Watery Discharge From the Neck...Now That Is Strange!

Tedra L. Simmons, DNP, CRNP, PNP-PC

Disclosures

Pediatr Nurs. 2013;39(5):254-255. 

In This Article

Summary

John is a 9-month-old boy being seen for a well-child examination and neck rash. He is awake, alert, and playful throughout the exam.

Differentials

Cellulitis. Bacterial infection usually caused by streptococci, staphylococci, or haemophilus influenzae. The infection is spread by contact. Patients will often present with fever, swollen lymph nodes, and/or an erythematous, infiltrated lesion. The lesion can start anywhere on the skin. A culture of the drainage will confirm the presence of the type of organism. John did not have a fever, no palpable lymph nodes, no erythema, no swelling, and no infiltration.

Impetigo. Infection caused by streptococcus or staphylococci and spread via contact. Often, the eruption begins as a superficial macular lesion that becomes vesicular in nature. Symptoms include multiple lesions with excudate that dries and forms a golden crust and pruritus (Perry, Hockenberry, Lowedermilk, & Wilson, 2010). Impetigo usually results from skin trauma, such as abrasions or bites. John has one single papular lesion, and does not have any crusting or apparent itching.

Insect Bite. A bite caused by mites, fleas, ants, bees, hornets, wasps, and several other insects (Perry et al., 2010). Insect bites usually present with intense urticaria, firm papules, and/or pinpoint vesicle. Symptoms include itching and mild erythema. John does not have any erythema, itching, or vesicular lesions.

Branchial Cleft Cyst. Caused by the incomplete closure of the sinus tract during embryonic life. Branchial cleft cyst can be inherited as an autosomal dominant trait (Burns, Dunn, Brady, Starr, & Blosser, 2009). Symptoms often present as clear, watery discharge along either side or both sides of the neck. There are usually no signs of infection, no obvious deformities, and no itching. The child appears well and not bothered by the drainage. John presented for a well-child exam with a threemonth history of rash with clear discharge on his neck.

Branchial cleft is also known as cleft sinus. Cysts are usually asymptomatic; however, they may become tender and swollen during upper respiratory infections (Hong & Crawford, 2012). Diagnosis is confirmed by the history and physical assessment. There are no specific laboratory or imaging studies recommended for diagnosis. Ultrason graphy can be used to determine if signs of infection are present (Hong & Crawford, 2012). Antibiotics are prescribed only if signs of infection are present, such as swelling, redness, pus drainage, or the presence of an abscess. Initial treatment is symptomatic care without the present of infection. Patients with a branchial cleft cyst should be referred to an otolaryngologist for excision.

The Management Plan

John was diagnosed with a unilateral branchial cleft cyst and was referred to an otolaryngologist. He was not prescribed any antibiotics at this time. He was sent to the local children's hospital referred testing office for a baseline neck ultrasound. His mother was informed that the cyst was benign. John's mother was presented with education on the signs and symptoms of infection. She was encouraged to return to clinic if these symptoms occur or for any further concerns.

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