Clinicopathological Presentation of Congenital Neck Mass in Children of Eastern Nepal

Background: Paediatric neck mass are common problem which often require surgical intervention. More than 90% of them are benign in nature and most of them are congenital in origin accounting up to 55%. They are asymptomatic in nature and may be associated with pain, infection and pressure symptoms. Methods: It was a prospective study conducted in the tertiary care centre over a period of one year from 15th June 2012 to 15th June 2013. All cases were evaluated clinico-radiologically followed by cytology and then underwent surgery. Histopathology report was taken as a confirmatory diagnosis. Result: Forty-five cases of congenital neck swelling were evaluated. Age of the patient range from 36 months to 15 years 4 months with male: female ratio of 1:1. About 58% of patient presented with lateral neck swelling and remaining were with midline neck swelling. Most common diagnosis was Thyroglossal duct cyst accounting for 48.8%. Conclusion: The most common congenital neck mass observed in eastern Nepal was thyroglossal duct cyst with most neck mass presenting as painless swelling.


Introduction
Paediatric neck mass are common worldwide often requiring surgical consultation in paediatric centers. 1,2 with 90% of the neck masses being benign and of these 55% congenital. 3 Congenital neck masses presenting to the otolaryngologist could be thyroglossal duct cyst, lymphangioma, branchial cysts, dermoids, thymic cysts, haemangiomas, ectopic thyroid, and congenital cervical teratoma. 4 Congenital neck mass can present as painless, soft, fluctuant and mobile swelling which can be infected and be painful. Few can have pressure symptoms like difficulty in swallowing and difficulty in breathing. These masses present diagnostic and therapeutic challenges especially in many resource-poor centers where affected children often present late and there may be a lack of sophisticated imaging facilities required for prompt and precise diagnosis. 5 We present our prospective evaluation of neck masses that had undergone diagnosis and treatment at our clinic in the last one year.

Materials and Methods
It was a prospective study in which 45 cases with congenital neck mass presenting in ENT OPD/ward between 15 th June 2012 to 15 th June 2013 were included to study the frequency and clinicopathological presentation of different congenital neck masses in eastern Nepal .Ethical approval from the institutional ethical review committee was taken.
Detail clinical history and thorough examination and ultrasonography with FNAC done to make out diagnosis. Histopathology followed in operated cases and diagnosis confirmed.
Data were recorded and analyzed. The inclusion criteria included all consented patients with congenital neck mass and neck swellings with infective origin were excluded.

Result
In our study the age of the patient ranges from 36 months to 15 years 4 months with male: female ratio of 1:1.14. All 45 cases presented with swelling in the neck, with 6 cases associated with pain and one with difficulty in breathing. Out of 45 cases, the commonest neck swelling diagnosed was thyroglossal cyst in 22 cases, followed by 9 branchial cyst, 5 each for hemangioma, lymphangioma and 4 cases for dermoid cyst. Table 1 Discussion Neck masses in pediatric age group are broadly of two types congenital and acquired. Congenital neck lesions reflect abnormal embryogenesis in head and neck development.
They can be cystic, solid or vascular and are benign in nature. They can present as midline or lateral neck swelling. Thyroglosslal duct anomaly is the commonest congenital lesion and more than 90% time located in midline. Whereas branchial cyst , laryngocele, lymphangioma, hemangioma, and fibromatosis coli are common congenital neck swellings located in lateral neck. [6] There is embryological difference between midline and lateral neck masses. Developmental malformations of branchial apparatus give rise to congenital neck masses mainly in lateral neck. There are four distinct branchial arches, and fifth arch is rudimentary which regresses latter one. Each arch coalesces with its contralateral counterpart ventrally on the midline and any faulty fusion of the arches in lateral region give rise to congenital lateral neck swelling. [7] Thyroglossal duct cysts result from failure of complete obliteration of the thyroglossal duct during development of the thyroid gland. Up to two third of thyrogossal duct cyst are located in sub hyoid region and others are in lingual, suprahyoid and suprasternal region. [8] The age of presentation range from 36 months to 15 years 4 months in the present study whereas it was 4 days to fifteen years in a 10 year study by Ratan K.N et al. 9 The male to female ratio was 1:1.14 in the present study which was in agreement to the study by Mahmut Öet al [10]but was different from Rattan et al.study.9 The commonest mode of presentation was painless neck swelling which was similar to the study by Taiseer H. A. et al. [11] The commonest neck swelling observed in our study was thyroglossal cyst which accounted for 48.88% similar to the finding observed by different authours. [10][11][12] The other neck swelling observed in our study were 9 branchial cyst, 5 each for hemangioma, lymphangioma and 4 cases for dermoid cyst which was consistent with the findings observed by Siddique et al. [13] Surgery is the only mode of treatment of thyroglossal duct cysts and every attempt should be made to completely remove the cyst entire tract to the base of the tongue and body of hyoid bone otherwise there will be high chance of recurrence. If the body of hyoid bone and a cuff of the tongue base are included in the specimen as described by Sistrunk recurrence rate drops to 3%. [14] Table1