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

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Introduction 0:00–0:21

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.

Unstable Patient 0:21–0:47

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.

Stable Patient/Malignancy 0:47–1:14

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.

Lymphoma 1:14–1:51

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 masses location.

Thyroid Nodule 1:51–3:00

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.
Youll 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, thats a thyroid nodule. Here's a clinical pearl.
When assessing a thyroid nodule. Remember to look at the patients TSH and free T four levels.
Most thyroid nodules don't affect thyroid function and TSH and free T four levels are normal. However, some thyroid nodules are called hot because they autonomously produce free T four independent of TSH.
Even with a hot thyroid nodule, the body maintains normal free T four levels by reducing TSH release. In this case, you'll see a low TSH and normal free T four 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.

Neuroblastoma 3:00–4:51

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 five 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 five.
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 workup, 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 4:51–5:24

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 rhabdomyoblast 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.

Infection 5:24–5:49

So if you find fever, warmth, erythema or tenderness, think infection next, assess the masses location. If it's in the cervical or posterior auricular chain, consider lymphadenitis.

Lymphadenitis 5:49–7:08

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 Bardella Hensley, which causes cat scratch disease when taking the history.
Remember to ask about sick contacts and animal exposures especially to cats as this might give a clue to the causative pathogen.
The exam typically reveals an enlarged lymph node that is tender, warm erythematous and sometimes fluctuant. You may also notice multiple enlarged nodes in the surrounding area.
With these findings, you can make a clinical diagnosis of lymphadenitis. Here's another clinical pearl lymphadenitis is an infection within one lymph node.
While reactive lymphadenopathy often means an immune response to a nearby infection. While primary lymphadenitis usually involves only one lymph node.
Reactive lymphadenopathy often involves multiple adjacent nodes within a chain. Now, if the mass with signs of infection involves the cheek and jaw consider parotitis, an infection of the parotid salivary glands.

Parotitis 7:08–7:53

Your patient may report facial pain, difficulty chewing or a dry mouth due to decreased saliva production. Remember to check the immunization status.
Since un immunized patients are at risk of mumps. Parotitis, parotitis can occur unilaterally or bilaterally and it usually presents with puffy cheeks and a swollen jaw, sometimes described as chipmunk cheeks.
The parotid is usually tender to palpation and the overlying skin might be warm and erythematous. With these findings diagnose parotitis, switching gears.
Let's go back and discuss patients without signs and symptoms of infection. In this case, consider developmental anomalies of the head and neck to evaluate further order imaging such as an ultrasound CT or MRI and assess the overlying skin color if it's reddish blue or hyperpigmented.

Developmental anomaly 7:53–8:10

Infantile hemangioma 8:10–8:45

Consider infantile hemangioma, a vascular tumor of infancy hemangiomas can be present at birth and are typically recognized during the neonatal period due to rapid expansion exam typically reveals a raised reddish blue or hyperpigmented mass that is soft and compressible.
Given its vascular nature, you may hear a bruit. If you auscultate the mass.
When looking at imaging, it should show a well defined hypervascular mass confirming the diagnosis of infantile hemangioma.
All right. If there's no skin discoloration, your next step is to assess the masses location.

Dermoid cyst 8:45–9:30

If its on the face or scalp, consider a dermoid cyst, a pocket of ectoderm that became trapped beneath the skin during fetal development as a quick reminder ectoderm is the outermost embryonic layer that develops into skin, hair, teeth and oil and sweat glands.
Dermoid cysts are present at birth and grow slowly as they fill with hair, oil and old skin cells. Exam typically reveals a small round, rubbery subcutaneous mass and imaging such as ultrasound.
Demonstrates a well defined cyst. In this case, diagnose a dermoid cyst.
On the other hand, a midline neck mass should make you consider a thyroglossal duct cyst. During fetal development, the thyroid forms near the base of the tongue and moves down the thyroglossal duct to its final location in the neck.

Thyroglossal duct cyst 9:30–10:48

At this point. The thyroglossal duct usually closes and disappears.
But if it doesn't fully degenerate, the remaining tissue forms a cystic pocket. Instead, thyroglossal duct cysts frequently present with intermittent swelling during upper respiratory infections due to inflammation and build up of secretions within the cyst.
Exam reveals a midline neck mass that moves slightly when your patient swallows or sticks their tongue out because they are connected to the tongue.
Thyroglossal duct cysts move with tongue movement. If on imaging, you see a well defined cyst near the hyoid bone, diagnosed thyroglossal duct cyst.
Here's another clinical pearl dermoid cysts typically form on the face and scalp, but in rare cases, they form along the neck midline.
You can distinguish a dermoid cyst from a thyroglossal duct cyst by asking your patient to swallow or stick out their tongue, dermoid cysts will not move with tongue movement.
While thyroglossal duct cysts will finally, if the mass is on the lateral neck, consider a branchial cleft cyst. These clefts are part of the embryonic pharyngeal arches that form various structures of the head and neck.

Branchial cleft cyst 10:48–11:55

If the clefts don't fully fuse, the remaining tissue forms a cystic pocket. Branchial cleft cysts often present with intermittent swelling during upper respiratory infections due to inflammation and build up of secretions within the cyst.
On exam, you'll see a lateral neck mass anterior to the sternocleidomastoid muscle and imaging will reveal a well defined cyst which confirms a branchial cleft cyst.
Here's the final clinical pearl. You'll often notice thyroglossal duct cysts and branchial cleft cysts in the setting of local infection and inflammation because they increase in size.
Sometimes you can identify them after bacterial superinfection due to tenderness and other systemic signs and symptoms. Its important to remember that thyroglossal duct cysts and branchial cleft cysts are developmental anomalies and are not caused by the infection itself.
All right. As a quick recap, pediatric head and neck masses could be caused by malignancy infection or a developmental anomaly if there are signs and symptoms, suggesting malignancy, think thyroid nodules, lymphoma, neuroblastoma or rhabdomyosarcoma signs and symptoms of infection are seen with lymphadenitis and parotitis.

Review 11:55–12:33

Finally, if there are no signs and symptoms of malignancy or infection, you might be dealing with benign developmental anomalies of the head and neck, including infantile hemangiomas, dermoid cysts, thyroglossal duct cysts and branchial cleft cysts.