1. Approach to a Patient with Lymphadenopathy

2. Lymphadenopathy Enlargement of the lymph nodes.
Can be considered normal: 1) soft, flat, submandibular nodes (<1cm) in healthy children and young adults; 2) palpabale inguinal lymph nodes of up to 2cm in diameter in healthy adults.
May be a primary or secondary manifestation of numerous disorders, both benign and malignant.

3. Clinical Assessment Medical History Physical Examination
Laboratory Tests
Excisional LN Biopsy

4. Medical History
Reveals the setting in which lymphadenopathy is occuring.
General information, accompanying symptoms, personal and social history.
Ex.: viral/bacterial URTI, toxoplasmosis, TB benign disorders in children and young adults; if>50 y/o increase incidence of malignant disorder.

5. Physical Examination
Extent of lymphadenopathy ( localized or generalized), size, texture, presence/ absence of tenderness, signs of inflammation over the node, skin lesions, and splenomegaly.
ENT exam indicated in an adult patient with cervical lymphanedopathy with history of tobacco use.

6. Extent of Lymphadenopathy
Localized/regional- involvement of a single anatomic site.
Generalized- involvement of 3 or more non-contiguous lymph node areas; usually indicates non- malignant disorder (except for ALL, CLL, and malignant lymphomas.)

7. Site of Localized Adenopathy
Occipital
Preauricular
Neck
Supraclavicular and scalene
Virchow’s nodes
Axillary
Inguinal

8. Size of the Node <1.0 cm2 –benign; non-specific causes.
>2.0 cm/ >2.25cm2 -malignant or granulomatous disease.

9. Texture and Presence of Pain
Acute leukemia- pain in nodes due to rapid enlargement.
Lymphoma- large, discrete, symmetric, rubbery, firm, and non-tender.
Metastatic cancer- hard, non-tender, and non moveable.
W/ splenomegaly- systemic illness (IM, lymphoma, acute or chronic leukemia, etc.)

10. Thoracic Adenopathy
Detected by CXR or work-up for superficial adenopathy.
May cause coughing/wheezing, hoarseness, dysphagia, and/or swelling of the face and neck.
Due to a primary lung disorder or systemic illness.

11. Abdominal and Retroperitoneal Adenopathy
Usually malignant.
TB mesenteric lymphadenitis; lymphoma; GCT in young men.

12. Laboratory Investigation
CBC
Serology
CXR
CT and MRI
Ultrasound

13. Lymph Node Biopsy Done if PE findings suggest malignancy.
Biopsy evident primary lesion first.
FNAB- not to be used as primary diagnostic procedure; for thyroid nodules or confirmation of relapse in patient whose primary diagnosis is known.
Guidelines: Older patients (>40y/o), large LN (>2.25cm2 ), hard and non-tender

14. Follow-up and Treatment
Follow-up at 2-4 weeks interval for benign causes.
Antibiotics are given only if there is strong evidence of bacterial infection.
DO NOT USE GLUCOCORTICOIDS-might obscure diagnosis or delay healing in cases of infection (EXCEPTION: life-threatening pharyngeal obstruction by enlarged lymph tissue in Waldeyer’s ring caused by IM.)