Abstract
This chapter covers common neck masses and infections of the soft tissues of the neck.
Keywords
neck infections, neck masses
1
A 4-year-old boy presents to urgent care for a lump on his neck. He has been well besides upper respiratory infection (URI) symptoms 2 weeks ago, with no fever, weight loss, trouble breathing, or change in activity level or behavior. He has a 2-cm palpable lymph node in the anterior cervical chain. What characteristics suggest it is benign?
Size <3 cm, no/mild erythema, no/mild tenderness, no generalized lymphadenopathy.
2
The patient’s mother is concerned the lump is cancerous. What characteristics raise concern for malignancy?
Location: supraclavicular nodes are malignant until proven otherwise. Nodes in the posterior triangle (behind or lateral to the sternocleidomastoid) are suspicious. Beware hard, irregular, firm, or rubbery nodes, or those that feel fixed to deep tissues. Fever, malaise, weight loss, or night sweats (B symptoms) raise concern for malignancy. Large nodes (initial size >3 cm) are more likely to be malignant, especially in the absence of signs of infection. Node persistence >6 weeks or increasing size during antibiotic therapy is concerning.
4
What are the most common organisms in bacterial lymphadenitis?
Staphylococcus aureus and group A streptococcus. Use cephalexin, amoxicillin-clavulanate, or clindamycin if you are starting empiric antibiotics. History should include pets (cat scratch fever), outdoor exposure (Lyme disease), and dental concerns (poor dentition or periodontal disease causing anaerobic infection). Lymphadenitis not improving with antibiotics is concerning for atypical mycobacterium.
5
A 5-year-old presents with a neck lump present for 1 week. He has had low-grade fever, fatigue, poor appetite, and malaise for 10 days. The family adopted a kitten 4 weeks ago. He has a swollen, tender, indurated, warm cervical lymph node on the right. What diagnosis do you consider?
Cat scratch disease (CSD; Bartonella henselae ). CSD is transmitted via scratch or bite of an infected cat. Many patients do not recall an initial scratch. A papule or pustule on the skin often develops 7–12 days after inoculation, followed by lymphadenopathy 1–2 weeks later. Approximately 25% of cases involve lymphadenopathy of the head or neck. Symptoms include fever, malaise, anorexia, headache, myalgia, arthralgia, arthritis, or vision changes. Diagnosis is by indirect immunofluorescent antibody (IFA) assay for serum antibodies, not culture.
6
What is the treatment for cat scratch disease?
Most cases spontaneously resolve in 4–6 weeks, although 10% of nodes will spontaneously suppurate. Avoid incision and drainage (I&D) of the node, to lessen risk of fistula. Use antibiotics (typically azithromycin) for acutely or severely ill immunocompetent patients, those with retinitis, hepatic, splenic involvement, or painful adenitis. All immunocompromised patients should be treated.
8
A 6-year-old female presents with neck swelling and tenderness. This is her third episode this year. The infections resolve completely, then recur. What should you consider?
Recurrent swelling or infection at the same location on the neck is suspicious for branchial cleft cyst or thyroglossal duct cyst. Location is the key difference. Midline: thyroglossal duct cyst. Lateral neck: branchial cleft cyst.
9
A 7-year-old febrile male patient is rushed to your urgent care with stridor, respiratory distress, and drooling. He appears toxic and anxious and nods urgently when asked about sore throat. He holds his neck hyperextended with his nose pointed up. He developed sore throat 3 hours ago but was well yesterday. What are you concerned for and what should you do?
Acute onset of sore throat and fever with rapid progression to drooling, stridor, anxiety, and maintaining the “sniffing” position is concerning for epiglottitis. Other symptoms include dysphagia, “hot potato”/muffled voice, and tenderness to palpation over the hyoid bone. Transfer to the emergency department immediately for urgent ears, nose, and throat (ENT) and anesthesia consult to arrange emergent intubation in the operating room (OR). Defer diagnostics (labs, intravenous [IV] placement, imaging) to avoid worsening respiratory distress. The classic “thumb sign” on lateral neck x-ray (severe edema of the epiglottis) has poor sensitivity and specificity. Humidified oxygen or racemic epinephrine may be used while awaiting transport. Treat with a second- or third-generation cephalosporin. Etiologies include group A strep, S. aureus, Klebsiella pneumoniae, H. parainfluenzae, and beta-hemolytic strep. H. flu type b, while less common in the post-Hib vaccination era, is still a potential cause.
11
What are the common symptoms of retropharyngeal abscess?
Fever, restricted neck movements, neck pain, and cervical lymphadenopathy. Others include drooling, trismus, torticollis, and dysphagia. Respiratory distress is rare. Of all cases, 80% occur in children under 5. Risk factors include recent URI or recent oropharyngeal trauma. Complications include sepsis, mediastinitis, airway obstruction, internal jugular vein thrombosis, and carotid artery aneurysms.
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