Normal Anatomy & Its Applied Aspect
ASHISH RANGHANIPG PART 2
GDCH, AHMEDABAD
Lymph nodes OF HEAD AND NECK
UNDER GUIDANCE OF
DR. J.S SHAH
PROFESSOR AND HEAD
ORAL MEDICINE AND
RADIOLOGY
GDCH
DATE- 28/06/2017 & 29/06/2017
CONTENTSIntroduction
Components of lymphatic system
Mechanism of lymphatic flow
Function of lymphatic system
Structure of lymph nodes
Classification of lymph nodes in head and neck region
Lymphatic drainage of the oral structures
Different lymph nodes examination methods
Evaluation of lymph nodes of the head and neck region
Causes of lymphadenopathy
Lymph node status in various conditions
Lymph nodes levels
Imaging of enlarged lymph nodes on head and neck
LYMPAHATIC SYSTEM
The lymphatic system is the part of the immune system comprising a
network of lymphatic vessels that carry a clear fluid called lymph
(from Latin lympha "water") in a unidirectional pathway.
Network of vessels & lymph nodes which are located in all major
tissues of body.
Lymphatic system is absent in CNS, cornea, superficial layer of skin,
bones, alveoli of lung.
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
The components of the lymphatic system are :-
Lymph
Lymphatic Channels
Lymph Nodes
Lymph Organs
Lymph, the recovered fluid usually a clear, colorless fluid, similar
to blood plasma but low in protein.
Origin of Lymph :- Lymph originates in microscopic vessels called
lymphatic capillaries.
Lymphatic vessels, which transport the lymph;
Components of Lymphatic system -
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
Smallest lymphatic vessels
They begin in the tissue spaces as blind-ended sacs.
These capillaries form plexuses which collect lymph from the
interstitial space mark the beginning of lymphatic system
LYMPHATIC CAPILLARIES
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
They are lined by a single layer of endothelial cells.
These are attached to C.T by anchoring filaments.
The edge of one endothelial cell overlaps the adjacent cell. The overlapping edges of the endothelial cells act as valve like flaps that can open and close.
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
When tissue fluid pressure is high, it pushes the flaps inward (open) and fluid flows into the lymphatic capillary.
When pressure is higher in the lymphatic capillary than in the tissue fluid, the flaps are pressed outward (closed).
Permits passage of high molecular weight substance.
• Lymph capillaries merge to form lymphatic
vessels.
• The lymphatic vessels form a one-way system
in which lymph flows only toward the heart.
• Resemble veins but
Thin walls (Diameter - 0.2 – 0.3 mm)
More valves (formed from folds of tunica
intima) more anastomose
Lymph Nodes are located at
interval along its course
• Have 3 coats (Tunica intima, Tunica media,
Tunica adventitia)
• BEADED in appearance (semilunar valves).
LYMPHATIC VESSELS
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
Flow of Lymph
• Thus, there is a continual recycling of fluid from blood to tissue fluid to
lymph and back to the blood
Lymphocytes, the main warriors of the immune system, arise in
red bone marrow
There are two main types of lymphocytes: B-lymphocytes and T-
lymphocytes. B cells differentiate into plasma cells, which produce
circulating antibodies. Antibodies circulate in the blood and react with
toxins, bacteria and some cancer cells. The body can then identify and
remove these unwanted substances.
When the body’s own cells have become infected and destroy them
directly. T-lymphocytes help the body fight viral infections and destroy
abnormal or cancerous cells (cellular immunity)
Lymphatic Cells and Tissues
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
LYMPHOID ORGANS
Primary or Central
lymphocytes are produced and undergo development and are
supplied to secondary organs.
Thymus
Bone marrow
Secondary or peripheral organs :
lymphocytes are activated to participate in specific immune response.
Lymph nodes
Spleen
Tonsils
LYMPHOID ORGANS
• Important role in redistribution of fluid in the body.
• Bacteria, toxins and other foreign bodies are removed from the
tissues.
• Maintenance of structural and functional integrity of tissue.
• In immune response of the body.
• Production and maturation of lymphocytes.
• End products of digestion are absorbed mainly by lymph channels.
• Lymph carries protein and large particulate matter away from the
tissue space.
FUNCTIONS OF LYMPHATIC SYSTEM
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
Lymph nodes have two basic functions, both concerned with body protection.
1. As lymph is transported back to the bloodstream, the lymph nodes act as lymph “filters.” Macrophages in the nodes remove and destroy microorganisms and other debris that enter the lymph from the loose connective tissues
2. They help activate the immune system.
• There are hundreds of lymph nodes in the body.
• They are especially concentrated in the cervical, axillary, and inguinal regions close to the body surface,
• Most of them are embedded in fat.
Lymph Nodes :-
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
A lymph node is an elongated or
bean-shaped structure, usually less
than 3 cm long, positioned along
the course of lymph vessel often
with a slight depression called
HILUS on one side.
It is enclosed in a fibrous capsule
with extensions (trabeculae) that
incompletely divide the interior of
the node into compartments.
Structure
Capsule Trabeculae
Hilum
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
A lymph node has two
histologically regions, the cortex
and the medulla.
The cortex consists mainly of
ovoid lymphatic nodules.
When the lymph node is fighting
a pathogen, these nodules acquire
light-staining germinal centers
where B cells multiply and
differentiate into plasma cells.
Medullary cords are thin inward
extensions from the cortical
lymphoid tissue, and contain both
types of lymphocytes plus plasma
cells
Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition
The lymph nodes in the
head and neck region
can be grouped into:
• Superficial nodes
• Deep nodes.
Classification of nodes
in head and neck region
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
Superficial cervical nodes
The superficial circle of
cervical lymph nodes is made
up of the following groups:
(1)Submental
(2)Submandibular;
(3)buccal and mandibular
(4)Preauricular (parotid);
(5)Postauricular (mastoid);
(6)Occipital;
(7)Anterior cervical; and
(8)Superficial cervical nodes.
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
Submental nodes
• These are three or four nodes situated across the midline below the chin in the submental triangle
Submandibular nodes
• These nodes are usually three in number & situated in the submandibular triangle in contact with the surface of the submandibular salivary gland and within its substance
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
Buccal Nodes
• The buccal node lies on the buccinator
• They drain part of the cheek and the lower eyelid.
Mandibular Nodes
• The mandibular node at the lower border of the mandible near the anteroinferior angle of the masseter, in close relation to the mandibular branch of the facial nerve
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
Parotid Lymph Nodes
• The parotid lymph nodes lie partly in the superficial fascia and partly deep to the deep fascia over the parotid gland. They drain:
• The temple,
• the side of the scalp,
• the lateral surface of the auricle,
• the external acoustic meatus,
• the middle car,
• the parotid gland,
• the upper part of the cheek,
• parts of the eyelids, and
• the orbit
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
Postauricular (Mastoid) Nodes
• lie on the mastoid process superficial to the sternocleidomastoid and deep to the auricularisposterior.
• They drain a strip of scalp just above and behind the auricle, the upper half of the medial surface and margin of the auricle, and the posterior wall of the external acoustic meatus.
Occipital Nodes
• The occipital nodes lie at the apex of the posterior triangle superficial to the attachment of the trapezius.
• They drain the occipital region of the scalp
The prelaryngeal and pretrachednodes lie deep to the investing fascia, the prelaryngeal nodes on the cricothyroid membrane, and the pretracheal in front of the trachea below the isthmus of the thyroid gland.
They drain the larynx, the trachea and the isthmus of the thyroid.
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
Prelaryngeal and Pretracheal Nodes
The paratracheal nodes lie on the sides of the trachea and oesophagus along the recurrent laryngeal nerves.
They receive lymph from the oesophagus, the trachea and the larynx, and pass it on to the deep cervical nodes.
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
Paratracheal Nodes
Deep cervical nodes
The entire lymph from the head
and neck drains ultimately into
the deep cervical nodes either
directly or through the
peripheral nodes.
The deep cervical nodes form a
vertical chain situated along the
entire length of the internal
jugular vein
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
The jugulodigastric node (upper deep cervical)
• It lies below the posterior belly of the digastric, between the angle of the mandible and the anterior border of the sternocleidomastoid
• It is the main node draining the tonsil.
The jugulo-omohyoid node (lower deep cervical)
• It lies just above the intermediate tendon of the omohyoid, under cover of the posterior border of the sternocleidomastoid.
• It is the main lymph node of the tongue
• RIGHT LYMPHATIC DUCT
• THORACIC DUCT
LYMPHATIC DUCTS
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
THORACIC / LEFT LYMPHATIC DUCT
38 – 45 cm long
Begins as a dilation called cisterna chyli
anterior to 2nd lumber vertebra.
Main duct for return of lymph to blood
Receives lymph from left side of head, neck,
Left upper limb, chest & entire body inferior
to ribs
Joins the venous system at the junction of Left
Sub clavian.
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
RIGHT LYMPHATIC DUCT
• 1.2 cm long
• 3 lymphatic trunks drain into Right lymphatic duct
– Right Jugular trunk-drains Right side of head & neck
– Rt subclavian trunk- Right upper limb
– Rt bronchomediastinal trunk-Rt side of thorax, Rt lung,
Rt side of heart , & part of liver
• Right lymphatic duct joins the venous system at the junction of Right Sub
clavian & Right internal jugular veins
BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition
The skin of the head and neck drains
Scalp Occipital, mastoid and parotid nodes
Lower eye lid and anterior cheek Buccal LNs
Cheeks Parotid, buccal and submandibular nodes
Upper lips and sides of the lower lips Submandibular nodes
Middle third of the lower lip Submental nodes
Skin of the neck Cervical nodes.
The drainage of the oral structures
Drainage of oral structures
Gingiva Submandibular, submental and upper deep cervical lymph nodes
Palate Upper deep cervical nodes
Teeth Submandibular and deep cervical lymph nodes
Anterior part of floor of mouth
Submental and upper deep cervical
Posterior part of floor of mouth
Submandibular and upper deep cervical
• Bilateral palpation of the pre auricular lymph nodes utilizing the mandibular ramus and coronoid process as a firm surface against which to palpate
• They are palpated anterior to the tragus of the ear.
Morton I. Lieberman and Thomas H. Ward, Clinical identification of head and neck
lymphadenopathy: a diagnostic obligation, www.agd.org General Dentistry July 2013
Are palpated behind the ear, on the
mastoid process
Palpated at the base\lower border of
skull
• They are palpated under the chin
• The clinician can stand behind the
patient to palpate.
• The patient is instructed to bend
his/her neck slightly forward so that
the muscles and fascia in that regions
relax.
• Fingers of both hands can be placed
just below the chin, under the lower
border of mandible and the lymph
nodes should be tried to be cupped
with fingers.
• Are palpated at the lower border of the
mandible approximately at the angle of the
mandible.
• The patient is instructed to passively flex
the neck towards the side that is being
examined. This helps relaxing the muscles
and fascia of neck, thereby allowing easy
examination.
• The fingers of the palpating hand should be
kept together to prevent the nodes from
slipping in between them.
• The palmar aspect of the fingers is pushed
on to the soft tissue below the mandible near
the midline, then the clinician should then
move the fingers laterally to draw the nodes
outwards and trap them against the lower
border of the mandible.
Are situated superficial to upper part of
sterno-cleido mastoid along its anterior
border.
• Palpated in the posterior triangle of
the neck close to the anterior border
of trapezius
• Examination of the cervical nodes
can be accomplished by instructing
the patients to turn the neck away
from the side to be examined.
• This position distends the Sterno
mastoid muscle and facilitate easier
examination of the lymph nodes of
anterior and posterior chain.
• Finger tips of the hand are placed
along the posterior border of
muscle while the thumb provides
counter pressure from the anterior
aspect of the muscle
Significance of lymph node examinations
There are 3 basic classes of lymph nodes.
1. Fibrotic nodes are palpated as scarred jelly bean-like structures that are freely movable and escape from the clinician’s fingers. They are usually representative of previous infection.
2. Tender, enlarged, and inflamed nodes are usually indicative of an active infection.
3. Stony hard and fixed nodes feel like marbles that cannot be moved from the underlying structures and usually represent some form of neoplasia.
Morton I. Lieberman and Thomas H. Ward, Clinical identification of head and neck
lymphadenopathy: a diagnostic obligation, www.agd.org General Dentistry July 2013
Lymphadenopathy define as nodes that are abnormal in either size, consistency or number
Lymphadenopathy: differential diagnosis and evaluation, robert ferrer, am fam physician. 1998
oct 15;58(6):1313-1320
Approach to the Patient with Lymphadenopathy
KEY FACTORS IN EVALUATION OF LYMPHADENOPATHY
Age of patient
Location of lymphadenopathy
Systemic signs/symptoms
Presence/absence of splenomegaly
Position, overlying surface, size, consistency, tenderness, and
fixation of lymph nodes
History of drug exposure
Approach to the patient with lymphadenopathy, bernard karnad, hospital physician july 2005
Age of patient
In patients younger than 30 years, lymph-adenopathy is due to a
benign underlying process approximately 80% of the time,
while in individuals older than 50 years, it is due to a malignant
process approximately 60% of the time
Approach to the patient with lymphadenopathy, bernard karnad, hospital physician july 2005
Location of lymphadenopathy
Whether the lymphadenopathy is generalized or localized.
In localized lymphadenopathy, the lymphatic drainage area
should be investigated for local infection or malignancy.
• A few conditions are known to cause generalized lymphadenopathy
• Eg: Lymphomas, Tuberculosis, lymphatic leukemia, Sarcoidosis etc…
Approach to the patient with lymphadenopathy, bernard karnad, hospital physician july 2005
Systemic signs/symptomsFor evaluation of patient with generalized lymphadenopathy should include careful history that focus on signs and symptoms like
• fever,
• chills,
• weight loss,
• night sweats
Physical examination, complete blood count, and chest radiograph.
In the adult patient, especially those aged 50 years or older, generalized lymphadenopathy usually represents a serious systemic illness.
Fever, weight loss, and night sweats may suggest tuberculosis or lymphoma.
Approach to the patient with lymphadenopathy, bernard karnad, hospital physician july 2005
• Special attention
should be given to
the presence or
absence of
splenomegaly
because this finding
makes a malignancy
of haematological
origin more likely
Position is important as it will not only give an idea as to which group of lymph node is affected, but also the diagnosis.
Eg: Hodgkin’s disease and the Tuberculosis affect the cervical lymph nodes in the earlier stages.
Position
Robert ferrer, lymphadenopathy: differential diagnosis and evaluation, Am fam physician. 1998
oct 15;58(6):1313-1320.
OVERLYING SKIN:
Robert ferrer, lymphadenopathy: differential diagnosis and evaluation, Am fam physician. 1998
oct 15;58(6):1313-1320.
Acute lymphadenitis Inflamed with redness, edema
Tuberculous lymphadenitis Red and glossy when they reach the point of bursting
Rapidly growing lymphoma Tense, stretched with dilated subcutaneous veins
Scar Bursting of abscess or operation.
Secondary carcinoma Skin may become fixed
Nodes are palpated for
• Consistency,
• Size,
• Tenderness,
• Fixity to the surrounding structures.
PALPATION
Robert ferrer, lymphadenopathy: differential diagnosis and evaluation, Am fam physician. 1998
oct 15;58(6):1313-1320.
While rolling the fingers over the lymph node, slight pressure has to be applied to know the consistency of the node.
CONSISTENCY
Very hard nodes Malignancy
Firm, rubbery nod Lymphoma
Softer nodes Infective or inflammatory conditions
Matted nodes
A group of lymph nodes that feels
connected and move as a unit is said to
be matted.
Malignant:
• Metastatic carcinoma
• Lymphomas
Other:
• Tuberculosis
Shotty nodes Viral aetiology
The problem of HIV-related lymphadenopathy, Wilandi jacobs, CME August 2010 vol.28 no.8
When a lymph node increases in size its capsule stretches and causes pain.
But pain may also be seen when there is hemorrhage into the necrotic center of a malignant node.
The presence or absence of tenderness does not necessarily differentiate benign from malignant nodes.
TENDERNESS
The problem of HIV-related lymphadenopathy, Wilandi jacobs, CME August 2010 vol.28 no.8
Nodes are generally considered to be normal if they are up to 1cm in diameter.
However, epitrochlear nodes larger than 0.5 cm or inguinal nodes larger than 1.5 cm should be considered abnormal.
SIZE:
• The enlarged nodes should be carefully palpated to know if they are
fixed to the skin, deep fascia, muscles.
• Any primary malignant growth or secondary carcinoma is often fixed
to the surroundings.
• First the deep fascia and the underlying muscle, the surrounding
structures and finally the skin is involved.
Fixity to the surrounding tissues
Robert ferrer, lymphadenopathy: differential diagnosis and evaluation, Am fam physician. 1998
oct 15;58(6):1313-1320.
Clinical Features to differentiate benign from malignant lymphadenopathy
Feature Malignant Benign
Size > 2cm < 2 cm , <1cm
Consistency Hard, Firm, rubbery Soft
Duration > 2 Weeks < 2 Weeks
Mobility Fixed Mobile
Surrounding Attached Not attached
Tenderness Usually non tender Usually Tender
Abdullah Abba and Mohmmad Khalil, Clinical approach to lymphadenopathy, Pk- practitioner,
Vol 16, Jan 2011
Congenital lesions
Congenital lesions that may be confused with lymphadenopathy and should be considered in the differential diagnosis of a neck mass in a young child include
1. Cystic hygroma,
2. Branchial cleft cyst,
3. Thyroglossal duct cyst
4. Cervical rib.
Evaluation and management of lymphadenopathy in children, alison m. Friedmann , pediatr. Rev.
2008;29;53-60
A cystic hygroma is a proliferation of lymphatic vessels
(a lymphangioma) that is soft and compressible and is
palpable in the lower neck above the clavicle; it will
transilluminate.
Branchial cleft cysts are in the lateral neck and usually
can be differentiated from lymphadenopathy by the
presence of a pit, dimple, or sinus along the anterior
margin of the sternocleidomastoid muscle.
Evaluation and management of lymphadenopathy in children, alison m. Friedmann , pediatr. Rev.
2008;29;53-60
Thyroglossal duct cysts occur in the midline at the level
of the thyrohyoid membrane and usually move up and
down with swallowing or protrusion of the tongue.
A cervical rib has a different contour and a hard, bony
consistency that distinguishes it from a lymph node.
LYMPH NODE STATUS IN
VARIOUS CONDITIONS 7,8,9,10,11,12,13,14,15
Localised Acute Conditions
Bacterial
• Acute periapical abscess
• Pericoronitis
• Cat scratch disease,
Viral
• Primary herpetic gingivostomatitis,
• Mumps,
• Chicken pox,
• Infectious mononucleosis,
• Rubella,
• Measles,
• Hepatitis
Infection
Localised Chronic Conditions
Infection
Bacterial
• Chronic dental abscess
• Chronic pericoronitis
• Chronic suppurativeosteomyelitis
• Chronic bacterial sialedenitis
• Tuberculosis
• Sarcoidosis
• Syphilis
Viral
• Infectious Mononucleosis
• Brucellosis
Fungal
• Histoplasmosis,
• Blastomycosis
Neoplastic
• Carcinoma
Auto immune
• Rheumatoid arthritis
• SLE
Hypersensitivity
• Serum sickness
• Drug sensitivity
• Carbamazepine
• Cephalosporins
• Penicillins
• Phenytoin
• Captopril
Generalized Conditions
1. Lymphomas,
2. Tuberculosis,
3. lymphatic leukemia,
4. Toxoplasmosis
5. HIV
ACUTE LYMPHADENOPATHY-
Two weeks duration
• Lymph node-
1. Tender
2. Soft
3. Elastic
4. Movable
5. difficult to hold at one place
Bacterial infections often result in acutely enlarged lymph nodes that are warm, erythematous, and tender.
Patients may have submandibular node involvement more than 50% of the time.
Common bacterial pathogens are Staphylococcus aureus and Streptococcus pyogenes.
Local infections may include tonsillar abscesses, salivary adenitis, and dental abscesses.
Upper respiratory infections
Acute bilateral cervical lymphadenopathy is commonly caused by viruses and bacteria that infect the upper respiratory tract in both adults and children.
Viruses that frequently cause upper respiratory infections include adenovirus, influenza virus.
Group A beta hemolytic Streptococcus is the most common cause of bacterial pharyngitis
Cervical lymph nodes may be bilateral, acutely swollen and tender, and may persist for weeks after the resolution of other symptoms.
Nodes may be palpable in the anterior triangle of the neck.
BACTERIAL INFECTIONS-
Acute bacterial lymphadenitis
Large (2-3 cm) solitary, tender, unilateral cervical lymph nodes that rapidly enlarge due to bacterial infection.
The most commonly involved lymph nodes in decreasing order of frequency are the submandibular, upper cervical, submental, occipital, and lower cervical nodes.
John R. Gosche, Laura Vick, Acute, subacute, and chronic cervical lymphadenitis in children, Seminars in Pediatric Surgery (2006) 15, 99-106.
Cat scratch disease
It is a lymphocutaneous syndrome characterized by regional lymphadenitis associated with a characteristic skin lesion at the site of inoculation.
Cat scratch disease follows inoculation of Bartonella henselaethrough broken skin or mucous membranes. A skin papule typically develops at the site of inoculation, followed by regional adenopathy 5 days to 2 months later.
The most common sites of lymphadenopathy are the axilla (52%) and the neck (28%). Patients typically present with a single large (4 cm) tender node.
Suppuration occurs in 30% to 50% of cases
John R. Gosche, Laura Vick, Acute, subacute, and chronic cervical lymphadenitis in children, Seminars in Pediatric Surgery (2006) 15, 99-106.
VIRAL INFECTIONS
Cervical adenopathy is a common feature of many viral infections.
These viruses include
• Epstein Barr virus (EBV),
• Cytomegalovirus (CMV),
• Human herpes virus (HHV-6)
• Rubella
Acute viral lymphadenitis
John R. Gosche, Laura Vick, Acute, subacute, and chronic cervical lymphadenitis in children, Seminars in Pediatric Surgery (2006) 15, 99-106.
Involved nodes are usually bilateral lymph nodes in the anterior triangle of the neck,
multiple, small, firm and tender, without warmth or
erythema of the overlying skin.
Virally induced adenopathy rarely suppurates and generally resolves spontaneously over a
short period of time
Rubella almost always presents with a maculopapular rash and
characteristic lymphadenopathy of the
posterior cervical triangle.
CHRONIC LYMPHADENOPATHY
CHRONIC INFECTIONS-
Lymph node-
Non tender,
Firm,
Movable,
No rise in local temperature,
Smooth surface
Tuberculous lymphadenitis
Tuberculous lymphadenitis most frequently involves the
cervical lymph nodes followed in frequency by
mediastinal, axillary, mesenteric, hepatic portal and
inguinal lymph nodes
It may present as a unilateral single or multiple painless
slow growing mass developing over weeks to months,
mostly located in the posterior cervical and less
commonly in supraclavicular region.
Prasanta Raghab Mohapatra, Ashok Kumar Janmeja, Tuberculous Lymphadenitis, JAPI, august 2009, VOL. 57.
Fistula formation was seen in nearly 10% of the
mycobacterial cervical lymphadenitis.
Cervical nodes in the submandibular region are
most commonly affected in children
Multiplicity, matting and caseation are three
important findings of tuberculous
lymphadenitis
Jones and Campbell classified peripheral tuberculous lymph nodes into following five stages.
Prasanta Raghab Mohapatra, Ashok Kumar Janmeja, Tuberculous Lymphadenitis, JAPI, august 2009, VOL. 57.
Stage 1 : enlarged, firm, mobile, discrete nodes showing non-specific reactive hyperplasia
Stage 2 : large rubbery nodes fixed to surrounding tissue
Stage 3 : central softening due to abscess formation
Stage 4 : collar-stud abscess formation
Stage 5 : sinus tract formation
SYPHILIS IN THE SECONDARY STAGE:
Causative organism - Treponema palladium.
Lymph nodes-
generalized enlargement of superficial node. Most characteristically there is enlargement of epitrochlear & suboccipital groups.
Firm in feel, descrete, shotty and not tender.
Infectious Mononucleosis
Alison M. Friedmann , Evaluation and Management of Lymphadenopathy in Children, Pediatr. Rev. 2008;29;53-60
Generalized involvement with firm, elastic and slight tender nodes
lymphadenopathy, characteristically with symmetric involvement of the posterior cervical nodes more than the anterior cervical.
Nodes may be large and kidney-shaped and typically peak in size over the first week of illness, gradually subsiding over the next few weeks.
Axillary and inguinal nodes also may be involved.
Cervical adenopathy may be severe enough to cause upper airway compromise.
Sarcoidosis
Sarcoidosis is a chronic granulomatous disease of unknown etiology.
The disease may affect almost any organ in the body, but the lung is most frequently affected.
The most common physical finding in children with this disease is peripheral lymphadenopathy.
Involved cervical nodes are usually bilateral, discrete, firm, and rubbery.
Supraclavicular nodes become involved in more than 80% of patients
John R. Gosche, Laura Vick, Acute, subacute, and chronic cervical lymphadenitis in children, Seminars in Pediatric Surgery (2006) 15, 99-106.
Lupus lymphadenopathy
• Lupus lymphadenopathy involves, mainly, the cervical and axillary regions
• The lymph nodes are soft, mobile, painful, and non-adherent to deep planes
Bernard karnad, Approach to the patient with lymphadenopathy, Hospital physician july 2005
AUTOIMMUNE DISORDERS
HIV-related lymphadenopathy
The problem of HIV-related lymphadenopathy, WILANDI JACOBS, CME AUGUST 2010 Vol.28 No.8
• After seroconversion HIV disease often remains silent except tor persistent generalized lymphadenopathy (PGL)
• The most frequently involved sites are the posterior and anterior cervical, submandibular, occipital. and axillary nodes.
• Nodal enlargement fluctuates, usually is larger than 1 cm, and varies from 0.5 to 5.0 cm
PGL include the following
• Lymph nodes remain stable in number, location and size
• Two or more non-contiguous sites
• Persists for more than 3 months
HODGKIN'S LYMPHOMA
The most common sites of initial presentation are the cervical and supraclavicular nodes (70% to 75%) or the axillary and mediastinal nodes (5% to 10% each).
lymph nodes are ovoid, smooth, dicrete, solid, firm & rubbery in consistency & are non tender.
In the early stages the involved lymph nodes are often movable as the condition progresses. the nodes become more matted and fixed to the surrounding tissues.
If it is untreated the condition spreads to other lymph node groups and involves the spleen and other extra lymphatic tissues.
NEVILLE Oral and Maxillofacial Pathology, 4ed
Ann Arbor system for Classification of Hodgkin's Lymphoma
It has 4 stages
Stage I:Hodgkin
lymphoma is found in only 1
lymph node area or
lymphoid organ
Stage II:Hodgkin
lymphoma is found in 2 or more lymph
node areas on the same side of (above or below) the diaphragm
Stage III:Hodgkin
lymphoma is found in lymph node areas on both sides of (above and below) the diaphragm
Stage IV:Hodgkin
lymphoma has spread widely into at least one organ
outside of the lymph system,
such as the liver, bone marrow, or
lungs
NEVILLE Oral and Maxillofacial Pathology, 4ed
Non Hodgkin's Lymphoma
Non Hodgkin's Lymphoma has a more frequent involvement of multiple peripheral nodes compared to HL which often remains localized to one group of nodes
The mesenteric nodes involvement are common in Non Hodgkin's Lymphoma, while their involvement is rare in HL
Extranodal involvement is common in Non Hodgkin's Lymphoma and uncommon in HL
ACUTE LYMPHOCYTIC LEUKEMIA
Acute leukemia can occur at any age, but ALL is commonly
found in children.
The bone marrow changes cause anemia, thrombocytopenia, and
a decrease in normally functioning neutrophils.
The anemia results in pallor, shortness of breath, and fatigue,
which is the most common presenting symptom.
Thrombocytopenia causes spontaneous bleeding, such as
petechiae, ecchymoses, epistaxis, melena and gingival bleeding,
when the platelet count falls below 25,000/mm3
Infiltration of organs and tissues by leukemic cells causes
lymphadenopathy, hepatomegaly, and splenomegaly.
CHRONIC LYMPHOCYTIC LEUKEMIA
Cervical lymphadenopathy and tonsillar enlargement are frequent head and neck signs of CLL.
Lymph nodes-generalised, painless, dicrete, firm, movable,
TOXOPLASMOSIS:
Causative organism- Toxmoplasmosis gondii, a parasite
Source of infection -cats, contact with infected uncooked or undercooked meat.
Generalized lymphadenopathy with firm, tender enlargement of the cervical nodes.
Fever, malaise, maculopapular rash, sore throat, myalgia, and headache.
Pre- and postauricular
• infection such as Cat scratch fever, or granulomatous changes,
• such as tuberculosis or sarcoidosis
Submandibular
• Soft, tender enlargement may indicate head and neck infection
• hard fixed nodes may indicate malignancy
Submental
• Abnormal nodes may result from viral infections such as Herpes simplex (herpes labialis), Varicella-Zoster (shingles), or bacterial dental infections
Supraclavicular
• Palpate with fingertips in the hollow above the clavicle. Nodes on the right side drain the mediastinum, esophagus, and lungs. Abnormalities may indicate malignancies of the lung or intestines
Morton I. Lieberman and Thomas H. Ward, Clinical identification of head and neck
lymphadenopathy: a diagnostic obligation, www.agd.org General Dentistry July 2013
Lymph node levels
LEVEL I
SUBLEVEL IA- submental lymph nodes
SUBLEVEL IIA – submandibular lymph nodes
LEVEL II (UPPER JUGULAR)
Internal jugular(deep cervical) chain from base of (upper jugular) skull to inferior border of the hyoid bone.
LEVEL III (MID JUGULAR)
Internal jugular(deep cervical ) from the hyoid bone to the inferior border of the cricoids arch
LEVEL IV (LOWER JUGULAR)
Internal jugular chain between the inferior border of the cricoids arch and the supraclavicular fossa.
LEVEL V (POSTERIOR TRIANGLE)- posterior triaqngle or spinal accessory nerve
SUBLEVEL VA- above the horizontal plane making the inferior border of the anterior cricoids arch
SUBLEVEL VB- below this level, nodes following transverse cervical vessels and supraclavicular node.(except Virchow’s node located in level IV)
LEVEL VI (ANTERIOR COMPARTMENT)
Central compartment nodes from hyoid bone to suprasternal notch (include pre- and paratracheal nodes and pre-cricoid(delphian nodes), perithyroid nodes)
LEVEL VII
Nodes inferior to the suprasternal notch in the upper mediastinum
Investigations
1) Lab diagnostic methods
2) Imaging
3) Tissue examination
4) Lymphangiography
S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
1)LABORATORY DIAGNOSIS METHODS
1. Hb%
2. Complete blood count
3. Peripheral smear examination
• Complete blood count (CBC) with differential would be
helpful to detect cases caused by infectious mononucleosis,
leukemia, or lymphoma.
• Lymphocytosis can be seen in leukemia, autoimmune
disorders, Epstein Bar virus, cytomegalovirus & tuberculosis
• Neutrophil leukocytosis is often seen in severe infections.
• Neutropenia and thrombocytopenia may be useful in
diagnosing systemic illnesses.
S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
5. ESR- Raised ESR is found in tuberculosis, secondary
carcinoma, lymphosarcoma
6. C reactive protein
7. Serological test for EBV, toxoplasma, HSV,
cytomegalovirus.
8. W.R. & Kahn test for syphilis
9. Biochemical & immunologic tests
S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
Head and neck carcinomas are the sixth most common malignancy reported worldwide.
LN metastasis is one of the most important prognostic factors in patients with head and neck carcinoma.
The major goals of diagnostic imaging in these patients is accurate prediction of LN metastasis.
Not only for the planning of appropriate treatment but also for monitoring the treatment response.
Imaging of enlarged LN on head and neck:
• Lateral oblique
• Orthopantomogram
Indications- for imaging calcifications in lymph nodes
Calcified lymph nodes-
Commonly involved nodes- submandibular and cervical
This occurs in lymph nodes that have been chronically inflamed because of various diseases (usually granulomatous diseases).
CONVENTIONAL RADIOGRAPH
The lymphoid tissue is replaced by hydroxyapatite like calcium salts nearly effacing all the nodal architecture.
Common diseases that cause calcified lymph nodes are-
Tuberculosis(scrofula or cervical tuberculous adenitis)
Sarcoidosis
Nodal Borders & margins:
Metastatic nodes have sharp borders.
Due to tumor infiltration and reduced fatty deposition within LN
Increased acoustic impedance difference between LN and the surrounding tissues.
USG Feature of Cervical Lymph Nodes:
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
Reactive nodes usually show un-sharp borders.
Un-sharp borders due to edema & inflammation of surrounding soft tissue.
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
Malignant and TB nodes round.
Reactive and normalnodes usually oval.
The L/S ratio was used to characterize this feature.
Shape Feature:
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
• Homogeneous hypo-echoic pattern with preserved echo-genic hilum mainly observed in benign nodes.
Echogeneity:
• Heterogeneous and
anechoic patterns with
loss echogenic hilum
are observed in
metastatic nodes.
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
Normal and reactive nodes predominantly hypo-echoic.
Metastatic nodes may be hypo or mixed hypo and eccentric hyper-echoic component.
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
Normal and reactive lymph nodes tend to have central hilar vascular pattern.
Vascular Pattern:
Metastatic and lympho-matous nodesusually show peripheral or mixed vascularity.
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
Nodal parenchyma exhibited
homogeneous and low echogenicity.
Regular margin and oval or flattened
in shape.
The hilum was identified as a highly
echogenic structure in the central part
of the node.
On Doppler, usually hypovascular or
has hilar vascular pattern.
USG Feature of Reactive LN:
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
Ill defined margin of enlarged
LN.
Central decreased echogenicity.
Loss hilum.
On Doppler, increase peripheral
vascularity.
U/S Feature of suppurative LN:
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
Nodal parenchyma exhibited in
homogeneous low or mixed
echogenicity.
Irregular margin with round shape.
Sharp borders.
Loss of normal hilar echogenicity.
On Doppler sonograms, has peripheral
or mixed vascular pattern.
U/S Feature of metastatic LN:
Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005
CT scan criteria
Smooth and well-defined kidney or cigar shaped soft-tissue structures .
The hilumcomposed of fat tissue attenuation.
Homogenous and uniform, enhancing criteria and attenuation.
CT feature of Non metastatic nodes:
Imaging of malignant cervical lymphadenopathy, SEJ Connor and JFC Olli, Dentomaxillofacial
Radiology (2000) 29, 133 -143
Rounded shape with ill defined margin.
Eccentric cortical hypertrophy.
Central necrotic content.
Heterogeneous enhancing
pattern.
CT feature of metastatic nodes:
Imaging of malignant cervical lymphadenopathy, SEJ Connor and JFC Olli, Dentomaxillofacial
Radiology (2000) 29, 133 -143
ULTRASONOGRAPHIC CRITERIACRITERIA Benign nodules Malignant nodes
Margins sharp margins irregularand blurred margins
Shape Usually oval or elongated rounded masses
Hilum present in normal and reactive nodes
Due to the proliferationof cells the hilum is absent
Absence or presence of flow
Small benign nodesdo not present Doppler flow within their volume.
Malignantnodes are vascularised due to their increasemetabolic requirements
Ultrasonography of head and neck lymph nodes, Mihai Dumitru, Ion Anghel, Romanian Journal of Rhinology, Vol. 4, No. 14, April-June 2014
POSITRON EMISSION TOMOGRAPHY
It is a functional imaging that can detect metastasis lesion by pin pointing regions of high metabolism.
It is better for assessing metastasis to lymph node that appear morphologically normal.
Draw back of PET is poor anatomical resolution.
Fused PET/CT is considerd most accurate for imaging nodal metastasis.
TISSUE DIGNOSIS
It is the gold standard in the evaluation of lymphedonopathy.
FINE NEEDLE ASPIRATION CYTOLOGY(FNA)
It is a safe, simple and cost-effective technique that provides rapid information and does not require a general anesthetic
Its findings are especially beneficial for verification of lymphoid origin of the enlarged growth and in differentiating between metastatic, infectious, reactive and lymphomatous causes of LAP.
Most patients who have a benign diagnosis on FNA do not require further evaluation.
ULTRASONOGRAPHY GUIDED FNAC-Gives more precise information than does blinded FNAC because it guides the needle to the most suspicious area of lymph nodes
S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
CORE NEEDLE BIOPSY:
Is another tissue diagnosis method which provides more specimen from the tissue than does FNAC
PERCUTANEOUS IMAGE GUIDED CORE NEEDLE BIOPSY
Is a safe & useful method for diagnosis & classification of malignant lymph nodes presenting with enlarged peripheral lymph nodes & superficial masses.
S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
BIOPSY
Obtaining a proper representative tissue for pathological diagnosis can be made by excisional surgical biopsy.
Ideally, the most accessible node is selected for biopsy.
May be necessary for definite histological proof of the diagnosis.
S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
LYMPHANGIOGRAPHY
Used in cases of lymphoedema, lymph node enlargement, sites of metasis in carcinoma as well as malignant melanoma
Radiopaque dye( lipiodol) is inserted into the localised lymph node and after that x- ray is taken.
Soap bubble appearance- hodgkin’s disease
Sun burst appearance- reticulosarcoma
Nodular pattern- lymphosarcoma
Irregular filling defect- malignancy
S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
Thank you
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