This article provides an overview for evaluation and management of the pediatric patient with cervical lymphadenopathy. A thorough history and physical examination are crucial in developing a differential diagnosis for these patients. Although infectious causes of lymphadenopathy are more prevalent in the pediatric population compared with adults, neoplasms should also be considered. Judicious use of imaging studies, namely ultrasound, can provide valuable information for accurate diagnosis. Common and uncommon infectious causes of cervical lymphadenopathy are reviewed. Surgical intervention is occasionally necessary for diagnosis and treatment of infections, and rarely indicated for the possibility of malignancy. Indications for surgery are discussed.
Key points
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The differential diagnosis for cervical lymphadenopathy in a pediatric patient is broad, but the most common cause is infectious.
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Thorough history and physical examination are essential to identify the correct diagnosis.
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Ultrasound is the initial imaging modality of choice for most pediatric patients who require further evaluation of cervical lymphadenopathy.
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Fine-needle aspiration biopsy (FNAB) may be used as the initial biopsy method in selected pediatric patients with cervical lymphadenopathy, possibly obviating the need for open biopsy in some cases.
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Clinical judgment should guide the clinician to open biopsy in the setting of negative FNAB and suspected malignancy.
Introduction
Cervical lymphadenopathy is common in the pediatric population, with estimates of 38% to 45% of otherwise healthy children having palpable lymphadenopathy. Park reported that 90% of children between the ages of 4 and 8 years have lymphadenopathy. In the head and neck, most providers consider nodes greater than 1 cm enlarged, except for anterior deep cervical (jugulodigastric) nodes, which may reach 1.5 cm before they are considered enlarged. Most cases represent benign lymphadenopathy and are self-limited. The differential diagnosis for cervical lymphadenopathy in children is broad, and a thorough history and physical examination are important in identifying the correct diagnosis. Infection is the most common cause of pediatric cervical lymphadenopathy and is the emphasis of the current discussion. The management of pediatric cervical lymphadenopathy is also discussed, including when imaging and biopsy should be considered.
Introduction
Cervical lymphadenopathy is common in the pediatric population, with estimates of 38% to 45% of otherwise healthy children having palpable lymphadenopathy. Park reported that 90% of children between the ages of 4 and 8 years have lymphadenopathy. In the head and neck, most providers consider nodes greater than 1 cm enlarged, except for anterior deep cervical (jugulodigastric) nodes, which may reach 1.5 cm before they are considered enlarged. Most cases represent benign lymphadenopathy and are self-limited. The differential diagnosis for cervical lymphadenopathy in children is broad, and a thorough history and physical examination are important in identifying the correct diagnosis. Infection is the most common cause of pediatric cervical lymphadenopathy and is the emphasis of the current discussion. The management of pediatric cervical lymphadenopathy is also discussed, including when imaging and biopsy should be considered.
Anatomic and physiologic considerations
The neck is often considered in several anatomic subsites ( Fig. 1 ), including the submental, submandibular, anterior cervical, posterior cervical, supraclavicular, and parotid (preauricular) sites. Anterior cervical nodes are located anterior to the posterior border of the sternocleidomastoid muscle (ie, in the anterior triangle of the neck) and are often divided into upper, middle, and lower groups. They may further be divided into superficial and deep nodes relative to their location along the external or internal jugular veins, respectively. Posterior cervical nodes are posterior to the posterior border of the sternocleidomastoid muscle (ie, in the posterior triangle of the neck). This basic subsite classification of cervical lymph nodes established by Hajek and colleagues has been reported to be the most reproducible classification scheme on neck ultrasound, which is an important imaging study in the pediatric population. Mastoid (postauricular) and suboccipital locations may also be included as anatomic subsites of cervical lymph nodes.
Clinical presentation and physical examination
A thorough history and physical examination are paramount in accurately diagnosing cervical lymphadenopathy in pediatric patients. Important historical questions should be asked to help narrow the differential diagnosis. The onset and duration of the neck mass, changes in mass size or character, recent illnesses, fever, anorexia, weight loss, night sweats, fatigue, recent travel, animal exposure, treatment (such as antibiotics), and response to treatment should all be addressed. During physical examination, mass locations (including laterality), size, mobility, tenderness, and characteristics on palpation (soft, rubbery, fluctuant, firm, warm), and overlying skin changes should be noted.
Key historical information and physical examination findings may indicate a benign versus malignant origin. Benign reactive lymphadenopathy with infectious origin may be suggested by an associated illness (viral or bacterial), such as an upper respiratory infection, pharyngitis, tonsillitis, or otitis media. Viral-associated cervical lymphadenopathy is often soft, small, bilateral, mobile, nontender, and without overlying skin changes, although this general rule may not be true with some of the more subacute and chronic viral infections, such as Epstein-Barr virus (EBV) and cytomegalovirus.
Bacterial-associated cervical lymphadenopathy is usually of acute onset and unilateral. Bacterial lymphadenitis develops more commonly in submandibular (50%–60%) or upper cervical (25%–30%) regions compared with other cervical lymph node subsites. Up to 25% of patients with acute bacterial lymphadenitis will demonstrate fluctuance on physical examination, and this is especially true with Staphylococcus aureus lymphadenitis.
Concerning findings that may suggest malignancy include nodes that are rapidly enlarging, firm, nontender, and fixed to the skin or underlying structures. Also, generalized lymphadenopathy, supraclavicular nodes regardless of size, lower cervical nodes, increased patient age (≥8 years), lymph nodes greater than 2 to 3 cm, and hepatosplenomegaly are associated with increased risk of malignancy. Associated systemic symptoms, such as weight loss, night sweats, unexplained fever, or fatigue, should initiate further workup for possible malignancy or chronic inflammatory conditions. Lymphadenopathy present for greater than 6 months is much less likely to be malignant.
Differential diagnosis
The differential diagnosis for a pediatric patient with cervical lymphadenopathy is broad and should include benign and malignant causes ( Box 1 ). In a study of 126 children initially diagnosed with lymphadenopathy, Yaris and colleagues reported that 22.2% actually had another disease process, such as a congenital neck mass; 76.6% of the patients had lymphadenopathy associated with benign disease; and 23.4% had malignancy. The current discussion focuses on the most common etiologies of pediatric cervical lymphadenopathy, which are infectious in nature ( Box 2 ). These are divided into acute, subacute, and chronic causes. Cases in the subacute and chronic categories are often a greater challenge to diagnose and manage.
Congenital
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Branchial cleft cyst
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Thyroglossal duct cyst
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Dermoid cyst
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Vascular malformation (eg, lymphatic malformation, venous malformation, arteriovenous malformation)
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Vascular tumor (eg, hemangioma)
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Sternocleidomastoid tumor
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Malignancy
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Lymphoma (eg, Hodgkin/Non-Hodgkin)
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Leukemia
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Thyroid cancer
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Rhabdomyosarcoma
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Nasopharyngeal carcinoma
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Parotid tumor
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Neuroblastoma
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Metastatic disease
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Other
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Kawasaki disease
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Sarcoidosis
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Drug-induced (eg, phenytoin, isoniazid, pyrimethamine)
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Vaccination-induced (eg, after diphtheria, tetanus, pertussis vaccine)
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Viral causes
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Upper respiratory tract infection (eg, rhinovirus, adenovirus, influenza virus)
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Epstein-Barr virus
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Cytomegalovirus
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HIV
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Herpes simplex virus
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Measles
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Mumps
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Rubella
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Bacterial causes
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Streptococcal infection
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Staphylococcal infection
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Anaerobic bacterial infection
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Mycobacterial infection
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Cat-scratch disease
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Other
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Toxoplasmosis
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Histoplasmosis
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