November 1, 2008 Table of Contents
MICHAEL F. DULIN, MD, PHD, and TIMOTHY P. KENNARD, MD, Carolinas Medical Center-Eastland Department of
Family Medicine, Charlotte, North Carolina
LAURA LEACH, MLIS, Carolinas Healthcare System, Charlotte Area Health Education Center, Charlotte, North
Clinical Commentary by RICHARD WILLIAMS, MD, University of Nevada, Reno, Nevada
What is the appropriate management of cervical lymphadenitis in a child?
Cervical lymphadenitis, defined as an acute symptomatic enlargement of the cervical lymph nodes, is a
common condition in children of all ages. Most cases of cervical lymphadenitis in children are self-limited
and can safely be monitored for spontaneous resolution over four to six weeks. (Strength of
Recommendation [SOR]: C, based on expert opinion). If there is a failure to regress, or symptoms are
consistent with a bacterial infection (e.g., unilateral lymphadenopathy, purulent skin drainage, tenderness,
fever, node size larger than 3 cm in diameter), obtaining cultures and initiation of empiric antibiotics
against Staphylococcus aureus or group A streptococcus are indicated. (SOR: C, based on disease-
oriented evidence and expert opinion). A diagnostic ultrasonography or fine-needle aspiration can help
guide further treatment. Excision of the cervical lymph node should be saved as a last resort because it
has the highest risk of complications. (SOR: C, based on case series and expert opinion).
There is limited evidence to suggest a single definitive approach to the work-up and treatment of a child
with cervical lymphadenitis. Nine studies examined the etiology of neck masses in small cohorts of
children presenting to referral centers after failure of conservative therapy (Table 11-6).1-5,7-10 Even in a
referral setting, most cases (87 to 100 percent) were related to a benign process, indicating that watchful
waiting is a valid initial approach. A study of 19 cases of cervical lymphadenitis in children who were
referred for surgical excision identified tenderness, bilateral lymphadenopathy, node size smaller than 3
cm in diameter, lack of systemic symptoms, and fluctuating node size to be associated with a reactive
process that did not require further treatment.1
Table 1. Potential Causes of Cervical Lymphadenitis
Viral infection: adenovirus, ainfluenza virus, respiratory syncytial virus, rhinovirus, Epstein-Barr virus
Bacterial infection: Staphylococcus aureus, group A streptococcus
Bacterial infection: Bartonella, atypical mycobacterium, Mycobacterium tuberculosis
Neoplastic disease: lymphoma
Collagen vascular diseases
Viral infection: cytomegalovirus, human immunodeficiency virus, rubella virus, mumps, varicella-zoster
Drugs: phenytoin (Dilantin), isoniazid, vaccines
Neoplastic: leukemia, neuroblastic tumors, neurofibromas, other soft tissue tumors
Information from references 1 through 6.
Two studies evaluated the usefulness of ultrasonography in the diagnosis of cervical lymphadenitis in
children.2,7 The first study, conducted in Greece, evaluated 102 consecutive children two months to 14
years of age who were referred for ultrasonography.2 The second study, conducted in Poland, examined
ultrasonography results in 87 children referred to an ear, nose, and throat specialist for evaluation of
cervical lymphadenitis.7 In both studies, ultrasonography findings were comed with a final diagnosis made
by biopsy.2,7 Based on these studies, ultrasonography appears to be a safe way to verify lymph node
involvement and to provide accurate measurements of enlarged lymph nodes; however, ultrasonography
was not able to differentiate benign and malignant forms of cervical lymphadenitis, and had a positive
predictive value for malignancy of only 20 percent.2
Fine-needle aspiration was used to make the diagnosis in most of the studies evaluating etiology. No
complications of fine-needle aspiration were reported, and no comisons were made to excisional biopsy.
One study examined 360 children undergoing excisional biopsy and found that 24 percent of patients had
complications, such as hypertrophic scarring, recurrence, hematoma formation, wound infection, and nerve
palsy, that were related to the procedure.3 All of the studies were conducted in an inpatient setting or
specialist office; therefore, results may not be applicable to the primary care setting.
Recommendations from Others
The textbook Principles and Practice of Pediatric Infectious Diseases recommends that cervical
lymphadenitis that is bilateral, with node size smaller than 3 cm, and that is not erythematous or
exquisitely tender should be observed without further evaluation or treatment.6 Cervical lymphadenitis
should be empirically treated with antibiotics if patients have no systemic symptoms, node size larger than
2 to 3 cm in diameter, unilateral lymphadenopathy, erythema, and tenderness. Antibiotics should be
targeted against S. aureus and group A streptococcus, and should include a 10-day course of oral
cephalexin (Keflex), amoxicillin/clavulanate (Augmentin), or clindamycin (Cleocin). Symptoms that
should prompt consideration of biopsy to rule out malignancy include supraclavicular node location, node
size larger than 2 cm in diameter, enlargement for more than two weeks, no decrease in size after four to
six weeks, lack of inflammation, firm or rubbery consistency, ulceration, failure to respond to antibiotic
therapy, and systemic symptoms (e.g., fever, weight loss, hepatosplenomegaly). Finally, cervical
lymphadenitis with abscess formation will require fine-needle aspiration or surgical excision.
Cervical lymphadenitis in children can be difficult to manage for physicians. The challenge is the many
potential etiologies. Also, the majority of cases of lymphadenitis are benign, but malignancy remains a
rare possibility. Very little evidence exists, so recommendations generally rely on expert opinion for
appropriate management. This review describes a common and acceptable approach of watchful waiting, a
trial of antibiotics, and, if the lymphadenitis does not resolve, a biopsy. As shown by the evidence, I have
not found ultrasonography to be helpful because it fails to differentiate benign from malignant
lymphadenitis, and it is generally not needed to diagnose an abscess. The clinical presentation is also an
important consideration. For example, if mononucleosis is likely, perhaps a serum mononucleosis spot
test or Epstein-Barr virus titer would be a more appropriate step than biopsy.
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Address correspondence by e-mail to Michael F. Dulin, MD, PhD, at email@example.com. Reprints are not available
from the authors.
Author disclosure: Nothing to disclose.
1. Srouji IA, Okpala N, Nilssen E, Birch S, Monnery P. Diagnostic cervical lymphadenectomy in children: a
case for multidisciplinary assessment and formal management guidelines. Int J Pediatr
2. Papakonstantinou O, Bakantaki A, Paspalaki P, Charoulakis N, Gourtsoyiannis N. High-resolution and
color Doppler ultrasonography of cervical lymphadenopathy in children. Acta Radiol.
3. Connolly AA, MacKenzie K. Paediatric neck masses-a diagnostic dilemma. J Laryngol Otol.
4. Torsiglieri AJ Jr, Tom LW, Ross AJ III, Wetmore RF, Handler SD, Potsic WP. Pediatric neck masses:
guidelines for evaluation. Int J Pediatr Otorhinolaryngol. 1988;16(3):199-210.
5. Yamauchi T, Ferrieri P, Anthony BF. The aetiology of acute cervical adenitis in children: serological and
bacteriological studies. J Med Microbiol. 1980;13(1):37-43.
6. Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric Infectious Diseases. 2nd ed.
New York, NY: Churchill Livingstone; 2003.
7. Niedzielska G, Kotowski M, Niedzielski A, Dybiec E, Wieczorek P. Cervical lymphadenopathy in
children-incidence and diagnostic management. Int J Pediatr Otorhinolaryngol. 2007;71(1):51-56.
8. Barton LL, Feigin RD. Childhood cervical lymphadenitis: a reappraisal. J Pediatr. 1974;84(6):846-852.
9. Dajani AS, Garcia RE, Wolinsky E. Etiology of cervical lymphadenitis in children. N Engl J Med.
10. Sundaresh HP, Kumar A, Hokanson JT, Novack AH. Etiology of cervical lymphadenitis in children. Am
Fam Physician. 1981;24(1):147-151.
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