Cervical Lympadenopathy

04/07/2304/07/23 Abou-ElhamdAbou-Elhamd 11


Cervical LymphadenopathyCervical Lymphadenopathy

Dr. Kamal Abou-Elhamd MDDr. Kamal Abou-Elhamd MD Professor in ENTProfessor in ENT

Al-Ahsa College of MedicineAl-Ahsa College of MedicineKing Faisal UniversityKing Faisal University

Email: Email: [email protected]@yahoo.comWebsite: Website: www.geocities.com/kamal375/papers.htmlwww.geocities.com/kamal375/papers.html

mailto:[email protected]

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Outlines of the topicOutlines of the topic1. Introduction2. Surgical anatomy of the neck3. The lymphatic system of the neck4. Clinical assessment of the lymph nodes5. Causes of cervical lymphadenopathy6. Differential diagnosis of cervical lymphadenopathy7. Investigations8. Treatment of it9. Conclusion


IntroductionIntroduction



Many patients worry about the cause of their abnormal lymph nodes

There are more than 800 lymph nodes in the human body, approximately 300 of them are located in the neck

About 38% to 45% of healthy children have palpable cervical lymph nodes

Cervical lymphadenopathy is usually defined as cervical lymph nodal tissue measuring more than 1 cm in diameter



Although, it is viral or bacterial in most of cases, The presence of a metastatic node on one side of the neck reduces the 5-year survival rate of 50%, and the presence of a metastatic node on both sides of the neck reduces the survival rate to 25%

The disease can present at any age but is more prevalent in adolescents and young adults.

The male to female ratio is 2:1. It usually presents as painless rubbery

lymphadenopathy involving the superficial lymph node groups.


Surgical anatomy of the neckSurgical anatomy of the neck

The divisions of the neck: The posterior triangle: is bounded by the anterior

border of the trapezius ms, the middle third of the clavicle and the posterior border of the sterno-mastoid muscle

The anterior triangle: the posterior border of the sterno-mastoid ms, the mandible and the midline of the neck



The two divisions of the neck are divided into six subdivisions:

The posterior triangle: by the inferior belly of omohyoid ms into:

a) The occipital triangle aboveb) The supraclavicular triangle below2. The anterior triangle:a) Submental triangleb) Submandibular trianglec) Muscular triangled) Carotid triangle



Fascial spaces of the neck is divided by: Superficial fascia: superficial to platysma ms Three layers of deep fascia:a) Investing external layer: investing trapezius ms,

sterno-mastoid ms, carotid sheath, submandibular & parotid glands

b) Visceral middle layer: surrounds pharynx, larynx, oesophagus, trachea & thyroid gland

c) Internal prevertebral layer: surrounds the deep ms of the neck


The lymphatic system of the neckThe lymphatic system of the neck

1. Superficial system: divided into 2 circlesa) Head circle: occipital, retro-auricular, parotid and

buccal lymph nodes draining scalp & faceb) Neck circle: submental, submandibular, superficial

cervical along the external jugular vein and anterior cervical nodes along the anterior jugular vein

c) Deep system: deep cervical lymph nodes




The cervical lymph nodesThe cervical lymph nodes

1. Submental & submandibular lymph nodes at level I2. Around upper third of the internal jugular vein from skull

base to carotid bifurcation at level II3. Around middle third of the internal jugular vein from

carotid bifurcation to cricothyroid notch at level III4. Around lower third of the internal jugular vein from

cricothyroid notch to clavicle at level IV5. Posterior triangle nodes at level V6. Anterior cervical nodes at level VI


Simplified numerical Simplified numerical classification systemclassification system

Level Location1. IA Submental lymph nodes2. IB Submandibular lymph nodes3. II Internal jugular (deep cervical) chain from the base of the skull to

the inferior border of the hyoid bone:A anterior to XI nerve, B Post4. III Internal jugular (deep cervical) chain from the hyoid bone to the

inferior border of the cricoid arch5. IV Internal jugular (deep cervical) chain between

the inferior border of the cricoid arch and the supraclavicular fossa

6. V Posterior triangle or spinal accessory nodes: A above inferior border of cricoid, B below this level

7. VI Central compartment nodes from the hyoid bone to the suprasternal notch

8. VII Nodes inferior to the suprasternal notch in the upper mediastinum


Clinical assessment of the cervical Clinical assessment of the cervical lymph nodeslymph nodes

1. History of neck swelling:Key questions for history-taking• How long has the node been noticeably enlarged?• Is the node changing in size with time?• Has the node been painful?• Is the patient systemically unwell?• Has there been a recent upper respiratory tract infection?• Is there difficulty in swallowing?• Have there been any rashes or skin lesions in the drainage

area of the node?



1. History of neck swelling:Key questions for history-taking• Has there been exposure to cats, pets, wild animals or raw/undercooked meat?• Has the patient travelled?• Has there been exposure to tuberculosis?• Is the patient taking medications?• What is the status of the teeth?• Have there been many previous infections suggestive of animmune deficiency syndrome?• If the patient is child, has he had recent immunizations?



1. History of neck swelling:Key questions for history-taking Fever, sore throat, and cough suggest an upper respiratory

tract infection Fever, night sweats & weight loss suggests TB or

lymphoma Unexplained fever, fatigue, and arthralgia raise the

possibility of a collagen vascular disease or serum sickness

Lymphadenopathy resulting after blood transfusion suggests cytomegalovirus, EBV, or HIV infection.



2. Clinical examination: all regions of the neck should be examined from behind the patient using both hands to palpate each side of the neck simultaneously starts with:

a) the submental & submandibular triangles, then b) the neck anterior to sterno-mastoid passing from

above downwards, the supraclavicular fossa, then c) upwards into the posterior triangle and d) forwards across the sterno-mastoid ms to the nodes

of the anterior triangle




Key features on clinical examination• Size: 1-2cm nodes (8% cancer), more than 2cm (35% cancer) & for

staging• Site: which node(s) are affected?• Mobility• Fixation• Tenderness: Pain is usually the result of an inflammatory process or

suppuration • Redness and warmth• Consistency: Stony-hard nodes are typically a sign of cancer, usually

metastatic. Very firm, rubbery nodes suggest lymphoma. Softer nodes are the result of infections

• Matting (coalescence of several nodes resulting in a larger mass): matted nodes can be either benign (e.g., tuberculosis or sarcoidosis) or malignant (e.g., metastatic carcinoma or lymphomas).



Key features on clinical examination

Examine the region drained by the nodes for evidence of infection, skin lesions or tumors

Are there any systemic signs present such as generalized lymphadenopathy or hepatosplenomegaly?



Key features on clinical examination Weight loss is with TB or malignancy Lymphoma or leukemia is more with generalized

lymphadenopathy Acute posterior cervical lymphadenitis is

classically seen in persons with rubella and infectious mononucleosis

Bilateral & soft small nodes & no overlying skin changes with viral infection



Key features on clinical examination Unilateral & tender nodes and overlying skin erythema

with bacterial infection Matted, painless & fluctuant nodes & adherent

discoloured overlying skin with TB Fluctuant painful nodes with staph. infection Hard or fixed nodes with malignancy Hepatosplenomegally is with cytomegalovirus, infectious

mononucleosis, leukemia or lymphoma Skin rash is with cytomegalovirus, rubella, Kawasaki Chorioretinitis suggests toxoplasmosis while

conjunctivitis suggests Kawasaki


Worrying features of enlarged nodesWorrying features of enlarged nodes

Onset in the neonatal period Rapid and progressive growth Skin ulceration Fixation to skin or deep fascia Mass larger than 3 cm with firm or hard

consistency Inflammatory mass >3 cm present for >6 weeks,

despite


Causes of cervical lymphadenopathyCauses of cervical lymphadenopathy

A. Infection1. Viral2. Bacterial3. ProtozoalB. Malignancies (1%): 25% of malignancy in children

occur in head & neck especially CL1. Neuroblastoma2. Leukemia3. Lymphoma:4. RhabdomyosarcomaC. Miscellaneous



1. Virala. Viral upper respiratory infectionb. Epstein-Barr virusc. Cytomegalovirusd. Rubellaf. Varicella-zoster virusg. Herpes simplexh. CoxsackievirusI. Human immunodeficiency virus



2. Bacteriala. Staphylococcus aureusb. Group A β-hemolytic streptococcic. Anaerobesd. Diphtheriae. Cat-scratch disease: Bartonella henslaef. Tuberculosis: 10% of ped. CL

3. Protozoala. Toxoplasmosis: CL is the sole presentation in 50% of

cases




C. Miscellaneous1. Kawasaki disease2. Collagen vascular diseases3. Serum sickness4. Drugs: phenytoin and isoniazid5. Postvaccination: diphtheria-pertussis-tetanus,

poliomyelitis, or typhoid fever vaccine6. Rosai-Dorfman disease7. Kikuchi-Fujimoto disease


Differential diagnosis of Differential diagnosis of cervical lymphadenopathycervical lymphadenopathy

Mumps: crosses the angle of jaw Thyroglossal cyst: moves with swallowing & tongue protrusion Branchial cleft cyst: fluctuant along lower anterior border of

sterno-mastoid ms Sternomastoid tumor: hard mass moves side to side and not up

down Cervical rib: bilateral hard & immovable Cystic hygroma: compessible mass Hemangioma: red or bluish mass Laryngocele: compressible mass increases with Valsalva’s

maneuvre Dermoid cyst: midline mass



InvestigationsInvestigations

1. CBC: a) Leucocytosis in bacterial infectionb) Atypical lymphocytosis is prominent in

infectious mononucleosisc) Pancytopenia or the presence of blast cells

suggests leukemia2. Skin tests for tuberculosis3. Chest radiography and serologic tests for EBV,

cytomegalovirus, and toxoplasmosis


InvestigationsInvestigations4. Ultrasonography and computed tomography might help to

differentiate a solid from cystic mass and to establish the presence and extent of suppuration or infiltration.

5. Fine-needle aspiration and culture of a lymph node to isolate the causative organism. All aspirated material should be sent for both gram and acid-fast stain and cultures for aerobic and anaerobic bacteria, mycobacteria, and fungi

(ultrasound-guided core biopsy)6. An excisional biopsy (3%) with microscopic examination of the

lymph node to establish the diagnosis if there are symptoms or signs of malignancy (advanced age, large swollen lymph nodes or high levels of serum sIL-2r (soluble interleukin-2 receptor) or LDH (lactate dehydrase))


Contrast-enhanced CT shows left level IIlymphadenopathy (white arrow). Level II nodes areinternal jugular nodes above the level of the hyoidbone. Note the carcinoma (red arrow) in the tonguebase.


Treatment Treatment Treatment of cervical lymphadenopathy depends on

the underlying cause. Most cases of lymphadenopathy are self-limited and

require no treatment other than observation The treatment of acute bacterial cervical

lymphadenitis appropriate oral antibiotics include cloxacillin, cephalexin, or clindamycin.

Failure of regression after 4 to 6 weeks might be an indication for a diagnostic biopsy


Infective lymphadenitisInfective lymphadenitis

They are acute soft tender lateral neck swellings

There is primary site of infection such as tonsillitis and fever

They disappear with systemic antibiotics


TuberculosisTuberculosis

They are chronic multiple painless large lateral neck swellings

There are associated symptoms such as night sweats and weight loss

Fine needle aspiration cytology (FNAC) may detect alcohol and acid fast bacilli

Treatment is by surgical excision


LymphomaLymphoma There is one or more slow growing bean-sized rubbery lateral

neck nodes There are associated symptoms such as night sweats and

weight loss Careful examination shows enlarged other body lymph node

groups Liver and spleen may be large It usually affects young and middle-aged adults Diagnosis is by surgical excisional biopsy of one of these

nodes and should be sent fresh Treatment depends on staging either radiotherapy or

chemotherapy


Metastatic lymphadenopathyMetastatic lymphadenopathy Up to 80% of patients with upper aerodigestive

malignancy will have cervical metastasis at presentation

It is single or multiple hard painless lateral neck swelling of short duration

There is history of smoking or and alcohol drinking There are symptoms of upper aerodigestive tract

affection such as dysphagia, hoarseness of voice or otalgia

Treatment should be in conjunction with the primary Surgical neck dissection is the usual treatment with

postoperative radiotherapy


Metastatic lymphadenopathy stagingMetastatic lymphadenopathy staging

Stage N1 denotes involvement of a single ipsilateral node 3 cm or less in diameter

Stage N2a denotes involvement of a single ipsilateral node between 3 and 6 cm in diameter

Stage N2b denotes involvement of multiple ipsilateral nodes not more than 6 cm in diameter

Stage N2c denotes involvement of ipsilateral and contralateral nodes not more than 6 cm in diameter

Stage N3 denotes involvement of one or more nodes larger than 6 cm in diameter


Occult primaryOccult primaryWhen there is hard lump in the neck of middle aged or

elderly patient, we consider it either primary or secondary mass from one of the following sites:

Nasopharynx Tonsil Tongue base or oral cavity Thyroid gland Supraglottic larynx Pyriform fossa Distant sites: bronchus, breast, stomach or esophagus


Occult primaryOccult primarySo, we perform panendoscopy to search for the primary: Nasopharyngoscopy Laryngoscopy Bronchoscopy Pharyngo-oesophagoscopy Lastly, Fine needle aspiration cytology (FNAC) of the

node In one third the primary is detected clinically and in

another one third, it is detected by investigations and the last one third is difficult to detect


Kawasaki diseaseKawasaki diseaseKD is a systemic vasculitis of unknown etiology that

occurs commonly in children under 5 years of age and results in coronary artery abnormalities (CAA) in 15 – 25% of untreated children

1. Cervical lymphadenopathy2. Bilateral bulbar conjunctival injection3. Changes in the mucosa of the oropharynx 4. Erythema or edema of the peripheral extremities5. Polymorphous rashTtt by i.v. gammaglobulin


Rosai-Dorfman diseaseRosai-Dorfman disease

It is a benign form of histiocytosis affects children in the first decade of life characterized by:

1. Massive and painless cervical lymphadenopathy2. Fever 3. Neutrophilic leukocytosis4. Polyclonal hypergammaglobulinemiaThe lymph nodes undergo spontaneous regression with

timeCorticosteroids, a variety of chemotherapeutic agents,

immunosuppressants such as cyclosporin, and radiotherapy are the medical treatment.


Kikuchi-Fujimoto diseaseKikuchi-Fujimoto diseaseNecrotizing lymphadenitis affects young Japanese femalesIt is most common in eastern AsiaThe aetiology remains unclear but certain infective agents,

including EBV and parvovirus B19, have been proposed1. Fever2. Cervical lymphadenopathy3. Nausea 4. Weight loss5. Night sweats6. Arthralgia 7. HepatosplenomegalyIt is self-limiting disease


ConclusionConclusion Enlargement of cervical lymph nodes is a common

childhood pathology. Bacterial and viral infections are the most common

causes of lymphadenopathy. Supraclavicular or posterior cervical lymphadenopathy

carries a much higher risk for malignancies than does anterior cervical lymphadenopathy.

Ultrasonographic imaging is extremely helpful in diagnostics, differentiation and following the treatment of lymphadenopathy.


ConclusionConclusion Excisional node biopsy is indicated after three- to four-

week period of observation in patients with unexplained unworried large cervical nodes or earlier for those with risk factors for malignancy .

Fine-needle aspiration is considered an alternative to excisional biopsy but often yields a high number of nondiagnostic results because of the small amount of tissue obtained and there is some risk of sinus tract formation.

Most cases of lymphadenopathy are self-limited and require no treatment.



Disorder Associated findings Test

Epstein-Barr virus* Splenomegaly in 50% of patients Monospot, IgM EA or VCA

Toxoplasmosis* 80 to 90% of patients are asymptomatic

IgM toxoplasma antibody

Cytomegalovirus* Often mild symptoms; patients may have hepatitis

IgM CMV antibody, viral culture of urine or blood

Initial stages of HIV infection*

"Flu-like" illness, rash HIV antibody

Cat-scratch disease Fever in one third of patients; cervical or axillary nodes

Usually clinical criteria; biopsy if necessary

Tuberculosis lymphadenitis*

Painless, matted cervical nodes PPD, biopsy

Lymphoma* Fever, night sweats, weight loss in 20 to 30% of patients

Biopsy

Leukemia* Blood dyscrasias, bruising Blood smear, bone marrow

Kawasaki disease* Fever, conjunctivitis, rash, mucous membrane lesions

Clinical criteria

EA=early antibody; VCA=viral capsid antigen; CMV=cytomegalovirus; HIV=human immunodeficiency virus; PPD=purified protein derivative; RPR=rapid plasma reagin;


Dr. Kamal Abou-Elhamd MDDr. Kamal Abou-Elhamd MD Professor in ENTProfessor in ENT

Al-Ahsa College of MedicineAl-Ahsa College of MedicineKing Faisal UniversityKing Faisal University

Email: Email: [email protected]@yahoo.comWebsite: Website: www.geocities.com/kamal375/papers.htmlwww.geocities.com/kamal375/papers.html

Thank YouThank You

Cervical LymphadenopathyCervical Lymphadenopathy

mailto:[email protected]

http://www.geocities.com/kamal375/papers.html

Cervical Lympadenopathy

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