Cervical lymphadenitis

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

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Aim

To guide Emergency Department (ED) staff with the assessment and management of cervical lymphadenitis.

Assessment^1,2

Cervical lymph nodes (LN) are commonly palpable in children even if not unwell.

Definition

Enlarged lymph node in the neck
Can be reactive, or infective: caused by viruses and bacteria
May be tender and inflamed

Clinical Examination

Enlarged, LN on palpation
Assess for:
- Surrounding inflammation and swelling
- Overlying cellulitis
- Tenderness
- Fluctuance
May have limited range of motion of the neck secondary to pain or muscle spasm, but no meningism.
There may be systemic signs of infection e.g.: fever, lethargy, other viral upper respiratory tract infection (URTI) symptoms.
Consider the source and examine ears, nose, throat and mouth and skin.

Investigations¹

The majority of children have mild disease and require no investigations.
Indicated only if systemic symptoms, suspicion of underlying infection or in immunocompromised patient.
- Full blood count, C-Reactive Protein (CRP) and blood cultures are indicated in the unwell or septic appearing child. Refer to Sepsis Recognition and Management (ED Guidelines)
Ultrasound may be considered if atypical or clinical doubt about drainable collection.

Management

Cervical lymphadenitis (acute)
Reactive lymph node (LN) Nodes are usually small, mobile, discrete, mildly or non-tender LN are mostly commonly reactive due to viral URTI and may persist for weeks Management is expectant with clinical review by GP Small risk of developing secondary bacterial infection
Acute bacterial cervical lymphadenitis¹ Large (>1cm), discrete, tender cervical LN +/- overlying cellulitis Usually anterolateral neck, may have scalp or dental sources Antibiotics – Refer to Skin and Soft Tissue (Paediatric Empiric Guidelines) (ChAMP). Most mild cases only require oral antibiotics. Admission for IV antibiotics should be considered for more unwell children, and those that have already failed oral antibiotics. Abscesses (fluctuant masses) require surgical review (+/- ultrasound) for consideration incision and drainage In lesions that persist for more than 2 weeks, consider atypical pathogens such as non-tuberculous mycobacteria, Bartonella henselae or non infectious conditions

Cervical lymphadenitis (acute)

Reactive lymph node (LN)

Nodes are usually small, mobile, discrete, mildly or non-tender
LN are mostly commonly reactive due to viral URTI and may persist for weeks
Management is expectant with clinical review by GP
Small risk of developing secondary bacterial infection

Acute bacterial cervical lymphadenitis¹

Large (>1cm), discrete, tender cervical LN +/- overlying cellulitis
Usually anterolateral neck, may have scalp or dental sources
Antibiotics – Refer to Skin and Soft Tissue (Paediatric Empiric Guidelines) (ChAMP). Most mild cases only require oral antibiotics.
Admission for IV antibiotics should be considered for more unwell children, and those that have already failed oral antibiotics.
Abscesses (fluctuant masses) require surgical review (+/- ultrasound) for consideration incision and drainage
In lesions that persist for more than 2 weeks, consider atypical pathogens such as non-tuberculous mycobacteria, Bartonella henselae or non infectious conditions

Nursing

Consider topical local anaesthetic e.g. lidocaine (lignocaine) with prilocaine (EMLA^®) application if patient condition is suggestive of requiring intravenous antibiotics.
Complete and record a full set of observations on the observation and response tool and record additional information on the Clinical Comments chart.
Minimum of hourly observations should be recorded whilst in the emergency department.

References

Healy CM & Edwards MS. Cervical lymphadenitis in children: Diagnostic approach and initial management. UpToDate. [Last updated March 2022. Cited: 3 November 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/cervical-lymphadenitis-in-children-diagnostic-approach-and-initial-management
Deosthali, Ankita et al. “Etiologies of Pediatric Cervical Lymphadenopathy: A Systematic Review of 2687 Subjects.” Global pediatric health vol. 6 27 Jul. 201

Endorsed by:	Nurse, Co-director, Surgical Services	Date:	Apr 2023
		Review date:	Mar 2026

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Cervical lymphadenitis

Disclaimer

Aim

Assessment^1,2

Definition

Clinical Examination

Investigations¹

Management

Nursing

References

Related CAHS internal policies, procedures and guidelines

Useful resources

Cervical lymphadenitis

Disclaimer

Aim

Assessment1,2

Definition

Clinical Examination

Investigations1

Management

Nursing

References

Related CAHS internal policies, procedures and guidelines

Useful resources

Assessment^1,2

Investigations¹