Approach to the Problem
Facial lumps cause concern for parents though many of these lesions are benign and self-limited. The more common pediatric facial lesions include dermoid cyst, epidermoid cyst, superficial and deep (subcutaneous) hemangioma, pilomatricoma, buccal cellulitis, pyogenic granuloma, Spitz nevus, and suppurative parotitis. Less common lesions include trichoepitheliomas, Pott puffy tumor, panniculitis, fat necrosis, juvenile xanthogranuloma, and mumps. Although many of these facial lumps do not require immediate therapy, it is important to correctly diagnose and identify those lesions requiring urgent medical attention.
Key Points in the History
• Trauma is usually associated with hematomas.
• Hemangiomas, juvenile xanthogranulomas, and dermoid cysts are present at birth or appear in early infancy.
• Epidermoid cysts can appear at any age but appear more commonly after puberty.
• Prolonged exposure to cold in the area of swelling suggests panniculitis. Fat necrosis often occurs secondary to cold trauma.
• Constitutional symptoms of fever and malaise may suggest mumps, suppurative parotitis, buccal cellulitis, or Pott puffy tumor.
• A history of recurrent parotid swelling or a family history of parotid swelling may indicate juvenile recurrent parotitis, a nonsuppurative parotid inflammation of unknown etiology.
• The history of an unimmunized child with parotid inflammation strongly suggests mumps.
• Chronic, nonpainful swelling of the parotid gland may be seen in patients with HIV infection.
Key Points in the Physical Examination
• Swelling that obscures the angle of the jaw suggests parotid inflammation or parotitis.
• Children with mumps are rarely ill-appearing.
• Suppurative parotitis, most commonly caused by Staphylococcus aureus, is associated with an ill-appearing child with purulent discharge from Stensen duct.
• Buccal cellulitis, panniculitis, hematoma, parotitis, and Pott puffy tumor produce painful lumps.
• Swelling associated with erythema of the overlying skin suggests buccal cellulitis, panniculitis, fat necrosis, or suppurative parotitis.
• Friable lesions are characteristic of pyogenic granulomas.
• A Spitz nevus is a rapidly growing dome-shaped, erythematous papule commonly found on the face and extremities.
• Lumps with an associated bluish hue suggest a pilomatricoma or deep (subcutaneous) hemangioma.
• A pilomatricoma is typically a rock-hard papule due to its propensity to calcify.
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