medical lecture otolaryngology

1. Cervical lymphadenopathy

2. Lymph Nodes
• Anatomy
– Collection of lymphoid cells attached to both vascular and
lymphatic systems
– Over 600 lymph nodes in the body

3. Anatomy
• Are small bean-shaped
organs
• Each node has fibrous
capsule & and has a
hilum at one side.
• It receives many afferent
vessels & gives efferent
vessel from its hilum.

4. • The lymph node is divided into an outer cortex and an inner medulla.
• Fibrous trabeculae extend from the deep surface of the capsule into
the cortex to divide it into compartments.
• Fibrous trabeculae in the medulla are irregular & called medullary
Cords.
• Lymphoid follicles form continuous row in the cortex and are absent
in the medulla.
Dr : Rabie Fahmy Zahran

5. Lymph
• Fluid similar in composition to blood plasma.
• Derived from blood plasma by filtration
through capillary walls at the arterial end.
• As soon as the interstitial fluid enters the
lymph capillaries, it is called lymph.
• Returning the fluid to the blood helps to
maintain normal blood volume and pressure.

6. Function
• To provide optimal sites for the concentration of free or cell-
associated antigens and recirculating lymphocytes –
“sensitization of the immune response”
• To allow contact between B-cells, T-cells and macrophages
• Lymph nodes and other lymphatic organs filter the lymph to
remove & destroy microorganisms and other foreign particles
• It returns excess interstitial fluid to the blood to maintain
blood volume and blood pressure .
• Absorption of fat and fat-soluble vitamins from the digestive
system by special lymph capillaries, called lacteals The lymph
in the lacteals has a milky appearance due to its high fat
content and is called chyle.

7. • CLASSIFICATION
1. Upper horizontal chain of nodes
(a) Submental
(b) Submandibular
(c) Parotid
(d) Postauricular
(e) Occipital
(f) Facial

8. • 2. Lateral cervical nodes. They include nodes,
superficial and deep to sternocleidomastoid
muscle and in the posterior triangle.
(a) Superficial external jugular group
(b) Deep group
(i) Internal jugular chain
(upper, middle and lower
groups)
(ii) Spinal accessory chain
(iii) Transverse cervical chain

9. • 3. Anterior cervical nodes
(a) Anterior jugular chain
(b) Juxtavisceral chain
• (i) Prelaryngeal
• (ii) Pretracheal
• (iii) Paratracheal

10. • They lie on the mylohyoid muscle in
the submental triangle, 2–8 in number.
Afferents come from the chin, middle part of lower lip, anterior
gums, anterior floor of mouth and tip of tongue.
Efferents go to submandibular nodes and internal jugular
chain.

11. • They lie in submandibular triangle in
relation to submandibular gland and
facial artery.
Afferents come from lateral part of
the lower lip, upper lip,cheek, nasal
vestibule and anterior part of nasal
cavity, gums,teeth, medial canthus,
soft palate, anterior pillar, anterior
part of tongue, submandibular and
sublingual salivary glands
and floor of mouth.
Efferents go to internal jugular chain.

12. • Parotid nodes
• They lie in relation to the parotid salivary
gland and are extraglandular and
intraglandular. Preauricular and
infraauricular nodes are part of the
extraglandular group.
• Afferents come from the scalp, pinna,
external auditory canal, face, buccal
mucosa.
• Efferents go to internal jugular or
external jugular chain.
• Postauricular nodes (mastoid nodes)
• They lie behindthe pinna over the
mastoid.
• Afferents come from the scalp, posterior
surface of pinna and skin of mastoid.
• Efferents drain into infra-auricular nodes
and into internal jugular chain.

13. • Occipital nodes.
 They lie both superficial and deep to
splenius capitus at the apex of the
posterior triangle.
 Afferents come from scalp, skin of upper
neck.
 Efferents drain into upper accessory
chain of nodes.
• Facial nodes.
 They lie along facial vessels and are
grouped
according to their location. They are
midmandibular, buccinator, infraorbital
and malar (near outer canthus) nodes.
 Afferents come from upper and lower
lids, nose, lips and cheek.
 Efferents drain into submandibular nodes.

14. LATERAL CERVICAL NODES
• Lateral Cervical Nodes
a) Superficial group – it lies
along external jugular vein
and drains into internal
jugular and transverse
cervical nodes.

15. b.Deep Group
• It consists of three chains,
1. the internal jugular chain
2. spinal accessory and
3. Transverse cervical
• Internal jugular chain
Lymph nodes of internal jugular chain lie anterior, lateral and
posterior to internal jugular vein.
Upper group (jugulodigastric node) – drains oral cavity, orpharynx,
nasopharynx, hypopharynx, larynx and parotid.
Middle group drains hypopharynx, larynx, throid, oral cavity,
oropharynx.
Lower jugular group drains larynx, thyroid and cervical oesophagus.

17. • Spinal accessory chain
Lies along the spinal
accessory nerve. Spinal
accessory chain drains
the scalp, skin of the
neck, the nasopharynx,
occipital and
postauricular nodes.
Efferents from this chain
drain into transverse
cervical chain

18. • Transverse cervical chain
(supraclavicular nodes)
It lies horizontally, along the
trasverse cervical vessels, in the
lower part of the posterior
triangle. The medial nodes of
the group called scalene nodes.
Afferents to those nodes come
from the accessory chain and
also infraclavicular structures,
e.d. breast, lung, stomach,
colon, ovary and testis.

19. Anterior Cervical Nodes
Anterior Cervical Nodes
They lie between the two carotids
and below the level of hyoid bone
and
consist of two chains:
(a) Anterior jugular chian - It lies
along anterior
jugular vein and drains the skin of
anterior neck.
(b) Juxtavisceral chain – It consists of
• prelaryngeal
• pretracheal
• and paratracheal nodes

20. (i) Prelaryngeal node (Delphian node)
lies on cricothyroid membrane and drains subgottic
region of larynx and pyriform sinuses.
(ii) Pretracheal nodes
lie in front of the trachea, and drain
thyroid gland and the trachea. Efferents from these
nodes go to paratracheal, lower internal jugular and
anterior mediastinal nodes.
(iii) Paratracheal Nodes
drain the thyroid lobes, subglottic
larynx, tracha and cervical oesophagus

25. AJCC(American Joint Committee on
Cancer) classification
• Level 1 –submental+ submandibular
• Level 2 –upper deep cervical nodes
• Level 3 –middle deep cervical nodes
• Level 4 –lower deep cervical nodes
• Level 5 –spinal accessory + transverse cervical
• Level 6 –pretracheal, prelaryngeal, paratacheal
• Level 7 –upper mediastinal nodes

26. Anatomic division
• Deep lateral cervical group
• Deep cervical chain
• Spinal accessory chain
• Transverse cervical chain
• Anterior cervical group
• Pretracheal
• Prelaryngeal
• Paratracheal
• Submental-Submandibular group
• Parotid group
• Retropharngeal group

27. • Post cervical: scalp, neck skin of arms thorax cervical and axillary nodes (lymphoma, head/neck ca)

28. What is lymphadenopathy
• Lymph nodes that are abnormal in size > 1cm,
consistency or number
• Localized – one area involved
• Generalized – two or more non-contiguous
areas

29. Why do lymph nodes enlarge?
• Increase in the number of benign lymphocytes
and macrophages in response to antigens
• Infiltration of inflammatory cells in infection
(lymphadenitis)
• In situ proliferation of malignant lymphocytes
or macrophages
• Infiltration by metastatic malignant cells
• Infiltration of lymph nodes by metabolite
laden macrophages (lipid storage diseases)

30. Epidemiology
• 0.6% annual incidence of unexplained
adenopathy in the general population
• 10% were referred to a subspecialist and 3.2 %
required a biopsy and 1.1% had a malignancy

31. When to worry?
• Age
• Characteristics of the node
• Location of the node
• Clinical setting associated with
lymphadenopathy

32. Age
• Children/young adults – more likely to
respond to minor stimuli with lymphoid
hyperplasia
– Lymph nodes in patients less than the age of 30
are clinically benign in 80% of cases whereas in
patients over the age of 50 only 40% are benign
– Biopsies done in patients less than 25 yrs have a
incidence of malignancy of <20% vs the over-50
age group has an incidence of malignancy of 55-
80%

33. Clinical examination
• Localized adenopathy should prompt a search
for an adjacent precipitating lesion and an
examination of other nodal areas to rule out
generalized lymphadenopathy. In general,
lymph nodes greater than 1 cm in diameter
are considered to be abnormal.
Supraclavicular nodes are the most worrisome
for malignancy. A three- to four-week period
of observation is prudent in patients with
localized nodes and a benign clinical picture.

34. • The body has approximately 600 lymph nodes,
but only those in the submandibular, axillary
or inguinal regions may normally be palpable
in healthy people.1 Lymphadenopathy refers
to nodes that are abnormal in either size,
consistency or number. There are various
classifications of lymphadenopathy, but a
simple and clinically useful system is to classify
lymphadenopathy as “generalized” if lymph
nodes are enlarged in two or more
noncontiguous areas or “localized” if only one
area is involved.

35. • First, are there localizing symptoms or signs to suggest
infection or neoplasm in a specific site?
• Second, are there constitutional symptoms such as fever,
weight loss, fatigue or night sweats to suggest disorders
such as tuberculosis, lymphoma, collagen vascular diseases,
unrecognized infection or malignancy?
• Third, are there epidemiologic clues such as occupational
exposures, recent travel or high-risk behaviors that suggest
specific disorders?
• Fourth, is the patient taking a medication that may cause
lymphadenopathy? Some medications are known to
specifically cause lymphadenopathy (e.g., phenytoin
[Dilantin]), while others, such as cephalosporins, penicillins
or sulfonamides, are more likely to cause a serum sickness-
like syndrome with fever, arthralgias and rash in addition to
lymphadenopathy

36. Characteristics of the node
• Nodes lasting less than 2 weeks or greater
than one year with no progression of size have
a low likelihood of being neoplastic – excludes
low grade lymphoma
• Cervical nodes – up to 56% of young adults
have adenopathy on clinical exam
• Inguinal adenopathy is common – up to 1-2
cm in size and often benign reactive nodes

37. Characteristics of the node
i. Consistency – Hard/Firm vs Soft/Shotty; Fluctuant
ii. Mobile vs Fixed/Matted
iii. Tender vs Painless
iv. Clearly demarcated
v. Size
i. When to worry – 1.5-2cm in size
ii. Epitroclear nodes over 0.5cm; Inguinal over 1.5cm
vi. Duration and Rate of Growth
vii. Mobile vs fixed
viii. Symmetrical vs asymmetrical

38. Consistency
• Stony hard: typical of cancer usually metastatic
• Firm rubbery: can suggest lymphoma
• Soft: infection or inflammation
• Fluctuant : Suppurated nodes.
• 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
lymphogranuloma venereum)
 or malignant (e.g., metastatic carcinoma or
lymphomas).

39. Pain/Tenderness
• When a lymph node rapidly increases in size,
its capsule stretches and causes pain. Pain is
usually the result of an inflammatory process
or suppuration, but pain may also result from
hemorrhage into the necrotic center of a
malignant node. The presence or absence of
tenderness does not reliably differentiate
benign from malignant nodes

40. size
• in one series of 213 adults with unexplained
lymphadenopathy,
 no patient with a lymph node smaller than 1 cm2 (1
cm × 1 cm) had cancer,
 while cancer was present in 8 percent of those with
nodes from 1 cm2 to 2.25 cm2 (1 cm × 1 cm to 1.5 cm
× 1.5 cm) in size, and
 in 38 percent of those with nodes larger than 2.25
cm2 (1.5 cm × 1.5 cm).
• In children, lymph nodes larger than 2 cm in diameter
(along with an abnormal chest radiograph and the absence
of ear, nose and throat symptoms) were predictive of
granulomatous diseases (i.e., tuberculosis, cat-scratch
disease or sarcoidosis) or cancer (predominantly
lymphomas).

41. Location of the node
• The anatomic location of localized adenopathy
will sometimes be helpful in narrowing the
differential diagnosis. For example, cat-scratch
disease typically causes cervical or axillary
adenopathy, infectious mononucleosis causes
cervical adenopathy and a number of sexually
transmitted diseases are associated with
inguinal adenopathy .

42. Location of the node
• Supraclavicular lymphadenopathy
 Highest risk of malignancy – estimated as 90% in
patients older than 40 years vs 25% in those
younger than 40 yrs
 Right sided node – cancer in mediastinum, lungs,
esophagus
 Left sided node (Virchow’s) – testes, ovaries,
kidneys, pancreas, stomach, gallbladder or
prostate
• Paraumbilical node (Sister mary Joseph’s)
– Abdominal or pelvic neoplasm

43. • Location helps guide differential dx
• Lateral neck most common site for metastatic disease from UADT
- upper neck anterior/deep to SCM
• Midline neck masses likely related to thyroid, elevates with
swallowing
Concerning features:
• any abnormality in other area of head and neck
- skin/scalp/ear lesions, mucosal lesion of nasal cavity, oral cavity,
pharynx, larynx
• enlarging or hard mass
• fixation to surrounding structures (skin, SCM, mandible)
• single, asymmetric node/mass ~ > 2 cm
• mass in supraclavicular fossa or parotid
• neurologic abnormalities (cranial nerves)
• multiple rapidly growing nodes may suggest lymphoma

45. Location of the node
• Epitroclear nodes
– Unlikely to be reactive
• Isolated inguinal adenopathy
– Less likely to be associated with malignancy

46. Generalized Lymphadenopathy
• Malignancy – lymphoma, leukemia, Kaposi’s
sarcoma, metastases
• Autoimmune – SLE, RA, Sjogren’s syndrome, Still’s
disease, Dermatomyositis
• Infectious – Brucellosis, Cat-scratch disease, CMV,
HIV, EBV, Rubella, Tuberculosis, Tularemia, Typhoid
Fever, Syphilis, viral hepatitis, Pharyngitis
• Other – Kawasaki’s disease, sarcoidosis, amyloidosis,
lipid storage diseases, hyperthyroidism, necrotizing
lymphadenitis, histiocytosis X, Castlemen’s disease

47. Unexplained Generalized
lymphadenopathy
• Always requires an evaluation
• Start with CXR and CBC
• Review Medications
• PPD (TB test), RPR(Rapid plasma reagin , a
blood test for syphilis) , Hepatitis screen, ANA,
HIV
• No yield on above test: Biopsy from most
abnormal node.

48. persistent generalized
lymphadenopathy
• Enlargement of the lymph nodes that persists for
at least three months in at least two extrainguinal
sites is defined as persistent generalized
lymphadenopathy and is common in patients in
the early stages of HIV infection. Other causes of
generalized lymphadenopathy in HIV-infected
patients include Kaposi's sarcoma,
cytomegalovirus infection, toxoplasmosis,
tuberculosis, cryptococcosis, syphilis and
lymphoma

49. Clinical Setting
• symptoms – fever, night sweats, weight loss,
Fatigue, Pruritis
• Evidence of other medical conditions –
connective tissue disease
• Young patient – mononucleosis type of
syndrome

50. History
• Identifiable cause for the lymphadenopathy?
– Localizing symptoms or signs to suggest
infection/neoplasm/trauma at a particular site
• URTI, pharyngitis, periodontal disease, conjunctivitis, insect bites,
recent immunization etc
• Constitutional symptoms(fever, night sweats, weight
loss, Fatigue, Pruritis)
• Epidemiological clues
– Occupational exposures, recent travel, high-risk behaviour
• Medications – serum-sickness syndrome

51. Physical Exam
• Full nodal examination – nodal characteristics
• Organomegaly
• Localized – examine area drained by the nodes
for evidence of infection, skin lesions or
tumours

52. Drugs
• Allopurinol
• Atenolol
• Captopril
• Carbamazepine
• Gold
• Hydralazine
• Penicillins
• Phenytoin
• Primidone
• Pyrimethamine
• Quinidine
• Trimethoprim/Sulfamet
hozole
• Suldinac

53. Management
• Identify underlying cause and treat as
appropriate – confirmatory tests
• Generalized adenopathy – usually has
identifiable cause
• Localized adenopathy
– 3-4 week observation period for resolution if not
high clinical suspicion for malignancy
– Biopsy if risk for malignancy - excisional

54. Radiographic Investigation of the Head
and Neck Masses
• MRI – Magnetic Resonance Imaging can clearly highlight soft tissue
pathologies better than the C.T. Scan.
– It uses a magnetic field rather than x-rays (radiation).
• CT SCAN – Computed tomography is less accurate than M.R.I for the
soft tissue examination, but is very useful to locate bony tumors
and their dimensions and extensions.
– C.T with contrast is used to enhance the visibility of abnormal tissue
during examination.
• PET (Positron Emission Tomography) and SPECT (Single Photon
Emission Tomography) are useful after diagnosis to help determine
the grade of a tumor or to distinguish between cancerous and dead
or scar tissue.
– They involve injection with a radioactive tracer.
• Gallium scanning

55. Fine Needle Aspirate
• Safe Convenient, less invasive, quicker turn-around time
• especially beneficial for verification of lymphoid
origin of the enlarged growth and in differentiating
between metastatic, infectious, reactive and
lymphomatous causes of lymphadenopathy. It also
helps in the determination of the extent of tumor;
detection of recurrence; monitoring of the course of
disease; obtaining of material for special studies such
as microbiological cultures, immunological or genetic
studies as well as electron microscopy. Furthermore
• Most patients with a benign diagnosis on FNA biopsy do
not undergo a surgical biopsy
• overall sensitivity was 92.7%, specificity 98.5%

56. • If the LN are
not palpable, endoscopic ultrasound-guided fine
needle aspiration (EUS-FNA) has been shown to
accurately diagnose mediastinal lymph node
pathology with diagnostic accuracy of 84%
• endobronchial ultrasound guided transbronchial
needle aspiration (EBUS-TBNA) have been shown
to
be highly sensitive and specific in the diagnosis of
mediastinal and hilar lesions

57. • Limitations of FNA:
– the lack of proper
tissue sample to run special studies including
cytogenetics, flow cytometry, electron microscopy,
– the potential risk of
seeding a tract with malignancy as a result of FNA

58. BIOPSY
• Can be done by bedside, open surgery, mediastinoscopy FNA
cannot distinguish between lymphomas (nodal architecture needs
to be intact) The preservation of nodal architecture is critical to the
proper diagnosis of lymphadenopathy, particularly when
differentiating lymphoma from benign reactive hyperplasia
• Biopsy should be avoided in patients with probable viral illness
because lymph node pathology in these patients may sometimes
simulate lymphoma and lead to a false-positive diagnosis of
malignancy.
• The diagnostic yield of the biopsy can be maximized by obtaining an
excisional biopsy of the largest and most abnormal node (which is
not necessarily the most accessible node). If possible, the physician
should not select inguinal and axillary nodes for biopsy, since they
frequently show only reactive hyperplasia.
• Patients should be cautioned to remain alert for the reappearance
of the nodes because lymphomatous nodes have been known to
temporarily regress.

60. TB abscess
Treatment should be
started following the
national TB
Guidelines.

66. Thank you

67. Creating a Differential
Chicago

68. Chicago
Cancer
• Heme. malignancies:
Hodgkin, NHL, acute and chronic
leukemia , waldenstroms , multiple
myeloma ( plastmocytomas)
• Metastatic: solid tumor breast, lung,
renal, cell ovarian.

69. cHicago
Hypersensitivity syndromes
• Serum sickness.
• Serum sickness
like illness.
• Drugs
• Silicone
• Vaccination
• Graft vs Host

70. Chicago
Infections
• Viral
• Bacterial
• Protozoan
• Mycotic
• Rickettsial (typhus)
• Helminthic (filariasis)

71. VIRAL
• EBV…mono spot test
• CMV….cmv titers, immunsuppresed, transplant
recipient, recent blood transfusion
• HIV…IV drug use, high risk sexual behavior
• Hepatitis….IV drug use
• Herpes Zoster….superficial cutaneous nodules

72. Bacterial
• Staph/strep: cutaneous source,
lymphadenitis
• Cat scratch: bartonella hensalae, two
weeks after inoculation
• Mycobacterium: TB and non-tb, host
characteristics (HIV, foreign born, low
socioeconomic status, homo….)

73. Spirochete
• Syphilis: Treponema pallidum
Primary localized inguinal lymph
nodes and secondary, non-
treponemal, treponemal
• Lyme disease( the most common tick-borne
disease caused by Borrelia )

74. Protozoan
• Toxoplasmosis: ELISA assay, intracellular
protozoan toxoplasmosis
gondii….bilateral, symmetrical, non-
tender cervical adenopathy
…consider undercooked meat, reactivation
in immun-compromised host

75. chicago
Connective Tissue Disease
• Rheumatoid Arthritis
• SLE
• Dermato-myositis
• Mixed connective tissue disease
• Sjogren

76. chicago
Atypical lymphoproliferative disorders
• Castleman’s disease.
• Wegener's granulomatosis ( a form of
vasculitis that affects the lungs, kidneys and other
organs..)
• Angio-immuonplastic lymph-
adenopathy with dysproteinemia.

77. chicaGo
Granulomatous
• Histoplasmosis.
• Mycobacterial infections.
• Cryptococcus.
• Silicosis: coal, foundry, ceramics, glass.
• Berylliosis: metal, alloys.
• Cat Scratch .

78. chicagO
OTHER…….• RARE
• Kikuchi (histiocytic necrotizing
lymphadenitis ( non-cancerous enlargement of
the lymph nodes)
• Rosi Dorfman disease (sinus histiocytosis with massive
lymphadenopathy, is a rare, benign disorder of unknown etiology )
• Kawasaki disease.