Clinical Practice Guidelines : Cervical lymphadenopathy

See also

• Febrile Child
• Kawasaki Disease

Key points

1. Cervical lymphadenopathy is common and may be found in more than one third of otherwise healthy children
2. Observation and reassurance without investigation is usually appropriate for the well appearing child with cervical lymphadenopathy

Background

• Cervical lymph nodes are often palpable in well children
• Cervical lymphadenopathy is abnormal enlargement of lymph nodes (LNs) in the head and neck usually >1 cm
• Most cases are benign and self-limited, however, the differential diagnosis is broad
• Viral upper respiratory tract infection is the most common cause of cervical lymphadenopathy in children. These enlarged “reactive” nodes may persist for weeks to months
• Acute bacterial lymphadenitis is characterised by enlarged nodes, which are tender, usually unilateral and may be fluctuant

Assessment

History

• Onset and duration of neck lump
• Location of neck lump
• Growth over time, colour, pain, and overlying skin changes
• Restriction of neck movement
• Recent illness
• Presence of fever
• Loss of weight
• Night sweats
• Bruising
• Lymphadenopathy noted elsewhere
• Features of deep tissue head and neck infection (eg trismus, muffled voice)
• Overseas travel, including possible exposure to tuberculosis 
• Exposure to animals (eg cats)
• Immunisation status (diphtheria, measles, mumps, rubella)
• Dental disease
• Response to antibiotic treatment

Examination

• LN groups in the head and neck region:

• Characterise the lump: location, size, colour, warmth, mobility, tenderness, overlying skin changes
• Unilateral or bilateral
• Features on palpation: eg soft, rubbery, firm, matted, fluctuant, discharging,
• Neck range of motion
• Lymphadenopathy at other sites
• Other focus of infection: scalp, face, ear, nose, throat or teeth
• Further examination should be guided by history and differential diagnosis

Differential diagnosis

Acute cervical lymphadenopathy

Cervical lymphadenitis secondary to viral infection

• Very common, usually with history of a viral prodrome
• LNs may be tender to palpation and unilateral or bilateral
• Usually resolves as other viral symptoms do
• Small risk of developing into a secondary bacterial lymphadenitis

Acute bacterial cervical lymphadenitis

• Common, usually unilateral and in the anterior part of the neck
• Associated with fever and neck swelling
• May be firm and tender with overlying erythema, limited neck range of motion
• Common bacterial causes: Staphylococcus aureus, group B streptococcus (in neonates), group A streptococcus, and anaerobic infections (associated with dental disease)
• A site of entry may be found (eg mouth or scalp)
• Cervical lymphadenitis may rarely be associated with serious deep head and neck infections such a retropharyngeal abscess.

Kawasaki disease

• Kawasaki disease may present with unilateral tender cervical lymphadenopathy and associated features

Persistent cervical lymphadenopathy

• Subacute cervical lymphadenopathy (2–6 weeks) – commonest cause viral infection
• Chronic cervical lymphadenopathy (>6 weeks) – has a number of possible cause. Many viruses will cause cervical lymphadenopathy lasting up to 6 weeks
• Some cases may be unexplained

Approach to differential diagnosis

Management

• Observation and reassurance without investigation is usually appropriate for the well-appearing child with cervical lymphadenopathy

Investigations

Treatment

• Most cases of cervical lymphadenopathy will be self-limited and do not require treatment
• If there are signs of bacterial lymphadenitis (unilateral, tender, fluctuant), consider the following:

Well – oral antibiotics for 7 days, with review in 48 hours

• Cefalexin 33 mg/kg (max 500 mg) oral tds

Unwell, or failed oral treatment – IV antibiotics

• Flucloxacillin 50 mg/kg (max 2 g) IV 6H

Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

Fluctuant node

• For fluctuant nodes not responding to IV antibiotics, consider consultation with general surgical team for incision and drainage
• Excision of whole node is preferred in suspected mycobacterial infection as incision and drainage may result in sinus formation

Consider consultation with local paediatric team when

• Neonate, unwell child, or persistent cervical lymphadenopathy despite oral antibiotics
• Features suggestive of systemic disease (Kawasaki Disease, malignancy, rheumatologic condition)

Consider transfer when

Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Last updated April 2021

Lymphadenopathy

This page was reviewed under our medical and editorial policy by

Leslie Popplewell, MD, Hematologist, City of Hope | Duarte.

This page was updated on June 5, 2023.

If you’ve ever felt swollen lumps in your neck when you’ve had a respiratory infection or a sore throat, you’ve experienced lymphadenopathy—swollen lymph glands. There are many lymph nodes throughout your body.

These glands also may swell when cancer cells from a tumor move to them. If you’ve been diagnosed with cancer, your doctor may wish to biopsy lymph nodes near your tumor to see whether any cancer cells have migrated there. If cancer cells are found, it could indicate they may be spreading through your blood and causing secondary tumors (metastasis) elsewhere in your body. If surgery is done to remove your tumor, neighboring lymph nodes may be removed, too.

The lymphatic system

In addition to the circulatory system of blood, blood vessels and the heart, another system exists that transports fluid, specialized cells and nutrients throughout your body—the lymphatic system. Lymph, a clear or whitish fluid surrounding your body’s tissues, drains into lymphatic vessels, eventually emptying into the circulatory system.

In addition to lymph, lymph vessels and nodes, the lymphatic system includes your spleen, tonsils, adenoids and thymus gland.

This system plays an important part in fighting infection and disease by filtering out bacteria, viruses, cancer cells and foreign material and attacking them in the lymph nodes. You have hundreds of these small kidney-shaped structures located in clusters under your arms and in your groin, neck, central chest and abdomen. They make more white blood cells when your body senses infection or diseased cells. This immune reaction may cause lymph nodes to swell.

Risk factors and associated cancers

Most cases of lymphadenopathy aren’t caused by cancer. Malignancies are reported in as few as 1.1 percent of primary-care patients with swollen lymph nodes, according to a review in American Family Physician.

Two factors that are more associated with a possible cancer diagnosis: swelling that lasts longer than two weeks, and the appearance of lymphadenopathy in middle-aged and older patients.

Some cancer-related lymphadenopathy cases start with cells that travel from a tumor to one or more lymph nodes. But cancer also may originate in the lymph nodes.

Lymphomas are cancers that begin in lymph nodes. A swelling in the neck, underarm or groin is often the first sign of Hodgkin lymphoma, and is a common early symptom of non-Hodgkin lymphoma.

Other cancers associated with lymphadenopathy are:

• Metastatic carcinomas of the breast, thyroid, kidneys, lungs and viscera of the gastrointestinal tract 
• Acute lymphoblastic and pediatric acute myelocytic leukemias
• Neuroblastoma
• Rhabdomyosarcoma

Symptoms and complications

Some lymph nodes lie close under the skin; some are buried deep in your body. You may be aware of swollen lymph nodes in your neck, armpits or groin because you see and feel the swelling. You may not be aware of swollen nodes in your chest or abdomen unless they’re detected through imaging or scans.

Sometimes swollen nodes press on other structures, causing pain or discomfort as well as symptoms such as:

• Swelling of a part of your body because lymph drainage is blocked
• Blood clot because blood vessels are compressed
• Difficulty breathing because part of your airway is compressed, in addition to a cough or hoarse voice
• Tingling and numbness because your spinal cord or nerves are compressed

If doctors remove some of your lymph nodes, it may block the route for lymph to flow out of the area, and fluid can build up in fatty tissue located under the skin. The amount of lymph nodes removed directly relates to the amount of increased risk of this problem, called lymphedema. It commonly occurs in the limbs, but it may happen in the head, neck and torso.

In addition to surgical removal of lymph nodes, radiation therapy may damage nodes or lymph vessels and cause lymphedema.

Lymphedema can be a lifelong condition ranging from a feeling of fullness and tight skin to disabling limits on movement. It also carries the risk of a serious infection in the swollen area called cellulitis.

Treatment and prevention tips for lymphadenopathy

Treatment for cancer-related lymphadenopathy would involve the same therapies used to treat cancer. Lymphadenopathy caused by cancer is a symptom or complication of cancer, not a separate disease. It’s your body reacting to the presence of cancer cells.

Since cancer is the cause, prevention tips would include taking steps to decrease your chances of developing cancer or to catch it early before it spreads to lymph nodes.

Below are some general tips:

• Adopt a healthy lifestyle by avoiding tobacco, reducing alcohol consumption, eating a balanced diet and limiting sun exposure.
• Get vaccinated against HPV (human papillomavirus) and hepatitis B virus, both of which may lead to cancer.
• Undergo screening tests, which may detect early presence of colorectal cancer, breast cancer and cervical cancer.

Lymph node involvement in cancer cases often means extra treatment with radiation and/or chemotherapy.

Enlarged lymph nodes caused by the presence of cancer cells may or may not be surgically removed. Laboratory analysis of biopsied lymph nodes may help your care team determine the stage of the cancer and provide information on its specific characteristics. This data may also aid in tailoring treatment to your individual case, which may include a combination of surgical removal, radiation, chemotherapy and immunotherapy.

Radiation therapy may shrink areas of lymphadenopathy and reduce symptoms, but it carries the risk of causing lymphedema.

In treatment of breast cancer, for example, if cancer cells are found in the axillary lymph nodes under the arm, this area and the affected breast may undergo radiation. Other clusters of lymph nodes located above the collarbone and in the middle of the chest may also be given radiation therapy.

Surgery isn’t often used to treat lymphomas. If a non-Hodgkin lymphoma is affecting only one area, targeted treatment with radiation would be chosen over surgery in most cases.

what does the study show, what diseases can be detected?

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Ultrasound

An ultrasound examination of the lymph nodes of the neck is one of the safest ways to obtain information about the state of these organs.

Ultrasound examination of the lymph nodes of the neck

Ultrasound diagnostics is often prescribed because of its availability, as well as the ability to undergo it as often as necessary to control the course of the disease and the effectiveness of the chosen treatment tactics.

Why is an ultrasound of the lymph nodes performed?

Ultrasound of the lymph nodes of the neck, as a rule, is necessary in case of their enlargement. Various seals of any size (the size of a pea or a pigeon’s egg) can appear in the lymph nodes, and lymphadenopathy can be benign or malignant.

At the same time, the task of ultrasound diagnostics is to clearly determine the cause of the seals. The reason may lie in inflammatory processes in the body of a different nature or in non-specific reactions, but it also happens that tumors and metastases are the cause of the increase.

Preparation for procedure

There is no need to specially prepare for an ultrasound to examine the lymph nodes of the neck. It is enough to make an appointment and visit the office at the appointed time. Additional preparation is not required.

Ultrasound of the lymph nodes of the neck: what shows

In order to find out what the ultrasound of the lymph nodes of the neck shows, the specialist will need to carefully examine each lymph node individually. The doctor evaluates and fixes:

• straight and transverse dimensions of each node;
• capsule condition;
• internal structure;
• the state of the vessels that supply blood to the lymph node.

During the examination, the doctor may also examine the soft tissues around the area being examined, which will provide a more complete picture.

The need to examine these organs for the presence of tumors and metastases is primarily due to their structure. The thing is that it is the lymph nodes that are the first to be affected when metastases occur in the body, and their detection plays a very important prognostic role. Thanks to the study of lymph nodes, it is possible to judge the stage of the disease, select treatment tactics, and also assess the amount of necessary surgical intervention.

How is the procedure?

To examine the lymph nodes of the neck on ultrasound, the patient will need to remove interfering clothing, as well as remove jewelry. After that, you will need to lie on the couch near the ultrasound machine, you can put a special roller or a small pillow under your head – the doctor will tell you about this. Then a special gel is applied to the neck. The doctor examines the lymph nodes using the image that is displayed on the screen of the device. All data and pathologies are carefully recorded and will later be entered into a conclusion, with which you can go to your doctor.

Ultrasound of the neck lymph nodes for a child

A child may need an ultrasound of the lymph nodes of the neck in the same way as an adult. The study itself does not cause any discomfort, and can last about twenty minutes. In the process of examining the lymph nodes, the baby’s parents can be next to him so that he does not worry. The only thing worth paying attention to is that the baby needs to be told not to move, since the results in this case may be inaccurate. Indications for ultrasound diagnostics are:

• persistent increase in nodules for two weeks after a cold or other illness;
• swollen lymph nodes without evidence of any infectious disease of the ears, throat or nose;
• probing under the skin of a dense enlarged node, which is tightly soldered to the surrounding tissue;
• with a significant increase in node compared to others.

It is worth knowing that the norm for ultrasound of the lymph nodes of the neck for a child is one centimeter. In this case, the node can be well felt under the skin, this should not cause concern. In the event that the lymph node increases to 1.5-2 centimeters, this is already a signal to visit a doctor.

Result interpretation

The results of the ultrasound of the lymph nodes of the neck (which the procedure shows, you can find out after it) will be recorded in a special conclusion drawn up by the doctor. As a rule, the interpretation of the results is done immediately after the examination, and the patient at this time is asked to wait outside the office. This process takes about 15-20 minutes; in difficult cases, other doctors may be involved to form a more accurate conclusion. A picture is attached to it, which shows the lymph nodes and their sizes are marked. With this conclusion, you can go to your doctor to establish a diagnosis and prescribe treatment.

Norm for cervical lymph nodes on ultrasound

If you do not know what the ultrasound of the lymph nodes of the neck shows, as well as what their normal sizes should be, you should familiarize yourself with the normal indicators. In adults, just like in children, the size of a lymph node of 1 centimeter is considered normal. An increase in the size of the node may indicate a pathological process, therefore, in this case, you should not hesitate to consult a doctor. If there are indications for the procedure, in addition to enlargement of the lymph nodes, the doctor will take into account the structure, location, contours and other parameters. Only in this case can one count on obtaining a general picture of the disease and the possibility of subsequent selection of effective treatment tactics.

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The doctor explained what cervical lymphadenitis is and why it occurs

In the autumn, when the air temperature and human immunity decrease, there are often problems with the lymph nodes, which are called the body’s natural filters. Their increase and compaction is a symptom of the development of the pathological process. What cervical lymphadenitis can signal and what are the symptoms of the disease, Elena Korneeva, a general practitioner at the Graal Family Medicine Center, told the readers of the Surgut Tribune.

Cleans out unnecessary

– Elena Viktorovna, what do the lymph nodes serve in our body?

– Lymph nodes cleanse the body of toxins – both internal and external, produce immune cells to protect against viruses and bacteria.

– And if a lymph node is inflamed, is it a signal that something is wrong with the body?

– Yes, this indicates that there is some source of infection in the body, inflammation, because the lymph nodes are the first to react to problems with the body, changes in the immune system or the appearance of some kind of infection.

– What are the symptoms of cervical lymphadenitis?

– There is an acute and chronic course of the disease – prolonged inflammation of the nodes. If a person has acute lymphadenitis, then a painful sensation will appear in the neck in some area, it can be detected by palpation. Reddening of this area is possible, general symptoms may appear: fever, headache, runny nose, weakness. Chronic lymphadenitis is a long-term inflammatory process, for example, this happens with caries. If a person has neglected his teeth and does not treat them, then the lymph nodes may become inflamed. And with such a chronic course of the disease, a person does not experience any sensations, he can simply find some kind of movable ball on his neck, which is not always painful or sensitive. There may or may not be other symptoms.

– What causes can provoke the occurrence of cervical lymphadenitis?

– Cervical lymph nodes are most often affected by inflammation of the upper half of the body, it can be inflammation of the ear, tonsils, nasal mucosa, rhinitis, fungal inflammation of the oral mucosa, which can develop against the background of prolonged use of antibiotics, as well as chronic inflammation of the dentition. Well, enlarged lymph nodes are usually alarming in relation to oncological diseases of the organs. Therefore, it is necessary to pay close attention to these body signals.

Signaling

– Why are inflamed lymph nodes dangerous if treatment is not started in time?

– If left untreated, complications may arise, phlegmon often develops – purulent fusion of this lymph node, an abscess. And then completely different methods of treatment are used. It is dangerous in relation to the whole organism, up to sepsis. The surgical method of treatment is resorted to as a last resort, if an abscess has begun, the node increases sharply, thickens, painful, the temperature rises, in other cases, anti-inflammatory or antibacterial therapy is carried out, depending on the cause of inflammation of the lymph node. But first you need to establish the source that causes inflammation.

– Who is at risk for this disease?

– Most often, cervical lymphadenitis affects people with reduced immunity, suffering from tuberculosis, or generally often suffering from viral diseases. Those who work outdoors are at risk of inflammation of the lymph nodes due to frequent hypothermia. Also at risk are people who have problems with the gastrointestinal tract and problems with the oral cavity, with advanced caries – often it is the cause of inflammation, so it is important to monitor the condition of the teeth.

– What diagnostic methods are used?

– Inflammation of the cervical lymph nodes is easily detected by palpation.