What is the appropriate management for a 3-year-old child with a palpable lymph node on the side of the neck?

Management of Palpable Cervical Lymph Node in a 3-Year-Old

In a 3-year-old child with a palpable neck lymph node, initial observation with clinical reassessment is appropriate if the node is <1.5 cm, mobile, soft, and without concerning features, while ultrasound should be performed as the first-line imaging if the mass persists beyond 2-4 weeks or has any worrisome characteristics. 1, 2

Initial Clinical Assessment

The first step is determining whether this represents benign reactive lymphadenopathy versus a concerning mass requiring immediate workup:

Key features to assess on physical examination:

• Size: Nodes <1 cm are generally within normal limits for cervical lymph nodes in children 1
• Consistency: Soft, mobile nodes suggest reactive etiology, while hard, firm, or rubbery consistency raises malignancy concern 1, 3
• Mobility: Fixed masses are concerning for malignancy 1, 3
• Location: Supraclavicular masses are high-risk and require urgent evaluation 2, 3
• Local signs of infection: Warmth, erythema, and tenderness support reactive/infectious etiology 1
• Associated symptoms: Fever suggests infection; night sweats, weight loss, or systemic symptoms raise concern for lymphoma 1

Management Algorithm Based on Clinical Features

Low-Risk Presentation (Small, Mobile, Soft Node Without Red Flags)

Observation is appropriate initially:

• Reactive lymphadenopathy from respiratory infections typically resolves within days to weeks 1
• Nodes <1.5 cm without concerning features can be observed without immediate imaging 1, 3
• Reassess in 2-4 weeks to confirm resolution 1, 3

If treated empirically with antibiotics for suspected bacterial infection:

• Target Staphylococcus aureus and group A streptococcus 3
• Reassess within 2 weeks 1
• Complete resolution confirms reactive etiology; persistence requires further workup 1

When to Obtain Imaging

Ultrasound is the initial imaging modality of choice for pediatric neck masses because it avoids radiation, differentiates solid from cystic lesions, and characterizes vascular flow using color-flow Doppler 4, 2, 5

Indications for ultrasound:

• Node persists beyond 2-4 weeks despite observation 1, 2
• Suspected congenital abnormality 4, 2
• Superficial infection requiring characterization 4, 2
• Any uncertainty about the nature of the mass 2, 6

High-Risk Features Requiring Urgent Evaluation

Red flags mandating immediate referral to head and neck surgery:

• Size >1.5-2 cm 1, 3
• Hard, firm, or rubbery consistency 1, 3
• Fixed or non-mobile mass 1, 3
• Supraclavicular location 2, 3
• Ulceration present 1, 3
• Persistent enlargement >2 weeks without improvement 3
• No decrease in size after 4-6 weeks of observation 3
• Failure to respond to appropriate antibiotic therapy 3
• Accompanying systemic B symptoms (fever, night sweats, weight loss) 1, 3

Advanced Imaging and Tissue Diagnosis

CT neck with IV contrast or MRI neck should be reserved for:

• Suspected malignancy based on clinical features 4, 2
• Deep neck infection or abscess requiring surgical drainage 4, 2
• Cases where ultrasound findings are indeterminate and malignancy remains a concern 2

Fine-needle aspiration (FNA) should be considered:

• When the node persists beyond 2-4 weeks despite appropriate observation and malignancy is suspected 7, 1
• Ultrasound guidance increases specimen adequacy 7
• If lymphoma is strongly suspected, core needle biopsy may be preferred over FNA due to higher sensitivity 7, 1

Excisional biopsy is indicated:

• When FNA is inadequate or indeterminate after repeat attempts 7
• When histological confirmation is necessary for suspected malignancy 7, 8

Common Pitfalls to Avoid

• Do not obtain CT as first-line imaging in children due to radiation exposure when ultrasound can provide adequate initial assessment 2, 5
• Do not rush to biopsy small reactive nodes that are likely infectious; most resolve with observation or antibiotics 9, 3
• Do not miss supraclavicular masses, which have higher malignancy risk and require urgent evaluation 2, 3
• Do not forget to document follow-up plans and educate families on red flags requiring re-evaluation 2