2. Lymphoma
More common in children
and young adults
Up to 80% of children with
Hodgkin’s have a neck
mass
Signs and symptoms
Lateral neck mass only
(discrete, rubbery,
nontender)
Fever
Hepatosplenomegaly
Diffuse adenopathy
3. Lymphoma
FNAB – first line diagnostic test
If suggestive of lymphoma – open biopsy
Full workup – CT scans of chest, abdomen,
head and neck; bone marrow biopsy
4. Salivary Gland Tumors
Enlarging mass
anterior/inferior to ear
or at the mandible
angle is suspect
Benign
Asymptomatic
except for mass
Malignant
Rapid growth, skin
fixation, cranial nerve
palsies
5. Salivary Gland Tumors
Diagnostic tests
Open excisional biopsy (submandibulectomy or
parotidectomy) preferred
FNAB
Shown to reduce surgery by 1/3 in some studies
Delineates intra-glandular lymph node, localized
sialadenitis or benign lymphoepithelial cysts
Accuracy >90% (sensitivity: ~90%; specificity: ~80%)
CT/MRI – deep lobe tumors, intra vs. extra-parotid
Be prepared for total parotidectomy with possible
facial nerve sacrifice
6. Carotid Body Tumor
Rare in children
Pulsatile, compressible mass
Mobile medial/lateral not
superior/inferior
Clinical diagnosis, confirmed by
angiogram or CT
Treatment
Irradiation or close observation in the
elderly
Surgical resection for small tumors in
young patients
Hypotensive anesthesia
Preoperative measurement of
catecholamines
8. Carotid paragangliomas
Treatment
Surgery
Mortality 8%, >5cm tumors had more
complications
Preop workup key – vascular surgeon,
anesthesia
Embolization – controversial
Radiation
9. Vagal paragangliomas
Most commonly at nodose ganglion
Painless mass at angle of mandible present
for many years – enlarging may get Horner’s,
CN XII, hoarseness
More multicentric (25%)
Malignancy (18%)
None produce catecholamines
11. Lipoma
Soft, ill-defined
mass
Usually >35 years
of age
Asymptomatic
Clinical diagnosis
– confirmed by
excision
12. Neurogenic Tumors
Arise from neural crest derivatives
Include schwannoma, neurofibroma, and
malignant peripheral nerve sheath tumor
Increased incidence in NF syndromes
Schwannoma most common in head &
neck
13. Schwannoma
Sporadic cases mostly
25 to 45% in neck when
extracranial
Most commonly between 20 and
50 years
Usually mid-neck in poststyloid
compartment
Signs and symptoms
Medial tonsillar displacement
Hoarseness (vagus nerve)
Horner’s syndrome
(sympathetic chain)
15. Epidermal and Sebaceous Cysts
Most common
congenital/developme
ntal mass
Older age groups
Clinical diagnosis
Elevation and
movement of overlying
skin
Skin dimple or pore
Excisional biopsy
confirms
16. Branchial Cleft Cyst
2nd cleft most common
(95%) – tract medial to
cnXII between internal
and external carotids
1st cleft less common –
close association with
facial nerve possible
3rd and 4th clefts rarely
reported
Present in older children
or young adults often
following URI
17. Branchial Cleft Cyst
Most common as smooth,
fluctuant mass underlying
the SCM
Skin erythema and
tenderness if infected
Treatment
Initial control of infection
Surgical excision,
including tract
May necessitate a total
parotidectomy (1st cleft)
18. Thyroglossal Duct
Cyst
Most common congenital neck
mass (70%)
50% present before age 20
Midline (75%) or near midline
(25%)
Usually just inferior to hyoid
bone (65%)
Elevates on
swallowing/protrusion of tongue
Treatment is surgical removal
(Sistrunk) after resolution of any
infection
19. Thyroglossal Duct Cyst
Most common congenital midline mass
Ectopic thyroid tissue vs. thyroglossal duct cyst
Asymptomatic mass at or below the hyoid bone
that elevates with tongue protrusion.
Ultrasound
Thyroid Scan in patients that do not
demonstrate a normal thyroid by US.
20. Vascular Tumors
Lymphangiomas and hemangiomas
Usually within 1st year of life
Hemangiomas often resolve spontaneously
lymphangiomas remain unchanged
CT/MRI may help define extent of disease
21. Vascular Birthmarks
Classification system
Hemangioma vs. malformation
Based on clinical, cellular, biologic factors
Older terms – “capillary”, “juvenile”, “strawberry”,
“cavernous”
23. Hemangiomas
Most common
tumor of infancy
(10%)
Slight female
predominance
60% arise in head
and neck – cosmetic
concerns
24. Hemangiomas
Clinical presentation
for diagnosis
Not seen at birth
Precursor lesion
Proliferative phase
Involution phase
Superficial vs. deep
25. Complications from Hemangiomas
Occur in 20%
Ulceration
Compression of vital structures
High-output cardiac failure
Bleeding
Kasabach-Merritt
syndrome
26. Laryngeal Hemangiomas
Usually in the
subglottis
Healthy infant with
biphasic stridor
(croup)
Behave similarly
50% with cutaneous
counterpart
27. Treatment of Hemangiomas
Why and when to treat?
Normal skin in 50%
that involute within 5
years
Other 50%-- 80%
substantial deformity
Pro’s and Con’s
28. Treatment of Hemangiomas
Observation
Serial photography important to document
involution
Regular visits with reassurance
29. Treatment of Hemangiomas
Systemic steroids
Careful selection criteria
Prednisone 2-4mg/kg for up to 6 weeks
Varied results (30%)
Side effects
30. Treatment of Hemangiomas
Intralesional
steroids
Usually for
vision
threatening
lesions
Combination
of beta-
methasone
and
triamcinolone
31. Treatment for Hemangiomas
Surgery
Eyelid lesions, bulky
lesions, vermillion
border, nasal tip,
eyebrow
CO2 laser for
subglottis
Arterial embolization
Radiation therapy
Alpha-2b interferon
32. Vascular malformations
Capillary, venous, arterial, lymphatic, mixed
By definition– present at birth
No proliferative or involution phase
Commensurate growth
33. Capillary malformations
Older term– “port-
wine stain”
Usually in
trigeminal
distribution
Most isolated
anomalies
Sturge-Weber
syndrome
38. Nasopharyngeal Angiofibroma
Most common benign tumor of nasopharynx
Older term– “juvenile nasopharyngeal
angiofibroma”, “JNA”
Presentation: recurrent epistaxis/nasal
congestion, hearing loss, orbital, CN
Arise where sphenoidal process of palatine
bone meets horizontal ala of vomer
41. Nasopharyngeal Angiofibroma
Treatment
Embolization and surgery
Autologous blood/Cell Saver
Approaches
Transnasal endoscopic, lateral
rhinotomy/MFD with medial maxillectomy or
LeFort I, transpalatal, facial
translocation/maxillary swing, infratemporal
approaches, craniotomy
Radiation therapy
Chemotherapy
42. Malignant Vascular Tumors
Angiosarcoma
Extremely rare (50% in
head and neck)
Prognosis on tumor size,
grade, margins
Radiation minimally
effective
Sinonasal tract less
aggressive
Poor survival
43. Malignant Vascular Tumors
Hemangiopericytoma
Pericytes of
Zimmerman
25% in head and neck
Surgical treatment
Grade important on
prognosis
Radiation/chemotherap
y for selected cases
45. Paragangliomas
Named for anatomic location
Arise in paraganglionic tissue (neural crest)
Type I cells (chief) – APUD cells – catecholamines
Type II cells (sustentacular)
Clusters together– “Zellballen”
Malignancy is clinical
46. Cervical Thymic Cysts
Failure of involution of the cervical
thymopharyngeal ducts.
Firm, mobile masses found in the lower
aspects of the neck.
CXR, CT scan
47. Dermoid Cysts
Mesoderm and Ectoderm
Midline, paramedian, painless masses that
usually do not elevate with tongue
protrusion.
Commonly misdiagnosed as Thyroglossal
Duct Cysts.
Treatment is simple surgical excision
48. Teratoid Cysts and Teratomas
All three germ cell layers- Endoderm,
mesoderm and ectoderm.
Larger midline masses, present earlier in life.
20% associated maternal polyhydramnios
Unlike adult teratomas, they rarely
demonstrate malignant degeneration.
Surgical excision.
49. Laryngoceles
Congenitally from an enlarged laryngeal
saccule.
Classified as internal, external, or both
Internal
Confined to larynx, usually involves the false cord
and aryepiglottic fold.
Hoarseness and respiratory distress vs. neck mass.
50. Plunging Ranula
Simple ranula- unilateral oral cavity cystic lesion.
Plunging ranula- pierce the mylohyoid to present
as a paramedian or lateral neck mass.
Cyst aspirate- high protein, amylase levels
CT scan/MRI
Treatment is intra-oral excision to include the
sublingual gland of origin.
51. Sternomastoid Tumor of
Infancy
Firm mass of the SCM,
(Pseudotumor) chin turned away and
head tilted toward the mass.
Hematoma with subsequent fibrotic
replacement.
Ultrasound
Physical therapy is very successful.
Myoplasty of the SCM only if refractory to PT.
52. Infectious and Inflammatory
Lesions
40% of infants have palpable LAD
55% of pediatric patients.
Most commonly involving the submandibular
and deep cervical nodes.
53. Lymphadenitis
Very common, especially within 1st decade
Tender node with signs of systemic infection
Directed antibiotic therapy with follow-up
FNAB indications (pediatric)
Actively infectious condition with no response
Progressively enlarging
Solitary and asymmetric nodal mass
Supraclavicular mass (60% malignancy)
Persistent nodal mass without active infection
54. Lymphadenopathy
Equivocal or suspicious FNAB in the pediatric
nodal mass requires open excisional biopsy to
rule out malignant or granulomatous disease
55. Granulomatous lymphadenitis
Infection develops over weeks to months
Minimal systemic complaints or findings
Common etiologies
TB, atypical TB, cat-scratch fever, actinomycosis,
sarcoidosis
Firm, relatively fixed node with injection of
skin
56. Granulomatous lymphadenitis
Typical M. tuberculosis Atypical M. tuberculosis
more common in Pediatric age groups
adults
Anterior triangle
Posterior triangle nodes
nodes
Brawny skin,
Rarely seen in our
population induration and pain
Usually responds to Usually responds to
anti-TB medications complete surgical
May require excisional excision or
biopsy for further curettage
workup
58. Bacterial Cervical Adenitis
Tender, enlarged nodes
Organisms- Staphylococcus, Group A
Streptococcus
Treatment- Beta-lactamase resistant
antibiotic
Fine Needle Aspiration
59. Viral Adenitis
Most common infectious process in the neck.
Rhinovirus, adenovirus, enterovirus.
60. Summary
Extensive differential diagnosis
Age of patient is important
Accurate history and complete exam essential
FNAB – invaluable diagnostic tool
Possibility for malignancy in any age group
Close follow-up and aggressive approach is
best for favorable outcomes