Patient Education
Many young children are noticed to have swelling of variable size on one side of the neck. The parents notice this first and often there are no symptoms. However, at times, there may be associated with fever or pain and/or redness. There may be no trauma locally prior to the onset of the swelling. Sometimes, the child may have had a cold with a cough just before the swelling has come up. The most common cause of this swelling is enlargement due to inflammation and infection of the lymph nodes in the neck.
Figure 1: Swelling In The Neck
The entire area of the head face and neck is drained into about 300 lymph nodes that are present in this region. Since the nodes are very tiny they are not visualized by the naked eye and are along the lines of drainage of the lymphatic system. Lymph is a clear fluid like the blood that circulates all over the body. These lymph nodes are situated in groups all over the body and drain fixed areas. From the nodes, the flow of lymph is carried to the upper part of the body and finally, the last lymph duct enters the main vein and thus goes into the bloodstream to be purified and circulated. If any part of the body is infected or inflamed, the organisms are captured in the lymphatics and kept in safe custody in the draining nodes. The infection is sought to be controlled by the body's immune system. This results in enlargement of the node or nodes depending on the type and severity of the infection. If the infection is severe, it results in the formation of tissue necrosis of the node and later pus. Thus an abscess is formed in the nodes, and this has to be drained. If the infection is not too severe, infection/inflammation may cause the nodes to enlarge and remain so until the infection is under control. The nodes will automatically regress in size soon after the inflammatory reaction settles down. Therefore the approach and the final therapy will vary from child to child - some requiring surgery, some biopsy.
Figure 2: Neck Node Being Excised
Figure 3: Node being excised
The commonest cause for enlargement of neck nodes in children in India is Tuberculosis, followed by nonspecific bacterial infection from the oral cavity and scalp. The importance of distinguishing other types of infections from tuberculosis is that while the therapy of non-specific infections is with a single antibiotic for a week, the therapy of tuberculosis is with 3 antibiotics for a period of 7-9 months minimum. In elder children near the age of 10-12 years, another common cause of enlarged nodes is Lymphoma - a type of Cancer of the Reticulo Endothelial system(Immune system). The nodes enlarge and are painless, with few symptoms like fever, weight loss, itching, loss of appetite. The diagnosis of this condition must be perfect and will require a biopsy of the nodes with a microscopic examination to know the exact subtype of cancer. This is followed by cycles of anti-Cancer Drugs (chemotherapy), and radiotherapy(x rays). Another type of blood cancer - leukemia can also be first detected as an enlarged node in the neck of a child of 10-12 years.
A child with pain redness, sudden enlargement of neck nodes; with or without fever is most likely to be infective/inflammatory in nature. The infection could be bacterial or viral in origin, on the other hand, it could be secondary to a primary focus in the oral cavity, face, or scalp. The commonest foci are in tonsils, tongue, teeth, gums, etc. Treatment of the infection will take care of the mass and nothing more needs to be done except a follow up to check that the swelling has subsided and there has been no recurrence. If the infection is severe, or the child has been brought late to the doctor, pus may have already formed or is almost starting to form in the nodes. Once pus has formed, no medicines will cure the mass, and the pus within the node cavity has to be drained surgically. Evacuation of the pus with a thorough cleansing of the cavity with alternate dressing along with oral antibiotic and anti-inflammatory medications have to be given until the infection is eradicated. Part of necrotic node tissue may be sent for microscopic examination to rule out tuberculosis.
In the case of tubercular infection, the group of nodes will be enlarged and the nodes are adherent to each other. There will be a Caseous(cheesy) necrosis which is typically seen in tuberculosis. The enlarged nodes are enlarged, nonpainful, and will not respond to routine antibiotics and will persistently remain the same size or even grow despite therapy. The ideal way to confirm the diagnosis is to do a node biopsy. In this surgical procedure, a single node or a part of a group of nodes is removed and sent for microscopic(histological) examination. This will confirm the diagnosis and specific ani tuberculous drugs can be started and given nonstop for about 9 months with a close follow up to look for a response and to monitor the side effects of the drugs. Caseation necrosis may have already set in by the time the child is seen. The caseous material can be scooped and sent for examination too and the cavity cleaned as before and dressed till it heals with the medications.
In an older child, a mass in the neck may be associated with similar enlargement of the nodes in other areas of the body - like the axillae, inguinal nodes, and enlarged spleen. In these children, it is vital to rule out malignancy like Lymphoma or Leukemia. Many of these children may have no other symptoms or nonspecific ones like loss of appetite. In fact, one of my own patients, who was a 10-year-old boy was unaware of the node mass on both sides of the neck till he went for his haircut. It was his barber who pointed out there was a swelling on each side of the neck and the child was brought to me for an opinion. I advised an immediate node biopsy which confirmed a type of Lymphoma and he went extensive therapy and is doing very well today. After confirmation of the diagnosis other investigations are required to be done. This is to know the stage of the disease - how far it has spread and how many nodes and parts of the system are involved already. Based on the detail of the staging, the type of chemotherapy and extent of the radiotherapy is planned and given in cycles till the cure is achieved. A close follow up is a must to look for recurrence in the future.
There are many other causes of enlarged nodes, but, I have highlighted only the common and important ones that occur in India.