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MerjaHelminen

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 large, or situated in an unusual place (e.g. the subclavicular fossa), or if 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 on the neck within a short period of time is almost invariably an infectious, enlarged lymph node, which can be caused by
  • Bacterial infection of a salivary gland
  • Dental abscess
  • Kawasaki disease (fever, rash, conjunctivitis; Kawasaki Disease).
  • 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 environmental 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 environmental mycobacteria.
  • Environmental mycobacteria usually cause unilateral lymphadenitis located in the areas of the neck or mandibular angle or anterior to the ear.
    • The child is afebrile and in good general condition.
    • The skin over the enlarged lymph node may appear bluish-red, and the skin may adhere to the gland if the infection is prolonged. A fistula often develops in the area, and purulent discharge can last for months.
    • The infection heals spontaneously.
    • If the clinical picture is typical, extensive examinations are usually not necessary. An ultrasound examination may show a necrotic lymph node and/or echo-free fluid cavity. The laboratory test that measures the number of lymphocytes in the blood that recognise TB bacterial antigens and release interferon gamma can be used in diagnostics. A positive reaction to PPD antigen may suggest an environmental mycobacterial infection.
    • The BCG vaccination protects a child not only against tuberculosis but also against infections caused by other mycobacteria.
      • In Finland, an increase in environmental mycobacterial infections was seen after the cessation of BCG vaccination.
    • Tuberculosis should be taken into account in differential diagnosis.
  • 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.

    References

    • Kontturi A, Soini H, Ollgren J, et al. Increase in Childhood Nontuberculous Mycobacterial Infections After Bacille Calmette-Guérin Coverage Drop: A Nationwide, Population-Based Retrospective Study, Finland, 1995-2016. Clin Infect Dis 2018;67(8):1256-1261. [PubMed]