pulses, systolic hypertension, exophthalmos) or deficiency Orthopnea or wheezing while supine may be an early sign of a mediastinal mass Failure to thrive or weight loss may also be associated with multiple causes of infection or oncologic illness, including HIV disease, histiocytosis X, mycobacterial infections, and others Likewise, generalized lymphadenopathy in conjunction with fever or rashes may indicate an inflammatory or oncologic process A full examination of the skin is therefore imperative, with special attention to any animal scratches or bites of the face and extremities Suspicion for malignancy increases with changes in the general appearance and color of the child, as with the presence of hepatosplenomegaly or an abdominal mass DIFFERENTIAL DIAGNOSIS Congenital Masses Thyroglossal duct cysts are the most common congenital cyst of the neck, resulting from failure of embryologic thyroglossal duct obliteration prior to hyoid bone formation More than half are diagnosed in children younger than 10 years of age Although 65% of these are found to be infrahyoid, they can develop anywhere in the anterior triangle (along the midline from the base of the tongue to the sternal notch) These may become apparent initially after an upper respiratory infection (URI) or an episode of hemorrhage Masses from thyroglossal duct cysts are classically soft, nontender, smooth, and may move cranially when the child swallows or protrudes the tongue When infected, they may be warm, erythematous, and drain externally If drainage occurs by way of the foramen cecum, there may be an associated foul taste in the mouth Antibiotics (for mouth and skin flora), warm compresses, and incision and drainage (if indicated) should be initiated for signs of infection Complete excision is the treatment of choice after resolution of the acute infection Branchial cleft anomalies most commonly occur from defects in the development of the second branchial arch, giving rise to firm posterior triangle masses (along the anterior border of the sternocleidomastoid muscle near the angle of the mandible) Branchial cleft sinuses present with a pit with or without drainage at the junction of the middle and lower thirds of the sternocleidomastoid muscle Blockage of the sinus tract may cause cysts which are usually fluctuant, mobile, and nontender Conversely, probing or injecting the tract may precipitate an infection, causing warmth and tenderness Consequently, incision and drainage should be avoided because it may result in fistula formation Ultrasonography (US) may be useful in identifying a thin-walled, anechoic, fluid-filled cyst Treatment with antibiotics is necessary if the sinus or cyst is infected Excision of the entire tract and cyst is important to prevent recurrence Cystic hygromas are lymphatic malformations occurring in the posterior triangle of the neck Many are identified at birth, and 90% present before a child’s second birthday These may be recognized only after “herniation” has occurred, generally, following injury, URI, crying, coughing, or other forceful Valsalva maneuvers Though variable in size, these discrete lesions are compressible, mobile, nontender, and may transilluminate Infection and airway compromise are rare, and additional signs would be as expected US is useful in confirming its cystic nature Chest radiograph is recommended to evaluate for extension into the mediastinum with resultant chylothorax or chylomediastinum Computed tomography (CT) or magnetic resonance imaging (MRI) can determine the extent and involvement of surrounding structures Spontaneous regression is rare; therefore, complete excision is the treatment of choice for small lesions Larger lesions may need intralesional sclerotherapy Hemangiomas (including capillary, strawberry, and capillary-cavernous subtypes) are common vascular malformations of the head and neck, with a threeto-one female predominance Generally noticed during a period of rapid growth over the first year of life, these subsequently involute over the next several years These lesions are bluish or reddish in color, and may exhibit increased warmth, a thrill or bruit, and capillary refill noted after palpation They are otherwise soft, mobile, and nontender to palpation Lesions in the beard distribution may be accompanied by glottic or subglottic hemangiomas, with an associated risk for airway compromise Other rare complications include thrombocytopenia from platelet consumption, disseminated intravascular coagulation, hemorrhage, congestive heart failure, ulceration, infection, and necrosis Treatment for most hemangiomas is conservative and nonoperative because the issues are almost solely cosmetic and short term Decisions about other treatments (corticosteroids, β-blockers, laser treatment, intralesional sclerotherapy, and resection) are best reserved for the pediatric surgeon or vascular malformation subspecialist Neonatal torticollis, often caused by fibromatosis colli (also called sternocleidomastoid tumor), results from sternocleidomastoid fibrosis and shortening of the muscle Presenting symptoms of torticollis occur in the first weeks of life, with the infant holding his/her head tilted toward the fibrous mass, but face and chin tilted away from the affected side Palpation reveals a firm mass apparently adherent to the muscle Physical therapy, including massage, range-ofmotion exercises, stretching exercises, and positional changes, is the preferred treatment Facial and cranial asymmetry can develop without intervention Surgical intervention is rarely needed Inflammatory Masses Cervical lymphadenopathy is the most common cause of neck masses in children Examination of children 12 years of age and younger may reveal palpable cervical lymph nodes measuring up to cm (1.5 cm if in the jugulodigastric chain) Children between the ages of and years can present with self-limited episodes of lymphadenopathy measuring up to to cm, approximately 90% of which may be idiopathic Lymphadenopathy in newborns and young infants is rare, however, and warrants investigation Potential etiologies for cervical lymphadenopathy include local, regional, or systemic illness in addition to viral or bacterial infections Anterior cervical nodes drain the oropharynx and become enlarged after URIs, oral, and pharyngeal infections Inflammation or infection of the scalp, and nasopharynx cause enlargement of posterior cervical nodes Conversely, supraclavicular lymphadenopathy is considered pathologic and warrants further investigation Though chronicity of findings is variable depending on etiology (e.g., rhinovirus, parainfluenza virus, respiratory syncytial virus [RSV], Cytomegalovirus, and Epstein–Barr virus [EBV]), adenopathy secondary to viral infections is self-resolving Lymphadenopathy from an underlying bacterial cause should resolve with appropriate antibiotic therapy Supraclavicular nodes should be referred to specialist for biopsy Cervical lymphadenitis represents an acute infection present within one or multiple nodes, frequently in the context of a recent URI, pharyngitis, tonsillitis, or otitis media (see Chapters 94 Infectious Disease Emergencies and 118 ENT Emergencies ) This manifests as enlargement, erythema, warmth, and tenderness of the involved lymph nodes Systemic symptoms of fever and malaise may be present Without antibiotic treatment, infection may progress with nodal enlargement, suppuration, and regional cellulitis Common bacterial causes include group A β-hemolytic streptococcus (GAS), Haemophilus influenzae, and anaerobic bacteria Most milder cases resolve with warm compresses and oral β-lactamase–resistant antibiotics The incidence of Staphylococcus aureus infection (possibly methicillin resistant), is on the rise, however While clindamycin is generally effective against methicillin-resistant S aureus, knowledge of local resistance patterns is important when selecting antibiotic coverage Failure of outpatient management warrants further diagnostic investigation, which may include serologies, ultrasound, fine needle aspiration, and incision and drainage Purulent fluid should be sent for Gram stain and aerobic and anaerobic cultures to guide antibiotic management For toxic and ill- appearing patients, admission and treatment with intravenous (IV) antibiotics are appropriate Cervical lymphadenitis may also be caused by viral infections including rhinovirus, parainfluenza virus, RSV, Cytomegalovirus, and EBV In addition to prominent posterior cervical nodes, EBV classically presents with a mononucleosis-like illness including fever, headache, malaise, and tonsillar hypertrophy Diffuse lymphadenopathy and the presence of hepatosplenomegaly are also frequently present Treatment for mononucleosis is generally supportive Exudative pharyngitis warrants evaluation for concurrent GAS, and should be treated with antibiotics if positive Corticosteroids (prednisolone/prednisone at mg/kg/day often prescribed as a short burst and then a taper) may be useful in patients with airway obstruction Cat-scratch disease also causes regional lymph node enlargement in children, typically presenting to weeks after a cat or kitten scratch Scratches to the head and neck result in cervical lymph node enlargement in 33% to 50% of those affected Fever and malaise precede the development of a single, enlarged node in 30% This is followed by local erythema, warmth, tenderness, and induration of the area Labs for Bartonella henselae (the causative agent), will be positive in approximately 84%, and 16% of patients within to weeks of symptoms, and to weeks of symptoms, respectively Needle aspiration has both therapeutic and diagnostic potential Conversely, surgical excision may create a draining sinus Bartonella henselae can be identified via immunofluorescent antibody assay to both IgM and IgG antibodies Symptomatic treatment generally results in resolution over to months Indications for antibiotic treatment include painful adenitis, systemic symptoms (hepatic or splenic involvement, endocarditis), or immunocompromise Azithromycin is the first-line antibiotic choice Rifampin, ciprofloxacin, parenteral gentamicin, and trimethoprim-sulfamethoxazole are moderately to highly effective in treating severe disease (hepatosplenic disease, persistent temperature >39.5°C, or severe systemic signs) Parenteral ceftriaxone and gentamicin, with or without oral doxycycline, are suggested for those with culture-negative endocarditis Bartonella-positive endocarditis is generally treated with doxycycline and gentamicin Mycobacterial infection of the cervical lymph nodes can be caused by the atypical strains of Mycobacterium avium-intracellulare (MAI), Mycobacterium scrofulaceum, or less frequently, Mycobacterium tuberculosis (M tb) Atypical mycobacterial infection presents with enlarged, erythematous, “rubbery” nodes which are generally submandibular in location, and minimally tender to palpation In contrast, the supraclavicular lymphadenopathy caused by M tb is more ... β-blockers, laser treatment, intralesional sclerotherapy, and resection) are best reserved for the pediatric surgeon or vascular malformation subspecialist Neonatal torticollis, often caused by fibromatosis