FIGURE 120.10 Lymphadenitis (Reprinted with permission from Fleisher GR, Ludwig W, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Salivary gland infections, sialadenitis and parotitis , may cause lateral neck or submental swelling Most salivary gland infections affect the parotid gland Involvement of the sublingual and submandibular glands are much less common When the parotid gland is involved, firm indurated swelling is found extending in an arc from the preauricular area down beneath the ear or under the mandible The degree of swelling is often sufficient to blunt the angle of the jaw, and the mass is usually mildly tender ( Fig 120.11 ) Patients complain of mild pain in the region of the pinna, which may increase with eating Viral agents (e.g., mumps virus, parainfluenza types and 3, influenza, Coxsackie virus, and rarely, human immunodeficiency virus) cause most of these infections Less commonly, parotitis is due to a bacterial agent such as S aureus In these cases, patients present with rapid gland enlargement and severe pain, and they often have high fever and signs of systemic toxicity On examination, overlying erythema and exquisite tenderness are present, and purulent material can sometimes be expressed from Stensen duct by massaging the gland An elevated amylase level can help confirm the diagnosis of parotitis In patients where the anatomy is obscured by significant swelling, ultrasound can help differentiate parotitis from other neck masses Symptomatic treatment of sialadenitis includes close attention to hydration and avoidance of foods that require excessive chewing Sour foods serve as sialagogues to hasten resolution If bacterial sialadenitis or parotitis is suspected, β-lactamase stable parenteral antibiotics (e.g., ampicillin-sulbactam) should be administered with the addition of MRSA coverage in areas with high rates of methicillin resistance Otolaryngologic consultation should be obtained if surgical drainage is needed because of the proximity of the facial nerve Much less commonly, parotid gland swelling is of noninfectious origin Causes include occlusion of Stensen duct by a calculus and traumatic insufflation of the gland with forceful blowing (e.g., trumpet blowing) or, in rare instances, primary parotid neoplasms Radiographs are highly sensitive for salivary stones though ultrasound can detect a range of pathologies and is radiation-sparing FIGURE 120.11 Parotitis (Reprinted with permission from Fleisher GR, Ludwig W, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) FIGURE 120.12 Lateral neck cystic hygroma (lymphangioma) in an infant Cystic hygromas (lymphangiomas) represent malformations of the lymphatic system They consist of dilated lymphatic channels and may be unilocular or multilocular They occur most often in the posterior triangle of the neck ( Fig 120.12 ) but may be found in the axillae, groin, popliteal fossae, or on the chest or abdominal wall ( Fig 120.13 ) When found in the neck, extension of the mass into the anterior triangle, sublingual space, retropharyngeal space, or mediastinum is possible Such infiltration can result in airway compromise and/or compression of vascular and neural structures Most cystic hygromas are present at birth or become apparent shortly thereafter Patients usually present with a slow-growing, painless neck mass that is soft and compressible, although some patients are brought for care because of sudden enlargement caused by secondary infection or hemorrhage within the lesion Anatomic delineation of the mass is best performed with an MRI or CT The potential risk to the airway and neurovascular structures, coupled with the possibilities of hemorrhage or lymphangitis, dictates the need for early intervention Consultation with an otolaryngologist is indicated Treatment options include percutaneous drainage, surgery, sclerotherapy, radiofrequency ablation, and medical therapy FIGURE 120.13 Lateral abdominal wall cystic hygroma (lymphangioma) Branchial cleft anomalies consist of a group of congenital malformations, including subcutaneous cysts, sinus tracts, and cartilaginous remnants They are caused by persistence of structures derived from the embryonic branchial arches Of these anomalies, 90% arise from the second branchial arch and are found along the anterior border of the sternocleidomastoid muscle Sinus tracts of second branchial arch remnants may end in an internal ostium located near the tonsillar fossa Less commonly, first branchial arch anomalies may be noted as masses or sinus tracts near the mandibular ramus Some first branchial arch remnants end in an internal ostium located in the external auditory canal Branchial cleft anomalies may be noted shortly after birth either as a firm, mobile mass with or without an overlying pore, or simply as an external ostium or pore without an underlying mass ( Fig 120.14 ) More commonly, branchial cleft cysts are detected later in childhood when they may present as an asymptomatic mass or with acute painful enlargement as a result of secondary inflammation or infection All branchial cleft anomalies should be referred for surgical excision for cosmetic purposes and to avoid potential morbidity, which includes infection and the development of carcinoma in situ When patients present with infection, initial therapy includes antimicrobial therapy and incision and drainage (if needed) Definitive excision should be deferred until antibiotics have quelled all signs of inflammation ... 120.11 Parotitis (Reprinted with permission from Fleisher GR, Ludwig W, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) FIGURE 120.12 Lateral