Cervical lymphadenopathy

Cervical lymphadeopthy

Dr. Maitham H Kenber
General surgeon

Definition

Lymphadenopathy refers to nodes that are abnormal in either size, consistency or number.
"generalized" if lymph nodes are enlarged in two or more noncontiguous areas
"localized" if only one area is involved.
Generalized lymphadenopathy almost always indicates the presence of a significant systemic disease.

General principles

Mostly diagnosed on the basis of a careful history and physical examination.
Localized adenopathy should prompt a search for an adjacent precipitating lesion.
In general, cervical, axillary lymph nodes greater than 1 cm and inguinal > 1.5 cm in diameter are considered to be abnormal.
Generalized adenopathy should always prompt further clinical investigation.

Lymph node anatomy

Normal lymph nodes are composed of a cortex and a medulla covered by a fibrous capsule
Each lymph node contains a main artery that enters at the hilus and branches into multiple arterioles.


Cortex contains tightly packed lymphocytes and is hypoechoic (u/s).

Medulla is made of trabeculae and medullary cords and sinuses and is echogenic (u/s)

Right & left groups
each divided into: horizontal (circular) and vertical
• The horizontal group include:
• > sub-mental
• > sub-mandibular
• > parotid
• > pre-auricular
• > post-auricular
• > occipital

• The vertical group include:

• > superficial (along external jugular vein)
• > deep (along internal jugular vein)
• > Prelaryngeal
• > Pretracheal
• > Paratracheal

• cont’d

Deep cervical lymph node

• cont’d

• Intra-

• Deep cervical lymph nodes cont’d
• - Retropharyngeal
• - Paratracheal
• - Infrahyoid
• - Prelaryngeal
• - Pretracheal
•

•

Base of skull

Bifurcation of carotid
or hyoid bone
Inferior border of cricoid
cartilage or omohyoid muscle
clavicle

Zones Landmarks and Nodal Group

IA Midline; anterior to the digastric muscle and superior to the hyoid bone. Submental -

IB Lateral to zone IA but medial or anterior to the submandibular gland Submandibular nodes

IIA Anterior or medial to the internal jugular vein but lateral/posterior to the submandibular gland; superior to the hyoid bone Upper internal jugular chain; more superiorly, the parotid nodes

IIB Posterior to the internal jugular vein Upper internal jugular chain; more superiorly, the parotid nodes

III From the level of the hyoid bone inferiorly to the cricoid arch; lateral to the common carotid artery Middle internal jugular chain

IV From the level of the cricoid arch inferiorly to the level of the clavicle; lateral to the common carotid artery Lower internal jugular chain

VA Posterior to the sternocleidomastoid muscle, from the base of the skull to the cricoid arch Supraclavicular fossa/posterior triangle (spinal accessory chain and transverse cervical chain) -

VB Posterior to the sternocleidomastoid muscle from the cricoid arch to the level of the clavicle Supraclavicular fossa/posterior triangle (spinal accessory chain and transverse cervical chain)

VI Anterior/medial to the common carotid arteries from the level of the hyoid to the manubrium Anterior cervical nodes, pre- and paratracheal

VII Anterior/medial to the common carotid arteries, inferior to the sternal notch Anterior, upper mediastinal nodes
Supraclavicular Lateral to the common carotid artery; at or inferior to the clavicle Supraclavicular nodes


Causes of lymphadenopathy

Medications That May Cause Lymphadenopathy

Allopurinol (Zyloprim) Atenolol (Tenormin) Captopril (Capozide) Carbamazepine (Tegretol) Cephalosporins Gold Hydralazine (Apresoline)
Penicillin Phenytoin (Dilantin) Primidone (Mysoline) Pyrimethamine (Daraprim) Quinidine Sulfonamides Sulindac (Clinoril)

How to evaluate

Thorough history and complete head and neck examination after assuring there is no other region involvement to exclude generalized lymphadenopathy

Physical examination

The following characteristics should be noted and described:
Location
Size. normal if < 1 cm in diameter;
Overlying skin color if red indicate acute lymphadenitis
Pain/Tenderness. inflammatory process or suppuration, hemorrhage into the necrotic center of a malignant node.
Consistency. Stony-hard nodes: cancer, usually metastatic.
Very firm, rubbery nodes: lymphoma.
Softer nodes: infections or inflammatory conditions.
Suppurant nodes may be fluctuant.
"shotty" (small nodes that feel like buckshot under the skin) cervical nodes of children with viral illnesses.
Matting. benign (e.g., tuberculosis, sarcoidosis)
malignant (e.g., metastatic carcinoma ).


PALPATION :
Number, size , tenderness , local temp , surface margins , consistency , fixation to underlying tissues
Acute infection --- large, soft, painful, mobile,
Lymphoma --- rubbery , discrete, painless and multiple
Metastatic cancer --- hard, fixed to the underlying tissues, painless.
Tuberculosis- Stage I: Lymph nodes enlarged without matting
• Stage II: Lymph nodes enlarged and matted
• Stage III: Cold abscess

LYMPH NODE EXAMINATION

Pt relaxed & unstrained position without head support

Depending on site

Bilateral ---- behind pt
Unilateral ---- front of pt

Palpation is done by placing flat surface of finger tips at same position on both sides

Commencing with most superior nodes & working down to the clavicle

Blood tests

WBC count and differential count, ESR, blood film and serology test (e.g. AIDS , toxoplasmosis etc)
Ultrasonography
Upper aerodigestive tree endoscopy ( nasopharynx , larynx and hypopharynx)
Computed Tomography
PET
MRI
FNAC +/- flow cytometry


BIOPSY

INVESTIGATIONS

Thank you

.