Pediatrics

Cervical lymphadenitis

OVERVIEW: What every practitioner needs to know

Are you sure your patient has cervical lymphadenitis? What are the typical findings for this disease?

Approximately 38%-45% of otherwise normal children have palpable cervical lymph nodes. Cervical lymphadenopathy is usually defined as cervical lymph node tissue measuring more than 10 mm in diameter. The most common causes of lymphadenopathy are reactive hyperplasia in response to an infectious stimulus in the head or neck and infection of the node itself. Lymphadenitis specifically refers to lymphadenopathies that are caused by inflammatory processes. Cervical lymphadenitis is usually caused by a viral upper respiratory infection.

The key symptom of lymphadenitis is the presence of a painful mass in the cervical area, often accompanied by fever, runny nose, sore throat, and cough.

Key signs include an enlarged tender node or nodes in the cervical area, often accompanied by fever, rhinorrhea, nasal congestion, erythematous pharynx and/or tonsils, facial swelling, and torticollis.

The prognosis depends on the underlying cause. In the majority of cases, it is infectious in origin se

Age of the child

Most children with cervical lymphadenitis are 1-4 years of age. Some organisms have a predilection for a specific age group.

Neonatal period:Staphylococcus aureus and group B streptococcus

Infancy:S. aureus, group B streptococci, and Kawasaki disease

Between 1 and 4 years of age: Viral agents, S. aureus, Streptococcus pyogenes (group A ß-hemolytic streptococcus), and nontuberculous mycobacteria (Mycobacterium avium-intracellulare, Mycobacterium scrofulaceum, Myocobacterium kansasii, Mycobacterium haemophilus, Mycobacterium lentiflavum, Mycobacterium malmoense, Mycobacterium florentinum, Mycobacterium interjectum), and others.

Between 5 and 18 years of age: Anaerobic bacteria, Toxoplasma gondii, Bartonella henselae, and Mycobacterium tuberculosi

Laterality and chronicity

Acute bilateral cervical lymphadenitis: Acute bilateral cervical lymphadenitis is usually caused by a viral upper respiratory tract infection (e.g., rhinovirus, adenovirus, enterovirus, herpes simplex virus [HSV], influenza virus) or bacterial pharyngitis (notably, S. pyogenes and, less commonly, Mycoplasma pneumoniae). It can also be part of a generalized reticuloendothelial response to a systemic infection.

Acute unilateral cervical lymphadenitis: Acute unilateral cervical lymphadenitis is caused by S. pyogenes and S. aureus in approximately 40%-80% of cases. In neonates, acute unilateral cervical lymphadenitis is generally caused by S. aureus and in young infants by Streptococcus agalactiae (group B streptococcus). Acute unilateral cervical lymphadenitis in older children with a history of periodontal disease is often caused by anaerobic bacteria.

Subacute or chronic cervical lymphadenitis: Subacute or chronic cervical lymphadenitis is often caused by B. henselae, T. gondii, Epstein-Barr virus (EBV), cytomegalovirus (CMV), human immunodeficiency virus (HIV), nontuberculous mycobacteria (M. avium-intracellulare, M. scrofulaceum, M. kansasii, M. haemophilus, M. lentiflavum, Mycobacterium bovis, M. malmoense, M. florentinum, M. interjectum, and others), and M. tuberculosis. Less frequent causes include syphilis, nocardiasis, brucellosis,and fungal infection.

Associated symptoms

Fever, sore throat, and cough suggest an upper respiratory tract infection.

Fever, night sweats, and weight loss suggest lymphoma or tuberculosis.

Recurrent cough and hemoptysis are indicative of tuberculosis.

Unexplained fever, fatigue, rash, and arthralgia raise the possibility of collagen vascular disease or serum sickness.

Concurrent illness and past health

Preceding tonsillitis suggests streptococcal infection.

Recent facial or neck abrasions or infection suggests staphylococcal or streptococcal infection.

Periodontal or dental disease suggests infection caused by anaerobic organisms.

Mouth sores suggests herpangina or herpes simplex gingivostomatitis.

Lymphadenopathy resulting from CMV, EBV, or HIV might follow a blood transfusion.

Immunization-related lymphadenopathy might follow diphtheria-pertussis-tetanus, poliomyelitis, or typhoid fever vaccination.

Response of cervical lymphadenopathy to specific antimicrobial therapies might help to confirm or exclude a diagnosis. Lymphadenopathy might also follow the use of medications such as phenytoin and isoniazid.

Exposure to an individual with an infectious disease suggests the corresponding disease. Examples include the following:

Upper respiratory tract infection

Streptococcal pharyngitis

CMV infection

EBV infection

Tuberculosis

Exposure to animals or their products

A history of cat scratch raises the possibility of B. henselae infection.

A history of a dog bite or scratch suggests specific causative agents such as Pasteurella multocida and S. aureus.

A history of exposure to sheep, cows, and goats suggests brucellosis.

A history of exposure to rabbits suggests tularemia.

A history of exposure to birds and fish suggests nontuberculous mycobacterial infection.

Ingestion of unpasteurized milk or dairy products suggests brucellosis or M. bovis infection.

Ingestion of undercooked meat suggests toxoplasmosis.

What should you be alert for in the physical examination?

General: Malnutrition or poor growth suggests a chronic disease such as tuberculosis, malignancy, or immunodeficiency.

Fever: Fever suggests an infectious process, notably a viral or bacterial infection.

Characteristics of the lymph tissue. The presence of erythema and warmth of the overlying skin suggests an acute pyogenic process. In patients with tuberculosis, the overlying skin might be erythematous or violaceous but is typically not warm. A "cold" abscess is characteristic of infection caused by mycobacteria, fungi, or B. henselae. In lymphadenopathy resulting from malignancy, signs of acute inflammation are characteristically absent.

Consistency. In lymphadenopathy resulting from a viral or bacterial infection, the nodes are usually soft or firm. Fluctuance suggests abscess formation, which may result from bacterial lymphadenitis. Typically, acute suppurative lymphadenitis is caused by S. aureus or S. pyogenes. In patients with tuberculous lymphadenitis, the nodes might be matted or fluctuant. Approximately 50% of patients with lymphadenitis caused by nontuberculosis mycobacteria develop fluctuance of the lymph node and spontaneous drainage. In lymphadenopathy resulting from malignancy, the lymph nodes are hard.

Tenderness. Tenderness of the lymph node often indicates an acute pyogenic bacterial process. In contrast, cervical lymphadenitis caused by nontuberculous mycobacteria (M. avium-intracellulare, M. scrofulaceum, M. kansasii, M. haemophilus, M. lentiflavum, M. bovis, M. malmoense, M. florentinum, M. interjectum, and others) and M. tuberculosis is nontender.

Location of the lymph node

Anterior cervical lymphadenopathy is most often caused by a viral agent (such as rhinovirus, adenovirus, enterovirus, HSV, influenza virus) or less commonly by a bacterial agent such as S. pyogenes, S. aureus, and M. pneumoniae.

Submandibular and submental lymphadenopathy is most often caused by an oral or dental infection, although it may also be a feature seen in cat-scratch disease and non-Hodgkin lymphoma.

Acute posterior cervical lymphadenitis is classically seen in persons with rubeola, rubella, and infectious mononucleosis. Acquired toxoplasmosis may also be present with posterior cervical lymphadenitis.

Posterior cervical lymphadenopathy carries a much higher risk for malignancy than anterior cervical lymphadenopathy.

Supraclavicular cervical lymphadenopathy carries a much higher risk for malignancy than anterior cervical lymphadenopathy.

Cervical lymphadenopathy associated with generalized lymphadenopathy is often caused by a viral infection (such as EBV, CMV, HIV). Rarely, generalized lymphadenopathy may be caused by bacterial infection such as brucellosis and leptospirosis. Malignancies (such as leukemia and lymphoma), collagen vascular diseases (such as juvenile rheumatoid arthritis and systemic lupus erythematosus), and medications (such as phenytoin and isoniazid) are also associated with generalized lymphadenopathy.

Laterality: In lymphadenopathy resulting from a viral infection, the nodes are usually bilateral, whereas in bacterial lymphadenitis, the nodes are either unilateral or bilateral. The classic cervical lymphadenopathy in Kawasaki disease is usually acute and unilateral. In patients with cervical lymphadenitis caused by M. tuberculosis, the lymph nodes are usually multiple and bilateral, whereas in patients with lymphadenitis caused by nontuberculous mycobacteria, the lymph node is usually solitary and unilateral.

Fixation to underlying structure: In lymphadenopathy resulting from a viral or bacterial infection, the nodes are usually mobile and not fixed to the underlying structure. Conversely, in lymphadenopathy resulting from malignancy, the lymph nodes are often fixed to the underlying tissue.

Sinus tract formation: This occurs in approximately 10% of patients with lymphadenitis caused by nontuberculous mycobacteria.

Associated signs. Acute viral cervical lymphadenitis is variably associated with fever, rhinorrhea, conjunctivitis, pharyngitis, and sinus congestion. A beefy red throat, exudate on the tonsils, petechiae on the hard palate, and a strawberry tongue suggest infection caused by S. pyogenes.

Unilateral facial or submandibular swelling, erythema and tenderness, ipsilateral otitis media, fever, and irritability in an infant suggest "cellulitis-adenitis" syndrome caused by group B streptococcal infection.

Diphtheria is characterized by serosanguineous, purulent, erosive rhinitis; sore throat; dysphagia; leather-like adherent membrane extending beyond the faucial area; and edema of the soft tissues of the neck. The latter together with enlarged cervical lymph nodes may give rise to a "bull neck" appearance.

Periodontal or dental disease suggests infection caused by anaerobic organisms. The presence of gingivostomatitis suggests infection with HSV, whereas herpangina suggests infection with coxsackievirus.

Hepatosplenomegaly and generalized lymphadenitis suggest an infection with EBV, CMV, or HIV or tuberculosis or syphilis.

Hepatosplenomegaly and generalized lymphadenopathy may also be present in patients with malignancies (such as leukemia and lymphoma) and collagen vascular diseases (such as juvenile rheumatoid arthritis and systemic lupus erythematosus).

A generalized rash and hepatosplenomegaly suggest EBV or CMV infection.

The presence of pharyngitis, maculopapular rash, and splenomegaly suggests EBV infection.

Conjunctivitis, maculopapular rash, and Koplik spots are characteristics of rubeola.

Pallor, petechiae, bruises, sternal tenderness, and hepatosplenomegaly suggest leukemia. Prolonged fever, conjunctival infection, oropharyngeal mucous membrane inflammation, peripheral edema or erythema, and a polymorphous rash are consistent with Kawasaki disease.

What other disease/condition shares some of these symptoms?

Differentiation from Other Neck Masses

The differential diagnosis of neck masses in children is related to a higher incidence of infectious diseases and congenital anomalies and the relative rarity of malignancies in the pediatric age group. Cervical masses in children might be mistaken for enlarged cervical lymph nodes. In general, congenital lesions are painless and are present at birth or identified shortly thereafter. Clinical features that may help distinguish the various conditions from cervical lymphadenopathy are as follows:

Mumps: The swelling of mumps parotitis crosses the angle of the jaw; the swollen tissues push the ear lobe upward and outward. In contrast, cervical lymph nodes are usually below the mandible. In mumps, the affected parotid gland is swollen and tender, particularly when chewing or tasting sour liquids such as lemon juice. The orifice of the Stensen duct is often erythematous and swollen. The condition is bilateral in 90% of cases.

Thyroglossal duct cyst: A thyroglossal duct cyst results when the thyroglossal duct fails to involute. Typically, a thyroglossal duct cyst presents as a midline mass between the hyoid bone and suprasternal notch. The mass may move with swallowing and may move upward with protrusion of the tongue. Although thyroglossal duct cysts are congenital, these lesions rarely present in the neonatal period. More commonly, thyroglossal duct cysts are noted in preschool children. Secondary bacterial infection is a possible complication, and the mass may become painful, erythematous, and warm.

Branchial cleft cyst:A branchial cleft cyst results from incomplete obliteration of the branchial clefts during embryogenesis. Approximately 95% of branchial cleft anomalies arise from the region of the second branchial arch. Typically, a branchial cleft cyst presents as a painless, smooth, mobile, and fluctuant mass located along the lower anterior border of the sternocleidomastoid muscle. Although branchial cleft cysts are congenital and might be noted at birth, most are not detected until the first or second decade of life. Secondary bacterial infection is a possible complication, and the mass may become painful, erythematous, and warm.

Sternocleidomastoid tumor: These tumors present in the first few weeks of life as a firm, discrete, fusiform or spindle-shaped mass within the sternocleidomastoid muscle. The mass may result from perinatal hemorrhage into the sternocleidomastoid muscle with subsequent healing by fibrosis, or it may be the sequela of an intrauterine or perinatal compartment syndrome. Typically, the mass is not fixed to the skin, and can be moved from side to side but not upward or downward. Bilaterality is rare. Shortening of the sternocleidomastoid muscle pulls the head toward the side of the lesion; this results in ipsilateral head tilt and contralateral chin deviation. Torticollis is aggravated by the inability of the affected muscle to grow normally and to keep pace with the normal muscle.

Cervical ribs: The cervical ribs develop from the costal (or ventral) process of the primitive vertebral arches. Normally, the costal element later regresses during embryogenesis. The continued development of the seventh cervical vertebral costal process may result in a cervical rib. The prevalence is between 0.03% and 0.5%, depending on the sex and race of the studied population. Cervical ribs are usually bilateral and are more common in females. In contrast to cervical lymphadenopathy, cervical ribs are hard and immovable. Although often asymptomatic, cervical ribs may cause compression of the lower branchial plexus trunk at the thoracic outlet. Diagnosis is established with a radiograph of the neck.

Cystic hygroma: A cystic hygroma is a multiloculated, endothelial-lined cyst that is diffuse, soft, and compressible. The lesion contains lymphatic fluid and typically transilluminates brilliantly. The lesion is not attached to the skin but might be attached to the underlying structures. Approximately 75% of cystic hygromas occur in the neck, typically in the posterior cervical triangle. Secondary bacterial infection is a possible complication, and the mass may become painful, erythematous, and warm.

Hemangioma: A hemangioma is a congenital vascular anomaly that often is present at birth or appears shortly thereafter. Superficial lesions are usually bright red, protuberant, and sharply demarcated. Deep lesions are bluish and dome-shaped. In contrast to cervical lymphadenopathy, hemangiomas are soft.

Laryngocele: A laryngocele is a cystic dilation of the laryngeal saccule. Typically, a laryngocele presents as a soft, cystic, compressible mass that extends out of the larynx and through the thyrohyoid membrane. It becomes larger with the Valsalva maneuver. There might be associated stridor, dysphonia, or hoarseness. A radiograph of the neck might show an air-fluid level in the mass.

Dermoid cyst: This type of cyst is a midline cystic mass lined by keratinizing stratified squamous epithelium, and contains dermal appendages such as hair follicles and sebaceous glands. It seldom transilluminates as brilliantly as a cystic hygroma. The lesion is usually solitary and asymptomatic. Dermoid cysts occur most frequently in the head and neck area.

Acute suppurative thyroiditis: This condition typically presents with pain/tenderness and swelling in the thyroid gland, fever, dysphagia, and preceding sore throat.

Differentiation from Noninfectious Causes of Lymphadenopathy

Malignancies: More than 25% of malignant tumors occur in the head and neck and may cause cervical lymphadenopathy. During the first 6 years of life, neuroblastoma and leukemia are the most common malignancies associated with cervical lymphadenopathy, followed by rhabdomyosarcoma and non-Hodgkin lymphoma. After 6 years of age, Hodgkin lymphoma is the most common tumor associated with cervical lymphadenopathy, followed by non-Hodgkin lymphoma and rhabdomyosarcoma.

Kawasaki disease: The presence of The presence of cervical lymphadenopathy is an important diagnostic feature of Kawasaki disease. The other features include fever lasting for at least 5 days, bilateral bulbar conjunctival injection, inflammatory changes in the mucosa of the oropharynx, erythema or edema of the peripheral extremities, and a polymorphous rash.

Collagen vascular diseases: These are a group of autoimmune diseases that can affect multiple organ systems, particularly the skin and joints. Generalized lymphadenopathy might be a feature of collagen vascular diseases such as systemic-onset juvenile rheumatoid arthritis and systemic lupus erythematosus.

Serum sickness: Serum sickness results from a type III immune complex–mediated reaction that may occur after primary or repetitive exposure to foreign proteins or haptens. Clinically, serum sickness may present with urticaria, fever, polyarthritis, myalgia, lymphadenopathy, hepatosplenomegaly, renal failure, and neurologic complications.

Drugs: Certain drugs—notably phenytoin, carbamazepine, phenobarbital, primidone, valproic acid, lamotrigine, ethosuximide, hydralazine, allopurinol, diltiazem, sulfonamides, minocycline, dapsone, and isoniazid—may cause generalized lymphadenopathy.

Vaccination: Cervical lymphadenopathy has been reported after immunization with diphtheria-pertussis-tetanus, poliomyelitis, or typhoid vaccine.

Periodic fever, aphthous ulcers, pharyngitis, cervical adenitis (PFAPA) syndrome: PFAPA syndrome is characterized by periodic episodes of fever greater than 39 ° C lasting 3 to 6 days and recurring every 3-8 weeks in association with aphthous ulcers, pharyngitis, and cervical adenitis.

Lipid storage diseases: Lipid storage diseases such as Gaucher disease and Niemann-Pick disease may also cause generalized lymphadenopathy. Affected children also have hepatosplenomegaly.

Sarcoidosis: This is a multisystem disease of unknown cause characterized by the formation of nonnecrotizing epithelial cell granulomas. It frequently presents with pulmonary disease, ocular disease, and skin lesions. The lymph nodes may also be involved. The diagnosis should be considered in an African or African American child with bilateral chronic cervical lymphadenopathy.

Rosai-Dorfman disease: This disease is a benign form of histiocytosis characterized by generalized proliferation of sinusoidal histiocytes. The disease usually manifests in the first decade of life with massive and painless cervical lymphadenopathy; and is often accompanied by fever, malaise, weight loss, neutrophilic leukocytosis, elevated erythrocyte sedimentation rate, and polyclonal hypergammaglobulinemia.

Kikuchi-Fujimoto disease: This disease (histiocytic necrotizing lymphadenitis) is a benign cause of lymph node enlargement, usually in the posterior cervical triangle. The involved nodes are often firm or rubbery, discrete, and rarely greater than 2 cm in diameter. In contrast to the 4:1 female predominance documented in adult series, the condition is more common in males in the pediatric age group. An upper respiratory prodrome is often present. Some patients may also have fever, rash, nausea, weight loss, night sweats, arthralgia, myalgia, and, rarely, hepatosplenomegaly. The exact cause Kikuchi-Fujimoto disease is not known, but a viral cause has been implicated. Classic pathologic findings include patchy areas of necrosis in the cortical and paracortical areas of the enlarged lymph nodes and a histiocytic infiltrate. Affected patients may have leukopenia, elevated C-reactive protein levels, elevated erythrocyte sedimentation rate, and elevated liver enzyme levels.

Hemophagocytic syndrome: Hemophagocytic syndrome is caused by a dysregulation in natural killer T-cell function, resulting in increased cytokine secretion and activation/proliferation of histiocytes with subsequent hemophagocytosis. The syndrome is characterized by prolonged fever, generalized lymphadenopathy, hepatosplenomegaly, maculopapular rash, pancytopenia, hypofibrinemia, hyperferritinemia, and abnormal liver function. The syndrome can be either primary (due to an underlying genetic defect) or secondary (associated with infections, autoimmune diseases, or malignancies).

What caused this disease to develop at this time?

The epidemiology of cervical lymphadenitis is that of its infectious agents. In general, predisposing factors are as follows:

Viral upper respiratory infection

Bacterial oropharyngeal infection

Otic infection

Skin infection involving the head and neck area

Poor dental hygiene/dental caries/periodontal disease

Lower socioeconomic status

Overcrowding

Daycare attendee

Immunodeficiency

Exposure to individual with contagious infection (upper respiratory infection, streptococcal pharyngitis, tuberculosis)

Exposure to infected animals, birds, and fish (cat-scratch disease, toxoplasmosis, brucellosis, tularemia, nontuberculous mycobacteria)

Consumption of undercooked meat (toxoplasmosis)

Consumption of unpasteurized animal milk or dairy products (brucellosis, nontuberculosis mycobacteria)

Recent travel to endemic area (tuberculosis, HIV infection, histoplasmosis, coccidioidomycosis, leishmaniasis)

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Laboratory tests are not necessary in the majority of children with cervical lymphadenopathy. Laboratory studies should be ordered when indicated by the history or physical examination.

Complete blood cell count. Bacterial lymphadenitis is often accompanied by leukocytosis with a shift to the left and toxic granulations. Atypical lymphocytosis is prominent in infectious mononucleosis. Pancytopenia, leukocytosis, or the presence of blast cells suggests leukemia.

Erythrocyte sedimentation rate and C-reactive protein. The erythrocyte sedimentation rate and C-reactive protein levels are usually significantly elevated in individuals with bacterial lymphadenitis.

Blood culture. A blood culture should be performed if the child appears toxic or if there is concomitant cellulitis. A positive blood culture result suggests bacterial lymphadenitis.

Rapid streptococcal antigen test. This test might be useful if group A ß-hemolytic streptococcal pharyngitis is suspected. A positive rapid streptococcal antigen test result is accepted as adequate for the diagnosis of group A ß-hemolytic streptococcal pharyngitis.

Throat culture: A throat culture is the gold standard for documenting group A ß-hemolytic streptococcal pharyngitis. Confirmation of a negative rapid streptococcal antigen test result with a throat culture is necessary, unless the physician has ascertained in his/her practice that the sensitivity of the rapid streptococcal antigen test used is comparable to that of a throat swab.

Electrocardiogram and echocardiogram: An electrocardiogram and echocardiogram are indicated if Kawasaki disease is suspected to look for coronary arteritis, coronary aneurysm, and other cardiovascular complications such as myocarditis, pericarditis, valvular insufficiencies, and myocardial infarction. Initial echocardiography should be performed as soon as the diagnosis is suspected and again at 6 weeks and 6 months after the acute illness.

Tuberculin skin test. Skin tests for tuberculosis should be performed in patients with subacute or chronic lymphadenitis. In the majority of children infected with M.tuberculosis,the tuberculin test is a useful diagnostic tool. A tuberculin test with greater than or equal to 15-mm induration points to infection with M. tuberculosis. False-negative results may occur in children younger than 6 months of age, children with advanced active tuberculosis, HIV infection (especially if the CD4 count is <200), concomitant viral infection (such as measles, mumps, varicella), concomitant bacterial infection (such as pertussis, typhoid fever, typhus, brucellosis), or recent vaccination with a virus vaccine (such as measles, mumps), and children who are immunosuppressed.

Improper storage of tuberculin material and improper administration of tuberculin (too little tuberculin or too deep injection of the tuberculin) may also result in false-negative results. Conversely, false-positive results can occur in the setting of previous vaccination with Bacille Calmette-Guérin (BCG) vaccine. Children with cervical lymphadenitis caused by nontuberculous mycobacteria, such as M. avium-intracellulare, may also have a positive tuberculin skin test result. This is because the purified protein derivative preparation, derived from M. tuberculosis, shares a number of antigens with nontuberculous mycobacteria species. These tuberculin skin test reactions usually measure less than 10 mm of induration but can measure more than 15 mm.

Serologic tests. Serologic tests for EBV, CMV, and HIV should be performed in children with bilateral subacute or chronic cervical lymphadenitis. Serologic tests for B. henselae, brucellosis, syphilis, histoplasmosis, coccidioidomycosis, and toxoplasmosis should be performed when indicated.

Fine-needle aspiration and culture of a lymph node:These procedures are safe and reliable for isolating the causative organism and determining the appropriate antibiotic when bacterial infection is the cause. Failure to improve or worsening of the patient`s condition while on antibiotic treatment is an indication for fine-needle aspiration and culture. All aspirated material should be sent for both Gram and acid-fast staining and cultures for aerobic and anaerobic bacteria, mycobacteria, and fungi. If the Gram stain provides positive results, only bacterial cultures are mandatory.

Excisional biopsy: An excisional biopsy with microscopic examination of the lymph node might be necessary to establish the diagnosis if there are symptoms or signs of malignancy or nontuberculous mycobacteria infection, or if the lymphadenopathy persists or enlarges despite appropriate antibiotic therapy and the diagnosis remains in doubt. The biopsy should be performed on the largest and firmest node that is palpable, and the node should be removed intact with the capsule. The lymph node tissue should be sent for histopathologic examination.

Would imaging studies be helpful? If so, which ones?

Imaging studies are not necessary in the majority of children with cervical lymphadenopathy. They should be ordered when indicated by the history, physical examination, or results of laboratory tests.

Chest radiography. Chest radiography should be performed if the tuberculin skin test result is positive or if an underlying chest pathologic condition is suspected, especially in the child with chronic or generalized lymphadenopathy. The most common finding in a child with tuberculosis is a primary complex, which consists of opacification with hilar or subcarinal lymphadenopathy, without notable parenchymal involvement. In contrast, adolescents with tuberculosis generally present with upper lobe infiltrates, cavitations, and pleural effusions.

Ultrasonography. Ultrasonography (US) is the most useful diagnostic imaging modality in the assessment of cervical lymphadenopathy. US may help to differentiate a solid mass from a cystic mass and to establish the presence and extent of suppuration or infiltration. High-resolution and color US can provide detailed information on the longitudinal and transverse diameter, morphologic features, texture, and vascularity of the lymph node. A long to short axis ratio greater than 2 suggests benignity, whereas a ratio less than 2 suggests malignancy. In lymphadenitis caused by an inflammatory process, the intranodal vasculature is dilated, whereas in lymphadenopathy secondary to neoplastic infiltration, the intranodal vasculature is usually distorted. Absence of an echogenic hilus and overall lymph node hyperechogenicity are suggestive of malignancy.

US can also be used to guide core needle biopsy for diagnosing the cause of cervical lymphadenopathy in patients without known malignancy and may obviate unnecessary excisional biopsy. Advantages of US include cost-effectiveness, noninvasiveness, and absence of radiation hazard. A potential drawback is its lack of absolute specificity and sensitivity in ruling out neoplastic processes as the cause of lymphadenopathy.

Magnetic resonance imaging. Diffusion-weighted magnetic resonance imaging (MRI) with apparent diffusion coefficient mapping can be helpful to differentiate malignant lymph nodes from benign lymph nodes and delineate the solid viable part of the lymph node for biopsy. The technique also allows detection of small lymphadenopathies.

If you are able to confirm that the patient has cervical lymphadenitis, what treatment should be initiated?

Treatment of cervical lymphadenopathy depends on the underlying cause.

Conservative treatment. Most cases of cervical lymphadenopathy are self-limited and require no treatment other than observation. This applies especially to small, soft, and mobile lymph nodes associated with upper respiratory infections, which are often viral in origin. These children require follow-up in 2-4 weeks.

Treatment of acute bacterial cervical lymphadenitis without a known primary infectious source: The treatment of acute bacterial cervical lymphadenitis without a known primary infectious source should provide adequate coverage for both S. aureus and S. pyogenes, pending the results of the culture and sensitivity tests if necessary. Appropriate oral antibiotics include cloxacillin (25-50 mg/kg/day divided into 4 doses), cephalexin (25-50 mg/kg/day divided into 2-4 doses), cefprozil (15 mg/kg/day divided into 2 doses), or clindamycin (8-25 mg/kg/day divided into 3-4 doses). The treatment course is usually 10 days. Antimicrobial therapy may have to be modified once a causative agent is identified, pending the clinical response to the existing treatment.

Treatment of cervical lymphadenitis caused by S. pyogenes. Because of its proven efficacy, safety, and narrow spectrum of antimicrobial activity, penicillin remains the drug of choice for lymphadenitis caused by S. pyogenes, except in patients allergic to penicillin. The recommended dosage of penicillin V is 25-50 mg/kg divided into 2 or 3 doses for 10 days. Amoxicillin is often preferred over penicillin because of the better taste of the suspension and its availability as chewable tablets. The dose of amoxicillin is 40 mg/kg/day divided into 3 doses. In patients allergic to penicillin, narrow-spectrum cephalosporins such as cephalexin (25-50 mg/kg/day divided into 2-4 doses) and the newer macrolides such as clarithromycin (15 mg/kg/day divided into 2 doses) and azithromycin (10 mg/kg on day 1 followed by 5 mg/kg/day once daily thereafter) are acceptable alternatives.

Treatment of cervical lymphadenitis caused by methicillin-resistant S. aureus: Methicillin-resistant S. aureus is often resistant to many kinds of antibiotics. Currently, vancomycin is the drug of choice. The dosage is 40-60 mg/kg/day divided into 3-4 doses given intravenously. Oral therapy with clindamycin (8-25 mg/kg/day divided into 3-4 doses) or trimethoprim-sulfamethoxazole (8-12 mg of trimethoprim and 40-60 mg of sulfamethoxazole divided into 2 doses) should be considered, depending on susceptibility testing if an isolate is available or alternatively based on local resistance patterns.

Treatment of cervical lymphadenitis associated with periodontal or dental disease: Children with cervical lymphadenitis associated with periodontal or dental disease should be treated with oral clindamycin (8-25 mg/kg/day divided into 3-4 doses) or a combination of amoxicillin and clavulanic acid (25-45 mg/kg/day divided into 2 doses), which provides coverage for anaerobic oral flora. Referral to a pediatric dentist for the treatment of the underlying periodontal or dental disease is warranted.

No symptomatic improvement after 72 hours of therapy: In the majority of patients, symptomatic improvement should be noted after 48 to 72 hours of therapy. Fine-needle aspiration and culture should be considered if there is no clinical improvement or if there is deterioration of the patient`s condition. If the lymph node becomes fluctuant, incision and drainage should be performed. Failure of regression of lymphadenopathy after 4-6 weeks of therapy might be an indication for a diagnostic biopsy. Indications for early excisional biopsy for histologic examination include a lymph node in the supraclavicular area, a lymph node greater than 3 cm, an affected lymph node in a child with a history of malignancy, and clinical findings of fever, night sweats, weight loss, and hepatosplenomegaly.

Treatment of immunocompromised children or children with toxic conditions: Immunocompromised children or those with toxic conditions as well as those who do not tolerate, will not take, or fail to respond to oral medication should be treated with intravenous nafcillin (50-200 mg/kg/day in 4-6 divided doses), cefazolin (25-100 mg/kg/day in 3-4 divided doses), clindamycin (20-40 mg/kg/day in 3-4 divided doses), or vancomycin (40-60 mg/kg/day divided into 3-4 doses).

Treatment of cervical tuberculous lymphadenitis: The current recommendation for the treatment of isolated cervical tuberculous lymphadenitis is 2 months of oral isoniazid (10-15 mg/kg/day), rifampin (10-20 mg/kg/day), and pyrazinamide (20-40 mg/kg/day), followed by 4 months of oral isoniazid (10-15 mg/kg/day) and rifampin (10-20 mg/kg/day) If possible drug resistance is a concern, oral ethambutol (15-25 mg/kg/day) or intramuscular streptomycin (20-40 mg/kg/day) should be added to the initial 3 drugs in consultation with an infectious disease specialist until drug susceptibilities are determined.

Treatment of cervical nontuberculous mycobacterial lymphadenitis: Cervical nontuberculous mycobacterial lymphadenitis is best treated with surgical excision of all visibly infected nodes. Incision and drainage are contraindicated because of the risk of sinus tract formation and increased risk of recurrence. Antimicrobial therapy provides no additional benefit. A recent randomized, controlled trial enrolled 100 children with cervical nontuberculous mycobacterial lymphadenitis to receive surgical excision (n = 50) or antibiotic therapy with clarithromycin and rifabutin (n = 50) for at least 12 weeks. Based on intention-to-treat analysis, the surgical cure rate was 96% versus 66% in the medical arm.

The major complication of surgery is permanent damage to the facial nerve, which occurs in about 2% of patients. Transient facial nerve involvement occurs in another 12%. Thus careful consideration must be given to the location of the cervical lymphadenitis in the determination of lymph node removal. Therapy with oral clarithromycin (15 mg/kg/day divided into 2 doses) or azithromycin (10 mg/kg on day 1 followed by 5 mg/kg/day once daily thereafter) combined with ethambutol (15-25 mg/kg/day) or rifampin (10-20 mg/kg/day), or rifabutin (10-20 mg/kg once daily or intermittently 2-3 times weekly) may be beneficial in children in whom surgery is not feasible because of risk of damage to the facial nerve, in whom surgical excision is incomplete, or in those with recurrent cervical nontuberculous mycobacterial lymphadenitis.

What are the adverse effects associated with each treatment option?

Conservative treatment

There is no adverse effect associated with this treatment option.

Treatment of acute bacterial cervical lymphadenitis

Adverse effects associated with oral cloxacillin include nausea, vomiting, diarrhea, pseudomembranous colitis, black or hairy tongue, oral candidiasis, hepatotoxicity, renal impairment, bone marrow suppression, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral cephalexin include abdominal pain, diarrhea, pseudomembranous colitis, superinfection, hepatic impairment, hemolytic anemia, neutropenia, thrombocytopenia, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral cefprozil include nausea, vomiting, abdominal pain, diarrhea, pseudomembranous colitis, diaper rash, dizziness, superinfection, hepatic impairment, renal impairment, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral clindamycin include nausea, vomiting, abdominal pain, diarrhea, pseudomembranous colitis, agranulocytosis, thrombocytopenia, hepatic impairment, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral penicillin V include nausea, vomiting, diarrhea, oral candidiasis, interstitial nephritis, seizure, hemolytic anemia, positive Coombs reaction, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral amoxicillin include nausea, vomiting, diarrhea, pseudomembranous colitis, black or hairy tongue, tooth discoloration, mucocutaneous candidiasis, hemolytic anemia, bone marrow suppression, hepatic impairment, crystalluria, agitation, dizziness, headache, seizure, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral clarithromycin include headache, nausea, vomiting, abdominal pain, dyspepsia, diarrhea, pseudomembranous colitis, abnormal taste, renal impairment, hepatic impairment, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral azithromycin include anorexia, nausea, vomiting, abdominal pain, dyspepsia, diarrhea, pruritus, vaginitis, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with intravenous vancomycin include hypotension accompanied by flushing, red neck or red man syndrome, drug rash with eosinophilia and systemic symptoms (DRESS), neutropenia, thrombocytopenia, chills, drug fever, phlebitis, fungal/bacterial superinfection, Stevens-Johnson syndrome, and nephrotoxicity.

Adverse effects associated with oral administration of a combination of trimethoprim and sulfamethoxazole include anorexia, nausea, vomiting, abdominal pain, diarrhea, pseudomembranous colitis, drug fever, agranulocytosis, aplastic anemia, thrombocytopenia, fulminant hepatic necrosis, crystalluria, hyperkalemia, hyperglycemia, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral administration of a combination of amoxicillin and clavulanic acid include diarrhea, nausea, vomiting, abdominal pain, pseudomembranous colitis, headache, black or hairy tongue, tooth discoloration, mucocutaneous candidiasis, interstitial nephritis, crystalluria, hepatic impairment, hemolytic anemia, agranulocytosis, thrombocytosis, and anaphylactoid/hypersensitivity reactions.

No symptomatic improvement after 72 hours of therapy

Adverse effects associated with fine-needle aspiration include pain, hemorrhage, hematoma formation, wound infection, and damage to the underlying structures.

Adverse effects associated with incision and drainage include pain, hemorrhage, hematoma formation, wound infection, scarring, and damage to the underlying structures such as the facial nerve.

Adverse effects associated with excisional biopsy include pain, hemorrhage, hematoma formation, wound infection, scarring, and damage to the underlying structures such as the facial nerve.

Treatment of immunocompromised children or those with toxic conditions

Adverse effects associated with intravenous nafcillin include pain at the injection site, phlebitis, thrombophlebitis, skin sloughing and tissue necrosis with extravasation, pseudomembranous colitis, bone marrow suppression, neurotoxicity (high doses), and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with intravenous cefazolin include pain at the injection site, phlebitis, nausea, vomiting, abdominal pain, diarrhea, pseudomembranous colitis, oral candidiasis, vaginitis, drug fever, seizure, renal impairment, hepatic impairment, bone marrow suppression, eosinophilia, thrombocytosis, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with intravenous clindamycin include thrombophlebitis, hypotension, cardiac arrest (rarely), nausea, vomiting, abdominal pain, metallic taste, diarrhea, pseudomembranous colitis, agranulocytosis, thrombocytopenia, hepatic impairment, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with intravenous vancomycin include hypotension accompanied by flushing, red neck or red man syndrome, DRESS, neutropenia, thrombocytopenia, chills, drug fever, phlebitis, fungal/bacterial superinfection, Stevens-Johnson syndrome, and nephrotoxicity.

Treatment of cervical tuberculous lymphadenitis

Adverse effects associated with oral isoniazid include anorexia, nausea, vomiting, epigastric discomfort/pain, hepatic impairment, peripheral neuritis, optic neuritis, pyridoxine deficiency, flushing, tachycardia, lethargy, gynecomastia, lymphadenopathy, hyperglycemia, metabolic acidosis, agranulocytosis, anemia (sideroblastic, hemolytic, or aplastic), eosinophilia, thrombocytopenia, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral rifampin include anorexia, nausea, vomiting, epigastric discomfort/pain, heartburn, diarrhea, pseudomembranous colitis, influenza-like syndrome, hepatic impairment, pancreatitis, pemphigoid reaction, orange discoloration of body secretions or urine, orange staining of contact lenses, flushing, ataxia, impaired concentration, drug fever, pruritus, bone marrow suppression, myalgia, renal impairment, interstitial nephritis, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral pyrazinamide include malaise, anorexia, nausea, vomiting, hepatic impairment, arthralgia, myalgia, hyperuricemia, interstitial nephritis, photosensitivity, acne, drug fever, sideroblastic anemia, thrombocytopenia, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral ethambutol include anorexia, nausea, vomiting, epigastric discomfort/pain, headache, dizziness, disorientation, optic neuritis, color blindness, peripheral neuritis, hepatic impairment, renal impairment, arthralgia, hyperuricemia, myocarditis, pericarditis, drug fever, lymphadenopathy, leukopenia, thrombocytopenia, eosinophilia, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with intramuscular streptomycin include nausea, vomiting, arthralgia, breathing difficulty, hypotension, headache, drug fever, paresthesia, tremor, neurotoxicity, ototoxicity, nephrotoxicity, superinfection, anemia, eosinophilia, and anaphylactoid/hypersensitivity reactions.

Treatment of cervical nontuberculous mycobacterial lymphadenitis

Adverse effects associated with surgical excision of all visibly infected nodes include pain, hemorrhage, hematoma formation, wound infection, scarring, and damage to the underlying structures such as the facial nerve.

Adverse effects associated with oral clarithromycin include headache, nausea, vomiting, abdominal pain, dyspepsia, diarrhea, pseudomembranous colitis, abnormal taste, renal impairment, hepatic impairment, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral azithromycin include anorexia, nausea, vomiting, abdominal pain, dyspepsia, diarrhea, pruritus, vaginitis, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral ethambutol include anorexia, nausea, vomiting, epigastric discomfort/pain, headache, dizziness, disorientation, optic neuritis, color blindness, peripheral neuritis, hepatic impairment, renal impairment, arthralgia, hyperuricemia, myocarditis, pericarditis, drug fever, lymphadenopathy, leukopenia, thrombocytopenia, eosinophilia, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral rifampin include anorexia, nausea, vomiting, epigastric discomfort/pain, heartburn, diarrhea, pseudomembranous colitis, influenza-like syndrome, hepatic impairment, pancreatitis, pemphigoid reaction, orange discoloration of body secretions or urine, orange staining of contact lenses, flushing, ataxia, impaired concentration, drug fever, pruritus, bone marrow suppression, myalgia, renal impairment, interstitial nephritis, and anaphylactoid/hypersensitivity reactions.

Adverse effects associated with oral rifabutin include nausea, taste perversion, vomiting, epigastric discomfort/pain, eructation, flatulence, skin rash, discoloration of urine, leukopenia, thrombocytopenia, headache, drug fever, hepatic impairment, myalgia, arthralgia, breathing difficulty, influenza-like syndrome, superinfection, and anaphylactoid/hypersensitivity reactions.

What are the possible outcomes of cervical lymphadenitis?

The prognosis depends on the underlying cause. In the majority of cases, it is infectious in origin secondary to a viral upper respiratory tract infection. Most children with cervical lymphadenitis do not require specific treatment, as the disease is self-limiting. They can be safely monitored for spontaneous resolution of the enlarged lymph nodes over 4-6 weeks. With early and appropriate antimicrobial therapy, complete resolution of cervical lymphadenitis caused by S. pyogenes and S. aureus is the rule.

What causes this disease and how frequent is it?

Viral infection. The most common cause is reactive hyperplasia resulting from an infectious process, most commonly a viral upper respiratory tract infection. Cervical lymphadenitis might be caused by rhinovirus, parainfluenza virus, influenza virus, respiratory syncytial virus, coronavirus, adenovirus, or reovirus. Other viruses associated with cervical lymphadenitis include EBV, CMV, rubella, rubeola, varicella-zoster virus, HSV, coxsackievirus, and HIV.

Bacterial infection. Bacterial cervical lymphadenitis is usually caused by S. pyogenes or S. aureus. Anaerobic bacteria (Peptococcus species, Peptostreptococcus species, Bacteroides species) can cause cervical lymphadenitis, usually in association with dental caries or periodontal disease. Group B streptococci and Haemophilus influenzae type b are less frequent causal organisms.

B. henselae (cat-scratch dsease), nontuberculous mycobacteria (M. avium-intracellulare, M. scrofulaceum, M. kansasii, M. haemophilus, M. lentiflavum, M. bovis, M. malmoense, M. florentinum, M. interjectum, and so on), and Mycobacterium tuberculosis ("scrofula") are important causes of subacute or chronic cervical lymphadenitis. Rare causes of bacterial cervical lymphadenitis include infection with Brucella species, Corynebacterium diphtheriae, Nocardia brasiliensis, Pasteurella multocida, Treponema pallidum, Francisella tularensis, and Leptospira interrogans.

Protozoal infection(rare)

T. gondii

Leishmania species

Trypanosoma species

Filaria species

Fungal infection (rare)

Candida albicans

Histoplasma capsulatum

Blastomyces dermatitides

Coccidiodes immitis

Aspergillus fumigatus

Cryptococcus neoformans

Sporothrix schenckii

How do these pathogens/genes/exposures cause the disease?

Offending microorganisms usually first infect the upper respiratory tract, anterior nares, oral cavity, or skin in the head and neck area before spreading to the cervical lymph nodes. The lymphatic system in the cervical area serves as a barrier to prevent further invasion and dissemination of these microorganisms. Offending microorganisms are transported by afferent lymphatic vessels to lymph nodes.

The superficial cervical lymph nodes lie on top of the sternocleidomastoid muscle and include the anterior group, which lies along the anterior jugular vein, and the posterior group, which lies along the external jugular vein. The deep cervical lymph nodes lie deep to the sternocleidomastoid muscle along the internal jugular vein and are divided into superior and inferior groups. The superior deep cervical lymph nodes lie below the angle of the mandible, whereas the inferior deep cervical lymph nodes lie at the base of the neck.

The superficial cervical lymph nodes receive afferents from the mastoid, tissues of the neck, and the parotid (preauricular) and submaxillary nodes. The efferent drainage terminates in the superior deep cervical lymph nodes. The superior deep cervical lymph nodes drain the palatine tonsils and the submental nodes. The inferior deep cervical lymph nodes drain the larynx, trachea, thyroid, and esophagus.

The nodal enlargement occurs as a result of proliferation of cells intrinsic to the node such as lymphocytes, plasma cells, monocytes, and histiocytes, or by infiltration of cells extrinsic to the node such as neutrophils. As infections involving the head and neck areas are common in children, so is cervical lymphadenitis common in this age group.

Other clinical manifestations that might help with diagnosis and management

Please refer to Table I.

Table I.

Differentiation of Nontuberculous Mycobacterial and M. TuberculosisCervical Lymphadenitis
Clinical Characteristics Nontuberculous Mycobacteria M. Tuberculosis
Age 1-4 yr All ages (most > 5yr)
Race Predominantly white  Predominantly black or Hispanic 
Exposure to tuberculosis Absent Present
Constitutional symptoms Absent Present
Cervical lymphadenitis Usually solitary, in the submanibular area Usually multiple, bilateral, in the posterior cervical or supraclavicular area
Sinus tract formation Approximately 10% Rare
Chest radiograph Normal (97%) Abnormal (20%-70%)
Residence Rural Urban
PPD >15 mm of induration* Uncommon Usual
Response to antimycobacterial drugs No Yes

What complications might you expect from the disease or treatment of the disease?

Complications are unusual if the infection is properly treated. Conversely, delay in establishing the diagnosis or initiating proper treatment may result in a prolonged clinical course and/or complications such as the following:

Cellulitis (S. pyogenes, S. aureus, anaerobic bacteria)

Bacteremia (S. pyogenes, S. aureus, anaerobic bacteria)

Suppuration and/or abscess formation (S. pyogenes, S. aureus, anaerobic bacteria, nontuberculous mycobacteria, M. tuberculosis)

Sinus tract formation (nontuberculous mycobacteria, B. henselae)

Acute glomerulonephritis (S. pyogenes)

Rheumatic fever (S. pyogenes)

Thrombosis of the jugular vein (very rare)

Mycotic carotid artery aneurysm (very rare)

Are additional laboratory studies available; even some that are not widely available?

The use of polymerase chain reaction assays to identify tuberculosis and nontuberculous mycobacteria in lymph node biopsy specimens will provide a much more rapid result than the conventional tests. Polymerase chain reaction testing is a fast and useful technique for the demonstration of mycobacterial DNA fragments. The test, however, is not yet routinely available.

How can cervical lymphadenitis be prevented?

The frequency of cervical lymphadenitis can be reduced by prompt and appropriate treatment of oropharyngeal infection, otic infection, skin infection in the head and neck area, and prompt and appropriate treatment of dental caries and periodontal disease. Maintenance of good oral and personal hygiene, including proper hand washing, and good nutrition are other means of reducing the frequency of this condition. Avoidance of overcrowded areas, including daycare settings, and exposure to individuals with contagious infections, such as upper respiratory tract infection, streptococcal pharyngitis, and tuberculosis, will minimize the likelihood of the development of cervical node infection in children. Other exposures to avoid include the following:

Exposure to infected animals, birds, and fish (cat-scratch disease, toxoplasmosis, brucellosis, nontuberculous mycobacteria, tularemia)

Consumption of undercooked meat (toxoplasmosis)

Consumption of unpasteurized animal milk or dairy products (brucellosis, nontuberculous mycobacteria)

Travel to endemic areas (tuberculosis, HIV, histoplasmosis, coccidioidomycosis, leishmaniasis)

What is the evidence?

Kimberlin, DW, Brady, MT, Jackson, MA. " Red Book: 2015 Report of the Committee on Infectious Diseases". American Academy of Pediatrics. 2015. pp. 831-839.

(The "Red Book" has been considered the Bible of pediatric infectious diseases. The opinions expressed in this book are authoritative.)

Chan, JM, Shin, LK, Jeffrey, RB. "Ultrasonography of abnormal neck lymph nodes". Ultrasound Q... vol. 23. 2007. pp. 47-54.

(A review article that outlines the usefulness of ultrasonography in the assessment of cervical lymphadenopathy.)

Gosche, JR, Vick, LV. "Acute, subacute, and chronic cervical lymphadenitis in children". Semin Pediatr Surg. vol. 15. 2006. pp. 99-106.

(An excellent article that addresses current approaches to the diagnosis and management of cervical lymphadenitis in children.)

Kim, BM, Kim, EK, Yang, WI. "Sonographically guided core needle biopsy of cervical lymphadenopathy in patients without known malignancy". J Ultrasound Med. vol. 26. 2007. pp. 585-591.

(A retrospective study that showed a high yield and accuracy of sonographically-guided core needle biopsy for diagnosing the cause of cervical lymphadenopathy.)

Kubba, H. "A child with cervical lymphadenopathy". Clin Otolaryngol. vol. 31. 2006. pp. 433-434.

(An excellent article that offers practical guidelines on the management of childhood cervical lymphadenopathy.)

Leung, AK, Davies, HD. "Cervical lymphadenitis: etiology, diagnosis and management". Curr Infect Dis Rep.. vol. 11. 2009. pp. 183-189.

(An excellent article that provides practical guidelines on the management of childhood cervical lymphadenitis.)

Lindeboom, JA, Kuijper, EJ, Bruijnesteijn van Coppernraet, ES. "Surgical excision versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children: a multicenter, randomized, controlled trial". Clin Infect Dis. vol. 44. 2007. pp. 1057-1064.

(This multicenter, randomized, controlled trial compared surgical excision versus antibiotic treatment for nontuberculous myocobacterial cervicofacial lymphadenitis in children.)

Niedzielska, G, Kotowski, M, Niedzielska, A. "Cervical lymphadenopathy in children—incidence and diagnostic management". Int J Pediatr Otorhinolaryngol. vol. 71. 2007. pp. 51-56.

(This article provides an excellent review of the various diagnostic tools.)
You must be a registered member of Endocrinology Advisor to post a comment.

Sign Up for Free e-Newsletters

CME Focus