The emergency physician is often called upon to evaluate an infant or child with a neck mass. Most of these neck masses are benign and result from reactive lymph nodes caused by viral infections.¹ Forty-one percent of infants will have a palpable cervical node in the first year of life.² Occasionally, a patient can present with a significant neck mass of unknown etiology. The challenge is to distinguish between the pathologic lesions that need expeditious management and those neck conditions that are benign but still cause a lot of parental anxiety. Presence or absence of respiratory involvement as well as location of the lesion can help direct the clinician’s evaluation (Fig. 11-1).

Inflammatory lymphadenopathy is the most common neck mass in children with a reported prevalence of 28% to 55% in otherwise normal infants and children.³ Congenital neck lesions include hemangiomas, which are the most common; thyroglossal duct cysts, which account for 70% of midline neck masses;^4,5 and branchial cleft sinuses or cysts, which occur in the anterior triangle of the lateral neck.^6,7

The neck can be divided into two compartments or triangles (Fig. 11-2). The anterior triangle is formed by the mandible, sternocleidomastoid muscle, clavicle, and the line running from the mental symphysis to the suprasternal notch. Vital structures located in this compartment include the larynx, trachea, esophagus, the thyroid and parathyroid glands, the carotid sheath, and the suprahyoid and infrahyoid muscles. Several lymph node chains are found in this area, including the jugulodigastric chain that lies anterior to the sternocleidomastoid muscle.⁸ The posterior triangle is defined inferiorly by the clavicle, laterally by the trapezius, and medially by the sternocleidomastoid muscle. Structures found in this area include the subclavian vessels, cervical roots of the brachial plexus, spinal accessory nerve, and also several lymph node chains.

It is important to have an understanding of the lymphatic drainage (Fig. 11-3) because this assists the clinician in locating the primary infection. The posterior part of the tongue, the tonsils, sinuses, nasopharynx, larynx, and pharyngeal regions drain into the superficial and deep anterior cervical lymph nodes. The anterior scalp, ear canal, pinna, and the conjunctiva drain into the preauricular lymph nodes; the temporal and parietal scalp regions drain into the postauricular nodes and the posterior scalp region drains into the occipital nodes. Thus, scalp infections such as tinea capitis or folliculitis can cause occipital lymphadenopathy. Conjunctivitis can cause enlargement of the preauricular lymph nodes and when seen together is called the “oculoglandular syndrome.” Infections of the cheek, anterior part of the nose, tongue, and buccal mucosa drain into the submandibular nodes. The right supraclavicular lymph nodes communicate with the lymphatics of the mediastinum, while the left side communicates with the thoracic duct.⁹

The cervical fascia planes can provide some degree of barrier to the spread of deep neck infections. The planes can generally be divided into three areas based on their relation to the hyoid.¹⁰ The peritonsillar, submandibular, and parapharyngeal spaces are above the hyoid, pretracheal space below, and the retropharyngeal and prevertebral spaces involve the entire neck.

Neck masses can be divided into four groups: inflammatory, congenital, neoplastic, and traumatic (Table 11-1).

Determining airway involvement should be the first issue addressed in a child presenting with a neck mass (Table 11-2). Children with stridor or hoarseness that mimic a pharyngeal or tracheal condition such as croup or bacterial tracheitis may require emergent airway provision. These children should be allowed to sit in a position of comfort and not forced to lie down as this may result in airway occlusion from a retropharyngeal or mediastinal mass compressing the trachea. Warm, humidified oxygen should be administered. Bronchodilators typically provide little or no relief since the problem is due to external compression of the upper airway. Endotracheal intubation may be considered for those with significant respiratory distress or signs of impending respiratory failure. Extreme care must be taken, as complete obstruction of the airway, making intubation exceedingly difficult, can occur after loss of airway tone with rapid sequence induction. Fiberoptic guidance may be useful, but in any case the clinician needs to be prepared to perform emergent cricothyrotomy or tracheostomy. If immediately available, consider emergent consultation with a subspecialist possessing advanced airway skills and experience.