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 ).

Tuberculosis- Stage I: Lymph nodes enlarged without matting 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

INVESTIGATIONS 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

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