QUICK FACTS!
- 90% of pediatric head and neck masses are benign, which is in stark contrast from adults (80% are neoplastic if age >45 years)
- 40% of healthy children (without symptoms) have palpable cervical LAD
- DDx mainly includes infectious, neoplastic, and congenital causes
- Infectious: reactive LAD secondary to viral infection (most common cause), bacterial lymphadenitis (second most common cause), and then subacute/chronic infectious processes (EBV, CMV, HIV, Bartonella, Mycobacterial infections, Nocardia, Toxoplasmosis)
- Neoplastic: <6 years-old think rhabdomyosarcoma or non-Hodgkin’s lymphoma; >6 years-old think Hodgkin’s lymphoma
- Congenital: midline neck masses (thyroglossal duct cyst, dermoid cyst), lateral (branchial cleft cysts)
- Don’t use steroids!!! This can delay diagnosis of leukemia, lymphoma, or histiocytic disease
WORRISOME FEATURES?!
- Systemic symptoms (fever >1 week, night sweats, weight loss [>10% of body weight])
- Supraclavicular (lower cervical) nodes
- Generalized LAD
- Fixed nontender nodes in the absence of other symptoms
- Nontender lymph nodes >1 cm with onset in the neonatal period
- Nontender lymph nodes ≥2 cm that increase in size from baseline or do not respond to 2 weeks of antibiotics
- Abnormal CXR (particularly mediastinal mass or hilar adenopathy)
- Abnormal CBC (eg, lymphoblasts, cytopenias in more than 1 cell line)
- Absence of symptoms in the ear, nose, and throat regions
- Persistently elevated ESR/CRP or rising ESR/CRP despite antibiotic therapy
WHEN TO BIOPSY?
- Suspicion of malignancy
- No resolution of LAD over 4-6 weeks
- LAD that steadily increases in size over 2-3 weeks
- LAD >2 cm
- Multiple lymph nodes that have concerning features on US or CT
KEY REFERENCES!
- Pediatric Neck Masses (Pediatrics in Review, 2013)
- Pediatric Cervical Lymphadenopathy (Pediatrics in Review, 2018)