Imaging of Cervical Lymphadenopathy in Children and Young Adults

OBJECTIVE. This article describes the role of imaging in evaluating cervical lymphadenopathy
in patients from birth to their mid-20s, illustrates imaging features of normal and abnormal lymph
nodes, and highlights nodal imaging features and head and neck findings that assist in diagnosis.
CONCLUSION. Cervical lymph node abnormalities are commonly encountered clinically and on
imaging in children and young adults. Although imaging findings can lack specificity, nodal
characteristics and associated head and neck imaging findings can assist in determining the
underlying cause.

C ervical lymph node abnormalities are a common reason for pediatric and otolaryngology office
visits and may be related to benign processes, such as reactive nodes, or to aggressive processes,
including malignancy. Although often considered nonspecific, cervical lymph node imaging
features, in conjunction with clinical presentation and related head and neck imaging findings, can
aid in determining the cause of the abnormality. Ultrasound, CT, and MRI may be used to confirm
the presence of lymphadenopathy, distinguish nodal abnormalities from congenital head and neck
lesions, and further characterize lymph nodes. In the pediatric population, ultrasound is the most
appropriate initial imaging modality because of the lack of ionizing radiation. CT and MRI are
complementary and can further characterize nodal abnormalities and related head and neck
imaging findings. It is critical for the interpreting radiologist to recognize the appearance of normal
cervical lymph nodes and to report nodal features typical of specific infections, inflammatory
conditions, and neoplasms to assist clinicians in subsequent management.

Clinical Approach to Cervical Lymph Nodes
Clinical evaluation of cervical lymph nodes in the pediatric population can be difficult because
palpable lymph nodes are common in healthy children. Previous studies have documented
palpable cervical lymph nodes in up to 90% of children 4–8 years old [1]. Clinicians rely on
history and physical examination to determine the possible causes of and the diagnostic workup
for lymphadenopathy. Physical examination findings of tender, mobile, soft nodes suggest
reactive adenopathy, whereas nontender, firm, nonmobile nodes raise concern for neoplastic
causes. Because infectious causes are most common, patients are often treated empirically with

and contrastenhanced neck MRI (rating. 7/9) for evaluation of children up to 14 years old who have solitary or multiple neck masses. or are accompanied by systemic symptoms. and follow-up of Hodgkin lymphoma relative to other imaging modalities. number. and perinodal soft tissues [3]. Role of Imaging Imaging may be performed to evaluate nodes lacking clinical features of benign causes. 9/9). In contrast. contrast-enhanced neck CT (rating. such as the deep fascia–defined spaces). Both contrast-enhanced CT and MRI may be used to further characterize the extent of sonographic abnormalities and to confirm deep nodal abnormalities. and evaluate the remainder of the head and neck (including areas not amenable to clinical examination. and evaluation of perinodal soft tissues and related head and neck findings. response to therapy. Currently. Benefits of ultrasound include the lack of ionizing radiation and the ability to characterize the nature of lymph nodes as either cystic or solid. determination of size. confirm lymph nodes as the cause of palpable abnormalities. the role of PET/CT is evolving in the setting of known malignancy. progress in size or number. shape. 8/9). both with and without fever [4]. further workup is necessary. borders. borders. vascularity. which often includes imaging. When nodes fail to resolve after 4–6 weeks of therapy. Ultrasound may be used to confirm the presence of an abnormal lymph node and characterize its size. with a significant (26. Benefits include superior anatomic localization. with studies showing superior accuracy of PET/CT in initial staging.antibiotics [2]. and the need for sedation must also be considered before CT and MRI in infants and young children. The ACR Appropriateness Criteria rate PET/CT evaluation of a solitary neck mass in a febrile child less than 14 years old and solitary or multiple neck mass in both febrile and afebrile children less than 14 years old as “usually not appropriate” (both rated 1/9) [4]. internal architecture. the American College of Radiology (ACR) Appropriateness Criteria support the use of ultrasound (rating. Diffusion-weighted imaging has been shown to increase conspicuity of subcentimeter lymph nodes due to suppression of background tissue and can aid in detection of lymph nodes relative to conventional sequences [5].8%) change in initial staging based on PET/CT findings [6]. and enhancement characteristics of nodes. if suspected [4]. These benefits must be weighed against the radiation risks of CT. . shape. internal architecture.

[7]. No specific size criteria have been defined for lymphadenopathy in the pediatric population. bacterial. 3). and perinodal soft tissues are complementary in lymph node evaluation. and rubella are common viral causes but typically require correlation with clinical or laboratory data to reach a definitive diagnosis.or hypoattenuating relative to muscle and show mild homogeneous enhancement after contrast administration. tonsils. Infectious mononucleosis and HIV infection have associated imaging findings and will be described in detail later. varicella. nodes are iso. and pharynx and thus are often enlarged [8. In adults. for which the upper limit of normal is 15 mm in adults. On ultrasound. Color Dopplersonography may show avascularity or radial symmetric hilar vascularity with low pulsatility index and low resistive index [3]. Thus. the upper limit of normal lymph node size is 10 mm when measured in terms of greatest long-axis dimension in the axial plane. 9] (Fig. including the teeth. 2).Normal Lymph Nodes Anatomic localization of cervical lymph nodes has been established on the basis of the previous description of metastatic adenopathy by Som et al. Such nodes are typically slightly enlarged and may show mild enhancement on CT or MRI and vascularity radiating from the hilum on Doppler ultrasound (Fig. Cytomegalovirus infection. additional imaging features including nodal morphology. although the preceding criteria are commonly used. nodes show low to intermediate signal on T1-weighted images. On CT. gums. with preserved fat planes with adjacent structures [8–10] (Fig. herpes simplex virus infection. with the exception of nodal stations IB and IIA. normal or reactive lymphcnodes are well defined and reniform in shape. Staphylococcus aureus and group A Streptococcus . Clinical Entities Reactive Lymph Nodes Reactive lymph nodes may result from viral. fungal. internal architecture. intermediate to high signal on T2-weighted images relative to muscle. Viral infections are the most common cause of reactive adenopathy [11] and typically result in bilateral mildly enlarged cervical lymph nodes without periadenitis. with fatty echogenic hila and a hypoechoic cortex relative to muscle (Fig. and homogeneous enhancement after IV contrast administration [8. rubeola (measles). Normal nodes are circumscribed. 1). or protozoal pathogens. 4). On MRI. The upper limit of normal for retropharyngeal nodes has been proposed as 8 mm [8–10]. this size allowance is because levels IB and IIA drain common sites of infection. 9].

with peripheral enhancement. The associated perinodal inflammatory change can assist in differentiation from central nodal necrosis due to metastatic disease. These infections commonly occur in children 1–4 years old. The peripheral enhancement on cross-sectional imaging in intranodal abscesses conforms to the nodal border. and histoplasmosis. with peripheral rim enhancement and perinodal inflammatory change. Differentiation is critical because intranodal abscesses are usually managed with antibiotics. 5). The single protozoal cause of lymphadenitis is toxoplasmosis. 6). MRI shows central T1 hypo. whereas true retropharyngeal abscesses show retropharyngeal fluid with enhancement corresponding to the borders of the retropharyngeal space. which otherwise can have a similar imaging appearance. On ultrasound. Both medial and lateral retropharyngeal nodes are present until about the age of 6 years and can exhibit intranodal abscess formation (Fig. Bacterial Infections Staphylococcus aureus and group A Streptococcus— Staphylococcus aureus and group A Streptococcus are the most common bacterial causes of cervical lymphadenitis and account for 53–89% of cases of unilateral cervical adenitis [12]. Fungal infections may be seen in endemic regions or immunocompromised patients and include cryptococcosis. features of suppurative adenopathy include anechoic regions.and T2 hyperintensity. They are seen as enlarged nodes with perinodal inflammatory change [10]. They often produce enlarged nodes with perinodal inflammatory change and may progress to suppurative adenopathy. 15]. defined as infection resulting in necrosis within lymph nodes (also referred to as intranodal abscess formation) [8. peripheral vascularity. .infections [12] are common bacterial causes of reactive lymph nodes. although any bacteria can cause lymphadenopathy. 10]. and possibly septations and posterior acoustic enhancement [13] (Fig. On CT. It is also important to differentiate between suppurative retropharyngeal lymph nodes and true retropharyngeal abscesses in children. suppurative nodes are hypoattenuating centrally. coccidiomycosis. whereas retropharyngeal abscesses often require surgical drainage [14.