Cervical lymphadenitis, defined as an acute symptomatic enlargement of the cervical lymph nodes, is a common condition in children of all ages. Most cases of cervical lymphadenitis in children are self-limited and can safely be monitored for spontaneous resolution over four to six weeks. (Strength of Recommendation [SOR]: C, based on expert opinion)

Dulin, Michael F.

Kennard, Timothy P.

Leach, Laura

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November 1, 2008 Table of ContentsMICHAEL F. DULIN, MD, PHD, and TIMOTHY P. KENNARD, MD, Carolinas Medical Center-Eastland Department ofFamily Medicine, Charlotte, North CarolinaLAURA LEACH, MLIS, Carolinas Healthcare System, Charlotte Area Health Education Center, Charlotte, NorthCarolinaClinical Commentary by RICHARD WILLIAMS, MD, University of Nevada, Reno, NevadaClinical QuestionWhat is the appropriate management of cervical lymphadenitis in a child?Evidence-Based AnswerCervical lymphadenitis, defined as an acute symptomatic enlargement of the cervical lymph nodes, is acommon condition in children of all ages. Most cases of cervical lymphadenitis in children are self-limitedand can safely be monitored for spontaneous resolution over four to six weeks. (Strength ofRecommendation [SOR]: C, based on expert opinion). If there is a failure to regress, or symptoms areconsistent with a bacterial infection (e.g., unilateral lymphadenopathy, purulent skin drainage, tenderness,fever, node size larger than 3 cm in diameter), obtaining cultures and initiation of empiric antibioticsagainst Staphylococcus aureus or group A streptococcus are indicated. (SOR: C, based on disease-oriented evidence and expert opinion). A diagnostic ultrasonography or fine-needle aspiration can helpguide further treatment. Excision of the cervical lymph node should be saved as a last resort because ithas the highest risk of complications. (SOR: C, based on case series and expert opinion).Evidence SummaryThere is limited evidence to suggest a single definitive approach to the work-up and treatment of a childwith cervical lymphadenitis. Nine studies examined the etiology of neck masses in small cohorts ofchildren presenting to referral centers after failure of conservative therapy (Table 11-6).1-5,7-10 Even in areferral setting, most cases (87 to 100 percent) were related to a benign process, indicating that watchfulwaiting is a valid initial approach. A study of 19 cases of cervical lymphadenitis in children who werereferred for surgical excision identified tenderness, bilateral lymphadenopathy, node size smaller than 3cm in diameter, lack of systemic symptoms, and fluctuating node size to be associated with a reactiveprocess that did not require further treatment.1Table 1. Potential Causes of Cervical Lymphadenitis http://www.aafp.org/afp/1 of 4 9/3/2009 1:17 PMCommonViral infection: adenovirus, ainfluenza virus, respiratory syncytial virus, rhinovirus, Epstein-Barr virusBacterial infection: Staphylococcus aureus, group A streptococcusUncommonBacterial infection: Bartonella, atypical mycobacterium, Mycobacterium tuberculosisNeoplastic disease: lymphomaCollagen vascular diseasesKawasaki diseaseRareFungal infectionViral infection: cytomegalovirus, human immunodeficiency virus, rubella virus, mumps, varicella-zostervirusAnaerobic bacteriaToxoplasmosisDrugs: phenytoin (Dilantin), isoniazid, vaccinesNeoplastic: leukemia, neuroblastic tumors, neurofibromas, other soft tissue tumorsInformation from references 1 through 6.Two studies evaluated the usefulness of ultrasonography in the diagnosis of cervical lymphadenitis inchildren.2,7 The first study, conducted in Greece, evaluated 102 consecutive children two months to 14years of age who were referred for ultrasonography.2 The second study, conducted in Poland, examinedultrasonography results in 87 children referred to an ear, nose, and throat specialist for evaluation ofcervical lymphadenitis.7 In both studies, ultrasonography findings were comed with a final diagnosis madeby biopsy.2,7 Based on these studies, ultrasonography appears to be a safe way to verify lymph nodeinvolvement and to provide accurate measurements of enlarged lymph nodes; however, ultrasonographywas not able to differentiate benign and malignant forms of cervical lymphadenitis, and had a positivepredictive value for malignancy of only 20 percent.2Fine-needle aspiration was used to make the diagnosis in most of the studies evaluating etiology. Nocomplications of fine-needle aspiration were reported, and no comisons were made to excisional biopsy.One study examined 360 children undergoing excisional biopsy and found that 24 percent of patients hadcomplications, such as hypertrophic scarring, recurrence, hematoma formation, wound infection, and nervepalsy, that were related to the procedure.3 All of the studies were conducted in an inpatient setting orspecialist office; therefore, results may not be applicable to the primary care setting.Recommendations from OthersThe textbook Principles and Practice of Pediatric Infectious Diseases recommends that cervicallymphadenitis that is bilateral, with node size smaller than 3 cm, and that is not erythematous orexquisitely tender should be observed without further evaluation or treatment.6 Cervical lymphadenitisshould be empirically treated with antibiotics if patients have no systemic symptoms, node size larger than2 to 3 cm in diameter, unilateral lymphadenopathy, erythema, and tenderness. Antibiotics should betargeted against S. aureus and group A streptococcus, and should include a 10-day course of oralcephalexin (Keflex), amoxicillin/clavulanate (Augmentin), or clindamycin (Cleocin). Symptoms thatshould prompt consideration of biopsy to rule out malignancy include supraclavicular node location, nodesize larger than 2 cm in diameter, enlargement for more than two weeks, no decrease in size after four tosix weeks, lack of inflammation, firm or rubbery consistency, ulceration, failure to respond to antibiotictherapy, and systemic symptoms (e.g., fever, weight loss, hepatosplenomegaly). Finally, cervical2 of 4 9/3/2009 1:17 PMlymphadenitis with abscess formation will require fine-needle aspiration or surgical excision.Clinical CommentaryCervical lymphadenitis in children can be difficult to manage for physicians. The challenge is the manypotential etiologies. Also, the majority of cases of lymphadenitis are benign, but malignancy remains arare possibility. Very little evidence exists, so recommendations generally rely on expert opinion forappropriate management. This review describes a common and acceptable approach of watchful waiting, atrial of antibiotics, and, if the lymphadenitis does not resolve, a biopsy. As shown by the evidence, I havenot found ultrasonography to be helpful because it fails to differentiate benign from malignantlymphadenitis, and it is generally not needed to diagnose an abscess. The clinical presentation is also animportant consideration. For example, if mononucleosis is likely, perhaps a serum mononucleosis spottest or Epstein-Barr virus titer would be a more appropriate step than biopsy.Copyright Family Physicians Inquiries Network. Used with permission.Address correspondence by e-mail to Michael F. Dulin, MD, PhD, at michael.dulin@carolinashealthcare.org. Reprints are not availablefrom the authors.Author disclosure: Nothing to disclose.REFERENCES1. Srouji IA, Okpala N, Nilssen E, Birch S, Monnery P. Diagnostic cervical lymphadenectomy in children: acase for multidisciplinary assessment and formal management guidelines. Int J PediatrOtorhinolaryngol. 2004;68(5):551-556.2. Papakonstantinou O, Bakantaki A, Paspalaki P, Charoulakis N, Gourtsoyiannis N. High-resolution andcolor Doppler ultrasonography of cervical lymphadenopathy in children. Acta Radiol.2001;42(5):470-476.3. Connolly AA, MacKenzie K. Paediatric neck masses-a diagnostic dilemma. J Laryngol Otol.1997;111(6):541-545.4. Torsiglieri AJ Jr, Tom LW, Ross AJ III, Wetmore RF, Handler SD, Potsic WP. Pediatric neck masses:guidelines for evaluation. Int J Pediatr Otorhinolaryngol. 1988;16(3):199-210.5. Yamauchi T, Ferrieri P, Anthony BF. The aetiology of acute cervical adenitis in children: serological andbacteriological studies. J Med Microbiol. 1980;13(1):37-43.6. Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric Infectious Diseases. 2nd ed.New York, NY: Churchill Livingstone; 2003.7. Niedzielska G, Kotowski M, Niedzielski A, Dybiec E, Wieczorek P. Cervical lymphadenopathy inchildren-incidence and diagnostic management. Int J Pediatr Otorhinolaryngol. 2007;71(1):51-56.8. Barton LL, Feigin RD. Childhood cervical lymphadenitis: a reappraisal. J Pediatr. 1974;84(6):846-852.9. Dajani AS, Garcia RE, Wolinsky E. Etiology of cervical lymphadenitis in children. N Engl J Med.1963;268:1329-1333.10. Sundaresh HP, Kumar A, Hokanson JT, Novack AH. Etiology of cervical lymphadenitis in children. AmFam Physician. 1981;24(1):147-151.Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family PhysiciansInquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine.Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength ofrecommendations and the level of evidence for individual studies are rated using criteria developed by theEvidence-Based Medicine Working Group (http://www.cebm.net/levels_of_evidence.asp).The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submittingquestions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.3 of 4 9/3/2009 1:17 PMCopyright © 2008 by the American Academy of Family Physicians.This content is owned by the AAFP. A person viewing it online may make one printout of the materialand may use that printout only for his or her personal, non-commercial reference. This material may nototherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whethernow known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.orgfor copyright questions and/or permission requests.4 of 4 9/3/2009 1:17 PM

Management of Cervical Lymphadenitis in Children

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