CERVICAL LYMPH NODES

CERVICAL LYMPHADENITISCauses

Inflammatory: reactive hyperplasia

Infective: viral EBV, infectious mononucleosis, cytomegalovirus, HIV

bacteria Strepto, Staphylococci, mycobacteria, actinomycosis, brucellosis

protozoan Toxoplsma

Neoplastic: primary secondary

ACUTE CERVICAL LYMPHADENITIS

• Commonly from tonsillitis or a dental abscess• Constitutional disturbances like pyrexia, anorexia and

general malaise are +• Affected nodes are enlarged, warm and tender• Blood exam. shows leucocytosis with preponderance of

polymorphs• Treatment is of primary focus• If, despite antibiotic therapy pain continues, or abscess

formation occurs in the lymph nodes, parapharyngeal or retropharyngeal space then surgical drainage is required.

CHRONIC CERVICAL LYMPHADENITIS

• Non-specific: low-grade pyogenic infection from caries teeth, ch. tonsillitis,

adenoids, scalp etc., Nodes are enlarged, not tender and consistency is firm or soft.

• By far the commonest ch. Cervical lymphadenitis in India is tuberculous.

Tuberculous cervical lymphadenitis• Commonest form of extra pulmonary tuberculosis esp. in

children and young adults, but may occur at any age.

• Caused by Mycobacterium tuberculosis; both by bovine and human strains. Now also by atypical mycobacteria esp. in immuno deficient pts., such as HIV. In most instances bacilli enter through the tonsil of the corresponding side. Deep cervical nodes are commonly affected, but there may be widespread cervical lymphadenitis.

• Supraclavicular represents upward extension of hilar and mediastinal lymphadenopathy. Axillary and inguinal nodes are involved by haematogenous or perhaps by retrograde lymphatic spread.

Tuberculous cervical lymphadenitis

• In 80% tuberculous process is limited to clinically affected group but primary focus in the lungs must always be suspected and investigated. As renal and pulmonary TB occasionally coexist, urine should be examined carefully .

Rarely, pt. develops natural resistance and the nodes may be detected as calcification on x-ray or after appropriate treatment

TB cervical adenitis-Pathology• Granulomatous inflammation with tubercle • Undergo caseation, necrosis and destruction• Spread to adjacent nodes- periadenitis; getting

adherent to each other- “matting” • Caseous nodes with periadenitis deep to deep

fascia perforates with the escape of caseous material into subcutaneous space resulting in “collar-stud abscess”.

• abscess gets adherent to skin and burst in the surface resulting in abscess or sinus

TB cervical adenitis-Pathology• Stage-1 The glands are enlarged, mobile, firm, and slightly tender.

Histologically, they show non-specific reactive hyperplasia.

• Stage-2 The nodes are large, firm and fixed to surrounding tissues and to each other. Histologically, they show periadenitis, typical tuberculous granulomatous tissue with lymphocytes, epithelioid cells, and caesation.

• Stage-3 The caesation is extensive giving rise to variable consistency with soft areas of cold abscesses and firm lymph nodes.

• Stage-4 The abscesses burst out of the lymph node mass and extends into subcutaneous tissue giving rise to a ‘collar-stud’ abscess

• Stage-5 The abscess bursts and gives rise to a persistent, discharging sinus. The discharge from sinus may infect the surrounding skin and cause extensive tuberculous ulcer. Ulcers have a typical pale, flabby, granulation tissue, under-mined edges, and a seropurulent discharge.

TB cervical adenitis- Types of clinical manifestations

• Acute type : Seen in infants and children < 5yrs. The glandular enlargement is painful, tender, and evolves within

few days. The overlying skin is red and oedematous. The child has moderate fever. The clinical picture resembles acute septic lymphadenitis.

• Caseating Type: Most common type seen in young adults: Glands are multiple, moderately enlarged and matted together. The caseation leads to softening, cold abscess and sinuses. The patient is anemic and moderately nourished. Constitutional features like fever anorexia and weight loss may be present.

TB cervical adenitis- Types of clinical manifestations

• Hyperplastic type in patients with good general resistance, lymph nodes show a marked degree of reactive, reticular and lymphoid hyperplasia. TB garanulomatous tissue is more productive with least caseation and periadinitis. The glands are notably enlarged and appear fleshy, elastic and freely mobile resembling those of Hodgekin’s disease.

• Atrophic type: Seen in elderly individual in whom lymphoid tissue undergoes natural process of involution, glands are comparatively small and soon burst with the onset of caesation.

TB cervical adenitis- Diagnosis

Clinical diagnosis is not difficult in classical case, where chronic iymphadenopathy in young individual is associated with matting and soft areas of caesation.

• A negative tuberculin test excludes. A positive test has no diagnostic value. ESR raised. Serum albumin falls and gamma globulins increase.

• An X-ray chest is mandatory for coexisting pulmonary lesion.

• Positive FNAC and biopsy are essential for confirming diagnosis. Typical tuberculous granuloma with epithelioid cells, giant cells and lymphocytes surrounding the area of caseation are characteristics.

• Besides M.tuberlcosis ,atypical bacteria such as M.scrofulaceum and M. intercellulare have been recovered from cases.

TB cervical adenitis- Treatment

• Multi drug regime• Initial phase for 4 drugs for 2 – 3 months.

Cap Rifampicin - 450-600 mg. daily. Tab Isoniazid - 300 mg daily. Tab Ethambutol – 1000 mg daily. Tab Pyrazinamide – 1500 mg daily.

• Subsequently 2 drugs for 4-6 months.

Cap Rifampicin and Tab Isoniazid. With full course of anti tuberculosis drug therapy, the glands subside

within 3 – 4 months and response is even quicker in children.

TB cervical adenitis- Treatment

• Cold absess: repeated non dependent aspiration; streptomycin may be instilled locally.

• Surgical excision is indicated (a) When the glands continue to persist after

adequate chemotherapy and localised to one single group.

(b) for persistent sinuses- secondary infection, necrotic and calcified material replacing the lymph nodes, and fibrosis are responsible for persistence of sinus even after the active disease has subsided.

SEC. CERVICAL LYMPH NODES

Prognostic factors• Presence or absence of cl. palpable nodes,• size, number, location• Involvement below crico-thyroid - Lower (Level IV) &

posterior (Level V) is ominous

• extra nodal spread to soft tissue• perivascular and perineural infiltration• tumour emboli in regional lymphatics

Levels of cervical nodes

• Level I Submental Gr. within the triangle bounded by ant. bellies of digastric and hyoid bone Submandibular gr. bounded by post. Belly of digastric and body of mandible

Levels of cervical nodes

• Level II (upper jugular) around upper 1/3 of IJV and adjacent spinal

accessory nerve extending from carotid bifurcation to skull base

Levels of cervical nodes

• Level III (middle jugular) around middle 1/3 of IJV from carotid

bifurcation superiorly to cricothyroid membrane inferiorly

Levels of cervical nodes

• Level IV (lower jugular) around lower 1/3 of IJV from cricothyroid

membrane to the clavicle inferorly

Levels of cervical nodes• Level V (posterior triangle) along the lower ½ of spinal accessory N. and tr. Cervical artery. Supraclavicular

nodes are included in this group Posterior border is anterior border of

trapezius and anterior boundary is posterior border of sternomastoid

Levels of cervical nodes• Level VI (anterior compartment group) from hyoid bone superiorly to

suprasternal notch inferiorly . Lateral boundary in each side is medial border of sternomastoid. Consists of pretracheal, paratracheal, prelaryngeal and precricord nodes.

OCCULT PRIMARY• Male : Female - 4 : 1• Age Peak incidence 65yrs for men 55 for women• 1/3 to1/2 Sq. cell ca., 1/4 anaplastic ca. 1/4 adeno ca. if supraclavicular is involved followed by miscellaneous tumours such as melanoma and thyroid gland tumours

• Primary sites in order of frequency Head and neck sites nasopharynx, tonsil, base of tongue, thyroid, supraglotic larynx, floor of mouth, palate and pyriform fossa Non head and neck sites bronchus, oesophagus, breast and stomach

Relative sites of Pr. sites

Thyroid 20% Lungs 20% Oropharynx 15% Nasopharynx 15% Hypopharynx 10% GI tract 10% Miscellaneous 10%

PATTRENS OF NECK METSTASIS

PATTRENS OF NECK METSTASIS

PATTRENS OF NECK METSTASIS

PATTRENS OF NECK METSTASIS

PATTRENS OF NECK METSTASIS

N stages of neck node metastasis