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Snapshot diagnosis - what's the swelling on this young boy's neck?

This smooth swelling on the neck of this child was worrying his mother. But what was it? Dr Mike Wyndham describes another case

This smooth swelling on the neck of this child was worrying his mother. But what was it? Dr Mike Wyndham describes another case

The patient

This boy was almost four and perfectly fit and healthy. At least, that was what his mother thought until she saw a swelling in his neck. He had no problems with swallowing and it became really obvious when he was looking upwards. In the consultation, her body language conveyed that she was pretty anxious.

First instinct

It certainly looked to be a smooth swelling. I'm aware that congenital lesions may appear some years after birth and this was an important consideration. I did try and reassure the boy's mother that malignancy was pretty uncommon in children. But I'm not sure that worked – particularly as I'd yet to lay a hand on the swelling.

Differential diagnosis

• Branchial cyst

• Thyroglossal duct cyst

• Lymph gland

• Cystic hygroma

Branchial cysts usually appear in the region of the sternomastoid muscle and so tend to be more lateral in the neck than this swelling. They are more likely to occur in the second and third decades of life.

Thyroglossal cysts certainly grow in the mid-line region of the neck and develop before the age of 20.

About 80-90% cystic hygromas have developed by the age of two. They have a soft feel, rather like dough. This lesion was a firm cyst making this diagnosis pretty unlikely.

There are many lymph glands present in the neck but it is rare to see enlarged glands in this region. When there is an infection like herpes simplex, the submental glands may enlarge. But there was no evidence of local infection and this swelling was somewhat distal to the submental region.

Getting on the right track

I always think of the thyroid when there is a midline swelling. So I gave the patient the opportunity to be rude and told him to stick out his tongue. Low and behold, like magic, the swelling moved upward. Although not a 100% definitive test, it was highly suggestive that this was a thyroglossal duct cyst. Referral to the paediatric surgeons confirmed the diagnosis and the cyst was successfully removed some weeks later.

Dr Mike Wyndham is a GP in Edgware, north London

What's caused the sudden swelling on this young boy's neck? Sudden neck swelling

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