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

FNAC is sensitive for carcinoma and therefore very useful in adults. It is less accurate in distinguishing low grade lymphoma from reactive hyperplasia and is therefore potentially less useful in children. Whether a child will tolerate FNA with local anaesthetic or would require sedation or a general anaesthetic is an important consideration. An investigation must have a high chance of providing useful information if a general anaesthetic is required to perform it, given the potential risks. Cutting needle biopsy requires further evaluation before it can be recommended. The issues of inadequate sampling and potential false negative mean we cannot recommend FNA as a routine test to exclude malignancy in children, but this does not mean it may have a place in certain situations i.e. confirming a solid tumour and therefore avoiding open biopsy. Even in children selected for excision biopsy, reactive hyperplasia and other inflammatory causes are much more common as a final diagnosis than malignancy. Complications can occur after excision biopsy of cervical lymph nodes in children, but the risk cannot be accurately estimated from the existing published data. Excision biopsy, therefore, should be reserved for those in whom a serious diagnosis is thought likely. There is a clear need for better quality research in this area. Prospective studies are required, and they should report on all children presenting with cervical lymphadenopathy. Ideally, a standard clinical diagnostic protocol should be applied in every case and work on multivariate predictive models would be particularly helpful. Until such studies are done, we suggest that a diagnostic algorithm such as that shown in Fig. 1, would be a sensible interpretation of the available evidence in the setting of a general ENT clinic. The general quality of evidence at present is poor. It would appear that larger lymph nodes and supraclavicular nodes are suspicious of serious pathology. Routine serology helps diagnose an infective cause in 10% of patients. The diagnostic utility of Chest X-Ray and FBC remain uncertain. Ultrasound is helpful but would appear to be operator dependant. Given that malignancy is rare in children, but must not be missed, tissue sampling methods with low sensitivity such as FNAC cannot be relied upon to exclude malignancy. Cutting needle biopsy requires further evaluation before it can be recommended. Multivariate predictive models may be of use in the future however further research is required. 5. Conclusion [1] G. Niezielska, M. Kotowski, A. Niedzielski, E. Dybiec, P. Wieczorek, Cervical lymphadenopathy in children – incidence and diagnostic management, Int. J. Pediatr. Otorhinolaryngol. 71 (2007) 51–56. [2] A. Connolly, K. MacKenzie, Paediatric neck masses – a diagnostic dilemma, J. Laryngol. Otol. 111 (1997) 541–545. [3] M.S. Linet, L.A. Ries, M.A. Smith, R.E. Tarone, S.S. Devesa, Cancer surveillance series: recent trends in childhood cancer incidence and mortality in the United States, J. Natl. Cancer Inst. 91 (12) (1999) 1051–1058. [4] A. Torsiglieri, L. Tom, A. Ross, R. Wetmore, S. Handler, W. Potsic, Pediatric neck masses: guidelines for evaluation, Int. J. Pediatr. Otorhinolaryngol. 16 (1988) 199–210. [5] C. Cummings, J. Fredrickson, L. Harker, C. Krause, M. Richardson, D. Schuller, Pediatric Otolaryngology Head & Neck Surgery, third ed., Mosby, St. Louis, 1998. [6] R. Cotton, C. Myer, Practical Pediatric Otolaryngology, Lippincott-Raven, Phila delphia, 1999. [7] C. Bluestone, S.E. Stool, C. Alper, E. Arjmand, M.L. Casselbrant, J. Dohar, R. Yellon, Pediatric Otolaryngology, fourth ed., Saunders, Philadelphia, 2002. [8] R. Wetmore, H.R. Muntz, T. McGill, W. Potsic, G. Healy, R. Lusk, Pediatric Otolar yngology: Principles and Practice Pathways, Thieme, New York, 2000. [9] H. Jeremy, C. Iain (James Lind Library), G. Paul, G. Trish, H. Carl, L. Alessandro, M. Ivan, P. Bob, T. Hazel, G. Olive, H. Mary, 2011 OCEBM Levels of Evidence Working Group*, The Oxford 2011 Levels of Evidence, http://www.cebm.net/index. aspx?o=5653. [10] P.A. Pizzo, D.G. Poplack, Principles and Practice of Pediatric Oncology, fifth ed., Lipincott, Williams and Wilkins, Philadelphia, 2005. References

presence of abnormalities on chest X-ray and history of recent ear, nose and throat symptoms. They went on to validate this model in a further group of 193 patients from 3 centres identified retrospectively from pathology records as having undergone excision biopsy of a lymph node [32]. The model has a sensitivity for serious pathology of 82–96% and a specificity of 80–92%. However, the model has not been validated on a prospectively assembled cohort, or on a cohort consisting only of children but it remains the only attempt to use a multivariate predictive model. The most obvious conclusion from our review of the literature is that the available published evidence on the management of the child with cervical lymphadenopathy is scanty and of poor quality. However, until better studies are done the following conclusions are reasonable. The authors acknowledge that this work is aimed at the management of patients referred to a general ENT clinic where a diagnosis of malignancy is unlikely, but cannot be missed. In particular the discussion is based on practice in the United Kingdom. Practices will vary in other clinic types, such as haematology/oncology and in other countries. We also acknowl edge that the spectrum of pathology differs in babies, young children and adolescents; however the studies available do not provide enough data to assess these age groups separately. With regard to clinical examination, palpable cervical lymph adenopathy is very common in otherwise healthy children and infants. Nodes 2 cm or larger are unusual and supraclavicular nodes are not normally palpable. There is evidence to suggest that such nodes, or hard nodes on clinical examination grounds are more likely to be malignant. Nodes which are small and which fluctuate in size are almost certainly reactive. Tables 2 and 3 point to this however these studies have a higher percentage of malignant cases than we would expect in our ENT practice. Fever, weight loss and organomegaly may be indicators of serious pathology, but duration of symptoms and consistency are not. Children who have had palpable lymph nodes for many months are, if anything, less likely to have malignancy, which makes a nonsense of the all-too common clinical practice of repeated clinic review over many months followed by open biopsy when parents or surgeon eventually decide that something has to be done. In an ideal world, the decision to proceed to open biopsy should be made as soon as possible to prevent diagnostic delay in those children who do have serious pathology. Abnormal chest X-ray is associated with serious causes for cervical lymphadenopathy in children, but the diagnostic utility of routine chest X-ray in this population is unknown. Ultrasound assessment of nodal architecture, margins, and shape (and possibly vascularity) shows considerable promise as a means of differenti ating reactive hyperplasia from malignancy but further studies in children are required. The use of ultrasound varies in different centres depending on local experience. In the United Kingdom the procedure is performed principally by radiologists or trained sonographers, however in other parts of the world, ENT surgeons may perform the procedure as a routine part of the head and neck examination. The implication being, the algorithm suggested is in the context of the UK practice. Abnormalities on the full blood count seem to be uncommon but are associated with serious cases for cervical lymphadenop athy in children when present. Given the low additional cost of the test, it is probably worthwhile if blood is being taken for other reasons. Otherwise, the diagnostic utility of the full blood count is unclear. Routine serological testing may identify a specific cause and therefore avoid open biopsy in around 10% of cases. 4. Discussion