Lymph nodes of head and neck: Normal anatomy and applied aspect

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 -


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


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.


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



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


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


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 :-


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


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


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.


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


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


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


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.


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.


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



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


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.


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


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.



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


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…


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.


• 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:


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


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


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


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


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


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



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.


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


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.


Malignant and TB nodes round.

Reactive and normalnodes usually oval.

The L/S ratio was used to characterize this feature.

Shape Feature:


• 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.


Normal and reactive nodes predominantly hypo-echoic.

Metastatic nodes may be hypo or mixed hypo and eccentric hyper-echoic component.


Normal and reactive lymph nodes tend to have central hilar vascular pattern.

Vascular Pattern:

Metastatic and lympho-matous nodesusually show peripheral or mixed vascularity.


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:


Ill defined margin of enlarged

LN.

Central decreased echogenicity.

Loss hilum.

On Doppler, increase peripheral

vascularity.

U/S Feature of suppurative LN:


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:


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


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.


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.


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


Thank you

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ajr:184, may 2005

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dentomaxillofacial radiology (2000) 29, 133 -143.

Health & Medicine

Lymph nodes of head and neck: Normal anatomy and applied aspect