Philadelphia, PA: Elsevier; 2019. Also, includes swollen lymph nodes in the armpit or groin, It's larger than the same node on the other side of the body. Your child's healthcare provider will perform more diagnostic tests in these circumstances: The treatment for lymphadenopathy depends on the cause. If your child has this condition, lymph nodes may become big, painful, and tender. Symptoms such as pain, feeling of lumps in the throat, and redness may indicate swollen lymph nodes. The diagnostic yield of the biopsy can be maximized by obtaining an excisional biopsy of the largest and most abnormal node (which is not necessarily the most accessible node). Serious and less common causes of lymphadenopathy in children include: These more severe cases of lymphadenopathy will not resolve until the cause is treated. Lymphadenopathy may be the only clinical finding or one of several nonspecific findings, and the discovery of swollen lymph nodes will often raise the specter of serious illness such as lymphoma, acquired immunodeficiency syndrome or metastatic cancer. If your child has a sore throat, fever, and the lymph nodes continue to grow or do not go away for weeks, take your child to a doctor. Swollen lymph nodes are sometimes referred to as swollen glands. Rarely, lymph nodes can enlarge due to cancer. Key Pointers. Patients should be cautioned to remain alert for the reappearance of the nodes because lymphomatous nodes have been known to temporarily regress. The physician should consider four key points when compiling a patient's history.1 First, are there localizing symptoms or signs to suggest infection or neoplasm in a specific site? Lumps forming under the jaw, armpits, groin, chest, back of the neck and stomach. Data Sources: A PubMed search was completed in Clinical Queries using the key term pediatric neck mass. In other cases, the diagnosis is less clear. Got the imaging and the radiologist report reveal not 1 not 2 not 3 but 4 supraclavicular nodes the biggest just under a centimeter. Results of a complete blood count with differential may be abnormal with infectious lymphadenitis. After the infection is gone, the nodes slowly return to normal size. However, lymphadenopathy develops whenever the lymphocytes proliferate or when a disease such as cancer or an immune disease affects the lymph nodes. The lymph nodes are filled with white blood cells. Am Fam Physician. 21st ed. Laboratory studies may be indicated if there is concern about a systemic disease or to confirm a diagnosis suspected from the history and physical examination. The head and neck region contains over 300 lymph nodes, of which include the supraclavicular lymph nodes. I'm waiting for the ENT appointment for my 8 year old daughter who has a large left supraclavicular swelling. tonsillitis. JEREMY D. MEIER, MD, AND JOHANNES FREDRIK GRIMMER, MD. Note: Fevers less than 102 F (39 C) are important for fighting infections. Although rarely present, a paraumbilical (Sister Joseph's) node may be a sign of an abdominal or pelvic neoplasm.12. There are over 600 lymph nodes located throughout the body, ranging from near the surface of the skin to deep in the abdominal, pelvic, and chest cavities. In general, lymph nodes greater than 1 cm in diameter are considered to be abnormal. Tooth Decay or Abscess. Nelson Textbook of Pediatrics. The primary care physician ultimately must determine whether further invasive workup or treatment is necessary, or if watchful waiting is appropriate. For all fevers: Keep your child well hydrated. These lymph nodes can be swollen in around half of all children between the ages of 3 and 5 who are perfectly healthy. Som PM, Curtin HD, Mancuso AA. Swollen lymph nodes are a sign that your immune system is fighting off infection or illness. Associated symptoms, such as persistent or unexplained fever, unintentional weight loss, fatigue, and night sweats can be signs of a serious condition. . When lymph nodes become infected, it's usually because an infection started somewhere else in your body. Nondiscrimination and Interpreters Notice. Pain/Tenderness. Such assertions overestimate the probability of malignancy in patients with lymphadenopathy because they exclude the 97 percent of patients with lymphadenopathy who do not undergo a biopsy. Antibiotic therapy for suspected bacterial lymphadenitis should target Staphylococcus aureus and group A streptococcus. Another choice is an ibuprofen product (such as Advil). Common congenital developmental masses in the neck include thyroglossal duct cysts, branchial cleft cysts, dermoid cysts, vascular malformations, and hemangiomas. Read our. Malignancy is more likely with an abnormally shaped lymph node compared with a lymph node that retains its normal architecture. Male patient have suffered more (60%) from malignant disease than that of female patient (40%). An enlarged node can be the first sign of gastric cancerand is often called Virchow's node, because the association between left supraclavicular lymphadenopathy and gastric cancer was first described by the German pathologist Rudolf Virchow (1821-1902). The anatomic location of localized adenopathy will sometimes be helpful in narrowing the differential diagnosis. Our understanding of the epidemiology of lymphadenopathy in family practice is limited by the scarcity of relevant literature. 2013;60(4):923-36. doi:10.1016/j.pcl.2013.04.005. This is an important aspect of the examination, as a study of primary care physicians found that generalized lymphadenopathy was identified in only 17 percent of the patients in whom it was present.9 Careful palpation of the submandibular, anterior and posterior cervical, supraclavicular, axillary and inguinal nodes can be accomplished in a short time and will identify patients with generalized lymphadenopathy. April 12, 2023 . Depending on the clinical history and physical examination findings, your child might have diagnostic tests to determine the cause of their lymphadenopathy. See dental infections guideline. Lymph nodes < 1cm are normal in children aged < 12 years. If your daughter is otherwise well, with no major symptoms apart from this swelling I would take some comfortfrom my experience and see that it does happen and in all fairness not one of the doctors apart from my GP were too worried, they said it's pretty common after infections or something that's happened way before for a childto have node that is stubborn and won't settle down, thatin some cases may never fully reduce and be sortof scarred without any effect other than it's being a little larger than normal. They may double in size. Search dates: August 25, 2011, and December 2, 2013. Node gets 1 inch (2.5 cm) or larger in size. Patients with localized lymphadenopathy and a worrisome clinical picture or patients with generalized lymphadenopathy will need further diagnostic evaluation that often includes biopsy (see the unexplained branch of the algorithm). Swollen supraclavicular lymph nodes may indicate an immune system reaction to infection or metastatic cancer. These occur due to the numerous respiratory infections that take place during childhood. It's a difficult and scary experience, not one I'll forget. They may also become tender. To help with the pain, give an acetaminophen product (such as Tylenol). If possible, the physician should not select inguinal and axillary nodes for biopsy, since they frequently show only reactive hyperplasia. We waited a few weeks and got that appointment, we went in the she was scanned quickly, they could give me results there and then but did say that the radiologist thought it look normal. In primary care settings, patients 40 years of age and older with unexplained lymphadenopathy have about a 4 percent risk of cancer versus a 0.4 percent risk in patients younger than age 40.4. This low prevalence of malignancy is supported by the results of two case series2,3 from family practice departments in the United States, in which none of 80 patients and three of 238 patients with unexplained lymphadenopathy were diagnosed with malignancy. All Rights Reserved. {"url":"/signup-modal-props.json?lang=us"}, Pacifici S, Weerakkody Y, Bell D, et al. Lymph fluid includes white blood cells and proteins to help fight infections. This is the most common cause of swelling in the lymph nodes in the neck. This content is owned by the AAFP. Constitutional type B symptoms such as fever, malaise, weight loss, and night sweats suggest a possible malignancy. Supraclavicular masses: results of a series of 309 cases biopsied by fine needle aspiration. This is about the size of a quarter. Certain lymph nodes, especially the supraclavicular, epitrochlear, and popliteal glands, are rarely swollen, even in children. Sci Rep. 2021 Jan 19;11(1):1762. doi:10.1038/s41598-021-81339-9. Palpation of the lymph nodes provides information about the possible presence of a malignant or inflammatory process and the localization or generalization of that process. Lymph nodes in the neck are about half an inch to one-inch in size and appear the same on both sides. This is when the body's immune system overreacts to a harmless substance, such as pollen or pet dander. This can help with lymphadenopathy too. Thank you, {{form.email}}, for signing up. We took her to the pharmacy initially and they thought it might be a cyst due to the location and size. Adequate knowledge about lymph nodes can help you seek treatment whenever necessary. The enlarged nodes are often seen or felt as lumps under the skin and are not usually painful. Gray H, Standring S. Gray's anatomy, the anatomical basis of clinical practice. The letter never came in within a week so I called snd the specialist said the letter was on its way and that it was good news , I still didn't believe it but a few days later wegot the letter saying that they believe this to be a reactive node and it will reduce over the next few months. Looking backI think most of the worry for me came from letting my mindrace ahead of what was actually happening at the time. It is the final common pathway of the lymphatic system as it joins the central venous system. Lymphadenopathy might not be as noticeable as the other effects of an allergy. Magnetic resonance imaging is the imaging study of choice when a vascular malformation is suspected. When they are, it's usually related to lymphoma or leukemia, which both involve the lymphatic system. If Epstein-Barr virus antibodies are absent, other causes of the mononucleosis syndrome should be considered. Children can have swollen lymph nodes, referred to as lymphadenopathy, for a variety of reasons. Abnormalities on chest X-ray are associated with serious causes but the diagnostic utility of routine chest X-ray is unknown. While swollen lymph nodes in children are common and often go away on their own, they could put unnecessary stress on parents and children both. If your swollen lymph nodes are a result of certain conditions, such as lupus or rheumatoid arthritis, treatment is directed at the underlying condition. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Lymph nodes are an important part of a body that help fight against infections and illnesses. Because generalized lymphadenopathy almost always indicates that a significant systemic disease is present, the clinician should consider the diseases listed in Table 4 and proceed with specific testing as indicated. However, you should show your child's pediatrician so they can decide if further testing is needed. There are about 600 lymph nodes in the body, some of which are mentioned below: Lymphadenopathy is when the lymph nodes begin to swell as the body fights off infections. In the case of tooth decay, only one node becomes swollen, and it is located under the jaw. Enlarged lymph nodes in different parts of the body may be caused due to different infections. scalp infection. However, swelling in the lymph nodes can raise concerns, especially if you notice them in your little ones. The cervical, axillary, and inguinal nodes are the ones most readily felt during a physical exam. Conversely, the presence of abnormally enlarged lymph nodes . your doctor. Little evidence exists to definitively determine the best approach for the child with a neck mass. Reference article, Radiopaedia.org (Accessed on 18 Apr 2023) https://doi.org/10.53347/rID-15432, Case 1: right supraclavicular nodal metastases, Case 2: right supraclavicular necrotic metastases, View Stefano Pacifici's current disclosures, View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, superior longitudinal muscle of the tongue, inferior longitudinal muscle of the tongue, levator labii superioris alaeque nasalis muscle, superficial layer of the deep cervical fascia, ostiomeatal narrowing due to variant anatomy. Sometimes the body is not able to effectively fight an infection, or the immune system is impaired. An asymptomatic lesion that appears to be an enlarged lymph node creates a difficult dilemma for the primary care physician. Thank you so much for replying I am trying my best to keep it together for my wife and daughter and not letting my other kids notice I am worried about something. Application of a prediction rule to select which patients presenting with lymphadenopathy should undergo a lymph node biopsy. In the majority of children, lymphadenopathy is usually reactive. The doctor has now given us a 2-weekreferral and never gave much more info ( I am calling her again tomorrow). Lymph nodes are present throughout the body. if you read my reply to Carrie below you will see I've detailed the whole process. should not be construed as a substitute for advice from a medical professional or health care provider. Reason: This may keep them from shrinking back to normal size. Sometimeslow-gradeinfections can take place during shaving of the legs. The approach to the child with peripheral lymphadenopathy . Severe infections and cancer can cause fluctuating, yet persistent lymphadenopathy. The supraclavicular lymph nodes (often shortened to the supraclavicular nodes) are a paired group of lymph nodes located on each side in the hollow superior to the clavicle, close to the sternoclavicular joint. Don't look for lymph nodes, because you can always find some. Ultrasonography should be performed when a thyroglossal duct cyst is suspected to determine the presence of a normal thyroid gland. A swollen node with a bacterial throat infection is usually just on one side. When a lymph node rapidly increases in size, its capsule stretches and causes pain. Ultrasonography may be helpful in documenting the extent of lymph node involvement and any changes in the lymph nodes. Viral infections are the most common cause of lymphadenopathy in children. supraclavicular lymph nodes swollen after covid shot. As swollen lymph nodes denote infections, your doctor will do a thorough examination to see which lymph nodes are swollen, how big they are, if they are red and tender, or rough and fixed in order to figure out the underlying cause and provide appropriate treatment. Laboratory tests that may be useful in confirming the cause of lymphadenopathy are listed in Table 4. Can an Armpit Lump Be a Symptom of Breast Cancer? 2016;94(11):896-903. We waited for the scan a few weeks and that was a grim wait, but we went and they couldn't give use results right away,but I asked their opinion and again the radiologist said it looked ok to him but he needed to wait for the the main consultant to look and write us back. This reaction is normal. There are various classifications of lymphadenopathy, but a simple and clinically useful system is to classify lymphadenopathy as generalized if lymph nodes are enlarged in two or more noncontiguous areas or localized if only one area is involved. However, cervical lymph nodes up to 1 cm in size are normal in children younger than 12 years,10 with the exception of the jugulodigastric lymph node, which can be as large as 1.5 cm. Vincent Iannelli, MD, is a board-certified pediatrician and fellow of the American Academy of Pediatrics. When biopsy is deferred, the physician should explain to the patient the rationale for waiting. When I seen the first ENT privately, he almost immediately wrote it off, because she never had unexplained weight loss, excessive night sweats, etc. Mononucleosis is most commonly due to Epstein-Barr virus infection. This article reviews the evaluation of patients with a central clinical finding of lymphadenopathy, emphasizing the identification of patients with serious illness. This is usually caused by infections in the blood, such as infectious mono, or widespread rashes such as eczema. You can use ice and anti-inflammatory medication as directed by your healthcare provider. Many young children temporarily develop swollen glands when they have an infection. Empiric antibiotic therapy with observation for four weeks is acceptable for children with presumed reactive lymphadenopathy. 2000;174 (3): 837-44. Consider arranging an urgent chest X-ray (within 2 weeks) for people aged 40 years and over with supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, to exclude a diagnosis of lung cancer (or tuberculosis or sarcoidosis), and arrange onward management as appropriate. This causes a swollen, tender node under the jawbone. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho. A complete blood count with differential is recommended in patients with a history and physical examination suggestive of infection or malignancy; however, good evidence to support the value of routine complete blood count is lacking. Troisier sign is the name given to left-sided supraclavicular lymphadenopathy, highly suggestive of abdominal malignancy. You can check with your child's pediatrician to see if using a pain reliever or non-steroidal anti-inflammatory for relief of symptoms would be helpful as well. So what I'd say is focus on the positive outcome, stay away from Google as it only made me worse, reading medical journals etc. Doctors can treat swollen supraclavicular lymph nodes by addressing the. To adequately address their fears, the physician should ask the patient about his or her concerns and respond to questions about specific diagnoses. Most malignant neck masses in children are asymptomatic and are not painful.4 However, acute infection in a necrotic, malignant lymph node can also occur. A more recent article on lymphadenopathy is available, HIV, syphilis, herpes simplex virus, cytomegalovirus, hepatitis B infection, Fishermen, fishmongers, slaughterhouse workers, Arizona, southern California, New Mexico, western Texas, Southeast Asia, India, northern Australia, African trypanosomiasis (sleeping sickness), American trypanosomiasis (Chagas' disease), East Africa, Mediterranean, China, Latin America, Mexico, Peru, Chile, India, Pakistan, Egypt, Indonesia, Tongue, submaxillary gland, lips and mouth, conjunctivae, Infections of head, neck, sinuses, ears, eyes, scalp, pharynx, Lower lip, floor of mouth, tip of tongue, skin of cheek, Mononucleosis syndromes, Epstein-Barr virus, cytomegalovirus, toxoplasmosiss, Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes, Tuberculosis, lymphoma, head and neck malignancy, Eyelids and conjunctivae, temporal region, pinna, Lung, retroperitoneal or gastrointestinal cancer, Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection, Infections, cat-scratch disease, lymphoma, breast cancer, silicone implants, brucellosis, melanoma, Infections, lymphoma, sarcoidosis, tularemia, secondary syphilis, Penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal, Infections of the leg or foot, STDs (e.g., herpes simplex virus, gonococcal infection, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum), lymphoma, pelvic malignancy, bubonic plague, Fatigue, malaise, fever, atypical lymphocytosis, Often mild symptoms; patients may have hepatitis, IgM CMV antibody, viral culture of urine or blood, Fever in one third of patients; cervical or axillary nodes, Usually clinical criteria; biopsy if necessary, Pharyngitis due to group A streptococcus, gonococcus, Fever, pharyngeal exudates, cervical nodes, Arthritis, rash, serositis, renal, neurologic, hematologic disorders, Clinical criteria, antinuclear antibodies, complement levels, Fever, night sweats, weight loss in 20 to 30% of patients, Fever, malaise, arthralgia, urticaria; exposure to antisera or medications, Fever, conjunctivitis, rash, mucous membrane lesions, Febrile, acutely ill with cluster of tender nodes, Fever, chills, headache, abdominal complaints, Clinical criteria, antinuclear antibody, rheumatoid factor. * To protect your identity do not use your full name. In the supraclavicular lymph nodes most often fall pathological cells from the organs located in the abdominal or thoracic cavity, because of what previously not palpable glands become palpable. The presence or absence of tenderness does not reliably differentiate benign from malignant nodes.4. However, in one series10 of 213 adults with unexplained lymphadenopathy, no patient with a lymph node smaller than 1 cm2 (1 cm 1 cm) had cancer, while cancer was present in 8 percent of those with nodes from 1 cm2 to 2.25 cm2 (1 cm 1 cm to 1.5 cm 1.5 cm) in size, and in 38 percent of those with nodes larger than 2.25 cm2 (1.5 cm 1.5 cm). Thyroglossal duct cysts are often located over the hyoid bone and elevate with tongue protrusion or swallowing, whereas dermoid cysts typically move with the overlying skin.6 Malignant anterior neck masses are usually caused by thyroid cancer. Supraclavicular lymph nodes or those in the posterior triangle (behind or lateral to the sternocleidomastoid muscle) have a higher incidence of malignancy than lymph nodes in the anterior triangle (anterior or medial to the sternocleidomastoid muscle).2 Generalized or multiple anatomic sites of lymphadenopathy increase the chance of malignancy.7,8. Suppurant nodes may be fluctuant. Copyright 2023 American Academy of Family Physicians. After completing this article, readers should be able to: Examining the lymph nodes is an important aspect of the general physical examination of both well and ill children and adolescents. What Are Lymph Nodes and Where Are They Found Over the Body? This syndrome involves the combination of conjunctivitis and associated preauricular nodes. This occurs because lymphadenopathy is typically a response to a condition in the body, and the lymph nodes that become the most swollen are generally located near the primary condition. Certain lymph nodes, especially the supraclavicular, epitrochlear, and popliteal glands, are rarely swollen, even in children. Supraclavicular lymph nodes or those in the posterior triangle (behind or lateral to the sternocleidomastoid muscle) have a higher incidence of malignancy than lymph nodes in the anterior. Workup for a neck mass may include a complete blood count; purified protein derivative test for tuberculosis; and measurement of titers for Epstein-Barr virus, cat-scratch disease, cytomegalovirus, human immunodeficiency virus, and toxoplasmosis if the history raises suspicion for any of these conditions. It is adjacent to the junction where incoming lymph is introduced back into the venous circulation through the left subclavian vein. common cold. Thank you so much for your post. Softer nodes are the result of infections or inflammatory conditions. Parents often worry when their child has swollen glands or lymph nodes. Doctors call it lymphadenopathy. The supraclavicular lymph nodes on the left side are called Virchow's nodes. If the swollen nodes are with a viral illness, your child can return to school. ADVERTISEMENT: Supporters see fewer/no ads. Nodes are generally considered to be normal if they are up to 1 cm in diameter; however, some authors suggest that epitrochlear nodes larger than 0.5 cm or inguinal nodes larger than 1.5 cm should be considered abnormal.7,8 Little information exists to suggest that a specific diagnosis can be based on node size. I know what it's like with our babies .. when my lad was young he got diagnosed type one diabetic and his life changed from that day .. but you know, we have to hold it together for our babies .. that's what we do .. panic inside but look calm outside for them and fingers crossed for a good result try to keep busy as poss there's far more have these tests and it turns out something else Chrissie x. It was swollen for months and never really started to reduce noticeably for a good while, but it never got larger in that time also. The study showed that mean age of the patient of supraclavicular lymphadenopathy that finally diagnosed as malignant was 49.7 years and that of non malignant was 33.7 years. While anyone with a suspicious lump should see a doctor, there are many simple causes of a lump in this area, including swollen lymph nodes from . Confirmatory testing should be performed in order to correctly identify the patient's illness (see the suggestive branch of the algorithm). What they mean and when to see a healthcare provider. I cryed for weeks untill he told me he could cope with that but not me crying all the time .. so I turned it around and learned everything I could to keep him healthy .. though I nearly lost him twice to hypos Once I took it on, we all coped better it's like my cancer now it's looking it square in the eye, and getting ready to fight it all the way .. then my lad panicked over me till we got that in control too .. you'll always find someone here to chat too .. we know how scary the weight is so if you need to yell or vent or just chat .. this is the place Chrissie x, my son 9 years old is going through the same. Increased size of one or more lymph nodes. Signs and symptoms of lymphoma may include: Painless swelling of lymph nodes in your neck, armpits or groin Persistent fatigue Fever Night sweats Shortness of breath Unexplained weight loss Itchy skin When to see a doctor Make an appointment with your doctor if you have any persistent signs or symptoms that worry you. Lymphadenopathy in children Lymphadenopathy (or 'swollen glands') is very common in children. I would be happy to receive news and updates from Cancer Chat, NICE suspected cancer referral guidelines, Cancer Research UK for Children & Young People, Child with swollen Supraclavicular Lymph node, My intuition is telling i have breast cancer. If you have found a pea-sized or bean-sized node, this is normal. Large lymph nodes and supraclavicular nodes are potential indicators of serious pathology. Supraclavicular lymphadenopathy has the highest risk of malignancy, estimated as 90 percent in patients older than 40 years and 25 percent in those younger than age 40.4 Having the patient perform a Valsalva's maneuver during palpation of the supraclavicular fossae increases the chance of detecting a node. Request an appointment Over a week ago my 8 year old daughternoticed a lump on the left hand side ofher neck. Swollen lymph nodes are rarely caused by cancer. Non-Hodgkin lymphoma may grow in lymph nodes under the skin (on the sides of the neck, in the underarm area, above the collar bone, or in the groin area). They are tiny filters that are responsible for catching the virus and bacteriathat infect the body, after which the white blood cells come in and destroy them. For example, it may be hard to swallow if your paratracheal lymph nodes are swollen. By and large, children have weak immune systems and are prone to infections. Gaddey HL, Riegel AM. Many patients worry about the cause of their abnormal lymph nodes. The lymph nodes are part of the body's lymphatic system, which includes lymph fluid, lymph vessels, the tonsils, the thymus gland, and the spleen. Lymphadenopathy can be especially prominent in the nodes closest to the site of infection. Some malignancies such as lung, head and neck, breast, esophageal, gastric, pancreatic, gynecologic, and prostate cancers have a propensity to metastasize to supraclavicular lymph nodes. Copyright 1998 by the American Academy of Family Physicians. It is normal to notice small lymph nodes in children; however, if they get bigger, it is a sign of an infection. This is often performed with a fine needle aspiration (FNA) in which a hollow-core needle is inserted through the skin into the lymph node. Patients with a benign clinical history, an unremarkable physical examination and no constitutional symptoms should be reexamined in three to four weeks to see if the lymph nodes have regressed or disappeared. Virchow lectured and practised at the Charit Medical School of the Humboldt . Enlargement of the lymph nodes that persists for at least three months in at least two extrainguinal sites is defined as persistent generalized lymphadenopathy and is common in patients in the early stages of HIV infection. Stony-hard nodes are typically a sign of cancer, usually metastatic. It is the final common pathway of the lymphatic system as it joins the central venous system. Children have larger lymph nodes than adults, and they can frequently become swollen because children are exposed to new infections that require their immune systems to make immune cells and antibodies. If malignancy is suspected (accompanying type B symptoms; hard, firm, or rubbery consistency; fixed mass; supraclavicular mass; lymph node larger than 2 cm in diameter; persistent enlargement for more than two weeks; no decrease in size after four to six weeks; absence of inflammation; ulceration; failure to respond to antibiotic therapy; or a thyroid mass), the patient should be referred to a head and neck surgeon for urgent evaluation and possible biopsy. [] In children with inguinal adenopathy or abdominal complaints, ultrasonography or CT scanning of the abdomen (or both) may be indicated.