Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Cervical Adenitis, Acute
CERVICAL ADENITIS, ACUTE
An acute infection of one or more cervical nodes. In children, bilateral cervical adenitis is generally associated with upper respiratory infections or acute streptococcal pharyngitis. A reactive hyperplasia in response to an infection of the ear, nose, mouth, or throat with pharyngitis or tonsillitis is the most common primary infection. Cervical adenitis is characterized by a 3-cm (or more) enlargement with tenderness and erythema of involved node(s). This protocol includes treatment for an acutely infected cervical node(s).
I. Etiology
A. Group A beta-hemolytic streptococci: 75% to 80% of cases
B. Staphylococci: Approximately 10% of cases
C. Viruses: Rubella, measles, herpes simplex, Epstein-Barr, and adenoviruses account for remainder of cases in a non-immunocompromised child.
II. Incidence
A. Seen most frequently in preschool children
B. Seventy percent to 80% of cases are seen in children 1 to 4 years of age.
III. Subjective data
A. Painful swelling of the neck; acute onset in 75% of cases
B. Fever: Variable; may be high
C. Complaint of malaise, anorexia, or vomiting is common.
D. Pertinent subjective data to obtain
1. History of upper respiratory infection, sore throat
2. History of toothache, impetigo of face, or severe acne
3. History of exposure to streptococcal pharyngitis
4. History of exposure to animals or history of cat scratch
5. History of exposure to tuberculosis
6. Duration of swelling, temperature, and concurrent or preceding illness
IV. Objective data
A. Fever
B. Cervical nodes: Generally unilateral
1. Enlarged: Measure size of node; usually 2.5 to 6 cm.
2. Tender
3. Erythematous if infection is present for several days without treatment
4. Firm, but may become fluctuant
C. Examine the following:
1. Ears for infection of canal or tympanic membrane
2. Nose for rhinitis, exudate
3. Throat for erythema, exudate, petechiae
4. Face and scalp for impetigo or infected acne
5. Mouth for gingivostomatitis
6. Teeth: Examine and percuss each tooth for evidence of infection.
7. For lymphadenopathy in other areas
8. Abdomen for hepatosplenomegaly
D. Laboratory tests
1. Elevated white count: Up to 20,000/mm3
2. Throat culture for streptococcal infection
3. Heterophil antibody or Monospot test indicated with posterior cervical adenitis or generalized adenopathy
V. Assessment
A. Consider streptococcal infection with history of acute onset, pain, elevated temperature, history of pharyngitis, petechiae of soft palate, and vomiting.
B. Consider staphylococcal or viral infection with a sustained high fever and no response to penicillin therapy.
C. Diagnosis is made by the history, clinical findings, and appropriate laboratory tests.
D. Differential diagnosis
1. Infectious mononucleosis: Posterior cervical and generalized adenopathy; heterophil or Monospot positive
2. Chronic adenitis: By history and presence of smaller, less tender node
3. Cat-scratch fever: By history and evidence of trauma; generally not acute onset
4. Tuberculosis: By Mantoux testing
5. Leukemia: Firm, nontender, more generalized involvement of glands characteristically in posterior triangle or supraclavicular areas; hepatosplenomegaly; peripheral blood changes
6. Mumps: Location of swelling (crosses the angle of the jaw) and no clear, palpable border; inflammation of Stensen’s duct; leukopenia
7. Thyroglossal duct cyst: Midline location, movement with protrusion of tongue; may become secondarily infected
VI. Plan
A. Throat culture
B. Tuberculin test
C. Antibiotic therapy: Empirical therapy directed against Staphylococcus aureus and group A streptococcus. Treat for a minimum of 10 days.
1. Augmentin: 45 mg/kg/d in two divided doses or
2. Cefprozil: 15 mg/kg every 12 hours or
3. Cephalexin: 25–50 mg/kg/d in 2 divided doses; over 40 kg, 250 mg qid or 500 mg q 12 hours
or, if community-acquired methicillin-resistant Staphylococcus aureus (MRSA) prevalent in community,
4. Clindamycin: 16–20 mg/kg/d
D. Antipyretics/analgesics
1. Tylenol: 10 to 15 mg/kg every 4 hours
2. Ibuprofen: 5 to 10 mg/kg every 6 to 8 hours if streptococcal infection has been ruled out
E. Local measures: Warm compresses to enlarged node for 10 minutes 5 to 6 times a day for symptomatic relief
VII. Education
A. Call back immediately:
1. If child
a. Seems worse
b. Has difficulty swallowing
c. Has difficulty breathing
2. If node
a. Enlarges
b. Becomes inflamed
c. Drains
d. Becomes fluctuant (“pointing” or looking like a pimple)
B. Encourage liquids; do not worry about solid food if child is anorexic.
C. Compresses: Use wet face cloth or other soft cloth with water that feels comfortably warm to wrist; reapply as soon as it cools. Will require the full attention of parent for a full 10-minute period. Consider using a disposable diaper for warm compresses; will retain heat for longer periods.
D. Give medication for 10 full days.
E. Tylenol or ibuprofen is of value only for the relief of discomfort or temperature control. Use only for these indications.
F. Node may not completely resolve for several weeks.
VIII. Follow-up
A. Telephone contact within 24 hours
B. Return to office if no improvement within 48 hours for aspiration to determine causative organism.
C. Return immediately if node enlarges or if child seems toxic, dysphagic, or dyspneic.
IX. Complications
A. Suppuration of node
B. Rarely, poststreptococcal acute glomerulonephritis or rheumatic fever
X. Consultation/referral
A. Child under 2 years of age
B. No improvement after 48 hours, or worsening of symptoms at any time
C. Fluctuant node: May require incision and drainage
D. Refer to dentist if dental abscess suspected.
E. Child toxic, dehydrated, dysphagic, or dyspneic
F. Significant enlargement beyond 4 to 8 weeks for excisional biopsy
G. Child with positive Mantoux (more than 15 mm induration)
H. Child with hepatomegaly or splenomegaly.