GGC Paediatric Guidelines
- Duration
- Rapidity of change
- Associated pyrexia
- Previous similar episodes
- Recent infection
- Trauma
- Immunisations
- Exposure to TB including recent travel
- Exposure to cats
- HIV risk factors
Paediatric neck lumps (diagnosis and management)
Warning
Objectives
Clear guidance for the assessment, diagnosis and management of paediatric neck lumps presenting to the Emergency Department.
Scope
Children with neck lumps.
Audience
Clinicians working in the Emergency Department.
November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.Neck lumps are a common presentation to the Emergency Department. The differential is wide and includes inflammatory, congenital and neoplastic lesions. Establishing chronicity and the presence of infection is central to establishing the diagnosis. 80-90% of lesions represent benign conditions and the prevalence of palpable cervical lymphadenopathy occurs in 28-55% of normal children. Lymphoma is the most common neoplastic mass found. Detailed history and examination will facilitate preliminary diagnosis and guide further investigation, management and referral.
Focused
- Size
- Texture
- Location
- Fixation
- Tender
- Skin changes
- Unilateral or bilateral
- Single or multiple
General
- Appearance
- Systemic examination
- Rash
- Organomegaly
- Lymphadenopathy
- Respiratory Symptoms
- Stridor
- Dysphagia/Drooling
- Torticollis
Inflammatory masses
- Reactive lymphadenopathy
- (Bacterial, Viral, Granulomatous, Mycobacterial, Histoplasmosis) - Abscess
- EBV – see EBV guideline
- Sarcoidosis
- Cat scratch disease
Congenital masses
- Thyroglossal duct cyst
- Branchial cleft cyst/sinus
- Vascular anomalies
- Dermoid cyst
- Bronchogenic cyst
- Teratoma
Neoplastic masses
- Benign
- (lipoma, fibroma, neurofibroma, thyroid nodule) - Malignant
- (Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, rhabdomyosarcoma, neuroblastoma, thyroid carcinoma, metastatic disease) - Factors associated with an increased risk of malignancy are:
- Persistent lymphadenopathy
- Single dominant nodes >6 wks
- Supraclavicular / posterior triangle nodes are associated with an increased risk of malignancy.
These patients will have a painful, tender often red swelling.
Abscess
- is likely to be a fluctuant collection
- Contact ENT SHO to arrange review. If 9-5pm Monday –Friday arrange an US.
- If systemically unwell treat early for infection with IV fluids and antibiotics.
Antibiotics – As per GG&C Protocol
- IV First line – Benzyl Penicillin + Flucloxacillin
- Oral – Penicillin V + Flucloxacillin
- If penicillin allergic – Erythromycin
Non fluctuant swelling / Lymphadenitis
If the patient is well, observations within normal limits and there are no red flag features, treat with oral antibiotics and return to the Emergency ENT clinic, with instructions to return if there is a change in condition or concern.
If the patient is unwell contact ENT and arrange imaging and IV antibiotics
Cervical Adenopathy
If the neck lump is the presenting complaint rather than a coincidental finding then advise parents to arrange follow up with GP. Treat source if indicated.
Document size, consistency and location and ensure follow up documented on discharge.
The type of swelling can often be determined by its location. Chronic neck swellings in the absence of red flag features can be referred to a routine ENT clinic. Refer patients for an outpatient US scan.
Midline Cystic
Ectopic Thyroid
Dermoid
Thryoglossal duct Cyst
Lateral
Posterior to Sternocleidomastoid muscle (SCM)
Dermoid/Teratoma
Anterior to SCM
Unilocular
Laryngocele
Branchial cyst
Pre-auricular sinus / cyst
Multilocular Cystic Hygroma
Vascular
Haemangioma
Vascular malformation
Malignancy suspected
FBC and film
+/- Imaging
Refer at the time of presentation to the appropriate specialty.
US is the first line and further imaging will be guided by ENT / Radiology. Attempt to arrange an US scan during attendance if 9 -5pm Monday to Friday. If out with this time, request an outpatient US on Trak.
The ED secretaries will arrange this using the ED notes, a referral letter is not required. Record on the front of the card that an ENT Out-patient clinic appointment is required and the time scale eg Emergency ENT clinic this week, appointment within 2-3 weeks. An appointment will be sent out to the family