Congenital Neck Masses

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Congenital neck masses are common in children but can occur in any age group. These are the most common cause of noninflammatory neck masses in the pediatric population. Classifying these into midline or lateral location helps in the workup because congenital neck masses occur in consistent anatomic sites (see eBox 19-10 online).

Midline Neck Masses

Thyroglossal duct cysts are the most common anterior midline neck masses in children. They are remnants of the descending tract of the thyroid gland from the foramen cecum at the base of the tongue to its normal position in the lower neck.

Hyoid Cancer
Figure 19-8 Photograph of 9-year-old child with midline neck mass (arrow) near the hyoid bone. Swallowing produced movement in the mass. Surgical excision with pathologic evaluation demonstrated a thyroglossal duct cyst.

Cysts or fistulas can occur anywhere along this tract and can intermittently become infected. Physical examination usually reveals a 2-cm to 4-cm mass in the anterior neck that moves with swallowing and elevates with tongue protrusion (Fig. 19-8). Treatment is surgical excision of the cyst and the tract, including the midhyoid bone, to the base of the tongue (Sistrunk procedure). There have been reports of neoplastic transformation of these cysts. Recurrence is possible.

Dermoid cysts typically develop along midline embryonic fusion planes and are composed of ectodermal and meso-dermal embryonic remnants. Their usual location in the neck is in the submental area. They are also found frequently along the dorsum of the nose. Dermoid cysts tend not to move with swallowing or elevate with tongue protrusion, unlike thyroglossal duct cysts. Treatment is surgical excision.

Ranulas are cystic lesions that are usually present in the floor of the mouth. They can become "plunging" and extend through muscle planes into the upper midneck area. Plunging ranulas are thought to occur from mucus extravasation from a blocked salivary duct. Physical examination of a plunging ranula reveals a cystic mass in the submental area with or without a cystic mass in the floor of the mouth.

Lateral Neck Masses

Branchial cleft cysts are common congenital abnormalities found in the lateral neck area and are caused by failure of obliteration of the embryonic branchial clefts during development. Abnormalities can also manifest as sinus tracts or fistulas in the skin. These can become intermittently infected, especially after URIs.

Second branchial cleft abnormalities are by far the most common. These usually manifest as masses anterior to the sternocleidomastoid muscle with or without a fistulous opening. The sinus tract passes between the external and internal carotid arteries and ends in the tonsillar fossa. Treatment is complete surgical excision of the cyst and sinus tract after control of infection with appropriate antibiotics. First branchial cleft cysts are less common and manifest as a duplication abnormality of the external auditory canal (type I) or as an infected mass near the angle of the mandible with a sinus tract passing superiorly through the parotid salivary gland (type II).

Lymphangiomas (cystic hygromas) are congenital lymphatic masses often found in the neck. They usually manifest during the first year of life and often enlarge after a URI. They can also increase in size after hemorrhage into the cystic cavities. Lymphangiomas form from a failure of complete development and subsequent obstruction of the lymphatic system. They are most frequently found as an asymptomatic mass in the posterior triangle of the neck but can also be found anteriorly, causing airway or swallowing problems. Physical examination reveals a nontender, fluctuant, soft, spongy mass without discrete margins. Surgery is the mainstay treatment for lymphangiomas, although other modalities of interest include intralesional injection sclerotherapy and systemic interferon.

Hemangiomas are the most common congenital malformations. Most are cutaneous, but they can also be found in deep tissues. The most common deep location in the head and neck is the masseter muscle. Hemangiomas are characterized by appearance at or after birth, followed by a rapid prolifera-tive phase at 6 to 18 months of age. The lesion then reaches a plateau phase, followed by a slow, involutional phase over 6 to 8 years. Even large, uncomplicated lesions left untreated usually undergo almost complete resolution. Conservative management is almost always recommended.

Certain locations, including the nasal tip, lips, and eyelids, can cause severe functional or cosmetic deformities, and referral for removal may be appropriate. Massive lesions can cause high-output heart failure or a consumptive coagulopa-thy (Kasabach-Merritt syndrome), whereas others can become ulcerated, infected, or hemorrhagic. Other forms of treatment for complicated lesions include interferon alfa-2b and cortico-steroids. Cutaneous lesions may be treated with laser therapy.

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