Enlarged Lymph Nodes and other Neck Lumps in Children
Essentials
Bilateral lymph node enlargement on the neck is in most cases connected with a viral infection.
A unilateral lymph node enlargement is often caused by group A beta-haemolytic streptococci.
The probability of a bacterial infection is high when the lymph node enlargement is unilateral, tender or erythematous, or when a salivary gland is inflamed.
The child must be referred to a hospital if the general condition is impaired, there is respiratory distress, or the lymph node is fluctuating or it is large and situated in an unusual place (e.g. the subclavicular fossa) or the blood picture is abnormal.
Refer to a specialist a child with a large (> 2 cm) lymph node that does not decrease in size during follow-up of one month.
Causes of neck lumps
A lump that has appeared quickly is almost invariably a lymph node that has enlarged because of an infection. The most important causative agents include
Tumours originating from the thyroid gland, parotid glands, or neuronal tissues
Lymphoma or leukaemia
Haematoma of the sternocleidomastoideus muscle
Dermoid cyst
A neck lump that has appeared acutely
In the majority of the cases an acute bilateral lymph node enlargement is associated with a viral infection (particularly adenovirus, Ebstein-Barr virus and cytomegalovirus). Less frequently the cause is streptococcal tonsillitis, which typically results in enlargement of the lymph nodes in the jaw angles.
An acute unilateral neck lump is a bacterial lymphadenitis caused by Staphylococcus aureus or group A betahaemolytic streptococci in 40-80% of the cases; rarely an anaerobic or mixed infection.
The lymph node is 2.5-6 cm in diameter, tender, warm, and red. Fever and other systemic symptoms may be absent.
A unilateral enlarged lymph node or lymph node package is also a typical finding in Kawasaki disease, in atypical mycobacterial infections and in the rare cat-scratch disease.
A neck lump that has been there for a long time
Long-lasting lumps in the jaw angles and beside the sternocleidomastoideus muscle are almost invariably innocent. More than a half of school-aged, asymptomatic children have at least one lymph node exceeding 1 cm in diameter.
It is important to observe the size of the lymph node and its enlargement during 2-4-week follow-up. Most lymph nodes detected by parents are "residuals" of an infection and they become smaller during follow-up.
Be much more careful with lymph nodes that are situated in places other than near the jaw angle (particularly the subclavicular fossa). If a suspicion of malignancy arises refer the child to a paediatric unit immediately.
The most common infectious causes of chronic lymphadenitis of the neck are toxoplasmosis and atypical mycobacteria.
Atypical mycobacteria often cause unilateral lymphadenitis. Lymph node enlargement is at first rapid, but it ceases within 2-3 weeks. The skin over the enlarged lymph node may be erythematous, and the skin may adhere to the gland if the infection is prolonged. The diagnosis is based on granulomatous inflammation seen in biopsy, nucleic acid detection test and/or culture of the biopsy specimen. Tuberculosis should be kept in mind in differential diagnostics.
When routine BCG vaccination of newborn children was ceased in Sweden in 1975, an increase in the incidence of lymphadenitis caused by atypical mycobacteria was noticed. This is explained by the protective effect of BCG vaccination not only against tuberculosis but also against other mycobacterial infections. Similar development is already seen also in other countries where BCG vaccination of the newborn is ceased.
In toxoplasmosis Toxoplasmosis a single enlarged, non-tender, and fluctuating lymph node is situated in the posterior part of the neck. The patients often are otherwise asymptomatic. A serum IgG avidity test is the most important diagnostic investigation (the more recent the infection, the weaker the avidity).
Cat-scratch disease is caused by the bacterium Bartonella henselae. In about 50% of the cases a cat bite or scratch precedes the onset, which is characterized by local erythema and swelling of the skin after 7-14 days, followed by a lymphadenitis. Diagnosis is based on a histological specimen or/and on antibody analysis.
Outpatient treatment
Bilateral acute lymphadenitis often needs no treatment, with the exception of lymphadenitis associated with group A streptococcal infection.
Treatment of a unilateral acute neck lump is directed against the most common causative agents, staphylococci and streptococci.