1. Cervical lymphadeopthy
Dr. Maitham H Kenber
General surgeon

2. 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.

3. 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.

4. 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)

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

6. The vertical group include:
> superficial (along external jugular vein)
> deep (along internal jugular vein)
> Prelaryngeal
> Pretracheal
> Paratracheal

12. cont’d

13. Deep cervical lymph node
cont’d
Intra-

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

19. Base of skull
Bifurcation of carotid
or hyoid bone
Inferior border of cricoid
cartilage or omohyoid muscle
clavicle

21. 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

22. 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

23. Causes of lymphadenopathy

24. 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)

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

26. 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 ).

27. 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

28. 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

29. 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

37. Thank you .