Lymph

Question 1

A mother brings her 6-year-old son to your office for evaluation because she found a lump in his neck below the jaw on the right side. She first noted it a week ago, about a week after he had recovered from an upper respiratory infection. She reports that her son feels well and is back to full, unrestricted activity.

When you examine the child you find an enlarged lymph node in the right anterior cervical chain of nodes. It measures 2 cm in diameter and is somewhat firm, mobile, and nontender. The remainder of the examination is normal.

Which one of the following would be most appropriate at this point? (check one)
Ultrasound evaluation of the lymph node
A fine-needle biopsy of the node
An excisional biopsy of the node
A 10-day course of antibiotics
Follow-up examination in 1 month

Answer 1

Follow-up examination in 1 month

Localized or generalized lymphadenopathy is a common complaint in children. Most cases are benign and related to infections or connective tissue disorders. Initial management involves watchful waiting for up to 4 weeks (SOR C). Evidence to support treatment with antibiotics is lacking and should be reserved for patients who show evidence of local inflammation. Malignancy should be excluded if lymphadenopathy persists beyond 4 weeks, or if other symptoms develop, such as fever, night sweats, weight loss, hepatosplenomegaly, or orthopnea. In this situation, the evaluation should include a CBC, blood smear, erythrocyte sedimentation rate, and chest radiography (SOR C).

Question 2

Lymphadenopathy of the head and neck at which one of the following sites is most likely to be malignant? (check one)
Anterior cervical
Posterior cervical
Preauricular
Submandibular
Supraclavicular

Answer 2

Supraclavicular

In patients with head and neck lymphadenopathy, supraclavicular nodes are the most likely to be malignant. Lymphadenopathy of these nodes should always be investigated, even in children. Overall, the prevalence of malignancy with this presentation is unknown, but rates of 54%–85% have been seen in biopsy series reports.

Question 3

A 45-year-old male sees you for a hypertension follow-up visit and points out a nonpainful bump that he noted on his neck 3–4 months ago. He does not use tobacco products and is otherwise healthy. He has not had any fever or pain. His blood pressure is controlled with lisinopril (Prinivil, Zestril). On further evaluation a firm, mobile, nontender 1.5-cm right anterior cervical lymph node is noted.

Which one of the following would be most appropriate at this point? (check one)
Watchful waiting
Discontinuation of lisinopril
Antibiotics
Corticosteroids
Fine-needle aspiration

Answer 3

Fine-needle aspiration

This patient is at high risk for malignancy based on his age, sex, and lymphadenopathy for more than 4–6 weeks. Fine-needle aspiration is an acceptable first-line test to evaluate for a reactive node versus malignancy. Further testing may be necessary to confirm the diagnosis. Watchful waiting could delay the diagnosis of a malignancy in a patient at high risk and would not be appropriate. Due to the duration of his symptoms and presentation, lymphadenitis is unlikely and antibiotics would not be appropriate. Corticosteroids are not recommended until a diagnosis is confirmed, as they may interfere with the cytology. While medications can cause lymphadenopathy, lisinopril has not been associated with this problem.