CERVICAL LYMPHADENOPATHY

1. CERVICAL LYMPHADENOPATHY Prof. SHANMUGASUNDARAM. P.N Professor and Head Department of General Surgery Kilpauk medical college

2. Introduction • Enlarged lymph nodes is one of the common presentation in head and neck patients. • Though they are easily recognizable, considerable clinical skill and expertise is required to categorize these swellings and manage them appropriately. • Recent advances in imaging have considerably improved the diagnostic and therapuetic facility for these patients.

3. definition • Cervical lymphadenitis is defined as enlarged, inflamed, and tender lymph node(s) of the neck. • Cervical lymphadenopathy refers simply to enlarged lymph node(s) of the neck. However, the two terms often are used interchangeably. • Generalized lymphadenopathy is the enlargement of more than two noncontiguous lymph node regions (ie, cervical and axillary) and is the result of systemic disease.

4. Clinical claSSIFICATION Cervical lymphadenopathy • Ref: 18th edition of Harrison's Principles of Internal Medicine Table 59–1 malignant Benign Infectious diseases Hematologic: Lymphoma, Hairy cell leukemia Immunological : RA, SLE , Serum sickness Endocrine diseases—hyperthyroidism Lipid storage diseases—Gaucher's, Niemann-Pick, Fabry, Tangier Metastatic Drug hypersensitivity Other causes : Kikuchi's disease (Histiocytic necrotizing lymphadenitis), Rosai-Dorfman disease(Sinus histiocytosis), Kawasaki's disease (Mucocutaneous lymph node syndrome)

5. Classification of nodes • The neck comprises of more than 300 lymph nodes • They can be classified as the superficial group and the deep group.

6. Classification of nodes • Superficial group of nodes • Preauricular • Postauricular • Occipital • Preparotid • Facial Adapted from Gray’s textbook of anatomy

7. Classification of nodes • The deep cervical nodes are classified in terms of important clinical/surgical landmarks. • They are classified into six neck levels. • Each level denotes a specific drainage areas which give important diagnostic clues.

8. Classification of nodes • Classification by the Memorial of Sloan Kettering. • Primarily used to describe the metastatic deposits from squamous cell carcinoma of head and neck.

9. SALIENT FEATURES IN HISTORY TAKING • Symptoms such as sore throat, cough, fever, night sweats, fatigue, weight loss, or pain in the nodes should be sought. • The patient's age, sex, occupation, exposure to pets, sexual behavior, a history of tobacco use and use of drugs such as di-phenyl hydantoin are other important historic points • After age 50, the incidence of malignant disorders increases and that of benign disorders decreases.

10. CLINICAL Examination • Size • Nodes greater than 3 cm are associated with malignancy in adult patients, • Nodes greater than 2 cm in children in the absence of ENT infection and absence of abnormal chest radiograph point to a underlying granulomatous disorder. • Pain/Tenderness • an inflammatory process or suppuration • hemorrhage into the necrotic center of a malignant node

11. Clinical examination • 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 or inflammatory conditions. • Suppurant nodes may be fluctuant. • The term “shotty” refers to small nodes that feel like buckshot under the skin, as found in the cervical nodes of children with viral illnesses. • Matting • A group of nodes that feels connected and seems to move as a unit is said to be “matted.” • Nodes that are matted can be either benign (e.g., tuberculosis, sarcoidosis ) or malignant (e.g., metastatic carcinoma or lymphomas).

12. CLINICAL EXAMINATION • POSTERIOR CERVICAL LYMPH NODE SUPPURATION WITH ABSENCE OF INFLAMATORY SIGNS USUALLY POINT TO TUBERCULOSIS • EXAMINATION OF THYROID FOR PALPABLE LESIONS • VIRCHOW’S NODE • LATERAL ABBERANT THYROID

13. Clinical examination • Signs usually indicating a systemic disease (LYMPHOMA,STORAGE DISORDERS) • PRESENCE OF SPLENOMEGALY • PRESENCE OF enlarged or ulcerated tonsils. • Thorough ENT examination • to rule out head and neck focus of infection or malignancy.

14. Investigations to aid diagnosis • ROUTINE LABORATORY INVESTIGATIONS • COMPLETE HEMOGRAM AND PERIPHERAL SMEAR CANNOT BE OVEREMPHASIZED TO DIAGNOSE CLINICAL CONDITIONS LIKE MONONUCLEOSIS OR HEMATOLOGICAL MALIGNANCIES. • IMAGING • NECK ULTRASOUND • CONTRAST ENHANCED COMPUTED TOMOGRAM • TISSUE DIAGNOSIS • FINE NEEDLE ASPIRATION CYTOLOGY. • LYMPH NODE BIOPSY

15. WHEN TO obtain a tissue biopsy? • ITS A CLINICAL DECISION MADE BY THE TREATING SURGEON. • CLINICALLY MALIGNANT LYMPH NODE. • SUSPECTED TUBERCULOSIS. • A PERSISTENT LYMPHADENOPATHY in the absence of ENT infection or abnormal chest radiograph and NOT RESPONDING TO CONSERVASTIVE MANAGEMENT. • Presence of gross splenomegaly

16. FNAC versus BIOPSY ?? • OP PROCEDURE • NO NEED FOR ANAESTHESIA • HIGH SENSITIVITY AND SPECIFICITY • LOW COST • CAN BE REPEATED IN THE SAME NODE. • DISADVANTAGE • HISTOLOGICAL EVALUATION IS LIMITED. • SUBTYPING OF LYMPHOMAS IS CURRENTLY DIFFICULT. • GOLD STANDARD TESTING • CAN BE DONE UNDER LOCAL ANAESTHESIA • INDICATED FOR IMMUNOHISTOCHEMISTRY AND SUBTYPING OF LYMPHOMAS. FNAC NODE BIOPSY

17. Various common clinical conditions • 10 YEAR OLD CHILD PRESENTING WITH UNILATERAL TONSILLAR ENLARGEMENT AND LYUMPHADENOPATHY USUALLY POINT TO LYMPHOMA.

18. HODGKIN’S LYMPHOMA • YOUNG MALE • PRESENTING WITH NIGHT SWEATS , FEVER, ITCHING { B symptoms} • bilateral neck nodes. • Unilateral Tonsillarenlargemnt

19. Infectious mononucleosis • Young female • Presenting with fever and throat pain • tonsillar membrane on examination . • Monospot test positive for EBV

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