8.13 Infectious Neck Masses in Children
Key Features
Cervical lymphadenitis is the most common infectious neck mass in children, but an abscess is also a possibility.
The age of the patient, the location, and the time frame to development of adenitis are important clues to the underlying etiology.
The diagnosis is commonly based on history and physical exam, not laboratory findings.
Medical management is appropriate for many causes.
Enlarged or inflamed lymph nodes are the cause of 95% of pediatric neck masses. A thorough physical examination is necessary because the lymph node groups are associated with different diseases, which will dictate proper management. Most of the lymphatics from the head and neck region drain to the submaxillary and deep cervical lymph nodes, explaining why these nodes are most commonly affected by cervical lymphadenitis. In the absence of cervical adenopathy, enlargement of the supraclavicular nodes can be indicative of thoracic or abdominal disease. The most common causes of isolated right supraclavicular node enlargement are Hodgkin′s and non-Hodgkin′s lymphoma. Isolated enlargement of the left supraclavicular nodes is most commonly associated with intraabdominal tumor or inflammation (Troisier sign).
Etiology
The underlying etiology of cervical lymphadenitis can be predicted based on the patient′s age. In neonates, group B streptococci are the most common cause of lymphadenitis. Staphylococcus aureus is usually the causative organism in patients 2 months to 1 year old. Along with Bartonella henselae (cat-scratch disease) and nontuberculous mycobacteria, S. aureus is also a common cause in 1- to 4-year-old patients. These organisms can be the cause of cervical adenitis in older patients along with tuberculosis, anaerobic bacteria, and toxoplasmosis. The timeframe is also an important factor to consider when determining the etiology of cervical adenitis. Acute bilateral disease is usually a response to acute pharyngitis but can also occur with Epstein-Barr virus, cytomegalovirus, herpes simplex virus, roseola, and enteroviruses. Acute unilateral lymphadenitis commonly presents with an associated cellulitis and is typically caused by S. aureus, Streptococcus pyogenes, and group B streptococci. Subacute or chronic unilateral lymphadenitis is much less common. It can be due to cat-scratch disease, mycobacterial infection, or toxoplasmosis.
Clinical
Signs
A thorough physical examination is essential. Note the size, location, laterality, firmness, and number of nodes. Erythema and tenderness are also important signs. Associated illnesses such as pharyngitis or systemic infection need to be noted.
Symptoms
Patients can present with unilateral or bilateral neck swelling, with or without any other symptoms. Tenderness of the affected nodes is commonly associated with acute infection.
Differential Diagnosis
Infectious causes are the most common. Malignancy is an important consideration in patients with no other signs of infection, with recent weight loss or fevers, or with isolated supraclavicular involvement. Noninfectious causes are much less common and include Kawasaki′s disease, sarcoidosis, sinus histiocytosis, histiocytic necrotizing lymphadenitis, and Kimura′s disease.
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