1. Pediatric Neck Mass Report:R3 楊書瑜

2. Visiting our ER…. 95/6/17 Gender: female Age:11 BT: 38C, HR 112/min, RR 20/min, BP 115/70 mmHg Chief complaint: Intermittent fever for a week

3. Present Illness There were four L’t neck mass a months ago. Neck mass became larger and tender recently. Intermittent spiking fever to 39C Cough(+), Rhinorrhea(+), Headache(+) BW loss 2kg/2wks Abdominal cramping yesterday Vomiting(-), diarrhea(-), Skin rash(-)

4. Present Illness No travel history Family history: father had hypertension

5. What more do you want to know in present Illness?

6. History helps our DDx.. Location of the mass, size, and shape of the mass, duration of symptoms, and a history of injury Systemic symptoms: fever, malaise, rash, arthralgias, nephritis Exposure to animal or pets

7. Physical Exam General appearance: fair, Appearance: fair HEENT: anicteric sclera, not pale conjunctiva, Tonsil: enlarged, injected and no exudate Neck: supple, non-movable neck mass with tenderness, about 4X2 cm in size, Local heat (+), swelling(+), Supraclavicle LAP(+) Chest: BS clear

8. Physical Exam Abdomen: soft, flat, no tender Liver/Spleen: implabable BoS: normal Extremities: freely movable Skin: no rash

9. PE is important Palpation of the mass, noting its location, size, shape, relationship, and attachment to normal structures in the neck The presence of movement of the mass BS with wheezing or stridor Rashes, generalized lymphadenopathy the presence of hepatosplenomegaly or an abdominal mass Airway compromised Tumor or inflammation Malignancy

10. Physical examination Area 1. Parotid: Cystic hygroma, hemangioma, lymphadenitis, parotitis, Sjogren's 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. Sternomastoid (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.

11. Impression L’t neck mass r/o abscess, r/o lympadenopathy

12. Initial Order CBCdC, CRP, B/C X 1 Set IV as D0.225S run 60cc/hr Acetaminophen 1pc po stat

13. Lab data WBC 7500 RBC 4.53 X10 6 Hb 12.7 PLT 270000 Seg 68.7% Lymphocyte 27.3% Mono 3.8% Eos 0.1% Baso 0.1% CRP 15.08

14. Next Order Consult ENT ENT consultion: patent airway, Bil injected tonsil with neck mass==>r/o lymphadenopathy

15. Diagnosis Neck mass r/o lymphoma, r/o TB lymphadenitis  admission to Pediatric hematological ward

16. Is that enough? CXR should be ordered for mediastinal LN or TB adenitis Throat swab was necessary for bacterial adenitis

17. Neck mass in children Four classifications: inflammatory, congenital, traumatic, and neoplastic The most common causes of neck masses in children are reactive adenopathy and adenitis

18. Congenital Masses Thyroglossal duct cysts  most common Cystic hygromas Branchial cleft anomalies Hemangiomas Neonatal torticollis

19. Inflammatory Masses Cervical lymphadenopathy Cervical lymphadenitis Cat-scratch disease Mycobacterial infection Kawasaki disease

20. Cervical lympadenopathy most often associated with systemic viral infections IM, adenovirus, herpesvirus, coxsackievirus, and CMV Bacteria including Staphylococcus aureus and Streptococcus pyogenes

21. Nontuberculous mycobacterial adenitis of the head and neck in children: experience from a tertiary care pediatric center. Laryngoscope. 2001 Oct;111(10):1791-6 Laryngoscope. 2001 Oct;111(10):1791-6. Mycobacterial infection PPD test??

22. OBJECTIVE A retrospective study to describe our experience with the diagnosis, surgical treatment, and outcome of nontuberculous mycobacterial (NTM) adenitis of the head and neck in children, and to present a preliminary report about the use of NTM skin tests in our institution.

23. Method The medical records of all children diagnosed with cervicofacial NTM adenitis were retrospectively reviewed for the period from January 1, 1995, through December 31, 2000. We also examined the use of intradermal skin tests for the diagnosis of NTM infection.

24. Results Fifty patients were diagnosed with NTM cervicofacial adenitis. All patients were treated with complete excision of their lesion at the first operation. No major complications were noted. Only one patient relapsed and required a second operation. Forty-one children were skin-tested with NTM antigens. Of these, 30 patients were dual-tested with Purified Protein Derivative (PPD) also. No adverse reactions were noted with the use of skin tests. Sensitivity of NTM antigens alone is 87%. Sensitivity of dual testing is 78%. No patient had a PPD-dominant reaction.

25. Conculsion Surgical excision is the treatment of choice of NTM adenitis because of the high cure rate with a single procedure, the excellent cosmetic result, and the low complication rate. NTM skin tests are safe and could be useful in early diagnosis of the infection but further investigation is needed.

26. Neoplasm Seldom the cause of neck mass Constitutional signs and symptoms observed in the leukemias are less reliable findings in the lymphomas (BW loss, Fever, Night sweating)

27. Criteria for Malignant Neck Mass Firm mass Larger than 3 cm in diameter Nonpainful Progressively enlarging Ulcerating Deep to fascia or fixed to tissue Discovered in a newborn High sensitivity but low specifity

28. When to undergo biopsy? When is lymph node biopsy indicated in children with enlarged peripheral nodes? Pediatrics. 1982 Apr;69(4):391-6

29. When is lymph node biopsy indicated in children with enlarged peripheral nodes? Method: 239 children who underwent peripheral lymph node biopsy were reviewed Result  those children should undergo early biopsy 1.supraclavicular adenopathy 2.children sick with fever of one week's duration 3.weight loss 4.fixation of the lymph node to the overlying skin

31. Key Point~ Keep in mind the life-threatening sign ( mass compromised to adjacent organ) Exam and observe the malignancy critieria History is important for unusual infection

32. Thanks for your attention.