N e u r o r a d i o l o g y / H e a d a n d N e c k I m a g i n g • C l i n i c a l Pe r s p e c t i ve

Ludwig et al.
Cervical Lymphadenopathy Imaging in the Young

Neuroradiology/Head and Neck Imaging

Clinical Perspective

Imaging of Cervical
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved

Lymphadenopathy in Children
and Young Adults
Benjamin J. Ludwig1 OBJECTIVE. This article describes the role of imaging in evaluating cervical lymphade-
Jimmy Wang1 nopathy in patients from birth to their mid-20s, illustrates imaging features of normal and ab-
Rohini N. Nadgir 1 normal lymph nodes, and highlights nodal imaging features and head and neck findings that
Naoko Saito 2 assist in diagnosis.
Ilse Castro-Aragon1 CONCLUSION. Cervical lymph node abnormalities are commonly encountered clini-
cally and on imaging in children and young adults. Although imaging findings can lack spec-
Osamu Sakai1
ificity, nodal characteristics and associated head and neck imaging findings can assist in de-
Ludwig BJ, Wang J, Nadgir RN, Saito N, Castro- termining the underlying cause.
Aragon I, Sakai O

Keywords: cervical lymphadenopathy, head and neck
imaging, head and neck infection, head and neck
malignancy, lymph nodes, pediatrics
DOI:10.2214/AJR.12.8629
Received January 17, 2012; accepted after revision
April 18, 2012.
1
Department of Radiology, Boston University Medical
Center, Boston University School of Medicine, 820
Harrison Ave, FGH Bldg, 3rd Flr, Boston, MA 02118.
Address correspondence to B. J. Ludwig
(benjamin.ludwig@bmc.org).
2
Department of Radiology, Saitama International Medical
Center, Saitama Medical University, Saitama, Japan.
AJR 2012; 199:1105–1113
0361–803X/12/1995–1105
© American Roentgen Ray Society
C
ervical lymph node abnormali-
ties are a common reason for pe-
diatric and otolaryngology office
visits and may be related to be-
nign processes, such as reactive nodes, or to
aggressive processes, including malignancy.
Although often considered nonspecific, cer-
vical lymph node imaging features, in con-
junction with clinical presentation and relat-
ed head and neck imaging findings, can aid
in determining the cause of the abnormality.
Ultrasound, CT, and MRI may be used to
confirm the presence of lymphadenopathy,
distinguish nodal abnormalities from con-
genital head and neck lesions, and further
characterize lymph nodes. In the pediatric
population, ultrasound is the most appropri-
ate initial imaging modality because of the
lack of ionizing radiation. CT and MRI are
complementary and can further characterize
nodal abnormalities and related head and
neck imaging findings. It is critical for the in-
terpreting radiologist to recognize the ap-
pearance of normal cervical lymph nodes
and to report nodal features typical of spe-
cific infections, inflammatory conditions,
and neoplasms to assist clinicians in subse-
quent management.
Clinical Approach to Cervical
Lymph Nodes
Clinical evaluation of cervical lymph nodes
in the pediatric population can be difficult be-
cause palpable lymph nodes are common in
healthy children. Previous studies have docu-
mented palpable cervical lymph nodes in up to
90% of children 4–8 years old [1].
Clinicians rely on history and physical ex-
amination to determine the possible causes
of and the diagnostic workup for lymphade-
nopathy. Physical examination findings of
tender, mobile, soft nodes suggest reactive
adenopathy, whereas nontender, firm, non-
mobile nodes raise concern for neoplastic
causes. Because infectious causes are most
common, patients are often treated empiri-
cally with antibiotics [2]. When nodes fail
to resolve after 4–6 weeks of therapy, prog-
ress in size or number, or are accompanied by
systemic symptoms, further workup is neces-
sary, which often includes imaging.
Role of Imaging
Imaging may be performed to evaluate
nodes lacking clinical features of benign
causes, confirm lymph nodes as the cause of
palpable abnormalities, and evaluate the re-
mainder of the head and neck (including ar-
eas not amenable to clinical examination,
such as the deep fascia–defined spaces).
Ultrasound may be used to confirm the
presence of an abnormal lymph node and
characterize its size, shape, borders, internal
architecture, vascularity, and perinodal soft
tissues [3]. Benefits of ultrasound include the
lack of ionizing radiation and the ability to
characterize the nature of lymph nodes as ei-
ther cystic or solid.
Both contrast-enhanced CT and MRI may
be used to further characterize the extent of

AJR:199, November 2012 1105


sonographic abnormalities and to confirm deep
nodal abnormalities, if suspected [4]. Benefits
include superior anatomic localization; de-
termination of size, number, shape, borders,
internal architecture, and enhancement char-
acteristics of nodes; and evaluation of peri-
nodal soft tissues and related head and neck
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved
findings. Diffusion-weighted imaging has
been shown to increase conspicuity of sub-
centimeter lymph nodes due to suppression
of background tissue and can aid in detection
of lymph nodes relative to conventional se-
quences [5]. These benefits must be weighed
against the radiation risks of CT, and the need
for sedation must also be considered before
CT and MRI in infants and young children.
Currently, the American College of Radi-
ology (ACR) Appropriateness Criteria support
the use of ultrasound (rating, 9/9), contrast-en-
hanced neck CT (rating, 8/9), and contrast-
enhanced neck MRI (rating, 7/9) for evalua-
tion of children up to 14 years old who have
solitary or multiple neck masses, both with
and without fever [4]. The ACR Appropriate-
ness Criteria rate PET/CT evaluation of a soli-
tary neck mass in a febrile child less than 14
years old and solitary or multiple neck mass
in both febrile and afebrile children less than
14 years old as “usually not appropriate” (both
rated 1/9) [4]. In contrast, the role of PET/CT
is evolving in the setting of known malignan-
cy, with studies showing superior accuracy of
PET/CT in initial staging, response to thera-
py, and follow-up of Hodgkin lymphoma rela-
tive to other imaging modalities, with a signif-
icant (26.8%) change in initial staging based
on PET/CT findings [6].
Normal Lymph Nodes
Anatomic localization of cervical lymph
nodes has been established on the basis of the
previous description of metastatic adenop-
athy by Som et al. [7]. In adults, the upper
limit of normal lymph node size is 10 mm
when measured in terms of greatest long-axis
dimension in the axial plane, with the excep-
tion of nodal stations IB and IIA, for which
the upper limit of normal is 15 mm in adults;
this size allowance is because levels IB and
IIA drain common sites of infection, includ-
ing the teeth, gums, tonsils, and pharynx and
thus are often enlarged [8, 9]. The upper lim-
it of normal for retropharyngeal nodes has
been proposed as 8 mm [8–10]. No specific
size criteria have been defined for lymphade-
nopathy in the pediatric population, although
the preceding criteria are commonly used.
Thus, additional imaging features including
1106 AJR:199, November 2012
Ludwig et al.
Fig. 1—7-year-old boy
with normal lymph node.
Gray-scale ultrasound
shows circumscribed,
ovoid node with cortical
hypoechogenicity
(arrowhead) and
relatively hyperechoic
hilum (arrow).
nodal morphology, internal architecture, and causes of reactive lymph nodes, although any
perinodal soft tissues are complementary in bacteria can cause lymphadenopathy. They
lymph node evaluation. are seen as enlarged nodes with perinodal in-
On ultrasound, normal or reactive lymph flammatory change [10].
nodes are well defined and reniform in shape, Fungal infections may be seen in endemic
with fatty echogenic hila and a hypoechoic regions or immunocompromised patients and
cortex relative to muscle (Fig. 1). Color Dop- include cryptococcosis, coccidiomycosis, and
pler sonography may show avascularity or ra- histoplasmosis. The single protozoal cause of
dial symmetric hilar vascularity with low pul- lymphadenitis is toxoplasmosis.
satility index and low resistive index [3].
On CT, nodes are iso- or hypoattenuating Bacterial Infections
relative to muscle and show mild homogene- Staphylococcus aureus and group A Strep-
ous enhancement after contrast administra- tococcus—Staphylococcus aureus and group
tion. Normal nodes are circumscribed, with A Streptococcus are the most common bacte-
preserved fat planes with adjacent structures rial causes of cervical lymphadenitis and ac-
[8–10] (Fig. 2). count for 53–89% of cases of unilateral cervi-
On MRI, nodes show low to intermediate cal adenitis [12]. These infections commonly
signal on T1-weighted images, intermediate occur in children 1–4 years old. They often
to high signal on T2-weighted images relative produce enlarged nodes with perinodal inflam-
to muscle, and homogeneous enhancement af- matory change and may progress to suppura-
ter IV contrast administration [8, 9] (Fig. 3). tive adenopathy, defined as infection resulting
Clinical Entities
Reactive Lymph Nodes
Reactive lymph nodes may result from vi-
ral, bacterial, fungal, or protozoal pathogens.
Such nodes are typically slightly enlarged
and may show mild enhancement on CT or
MRI and vascularity radiating from the hi-
lum on Doppler ultrasound (Fig. 4).
Viral infections are the most common cause
of reactive adenopathy [11] and typically re-
sult in bilateral mildly enlarged cervical lymph
nodes without periadenitis. Cytomegalovirus
infection, herpes simplex virus infection, vari-
cella, rubeola (measles), and rubella are com-
mon viral causes but typically require correla-
tion with clinical or laboratory data to reach a
definitive diagnosis. Infectious mononucleo-
sis and HIV infection have associated imaging Fig. 2—18-year-old woman with normal lymph nodes.
findings and will be described in detail later. Contrast-enhanced axial CT image shows multiple
ovoid, circumscribed left level II nodes with fatty hila
Staphylococcus aureus and group A Strep- (arrow), which are hypo- to isoattenuating relative
tococcus infections [12] are common bacterial to muscle.
 Cervical Lymphadenopathy Imaging in the Young

retropharyngeal space. Differentiation is crit-

ical because intranodal abscesses are usual-
ly managed with antibiotics, whereas retro-
pharyngeal abscesses often require surgical
drainage [14, 15].
Mycobacterial infection—Head and neck
involvement with Mycobacterium tubercu-
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved

losis infection accounts for 12–15% of cases

of extrapulmonary tuberculosis [8, 16–18]. In
the acute phase, tuberculous granulomas may
produce nodal enlargement and enhancement.
Subacute disease is characterized by forma-
tion of suppurative nodes and intranodal ab-
scesses [10, 18]. Nodal calcification can be
seen in the chronic phase or after treatment,
although calcification within cervical nodes is
A B much less common than in mediastinal or hi-
lar lymph nodes [19]. Levels II and V nodes
Fig. 3—21-year-old man with normal lymph nodes.
A, Axial T1-weighted MR image shows ovoid right level IIA node with low to intermediate T1 signal relative to
are most commonly involved [8, 10, 16–18].
muscle (arrow). Ultrasound, CT, and MRI can depict all
B, Axial T2-weighted MR image shows intermediate to high T2 signal within same node (arrow). stages of disease. Subacute disease is most
commonly encountered on imaging and
in necrosis within lymph nodes (also referred metastatic disease, which otherwise can have characterized by intranodal abscess forma-
to as intranodal abscess formation) [8, 10]. On a similar imaging appearance. tion, which classically lacks perinodal in-
ultrasound, features of suppurative adenopa- It is also important to differentiate between flammatory change [10, 18] (Fig. 7). Because
thy include anechoic regions, peripheral vas- suppurative retropharyngeal lymph nodes and of the lack of periadenitis in tuberculosis,
cularity, and possibly septations and posteri- true retropharyngeal abscesses in children. Both metastatic adenopathy is the main differen-
or acoustic enhancement [13] (Fig. 5). On CT, medial and lateral retropharyngeal nodes are tial diagnosis and fine-needle aspiration may
suppurative nodes are hypoattenuating cen- present until about the age of 6 years and can be required for diagnosis. When tuberculous
trally, with peripheral rim enhancement and exhibit intranodal abscess formation (Fig. 6). adenitis is suspected, imaging of the chest
perinodal inflammatory change. MRI shows The peripheral enhancement on cross-section- should be performed to assess whether ac-
central T1 hypo- and T2 hyperintensity, with al imaging in intranodal abscesses conforms to tive pulmonary disease is present [8, 10, 18].
peripheral enhancement. The associated peri- the nodal border, whereas true retropharyngeal Atypical, nontuberculous mycobacterial in-
nodal inflammatory change can assist in dif- abscesses show retropharyngeal fluid with en- fection may also result in cervical lymphadeni-
ferentiation from central nodal necrosis due to hancement corresponding to the borders of the tis. In children less than 5 years old, the most

A B
Fig. 5—6-year-old boy with suppurative lymph node
Fig. 4—8-year-old boy with reactive lymph node due to Streptococcus pharyngitis. due to Staphylococcus aureus. Gray-scale color
A, Gray-scale ultrasound shows increased cortical echogenicity (arrow) and lack of echogenic hilum. Doppler ultrasound shows enlarged cervical lymph
B, Axial contrast-enhanced CT image in same patient shows enhancing, round, node with central hypoechogenicity and peripheral
enlarged level II node (arrowhead) with perinodal inflammatory change. Note reactive Doppler vascularity.
retropharyngeal edema (arrow).

AJR:199, November 2012 1107


Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved
Fig. 6—6-year-old boy with intranodal abscess
within lateral retropharyngeal lymph node. Axial
contrast-enhanced CT image shows central fluid
attenuation and peripheral enhancement within
enlarged left lateral retropharyngeal lymph node
(arrow) with surrounding phlegmon.
common cause of nonmycobacterial TB is
Mycobacterium avium-intracellulare. Affect-
ed children usually do not have a history of tu-
berculosis exposure, and the tuberculin skin test
is usually normal or only minimally indurated
[10]. Children present with an isolated enlarg-
ing neck mass with overlying skin discolor-
ation. On imaging, the most common findings
include a dominant centrally necrotic peripher-
ally enhancing neck mass, typically in the pa-
rotid or submandibular region (Fig. 8). Multi-
ple separate adjacent nodal masses and minimal
periadenitis have also been described [20].
Distinction between tuberculous and non-
tuberculous mycobacterial adenitis has im-
portant treatment implications. Whereas tu-
berculous mycobacterial adenitis responds to
antituberculosis therapy [8], medical therapy
is not effective in nontuberculous mycobac-
terial adenitis and the treatment of choice is
surgical excision [21].
Cat-scratch disease—Regional lymphad-
enitis secondary to Bartonella (formerly Ro-
chalimaea) henselae infection, also referred to
as cat-scratch disease, most commonly affects
children and young adults. The majority of
cases are related to cat scratches or bites, with
regional lymphadenopathy identified approx-
imately 3 weeks after inoculation. Cervical
lymphadenopathy is the third most common
site of involvement after axillary and epitroch-
lear nodes [22]. Isolated head and neck nod-
al involvement occurs in 25% of cases, often
with solitary nodal involvement [23].
1108 AJR:199, November 2012
Ludwig et al.
Fig. 7—18-year-old boy with tuberculous adenitis.
Axial contrast-enhanced CT image shows multiple
enlarged bilateral level II lymph nodes with central
fluid attenuation and thick, irregular peripheral
enhancement (arrows). Lack of perinodal fat
stranding is characteristic finding of tuberculous
adenitis.
Because exposure history is often not re-
called, children may undergo imaging for
the evaluation of a new solitary neck mass.
Unfortunately, the imaging findings in cat-
scratch disease are variable, ranging from en-
hancing to necrotic lymphadenopathy. The
diagnosis can be confirmed by an enzyme im-
munoassay (EIA), polymerase chain reaction,
skin or nodal biopsy [22].
Viral Infections
Infectious mononucleosis—Infectious mono-
nucleosis is caused by Ebstein-Barr virus [8],
but illnesses that clinically simulate mononucle-
osis may result from other viruses. Children
present with pharyngitis, fatigue, and fevers.
Heterophile antibody (monospot) tests may
be diagnostic when clinical suspicion is high.
However, imaging may also be used when the
clinical course is less characteristic. Lymphade-
nopathy is classically diffuse and lacks perinod-
al inflammatory change. Associated head and
neck findings can aid in diagnosis, particularly
adenoid and palatine tonsil enlargement [13]
(Fig. 9). The disease is typically self-limiting
with resolution after 3–4 weeks.
HIV—Diffuse lymphadenopathy is present
in nearly all patients with HIV infection or
AIDS and is a common initial presentation [8,
10, 24]. Lymphadenopathy is present in 40–
70% of children who are HIV-positive [12].
On imaging, findings are typical of reactive
viral-infected nodes. Identification of multiple,
bilateral parotid lymphoepithelial lesions (cysts)
Fig. 8—2-year-old boy with nontuberculous
mycobacterial infection. Axial contrast-enhanced CT
image shows enlarged, hypoattenuating left intra-
and periparotid, level V, and lateral retropharyngeal
nodes with thick irregular enhancement and
septations (arrows). Note perinodal inflammatory
change posteriorly.
suggests underlying HIV infection when seen
in conjunction with generalized cervical
lymphadenopathy [8, 10, 24] (Fig. 10). Lym-
phoid hyperplasia and adenoid hypertrophy
can be seen but may not be present in patients
with low CD4 counts due to inability to
mount an immune response. Upon recogniz-
ing such imaging findings, the radiologist
may be the first to raise suspicion for HIV in-
fection and can facilitate early diagnosis be-
fore disease progression and development of
associated complications [8, 10, 24].
Lymphadenopathy Associated with
Clinical Syndromes
Cervical lymphadenopathy is a component
of many clinical syndromes. Entities in which
associated head and neck imaging findings
may aid in determining potential causes are
discussed in this section. Unfortunately, many
disease processes, including systemic lupus
erythematosus, juvenile rheumatoid arthritis,
posttransplantation lymphoproliferative disor-
der, and sickle cell disease, lack distinguishing
imaging findings but may be considered on the
basis of patient history and demographics.
Kawasaki disease—First described in Japa-
nese children, Kawasaki disease (febrile muco-
cutaneous lymph node syndrome) is now rec-
ognized in infants and young children of all
demographics [25]. The most common age of
onset is 6 months in Japan and between 13 and
24 months in North America [26]. Diagnostic
criteria include fever lasting at least 5 days; lack
 Cervical Lymphadenopathy Imaging in the Young
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved

Fig. 9—16-year-old boy with infectious
mononucleosis. Axial contrast-enhanced CT image
shows enlarged palatine tonsils bilaterally (arrows)
and enlarged left level IIA lymph node (arrowhead).
A B
Fig. 10—25-year-old woman with HIV infection.
A, Axial contrast-enhanced CT image shows multiple, mildly enlarged nonspecific level II nodes (arrow).
B, Additional image shows multiple left parotid lymphoepithelial cysts (arrow).

of evidence of concurrent disease to explain may be confused with bacterial lymphadeni- may also be observed in Kawasaki disease
clinical features; and meeting at least four of tis early in the course of Kawasaki disease; (Fig. 11). Early recognition facilitated by im-
five clinical components, one of which is cer- differentiation between the two entities has aging and treatment with IV immunoglobu-
vical lymphadenopathy (> 1.5 cm in diameter), been described on ultrasound, in which nod- lin can reduce the risk of cardiac complica-
usually unilateral [27]. al involvement consists of a coalescent nodal tions, including coronary artery aneurysms
Even though cervical adenopathy is the mass resembling a cluster of grapes formed and associated devastating consequences.
least often fulfilled diagnostic criterion and by multiple hypoechoic nodes as opposed to Kikuchi-Fujimoto disease—Kikuchi-Fujimo-
is present in less than 50% of confirmed cas- mildly enlarged or centrally cystic vascular to disease, or histiocytic necrotizing lymphade-
es [28], it has been described as the dominant nodes in bacterial infection [29]. Head and nitis, is a self-limiting disease of unknown cause.
manifestation of the disease in its early stag- neck findings of mucositis, including tonsil- There is a slight female predominance, and
es [26]. The presence of lymphadenopathy lar enlargement and retropharyngeal edema, patients are typically less than 30 years old.
Patients present with cervical lymphadenopathy,
often with systemic symptoms, including fever,
fatigue, nausea, vomiting, diarrhea, and weight
loss [30]. Because no laboratory tests are diag-
nostic of the entity, imaging plays a crucial role
in diagnosis, surgical planning, and follow-up.
Imaging findings in Kikuchi-Fujimoto dis-
ease have been described with great variabil-
ity. Unilateral cervical nodal involvement or
asymmetric bilateral nodal involvement is
most typical, with levels II, V, and III nodes
most often involved. Most nodes show ho-
mogeneous attenuation, enhancement, and
perinodal inflammatory change (Fig. 12), and
some show intranodal necrosis.
Because the differential diagnosis includes
both infection and malignancy, definitive di-
agnosis relies on biopsy. The natural history
of the disease is usually benign, with sponta-
A B
neous resolution occurring 1–6 months after
Fig. 11—4-year-old girl with Kawasaki disease. symptom onset [31].
A, Axial contrast-enhanced CT image shows bilateral palatine tonsil hypertrophy (arrows) and retropharyngeal Castleman disease—Castleman disease, or
edema (arrowhead).
B, Additional image in same patient shows multiple enlarged right level II nodes, including conglomerate angiofollicular lymphoid hyperplasia, common-
adenopathy (arrow) with periadenitis. Findings are consistent with mucositis and reactive lymphadenopathy. ly presents with cervical lymphadenopathy.

AJR:199, November 2012 1109

 Ludwig et al.

Fig. 13—9-year-old
boy with Castleman
disease. Axial
contrast-enhanced fat-
saturated T1-weighted
MR image shows
markedly enlarged,
homogeneously
enhancing, nonnecrotic,
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved

intermediate-signal
left level II and lateral
retropharyngeal lymph
nodes (arrows). 

Fig. 12—22-year-old woman with Kikuchi-

Fujimoto disease. Axial contrast-enhanced CT
shows homogeneously enhancing mass in right
submandibular space (arrow) with surrounding
inflammatory change.
Isolated cervical lymphadenopathy is more
common in the hyaline vascular subtype, in
which younger patients tend to present with
asymptomatic cervical nodal masses. Over-
all, the mediastinum is the most common site
followed by the head and neck [8, 10].
On ultrasound, marked nodal enlargement
is present, typically with Doppler hypervascu-
larity. Moderate to intense enhancement has
been described on CT [32]. Nodal calcifica-
tion has been described including punctate and
“arborizing” calcifications within pelvic lymph
nodes [33]. On MRI, lesions are typically T1
hypointense relative to muscle and T2 hyperin-
tense with linear, stellate T2 hypointensity cen-
trally. The finding of central T2 hypointensity
correlates with sinusoidal fibrosis, vessels, and
calcification on histopathology [34] (Fig. 13).
Central lack of enhancement, indicative of fi-
brosis, within an enhancing nodal mass on CT
has been described as suggestive of Castleman
disease [32]. Surgery is typically curative; how-
ever, lesions can recur if incompletely excised.
Kimura disease—Kimura disease is a chron-
ic inflammatory disorder that affects the sub-
cutaneous tissues, lymph nodes, and salivary
glands. This entity is most common in boys
and men of Asian descent during the 2nd and
3rd decades of life [35]. Patients present with
nontender soft-tissue masses, most frequently
within the submandibular or parotid regions,
with involvement of adjacent lymph nodes or
salivary glands [35]. Peripheral eosinophilia
and elevated serum IgE levels are characteris-
tic laboratory features.
On ultrasound, focal hypervascular hypo-
echoic lesions within the subcutaneous tissues
are characteristic (Fig. 14A). Similarly, involved
lymph nodes are enlarged and hypervascular.
Contrast-enhanced CT depicts enhancing subcu-
taneous masses, regional cervical lymphadenop-
athy, and often focal or infiltrative salivary gland
lesions. On MRI, involved nodes show low to
intermediate signal on T1-weighted images,
intermediate to high signal on T2-weighted
images relative to muscle, and enhancement
after contrast administration [35] (Fig. 14B).
Kimura disease usually follows a benign
course with surgical excision performed for
both diagnosis and treatment. Imaging find-
ings are not diagnostic of Kimura disease, but
the entity should be considered, particularly in
young adults of Asian descent with enhancing
subcutaneous head and neck lesions, nodal and
salivary gland involvement, cervical lymphade-
nopathy, and peripheral eosinophilia.
Neoplasia
Malignancy is the most feared cause of cer-
vical lymphadenopathy. Suspicious clinical
features—including hard, nonmobile, painless

A B
Fig. 14—14-year-old boy with Kimura disease involving right parotid gland and intraparotid lymph nodes.
A, Gray-scale color Doppler ultrasound image shows hypoechoic parotid mass (arrow) with increased vascularity.
B, Axial STIR MR image shows hyperintense right parotid lesion (arrow).

1110 AJR:199, November 2012

 Cervical Lymphadenopathy Imaging in the Young
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved
Fig. 15—21-year-old man with Hodgkin lymphoma.
Axial contrast-enhanced CT image shows multiple,
markedly enlarged homogeneous left level II lymph
nodes (arrow) without necrosis or periadenitis.
lymph nodes; progressive nodal enlargement;
lack of response to antibiotic therapy; or sys-
temic symptoms—most often lead to imaging.
Sonographic features of malignant lymph-
adenopathy include nodal enlargement, round
shape, absent or eccentric echogenic hilum, hy-
poechoic parenchyma, and tendency of nodes
to aggregate into a mass [36]. Color Doppler
features, including subcapsular vessels, dis-
placement of hilar vasculature, and absent seg-
ments of nodal vessels, have been suggested to
be related to tumor infiltration [37]. Increased
pulsatility and resistive indices have also been
described as secondary to compression of
nodal vasculature by infiltrative tumor [37].
Nodal enlargement, enhancement, and intra-
nodal necrosis without periadenitis are com-
mon on CT or MRI. Diffusion-weighted MRI
has been reported to differentiate between en-
larged benign and malignant lymph nodes on
the basis of decreased apparent diffusion coef-
ficient values in some malignancies [38]. When
imaging features suspicious for malignancy
are identified in pediatric and young-adult pa-
tients, leukemia, lymphoma, and metastasis
should be considered.
Lymphoma—Lymphoma accounts for 10–
15% of all childhood malignances and is di-
vided into two main subtypes: Hodgkin and
non-Hodgkin lymphoma. In young adults, the
most common age of onset of Hodgkin lym-
phoma is in the mid to late 20s. In these pa-
tients, cervical lymphadenopathy is the most
AJR:199, November 2012 1111
Fig. 16—20-year-old man with nodal metastasis due
to oral tongue cancer. Axial contrast-enhanced CT
shows large left level II node (arrow) with intranodal
necrosis and irregular, peripheral enhancement.
Biopsy revealed squamous cell carcinoma, and
primary tongue neoplasm was subsequently
identified on physical examination.
common manifestation of the disease [36].
Non-Hodgkin lymphoma is the more common
of the two subtypes and increases in preva-
lence with age. Extranodal disease is more
common in non-Hodgkin lymphoma and is
present at the onset of disease [36].
Imaging cannot reliably distinguish be-
tween Hodgkin lymphoma and non-Hodgkin
lymphoma, and biopsy remains the primary
means of definitive diagnosis. Nevertheless, it
remains critical for the interpreting radiologist
A B
Fig. 17—26-year-old woman with cystic nodal metastases secondary to papillary thyroid cancer.
A, Axial T2-weighted MR image shows enlarged hyperintense left level II/III node (arrow).
B, Coronal T1-weighted MR image shows hyperintensity within enlarged node (arrow), which may be related to
thyroglobulin content or hemorrhage.
to be familiar with characteristics of the dis-
ease and associated head and neck findings to
raise suspicion of lymphoma and guide clin-
ical management. Involved nodes show the
characteristic features of malignant adenopa-
thy, typically with homogeneous density and
mild enhancement (Fig. 15). Nodal calcifi-
cation may be seen in both subtypes of lym-
phoma and is a hallmark of treated disease,
although calcification has also been reported
in lymphomatous nodes before treatment. As-
sociated head and neck findings of Waldey-
er ring involvement may be seen in Hodgkin
lymphoma but is rare in children [36].
Leukemia—Leukemia is the most common
childhood malignancy; however, diagnosis
relies on clinical evaluation, laboratory tests,
and bone marrow biopsy. Cervical lymph-
adenopathy is a common presentation of
acute lymphocytic leukemia [13] but is com-
monly seen in all forms of childhood leuke-
mia. On imaging, nodal involvement is very
similar to lymphoma [8, 10] and thus requires
correlation with clinical data.
Metastatic disease—Approximately 25% of
malignant childhood tumors occur in the head
and neck, and cervical lymph nodes are com-
mon sites of metastatic disease [11]. Neuro-
blastoma, leukemia, rhabdomyosarcoma, and
non-Hodgkin lymphoma are the most com-
mon primary malignancies associated with
cervical lymph node involvement in children
up to 6 years old [11]. After the age of 6
years, Hodgkin lymphoma is most common,
followed by rhabdomyosarcoma and non-
Hodgkin lymphoma [11].

Identification of malignant lymphadenopa-
thy is critical to diagnosis, staging, and clinical
management and can be facilitated through
imaging. Unfortunately, current imaging tech-
niques are not able to resolve microscopic nod-
al disease, and metastasis may be present in
lymph nodes that are normal by imaging crite-
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved
ria. The most accurate criterion for the diag-
nosis of nodal metastasis is central nodal ne-
crosis [8, 9]. Ultrasound, CT, and MRI depict
central nodal necrosis with a lack of periad-
enitis (Fig. 16). Extracapsular tumor spread is
suggested by ill-defined nodal margins and en-
hancement extending into the perinodal soft tis-
sues and is associated with an increased risk of
distant metastasis and a poor prognosis [8–10].
When CT or MRI of potential metastat-
ic lymphadenopathy is undertaken, it is also
important to evaluate for the primary malig-
nancy in the head and neck. In particular, on
the basis of a recent increase in incidence in
young adults, nodal metastases from oropha-
ryngeal neoplasms and thyroid cancer should
be considered [39, 40]. Oropharyngeal neo-
plasms, specifically tonsillar and oral tongue
cancers, have increased in incidence from
2.1% in 1973 to 3.9% in 2001 among pa-
tients 20–44 years old [39]. This increase has
been attributed to infection by human papillo-
mavirus (HPV), specifically type 16, which is
hypothesized to be sexually transmitted [40].
Although established as causative, HPV posi-
tivity is a favorable prognostic factor with im-
proved response to induction chemotherapy
and chemoradiation [40].
Thyroid cancer is currently the fourth most
common malignancy in young adults 15–29
years old with the most common age of di-
agnosis between 20 and 24 years [41]. The
majority of cases presenting before age 30
years are well-differentiated carcinomas, ei-
ther papillary or medullary, and are more
common in women [41]. The incidence has
increased steadily from 1975 to 2000 [41].
Nodes related to metastatic papillary thy-
roid cancer range in appearance from mim-
icking reactive nodes to enhancing, cystic, or
necrotic nodes. Fine calcifications on CT or
punctate hyperechogenicities on ultrasound
may be seen secondary to psammoma bod-
ies in papillary thyroid metastases [8, 9, 13].
MRI features include T1 nodal hyperintensi-
ty, thought to be due to thyroglobulin or in-
tranodal hemorrhage [8–10] (Fig. 17).
Conclusion
Enlarged cervical lymph nodes are common-
ly encountered in the pediatric population, both
1112 AJR:199, November 2012
Ludwig et al.
clinically and on imaging. Clinicians and radi-
ologists often struggle with the nonspecific fea-
tures of such nodes, which are most commonly
reactive secondary to infection but can also be
related to more aggressive processes, including
malignancy. Appropriate clinical evaluation is
paramount in the assessment of enlarged lymph
nodes. Imaging plays an important role, partic-
ularly when lymph nodes lack benign features
or fail to resolve with treatment. Imaging can
characterize nodal features including size, dis-
tribution, internal architecture, vascularity, and
enhancement. Ultrasound is an excellent initial
modality because of the lack of ionizing radia-
tion, and CT and MRI may add additional de-
tail regarding deep spaces of the neck and eval-
uation of associated head and neck pathology.
It is important for the radiologist to be famil-
iar with nodal pathology, particularly nodal fea-
tures that aid in distinguishing between causes
and related head and neck imaging findings to
guide clinical management.
References
1. Park YW. Evaluation of neck masses in children.
Am Fam Physician 1995; 51:1904–1912
2. Nield LS, Kamat D. Lymphadenopathy in chil-
dren: when and how to evaluate. Clin Pediatr
(Phila) 2004; 43:25–33
3. Ahuja AT, Ying M. Sonographic evaluation of
cervical lymph nodes. AJR 2005; 184:1691–1699
4. American College of Radiology. ACR Appropriate-
ness Criteria: neck mass/adenopathy. American
College of Radiology Website. www.acr.org/~/
media/ACR/Documents/AppCriteria/Diagnostic/
NeckMassAdenopathy.pdf. Accessed June 27, 2012
5. Vandecaveye V, De Keyzer F, Vander Pooten V, et
al. Head and neck squamous cell carcinoma: val-
ue of diffusion-weighted MR imaging for nodal
staging. Radiology 2009; 251:134–146
6. Riad R, Omar W, Kotb M, et al. Role of PET/CT
in malignant pediatric lymphoma. Eur J Nucl
Med Mol Imaging 2010; 37:319–329
7. Som PM, Curtin HD, Mancuso AA. Imaging-
based nodal classification for evaluation of neck
metastatic adenopathy. AJR 2000; 174:837–844
8. Som PM, Brandwine-Gensler MS. Lymph nodes
of the neck. In: Som PM, Curtin HD, eds. Head
and neck imaging, 5th ed. St. Louis, MO: Mosby,
2011:2287–2384
9. Som PM. Detection of metastasis in cervical
lymph nodes: CT and MR criteria and differential
diagnosis. AJR 1992; 158:961–969
10. Som PM, Curtin HD, Mancuso AA. An imaging-
based classification for the cervical nodes designed
as an adjunct to recent clinically based nodal classifi-
cations. Arch Otolaryngol Head Neck Surg 1999;
125:388–396
11. Leung AK, Robson WL. Childhood cervical lymph-
adenopathy. J Pediatr Health Care 2004; 18:3–7
12. Chesney PJ. Cervical adenopathy. Pediatr Rev
1994; 15:276–284
13. Restrepo R, Oneto J, Lopez K, Kukreja K. Head
and neck lymph nodes in children: the spectrum
from normal to abnormal. Pediatr Radiol 2009;
39:836–846
14. Shefelbine SE, Mancuso AA, Gajewski BJ, Ojiri
H, Stringer S, Sedwick JD. Pediatric retropharyn-
geal lymphadenitis: differentiation from retropha-
ryngeal abscess and treatment implications. Oto-
laryngol Head Neck Surg 2007; 136:182–188
15. Wesolowski JR, Mukherji SK. Pathology of the
pharynx. In: Som PM, Curtin HD, eds. Head and
neck imaging, 5th ed. St. Louis, MO: Mosby,
2011:1749–1809
16. Reede DL, Bergeron RT. Cervical tuberculous ad-
enitis: CT manifestations. Radiology 1985; 154:
701–704
17. Lee Y, Park KS, Chung SY. Cervical tuberculous
lymphadenitis: CT findings. J Comput Assist To-
mogr 1994; 18:370–375
18. Moon WK, Han MH, Chang KH, et al. CT and
MR imaging of head and neck tuberculosis. Ra-
dioGraphics 1997; 17:391–402
19. Eisenkraft BL, Som PM. The spectrum of benign
and malignant etiologies of cervical node calcifi-
cation. AJR 1999; 172:1433–1437
20. Bagla S, Tunkel D, Kraut MA. Nontuberculous
mycobacterial lymphadenitis of the head and
neck: radiologic observations and clinical context.
Pediatr Radiol 2003; 33:402–406
21. Stewart MG, Starke JR, Coker NJ. Nontubercu-
lous mycobacterial infections of the head and
neck. Arch Otolaryngol Head Neck Surg 1994;
120:873–876
22. Dong PR, Seeger LL, Yao L, Panosian CB, John-
son BL, Eckardt JJ. Uncomplicated cat scratch
disease-findings at CT, MR imaging, and radiog-
raphy. Radiology 1995; 3:837–839
23. Twist CJ, Link MP. Assessment of lymphadenop-
athy in children. Pediatr Clin North Am 2002;
49:1009–1025
24. Holliday RA, Cohen WA, Schinella RA, et al. Be-
nign lymphoepithelial parotid cysts and hyperplas-
tic cervical adenopathy in AIDS-risk patients: a
new CT appearance. Radiology 1988; 198:439–441
25. Chung CJ, Stein L. Kawasaki disease: a review.
Radiology 1998; 208:25–33
26. Kao HT, Huang YC, Lin TY. Kawasaki disease
presenting as cervical lymphadenitis or deep neck
infection. Otolaryngol Head Neck Surg 2001;
124:468–470
27. Council on Cardiovascular Disease in the Young;
Committee on Rheumatic Fever, Endocarditis,
and Kawasaki Disease; American Heart Associa-
tion. Diagnostic guidelines for Kawasaki disease.
 Cervical Lymphadenopathy Imaging in the Young

Circulation 2001; 103:335–336
28. Chakrabartty S, Pramani S, Thapa R. Difficulties
in the diagnosis of Kawasaki disease. Indian Pe-
diatr 2006; 43:728–731
29. Tashiro N, Matsubara T, Uchida M, Katayama K,
Ichiyama T, Furukawa S. Ultrasonographic evalu-
ation of cervical lymph nodes in Kawasaki dis-
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved
Br J Radiol 2004; 77:253–256
33. Meador TL, McLarney JK. CT features of Castle-
man disease of the abdomen and pelvis. AJR
2000; 175:115–118
34. Glazer M, Rao VM, Reiter D, McCue P. Isolated
Castleman disease of the neck: MR findings.
AJNR 1995; 16:669–671
ease—color Doppler US assessment of intranodal
architecture. Radiology 1998; 208:117–123
38. Abdel Razek AA, Soliman NY, Elkhamary S,
Alsharaway ML, Tawfik A. Role of diffusion-
weighted MR imaging in cervical lymphadenopa-
thy. Eur Radiol 2006; 16:1468–1477
39. Fakhry C, Gillison ML. Clinical implications of

ease. Pediatrics 2002; 109:E77
30. Kwon SY, Kim TK, Kim YS, Li KY, Lee NJ, Seol
HY. CT findings in Kikuchi disease: analysis of
96 cases. AJNR 2004; 25:1099–1102
31. Lin HC, Su CY, Huang CC, Hwang CF, Chien CY.
Kikuchi’s disease: a review and analysis of 61 cases.
Otolaryngol Head Neck Surg 2003; 128:650–653
32. Tan TY, Pang KP, Goh HK, Teo EL, Abhilash B,
Walford N. Castleman’s disease of the neck: a de-
scription of four cases on contrast-enhanced CT.
35. Takahashi S, Ueda J, Furukawa T, et al. Kimura
disease: CT and MR findings. AJNR 1996; 17:
382–385
36. Toma P, Granata C, Rossi A, Garaventa A. Multi-
modality imaging of Hodgkin disease and non-
Hodgkin lymphomas in children. RadioGraphics
2007; 27:1335–1354
37. Tschammler A, Ott G, Scheng T, Seelbach-Goeb-
el B, Schwager K, Hahn D. Lymphadenopathy:
differentiation of benign from malignant dis-
human papillomavirus in head and neck cancers.
J Clin Oncol 2006; 24:2606–2611
40. Goon PK, Stanley MA, Ebmeyer J, et al. HPV &
head and neck cancer: a descriptive update. Head
Neck Oncol 2009; 1:36
41. Bleyer A, O’Leary M, Barr R, Ries LA. Cancer epi-
demiology in older adolescents and young adults 15
to 29 years of age, including SEER incidence and
survival: 1975–2000. Bethesda, MD: National Can-
cer Institute, NIH Pub. No. 06-5767, 2006

F O R YO U R I N F O R M AT I O N
The American Roentgen Ray Society now provides instant Web exclusive access to its annual meeting
abstracts. The abstracts, featured as a supplement to the AJR, summarize the latest comprehensive and
clinically important information presented at ARRS’s annual meetings. The abstracts can be viewed
online by visiting www.ajronline.org.

AJR:199, November 2012 1113

 This article has been cited by:

1. Carson Wills, Katherine Mercer, Jozef Malysz, Lidys Rivera Galvis, Chandrika Gowda. 2022. Chronic Generalized
Lymphadenopathy in a Child—Progressive Transformation of Germinal Centers (PTGC). Children 9:2, 214. [Crossref]
2. Magali Saguintaah, Jenny Eulliot, Margaux Bertrand, Olivier Prodhomme, Nancy Béchard, Julie Bolivar-Perrin, Ikram Taleb
Arrada, Anne-Hélène Simon, Catherine Baud, Ingrid Millet. 2022. Canal of Nuck Abnormalities in Pediatric Female Patients.
RadioGraphics 23. . [Crossref]
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved

3. Oleksii O. Tymofieiev, Natalia O. Ushko, Ievgen I. Fesenko, Olexander O. Tymofieiev, Maria O. Yarifa, Olha S. Cherniak.
2021. Suppurative mastoid lymphadenitis mimicking mastoiditis: a case report. Journal of the Korean Association of Oral and
Maxillofacial Surgeons 47:5, 398-402. [Crossref]
4. Sunyoung Park, Ji Young Kim, Young Jin Ryu, Hyunju Lee. 2021. Kikuchi Cervical Lymphadenitis in Children. Journal of
Ultrasound in Medicine 40:10, 2069-2078. [Crossref]
5. Tian-Zhuo Yu, Ying Zhang, Wen-Zhi Zhang, Gao‑Yi Yang. 2021. Role of ultrasound in the diagnosis of cervical tuberculous
lymphadenitis in children. World Journal of Pediatrics 17:5, 544-550. [Crossref]
6. Keita Onoue, Noriyuki Fujima, V. Carlota Andreu-Arasa, Bindu N. Setty, Osamu Sakai. 2021. Cystic cervical lymph nodes of
papillary thyroid carcinoma, tuberculosis and human papillomavirus positive oropharyngeal squamous cell carcinoma: utility of
deep learning in their differentiation on CT. American Journal of Otolaryngology 42:5, 103026. [Crossref]
7. Ahmed Elgendy, Eslam Elhawary, Mohamed M. Shareef, Marwa Romeih, Ahmed Ebeed. 2021. Ultrasound Elastography in
the Diagnosis of Malignant Cervical Lymphadenopathy in Children: Can It Replace Surgical Biopsy?. European Journal of
Pediatric Surgery 71. . [Crossref]
8. Pratap Kumar Patra, Aaqib Zaffar Banday, Naveen Bhagat, Pandiarajan Vignesh, Surjit Singh. 2021. A febrile child with a
‘bunch of grapes’ appearance on neck ultrasonography. Tropical Doctor 51:2, 233-235. [Crossref]
9. J. Alves Rosa, J.S. Calle-Toro, M. Kidd, S. Andronikou. 2021. Normal head and neck lymph nodes in the paediatric population.
Clinical Radiology 76:4, 315.e1-315.e7. [Crossref]
10. Eduard H. Panosyan, Moran Gotesman, Joseph L. Lasky. Lymphadenopathy . [Crossref]
11. Hugo A. Heij. Lymph Node Disorders 11-20. [Crossref]
12. Anastasia L. Hryhorczuk, Harriet J. Paltiel. Pancreas, Adrenal Glands, and Retroperitoneum 563-628. [Crossref]
13. Keita Onoue, Noriyuki Fujima, V. Carlota Andreu-Arasa, Bindu N. Setty, Muhammad Mustafa Qureshi, Osamu Sakai. 2020.
Cystic cervical lymph nodes of papillary thyroid carcinoma, tuberculosis and human papillomavirus positive oropharyngeal
squamous cell carcinoma: Comparative CT analysis for their differentiation. European Journal of Radiology 132, 109310.
[Crossref]
14. Maria Navallas, Alan Daneman, Afsaneh Amirabadi, Bo-Yee Ngan, Jonathan Wasserman. 2020. Utility of sonography for
identifying metastatic cervical adenopathy in children with differentiated thyroid carcinoma at presentation. Pediatric Radiology
20. . [Crossref]
15. Vigil James, John Samuel, Gene Yong-Kwang Ong. 2020. Point-of-Care Ultrasound for Evaluating Lymphadenopathy in the
Pediatric Emergency Department: Case Series and Review of Literature. The Journal of Emergency Medicine 59:1, 75-83.
[Crossref]
16. Philippa Anna Stilwell, Fergus Robertson, Sanjay Bhate, Alastair G Sutcliffe. 2020. A child in shock: carotid blowout syndrome.
Archives of disease in childhood - Education & practice edition 105:3, 177-184. [Crossref]
17. Alaa Elmanzalawy, Reza Vali, Govind B. Chavhan, Abha A. Gupta, Yusuf Omarkhail, Afsaneh Amirabadi, Amer Shammas.
2020. The impact of 18F-FDG PET on initial staging and therapy planning of pediatric soft-tissue sarcoma patients. Pediatric
Radiology 50:2, 252-260. [Crossref]
18. Hugo A. Heij. Lymph Node Disorders 1-10. [Crossref]
19. Sandra Butler. Head and Neck 7-76. [Crossref]
20. Suzanne Spijkers, Annemieke S. Littooij, Rutger A. J. Nievelstein. 2019. Measurements of cervical lymph nodes in children
on computed tomography. Pediatric Radiology 47. . [Crossref]
21. Mark D. Mamlouk, Christina Danial, William P. McCullough. 2019. Vascular anomaly imaging mimics and differential
diagnoses. Pediatric Radiology 49:8, 1088-1103. [Crossref]
22. Chiara Della Bella, Elisabetta Venturini, Savannah Devente, Paola Piccini, Simona Tapinassi, Leila Bianchi, Alessia Grassi,
Marisa Benagiano, Heba F. Mustafa Alnwaisri, Carlotta Montagnani, Elena Chiappini, Wilbert Bitter, Mario M. D’Elios,
 Maurizio de Martino, Luisa Galli. 2019. Role of Mycobacterium avium lysate INF-γ, IL-17, and IL-2 ELISPOT assays in
diagnosing nontuberculous mycobacteria lymphadenitis in children. European Journal of Clinical Microbiology & Infectious
Diseases 38:6, 1113-1122. [Crossref]
23. Alain Cunqueiro, William A. Gomes, Peter Lee, R. Joshua Dym, Meir H. Scheinfeld. 2019. CT of the Neck: Image Analysis
and Reporting in the Emergency Setting. RadioGraphics 39:6, 1760. [Crossref]
24. Daniela Pinto, Sílvia Costa Dias. Value-Based Radiology in Pediatric Imaging 143-157. [Crossref]
25. Paolo Indolfi, Silverio Perrotta, Francesca Rossi, Martina Di Martino, Elvira Pota, Daniela Di Pinto, Giovanna Gualdiero, Emilia
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved

Boccieri, Cristiana Indolfi, Fiorina Casale. 2019. Childhood Head and Neck Lymphadenopathy. Journal of Pediatric Hematology/
Oncology 41:1, 17-20. [Crossref]
26. Michael S. Weinstock, Neha A. Patel, Lee P. Smith. 2018. Pediatric Cervical Lymphadenopathy. Pediatrics In Review 39:9,
433-443. [Crossref]
27. Anmol Gupta Bansal, Rebecca Oudsema, Joy A. Masseaux, Henrietta Kotlus Rosenberg. 2018. US of Pediatric Superficial
Masses of the Head and Neck. RadioGraphics 38:4, 1239-1263. [Crossref]
28. . Histiocytic Necrotizing Lymphadenitis (Kikuchi-Fujimoto) 140. [Crossref]
29. S.J. Pomeroy, R. Ndikumana, J.P. Cavanagh. 2017. Lamotrigine induced lymphadenopathy: Case report and literature review.
International Journal of Pediatric Otorhinolaryngology 98, 82-84. [Crossref]
30. Reza Vali, Alaa A. Bakari, Eman Marie, Mahnaz Kousha, Martin Charron, Amer Shammas. 2017. FDG uptake in cervical
lymph nodes in children without head and neck cancer. Pediatric Radiology 47:7, 860-867. [Crossref]
31. Maria Regina Marrocos Machado, Marcos Roberto Tavares, Carlos Alberto Buchpiguel, Maria Cristina Chammas. 2017.
Ultrasonographic Evaluation of Cervical Lymph Nodes in Thyroid Cancer. Otolaryngology–Head and Neck Surgery 156:2,
263-271. [Crossref]
32. Jaehyung Lee, Eun Soo Kim, Yul Lee, Kwanseop Lee, Mi Jung Kwon, Jin Hee Moon, Hye Jeong Kim, Dae Young Yoon. 2017.
Primary Retropharyngeal Neuroblastoma in an Infant: A Case Report with Literature Review. Journal of the Korean Society
of Radiology 77:4, 258. [Crossref]
33. Sebastian K King. 2017. Lateral neck lumps: A systematic approach for the general paediatrician. Journal of Paediatrics and
Child Health 53:11, 1091. [Crossref]
34. . Histiocytic Necrotizing Lymphadenitis (Kikuchi-Fujimoto) 326-327. [Crossref]
35. Hayato Tomita, Tsuneo Yamashiro, Hirotaka Ikeda, Atsuko Fujikawa, Yoshiko Kurihara, Yasuo Nakajima. 2016. Fluid collection
in the retropharyngeal space: A wide spectrum of various emergency diseases. European Journal of Radiology 85:7, 1247-1256.
[Crossref]
36. Mai-Lan Ho, Jesse Courtier, Christine M. Glastonbury. 2016. The ABCs (Airway, Blood Vessels, and Compartments) of
Pediatric Neck Infections and Masses. American Journal of Roentgenology 206:5, 963-972. [Abstract] [Full Text] [PDF] [PDF
Plus]
37. Neil Thayil, Margaret N. Chapman, Naoko Saito, Akifumi Fujita, Osamu Sakai. 2016. Magnetic Resonance Imaging of Acute
Head and Neck Infections. Magnetic Resonance Imaging Clinics of North America 24:2, 345-367. [Crossref]
38. Derek B. Allison, James A. Miller, Stephanie F. Coquia, Zahra Maleki. 2016. Ultrasonography-guided fine-needle aspiration
with concurrent small core biopsy of neck masses and lymph nodes yields adequate material for HPV testing in head and neck
squamous cell carcinomas. Journal of the American Society of Cytopathology 5:1, 22-30. [Crossref]
39. Elena Chiappini, Angelo Camaioni, Marco Benazzo, Andrea Biondi, Sergio Bottero, Salvatore De Masi, Giuseppe Di Mauro,
Mattia Doria, Susanna Esposito, Giovanni Felisati, Dino Felisati, Filippo Festini, Renato Maria Gaini, Luisa Galli, Claudio
Gambini, Umberto Gianelli, Massimo Landi, Marco Lucioni, Nicola Mansi, Rachele Mazzantini, Paola Marchisio, Gian Luigi
Marseglia, Vito Leonardo Miniello, Marta Nicola, Andrea Novelli, Marco Paulli, Marina Picca, Marta Pillon, Paolo Pisani,
Carlotta Pipolo, Nicola Principi, Iacopo Sardi, Giovanni Succo, Paolo Tomà, Enrico Tortoli, Filippo Tucci, Attilio Varricchio,
Maurizio de Martino, Italian Guideline Panel for the Man. 2015. Development of an algorithm for the management of cervical
lymphadenopathy in children: consensus of the Italian Society of Preventive and Social Pediatrics, jointly with the Italian
Society of Pediatric Infectious Diseases and the Italian Society of Pediatric Otorhinolaryngology. Expert Review of Anti-infective
Therapy 13:12, 1557-1567. [Crossref]
40. Tara L. Rosenberg, Abby R. Nolder. 2014. Pediatric Cervical Lymphadenopathy. Otolaryngologic Clinics of North America 47:5,
721-731. [Crossref]
41. O. Kenechi Nwawka, Rohini Nadgir, Akifumi Fujita, Osamu Sakai. 2014. Granulomatous Disease in the Head and Neck:
Developing a Differential Diagnosis. RadioGraphics 34:5, 1240-1256. [Crossref]
Downloaded from www.ajronline.org by 212.174.9.6 on 03/01/22 from IP address 212.174.9.6. Copyright ARRS. For personal use only; all rights reserved

567-570. [Crossref]
42. Abby R. Nolder. 2013. Paediatric cervical lymphadenopathy. Current Opinion in Otolaryngology & Head and Neck Surgery 21:6,