What is the approach to managing cervical lymphadenopathy in children?

Approach to Cervical Lymphadenopathy in Children

The management of cervical lymphadenopathy in children should follow a structured diagnostic approach based on clinical presentation, with excisional surgery being the recommended first-line treatment for nontuberculous mycobacterial (NTM) lymphadenitis, which accounts for most persistent unilateral cases. 1, 2

Initial Assessment

History

• Duration of lymphadenopathy
• Associated symptoms: fever, weight loss, night sweats
• Recent upper respiratory infections
• Exposure to animals (cat scratch disease)
• Travel history
• Medication use
• Family history of autoimmune disorders or malignancy

Physical Examination

• Size: nodes ≥1.5 cm warrant further evaluation 1, 2
• Location: supraclavicular nodes are abnormal and concerning for malignancy
• Characteristics:
  • Acute bacterial: warm, tender, erythematous, fluctuant
  • Viral: bilateral, mobile, non-tender
  • NTM: unilateral, non-tender, firm, violaceous skin changes
  • Malignancy: firm, fixed, non-tender, rapidly enlarging

Differential Diagnosis

1. Infectious causes (most common):

   • Viral upper respiratory infections (most common overall)
   • Bacterial infections (Streptococcus, Staphylococcus)
   • Nontuberculous mycobacterial infections (MAC - 80% of culture-proven NTM cases) 1, 2
   • Tuberculosis (10% of mycobacterial cervical lymphadenitis in US children) 2
   • Cat scratch disease (Bartonella henselae)
   • EBV, CMV

2. Non-infectious causes:

   • Kawasaki disease (may present with unilateral cervical lymphadenopathy ≥1.5 cm) 1, 2
   • Rosai-Dorfman-Destombes disease (bilateral, massive, painless cervical lymphadenopathy) 1, 2
   • Malignancy (lymphoma, leukemia)
   • Autoimmune disorders

Diagnostic Algorithm

1. For acute, unilateral, tender lymphadenopathy with systemic symptoms:

   • Presumptive diagnosis: bacterial lymphadenitis
   • Initial management: empiric antibiotics covering Staphylococcus and Streptococcus
   • Follow-up in 48-72 hours

2. For bilateral, mobile, small nodes with viral symptoms:

   • Presumptive diagnosis: viral lymphadenitis
   • Management: supportive care, follow-up in 2-4 weeks

3. For persistent (>4-6 weeks), unilateral, non-tender lymphadenopathy:

   • Ultrasound imaging (first-line imaging modality) 2, 3
   • Consider tuberculin skin test
   • If suspicious features present, proceed to diagnostic intervention

4. Indications for further investigation:

   • Size >2 cm 3
   • Supraclavicular location
   • Fixed, firm consistency
   • Absence of inflammation
   • Persistent or progressive enlargement despite antibiotics
   • Systemic symptoms (fever, weight loss, night sweats)

Diagnostic Interventions

Laboratory Testing

• Complete blood count with differential
• C-reactive protein and ESR
• Specific serologies based on clinical suspicion (EBV, CMV, Bartonella)
• Tuberculin skin test or interferon-gamma release assay

Imaging

• Ultrasound: initial imaging of choice 2, 4
  • Helps differentiate reactive from pathologic nodes
  • Identifies abscess formation requiring drainage
• CT or MRI: reserved for suspected deep space infections or malignancy

Biopsy Options

• Fine-needle aspiration: useful for initial assessment
• Core needle biopsy: higher diagnostic yield than FNA
• Excisional biopsy: gold standard for definitive diagnosis

Management Based on Etiology

1. Viral lymphadenitis:

   • Supportive care
   • Reassurance and observation

2. Bacterial lymphadenitis:

   • Antibiotics (beta-lactamase resistant)
   • Duration: 10-14 days
   • Incision and drainage if fluctuant

3. Nontuberculous mycobacterial lymphadenitis:

   • Excisional surgery without chemotherapy is the recommended treatment 1
   • Success rate approximately 95% 1
   • Avoid incisional biopsy alone (risk of chronic drainage and sinus tract formation) 1
   • For recurrent disease: consider clarithromycin-based multidrug regimen 1

4. Tuberculous lymphadenitis:

   • Anti-tuberculosis therapy
   • Consider excision for persistent disease

5. Kawasaki disease:

   • IVIG and aspirin therapy
   • Cardiology consultation

Follow-up and Monitoring

• Reassess in 2-4 weeks for uncomplicated cases
• For persistent lymphadenopathy despite treatment:
  • Reassess diagnosis
  • Consider additional imaging
  • Consider referral to pediatric otolaryngology or infectious disease specialist

Red Flags Requiring Urgent Evaluation

• Supraclavicular lymphadenopathy
• Rapidly enlarging nodes
• Associated hepatosplenomegaly
• Significant weight loss, night sweats, or persistent fever
• Mediastinal widening on chest radiograph
• Failure to respond to appropriate antibiotic therapy

Remember that while infectious causes predominate in children, malignancy should remain in the differential diagnosis, particularly with concerning features or lack of response to appropriate therapy.