What is the appropriate treatment for swollen lymph nodes?

Management of Swollen Lymph Nodes

For swollen lymph nodes, observation is the recommended first-line approach for benign-appearing nodes (fatty hilum present, <1.5 cm, no concerning features), with follow-up imaging at 3 months to confirm stability or resolution. 1

Initial Assessment

When evaluating swollen lymph nodes, focus on these specific features:

• Duration: Lymphadenopathy persisting beyond 4 weeks warrants further investigation 2
• Size: Nodes >2 cm are concerning for malignancy or granulomatous disease 2
• Location: Epitrochlear or supraclavicular nodes have higher malignancy risk 2
• Characteristics: Hard, matted/fused nodes suggest malignancy or granulomatous disease 2
• Associated symptoms: Fever, night sweats, unintentional weight loss indicate systemic disease 2

Differentiate localized from generalized lymphadenopathy, as generalized lymphadenopathy typically indicates underlying systemic disease 2

Treatment Algorithm

For Benign-Appearing Nodes (Fatty Hilum, <1.5 cm):

• Observe without intervention 1
• Schedule follow-up ultrasound at 3-6 months to confirm stability 1
• Reactive nodes may persist for weeks to months after successful treatment of underlying cause 1

For Suspected Infectious Etiology:

• Administer antibiotics if cellulitis or bacterial infection suspected 1, 2
• Most common cause globally is tuberculosis (52.7% in endemic areas), followed by reactive hyperplasia (16.1%) 3
• Perform follow-up imaging after antibiotic course to assess resolution 1
• Avoid corticosteroids as they mask histologic diagnosis of lymphoma or malignancy 2

For Persistent or Concerning Nodes:

When nodes persist >4 weeks or demonstrate concerning features, obtain:

• Complete blood count with differential 2
• C-reactive protein and erythrocyte sedimentation rate 2
• Tuberculosis testing 2
• Imaging (ultrasound for superficial, CT/MRI for deep structures) 1

Indications for Biopsy

Proceed to excisional biopsy when:

• Nodes continue to enlarge despite treatment 1
• Nodes demonstrate concerning imaging features (necrosis, extra-nodal extension, loss of fatty hilum) 1
• Nodes increase >20% in at least two dimensions 1
• Lymphadenopathy persists beyond 4 weeks with systemic symptoms 2

Fine-needle aspiration cytology is highly accurate (98% diagnostic yield) and should be the initial biopsy approach, reserving excisional biopsy for cases where FNAC is inconclusive 3. However, excisional biopsy provides the most definitive diagnosis when malignancy is suspected 1.

Critical Pitfalls to Avoid

• Do not perform immediate biopsy on all reactive-appearing nodes - this leads to overtreatment of benign lymphadenopathy 1
• Do not assume resolution without follow-up imaging - reactive nodes require 3-month imaging to confirm stability 1
• Do not delay biopsy in high-risk presentations - 38% of persistently swollen cervical nodes prove malignant (metastatic disease or lymphoma) 4
• Do not use corticosteroids empirically - they obscure lymphoma diagnosis 2

Special Consideration: Post-Vaccination Lymphadenopathy

Axillary lymph node swelling can occur after COVID-19 vaccination (particularly after booster doses), typically resolving spontaneously 5. Consider vaccination history when evaluating axillary lymphadenopathy to avoid unnecessary biopsies 5.