Solid Neck Mass in A Child

Solid Neck Mass in A Child
Bernadette L. Koch, MD
DIFFERENTIAL DIAGNOSIS
Common
  • Reactive Lymph Nodes
  • Hodgkin Lymphoma, Lymph Nodes
  • Infantile Hemangioma
  • Neurofibromatosis Type 1
  • Non-Hodgkin Lymphoma, Lymph Nodes
Less Common
  • Lipoma
  • Metastatic Neuroblastoma
  • Differentiated Thyroid Carcinoma, Nodal
Rare but Important
  • Pilomatrixoma
  • Primary Cervical Neuroblastoma
  • SCCa, Nodes
  • Rhabdomyosarcoma
  • Cervical Thymus
ESSENTIAL INFORMATION
Helpful Clues for Common Diagnoses
  • Reactive Lymph Nodes
    • Key facts
      • “Reactive” implies benign etiology
      • Acute or chronic; any H&N nodal group
      • Response to infection/inflammation
    • Imaging
      • Enlarged oval-shaped lymph nodes
      • ± enlargement of lingual, faucial, or adenoidal hypertrophy
      • ± stranding of adjacent fat (cellulitis)
      • ± edema in adjacent muscles (myositis)
      • ± suppurative nodes or abscess
      • Variable enhancement, usually mild
  • Hodgkin Lymphoma, Lymph Nodes
    • Key facts
      • B-cell origin; histology shows Reed-Sternberg cells
      • Cervical & mediastinal nodes common
      • Waldeyer ring or extranodal < 1%
      • Tumors EBV positive in up to 50%
    • Imaging
      • Cannot distinguish Hodgkin from non-Hodgkin lymphoma
      • Homogeneous lobulated nodal masses
      • Single or multiple nodal chain
      • Variable contrast enhancement
      • Necrotic center may be present
  • Infantile Hemangioma
    • Key facts
      • True vascular neoplasm
      • Usually not present at birth; typically presents in 1st few months of life
      • Rapid growth and spontaneous involution typical
    • Imaging
      • Solid, avidly enhancing mass
      • Intralesional high-flow vessels
      • Fatty infiltration during involution
      • PHACES syndrome: Posterior fossa abnormalities, hemangiomas, arterial abnormalities, cardiovascular defects, eye abnormalities, sternal clefts
  • Neurofibromatosis Type 1
    • Key facts
      • Carotid space, perivertebral space (brachial plexus) common
      • Localized, diffuse, or plexiform
      • Single or multiple
    • Imaging
      • Localized: Well-circumscribed, smooth, solid masses with variable enhancement
      • Diffuse: Plaque-like thickening of skin with poorly defined linear branching lesion in subcutaneous fat
      • Plexiform: Lobulated, tortuous, rope-like expansion in major nerve distribution; “tangle of worms” appearance
  • Non-Hodgkin Lymphoma, Lymph Nodes
    • Key facts
      • All nodal chains involved
      • 30% extranodal: Lymphatic (palatine or lingual tonsil and adenoids) or extralymphatic (paranasal sinuses, skull base, and thyroid)
    • Imaging
      • Cannot distinguish non-Hodgkin from Hodgkin lymphoma
      • Single dominant node or multiple nonnecrotic enlarged nodes
Helpful Clues for Less Common Diagnoses
  • Lipoma
    • Key facts: Any space, may be trans-spatial
    • Imaging
      • Homogeneous fat density (CT) or signal (MR) without significant enhancement
      • If enhancement, suspect liposarcoma
  • Metastatic Neuroblastoma
    • Key facts
      • Most cervical disease is metastatic
    • Imaging
      • Large lymph nodes, rarely necrotic
      • Bilateral skull base metastasis common
      • Enhancing masses with aggressive osseous erosion and intracranial/intraorbital extension
  • Differentiated Thyroid Carcinoma, Nodal
    • Key facts
      • Nodal spread common in papillary, distant spread common in follicular
      • 3x more common in women
      • Usually 3rd & 4th decade, occasionally in adolescents, rare in young children
    • Imaging
      • Variable: Small to large, “reactive” in appearance or heterogeneous, hemorrhagic, or cystic necrosis
      • Focal calcifications and solid foci of enhancement may be present
Helpful Clues for Rare Diagnoses
Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Solid Neck Mass in A Child

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