A good proportion of healthy children will have palpable lymph nodes in the neck.  Mostly these will be under 1cm in diameter.  Acute enlargement as part of an upper respiratory tract infection is usually accompanied by tenderness, and affected nodes will reduce in size over 4-6 weeks.

Guidance from NICE and the Scottish Government provide criteria when children with lymphadenopathy should be urgently referred for suspected cancer.

These criteria include the following:

• lymph nodes are non-tender and firm/hard
• lymph nodes are greater than 2 cm in size
• lymph nodes are progressively enlarging
• other features of general ill-health, fever or weight loss
• the axillary nodes are involved (in the absence of local infection or dermatitis)
• the supraclavicular nodes are involved.

But caveat is “Always refer any patient with Repeat presentations (3 or more times) of any physical symptoms which do not appear to be resolving or following a normal pattern, taking into account parental and patient concern”.

No need to do bloods in the absence of any of these criteria. Not that cancer is the only concern – differential includes developmental lesions (branchial cysts etc), TB, Cat-scratch disease, non-tuberculous mycobacterial infection (esp in neck).  These are always more than 2cm and there may also be systemic features and/or overlying skin discolouration too.

Malignancies often present in the head/neck region.  Hodgkins lymphoma usually affects teenagers, Non-hodgkins tends to affect school age children, neuroblastoma tends to affect pre-school children.  B-symptoms (recurrent fever, weight loss, night sweats, pruritus, lethargy) are only seen in a minority but does suggest more advanced disease, of course.  Airway or voice changes, swallowing difficulty, Horner’s syndrome, superior vena cava syndrome may all be seen due to mass effect. Most neuroblastomas have an abdominal mass.  Nasopharyngeal carcinomas are seen so look in the nose/throat.