Photo Quiz

Acute Neck Swelling in a Child

 

Am Fam Physician. 2021 Apr 1;103(7):437-438.

A five-year-old child presented for evaluation of midline neck swelling that had been growing slowly for two weeks. The swelling was not painful and did not interfere with swallowing or speech. The child had no injury or trauma to the neck. The swelling had never drained, ruptured, or ulcerated. The child had a history of eczema and mild intermittent asthma that was treated with an albuterol inhaler as needed. The child's mother reported having a similar midline mass that was surgically removed when she was about the same age as the patient.

On physical examination, the swelling measured 5 cm × 3.5 cm in size (Figure 1 and Figure 2). It was nontender, well-circumscribed, smooth, and fluctuant, with mild surface erythema. The lesion elevated with tongue protrusion. Palpation indicated that it was deep to the hypodermis. Examination of the head, eyes, ears, nose, and throat was otherwise unremarkable.

FIGURE 1


FIGURE 1

FIGURE 2


FIGURE 2

Ultrasonography of the swelling showed a mildly complex hypoechoic lesion anterior to the trachea. The patient's vital signs were normal. The metabolic panel and thyroid studies were within normal limits, but the compete blood count showed an elevated leukocyte level (16,500 per μL [16.50 × 109 per L]).

Question

Based on the patient's history, physical examination, and test findings, which one of the following is the most likely diagnosis?

  • A. Infected branchial cleft cyst.

  • B. Infected epidermal inclusion cyst.

  • C. Infected thyroglossal duct cyst.

  • D. Suppurative lymphadenitis.

  • E. Thyroid nodule.

Discussion

The answer is C: infected thyroglossal duct cyst. Thyroglossal duct cysts and dermoid cysts are the most common anterior midline neck masses in children.1 Thyroglossal duct cysts are an epithelial remnant of thyroid gland development in the embryo. During the fourth week of gestation, a posterior portion of the tongue migrates down the neck toward the anterior tracheal rings. This thyroglossal tract consists of thyroid tissue and typically atrophies by the 10th week of gestation, leaving the thyroid gland in the anterior midline of the neck. Portions of the thyroglossal tract can persist and become infected, usually following an upper respiratory tract infection. Despite being a common cause of anterior neck masses, thyroglossal cysts are rarely familial.2 Thyro

Address correspondence to Nandhini Veeraraghavan, MD, at nandhini.veeraraghavan@starwellness.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Meier JD, Grimmer JF. Evaluation and management of neck masses in children. Am Fam Physician. 2014;89(5):353–358. Accessed February 3, 2021. https://www.aafp.org/afp/2014/0301/p353.html...

2. Schader I, Robertson S, Maoate K, et al. Hereditary thyroglossal duct cysts. Pediatr Surg Int. 2005;21(7):593–594.

3. Rayess HM, Monk I, Svider PF, et al. Thyroglossal duct cyst carcinoma: a systematic review of clinical features and outcomes. Otolaryngol Head Neck Surg. 2017;156(5):794–802.

4. Thompson LDR, Herrera HB, Lau SK. A clinicopathologic series of 685 thyroglossal duct remnant cysts. Head Neck Pathol. 2016;10(4):465–474.

5. Luna MA, Pineda-Daboin K. Developmental cysts. In: Cardesa A, Jahannes Slootweb P, eds. Pathology of the Head and Neck. Springer; 2006:264–266.

6. Haynes J, Arnold KR, Aguirre-Oskins C, et al. Evaluation of neck masses in adults. Am Fam Physician. 2015;91(10):698–706. Accessed February 3, 2021. https://www.aafp.org/afp/2015/0515/p698.html

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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