Approach to head and neck masses (pediatrics): Clinical sciences

Head and neck masses are a relatively common presenting concern in children, which are usually benign. Most pediatric head and neck masses can be categorized as possible malignancies, infections, or developmental anomalies.

If a pediatric patient presents with a head or neck mass, perform an ABCDE assessment to determine if they are stable or unstable. If unstable, stabilize the airway, breathing, and circulation, and intubate your patient if you need to secure the airway. Then, obtain IV access, and consider giving IV fluids. Finally, begin continuous vital sign monitoring, and provide supplemental oxygen if needed.

When it comes to stable patients, obtain a focused history and physical examination, and then assess for characteristics suggesting malignancy.

These include masses that are firm, have irregular borders, are immobile and matted, and grow rapidly. If any of these findings are present, consider malignancy, and obtain imaging, such as an ultrasound, CT scan, or MRI; as well as a tissue biopsy.

Next, assess for systemic B symptoms. These include fever, night sweats, or weight loss. If your patient reports any B symptoms, consider lymphoma.

Typical exam findings include a lateral neck mass with cervical lymphadenopathy, and you might detect a supraclavicular lymph node, which should raise your suspicion for malignancy. Imaging usually reveals enlarged lymph nodes, and in some cases a mediastinal mass. Finally, the presence of neoplastic lymphocytes on biopsy confirms lymphoma.

On the flip side, if systemic B symptoms are absent, your next step is to assess the mass’s location. If it’s in the midline, consider a thyroid nodule, which carries a significant risk of malignancy in children.

History may reveal previous head and neck radiation. On exam, you’ll detect a midline neck mass, and imaging may reveal a cystic or solid thyroid mass. Results of tissue biopsy could be benign, indeterminate, or consistent with thyroid cancer, but regardless of histology, that’s a thyroid nodule.

Here’s a clinical pearl! When assessing a thyroid nodule, remember to look at the patient’s TSH and free T4 levels. Most thyroid nodules don’t affect thyroid function, and TSH and free T4 levels are normal. However, some thyroid nodules are called “hot” because they autonomously produce free T4, independent of TSH. Even with a “hot” thyroid nodule, the body maintains normal free T4 levels by reducing TSH release. In this case, you’ll see a low TSH and normal free T4 level.

Now let’s move on and talk about neck masses that are not located along the midline. In this case, you should assess for signs and symptoms of catecholamine secretion.

An overproduction of catecholamines, such as dopamine, norepinephrine, and epinephrine results in sympathetic overstimulation. This can cause hypertension, tachycardia, flushing, sweating, and diarrhea. If your patient has any of these, think neuroblastoma, which is a sympathetic nervous system tumor.

These children are under 5 years of age and present with a lateral neck mass. If there is nerve compression, you may see Horner syndrome on the ipsilateral side, with ptosis, miosis, and facial anhidrosis, or inability to sweat. Next, imaging typically shows a mass in the chest likely involving the cervical sympathetic ganglia. If the tissue biopsy reveals neoplastic neuroblasts, diagnose neuroblastoma.

Here’s another clinical pearl! Neuroblastoma is the most common cancer in infants and children under 5. These tumors can arise anywhere in the sympathetic nervous system, but they’re usually found on the adrenal glands or somewhere along the ganglionated sympathetic chain that runs down the spine. Overall, cervical neuroblastomas are rare, and you’re more likely to see neuroblastoma present as an abdominal mass.

Let’s follow that up with a high-yield fact! Because neuroblastoma tumors secrete catecholamines, you can measure the catecholamine metabolites vanillylmandelic acid, VMA; and homovanillic acid, HVA, as part of your work-up. Elevated serum or urine VMA and HVA levels indicate catecholamine over-secretion, suggesting neuroblastoma.

Finally, if signs and symptoms of catecholamine secretion are absent, consider rhabdomyosarcoma, which is the most common soft tissue cancer in children. Rhabdomyosarcoma may occur on the head, neck or even the facial features. A periorbital mass might cause proptosis, while a mass near or inside the nose can cause nasal or sinus obstruction. When it comes to imaging, it shows a soft tissue mass. The presence of neoplastic rhabdomyoblasts on tissue biopsy confirms rhabdomyosarcoma.

Going back to the top, let’s consider masses without signs or symptoms of malignancy. Non-malignant masses are usually soft; have smooth, well-defined borders; are mobile; and grow slowly. If these characteristics are present, assess for signs and symptoms of infection. So, if you find fever, warmth, erythema, or tenderness, think infection.

Next, assess the mass’s location. If it’s in the cervical or posterior auricular chain, consider lymphadenitis. Primary lymphadenitis is commonly caused by bacteria such as Staphylococcus aureus and group A Streptococcus. On the other hand, various pathogens can cause lymphadenitis in one or more lymph nodes, including Epstein-Barr virus, Cytomegalovirus, tuberculous and nontuberculous mycobacteria, and Bartonella henselae, which causes cat-scratch disease.