TITLE: Pediatric Cervical Lymphadenopathy
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: September 24, 2009
RESIDENT PHYSICIAN: Andrew Coughlin, MD
FACULTY PHYSICIAN: Shradda Mukerji, MD
DISCUSSANTS:
SERIES EDITORS: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Qui=
nn, MS(ICS)
&q=
uot;This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
ose
of stimulating group discussion in a conference setting. No warranties,
either express or implied, are made with respect to its accuracy, completen=
ess,
or timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
Introduction
Pediatric cervical lymphadenopathy is a challeng= ing medical condition for the patient, the parent, and the physician. 38-45% of normal healthy children (Larsson) and 90% of children aged 4-8 years old (P= ark) will have cervical lymphadenopathy. Although the majority of these masses w= ill be benign the fear of malignancy is ever present. In this review I will describe the important history and physical findings, including work up, associated with cervical lymphadenopathy. Next I will touch on common patho= gens present in both acute and subacute lymphadenitis. I will next review the literature for insight into the most common pathogens, presentations, ancil= lary tests and management strategies in treating lymphadenopathy, and finally I = will propose a plan based on the literature for properly treating children with = this disease process.
Definitions
A pathologic or abnormal lymph node is commonly = quoted to be >1cm in size however in the pediatric population >2cm is consid= ered abnormal (Cummings). Acute lymphadenopathy is 2 weeks duration, subacute is= 2-6 weeks duration, and chronic is considered any lymphadenopathy that does not resolve by 6 weeks.
Pathophysiology of Lymphadenopathy
An initial insult such as an upper respiratory infection, pharyngitis, odontogenic infection or otitis media starts in the head and neck region. After a local inflammatory reaction occurs, organisms from the initial site are carried to the draining lymph nodes via afferent lymphatics. Once in the lymph nodes dendritic cells and macrophages trap, phagocytose, degrade, and present the organisms as antigens on MHC molecule= s. These antigens are presented to T cells for which leads to proliferation of clonal cells and release of cytokines important for chemotaxis of other inflammatory cells. One such cell is the B cell. B cells, with the help of T cells are activated, proliferate, and release immunoglobulins that aid in t= he immune response. The result of this immune response within the lymph node is cellular hyperplasia, leukocyte infiltration, tissue edema, vasodilation and capillary leak, and capsule distension leading to tenderness.
History
Now that a mass is observed there are a plethora= of historical and clinical findings that are vital to help differentiate what = the cause of the mass is. Certainly you want to start with the pneumonic OLDCAR= TS as you do with all patients: “Onset, Location, Duration, Character, A= ggravating factors, Relieving factors, Timing, and Situations in which the problem is occurring”. You want to make sure and inquire about symptoms of fever, malaise, fatigue, and anorexia which may suggest a systemic disease process. You want to ask about recent head and neck infections such as URI’s, pharyngitis, ear infections or tooth infections. Insect bites, exposure to animals, and exposure to sick contacts are important. Finally medications a= nd immunizations are also important to ask about.
Physical Exam
After a thorough history, a solid methodical phy= sical exam is the next step. It is important to start generally and just look at = the child and ask yourself, “How sick are they?” If the child is febrile or toxic appearing it is perfectly reasonable to admit the child, s= tart antibiotics, and consider some type of imaging to evaluate for abscess formation. Next you are going to evaluate the skin for signs of cellulitis, impetigo and rash. Cellulitis may suggest bacterial cause while a rash may = just suggest a viral xanthem. On your ENT exam focus on primary sites of infecti= on as described previously.
The neck exam is vital to your differential. Thi= ngs you cannot forget to evaluate and document are size, unilateral vs bilatera= l, tender vs nontender, mobile vs fixed, and hard vs soft. Not only are these parameters important initially but they can also help guide decision making= in the future should any of these findings change significantly.
Ancillary but important exam systems are lung, abdomen, and extremities. Lymphadenopathy should be considered a systemic disease process until proven otherwise. Therefore, you should listen to the lungs to evaluate for consolidations that might suggest TB. You should palp= ate the abdomen for hepatosplenomegaly a sign found in lymphoma and infectious mononucleosis. Finally you should palpate the inguinal and axillary regions= for adenopathy as well.
A good history and physical exam will go a long = way to helping you differentiate not only benign from malignant but also lymphadenopathy from other forms of neck masses that may resemble a lymph n= ode but truly be something different.
Differential Diagnosis
Although the majority of masses diagnosed as bei= ng lymphadenopathy will be just that, approximately 22% (Yaris) of patients wi= ll have some other type of head and neck mass. The following is a list, however not exhaustive, of the differential diagnosis of lymphadenopathy, including history and physical findings that can help aid making the correct diagnosi= s.
|
Thyroglossal duct cyst |
Moves with tongue protrusion and is midline. |
|
Dermoid Cyst |
Midline and often has calcifications on plain films.= |
|
Branchial Cleft Cyst |
Smooth and fluctuant along SCM border. |
|
Laryngocele |
Enlarges with valsalva. |
|
Hemangioma |
Mass is presents after birth, rapidly grows, plateau= s, and is red or bluish in color |
|
Cystic Hygroma |
Transilluminates and is compressible |
|
Sternocleidomastoid Tumor |
Presents with torticollis, lymphadenopathy does not<= /p> |
|
Cervical Ribs |
Bilateral, hard and immobile |
|
Mumps |
Mass palpated superior to jaw line, not just inferio= r to it. |
Further workup
For most patients who present with acute, unilat=
eral
lymphadenopathy minimal workup is necessary. Many patients will get a CBC w=
ith
differential. Subacute disease or disease that is not responding to therapy
needs to be further evaluated. Common laboratory tests are as follows: ESR,
Rapid Streptococcal test, serology (EBV, Toxoplasmosis, Bartonella, CMV,
Syphilis, and HIV), PPD placement, urine VMA and LDH. Many of these tests a=
re
self explanatory however others can be very specific to disease processes. =
ESR
may be significantly elevated in
Imaging can include
Common findings in lymphadenopathy
In 2006 Yaris et al. performed a retrospective r= eview of 126 patients in Clinical Pediatrics. Their aim was to identify clinical = and laboratory findings that aided in the diagnosis of lymphadenopathy. Here th= ey pointed out the importance of history and physical exam with the help of laboratory findings produced a diagnosis in 61.2% of cases. They went on to= say that biopsy helped identify the diagnosis in an additional 38.8% of cases. = Of the 126 patients 22.2% were found to have disease other than lymphadenopath= y. Of those with lymphadenopathy, 76.6% had benign disease and 23.4% had malignancies.
Location of lymphadenopathy was also important. = The most common area for benign and malignant lymphadenopathy was is the submandibular gland followed by the superior cervical region. In terms of lymphadenitis vs reactive lymphadenopathy, lymphadenitis was more commonly associated with nodal size of >3cm and localized disease.
Finally they looked at risk factors for malignant disease. They found that old age, supraclavicular nodes, generalized lymphadenopathy, nodal size >3cm, hepatosplenomegaly, enlarged mediastin= al nodes, and elevated LDH levels were all statistically significant and associated with malignant disease. Interestingly, supraclavicular lymphadenopathy has been quite a significant risk factor. In a study perfor= med by Ellison et al in 1999 of 309 supraclavicular fine needle aspirations, th= ey found that 55% of nodes sampled were malignant. Therefore it is recommended that any supraclavicular node be biopsied due to its malignant potential. <= /p>
Acute Lymphadenopathy
Acute lymphadenopathy is almost always due to infectious causes and again lasts less than 2 weeks duration. Viral lymphadenopathy is the most common form of reactive lymphadenopathy. Common= viruses implicated in the formation of lymphadenopathy are Adenovirus, Rhinovirus, Enterovirus’ such as Coxsackie A and B, and Epstein Barr Virus just to name a few. Lymphadenopathy is often diffuse, bilateral, and nontender. Patients will commonly complain of cough, rhinorrhea, and low grade fever. Management is usually expectant however because lymph nodes often persist longer than 2 weeks they are commonly biopsied. Secondary bacterial infecti= on does occur at times in these patients.
Suppurative bacterial lymphadenopathy is most co= mmonly caused by Group A Streptococci and S. aureus<= /i>. These represent about 57.5% of all cases of lymphadenitis and 70% of bacter= ial cases are represented by unilateral lymphadenopathy. Common physical findin= gs included erythema or tenderness of the overlying skin in 48.3% and fever in 24.1% of cases. Diagnostically 31% of patients with bacterial lymphadenitis= had a phlegmon, infiltrate or abscess (Niedzielska). Management is with oral or intravenous antibiotics depending on the general appearance and reliability= of the parents of the child. CT with contrast and Ultrasound is an important adjunct in the evaluation if abscess is suspected. Common findings of absce= ss formation would be spiking fevers, fluctuance, dysphagia, or airway comprom= ise.
Subacute Lymphadenitis
Subacute lymphadenopathy persists for 2-6 weeks = and again is most commonly infectious in nature. These patients are typically treated with antibiotics first, however when they don’t get better, p= arents want to know “What is this mass growing on my child’s neck?” Therefore more aggressive workup is necessary. In 1995 Margalith et al looked at the most = common causes of subacute lymphadenitis and showed that Atypical Mycobacteria, Cat Scratch disease, and Toxoplasmosis are the most common causative organisms found. To a lesser extent EBV and CMV are also implicated at times.
In 2009 Choi et al retrospectively reviewed 60 patients less than 18 years old who had subacute lymphadenopathy and negati= ve cultures at 48 hours. They evaluated the usefulness PCR as a tool to rapidly diagnose the causative organism, what organisms were most commonly diagnose= d, and what type of surgical therapy was most effective in curing disease. The average age of patients was 4.7 years old with a slight female predominance= of 53%. Average lymph node size was 3.2cm and superior cervical and submandibu= lar lymphadenopathy were the most common presenting site.
Mycobacteria was implicated in 61.7% of cases an= d M. avium-intracellulare w= as the most common pathogen. Legionella and Bartonella were both implicated in= 10% of cases and in 18.3% of cases no organism was identified. Acid fast stain, culture and PCR were all relatively good at identifying mycobacteria, howev= er acid fast stains are not specific for tuberculous vs non-tuberculous types = and cultures often take up to 2 weeks or longer. In terms of Bartonella and Legionella infections, PCR was the only diagnostic modality to identify the= se pathogens. Therefore PCR is superior to stain and culture if available beca= use it provides a diagnosis within 2-3 days so that proper treatment recommendations can be instituted.
Finally this study looked at the ability of diff= erent surgical techniques to cure lymphadenitis. They found that incision and drainage, curettage, and lymphadenectomy had cure rates of 22%, 58%, and 95% respectively. They concluded then that lymphadenectomy is the treatment of = choice in patients with subacute mycobacterial lymphadenitis, but that the sample = size was not large enough in either the Legionella or Bartonella subgroups to ma= ke a definitive statement. It is important to note, however, that in the case of Legionella infections, 6/7 cases treated with incision and drainage plus postoperative antibiotics had recurrences. It appears then that lymphadenec= tomy might also be required for Legionella disease as well, but more studies are needed.
Atypical Mycobacteria
Atypical Mycobacterial infections are the most c= ommon cause of subacute lymphadenopathy. The most commonly involved species inclu= de M. avium-intracellulare, M. haemophilum, and M. scrofulaceum. These infections develop over weeks to months and untreated cases usually will develop sinus tracts and cutaneous drainage for up to 12 months. Common fin= dings on physical exam are lymph nodes that are tender, rubbery and have a violac= eous discoloration of the overlying skin. Diagnosis can be made by acid fast sta= in, culture and even PCR as described earlier. Historically treatment has been surgical excision however there is some evidence that expectant management = may be the best treatment. It is important to note that atypical infections dif= fer from tuberculous mycobacterial lymphadenopathy in that tuberculous adenopat= hy is often an ominous signs of disseminated disease and needs to be treated m= ore aggressively.
A study by Zeharia et al in 2008 was performed retrospectively on 92 children diagnosed with atypical mycobacterial lymphadenopathy. The parents of all 92 children in this study opted for non-surgical and non-medical conservative management, and patients were followed for a minimum of 2 years. Diagnostic characteristics were as follo= ws:
· 80% of patients were less th= an 4 years old
· 80% of patients had lymphadenopathy greater than 3cm in size
· 90% of patients had unifocal lymphadenopathy
· Lymphadenopathy was most com= monly found in Submandibular (50%), Cervical (25%), Preauricular (10%) regions
· 85% of patients had a positi= ve PPD (>10mm)
· 90% of cases were due to M. avium-intracellulare and M. haemophilum
· 97.4% of patients had a domi= nant node with purulent drainage for 3-8 weeks
Lymph node size and purulent drainage of lymph n= odes speaks highly about the severity of disease in these children. Amazingly, however, patients showed total resolution of the lymphadenopathy at 6 months (71%), 9 months (98%), and 12 months (100%) with the only complication bein= g a flat, skin colored scar in the area of cutaneous drainage.
A previous randomized, controlled study by Linde= nboom et al. in 2007 showed that surgical management of atypical mycobacterial infections was superior to antibiotic therapy. Although surgical therapy was superior they also found that approximately 28% of surgical cases had complications such as secondary wound infections, and transient for permane= nt facial nerve injury. Zeharia concluded then, that observation is superior to surgical therapy because although patients may have a protracted course of illness, you avoid the complications of surgical management.
Cat Scratch Disease
Cat Scratch disease is a form of lymphadenitis c=
aused
by Bartonella henselae. Age of onset is usually less than 20 years of
age and there is a male predominance. 90% of patients have been exposed to a
cat bite or scratch, however fleas and dogs have also been known to carry t=
he
organism. Lymphadenopathy can take up to 2 weeks to develop and is usually
tender, but systemic signs of malaise and fever are mild and present in less
than 50% of patients (Twist). Diagnosis is made with serology and or PCR if
available. Historically antibiotic treatment has been reserved for patients
with severe disease and normal management has been expectant (
In 1998 Bass et al published a prospective, randomized, double-blinded, placebo controlled trial comparing 5 days of az= ithromycin therapy to no treatment at all. Patients were followed for by ultrasound an= d a success rate was determined to be a reduction in the size of lymphadenopath= y to 20% its original size. They found that 50% of patients treated with azithromycin met this criterion at the 30 day follow up, but only 7% met th= is criterion in the placebo group. After 30 days however there was no statistically significant difference between groups. So although antibiotics were good at rapidly decreasing the size of lymphadenopathy, in the long run observation proved to be just as effective.
Toxoplasmosis
Toxoplasma gondii is the causative organi= sm in toxoplasmosis. The consumption of undercooked meat or ingestion of oocytes = from cat feces are the most common route of transmission. Symptoms include malai= se, fever, sore throat and myalgias, and 90% of patients will have cervical lymphadenopathy. The diagnosis is made by serologic antibody testing. Complications include pneumonitis, myocarditis, and risk of transmission to= the fetus of pregnant women leading to TORCH infection. Treatment is absolutely necessary given the complications and antibiotic choices include pyrimetham= ine or sulfonamides.
Infectious Mononucleosis
Epstein Barr Virus is the most common pathogen c= ausing this disease process however Cytomegalovirus has also been found to be involved. Interestingly 50% of us have been exposed and are seropositive by= 5 years old and 90% are seropositive by 25 years of age. Signs and symptoms include fever, a grey colored exudative pharyngitis, painless and generaliz= ed lymphadenopathy, and axillary lymphadenopathy with splenic enlargement increases the likelihood of the diagnosis. On peripheral blood smear patien= ts will have greater than 50% lymphocytosis and greater that 10% of the lymphocytes will appear atypical. Diagnosis is confirmed with monospot test= or a positive serum heterophile antibody test.
Treatment of patients with infectious mononucleo= sis is supportive, however there are several important considerations and things to counsel patients about with respect to this disease. First, airway edema and swelling can become significant enough to cause obstruction. You must pay special attention to the airway in these patients and be ready to obtain a definitive airway if necessary. Prophylac= tic steroids in the acute phase can help prevent airway compromise. Second, you should not treat these patients with ampicillin as up to 80% will develop a= nd iatrogenic maculopapular rash due to circulating immune complexes. Finally,= you must counsel patients against contact sports for 2 months to prevent spleni= c rupture in the case of splenomegaly.
Noninfectious Lymphadenopathy
In addition to infectious and inflammatory cause= s of lymphadenopathy there are several rare forms of noninfectious lymphadenopat= hy to know about in case a child does present with the common constellation of symptoms.
1. This disease is also known as Lymphomucocutaneous
disease. There are 5 characteristic signs and symptoms associated with the
disease and 4/5 are required for diagnosis. The five signs are fever for mo=
re
than 5 days, cervical lymphadenopathy that is usually unilateral, edema and
erythema of the palms and soles that eventually leads to desquamation of sk=
in,
non-purulent bilateral conjunctivitis, and a strawberry tongue. Complicatio=
ns
include coronary artery aneurysms, coronary thromboses, and myocardial
infarction. All patients suspected of having this disease process should ge=
t an
EKG and echocardiogram to evaluate the heart. Treatment is with IVIG and
Aspirin to prevent the inflammatory insults on the heart. 2. Kikuchi-Fujimoto Disease This disease is also known as necrotizing
lymphadenitis. It presents in young Japanese females and is a benign disord=
er.
Associated signs and symptoms include fever, malaise, arthralgias, weight l=
oss,
nausea, night sweats and in some cases hepatosplenomegaly. The etiology is
thought to be viral or autoimmune. Treatment is expectant as the majority of
cases regress within 6 months however there have been reports of recurrent
disease. 3. Rosai-Dorfman Rosai-Dorfman disease is a benign disease that u=
sually
presents in the first decade of life with males twice as affected as female=
s.
The cause is a generalized proliferation of sinusoidal histiocytes. Fever,
neutrophilic leukocytosis, and polyclonal hypergammaglobulinemia are common associated findings but=
the
massive, painless, and bilateral cervical adenopathy is the most alarming
finding. Most patients will get a biopsy due to the nature of the
lymphadenopathy. The biopsy findings are diagnostic showing sinus expansion
with histiocytes and phagocytosed lymphocytes (Foucar). Treatment is suppor=
tive
and most patients have spontaneous regression. 4. Langerhans Cell Histiocytosis There is a wide spectrum as to the severity of t=
his
disease process. One third of patients will have background lymphadenopathy=
and
histopathology shows normal lymph node architecture but increased sinusoidal
Langerhans’ cells, macrophages and eosinophils. Eosinophilic granulom=
a is
the mildest form of the disease and it is characterized by solitary bone, s=
kin,
lung, or stomach lesions. Treatment is with either topical or systemic ster=
oids
and possible enucleation of bone lesions. Hands-Schuller-Christian disease =
is a
triad including diabetes insipidus, exophthalmos, and lytic bone lesions. T=
his
more moderate form of disease is often treated with systemic steroids and
desmopressin for the diabetes insipidus. The most severe form is Litterer-S=
iwe
disease and is a life threatening multisystem disorder with a 50% 5 year
survival. This is treated with systemic steroids and even chemoradiation
therapy has been used. Chronic Lymphadenitis Once a lymph node has been present for greater t=
han 6
weeks, the risk of malignancy increases especially if the mass is enlarging=
or
the patient is experiencing systemic signs and symptoms. Subacute pathogens,
however, are still implicated as it can take months for subacute disease, o=
nce
diagnosed, to resolve without surgical therapy. Because malignancy is more
common in this group than any other it is important to know the demographic=
s of
the patients you are taking care of. In children, there are very few common
malignancies found to cause lymphadenopathy. Leukemia and lymphoma are by f=
ar
the most common. Aside from these two entities, Neuroblastoma,
Rhabdomyosarcoma, and nodal metastases from a Nasopharyngeal carcinoma are =
the
next most common malignancies. It is important to remember the risk factors=
for
malignancy found by Yaris et al in 2008 as previously described.
Supraclavicular (Ellison) and posterior triangle (Putney) lymphadenopathy a=
re
all much more suspicious for malignancy. Almost all of the patients in this chronic
lymphadenopathy group will receive a biopsy, most often a fine needle
aspiration. Excisional biopsy is often needed, however, because FNA often t=
imes
does not provide enough tissue for diagnosis if a malignancy is present.
Management of malignancy is often a referral to the medical oncologist given
the age of these patients and the types of cancers that they face. Drug Induced Lymphadenopathy There are very few medications that can cause
lymphadenopathy but knowing about them can help you find a benign cause for=
a
relatively worrisome lymphadenopathy. Dilantin is classically the most comm=
on
medication causing lymphadenopathy. Any child with a seizure disorder that =
has
been on it for some time may be at risk. Other medications implicated are
isoniazide, phenylbutazone, allopurinol, pyrimethamine. Lymphadenopathy usu=
ally
resolves once the medication has been discontinued but long term dilantin u=
se
has reports of prolonged adenopathy. Immunizations can also cause adenopathy. Histori=
cally
the small pox vaccine was one of the most common but now in children MMR, D=
PT,
and polio vaccines are the most commonly implicated. Typhoid fever vaccine =
can
also be a cause, but adenopathy usually resolves with time. The Role of Ultrasound In 2005 Ahuja et al described the use of ultraso=
und to
differentiate reactive from malignant lymphadenopathy. Reactive lymphadenop=
athy
had the following characteristics; size less than 1 cm, oval shape with
short:long ratio less than 0.5, normal hilar vascularity, and a low resisti=
ve
index with high blood flow when using Doppler technology. Malignant
lymphadenopathy had the characteristics of being greater than 1cm, round wi=
th a
short:long ratio greater than 0.5, necrotic center, no echogenic hilus, a h=
igh
resistive index with low blood flow, and the ability to identify extracapsu=
lar
spread. Using these parameters they found a sensitivity of 95% and a
specificity of 83% success rate of differentiating reactive from malignant
lymph nodes. The Role of Biopsy Fine needle aspiration is by far and away the le=
ast
invasive form of biopsy and with the help of ultrasound you are much more a=
ble
to biopsy the area of choice. The problem with FNA is that it is not as
reliable in children as it is in adults, and therefore you can only trust a
positive biopsy (Twist). Chau et al in 2003 looked at 289 fine needle
aspirations out of 550 patients that were referred to a lymphadenopathy cli=
nic
in Although fine needle aspiration has such a low s=
ensitivity
and high false negative rate it should still be the first line biopsy due to
its relative ease and ability to be performed without general anesthesia. If
FNA is inconclusive or negative, however, and suspicion is still high for
malignancy, excisional biopsy should be performed. Throughout the literature
excisional biopsy is considered the gold standard. The biopsy must be carri=
ed
out so that the largest and firmest node palpable node is excised with the
capsule intact (Twist). This prevents seeding in the case of malignancy or
bacterial pathogens. Plan of Action After reviewing the literature regarding the wor=
kup
and management of cervical lymphadenopathy, the following recommendations c=
an
be made. 1.=
A thorough history and physical exam is vital to forming a valid
differential diagnosis and can be very helpful in directing treatment. 2.=
Any acute lymphadenitis should be treated with 2 weeks of broad
spectrum antibiotics as an outpatient unless the patient appears toxic. In =
this
case the patient should be admitted and receive intravenous antibiotics plu=
s or
minus CT/MRI/Ultrasound to evaluate for abscess formation 3.=
When patients present or return for re-evaluation with a history =
of 2-6
weeks of lymphadenopathy at minimum patients should get a PPD and CXR to lo=
ok
for signs of malignancy or mycobacterial infection. Additional serologic
testing can be sent at this time should there be history that predisposes
patients to other less common causes (Cat Scratch, Toxoplasmosis,
Mononucleosis, HIV, Syphilis). 4.=
If available PCR can be used to obtain a very quick diagnosis so =
that
treatment options can be discussed without a prolonged worrisome waiting
period. 5.=
If patient is found to have Atypical Mycobacterial infection pati=
ents
should be counseled about the possible protracted course cutaneously draini=
ng
lymph node, skin discoloration and scar with observation only. They should =
also
be counseled that surgical therapy has it’s own complications, and
patients should be allowed to decide the type of therapy they want. =
6.=
If a patient is found to have Cat Scratch disease, parents should=
be
counseled that the condition is benign in most cases and that it will go aw=
ay
on its own, however, 5 days of antibiotics have been shown to rapidly decre=
ase
the size and deformity of lymphadenopathy. 7.=
If you are unsure whether or not to biopsy a lymph node, ultrasou=
nd
with Doppler can be a very useful adjunct to tell you whether the node is j=
ust
reactive or abnormal. 8.=
FNA biopsy should be performed if: a. =
The patient has an enlarged
supraclavicular node b. =
The node has been present for 2-6 w=
eeks
and the patient has con=
current
systemic signs of disease that put them at increased risk for malignancy. c. =
The node is larger than 3 cm, has n=
ot
responded to antibiotics, has &=
nbsp; been
present for 2-6 weeks. d. =
The node has been present for over 6
weeks 9.=
Excisional biopsy should be performed in all children when FNA has
returned inconclusive or negative and the suspicion for malignancy is still
high. Conclusion Cervical Lymphadenopathy is a challenging clinic=
al
problem especially in children. History and physical exam are very helpful =
in
determining the cause of lymphadenopathy. The good news is that in the majo=
rity
of patients the causative organisms or pathology is benign, but it is impor=
tant
to be vigilant and pay careful attention to objective data to drive your
decision on when to be conservative or aggressive with both workup and ther=
apy.
DISCUSSION:
Shraddha S. Mukerji, MD -- Lymphadenitis in chi=
ldren As Andrew mentioned, majority =
of the
head and neck masses in children are benign. Important benign differentials
include congenital causes and inflammatory/infectious lesions. A systematic approach is requi=
red to
clinically evaluate cervical lymphadenopathy in children. When there is a high likelihoo=
d that
a lymph node is reactive because of atypical mycobacteria, then surgery sho=
uld
be offered if the lymph node is at a accessible =
site.
Two important differentials include lymphoma and tuberculous
lymphadenopathy. Chest Many a time excisional biopsy is not possible, because=
the
lymphoid tissue is soft and curettage may be another option. The latter is
associated with a slightly lower rate of complication. Biopsy suspicious lesions. If there is a question about a=
bscess
or not, I always order a CT with contrast. If the child is showing clinical
improvement, no imaging is required. If the child does =
not
show improvement on a confirmed abscess, I will follow with a DISCUSSION: Harold Pine, MD -- =
Lymphadenitis in
Children. Seeing the pediatric patient w=
ith
enlarged lymph nodes can be quite a challenge not only because there is an
extensive differential diagnosis but also because it’s never clear
exactly when to offer an FNA or surgery for biopsy and culture. If the patient is sent from the
hematologist and or infectious disease specialist asking specifically for an
open biopsy, then I will usually offer this service and the family already
comes in expecting a surgery. The
more common scenario is that the parent and or the pediatrician feel an
incidental node and the child is sent to the ENT
surgeon for evaluation. In these cases, a good understanding of the entities
that cause enlarged nodes in children can help direct the appropriate work =
up
including lab tests, radiographic evaluations and possibly surgical
intervention. As many of the
infectious/inflammatory conditions that affect the head and neck may cause
prolonged lymph node enlargement, it is certainly reasonable to tease out a
recent history of infection and possibly send off titers to the common
etiologic agents like EBV (Mono) and Bartonella henselae (Cat Scratch). Many of the patients that get refe=
rred
in to see me have already been on a good course of antibiotics and have been
ruled out for the above.
Occasionally I will send the child to see the infectious disease
specialist for their opinion. They
are likely to send off additional titers to some of the more esoteric
causes. They are often the on=
es who
will place a PPD, get a CXR and try a different antibiotic, usually a
combination of two for the best coverage. If radiographic tests have n=
ot
been done yet, an ultrasound and or CT with contrast can help sort out the
simple enlarged node vs. generalized adenopathy. In the end, the underlying con=
cern
driving many of our decisions is the issue of whether the node is
representative of a cancer. A=
s ENT
surgeons, we would hate to offer reassurance only to find out later that
another surgeon did a biopsy and it came back cancer. The main cancers to
consider of course are lymphomas, sarcomas, followed by thyroid carcinomas,
nasopharyngeal carcinomas (in adolescents), salivary gland malignancies, and
neuroblastomas (especially if child is under 1). Except in some special cente=
rs
around the country, an open biopsy is superior to FNA for the diagnosis of
lymphoma. Don’t forget to send the tissue “fresh” to the
pathologist. When a node or group of nodes =
is
rapidly enlarging and especially when they present in the supraclavicular
region, suspicion for cancer should go up and I would tend to offer excisio=
nal
biopsy rather early. When the=
re are
some small nodes in the cervical chain and they are not getting bigger, and=
the
child is healthy without constitutional symptoms, and has an otherwise norm=
al
head and neck exam, I think watchful waiting is certainly quite reasonable.=
Bad
things tend to get worse and so with good follow up at reasonable intervals,
the clinical situation will improve or change allowing for a reasonable
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