Thursday, July 15, 2010

Lumps and Bumps on the Head

I was recently scanning an online forum about pediatric health concerns. (What can I say?  I sometimes need inspiration.) There was one thread within the forum that was significantly longer than any other. Parent after parent posted about how they had noticed a knot on their infant or toddler. This concern parallels what I see in practice. An unexplained knot on the head is a common reason parents bring their child to be evaluated.

The first thing that comes to parents minds is that the lump represents something bad, like cancer. Fortunately, these lumps are almost always nothing to be concerned about. Worst case scenario is some lumps (cysts) may need to be surgically removed, but this is rare.

These are the things that parents notice:
  • Lymph Nodes.  By far these are the most common lumps that parent notice and worry about.  Most parents realize that lymph nodes can be found in the neck, but do not know that they are also found around the ears and at the back of the skull.  A pea-sized, rubbery knot beneath the skin is nothing to worry about. Often these are found in young infants (2 months old), leading to an office visit (if you have an infant, feel the back of his skull a few inches above the neck... you see what I mean?).  Healthy lymph nodes fluctuate in size, they grow and they shrink.  Bad lymph nodes keep growing and are not subtle.  If a lymph node is the same size that it was a month ago, it is healthy.  A lymph node needs to at least the size of a marble before I even bat an eyelash at it.  Even then, I will simply recheck it in a few weeks to make sure it is not continuing to grow. 
  • Congenital Cysts.  There are certain locations on the head that children can be born with a congenital cyst.  These can sometimes get infected and lead to problems.  However, some people could go their whole life with a cyst without having any problems.  Typical locations are in front of the ear (preauricular cyst), in the front middle of the neck (thyroglossal duct cyst), or the sides of the neck (brachial cleft cyst).  Cysts in these locations may also have dimples or tunnel from the skin down to the cyst.  Occasionally, these will need to be surgically removed.  Other times, they can be simply observed for problems.  (Your beloved, middle aged, blogging pediatrician has a thyroglossal duct cyst.  It has never caused me any problems and is not very noticeable, so I have just lived with it.) 
  • Dermoid Cysts.  I have probably seen 3 to 4 kids in my career with a cyst in their eyebrow.  These are typically located at the part of the eyebrow closest to the temple.  They are rubbery and the size of a pea or lima bean.  Because these can sometimes rupture due to trauma and cause a strong inflammatory reaction, they are often surgically removed. 
  • Bony Knot on an Infant's Skull.  Infants will often have swelling or bruising of their skull from delivery.  These areas of injury will sometimes calcify leading to a hard bony knot on the skull.  This is definitely something parents notice and worry about.  This calcified area is not dangerous and tends to remodel and go away as the skull grows, typically within several months.
These lumps certainly generate a disproportionate amount of anxiety relative to the true risk that exists from them.  If the lump is small and difficult for someone else to find, the chance it represents something that needs to be urgently evaluated is probably zero.  Things that make me concerned are typically blatantly obvious.  In other words, I can see it from across the room.  Otherwise, watchful waiting is probably going to be the safest, least invasive and most cost-effective approach to lumps and bumps on the head.


  1. Hi Dr Gonzalez, I am interested in your thoughts on thyroglossal cysts. You mentioned that you have had one your entire life that has caused no problems. When did your appear? How did you/your parents decide to wait and watch? Are there any numbers out there on how often TDCs become infected? I have scoured the internet and I cannot find any info except that surgery is usually reccomended. Your blog is the first place I have found someone who waited to see if it would cause problems. My 3 year old son has just been diagnosed with a TDC and the ENT who saw him (at a Children's Hospital) is very keen on removing it. He said it is a non-emergency but that they always end up getting infected and that once it is infected it will be much harder to remove and will cause tissue damage. We are more natural medicine minded and not as inclined to do the surgery. Plus our son has asthma, a deathly peanut/sesame allergy, and verbal apraxia with a significant speech delay. The idea of doing GA and cutting open his neck and removing tissue up to and into his tongue seems like it could be a bad idea. But the ENT has said that it is only a matter of time before it will get infected and that the surgery is no big deal. I don't know. It's our son being put under GA and cut open. Seems like a big deal to me.
    I know you are not our doctor but I am curious as to what your thoughts would be on something like this. His cyst is currently very small and not infected. It appeared four months ago after a cold.

  2. I would prefer not to make any specific recommendations regarding your child, as I believe that is best left between you and his doctors. I will tell you about my thyroglossal duct cyst and what a pediatric ENT, who I respect, told me.

    Mine was noted by my mother when I was 18 or 19 years old. It was pea-sized. She freaked out and sent me to an ENT who recommended just watching it. I did not give it much thought until a few years ago it enlarged to the size of a marble. I went to a different ENT and she did not recommend surgery unless it kept getting larger. It subsequently went back down to the pea size. It has never been infected.

    A pediatric ENT told me that he gives parents the option of removal or watching it. With the caveat that if it gets infected it would likely require two procedures. One to drain the infection, then a later surgery to remove it. At that point, removing it is much more challenging and higher risk due to scarring from the infection. If asked for his definitive recommendation based on his experience, he recommends removal. He also recommends the surgery be done by someone who has a lot of experience with this surgery (i.e., a pediatric ENT), because if it is not completely removed it will recur and subsequent surgery to remove it is even more difficult.

  3. Thank you for this post, Dr. Gonzalez. I have a two month old with a bump on the back of her skull, which the pediatrician identified as a lymph node. Our pediatrician did not seem concerned but also did not provide an explanation for the occurrence of the lymph node, so I decided to search the internet for information and found your blog.

    Despite my doctoral training in epidemiology (specifically infectious diseases), I find myself to be quite the anxious parent -- even when it comes to giving my baby vaccines. (I don't worry about the unfounded autism link, but rather other known but rare outcomes such as seizures, etc.) So after finding the post about lumps on the head, I read all of your other posts and found them to be interesting and reassuring. I hope that you continue to post entries for anxious parents like me in the coming year.