Postnatal Cervical Teratoma in Infancy: Diagnostic Considerations in a Rare Presentation

Postnatal Cervical Teratoma in Infancy: Diagnostic Considerations in a Rare Presentation | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 16 September 2025 V1 Latest version Share on Postnatal Cervical Teratoma in Infancy: Diagnostic Considerations in a Rare Presentation Authors : Jose Morales Hernandez 0000-0003-4088-1941 [email protected] , Mildred C. Franco-Liñan , Hope Morales , Craig Warlen , and Ziad Khatib Authors Info & Affiliations https://doi.org/10.22541/au.175801704.43814832/v1 208 views 100 downloads Contents Abstract Discussion References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract We present a rare case of a 4-month-old female with an enlarging left cervical mass ultimately diagnosed as a mature cystic teratoma. Unlike most cervical teratomas detected prenatally or in the immediate neonatal period, this case highlights an atypical postnatal presentation without airway compromise. Imaging revealed a complex mass with features suggestive of teratoma, and surgical excision confirmed the diagnosis. This report emphasizes the importance of including teratomas in the differential diagnosis of pediatric neck masses and illustrates the variable clinical and anatomical presentations that may occur beyond the perinatal period. Postnatal Cervical Teratoma in Infancy: Diagnostic Considerations in a Rare Presentation Authors: Jose Morales Hernandez, DO Nicklaus Children’s Hospital Mildred C. Franco-Liñan, MD, Nicklaus Children’s Hospital Hope Morales, BA; MPH, FAAP, Herbert Wertheim College of Medicine Craig Warlen, MBME, BS, Herbert Wertheim College of Medicine Ziad Khatib, MD, Nicklaus Children’s Hospital Word Count: Abstract word Ct: 91 Main text word Ct: 1,299 Figures: 2 Key words: Cervical teratoma, Infant neck mass, Postnatal presentation, Germ cell tumor, Airway compromise Abbreviation Key Table MRI Magnetic resonance imaging ED Emergency Department CBC Complete Blood Count CMP Comprehensive Metabolic Panel CT Computed Tomography Abstract We present a rare case of a 4-month-old female with an enlarging left cervical mass ultimately diagnosed as a mature cystic teratoma. Unlike most cervical teratomas detected prenatally or in the immediate neonatal period, this case highlights an atypical postnatal presentation without airway compromise. Imaging revealed a complex mass with features suggestive of teratoma, and surgical excision confirmed the diagnosis. This report emphasizes the importance of including teratomas in the differential diagnosis of pediatric neck masses and illustrates the variable clinical and anatomical presentations that may occur beyond the perinatal period. Word Ct: 91 The differential for neck masses in infancy can be quite broad, ranging from congenital, inflammatory, and neoplastic causes. Common congenital lesions include thyroglossal duct cysts, branchial cleft cysts, and infantile hemangiomas 1,2 . Lymphatic malformations such as cystic hygromas may also be seen posteriorly 1 . Inflammatory causes may include reactive lymphadenopathy or infectious lymphadenitis 1 . While encountered less often, neoplastic etiologies must still be considered and may consist of teratomas, salivary gland tumors, rhabdomyosarcomas, and fibromas 2,3 . Teratomas are germ cell tumors composed of all three mesenchymal layers. The incidence of these tumors is between 1 in 20,000 and 1 in 40,000 births 3 . A mixture of cystic and solid components with calcifications can be seen on initial ultrasound imaging 4 . Definitive management of these lesions normally involves additional imaging workup utilizing MRI and surgical resection 4,5 . Monitoring tumor marker levels, such as alpha feto-protein (AFP) post-resection can facilitate the assessment of residual or recurrent disease 4,6 . This specific subset of germ cell tumors are commonly diagnosed prenatally or shortly after birth utilizing ultrasound modalities 3 . The most common location of a pediatric teratoma is in the sacrococcygeal region, accounting for approximately 60% of cases; other well reported sites for teratoma development are in the ovaries (25%), the mediastinum (7%), testis (3-5%), retroperitoneum (2-5%), and cervicofacial region (2%) 3 . Cervical teratomas in particular are more commonly found in the pre or immediate perinatal period 2 . Primary concerns for management purposes include assessing potential airway compromise and monitoring for malignant transformation. Much of the current literature focuses on describing the management of these lesions in the fetal and neonatal periods, as these neoplasms are exceedingly rare to present at other points in infancy 2,5 . In addition, urgent forms of treatment, such as the ex utero intrapartum procedure are more necessary within the perinatal period since this patient population is at a much higher risk for immediate airway compromise 2 . While it is unlikely, teratomas presenting in the cervicofacial region within the postnatal period may still remain as diagnoses to consider. This report will focus on the identification, proper diagnosis, and management of a rare and enlarging cervical mass that presented acutely in a postnatal, 4 month-old female with no significant past medical history. Word Ct: 358 We introduce a case of a 4 month-old female with no significant past medical history who presented with an acute onset of a cervical mass on the left side of her face. The lesion was located between the jaw and neck region. The parents first noticed the mass appear 3 days before presentation, and did not report any associated symptoms or overlying skin changes. Due to the growing nature of the mass, the parents brought the patient to the emergency department (ED). In the ED, a CBC, CMP, and inflammatory markers were collected; the CBC was remarkable for slightly elevated platelet count at 436,000 platelets/microliter. An ultrasound of the head and neck region was completed which showed nonspecific findings, identifying a large heterogeneous soft tissue lesion in the left anterior neck approximately 4.2 x 4.4 x 4.5 cm with minimal internal vascularity. Based on the location and appearance of the mass, plausible differentials included paraganglioma, rhabdomyosarcoma, branchial cleft cyst, and myofibroma. Hematology and oncology were consulted, and recommended further evaluation with an MRI for better visualization and collection of urine catecholamines. The pediatric surgery team was also consulted at this time. The patient was born full term and did not experience any complications during the pregnancy, birth, or immediate postpartum period. She did not have a history of surgeries or prior hospitalizations. The parents denied fevers, congestion, cough, episodes of emesis, swallowing dysfunction, respiratory distress, and history of other masses in the patient. The patient had been meeting developmental milestones and gaining weight appropriately. Her oral intake had not deviated from baseline according to her parents. The patient was not up to date on immunizations; she had not received the pneumococcal vaccine doses. Upon physical exam, the patient was in no distress and did not display any neurologic deficits. Respirations were non-labored with no retractions. A firm, immobile, nontender mass was palpated in the left submandibular area. The mass did not transilluminate, and did not move during swallowing or feeding. There was full range of motion of the neck. Vital signs were all within normal limits. The rest of the physical exam was unremarkable. Additional workup was pursued based on consult recommendations. A subsequent bone survey and an ultrasound of the abdomen were negative. An MRI was able to visualize the neck mass as displacing the surrounding medial and lateral pterygoid muscles and muscles of mastication with some encroachment on the left oropharynx. The mass extended along the left orbital facial region and had comparable signal intensity to the subcutaneous fat around it. Supplementary differentials suggested at this time were teratoma, lipoma, or lipoblastoma. A CT scan was recommended for further evaluation of the mandible soft tissue. The CT showed findings suggestive of a teratoma diagnosis, as there were various attentuations encountered within the mass consistent with calcifications, fat, and soft tissue. The mass was seen displacing the tonsil, tongue, and airway with inferior displacement of the submandibular gland. Some bony displacement of the left hyoid and condyle in the parapharyngeal region was reported as well. Findings were negative for cervical lymphadenopathy and invasion of vasculature. Based on these results, the decision was made to perform elective surgical excision of the mass with pediatric surgery and otolaryngology. Complete removal of the mass was performed with no intraoperative complications. The surgical teams excised a large, well-encapsulated left neck mass measuring approximately 7 cm x 4 cm x 4 cm. The lesion extended from the left mandible towards the skull base, and involved the masticator, parapharyngeal, and submandibular spaces. The mass was adherent to the tonsillar fossa and pharynx, and closely associated to the common carotid bifurcation and hypoglossal nerve. Nerve monitoring with facial nerve electromyography was utilized to preserve the marginal mandibular nerve. Final pathology confirmed a mature cystic teratoma containing a variety of tissue from each mesenchymal layer such as skin, nerve tissue, smooth muscle, adipose tissue, and gastrointestinal epithelium. Word Ct: 650 Coronal STIR (Figure 1.1) and Sagittal T2 (Figure 1.2) demonstrate the proximity of the tumor to the pharynx (blue arrow) as well as a fatty component (orange arrow) and solid component (green arrow) consistent with the diagnosis of teratoma Discussion This case contributes to the limited literature on the delayed presentation of cervical teratomas, and underscores the importance of maintaining a broad differential diagnosis for pediatric neck masses in otherwise healthy, asymptomatic infants. Cervical teratomas are rare germ cell tumors that account for 2-5% of all pediatric teratomas, and are most frequently diagnosed in the fetal or immediate neonatal period due to their potential for airway obstruction at this critical time 2,3 . Postnatal presentation, as in this 4 month-old patient with no respiratory symptoms, highlights an atypical clinical course. This case described a mature cervical teratoma presenting in an infant with no past medical history, whose mass was noted only days before initial visit to our institution. The delayed course of presentation contrasts with most reports in the literature, which emphasize prenatal detection through fetal ultrasound and MRI, and urgent perinatal management strategies 4,5 . The existing literature focuses mainly on the importance of securing the airway due to the large size, compressive nature, and anterior neck location of many of these lesions 2,6 . In contrast, our case demonstrates that postnatal cervical teratomas can present without immediate airway compromise in a more subtle fashion, necessitating high clinical suspicion and comprehensive imaging to avoid misdiagnosis. The tumor’s deeper extension into the parapharyngeal and masticator spaces also reflects variable anatomical presentations to consider. This report both corroborates and reinforces existing knowledge about the histological and radiographic characteristics of teratomas while challenging the assumption that cervical teratomas may usually present in the perinatal period or with respiratory distress. As such, it helps to broaden clinical awareness, encouraging continued vigilance in evaluating pediatric neck masses. Recognizing that delayed presentations can occur may add valuable nuance to clinical practice and underscores the significance of multidisciplinary evaluation and timely surgical intervention. Word Ct: 291 Total Word Ct: 1,299 Sagittal T2 (Figure 1.2) Solid component (green arrow) consistent with the diagnosis of teratoma References 1. Meier JD, Grimmer JF. Evaluation and management of neck masses in children. Am Fam Physician. 2014;89(5):353-358. Google Scholar 2. Jackson DL. Evaluation and management of pediatric neck masses: an otolaryngology perspective. Physician Assist Clin. 2018;3(2):245-269. Crossref Google Scholar 3. Barksdale EM Jr, Obokhare I. Teratomas in infants and children. Current Opinion in Pediatrics. 2009;21(3):344-349. Crossref Google Scholar 4. Green, J., Dickinson, F., Rickett, A. et al. MRI in the assessment of a newborn with cervical teratoma. Pediatric Radiology 1998; 28, 709–710. Crossref Google Scholar 5. Lakhoo K. Neonatal teratomas. Early Hum Dev. 2010;86(10):643-647. Crossref Google Scholar 6. April, M.M., Ward, R.F. and Garelick, J.M. Diagnosis, management, and follow-up of congenital head and neck teratomas. The Laryngoscope 1998;108: 1398-1401. Crossref Google Scholar 7. Figure Legend Google Scholar Information & Authors Information Version history V1 Version 1 16 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords germ cell tumor oncology pediatric hematology/oncology surgery teratoid/rhabdoid tumors Authors Affiliations Jose Morales Hernandez 0000-0003-4088-1941 [email protected] Nicklaus Children's Hospital View all articles by this author Mildred C. Franco-Liñan Nicklaus Children's Hospital View all articles by this author Hope Morales Florida International University Herbert Wertheim College of Medicine View all articles by this author Craig Warlen Florida International University Herbert Wertheim College of Medicine View all articles by this author Ziad Khatib Nicklaus Children's Hospital View all articles by this author Metrics & Citations Metrics Article Usage 208 views 100 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Jose Morales Hernandez, Mildred C. Franco-Liñan, Hope Morales, et al. Postnatal Cervical Teratoma in Infancy: Diagnostic Considerations in a Rare Presentation. Authorea . 16 September 2025. 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