BASICS OF NECK NODES ANATOMY AND CLINICAL EVALUATION. FOR BEST UNDERSTANDING FOR UG AND PG STUDENTS

1. ANATOMY OF LYMPH NODES IN NECK
&
ETIOLOGY AND CLINICAL EVALUATION
OF CERVICAL LYMPHANDENOPATHY
PRESENTED BY:
Dr Mohan Krishna – SR , Department of ENT, SSIMS
Dr Shruti Dubey, Assistant Professor, Department of
ENT, SSIMS

2. INTRODUCTION
• Around 800 lymph nodes in our body
• Not less than 300 in the neck.
• Enlargement more than 1cm2 - clinical
manifestation of regional or systemic disease.

3. DEVELOPMENT OF LYMPHATIC SYSTEM
• 5th week of gestation –
– Multiple endothelial sacs -
outgrowths from the venous
channels.
– Paired jugular sacs in the neck-
– Unpaired Cisterna chyli – initially
located at the mesenteric root in
the retroperitoneal space. Later
develops dorsal to the mesenteric
sac.
– Paired posterior (iliac) sacs
– Ninth week - Linked together by
multiple endothelial channels to
form a complicated network of
lymphatic vessels .

4. DEVELOPMENT OF LYMPH NODE
• During early fetal development, Mesenchyme
cells invade these sacs, converting them into
groups of lymph nodes.
• Primary sacs + confluences of capillary
plexuses. –LYMPH NODE
• Each mass gets enclosed by Connective tissue
Capsule.

5. DEVELOPMENT OF LYMPH NODE
• Original lymphoid tissue
transforms into,
– Medullary cords
– Cortical nodules
• Lymphatic capillaries
form the peripheral
lymph sinus.

6. FUNTIONAL UNIT- LYMPH NODE
• Multiple Afferents and
single Efferent vessels
– Cortex(outer)
– Medulla(Inner)
– Capsule with Fibrous
trabaeculae.
• Lymphatic nodules
present in the cortex

7. FUNCTIONS OF LYMPHATIC SYSTEM
• Fluid balance during gases and
nutrient exchange at capillary
plexus.
• Filtration of Lymph for removing
foreign particles and destroy
microorganisms.
• Absorption of fat and fat soluble
vitamins into lacteals- giving
milky appearance of Chyle.
• Sensitisation of immune
response - Optimal site for
concentration of recirculating
lymphocytes.

8. TRIANGLES OF NECK
• Anterior triangles
– Submental
– Submandibular
– Carotid
– Muscular
• Posterior triangles
– Occipital
– Supraclavicular

9. CLASSIFICATION OF NECK NODES
UPPER HORIZONTAL
CHAIN
LATERAL CERVICAL NODES ANTERIOR CERVICAL
NODES
(a) Submental
(b) Submandibular
(c) Parotid
(d) Postauricular
(e) Occipital
(f) Facial
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
(a) Anterior jugular chain
(b) Juxtavisceral chain
(i) Prelaryngeal
(ii) Pretracheal
(iii) Paratracheal

11. SUBMENTAL NODES
• 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.

12. SUBMANDIBULAR NODES
• 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,
– Medial canthus,
– Gums,teeth, soft palate, anterior pillar,
anterior part of tongue, and floor of
mouth.
– Submandibular and sublingual salivary
glands
• Efferents go to internal jugular chain.

13. • 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 behind the 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.

14. • 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.

15. LATERAL CERVICAL NODES
(a)Superficial external
jugular group
(b)Deep group
(i)Internal jugular chain
Upper
Middle
Lower
(ii) Spinal accessory
chain
(iii) Transverse cervical
chain

16. • Internal jugular chain
– 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
– Drains the
• scalp, skin of the neck
• Nasopharynx,
• Occipital and Postauricular
nodes.
– Efferents from this chain
drain into
• Transverse cervical chain

18. • Transverse cervical chain
(supraclavicular nodes)
– The medial nodes of the
group called scalene nodes.
– Afferents
• Accessory chain and
• Infraclavicular structures,
e.d. breast, lung, stomach,
colon, ovary and testis.
– VIRCHOWS NODE: (Left
supraclavicular node).
• Afferents- Left head, neck,
chest, abdomen, pelvis, and
bilateral lower extremities,
• Drains into- Jugulo-
subclavian venous junction
via the thoracic duct (TROISIER SIGN)

19. ANTERIOR CERVICAL NODES
• Anterior jugular chian –
– Along Anterior jugular vein and skin
of anterior neck.
• Juxtavisceral chain –
– Prelaryngeal node (on cricothyroid
membrane )
• (DELPHIAN NODE)
• Drains subgottic region of larynx and
pyriform sinuses.
– Pretracheal nodes (lie in front of the
trachea)
• Drain thyroid gland and the trachea.
• Efferents from these nodes go to
paratracheal, lower internal jugular and
anterior mediastinal nodes.
– Paratracheal nodes
• Drain the thyroid lobes, subglottic
larynx, tracha and cervical oesophagus

20. 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

21. LYMPH NODES IN THE NECK

23. What is Lymphadenopathy
• Lymph nodes that are abnormal in
– Size > 1cm
– Consistency
– Number
• Localized – one area involved
• Generalized – two or more non-contiguous
areas

24. WHY DO LYMPH NODES ENLARGE?
• Increase in the number of benign lymphocytes and
macrophages in response to antigens(Acute infections)
• Infiltration of inflammatory cells in infection (lymphadenitis)
• In situ proliferation of malignant lymphocytes or
macrophages( primary Lymphoma)
• Infiltration by metastatic malignant cells (Secondaries)
• Infiltration of lymph nodes by metabolite laden macrophages
(lipid storage diseases)

25. • The commonest causes for cervical
lymphadenopathy are
– tuberculous lymphadenitis (extra-pulmonary
manifestation)
– Secondaries as metastatic nodes,
– lymphomas and nonspecific lymphadenitis2.
• The human immunodeficiency virus (HIV)
epidemic - associated with an increase in the
total incidence of extrapulmonary TB including
lymphadenitis.

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

27. AGE DISTRIBUTION
YOUNG AGE(COMMON CONDITIONS) OLD AGE
Infections :
Non specific : URTI, Ear infections,
Tonsillitis, dental infections, parasitic
infestations.
Specific: Measles, Mumps, chicken pox,
primary syphilis, rubella.
Malignancies:
Acute lymphocytic Leukemia,
Primary malignant lymphoma
Autoimmune disorders: Juvenile
Rheumatiod arthritis, SLE
Recent vaccination
Infections:
Non specific: URTI, Ear infections,
Dental abscess, Scalp or skin infections.
Specific : chronic siladenitis, HIV,
Tuberculosis
Malignancies:
Oral cavity cancers, Chronic
Lymphocytic leukemia, Secondary
malignant disease.
Autoimmune disease:
Rheumatic arthritis, SLE, Sjogrens
syndrome
Drugs intake

28. • Association with PAIN
– PAIN: Acute specific and non specific infections
– PAINLESS: Chronic infections, Malignancies,
Granulomatous and Autoimmune diseases, Drug
reactions
• DURATION:
– Acute : <2weeks
– Subacute: 2-6 weeks
– Chronic: > 6weeks

29. • Constitutional symptoms(fever, night sweats, weight loss,
Fatigue, Pruritis)
• Any Identifiable cause for the lymphadenopathy? –
– Localizing symptoms or signs to suggest
infection/neoplasm/trauma at a particular site
• Epidemiological clues
– Occupational exposures: Fishermen, Butcher house workers, sex
workers
• Animal exposure, insect bites.
• Recent Blood transfusions, IV drug users.

30. • Recent history of travel:
– Coccidioidomycosis , Bubonic plague , Histoplasmosis ,
Scrub typhus, African trypanosomiasis (sleeping
sickness) , American trypanosomiasis (Chagas'
disease) , Kala-azar (leishmaniasis) ,Typhoid fever
• Medications/drugs:
– Allopurinol, Atenolol, Captopril, Carbamazepine,
Cephalosporins, Gold, Hydralazine, Penicillin,
Phenytoin, Primidone, Pyrimethamine, Quinidine
Sulfonamides, Sulindac.

31. • PAST HISTORY: -
– Enlargement of epitrochlear and suboccipital
group of lymph nodes(past history of primary
syphilis)
– Enlargement of cervical group of lymph
nodes(past history of tuberculosis, recurrence of
infection)
• FAMILY HISTORY: - Tuberculosis -
Lymphosarcoma

32. PHYSICAL EXAMINATION
• GENERAL SURVEY:
– Malnutrition in cases of tuberculous lymphadenitis,
– Primary and secondary Cachexia of malignant
lymphadenopathy
– Anemia
– Loss of weight
• LOCAL EXAMINATION:
– LOCATION: Along with complete ENT examination, specific
areas examined, as localized- enlargement of certain
lymph nodes can be characteristic for the area drained.
– Identifying a primary disease during examination is of at
most importance.

33. EXAMINATION OF NECK NODE
• Size :When to worry
– 1.5-2cm in size
– Epitroclear nodes over 0.5cm
– Inguinal over 1.5cm
• SURFACE
• Smooth- Acute and chronic infections
• Bosselated- tuberculous lymphadenitis due to matted
lymph nodes
• Ulcerated- bursting of cold abscess

34. SKIN OVERLYING THE SWELLING:
– ACUTE LYMPHADENITIS- skin
becomes inflamed with
redness, oedema, and
brawny induration

35. – CHRONIC
LYMPHADENITIS- skin
over the swelling does
not show such angriness

36. – TUBERCULOUS
LYMPHADENITIS AND
COLD ABSCESS- skin
remains cold till they
reach the point of
bursting when skin
becomes red and glossy
TB LYMPHADENITIS WITH HEALING SINUS

37. – LYMPHOSARCOMA-
tense overlying skin,
shining with dilated
subcutaneous veins
– SECONDARY
CARCINOMA- free in
early stage, fixed in later.
Scar often indicates
previous bursting of cold
abscess or previous
operation.

38. PALPATION OF NECK NODES

39. • TENDERNESS
• Pain & tenderness on a lymph node is a non-specific
finding typically due to infection
• In some cases, pain is induced by
– Hemorrhage into the necrotic center of a neoplastic node
– Immunologic stimulation of pain receptors
– Rapid tumor expansion.

40. • Rise in local temperature
– Acute infections
• No local rise in temperature
– Chronic infections,
– Malignant neoplasm(carcinoma, metastasis,
lymphoma, leukemia)
– Granulomatous diseases (tuberculous
lymphadenitis, cold abscess, syphilis)
– HIV Infections `

41. • MOBILITY
– Movable
• Lymph node enlargement in infections & collagen
vascular disease, lymphoma
– Fixed
• lymph nodes may be fixed to the skin , the deep fascia
,the musclses ,nerves,etc. eg. primary malignant
growth (lymphosarcoma, reticulosarcoma
,histosarcoma) or secondary carcinoma.

42. Consistency
• Stony hard: typical of cancer usually
metastatic
• Firm rubbery: can suggest lymphoma
• Soft: infection or inflammation
• Fluctuant : Suppurated nodes.
• Matted : . A group of nodes that feels
connected and seems to move as a unit is said
to be “matted.”

43. • Nodes that are matted
can be either
– Benign (e.g.,
tuberculosis, sarcoidosis
or lymphogranuloma
venereum)
– Malignant (e.g.,
metastatic carcinoma or
lymphomas).

44. DIFFERENTIATION OF NODE FROM
OTHER STRUCTURES IN NECK

45. CAUSES
INFECTIONS NEOPLASMS MISCELLANEOUS
1. Viral – Rhinovirus,
Influenza, Parainfluenza,
EBV, CMV, HIV
2. Bacterial- H.influenzae,
M.tuberculosis,
Staph.aureus,
Strep.pyogenes,
Anaerobes, C.diphtheria
3. Protozoal- Toxoplasma,
Leishmania species
Fungal - Candida albicans,
Histoplasma capsulatum,
Blastomyces dermatitides,
Aspergillus fumigatus
1. Benign
2. Malignant
-Primary lymphomas or
leukaemia’s
-Secondary
(carcinoma from larynx,
pharynx, esophagus, cheek,
tongue, gastrointestinal tract,
thyroid, breast, lungs)
-Malignant melanoma
-From unknown origin
1. Allergic lymphadenopathy
2. Post vaccination
3. Amyloidosis
4. Lipid and Glycogen storage
disease
5. Sarcoidosis
6. Anticonvulsant drugs
7. Histiocytic necrotizing
lymphadenitis, also known as
Kikuchi Fujimoto disease
8. Connective tissue disorders
9. Immunodeficiency states
10. Kawasaki’s disease

49. LEVELS OF LYMPH NODES IN THE NECK

50. • Unencapsulated lymphoid tissue located
within the meshwork of lymphatic channels.
↓
• The lymphoid mass separates into smaller
portions allowing the inward growth of blood
vessels and the lymphatic network.

51. • Each node consists of
multiple lymphatic
lobules

52. Characteristics of the node
• Consistency – Hard/Firm vs Soft/Shotty;
Fluctuant
• Mobile vs Fixed/Matted
• Tender vs Painless
• Clearly demarcated
• Duration and Rate of Growth
• Mobile vs fixed
• Symmetrical vs asymmetrical