Endocrine, Head and Neck, and Soft Tissue Surgery
The paediatric neck lump
Midline: a thyroglossal duct cyst elevates on tongue protrusion and is treated by the Sistrunk procedure, excising the cyst, tract and central hyoid; simple excision recurs. A dermoid cyst is midline but does not move with the tongue. Lateral: the second branchial cleft cyst is the commonest, lying anterior to the sternocleidomastoid, and needs complete excision because a tract may discharge. Cystic hygroma sits in the posterior triangle, transilluminates, and responds to sclerotherapy (OK-432, bleomycin) or surgery.
Vascular anomalies
Use the ISSVA framework. Infantile haemangioma appears after birth, proliferates and involutes; propranolol is first-line for problematic lesions. Vascular malformations - lymphatic, venous, arteriovenous - are present at birth, grow with the child and are managed with sclerotherapy, sirolimus or embolisation.
Thyroid: a solitary nodule in a child carries a higher malignancy risk than in an adult, so evaluate with ultrasound and fine-needle aspiration. Papillary carcinoma predominates and often requires total thyroidectomy with nodal dissection.
Traps
Congenital muscular torticollis (sternocleidomastoid tumour) is managed with physiotherapy, not surgery. Do not biopsy a vascular malformation without imaging, because of bleeding risk. Do not mistake a thyroglossal duct cyst for a dermoid, and do not treat a branchial cyst by aspiration.
Worked example
A 4-year-old has a 1.5 cm midline neck lump that rises with swallowing and tongue protrusion. Rule of thumb: this is a thyroglossal duct cyst - perform a Sistrunk procedure, not simple excision, or it will recur.