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Abou-Elhamd

Cervical Lymphadenopathy

Dr. Kamal Abou-Elhamd MD Professor in ENT Al-Ahsa College of Medicine King Faisal University
04/28/12

Email: Kamal375@yahoo.com Website: www.geocities.com/kamal375/papers.html Abou-Elhamd

Outlines of the topic

1. 2. 3. 4. 5. 6. 7. 8. 9. Introduction Surgical anatomy of the neck The lymphatic system of the neck Clinical assessment of the lymph nodes Causes of cervical lymphadenopathy Differential diagnosis of cervical lymphadenopathy Investigations Treatment of it Conclusion
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Introduction

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Introduction
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
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Introduction
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.
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Surgical 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 sternomastoid muscle The anterior triangle: the posterior border of the sterno-mastoid ms, the mandible and the midline of the neck
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Surgical anatomy 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 above b) The supraclavicular triangle below 2. The anterior triangle: a) Submental triangle b) Submandibular triangle c) Muscular triangle d) Carotid triangle
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Surgical anatomy of the neck

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 04/28/12 the neck Abou-Elhamd 9

The lymphatic system of the neck

1. Superficial system: divided into 2 circles a) Head circle: occipital, retro-auricular, parotid and buccal lymph nodes draining scalp & face b) 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
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The cervical lymph nodes

1. Submental & submandibular lymph nodes at level I 2. Around upper third of the internal jugular vein from skull base to carotid bifurcation at level II 3. Around middle third of the internal jugular vein from carotid bifurcation to cricothyroid notch at level III 4. Around lower third of the internal jugular vein from cricothyroid notch to clavicle at level IV 5. Posterior triangle nodes at level V 6. Anterior cervical nodes at level VI
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Simplified numerical classification system

Level Location 1. IA Submental lymph nodes 2. IB Submandibular lymph nodes 3. 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 Post 4. III Internal jugular (deep cervical) chain from the hyoid bone to the inferior border of the cricoid arch 5. 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 Abou-Elhamd 14 8. 04/28/12 VII Nodes inferior to the suprasternal notch in the upper mediastinum

Clinical assessment of the cervical lymph 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 04/28/12the node? Abou-Elhamd 15

Clinical assessment of the cervical lymph nodes

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 an immune deficiency syndrome? 04/28/12 Abou-Elhamd If the patient is child, has he had recent immunizations? 16

Clinical assessment of the cervical lymph nodes

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.
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Clinical assessment of the cervical lymph nodes

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
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Clinical assessment of the cervical lymph nodes

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 04/28/12 Abou-Elhamd 20 malignant (e.g., metastatic carcinoma or lymphomas).

Clinical assessment of the cervical lymph nodes

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?
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Clinical assessment of the cervical lymph nodes

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
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Clinical assessment of the cervical lymph nodes

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
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Worrying 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
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Causes of cervical lymphadenopathy

A. Infection 1. Viral 2. Bacterial 3. Protozoal B. Malignancies (1%): 25% of malignancy in children occur in head & neck especially CL 1. Neuroblastoma 2. Leukemia 3. Lymphoma: 4. Rhabdomyosarcoma C. Miscellaneous
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Causes of cervical lymphadenopathy

1. Viral a. Viral upper respiratory infection b. Epstein-Barr virus c. Cytomegalovirus d. Rubella f. Varicella-zoster virus g. Herpes simplex h. Coxsackievirus I. Human immunodeficiency virus
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Causes of cervical lymphadenopathy

2. Bacterial a. Staphylococcus aureus b. Group A -hemolytic streptococci c. Anaerobes d. Diphtheria e. Cat-scratch disease: Bartonella henslae f. Tuberculosis: 10% of ped. CL 3. Protozoal a. Toxoplasmosis: CL is the sole presentation in 50% of cases
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Causes of cervical lymphadenopathy

C. Miscellaneous 1. Kawasaki disease 2. Collagen vascular diseases 3. Serum sickness 4. Drugs: phenytoin and isoniazid 5. Postvaccination: diphtheria-pertussis-tetanus, poliomyelitis, or typhoid fever vaccine 6. Rosai-Dorfman disease 7. Kikuchi-Fujimoto disease
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Differential diagnosis of cervical 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 Valsalvas maneuvre Dermoid cyst: midline mass
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Investigations
1. CBC: a) Leucocytosis in bacterial infection b) Atypical lymphocytosis is prominent in infectious mononucleosis c) Pancytopenia or the presence of blast cells suggests leukemia 2. Skin tests for tuberculosis 3. Chest radiography and serologic tests for EBV, cytomegalovirus, and toxoplasmosis
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Investigations
4. 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))
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Contrast-enhanced CT shows left level II lymphadenopathy (white arrow). Level II nodes are internal jugular nodes above the level of the hyoid bone. Note the carcinoma (red arrow) in the tongue base.
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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
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Infective 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

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Tuberculosis
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
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Lymphoma
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

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Metastatic 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
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Metastatic 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

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Occult primary
When 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
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Occult primary
So, 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
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Kawasaki disease
KD 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 lymphadenopathy 2. Bilateral bulbar conjunctival injection 3. Changes in the mucosa of the oropharynx 4. Erythema or edema of the peripheral extremities 5. Polymorphous rash Ttt by i.v. gammaglobulin
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Rosai-Dorfman disease
It is a benign form of histiocytosis affects children in the first decade of life characterized by: 1. Massive and painless cervical lymphadenopathy 2. Fever 3. Neutrophilic leukocytosis 4. Polyclonal hypergammaglobulinemia The lymph nodes undergo spontaneous regression with time Corticosteroids, a variety of chemotherapeutic agents, immunosuppressants such as cyclosporin, and radiotherapy are the medical treatment.
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Kikuchi-Fujimoto disease
Necrotizing lymphadenitis affects young Japanese females It is most common in eastern Asia The aetiology remains unclear but certain infective agents, including EBV and parvovirus B19, have been proposed 1. Fever 2. Cervical lymphadenopathy 3. Nausea 4. Weight loss 5. Night sweats 6. Arthralgia 7. Hepatosplenomegaly It is self-limiting disease
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Conclusion
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.
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Conclusion
Excisional node biopsy is indicated after three- to fourweek 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.
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Epstein-Barr virus* Toxoplasmosis* Cytomegalovirus* Initial stages of HIV infection* Cat-scratch disease

Splenomegaly in 50% of patients 80 to 90% of patients are asymptomatic Often mild symptoms; patients may have hepatitis "Flu-like" illness, rash
Associated findings Disorder Test

Monospot, IgM EA or VCA IgM toxoplasma antibody IgM CMV antibody, viral culture of urine or blood HIV antibody

Fever in one third of patients; cervical Usually clinical criteria; biopsy or axillary nodes if necessary PPD, biopsy

Tuberculosis lymphadenitis* Painless, matted cervical nodes Lymphoma* Leukemia* Kawasaki disease*

Fever, night sweats, weight loss in 20 Biopsy to 30% of patients Blood dyscrasias, bruising Fever, conjunctivitis, rash, mucous membrane lesions Blood smear, bone marrow Clinical criteria

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

Thank You
Dr. Kamal Abou-Elhamd MD Professor in ENT Al-Ahsa College of Medicine King Faisal University
04/28/12

Email: Kamal375@yahoo.com Website: www.geocities.com/kamal375/papers.html Abou-Elhamd

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