Evaluation and Management of Neck Lumps in Children

Initial Imaging Assessment

Ultrasound is the initial imaging modality of choice for most pediatric neck masses, particularly when congenital abnormalities or superficial infections are suspected, with CT or MRI reserved for cases concerning for malignancy or deep neck infections requiring surgical intervention 1, 2
The American College of Radiology recommends ultrasound as the first-line imaging for suspected congenital abnormalities, superficial infections, and discriminating high-flow from low-flow vascular malformations 1, 2
Ultrasound is useful for guiding fine-needle aspiration and characterizing vascular flow in solid lesions using color-flow Doppler 1, 2, 3

CT neck with IV contrast is usually appropriate when malignancy is suspected based on clinical features or when deep neck infection or abscess requiring surgical drainage is present 1, 2
MRI neck is usually appropriate when malignancy is suspected and soft tissue characterization is needed, or for evaluating deep neck abscesses 1, 2, 3
The American College of Radiology states that CT and MRI are equivalent alternatives and may be complementary to ultrasound 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends advising patients/families of criteria triggering need for additional evaluation and documenting follow-up plans to assess resolution in low-risk masses 4
High-risk masses concerning for malignancy require urgent referral to a head and neck surgeon, with red flags including fixed masses, supraclavicular location, size >2 cm, and ulceration present 1, 2, 3