Cervical Lymphadenopathy in Children

Background

• Cervical lymphadenopathy refers to neck lymph nodes of abnormal size or consistency due to any disease process.
  • A cervical lymph node > 1 cm is generally considered to be enlarged, with the exception of anterior deep cervical lymph nodes, which may be considered normal up to a diameter of 1.5 cm.
  • Enlarged cervical lymph nodes are a common finding in childhood, with palpable lymphadenopathy occurring in an estimated 38%-45% of otherwise healthy school-aged children. Young children tend to have smaller lymph nodes than older children and adolescents.
• Infection (usually viral or bacterial) is the most common cause of cervical adenopathy in children, but malignancy must be considered, as well as less common infectious agents, systemic disorders, and other etiologies such as medications.
• Children typically present with 1 or more neck swellings.
  • Adenopathy must be differentiated from other neck masses.
  • Clinical presentation helps differentiate between benign reactive lymph nodes, inflammatory lymph nodes, and more serious adenopathy.
    • Acute lymph node enlargement associated with pain, skin changes, fluctuance, and/or fever suggests inflammation (lymphadenitis).
    • Subacute or chronic cervical adenopathy may suggest more serious or uncommon disorders.

Evaluation

• Consider testing to confirm suspected etiology, or if systemic disorder or malignancy is suspected.
  • Clinical findings are usually sufficient for diagnosing acute cervical lymphadenitis.
  • Testing is generally indicated for subacute, chronic, and generalized lymphadenopathy.
• Diagnostic approach should be based on clinical findings; consider for example
  • For adenopathy associated with fever, other systemic symptoms or signs, and/or nonstreptococcal pharyngitis that shows no regression after 3-5 days of watchful waiting - blood tests, including
    • Complete blood count (CBC) with differential
    • C-reactive protein (CRP)
    • Liver enzymes
    • Serology for Epstein-Barr virus (EBV)
  • For lymph nodes > 2 cm with no inflammatory signs, nodes ≤ 2 cm with inflammatory signs that do not improve with 7 days of antibiotics, and noninflammatory nodes ≤ 2 cm that do not regress after 4-6 weeks of watchful waiting
    • blood tests including CBC, CRP, liver enzymes, lactate dehydrogenase, and serology for EBV, tuberculin skin test, and ultrasound
    • serology for other common pathogens if diagnosis is still unclear
    • imaging studies, and oncology and surgery consultations to consider a lymph node biopsy if any finding is suspicious for malignancy or if the diagnosis remains unclear

Management

• Treatment depends on the suspected or known underlying cause.
• Management of infectious causes of cervical lymphadenitis
  • For acute viral lymphadenitis, antiviral therapy usually is not indicated unless the patient is immunocompromised.
  • For acute bacterial lymphadenitis, start empiric antibiotics. Ensure anaerobic coverage in children with dental or periodontal disease.
  • Pathogen-specific antimicrobial therapy is indicated for most lymphadenitis due to bacterial, fungal, parasitic, and other nonviral infections; however the role of antibiotics is unclear in immunocompetent children with Bartonella henselae infection (cat-scratch disease).
  • Consider lymph node drainage (via needle aspiration or incision and drainage) for suppurative lymphadenitis.
  • Consider lymph node excision or curettage for lymphadenitis refractory to antimicrobial therapy, especially in children with nontuberculous mycobacterial lymphadenitis.
• Management of other causes of cervical lymphadenopathy is highly disease-specific, and may include medications, surgery, and other treatment modalities.