Pediatric Medicine Cervical Lymphadenitis in the Peiatric Age Group

1. Cervical Lymphadenitis in
the Pediatric Age Group
by
SAHAR AWADA, MD
Pediatric Resident
Lebanese University Medical School

2. Case Presentation
• 1y 2m old boy previously healthy presenting
for Right Neck mass
• 4 days ptp, pt started to develop HGF with no
other sx
• In the next day, HGF continued and the
mother noticed a right neck swelling with
edema and erythema
• 2 days ptp, mass increased progressively in
size, the parents seeked medical advice and
the pt was started on antibiotic(Amoclan)

3. Case Presentation
• Despite antibiotic therapy, pt continued to be
febrile with no decrease in mass size
• On the day of presentation, U/S neck was
done in another hospital and showed:
A right submandibular cystic mass of 2.5 cm in
diameter resembeling an abscess collection
just next to a lymph node of 1 cm in diameter

4. Case Presentation
• No chills, night sweat, rinorrhea , cough ,
dyspnea, drooling, dysphagia or any other GI
Sx, no change in voice quality, arthralgia,
weight loss , fatigue
• No hx of trauma, insect bite, ingestion of
unpasteurized animal milk, undercooked meat
or new drug intake
• No hx of Dental problems or mouth sores
• No hx of animal exposure or recent travel

5. Case Presentation
• PMH: ftb, nvd, no ICN admission, no hx of
recurrent infection
• PSH: neg
• PFH: simultaneous acute viral illness(sister)
• Diet: regular for age
• Home med: Amoclan, Profinal, Panadol
• Vaccination: uptodate until the age of 1 yr( 1st
MMR dose not yet received)

6. Physical exam
• Pt looked ill, NAD, febrile(39.2)
• Anicteric sclera, well injected conjunctiva,no mouth
sore or apthous lesions, nrl tonsills
• Ears: nrl
• Right submandibular mass, hard, non mobile,
tender, warm and erythemateous, measuring 3x3 cm
• Heart: rr, nrl s1s2
• Lungs: GBAE, no adventitious sounds
• Abdomen : non distended, +BS, non tender, no HSM
• Normal genitaliae, no palpable axillary or inguinal LN

7. Lab tests
• Cbcd
– WBC 24000
– Neutro 70%
– Lympho 20%
– Hb 11
– Hct 34
– MCV 80
– Plt 518
• Electrolytes nrl
• CRP 22

8. Imaging
• CXR nrl
• CT neck with contrast:
– Right submandibular abscess measuring 3.4cm in
diameter next to a small centimetric LN with
several small bilateral LN

9. Pediatric Neck Masses

10. Classification
• Congenital
• Acquired
– Inflammatory
• Infectious
• Non infectious
– Neoplastic
• Benign
• Malignant

11. Classification

12. Congenital neck masses

13. Inflamatory neck masses
• Infectious
– Reactive viral lymphadenopathy
– Bacterial lymphadenopathy
– Parasitic lymphadenopathy
• Non infectious
– Connective tissue disorder
– Sarcoidosis
– Kawasaki disease

14. Neoplastic neck masses
• Metastatic head and neck carcinomas
• Thyroid mass
• Salivary gland neoplasms
• Schwanoma
• Lymphoma
• Lipoma and benign skin cysts

15. Initial evaluation(History(
• Age(BIRTH=CONGENITAL)
• Onset
• Rapidity of growth(rapid enlargement=inflammatory)
• Fluctuation in size
• Pain
• Infection
• Trauma
• Skin lesion(HS, staph, cat scratch disease)
• Associated symptoms (weight loss, fever, arthralgias,
sore throat)
• Dental problems(anaerobes)
• mouth sores(HSV, Enterovirus herpangina)

16. Initial evaluation(History(
• Travel
• Ingestion of unpasteurized animal
milk(brucellosis, mycobacterium bovis)
• Animal exposures(cat scratch disease,
toxoplasmosis [cats], brucellosis [especially
goats], tularemia [especially rabbits])
• Immunization status(diphtheria, measles,
mumps)
• Medications (phenytoin, carbamazepine)

17. Initial evaluation(physical exam(
• Size
• Multiplicity
• Laterality
• Consistency(firm, rubbery, matted)
• Color
• Mobility(fixed or mobile)
• Tenderness
• Fluctuation

18. Initial evaluation(physical exam(
• "Reactive" LN are usually discrete, mobile,
rubbery, and minimally tender
• Infected LN are usually isolated, asymmetric,
tender, warm, and erythematous; they may
be fluctuant; less mobile and discrete than
reactive LN
• Malignant LN often are hard, nontender, and
fixed to the underlying structures

19. Initial evaluation(physical exam(
• Oral cavity: search for evidence of periodontal
disease, herpangina, HSV gingivostomatitis, or
pharyngitis
• Eyes : conjunctival injection may indicate Parinaud
oculoglandular syndrome (associated with cat
scratch disease) or Kawasaki disease
• Skin : a generalized rash may suggest a viral illness,
whereas a localized skin lesion may indicate a more
specific etiology(cat scratch disease, HSV, etc.)
• Less common infections in which a papular or
pustular lesion is suggestive of an inoculation site

20. Initial evaluation(physical exam)
Location location location
Midline
• Thyroglossal cyst
• Submental
lymphadenopathy
• Dermoid and
epidermoid cysts
• Teratoma
• Cervical cleft
Lateral
• Branchial cleft anomaly
• Lymphatic/vascular
malformation
• Lymphadenopathy
• Thyroid nodule
• Thymic cyst
• Laryngocele
• Sialadenitis
• Soft tissue tumor

21. Initial evaluation(lab tests(
• Cbcd with differential
• Electrolytes: high ca level ->sarcoidosis
• Serology testing for EBV, CMV, toxo, syphilis,
cat scratch disease
• Thyroid function test
• PPD
• Urinary collection for VMA (vanillylmandelic
acid) ->neuroblastoma

22. Initial evaluation(imaging(
• CXR to R/O malignancy, TB, Sarcoidosis
• Lateral neck Xray essential in evaluation of
nasopharynx, cervical spine and retro-
pharyngeal region
• U/S to differentiate cystic structure from solid
mass and to evaluate thyroid mass
• CT WITH CONTRAST to differentiate cellulitis
from abscess and to identify vascular mass

23. Initial evaluation(surgical
diagnosis(
• FNA to decompresse the mass and to provide
material for cx
• If malignancy suspected => incisional or
exicional bx indicated

24. Congenital neck masses

25. Branchial cleft cysts
• 1/3 of congenital neck masses
• Nontender, fluctuant masses that may become
inflamed and lead to abscess formation during an
upper respiratory infection
• First branchial cleft cysts, rare, typically present near
the angle of the mandible
• Second branchial cysts are found high in the neck
and deep to the anterior border of the
sternocleidomastoid muscle
• Third branchial cleft cysts, also rare, are seen near
the upper pole of the thyroid gland

26. Branchial cleft cyst
• Ultrasound shows a fluid-filled cyst and can
differentiate cystic lesions from solid masses
• CT and MRI also confirm the cystic
characteristics of the mass and, more
importantly, delineate the relationship of the
cyst to surrounding structures
• Management of branchial cleft cysts is surgical
excision

27. Branchial cleft cyst

28. Thyroglossal duct cyst
• Forms in a persistent thyroid descent tract
that begins as an elongation of the thyroid
diverticulum
• Most in the midline near the level of the
hyoid bone, elevate with swallowing, and can
rarely present laterally
• A thyroglossal duct cyst usually presents as an
asymptomatic mass but may be associated
with mild dysphagia
• infrequently, may get infected and rapidly
enlarge

29. Thyroglossal duct cyst

30. Dermoid cyst
• Dermoid cysts consist of epithelium-lined
cavities filled with skin appendages (e.g., hair,
hair follicles, sebaceous glands)
• Typically, dermoid cysts are seen in the
midline of the neck, usually in the submental
region
• They are attached to and move with the
overlying skin and are painless unless infected
• Management is by complete surgical excision

31. Dermoid cyst

32. Lymphatic malformation
• Previously termed lymphangioma
• Congenital malformations of lymph tissue that result
from the failure of lymph spaces to connect to the
rest of the lymphatic system
• Soft, smooth, nontender mass that is compressible
and can be transilluminated
• Macrocystic lymphatic malformations (previously
termed cystic hygroma) contain large thickwalled
cysts that have less infiltration of surrounding tissue
• lymphatic malformations fluctuate in size as a result
of infection or hemorrhage

33. Cystic Hygroma

34. Infectious neck masses
Acute
unilateral cervical
lymphadenitis
Subacute/chronic
unilateral lymphadenitis
Acute
bilateral cervical
lymphadenitis
Subacute/chronic
bilateral lymphadenitis

35. Acute bilateral cervical
lymphadenitis
• Is the most common infectious neck mass
• Viral
– Caused by a benign, self-limited viral upper
respiratory infection (eg, enterovirus, adenovirus,
influenza virus)
– The LN(reactive LN) typically are small, rubbery,
mobile, discrete, minimally tender, and without
erythema or warmth
-Baterial: GAS pharyngitis is a common cause of
bilateral cervical lymphadenitis, which is often
tender

36. Acute unilateral cervical
Lymphadenitis
Acute unilateral cervical lymphadenitis is usually
caused by bacteria
-S. Aureus
-GAS
-In young infants, Streptococcus agalactiae
(group B streptococcus(

37. S. aureus and GAS
-Between 40 and 80 % of cases
-Most of these infections occur in children younger than
5 years of age
-Patients may have a history of a recent URI or impetigo
-Submandibular nodes are affected in more than 50%
-The lymph node usually is 3 to 6 cm in diameter, tender,
warm, erythematous, nondiscrete, and poorly mobile
-One-fourth to one-third of infected nodes suppurate and
become fluctuant

38. Other causes
-Acute unilateral cervical lymphadenitis in
older children with history of periodontal
disease usually is caused by an infection with
anaerobic bacteria
-Tularemia

39. Subacute/chronic bilateral cervical
lymphadenitis
-Most often caused by EBV or CMV infection
-EBV causes infectious mononucleosis that may
manifest as fever, exudative pharyngitis,
lymphadenopathy, and hepatosplenomegaly
-CMV also can cause a mononucleosis-like
illness

40. Subacute/chronic unilateral cervical
lymphadenitis
-Nontuberculous mycobacteria (NTM)
infections
-Bartonella henselae-cat scratch disease (CSD(
-TB
-Toxoplasmosis

41. Treatement
• Acute bilateral LN — Treatment is
not usually necessary for acute
bilateral lymphadenitis (LN), which
most frequently is related to a self-
limited viral illness. The treatment of
those with severe, progressive, or
persistent cervical lymphadenitis
depends upon the etiology

42. Treatement
• Acute unilateral LN — The initial treatment depends upon
the severity of symptoms
• In well-appearing children with a slightly enlarged and
minimally tender cervical lymph node, it is suggested to
measure the lymph node and monitoring it over time
• In children with moderate symptoms (eg, fever, warm
and/or tender adenitis without evidence of fluctuance), a
course of oral antimicrobial therapy is recomended. FNA
of the inflamed node before initiation of oral therapy may
help to guide antimicrobial coverage
• In children with severe symptoms (eg, fever, fluctuant
node, cellulitis), parenteral antimicrobial therapy after
incision and drainage of the inflamed node is recomended

43. Treatement
• Treatment failure — If the child fails to
respond to empiric therapy, the differential
diagnosis needs to be expanded to include
uncommon causes of acute unilateral cervical
adenitis, including noninfectious causes. The
history needs to be re-reviewed. Surgical
excision, drainage, or biopsy may be
necessary

44. Back to our case
• Acute unilateral cervical lymphadenitis
• ENT consult was ordered
• A decision to drain the abscess was taken in the
same day of presentation
• Pus cx was taken intraoperatively
• A 2 weeks course of Augmentin was started
• The patient did very well postoperatively and was
free of symptoms
• Cx was positive for Staph Aureus
• Pt was discharged home on oral Augmentin 4 days
after his admission to the hospital