FLEX February 2024

396

R. Locke et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 393–401

Table 1 ( Continued )

Author

Title

Level of evidence

Type

Number

Schaller R

The usefulness of percutaneous fine-needle aspiration biopsy in infants and children 5

Mechanism

32

52

Cohen M Eisenhut C

The use of fine needle aspiration biopsy in children

3 3

Non consecutive

84

53 54

Fine needle biopsy of pediatric lesions: a three-year study in an outpatient biopsy clinic Spectrum of Head and Neck Lesions Diagnosed by Fine-Needle Aspiration Cytology in the Pediatric Population Clinicopathologic profile of significant cervical lymphadenopathy in children aged 1–12 years When to perform biopsies of enlarged peripheral lymph nodes in young patients 3 Fine needle aspiration biopsy: role in diagnosis of paediatric head and neck masses 3 4 Pediatric fine needle aspiration biopsy 4 3

Inconsistent

288

Rapkiewicz A

Case control

85

55

Silverman J

Poor ref standard

123 336

56 57

Annam

Inconsistent ref standard

Slap G

Non consecutive

123

58

Anne S

Case control

71

59

used to decide the need for excision biopsy are not stated, but clearly the children in these studies represent a selected subset of children presenting with neck lumps. The proportion of patients with cervical lymphadenopathy due to malignant disease may vary according to specialty (otolaryn gology, general surgery, family practice, haematology–oncology) and local referral pattern. In 5 studies [2,4,19,21–23], the proportion of cervical lymph nodes with malignant disease (mostly Hodgkin’s disease or non-Hodgkin’s lymphoma) is between 13% and 33%. One prospective study also contained children presenting with acute lymphadenitis [24]. The other, Karadeniz et al. is of a series of 382 children presenting to a paediatric haematologyoncology department in Turkey. The diagnosis was based on clinical findings, blood count, serology, chest X-ray and tuberculin testing, with excision biopsy for selected cases. In this series, 27% had a malignancy (the majority being lymphoma, or leukaemia) and the remainder were inflammatory (of which two thirds were reactive hyperplasia) [20]. This study however includes lymphadenopathy in the groin and axillae as well as the neck, with no indication of what proportion were cervical. The study also does not describe the reasons for referral and if malignancy was suspected. A recent review from an institution in the United Kingdom has suggested a 15% rate of malignancy in bioposies. This study however encompasses multiple neck pathologies rather than purely cervical lymphadenopathy; it also speculates on changes in threshold for performing biopsies [24]. The referral pattern to a haematological oncology clinic is likely to differ to that of an ENT clinic therefore it would be no surprise if a high proportion of those referred to haematology had a malignancy. It is also possible that the range of problems encountered in Turkey differs, and it is unclear how much this reflects practice in the UK and North America. Studies from the developing world show a different pattern of diagnoses with infectious causes, such as tuberculosis, being more common [16,25–28]. Only two retrospective studies have mentioned the complica tion rate attributable to excision open biopsy of cervical lymph nodes in children [2,4]. Knight et al. in a series of 245 children recorded no complications from cases which were not acutely infected at the time of surgery [15]. Connolly and MacKenzie reported 360 operations to excise neck lumps (not just lymph nodes) with complications in 11%, comprising 14 hypertrophic scars, 9 haematomas, 4 wound infections and 3 nerve injuries [2]. In addition, a number of studies mention cases where a diagnosis of reactive hyperplasia or no clear diagnosis is made after open biopsy of a lymph node only for subsequent excision biopsies 3.3. Complications of open biopsy

et al. found in a study of 223 children attending routine health checks palpable cervical lymphadenopathy was present in 62% aged 3 weeks to 6 months, 52% of those aged 7–23 months and up to 41% of those aged 2–5 years. In this and another study all nodes were less than 16 mm in diameter and enlarged supraclavicular nodes were never found [12]. Mills and Hibbert published a study of children with recurrent tonsillitis [13] which is notable in that it had a control group of 50 children aged 4–10 years without sore throats undergoing treatment in the ophthalmology, orthopaedic and surgical clinics. In this control group 40% had a single palpable cervical node up to 1 cm in size, 22% had single or multiple nodes up to 2 cm in size and 6% had at least one node larger than 2 cm. In the tonsillectomy group, 100% had palpable lymphadenopathy. Larsson et al. evaluated the prevalence of palpable neck lymph nodes in 3592 healthy school children aged 8 or 9 years old in Sweden [14]. A total of 991 (28%) had palpable lymphadenopathy in submandibular, cervical or supraclavicular areas. The largest of these nodes were between 10 and 15 mm in diameter and were present in only 10 of the children. Children were otherwise healthy, and the nodes were neither firm nor immobile and in none of these cases were investigations other than repeat examination considered. Supraclavicular nodes were present transiently in 70 (2%) of the children. In 49 (1%) of these cases this was in combination with enlarged cervical or submandibular nodes. We could find no evidence regarding the natural history of reactive lymphadenopathy or frequency of presentation to general practice or hospital with cervical lymphadenopathy as the complaint. We were able to identify only 2 prospective studies of the management of cervical lymphadenopathy with the majority of studies identified based on retrospective reviews of the histopa thology records of all excised lymph nodes. This usually makes it impossible to know how the children presented (possible reactive node, obvious rapidly-growing tumour or acute infection) or whether any children were successfully managed without recourse to excision biopsy. Many review articles offer tables with the causes of lymph adenopathy in children [2,15,16]. On returning to the original sources however the patients concerned were those who on clinical grounds were considered to need excision biopsy. This is not therefore a true reflection of those presenting to hospital departments with palpable nodes. Some studies included thyroid and salivary swellings, others included congenital lesions [4,17,18]. Some include lymphade nopathy in other regions as well as the neck [15,19,20]. The criteria 3.2. How likely is serious pathology in a child presenting with a cervical lymph node swelling?