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Neck Masses

Neck masses. The first group is in newborns and the first one is lymphangioma, also called cystic hygroma. Patterns for these are that they are soft, diffuse, painless, non-erythematous. They transilluminate extremely well. Often found in the posterior triangle but can be anterior as well. Really serious problems. These do not regress.

Hemangiomas. A pattern here is that they are also soft. They often have some color though to them, unlike the lymphangioma or cystic hygroma. They may have a dusty blue or reddish color to them and you may have an associated surface hemangioma in about 50% of the time. The course that you will see with these is that is that you will get rapid growth for the first six months.

Thyroglossal duct cysts. The pattern here is a painless midline, and the key is midline mass that usually is between the hyoid and the thyroid. Skin overlying is normal. It moves with swallowing. These things can get infected so you may have erythema and some tenderness, but oftentimes it is just a painless midline mass that a family member notices.

Sternocleidomastoid tumor or torticollis. Pathogenesis is secondary to birth trauma. You will get hematoma within the body of the sternocleidomastoid muscle so you’ll get this mass in the sternocleidomastoid muscle. Important to pick up because that hematoma will fibrose and as it fibroses will shorten the sternocleidomastoid muscle.

Tuberculosis: two types of tuberculosis that you’ll see, MTB in which you will generally have pulmonary involvement and then in addition to the pulmonary involvement can have often bilateral cervical adenopathy.

Cat scratch disease: this is an interesting one. This is one that again pattern recognition is key. It’s usually a subacute or chronic problem. So this isn’t going to be something where somebody develops a node over a day or two, like you might see with other bacteria. Usually it is fairly warm, red and tender and even though cat scratch disease is sometimes called "cat scratch fever" only about 30% of kids will actually be febrile. The key thing to this diagnosis is looking for a papule or vesicle, sometimes a granulomatous appearance, at the inoculation site where the child got scratched. 

Some of the patterns that you may see in addition to cervical adenopathy are things like epitrochlear or axillary lymphadenopathy where the child gets scratched on the extremity, you get a little papule there and then a large regional lymph node. One syndrome which I did not write down in your syllabus which I think is worth mentioning - I’m not sure it comes up anywhere else in our course - is something called Parinaud’s ocular glandular syndrome, and that’s where you get a primary inoculation.

Mononucleosis. The pattern here is usually older kids, although it can be seen in younger kids. What you are looking for is evidence of generalized lymphadenopathy. So you have these whopping cervical lymph nodes. If you have somebody with whopping cervical lymph nodes it’s absolutely critical that you feel the axillary nodes, feel the inguinal nodes and also check for hepatosplenomegaly. And you expect to see those things with mono. Also we will see an exudative pharyngitis often and malaise. If you give them ampicillin as well you may very likely develop a very impressive rash. Diagnosis for mono is Monospot.

Neoplastic: a bunch of different causes. Hodgkin's, leukemia, lymphoma, etc. Pattern here is firm, non-tender, non-erythematous cold fixed nodes. Locations: things like supraclavicular is particularly worrisome, may have associated symptoms like fever, night sweats, weight loss, pallor, bleeding, hepatosplenomegaly.

Kawasaki’s: Classical pattern consists of cervical lymphadenopathy, conjunctivitis, rash and mucus membrane inflammation.

Differential diagnosis for cervical masses: we already talked about the thyroglossal ductus, which is going to be midline. Branchial cleft cysts, which may be lateral, may become infected and you may see a sinus track. To if you are seeing kind of a swelling of one of the sides of the neck and you don’t get the sense that it’s a swollen lymph node, look carefully at the skin.

Stridor. In newborns, laryngomalacia is probably the most common cause of stridor in newborns. Key to this diagnosis is that it improves when the child is prone. Lay the child on their back, they are going to have much more stridor, lay them on their stomach and they are going to seem better. Also tends to worsen when a child is agitated.

Foreign body aspiration: peak incidence is younger ages, six months to four years and clinical manifestation is sudden onset - and that’s key - sudden onset of coughing, gagging, choking, dyspnea, afebrile. And also an object that was previously visible is no longer visible. It’s very suggestive. If it is extrathoracic you are likely to hear stridor and a croupy cough. If it has gone down intrathoracic you are going to see more cough and wheezing. Diagnosis: extrathoracic, x-rays are helpful if it is radiopaque.

Management of these: extrathoracic; if you have partial obstruction don’t try to dislodge it because it may lead to complete obstruction and you want to arrange for emergency bronchoscopy. Intrathoracic, you just need to arrange for bronchoscopy.

Okay, our last section is on hearing loss. Two major forms that we’ll have is conductive hearing loss and then sensorineural hearing loss, but you also can see mixed forms as well. Conductive loss is caused by interference with transmission of sound.

Conductive hearing loss: can be either acquired or inherited. Acquired is much more common. Tends to be transient and is often mild to moderate hearing loss. Most often due to things like earwax or sometimes middle ear effusion. If you see more significant loss or a more chronic loss, it’s generally caused by damage to the tympanic membrane and/or the ossicles. So things like chronic perforation, which we mentioned before, cholesteatoma, otosclerosis, or more seriously ossicular chain disruptions, will lead to serious conductive hearing losses. Some inherited forms that are worth mentioning: they generally present.

Sensorineural hearing losses can be acquired or inherited. The acquired ones may be infectious so TORCH infections in newborns, particularly Rubella, can cause sensorineural hearing loss. Bacterial meningitis, especially H. flu can cause hearing loss. And then medications, aminoglycosides, diuretics are two of the most notorious but there are others as well. And then generally not a problem in kids but maybe later on, certainly for "baby-boomers", is a problem of acoustic trauma from listening.