See also

• Febrile Child
• Kawasaki Disease

Key points

1. Cervical lymphadenopathy is common and may be found in more than one third of otherwise healthy children
2. Observation and reassurance without investigation is usually appropriate for the well appearing child with cervical lymphadenopathy

Background

• Cervical lymph nodes are often palpable in well children
• Cervical lymphadenopathy is abnormal enlargement of lymph nodes (LNs) in the head and neck usually >1 cm
• Most cases are benign and self-limited, however, the differential diagnosis is broad
• Viral upper respiratory tract infection is the most common cause of cervical lymphadenopathy in children. These enlarged "reactive" nodes may persist for weeks to months
• Acute bacterial lymphadenitis is characterised by enlarged nodes, which are tender, usually unilateral and may be fluctuant

Assessment

History

• Onset and duration of neck lump
• Location of neck lump
• Growth over time, colour, pain, and overlying skin changes
• Restriction of neck movement
• Recent illness
• Presence of fever
• Loss of weight
• Night sweats
• Bruising
• Lymphadenopathy noted elsewhere
• Features of deep tissue head and neck infection (eg trismus, muffled voice)
• Overseas travel, including possible exposure to tuberculosis 
• Exposure to animals (eg cats)
• Immunisation status (diphtheria, measles, mumps, rubella)
• Dental disease
• Response to antibiotic treatment

Examination

• LN groups in the head and neck region:
  
  

• Characterise the lump: location, size, colour, warmth, mobility, tenderness, overlying skin changes
• Unilateral or bilateral
• Features on palpation: eg soft, rubbery, firm, matted, fluctuant, discharging,
• Neck range of motion
• Lymphadenopathy at other sites
• Other focus of infection: scalp, face, ear, nose, throat or teeth
• Further examination should be guided by history and differential diagnosis

Differential diagnosis

Acute cervical lymphadenopathy

Cervical lymphadenitis secondary to viral infection

• Very common, usually with history of a viral prodrome
• LNs may be tender to palpation and unilateral or bilateral
• Usually resolves as other viral symptoms do
• Small risk of developing into a secondary bacterial lymphadenitis

Acute bacterial cervical lymphadenitis

• Common, usually unilateral and in the anterior part of the neck
• Associated with fever and neck swelling
• May be firm and tender with overlying erythema, limited neck range of motion
• Common bacterial causes: Staphylococcus aureus, group B streptococcus (in neonates), group A streptococcus, and anaerobic infections (associated with dental disease)
• A site of entry may be found (eg mouth or scalp)
• Cervical lymphadenitis may rarely be associated with serious deep head and neck infections such a retropharyngeal abscess.

Kawasaki disease

• Kawasaki disease may present with unilateral tender cervical lymphadenopathy and associated features

Persistent cervical lymphadenopathy

• Subacute cervical lymphadenopathy (2–6 weeks) – commonest cause viral infection
• Chronic cervical lymphadenopathy (>6 weeks) - has a number of possible cause. Many viruses will cause cervical lymphadenopathy lasting up to 6 weeks
• Some cases may be unexplained

Approach to differential diagnosis

Management

• Observation and reassurance without investigation is usually appropriate for the well-appearing child with cervical lymphadenopathy

Investigations

Treatment

• Most cases of cervical lymphadenopathy will be self-limited and do not require treatment
• If there are signs of bacterial lymphadenitis (unilateral, tender, fluctuant), consider the following:

Well - oral antibiotics for 7 days, with review in 48 hours

• Cefalexin 33 mg/kg (max 500 mg) oral tds

Unwell, or failed oral treatment - IV antibiotics

• Flucloxacillin 50 mg/kg (max 2 g) IV 6H

Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

Fluctuant node

• For fluctuant nodes not responding to IV antibiotics, consider consultation with general surgical team for incision and drainage
• Excision of whole node is preferred in suspected mycobacterial infection as incision and drainage may result in sinus formation

Consider consultation with local paediatric team when

• Neonate, unwell child, or persistent cervical lymphadenopathy despite oral antibiotics
• Features suggestive of systemic disease (Kawasaki Disease, malignancy, rheumatologic condition)

Consider transfer when

Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Last updated April 2021