Diagnostic Approach for Bilateral Neck Swellings in Children

Rationale for FNA as First-Line Diagnostic Approach

Fine needle aspiration (FNA) of one side is the most appropriate initial diagnostic step for a child presenting with bilateral neck swellings that are mostly lymph nodes, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
FNA is a simple, quick, and minimally invasive technique that is an excellent screening tool in pediatric patients, where congenital etiologies should be considered alongside infectious and malignant causes 2

The American Academy of Otolaryngology-Head and Neck Surgery guidelines consider FNA in parallel with imaging for timing of diagnostic evaluation 5
FNA can be performed in an outpatient setting and is well-tolerated by most patients, allowing for rapid referral of suspected malignancies to tertiary care centers when needed 1

CT with IV contrast should not be the initial diagnostic step in children suspected of having malignancy or deep neck infection, as it exposes the child to radiation and cannot provide definitive tissue diagnosis 2, 3
Excisional or incisional biopsy is more invasive and carries higher risks than FNA, and bilateral biopsies would subject the child to unnecessary surgical procedures when a unilateral FNA might provide sufficient diagnostic information 1, 4

Ultrasound guidance can increase specimen adequacy, especially for cystic or necrotic masses, and on-site evaluation by a cytopathologist can reduce the inadequacy rate of FNA 1
If lymphoma is strongly suspected based on clinical findings, core needle biopsy may be considered as it has higher sensitivity than FNA for lymphoma diagnosis 1

If FNA results are inadequate or indeterminate, repeat FNA should be attempted before resorting to open biopsy, and for cases where FNA suggests malignancy, appropriate imaging studies can then be performed to guide further management 1, 2, 3