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Cervical lymphadenitis in the pediatric age group


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Pediatric Medicine
Cervical Lymphadenitis in the Peiatric Age Group

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Cervical lymphadenitis in the pediatric age group

  1. 1. Cervical Lymphadenitis in the Pediatric Age Group by SAHAR AWADA, MD Pediatric Resident Lebanese University Medical School
  2. 2. Case Presentation • 1y 2m old boy previously healthy presenting for Right Neck mass • 4 days ptp, pt started to develop HGF with no other sx • In the next day, HGF continued and the mother noticed a right neck swelling with edema and erythema • 2 days ptp, mass increased progressively in size, the parents seeked medical advice and the pt was started on antibiotic(Amoclan)
  3. 3. Case Presentation • Despite antibiotic therapy, pt continued to be febrile with no decrease in mass size • On the day of presentation, U/S neck was done in another hospital and showed: A right submandibular cystic mass of 2.5 cm in diameter resembeling an abscess collection just next to a lymph node of 1 cm in diameter
  4. 4. Case Presentation • No chills, night sweat, rinorrhea , cough , dyspnea, drooling, dysphagia or any other GI Sx, no change in voice quality, arthralgia, weight loss , fatigue • No hx of trauma, insect bite, ingestion of unpasteurized animal milk, undercooked meat or new drug intake • No hx of Dental problems or mouth sores • No hx of animal exposure or recent travel
  5. 5. Case Presentation • PMH: ftb, nvd, no ICN admission, no hx of recurrent infection • PSH: neg • PFH: simultaneous acute viral illness(sister) • Diet: regular for age • Home med: Amoclan, Profinal, Panadol • Vaccination: uptodate until the age of 1 yr( 1st MMR dose not yet received)
  6. 6. Physical exam • Pt looked ill, NAD, febrile(39.2) • Anicteric sclera, well injected conjunctiva,no mouth sore or apthous lesions, nrl tonsills • Ears: nrl • Right submandibular mass, hard, non mobile, tender, warm and erythemateous, measuring 3x3 cm • Heart: rr, nrl s1s2 • Lungs: GBAE, no adventitious sounds • Abdomen : non distended, +BS, non tender, no HSM • Normal genitaliae, no palpable axillary or inguinal LN
  7. 7. Lab tests • Cbcd – WBC 24000 – Neutro 70% – Lympho 20% – Hb 11 – Hct 34 – MCV 80 – Plt 518 • Electrolytes nrl • CRP 22
  8. 8. Imaging • CXR nrl • CT neck with contrast: – Right submandibular abscess measuring 3.4cm in diameter next to a small centimetric LN with several small bilateral LN
  9. 9. Pediatric Neck Masses
  10. 10. Classification • Congenital • Acquired – Inflammatory • Infectious • Non infectious – Neoplastic • Benign • Malignant
  11. 11. Classification
  12. 12. Congenital neck masses
  13. 13. Inflamatory neck masses • Infectious – Reactive viral lymphadenopathy – Bacterial lymphadenopathy – Parasitic lymphadenopathy • Non infectious – Connective tissue disorder – Sarcoidosis – Kawasaki disease
  14. 14. Neoplastic neck masses • Metastatic head and neck carcinomas • Thyroid mass • Salivary gland neoplasms • Schwanoma • Lymphoma • Lipoma and benign skin cysts
  15. 15. Initial evaluation(History( • Age(BIRTH=CONGENITAL) • Onset • Rapidity of growth(rapid enlargement=inflammatory) • Fluctuation in size • Pain • Infection • Trauma • Skin lesion(HS, staph, cat scratch disease) • Associated symptoms (weight loss, fever, arthralgias, sore throat) • Dental problems(anaerobes) • mouth sores(HSV, Enterovirus herpangina)
  16. 16. Initial evaluation(History( • Travel • Ingestion of unpasteurized animal milk(brucellosis, mycobacterium bovis) • Animal exposures(cat scratch disease, toxoplasmosis [cats], brucellosis [especially goats], tularemia [especially rabbits]) • Immunization status(diphtheria, measles, mumps) • Medications (phenytoin, carbamazepine)
  17. 17. Initial evaluation(physical exam( • Size • Multiplicity • Laterality • Consistency(firm, rubbery, matted) • Color • Mobility(fixed or mobile) • Tenderness • Fluctuation
  18. 18. Initial evaluation(physical exam( • "Reactive" LN are usually discrete, mobile, rubbery, and minimally tender • Infected LN are usually isolated, asymmetric, tender, warm, and erythematous; they may be fluctuant; less mobile and discrete than reactive LN • Malignant LN often are hard, nontender, and fixed to the underlying structures
  19. 19. Initial evaluation(physical exam( • Oral cavity: search for evidence of periodontal disease, herpangina, HSV gingivostomatitis, or pharyngitis • Eyes : conjunctival injection may indicate Parinaud oculoglandular syndrome (associated with cat scratch disease) or Kawasaki disease • Skin : a generalized rash may suggest a viral illness, whereas a localized skin lesion may indicate a more specific etiology(cat scratch disease, HSV, etc.) • Less common infections in which a papular or pustular lesion is suggestive of an inoculation site
  20. 20. Initial evaluation(physical exam) Location location location Midline • Thyroglossal cyst • Submental lymphadenopathy • Dermoid and epidermoid cysts • Teratoma • Cervical cleft Lateral • Branchial cleft anomaly • Lymphatic/vascular malformation • Lymphadenopathy • Thyroid nodule • Thymic cyst • Laryngocele • Sialadenitis • Soft tissue tumor
  21. 21. Initial evaluation(lab tests( • Cbcd with differential • Electrolytes: high ca level ->sarcoidosis • Serology testing for EBV, CMV, toxo, syphilis, cat scratch disease • Thyroid function test • PPD • Urinary collection for VMA (vanillylmandelic acid) ->neuroblastoma
  22. 22. Initial evaluation(imaging( • CXR to R/O malignancy, TB, Sarcoidosis • Lateral neck Xray essential in evaluation of nasopharynx, cervical spine and retro- pharyngeal region • U/S to differentiate cystic structure from solid mass and to evaluate thyroid mass • CT WITH CONTRAST to differentiate cellulitis from abscess and to identify vascular mass
  23. 23. Initial evaluation(surgical diagnosis( • FNA to decompresse the mass and to provide material for cx • If malignancy suspected => incisional or exicional bx indicated
  24. 24. Congenital neck masses
  25. 25. Branchial cleft cysts • 1/3 of congenital neck masses • Nontender, fluctuant masses that may become inflamed and lead to abscess formation during an upper respiratory infection • First branchial cleft cysts, rare, typically present near the angle of the mandible • Second branchial cysts are found high in the neck and deep to the anterior border of the sternocleidomastoid muscle • Third branchial cleft cysts, also rare, are seen near the upper pole of the thyroid gland
  26. 26. Branchial cleft cyst • Ultrasound shows a fluid-filled cyst and can differentiate cystic lesions from solid masses • CT and MRI also confirm the cystic characteristics of the mass and, more importantly, delineate the relationship of the cyst to surrounding structures • Management of branchial cleft cysts is surgical excision
  27. 27. Branchial cleft cyst
  28. 28. Thyroglossal duct cyst • Forms in a persistent thyroid descent tract that begins as an elongation of the thyroid diverticulum • Most in the midline near the level of the hyoid bone, elevate with swallowing, and can rarely present laterally • A thyroglossal duct cyst usually presents as an asymptomatic mass but may be associated with mild dysphagia • infrequently, may get infected and rapidly enlarge
  29. 29. Thyroglossal duct cyst
  30. 30. Dermoid cyst • Dermoid cysts consist of epithelium-lined cavities filled with skin appendages (e.g., hair, hair follicles, sebaceous glands) • Typically, dermoid cysts are seen in the midline of the neck, usually in the submental region • They are attached to and move with the overlying skin and are painless unless infected • Management is by complete surgical excision
  31. 31. Dermoid cyst
  32. 32. Lymphatic malformation • Previously termed lymphangioma • Congenital malformations of lymph tissue that result from the failure of lymph spaces to connect to the rest of the lymphatic system • Soft, smooth, nontender mass that is compressible and can be transilluminated • Macrocystic lymphatic malformations (previously termed cystic hygroma) contain large thickwalled cysts that have less infiltration of surrounding tissue • lymphatic malformations fluctuate in size as a result of infection or hemorrhage
  33. 33. Cystic Hygroma
  34. 34. Infectious neck masses  Acute unilateral cervical lymphadenitis Subacute/chronic unilateral lymphadenitis Acute bilateral cervical lymphadenitis Subacute/chronic bilateral lymphadenitis
  35. 35. Acute bilateral cervical lymphadenitis • Is the most common infectious neck mass • Viral – Caused by a benign, self-limited viral upper respiratory infection (eg, enterovirus, adenovirus, influenza virus) – The LN(reactive LN) typically are small, rubbery, mobile, discrete, minimally tender, and without erythema or warmth -Baterial: GAS pharyngitis is a common cause of bilateral cervical lymphadenitis, which is often tender
  36. 36. Acute unilateral cervical Lymphadenitis  Acute unilateral cervical lymphadenitis is usually caused by bacteria -S. Aureus -GAS -In young infants, Streptococcus agalactiae (group B streptococcus(
  37. 37. S. aureus and GAS -Between 40 and 80 % of cases -Most of these infections occur in children younger than 5 years of age -Patients may have a history of a recent URI or impetigo -Submandibular nodes are affected in more than 50% -The lymph node usually is 3 to 6 cm in diameter, tender, warm, erythematous, nondiscrete, and poorly mobile -One-fourth to one-third of infected nodes suppurate and become fluctuant
  38. 38. Other causes  -Acute unilateral cervical lymphadenitis in older children with history of periodontal disease usually is caused by an infection with anaerobic bacteria -Tularemia
  39. 39. Subacute/chronic bilateral cervical lymphadenitis -Most often caused by EBV or CMV infection -EBV causes infectious mononucleosis that may manifest as fever, exudative pharyngitis, lymphadenopathy, and hepatosplenomegaly -CMV also can cause a mononucleosis-like illness
  40. 40. Subacute/chronic unilateral cervical lymphadenitis -Nontuberculous mycobacteria (NTM) infections -Bartonella henselae-cat scratch disease (CSD( -TB -Toxoplasmosis
  41. 41. Treatement • Acute bilateral LN — Treatment is not usually necessary for acute bilateral lymphadenitis (LN), which most frequently is related to a self- limited viral illness. The treatment of those with severe, progressive, or persistent cervical lymphadenitis depends upon the etiology
  42. 42. Treatement • Acute unilateral LN — The initial treatment depends upon the severity of symptoms • In well-appearing children with a slightly enlarged and minimally tender cervical lymph node, it is suggested to measure the lymph node and monitoring it over time • In children with moderate symptoms (eg, fever, warm and/or tender adenitis without evidence of fluctuance), a course of oral antimicrobial therapy is recomended. FNA of the inflamed node before initiation of oral therapy may help to guide antimicrobial coverage • In children with severe symptoms (eg, fever, fluctuant node, cellulitis), parenteral antimicrobial therapy after incision and drainage of the inflamed node is recomended
  43. 43. Treatement • Treatment failure — If the child fails to respond to empiric therapy, the differential diagnosis needs to be expanded to include uncommon causes of acute unilateral cervical adenitis, including noninfectious causes. The history needs to be re-reviewed. Surgical excision, drainage, or biopsy may be necessary
  44. 44. Back to our case  • Acute unilateral cervical lymphadenitis • ENT consult was ordered • A decision to drain the abscess was taken in the same day of presentation • Pus cx was taken intraoperatively • A 2 weeks course of Augmentin was started • The patient did very well postoperatively and was free of symptoms • Cx was positive for Staph Aureus • Pt was discharged home on oral Augmentin 4 days after his admission to the hospital