© Borgis - New Medicine 2/2003, s. 22-25
Anna Bielicka, Małgorzata Dębska, Eliza Brożek, Mieczysław Chmielik
Neck masses in children in Department of Paediatric Otorhinolaryngology records, Warsaw, 1998 to 2002
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
The most common group of neck tumours in children are inflammatory lesions. In these cases pharmacological treatment is usually sufficient. Tumours requiring surgical treatment relatively more often have a congenital character. Usually they are imperceptible in early childhood, and increase during general or local infection. Among congenital changes the most common are median or lateral neck cysts. Malignant neoplasms of the neck are rarely seen in children, but in the case of a tumour in this region the possibility of a neoplastic proliferation should be checked. In differential diagnosis radiological investigations (ultrasonography, computed tomography and nuclear magnetic resonance) are helpful. In our study we carried out an analysis of age, sex, case history, character of neck change, methods of diagnosis and treatment.
Tumours of the neck in children are usually divided into three groups: inflammatory lesions, congenital masses, and neoplasms.
The most common neck tumours are enlarged lymphatic nodes. An enlargement may concern one lymph node, may appear as local uni- or bilateral enlargement of lymph nodes, or as a generalised enlargement of lymph nodes. In all these cases the fundamental principle is to rule out a neoplastic disease or neoplastic metastases. Primary occupation of lymph nodes may appear in Hodgkin´s disease, non-Hodgkin´s lymphomas, and in leukaemia. Metastases to cervical lymph nodes in children most commonly give: lymphoepithelioma, retinoblastoma, neuroblastoma, rhabdomyosarcoma, nephroblastoma, Ewing´s sarcoma, and thyroid carcinomas (1).
Inflammatory lesions within the neck most frequently concern lymph nodes, but may appear as infection of median or lateral neck cysts too. Inflammation of the cervical lymph nodes can have a specific or non-specific character. Non-specific inflammations may accompany bacterial infection (angina, peritonsillar abscess, caries, purulent dermal lesions) or viral infection (mononucleosis). Specific lymph node inflammation within the neck appears in tuberculosis, sarcoidosis, syphilis, diphtheria, cat-scratch fever, toxoplasmosis, AIDS.
Congenital neck masses are a very differentiated group, including amongst others: median neck cysts (thyroglossal duct cysts) or lateral neck cysts (branchial cleft cysts), lymphangiomas, and haemangiomas. The most frequent congenital masses within this region are median neck fistulas and cysts. They are formed by incomplete obliteration of the thyroglossal duct during embryonic development, and their location corresponds to the site of the thyroglossal duct and the ostium of the cyst or fistula. Most frequently they are in the median line, from the level of the superior margin of the thyroid cartilage to the level of the hyoid bone. In these cases diagnosis is usually made quikly on the basis of the presence of a smooth, painless, elastic tumour in the anterior part of the neck, which slowly increases and in ultrasonography gives a characteristic cyst picture with a hypoechogenic centre, clearly visible wall, and intensification of the posterior wall echo (2). Because there may be a fragment of thyroid tissue in the region of the caecal foramen of the tongue which is the sole active part of this gland and which may be removed during a median neck cyst operation, the scintigraphy of the thyroid should be carried out beforehand. This shows if there is thyroid tissue correctly taking up the radioactive marker in the normal thyroid site.
Lateral neck cysts arise from the second branchial cleft, and can be found from the oropharyngeal tonsillar fossa to the supraclavicular region of the neck (3). Lateral neck fistulas arise from the first branchial cleft (2, 4). The ostium of a lateral neck fistula is most frequently near the anterior margin of the sternocleidomastoid muscle, and the internal ostium in the region of the supratonsillar fossa (2). Bailey divided lateral neck cysts into four types depending on their location in relation to other cervical structures: type I – cysts localized superficially under the cervical fascia, type II – cysts localized deeper on the angioneurotic fascicle, type III – cysts extending towards the lateral pharynx wall, between the external and internal carotid arteries, and ranging to the base of the skull, type IV – cysts localized longitudinally to the lateral pharynx wall, and medially to the internal carotid artery (5).
Teratomas and dermoid cysts represent congenital benign neoplasms, and are relatively rare within the neck region (6).
Treatment of congenital neck masses usually requires their surgical excision. The remainder of these changes gives a risk of recurrent infections, airway obstruction during increase of the tumour, or the risk of malignant transformation (6, 7).
Lymphomas, rhabdomyosarcoma and neuroblastoma are malignant neoplasms which may also manifest as neck masses in childhood.
MATERIALS AND METHODS
We reviewed patients admitted with neck masses to the Department of Paediatric Otorhinolaryngology, Medical University of Warsaw from 1998 to 2002. Eighty – seven children were admitted of whom 74 with full documentation were analyzed. The study group consisted of 46 males and 28 females. The age of children ranged from 3 weeks to 15 years, mean age – 5.7 years. An analysis of age, sex, case history, character of neck change, methods of diagnosis and treatment was performed.
The most common tumours of the neck were inflammatory lesions. They were recognised in 47 children (63.5%), 33 boys and 14 girls. The youngest child was two weeks old, the oldest 13 years. Mean age 5.5 years. In 43 children (95%) the inflammation concerned the lymph nodes; in single cases a Hashimoto´s goitre, a suppurative inflammation of the submandibular gland, sialadenitis lymphocytica of the submandibular gland, and an abscess in the site of an incomplete removed of a lateral neck cyst were found. The time from the appearance of the first symptoms of a neck tumour to admission to the hospital was from several hours to 30 days, average 6 days. Fever before hospitalisation was present in 30 children (64%); tenderness on palpation or spontaneous pain in the tumour in 21 children (45%); reddening of skin over the change in 12 children (25%). Leucocytosis on admission to the hospital was from 10 to 40 thousand/mm3, average 17.3 thousand/mm3; erythrocyte sedimentation rate (ESR) was from 9 to 112 millimetres per hour, average 39 millimetres per hour.
Fifteen children (32%) were treated with antibiotic before admission to the hospital. Inflammatory changes were most frequently recognised in the region of the mandible angle (23 children) and in the submandibular region (11 children). In one child an abscess of the parapharyngeal space was diagnosed, and in two cases an inflammatory infiltration of the parapharyngeal space was observed. Inflammatory changes were usually localized on one side (72%). In 11 cases bacteriological examination of the abscess contents was performed; in 7 cases cultures were positive. In 4 cases mononucleosis was recognised. In another 4 cases, on the basis of levels of immune antibodies group G and M, a previous infection of Epstein – Barr virus (EBV) was recognised, and in one case toxoplasmosis was found. In the remaining cases (66%) the aetiology of the condition was unknown (Table 1).
Table 1. Aetiological factors of inflammatory changes within the neck.
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|Aetiological factors||Number of children||%|
|Unknown aetiology ||31||66%|
|Bacterial infection |
- Staphylococcus aureus
- Staphylococcus hominis
- Enterococcus faecalis
- Neisseria species
|Status post EBV infection ||4||8.5%|
The duration of hospitalisation of children with inflammatory lesions was 3 to 21 days, average 10 days. All children were initially treated with antibiotic given intravenously. In 12 children (25.5%) incision of an abscess was performed, with pus obtained in all cases. In one child spontaneous evacuation of pus contents was observed, and in one child the remains of a lateral neck cyst were re-operated. In 4 children, because of lack of improvement after pharmacological treatment, the enlarged lymph nodes were taken surgically for histopathological examination. In all these cases a histopathological examination give a picture of a chronic inflammatory process. In one case a bone marrow puncture was performed.
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