Evaluation and Management of Left-Sided Neck Swelling in a Child
Ultrasound is the first-line imaging modality for evaluating pediatric neck masses, with CT or MRI reserved for cases concerning for malignancy or deep neck infection requiring surgical intervention. 1
Initial Clinical Assessment
Risk Stratification Features
High-risk features requiring aggressive workup include:
- Mass present ≥2 weeks without significant fluctuation 1
- Firm consistency, size >2 cm, or fixation to adjacent tissues 1
- Supraclavicular location or ulceration of overlying skin 1
- Absence of clear infectious etiology 1
Common presenting symptoms to evaluate:
- Fever (present in 93.3% of deep neck infections) and painful neck swelling (70% of cases) 2
- Cervical lymphadenopathy, which may indicate infectious causes (tonsillitis, upper respiratory infection) or malignancy 2, 3
- Neurologic symptoms including upper extremity weakness or radiating pain, which may indicate spinal cord compression from malignancy 4
Most Common Etiologies by Age
In the pediatric population, the differential includes:
- Infectious causes: Cervical lymphadenitis (most common), deep neck space infections (peritonsillar and parapharyngeal spaces most frequent at 24.3% each), submandibular space infections (18.9%) 2
- Congenital lesions: Thyroglossal duct remnants (54.2% of congenital neck lesions), branchial cleft anomalies (34.7%), dermoid cysts (11.1%) 5
- Malignancy: Hodgkin lymphoma, non-Hodgkin lymphoma, rhabdomyosarcoma (rare but critical to identify) 4, 3
Imaging Algorithm
First-Line Imaging
Ultrasound should be performed initially for:
- Suspected congenital abnormalities 1
- Superficial infections 1
- Characterizing vascular flow in solid lesions using color-flow Doppler 1
- Guiding fine-needle aspiration if needed 1
Advanced Imaging Indications
CT neck with IV contrast is usually appropriate when:
- Malignancy is suspected based on high-risk clinical features 1
- Deep neck infection or abscess requiring surgical drainage is present 2
- Computed tomography should be performed promptly in children presenting with fever and painful neck swelling to identify deep space involvement 2
MRI neck is usually appropriate when:
- Malignancy is suspected and superior soft tissue characterization is needed 1
- Evaluating deep neck abscesses 1
- Assessing for spinal cord involvement in patients with neurologic symptoms 4
Management Approach
Low-Risk Masses
For masses without high-risk features:
- Document specific follow-up plans to assess resolution 1
- Advise families of criteria triggering need for additional evaluation 1
- Most infectious lymphadenitis resolves with appropriate antimicrobial therapy targeting Staphylococcus aureus and viridans streptococci (the most common pathogens at 27.3% and 22.7% respectively) 2
High-Risk Masses
Urgent referral to pediatric head and neck surgeon is required for:
- Fixed masses, supraclavicular location, size >2 cm, or ulceration 1
- Masses present >2 weeks without infectious etiology 1
- Any neurologic signs suggesting spinal cord compression 4
If diagnosis remains uncertain after imaging:
- Fine-needle aspiration is recommended rather than open biopsy 6
- Open biopsy should not be performed before completing workup, as it disrupts tissue planes and complicates subsequent surgery 6
Critical Pitfalls to Avoid
Do not administer empiric antibiotics without clear infectious signs, as this may delay diagnosis of malignancy 6
Do not assume cystic masses are benign, as cystic metastases occur in pediatric head and neck cancers 6
Do not delay imaging in high-risk patients, as CT or MRI is mandatory for risk stratification and surgical planning 6, 1
Do not perform open biopsy as the initial diagnostic procedure, as examination under anesthesia with panendoscopy should precede open biopsy if FNA and imaging are non-diagnostic 6
Surgical Considerations
For confirmed congenital lesions: