2015 HSC Section 1 Book of Articles

Neck Masses

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence rating References Comments

Clinical recommendation

When indicated, ultrasonography is the preferred initial imaging study for most children with a neck mass. Empiric antibiotic therapy with observation for four weeks is acceptable for children with presumed reactive lymphadenopathy. C Excision of presumed congenital neck masses in children is recommended to confirm the diagnosis and to prevent future problems. C In children, enlarged lymph nodes that are rubbery, firm, immobile, or that persist for longer than six weeks or that enlarge during a course of antibiotics should be considered for biopsy. C C

12

Based on expert opinion

11

Based on a consensus- based practice guideline Based on observational studies From a consensus guideline based on observational studies

1

19, 20

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

count with differential may be abnormal with infectious lymphadenitis. A complete blood count with differential is recommended in patients with a history and physi- cal examination suggestive of infection or malignancy; however, good evidence to support the value of routine complete blood count is lacking. Atypical lymphocyto- sis can occur in mononucleosis, and pancytopenia with blast cells suggests leukemia. 11 If there was recent expo- sure to cats, measurement of Bartonella henselae titers to evaluate for cat-scratch disease should be considered. Measurement of titers for Epstein-Barr virus, cytomega- lovirus, human immunodeficiency virus, and toxoplas- mosis also should be considered if the history suggests possible exposure or if a presumed inflammatory mass is not responding to antibiotics. Imaging may help with diagnosis and with planning for invasive intervention. The American College of Radi- ology considers ultrasonography, computed tomogra- phy with intravenous contrast media, and magnetic resonance imaging with or without intravenous con- trast media appropriate imaging studies for a child up to 14 years of age presenting with a neck mass. 12 Ultrasonog- raphy is the preferred initial imaging study in an afebrile child with a neck mass or a febrile child with a palpa- ble neck mass. 12 Ultrasonography is a relatively quick, inexpensive imaging modality that avoids radiation and helps define the size, consistency (solid vs. cystic), shape, vascularity, and location of the mass. Malignancy is more likely with an abnormally shaped lymph node compared with a lymph node that retains its normal architecture. If fine-needle aspiration is warranted for deep neck masses, ultrasonographic guidance can help. Ultrasonography should be performed when a thyro- glossal duct cyst is suspected to determine the presence

of a normal thyroid gland. Ultrasonography also should be the initial imaging study for the evaluation of a thy- roid mass. Computed tomography with intravenous contrast media is the preferred study for evaluating a malignancy or a suspected retropharyngeal or deep neck abscess that may require surgical drainage. 12 Computed tomography with contrast media should not be ordered for a thyroid mass; uptake of contrast media by thyroid tissue could delay subsequent radioactive iodine treatment if needed. Magnetic resonance imaging better defines soft tissue anatomy 13 and avoids the radiation exposure from com- puted tomography. However, the expense and frequent need for sedation often limit magnetic resonance imag- ing as the initial imaging study of choice. Magnetic res- onance imaging is the imaging study of choice when a vascular malformation is suspected. Fine-needle aspiration may provide critical diagnostic information and avoid the need for open biopsy. Sensitiv- ity of fine-needle aspiration in children is usually greater than 90% 14-16 and specificity is approximately 85%. 16 However, in one series, 76% of the children required general anesthesia; a cytopathologist who has experience with neck lesions in children is essential. 16 Occasionally, fine-needle aspiration does not provide sufficient tissue or adequate evaluation of lymph node architecture, and an open biopsy is needed to determine the diagnosis. Initial Treatment and Referral Little evidence exists to definitively determine the best approach for the child with a neck mass. Current sug- gested algorithms are based on expert opinion. 17 Obser- vation is recommended initially in children with cervical lymphadenitis that is bilateral, whose lymph nodes are

American Family Physician

www.aafp.org/afp

Volume 89, Number 5 ◆

March 1, 2014

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