Singapore Med J 2020; 61(11): 569-577 Practice Integration & Lifelong Learning https://doi.org/10.11622/smedj.2020151 CMEARTICLE An approach to cervical lymphadenopathy in children Serena Su Ying Chang1, MMed, MRCPCH, Mengfei Xiong2, MBBS, Choon How How3,4, MMed, FCFP, Dawn Meijuan Lee1, MBBS, MRCPCH Mrs Tan took her daughter Emma, a well-thrived three-year-old girl, to the family clinic for two days of fever, sore throat and rhinorrhoea. Apart from slight decreased appetite, Mrs Tan reported that Emma’s activity level and behaviour were not affected. During the examination, Emma was interactive, her nose was congested with clear rhinorrhoea, and there was pharyngeal injection without exudates. You discovered bilateral non-tender, mobile cervical lymph nodes that were up to 1.5 cm in size. Mrs Tan was uncertain if they were present prior to her current illness. There was no organomegaly or other lymphadenopathy. You treated Emma for viral respiratory tract illness and made plans to review her in two weeks for her cervical lymphadenopathy. WHAT IS LYMPHADENOPATHY? masses in children can be classified into congenital or acquired Lymphadenopathy is defined as the presence of one or more causes. Congenital lesions are usually painless and may be identified lymph nodes of more than 1 cm in diameter, with or without an at or shortly after birth. They may also present with chronic drainage abnormality in character.(1) In children, it represents the majority or recurrent episodes of swelling, which may only be obvious in later of causes of neck masses, which are abnormal palpable lumps life or after a secondary infection. The location of the mass is often or swellings. useful in narrowing down the diagnosis. Notably, midline masses are often not due to lymphadenopathy. The sternocleidomastoid HOW RELEVANT IS THIS TO MY muscle is used as an important surface landmark to distinguish PRACTICE? between the anterior and posterior triangles of the neck. Cervical lymphadenopathy in the paediatric population is A thorough history and physical examination are fundamental common in general medical practice and presents either as a steps in the evaluation of a child with the complaint of a neck mass. primary complaint of neck mass or as an incidental finding during clinical examination. Park reported that 90% of all children aged History 4–8 years have palpable lymphadenopathy.(2) In a systematic The following questions are important in evaluating for the various review of paediatric cervical lymphadenopathy involving 2,687 possible causes of neck masses in children: patients, two thirds of the cases were due to non-specific benign • Patient’s age aetiology with no definitive diagnosis, and 4.7% were secondary • Duration of neck mass: (a) present since birth or recently to malignancy.(3) discovered, and for how long; and (b) recurrence of neck mass When first reviewing a child with cervical lymphadenopathy, • Associated symptoms: (a) focal symptoms (e.g. pain, erythema); the primary care physician is faced with a conundrum – manage (b) infective symptoms (e.g. fever, sore throat, other localising at primary care or refer for specialist review? We propose that symptoms of infection); (c) rashes, arthralgia and other the physician’s familiarity with the differential diagnoses of features of Kawasaki disease (KD), including conjunctival lymphadenopathy and neck masses increases the success rate injection, erythema/cracking of lips and tongue, and of managing this in primary care. An evidence-based evaluation erythema/swelling of hands and feet; and (d) weight loss, loss framework may reduce unnecessary diagnostic tests and of appetite, night sweats, fatigue, easy bruising and pallor therapies, as well as enable physicians to counsel their patients • Recent illnesses (e.g. pharyngitis, tonsillitis, dental infections) and caregivers appropriately. • History of recurrent infections, recurrent skin abscesses or recurrent lymphadenopathy WHAT CAN I DO IN MY PRACTICE? • Drug history, including any treatment with antibiotics Clinical approach • Exposure to animals (particularly cats), insects, sick persons, In the initial approach, it is important to first consider the broad persons with tuberculosis or chronic cough differential diagnosis of cervical lymphadenopathy, including other • Recent travel history causes of neck masses that may mimic it closely (Table I).(4) Neck • Immunisation status 1Department of Paediatric Medicine, KK Women’s and Children’s Hospital, 2Resident, Family Medicine Programme, SingHealth Residency, 3Care and Health Integration, Changi General Hospital, 4Family Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore Correspondence: Dr Serena Chang Su Ying, Associate Consultant, Department of Paediatric Medicine, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899. [email protected] 569 Practice Integration & Lifelong Learning Table I. Differential diagnoses of neck masses. Location Congenital Acquired Anterior • Thyroglossal cyst • Thyroid lesions: goitre, Postauricular midline or • Dermoid cyst thyroiditis, rarely thyroid Preauricular paramedian • Thymic cyst cancer Occipital Parotid Anterior • Branchial cleft • Lymphadenopathy Tonsillar triangle anomalies • Submandibular gland Upper cervical (Jugulodigastric) Submental • Congenital enlargement (e.g. Middle cervical muscular torticollis sialadenitis, sialolithiasis, Submandibular • Vascular lesions rarely neoplasm) Posterior cervical (haemangioma, • Epidermoid cyst Lower cervical lymphangioma) Supraclavicular • Cervical rib Fig. 1 Illustration shows an overview of the lymph node regions of the neck (reproduced with permission from Dr Marc Ong Weijie). Angle of the – • Parotid gland enlargement mandible (e.g. acute or recurrent Table II. Summary of drainage areas for cervical lymph node groups. parotitis, sialolithiasis, rarely neoplasm) Region Drainage areas Posterior Cystic hygroma • Lymphadenopathy Submental Bottom lip, floor of mouth, skin of cheeks triangle • Epidermoid cyst Submandibular Mouth, lips, tongue, submandibular gland, • Malignant neoplasm cheek (e.g. rhabdomyosarcoma, Preauricular Anterior and temporal scalp, anterior ear neuroblastoma) canal and pinna, conjunctiva, parotids Postauricular Temporal and parietal scalp Occipital Posterior scalp Upper, middle and Tongue, tonsils, larynx, oropharynx, anterior lower cervical neck, scalp, lower ear canal, parotid Posterior cervical Scalp and neck Physical examination Supraclavicular Mediastinum, lungs, abdomen A complete physical examination always includes a general inspection of the child’s growth parameters (i.e. growth charts) and general health status. The presence of pallor or jaundice WHAT ARE THE MAIN CAUSES? should be determined. In addition to the location of the neck In a child with cervical lymphadenopathy, the duration of mass, it is important to examine the following: lymphadenopathy is a key consideration in determining • Size of lesion its possible aetiology, which can be categorised into four • Quality of lesion: (a) tenderness, warmth, mobility, main groups: infectious, immunologic, malignancy and fluctuance, consistency and erythema; and (b) other overlying miscellaneous causes. The causes can then be classified skin changes such as cutaneous sinus tract according to the origin and time course of symptoms, as • A sequential examination of the lymph node chains of the presented in Table IV.(5,6) head and neck (Fig. 1) should be performed. If cervical lymphadenopathy is suspected, other areas of peripheral Acute cervical lymphadenopathy lymphadenopathy should also be palpated (i.e. axillary, Infective causes epitrochlear, inguinal, popliteal) to determine if the The most common scenario of acute cervical lymphadenopathy lymphadenopathy is localised or generalised. Of note, the is enlargement of bilateral lymph nodes in the correct nodal finding of an enlarged lymph node in the supraclavicular drainage chain during an acute infection. This represents a self- region is concerning, as it may be associated with an limiting, transient response of lymphatic tissue hyperplasia to a underlying malignancy. local infective process that improves with resolution of the viral • A quick examination of the eyes, ears, nose, mouth and throat illness. In the absence of red flags, it can be managed according should be performed to look for common sources of infection to Fig. 2. The use of systemic antibiotics is often not warranted. that could cause cervical lymphadenopathy (Table II). Ebstein-Barr virus (EBV) and cytomegalovirus (CMV) • To complete the examination, assess for the presence of infections may be more common in older children of school-going rashes, KD features, petechiae/purpura and joint swelling, age and adolescents. Children with EBV infection often present and palpate the abdomen to assess for hepatosplenomegaly with a clinical picture of infectious mononucleosis, characterised or abdominal masses. Table III shows some of the more by generalised lymphadenopathy, sore throat, fatigue and commonly seen congenital neck masses, with characteristic fever. This may be accompanied by exudative tonsillitis and features that may aid in their diagnosis.(4) hepatosplenomegaly. 570 Practice Integration & Lifelong Learning Table III. Common congenital neck masses. Neck mass Characteristics Common age of presentation Thyroglossal duct cysts • Most common congenital neck mass 2–10 years • Moves up with tongue protrusion Branchial cleft