Head and neck lumps
Causes:
The most common lumps are neck lymph nodes swelling from infections and congenital thyroglossal and branchial cysts. Other lumps are vascular lesions, lymphangiomas, salivary gland (parotid, thyroid and sublingual) and floor of mouth lesions. Cancers are less common in children, with many malignancies being blood cell origin.
Importance:
Lymph nodes more than 2 cm diameter, rubbery, enlarging or fixed require further evaluation. Repeated infections, pain, discharge is possible. Swallowing and voice may sometimes be affected. Malignancies though rarer must be excluded.
Investigations:
- Clinic examination and palpation may need to be supplemented with flexible nasolaryngoscopy of the upper airway
- Ultrasound scans of the neck and superficial lumps
- Fine needle aspiration cytology to differentiate benign and cancer lumps
- CT or MRI scan
Treatments offered:
- Medication (oral, injectable) for infections, hemangioma, lymphangioma
- Surgical excision for bioipsy, noresolving lumps and for definitive diagnosis
- Lymphangiomas and vascular hemangiomas can be particularly challenging with infiltration between important head and neck regions harboring key vessels and structures, with higher risk of residual and recurrent disease
Pediatric airway, voice and feeding
Drooling
Most children can control drooling by 4 years old. Excessive drooling may result in your child
experiencing skin irritations around the corners of the lips and chin area. In a normal child, they
may experience teasing from friends in school and playgroups.
Excessive drooling often results from poor oromotor control of the mouth and tongue muscles.
Assessments are done by a group of health providers which could include the Pediatric
otolaryngologist, speech pathologist and orthodontist. Children with underlying neuromuscular
issues should be reviewed by a Pediatric Neurologist as well.
Treatment
- Speech therapy, orthodontic treatment, management of nasal obstruction that results in chronic mouth breathing and poor oral tone.
- Oral medications to help reduce the amount of saliva produced.
- Botox injections into the salivary glands under Ultrasound guidance.
- Drool procedure (removal of the salivary glands and ligation of the parotid ducts)
What is stridor (noisy breathing)?
Stridor ( noisy breathing) is often a symptom of airway obstruction, which can be present at birth or a few weeks
after. It is a high-pitched sound which can be present when your child is inhaling (inspiration) or exhaling
(expiratory). Depending on the cause, it can be aggravated when your child is crying or running around.
Causes of stridor
The pediatric airway is divided into the supraglottic area, glottic area and subglottic area. The narrowest part of
the airway in children is the subglottic area (area directly below the vocal cords). Anything that causes narrowing
of the airway can result in stridor. It could be due to congenital disorder, infections, foreign body, tumor, trauma,
and allergy.
Congenital disorders
Subglottic stenosis: narrowing of the airway right below the vocal cords.
Vocal cord paralysis: when one or both the vocal cords are not moving.
Laryngomalacia: the most common congenital cause of stridor in children, often due to the collapse of the
laryngeal structures inwards when your child breathes in. This condition is frequently self-resolving and most
children improve by 18 months old.
Acquired causes of stridor
Infection
- Croup: viral infection resulting in swelling of the subglottic area.
- Epiglottitis: a life-threatening condition when there is severe obstruction of the airway, blocking the movements of air into the windpipe and lungs.
- Deep neck infections- retropharyngeal abscess, parapharyngeal abscess, peritonsillar abscess. These can happen in children after an upper respiratory tract infection.
Foreign body: An inhaled foreign body can result in airway obstruction and is an emergency. The child with partial
obstruction may present with noisy breathing.
Trauma: Physical trauma and chemical injury (from burns, toxic chemicals, poisons) can lead to swelling of the
airway and lead to airway obstructions.
Allergic reactions: severe allergy reactions can cause swelling of the airway. It may be due to food allergy, drug
allergy. The patient may have hives, eyes, tongue and lips swelling.
Craniofacial disorders (Syndromic children)
Some syndromic children with small and receded chin (Pierre robin sequence, Treacher Collins syndrome et al )
may also be predisposed to airway obstruction at birth due to the tongue falling backwards and blocking the
airway. These patients may present with stridor at birth and may require emergency airway intervention ranging
from the use of nasal/ oral airway devices, non-invasive positive pressure support( CPAP), to airway procedures
such as tracheostomy.
Treatment
A flexible nasoendoscopy may be passed through the nostril and into the airway. This can be done when your child
is awake in the clinic. It is not painful but can be slight uncomfortable.
Xray of the neck and chest may be performed to look at the airway for narrowing of the airway or radiopaque
foreign body.
In some patients, a microlaryngobronchoscopy (MLB) may be needed. This is a scope that passes through the vocal
cords and allows us visualization of the airway below the vocal cords and down the wind pipe to the carina.
Depending on the cause, the child may be treated with medications to reduce the swelling and reflux disease. A
temporary airway support such as CPAP, intubation may be needed. In some cases, an open tracheostomy, a
laryngeal reconstruction surgery (LTP) or a mandibular ( jaw) distraction procedure may be required.
