and malignancy can cause diffuse adenopathy that includes the cervical chain (see Chapter 47 Lymphadenopathy ) Therefore, any child with a neck mass deserves a complete examination to look for the presence of generalized adenopathy and other signs of systemic disease Reactive cervical adenopathy refers to mild enlargement of cervical lymph nodes that accompanies a viral or bacterial upper respiratory tract infection Reactive lymphadenopathy can also be seen in cases of infectious mononucleosis Involved nodes are typically located in the upper portion of the cervical chain They are usually discrete, firm, mobile, and less than cm in diameter They may be mildly tender but have no overlying erythema, edema, fluctuance, or warmth Regression within to weeks of resolution of the primary infection is the rule, although occasionally more persistent mild enlargement of the nodes may be seen, if fibrosis has occurred Local infection of a lymph node itself is termed acute lymphadenitis The involved node is usually solitary, typically to cm or larger in diameter, and extremely tender As the infection proceeds, overlying swelling, erythema, and warmth develop and become more pronounced ( Fig 120.10 ) Initially the node is firm, but later it may become fluctuant if the node suppurates Acute suppurative lymphadenitis is most often caused by streptococcal or staphylococcal organisms Because of the high incidence of β-lactamase production by S aureus, β-lactamase stable antibiotics (amoxicillin-clavulanate, cephalexin, or clindamycin) are the treatment of choice In patients with poor dentition, antibiotic coverage should include oral anaerobes Most patients respond to oral antimicrobial therapy and application of warm compresses However, ultrasound may be indicated if abscess is suspected and if so, incision and drainage may be warranted In children with signs of systemic illness, blood culture, complete blood count, and inflammatory markers can be helpful in identifying potential causative organisms and monitoring response to therapy Other potential causative organisms of acute, subacute, or chronic lymphadenitis include anaerobic bacteria, Pasteurella multocida (following animal bites), Haemophilus influenzae, Streptococcus agalactiae, Francisella tularensis, Brucella species, Bartonella henselae (cat-scratch disease), mycobacteria, and actinomycoses Oral antimicrobial therapy for MRSA should be considered if there is clinical suspicion, in regions with high prevalence, or if the infection is not improving Kawasaki disease should be considered in children with an acutely enlarged cervical node when other clinical criteria are present (fever for more than days, conjunctivitis, extremity and oral changes, and rash) ... synthesis or the thyroid-stimulating hormone (TSH) receptor By far, the most common acquired cause of pediatric thyroid enlargement is chronic lymphocytic thyroiditis (also called Hashimoto thyroiditis... low TSH level and presence of TSH receptor antibodies confirms the diagnosis Consultation with a pediatric endocrinologist is indicated with initial focus on managing the symptoms of hyperthyroidism