ORIGINAL ARTICLE
The Management of Pediatric Neck Masses
Han Shengwei, PhD,*† Wang Zhiyong, MD, PhD,* Han Wei, MD, PhD,*† and Hu Qingang, MD, PhD*
Abstract: Neck masses are a common clinical concern both in
adults and children. The differential diagnosis is quite broad, from
congenital lesions to malignant tumors. Based on the different path-
ologic diagnosis, the treatments are varied. To the best of our knowl-
edge, limited reports, which specifically discuss the incidence and
distribution of neck diseases in early childhood, have been pub-
lished. Because of the great population in China, a thorough review
of the previous clinical data for pediatric neck masses might be poten-
tially valuable for oral and maxillofacial surgeons, which might pro-
vide a deeper understanding and better the accuracy of our clinical
diagnosis and management. In this article, a 10-year retrospective re-
view was completed; the whole cases were diagnosed and treated in
the same major clinical institute in east China, which might represent
as a typical cohort for the patient population and serve as a reference
for future clinical management.
Key Words: Pediatric neck mass, retrospective review, clinical
management
(J Craniofac Surg 2015;26: 399–401)
N eck masses are a common clinical concern in infants, children,
and adolescents. The differential diagnosis for a neck mass in
these age groups is broad, which includes congenital, inflammatory,
and neoplastic lesions.1Congenital lesions most commonly found in
the pediatric population include thyroglossal duct cyst and branchial
cleft cyst. Hemangiomas and lymphatic malformations are other
common congenital lesions.2 Inflammatory masses are secondary
to local or systemic infections. Neck masses due to inflammatory
lymphadenitis are common in children because of the frequency
of upper respiratory tract infections. The most common etiology
for neck masses in children is reactive lymphadenopathy following
a viral or bacterial illness. Persistent unilateral adenopathy is con-
cerning and can have an acquired cause such as mycobacterial
tuberculosis, a granulomatous process, or cat-scratch disease.3 A
typical feature in the pediatric population is that 80% to 90%
of all neck masses represent benign conditions.1 Because of the
From the *Department of Oral and Maxillofacial Surgery and †Central Lab-
oratory of Stomatology, Stomatological Hospital Affiliated Medical
School, Nanjing University, Nanjing, People’s Republic of China.
Received June 17, 2014.
Accepted for publication September 13, 2014.
Address correspondence and reprint requests to Han Wei and Hu Qingang,
Department of Oral and Maxillofacial Surgery, Nanjing Stomatological
Hospital, No. 30 Zhongyang Road, Nanjing 210008, Jiangsu, China;
E-mail: doctorhanwei@hotmail.com; qghu@nju.edu.cn
This study was financially supported by the National Natural Science
Foundation of China (81302351), Jiangsu Provincial Natural Science
Foundation (grant BK2012075,BK 20131080), and Nanjing Municipal
Science and Technology Planning Project (201303023).
The authors report no conflicts of interest.
Copyright © 2014 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000001342
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
frequency of neck masses in the pediatric population and the array
of different histopathologic types, diagnosis and treatment are chal-
lenging. Because of the great population in China, a thorough
review of the previous clinical data for pediatric neck masses might
be potentially valuable for oral and maxillofacial surgeons and help
us to better define the incidence and type of pediatric neck masses.
In this article, a 10-year retrospective review was conducted; the
whole cases were diagnosed and treated in the same major clinical
institute in east China, which might represent as a typical cohort
for the patient population and will serve as a reference.
PATIENTS AND METHODS
From January 2002 to January 2011, 78 patients 14 years or
younger with neck masses were diagnosed and treated at the
Stomatology Hospital, Nanjing University, China. Of these cases,
9 were neck tumors. Information on patient, clinical, and histopath-
ologic characteristics was obtained from the medical records. Histo-
pathologic specimens were reevaluated on hematoxylin-eosin slides.
RESULTS
Benign and Malignant Tumors
Among 78 patients 14 years or younger with a neck mass,
9 (11.5%) had a neck tumor. Two of these were male and 7 were
female, a female-to-male ratio of 3.5:1; their mean age was
11.9 years (range, 2–14 years), and 7 of the 9 patients (77.8%) were
older than 10 years at the time of their initial visit. Of the 9 neck
tumors, 7 (77.8%) were benign, and 2 (22.2%) were malignant
(Table 1). The mean age of the patients with benign tumors was
12.4 years (range, 4–14 years), and the mean age of those with ma-
lignant tumors was 10 years. The female-to-male ratio for benign
tumors was 1.5:1, and both patients with malignant tumors were
female.
Benign Tumors
The benign neck tumors were diagnosed as neurilemmoma in
6 patients (85.7%) and osteochondroma in 1 (14.3%). All of the
patients with neurilemmoma were older than 10 years at the time
of their initial visit (Table 2). The most common presenting sign
or symptom was a painless, slow-growing mass in the neck region.
No pain, numbness, or facial nerve weakness occurred in any of the
7 patients. Tumor size ranged from 1.0 to 3.5 cm. None of the pa-
tients had received previous treatment in another institution. The
initial treatment for all 7 patients was surgical removal of the
tumors. No patient experienced recurrence after surgery(Table 2).
Malignant Tumors
Surprisingly, only 2 cases of malignant tumor were found in
this cohort. One patient was diagnosed with malignant lymphoma,
the other with neuroblastoma (Table 3). Both patients were female.
They underwent surgery and refused radiotherapy. The patient with
malignant lymphoma died 3 years later; the other patient was lost to
follow-up after 2.5 years.
399
Shengwei et al The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015

TABLE 1. Gender and Age Distribution of 9 Cases of Pediatric Neck Tumor TABLE 3. Summary of 2 Cases With Malignant Tumor

Benign Malignant Tumor Recurrence/

Case No. Sex Age, y Side Histological Type Size, cm Interval, mo
Age, y M F Total % M F Total %
1 F 14 R Malignant lymphoma 3.5 DOD, 3 y
0–10 1 0 1 14.3 0 1 1 50
2 F 2 R Neuroblastoma 4.5 LFU, 2.5 y
11–14 1 5 6 85.7 0 1 1 50
Total 2 5 7 100 0 2 2 100 DOD indicates death due to disease; LFU, lost to follow-up.

M indicates male; F, female.

the first-choice treatment. Having a working knowledge of the

Infectious/Inflammatory Lesions lesions that occur in this region together with a thorough history
Of 78 patients 14 years or younger with a neck mass, 25 and physical examination generally enables the clinician to establish
(32.1%) had an infectious or inflammatory lesion. Inflammatory a diagnosis.6
masses are secondary to local or systemic infections. There were Some general information can be helpful for the evaluation
14 males and 11 females, a male-to-female ratio of 1.3:1. Their mean of pediatric neck masses. Features from the history and examination
age was 12.4 years (range, 2–14 years), and 22 (88%) of the 25 were should help to narrow the etiology. Patient demographics, such as
older than 10 years at the time of their initial visit. Among these age, gender, area of residence, and genetics, can help in generating
25 cases, 6 (24%) had reactive hyperplasia of lymph nodes, 3 a differential diagnosis. For example, lymphoma of the neck region
(12%) were cat-scratch disease, 7 infective lymphadenitis (28%), 3 in pediatric patients rarely occurs before 3 years of age.7
scrofula (12%), 4 granulomatous inflammatory lesions (16%), and In our review of pediatric neck masses treated at the
2 spreading inflammation of subcutaneous tissue (8%). Their infor- Stomatology Hospital of Nanjing University from 2002 to 2011,
mation is presented in Table 4. Clinically, the most common etiology there were 78 cases. In accord to other reports, most of the masses
for cervical adenopathy in children is reactive lymphadenopathy fol- were benign (97.4%). The etiology of these benign lesions was most
lowing a viral or bacterial illness. The infected nodes are often pain- commonly congenital, followed by inflammatory and rarely neo-
less, are firm, and are not mobile. plastic. Surprisingly, among the 78 cases, only 2 patients had malig-
nant disease. The incidence of pediatric malignant tumors (2.6%) in
the current study is less than that in other reports, which are as high
Congenital Lesions as 11% to 15%.8 It is important for surgeons to appreciate the rele-
Congenital neck masses account for more than half of the vant embryology, anatomy, and natural history of head and neck le-
whole cases; in total, there were 44 patients (56.4%). Nineteen sions and to be familiar with their appropriate evaluation and
had a branchial cyst, and 6 had a thyroglossal cyst, 14 had a vascu- management. Although in most cases pediatric neck masses are of
lar anomaly (hemangioma, lymphatic or mixed), 4 had a dermoid
cyst, and 1 had an ectopic thyroid gland. Their average age was
10.8 years (range, 1–14 years). There were 26 males and 18
females, a male-to-female ratio of 1.4:1. Their detailed information
is displayed in Table 5. Although present at birth, many congenital TABLE 4. Summary of 25 Cases With Infectious/Inflammatory Lesions
abnormalities do not become evident until later in infancy or child- Case No. Sex Age, y Side Histological Type Size, cm
hood. It is common for these anomalies to become infected, causing
1 M 14 R Reactive lymphadenopathy 3.5
significant morbidity.4,5
2 F 14 L Reactive lymphadenopathy 3.0
3 M 14 R Reactive lymphadenopathy 2.5
DISCUSSION 4 M 8 R Reactive lymphadenopathy 2.5
Pediatric neck masses may have an infectious, inflammatory, 5 F 14 R Reactive lymphadenopathy 3.0
tumoral, traumatic, lymphovascular, immunologic, or congenital 6 M 14 L Reactive lymphadenopathy 2.0
cause. Many are asymptomatic and noticed incidentally by the pa- 7 M 10 R Cat-scratch disease 2.0
tient or parents or on physical examination, whereas others are 8 F 12 R Cat-scratch disease 3.5
brought to clinical attention because of a mass effect on the 9 F 14 L Cat-scratch disease 3.0
aerodigestive tract (fever or inflammatory disease). Surgery is often 10 M 2 R Infective lymphadenitis 2.0
11 M 14 L Infective lymphadenitis 2.5
12 M 14 R Infective lymphadenitis 2.0
13 M 14 R Infective lymphadenitis 3.0
TABLE 2. Summary of 7 Cases With Benign Tumor
14 F 12 L Infective lymphadenitis 3.0
Tumor Recurrence/ 15 M 14 R Infective lymphadenitis 2.0
Case No. Sex Age, y Side Histological Type Size, cm Interval, mo 16 M 14 R Infective lymphadenitis 3.0
1 17 F 14 R Scrofula 2.5
M 14 R Neurilemmoma 2.5 No
18 F 14 R Scrofula 3.0
2 F 14 R Neurilemmoma 3.0 No
19 M 13 L Scrofula 2.5
3 F 14 R Neurilemmoma 3.0 No
20 F 13 L Granulomatous 2.0
4 F 14 R Neurilemmoma 3.5 No
21 F 14 L Granulomatous 3.5
5 F 13 L Neurilemmoma 2.5 No
22 F 12 L Granulomatous 3.0
6 F 11 L Neurilemmoma 2.0 No
23 M 14 R Granulomatous 2.5
7 M 4 R Osteochondroma 1.0 No
24 M 3 R Inflammation of subcutaneous tissue 1.5
L indicates left; R, right. 25 M 14 R Inflammation of subcutaneous tissue 2.0

400 © 2014 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015 Management of Pediatric Neck Masses

TABLE 5. Summary of 44 Cases With Congenital Lesions

Branchial Cyst Thyroglossal Cyst

Age, y M F Total % M F Total %
0–10 2 1 3 15.8 4 0 4 66.7
11–14 5 11 16 84.2 1 1 2 33.3
Total 7 12 19 100 5 1 6 100
Vascular Anomalies Dermoid Cyst

Age, y M F Total % M F Total %

0–10 5 0 5 35.7 3 1 4 100

11–14 5 4 9 64.3 0 0 0 0
Total 10 4 14 100 3 1 4 100

Distribution of Congenital Neck Masses

Category No. % Of category

Branchial cyst 19 43.2

Thyroglossal cyst 6 13.6
Vascular anomalies 14 31.8
Dermoid cyst 4 9.1
Ectopic thyroid gland 1 2.3
Total 44 100

benign etiology, rapidly enlarging or longstanding adenopathy, par-
ticularly within the supraclavicular space or posterior cervical trian-
gle, should raise suspicion of malignant disease.1
Clinically, the correct diagnosis of a congenital pediatric
neck mass can be often predicted from the location of the mass.
For example, second branchial cleft cysts are typically located in
the submandibular region, whereas thyroglossal duct cysts are usu-
ally located in the infrahyoid region.9 Radiographs and histopatho-
logic examination can also provide information about the disease.8
Congenital neck masses more commonly found in the pediatric
population include thyroglossal duct cysts and branchial cleft and
arch anomalies.6 Tumors, especially malignant tumors such as met-
astatic carcinoma of lymph nodes, are more often found in adults.10
Traditionally, surgery has been the primary therapeutic
approach to neck masses in pediatric patients, supplemented with
broad-spectrum antibiotics. For vascular anomalies, additional
options include corticosteroids or injection of sclerosing agents
(ethanol, bleomycin). An understanding of the anatomic structure
aids surgery and improves the results of treatment.
In pediatric patients with a malignant neck mass, we often do
not suggest adjuvant radiotherapy after surgery. We recommend
limiting adjuvant radiotherapy to highly selected pediatric patients
because of the higher risk of postirradiation complications in chil-
dren, including facial growth retardation, long-term trismus, osteo-
radionecrosis, and second neoplasms. Indications for radiation
therapy in pediatric patients after tumor resection include highly
aggressive histological features, perineural invasion, multiple-level
nodal metastasis, and incomplete surgery. In the current study,
neither of the patients with a malignant tumor received adjuvant
radiotherapy, and follow-up revealed no recurrence.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.