Beyond infancy, the techniques for examining the neck are the same as for adults. Lymphadenopathy is unusual during infancy but very common during childhood. The child's lymphatic system reaches its zenith of growth at 12 years, and cervical or tonsillar lymph nodes reach their peak size between 8 and 16 years.

The vast majority of enlarged lymph nodes in children are due to infections (mostly viral, but sometimes bacterial) and not due to malignant disease, even though the latter is a concern for many parents. It is important to differentiate normal lymph nodes from abnormal ones or from congenital cysts of the neck.

Check for neck mobility. It is important to ensure that the neck of all children is supple and easily mobile in all directions. This is particularly important when the patient is holding the head in an asymmetric manner and when central nervous system disease such as meningitis is suspected.

In children, the presence of nuchal rigidity is a more reliable indicator of meningeal irritation than Brudzinski sign or Kernig sign. To detect nuchal rigidity in older children, ask the child to sit with legs extended on the examining table. Normally, children should be able to sit upright and touch their chins to their chests. Younger children can be persuaded to flex their necks by having them follow a small toy or light beam. You also can test for nuchal rigidity with the child lying on the examining table, as shown in Figure 1. Nearly all children with nuchal rigidity will be extremely sick, irritable, and difficult to examine. In many countries the incidence of bacterial meningitis has plummeted because of vaccinations.

FIGURE 1. Inspect the neck for nuchal rigidity.

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