Introduction

Cervical lymphadenopathy is a common condition in children that can lead to considerable anxiety for both parents and doctors. While this condition is typically benign and self-limiting, it can sometimes indicate a more serious pathology. Understanding the various causes, proper evaluation, and management strategies for cervical lymphadenopathy is crucial in differentiating between common, harmless causes and those that require urgent medical attention.

When a cervical lymph node is palpable, it could be one of the following:

1. Palpable cervical lymph nodes: Cervical lymph nodes are usually palpable in children due to their thin subcutaneous fat layer. These nodes are generally <1 cm in diameter, non-tender, fluctuate in size over time and are mobile. 
   
2. Lymphadenitis: Infection/ inflammation of the lymph nodes. The lymph node is painful and tender, and there can be overlying skin erythema. 
   
3. Lymphadenopathy: This refers to abnormal size, number or consistency.  This can be further categorised based on the duration: acute (less than 2 weeks), sub-acute (2-6 weeks and chronic (> 6 weeks)

Causes of Acute Lymphadenopathy

• Viruses: Rhinovirus, Epstein-Barr virus (EBV), Cytomegalovirus (CMV), Herpes simplex virus, Adenovirus, Enterovirus, Influenza.
• Bacterial infections: Staphylococcus, Streptococcus, Mycoplasma pneumoniae.
• Inflammatory conditions: Kawasaki disease, MIS-C (Multisystem Inflammatory Syndrome in Children), PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis).

Causes of Chronic Lymphadenopathy

• Infections: EBV, CMB, HIV, HSV Toxoplasmosis, Borrelia burgdorferi 
  
• Granulomatous diseases: Cat-scratch disease, atypical mycobacteria, TB
  
• Malignancies: Lymphoma, leukaemia, Metastasis, HLH
  
• Miscellaneous: Kawasaki disease, Post-vaccination, Kikuchi disease, Juvenile idiopathic arthritis, Systemic lupus erythematosus 

Evaluation of a patient with cervical lymphadenopathy

History

Key questions to ask during the history-taking include:

• Age of the child and the duration of lymphadenopathy.
• Characteristics of the lymph node: location, rapidity of growth, pain, overlying skin changes, any other lymph node affected
• History of recent infections, including upper respiratory tract infections, infections of scalp/ head lice, or dental issues.
• Constitutional symptoms like fatigue, weight loss, fever, night sweats, pruritus, joint pain/ swelling, rashes, bleeding manifestations
• Exposure to animals, tuberculosis (TB), or known risk factors for malignancy (e.g. Trisomy 21)
• Recent immunisations

Examination

• General appearance: Is the child well or unwell?
• Signs of systemic involvement like pallor, joint swelling, or skin rashes/ petechiae/ecchymosis
• Lymph node characteristics: Size (larger than 2 cm is concerning), location, consistency (rubbery, firm, or hard), tenderness, and any overlying skin changes (e.g. erythema).
• Other areas: Examination of the head, neck, scalp, mouth, and abdomen, checking for signs of systemic illness such as hepatosplenomegaly or respiratory distress. The drainage areas and common causes for each cervical lymph node group are listed in Table 1.1.

Table 1.1: Anatomical location of cervical lymph nodes, its drainage and causes for enlargement. 

Anatomical Location	Lymphatic drainage	Selected causes of localised lymphadenopathy
Anterior cervical	Throat, posterior pharynx, tonsils, thyroid gland	Local infections in the ear, nose and throat, infectious mononucleosis, cytomegalovirus infection, toxoplasmosis
Posterior cervical	Scalp and neck, thorax, cervical and axillary nodes	Local infections in the scalp, tuberculosis, lymphoma, head and neck malignancy
Tonsillar	Tonsillar and posterior pharyngeal regions	Infections of the throat
Submandibular	Floor of the mouth, submandibular gland, tongue, lips, conjunctivae	Dental disease infection in the ear, nose, throat and eyes
Submental	Lower lip, floor of mouth, tip of tongue, cheek	Dental disease, local infections
Supraclavicular	Mediastinum, lungs, esophagus, abdomen via thoracic duct.	Lymphoma, thoracic or gastrointestinal cancer

Investigations

First-line Investigations

• Full blood count (FBC): See important considerations below. 
• Blood picture: See important considerations below. 
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Liver function tests (ALT/AST)
• Lactate dehydrogenase (LDH): See important considerations below. 

Second-line Investigations

• Ultrasound (USS) to check for abscess formation or neoplastic lesions.
• Serology: EBV (Monospot/EBV viral capsid antigen IgM), Mantoux test for TB.
• Chest X-ray: To rule out mediastinal masses or other thoracic pathology.
• Mantoux test
• Lymph node biopsy: This is often performed if there is suspicion of malignancy or mycobacterial infection, particularly in cases where nodes are larger than 2 cm, growing rapidly, or persist beyond 6-12 weeks.
• Bone marrow biopsy

Lymph Node Biopsy vs Fine Needle Aspiration (FNA)

Lymph node biopsy is considered the definitive test for diagnosing malignancies or infections like TB. It is performed on the largest or most abnormal lymph node, with the highest yield often found in the supraclavicular or lower cervical regions. However, caution is required if mediastinal lymphadenopathy is suspected, as this can lead to complications like collapse of the upper airways during anaesthesia. 

Suggested algorithm for evaluating/managing of cervical lymphadenopathy

Important Considerations

1. Size matters: Lymph nodes larger than 2 cm are considered significant, and larger nodes are often associated with a higher likelihood of serious pathology.
2. Location: Supraclavicular lymphadenopathy is particularly concerning and may suggest malignancies such as lymphoma, thyroid cancer, neuroblastoma, or gastrointestinal (GIT) cancers.
3. Growth pattern of the nodes: Persistent or enlarging lymph nodes that do not regress after several weeks should raise suspicion for malignancy or chronic infection.
4. Systemic signs: Constitutional symptoms like fever, weight loss, night sweats, or bone pain warrant further investigation, including a lymph node biopsy.
5. Accurate documentation: Always document the size, location, and characteristics of the lymph nodes carefully for monitoring and follow-up.
6. FBC/ Blood picture can be normal in lymphoma
7. LDH is non-specific and not a screening test for lymphoma

References

1. King D, Ramachandra J, Yeomanson D. Lymphadenopathy in children: refer or reassure? Archives of Disease in Childhood – Education and Practice 2014;99:101-110.
2. Ruffle A, Beattie G, Prasai A, et al.Fifteen-minute consultation: A structured approach to the child with palpable cervical lymph nodes. Archives of Disease in Childhood – Education and Practice 2023;108:326-329.

Dr P. W. Prasad Chathurangana
MBBS (Col), MD (Paed), PGCert (MedEd), MRCPCH (UK)  
Senior Lecturer, Faculty of Medicine, University of Colombo  
Honorary Consultant Paediatrician, Professorial Unit, Lady Ridgeway Hospital, Colombo