Cervical lymphadenopathy

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    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


    • 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



    • 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


    • LN groups in the head and neck region:
      Cervical Lymphadenopathy 1
    • 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

    Persistent cervical lymphadenopathy

    Clinical features

    Viruses (EBV, CMV, Rubella)

    May be associated with generalised lymphadenopathy and hepatosplenomegaly

    Mycobacterium tuberculosis

    Non-tender nodes. History of exposure. Systemic symptoms of fever, malaise, weight loss

    Atypical mycobacterial infections

    Indolent, chronic unilateral cervical lymphadenopathy, violaceous hue, usually in children <5 yo

    Bartonella henselae (cat scratch disease)

    Enlarged nodes are usually tender and located in the axillary region

    Toxoplasmosis gondii

    Non-suppurative generalised lymphadenopathy. Systemic features of fatigue or myalgia

    Malignancy (lymphoma, leukaemia)

    Consider if prolonged, painless, firm lymphadenopathy. May be associated loss of appetite, weight loss, night sweats, easy bruising, hepatosplenomegaly, mediastinal mass


    Persistent head and neck eczema may cause prominent posterior cervical LNs

    Rheumatologic conditions (JIA, SLE)

    May be associated with rash, joint pain, conjunctival changes

    Approach to differential diagnosiscervical_lymphadenopathy_2


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


    Acute Cervical Lymphadenopathy (<2 weeks

    Persistent Cervical Lymphadenopathy (2-6 weeks)


    • No investigations routinely required


    Consider neck USS if suspected abscess
    MCS if performing incision and drainage


    • FBE, blood film
    • CRP, ESR, LDH
    • LFT
    • Serology (when specific infectious cause suspected) – EBV, CMV, HIV
    • Toxoplasmosis, Bartonella henselae
    • Tuberculin skin test, Quantiferon Gold (if TB suspected)
    • Chest X-ray (if malignancy suspected)
    • Neck USS
    • CT or MRI may be required pre-operatively
    • Biopsy (excisional biopsy remains gold standard; FNA less helpful)


    • 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

  • Reference List

    1. Chiappini, E et al. Italian Guideline Panel For Management Of Cervical Lymphadenopathy In Children. Development of an algorithm for the management of cervical lymphadenopathy in children: consensus of the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Society of Pediatric Infectious Diseases and the Italian Society of Pediatric Otorhinolaryngology. Expert review of anti-infective therapy. 2015. 13(12), 1557–1567.
    2. Deosthali, A et al. Etiologies of Pediatric Cervical Lymphadenopathy: A Systematic Review of 2687 Subjects. Glob Pediatr Health. 2019. 6:2333794X19865440. Retrieved from 10.1177_2333794X19865440.pdf (nih.gov)
    3. Lang, S et al. Cervical lymph node diseases in children. GMS current topics in otorhinolaryngology, head and neck surgery. 2014. Retrieved from Untitled (nih.gov)
    4. Rosenberg, T et al. Pediatric cervical lymphadenopathy. Otolaryngologic clinics of North America. 2014. 47(5), 721–731.
    5. Weinstock, M et al. Pediatric Cervical Lymphadenopathy. Pediatrics in review. 2018. 39(9), 433–443.
    6. Chiocca, M. Study Guide to Accompany Advanced Pediatric Assessment, Second Edition : A Case Study and Critical Thinking Review. 2014.Springer Publishing. New York, USA.