Swollen Neck Nodes

History

Everyone has lymph nodes; they act as filters of the blood and lymph.

When lymph nodes swell, it is in reaction to something; this is called lymphadenopathy. Lymphadenopathy may be a reaction to an infection, or something noninfectious (such as a lymphoma).

Lymphadenopathy resulting from infection is usually acute and painful; the nodes are tender to the touch, and the patient may have a fever or a sore throat.
Lymphadenopathy resulting from a malignancy is usually chronic, painless, hard (wood-like), and fixed to the underlying structures.

Neck nodes are referred to as “cervical nodes.” Anterior cervical lymphadenopathy is common. Posterior cervical lymphadenopathy (around the trapezius muscle) is unusual, and should suggest either a viral infection (mononucleosis, CMV, or HIV) or a tumor.

Location of Cervical Lymph Nodes

Common infectious causes of cervical lymphadenopathy include:

Group A streptococcal infection
Mononucleosis (Ebstein Barr Virus, or EBV)
Cytomegalovirus (CMV, closely related to EBV)
HIV

Unusual infectious causes include:

Cat scratch disease (usually from a kitten)
Tularemia (ask about hunting rabbits)
Anthrax
Lupus
Rarely, women who get a “hair-do” get reactive cervical nodes; these may be tender, but the patient is otherwise nontoxic.

Physical Exam

Note the temperature and the patient’s general condition.
Look in the pharynx for an exudate; with pharyngitis, a fetid odor to the breath may be noted.
Note the lymph nodes: their distribution and size, and whether they are tender, firm, or fixed.
Have the patient bend the head forward and palpate along the trapezius.
Have the patient lift their chin and palpate under the mandible.
Palpate along the sides of the neck. Lymph nodes above the clavicle are always abnormal.
With mononucleosis, splenomegaly (or tenderness) may be elicited in the left upper quadrant of the abdomen.

Laboratory Tests

If possible, culture the pharyngeal exudate. Group A streptococcus is the only significant bacterial isolate from the pharynx; many other bacteria can be grown, but none are clinically significant, and many (including Hemophilus influenza, Neisseria meningitidis, and Streptococcus pneumoniae) are colonizers.
A monospot can be useful, but may be negative early, and may persist positive for over a year after resolution of mononucleosis
CBC with differential is very helpful, and can suggest strep or mono.

Medications

An empiric trial of penicillin may be warranted (provided the patient is not penicillin allergic), especially if there is no way to confirm or exclude the diagnosis of “strep throat.” Patients with mononucleosis almost always develop a rash if they are placed on ampicillin; this rash can be diagnostic of mononucleosis, and should not be confused with a penicillin-rash. Rarely, corticosteroids are useful in mono.

Medevac

Some of these patients may be very ill. Fever, prostration, dysphagia, and odynophagia can all lead to dehydration. If the patient is unable to swallow, attempt IV fluids. Monitor the blood pressure, or, if no sphygmomanometer is available, the pulse (and its quality) are important.

This section provided by CDR Wesley Emmons, MC, USN, Head of Infectious Diseases, Naval Medical Center Portsmouth

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