Download Pediatric Neck Masses

Pediatric Neck Masses
A N D R EW R . S I M O N S E N , D.O.
P E D I ATRI C OTO L A RYN GO LOGY
JAC KS O N V I LL E, F L
Pediatric neck masses
Unlike adults most are benign
1 in 10 of all pediatric neck masses after excision are malignant.
29% of biopsied benign appearing neck masses are malignant.
◦ Torsiglieri AJ Jr, Tom LW, Ross AJ 3rd, et al. Pediatric neck masses: guidelines for evaluation. Int J Pediatr Otorhinolaryngol 1988;16(3):199–210
Objectives
1.
Systematic approach
◦ Inflammatory, congenital, neoplastic
2.
Appropriate and cost effective studies
3.
Rule out malignancy
4.
Diagnosis 5.
Timely resolution
H&P
Lymph node
H&P
Neck mass
Abscess
Congenital
History
Age of onset
Duration of signs and symptoms
Pain Change in size
◦ Rate of change
Involvement of other organ systems
◦ Recent H&N infections ◦ Fatigue, weight loss, fever, night sweats Environmental exposures
◦ Cats, nondomestic animals, insects, travel, humans with TB
Prior treatment
Physical
Complete H&N exam
◦ Begin away from mass
◦ Scalp
Full body exam
◦ Primary inoculation site
◦ Adenopathy
◦ Skin lesions
◦ Hemangiomas, café au lait spots
◦ Liver, spleen
Physical Location of the mass
◦ May M. Neck masses in children: diagnosis and treatment. Pediatr Ann 5:8, 1976.
Palpation of the mass
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Tender
Cystic
Lymph node Enlarges with straining
Draining fistula
Diagnostic studies
Labs
Radiologic
FNA
Prenatal
Congenital
TGDC
Imaging
Dermoid
Congenital
Branchial anomaly
Vascular malformation
Congenital ‐‐ midline
Thyroglossal duct cyst
◦ May present after birth with infection
◦ Moves superiorly with swallowing or protrusion of the tongue
◦ Ultrasound of mass and thyroid
◦ Excision ‐ Sistrunk
Dermoid
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Present at birth
Moves independently with skin
Doughy
Epidermal and dermal components
Neck is second most common site
◦ Pryor SG. Pediatric dermoid cysts of the head and neck. Otolaryngol Head Neck Surg 2005;132:938‐42
◦ 18% on the neck
◦ No imaging was necessary
◦ Ultrasound
◦ Simple excision
Congenital ‐‐ branchial
Branchial cleft cysts
◦ First
◦ Work types I and II1
◦ Second
◦ Third/fourth
Studies
◦ CT/MRI
Treatment
◦ Excision
1WORK W. NEWER CONCEPTS OF FIRST BRANCHIAL CLEFT DEFECTS. LARYNGOSCOPE 1972;82:1581‐93
First branchial arch
ADAPTED FROM: BLUESTONE, SURGICAL ATLAS OF PEDIATRIC OTOLARYNGOLOGY 2002, DC DECKER
Second branchial arch
ADAPTED FROM: BLUESTONE, SURGICAL ATLAS OF PEDIATRIC OTOLARYNGOLOGY 2002, DC DECKER
Figure 2 (A) Artist rendition of excision of second BA cyst with sinus tract extending into the
pharynx above the carotid bifurcation.
Schroeder J W et al. Otolaryngology -- Head and Neck
Surgery 2007;137:289-295
Copyright © by American Academy of Otolaryngology- Head and Neck Surgery
Second branchial arch cyst
PHOTOS COURTESY OF AIYSHA BALBOSA, D.O. DRISCOLL CHILDREN'S HOSPITAL, CORPUS CHRISTI, TX
Third branchial arch
ADAPTED FROM: BLUESTONE, SURGICAL ATLAS OF PEDIATRIC OTOLARYNGOLOGY 2002, DC DECKER
Figure 2 Theoretical pathway of a third branchial arch fistula.
Nicoucar K et al. Otolaryngology -- Head and Neck Surgery
2010;142:21-28
Copyright © by American Academy of Otolaryngology- Head and Neck Surgery
Fourth branchial arch
ADAPTED FROM: BLUESTONE, SURGICAL ATLAS OF PEDIATRIC OTOLARYNGOLOGY 2002, DC DECKER
Fourth branchial arch
Congenital ‐ Vascular
Lymphatic malformations
◦ Perkins JA. Lymphatic malformations: Review of current treatment. Otolaryngol Head Neck Surg 2010;142:795‐803.
◦ Imaging
◦ CT/MRI
◦ Staging ◦ de Serres LM. Lymphatic malformations of the head and neck. A proposal for staging. Arch Otolaryngol Head Neck Surg 1995;121:577‐82.
◦ Macro v microcystic
◦ Sclerotherapy v excision
Perkins J A et al. Otolaryngology -- Head and Neck Surgery
2010;142:795-803.e1
Copyright © by American Academy of Otolaryngology- Head and Neck Surgery
3 year old Female
Right neck mass Presented after diagnosed with ear infection by pediatrician
Unchanged >3 months
Asymptomatic
Branchial cyst? Lymphatic malformation?
Plan for the worst
Lymphatic malformation
Lymphatic malformation
Congenital ‐ Vascular
Hemangiomas
◦ Complete resolution
◦ 50% by 5 years
◦ 70% by 7 years ◦ Propranolol
◦ Leaute‐Labreze C, Dumas de la Roque E, Hubiche T, et al. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358:2649‐2651.
◦ Cushing SL. Initial experience with a multidisciplinary strategy for initiation of propranolol therapy for infantile Hemangiomas. Otolaryngol Head Neck Surg 2011;144:78‐
84.
Hemangioma
Lymphadenopathy
Infectious
???
Inflammatory
Lymphadenopathy
Non‐infectious
Neoplastic
Lymphadenopathy (>2 cm)
90% of children 4‐8 yrs will have cervical adenopathy
◦ Park YW. Evaluation of neck masses in children. Am Family Physician 1995;51:1904‐1912
Infection v Cancer?
When to biopsy?
FNA v Excisional biopsy?
Infectious
Viral (most common)
◦ Nonspecific (URI)
◦ Epstein‐Barr virus
◦ HIV
Bacterial
◦ AOM, pharyngitis, odontogenic, sinusitis, cat scratch, mycobacteruim
◦ Timothy T. The rising incidence of methicillin‐resistant Staphylococcus aureus in pediatric neck abscesses. Otolaryngol Head Neck Surg. 137; 2007
◦ 245 patients, Dallas TX
◦ MRSA 27%
◦ MSSA 23%
◦ Group A Strep 20%
◦ B. henselae 2%
◦ Mycobacterium <1%
Non‐infectious
◦ Kawasaki disease
◦ 19/100,000 children in US
◦ Fever >5 days
◦ Cervical lymphadenopathy
◦ Edema/erythema palms/soles
◦ B/L conjunctivitis
◦ Strawberry tongue
◦ Kikuchi‐Fujimoto disease
◦ Rosai‐Dorfman
◦ Langerhans cell histiocytosis
JONATHAN D.K. TRAGER, M.D. KAWASAKI'S DISEASE. N ENGL J MED 1995; 333:1391
Neoplastic
Lymphoma (most common in children)
Rhabdomyosarcoma (second most common in children)
Thyroid carcinoma (third most common), (adolescent girls)
Salivary gland (uncommon)
Neurogenic sarcoma, NPC, neuroblastoma
Lymphadenopathy – Clinical approach
Acute < 2 weeks
◦ Broad spectrum antibiotic – 2 week course
Subacute 2‐6 weeks
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CBC
PPD
CXR
EBV
Bartonella
? Toxoplasma, HIV, Syphilis, LDH (lymphoma), urine VMA (neuroblastoma)
? Biopsy
Chronic > 6 weeks
◦ Biopsy
Lymphadenopathy ‐‐ Clinical approach
Biopsy
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Supraclavicular node
2‐6 weeks, > 3 cm, no response to abx, 2‐6 weeks with risk factors for malignancy
> 6 weeks
FNA?
◦ Excisional bx is gold standard
◦ Chau et al. Rapid access multidisciplinary lymph node clinic: analysis of 550 patients. Br J Cancer 2003;10:354‐61.
◦ 289 lymph node FNAs
◦ 97% specificity, 49% sensitivity, 45% false negative rate
◦ 83% of false negatives were lymphomas
Atypical mycobacterium
M. avium‐intracellulare, M. haemophilum (90%)
Submandibular (50%), cervical (25%), preauricular (10%)
PPD + (85%)
Observation +/‐ abx
◦ 6 months (71%)
◦ 9 months (98%)
◦ 12 months (100%)1
Surgical excision or curettage
1ZAHARIA A. MANAGEMENT OF NONTUBERCULOUS MYCOBACTERIA‐INDUCED CERVICAL LYMPHADENITIS WITH OBSERVATION ALONE. PEDIATR INFECT DIS J
2008;27:920‐2
Cat scratch disease
Bartonella Henselae
C. Felis (cat fleas)
Primary inoculation lesion
Serology
Self limited, 6‐12 weeks
Doxycycline, erythromycin
◦ Immunocompromised patient
Surgery rarely indicated
◦ Biopsy often negative