Dr. Matamoros is with the Department of Radiology; Drs.
Lydiatt are with the Department of Otolaryngology-Head and Neck
Surgery; and Ms. Mahoney is a medical student at the University
of Nebraska Medical Center, Omaha, NE.
Neck masses in children are common and can be evaluated by
various imaging modalities. Ultrasound is usually the initial
imaging modality used for locating and identifying a neck mass and
for determining solid versus cystic components. Computed tomography
(CT) and magnetic resonance imaging (MRI) are effective imaging
techniques for noninvasive evaluation of a neck mass and its
relationship to adjacent soft tissues and bony structures. MRI has
distinct advantages over CT, since it uses no ionizing radiation,
has multiplanar capability, and has much better intrinsic
soft-tissue contrast. MRI takes more time to image, however, which
can be difficult in pediatric patients. The imaging modalities
selected should complement the clinical evaluation of the neck mass
in a patient. This article will present a brief overview of neck
masses in children and give examples of those more commonly seen in
The vast majority of neck masses in children are benign lesions.
Despite this, special concern should be given for the possibility
of a malignancy. In the United States each year, cancer is
diagnosed in 1 in 333 persons younger than 20 years of age. It
affects 7,500 children prior to age 15 and 3,500 young adults
between 15 and 20 years of age.
Cancer is second only to accidents as the most common cause of
death after the first year of life.
The etiologies of these pediatric neck masses can be organized into
three general categories: congenital, inflammatory, and neoplastic.
The latter is subdivided into benign and malignant neoplasms.
Congenital neck masses
A neck mass present at birth is likely to be a congenital cyst
or a benign lesion. Malignant masses in neonates are very rare. Not
all congenital neck masses are recognized in the neonatal period.
Some congenital neck masses are not discovered until adulthood,
usually following an infection which leads to enlargement. A neck
mass that grows slowly is likely to be congenital or benign. More
rapidly growing neck masses that usually occur within 2 months are
likely to be malignant.
Thyroglossal duct cyst--Thyroglossal duct cysts result from
persistence of the embryonic thyroglossal duct that connects the
foramen cecum at the base of the tongue to the thyroid gland. The
majority of these thyroglossal duct cysts present in childhood but
can be aysmptomatic and be seen in adults. Up to one-third of these
masses may present after age 20.
The thyroglossal duct cyst is usually located in the midline of
the neck at or below the level of the hyoid bone. At times, these
neck masses can be seen located lateral to the midline. Lymph nodes
and a dermoid cyst can mimic a thyroglossal duct cyst (figure 1).
On CT scans, an uncomplicated thyroglossal duct cyst demonstrates
well-defined walls, and near water attenuation value of the cystic
component. If infected, the internal fluid within these cystic
lesions increases in attenuation value and the walls become thicker
and enhance following the administration of intravenous contrast.
On MR imaging, these thyroglossal duct cysts show low signal
intensity on T1-weighted images and high signal intensity on
Branchial cleft cyst--Branchial cleft cysts arise from failure
of obliteration of embryologic bronchial tissues. These anomalies
arising from the bronchial system can give rise to branchial cleft
cysts, sinuses, or fistulae. Branchial cleft cysts can be
recognized in later childhood or in early adulthood, though at
times they become apparent due to superimposed infection (figure
2). Approximately 90% of bronchial abnormalities arise from the
second branchial cleft, 8% from the first branchial cleft, and the
remainder from the third branchial cleft.
The branchial cleft cyst is commonly located along the anterior
border of the sternocleidomastoid muscle. About 5% of these
branchial cleft cysts are bilateral.
Suppurative thyroiditis in children may be due to infected
thyroglossal duct cysts and third branchial cleft cysts.
On CT, uninfected branchial cleft cysts appear as a thin-walled,
well-marginated, low-attenuation cystic masses. If the branchial
cleft cyst becomes infected, the walls become thicker and are less
well marginated with inflammatory changes seen in adjacent
soft-tissues. The cystic component increases in attenuation value.
On MRI, these lesions appear slightly hyperintense to muscle on
T1-weighted images and are hyperintense on T2-weighted images.
Lymphangiomas--Lymphangiomas arise from abnormal development of
primordial lymphatic channels. Histologically, these lesions are
divided into three types: simple, cavernous, and cystic. Sixty-five
percent of lymphatic malformations are present at birth, and 90%
present by the end of the second year of life.
Some of these lesions may present later in life with acute
enlargement that may be due to inflammation from an upper
respiratory infection or from hemorrhage into the cystic mass.
These lesions tend not to involute over time, as can be seen in
hemangiomas. On CT, uncomplicated lymphangiomas are non-enhancing,
low dense lesions. On T1-weighted images, lymphangiomas usually
have a low signal, but can also present with high signal if there
is fat or methemoglobin. On T2-weighted images, these lesions have
high signal intensity (figure 3).
Hemangiomas--Hemangiomas are classified as capillary or
cavernous. These lesions present within the first 6 months of life,
followed by a period of rapid growth, and then undergo spontaneous
slow regression. Hemangiomas are subcutaneous masses, or may
present as a cutaneous lesion, both accounting for the bluish
discoloration. Variable degrees of enhancement can be seen
following the administration of intravenous contrast on CT and MRI
Ranulas--A ranula is an abnormal cystic dilatation of an
obstructed sublingual or minor salivary gland in the floor of the
Two types of ranulas can be seen: simple and plunging. The simple
ranula is more common and is located in the sublingual space. The
plunging ranula descends beyond the mylohyoid muscle and into the
lower neck. On CT, the simple ranula shows thin-walled,
well-marginated, low density, nonenhancing cystic mass cephalad to
the mylohyoid muscle. A plunging ranula tends to have less
well-defined margins and has a higher attenuation value of its
contents (figure 4).
On MRI, ranulas tend to have a low signal on T1-weighted images and
high signal intensity on T2-weighted images.
Dermoids/teratomas-- Dermoid cysts arise from endoderm and
mesoderm germ cell layers. The internal contents include epidermal
appen-dages such as sebaceous glands, hair, and hair follicles.
Occasionally, focal calcification can be see within the lesion.
These cystic masses tend to be located above the level of the
The internal contents of the cystic mass will dictate their
appearance on CT and MRI. On CT, the low attenuation values are
due, in part, to the fatty tissue from the germ cell layers. MRI
will show the low signal from the fatty tissue.
Teratomas contain tissue elements from all three germ layers.
These lesions are usually present at birth and 20% are associated
with maternal polyhydramnios.
Teratomas tend to be located off the midline next to the thyroid
gland or project within it. Teratomas present with similar imaging
characteristics as dermoids.
Inflammatory neck masses
Cervical adenitis--Benign cervical adenopathy is most common
cause of neck masses in children. The lymphadenitis may be due to
bacterial, viral, fungal, parasitic, or noninfectious etiologies.
These nodes are likely to be located in the submandibular or deep
cervical nodes in 80% of children.
An upper respiratory tract infection tends to be the most common
cause for the cervical lymphadenopathy. The most common cause for
bacterial cervical lymphadenopathy is Staphylococcus aureus and
group A streptococci.
Cellulitis and abscess formation are the two most common
complications of cervical infections. CT will likely be the imaging
study used to evaluate the cervical soft tissues. On CT, cellulitis
presents as a nidus of soft-tissue swelling with loss of adjacent
soft tissue planes and no obvious necrotic center. An abscess will
show an enhancing ring surrounding a low dense focus of necrotic
tissue with or without gas present within the necrotic tissue
(figure 5). An abscess tends to have a low signal on T1-weighted
images and high signal on T2-weighted images.
Mycobacterial cervical adenitits can be another cause of
cervical adenopathy in pediatric patients. Both tuberculous and
nontuberculous mycobacteria are etiologic agents. On CT, the
cervical adenopathy likely will be a clustered collection of lymph
nodes, showing central necrosis, rim enhancement, adjacent
inflammatory changes, and occasional calcifications.
Other causes of infectious cervical adenitis include cat-scratch
fever, tularemia, mononucleosis, and fungal and parasitic
infections. Noninfectious inflammatory cervical adenitis can be
seen in Kawasaki disease, sarcoidosis, sinus histiocytosis with
and the FAPA syndrome (periodic fever, aphthous stomatitis,
pharyngitis, and cervical adenitis).
Acquired immunodeficiency syndrome (AIDS) is another cause for
cervical adenitis. The consideration of HIV infection is warranted
when there is cervical adenitis, nasopharyngeal hyperplasia, and
cystic parotid lesions that can be seen on CT and MRI evaluation.
Malignant neoplasms in the pediatric population are uncommon. In
a study of 445 children who underwent excision of any neck mass
(including lymph nodes), Torsiglieri et al
found 55% congenital masses, 27% inflammatory lesions, 5%
non-inflammatory benign lesions, 3% benign neoplasms, and 11%
malignancies. The majority of pediatric malignancies are due
leukemias and lymphomas (48%) and central nervous system tumors
In the United States, lymphomas account for more than 50% of
pediatric neck malignancies,
and rhabdomyosarcomas represent the most common pediatric
soft-tissue malignancy of the head and neck.
The two more common lymphomas include Hodgkin's disease (HD) and
non-Hodgkin's lymphoma (NHL). Non-Hodgkin's lymphoma accounts for
60% of newly diagnosed lymphomas.
Lymphoma commonly presents with painless cervical ad-enopathy.
Upper-neck lymph nodes are more commonly involved than lower-neck
lymph nodes. Hodgkin's disease also presents as a painless mass but
usually of the lower neck and supra-clavicular fossa.
Hodgkin's disease--Even though HD is less common than NHL, it
presents more frequently in the neck due to its unusual pattern of
extranodal involvement which is a more common pattern with NHL. HD
is more commonly seen after the age of 15 years and is rare before
the age of 10, and it is more common in males.
On CT, these lymph nodes may be individually enlarged or present as
a cluster of matted lymph nodes. A low dense center is consistent
with necrosis (figure 6). This CT appearance can mimic lymph nodes
involved with infection. On MRI, the involved lymph nodes tend to
be isointense to muscle on T1-weighted images and hyperintense to
muscle on T2-weighted images.
Non-Hodgkin's lymphoma--The peak incidence of NHL in children is
between 7 and 11 years of age.
The male to female ratio is 3:1 with a Caucasian to
African-American ratio of 2:1.
Childhood NHL tends to be more malignant, poorly differentiated,
and a more clinically aggressive tumor when compared with that of
adults. NHL is more likely to be disseminated and extranodal. The
CT and MRI findings are typical to those seen with HD.
Rhabdomyosarcomas--Rhabdomyosarcoma (RMS) is the most common
soft-tissue sarcoma of childhood and 35% to 40% arise in the head
The peak incidence of these tumors occurs between 2 and 5 years
with a secondary peak between 15 and 19 years of age.
RMS tend to be aggressive and infiltrating neoplasms. Orbital and
skull base RMS are more common than primary cervical RMS, with less
than 10% of those with primary head RMS developing cervical lymph
CT and MRI can be used for local staging; MRI, with its inherent
soft-tissue contrast is better at delineating the involved soft
tissues. On CT, RMS presents as a soft-tissue mass, with variable
internal necrosis or rim enhancement. On MRI, the involved soft
tissues are better seen with low signal on T1-weighted images and
high signal on T2-weighted images. High signal can also be seen on
T1-weighted images if there has been hemorrhage or a biopsy prior
to MR imaging. Contrast en-hancement of the tumor margins can be
seen with gadolinium.
Neuroblastoma--Approximately 2% to 4% of neuroblastomas occur in
These tumors arise from primitive neuroblasts and neural crest
cells and are the second most common solid tumor of childhood
occurring before 5 years of age. Aside from a cervical mass or
adenopathy, a Horner's syndrome may be present. Since neuroblastoma
is considered to have systemic involvement, CT and MRI are used to
evaluate for metastatic disease, with CT better for evaluation of
the chest and abdomen. On CT, neuroblastoma presents as a
paraspinal low attenuation soft-tissue mass with one-half of the
tumors containing calcifications.
MRI is better at identifying intraspinal involvement. On MRI,
neuroblastoma shows an intermediate signal on T1-weighted images
and slightly higher signal on T2-weighted images. Neuroblastomas
enhance after contrast administration.
Up to 3% of pediatric malignancies are due to thyroid carcinoma.
The majority of these tumors occur between 15 and 19 years of age
with a female to male ratio of 2:1.
On clinical presentation, 70% to 90% of these patients present with
and histologic examination reveals that nearly 90% have cervical
lymph node metastases.
Papillary carcinoma (>70%) is the most common type, followed by
follicular type (15% to 20%), medullary type (3% to 10%), and
anaplastic type (3%).
Low dense masses, with variable defined margins and calcifications,
can be seen on CT evaluation. Metastatic disease to lymph nodes can
demonstrate central necrosis and calcifications.
Other malignancies--Other pediatric neck malignancies that may
be seen include: other soft tissue sarcomas, nasopharyngeal
malignancies, salivary gland neoplasms, and metastatic disease.
Pediatric neck masses are common and most of these are benign
diseases. CT and MRI can be used effectively to complement the
clinical evaluation and help guide individual patient management.
CT and MRI each have particular imaging characteristics that should
be taken into account in the evaluation of pediatric neck
1. Torsiglieri AJ Jr, Tom LW, Ross AJ III, et al: Pediatric neck
masses: Guidelines for evaluation. Int J Pediatr Otorhinolaryngol
2. Cunningham MJ: The management of congenital neck masses. Am J
Otolaryngol 13:78-92, 1992.
3. Miller BA, et al: Cancer statistics review: 1973-1988, NIH
Report No 92-2789, Bethesda, MD, National Cancer Institute,
4. Lange B, Halpern S: Oncologic emergencies. In: Fleisher G,
Ludwig S, eds. Textbook of Pediatric Emergency Medicine, 2nd ed.
Baltimore. Williams & Wilkins, 1988.
5. Handler SD, Raney RB Jr: Management of neoplasms of the head
and neck in children. I. Benign tumors. Head Neck Surg 3:395-405,
6. Guarisco JL: Congenital head and neck masses in infants and
children. Part I. Ear Nose Throat J 70:40-47, 1991.
7. Guarisco JL: Congenital head and neck masses in infants and
children. Part II. Ear Nose Throat J 70:75-82, 1991.
8. Donegan JO: Congenital neck masses. pp. 1555-1565. In:
Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology:
Head and Neck Surgery, 2nd ed. St. Louis: Mosby, 1993.
9. Weissman JL: Nodal masses of the neck. pp. 794-822. In: Som
PM, Curtin HD, eds. Head and Neck Imaging, 3rd ed. St. Louis,
10. Zadvinskis DP, Benson MT, Som PM, et al: Embryology and
congenital cystic lesions. pp. 747-771. In: Som PM, Curtin HD, eds.
Head and Neck Imaging, 3rd ed. St. Louis, Mosby, 1995.
11. Takai S, Miyauchi A, Matsuzuka F, et al: Internal fistula
route of infection in acute suppurative thyroiditis. Lancet
12. Montgomery GL, Ballantine TV, Kleinman MB, et al: Ruptured
bronchial cleft cyst presenting as acute thyroid infection. Cin
Pediatr 21:380-383, 1982.
13. Radkowski D, Arnold J, Healy GB, et al: Thyroglossal duct
remnants. Preoperative evaluation and management. Arch OtolaryngoI
Head Neck Surg 117:1378-1381, 1991.
14. Coit WE, Harnsberger HR, Osbome AG, et al: Ranulas and their
mimics: CT evaluation. Radiology 163:211-216, 1987.
15. Rosenfeld CR, Coln CD, Duenhoelter JH: Fetal cervical
teratomas as acuse of polyhydramnios. Pediatrics 64:176-179,
16. Rosenfeld RM: Cervical adenopathy. pp. 1512-1524. In:
Bluestone CD, Stool SE, Kenna NM, eds. Pediatric Otolaryngology.
Philadelphia, Saunders 1996.
17. Baker CJ: Group B streptococcal cellulitis-adenitis in
infants. Am J Dis Child 136:631-633, 1982.
18. Dajani AS, Garcia RE, Wolinski E: Etiology of cervical
lymphadenitis in children. N Engl J Med 268:1329, 1963.
19. Siegel MJ, Shackelford GD, McAlister WU: Sinus
histiocytosis: Some radiologic observations. AJR 132:783-785,
20. Marshall GS, Edwards KM, Butler J, et al: Syndrome of
periodic fever, pharyngitis and aphthous stomatitis. J Pediatr
21. Kirshenbaum KJ, Nadimpalli SR, Friedman M, et al: Benign
lymphoepithelial parotid tumors in AIDS patients: CT and MRI
findings in nine cases. AJNR 12:271-274, 1991.
22. Soberrnan N, Leonidas JC, Berdon WE, et al: Parotid
enlargement in children seropositive for human immunodeficiency
virus: Imaging findings. AJR 157:553-556, 1991.
23. Pizzo PA, Miser JS, Cassady JR, et al: Solid tumors of
childhood. pp. 1511-1545. In: DeVita VT Jr, Hellman S, Rosenberg
SA, eds: Cancer: Principles and Practice of Oncology, 2nd ed.
Philadelphia, Lippincott, 1985.
24. Knight PJ, Mulne AF, Vassey LE: When is lymph node biopsy
indicated in children with enlarged peripheral nodes? Pediatrics
25. Raney R, Handler S: Management of neoplasms of the head and
neck in children. II. Malignant tumors. Head Neck 3:500-507,
26. Rubin LL: General principle of the epidemiology of childhood
cancer. In: Pizzo PA, Poplak DG, eds. Principles and Practice of
Pediatric Oncology, 2nd ed. Philadelphia, Lippincott. 1993.
27. Williams J, Thompson E, Smith KL: Long-term results of
treatment of children and adolescents with Hodgkin's disease.
Cancer 46: 2123-2125, 1980.
28. Altman AJ: Symposium on pediatric oncology. Pediatr Clin
North Am 32:541-862, 1985.
29. Sandfund JT, Downing JR, Crist WM: Non-Hodgkin's lymphoma in
childhood. N Engl J Med 334:1238-1248, 1996.
30. Latack JT, Hutchinson RJ, Heyn RM: Imaging of
rhabdomyosarcomas of the head and neck. AJNR 8:353-358, 1987.
31. Maurer HM, Abdelsalam HR: Rhabdomyosarcomas. pp. 491-515.
In: Fernbach DJ, Vietti TJ, eds. Clinical Pediatric Oncology. St.
Louis, Mosby, 1991.
32. Malogolowkin NH, Orega JA: Rhabdomyosarcoma of childhood.
Pediatr Ann 17:251, 254-268, 1988.
33. Sercarz JA, Mark RJ, Nasri S, et al: Pediatric
rhabdomyosarcoma of the head and neck. Int J Pediatr
Otorhinolaryngol 31:15-22, 1995.
34. Brown RJ, Syzmula NJ, Lore JM Jr.: Neuroblastoma of the head
and neck. Arch Otolaryngol 104:395-398, 1978.
35. Bousvaros A, Kirks DR, Grossman H: Imaging of neuroblastoma:
An overview. Pediatr Radiol 16:89-106, 1986.
36. Winship T, Rosvot RV: Childhood thyroid carcinoma. Cancer
37. Goepfert J, Dichtel WJ, Samaan NA: Thyroid cancer in
children and teenagers. Arch Otolaryngol 110:72-75, 1984.
38. Desjardins JG, Kahn AH, Montupet P, et al: Management of
thyroid nodules in children: A 20 year experience. J Pediatr Surg
39. Geiger JD, Thompson NW: Thyroid tumors in children.
Otolaryngol Clin North Am 4:711-719, 1996.
40. Millman B, Pellitteri PK: Thyroid carcinoma in children and
adolescents. Arch Otolaryngol Head Neck Surg 121:1261-1264, 1995.