Anatomy, etiology, clinical evaluation of neck nodes

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 1cm 2 - clinical manifestation of regional or systemic disease.

3. DEVELOPMENT OF LYMPHATIC SYSTEM 5 th 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 Submental Submandibular Parotid Postauricular Occipital Facial They include nodes, superficial and deep to sternocleidomastoid muscle and in the posterior triangle. Superficial external jugular group 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

10. 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.

11. 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.

12. 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.

13. 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.

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

15. 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 .

16. Spinal accessory chain Drains the scalp, skin of the neck Nasopharynx , Occipital and Postauricular nodes. Efferents from this chain drain into Transverse cervical chain

17. 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)

18. 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

19. 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

20. LYMPH NODES IN THE NECK

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

22. 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)

23. The commonest causes for cervical lymphadenopathy are tuberculous lymphadenitis (extra-pulmonary manifestation) Secondaries as metastatic nodes, lymphomas and nonspecific lymphadenitis 2 . The human immunodeficiency virus (HIV) epidemic - associated with an increase in the total incidence of extrapulmonary TB including lymphadenitis.

24. 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

25. 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

26. 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

27. 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.

28. 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 .

29. 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

30. 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.

31. 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 

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

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

34. 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

35. 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.

36. PALPATION OF NECK NODES

37. 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.

38. 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 `

39. 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.

40. 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.”

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

42. DIFFERENTIATION OF NODE FROM OTHER STRUCTURES IN NECK

43. CAUSES INFECTIONS NEOPLASMS MISCELLANEOUS Viral – Rhinovirus, Influenza, Parainfluenza , EBV, CMV, HIV Bacterial- H.influenzae , M.tuberculosis , Staph.aureus , Strep.pyogenes , Anaerobes, C.diphtheria 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

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45. LEVELS OF LYMPH NODES IN THE NECK

46. 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.

47. Each node consists of multiple lymphatic lobules

48. 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