Head and Neck Masses in Children

Masses in the head and neck fall into two groups: benign, meaning not cancer, and malignant, meaning cancer.

In children they are usually benign. The commonest causes are infection, swelling of the tissue, remnants of tissue or cysts present from birth, enlarged lymph nodes, and benign tumours. Malignant tumours are rare.

The commonest benign masses

In children the masses seen most often are the adenoid and large tonsils. A malignant tumour in these areas is extremely rare. If the growth is uneven or on one side only, it must be assessed carefully.

Lymph nodes

Enlarged lymph nodes in the neck are common in children, and they almost always follow an infection.

See an ear, nose and throat specialist if the nodes do not get smaller with time, if the number of enlarged nodes rises, or if they keep growing.

Cysts

The other common group of benign masses in the head and neck are cysts filled with fluid. They form when structures that should disappear before birth do not, and turn into cysts: branchial cleft cysts, thyroglossal duct cysts, dermoid cysts and cystic hygroma.

They are treated because they are uncomfortable as a mass, because they carry a risk of infection, and because they carry a long-term risk of becoming malignant.

Masses of the nose and the sinuses

These usually cause a blocked nose and bleeding.

The commonest malignant masses in children are rhabdomyosarcoma, which starts in soft tissue, and non-Hodgkin lymphoma. Early diagnosis is very important, so a child with a blocked nose that does not clear despite proper treatment, and with repeated nosebleeds, must be examined by an ENT specialist.

Nasopharyngeal angiofibroma is a benign mass seen in boys around and before puberty. It causes repeated heavy nosebleeds. Because it grows locally, it presses on and spreads into the important structures around it. Once found, it must be treated properly.

Nasal polyps are rarer in children than in adults. A child with many polyps must be assessed for cystic fibrosis. Allergic rhinitis and allergic fungal sinusitis also cause polyps inside the nose.

Meningocele appears inside the nose as a polyp. It forms when the covering of the brain herniates into the nose through an opening in the bone of the nasal roof that has been there since birth. The herniated tissue can be only the brain covering, and it can also contain brain tissue, which is called meningoencephalocele. Consider this possibility in every child with a single polyp inside the nose, before deciding on treatment.

Salivary gland tumours

The parotid gland in front of the ear, the gland under the jaw and the gland under the tongue are the major salivary glands. The many small glands inside the mouth are the minor glands.

A mass arising in a minor gland is more likely to be malignant. Every mass arising in a salivary gland must be assessed by an ENT specialist.

Masses of the thyroid gland

The thyroid gland sits in the front midline of the neck. Thyroid masses are extremely rare in children, and even so they need a detailed assessment.

Thyroglossal duct cyst

This is a benign structure found in the midline of the neck, and it is the commonest congenital neck cyst.

The thyroglossal duct is the channel along which the thyroid gland develops in the unborn baby. It starts at the base of the tongue and runs to the midline of the neck where the thyroid forms, letting the necessary stem cells travel to that place.

A large cyst causes difficulty swallowing. An important sign is that the mass moves when the child swallows and when the tongue moves.

The diagnosis is made from the history and the physical examination. A full blood count and thyroid function tests are needed. Ultrasound helps: it shows whether the thyroid sits in its normal place and what the cyst is like. A thyroglossal duct cyst can contain thyroid tissue. There are even patients with no thyroid tissue in its normal place, whose only thyroid tissue is inside the cyst.

The operation is called the Sistrunk procedure. The surgeon removes the cyst, its extension up to the base of the tongue, and the middle part of the hyoid bone together. The removed specimen is sent to pathology for examination.