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self limiting and benign. Clinicians must therefore be aware of the potential causes of lymph node enlargement in children and the indicators of serious pathology.

18.2  Differential Diagnosis

of Lateral Neck Lumps

18.2.1  Lymph Nodes

The causes of lymphadenopathy in the neck are

18.2.1.1  Infective

Viral: Upper respiratory viral infections may cause lymphadenopathy which is usually self limiting. Other common childhood viral infections such as measles, mumps, and rubella can also cause lymphadenopathy.

Infectious mononucleosis, caused by Epstein Barr virus infection, can cause massive lymphadenopathy, often accompanied by tonsillitis, fever, lethargy, and malaise. The diagnosis can often be confirmed with a serological test (such as the Monospot or Paul Bunnell) and there are often atypical lymphocytes on the blood film.

Human Immunodeficiency Virus may present with persistent generalized lymphadenopathy. The transmission in children is usually vertical from mother to child. They may be a history of recurrent or opportunistic infections. This is a diagnosis which could be considered in any patient with an unknown cause of lymphadeopathy.

Bacterial: Acute lymphadenitis may occur with infection with pyogenic organisms, most commonly streptococci and staphylococci. Occasionally gram negative organisms may be responsible. If untreated this may progress to an acute inflammatory mass and/or suppuration to form an abscess (Fig. 18.1). Often these are relatively superficial and require an external incision and drainage. Infection within the deep neck spaces can present more of a management challenge

Chapter 18.  Neck Swellings/Lumps: Lateral Neck Lumps 179

FIGURE 18.1.  A superficial neck abscess in a baby.

and carry a risk of airway obstruction or progression to medistinal infection.

Mycobacterial infection: Tuberculosis presenting in the neck is rare in UK practice. More common is non-tuberculous mycobacterial infection, sometimes referred to as atypical mycobacterial infection or incorrectly as atypical TB. These organism cause infection via an oral route and tend to infect those lymph nodes draining the oral cavity (i.e., submandibular and intraparotid nodes most commonly). They most commonly present as a painless mass in an otherwise entirely healthy child. If left untreated the skin over the lump develops a violaceous discoloration and given more time eventually breaks down to form a discharging sinus (Fig. 18.2). If left untreated this situation is likely to continue for some months or years before the wound heals, often with an unpleasant puckered scar.Treatment of this condition is either medical (and a variety of antibiotic have been employed including clarithromycin, azithromycin, ciprofloxacin as well as more traditional antituberculous drugs) or surgery. The resistance of mycobacteria to antibiotic treatment means that, if medical treatment is planned, antibiotic treatment often requires several weeks or months of treatment. There is little doubt that surgery is technically easier and has a greater chance of a good outcome in early disease.

180 N. Bateman

FIGURE 18.2.  Non-tuberculous mycobacterial infection in the parotid gland showing the characteristic skin discoloration.

Other bacterial infection which can present with lymphadenopathy include brucellosis, cat scratch disease, actinomycosis, and syphilis.

18.2.1.2  Inflammatory

Kawasakis disease is an inflammatory, non infective disease which presents with cervical lymphadenopathy, pyrexia, desquamation of the hands and feet, erythema of the oral cavity and conjunctivitis. It is an important diagnosis to consider­ as there is a potential mortality of 1–2% due to cardiac complications. The treatment is by gamma globulin administration.

18.2.1.3  Neoplastic

Fortunately head and neck malignancy is rare in children but cancer is the second commonest cause of childhood death in the UK and a significant proportion of pediatric cancers involve the head at some stage. Early diagnosis and appropriate management in a specialist centre is of vital importance to a good outcome.

Chapter 18.  Neck Swellings/Lumps: Lateral Neck Lumps 181

Hodgkin’s disease occurs most commonly in teenagers and young adults and characteristically affects lymph nodes rather than extra-nodal sites. The typical history is progressive enlargement of cervical lymph nodes. There may be systemic symptoms such as anorexia, weight loss and night sweats. Hepatosplenomegaly indicates more advanced spread of the disease. Diagnosis is by lymph node biopsy and treatment by chemotherapy and/or radiotherapy.

Non-Hodgkin’s Lymphoma is a heterogeneous group of malignancies distinguished pathologically from Hodgkin’s disease by the absence of Reed Sternberg cells. Extra-nodal sites (e.g., tonsil, adenoids) may be affected in the head and neck rather than lymph nodes. A younger age group (2–12 years) is more typically affected. Diagnosis is by a biopsy and treatment modalities similar to that of Hodgkin’s disease.

Other malignancies presenting as neck lumps include rhabdomyosarcoma, thyroid malignancy and salivary gland tumors. Congenital teratomata may present as large masses in the head and neck.

18.2.2  Vascular Malformations

and Vascular Tumors

Hemangiomata should be clearly distinguished from vascular malformations. Hemangiomata are benign neoplasms of endothelium which grow rapidly in the first few weeks of life, often having been undetectable at birth. They commonly affect the parotid area and can appear alarming to parents and doctors alike.Although they are known to respond to systemic steroids or propranolol treatment as well as being amenable to surgical excision they will, if left alone, involute spontaneously so treatment is only really required for lesions causing a functional problem (such as swallowing or airway problems, or in facial lesions where there is closure of one eye).

Vascular malformations are present at birth and are a developmental abnormality. Lymphatic malformations

(cystic hygroma, lymphangioma) may be considered with this