Cervical lymphadenopathy Introduction There are various classifications of lymphadenopathy, but a simple and clinically useful system is to classify lymphadenopathy as "generalized" if lymph nodes are enlarged in two or more noncontiguous areas or "localized" if only one area is involved Over a quarter of the lymph nodes in the body are connected with cervical lymph nodes situated in the head and the neck. It is not surprising that awide range of disease may present with lesion in the neck, but the most common complaint is of swelling and \or pain in the lymph nodes. The dental surgeon can often detect serious disease through neck examination, tenderness and swelling should be documented Etiology: The cause of lymphadenopathy is often obvious: for example, the child who presents with a sore throat, tender cervical nodes and a positive rapid strep test, or the patient who presents with an infection of the axillary lymphadenopathy. In other cases, the diagnosis is less clear. Lymphadenopathy may be the only clinical finding or one of several nonspecific findings, and the discovery of swollen lymph nodes will often raise the specter of serious illness such as lymphoma, acquired. Lymph nodes swallen from acute infection are usually tender, soft, discrete, While chronic infection give firm lumph nodes,trnderless,and mobile. Nodes that are increasing in size and are hard, or fixed to adjacent tissues may be malignant. Nodes that are enlarged and firm and matted or rubbery may be to leukaemia. ١
Head and neck lymphadenopathy is common in benign and malignant disease. In young patients, therapeutically significant pathology is uncommon. The prevalence of malignant lymphadenopathy increases with age and is higher in patients with known malignancy. The most common causes of malignant cervicofacial lymphadenopathy are lymphoma and metastatic squamous cell carcinoma, but primary tumors of the chest, abdomen, and pelvis may metastasize to the neck. In patients with de novo lymphadenopathy. Cervical Lyumphadenopathy Main causes of cervical lymph node enlargement: Infection: Oral or local in the drainage area. Upper respiratory tract. systemic. Malignant disease: Oral or in the drainge area. Upper respiratory trast. Lymphoreticular others Infection ٢
Viral upper respiratory tract : an enlarged jugulodigastric ( tonsillar) lymph node, is common Oral or local in the draingae area (dental, ear, nose,or throat) : including cat scratch fever and staphylococal and mycobacterial lymphadenitis. Systemic : Viral (eg cytomegalovirus, HIV infection) Bacterial, syphilis, tuberculosis. Fungal: histoplasmosis Parasitic : leishmaiasis tularaemia Malignant disease: Oral or in the drainage area (usually oral, scalp, ear, nose, throat, rarely thyroid) Lymphoreticular (leukaemia,lymphoma) Others: Drugs (e.g. Phenytoin) Mucocutaneous lymph node syndrome (Kawasaki disease ) Connective tissue disease The location of a lump or swelling in the neck will often give a good indication of the tissue of origin, The age of the patient may help suggest the most likely diagnosis, The duration of the lesion : one that has been present since an early age is likely to be of congenital origin, while a lump appearing in later life and persisting may be malignant. ٣
Most common causes of swellings in the neck at different ages Child ( first decade) Lymphadenitis due to viral respiratory tract infection Kawasaki disease Adolescent and teenager Lymphadenitis due to viral respiratory tract infection Bacterial infection Glandular fever syndromes HIV infection Malignancy After fourth decade Lymphadenitis Malignancy Diagnostic Approach to Lymphadenopathy A careful history and physical examination will identify a readily diagnosable cause of the lymphadenopathy, such as upper respiratory tract infection, pharyngitis, periodontal disease, conjunctivitis, lymphadenitis, insect bites, recent immunization, cat-scratch disease or dermatitis. It is important to consider the whole body when dealing with lymph node swellings; examination of other sites, particulary other nodes, liver and spleen may be necessary. ٤
Discrete swellings in the neck may be caused by disorders in : The salivary glands Thyroid gland other structures More diffuse swelling of the neck may be caused by : Infection Oedema Maljgnant infiltration Surgical emphysema The complaint is usually of swelling, tenderness may have drawn the patient s attention to their presence. The history should include; date of onset of symptoms, detail of any swelling, such as duration and character,and detail of pain experienced,such as duration, character, aggravating and relieving factors and associated phenomena. Most disease is detected in nodes in the anterior triangle of the neck. If lymphadinopathy is located in this area, that means local disease caused the swelling especially if one side is affected. Enlargement of the cervical lymph nodes alone usually arise because they are involved in immune response. Enlargement of the cervical lymph nodes only may occur when there is reactive hyperplasia to a malignant tumor in the drainage area, or metastatic infiltration. ٥
The node is hard and bound down to adjacent tissue (fixed). Sometimes ulcerated. Usually one or more anterior cervical nodes are involved, often unilaterally in oral neoplasms anteriorly in the mouth. Rare causes of cervical metastases include metastases from the stomach or even testicular tumours to the lower cervical nodes Lymphoid maligancies :There is usually swelling both of anterior and posterior cervical lymph nodes together with generalised lymph node enlargement and often hepatospleenomegaly. ٦