Evaluation and Management

of Neck Masses in Children

JEREMY D. MEIER, MD, and JOHANNES FREDRIK GRIMMER, MD
University of Utah School of Medicine, Salt Lake City, Utah

Neck masses in children usually fall into one of three categories: developmental, inflammatory/reactive, or neoplastic.
Common congenital developmental masses in the neck include thyroglossal duct cysts, branchial cleft cysts, dermoid
cysts, vascular malformations, and hemangiomas. Inflammatory neck masses can be the result of reactive lymphade-
nopathy, infectious lymphadenitis (viral, staphylococcal, and mycobacterial infections; cat-scratch disease), or Kawa-
saki disease. Common benign neoplastic lesions include pilomatrixomas, lipomas, fibromas, neurofibromas, and
salivary gland tumors. Although rare in children, malignant lesions occurring in the neck include lymphoma, rhab-
domyosarcoma, thyroid carcinoma, and metastatic nasopharyngeal carcinoma. Workup for a neck mass may include
a complete blood count; purified protein derivative test for tuberculosis; and measurement of titers for Epstein-Barr
virus, cat-scratch disease, cytomegalovirus, human immunodeficiency virus, and toxoplasmosis if the history raises
suspicion for any of these conditions. Ultrasonography is the preferred imaging study for a developmental or palpable
mass. Computed tomography with intravenous contrast media is recommended for evaluating a malignancy or a sus-
pected retropharyngeal or deep neck abscess. Congenital neck masses are excised to prevent potential growth and sec-
ondary infection of the lesion. Antibiotic therapy for suspected bacterial lymphadenitis should target Staphylococcus
aureus and group A streptococcus. Lack of response to initial antibiotics should prompt consideration of intravenous
antibiotic therapy, referral for possible incision and drainage, or further workup. If malignancy is suspected (accom-
panying type B symptoms; hard, firm, or rubbery consistency; fixed mass; supraclavicular mass; lymph node larger
than 2 cm in diameter; persistent enlargement for more than two weeks; no decrease in size after four to six weeks;
absence of inflammation; ulceration; failure to respond to antibiotic therapy; or a thyroid mass), the patient should
be referred to a head and neck surgeon for urgent evaluation and possible biopsy. (Am Fam Physician. 2014;89(5):353-
358. Copyright © 2014 American Academy of Family Physicians.)

P
CME This clinical content
rimary care physicians commonly History and Physical Examination
conforms to AAFP criteria
for continuing medical
see children with a neck mass. Neck masses in children typically fall
education (CME). See These masses often cause signifi- into one of three categories: developmen-
CME Quiz Questions on cant alarm and anxiety to the care- tal, inflammatory/reactive, or neoplastic
page 327. giver; however, a neck mass in a child is (Table 1). Important aspects of the history
Author disclosure: No rel- seldom malignant.1 In a review of children and physical examination can help narrow
evant financial affiliations. with neck masses that were biopsied in a ter- the differential diagnosis into one of these
tiary referral center, 11% were cancerous.2 It categories (Table 2).
is likely that the malignancy rate would be
TIMING
much lower in a primary care physician’s
office. In one series, 44% of children younger The onset and duration of symptoms should
than five years had palpable lymph nodes, be elicited during the initial history. A mass
suggesting that benign lymphadenopathy is present since birth or discovered during
common in this population.3 Recognizing the neonatal period is usually benign and
the possibilities within a broad differential developmental. Vascular malformations
diagnosis will allow the experienced phy- present at birth and grow with the child,
sician to effectively evaluate and identify whereas hemangiomas develop a few weeks
these lesions. Understanding the appropriate after birth and have a rapid growth phase.
workup and indications for intervention will Developmental masses may present later
prevent use of unnecessary diagnostic tests in life, either with superimposed infection
and therapies. or with growth over time. A new, rapidly

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Neck Masses
Table 1. Differential Diagnosis of Neck Masses in Children

Diagnosis

Location Developmental Inflammatory/reactive Neoplastic

Anterior Branchial cleft cyst,* Reactive lymphadenopathy,* lymphadenitis (viral, Lymphoma

sternocleidomastoid vascular malformation bacterial),* sternocleidomastoid tumor of infancy

Midline Thyroglossal duct cyst,* — Thyroid tumor

dermoid cyst*

Occipital Vascular malformation Reactive lymphadenopathy,* lymphadenitis* Metastatic lesion

Preauricular Hemangioma, vascular Reactive lymphadenopathy,* lymphadenitis,* Pilomatrixoma, salivary

malformation, type I parotitis,* atypical mycobacterium gland tumor
branchial cleft cyst

Submandibular Branchial cleft cyst,* Reactive lymphadenopathy,* lymphadenitis,* Salivary gland tumor
vascular malformation atypical mycobacterium

Submental Thyroglossal duct cyst,* Reactive lymphadenopathy,* lymphadenitis (viral, —

dermoid cyst* bacterial)*

Supraclavicular Vascular malformation — Lymphoma,*

metastatic lesion

*—Type of lesions that are more commonly found in that location.

growing mass is usually inflammatory. If the mass per- etiology (Figure 1). Most malignant neck masses in chil-
sists for six weeks, or enlarges after initial antibiotic dren are asymptomatic and are not painful.4 However,
therapy, a neoplastic lesion must be considered. Concern acute infection in a necrotic, malignant lymph node can
for airway involvement or malignancy should prompt also occur. An upper respiratory tract infection preceding
immediate referral or imaging. A slowly enlarging mass the onset of the mass suggests possible reactive lymph-
over months to years suggests benign lesions such as adenopathy or a secondary infection of a congenital cyst.
lipomas, fibromas, or neurofibromas. Constitutional type B symptoms such as fever, malaise,
weight loss, and night sweats suggest a possible malig-
ASSOCIATED SYMPTOMS nancy. Lymphadenopathy with high fever, bilateral con-
Fevers, rapid enlargement or tenderness of the mass, junctivitis, and oral mucosal changes with a strawberry
or overlying erythema indicates a likely inflammatory tongue likely represents Kawasaki disease.

RECENT EXPOSURES
Table 2. History and Physical Examination Recent upper respiratory tract infections; animal expo-
Clues to Diagnosis in Children sures (cat scratch, cat feces, or wild animals); tick bites;
with a Neck Mass
contact with sick children; contact with persons who
have tuberculosis; foreign travel; and exposure to ion-
Finding Diagnosis
izing radiation should be reviewed.5 Medications should
History also be reviewed because drugs such as phenytoin (Dilan-
Fevers, pain Inflammatory tin) can cause pseudolymphoma or can cause lymphade-
Present at birth Developmental nopathy associated with anticonvulsant hypersensitivity
Rapidly growing mass Inflammatory, malignancy syndrome.
Physical examination
LOCATION
Hard, irregular, firm, immobile Malignancy
Larger than 2 cm Malignancy The location of the neck mass provides many clues to the
Midline location Thyroglossal duct cyst, diagnosis. The most common midline cystic neck masses
dermoid cyst, thyroid mass are thyroglossal duct cysts and dermoid cysts (Figure 2).
Shotty lymphadenopathy Reactive lymph nodes Thyroglossal duct cysts are often located over the hyoid
Supraclavicular location Malignancy bone and elevate with tongue protrusion or swallowing,
whereas dermoid cysts typically move with the overlying

354  American Family Physician www.aafp.org/afp Volume 89, Number 5 ◆ March 1, 2014
 Neck Masses

skin.6 Malignant anterior neck masses are

usually caused by thyroid cancer. Congeni-
tal masses in the lateral neck include bran-
chial cleft anomalies, vascular or lymphatic
malformations, and fibromatosis colli.
Lymphadenopathy in the lateral neck can be
inflammatory or neoplastic. Supraclavicular
A B
lymph nodes or those in the posterior tri-
angle (behind or lateral to the sternocleido- Figure 1. (A) Lateral neck mass in a seven-month-old girl. She presented
mastoid muscle) have a higher incidence of with fever, swelling for three days, overlying erythema, tenderness,
malignancy than lymph nodes in the ante- and an elevated white blood cell count. (B) Computed tomography
with contrast media showed a cystic mass (arrow) with enhancing rim
rior triangle (anterior or medial to the ster- suggestive of suppurative lymphadenitis. The abscess was incised and
nocleidomastoid muscle).2 Generalized or drained, and was found to be positive for Staphylococcus aureus.
multiple anatomic sites of lymphadenopathy
increase the chance of malignancy.7,8

PALPATION

The consistency of the mass provides useful

information. Shotty lymphadenopathy refers
to the presence of multiple small lymph
nodes that feel like buckshot under the skin.9
In the neck, this usually implies a reactive
lymphadenopathy from an upper respira-
tory tract infection. A hard, irregular mass,
or a firm or rubbery mass that is immobile
or fixed to the deep tissues of the neck may
indicate malignancy. Figure 2. Midline neck mass in a four-year-old boy consistent with a
thyroglossal duct cyst.
SIZE

Size alone cannot confirm or exclude a diag-

nosis. However, cervical lymph nodes up to Table 3. Indications for Ordering Clinical Laboratory or
1 cm in size are normal in children younger Imaging Studies in the Workup of a Child with a Neck Mass
than 12 years,10 with the exception of the
jugulodigastric lymph node, which can be Test Indication
as large as 1.5 cm. Persistent enlarged lymph
Bartonella henselae titers Recent exposure to cats
nodes greater than 2 cm that do not respond
Complete blood count Serious systemic disease suspected
to empiric antibiotic therapy should be eval- (e.g., leukemia, mononucleosis)
uated for possible biopsy. Computed tomography Imaging study for retropharyngeal
or deep neck abscess, or suspected
Initial Diagnostic Testing malignancy
The primary care physician ultimately must Magnetic resonance imaging Preferred if vascular malformation is
determine whether further invasive workup suspected
or treatment is necessary, or if watchful wait- Purified protein derivative (PPD) Exposure to tuberculosis, young child in
ing is appropriate. Laboratory studies may be test for tuberculosis rural community (atypical tuberculosis)
indicated if there is concern about a systemic Ultrasonography Recommended initial imaging study
for a developmental mass, palpable
disease or to confirm a diagnosis suspected mass, or suspected thyroid problem
from the history and physical examination. Viral titers If history suggests exposure or a
Ordering routine studies in a shotgun style (cytomegalovirus, Epstein- suspected inflammatory mass is not
approach is rarely indicated and seldom Barr virus, human immuno­ responding to antibiotics
can reliably rule in or out a specific dis- deficiency virus, toxoplasmosis)
ease (Table 3). Results of a complete blood

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Neck Masses

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References Comments

When indicated, ultrasonography is the preferred initial imaging study C 12 Based on expert opinion
for most children with a neck mass.
Empiric antibiotic therapy with observation for four weeks is acceptable C 11 Based on a consensus-
for children with presumed reactive lymphadenopathy. based practice guideline
Excision of presumed congenital neck masses in children is recommended C 1 Based on observational
to confirm the diagnosis and to prevent future problems. studies
In children, enlarged lymph nodes that are rubbery, firm, immobile, or C 19, 20 From a consensus
that persist for longer than six weeks or that enlarge during a course guideline based on
of antibiotics should be considered for biopsy. observational studies

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

count with differential may be abnormal with infectious of a normal thyroid gland. Ultrasonography also should
lymphadenitis. A complete blood count with differential be the initial imaging study for the evaluation of a thy-
is recommended in patients with a history and physi- roid mass.
cal examination suggestive of infection or malignancy; Computed tomography with intravenous contrast
however, good evidence to support the value of routine media is the preferred study for evaluating a malignancy
complete blood count is lacking. Atypical lymphocyto- or a suspected retropharyngeal or deep neck abscess that
sis can occur in mononucleosis, and pancytopenia with may require surgical drainage.12 Computed tomography
blast cells suggests leukemia.11 If there was recent expo- with contrast media should not be ordered for a thyroid
sure to cats, measurement of Bartonella henselae titers mass; uptake of contrast media by thyroid tissue could
to evaluate for cat-scratch disease should be considered. delay subsequent radioactive iodine treatment if needed.
Measurement of titers for Epstein-Barr virus, cytomega- Magnetic resonance imaging better defines soft tissue
lovirus, human immunodeficiency virus, and toxoplas- anatomy 13 and avoids the radiation exposure from com-
mosis also should be considered if the history suggests puted tomography. However, the expense and frequent
possible exposure or if a presumed inflammatory mass is need for sedation often limit magnetic resonance imag-
not responding to antibiotics. ing as the initial imaging study of choice. Magnetic res-
Imaging may help with diagnosis and with planning onance imaging is the imaging study of choice when a
for invasive intervention. The American College of Radi- vascular malformation is suspected.
ology considers ultrasonography, computed tomogra- Fine-needle aspiration may provide critical diagnostic
phy with intravenous contrast media, and magnetic information and avoid the need for open biopsy. Sensitiv-
resonance imaging with or without intravenous con- ity of fine-needle aspiration in children is usually greater
trast media appropriate imaging studies for a child up to than 90%14-16 and specificity is approximately 85%.16
14 years of age presenting with a neck mass.12 Ultrasonog- However, in one series, 76% of the children required
raphy is the preferred initial imaging study in an afebrile general anesthesia; a cytopathologist who has experience
child with a neck mass or a febrile child with a palpa- with neck lesions in children is essential.16 Occasionally,
ble neck mass.12 Ultrasonography is a relatively quick, fine-needle aspiration does not provide sufficient tissue
inexpensive imaging modality that avoids radiation or adequate evaluation of lymph node architecture, and
and helps define the size, consistency (solid vs. cystic), an open biopsy is needed to determine the diagnosis.
shape, vascularity, and location of the mass. Malignancy
is more likely with an abnormally shaped lymph node Initial Treatment and Referral
compared with a lymph node that retains its normal Little evidence exists to definitively determine the best
architecture. If fine-needle aspiration is warranted for approach for the child with a neck mass. Current sug-
deep neck masses, ultrasonographic guidance can help. gested algorithms are based on expert opinion.17 Obser-
Ultrasonography should be performed when a thyro- vation is recommended initially in children with cervical
glossal duct cyst is suspected to determine the presence lymphadenitis that is bilateral, whose lymph nodes are

356  American Family Physician www.aafp.org/afp Volume 89, Number 5 ◆ March 1, 2014
 Neck Masses

smaller than 3 cm and are not erythematous or exqui-

sitely tender.18 An empiric course of antibiotics should Table 4. Indications for Referral in Children
be considered for patients with cervical lymphadenitis if with a Neck Mass
they have systemic symptoms (e.g., fever, chills), unilat-
eral lymphadenopathy, or erythema and tenderness, or Developmental mass requiring excision for definitive therapy
if their lymph nodes are larger than 2 to 3 cm.18 If an Infectious lymphadenitis requiring incision and drainage
antibiotic is prescribed, a 10-day course of oral cepha- Mass suggests malignancy
lexin (Keflex), amoxicillin/clavulanate (Augmentin), or Enlarged lymph node persistent for six weeks
clindamycin is recommended based on expert opinion, Firm, rubbery lymph node > 2 cm in diameter
because the most common organisms are Staphylococcus Hard, immobile mass
aureus and group A streptococcus.11 Empiric antibiotic Size increasing during antibiotic therapy
therapy with observation for four weeks is acceptable Supraclavicular mass
for presumed reactive lymphadenopathy.11 Figure 3 is an Thyroid mass
algorithm for the treatment of a child presenting with a
neck mass.
Children with congenital neck masses should be suppurative lymphadenitis or a neck abscess that does
referred to a specialist to consider definitive exci- not respond to oral antibiotic therapy should be referred
sion (Table 4). Excision is recommended to confirm for intravenous antibiotics, possible incision and drain-
the diagnosis and to prevent future problems (e.g., age, or further workup. If malignancy is suspected
potential growth, secondary infection).1 Patients with (accompanying type B symptoms; hard, firm, or rubbery

Treatment of Children with Neck Masses

Child presents with a neck mass

Signs of infection (e.g., erythema,

fevers, chills, tenderness)?

Yes No

Consider trial of Suspicious for malignancy (e.g., initial size

oral antibiotics greater than 3 cm; hard, firm, immobile mass;
associated type B symptoms; thyroid mass)?

Improvement in
two to three days? Yes No

Urgent referral to head Developmental mass suspected

and neck surgeon (e.g., thyroglossal duct or dermoid
Yes No
cyst, vascular malformation)?
Complete 10-day Order imaging
course of antibiotics (e.g., ultrasonography)
Yes No

Abscess seen on imaging? Referral to a head Observation for

and neck surgeon four to six weeks

Yes No
Consider referral to head and neck surgeon
Consultation for Consider intravenous antibiotics, if the mass enlarges during observation or
surgical drainage consultation with infectious disease if an asymptomatic mass larger than 2 cm
or ear, nose, and throat specialist persists longer than four to six weeks

Figure 3. Algorithm for the treatment of children with neck masses.

March 1, 2014 ◆ Volume 89, Number 5 www.aafp.org/afp American Family Physician 357

Neck Masses

consistency; fixed mass; supraclavicular mass; lymph 2. Torsiglieri AJ Jr, Tom LW, Ross AJ III, Wetmore RF, Handler SD, Potsic WP.
Pediatric neck masses: guidelines for evaluation. Int J Pediatr Otorhino-
node larger than 2 cm in diameter; persistent enlarge- laryngol. 1988;16(3):199-210.
ment for more than two weeks; no decrease in size after 3. Herzog LW. Prevalence of lymphadenopathy of the head and neck in
four to six weeks; absence of inflammation; ulceration; infants and children. Clin Pediatr (Phila). 1983;22(7):485-487.
failure to respond to antibiotic therapy; or a thyroid 4. Cunningham MJ, Myers EN, Bluestone CD. Malignant tumors of the
head and neck in children: a twenty-year review. Int J Pediatr Otorhino-
mass), the patient should be referred to a head and laryngol. 1987;13(3):279-292.
neck surgeon for urgent evaluation and possible biopsy. 5. Bauer PW, Lusk RP. Neck masses. In: Bluestone CD, Stool SE, Alper CM,
Although rare, malignant lesions such as lymphoma, et al., eds. Pediatric Otolaryngology. 4th ed. Philadelphia, Pa.: Saunders;
2003:1629-1647.
rhabdomyosarcoma, thyroid carcinoma, and metastatic
6. Acierno SP, Waldhausen JH. Congenital cervical cysts, sinuses and fistu-
nasopharyngeal carcinoma can occur in children. lae. Otolaryngol Clin North Am. 2007;40(1):161-176, vii-viii.
An asymptomatic lesion that appears to be an enlarged 7. Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood
lymph node creates a difficult dilemma for the primary peripheral lymphadenopathy. J Pediatr Surg. 1999;34(10):1447-1452.
care physician. Usually, the patient or caregiver is anx- 8. Yaris N, Cakir M, Sözen E, Cobanoglu U. Analysis of children with
peripheral lymphadenopathy. Clin Pediatr (Phila). 2006;45(6):544-549.
ious for a diagnosis and an intervention. Most cases
9. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am
of lymphadenopathy are self-limited and require only Fam Physician. 1998;58(6):1313-1320.
observation and patience.11 Enlarged lymph nodes that 10. Park YW. Evaluation of neck masses in children. Am Fam Physician.
are rubbery, firm, immobile, or that persist for longer 1995;51(8):1904-1912.
than six weeks or enlarge during a course of antibiotics 11. Leung AK, Robson WL. Childhood cervical lymphadenopathy. J Pediatr
Health Care. 2004;18(1):3-7.
should be evaluated by a head and neck surgeon, and a
12. American College of Radiology. ACR Appropriateness Criteria. Neck mass/
biopsy is recommended.19-21 adenopathy. http://www.acr.org/~/media/ACR/Documents/AppCriteria/
Diagnostic/NeckMassAdenopathy.pdf. Accessed December 2, 2013.
Data Sources: A PubMed search was completed in Clinical Queries using
the key term pediatric neck mass. The search included systematic reviews, 13. Turkington JR, Paterson A, Sweeney LE, Thornbury GD. Neck masses in
meta-analyses, consensus development conferences, and guidelines. Also children. Br J Radiol. 2005;78(925):75-85.
searched was the Cochrane database. Search dates: August 25, 2011, and 14. Ramadan HH, Wax MK, Boyd CB. Fine-needle aspiration of head and
December 2, 2013. neck masses in children. Am J Otolaryngol. 1997;18(6):400-404.
15. Mobley DL, Wakely PE Jr, Frable MA. Fine-needle aspiration biopsy:
application to pediatric head and neck masses. Laryngoscope. 1991;101
The Authors (5):469-472.
16. Anne S, Teot LA, Mandell DL. Fine needle aspiration biopsy: role in diag-
JEREMY D. MEIER, MD, is an assistant professor in the Division of Otolar- nosis of pediatric head and neck masses. Int J Pediatr Otorhinolaryngol.
yngology at the University of Utah School of Medicine in Salt Lake City. 2008;72(10):1547-1553.
JOHANNES FREDRIK GRIMMER, MD, is an associate professor in the Divi- 17. Dulin MF, Kennard TP, Leach L, Williams R. Management of cervical
sion of Otolaryngology at the University of Utah School of Medicine. lymphadenitis in children. Am Fam Physician. 2008;78(9):1097-1098.
18. Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric
Address correspondence to Jeremy D. Meier, MD, University of Utah, Infectious Diseases. 2nd ed. New York, NY: Churchill Livingstone; 2003.
50 N. Medical Dr., Rm 3C120 SOM, Salt Lake City, UT 84132 (e-mail: 19. Dickson PV, Davidoff AM. Malignant neoplasms of the head and neck.
[email protected]). Reprints are not available from the authors. Semin Pediatr Surg. 2006;15(2):92-98.
20. Citak EC, Koku N, Demirci M, Tanyeri B, Deniz H. A retrospective chart
review of evaluation of the cervical lymphadenopathies in children.
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358  American Family Physician www.aafp.org/afp Volume 89, Number 5 ◆ March 1, 2014