Baylor University Medical Center Proceedings October 2017 - 461

Submandibular neck mass in a newborn
Hunter Skoog, BS, and David W. Clark, MD

A deep neck abscess is uncommon in the newborn period. In this case,
we noted a clindamycin-sensitive methicillin-resistant Staphylococcus
aureus infection characterized as a deep neck abscess in an 8-day-old
boy. He was admitted to the pediatric intensive care unit with a progressively enlarging indurated mass below the mandible. Imaging confirmed
the mass as a submandibular abscess. The patient received antibiotics in
addition to incision and drainage, with resolution of the abscess.

eep neck abscesses can lead to complications such as
sepsis, mediastinitis, or airway compromise if not treated appropriately and in a timely manner (1). Abscesses
commonly arise as a sequela of odontogenic, rhinogenic, otogenic, or aerodigestive tract infections, and common
microbacterial causes include Staphylococcus aureus, Streptococcus
pyogenes, Streptococcus viridans, anaerobic gram-negative bacilli,
and Peptostreptococcus species (2). These infections, however, are
rare in the neonatal period, and here we describe a case of a
neonatal neck abscess caused by methicillin-resistant Staphylococcus aureus (MRSA).
CASE DESCRIPTION
A healthy male newborn was born at 37 weeks' gestation
to a 22-year-old gravida 2 para 1 mother who was induced
due to preeclampsia. The birth had no noted complications,
including trauma or procedures. The mother was negative for
group B Streptococcus. The infant spent 6 days in the nursery
due to physiologic jaundice, received phototherapy, and was
transitioned to home without diﬃculty. He presented 1 day after
discharge on the 8th day of life for newborn follow-up and was
noted to have left lateral neck swelling under the angle of the
mandible, which had started the previous night. The patient
did not have fever, vomiting, or diarrhea. The mass measured 4
to 6 cm and was noted to be indurated and tender to palpation
with erythema and ill-deﬁned borders. There was no sign of
trauma or ﬁstula in the skin. No stridor, respiratory distress, or
retropharyngeal or parapharyngeal fullness was noted on exam.
Hematologic workup showed a white blood cell count of
27.6 cells/μL (normal range 5-21) and a C-reactive protein of
22.6 mg/L (normal range <10). Blood and cerebrospinal ﬂuid
cultures were negative for organisms. An ultrasound demonProc (Bayl Univ Med Cent) 2017;30(4):461-462

strated a heterogeneous mass measuring 2.0 cm with prominent
lymph nodes along the left cervical chain. The patient was given
broad-spectrum intravenous antibiotics. Repeat imaging with
computed tomography showed a multiloculated abscess below
the left mandibular angle (Figure). Incision and drainage of
the abscess demonstrated purulence, and cultures were positive
for clindamycin-sensitive MRSA. The patient was managed
postoperatively for 8 days with culture-directed therapy and
was discharged home. An immunologic workup was negative
for any deﬁciencies.
DISCUSSION
Infection is the most common cause of neck swelling in the
pediatric population, with lymphadenitis being the predominant etiology. Other potential causes of neck swelling include
a variety of congenital, inﬂammatory, benign, and malignant
lesions. In the neonatal period, the most common pediatric
neck lesions are thyroglossal duct remnant and branchial cleft
anomalies (3). However, in our patient, the abrupt onset, associated induration and erythema, and posterolateral location at the
angle of the mandible suggested an inﬂammatory process, which
was conﬁrmed upon imaging to be suppurative lymphadenitis.
In a study of 445 neck masses in children, 2% were diagnosed with suppurative lymphadenitis, with MRSA being the
most common pathogen. The average age for this cause was 7.3
years, with a range from 4 months to 15 years (4). A review of
the literature revealed a paucity of data regarding neonatal neck
infections. One study from Texas Children's Hospital looking
at children up to 60 days old from whom S. aureus was isolated demonstrated that two-thirds (67%) of abscesses isolated
MRSA (5).
A highly prevalent location of suppurative lymphadenitis is
along the anterior jugular chain, which is consistent with the
location of our patient's abscess. The lymph node involvement
is usually unilateral and is a result of a pyogenic infection of
From Texas A&M Health Science Center College of Medicine (Skoog) and the
Department of Otolaryngology-Head & Neck Surgery, Baylor Scott & White Health,
Temple, Texas.
Corresponding author: David W. Clark, MD, Department of Otolaryngology-Head
& Neck Surgery, Baylor Scott & White Health, 2401 South 31st Street, Temple,
TX 76508 (e-mail: David.Clark1@BSWHealth.org).
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