Lymph nodes of head & neck, Normal anatomy and its applied aspect

Normal Anatomy & Its
Applied Aspect
ASHISH
RANGHANI
PG 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

CONTENTS
Introduction
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

LYMPAHATICSYSTEM
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

FlowofLymph
• 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

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 auricularis
posterior.
• 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 pretrached
nodes 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

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/LEFTLYMPHATICDUCT
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.

RIGHTLYMPHATICDUCT
• 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 baselower 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

Significanceoflymphnodeexaminations
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

KEYFACTORSINEVALUATION OFLYMPHADENOPATHY
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/symptoms
For 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.

OVERLYINGSKIN:
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

LocalisedAcute 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 suppurative
osteomyelitis
• 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.

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 henselae
through 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

VIRALINFECTIONS
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

JonesandCampbellclassifiedperipheraltuberculouslymphnodesintofollowingfive
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 INTHE SECONDARYSTAGE:
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

AnnArborsystemforClassificationof Hodgkin'sLymphoma
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

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)LABORATORYDIAGNOSISMETHODS
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.
ImagingofenlargedLNonheadandneck:

• 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).
CONVENTIONALRADIOGRAPH

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 normal
nodes 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 nodes
usually 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:

Smooth and well-
defined kidney or
cigar shaped soft-
tissue structures .
The hilum
composed of fat
tissue attenuation.
Homogenous and
uniform,
enhancing criteria
and attenuation.
CTfeature 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.
CTfeature of metastatic nodes:
Imaging of malignant cervical lymphadenopathy, SEJ Connor and JFC Olli, Dentomaxillofacial
Radiology (2000) 29, 133 -143

ULTRASONOGRAPHIC CRITERIA
CRITERIA Benign nodules Malignant nodes
Margins sharp margins irregular
and blurred margins
Shape Usually oval or elongated rounded masses
Hilum present in normal and
reactive nodes
Due to the proliferation
of cells the hilum is absent
Absence or presence of
flow
Small benign nodes
do not present Doppler
flow within their volume.
Malignant
nodes are vascularised due
to their increase
metabolic requirements
Ultrasonography of head and neck lymph nodes, Mihai Dumitru, Ion Anghel, Romanian Journal
of Rhinology, Vol. 4, No. 14, April-June 2014

POSITRON EMISSIONTOMOGRAPHY
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.

TISSUEDIGNOSIS
It is the gold standard in the evaluation of lymphedonopathy.

FINE NEEDLEASPIRATION 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

REFERENCES
1. Human anatomy & physiology, Elaine n. Marieb & Katja Hoehn, Eighth edition
2. Anatomy of head neck and brain, Vishram singh
3. BD chaurasia's human anatomy, head, neck & brain, volume 3, Fourth edition
4. Grays-anatomy-for-students-2nd-edition
5. S. Das, A Manual of Clinical Surgery, 5th edition, page no. 80-89
6. Neville oral and maxillofacial pathology, 4ed
7. Clinical identification of head and neck lymphadenopathy: a diagnostic obligation,
morton i. Lieberman and thomas h. Ward, www.Agd.Org general dentistry july
2013
8. Lymphadenopathy: differential diagnosis and evaluation, robert ferrer, am fam
physician. 1998 oct 15;58(6):1313-1320.
9. Tuberculous lymphadenitis, prasanta raghab mohapatra, ashok kumar janmeja, japi,
august 2009, vol. 57.
10. Acute, subacute, and chronic cervical lymphadenitis in children, john r. Gosche,
laura vick, seminars in pediatric surgery (2006) 15, 99-106.

10. Lymphadenopathy and systemic lupus erythematosus, nilton salles rosa neto,
karina rossi bonfiglioli, bras j rheumatol 2010;50(1):96-101
11. Phadenopathy, habermann, thomas, mayo clinic proceedings, issue: volume
75(7), july 2000, pp 723-732
12. Clinical approach to lymphadenopathy, abdullah abba and mohmmad khalil,
pk- practitioner, vol 16, jan 2011
13. Evaluation and management of lymphadenopathy in children, alison m.
Friedmann , pediatr. Rev. 2008;29;53-60
14. Approach to the patient with lymphadenopathy, bernard karnad, hospital
physician july 2005
15. The problem of hiv-related lymphadenopathy, wilandi jacobs, cme august
2010 vol.28 no.8
16. Ultrasonography of head and neck lymph nodes, mihai dumitru, ion anghel,
romanian journal of rhinology, vol. 4, no. 14, april-june 2014
17. Sonographic evaluation of cervical lymph nodes, anil t. Ahuja, michael ying,
ajr:184, may 2005
18. Imaging of malignant cervical lymphadenopathy, sej connor and jfc olli,
dentomaxillofacial radiology (2000) 29, 133 -143.

Lymph nodes of head & neck, Normal anatomy and its applied aspect

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