Cervical lymph gland enlargement commonly occurs in children. In most cases the enlargement is a transient response to a benign local or generalized viral infection. Almost all children have small palpable cervical, axillary, and inguinal nodes. About 5% have small palpable suboccipital nodes. Distinctly uncommon are palpable postauricular, supraclavicular, epitrochlear, or popliteal nodes.
Often the cause of the adenopathy is obvious, such as with lymph glands draining an obvious source of infection. Malignancy is suggested by painless adenopathy in the posterior or lower cervical chains, particularly in older children.
Almost all adenopathy in the anterior cervical triangle (anterior to the sternomastoid muscle) is benign. Fifty percent of masses in the posterior triangle are malignant.
Etiology and epidemiology
Infection is the most common cause of cervical adenopathy in children.
Viral agents are the most common infectious agents causing cervical adenopathy. Human herpesvirus 6, adenoviruses, herpes simplex virus, rubella,mumps virus,Epstein-Barr,cytomegalovirus, varicella, human immunodeficiency virus and respiratory viruses may cause cervical adenitis.
Bacterial infection may be caused by oropharyngeal flora (anaerobes, group B streptococci,Staphylococcus aureus, Streptococcus pyogenes [GABS], atypical mycobacteria, Haemophilus sp, Actinomyces israelii, or Nocardia sp).
Group Abeta-hemolytic Streptococci,Mycobacterium tuberculosis, or corynebacterium diphtheriae may result form person-to-person spread by airborne droplets.
Contact with domestic or wild animals or with feeding insects may result in lymphadenitis due to Toxoplasma gondii, Francisella tularensis, Yersinia pestis, Rochalimaea henselae, or Pasteurella multocida.
Cat-scratch disease (Bartonella henselae) most often occurs after a lick or scratch from a cat or dog, or inoculation by a wood splinter, pin, fish hook, cactus spike, or porcupine quill.
Toxoplasma gondii may result from contact with cat feces, undercooked meat, or contaminated vegetables.
Brucellosis may result from contact with or ingestion of contaminated meat or dairy products, which can include those from cattle, swine, goats, dogs, or sheep.
Leptospirosis results most often from contact with water or soil contaminated by cats, dogs, rodents, or livestock.
Pasteurella multocida is an aerobic cocco bacillus found in the normal flora of the mouth of many animals and occasionally of humans.
Kawasaki syndrome may cause unilateral cervical lymphadenopathy in infants and toddlers.
Clinical evaluation of cervical adenopathy
Seventy to 80% of acute unilateral cervical adenitis cases, caused by GABS or staphylococcal infection, occur in those aged 1 to 4 years who frequently have a history of upper respiratory symptoms. The submandibular nodes are involved most commonly.
Group Abeta-hemolytic streptococcal disease should be suspected when impetigo or pharyngitis is present.
Staphylococcus aureus and group B streptococci are the most common causes of cervical lymphadenitis in newborn infants. In older infants whose mean age is 5 weeks, group B streptococcus causes the “cellulitis-adenitis” syndrome.
A papular or pustular lesion distal to the adenopathy, suggesting an inoculation site, should lead to consideration of tularemia, Nocardia, actinomycosis, plague, cutaneous diphtheria, and cat-scratch disease.
Tularemia is a disease of acute onset associated with fever, chills, and headaches. It is characterized by tender swollen lymph nodes and a painful swollen papule, which develops distal to the involved nodes. The papule then ruptures to form an ulcer. Fifty percent of the lymph nodes will suppurate and drain while the other 50% remain enlarged and tender for several months.
Toxoplasmosis most often is an asymptomatic infection accounting for significant adenopathy. The lymph nodes are discrete, rarely more than 3 cm in diameter, usually not tender, and do not suppurate. The clinical course is self-limited, lasting for up to 12 months.
Cat-scratch disease presents as a small papule that appears at the inoculation site 7 to 12 days after inoculation. Over the next 4 weeks, regional lymphadenitis appears. The involved regional lymph nodes are tender, warm, red, and indurated. The lymphadenitis runs an indolent course of 4 to 6 weeks.
Brucellosis, causes mild cervical or inguinal adenopathy, malaise, and fever within 1 week to several months of ingesting or inhaling the organism.
Pasteurella multocida infections cause an acute edematous cellulitis of the inoculation site, with fever, headache, and regional adenopathy.
Diagnosis of cervical adenopathy
Acute pyogenic bacterial infection most often will be associated with an acute onset of 5 days or less,tender, enlarged nodes, and fever.The adenopathy may be bilateral if pharyngitis was the primary focus or unilateral if the focus is a dental or skin abscess. Associated generalized adenopathy suggests a generalized infection.
Sub acute or chronic adenopathy : When the involved nodes are well localized, nontender, and unilateral, a granulomatous infection or malignancy is most likely.
A history of exposure to an individual who has tuberculosis or to ticks or other insects, cats, rodents, or other wild animals may suggest an etiology. If the adenopathy is generalized, tuberculosis, brucellosis, and histoplasmosis are more likely.
If the adenopathyis unilateral,an atypicalmycobacterial infection or cat-scratch disease is more likely.
Physical examination. Characteristics of the involved nodes and possible foci of infection or inoculate should be assessed.Fever,generalized adenopathy, hepatosplenomegaly, rash, joint swelling, and pulmonary findings should be sought.
Tumors, particularly neuroblastomas in younger children and lymphomas in older children, should be considered when evaluating any subacute or chronic,painless,firm,and non inflamed cervical mass. A malignancy is of particular concern in older children when the node is in the posterior triangle or extends across the sternomastoid muscle to involve the anterior triangle.
Aspiration, biopsy, and laboratory tests
A specific diagnosis of cervical adenitis depends either on demonstration of the organism by Gram stain, culture of aspirated or biopsied tissue, elevated IgM antibody titers, or skin testing. A complete blood count, erythrocyte sedimentation rate,liver function tests, or radiographic studies may help define the extent of involvement.
Needle aspiration of acutely inflamed nodes should be performed if 48 hours of antimicrobial therapy has failed, or if the infection is severe enough to require parenteral therapy.
After cleansing and anesthetizing the skin, the aspiration is performed with a 18-to 20-gauge needle and a 10- to 20-cc syringe. If no material is aspirated,1 to 2 mL of sterile saline is injected and reaspirated.
Nodes should be incised and drained if pus is demonstrated on needle aspiration.
Excisional node biopsy should be performed for adenopathysuggestive of a malignancy. Excisional biopsy or incision and drainage are indicated for noninflamed hard nodes, nodes fixed to adjacent structures (particularly in the posterior triangle), and in older children, who have an increased incidence of lymphoma.