Lymphadenopathy is a significant clinical finding associated with acute infection, granulomatous disease, autoimmune disease, and malignancy. The involvement of specific nodal groups is an indicator of pathologically-affected organs and tissues, especially in the context of malignancy. As such, intimate knowledge of the anatomic relationships of the lymphatic nodal levels and the structures they drain is critical in the delivery of appropriate therapy in many patients with cancers of the head and neck.
Lymph nodes are small round organs that are part of the body’s lymphatic system. The lymphatic system is a part of the immune system. It consists of a network of vessels and organs that contains lymph, a clear fluid that carries infection-fighting white blood cells as well as fluid and waste products from the body’s cells and tissues. In a person with cancer, lymph can also carry cancer cells that have broken off from the main tumor.
Types of Lymphadenopathy
These include the nasopharynx, pharyngeal wall, base of the tongue, soft palate, and larynx. The lymph nodes of the neck are further classified by level. These levels are Ia, Ib, II, III, IV, V, VI, VII, VIII, IX, X. [rx][rx][rx][rx][rx]
Level Ia: Submental Group
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Anatomy
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Level I nodes are those bounded by the mandible superiorly and laterally and by the hyoid bone inferiorly. Level Ia contains the submental nodal group, bounded superiorly by the symphysis menti and inferiorly by the hyoid bone. It is bounded anteriorly by the platysma muscle, posteriorly by the mylohyoid muscles, laterally by the anterior belly of the digastric muscle, and medially by the virtual anatomic midline. These boundaries form a triangular region also termed the submental triangle.
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Drainage
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This group drains the skin of the mental region, or chin, the mid-lower lip, the anterior portion of the oral tongue, and the floor of the mouth.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the floor of the mouth, anterior oral tongue, mandibular alveolar ridge, and lower lip.
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Level Ib: Submandibular Group
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Anatomy
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Level Ib contains the submandibular nodal group, bounded superiorly by the mylohyoid muscle and inferiorly by the hyoid bone. It is bounded anteriorly by the symphysis menti, posteriorly by the posterior edge of the submandibular gland, laterally by the inner surface of the mandible, and medially by the digastric muscle. These boundaries form a triangular region also termed the submandibular triangle.
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Drainage
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They drain the efferent lymphatics from level Ia, the lower nasal cavity, both the hard and soft palates, and both maxillary and mandibular alveolar ridges. They also drain them from the skin and mucosa of the cheek, both upper and lower lips, the floor of the mouth, and the anterior oral tongue.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the oral cavity, anterior nasal cavity, soft-tissues of the mid-face, and submandibular gland.
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Level II: Upper Jugular Group
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Anatomy
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Level II represents the beginning of the jugular chain. It contains the upper jugular nodal group, adjacent to the top third of the internal jugular vein (IJV) and upper spinal accessory nerve. It is bounded superiorly by the insertion of the posterior belly of the digastric muscle into the mastoid process, and inferiorly by the caudal border of the hyoid bone or alternatively, as a surgical landmark, the carotid bifurcation. It is bounded anteriorly by the posterior edge of the submandibular gland, posteriorly by the posterior edge of the sternocleidomastoid muscle (SCM), laterally by the medial surface of the SCM, and medially by the internal carotid artery and scalenus muscle.
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Drainage
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This group drains the efferent lymphatics of the face, parotid gland, level Ia, level Ib, and retropharyngeal nodes. It receives direct drainage from the nasal cavity, the entire pharyngeal axis, larynx, external auditory canal, middle ear, and the sublingual and submandibular glands.
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Level III: Middle Jugular Group
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Anatomy
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Level III contains the middle jugular nodal group, adjacent to the middle third of the IJV. It is bounded superiorly by the caudal border of the hyoid bone, and inferiorly by the caudal edge of the cricoid cartilage or alternatively, as a surgical landmark, the plan where the omohyoid muscle crosses the IJV. It is also bounded anteriorly by the anterior edge of the SCM, or the posterior third of the thyrohyoid muscle, and posteriorly by the posterior border of the SCM. Finally, it is bordered laterally by the medial surface of the SCM, and medially by the internal carotid artery and scalenus muscle.
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Drainage
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This group drains the efferent lymphatics from level II and level V, and partially from the retropharyngeal, pretracheal, and recurrent laryngeal nodes. It receives direct drainage from the base of the tongue, tonsils, larynx, hypopharynx, and thyroid gland.
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Level IVa: Lower Jugular Group
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Anatomy
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Level IVa contains the lower jugular nodal group adjacent to the inferior third of the IJV. It is bounded superiorly by the caudal border of the cricoid cartilage, and inferiorly by a virtual level two centimeters superior to the sternoclavicular joint, based off surgical conventions of level IVa dissection. It is bounded anteriorly by the anterior edge of the SCM (more superiorly) and the body of the SCM (more inferiorly), and posteriorly by the posterior edge of the SCM (more superiorly) and the SM(more inferiorly. This group is also laterally bound by the medial edge of the SCM (more superiorly) and the lateral edge of the SCM (more inferiorly). Finally, it is medially bordered by the medial edge of the common carotid artery, the medial edge of the thyroid gland and scalenus muscle (more superiorly), and the medial edge of the SCM (more inferiorly).
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Drainage
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This group drains the efferent lymphatics from levels III and V, and partially from the retropharyngeal, pretracheal, and recurrent laryngeal nodes. It receives direct drainage from the larynx, hypopharynx, and thyroid gland.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the hypopharynx, larynx, thyroid, cervical esophagus, and rarely, the anterior oral cavity. Deposits from the anterior oral cavity can manifest without proximal nodal involvement.
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Level IVb: Medial Supraclavicular Group
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Anatomy
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This nodal group is a continuation of level IVa to the superior edge of the sternal manubrium. It is bounded anteriorly by the deep surface of the SCM. Posteriorly, it is bound by the anterior edge of the scalenus muscle (more superiorly) and the lung apex, brachiocephalic vein, and artery on the right, as well as the common carotid and subclavian arteries on the left (more inferiorly). It is bounded laterally by the lateral edge of the scalenus muscle, and medially by the medial border of the common carotid artery which is also adjacent to level VI.
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Drainage
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This group drains the efferent lymphatics from levels IVa and Vc, and partially from the pretracheal and recurrent laryngeal nodes. It receives direct drainage from the larynx, trachea, hypopharynx, esophagus, and thyroid gland.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the hypopharynx, subglottic larynx, trachea, thyroid, and cervical esophagus.
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Level Va and Vb: Posterior Triangle Group
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Anatomy
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These nodal groups are contained with the posterior triangle. They are situated posteriorly to the SCM, and adjacent to the inferior portion of the spinal accessory nerve and transverse cervical vessels. It is bounded superiorly by the superior edge of the hyoid bone and inferiorly by a virtual plane crossing the transverse vessels. It is bound anteriorly by the posterior margin of the SCM, and posteriorly by the anterior border of the trapezius muscle. It is also bound by the platysma muscle and skin laterally, and by the levator scapulae (more superiorly) and scalenus muscle (more inferiorly) medially. A virtual plane at the inferior edge of the cricoid cartilage divides this group into upper, or Va, and lower, or Vb, posterior triangles.
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Drainage
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These nodal groups drain the efferent lymphatics from the occipital, retro-auricular, occipital, and parietal scalp nodes. It receives direct drainage from the skin of the lateral and posterior neck and shoulder, the nasopharynx, oropharynx, and thyroid gland.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the nasopharynx, oropharynx, and thyroid.
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Level Vc: Lateral Supraclavicular Group
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Anatomy
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This nodal group is a continuation of levels Va and Vb; it contains the lateral supraclavicular group. It is bounded superiorly by a virtual plan crossing the transverse vessels, and inferiorly by a virtual plan 2 cm superior to the sternoclavicular joint. It is also bounded anteriorly by the skin and posteriorly by the anterior border of the trapezius muscles (more superiorly) and the serratus anterior (more inferiorly). Laterally, it is bounded by the trapezius muscle (more superiorly) and the clavicle (more inferiorly). Medially, it is bordered by the scalenus muscle and lateral edge of the SCM and is directly adjacent to the lateral edge of level IVa.
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Drainage
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This group drains the efferent lymphatics from levels Va and Vb.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the nasopharynx.
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Level VI: Anterior Compartment Group
The anterior compartment contains this nodal group, which is symmetric about the anatomic midline. It is also further subdivided into the superficially-located anterior jugular nodes or level VIa, and the deeper pre-laryngeal, pre-tracheal, and para-tracheal (recurrent laryngeal) nodes, or level VIb. Level VIa
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Anatomy
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Level VIa is bounded superiorly by the inferior edge of level Ib and inferiorly by the superior edge of the sternal manubrium. It is bounded anteriorly by the skin and platysma, posteriorly by the anterior surface of the infrahyoid muscles, and bilaterally by the anterior edges of the SCMs.
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Drainage
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Level VIa drains the integuments of the lower face and the anterior neck.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the lower lip and soft tissues of the chin, such as advanced gingiva-mandibular carcinoma.
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Level VIb
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Anatomy
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Level VIb is bounded superiorly by the superior edge of the thyroid cartilage and inferiorly by the superior border of the sternal manubrium. It is also bounded anteriorly by the posterior margin of the infrahyoid muscles, and posteriorly by the anterior larynx, thyroid gland, and trachea at the midline, the pre-vertebral muscles on the right, and the esophagus on the left. This group is bordered laterally by the common carotid artery and medially by the lateral aspects of the trachea and esophagus.
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Drainage
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Level VIb drains the efferent lymphatics from the anterior floor of the mouth, tip of the oral tongue, lower lip, thyroid gland, glottic and supraglottic larynx, hypopharynx, and cervical esophagus.
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Level VII: Prevertebral Compartment Group, including Levels VIIa and VIIbLevel VIIa
Retropharyngeal Nodes
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Anatomy
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These nodes are contained in the retropharyngeal space. They are divided into medial and lateral subgroups. The lateral groups are bounded superiorly by the superior edge of the C1 vertebral body, or the hard palate, and inferiorly by the superior edge of the body of the hyoid bone. Anteriorly, they are bounded by the posterior edge of the superior/middle pharyngeal constrictor muscles. They are bordered posteriorly by the longus capitis and longus colli muscles, laterally by the medial edge of the internal carotid artery, and medially by a virtual line parallel to the lateral edge of the longus capitis muscle. The medial groups are approximated at the midline and not well-defined.
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Drainage
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These nodes drain the efferent lymphatics from the nasopharynx, eustachian tube, and soft palate.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the nasopharynx, pharyngeal wall, and oropharynx including tonsillar fossa and soft palate.
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Level VIIb: Retrostyloid Nodes
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Anatomy
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These nodes are contained in the fatty space surrounding the large vessels of the neck leading to the jugular foramen. They are the superior continuation of level II. Level VIIb is bounded superiorly by the jugular foramen at the base of the skull, and inferiorly by the inferior edge of the lateral process of the C1 vertebral body, the superior boundary of level II. These nodes are bounded anteriorly by the posterior edge of the prestyloid parapharyngeal space, and posteriorly by the C1 vertebral body and base of the skull. Finally, they are bordered laterally by the styloid process and deep parotid lobe, and medially by the medial edge of the internal carotid artery.
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Drainage
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These nodes drain the efferent lymphatics from the nasopharynx.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the nasopharynx and anywhere in the head and neck resulting in significant infiltration of upper-level II nodes causing via retrograde flow.
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Level VIII: Parotid Group
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Anatomy
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This group includes the subcutaneous pre-auricular, superficial and deep intracarotid, and subparotid nodes. It is bounded superiorly by the zygomatic arch and external auditory canal, and inferiorly by the mandibular angle. This group is bounded anteriorly by the posterior edge of the mandibular ramus, the posterior edge of the masseter muscle (more laterally), and medial pterygoid muscle (medially). It is also bordered posteriorly by the anterior edge of the SCM (more laterally) and posterior belly of the digastric muscle (more medially). These nodes are bordered laterally by superficial muscular aponeurotic system (SMAS) layer within the subcutaneous tissues, and medially by the styloid process and muscle.
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Drainage
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These nodes drain the efferent lymphatics from the frontal and temporal skin, eyelids, conjunctivae, auricles, external acoustic meatus, tympanum, nasal cavities, the root of the nose, nasopharynx, and the eustachian tube.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the previously named draining structures, as well as the orbit, external auditory canal, and parotid gland.[rx]
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Level IX: Buccofacial group
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Anatomy
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This group contains the malar and the buccofacial nodes. These are superficial nodes surrounding the facial vessels on the external surface of the buccinator muscle. It is bounded superiorly by the inferior edge of the orbit and inferiorly by the inferior border of the mandible. It is also bounded anteriorly by the SMAS layer within the subcutaneous tissue, and posteriorly by the anterior edge of the masseter muscle and the corpus adiposum buccae. The lateral border is the SMAS layer, and the medial border is the buccinator muscle.
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Drainage
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These nodes drain the efferent vessels of the nose, eyelids, and cheek.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the facial skin, nose, and buccal mucosa, as well as the maxillary sinus if invading soft tissues of the cheek.
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Level X: Posterior Skull Group, including Levels Xa and Xb
Level Xa: Retroauricular and Subauricular Nodes
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Anatomy
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This group includes superficial nodes on the mastoid process. It is bounded superiorly by the superior edge of the external auditory canal, and inferiorly by the mastoid tip. It is also bounded anteriorly by the anterior edge of the mastoid (inferiorly) and posterior edge of the external auditory canal (superiorly), and posteriorly by the posterior edge of the SCM. This group is bordered laterally by subcutaneous tissue, and medially by the splenius capitis muscles (inferiorly) and the temporal bone (superiorly).
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Drainage
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These nodes drain the efferent vessels from the posterior auricular surface, external auditory canal, and adjacent scalp.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the retro-auricular skin.
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Level Xb: Occipital Nodes
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Anatomy
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This group is the superior and superficial continuation of level Va. It is bounded superiorly by the external occipital protuberance, and inferiorly by the superior border of level V. It is also bounded anteriorly by the posterior edge of the SCM, which is the posterior border of level Xa, and posteriorly by the anterior/lateral side of the trapezius muscle. Finally, this group is bordered laterally by subcutaneous tissues, and medially by the splenius capitis muscle.
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Drainage
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These nodes drain efferent vessels from the posterior hairy scalp.
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Associated primary malignancies
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These nodes most often contain metastatic deposits from malignancies of the occipital skin. [rx]
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Causes of Lymphadenopathy
The etiology of lymphadenopathy includes the following:
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Infectious disease
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Neoplasm
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Inflammatory disease
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Autoimmune disease
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Inborn metabolic storage disorder
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Exposure to toxic/medication
Infectious disease can be of viral, bacterial, mycobacterial, fungal or parasitic etiology
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Fungal – etiology of lymphadenopathy include coccidiomycosis and Candida
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Parasitic – etiology of lymphadenopathy include toxoplasmosis, histoplasmosis, Chagas, and many of the ectoparasites
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Neoplastic – causes of lymphadenopathy include both primary malignancies and metastatic malignancies: Acute lymphoblastic leukemia (ALL), Hodgkin lymphoma, non-Hodgkin lymphoma, neuroblastoma, pediatric acute myelocytic leukemia, rhabdomyosarcoma, metastatic carcinoma of the lung, metastatic carcinoma of the viscera of the gastrointestinal (GI) tract, metastatic breast cancer, and metastatic thyroid cancer and metastatic renal cancer.
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Autoimmune disease – these causes of lymphadenopathy include sarcoidosis, juvenile rheumatoid arthritis (JRA), serum sickness, systemic lupus erythematosus (SLE)
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Exposures to toxins – and medications that are common causes of lymphadenopathy include the medications allopurinol, atenolol, captopril, carbamazepine, many of the cephalosporins, gold, hydralazine, penicillin, phenytoin, primidone, para methylamine, quinidine, the sulfonamides, and sulindac. The lifestyle exposures to alcohol, ultraviolet (UV) radiation, and tobacco can cause cancers with secondary lymphadenopathy.
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Inborn metabolic – storage disorders (including Niemann-Pick disease and Gaucher disease) are possible additional causes of lymphadenopathy.
Generalized Lymphadenopathy
Common Infectious Causes
- Infectious Mononucleosis (Epstein-Barr Virus)
- Toxoplasmosis
- Cytomegalovirus
- Cat Scratch Disease (Cat Scratch Fever, Bartonella)
- Upper Respiratory Infections (e.g. Pharyngitis, Adenovirus)
- Tuberculosis
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Mononucleosis
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HIV
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Tuberculosis
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Typhoid fever
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Syphilis
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Plague
- Scarlet Fever
- Scabies
- Herpes Zoster virus (Shingles)
- Cellulitis, Impetigo and other Skin Infections (Streptococcus and Staphylococcus)
Sexually Transmitted Disease Causes of Lymphadenopathy
- Hepatitis B
- Acute Retroviral Syndrome in HIV Infection
- See Lymphadenopathy in HIV
- Primary Syphilis and Secondary Syphilis
- Lymphogranuloma venereum
- Chancroid
Less Common Infectious Causes
- Miscellaneous fungal and Helminth infections
- Fungal Lung Infections (Histoplasmosis, Coccidioidomycosis, Cryptococcosis)
- Lyme Disease
- Rocky Mountain Spotted Fever (and other Rickettsia infection)
- Measles
- Rubella
- Tularemia
- Brucellosis
- Bubonic Plague
- Typhoid Fever
- Scrub Typhus
- African Trypanosomiasis (African Sleeping Sickness)
- Chagas’ Disease
- Kala-azar
- Sporotrichosis
Malignancies
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Acute leukemia
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Hodgkin’s lymphoma
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Non-Hodgkin’s lymphoma
Metabolic Storage Disorders
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Gaucher disease
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Niemann-Pick disease
Medication Reactions
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Allopurinol
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Atenolol
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Captopril
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Carbamazepine
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Cephalosporin(s)
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Gold
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Hydralazine
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Penicillin
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Phenytoin
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Primidone
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Pyrimethamine
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Quinidine
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Sulfonamides
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Sulidac
Autoimmune Disease
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Sjogren syndrome
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Sarcoidosis
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Rheumatoid arthritis
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Systemic lupus erythematosus
Localized Peripheral Lymphadenopathy
Head and Neck Lymph Nodes
Viral infection
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Viral URI
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Mononucleosis
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Herpes virus
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Coxsackievirus
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Cytomegalovirus
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HIV
Bacterial infection
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Staphylococcal aureus
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Group A Streptococcus pyogenes
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Mycobacterium
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Dental abscess
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Cat scratch disease
Malignancy
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Hodgkin disease
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Non-Hodgkin lymphoma
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Thyroid cancer
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Squamous cell carcinomas of the head and neck
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Lymphoma
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Squamous cell carcinoma of genitalia
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Malignant melanoma
Inguinal Peripheral Lymphadenopathy
Axillary Lymphadenopathy
Infection
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Localized Staphylococcal aureus
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Cat-scratch disease
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Brucellosis
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Mycobacteria
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Fungi
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STDs
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Cellulitis
Malignancy
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Lymphoma
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Breast cancer
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Melanoma
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Thoracic and abdominal neoplasms
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Hodgkin disease
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Non-Hodgkin lymphoma
Reaction to breast implants
Supraclavicular Adenopathy
Collagen Vascular Causes of Lymphadenopathy
Common
- Systemic Lupus Erythematosus
- Rheumatoid Arthritis
- Sjogren Syndrome
Less Common
- Still’s Disease
- Dermatomyositis
- Sarcoidosis
Neoplastic Causes of Lymphadenopathy
- Hodgkin’s Lymphoma
- Lymphosarcoma
- Histiocytic Medullary Reticulosis
- Leukemia
- Lymphocytic Leukemia
- Myelocytic Leukemia
- Metastatic cancer
- Melanoma and other skin cancers
- Kaposi’s Sarcoma
- Neuroblastoma
- Seminoma
- Lung Cancer
- Breast Cancer
- Prostate Cancer
- Renal carcinoma
- Head and neck cancers
- Gastrointestinal tract cancers
Miscellaneous Causes of Lymphadenopathy
Common
- Serum Sickness
- Sarcoidosis
- Hyperthyroidism
Less Common
- Kawasaki Disease
- Amyloidosis
- Niemann-Pick Disease
- Gaucher’s Disease
- Berylliosis
- Silicosis
- Angiofollicular lymph node hyperplasia (Castleman Disease)
- Histiocytosis
- Kituchi Lymphadenitis
- Kimura Disease
Symptoms of Lymphadenopathy
- Morbilliform rashes may mimic rubella or a drug-induced eruption
- Facial erythema, sometimes resembling the butterfly rash of systemic lupus erythematosus (SLE)
- Erythematous macules, plaques, and acneiform eruptions on the face
- Indurated papules on the back and arms
- Scaling
- Pruritus
- Alopecia
- Oropharyngeal redness and ulceration.
- Body aches
- Fever
- Loss of appetite
- Respiratory symptoms such as cough or congestion
- Fatigue
- Headache
Diagnosis of Lymphadenopathy
History and Physical
A history and physical examinations are the cornerstones of time and cost-effective diagnosis of adenopathy. The depth and the extent of the H&P conducted are proportional to the obscurity of the etiology of the adenopathy. The obvious presence of strep pharyngitis and its related localized anterior cervical adenopathy requires far less clinical brain-power than generalized adenopathy secondary to sarcoidosis or a Gaucher disease.
The history itself involves gathering 5 important components: chronicity, localization, concomitant symptoms, patient epidemiology, and pharmacological exposure.
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Chronicity – The accepted definition of “chronic adenopathy” is a duration of greater than 3 weeks and the observation that duration of fewer than 2 weeks or greater than 1 year is usually associated with benign causality.
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Localization – The first determination is if the adenopathy can be viewed as localized or generalized. The accepted definition of generalized lymphadenopathy is clinical lymphadenopathy in 2 or more non-contiguous areas. Generalized adenopathy may be indicative of systemic illness, and the workup is typically more laboratory and imaging-intensive and pursued more rapidly. Localized beds of enlarged nodes reflect possible localized pathology in the areas in which they drain.
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Physical characterization – of the node itself
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Concomitant symptoms – The presence or absence of constitutional symptoms is a major cue in the determination of the pace and depth of the workup in lymphadenopathy when taken in the clinical context. For example fever, chills, night sweats, weight loss, and fatigue are worrisome in the setting of generalized lymphadenopathy. However, similar symptoms are acceptable in the setting of localized cervical lymphadenopathy and concomitant Flu or Strep.
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Epidemiology – Included in the epidemiological search for lymphadenopathy, will be questions pertaining to Dietary exposure, pet exposure, insect bite, recent blood exposure, high-risk sexual behavior or intravenous drug use, occupational exposure to animals, and travel-related epidemiology especially attention to travel to the third world or the Southwest in the United States.
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Pharmacological exposure – A thorough medical history is necessary including prescription medications, over-the-counter medications, supplements and herbal medicines.
The physical examination can be quite revealing especially with the location of the adenopathy and consideration of the lymphatic drainage of the related areas. Once the determination has been made that the lymphadenopathy is either localized or general, strict attention to the localized area must be paid. For example:
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Submandibular nodes typically drain the tongue the lips and the mouth and the conjunctiva
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Submental nodes typically drain the lower lip portions of the oropharynx and the cheek
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Jugular lymphadenopathy typically drains the tongue, the tonsils, the pinna, and the parotid gland
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Posterior cervical adenopathy typically is indicative of scalp, neck, skin of the arms and legs
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Pectoral thoracic cervical and axillary drainage
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Suboccipital nodes reflect drainage of the scalp in the head, and preauricular nodes reflect drainage the eyelids, conjunctiva temporal region, and pinna.
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Postauricular nodes reflect drainage at the scalp in the external auditory meatus.
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The right supraclavicular node represents drainage of the mediastinum the lungs in the esophagus
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Axillary nodes typically creating the arm at the thoracic wall and the breast.
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The epitrochlear nerve roots typically drain the ulnar aspect of the forearm and the hand.
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Inguinal nodes drain the penis, the scrotum, the vulva, vagina, the perineum, the gluteal region, and the lower abdominal wall and portions of the lower anal canal
Characterization of the node morphology itself
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Tenderness-pain – may result from an inflammatory process or perforation and also may result from hemorrhage into the necrotic center of a malignant node. (Presence or absence of pain not a reliable differentiating factor for malignant nodes though.)
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Consistently firm rubbery nodes – may suggest lymphoma; softer nodes are usually the result of infection or inflammatory conditions; hard stonelike nodes are typically a sign of cancer more commonly metastatic than primary.
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“Shotty” nodes refer to very small – scattered nodes that feel like shotgun pellets under the skin. This configuration is typically is found in cervical nodes of children with viral illnesses
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The designation of a “matting – the configuration of nodes describes the pattern of clustered, seemingly conjoined lymph nodes. This is indicative of, but not pathognomonic, for malignancy.
Evaluation
Laboratory Evaluation of Lymphadenopathy
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CBC with manual differential – This is a foundational test in the diagnosis of both generalized and regional lymphadenopathy. The number and differential of the white blood cells can indicate bacterial, viral, or fungal pathology. In addition, characteristic white blood cell (WBC) patterns are observed with several of the hematological neoplasms producing lymphadenopathy
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EBV serology – Epstein-Barr viral mono is present causing regionalized lymphadenopathy
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Sedimentation rate – A measure of inflammation though not diagnostic, it can contribute to diagnostic reasoning
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Cytomegalovirus titers – This viral serology is indicative of possible of CMV mononucleosis
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HIV serology – This serology can be used to diagnose acute HIV syndrome-related lymphadenopathy or to infer the diagnosis of secondary HIV-elated pathologies causing lymphadenopathy.
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Bartonella henselae serology – Serology that may be indicative of the diagnosis of cat-scratch lymphadenopathy
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FTA\RPR – These tests can establish if syphilis is a cause of lymphadenopathy
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Herpes simplex serology – Serological testing to discern if the herpes-related, mononucleosis-like syndrome is present or if regionalized inguinal adenopathy is secondary to herpes simplex exposure
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Toxoplasmosis serology – These serological tests can lead to a diagnosis of acute toxoplasmosis as a cause of lymphadenopathy
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Hepatitis B serology – Serological tests for hepatitis B to establish it as a contributing factor for lymphadenopathy
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ANA – A serological screening test for SLE that can help establish it as a cause for generalized lymphadenopathy
Diagnostic Radiological Testing
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Chest x-ray – This radiological imaging modality can reveal tuberculosis, pulmonary sarcoidosis, and pulmonary neoplasm.
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Chest CAT scan – This modality of radiological imaging can define the above processes and reveal hilar adenopathy.
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Abdominal and pelvic CAT scan – These images, in combination with a chest CAT scan, can be revealed in cases of supraclavicular adenopathy and the diagnosis of secondary neoplasm.
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Ultrasonography – This imaging modality can be used in the assessment of number, size, size, shape, the marginal definition, and internal structures in patients with lymphadenopathy. Of note, color Doppler ultrasonography is of use in distinguishing the vascular pattern between older pre-existing lymphadenopathy and recent (newly active) lymphadenopathy. Studies have indicated that a low long axis to short axis ratio of lymphadenopathy as measured by ultrasound can be a significant indicator of lymphoma and metastatic cancer as a cause of lymphadenopathy.
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MRI scanning – As with CAT scanning, this modality of diagnostic imaging has great utility in the evaluation of thoracic, abdominal, and pelvic masses.
PPD
- Tuberculosis is among the leading cause of both regional and generalized adenopathy in the non-industrialized world
Treatment of Lymphadenopathy
Patient education plays a significant role in the deterrence of the processes that can cause pathological lymphadenopathy.
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Smoking cessation, alcohol moderation, modification of unsafe sexual practices, and avoidance of drug use can significantly decrease the rate of cancers, HIV, hepatitis B and C, and sexually transmitted infections.
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Appropriate vaccination, good hygiene, good public sanitation, and careful infectious disease protocols can significantly decrease the rate of recurrence, and transmission of infections causing lymphadenopathy.
The management and treatment of lymphadenopathy are dependent on its etiology. For example:
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Lymphadenopathy caused by a primary neoplasm – Treatment of the neoplasm
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Lymphadenopathy caused by metastasis-diagnosis of the primary – Treatment of the metastasis and primary
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Lymphadenopathy caused by bacterial disease – Supportive care, antibiotics, and elimination of nidus of infection if applicable
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Lymphadenopathy caused by viral disease – Observation and supportive care or treatment of the virus if particular antiviral medications exist
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Lymphadenopathy caused by a toxin or medication exposure – Removal of offending medication if possible or avoidance of toxin
Complications
Pitfalls and pearls of the diagnosis and treatment of lymphadenopathy include:
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There is no substitute for a thorough history and careful physical examination in the workup of lymphadenopathy.
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The majority of both localized and generalized lymphadenopathy have a relatively benign treatable cause.
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All generalized lymphadenopathy merits careful evaluation and workup.
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The gold standard for diagnosis of lymphadenopathy remains tissue diagnosis of the node by incisional biopsy.
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A careful review of the patient’s epidemiological and personal medical history provides daily clues as to when lymphadenopathy can be safely observed for change or resolution over a period of 2 to 4 weeks.
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Supraclavicular lymphadenopathy is almost universally indicative of underlying thoracic or abdominal malignancy.
References
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