FIGURE 120.14 Second branchial cleft pit that had an underlying sinus tract The combination of torticollis and a lateral neck mass in early infancy is highly suggestive of a sternocleidomastoid tumor (nonmalignant) or fibromatosis colli of infancy that can be associated with primiparous births, breech presentations, and difficult labor Clinically, a nontender, firm, ovoid 1- to 3-cm mass is found along the inferior or middle third of the sternocleidomastoid muscle The mass represents local muscle hemorrhage or infarction that subsequently undergoes fibrosis It is believed to be the result of traumatic extraction of the head during delivery or secondary to fibrous dysplasia related to intrauterine positioning While some are noted at birth, others become apparent within the ensuing few weeks The head and ear bend toward, and the chin away from, the affected sternocleidomastoid, and limitation of bending to the opposite side and rotation toward the involved side are noted Initial treatment consists of passive stretching exercises and positioning of the infant so that he or she has to turn from the affected side to see others If this fails, surgical release of the contracture is indicated to prevent secondary facial deformity with growth Infants with this disorder should be carefully assessed for associated hip dysplasia, which coexists in up to 20% of cases The possibility of malignancy must be considered in the differential diagnosis of any child with a cervical mass History regarding the presence of persistent fevers, malaise, night sweats, weight loss, and other constitutional symptoms should be sought, and the child assessed for presence of pallor, petechiae, generalized adenopathy, and hepatosplenomegaly Primary lymphoid malignancies, such as leukemia and lymphoma, may present initially with a rapidly enlarging neck mass In contrast to infectious adenopathy, involved nodes tend to be firm, matted, nontender, and poorly mobile Posterior triangle and supraclavicular masses carry a much higher risk for neoplasm than anterior triangle masses Metastatic tumors, such as rhabdomyosarcoma and neuroblastoma, may also initially manifest as a neck mass If malignancy is suspected, the ED workup should include a complete blood cell count, electrolytes, uric acid, lactate dehydrogenase, liver function studies, heterophile antibody titer, and a chest radiograph to evaluate for mediastinal mass or adenopathy Further evaluation, including imaging and biopsy, should be performed in consultation with a pediatric oncologist SURFACE LESIONS CLINICAL PEARLS AND PITFALLS While most surface lesions are not dangerous, a thorough history and physical examination should be performed to evaluate for associated systemic illnesses Infantile hemangiomas present at a young age and will initially become larger before involuting Acute or persistent bleeding from a pyogenic granuloma often requires cauterization with silver nitrate or application of a hemostatic dressing Neurofibroma can often be distinguished from other soft tissue lesions by their central invagination with digitation pressure (i.e., button holing) Vascular Malformations Vascular malformations result from errors in vascular morphogenesis Unlike hemangiomas (discussed later), they are present at birth, grow only in proportion to the child, and not undergo regression They may be of capillary, venous, or arterial origin or combinations of vessel types may exist within the same lesion Clinical manifestations of vascular malformations are determined by their type and anatomic location Port-wine stains are among the more common capillary vascular malformations They have a characteristic deep red to purple hue ( Fig 120.15 ) Children with facial port-wine stains that lie in the distribution of the ophthalmic branch of the trigeminal nerve (which includes the forehead, upper eyelids, and nose) merit careful evaluation for associated anomalies Specifically, Sturge– Weber syndrome is characterized by ipsilateral vascular angiomatosis of the leptomeninges and ocular vessels Clinical manifestations may include seizures, intellectual disability, hemiplegia, and glaucoma These children should be referred to neurology for consideration of neuroimaging and EEG, as well as ophthalmology for a thorough eye examination Serial neuroimaging performed on these children often demonstrates evolution of serpiginous calcifications and progressive atrophy of the cerebral cortex underlying the pial vascular malformations Treatment consists of seizure control, or surgical resection in cases of failed medical management Children with port-wine stains involving an extremity may develop hemihypertrophy of the affected limb as a result of the unusually rich underlying blood supply, known as Klippel–Trenaunay–Weber syndrome All cosmetically significant port-wine lesions should be referred to a dermatologist for consideration of laser therapy (see Chapter 88 Dermatologic Urgencies and Emergencies ) Salmon patches are the most common form of vascular malformation seen in infancy and occur in 30% to 40% of all newborns These flat pink lesions, which become more prominent with crying or exertion, are most commonly located on the nape of the neck (stork bites), on the glabella, or over the eyelids (angel kisses) They consist of distended dermal capillaries and almost always fade or resolve by the end of the first year of life, although nuchal salmon patches may persist into adulthood Lymphatic malformations are errors in lymphatic vessel morphogenesis Presentation is usually before years of age, however can be as late as adulthood They may be isolated or combined with other vessels in the same lesion such as in CLOVES syndrome Similar to other vascular malformations, lymphatic malformations vary in size, grow with the child, and can cause bony overgrowth of the affected side, leading to asymmetry These lesions range from superficial skin vesicles to a large multilobular mass Clear lymph fluid can turn purple or red with intralesional bleeding Complications are related to interference with, or invasion of surrounding structures as mentioned in lateral neck lesions above Limb lymphatic malformations can lead to elephantiasis, usually later in life These lesions are also prone to recurrent cellulitis ED treatment should include pain management, evaluation for infection, and referral to a specialist FIGURE 120.15 Facial port-wine stain (Reprinted with permission from Weber J, Kelley J Health Assessment in Nursing 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) Infantile Hemangiomas Infantile hemangiomas , the most common benign neoplasm of infancy, occur in more than 10% of children younger than year of age Histologically, they are composed of hyperplastic vascular endothelium that develops from angioblastic tissue that has failed to connect normally with the vascular system during gestation Although infantile hemangiomas are rarely evident at birth (2.5% of cases), most become apparent within the first month of life There is an increased incidence in Caucasian, female, and premature infants Sixty percent of all infantile hemangiomas are located in the head/neck region Lesions tend to undergo a period of rapid growth over the first to 12 months, then plateau Subsequently, a slow process of involution begins, usually by 18 months Approximately 50% of lesions involute completely by years of age, and 95% by ... adenopathy Further evaluation, including imaging and biopsy, should be performed in consultation with a pediatric oncologist SURFACE LESIONS CLINICAL PEARLS AND PITFALLS While most surface lesions are