Radiographic studies are usually not necessary for evaluation of recent onset of masses that appear to be inflammatory. However, persistent or progressively enlarging adenopathy warrants a chest x-ray. A plain chest x-ray may detect pulmonary or mediastinal lesions as a source for cervical or supraclavicular adenopathy (14). Plain radiographs have been supplanted by the use of other more advanced imaging techniques in many situations. Currently, the main use of plain radiographs is for evaluation of the chest for the presence of lymphadenopathy or other pulmonology pathology, as well as soft tissue lateral neck radiographs to assess the airway and prevertebral soft tissue thickening. Initial workup for children with a potential cervical neoplasm should include PA and lateral chest radiograph. This may reveal mediastinal lymph node enlargement as the underlying cause of the airway obstruction or superior vena cava syndrome.

Ultrasonography has some important advantages for use in the pediatric population; it does not involve ionizing radiation and is readily available (14). Ultrasound is often considered the first-line diagnostic imaging study by many centers (6, 15, 16). Ultrasound can easily distinguish solid from cystic lesions. Ultrasound is helpful in evaluating the thyroid and parotid lesions and may help diagnosing confusing congenital lesions (14). High-resolution ultrasound is able to assess nodal morphology and internal architecture as well as characterize the echogenic patterns of a mass, classifying them as cystic, solid, or complex in nature. Doppler ultrasound may be used to assess the presence of perfusion and its distribution as well as obtain measures of vascular resistance. Advantages of ultrasound are that it is noninvasive, avoids ionizing radiation, is portable and inexpensive, and can be performed without sedation in most patients. Drawbacks include difficulty to interpret, subject to skill level of operator, may not be able to visualize deeper lesions, and lack of anatomic information for surgical planning (17, 18, 19). High-frequency transducers are utilized to evaluate the lymph nodes in the neck as they provide better detail. A normal node as evaluated by ultrasound is a well-defined, elliptical structure with a hypoechoic halo and central sharp linear hyperechoic fatty hilum containing a single vessel (15). Power Doppler imaging of the vascularity of nodes can be useful in differentiating benign from malignant processes. This, however, requires the patient’s cooperation, which is sometimes difficult to achieve in young children. Sonographically, neurogenic tumors are elliptical or round hypoechoic solid masses posterior to the carotid sheath vessels in a paraspinal location, with or without intraspinal extension and with or without calcifications (16). Ultrasound does not have a high specificity in distinguishing benign from malignant nodes, and there is significant feature overlap. The features, when combined, that increase the suspicion of malignancy include round shape, absent or eccentric hilum, irregular borders, cystic necrosis, and chaotic capsular blood flow pattern (15). On ultrasound of lymphoma, the enlarged hypoechoic nodes show sharp borders with an absent or eccentric echogenic hilum and a tendency to form masses (20). In Hodgkin lymphoma and non-Hodgkin lymphoma, the affected lymph nodes tend to be round, hypoechoic, and without an echogenic hilum and are likely to demonstrate intranodal reticulation (16). Sonographically, most thyroid cancers are hypoechoic, and the tumor may be irregular and ill defined or smooth and well delineated. A sonolucent rim or halo may completely or partially surround the mass.

Contrast-enhanced CT is the standard of imaging for rapid, accurate diagnosis of an acute deep neck abscesses. In a survey of pediatric otolaryngologist, CT scan was the imaging modality of choice for the evaluation of children with suspected deep neck infections (21). CT is able to differentiate between cellulitis and abscess and is also able to assess the location of the abscess in relation to important anatomical structures, helping to provide a surgical road map (17, 22). However, differentiation between phlegmon and abscess is sometimes not easy, and without the addition of intravenous contrast, it is impossible (23). Workup of a neck mass with possible neoplastic characteristics should include CT with contrast of the neck (24). On CT scan, lymph nodes are noted to have homogeneous soft tissue attenuation and present as elongated structures with well-defined, sharp margins with preserved adjacent fat planes and the occasional fatty hilum. However, the internal architecture of nodes is, for the most part, beyond the limits of CT evaluation (15). The CT scan is valuable in differentiating between cystic and solid lesions, establishing the location and exact size of the lesion, identifying other nonpalpable masses, determining the relationship of the mass with the surrounding tissues, assessing bony erosion or remodeling of the bone, and assessing the vascularity within the mass when the study is done with contrast. The high spatial resolution for high-contrast structures makes CT the imaging modality of choice for osseous and fibroosseous lesions in the head and neck (25). On CT, teratomas appear heterogenous, sharply circumscribed, with solid and cystic areas with variable enhancement of the solid component (26). Staging for a number of pediatric malignancies, such as lymphoma, requires CT of the head and neck as well as mediastinum. An abdominal CT scan is used to assess the involvement of the spleen liver and retroperitoneal lymph nodes. On a CT scan, nasopharyngeal carcinoma (NPC) shows a large enhancing mass filling the nasopharyngeal airway (26). CT scan does expose the patient to low doses of radiation, but it is faster than an MRI and, therefore, usually does not require sedation.

MRI has the advantage of exquisite sensitivity for soft tissue imaging with excellent anatomic detail. Some studies have shown it to be more successful than CT in distinguishing cellulitis or phlegmon from a true abscess collection; however, CT still remains the standard imaging technique for the evaluation of the acute neck abscess (25, 27). Advantages of MRI include the increased sensitivity of soft tissues, ability to provide multiplanar images, and the lack of radiation exposure. Lymph nodes are best seen on fluid-sensitive sequences (T2 or STIR) because they are isointense to muscle on T1 weighting (15). For assessing possible neoplastic masses, MRI provides much greater soft tissue detail and better vascular delineation. Disadvantages of MRI are the need for expensive imaging machinery and obtaining the scan often requires sedation secondary to the longer image capture times necessary. For osseous lesions, MRI can help assess the effect of an osseous lesion on the surrounding structures but should not be seen as a substitute for the CT scan (25). Neurofibromas and schwannomas are heterogenous, isointense to muscle on T1-weighted images, irregularly hyperintense on T1-weighted images, and enhance variably after gadolinium administration. T2-weighted images and fat suppression post-gadolinium-enhanced T1-weighted images are also very helpful (26). MRI has a distinct advantage over CT in evaluating for intracranial extension of tumor. Direct coronal imaging with fat suppression best demonstrates skull base involvement (26). Perfusion MRI is a noninvasive promising method that can be used for differentiation of malignant from benign cervical lymph nodes, and it helps in the characterization of malignant cervical lymphadenopathy (28).

In specific clinical circumstances, radionuclide scans, PET scans, or angiographic scans may be useful. Workup of malignant disease includes searching for distant metastasis. Whole body bone scans are often used in metastatic workup such as for neuroblastoma. If alkaline phosphatase levels are elevated or there is bone pain, bone scans should be done. Gallium scanning is sensitive for identifying the sites of involvement. Recently, fluorodeoxyglucose positron emission tomography has been shown to be superior to the gallium scanning and has become the recommended procedure (29). Bone marrow core biopsies and aspirates are also part of the workup of staging in some malignant tumors such as lymphoma.

Many cases of bilateral cervical adenitis are caused by upper respiratory tract infections of viral etiology, including rhinovirus, parainfluenza virus, respiratory syncytial virus, CMV, EBV, coronavirus, adenovirus, and reovirus. Less common viral agents include mumps, measles, rubella, herpes simplex, human herpes simplex 6 (roseola), and coxsackie viruses (6, 35). Involved nodes are usually multiple, relatively small, and without warmth or erythema of the overlying skin. Acute bilateral or diffuse cervical lymphadenopathy is often the result of a recent viral infection and is usually a self-limited process (14). Viral-induced adenopathy rarely suppurates and generally resolves spontaneously over a short period of time (6). Acute viral lymphadenitis is variably associated with fever, conjunctivitis, pharyngitis, and other upper respiratory tract symptoms. Rashes and hepatosplenomegaly may also be present, particularly when CMV is the causative organism. These infections rarely require additional diagnostic testing or specific therapy. Treatment is directed at symptom relief and specific antiviral therapy is seldom indicated except in the rare patient with severe respiratory tract or hepatic involvement, or in the immunocompromised patient (6).

Bacterial etiologies of cervical lymphadenopathy tend to be unilateral in nature. While the source of the initial infection may raise the suspicion for specific bacterial organisms, S. aureus and group A beta-hemolytic Streptococcus (Streptococcus pyogenes) are the most frequently isolated bacterial organisms from all cervical sites as a whole (36, 37, 38, 39). Bacterial-induced adenopathy tends to produce larger (greater than 2 to 3 cm), solitary, tender, unilateral lymph nodes that rapidly enlarge. Suppurative adenitis indicates an infected lymph node that has undergone liquefaction necrosis. Fluctuance develops in about 25% of patients with acute bacterial adenitis (6, 14). Common symptoms include fever, malaise, poor feeding, irritability, and swelling over the infected area with overlying skin erythema.

Over the past 10 to 15 years, there has been a sharp increase in the number of methicillin-resistant Staphylococcus aureus (MRSA) cases that have been reported. Reports from different hospitals/geographical areas indicate a 6% to 65% (22, 39, 40, 41, 42, 43) increase in incidence with time, and reports of resistance to other antibiotics have varied. With this trend noted, selection of an appropriate antibiotic for treatment needs to address the local incidence and antibiotic susceptibility of the common offending organisms. Usually antibiotics that are beta-lactamase stable or those that inhibit beta-lactamase are most desirable. The combination ampicillin-sulbactam has been used with good success in multiple studies and has activity against gram-positive, gram-negative, and anaerobic bacteria (44, 45, 46). When the patient has improved sufficiently to change from intravenous to oral therapy, the oral form of ampicillin-sulbactam, the prodrug sultamicillin, as well as amoxicillin-clavulanate are appropriate agents. Other good choices include cefuroxime axetil, cefprozil, and clindamycin. If there is suspicion for MRSA, recent studies have shown the majority of the community-acquired MRSA is still sensitive to clindamycin and Bactrim (22, 43). Anaerobic bacteria may be found in older children with dental caries or periodontal disease. The most commonly isolated anaerobic bacteria are Bacteroides sp., Peptococcus sp., Peptostreptococcus sp., Propionibacterium acnes, Fusobacterium nucleatum, Eikenella corrodens, and Prevotella sp. (6, 47).

Other more rare bacterial isolates include gram-negative bacilli such as Francisella tularensis, Pasteurella multocida, Yersinia pestis, Haemophilus influenzae, Klebsiella sp., Serratia marcescens, and Moraxella catarrhalis (6

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