The British Journal of Radiology, 78 (2005), 7585

DOI: 10.1259/bjr/15273006

2005 The British Institute of Radiology

Pictorial review

Neck masses in children

J R A TURKINGTON, FRCR, A PATERSON, FRCR, L E SWEENEY, FRCR and G D THORNBURY, FRCR
Department of Radiology, Royal Belfast Hospital for Sick Children, 180 Falls Road, Belfast BT12 6BE, UK

Abstract. Infants and children with neck masses frequently present to the radiologist for further evaluation. The
role of the radiologist is to differentiate between conditions using imaging modalities such as ultrasound with
colour Doppler, CT and MRI. Where appropriate, the radiologist will also stage lesions for management
purposes and aid in guiding aspiration or biopsy. This paper presents a pictorial review of paediatric neck
masses and their imaging features. Particular emphasis is applied to the anatomical site of the mass to aid in
differential diagnosis. It must be emphasised that the radiological findings should always be interpreted in
conjunction with the patients age, the clinical history and the findings on physical examination.

Neck masses are not uncommon in children. The most

common aetiologies include congenital lesions and their
complications, lymphadenopathy, vascular, inflammatory
and malignant lesions. The role of the radiologist is to
differentiate between these conditions using imaging
modalities such as ultrasound (US) with colour Doppler,
CT and MRI. US is useful to determine if a mass is
cystic or solid and Doppler tells us if it is vascular. US
should be considered as the first-line investigation because
it is non invasive, does not require sedation and does
not involve ionizing radiation [1]. CT and MRI can then
be used to determine the extent of the lesion and
whether local invasion is present. Both CT and MRI
can provide multiplanar images, however MRI will more
effectively demonstrate the soft tissue characteristics of a
lesion.

Anatomy
The neck can be divided into the anterior and posterior
triangles by the sternocleidomastoid (SCM) muscle
(Figure 1). To aid the radiologist, we have divided neck
masses into cystic or solid lesions and listed them
according to their anatomical location (anterior, posterior
or either neck triangle). Lesions arising in the SCM muscle
itself are discussed separately.

Anterior triangle masses

Thyroglossal cyst
Thyroglossal cysts usually manifest as an asymptomatic
mass during childhood and lie within the anterior triangle
[1]. They arise from a remnant of the thyroglossal duct.
This extends from the foramen caecum at the base of the
tongue to the pyramidal lobe of the thyroid gland, and
usually involutes by the 8th week of intrauterine life.
Remnants of a portion of the duct may lead to cyst
formation or ectopic thyroid tissue. Thyroglossal cysts are
midline or just off midline in position, and can be found at
any level from the base of the tongue to the isthmus of the
Received 22 December 2003 and in revised form 15 June 2004, accepted
13 August 2004.

The British Journal of Radiology, January 2005

thyroid gland. Most (65%) are infrahyoid [5, 9]. On US

they appear as a well-defined, thin-walled, anechoic mass
with through enhancement (Figure 2). A mass with mixed
echogenicity suggests infection of the cyst [5].

Branchial cyst
The branchial apparatus, consisting of six branchial
arches separated by five branchial clefts appears by the
15th day of intrauterine life. Incomplete obliteration of the
branchial apparatus, predominately the cleft, is postulated
to lead to branchial cleft anomalies such as cysts, sinuses
or fistulae [1]. Cysts may occur along the course of the first
or second branchial clefts, however the majority (75%)
arise from remnants of the second branchial cleft [9]. They
occur in children and adolescents as a mass situated
anterior to the SCM muscle and near to the angle of the
mandible. A thin-walled, anechoic fluid-filled cyst is seen
on US [5] (Figure 3a). With CT, the centre of the mass will
have an attenuation value similar to water and if the cyst is
infected, a thickened, enhancing wall will be present [9]
(Figure 3b).
Dermoid/teratoma
Developmental anomalies which involve pleuripotent
embryonal stem cells result in dermoid cysts and teratomas
[1, 7]. Most occur in children less than 3 years of age and
are situated in the midline [7]. They are usually
suprahyoid, in contrast to thyroglossal cysts. On CT an
inhomogenous, multiloculated mass that contains calcification and low attenuation fat enables the diagnosis [1, 7]
(Figure 4). MR will show the fat component as high signal
on T1 weighted images.
The thyroid gland
Thyroid masses are uncommon in childhood. They are
best evaluated with US and radioisotope imaging. Diffuse
enlargement of the gland can occur in thyrotoxicosis and
Hashimotos thyroiditis. The latter shows enlargement
with variable echogenicity. In thyrotoxicosis the gland is
enlarged, but the echopattern is similar to that of normal
thyroid tissue [8]. With a focal thyroid mass US can easily
differentiate whether the mass is solid or cystic. Most
cystic masses in the region of the thyroid are likely to be
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J R A Turkington, A Paterson, L E Sweeney and G D Thornbury

thyroglossal cysts. Solid masses all have a similar US

appearance of an echogenic mass. An adenoma is
characteristically echogenic with a surrounding hypoechoic
halo, carcinomas tend to demonstrate heterogeneous
echogenicity. The differential diagnosis of a solid mass
would also include lymphoma. A focal thyroid mass
should be further investigated with an isotope thyroid scan
and a cold nodule ultimately requires fine needle
aspiration (FNA) or biopsy for histological diagnosis
(Figure 5).

Salivary gland masses

Most salivary gland calculi occur in the submandibular
gland in adolescents. The calculi may be identified on
occlusal radiographs or with US. A sialogram will
demonstrate a filling defect of a ductal stone and may
also show glandular sialectasis due to ductal obstruction.
Sialadenitis or inflammation of the salivary gland tends to
affect the parotid gland in debilitated patients. The cause
is usually due to oral cavity or dental sepsis with
Staphylococcus aureus the most common pathogen [3]. It
can also occur due to the mumps virus. US will
demonstrate gland enlargement with abscess formation.
Recurrent parotiditis is rare but may result in unilateral,
periodic, parotid swelling. The aetiology is unknown and
non-obstructive sialectasis occurs. US shows hypoechoic
intraglandular ductal dilatation, which can also be
demonstrated with a sialogram or MRI [3] (Figure 6).

Posterior triangle masses

Lymphatic malformations
Congenital vascular and lymphatic malformations of the
head and neck can be classified into two groups: vascular
and lymphatic malformations and infantile haemangiomas
[2]. The latter will be discussed later in this review.
Vascular and lymphatic malformations grow in proportion
to the child and almost never spontaneously involute. This
group includes venous malformations (cavernous haemangiomas), capillary malformations (Port-wine stain) and
lymphatic malformations (lymphangiomas and cystic
hygromas). The previous terminology is listed in the
brackets.
Lymphatic malformations (cystic hygromas) are congenital malformations resulting from blockage of
lymphatic channels [6]. They usually present at birth as
a painless swelling, and most lesions (90%) appear before
the age of 2 years [2, 5, 6]. They are situated posterior to
the SCM muscle in the posterior triangle. They tend to
insinuate themselves around normal structures and can
extend caudad into the superior mediastinum. Most are
slow growing; however, sudden enlargement can occur
following infection of or haemorrhage into the lesion, and
may result in airway compression [2, 5, 6]. On US an
anechoic or mixed echogenicity mass with septae of
variable thickness will be identified [2, 4, 6].
Haemorrhage can lead to increased echogenicity or
fluidfluid levels being identified [2, 9]. The margins of
the mass and the presence of mediastinal extension are
better delineated with CT or MRI. CT will show a
septated, low density, poorly circumscribed mass.
Haemorrhage or infection causes an increase in attenuation. MRI will demonstrate a septated, cystic mass usually
76

of high signal on T2 and low signal on T1 weighted images

(Figure 7). Any high signal on T1 weighted images may
reflect haemorrhage or a high lipid content. The insinuation around normal structures is well demonstrated on
MRI and this can make complete surgical removal of the
lesion difficult [6].

Lipoma
This benign tumour of fat most commonly occurs in the
posterior triangle of the neck. They are rare in children
and appear as a solid, homogeneous mass of similar
echogenicity to that of the subcutaneous fat [8]. On CT
they will have low attenuation values of between 265 and
2125 Hounsfield units indicating fat [1]. They often
displace or compress adjacent structures; they are rarely
infiltrative.
Lesions of the sternocleidomastoid muscle
Fibromatosis coli
This rare, benign condition presents in the neonatal
period as a mass in the SCM muscle. Microscopically
muscle is replaced by dense fibrous tissue [4]. A history of
birth trauma and resulting torticollis is common. The
clinical course is that of spontaneous resolution over a
period of 48 months, with no treatment or with stretching
exercises [4, 9]. US shows a uniformly isoechoic or
hypoechoic mass within the muscle [4] (Figure 8). The
mass can be seen to move with the muscle on real time
ultrasound.
Lesions presenting in either triangle of the neck
Infantile haemangioma
In contrast to congenital vascular and lymphatic
malformations, infantile haemangiomas grow faster than
the child and then spontaneously involute. Infantile
haemangiomas of the head and neck usually occur in
children less than 6 months of age, and this term includes
the previously classified capillary haemangiomas, strawberry haemangiomas and capillary-cavernous haemangiomas [2]. Infantile haemangiomas usually grow rapidly until
910 months of age and then spontaneous regression
occurs, which can take up to 10 years. Plain radiographs
may show a soft tissue mass with areas of calcification
representing phleboliths [9] (Figure 9). US demonstrates a
mild to moderately echogenic mass, with echogenic
septations that are vascular on colour Doppler interrogation. MRI is better at showing the relationship of the mass
to the surrounding normal structures. The well-defined
mass will be of high signal on T2 weighted images and
contain flow voids, representing feeding and draining
vessels [9] (Figure 9). An involuting haemangioma is less
vascular and contains fibrofatty tissue and this is best
demonstrated with MRI [2].
Lymphadenitis
Cervical lymphadenitis usually results from a site of
infection in the head and neck, such as the tonsils, pharynx
or teeth [1]. US identifies numerous, discrete, enlarged,
tender, oval masses of reduced echogenicity (Figure 10).
Increased, branching vascularity is demonstrated with
The British Journal of Radiology, January 2005

Pictorial review: Neck masses in children

colour Doppler interrogation [8]. A necrotic lymph node

will have a cystic hypoechoic centre [8].

Abscesses
Abscesses can occur in either triangle of the neck and
also within the retropharyngeal space. On US a thickwalled, partially or fully fluid-filled mass will be present
(Figure 11). Gas forming organisms cause small pockets
of hyperechoic air within the collection. Enlarged,
hypoechoic lymph nodes may be identified surrounding
the abscess. Retropharyngeal abscesses commonly result
from tonsillar infection and pre-vertebral soft tissue
thickening can be identified on plain radiographs [9]
(Figure 11).

Rhabdomyosarcoma
This is the most common childhood soft tissue sarcoma
and 40% occur in the head and neck [1, 11]. Embryonal
rhabdomyosarcoma is the most common form, accounting for 60% of cases and occurring in the orbit,
nasopharynx, middle ear, nasal cavity and paranasal
sinuses [11]. Contrast enhanced CT and MRI are the
best imaging modalities for diagnosis and staging. CT is
valuable in demonstrating associated bony destruction.
An enhancing aggressive soft tissue mass that may have
foci of necrosis within it, is commonly demonstrated
(Figure 12).

Neuroblastoma
Most neuroblastomas arise in the adrenal glands,
however they may originate anywhere along the sympathetic chain [9]. Most present before the age of 5 years [10]
and those arising in the neck (5%) have a better prognosis
than those tumours of adrenal origin [1]. Neuroblastoma
can present as an asymptomatic mass, or along with local
compressive symptoms, such as dysphagia, hoarseness, airway obstruction, Horners syndrome or cranial nerve
palsies. Imaging findings depend on the histology of the
tumour and vary from a homogeneous well defined mass
to a heterogeneous one with necrosis and haemorrhage.
Calcification can be present, but is less common than in
abdominal neuroblastomas [10]. US typically shows an
echogenic mass. An unenhanced CT can demonstrate any
calcification [1]. Following intravenous contrast medium,
the mass of soft tissue density will enhance heterogeneously (Figure 13). MRI shows a tumour of high signal
on T2 weighted sequences and enhancement is seen following the administration of intravenous gadolinium [10].
Lymphoma
Lymphoma accounts for more than 55% of head and
neck tumours in children [1]. Upper neck nodes are usually
involved. If lower cervical nodes are involved, mediastinal
nodes are also usually found. On US or CT large
lymphomatous masses are identified and the involved
lymph nodes are no longer discrete [1] (Figure 14). Central
areas of necrosis within the nodal masses may also be seen.

Figure 1. Anatomical diagram illustrating the anterior and

posterior triangles of the neck.

The British Journal of Radiology, January 2005

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J R A Turkington, A Paterson, L E Sweeney and G D Thornbury

Figure 2. Thyroglossal cyst. (a) Ultrasound shows a midline

hypoechoic, avascular mass (arrow). (b) Axial short tau inversion recovery MRI confirms a high signal, well defined cyst
(arrow).

(a)

(b)

Figure 3. (a) Ultrasound of an uncomplicated branchial cyst.

Note the absence of septations and the through enhancement.
(b) Axial contrast enhanced CT showing a right sided low
attenuation branchial cyst.

(a)

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(b)

The British Journal of Radiology, January 2005

Pictorial review: Neck masses in children

Figure 4. Axial T1 weighted MRI of a mixed signal, right

sided teratoma (arrows). The low signal cystic components and
the intermediate signal fat can be identified.

(a)

(b)

Figure 5. (a) Isotope scan of thyroid demonstrating a photopenic area within the left lobe. (Reproduced with permission of
Springer-Verlag [12]). (b) Axial contrast enhanced CT of the same patient shows a solid mass within left lobe of thyroid (arrows).
Lymphoma was proven by biopsy.

The British Journal of Radiology, January 2005

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J R A Turkington, A Paterson, L E Sweeney and G D Thornbury

(a)

(b)

Figure 6. (a) Parotid ultrasound demonstrating multiple hypoechoic areas representing dilated ducts (reproduced with permission of
Springer-Verlag [12]). (b) Sialogram of same patient confirming intraglandular ductal beading of sialectasis of the left parotid gland.

80

The British Journal of Radiology, January 2005

Pictorial review: Neck masses in children

Figure 8. Ultrasound of isoechoic mass (arrows) consistent

with fibromatosis coli within the sternocleidomastoid muscle.

(a)

(b)

Figure 7. (a) Ultrasound of a hypoechoic septated cystic hygroma. (b) Axial T2 weighted MRI of a well defined high signal right
sided cystic hygroma (arrows). Note the insinuation around normal structures.

The British Journal of Radiology, January 2005

81

J R A Turkington, A Paterson, L E Sweeney and G D Thornbury

(a)

(c)

82

(b)

Figure 9. (a) Lateral soft tissue neck radiograph of a haemangioma containing phleboliths (arrows). (b) Ultrasound demonstrating a soft tissue density mass with hypoechoic branching
vascular channels. These were vascular on colour Doppler.
(c) Axial T1 weighted MRI of a left sided, high signal haemangioma with vascular flow voids.

The British Journal of Radiology, January 2005

Pictorial review: Neck masses in children

Figure 10. Ultrasound of well defined hypoechoic enlarged

lymph nodes (arrows).

Figure 11. (a) Ultrasound of a mixed echogenic, thick walled,

ill defined mass with central necrosis consistent with an abscess.
(b) Radiograph showing extensive pre-vertebral soft tissue swelling of a retropharyngeal abscess (reproduced with permission
of Springer-Verlag [12]).

(a)

The British Journal of Radiology, January 2005

(b)

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J R A Turkington, A Paterson, L E Sweeney and G D Thornbury

Figure 14. Axial contrast enhanced CT demonstrating multiple

left sided lymph nodes and a right sided lymphomatous mass
(arrows). Biopsy revealed Hodgkins lymphoma.

Table 1. Classification of soft tissue neck masses by anatomical site and predominant imaging characteristics
Anterior
triangle

Posterior
triangle

Either
triangle

Solid

Dermoid/
teratoma
Thyroid
mass

Lipoma

Infantile
haemangioma
Rhabdomyosarcoma
Lymphadenitis
Neuroblastoma
Lymphoma

Cystic

Thyroglossal
cyst
Branchial
cyst
Salivary
gland
Mass

Lymphatic
malformations

Figure 12. Axial contrast enhanced CT of an inhomogeneous,

enhancing, left sided, soft tissue mass within the anterior triangle (arrows). Histological diagnosis was rhabdomyosarcoma.

Mixed

Abscess

Conclusions
Neck masses are common in children and are a frequent
cause of attendance in the Emergency Department. They
can be classified according to their anatomical position in
the neck and their appearance. The details in Table 1 can
be used as an aide-memoir for the radiological
differential diagnosis of paediatric soft tissue neck
masses. After clinical examination, US should be the
first modality used for investigation as it is readily
available and does not involve ionizing radiation, unlike
CT, and does not require sedation as is often the case with
MRI in infants. It is particularly useful in assessing
thyroid masses, thyroglossal and branchial cysts and
parotid lesions. For other causes of neck masses it
should still be the first line of investigation, after which
CT and MRI can be used to determine the extent of the
mass and better define its tissue characteristics.

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Figure 13. Axial contrast enhanced CT demonstrating an irregular, enhancing right sided, biopsy proven neuroblastoma.

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Conference paper
Turkington JRA, Sweeney LE, Thornbury G, Paterson A.
Neck masses in infants and children: a pictorial review. In: Royal
College of Radiologists Annual Scientific Meeting, 10th12th
September 2003, London.

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