Solid Neck Mass in A Child
Bernadette L. Koch, MD
DIFFERENTIAL DIAGNOSIS
Common
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Reactive Lymph Nodes
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Hodgkin Lymphoma, Lymph Nodes
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Infantile Hemangioma
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Neurofibromatosis Type 1
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Non-Hodgkin Lymphoma, Lymph Nodes
Less Common
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Lipoma
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Metastatic Neuroblastoma
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Differentiated Thyroid Carcinoma, Nodal
Rare but Important
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Pilomatrixoma
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Primary Cervical Neuroblastoma
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SCCa, Nodes
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Rhabdomyosarcoma
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Cervical Thymus
ESSENTIAL INFORMATION
Helpful Clues for Common Diagnoses
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Reactive Lymph Nodes
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Key facts
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“Reactive” implies benign etiology
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Acute or chronic; any H&N nodal group
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Response to infection/inflammation
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Imaging
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Enlarged oval-shaped lymph nodes
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± enlargement of lingual, faucial, or adenoidal hypertrophy
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± stranding of adjacent fat (cellulitis)
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± edema in adjacent muscles (myositis)
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± suppurative nodes or abscess
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Variable enhancement, usually mild
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Hodgkin Lymphoma, Lymph Nodes
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Key facts
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B-cell origin; histology shows Reed-Sternberg cells
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Cervical & mediastinal nodes common
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Waldeyer ring or extranodal < 1%
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Tumors EBV positive in up to 50%
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Imaging
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Cannot distinguish Hodgkin from non-Hodgkin lymphoma
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Homogeneous lobulated nodal masses
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Single or multiple nodal chain
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Variable contrast enhancement
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Necrotic center may be present
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Infantile Hemangioma
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Key facts
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True vascular neoplasm
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Usually not present at birth; typically presents in 1st few months of life
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Rapid growth and spontaneous involution typical
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Imaging
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Solid, avidly enhancing mass
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Intralesional high-flow vessels
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Fatty infiltration during involution
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PHACES syndrome: Posterior fossa abnormalities, hemangiomas, arterial abnormalities, cardiovascular defects, eye abnormalities, sternal clefts
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Neurofibromatosis Type 1
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Key facts
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Carotid space, perivertebral space (brachial plexus) common
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Localized, diffuse, or plexiform
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Single or multiple
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Imaging
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Localized: Well-circumscribed, smooth, solid masses with variable enhancement
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Diffuse: Plaque-like thickening of skin with poorly defined linear branching lesion in subcutaneous fat
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Plexiform: Lobulated, tortuous, rope-like expansion in major nerve distribution; “tangle of worms” appearance
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Non-Hodgkin Lymphoma, Lymph Nodes
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Key facts
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All nodal chains involved
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30% extranodal: Lymphatic (palatine or lingual tonsil and adenoids) or extralymphatic (paranasal sinuses, skull base, and thyroid)
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Imaging
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Cannot distinguish non-Hodgkin from Hodgkin lymphoma
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Single dominant node or multiple nonnecrotic enlarged nodes
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Helpful Clues for Less Common Diagnoses
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Lipoma
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Key facts: Any space, may be trans-spatial
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Imaging
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Homogeneous fat density (CT) or signal (MR) without significant enhancement
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If enhancement, suspect liposarcoma
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Metastatic Neuroblastoma
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Differentiated Thyroid Carcinoma, Nodal
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Key facts
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Nodal spread common in papillary, distant spread common in follicular
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3x more common in women
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Usually 3rd & 4th decade, occasionally in adolescents, rare in young children
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Imaging
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Variable: Small to large, “reactive” in appearance or heterogeneous, hemorrhagic, or cystic necrosis
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Focal calcifications and solid foci of enhancement may be present
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Helpful Clues for Rare Diagnoses
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Pilomatrixoma
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Key facts
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Calcifying epithelioma of Malherbe
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Usually benign in children
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Imaging
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Enhancing mass in subcutaneous fat
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Variable calcification, adherent to skin
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Primary Cervical Neuroblastoma
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Key facts
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< 5% of neuroblastomas are primary cervical lesions
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Range from immature neuroblastoma to mature, benign ganglioneuroma
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Imaging
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Well-defined solid mass closely associated with carotid sheath
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Intraspinal extension rare
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Calcifications may be present
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SCCa, Nodes
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Key facts
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Unknown primary SCCa rare in children
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Nasopharyngeal carcinoma with adenopathy may occur in teenagers
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Imaging
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Enlarged, round nodes
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May be heterogeneous ± multiple confluent nodes
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Rhabdomyosarcoma
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Key facts
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Most common location in H&N is parameningeal (middle ear, paranasal sinus, nasopharynx)
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Intracranial extension in up to 55% of parameningeal lesions
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