Lymph nodes of head and neck: Normal anatomy and applied aspect

Anatomy of Lymphatic system, Causes of lymphadenopathy, Imagining tech

1. 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

2. 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

3. LYMPAHATIC SYSTEM 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

4. 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 - Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

5. 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 Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

6. 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. Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

7. 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.

8. 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 Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

9. Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition Flow of Lymph Thus, there is a continual recycling of fluid from blood to tissue fluid to lymph and back to the blood

10. 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 Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

11. LYMPHOID ORGANS

12. 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

13. 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 Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

14. Lymph nodes have two basic functions, both concerned with body protection. 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 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 :- Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

15. A lymph node is an elongated or bean-shaped structure, usually less than 3 cm long , p ositioned 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 Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

16. 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 Human Anatomy & Physiology, Elaine N. Marieb & Katja Hoehn, Eighth Edition

17. 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

18. Superficial cervical nodes The superficial circle of cervical lymph nodes is made up of the following groups: Submental Submandibular; buccal and mandibular Preauricular (parotid); Postauricular (mastoid); Occipital; Anterior cervical; and Superficial cervical nodes.

19. BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

20. BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

21. BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

22. BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

23. 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. BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition Prelaryngeal and Pretracheal Nodes

24. 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 . BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition Paratracheal Nodes

25. Deep cervical nodes

26. 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 BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

27. BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

28. RIGHT LYMPHATIC DUCT THORACIC DUCT LYMPHATIC DUCTS BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

29. THORACIC / LEFT LYMPHATIC DUCT 38 – 45 cm long Begins as a dilation called cisterna chyli anterior to 2 nd 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 . BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

30. RIGHT LYMPHATIC DUCT 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 BD Chaurasia's Human Anatomy, Head, Neck & Brain, Volume 3, Fourth Edition

31. 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.

32. 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

33. 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. METHOD OF PALPATION PRE AURICULAR NODES Morton I. Lieberman and Thomas H. Ward, Clinical identification of head and neck lymphadenopathy: a diagnostic obligation, www.agd.org General Dentistry July 2013

34. POSTERIOR AURICULAR NODES Are palpated behind the ear, on the mastoid process

35. OCCIPITAL NODES Palpated at the base\lower border of skull

36. Sub mental nodes 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.

37. Sub mandibular nodes 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.

38. Superficial cervical nodes Are situated superficial to upper part of sterno-cleido mastoid along its anterior border.

39. Posterior superficial nodes 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

40. Significance of lymph node examinations There are 3 basic classes of lymph nodes. 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. Tender, enlarged, and inflamed nodes are usually indicative of an active infection. Stony hard and fixed nodes feel like marbles that cannot be moved from the underlying structures and usually represent some form of neoplasia. Morton I. Lieberman and Thomas H. Ward, Clinical identification of head and neck lymphadenopathy: a diagnostic obligation, www.agd.org General Dentistry July 2013

41. 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

42. Approach to the Patient with Lymphadenopathy

43. KEY FACTORS IN EVALUATION OF LYMPHADENOPATHY Age of patient Location of lymphadenopathy Systemic signs/symptoms Presence/absence of splenomegaly Position, overlying surface, s ize , consistency, tenderness, and fixation of lymph nodes History of drug exposure Approach to the patient with lymphadenopathy, bernard karnad , hospital physician july 2005

44. 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 6 % of the time Approach to the patient with lymphadenopathy, bernard karnad , hospital physician july 2005

45. 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 … Approach to the patient with lymphadenopathy, bernard karnad , hospital physician july 2005

46. 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 P hysical 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. Approach to the patient with lymphadenopathy, bernard karnad , hospital physician july 2005 Special attention should be given to the presence or absence of splenomegaly because this find ing makes a malignancy of haematological origin more likely

47. 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.

48. OVERLYING SKIN: Robert ferrer , lymphadenopathy: differential diagnosis and evaluation, Am fam physician. 1998 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

49. Nodes are palpated for Consistency, Size, Tenderness, Fixity to the surrounding structures. PALPATION Robert ferrer , lymphadenopathy: differential diagnosis and evaluation, Am fam physician. 1998 oct 15;58(6):1313-1320.

50. 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

51. 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:

52. 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 Robert ferrer , lymphadenopathy: differential diagnosis and evaluation, Am fam physician. 1998 oct 15;58(6):1313-1320.

53. 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

54. 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 Cystic hygroma , Branchial cleft cyst, Thyroglossal duct cyst Cervical rib. Evaluation and management of lymphadenopathy in children, alison m. Friedmann , pediatr . Rev. 2008;29;53-60

55. 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

56. 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.

57. LYMPH NODE STATUS IN VARIOUS CONDITIONS 7,8,9,10,11,12,13,14,15

58. Localised Acute Conditions Infection

59. Localised Chronic Conditions Infection

60. Generalized Conditions Lymphomas, Tuberculosis , lymphatic leukemia, Toxoplasmosis HIV

61. ACUTE LYMPHADENOPATHY- Two weeks duration Lymph node- Tender Soft Elastic Movable difficult to hold at one place

62. 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.

63. 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.

64. BACTERIAL INFECTIONS-

65. 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.

66. 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 John R. Gosche , Laura Vick, Acute, subacute, and chronic cervical lymphadenitis in children, Seminars in Pediatric Surgery (2006) 15, 99-106.

67. VIRAL INFECTIONS 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

68. Acute viral lymphadenitis John R. Gosche , Laura Vick, Acute, subacute, and chronic cervical lymphadenitis in children, Seminars in Pediatric Surgery (2006) 15, 99-106.

69. CHRONIC LYMPHADENOPATHY CHRONIC INFECTIONS- Lymph node- Non tender, Firm , Movable , No rise in local temperature, Smooth surface

70. 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.

71. 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

72. Jones and Campbell classified peripheral tuberculous lymph nodes into following five stages . Prasanta Raghab Mohapatra , Ashok Kumar Janmeja , Tuberculous Lymphadenitis, JAPI, august 2009, VOL. 57.

73. SYPHILIS IN THE SECONDARY STAGE : 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 .

74. Infectious Mononucleosis Alison M. Friedmann , Evaluation and Management of Lymphadenopathy in Children, Pediatr . Rev. 2008;29;53-60

75. 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 John R. Gosche , Laura Vick, Acute, subacute, and chronic cervical lymphadenitis in children, Seminars in Pediatric Surgery (2006) 15, 99-106.

76. Bernard karnad , Approach to the patient with lymphadenopathy, Hospital physician july 2005 AUTOIMMUNE DISORDERS

77. HIV-related lymphadenopathy The problem of HIV-related lymphadenopathy, WILANDI JACOBS, CME AUGUST 2010 Vol.28 No.8

78. 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

79. Ann Arbor system for Classification of Hodgkin's Lymphoma It has 4 stages NEVILLE Oral and Maxillofacial Pathology, 4ed

80. 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

81. 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.

82. CHRONIC LYMPHOCYTIC LEUKEMIA Cervical lymphadenopathy and tonsillar enlargement are frequent head and neck signs of CLL . Lymph nodes- generalised , painless, dicrete , firm, movable,

83. 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.

84. Morton I. Lieberman and Thomas H. Ward, Clinical identification of head and neck lymphadenopathy: a diagnostic obligation, www.agd.org General Dentistry July 2013

85. Lymph node levels

86. 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

87. Investigations 1) Lab diagnostic methods 2) Imaging 3) Tissue examination 4) Lymphangiography S. Das, A Manual of Clinical Surgery, 5 th edition, page no. 80-89

88. 1)LABORATORY DIAGNOSIS METHODS Hb % Complete blood count 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. S. Das, A Manual of Clinical Surgery, 5 th edition, page no. 80-89

89. ESR- Raised ESR is found in tuberculosis, secondary carcinoma, lymphosarcoma C reactive protein Serological test for EBV, toxoplasma, HSV, cytomegalovirus. W.R. & Kahn test for syphilis Biochemical & immunologic tests S. Das, A Manual of Clinical Surgery, 5 th edition, page no. 80-89

90. 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 . Imaging of enlarged LN on head and neck:

91. 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). CONVENTIONAL RADIOGRAPH

92. 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

93. 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

94. Reactive nodes usually show un-sharp borders. Un-sharp borders due to edema & inflammation of surrounding soft tissue. Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

95. Malignant and TB nodes round. Reactive and normal nodes usually oval. The L/S ratio was used to characterize this feature. Shape Feature: Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

96. 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. Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

97. Normal and reactive nodes predominantly hypo-echoic. Metastatic nodes may be hypo or mixed hypo and eccentric hyper-echoic component. Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

98. 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. Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

99. 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: Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

100. Ill defined margin of enlarged LN . Central decreased echogenicity . Loss hilum . On Doppler, increase peripheral vascularity. U/S Feature of suppurative LN: Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

101. 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: Sonographic Evaluation of Cervical Lymph Nodes, Anil T. Ahuja, Michael Ying, AJR:184, May 2005

102. CT scan criteria

103. 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. CT feature of Non metastatic nodes: Imaging of malignant cervical lymphadenopathy, SEJ Connor and JFC Olli, Dentomaxillofacial Radiology (2000) 29, 133 -143

104. Rounded shape with ill defined margin. Eccentric cortical hypertrophy. Central necrotic content. Heterogeneous enhancing pattern. CT feature of metastatic nodes: Imaging of malignant cervical lymphadenopathy, SEJ Connor and JFC Olli, Dentomaxillofacial Radiology (2000) 29, 133 -143

105. 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

106. POSITRON EMISSION TOMOGRAPHY 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.

107. TISSUE DIGNOSIS It is the gold standard in the evaluation of lymphedonopathy . 

108. FINE NEEDLE ASPIRATION 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 S. Das, A Manual of Clinical Surgery, 5 th edition, page no. 80-89

109. 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 . S. Das, A Manual of Clinical Surgery, 5 th edition, page no. 80-89

110. 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. S. Das, A Manual of Clinical Surgery, 5 th edition, page no. 80-89

111. 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 S. Das, A Manual of Clinical Surgery, 5 th edition, page no. 80-89

112. Thank you

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