Neck Swellings in Children Imran Afzal

Outline of PresentationThe CaseBrief Anatomy/ EmbryologyCommon causesRarer CausesSources

The CaseI saw 8 year old girl brought by

mum to A&E at 11pm ,from friend’s home

Mum noticed midline neck swelling 1 week ago, saw GP thought was a lymph node

Friend suggested visiting A&E on eve of presentation as swelling was not settling, infact increasing in size and became red

The CasePatient was frightenedShe had a midline neck swelling

with a redness developing at the tip

She was systemically wellShe wont cooperate enough to do

tongue protrusionThere was no local lymph nodes

palpable

Neck Swellings in ChildrenNeck lumps constitute important

diagnostic categoryMalignancy less than 1%Categories: Congenital Inflammatory/

Infective Embryological knowledge

important for diagnosis and treatment( ?excision)

Branchial cleft apparatus and its derivatives

The branchial arches are ridges, visible in the cervical region of the embryo from the fourth to the eighth week of gestation

1st arch: mandible, Eustachian tube and

some bones of middle ear

2nd arch: hyoid bone and tonsillar fossa

Branchial cleft apparatus and its derivatives

Branchial derivativesThese may take the form of

cysts, sinuses, or cartilaginous remnants, possible to identify the relevant branchial arch from the anatomical position.

Strangely, usually been present since birth, branchial cysts most commonly present in adolescence

Preauricular and first branchial remnants—Small sinuses and cartilage remnants just in front of the ear are the commonest finding but are probably not of branchial origin.

Second branchial remnants—The external opening of a branchial sinus or fistula is almost always related to the anterior border of the sternomastoid

Brachial derivativesTreatment—Uninfected

derivatives should be treated by formal surgical excision, with a careful attempt made to identify any deeper components.

Thyroglossal derivatives

The thyroid gland develops from tissue originally derived from the posterior third of the tongue, which descends during fetal life to its final position anterior to the tracheal rings

Thyroglossal cysts:The key diagnostic features of these neck lumps are their midline position and movement on tongue protrusion and swallowing.

Most are intimately related to the hyoid bone, which explains their relation to the tongue and muscles of swallowing.

The Case

Thyroglossal cyst-examination and treatmentAlthough clinical examination is

often sufficient for diagnosis, some surgeons obtain a radioisotope thyroid scan before excision to ensure that a normal thyroid gland is present. Excision of the middle third of the hyoid bone in continuity with the cyst (Sistrunk's operation) should be performed to reduce the possibility of recurrence.

Cervicofacial dermoidsThe soft tissues of the face are formed

by the convergence of three facial processes (frontal, maxillary, and mandibular)

As a consequence, there are lines of fusion where islands of ectodermal tissue may become submerged, later to secrete sebaceous material and present as obvious cystic swellings known as dermoids.

Any suspicion that a dermoid may be fixed to the bone should prompt an x ray examination or even computed tomography to test this possibility. Dermoids should be treated by excision.

Cystic hygromaThese are hamartomatous, lymphatic

malformations that result in a multicystic mass which infiltrates tissue planes and has no tendency to spontaneous resolution. Over 60% are found in the neck region, but other sites of origin may include the axilla and chest wall

Treatment: surgical excision or inactivated streptococcal organism-on named patient basis from Japan

Cervical lymphadenopathy, lymphadenitis, and abscess

Characteristic features of lymphadenopathy

Found along jugular veinMostly benignRelated to respiratory and throat

infectionsHistological appearance of

reactive hyperplasia

Characteristic features of lymphadenitis

Acute tendernessPainSwellingErythema of overlying skinIf pus is formed it requires

surgical drainage

Neck SwelllingsMycobacterial lymphadenitis—If

the history of the condition is longer (perhaps over a period of weeks), less acutely tender, and responds only partially or not at all to an appropriate antibiotic then lymphadenitis due to mycobacterial organisms should be considered. In Britain the causative organism is usually an atypical mycobacterium (such as Mycobacterium avium-intracellulare).

Chronic lymphadenitis due to atypical mycobacterial infection.

Davenport M BMJ 1996;312:368-371

©1996 by British Medical Journal Publishing Group

Case resolutionPatent disucussed with ENT, BRI

asked to prescribe antibioticsNext day seen there thought was

an infected thyroglossal cystPlan is after infection settles then

surgical excision

SourcesMainly:ABC

of general surgery in children: lumps and swellings of the head and neck

M Davenport - BMJ, 1996 - bmj.com

Thanks