Lymphadenopathy / dental implant courses by Indian dental academy

SEMINAR
CERVICAL
LYMPHADENOPATHY
www.indiandentalacademy.com

LEARNING OBJECTIVES
At the end of the seminar learner should be able to:-
 Enumatare the infectious, immunological,
malignant and other causes of cervical
lymphadenopathy.
 Differentiate the cervical lymphadenopathy from
clinical examination.
 Enumarate the imaging methods for cervical
lymphadenopathy.
 Enumarate the characteristic features of lymph
node on various imaging .www.indiandentalacademy.com

CONTENT
 Introduction
 Causes of lymphadenopathy
 Differential diagnosis of cervical
lymphadenopathy
 Clinical approach
 Conclusion
 References

 Level I Submental (IA) Submandibular (IB)
 Level II Upper jugular
 Level III middle jugular
 Level IV Lower jugular
 Level V Posterior triangle group
 Level VI
Prelaryngeal
Pretracheal
Paratracheal
 Level VII
Nodes of upper mediastinum
LEVELS OF LYMPH NODES

INTRODUCTION
 Lymph node enlargement is part of our body’s norm
immune response.
 Lymph nodes are distributed along the lymphatic
system and found throughout the humanbody; they
are centers for antigen presentation, antigen
processing, and antigen recognition.
 The cell population within a lymph node consists
mainly of macrophages, dendritic cells, B-
lymphocytes, and T-lymphocytes.www.indiandentalacademy.com

 These cells function to coordinate an antigenic
response.
 Upon detection of foreign proteins and
microorganisms, the macrophages and dendritic
cells, or antigen presenting cells, are carried
through lymphatic channels to the nearest lymph
node.
 These antigen-presenting cells travel through the
lymph node, presenting antigens to lymphocytes
found within the node.

 B-cells are found within the lymphoid follicles of
the cortex and T-cells reside in the para cortical
regions.
 When antigen recognition occurs, B-cell surface
immunoglobulin binds with the antigen and forms a
germinal center within the lymph node.
 Next, an immunoglobulin gene with higher affinity
for the antigen is produced.

 Migration of the B-cell to the medullary region
occurs, followed by differentiation of the B-cell
to a plasma cell, which then secretes modified
immunoglobulin.
 When T-cells encounter antigen and recognition
occurs the T-cell proliferates and produces T-
cells specific for the inciting antigen.

 Consequently, this humoral and cell-mediated
response results in expansion of the lymph node.
 Antibodies and specified T-cells spill from the node,
entering the lymphatic circulation and eventually
travel into the bloodstream, where they will be able
to localize to the site of infection.

 In general, there are two mechanisms of
lymphadenopathy—hyperplasia and infiltration.
 The former occurs in response to immunologic or
infectious stimuli, and the latter is the result of
infiltration by various cell types, including cancer
cells, lipid cells, glycoprotein-laden macrophages
when this occurs, lymph nodes may be detected
clinically.
 Lymphadenopathy is the term used to describe the
clinical sign of swelling of the lymph nodes.www.indiandentalacademy.com

 Lymphadenitis is the pathologic term for
inflammation of the lymph nodes.
 When enlarged lymph nodes are detected, a
cause can be find out, on basis of physical
examination, judicious selection of
laboratory tests and, if necessary, lymph
node biopsy.

CAUSES OF
LYMPHADENOPATHY
I. Infectious Diseases
 a. Viral—infectious mononucleosis (EBV, CMV), infectious
hepatitis, herpes simplex,VZV, rubella, measles, adenovirus,
HIV
 b. Bacterial—streptococcus, staphylococcus, cat-scratch disease,
brucellosis, tularemia, chancroid, tuberculosis, atypical
mycobacterial infection, primary and secondary syphilis,
diphtheria, leprosy
 c. Fungal—histoplasmosis, coccidioidomycosis,
paracoccidioidomycosis
 d. Chlamydial—lyphogranuloma venereum, trachoma
 e. Parasitic—toxoplasmosis, leismaniasis, trypanosomiasis,
filariasis
 f. Rickettsial—scrub typhus, richettsialpoxwww.indiandentalacademy.com

 II. Immunologic diseases
a. Rheumatoid arthritis
b. Mixed connective tissue disease
c. Systemic lupus erythematosus
d. Dermatomyositis
e. Sjogren’s syndrome
f. Serum sickness
g. Drug hypersensitivity
h. Primary biliary cirrhosis
i. Graft-vs-host disease

 III. Malignant diseases
a. Hematologic (Hodgkin’s, non-Hodgkin’s, ALL,
CLL, hairy cell leukemia, malignant histocytosis, T-
cell lymphoma, multiple myeloma with
amyloidosis)
b. Metastatic—from primary sites
 IV. Lipid storage disease—Gaucher’s,
Niemann-Pick, Tangier
 V. Endocrine disease—Hyperthyroid, adrenal
insufficiency, thyroiditiswww.indiandentalacademy.com

VI. Other disorders
a. Castleman’s disease (giant lymph node
hyperplasia)
b. Sarcoidosis
c. Dermatopathic lymphadenitis
d. Lymphomatoid granulomatosis
e. Kikuchi’s disease (histiocytic nectrotizing
lymphadenitis)
f. Kawasaki’s disease (mucocutaneous lymph node
syndrome)
g. Histocytosis X
h. Severe hypertriglyceridemiawww.indiandentalacademy.com

DIAGNOSIS OF
LYMPHADENOPATHY
 The differential diagnosis for enlarged
lymphnodes is extensive.
 Lymphadenopathy maybe caused by drug
reactions, infections, immunologic
disorders, malignancies, and several other
disorders of uncertain etiology.

DRUG REACTION
Multiple medications have been associated with
systemic signs and symptoms, including
lymphadenopathy:-
 Diphenylhydantoin and Carbamazepine
 Hydralazine, Allopurinal
 Primidone
 Cephalosporins
 Captopril
 Atenolol

 Anticonvulsants and sulphonamides are most
commonly associated with causing
lymphadenopathy although the mechanism is
largely unknown it may be related to a
hypersensitivity response.
 This hypersensitivity response can present with
mucocutaneous eruptions, fever, hematologic
abnormalities, organ involvement such as hepatitis
or interstitial nephritis, and lymphadenopathy.

 Although the reaction resolves upon drug
withdrawal, the mortality rate may be as
high as 10%.
 Complications can be avoided by early
recognition of the hypersensitivity reaction
and consequent withdrawal of the
suspected medication.

INFECTIONS
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, and
respiratory syncytial virus.

 Group A beta hemolytic Streptococcus is the most
common cause of bacterial pharyngitis, which is a
type of upper respiratory infection.
 Other common bacteria causing infection include
groups B, C, and G hemolytic Streptococci
Cornybacteria, and several anaerobes.
 Symptoms suggestive of upper respiratory
infections include cough, sinus congestion,
rhinorrhea, and occasionally fever and malaise.

 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.
 Diagnosis is often based on symptomatology.

 Bacterial throat cultures or serologic antigen
detection may be useful in cases of persistent
infection due to the self-limiting nature of upper
respiratory infections, proper management is
dependent upon the etiology.
 Diagnostic tests are useful when the patient has
persistent symptoms and may aid in selection of the
appropriate treatment.
 Palliative treatment is often the only recommended
therapy for viral pharyngitis, however, antibiotics
may also be indicated for bacterial infections

LOCAL INFECTION
 Cervical lymphadenopathy is a common feature of
localized infection. Local bacterial infections of the
head and neck often cause cervical adenopathy
when draining nodes respond to local infection, or
when the infection localizes within the node itself.
 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.

 The infection can cause cervical
lymphadenopathy, which begins as enlarged
tender nodes that may become fluctuant Common
bacterial pathogens are Staphylococcus aureusStaphylococcus aureus
and Streptococcus pyogenesStreptococcus pyogenes.
 Local infections may include tonsillar abscesses,
salivary adenitis, and dental abscesses.
 Cervical lymphadenopathy from local infection
may also be of viral origin, commonly herpes
simplex virus or Coxsackie viruswww.indiandentalacademy.com

 These viruses cause primary herpetic stomatitis
and herpangina, respectively, and often affect
children and adolescents.
 Common clinical findings include acute painful
ulcers of the oral cavity or oropharynx, enlarged
bilateral tender lymph nodes in the anterior
triangle of the neck, impressive submandibular
and submental adenopathy and occasionally fever
and malaise.

 These viral infections generally do not present
with other systemic complications, such as
hepatosplenomegaly or generalized
lymphadenopathy.
 Chronic cervical lymphadenopathy is the most
common presentation of nontuberculous
mycobacteria (NTM) in children.
 Bacterium avium and M scrofulaceum are often
the most common isolates of NTM.

 Atypical tuberculosis (TB) is more common in
children, presenting as a nontender mass in the
submandibular region.
 The patient may have a weakly positive or negative
tuberculin skin test, and will likely not have
pulmonary symptoms.
 This type of infection is often insidious, with nodal
enlargement occurring within weeks to months.

 Symptoms often resemble acute pyogenic
cervical lymphadenitis.
 Untreated NTM may resolve, but infections
may progress to form sinus tracts that lead
to scarring.

SYSTEMIC INFECTION
 Several acute and chronic infections cause cervical
lymphadenopathy as part of the clinical findings.
 Cervical adenopathy is a common feature of many
viral infections.
 Systemic viral infections may cause acute
syndromes such as hand, foot and mouth disease,
chickenpox, measles, and rubella.

 These viruses include Epstein Barr virus (EBV),
human immunodeficiency virus (HIV),
cytomegalovirus (CMV), and human herpes virus 6
(HHV-6) infections.
 Sometimes these viruses cause oral lesions, rashes,
fever, malaise, hepatosplenomegaly, and bilateral
cervical lymphadenopathy of both anterior and
posterior nodes.
 Enlarged lymph nodes resulting from these viral
infections are firm and tender, and characteristically
not warm or erythematous.

 Infectious mononucleosis often presents with
posterior and anterior cervical adenopathy.
 Other infections associated with cervical
adenopathy could be bacterial or protozoal in
nature

CAT-SCRATCH DISEASE
 Subacute adenopathy involving the cervical region
is a clinical feature of cat-scratch disease.
 The causative organism of cat-scratch disease
belongs to the BartonellaBartonella species.
 Specifically, B henselaeB henselae, a gram-negative bacterium
is known to be pathogenic to humans

 Typically, fever, headache, and malaise develop,
along with cervical lymphadenopathy involving
the parotid and submandibular glands.
 These symptoms develop in 10 to 30 days after an
infected pet inoculates the host usually through a
scratch.
 At the site of inoculation, pustular skin lesions
form, with associated adenopathy of local lymph
nodes.

 The area around these nodes is often warm,
tender, erythematous, and may be indurated or
suppurative.
 Apart from cat-scratch disease, infection With
Bartonella species may cause conjunctivitis,
encephalopathy, bacillary angiomatosis
peliosis hepatitis, and bacteremia bacillary
angiomatosis has even been diagnosed as an
oral manifestation of cat-scratch disease.

TUBERCULOSIS
 TB remains a worldwide threat to humans; It is mostly
caused by M tuberculosisM tuberculosis , an infectious and
communicable organism.
 Less frequently, other species of mycobacteria, such As
M avium complex, M kansasii or Mabscessus may
cause systemic or cutaneous disease.
 It is common for individuals with TB to have no
definitive signs or symptoms until the infection has
disseminated www.indiandentalacademy.com

 If and when symptoms become apparent, infected
individuals may have constitutional signs and
symptoms of weight loss, night sweats, fever,
malaise, or anorexia.
 Persistent cough is commonly associated with
pulmonary TB Hemoptysis & nonpurulent sputum
may be present and help in the diagnosis.
 Tuberculous cervical lymphadenitis, or scrofula, is
one of the most common extrapulmonary
manifestations of tuberculosis.www.indiandentalacademy.com

 Peripheral node disease accounts for approximately
20% of extrapulmonary tuberculosis.
 Primary pulmonary infection produces lesions in the
lungs that cause an inflammatory and fibrotic
response.
 The inflammatory and fibrotic changes in the lungs
may not produce radiographic changes immediately;
however, hilar lymph nodes will likely become
enlarged.
 The infection may then regress, or may become
dormant and remain seeded in any site including
lymph nodes, until reactivatedwww.indiandentalacademy.com

TOXOPLASMOSIS
 Toxmoplasmosis gondiiToxmoplasmosis gondii is a parasite that infects a
broad range of warm-blooded vertebrates,
including up to 30% of the human population
worldwide.
 Although the source of infection has long been
thought to be from cats, contact with infected
uncooked or undercooked meat is likely a more
common cause of infection.

 Because T gondiiT gondii is excreted in feces and
survives in soil for up to one year, infection
can occur by ingesting cysts or oocysts
directly from infected soil or present in
infected meat.
 In the United States6% to 21% of children
and 10% to 67% of adults over the age of 50
show serologic evidence of prior infection
with toxoplasmosis

 Along with the modes of transmission men-tioned,
T gondii can be transmitted to humans through
organ transplant procedures, blood transfusions, or
transplacental transmission.
 In immunocompetent patients, this parasitic
infection usually ranges from subclinical
lymphadenopathy to fatal fulminant infection.
 The most common manifestation is lympha-
denopathy, with firm, tender enlargement of the
cervical nodes. www.indiandentalacademy.com

Less than one-fourth of patients will develop a
mononucleosis-type syndrome upon initial infection
and have self limited symptoms, including generalized
lymphadenopathy, fever, malaise, maculopapular rash,
sore throat, myalgia, and headache
After the initial infection phase, pseudocysts disperse
to other organ tissue and proliferation of the organism
ceases with the host response.
The cysts that form lie dormant an intact within the
host, unless the patient’s immune system becomes
suppressed.

 This infection is generally more serious in
immunocompromised individuals and pregnant
women.
 In the former, the infection is usually caused by
reactivation of latent disease.
 Most commonly, toxoplasmosis in these
individuals affects the central nervous system
(CNS), leading to meningoencephalitis,
encephalopathy, or mass lesions that can cause
mental status changes or seizures.www.indiandentalacademy.com

 In pregnant women, risk of fetal infection is
approximately 30% when the woman becomes
acutely infected during pregnancy
 The most serious consequences occur in first
trimester infection; however, the highest level of
transmission occurs during the last trimester.
 The sequelae of congenital infection include mild
nonspecific disease, failure to thrive,
lymphadenopathy, CNS involvement, intracerebral
calcification, ocular disease and myocarditis

 Diagnosis of toxoplasmosis infection is based on
history and exam findings, and is confirmed by rising
antibody titers—IgG titers are typically high during
acute infection and will persist at low titers for life.
 IgM titers are also indicative of acute infection and
are useful markers during pregnancy.
 Other diagnostic methods include isolation of T
gondii from blood or other bodily fluids, or detection
of the parasite by polymerase chain reaction in tissue
or body fluids. www.indiandentalacademy.com

 In general, an asymptomatically infected healthy
individual does not require treatment.
 For symptomatic illness, combination therapy with
pyrimethamine and sulfonamides has been the
most effective.
 Alternatives to this regimen in
immunocompromised patients include clindamycin
and, less commonly, clarithromycin, azithromycin,
or dapsone www.indiandentalacademy.com

OTHER INFECTIOUS AGENTS
 There is a broad array of infective organisms that
may potentially cause cervical lymphadenitis.
 It is often difficult for clinicians to explore all of
the possibilities.
 In many infections, there are typical signs and
symptoms accompanying lymphadenopathy.

 For instance, in the primary form of syphilis, which
is caused by Treponema pallidum, a spirochete, an
oral chancre, is usually accompanied by cervical
lymphadenopathy
 In Lyme disease, adenopathy, malaise, fever, and
multiple systemic findings, including a typical rash,
may occur.
 Rubella almost always presents with a
maculopapular rash and characteristic
lymphadenopathy of the posterior cervical triangle.

 Cervical lymphadenopathy is usually present
during the acute seroconversion stage of HIV
infection.
 Disseminated lymphadenopathy may also be
present during this stage of HIV infection and
may either be painless or associated with flulike
symptoms

MALIGNANCY
 Enlarged palpable lymph nodes of the head
and neck may be present in many malignant
conditions.
 There are several metastatic tumors that may
present as cervical lymphadenopathy; these are
tumors of the skin and appendages,
oropharynx, larynx, thyroid gland, salivary
gland, and nasopharynx.

 Widespread lymphadenopathy may be seen with
many solid tumors malignancies arising from cells
in the immune system may also cause
lymphadenopathy.
 The initial manifestation of Hodgkin’s disease and
non-Hodgkin’s lymphoma is lymphadenopathy at
any site; chronic lymphocytic leukemia and myeloid
leukemia may also present with initial signs of
lymphadenopathy.

 Supraclavicular lymph nodes are more likely to
present in metastasis from remote sites than
cervical nodes.
 Primary sites of tumor presenting with
supraclavicular lymphadenopathy include ovaries,
lungs, and gastrointestinaltract.
 Breast cancer is more likely to present with
metastatic ipsilateral or contralateral axillary lymph
nodes. www.indiandentalacademy.com

 The clinician should be guided by the patient’s
medical history and a clinical examination.
 Although the features of lymphadenopathy may
not always follow a specific pattern, there are
typical presentations of malignancy involving
enlarged lymph nodes.
 The duration of lymphadenopathy in a malignant
process is typically for a longer period of time
and associated with gradual enlargement.

 The individual may complain of fever, sweats,
weight loss, and anorexia, particularly with acute
hematologic malignancies.
 Other signs and symptoms may include hoarseness,
paresthesia, hemoptosis, hematuria, occult blood in
the stool, or abdominal pain.
 The clinical features of malignant lymph nodes in
later stages include firm, rock hard and fixed-to-
deeper tissues nodes.

 Nodes may present as unilateral and multiple, or there
can be bilateral involvement.
 In lymphoma, nodes may be large, symmetric, firm
mobile, and nontender.
 In cases of rapidly progressive neoplasia, such as
acute leukemia, lymph node enlargement may be
painful or tender due to rapid expansion of the node
causing pain.
 Lymph node biopsies and further diagnostic tests are
indicated to help in the diagnosis of malignancy and to
establish the origin of the tumor.www.indiandentalacademy.com

CLINICAL APPROACH
Complete medical history
 A clinician’s diagnostic skills are strongly based on
his or her ability to elicit a complete history of
present illness.
 This information should reveal important facts
regarding the etiology of the enlarged nodes.
 The duration of lymphadenopathy may be
suggestive of an infectious cause if there is a recent
onset, less than 15 days.www.indiandentalacademy.com

 Also, the presence of constitutional symptoms,
including fever, sweats, weight loss, and anorexia,
may also be indicative of an acute process.
 HIV-related lymphadenopathy may have an acute
onset during the acute retroviral syndrome, and may
be associated with constitutional symptoms in
addition to sore throat and myalgia this process, the
HIV-1 virus disseminates throughout the body,
invading the lymphoid system and eliciting both
humoral and cellular immune responses

 The resulting viremia and heightened immune
response are associated with the symptoms
mentioned.
 Toxoplasmosis infection mimics this process,
however, the lymphadenopathy persists for weeks
to months and eventually resolves.
 Malignancy such as lymphoma or metastatic
disease may cause gradual, non painful
enlargement of lymph nodes, while rapid, painful
enlargement is often seen in acute leukemia.www.indiandentalacademy.com

 Animal exposures are important causes of cervical
lymphadenitis, and a history of animal exposure
may lead to early diagnosis or detection of cat-
scratch disease, tularemia burcellosis, or plaque.
 Additionally, history of recent travel to Europe or
tropical regions may be useful in leading to a
diagnosis.

 The patient’s past medical history should reveal
the setting in which lymphadenopathy is present.
 A history of malignancy or infection could point
to a recurrence.
 The medication history, including any drug
hypersensitivity reaction, is also important. A
review of systems may reveal information left
out by the patient

 The patient may describe associated constitutional
symptoms or other nonspecific signs or symptoms
including oral lesions, dental problems, recent trauma,
breathing difficulty and dysphagia.
 The practitioner should review the symptoms of
malignancy including hoarseness, paresthesia,
hemoptysis, hematuria, occult blood in the stool, or
abdominal pain.
 Also, symptoms of a skin rash may be indicative of
rubella, measles, infectious mononucleosis, secondary
syphilis, or drug hypersensitivitywww.indiandentalacademy.com

SOCIAL AND FAMILY
HISTORY
 The patient’s age, occupation, travel experiences,
exposure to pets, dietary habits, sexual orientation,
or history of drug use are other salient points within
the history that may lead the practitioner to the
cause of lymphadenopathy.
 For example, an infectious etiology would be
suspected in a child or young adult, whereas the risk
of malignant disorders increases significantly in
ages over 50.

 In cases where a definitive diagnosis can not be
made based on the patient’s history and physical
examination, a clinical examination may reveal a
cause.
 When the history suggests a particular etiology,
confirmatory testing is necessary to correctly
identify the illness.

CLINICAL FEATURES
 Physical examination is another component of the
patient’s clinical assessment.
 The first step toward clinical evaluation requires an
understanding of head and neck surface anatomy.
 Recognition of the major structures, along with
knowledge of the distribution of lymph nodes in the
head and neck will help identify normal versus
abnormal and help to describe the physical findings.www.indiandentalacademy.com

 Thorough physical examination includes
evaluation of the skin, neck, ears, eyes, nose
and throat.
 Intraorally, the patient’s oropharynx should be
visualized.
 The oral mucosa tongue, periodontium, and
dentition should also be examined.

 In general, palpable lymphadenopathy is common in
young children; they are constantly exposed to new
antigens, and enlarged nodes are typical.
 However, lymphnodes larger than 1 cm are not
considered normal in either adults or children.
 Notably, palpable nodes less than 1 cm in the groin
is frequently considered normal in adults although
size is important criteria for lymphadenopathy,
further clinical assessment will help to identify any
abnormality. www.indiandentalacademy.com

1.Location
A.Anatomical site
B.Presence of single or multiple nodes
C.Presence of localized or
disseminated nodes
D.Palpable nodes are unilateral or
bilateral
2.Consistency
A.Firm
B.Soft
C.Rubbery
D.Rock hard
3. Mobility
A.Movable
B.Fixed
4.Size
A.<1 cm or >1cm
B.If nodes are
bilateral,check for
symmetry
5.Symptoms
A.Symptomatic
B.Tender
C.Painful
D.Associated with
systemic symptoms
or not

 The consistency of the node is extremely
relevant; A soft, flat node is more likely to be
benign, whereas a firm or rubbery node is
suggestive of a more morbid process.
 Additionally, a fixed, non movable node is a
classic sign of malignancy.
 Lymph node tenderness or inflammation over
the node is an indication of an inflammatory
process.

LOCATION
 The extent of lymphadenopathy is important in
distinguishing between localized and disseminated
disease.
 Location of enlarged lymph nodes may lead to a
source of infection, particularly if the node is tender
with inflammation of the surrounding structures;
cervical lymph nodes are found to be enlarged most
frequently.

 Submandibular and submental lymphadenopathy is
most often caused by oral or dental infections;
catscratch disease and non-Hodgkin’s lymphoma
typically cause lymphadenopathy of these nodes.
 Pre-auricular and auricular nodes are often enlarged
in the presence of ocular disease, rubella, or cat-
scratch disease.
 Suboccipital nodes may be associated with scalp
infections

 When supraclavicular nodes are enlarged, there is a
strong suspicion of malignant disease, particularly
lymphoma or metastatic disease.
 Virchow’s node may be present in the left
supraclavicular region, indicating metastatic
infiltration from a primary cancer.
 The clinical features that should be observed by the
examining in the presence of unexplained localized
lymphadenopathy and a reassuring clinical scenario,
a 2- to 4-week observation period is recommended
before referring the patient for a biopsy.

 Because lymph node enlargement may gradually
regress within this time period an unnecessary
procedure may be avoided individuals presenting
with a worrisome clinical picture and localized
lymphadenopathy require further diagnostic
evaluation without an observation period.
 When generalized lymphadenopathy is present,
further diagnostic evaluation is warranted and may
include biopsy and laboratory evaluation.

HEMATOLOGIC TESTING
 Laboratory evaluation should be used to elucidate
the patient’s medical history and physical findings.
 As a practitioner, ordering a complete blood count
(CBC) with differential would be helpful to detect
cases caused by infectious mononucleosis,
leukemia, or lymphoma.
 Neutrophil leukocytosis is often seen in severe
infections; neutropenia and thrombocytopenia may
be useful in diagnosing systemic illnesses.www.indiandentalacademy.com

 Serology studies may be used detect the presence
of antibodies to specific components of agents such
as toxoplasma, EBV, CMV, herpes simplex virus
(HSV), or chlamydia.
 During the early phase of HIV infection, serum
antibodies may not be present, ELISA titer results
may not be accurate therefore, viral load should be
measured to detect the presence of viral particles.
 Additionally, other laboratory studies may be
ordered, tailored to the patient’s casewww.indiandentalacademy.com

OTHER DIAGNOSTIC TOOLS
 Ultrasonography
 CT Scan
 Magnetic Resonance Imaging
 FNAC
 FNAB

ULTRASONOGRAPHY
 Ultrasound is a useful imaging modality in
evaluation of cervical lymphadenopathy because of
its high sensitivity (98%) and specificity (95%)
when combined with fine-needle aspiration
cytology.
 With the use of power Doppler sonography, the
vasculature of the lymph nodes can also be
evaluated which provides additional information in
the sonographic examination of cervical lymph
nodes.

 Distribution:- Normal cervical lymph nodes are
usually found in submandibular, parotid, upper
cervical and posterior triangle regions.
 Metastatic cervical lymph nodes are site-specific.
 In patients with a known primary tumour, the
distribution of metastatic nodes helps to identify
metastases and assists tumour staging.

 Size:- Malignant nodes tend to be large. However,
inflammatory nodes can be as large as malignant
nodes. Moreover, metastatic deposit can be found in
small nodes. Therefore, size of lymph nodes cannot
be used as the sole criterion in differential diagnosis.
However, in clinical practice, size of lymph nodes is
useful when there is an increase in nodal size on
serial examinations in a patient with known primary
tumour, which is highly suggestive for metastases.

 Shape:- Malignant and tuberculous nodes are
usually round in shape with a short axis to long axis
(S/L) ratio greater than or equal to 0.5, whereas
reactive and normal nodes are usually long or oval-
shaped

 Nodal border:-Metastatic and lymphomatous nodes
tend to have sharp borders, whereas reactive and
normal nodes usually show un-sharp borders.
 Un-sharp borders are common in tuberculous nodes
and these are due to the edema and inflammation of
the surrounding soft tissue

 Echogenic hilus:- Echogenic hilus is a normal
sonographic feature of most of the normal cervical
lymph nodes.
 Metastatic, lymphomatous and tuberculous nodes
tend to have absent hilus.

 Echogenicity:- Normal, reactive, lymphomatous
and tuberculous nodes are predominantly
hypoechoic when compared with the adjacent
muscles. Metastatic nodes are usually hypoechoic,
except for metastases from papillary carcinoma of
the thyroid which tend to be hyperechoic

 Calcification:- Intranodal calcification is rarely
found in cervical lymphadenopathy. However, about
50-69% of metastatic nodes from papillary
carcinoma of the thyroid show calcification

 Intranodal necrosis:- Lymph nodes with intranodal
necrosis are considered to be pathologic.

 Ancillary features:- Ancillary features that help
in the evaluation of cervical lymphadenopathy are
adjacent soft tissues edema and matting. On
ultrasound, soft tissues edema appears as an
diffuse hypoechogenic area with loss of fascial
planes, whereas matting is clumps of multiple
abnormal lymph nodes with abnormal intervening
soft tissues.

 Vascular pattern:- Normal and reactive lymph
nodes tend to have hilar vascularity or appear
apparently avascular, whereas metastatic nodes
usually show peripheral or mixed vascularity,
 Tuberculous nodes have varied vascular pattern,
which simulates both benign and malignant
conditions . In spite of the varied vascular pattern,
displaced vascularity and apparent avascularity are
common in tuberculous nodes, which are related to
the high incidence of cystic necrosis in tuberculous
lymph nodes

CT SCAN
 It has low diagnostic value as compared to USG in
imaging of cervical lymphadenopathy
 The presence of nodal necrosis, irrespective of size,
indicates metastatic involvement.
 Although this sign is highly specific for metastatic
disease it is of limited usefulness in clinical practice.
 This is because most nodes with nodal necrosis are
larger than 10 mm.

 Nodal necrosis may be confused in two conditions.
Firstly, fat deposition may produce a low
attenuation focus in the suspected node on CT.
 Density measurements are of limited value in small
lesions because of partial volume averaging.
 The location of the low attenuation focus is of help
as necrosis is generally situated centrally while fat is
usually deposited around the hilum.

 Secondly, suppurative nodes frequently show
central areas of low attenuation indicating the
formation of pus.
 These nodes usually have irregular and ill defined
margins indicating the presence of inflammation.
 Suppurative lymphadenitis is usually evident
clinically and radiologically.
 The presence of cellulitis helps to separate
metastasis from inflammation.www.indiandentalacademy.com

MRI
 MRI may also be used to evaluate the extent of
lymphadenopathy; however compared with CT,
it produces more artifacts and has poorer
resolution quality.
 MRI can be used in cervical lymphadenopathy
as a imaging tool to differentiate malignant from
the benign on Apparent Diffusion Coefficient
Mapping (ADC)

FNAC/FNAB
 The indications for these invasive procedures are
nonprecise; however, they are valuable diagnostic
tools.
 Prior to lymph node biopsy, serologic testing is
often performed to narrow the differential
diagnosis.
 In addition, keep in mind that individuals with
altered immune responses may not have typical
presentation of infection with various organisms.www.indiandentalacademy.com

CONCLUSIONS
There are, however, several salient points to
remember:-
 Most patients do not require a biopsy.
 Almost half of patients do not require laboratory
evaluation.
 Antibiotics are not indicated unless there is strong
evidence of a bacterial infection.
 Location, symptomatology, and consistency need to be
addressed during the clinical examination.
 If the history and physical findings suggest a benign
cause of lymphadenopathy, follow up is recommended
in 2 to 4 weeks.
 The patient should be instructed to return sooner if the
nodes increase in size

REFERENCES
 Timothy R. Peters,Kathryn M. Edwards. Cervical Lymphadenopathy
and Adenitis. Pediatrics in Review December 2000;21(12):399-404.
 Ernesta Parisi, Michael Glick. Cervical lymphadenopathy in the
dental patient: A review of clinical approach. Quintessence
international 2005;3 6(6):423-436.
 Sambandan T, Cristeffi Mabel R. Cervical Lymphadenopathy: a
Review. JIADS 2011;2(1):31-33.
 A.T.Ahuja, M. Ying, S.Y. Ho. Ultrasound of malignant cervical
lymph nodes. Cancer Imaging 2008;8(1):48–56.
 Vincent Chong.Cervical lymphadenopathy: what radiologists need to
know. Cancer Imaging 2004;4:116–120.
 Anna Perronea, Pietro Guerrisia, Luciano Izzob, Ilaria D’Angelic,
Simona Sassi. Diffusion-weighted MRI in cervical lymph nodes:
Differentiation between benign and malignant lesions. European
Journal of Radiology 77 (2011) 281–286.

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