Neck Masses: Causes of Neck Masses in Children

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Neck Masses: Causes of Neck Masses in Children




Guest:  Dr. David White - Otolaryngology

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m talking, today, with Dr. David White who is Assistant Professor of Ear, Nose & Throat, Otolaryngology, here at the Medical University of South Carolina, working in the Children’s Hospital.  You work primarily with children, is that correct?


Dr. David White:  Almost exclusively with children, yes.


Dr. Linda Austin:  So, in this podcast, let’s talk about neck masses in children.  When a parent first brings you a child and, indeed, you can feel that there is some sort of neck mass, what are some of the first things you think about?


Dr. David White:  The first thing I that I think about is trying to figure out whether or not this is a mass which has grown quickly or is something that’s been there for a long time.  The other thing that I want to consider is how it’s been treated.  The most common types of neck masses that are seen in children include enlarged lymph nodes which can be quite benign and treated, usually, with a course of antibiotics or, sometimes, just with time and they’ll go away on their own.  If a neck mass has been there for more than a month or if it appears to be involving the skin or underlying structures, at that point we usually think about imaging studies to get a better diagnosis. 


Dr. Linda Austin:  Well, let’s start with the most simple and benign reason for a lump in the neck which, surely, would be a swollen lymph node.  First of all, is there a characteristic place in the neck where you find those?


Dr. David White:  We typically see those underneath the, kind of, angle of the jaw which is kind of up in the corner of the neck, below and in front of the ear.  Those masses tend to be non-tender.  Sometimes they do get a little bit tender if it’s during a cold or other type of infection but, generally speaking, they aren’t too bothersome and they usually last for less than a few weeks.  If it lasts for more than a week or two, we typically recommend that it be evaluated by a physician.


Dr. Linda Austin:  How large can those lumps get to be?


Dr. David White:  They can get to be quite large, up to about 3 cm in size, and there can be more than one of them.  They can be in kind of a chain up and down the neck.


Dr. Linda Austin:  So, that’s really golf ball size then, right?


Dr. David White:  Just about.  They can get even that large.  Typically, they’re quite a bit smaller than that, which would be about a centimeter in size, kind of like the size of, maybe, a shooter marble.


Dr. Linda Austin:  And there often associated with some sort of infection or cold, or something, is that right?


Dr. David White:  That’s right.


Dr. Linda Austin:  They don’t hurt and they kind of come and go and there’s not much there.


Dr. David White:  That’s right.  Usually, they’re associated with an upper respiratory infection of some kind, probably, most commonly, a sore throat, pharyngitis type of picture.  They can also be associated with sinusitis or just a common cold.


Dr. Linda Austin:  So, how about the sorts of lumps or masses that you find more concerning, what are some of the characteristics of those?


Dr. David White:  So, any lump or mass that has been there for more than a month, I would be concerned about, even if it is consistent with a lymph node.  At that point, the fact that it has not improved after that amount of time suggests that intervention is required.  Now, initially, this usually would require treatment with antibiotics, which would be taken by mouth for a period of time.  If there was not improvement with antibiotics then a biopsy, oftentimes, would be suggested.  The reason for this is that even masses that are consistent with enlarged lymph nodes can be a sign of other things going on, such as a lymphoma.


Other types of neck masses that you can see in the neck, which might be there for a longer period of time, would be various types of cysts, most of which are things that children are born with and that appear at various points throughout childhood.  This can include a thing such as thyroglossal duct cyst which comes from a little leftover tract from the thyroid gland, when it descends from the back of the tongue down into the neck.  This is usually seen in the middle of the neck, so kind of in the midline.  If cysts are seen off of the midline, there can be certain types, called branchial cleft cysts, which are remnants from the little gill apparatuses that are present in the embryo and then gradually resolve during development.  Sometimes there’s a little bit of leftover epithelium, or lining, there that can then cause a cyst. 


Finally, another relatively common type of neck mass that we see is broadly classified as different kinds of vascular malformations.  These, again, are things that children are born with and include things such as hemangiomas, lymphatic malformations.  These are treated in various ways, including treatment with steroids, surgery and something called sclerotherapy, where the contents of a cyst is aspirated, or removed, and then a substance is injected into the cyst which can cause it to scar closed and disappear in that way.


Dr. Linda Austin:  So, it sounds as if the cysts, really, even though they may need treatment, are fairly readily treated, is that right, and are not worrisome long-term?


Dr. David White:  That’s true.  The cysts, by and large, are benign problems.  The main risk of leaving a cyst untreated is that it can become recurrently infected.  When this happens, it’s very difficult to clear it completely of infection, so it tends to lead to problems where infections occur multiple times per year and sometimes even more frequently than that.  The more these things get infected, the more scarred they become and the more obvious they become on sort of cosmetic evaluation, and also the more difficult they become to treat with an operation. 


So, certainly, when we see cysts of any kind, the first mode of treatment is to think about surgical resection.  There are occasions where parents will choose to observe these cysts for awhile.  Certainly, once there’s a sign of any infection in the cyst, typically, suggests strongly that it be removed.


Dr. Linda Austin:  Now, we skipped over lymphoma pretty quickly and I know that’s every parents concern, could it be something more serious, so let’s pause and talk a little bit about a lymphoma, just what is that?


Dr. David White:  A lymphoma is a cancer of the type of cells that compose a lymph node.  It’s one of two or three types of childhood cancers that are seen in the head and neck.  All of these have a relatively standard presentation in that they present with an enlarging neck mass.  A lot of times there are signs of fever, low-grade fever, and loss of appetite that don’t get better with time.


Dr. Linda Austin:  And they grow over what period of time?


Dr. David White:  They usually grow over the course of weeks to months.  It can be more accelerated in the case of more aggressive tumors.  Any time that a mass is felt in the neck and it’s been there for more than several weeks, we recommend working it up further to make sure that it’s not cancerous.  When cysts are seen in the neck, they’re typically benign.  So, the more solid masses, such as an enlarged lymph node, if it’s something that has not gotten better with time, we would be more interested in biopsy and evaluating more closely to make sure it’s not a type of cancer. 


Dr. Linda Austin:  Let’s talk more about lymphomas in another podcast.  But before we end with this topic, you mentioned, briefly, that in the evaluation you do imaging, what kind of imaging do you order?


Dr. David White:  The type of imaging that we use to evaluate neck masses would start, usually, with an ultrasound.  That’s something that is done in the clinic during a clinic visit, usually during the first clinic visit.  That would help us to establish whether or not it is a solid mass or a cyst.  Once we establish that, we, depending on the problems that the child is having, would consider other types of imaging, such as a CAT scan or an MRI.  The CAT scan and MRI help differentiate between other types of neck masses. 


Dr. Linda Austin:  Thank you very much.


Dr. David White:  Thank you.


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