Swollen Glands (Cervical Lymphadenopathy)
Summary
Cervical lymphadenopathy is one of the most common presentations in paediatrics. Palpable lymph nodes are present in up to 45% of healthy children. The vast majority (>90%) are Reactive (viral/bacterial infection) and self-limiting. The clinician's role is to confidently differentiate these innocent nodes from the rare but serious causes like Malignancy (Leukaemia/Lymphoma), Kawasaki Disease, or Mycobacterial infections. [1,2]
Key Facts
- Reactive vs Malignant:
- Reactive: Soft, tender, mobile, follows an URTI, usually bilateral.
- Malignant: Firm/Hard, non-tender, fixed, >2cm, supraclavicular, unilateral (sometimes).
- Rule of Thumb:
- less than 1cm: Normal (especially if "shotty" - small, mobile, like buckshot).
- 1-2cm: Reactive.
- >2cm: Needs monitoring/investigation.
- >3cm: Urgent referral.
Clinical Pearls
The Supraclavicular Rule: A palpable node in the supraclavicular fossa (Virchow's Node on left, or right side) is Pathological until proven otherwise. It drains the chest and abdomen. Think Lymphoma, Neuroblastoma, or TB.
Don't Incise the Violet Node: A cold, painless node that turns the overlying skin violet/purple is typical of Atypical Mycobacteria. Incision and Drainage (I&D) causes a chronic discharging sinus fistula. It requires complete excision by ENT.
Generalised vs Local: Always check the axilla, groins, liver and spleen. Generalised lymphadenopathy + Hepatosplenomegaly suggests Leukaemia (ALL) or EBV, not a simple throat infection.
Demographics
- Peak Age: 2-5 years (high exposure to new viral pathogens).
- Prevalence: Very common.
- Malignancy Risk: Low (less than 1% of primary care presentations), but rises with age (Teenagers -> Hodgkin Lymphoma).
Anatomy
- Anterior Cervical: Drains throat, tonsils, mouth. (Most common site).
- Posterior Cervical: Drains scalp (check for nits/eczema) and nasopharynx (EBV).
- Submandibular: Drains teeth/tongue.
Aetiology
- Viral: Adenovirus, Rhinovirus, EBV, CMV. (Most common).
- Bacterial: Staph aureus, Strep pyogenes (Lymphadenitis). Bartonella (Cat Scratch).
- Mycobacterial: Tuberculosis, Non-Tuberculous Mycobacteria (NTM).
- Malignant: ALL, Hodgkin/Non-Hodgkin Lymphoma, Neuroblastoma, Rhabdomyosarcoma.
- Inflammatory: Kawasaki Disease, PFAPA, Sarcoidosis (rare in kids).
History
Physical Evaluation
- Neck: Palpate all chains from behind.
- Abdomen: Palpate Liver and Spleen (Down to left iliac fossa).
- Skin: Petechiae/Bruising (Leukaemia). Pallor.
- ENT: Inspect tonsils and teeth.
First Line (Persistent Nodes > 2-3 weeks)
- FBC + Film: Essential. Rules out Leukaemia (Blasts) and supports EBV (Atypical mononuclear cells).
- CRP/ESR: Inflammatory markers.
- Viral Serology: EBV, CMV.
- Bartonella: If cat exposure.
Imaging
- Ultrasound Neck:
- Reactive: Oval shape, preserved fatty hilum, vascularity at hilum.
- Malignant/Abscess: Round, loss of hilum, chaotic vascularity, necrosis.
- CXR: If Lymphoma suspected (Mediastinal widening).
Diagnostic
- Biopsy: Excision Biopsy is the gold standard for suspected lymphoma. Fine Needle Aspiration (FNA) is insufficient for architecture (Hodgkins classification) and often non-diagnostic in kids.
Management Algorithm
CHILD WITH NECK LUMP
↓
┌──────────────────┴──────────────────┐
ACUTE (less than 2w) CHRONIC (>2-4w)
↓ ↓
Red/Hot/Tender? Red Flags?
(Lymphadenitis) (Supraclavicular,
↓ Systemic, Hard/Fixed)
YES: Oral Abx (Fluclox) │
NO: Observe (Viral) │
↓ ↓
Improved? ┌──────────┴──────────┐
├─> YES: Discharge YES NO
└─> NO: Scan ↓ ↓
URGENT REFERRAL BLOODS + US
(Paeds/ENT) (Screening)
↓
Persistent?
↓
CONSIDER BIOPSY
1. Reactive / Viral
- Observe. Safety net.
- Reassure parents it may take weeks to typically resolve.
2. Bacterial Lymphadenitis
- Antibiotics: Flucloxacillin or Co-Amoxiclav (cover Staph/Strep).
- Abscess: If fluctuant, refer ENT for aspiration/drainage.
3. Atypical Mycobacteria
- No Surgery (I&D).
- Refer to specialist.
- Options: Watch and wait (takes months to resolve), Clarithromycin + Rifampicin, or Total Excision.
4. Malignancy
- Immediate referral to Paediatric Oncology.
- Suppuration/Abscess: Rupture through skin.
- Compression: Rare. Airway or Great Vessel compression by massive lymphadenopathy (Lymphoma).
- Reactive: Cure. Recurrence common with new colds.
- Malignancy: Depends on type. Childhood Leukaemia has high cure rates (>90%) if caught early.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| CKS Lymphadenopathy | NICE (2021) | Explains 'Wait and See' approach for benign nodes. Referral criteria. |
| Lumps and Bumps | RCPCH | Guidelines on imaging indications. |
Landmark Knowledge
1. Why Biopsy matters
- In Hodgkin Lymphoma, the "Reed-Sternberg" cells are sparse. An FNA might miss them or only show the surrounding reactive lymphocytes, leading to a false negative. Excision provides the whole lymph node architecture.
What are swollen glands?
Glands (lymph nodes) are the "police stations" of the immune system. When the body fights a cold, tonsillitis, or a scrape, the police stations fill up with cells to fight the infection. This makes them swell up.
Is it cancer?
Usually, no. In children, swollen glands are almost always due to simple infections. They are a sign the immune system is working well.
How long will it last?
They can stay up for a few weeks, even after the cold has gone. Sometimes tiny "pea-sized" glands can be felt for months. This is normal.
When should I worry?
If the lump keeps growing, gets stuck to the skin, appears just above the collarbone, or if your child has night sweats, weight loss, or unexplained bruises.
Primary Sources
- NICE Clinical Knowledge Summaries. Lymphadenopathy. 2021.
- Bazemore AW, et al. Lymphadenopathy and malignancy in primary care. Am Fam Physician. 2002.
- Nield LS, et al. Lymphadenopathy in children: when and how to evaluate. Clin Pediatr (Phila). 2004.
Common Exam Questions
- Paediatrics: "Child with fever >5 days, red eyes, rash, cervical node >1.5cm?"
- Answer: Kawasaki Disease.
- Oncology: "Site of highest risk node?"
- Answer: Supraclavicular.
- Pathology: "FNA vs Excision for Lymphoma?"
- Answer: Excision is superior (Need architecture).
- Infectious: "Cat scratch disease organism?"
- Answer: Bartonella henselae.
Viva Points
- Virchow's Node: (Troisier's sign). Left supraclavicular node. Drains thoracic duct (Abdomen). Indicative of gastric/abdominal malignancy (though rare in kids, think Neuroblastoma/Abdo Lymphoma).
- PFAPA Syndrome: Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis. A diagnosis of exclusion for recurrent regular tonsillitis/nodes.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.