The pediatric surgeon is often asked to evaluate a child with long-standing cervical lymphadenopathy. Careful questioning may reveal a history of frequent upper respiratory infections, otitis media, tonsillitis, sinusitis, or allergies associated with rhinitis. The lymphadenopathy may fluctuate in size, depending on whether the child has an active infection. The nodes are usually mobile and located in the upper anterior cervical areas. They may be bilateral and slightly tender in the presence of active infection. In most cases, this adenopathy can be treated conservatively, and an associated identified bacterial infection is treated with antimicrobial agents.

If biopsy seems indicated, an FNA or biopsy can be done and usually reveals reactive lymphadenopathy, allowing continued observation and alleviating parental anxiety. An aspirate can also be obtained for culture, although culture proves positive in only about 15% of cases (3).

Bacterial lymphadenitis most typically involves Staphylococcus aureus or group A β-hemolytic streptococcal etiologies. Bacterial infections may also be characterized by rapid nodal enlargement followed by slow evolution to an abscess or suppurative lymphadenitis with overlying skin erythema and fluctuance. Young children tend to have associated fever until the abscess matures and can be drained, despite appropriate antimicrobial therapy. Ultrasound may help to plan optimal timing of the surgical drainage.

The timing and approach to surgical therapy of a probable phlegmon or abscess is dictated by suspected etiology and the need for diagnosis versus therapy. The vast majority of neck abscesses should be drained under general anesthesia in the operating room. This allows for adequate drainage, identification of any loculations, ensures control of the airway, and allows for control of any bleeding. A transverse incision is made over the main area of fluctuance unless this is inappropriate for cosmetic reasons, and it should be long enough to enable the surgeon to probe the abscess cavity and break up any loculations. This ensures adequate drainage and allows placement of a passive drain, such as a Penrose, or packing material. Incisions made very high or very low in the neck should be made parallel to the mandible or clavicle, respectively, and at least 1 or 1.5 cm away from these bony landmarks to preclude significant scarring.

Adequate surgical drainage in combination with appropriate antimicrobial therapy usually resolves simple suppurative processes. Identification of an unusual organism or abscess recurrence may indicate an underlying immunosuppressive illness or congenital anomaly and should prompt an appropriate workup.

The oropharynx and respiratory tract act as the reservoir for these infections because atypical mycobacteria (AMB) can also be cultured from these sites in asymptomatic patients. The most common organisms causing infection in humans are Mycobacterium avium, Mycobacterium intracellularis, and Mycobacterium scrofulaceum. The collective group is now known as the M. avium complex (MAC). Unlike Mycobacterium tuberculosis (TB), person-to-person transmission of MAC has not been documented (4,5).

Uncomplicated cases of AMB often present as a group of upper cervical nodes, which are initially rubbery, firm, and nontender, located close to the mandible. They later become matted together to form a confluent mass. The child is usually otherwise well, whereas cases of TB are more common in immunocompromised children and are accompanied by symptoms or signs of illness, such as fever and respiratory complaints. An occasional patient has a superimposed pyogenic infection with fever, and an acid-fast stain and culture for mycobacteria at the time of abscess drainage may prove helpful in diagnosis if the wound later fails to heal properly.

An intradermal skin test with standard tuberculin antigens may be helpful because there is a cross-reactivity between AMB and TB. Reactions to intermediate-strength purified protein derivative (5 tuberculin units) are usually 5 to 10 mm in diameter in cases of AMB, and significantly greater than 10 mm in TB cases. FNA or incisional biopsy in cases of both AMB and TB is diagnostic.

If tuberculosis is strongly suspected, a trial of antituberculous therapy may be indicated pending culture results. Atypical mycobacteria infections generally respond poorly to chemotherapy. Incision and drainage or incomplete nodal excision of AMB invariably leads to recurrence or cutaneous draining sinuses. Complete excision is ordinarily curative, although there may be a role for adjunctive antimicrobial therapy with clarithromycin and rifabutin (6,7,8,9).

Fungal infections are less frequent and more often seen in immunocompromised patients. The most frequently reported pathogen is Candida albicans.

The lymphadenopathy associated with mononucleosis is usually bilateral and more common in the adolescent than the child. Hepatosplenomegaly may be present, and a heterophil antibody test (monospot) or Epstein-Barr virus (EBV) titers are positive. Young children with acute EBV infection are likely to be heterophil antibody negative, although this rapid test may be useful in the older
child or adolescent. Cytomegalovirus (CMV) can also cause mononucleosis with associated adenopathy. Up to 75% of patients with CMV infections will have cervical adenopathy. The lymphadenopathy resolves within weeks.

An occasional patient with a history of mononucleosis later develops Hodgkin’s disease or non-Hodgkin’s lymphoma, but the association is not common enough to warrant routine node biopsy in every patient with mononucleosis. Cervical node biopsy is warranted in patients who have persistent or recurrent lymphadenopathy in the face of normal or declining EBV titers following a documented case of mononucleosis.

The classic features of CSD include self-limited, regional lymphadenopathy occurring in healthy people following a cat scratch or bite distal to the affected node. Common sites of node enlargement other than the neck are the axilla, elbow, and groin (10). Other animals, such as dogs and monkeys, have also been implicated in transmission (11).

Bartonella henselae, a member of the Rickettsiaceae family, is the etiologic agent (10,12). A B. henselae-based serologic indirect fluorescent-antibody test appears to be both a sensitive and specific diagnostic tool. Enzyme immunoassays for detection of antibodies to B. henselae have also been used. Tissue can be tested by polymerase chain reaction. The domestic cat is a major persistent reservoir for the organism, and the cat flea (Ctenocephalides felis) is a vector.

Most children have mild symptoms and a benign clinical course. Severe complications, including encephalitis, follicular conjunctivitis, and neuroretinitis, have also been described. A papule may form at the site of primary inoculation. In most cases, the disease resolves spontaneously within a few months. Lymph node biopsy reveals multiple microabscesses or granulomas. Occasionally, nodes suppurate and require drainage. Antibiotics with activity against Bartonella include azithromycin, gentamicin, rifampin, trimethoprim-sulfamethoxazole, and ciprofloxacin (13).

Other causes of cervical lymphadenitis include actinomyces, toxoplasmosis, tularemia, Yersinia pestis, Nocardia species, Mycoplasma pneumoniae, and Pasturella multocida (after an animal bite or scratch). Viral causes include adenovirus, enterovirus roseola (herpesvirus 6), rubella, and Parvovirus B 19 (the latter can cause bilateral cervical and intraparotid adenopathy).

There are a few more unusual or rare noninfectious causes of lymphadenopathy, including Kawasaki and Kikuchi disease, sarcoidosis, Rosai-Dorfman (sinus histiocytosis with massive lymphadenopathy), and histiocytosis X.

In cases of cervical lymphadenitis that do not respond to a course of standard antimicrobial therapy or TB therapy, or lymphadenitis that is persistent or enlarges after diagnosis of mononucleosis or CSD, surgical excision for diagnosis is appropriate. In cases of cervical lymphadenitis that fit the diagnosis of AMB infection clinically, surgical excision without drainage is the recommended treatment (4). Definitive surgery in the latter circumstance should involve complete excision of all involved sinus tracts and nodes, if feasible. Cases of parotid involvement that are treated with superficial parotidectomy, or that have neural involvement that precludes complete resection of involved nodes, usually heal normally (5,9). Adjunctive antimicrobial therapy for cases of AMB or CSD should probably be reserved for disseminated or problematic disease.

Enlarged cervical nodes may require biopsy in almost any site in the neck. A small transverse incision made in a skin crease overlying the node is usually sufficient for biopsy. Nodes in the posterior triangle are usually superficial and easily excised, with careful avoidance of the spinal accessory nerve. In most cases, nodal tissue can be directly approached and then teased away from surrounding tissue using blunt dissection to avoid damage to important structures.

To approach the supraclavicular area, an incision is made over the lateral edge of the sternocleidomastoid muscle. After incising the platysma, the nodal tissue between the omohyoid muscle superiorly, external jugular vein laterally, carotid sheath medially, and clavicle inferiorly are dissected free. The anterior scalene muscle, brachial plexus, and phrenic nerve can be visualized at the base of the dissection. Submandibular node excision requires careful avoidance of the mandibular branch of cranial nerve VII.