Neck Swelling - Case 13-3: 2-Month-Old Boy
I. History of Present Illness
A 2-month-old boy presented with a 3-day history of neck swelling. The parents
did not think that there had been any swelling before the past 3 days. He had
had fevers at home for the past day. His oral intake had been adequate. There
was no emesis, diarrhea, respiratory symptoms, or rash. There was no exposure
to cats or to persons with tuberculosis. The parents noted small lesion on the
boy
's right neck and a question of an abrasion.
II. Past Medical History
There had been no hospitalizations. The patient was born at term during an
uncomplicated delivery. He had not yet received any immunizations. There were
no known allergies. The patient had not received any medications. Family
history was notable for no significant illnesses. The mother and father had
arrived from West Africa 6 months earlier.
III. Physical Examination
T, 38.5°C; RR, 44/min; HR, 176 bpm; BP, 112/76 mm Hg; SpO2, 97% in room air
Weight, 6.2 kg (75th to 90th percentile); length, 60 cm (90th percentile); head
circumference, 41cm (90th percentile).
On examination, the infant was not in any distress. The head was normocephalic,
and the anterior fontanelle was open and flat. The oropharynx was clear. The
right side of the neck was indurated. An erythematous mass arose from the angle
of the jaw and extended to the chin. There was no fluctuance. The lung and
heart sounds were normal. There was no hepatomegaly.
IV. Diagnostic Studies
The CBC revealed 15,300 WBCs/mm3, with 9% band forms, 65% segmented neutrophils, and 26% lymphocytes. The
hemoglobin was 11.7 g/dL, and the platelets were 296,000/mm
3. Serum electrolyte values were as follows: sodium, 135 mEq/L; potassium, 5.3
mEq/L; chloride, 103 mEq/L; bicarbonate, 24 mEq/L; blood urea nitrogen, 4
mg/dL; creatine, 0.2 mg/dL; and glucose, 113 mg/dL. Cerebrospinal fluid
examination revealed 1 WBC, no red blood cells, and a glucose concentration of
68 mg/dL. There were no bacteria on Gram staining. Blood, cerebrospinal fluid,
and urine culture were obtained. CT scan revealed an abscess in the right neck.
V. Course of Illness
On day 2 of hospitalization, there was significant drainage from the lesion on
the neck. The patient underwent operative drainage of the mass.
Discussion: Case 13-3
I. Differential Diagnosis
This mass was obviously congenital in origin, because it was manifested at age 2
months. Its location was adjacent to the angle of the jaw, again pointing to a
branchial cleft cyst that had become infected. The mass was warm, erythematous,
and increasing in size, indicating that an infection had complicated the
anomaly. The child was febrile, another likely marker of infection. Other
possible lesions besides a branchial cleft cyst are cystic lymphoma and
hemangioma. Congenital injury to the sternocleidomastoid muscle is usually
present at birth and does not expand over time. Congenital torticollis lesions
also have a firm, almost calcified, feel to them. A tumor is possible but less
likely in this age range. Also, a tumor would not have the inflammatory signs
that were evident in this child.
II. Diagnosis
The diagnosis is branchial cleft cyst with secondary infection.
III. Incidence and Epidemiology
Branchial cleft cysts are the most common congenital lesions on the midline
structure. Most thyroglossal duct cysts occur above the level of the thyroid
bed, but the location of branchial cleft cysts depends on which branchial arch
is the source of the congenital defect. The first arch is located in the
parotid region. The second is located off the angle of the mandible. The third
branchial cleft is located in the middle to lower part of the neck. The fourth
branchial cleft occurs in the lower neck area.
IV. Clinical Presentation
The clinical presentation depends on the location and on the state of infection
of the cyst. Most do not cause any symptoms other than the local effects.
V. Diagnostic Approach
The diagnosis may be aided by ultrasound examination but is primarily made by CT
scan of the neck. There are no supportive studies to lead to the diagnosis.
VI. Treatment
The therapy is excision. Removal of the entire cyst is often difficult, and
recurrences do occur if remnants are left
in situ. Antibiotic treatment is used to decrease the acute inflammatory response before
surgery. Broad-spectrum antibiotics aimed at gram-positive organisms are
typically used.
VII. References
1. Nusbaum AO, Som PM, Rothschild MA, et al. Recurrence of a deep neck
infection: a clinical indication of an underlying congenital lesion.
Arch Otolaryngol Head Neck Surg 1999;125:1379–1382.
2. Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections
in infants and children.
Otolaryngol Head Neck Surg 1995;112:375–382.
3. Mouri N, Muraji T, Nishijima E, et al. Reappraisal of lateral cervical cysts
in neonates: pyriform sinus cysts as an anatomy-based nomenclature.
J Pediatr Surg 1998;33:1141–1144.
4. Palacios E, Valvassori G. Branchial cleft cyst. Ear Nose Throat J 2001;80:302.
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
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