DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
SWELLING IN THE NECK IN CHILDREN
Many young children are noticed to have a 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 fever or pain and /or
redness. There may be no trauma locally prior to onset of the swelling.
Sometimes, the child may have had a cold with 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.
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 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 blood stream 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 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 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 till 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.
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HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE: 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
Swelling in neck
Node being excised
The commonest cause for enlargement of neck nodes in children in
India is Tuberculosis, followed by non specific 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 a 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
microscopic examination to know the exact sub type of the 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 thorough cleansing of the cavity with alternate dressing along with
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HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE: 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
oral antibiotic and anti inflammatory medications have to be given till the
infection is eradicated. Part of necrotic node tissue may be sent for
microscopic examination to rule out tuberculosis.
In case of a 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, non painful, 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 speifi ani tuberculous drugs can be started and given non stop for about
9 months with a close follow up to look for 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 non specific ones like loss of appetite. In fact, one of
my own patient , 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 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.
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HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE: 98210 52680
Website: www.addlifesurgikids.com
DR. VIVEK M. REGE
PEDIATRIC SURGEON & PEDIATRIC UROLOGIST
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HURKISONDAS HOSPITAL
B J WADIA HOSPITAL FOR CHILDREN
WOCKHARDT HOSPITAL
MOBILE: 98210 52680
Website: www.addlifesurgikids.com