Differential Diagnosis of Bilateral Lower Jaw/Neck Swelling in Children

Infectious Etiologies

Kawasaki disease presents with bilateral cervical lymphadenopathy, fever ≥5 days, "strawberry tongue," polymorphous rash, and swollen extremities, which is critical to identify due to the risk of coronary artery aneurysm, as recommended by the American Academy of Ophthalmology 1
Scarlet fever, caused by Group A Streptococcus, is characterized by "strawberry tongue" and cervical lymphadenopathy with a characteristic rash, most common in children aged 5-15 years, according to the American Academy of Pediatrics 2

Burkitt lymphoma and diffuse large B-cell lymphoma commonly present with painless bilateral cervical lymphadenopathy in children, with firm, non-tender, fixed nodes >1.5 cm, B-symptoms, and rapid growth, as stated by the National Comprehensive Cancer Network 3
Lymphoma may cause jaw/gingival/maxillary swelling, difficulty swallowing, and vision changes, and oncologic emergencies such as tumor lysis syndrome, airway compromise, and superior vena cava syndrome are possible, as warned by the National Comprehensive Cancer Network 3

A duration of symptoms >2 weeks without fluctuation increases the risk of malignancy, as indicated by the American Academy of Otolaryngology-Head and Neck Surgery 4
Fever ≥5 days with rash and extremity swelling is suggestive of Kawasaki disease, which requires urgent treatment to prevent coronary complications, as recommended by the American Academy of Ophthalmology 1
Fixed nodes, firm consistency, size >1.5 cm, or ulceration of overlying skin are red flags for malignancy, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 4
Painless, non-tender nodes are more concerning for malignancy, as noted by the National Comprehensive Cancer Network 3

Ultrasound is the first-line imaging modality for pediatric neck masses, as it distinguishes solid vs. cystic, assesses vascularity, and has no radiation exposure, as recommended by the American Academy of Pediatrics 5

Excisional or incisional biopsy is preferred for suspected malignancy, with fresh tissue in saline, as stated by the National Comprehensive Cancer Network 3
Fine needle aspiration can be performed but may be inadequate in children, as noted by the National Comprehensive Cancer Network 3

In any child presenting with neck swelling, immediately assess for airway compromise, deep neck infection requiring surgical drainage, and multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19, as recommended by the American Academy of Pediatrics and the American College of Rheumatology 6, 7
Airway obstruction from retropharyngeal or parapharyngeal abscess requires urgent evaluation for stridor, drooling, respiratory distress, or inability to swallow, with a high risk of complications if not promptly addressed 7
MIS-C presents with neck swelling as part of a constellation including fever ≥3 days, multiorgan involvement, elevated inflammatory markers, and recent COVID-19 exposure within 4 weeks, with a strong recommendation for prompt recognition and treatment by the American College of Rheumatology 6, 8

Ultrasound is the first-line imaging modality for pediatric neck masses, distinguishing solid from cystic lesions, assessing vascularity, and avoiding radiation exposure, as recommended by the American College of Radiology 7, 9, 10
CT neck with IV contrast is indicated for suspected malignancy or deep neck infection requiring surgical drainage, with shorter examination time reducing sedation requirements, according to the American College of Radiology 7, 9, 10
MRI neck without and with IV contrast is appropriate for suspected malignancy or deep neck abscess requiring surgical drainage, particularly when detailed soft tissue characterization is needed, as recommended by the American College of Radiology 7, 9, 10

Congenital etiologies must be added to differential considerations in children, including thyroglossal duct cysts, branchial cleft cysts, dermoid cysts, and vascular malformations, with a recommendation for imaging and further evaluation by the American College of Radiology 9, 10