The Neck

Beyond infancy, the techniques for examining the neck are the same as for adults. Several important and somewhat unique aspects of the pediatric examination of the neck are described below.

Palpate the lymph nodes of the neck and assess the presence of any additional masses such as congenital cysts. Because the necks of infants are short, it is best to palpate the neck while infants are lying supine, whereas older children are best examined while sitting. Check the position of the thyroid cartilage and trachea.

Lymphadenopathy is unusual during infancy but very common during childhood. As shown on p. 656, the child's lymphatic system reaches its zenith of growth at 12 years, and cervical or tonsillar lymph nodes reach their peak size between 8 and 16 years. The vast majority of enlarged lymph nodes in children are due to infections (mostly viral but frequently bacterial) and not to malignant disease, even though the latter is a concern for many parents. It is important to differentiate normal lymph nodes from abnormal ones or from congenital cysts of the neck.

The following figure illustrates the typical location of congenital cysts, including thyroglossal duct cysts, branchial cleft cysts, cystic hygromas, epidermal (dermoid) cysts, and preauricular cysts or sinuses.

Lymphadenopathy is usually due to viral or bacterial infections (see Table 17-13, Abnormalities of the Neck, p. 770).

Malignancy is more likely if the node is greater than 2 cm, is hard or fixed to the skin or underlying tissues (i.e., not mobile), is accompanied by serious systemic signs such as weight loss, and, in the case of cervical lymph nodes, if the chest x-ray findings are abnormal.

In young children with small necks, it may be difficult to differentiate low posterior cervical lymph nodes from supraclavicular lymph nodes (which are always abnormal and raise suspicion for malignancy).

Branchial cleft cysts appear as small dimples or openings anterior to the midportion of the sternocleidomastoid muscle. They may be associated with a sinus tract.

Preauricular cysts and sinuses are common, pinhole-size pits, usually located anterior to the helix of the ear. They are often bilateral and may occasionally be associated with hearing deficits.

Posterior Cervical Nodes Children

Thyroglossal duct cysts are located at the midline of the neck, just above the thyroid cartilage. These small, firm, mobile masses move upward with tongue protrusion or with swallowing. They are usually detected after 2 years.

Check for neck mobility. It is important to ensure that the neck of all infants and children is supple and easily mobile in all directions. This is particularly important when the patient is holding the head in an asymmetric manner, and when central nervous system disease such as meningitis is suspected.

Congenital torticollis, or a "wry neck," is due to bleeding into the sternocleidomastoid muscle during the stretching process of birth. A firm fibrous mass is felt within the muscle 2-3 weeks after birth and generally disappears over months.

In infants and children, the presence of nuchal rigidity is a more reliable indicator of meningeal irritation than Brudzinski's sign or Kernig's sign. To detect nuchal rigidity in older children, ask the child to sit with legs extended on the examining table. Normally, children should be able to sit upright and touch their chins to their chests. Younger children can be persuaded to flex their necks by having them follow a small toy or light beam. You also can test for nuchal rigidity with the child lying on the examining table, as shown on the next page. Nearly all children with nuchal rigidity will be extremely sick, irritable, and difficult to examine.

Nuchal rigidity is marked resistance to movement of the head in any direction. It suggests meningeal irritation due to meningitis, bleeding, tumor, or other causes. These children are extremely irritable and difficult to console and may have "paradoxical irritability"— increased irritability when being held.

Chin Chest Meningitis Test

When meningeal irritation is present, the child assumes the tripod position and is unable to assume a full upright position to perform the chin-to-chest maneuver.

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In newborns, palpate the clavicles and look for evidence of a fracture. If present, you may feel a break in the contour of the bone, tenderness, crepitus at the fracture site, and limited movement of the arm on the affected side.

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A fracture of the clavicle may occur during delivery, particularly during difficult arm or shoulder extractions.

We must teach our children to dream with their eyes open.

—HHarry Edwards

You will have to be clever to examine the eyes of infants and young children and use some tricks to get them to cooperate. Small colorful toys are useful as fixation devices in examining the eyes.

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Responses

  • isaias
    Can touch and feelposterrior auricilar?
    1 year ago

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