Workup for Neck Lump in a 3-Year-Old Child
The initial workup for a neck lump in a 3-year-old should include a thorough history, physical examination, and targeted imaging with ultrasound as the preferred first-line imaging modality, followed by appropriate laboratory tests based on clinical suspicion.
Initial Assessment
History
- Duration of the mass: Has it been present for ≥2 weeks without fluctuation?
- Associated symptoms:
- Fever, night sweats, weight loss
- Difficulty swallowing or breathing
- Voice changes
- Recent infections (ear, throat, respiratory)
- Pain or tenderness of the mass
- Recent illnesses or exposures:
- Recent upper respiratory infections
- Animal exposures (cat-scratch disease)
- TB exposure
- Growth pattern of the mass:
- Rapid growth vs. slow growth
- Fluctuation in size
Physical Examination
- Characteristics of the mass:
- Location (midline vs. lateral)
- Size (document measurements)
- Consistency (soft, firm, hard)
- Mobility (fixed vs. mobile)
- Overlying skin changes
- Tenderness
- Complete head and neck examination:
- Oral cavity inspection
- Ear examination
- Throat examination
- Assessment of other lymph node regions
Diagnostic Approach
Imaging
Ultrasound is the preferred initial imaging study for pediatric neck masses 1
- Non-invasive, no radiation exposure
- Can differentiate solid from cystic lesions
- Can assess vascularity and lymph node characteristics
CT with contrast should be considered if:
- Deep neck infection is suspected
- Mass extends into deep neck spaces
- Malignancy is suspected based on clinical features 1
Laboratory Studies
Based on clinical suspicion:
- Complete blood count (CBC) with differential
- Purified protein derivative (PPD) test if TB exposure is suspected
- Targeted serologic tests if indicated:
- EBV titers
- Cat-scratch disease titers
- CMV titers
- Toxoplasmosis titers 1
Classification and Management Approach
Congenital/Developmental Masses (Common in children)
- Thyroglossal duct cysts (midline)
- Branchial cleft cysts (lateral)
- Dermoid cysts
- Vascular malformations
- Hemangiomas 2, 1
Inflammatory/Reactive Masses
- Reactive lymphadenopathy (most common cause in children)
- Infectious lymphadenitis:
- Viral (EBV, CMV)
- Bacterial (Staphylococcus, Streptococcus)
- Mycobacterial
- Cat-scratch disease 1
Neoplastic Masses
- While rare in children, they represent 11-15% of pediatric neck masses 2
- Consider if:
- Mass >2 cm in diameter
- Firm or hard consistency
- Fixed to surrounding tissues
- Persistent enlargement >2 weeks
- No response to antibiotics
- Supraclavicular location 1
Important Considerations
When to Consider Antibiotics
- Antibiotics should not be routinely prescribed unless there are clear signs of bacterial infection 3, 4
- Signs suggesting bacterial infection:
- Erythema
- Warmth
- Fluctuance
- Fever
- Acute onset
When to Refer
Immediate referral to pediatric otolaryngology is warranted if:
- Mass persists >2-3 weeks without improvement
- Size >2 cm
- Fixed, firm, or hard consistency
- Supraclavicular location
- Associated systemic symptoms
- Concerning imaging findings 1
Follow-up
- For masses not considered high-risk, establish clear follow-up plan
- Document criteria that would trigger additional evaluation
- Ensure follow-up until resolution or final diagnosis 3
Pitfalls to Avoid
- Assuming all pediatric neck masses are benign
- Prolonged antibiotic trials without appropriate workup
- Failure to obtain imaging for persistent masses
- Performing open biopsy as initial diagnostic procedure
- Losing patients to follow-up before definitive diagnosis