• 
• 

Three Part Question

In [children who present to the ED with cervical lymphadenopathy], is [ultrasound] useful in [helping to make a diagnosis]?

Clinical Scenario

A 12 year old boy came into the ED brought by his parents who were concern that an enlarged lymph node in the boy's neck has not subsided since it was present about 3 months ago. Initial history and clinical investigations were done. Should the boy undergo ultrasound to further assess the lymphadenopathy?

Search Strategy

Ovid MEDLINE(R) 1948 to June Week 3 2011 and
Embase 1980 to 2011 Week 25 and
CINAHL

[lymphadenopath$.mp. OR exp Lymph/ OR node$.mp.]

AND

[exp Neck/ or neck.mp. OR cervical.mp. OR anterior triangle.mp. OR posterior triangle.mp. OR lymph nodes.mp. OR exp Lymph Nodes/]

AND

[exp child/ OR child$.mp. OR exp pediatrics/ OR pediatric$.mp. OR paediatric$.mp. OR perinat$.mp. OR neonat$.mp. OR newborn$.mp. OR infan$.mp. OR bab$.mp. OR toddler$.mp. OR boy$.mp. OR girl$.mp. OR kid$1.mp. OR school?age.mp. OR juvenil$.mp. OR under?age$.mp. OR teen$.mp. OR minor$.mp. OR pubescen$.mp. OR adolescen$.mp. OR infan$.jw. OR child$.jw. OR pediatric$.jw. OR paediatric$.jw. OR adolescen$.jw.]

limit to (english language and humans)

Search Outcome

2044 papers were found in Medline, 2644 in Embase and 110 results obtained from CINAHL.
Only 4 papers were relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Khanna R. et al. 30/6/2011 India	192 patients with reactive lymph node, tubercular, metastatic or lymphoma underwent ultrasonographic examination followed by FNAC of the most representative lymph node.		Correlation between ultrasonographic findings and tissue diagnosis (FNAC)	Ultrasound is useful when used as an adjunct to FNAC. Ultrasound is useful in distinguishing between normal and abnormal cervical lymph nodes but there is a considerable characteristic overlap between tubercular, metastatic and lymphamatous lymph nodes.	No study sample power calculation. Primary and/or secondary outcome was not stated. It wasn't clear if the same technician conducted the ultrasonographic examination on all patients. Basic data was not adequately described.
Tashiro N. et. al 30/6/2011 Japan	Patients who presented with fever and lymphadenopathy (anterior or posterior cervical mass) were included which consists of 22 patients with Kawasaki (KD), 8 with presumed bacterial lymphadenitis and 5 with EBV infectious mononucleosis		Compare ultrasonographic features of cervical lymph nodes in patients with KD, bacterial lymphadenitis and infectious mononucleosis	The ultrasonographic features of KD was similar to infectious mononucleosis but different from bacterial lymphadenitis.	Small sample size. Statistical analysis of outcome was not done.
Lindeboom JA. et. al 30/6/2011 The Netherlands	Ultrasonography was performed in 145 children with confirmed non-tuberculous mycobacterium (NTM) cervicofacial lymphadenitis from a large randomized, prospective, multicentre trial (CHIMED) to evaluate the effectiveness of surgery vs medication for NTM cervicofacial lymphadenitis.	Descriptive study	To assess the sonographic findings of NTM cervicofacial lymphadenitis inchildren	There was marked decrease echogenicity in all cases, liquesfaction with intranodal cystc necrosis, nodal matting and adjacent soft-tissue oedema. Multiple intranodal calcifications characteristic of end-stage disease.	No comparison was made with other causes of cervical lymphadenopathy. Only descriptive statistics were used to analyze the data. Small sample size.
Gupta KB. et. al 30/6/2011 India	27 patients with tuberculous cervical lymphadenitis taking anti-tuberculosis treatment presenting with big lymph node mass and complications during treatment.	Descriptive study	To evaluate cervical tuberculous lymphadenitis by ultrasonography	All lesions were hypoechoic (100%) and showed necrosis (100%). Sharp margins (70.4%), hilum (22.2%), abnormal surrounding tissue (85.2%), matting (37%), calcification (29.6%) and posterior enhancement (22.2%)	Descriptive analysis only. No statistical analysis. Small sample size.

Comment(s)

Most of the papers found on this topic were descriptive ultrasonographic findings of spesific differentials of cervical lymphdenopathy. None actually studied the effectiveness of ultrasound as a diganostic tool. However, from the papers above, it is evident that there are certain characteristics associated with the different differentials that may be of use as an adjunct to clinical history, clinical examination and preliminary investigations in order to reach a diagnosis. More advanced form of US (e.g. US elastography, Doppler US etc) have also been evaluated, however, it was thought to be too specialized to be included in this study as it may not be relevant to the ED.

Clinical Bottom Line

Although evidence are scarce, ultrasound is a useful adjunct to aid in the diagnosis of cervical lymphadenopathy but should not be relied on its own.

References

1. Khanna R. et al. Usefulness of ultrasonography for the evaluation of cervical lymphadenopathy. World Journal of Surgical Oncology. 2011
2. Tashiro N. et. al Ultrasonographic evaluation of cervical lymph nodes in Kawasaki disease Pediatrics 2002
3. Lindeboom JA. et. al The sonographic characteristics of nontuberculous mycobacterial cervicofacial lymphadenitis in children Pediatric radiology 2006
4. Gupta KB. et. al Role of ultrasonography and computed tomography in complicated cases of tuberculous cervical lymphadenitis. Indian Journal of Tuberculosis 2007