What specialty evaluates a swollen lymph node?

Evaluation of a Swollen Lymph Node: Specialty Referral Guidelines

A swollen lymph node should be initially evaluated by a primary care physician, with referral to a specialist determined by location, characteristics, and suspected etiology, most commonly hematology/oncology, otolaryngology (ENT), or surgical oncology.

Initial Assessment Considerations

The evaluation of lymphadenopathy requires careful assessment of several key factors:

• Duration: Persistence beyond 4 weeks without fluctuation is concerning for malignancy 1
• Size: Nodes >1.5 cm in short axis are suspicious 1
• Consistency: Firm, fixed nodes suggest malignancy; soft, mobile nodes suggest benign causes 1
• Location: Supraclavicular nodes have higher risk of malignancy 1
• Associated symptoms: Presence of B symptoms (fever, night sweats, weight loss) may indicate lymphoma 2

Specialist Referral Algorithm

1. Primary Care Physician

• Should perform initial evaluation of all lymphadenopathy
• May treat with antibiotics if signs of infection are present
• Should reassess within 2 weeks of antibiotic treatment 1

2. Specialty Referral Based on Findings:

A. Hematology/Oncology

• Refer when:
  • Multiple enlarged nodes in different regions
  • Persistent lymphadenopathy >4 weeks despite antibiotics
  • Presence of B symptoms (fever, night sweats, weight loss)
  • Abnormal complete blood count
  • Suspicion of lymphoma or leukemia 2

B. Otolaryngology (ENT)

• Refer when:
  • Cervical, head and neck lymphadenopathy
  • Posterior auricular lymphadenopathy with suspicious features
  • Need for excisional biopsy of cervical nodes 1, 3
  • Nodes associated with upper respiratory or ear infections that don't resolve

C. Surgical Oncology

• Refer when:
  • Axillary lymphadenopathy with suspicion of breast cancer
  • Inguinal lymphadenopathy with suspicion of lower extremity or pelvic malignancy
  • Need for excisional biopsy when malignancy is suspected 1

D. Infectious Disease

• Refer when:
  • Lymphadenopathy associated with unusual infections
  • HIV-related lymphadenopathy
  • Travel-related or exposure-related lymphadenopathy

Diagnostic Workup Before Specialist Referral

Imaging

• Ultrasound: First-line imaging for initial evaluation 1
• CT/MRI with contrast: For nodes ≥5 cm, suspicion of deep extension, or when malignancy is suspected 1
• PET/CT: When lymphoma is suspected, especially for staging 2

Biopsy Options

• Fine-needle aspiration (FNA): For initial sampling of suspicious nodes 1
• Core needle biopsy: When FNA is inconclusive but more tissue is needed
• Excisional biopsy: Gold standard for lymphoma diagnosis, typically performed by surgical specialists 2

Important Considerations

• Lymph node evaluation is critical for accurate staging in malignancies 2
• Sentinel lymph node biopsy may be indicated for certain malignant cutaneous tumors 1
• Post-vaccination lymphadenopathy (especially after COVID-19) should be considered in the differential diagnosis 1
• Pediatric lymphadenopathy often has different etiologies than adult cases and may require pediatric specialist evaluation 3

Pitfalls to Avoid

• Delaying biopsy of suspicious nodes (>4 weeks persistence)
• Incomplete sampling during biopsy procedures
• Missing deep nodes by focusing only on palpable lymphadenopathy
• Attributing all lymphadenopathy to infection without appropriate follow-up
• Failing to consider lymphoma in patients with persistent lymphadenopathy

The proper specialist referral ensures timely diagnosis and treatment, potentially improving morbidity and mortality outcomes for patients with concerning lymphadenopathy.