Cervical Lymphadenopathy

Supervised by Dr.Hussein Shatti

Presented by:
Mustafa Wissam
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Ali Esam
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Mojtaba Body Haider
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Taleb Alaa
Afnan Abdulrazaq
Ola Hassan
Contents
Introduction to lymphatic system
What are lymph nodes
Cervical lymph nodes
Cervical lymphadenopathy
Clinical examination of cervical lymph nodes
Investigations to aid diagnosis
Causes of cervical lymphadenopathy
Lymphatic system
The lymphatic system, is an in organ system

vertebrates that is part of the and immune system,

complementary to the It consists of a circulatory system.

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large network ofOne lymphoid organs,
lymphatic vessels, lymph nodes,

and .
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lymphoid tissues lymph

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Lymph

Fluid similar in composition to blood

plasma.
Derived from blood plasma by filtration
through capillary walls at the arterial end.
As soon as the interstitial fluid enters the
lymph capillaries, it is called lymph.
Returning the fluid to the blood helps to
maintain normal blood volume and
pressure.
Lymph nodes
lymph nodes (or lymph
glands) are small lumps of
tissue that contain white
blood cells,They are part of
your body's immune system.
They filter your lymph fluid,
which is composed of fluid
and waste products created
by the body's tissues.
Lymph nodes help to fight
infections.
 Major lymph nodes in head and neck region
Submental
Submandibular
Pre auricular
Post auricular
Occipital
Cervical lymph nodes in relation to
sternocleidomastoid muscle can be
further divided to:
A_superficial cervical
B_Deep cervical
Supraclavicular
Infraclavicular
 Cervical lymphadenopathy

Abnormal enlargement of lymph nodes (LNs) in the head and

neck usually >1 cm. Lymphadenopathy is a common clinical
finding in a patient seeking oral health care. It may be in a
localized or generalized form. Malignancies, infections,
autoimmune disorders, iatrogenic, and other conditions are
considered as the causes for cervical lymphadenopathy.
Unexplained cervical lymphadenopathy is a cause of concern
for physician and patient because sometimes it could be the
manifestation of an underlying malignancy.
 Clinical examination of cervical lymph nodes

Consistency

Stony-hard nodes are typically a sign of cancer, usually

metastatic.
Very firm, rubbery nodes suggest lymphoma.
Softer nodes are the result of infections or inflammatory
conditions.
Suppurant nodes may be fluctuant.
 Clinical examination of cervical lymph nodes

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 Clinical examination of cervical lymph nodes
Matting

A group of nodes that feels connected and seems to move as a unit

said to be “MATTED”
• Nodes that are matted can be either benign (e.g., tuberculosis,
sarcoidosis ) or malignant (e.g., metastatic carcinoma or lymphomas).
 Investigations to aid diagnosis
ROUTINE LABORATORY INVESTIGATIONS

IMAGING
NECK ULTRASOUND
CONTRAST ENHANCED COMPUTED TOMOGRAM
TISSUE DIAGNOSIS
FINE NEEDLE ASPIRATION CYTOLOGY
LYMPH NODE BIOPSY
WHEN TO OBTAIN A TISSUE BIOPSY?
Slide Title
ITS A CLINICAL DECISION MADE BY THE TREATING SURGEON.
CLINICALLY MALIGNANT LYMPH NODE.
SUSPECTED TUBERCULOSIS.
A PERSISTENT LYMPHADENOPATHY in the absence of ENT
infection or abnormal chest radiograph and NOT RESPONDING TO
CONSERVASTIVE MANAGEMENT.
Presence of gross splenomegaly
 Two types of biopsy
Slide Title
FNAC NODE BIOPSY

OP PROCEDURE Gold standard

testing
NO NEED FOR ANAESTHESIA done under local
anaesthesia
HIGH SENSITIVITY AND SPECIFICITY
LOW COST
CAN BE REPEATED IN THE SAME NODE.
Disadvantages
Histological evaluation is limited
 Causes of cervical lymphadenopathy
There are so many potential causes
of enlargement of the cervical
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lymph nodes that differential
diagnosis is complex and requires
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knowledge of many diseases.
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Dental causes are common and the
primary role
Bodyof dentist is to exclude
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them. Body Level Five
 Causes of cervical lymphadenopathy
1. Infections
Bacterial

Dental
Apical abscess
Cellulitis
Periodontitis
Tuberculosis
Syphilis
Lyme disease
Cat scratch
Viral

Infectious mononucleosis
Herpetic stomatitis
HIV infection
Parasitic

toxoplasmosis
 Causes of cervical lymphadenopathy
2. Neoplasms
A.

A.

A. Primary

Hodgkins lymphoma
Non Hodgkins lymphoma
Leukemia
B. Secondary

Malignant melanoma
Metastasis
3. Miscellaneous

Sarcoidosis
Drug reaction
 Causes of cervical lymphadenopathy
Tuberculosis
●One-third of the world’s population is infected by Mycobacterium tuberculosis but only 10%
will develop clinical
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●In the Body

UK, infection
Level Tworates for tuberculosis (TB) can reach 1% in high incidence areas, and is
increasing epically in low socioeconomic or marginalised social groups.
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●Cervical lymph node enlargement indicates spread beyond the lungs.
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●Extrapulmonary spread is seen
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the immunosuppressed. In 5% of cases, the cervical nodes are the presenting sign.
●Cervical node infection by Mycobacterium tuberculosis accounts for 95% of cases.
Slide Title
Patients are mostly adults. Non-tuberculous (‘atypical’) mycobacteria account for the
remaining 5% particularly Mycobacterium avium intracellulare or Mycobacterium
scrofulaceum transmitted from pets such as birds and not spread person to person.

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Slide TitleTypical clinical features of tuberculous lymphadenitis
• Firm swelling, usually of a group of nodes• Nodes usually at levels 2 and 3 in the neck
• Bilateral involvement in one-third of patients• Nodes typically become matted•
Abscess (‘cold abscess’) or sinus formation, if neglected • Malaise, fever or weight loss
in up to half of patients• Chest radiography rarely detects pulmonary disease• Calcified
nodes from past, healed disease
Slide Titleis rare and a complication of
Oral tuberculosis
active pulmonary disease in which the mucosa is
infected from the sputum.

The typical lesion is an ulcer on the middorsum

of the tongue; the lip or other parts of the mouth
are infrequently affected. The ulcer is typically
angular or stellate, with overhanging edges and a
pale floor, but can be ragged and irregular.

It is painless in its early stages, and regional

lymph nodes are usually unaffected. A second
typical presentation is a non-healing extraction
socket. The diagnosis is rarely suspected before
biopsy.
 Causes of cervical lymphadenopathy
Syphilis
●Syphilis infection caused by Treponema pallidum transmitted usually by sexual
intercourse(STD). Affects both man & women in age group of 20-40 years.

●Since the mid-1990s, the prevalence has risen steadily. There are currently approximately
3000 new cases of syphilis a year in the UK, the highest levels since the 1950s.

●There are 10,000 new cases a year in the US.

●No accurate estimate for Africa where the incidence is highest.

 Causes of cervical lymphadenopathy
SYPHILIS
The cervical lymph nodes are enlarged, soft and rubbery when the primary chancre is in the
mouth or on the lip. Cervical nodes are also involved in the widespread lymphadeopathy of the
secondary stage.
Slide Title

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 Causes of cervical lymphadenopathy
Lyme disease
Lyme disease is caused by a spirochaete, Borrelia burgdor- feri, which is transmitted by
insects, particularly deer ticks.
The disease is found in the temperate northern hemisphere but is far more common in the
United States than in the UK. However, the disease is underrecognised in the UK and likely
to increase with global warming.
Diagnosis is by the history and clinical picture. It is con- firmed serologically or,
Slide Title
sometimes, by demonstration of the spirochaete by silver staining of a skin biopsy.
Antibiotics are effective. However, joint pains may recur or destructive arthritis may develop
later.
CAT-SCRATCH DISEASE

This infection is common in the United States and is frequently found in Britain. Ticks spread
the causative organism Bartonella henselae, a small Gram- negative bacillus, among cats, and
cats transmit the infec- tion to humans through scratches or saliva. However, it may also be
spread by dogs, rabbits, guinea pigs and probably other pets.
Slide Title
Typical features of cat-scratch disease
• Children frequently affected
• Frequently a history of a scratch by a cat or other animal
• Formation of papule, which may suppurate, at the site of
inoculation
• Mild fever, malaise and regional lymphadenitis 1–3
weeks after exposure
• Lymph nodes soften and typically suppurate
• Conjunctivitis may be associated
• Encephalitis is a rare complication
 Causes of cervical lymphadenopathy
Infectious mononucleosis
The Epstein–Barr virus (EBV) is the main cause of this self- limiting lymphoproliferative
disease. Infection is by saliva, but with relatively low infectivity. The virus replicates in
pharyngeal epithelium and tonsils, from where it disseminates by infection of B lymphocytes.
By early adulthood, almost all individuals are immune through subclinical infection.
 Causes of cervical lymphadenopathy
Oral manifestations of infectious mononucleosis
Infectious mononucleosis is characterised by
sore throat

enlargement of lymphoid tissue

in the pharyngeal tonsils and
lateral borders of the tongue.

Petechiae on the palate are frequently seen in infectious mononucleosis.

 Causes of cervical lymphadenopathy

Herpetic stomatitis
Herpetic stomatitis is an infection caused by herpes simplex virus,Young children commonly
get it when they are first exposed to HSV. The first outbreak is usually the most severe.
The great majority of primary infections are subclinical or completely asymptomatic. Only 1%
of those infected develop any symptoms, and these are often minimal. Most patients with
clinical infection are children aged younger than 6 years.
 Causes of cervical lymphadenopathy

Clinical and oral features

High temperature.
Gingivitis (this is the most striking feature with markley swollen gums).
Tender regional lymphadenopathy.
Vascular lesions this develop on the oral mucosa , tongue , lips and later rupture and coalesce leaving
ulcerated plaques.
Anoxia and fatigue.
 Causes of cervical lymphadenopathy
Toxoplasmosis
Toxoplasma gondii is a common intestinal parasite of many domestic animals, particularly cats.
T. gondii is a low-grade pathogen in humans but can affect previously healthy persons,
particularly young women. Infection is acquired by ingestion of parasites in poorly cooked
foods or contact with cat litter.
 Causes of cervical lymphadenopathy
Hodgkin lymphoma
A type of cancer that affects the lymphatic System.

Patients are either adolescents or young adults, or elderly. Three-quarters of patients present with, or
have, enlarged cervical lymph nodes. Nodes are rubbery and mobile and often very large. The
mouth is almost never involved.

Diagnosis is made on fine needle aspiration or node biopsy. Excision of cervical nodes is best
avoided because of scarring.
Causes of cervical lymphadenopathy
 Causes of cervical lymphadenopathy
Non-Hodgkin lymphoma
A disease in which malignant cells form in the lymphatic system.

Adults are predominantly affected and, within the mouth, usually soft, painless swellings,
which may ulcerate and resorb adjacent bone. Many patients present with enlarged
cervical lymph nodes as in Hodgkin’s lymphoma.
 Causes of cervical lymphadenopathy
Clinical and oral signs of non-Hodgkin's lymphoma
The most common symptom of non-Hodgkin's lymphoma is enlarged swollen cervical lymph
nodes and painless alterations in the oral cavity.
 Causes of cervical lymphadenopathy
Malignant melanoma
A melanoma is a tumour produced by malignant transformation of melanocytes. Melanocytes
are derived from the neural crest; consequently, melanomas, although they usually occur on
the skin, can arise in other locations where neural crest cells migrate, such as the
gastrointestinal tract and brain.
 Causes of cervical lymphadenopathy
Clinical and oral manifestations of malignant melanoma
The clinical aspect of oral melanoma is varied. Still, it usually presents as a black-brown
patch or nodular lesion with different shades of grey, red, purple, or areas of depigmentation
 Causes of cervical lymphadenopathy
sarcoidosis
an inflammatory disease in which the immune system overreacts, causing groups of cells to
form clusters of inflamed tissue called "granulomas" in one or more organs of the body
The cause of sarcoidosis is unknown. Experts think that bacteria,
viruses, or chemicals might trigger the disease. It may also be
genetic. This means a person is more likely to develop sarcoidosis if
someone his or her close family has it.
 Causes of cervical lymphadenopathy

Oral manifestations of sarcoidosis

Clinically most cases appear as non-tender swelling or nodular lesions firm to touch.
sarcoidosis localisation of the mouth was described most often in the lips ,hard and soft
palate ,buccal mucosa, tongue and tonsils.
 Drug associated lymphadenopathy
Lymphadenopathy is an occasional adverse effect of long-term
treatment with the antiepileptic drug phenytoin. is not associated with
systemic symptoms and frequently first affects the neck before
becoming widespread. Substitution of phenytoin with an alternative
usually leads to resolution.

●Other drugs that can cause lymphadenopathy do so very rarely for

example, tetracycline and penicillin.
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