2015 HSC Section 1 Book of Articles

Neck Masses

American Family Physician

www.aafp.org/afp

Volume 89, Number 5

◆

March 1, 2014

count with differential may be abnormal with infectious

lymphadenitis. A complete blood count with differential

is recommended in patients with a history and physi-

cal examination suggestive of infection or malignancy;

however, good evidence to support the value of routine

complete blood count is lacking. Atypical lymphocyto-

sis can occur in mononucleosis, and pancytopenia with

blast cells suggests leukemia.

If there was recent expo-

sure to cats, measurement of

Bartonella henselae

titers

to evaluate for cat-scratch disease should be considered.

Measurement of titers for Epstein-Barr virus, cytomega-

lovirus, human immunodeficiency virus, and toxoplas-

mosis also should be considered if the history suggests

possible exposure or if a presumed inflammatory mass is

not responding to antibiotics.

Imaging may help with diagnosis and with planning

for invasive intervention. The American College of Radi-

ology considers ultrasonography, computed tomogra-

phy with intravenous contrast media, and magnetic

resonance imaging with or without intravenous con-

trast media appropriate imaging studies for a child up to

14 years of age presenting with a neck mass.

Ultrasonog-

raphy is the preferred initial imaging study in an afebrile

child with a neck mass or a febrile child with a palpa-

ble neck mass.

Ultrasonography is a relatively quick,

inexpensive imaging modality that avoids radiation

and helps define the size, consistency (solid vs. cystic),

shape, vascularity, and location of the mass. Malignancy

is more likely with an abnormally shaped lymph node

compared with a lymph node that retains its normal

architecture. If fine-needle aspiration is warranted for

deep neck masses, ultrasonographic guidance can help.

Ultrasonography should be performed when a thyro-

glossal duct cyst is suspected to determine the presence

of a normal thyroid gland. Ultrasonography also should

be the initial imaging study for the evaluation of a thy-

roid mass.

Computed tomography with intravenous contrast

media is the preferred study for evaluating a malignancy

or a suspected retropharyngeal or deep neck abscess that

may require surgical drainage.

Computed tomography

with contrast media should not be ordered for a thyroid

mass; uptake of contrast media by thyroid tissue could

delay subsequent radioactive iodine treatment if needed.

Magnetic resonance imaging better defines soft tissue

anatomy

and avoids the radiation exposure from com-

puted tomography. However, the expense and frequent

need for sedation often limit magnetic resonance imag-

ing as the initial imaging study of choice. Magnetic res-

onance imaging is the imaging study of choice when a

vascular malformation is suspected.

Fine-needle aspiration may provide critical diagnostic

information and avoid the need for open biopsy. Sensitiv-

ity of fine-needle aspiration in children is usually greater

than 90%

14-16

and specificity is approximately 85%.

However, in one series, 76% of the children required

general anesthesia; a cytopathologist who has experience

with neck lesions in children is essential.

Occasionally,

fine-needle aspiration does not provide sufficient tissue

or adequate evaluation of lymph node architecture, and

an open biopsy is needed to determine the diagnosis.

Initial Treatment and Referral

Little evidence exists to definitively determine the best

approach for the child with a neck mass. Current sug-

gested algorithms are based on expert opinion.

Obser-

vation is recommended initially in children with cervical

lymphadenitis that is bilateral, whose lymph nodes are

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation

Evidence

rating References Comments

When indicated, ultrasonography is the preferred initial imaging study

for most children with a neck mass.

Based on expert opinion

Empiric antibiotic therapy with observation for four weeks is acceptable

for children with presumed reactive lymphadenopathy.

Based on a consensus-

based practice guideline

Excision of presumed congenital neck masses in children is recommended

to confirm the diagnosis and to prevent future problems.

Based on observational

studies

In children, enlarged lymph nodes that are rubbery, firm, immobile, or

that persist for longer than six weeks or that enlarge during a course

of antibiotics should be considered for biopsy.

19, 20

From a consensus

guideline based on

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.

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