Paediatric neck lumps (diagnosis and management)

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Objectives

Clear guidance for the assessment, diagnosis and management of paediatric neck lumps presenting to the Emergency Department. 

Scope

Children with neck lumps.

Audience

Clinicians working in the Emergency Department.

Neck lumps are a common presentation to the Emergency Department. The differential is wide and includes inflammatory, congenital and neoplastic lesions. Establishing chronicity and the presence of infection is central to establishing the diagnosis. 80-90% of lesions represent benign conditions and the prevalence of palpable cervical lymphadenopathy occurs in 28-55% of normal children. Lymphoma is the most common neoplastic mass found. Detailed history and examination will facilitate preliminary diagnosis and guide further investigation, management and referral. 

 

1) Relevant factors in History
  • Duration
  • Rapidity of change
  • Associated pyrexia
  • Previous similar episodes
  • Recent infection
  • Trauma
  • Immunisations
  • Exposure to TB including recent travel
  • Exposure to cats
  • HIV risk factors
2) Examination

Focused

  • Size
  • Texture
  • Location
  • Fixation
  • Tender
  • Skin changes
  • Unilateral or bilateral
  • Single or multiple

General

  • Appearance
  • Systemic examination
  • Rash
  • Organomegaly
  • Lymphadenopathy
  • Respiratory Symptoms
  • Stridor
  • Dysphagia/Drooling
  • Torticollis
3) Red Flags should prompt you to seek senior help and/or refer to ENT at the time of presentation
  • Sepsis
  • Unwell Child
  • Poor feeding /Dysphagia
  • Stridor / Airway compromise
  • Change in voice quality
  • Rapid progression
4) Differential Diagnosis of Neck Lumps

Inflammatory masses

  • Reactive lymphadenopathy
    - (Bacterial, Viral, Granulomatous, Mycobacterial, Histoplasmosis)
  • Abscess
  • EBV – see EBV guideline
  • Sarcoidosis
  • Cat scratch disease

Congenital masses

  • Thyroglossal duct cyst
  • Branchial cleft cyst/sinus
  • Vascular anomalies
  • Dermoid cyst
  • Bronchogenic cyst
  • Teratoma

Neoplastic masses

  • Benign 
     - (lipoma, fibroma, neurofibroma, thyroid nodule)
  • Malignant 
     - (Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, rhabdomyosarcoma, neuroblastoma, thyroid carcinoma, metastatic disease)
  • Factors associated with an increased risk of malignancy are: 
     - Persistent lymphadenopathy 
     - Single dominant nodes >6 wks 
     - Supraclavicular / posterior triangle nodes are associated with an increased risk of malignancy.
5) Management of Inflammatory Masses

These patients will have a painful, tender often red swelling.

Abscess 

  • is likely to be a fluctuant collection
  • Contact ENT SHO to arrange review. If 9-5pm Monday –Friday arrange an US.
  • If systemically unwell treat early for infection with IV fluids and antibiotics. 

Antibiotics – As per GG&C Protocol.

  • IV First line – Benzyl Penicillin + Flucloxacillin
  • Oral – Penicillin V + Flucloxacillin
  • If penicillin allergic – Erythromycin

Non fluctuant swelling / Lymphadenitis

If the patient is well, observations within normal limits and there are no red flag features, treat with oral antibiotics and return to the Emergency ENT clinic, with instructions to return if there is a change in condition or concern.
If the patient is unwell contact ENT and arrange imaging and IV antibiotics

Cervical Adenopathy 

If the neck lump is the presenting complaint rather than a coincidental finding then advise parents to arrange follow up with GP. Treat source if indicated. 
Document size, consistency and location and ensure follow up documented on discharge.

6) Management of Non Inflammatory Masses

The type of swelling can often be determined by its location. Chronic neck swellings in the absence of red flag features can be referred to a routine ENT clinic. Refer patients for an outpatient US scan.

Midline Cystic 

Ectopic Thyroid 
Dermoid 
Thryoglossal duct Cyst

Lateral

Posterior to Sternocleidomastoid muscle (SCM) 
Dermoid/Teratoma

Anterior to SCM 
Unilocular 
Laryngocele 
Branchial cyst 
Pre-auricular sinus / cyst
Multilocular Cystic Hygroma

Vascular

Haemangioma 
Vascular malformation

Malignancy suspected

FBC and film 
+/- Imaging 
Refer at the time of presentation to the appropriate specialty.

7) Imaging of Neck Lumps

US is the first line and further imaging will be guided by ENT / Radiology. Attempt to arrange an US scan during attendance if 9 -5pm Monday to Friday. If out with this time, request an outpatient US on Trak.

8) ENT follow-up

The ED secretaries will arrange this using the ED notes, a referral letter is not required. Record on the front of the card that an ENT Out-patient clinic appointment is required and the time scale eg Emergency ENT clinic this week, appointment within 2-3 weeks. An appointment will be sent out to the family

Editorial Information

Last reviewed: 01 December 2014

Next review: 13 December 2016

Author(s): Fiona Russell, David Lowe

Approved By: Clinical Effectiveness