Endgames Picture Quiz

A midline neck lump in a child

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4447 (Published 30 July 2013) Cite this as: BMJ 2013;347:f4447
  1. Ian C C King, core surgical trainee year 2 in plastic surgery 1,
  2. Neil A Brierley, registrar in plastic surgery1,
  3. Kajetan Erdinger, consultant plastic surgeon1
  1. 1Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough TS4 3BW, UK
  1. Correspondence to: I C C King ianccking{at}doctors.org.uk

An 11 year old girl presented with a six month history of a swelling in the midline of her neck, overlying her hyoid bone. Three weeks previously, the skin overlying the swelling had broken down and the area had bled and been painful ever since. She was fit and well and denied trauma to the area. She was taking no drugs and reported no allergies. Her maternal grandmother had a multinodular goitre removed when she was 30 years of age.

Examination showed a bright red exophytic lesion with a diameter of 7 mm in the midline of her neck (figure). The lump moved upwards when she protruded her tongue. Intraoral examination was grossly normal. There was no palpable lymphadenopathy.

Questions

  • 1 What are the differential diagnoses for this lesion?

  • 2 How should this lesion be investigated?

  • 3 How should this case be managed?

Answers

1 What are the differential diagnoses for this lesion?

Short answer

The main causes of a midline swelling of the neck in a child are congenital abnormalities (thyroglossal cysts, ranulas, ectopic thyroid cysts, dermoid cysts), infection (abscess), trauma (pyogenic granulomas), cancer (lymphoma, lymphadenopathy), and vascular abnormalities (haemangioma, lymphangioma).

Long answer

Thyroglossal cysts account for about 75% of congenital midline swellings in childhood,1 2 and they are the most common abnormality of the midline neck seen in children.2 3 4 Most present by age 5 years …

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