Cervical lymphadenopathy

Cervical lymphadenopathy refers to swelling of the cervical lymph node(s) and encompasses both infectious (e.g., bacterial or viral infections) and noninfectious causes (e.g., malignancy). Inflammatory cervical lymphadenopathy is more specifically referred to as cervical lymphadenitis, but terms may be used synonymously. Cervical lymphadenopathy is most often seen in children under 5 years of age and typically affects the submandibular or deep cervical lymph nodes. Unilateral cervical lymphadenopathy (UCL) refers to localized swollen lymph node(s) on one side of the neck and is usually associated with bacterial infections. Acute UCL is most commonly caused by S. aureus and Streptococcus species, while chronic UCL can be the result of tuberculous or nontuberculous mycobacterial infections. Bilateral cervical lymphadenopathy (BCL), which refers to swelling on both sides of the neck, is most commonly caused by viral infections of the upper respiratory tract. Adenoviruses and enteroviruses are the most common causes of acute BCL, while Epstein-Barr virus (EBV) and cytomegalovirus (CMV) are most commonly responsible for subacute/chronic BCL. In acute UCL, affected lymph nodes are often enlarged, tender, warm, and mobile, and may be accompanied by fever and malaise. In acute BCL, lymph nodes are usually small, mobile, and mildly tender without erythema or warmth. Chronically inflamed lymph nodes are typically nontender and become indurated and matted over time. Diagnosis involves laboratory tests for inflammatory markers, serology, and bacterial cultures from pus samples that are used to detect pathogens and to monitor the course of the disease. Biopsy may be needed to rule out malignancy. Mild cases without fever, lymph node tenderness, or suspicion of group A streptococcal (GAS) tonsillitis can be managed conservatively with active observation for disease regression. Most cases are treated empirically with antibiotics to cover the most common pathogens. Surgical incision and drainage may be indicated in cases with suppurative lymphadenitis.

• Age: most common in children < 5 years

Epidemiological data refers to the US, unless otherwise specified.

Infectious

Unilateral cervical lymphadenopathy (UCL)

• Acute unilateral cervical lymphadenopathy: most commonly caused by bacterial infections (> 80%)
  • S. aureus
  • Group A Streptococcus (e.g., Streptococcus pyogenes)
  • Oral anaerobes
  • Group B Streptococcus (GBS)
  • Francisella tularensis
• Subacute/chronic unilateral cervical lymphadenopathy
  • Nontuberculous mycobacteria (e.g., M. avium-intracellulare; and M. scrofulaceum)
  • Mycobacterium tuberculosis
  • Bartonella henselae
  • Toxoplasma gondii

Bilateral cervical lymphadenopathy (BCL)

• Acute bilateral cervical lymphadenopathy: most commonly caused by viral infections of the upper respiratory tract
  • Adenovirus
  • Enterovirus
  • Influenza virus
  • Group A Streptococcus
  • Other pathogens include EBV, CMV, and HSV-1
• Subacute bilateral cervical lymphadenopathy
  • Predominantly caused by EBV and CMV
  • Mycobacterium tuberculosis
  • Other, uncommon pathogens include: HIV, Toxoplasma gondii, and Treponema pallidum

Noninfectious

• Malignancies
  • Leukemia
  • Lymphoma
  • Metastasis of oral mucosa cancers
  • Kaposi sarcoma
• Connective tissue disorders
  • Juvenile rheumatoid arthritis
  • Systemic lupus erythematosus
• Rare syndromes
  • Kawasaki disease
  • PFAPA syndrome
  • Kikuchi-Fujimoto disease
• Medication: allopurinol, carbamazepine, phenobarbital

Unilateral cervical lymphadenopathy

• Symptoms
  • Usually patient appears healthy
  • Recent or current symptoms of bacterial infections (e.g., upper respiratory tract infection, dental conditions)
• Lymph node involvement
  • Most commonly submandibular or deep cervical nodes (> 80% of cases)
  • Enlarged (3–6 cm), tender nodes with warmth and possibly erythematous skin over the node
  • May become fluctuant and form an abscess over time or become indurated
  • Chronic cases: insidious enlargement; nontender, immobile, matted nodes; may form to sinus tracts

Supraclavicular and posterior cervical lymphadenopathy are indicative of serious underlying conditions, including malignancy, tuberculosis, and toxoplasmosis.

Bilateral cervical lymphadenopathy

• Symptoms
  • Patient typically appears well
  • Symptoms of upper respiratory tract infection may be present (e.g., rhinorrhea, cough, fever, sore throat, malaise)
• Lymph node involvement
  • Typically small, mobile, mildly tender nodes without erythema or warmth
  • Submandibular or deep cervical nodes are most commonly affected
  • Lymphadenopathy may last for up to several weeks

• Clinical diagnosis
  • Based on physical exam findings
  • In case of mild disease and no suspicion of GAS tonsillitis, no further testing is necessary.
  • Further diagnostic evaluation is indicated to identify the underlying cause in patients with cervical lymphadenopathy who are symptomatic (e.g., fever, ill appearance, tender node)
• Laboratory tests
  • CBC, ESR, CRP
  • Liver function tests
  • Serology
    • If tularemia or cat-scratch disease is suspected
    • In case of bilateral lymphadenopathy: EBV, CMV, HIV
  • Tuberculin skin test and/or interferon-gamma release assay in chronic cases
• Bacterial culture
  • Blood culture
  • Throat swab and oral swab
  • Rapid antigen detection test and/or throat culture to rule out GAS tonsillitis
• Biopsy
  • Fine needle aspiration and subsequent Gram stain and culture of obtained material
  • Excisional biopsy with histopathological evaluation
• Imaging: ultrasound exam or CT scan

• Submandibular abscess
• Thyroid tumors
• Congenital neck masses, including:
  • Branchial cleft cysts
  • Cystic hygromas
  • Thyroglossal duct cysts
  • Epidermoid cysts
  • Sternocleidomastoid tumors
• Metastatic cancer
• Postvaccination reaction
• See also “Localized lymphadenopathy” and “Differential diagnoses of lymphadenopathy”

The differential diagnoses listed here are not exhaustive.

Unilateral cervical lymphadenopathy

• No fever and nontender lymphadenopathy: conservative management with active observation for disease regression
• All other cases
  • Oral antibiotics for 10–14 days (e.g., clindamycin)
  • In cases of MRSA or clindamycin-resistance: TMP-SMX, doxycycline
  • Supportive therapy: antipyretics, analgesics, warm compresses
  • Incision and drainage of large abscesses

Bilateral cervical lymphadenopathy

• Mild disease/no suspicion of GAS tonsillitis: conservative management with active observation for disease regression
• Suspected or confirmed GAS tonsillitis: oral antibiotics (e.g., penicillin V, cephalexin)
• Severe disease or chronic lymphadenopathy (> 6–8 weeks): treatment dependent on etiology