Acute infectious cervical lymphadenitis—clinical features associated with the need for drainage

Introduction

Acute cervical lymphadenitis is commonly diagnosed in paediatric emergency departments (EDs) (1). It has a broad differential diagnosis encompassing infectious, malignant, and autoimmune aetiologies (2). Most cases of acute infectious cervical lymphadenitis (AICL) are self-limiting and viral in origin. However, bacterial invasion of lymphatic tissue can result in abscess formation, necessitating antibiotics and, in some cases, surgical drainage (1,3,4). Clinically differentiating suppurative and non-suppurative lymphadenitis can be challenging. Imaging studies such as computed tomography (CT) and ultrasonography (US) may identify drainable collections, however, CT use must be judicious due to the risks of radiation exposure, particularly in the paediatric head and neck region (5,6). Identifying clinical features that predict the need for drainage may facilitate timely intervention while reducing reliance on imaging (7).

The role of surgical drainage in managing AICL is debated. Recent studies have challenged traditional practices that reserve surgical drainage for refractory suppurative nodes, instead advocating for greater use of high-dose intravenous antibiotics (8,9). Additionally, there are no established guidelines or clinical trials to define which patients are candidates for CT imaging or surgery. With limited consensus on the role of surgical management and concerns regarding CT overuse, further investigation into the role of drainage for AICL is warranted (10). Notably, there is limited data from Australian tertiary referral centres assessing predictors of drainage in paediatric AICL.

This study primarily aimed to identify clinical features associated with the need for AICL drainage in children presenting to a tertiary paediatric centre in Western Australia. The secondary objectives were to describe the demographics and hospital management of patients with AICL. In addition, the role of CT in identifying suppuration and its association with drainage was assessed.

Methods

Patient selection

A single-year retrospective case-series at the sole tertiary paediatric centre in Perth, Western Australia was performed. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethics approval was obtained from the Child and Adolescent Health Service (CAHS) Clinical Governance Unit [Governance Evidence Knowledge Outcomes (GEKO) Quality Activity #52753). Individual consent for this retrospective analysis was waived. The hospital database was searched from 1^st January 2023 to 31^st December 2023 for all patients diagnosed with cervical chain lymphadenitis. Patients were then screened for eligibility against inclusion and exclusion criteria (shown in Table 1). This study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-38/rc).

Data collection and definitions

A medical chart review was performed for all eligible patients by two independent reviewers. Data was collected on patient demographics, including age, sex, Aboriginal and Torres Strait Islander (ATSI) status and whether patients were transferred from a rural hospital. Rurality was defined using the Modified Monash (MM) model, and all patients transferred from centres located in MM2–MM7 regions were classified as “rural transfers” (11). Vaccination status was assessed according to the Australian National Immunisation Program Schedule. Patients were classified as unvaccinated, partially vaccinated, or fully vaccinated in accordance with national standards. Data was collected on clinical features, including the presence of unilateral or bilateral lymphadenitis, fever (oral temperature ≥38.0 ℃), lethargy, loss of appetite, reduced neck range of motion and the presence of a fluctuant or non-fluctuant neck mass. Symptom onset was defined as the number of symptomatic days prior to presentation in the ED.

Blood tests taken on presentation to ED were reviewed and data was collected on haemoglobin (Hb) concentrations, C-reactive protein (CRP) level, and white cell count (WCC). Radiological reports written by trainees or fellows of the Royal Australian and New Zealand College of Radiologists were accessed to evaluate the frequency and results of US and CT imaging. Evidence of neck space suppuration on CT was defined as the presence of necrotic or liquefied cervical chain lymph nodes, and/or fluid collection with rim enhancement, and/or radiological suspicion of abscess formation. US features including the presence of lymphadenopathy, inflammation, node necrosis, the presence of a drainable collection and vascular complications were collected. Inpatient management was assessed by review of medical progress notes, including antibiotic usage and the need for drainage. Drainage was defined as fine needle aspiration (FNA) or surgical incision and drainage (I&D) under general or local anaesthetic.

Statistics

Descriptive statistics were used to summarise and present findings. Categorical data were presented with counts or proportions and continuous data were assessed for normality using the Shapiro-Wilk test. Parametric data were presented as mean ± standard deviation and analysed using the independent sample Student’s t-test. The Chi-squared test was used to compare nominal variables. Multivariate logistic regression was performed to assess the association between blood test results and the need for drainage. Statistical significance was defined as P<0.05, and analyses were performed using R commander (version 4.2.3).

Results

Patient demographics

Eighty-three patients (mean age 4.4±3.1 years) were included; 49.4% (n=41) were female; 13.3% (n=11) were of ATSI descent; and 21.7% (n=18) were rural transfers. One child was unvaccinated, the remaining cohort was fully up to date with the immunisation schedule. The median length of hospital stay was 3 days (range, 1–17 days), and seven patients (8.4%) required readmission. Patients were admitted under the care of general paediatric medicine (59.0%), otolaryngology (37.3%) or other surgical subspecialties (3.6%).

Clinical features

The commonest clinical features included the presence of an enlarged neck mass (96.4%); lethargy (64.4%); fevers (57.8%); loss of appetite (51.8%) and reduced neck range of motion (45.3%). Bilateral lymphadenitis was present in 15.7% (n=13) of patients and 26.8% (n=15) of children had a fluctuant neck mass on examination. The mean symptom onset was 5.3±6.8 days. There was no significant difference in mean symptom onset among rural and non-rural patients (8.7 vs. 4.3 days, P=0.16). On presentation, mean Hb, WCC and CRP levels were 112±15 g/L, (16±8)×10⁹ and 79±68 mg/L, respectively.

Imaging

US was performed at least once in 79.5% (n=66) of patients, and CT in 26.5% (n=22) of patients. All children undergoing US had evidence of cervical lymphadenopathy, and 45.5% (n=30) had evidence of surrounding soft tissue oedema and inflammation. Neck US demonstrated a hypoechoic focus without a drainable collection in 33.3% (n=22) of patients, a suppurative collection amenable to drainage in 21.2% (n=14) of patients, and necrotic lymph node change in 15.2% (n=10) of patients. Compression of the internal jugular vein (IJV) without thrombophlebitis was demonstrated on US in one patient.

Of the 54.5% (n=12) of patients with evidence of suppuration on CT, two-thirds underwent drainage. CT evidence of neck space suppuration was associated with the progression to drainage [P=0.043, odds ratio (OR): 8.0, 95% confidence interval (CI): 1.1–56.8]. CT revealed IJV compression in 15.7% (n=13) of patients, one case of IJV thrombophlebitis, and no instances of airway compromise.

Management

I&D was performed in 31.3% (n=26) of patients (shown in Table 2), primarily under general anaesthesia (92.3%). No patients underwent FNA. Drainage was more common in younger patients (2.8 vs. 5.2 years, P<0.001), those transferred from rural centres (38.5% vs. 14.0%, P=0.01, OR: 3.8, 95% CI: 1.3–11.7), patients presenting with fluctuant neck lumps (40.9% vs. 12.0%, P=0.006, OR: 4.5, 95% CI: 1.4–14.8), children with longer symptom duration (9 vs. 3 days, P=0.01) and patients with lower Hb concentrations (106 vs. 114 g/L, P=0.03). No significant association was observed between the need for surgical intervention and the time from presentation at a rural site until transfer to tertiary care (2.3 vs. 1.6 days, P=0.18). On multivariate analysis (shown in Table 3), lower Hb levels were associated with an increased likelihood for drainage (P=0.03, OR: 0.96, 95% CI: 0.93–0.99).

Intravenous antibiotics were given to 97.6% (n=81) of patients, one received oral antibiotics, and one patient who underwent immediate I&D on presentation received no antibiotics post-operatively. The mean length of inpatient antibiotic treatment was 3.8±2.4 days.

Discussion

The management of paediatric AICL is an area of ongoing research, however, there is a lack of data in Australian settings that evaluate predictors of patient outcomes. Our findings suggest that patient demographics, duration of symptoms, examination findings and Hb concentrations may predict the need for surgical drainage in children with AICL. These characteristics could aid clinicians in identifying children at a higher risk of abscess formation, thus influencing patient management. Findings from this study underscore the importance of thorough clinical evaluation and are intended to limit the overuse of CT imaging at our institute.

Several predictors of neck abscess drainage have been described in the literature. Data from this study support the findings of Sauer et al. which found fluctuance on presentation to the ED associated with the need for surgical drainage in acute neck infections (10). The relationship between age and the need for drainage in acute neck infections remains inconsistent. While some studies have reported drainage to be more likely in younger age groups (3,10,12,13), others have found no association between the two (7,14). Data from our study demonstrated that younger children were more likely to undergo I&D for AICL (mean age 2.8±2.5 vs. 5.2±3.1 years, P<0.01). At our institution, the higher likelihood of surgery may reflect a more aggressive approach to abscess treatment in younger patients. Additionally, authors have theorised that younger children with neck infections may have a more complicated clinical course, thus necessitating the need for surgical intervention (13,14).

Laboratory markers commonly regarded as indicators of infection severity, including WCC and CRP, had no association with the need for surgical intervention in several studies, including our own (7,10,13,14). To our knowledge, no other publications have demonstrated an association with lower Hb levels and drainage of paediatric AICL. In our cohort, lower Hb levels were observed in the surgical group compared with those managed conservatively (106±15 vs. 114±15 g/L, P=0.03). The clinical significance of this observation remains uncertain. Statistical differences in Hb may reflect the association of anaemia in children with acute bacterial infection, as previously documented (15,16). Longer symptom onset and a prolonged course of inflammation in the drainage group could also explain differences in Hb levels (15). Although our data did not assess iron deficiency, its role in impairing immunity and lowering Hb may have contributed to higher infection severity and the need for surgical intervention (17). Whether the risk of suppuration increases below a clinically meaningful threshold of Hb remains unclear and warrants further investigation.

Our cohort had similar demographics to those of other Australian publications on cervical lymphadenitis (18). Findings demonstrate that AICL commonly affects otherwise healthy children around the ages of three to five years. We report a higher proportion of ATSI patients compared to that of Howard-Jones et al. (13.3% vs. 2.7%) (18). Additionally, our drainage group had higher proportions of ATSI children compared to those not requiring surgery (23% vs. 9%), although this difference did not reach statistical significance (P=0.08). Over-representation of ATSI patients in our study reflects ongoing health disparities in Australia, especially with regards to skin and soft tissue infections in children (19). Of note, patients transferred from rural centres were more likely to undergo surgical drainage (38.5% vs. 14.0%, P=0.01), despite having no significant difference in mean symptom onset duration (8.7 vs. 4.3 days, P=0.16). However, our data could lack statistical power to identify variations in onset. Rural patients may have been transferred later in the infectious course once suppuration had already occurred, highlighting geographic disparities and delays to tertiary care access in Western Australia.

Given the absence of guidelines defining which patients should undergo CT imaging, variability exists amongst its use for neck abscess evaluation (10,20). Findings from this study emphasise the importance of a thorough clinical assessment among children with acute neck infections. Our results suggest certain clinical features reliably predict a higher risk of suppuration and surgical intervention. In select, non-emergent cases, these features may preclude the need for imaging. Nevertheless, CT remains a valuable resource, particularly when examination is inconclusive. Studies have supported its use in evaluating airway compromise, retropharyngeal collections, and local complications in paediatric neck infections (20). In our cohort, CT evidence of neck space suppuration was significantly associated with the need for surgery, demonstrating its utility in guiding management of AICL at our institute. Incorporating these considerations into decision-making frameworks and local guidelines may facilitate more targeted use of imaging.

There are some limitations to this study. Data was retrospectively collected from the sole tertiary paediatric centre in Western Australia, likely resulting in selection bias for more severe cases of AICL. Given our unique patient cohort, findings may not be generalisable to other Australian centres. The data collection process was limited by interpretation of medical progress notes and discharge summaries. Additionally, our findings are limited to a single year of data and are unable to describe temporal trends or seasonal variations in management or patient characteristics. Multivariate analysis of history and examination findings with the need for drainage was precluded by our small sample size.

Conclusions

At our Western Australian paediatric centre, predictors of AICL drainage included younger age, rural transfer, fluctuance on examination, prolonged symptom onset and low Hb concentrations. Early identification of these features may guide targeted use of imaging studies and aid clinicians in identifying children at high risk of abscess formation. Our data may be used to guide development of local, evidence-based guidelines and adds to a growing body of literature on acute paediatric neck infections.

Acknowledgments

This manuscript was presented as a verbal presentation at the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) Annual Scientific Meeting 2025.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-38/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-38/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-38/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-38/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics board of the Child and Adolescent Health Service (CAHS) Clinical Governance Unit [Governance Evidence Knowledge Outcomes (GEKO) Quality Activity #52753] and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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