Pediatric emergency medicine trisk 237
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (193.85 KB, 4 trang )
Epidermoid
Lipoma, fibroma, neurofibroma
Keloid
Goiter (with or without thyroid hormone disturbance)
Osteochondroma
Teratoma (may be malignant)
Malignant
Lymphoma—Hodgkin disease, non-Hodgkin lymphoma
Leukemia
Other—rhabdomyosarcoma, neuroblastoma, histiocytosis X,
nasopharyngeal squamous cell carcinoma, thyroid, or salivary gland
tumor
“Normal” anatomy or variant
FIGURE 48.1 Evaluation of the child with a neck mass. a Malignancy: nontender, >3 cm
diameter (and firm), enlarging mass of several weeks’ duration, ulceration, location deep to
superficial fascia or fixed to tissue, supraclavicular mass, systemic lymphadenopathy and
bruising, superior vena cava syndrome.
After obtaining a thorough account of the mass itself, it is critical to assess the
involvement of other organ systems. Constitutional symptoms of fever, fatigue,
weight loss, night sweats, or adenopathy elsewhere are revealing. ENT and
respiratory symptoms such as noisy breathing (e.g., wheezing or stridor),
dyspnea, sore throat, and neck pain are likewise significant. Eliciting an exposure
history will further inform the differential. Temporal exposure to known sick
contacts, or recent trauma from animal scratches and bites can contribute to the
differential diagnosis. Antibiotic or antiepileptic drug exposure may cause
symptoms like serum sickness (e.g., fever, malaise, rash, arthralgias, nephritis) or
pseudolymphoma, respectively (see Fig. 48.1 ).
Physical Examination
The child presenting with a neck mass should have a thorough head-to-toe
examination, beginning with assessment for critical illness. A meticulous neck
evaluation may be deferred until after completion of the remaining examination.
Inspection of the oral cavity should describe structures such as oral mucosa,
dentition, Stensen duct (i.e., the parotid duct), and other glands. Movement of the
mass with swallowing or tongue protrusion is important to note. Further
inspection should include assessment of the scalp, ears, sinuses, and nasopharynx.
Evaluate remaining structures to determine if additional lesions are present.
The neck examination describes the location of the mass, including visual
inspection and palpation while in flexion and extension. Figure 48.2 diagrams
common locations of neck mass. Those in the supraclavicular area or the
posterior triangle (superior to the clavicle, and posterior or lateral to the
sternocleidomastoid), have a higher incidence of being neoplastic than those in
the anterior triangle (anterior or medial to the sternocleidomastoid). Palpation
provides critical characteristics of the mass including size, shape, consistency,
mobility, existence, and severity of tenderness. Presence of crepitation, thrill,
bruit, fluctuance, or overlying skin changes should also be noted. Characteristics
that may be associated with malignancy include masses that are firm, larger than
2 cm in diameter, nonpainful, progressively enlarging, ulcerating, deep to fascia
or fixed to tissue, longer duration (i.e., weeks), or discovered in a newborn. These
criteria are sensitive but not specific for cancer.
FIGURE 48.2 Differential diagnosis of neck mass by location. Area 1. Parotid: cystic
hygroma, hemangioma, lymphadenitis, parotitis, Sjögren and Caffey–Silverman syndrome,
lymphoma. Area 2. Postauricular: lymphadenitis, branchial cleft cyst (1st), squamous epithelial
cyst. Area 3. Submental: lymphadenitis, cystic hygroma, sialadenitis, tumor, cystic fibrosis.
Area 4. Submandibular: lymphadenitis, cystic hygroma, sialadenitis, tumor, cystic fibrosis.
Area 5. Jugulodigastric: lymphadenitis, squamous epithelial cyst, branchial cleft cyst (1st),
parotid tumor, normal—transverse process C2, styloid process. Area 6. Midline neck:
lymphadenitis, thyroglossal duct cyst, dermoid, laryngocele, normal—hyoid, thyroid. Area 7.
Sternocleidomastoid (anterior): lymphadenitis, branchial cleft cyst (2nd, 3rd), pilomatrixoma,
rare tumors. Area 8. Spinal accessory: lymphadenitis, lymphoma, metastasis (from
nasopharynx). Area 9. Paratracheal: thyroid, parathyroid, esophageal diverticulum. Area 10.
Supraclavicular: cystic hygroma, lipoma, lymphoma, metastasis, normal—fat pad,
pneumatocele of upper lobe. Area 11. Suprasternal: thyroid, lipoma, dermoid, thymus,
mediastinal mass. (From May M. Neck masses in children: diagnosis and treatment. Pediatr
Ann 1976;5(8):517–535. Reprinted by permission.)
Thoracoabdominal examination should pay special attention to auscultation
and consideration for other signs of systemic illness. Extrathoracic compression
of the upper airway may manifest only as faint inspiratory stridor. A goiter may
be coupled with signs of thyroid hormone excess (e.g., tachycardia, bounding
