eMedicine Specialties > Pediatrics: Surgery > General Surgery

Lymph Node Disorders: Treatment

Author: Kenneth William Gow, MD, FRCSC, MSc, BSc, FACS, FAAP, Associate Professor of Surgery and Pediatrics, Department of Surgery, University of Washington; Consulting Staff, Children's Hospital and Regional Medical Center and University of Washington Hospitals
Contributor Information and Disclosures

Updated: Jan 14, 2008

Treatment

Medical Therapy

The medical therapy chosen is based on the most likely etiology if a biopsy has not been performed.

  • In the case of bacterial infection, the most likely culprits include Staphylococcus and Streptococcus species; therefore, a beta-lactamase–resistant antibiotic is chosen. In patients with tuberculosis, rifampin and isoniazid are chosen.
  • In cases of nontuberculous mycobacterial adenitis, most still advocate surgical management. However, some patients with lymphadenopathy in anatomic locations of concern may benefit from drugs such as clarithromycin, azithromycin, rifampin, rifabutin, or ethambutol.12
  • Most patients with viral etiology for lymphadenopathy may be treated expectantly.
  • Patients with some of the more obscure diagnoses, such as Kawasaki disease, systemic lupus erythematosus (SLE), and Langerhans cells histiocytosis, may require immunosuppressants.

Surgical Therapy

Enlargement of a cervical lymph node to 1 cm in diameter is considered abnormal and should be considered for biopsy. Biopsy of the lymph node may involve one of two methods. The most commonly used method is the surgical biopsy in which either a portion of the node or the complete node is excised.

Preoperative Details

Before the procedure, the patient and family are instructed in the steps involved and the risks and benefits; a consent form is obtained. Before removal of the node, the pathologist should be informed about the biopsy so the appropriate tests may be immediately performed after the specimen is received. The procedure is performed either in the operating room suite under general anesthetic or in a minor procedure room under conscious sedation.

Intraoperative Details

An incision is made in the skin overlying the enlarged node, and the surrounding tissue is carefully dissected away from the node. Care must be taken to avoid surrounding nerves, especially in areas around the neck. To assist in the removal of the node, a suture may be placed through the center of the node to provide traction to pull the node into view (see Media files 4-5). The node must then be sent fresh to the pathologist for processing (see Media file 6). Usually one large node or a group of smaller nodes is sent to the pathologist for diagnosis.

Although lymph node biopsy via an open technique is the standard approach, with the advent of minimally invasive techniques, surgeons are applying these methods to lymph node biopsies in the thoracic cavity and the abdomen. Although ultrasonography or CT-guided percutaneous lymph node biopsy often does not supply sufficient tissue for the histopathologic diagnosis of a lymphoma, laparoscopic lymph node biopsy has the advantage of obtaining the entire lymph node and avoiding the invasiveness and possible complications of a laparotomy.13

Postoperative Details

Lymph node biopsies are usually performed on an outpatient basis. Before the patient is discharged from the hospital, he or she is usually treated in the day surgery area, where the wound is assessed for swelling and bleeding. The wound area should be kept dry for at least 2 days, and appropriate analgesia should be administered.

Follow-up

Patients and their families should be contacted with the results as soon as the report is finalized. If further therapy is necessary, patients should return to the hospital or be referred to the appropriate specialists for therapy.

Complications

The known complications of the biopsy itself arise from the injury of surrounding structures around the node, including the soft tissue, blood vessels, and nerves. Other potential complications in patients with malignancy include the spread of tumor cells in the area of the biopsy, production of a draining sinus in the case of atypical Mycobacterium infection (if the entire node is not excised), and the risks associated with general anesthetics, especially if the patient has an anterior mediastinal mass.

More on Lymph Node Disorders

Overview: Lymph Node Disorders
Workup: Lymph Node Disorders
Treatment: Lymph Node Disorders
Follow-up: Lymph Node Disorders
Multimedia: Lymph Node Disorders
References
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References

  1. Ghirardelli ML, Jemos V, Gobbi PG. Diagnostic approach to lymph node enlargement. Haematologica. Mar 1999;84(3):242-7. [Medline].

  2. Kelly CS, Kelly RE Jr. Lymphadenopathy in children. Pediatr Clin North Am. Aug 1998;45(4):875-88. [Medline].

  3. Segal GH, Perkins SL, Kjeldsberg CR. Benign lymphadenopathies in children and adolescents. Semin Diagn Pathol. Nov 1995;12(4):288-302. [Medline].

  4. Karadeniz C, Oguz A, Ezer U, et al. The etiology of peripheral lymphadenopathy in children. Pediatr Hematol Oncol. Nov-Dec 1999;16(6):525-31. [Medline].

  5. Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood peripheral lymphadenopathy. J Pediatr Surg. Oct 1999;34(10):1447-52. [Medline].

  6. Karmazyn B, Werner EA, Rejaie B, Applegate KE. Mesenteric lymph nodes in children: what is normal?. Pediatr Radiol. Aug 2005;35(8):774-7. [Medline].

  7. Depas G, De Barsy C, Jerusalem G, et al. 18F-FDG PET in children with lymphomas. Eur J Nucl Med Mol Imaging. Jan 2005;32(1):31-8. [Medline].

  8. van de Schoot L, Aronson DC, Behrendt H, Bras J. The role of fine-needle aspiration cytology in children with persistent or suspicious lymphadenopathy. J Pediatr Surg. Jan 2001;36(1):7-11. [Medline].

  9. Ponder TB, Smith D, Ramzy I. Lymphadenopathy in children and adolescents: role of fine-needle aspiration in management. Cancer Detect Prev. 2000;24(3):228-33. [Medline].

  10. Buchino JJ, Jones VF. Fine needle aspiration in the evaluation of children with lymphadenopathy. Arch Pediatr Adolesc Med. Dec 1994;148(12):1327-30. [Medline].

  11. Sklair-Levy M, Amir G, Spectre G, et al. Image-guided cutting-edge-needle biopsy of peripheral lymph nodes and superficial masses for the diagnosis of lymphoma. J Comput Assist Tomogr. May-Jun 2005;29(3):369-72. [Medline].

  12. Loeffler AM. Treatment options for nontuberculous mycobacterial adenitis in children. Pediatr Infect Dis J. Oct 2004;23(10):957-8. [Medline]. [Full Text].

  13. Casaccia M, Torelli P, Cavaliere D, et al. Laparoscopic lymph node biopsy in intra-abdominal lymphoma: high diagnostic accuracy achieved with a minimally invasive procedure. Surg Laparosc Endosc Percutan Tech. Jun 2007;17(3):175-8. [Medline].

  14. Bodenstein L, Altman RP. Cervical lymphadenitis in infants and children. Semin Pediatr Surg. Aug 1994;3(3):134-41. [Medline].

  15. Luu TM, Chevalier I, Gauthier M, et al. Acute adenitis in children: clinical course and factors predictive of surgical drainage. J Paediatr Child Health. May-Jun 2005;41(5-6):273-7. [Medline].

  16. Evans MJ, Smith NM, Thornton CM, et al. Atypical mycobacterial lymphadenitis in childhood--a clinicopathological study of 17 cases. J Clin Pathol. Dec 1998;51(12):925-7. [Medline].

  17. Pumberger W, Hallwirth U, Pawlowsky J, Pomberger G. Cervicofacial lymphadenitis due to atypical mycobacteria: a surgical disease. Pediatr Dermatol. Jan-Feb 2004;21(1):24-9. [Medline].

  18. Waagner DC. The clinical presentation of tuberculous disease in children. Pediatr Ann. Oct 1993;22(10):622-8. [Medline].

  19. Oguz A, Karadeniz C, Temel EA, Citak EC, Okur FV. Evaluation of peripheral lymphadenopathy in children. Pediatr Hematol Oncol. Oct-Nov 2006;23(7):549-61. [Medline].

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Further Reading

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Keywords

lymph node disorders, lymphadenopathy, lymphadenitis, enlarged lymph node, swollen lymph node, lymph node removal, jugular trunk, viral-associated lymphadenopathy, Epstein-Barr virus, EBV, cytomegalovirus, CMV, bacterial-associated lymphadenopathy, Staphylococcus aureus, group B streptococci, atypical mycobacterium, Mycobacterium scrofulaceum, Mycobacterium avium-intracellulare, Mycobacterium tuberculosis, scrofula, catscratch disease, lymphoma, Hodgkin disease, HD, non-Hodgkin lymphoma NHL, leukemia, metastatic solid tumors, Kawasaki disease, mucocutaneous lymph node syndrome, sarcoidosis, Kikuchi lymphadenitis, histiocytic necrotizing lymphadenitis, systemic lupus erythematous, SLE, Langerhans cell histiocytosis, histiocytosis X, rhabdomyosarcoma, neuroblastoma

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Contributor Information and Disclosures

Author

Kenneth William Gow, MD, FRCSC, MSc, BSc, FACS, FAAP, Associate Professor of Surgery and Pediatrics, Department of Surgery, University of Washington; Consulting Staff, Children's Hospital and Regional Medical Center and University of Washington Hospitals
Kenneth William Gow, MD, FRCSC, MSc, BSc, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Pediatric Surgical Association, American Society of Clinical Oncology, Association for Academic Surgery, Canadian Association of Pediatric Surgeons, Children's Oncology Group, College of Physicians and Surgeons of British Columbia, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Aviva L Katz, MD, Assistant Professor of Surgery, University of Pittsburgh School of Medicine; Consulting Staff, Division of General and Thoracic Surgery, Children's Hospital of Pittsburgh
Aviva L Katz, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association of Women Surgeons, Physicians for Social Responsibility, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Pediatric Oncology Group, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD, Professor of Surgery, Feinberg School of Medicine, Northwestern University; Interim Head, Division of Pediatric Surgery, Department of Surgery, Children's Memorial Hospital of Chicago
Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association
Disclosure: Nothing to disclose.

 
 
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