Tumours of the neck in children are usually divided into three groups: inflammatory lesions, congenital masses, and neoplasms.

The most common neck tumours are enlarged lymphatic nodes. An enlargement may concern one lymph node, may appear as local uni- or bilateral enlargement of lymph nodes, or as a generalised enlargement of lymph nodes. In all these cases the fundamental principle is to rule out a neoplastic disease or neoplastic metastases. Primary occupation of lymph nodes may appear in Hodgkin´s disease, non-Hodgkin´s lymphomas, and in leukaemia. Metastases to cervical lymph nodes in children most commonly give: lymphoepithelioma, retinoblastoma, neuroblastoma, rhabdomyosarcoma, nephroblastoma, Ewing´s sarcoma, and thyroid carcinomas (1).

Inflammatory lesions within the neck most frequently concern lymph nodes, but may appear as infection of median or lateral neck cysts too. Inflammation of the cervical lymph nodes can have a specific or non-specific character. Non-specific inflammations may accompany bacterial infection (angina, peritonsillar abscess, caries, purulent dermal lesions) or viral infection (mononucleosis). Specific lymph node inflammation within the neck appears in tuberculosis, sarcoidosis, syphilis, diphtheria, cat-scratch fever, toxoplasmosis, AIDS.

Congenital neck masses are a very differentiated group, including amongst others: median neck cysts (thyroglossal duct cysts) or lateral neck cysts (branchial cleft cysts), lymphangiomas, and haemangiomas. The most frequent congenital masses within this region are median neck fistulas and cysts. They are formed by incomplete obliteration of the thyroglossal duct during embryonic development, and their location corresponds to the site of the thyroglossal duct and the ostium of the cyst or fistula. Most frequently they are in the median line, from the level of the superior margin of the thyroid cartilage to the level of the hyoid bone. In these cases diagnosis is usually made quikly on the basis of the presence of a smooth, painless, elastic tumour in the anterior part of the neck, which slowly increases and in ultrasonography gives a characteristic cyst picture with a hypoechogenic centre, clearly visible wall, and intensification of the posterior wall echo (2). Because there may be a fragment of thyroid tissue in the region of the caecal foramen of the tongue which is the sole active part of this gland and which may be removed during a median neck cyst operation, the scintigraphy of the thyroid should be carried out beforehand. This shows if there is thyroid tissue correctly taking up the radioactive marker in the normal thyroid site.

Lateral neck cysts arise from the second branchial cleft, and can be found from the oropharyngeal tonsillar fossa to the supraclavicular region of the neck (3). Lateral neck fistulas arise from the first branchial cleft (2, 4). The ostium of a lateral neck fistula is most frequently near the anterior margin of the sternocleidomastoid muscle, and the internal ostium in the region of the supratonsillar fossa (2). Bailey divided lateral neck cysts into four types depending on their location in relation to other cervical structures: type I – cysts localized superficially under the cervical fascia, type II – cysts localized deeper on the angioneurotic fascicle, type III – cysts extending towards the lateral pharynx wall, between the external and internal carotid arteries, and ranging to the base of the skull, type IV – cysts localized longitudinally to the lateral pharynx wall, and medially to the internal carotid artery (5).

Teratomas and dermoid cysts represent congenital benign neoplasms, and are relatively rare within the neck region (6).

Treatment of congenital neck masses usually requires their surgical excision. The remainder of these changes gives a risk of recurrent infections, airway obstruction during increase of the tumour, or the risk of malignant transformation (6, 7).

Lymphomas, rhabdomyosarcoma and neuroblastoma are malignant neoplasms which may also manifest as neck masses in childhood.

We reviewed patients admitted with neck masses to the Department of Paediatric Otorhinolaryngology, Medical University of Warsaw from 1998 to 2002. Eighty – seven children were admitted of whom 74 with full documentation were analyzed. The study group consisted of 46 males and 28 females. The age of children ranged from 3 weeks to 15 years, mean age – 5.7 years. An analysis of age, sex, case history, character of neck change, methods of diagnosis and treatment was performed.

The most common tumours of the neck were inflammatory lesions. They were recognised in 47 children (63.5%), 33 boys and 14 girls. The youngest child was two weeks old, the oldest 13 years. Mean age 5.5 years. In 43 children (95%) the inflammation concerned the lymph nodes; in single cases a Hashimoto´s goitre, a suppurative inflammation of the submandibular gland, sialadenitis lymphocytica of the submandibular gland, and an abscess in the site of an incomplete removed of a lateral neck cyst were found. The time from the appearance of the first symptoms of a neck tumour to admission to the hospital was from several hours to 30 days, average 6 days. Fever before hospitalisation was present in 30 children (64%); tenderness on palpation or spontaneous pain in the tumour in 21 children (45%); reddening of skin over the change in 12 children (25%). Leucocytosis on admission to the hospital was from 10 to 40 thousand/mm³, average 17.3 thousand/mm³; erythrocyte sedimentation rate (ESR) was from 9 to 112 millimetres per hour, average 39 millimetres per hour.

Fifteen children (32%) were treated with antibiotic before admission to the hospital. Inflammatory changes were most frequently recognised in the region of the mandible angle (23 children) and in the submandibular region (11 children). In one child an abscess of the parapharyngeal space was diagnosed, and in two cases an inflammatory infiltration of the parapharyngeal space was observed. Inflammatory changes were usually localized on one side (72%). In 11 cases bacteriological examination of the abscess contents was performed; in 7 cases cultures were positive. In 4 cases mononucleosis was recognised. In another 4 cases, on the basis of levels of immune antibodies group G and M, a previous infection of Epstein – Barr virus (EBV) was recognised, and in one case toxoplasmosis was found. In the remaining cases (66%) the aetiology of the condition was unknown (Table 1).

The duration of hospitalisation of children with inflammatory lesions was 3 to 21 days, average 10 days. All children were initially treated with antibiotic given intravenously. In 12 children (25.5%) incision of an abscess was performed, with pus obtained in all cases. In one child spontaneous evacuation of pus contents was observed, and in one child the remains of a lateral neck cyst were re-operated. In 4 children, because of lack of improvement after pharmacological treatment, the enlarged lymph nodes were taken surgically for histopathological examination. In all these cases a histopathological examination give a picture of a chronic inflammatory process. In one case a bone marrow puncture was performed.

A sonographic evaluation was carried out on 41 children; in 24 this examination was performed two or more times. The size of single nodes in sonographic examination ranges from 10 to 35 millimetres, in 18 children less than 20 millimetres, and in the remaining 23 children over 20 millimetres. In all cases, when sonography showed a fluid to be present within the lymph nodes, a puncture was performed and pus was obtained.

Congenital lesions were diagnosed in 20 children (27%): median neck cysts in 11 children (15%), lateral neck cysts in 3 children (4%), lymphangiomas in 4 children (4.5%), haemangioma in 1 child, and torticollis in one child. The age of children with congenital lesions ranged from 1 month to 13 years, mean 4 years and 9 months. Congenital lesions were observed more frequently in girls (61% girls and 39% boys). The mean period between the appearance of the change and diagnosis was 17 months. In all cases, when a median neck cyst was suspected, a scintigraphic examination with Technet (Tc 99) was performed, to verify correct isotopic marker uptake by the thyroid gland localized in its normal site. In cases of median neck cysts the compatibility of the preliminary diagnosis on the basis of clinical and sonographic examination, and the final diagnosis after histopathological examination was 100%. Torticollis in a 1 month-old child was recognised after histopathological examination. Operative treatment was applied in 11 children with median or lateral neck cysts, while in 3 children with neck cysts treatment was carried out in other centres, and in the remaining 5 children further observation was applied (lymphangiomas and haemangioma).

In two cases benign neoplasms were diagnosed: a mixed tumour of the submandibular salivary gland in a 14-year-old girl, and lipoma in the submandibular region in a 6-year-old girl. In both cases the tumours were removed surgically.

Malignant neoplasms were recognised in two boys. These were non-Hodgkin´s lymphoma and Burkitt´s lymphoma.

In single cases sialolithiasis, sialosis, and unilateral jugular vein dilation were recognised.

The distribution of neck lesions in the analysed material is shown in table 2.

Neck masses are frequent findings in the paediatric population. A neck location suggests early observation of changes by parents and doctors, watching the dynamics and applying non-invasive diagnostic methods (ultrasonography).

Depending on the aetiology, many authors divide these changes into three groups: congenital lesions, inflammatory lesions, and neoplasms. In our study the most numerous group were inflammatory lesions (66%). Other authors who have analysed the aetiology of neck masses in children, have obtained diverse results; for example, in Torsiglieri 55% of patients had congenital lesions and only 27% had inflammatory lesions (8). These differences may result from differences in the centres in which children with neck masses are diagnosed and treated (paediatric otolaryngology, paediatric surgery, paediatric ward, and paediatric oncology).

In recent years many authors have underlined the role of sonography in the diagnosis of neck masses in children (9). Sonography allows the division of neck masses into two groups: the first are sonospecific masses, where the initial ultrasound investigation gives a relatively accurate presurgical diagnosis (thyroid tissue, cystic hygroma, cervical myelomeningocele). The second group contains non – specific neck masses (dermoid cysts, lateral neck masses, haemangioma, lymphangioma, neoplasms) (10). Sonography allows evaluation of the extent of the mass, its relationship to the thyroid gland and major cervical vessels, and indicates the best site for tissue biopsy or abscess incision. In children this examination has great significance because of its non-invasive character, possibility of multiple repetition and particular usefulness in diagnosis of changes within the salivary glands. Sonography allows us to differentiate between an inflammatory condition, sialolithiasis, and non-inflammatory masses within the salivary glands. A clear sonographic image is very characteristic of recurrent sialadenitis, and so sialography, which is an invasive examination, is now very rarely performed in children. In the case of median neck cysts, compatibility of the preliminary diagnosis on the basis of sonographic examination, and final diagnosis after histopathological examination, is almost perfect (9). Certain changes relating to lymph nodes can be accurately diagnosed presurgically by sonography (abscess), but a distinction between inflammatory and neoplastic adenophathy is not usually possible by sonography (10).

The greatest difficulty in differential diagnosis between the inflammatory and neoplastic aetiology of neck masses in children occurs in cases of subacute and chronic lymphadenopathy. Malignant changes are usually present later in childhood or in the teenage years, whereas congenital and inflammatory lesions are present in infancy and early childhood. We must however remember that some malignant lesions can be present at birth (neuroblastoma). Inflammatory changes usually have a short duration or recur at intervals. Lesions of long duration, identified at, or shortly after, birth would more likely be congenital and benign. Painless, rapidly enlarging masses are more often malignant (11).

Tumours of the neck in children are most often inflammatory or congenital in origin, malignant changes in this region being rare. A careful case history and close physical examination are very helpful in establishing an accurate diagnosis. The particular importance have the estimation of location, size of change, mobility to adjacent tissues and skin, and observation of tumour size after applied pharmacological treatment. In differential diagnosis a knowledge of the most common locations of particular cervical changes is helpful. Ultrasonography, x-ray films, computed tomography, and angiography are used in further diagnostics. A misdiagnosis leads to inappropriate treatment, with recurrences and cosmetic changes. The treatment of congenital lesions usually involves surgical removal, and in cases of neoplastic changes co-operation with the laryngologist and oncologist is necessary.