Cervical Lymphadenopathy

Intro & Anatomy - Neck Node Know-How

• Cervical Lymphadenopathy: Enlargement of neck lymph nodes.

• Node Assessment:

  • Normal: < 1 cm (Jugulodigastric up to 1.5 cm), mobile, soft.
  • Abnormal: > 1 cm, firm, matted, fixed; suggests pathology.

• Neck Node Levels (Robbins):

  • I: Submental (IA), Submandibular (IB)
  • II: Upper Jugular (IIA/IIB by SAN)
  • III: Middle Jugular
  • IV: Lower Jugular
  • V: Posterior Triangle (VA/VB)
  • VI: Anterior Compartment (central nodes)
  • (VII): Superior Mediastinal

• 📌 Mnemonic (I-VI): Smart University Medicos Love Practical Anatomy. (S-Submental/mandibular, U-Upper, M-Middle, L-Lower Jugular, P-Posterior, A-Anterior).

• ⭐ Level IV (Supraclavicular) Nodes: Left-sided (Virchow's node) may indicate gastric, thoracic, or pelvic malignancy.

Etiology - The Culprit Countdown

• Infectious:
  • Bacterial: S. aureus, S. pyogenes (acute, tender); TB (scrofula: chronic, matted); B. henselae (cat scratch).
  • Viral: EBV (mono: posterior triangle, fever, pharyngitis); CMV; HIV; Adenovirus.
  • Parasitic: Toxoplasmosis (posterior cervical).
• Inflammatory (Non-infectious):
  • Kawasaki Disease (children <5 yrs, fever >5 days, mucocutaneous signs, coronary risk).
  • Sarcoidosis (bilateral, firm, non-tender, non-caseating granulomas).
  • Kikuchi-Fujimoto Disease (young adults, fever, self-limiting).
• Neoplastic:
  • Primary: Lymphoma (Hodgkin's, NHL), Leukemia.
  • Metastatic: SCC (H&N primary: hard, fixed); Thyroid Ca; Nasopharyngeal Ca (NPC - Level V).
  • 📌 VIRCHOW (GI Malignancy): Left supraclavicular node (Troisier's sign).

⭐ Virchow's node (left supraclavicular) strongly suggests metastatic gastric cancer (Troisier's sign), but also other abdominal/thoracic malignancies.

Clinical Evaluation - Detective Work

• History:
  • Duration: Acute (<2 wks), Chronic (>6 wks).
  • Symptoms: Pain, fever, B-symptoms (weight loss, night sweats) ⚠️.
  • Exposures: TB, smoking, HIV risks. Prior malignancy.
• Examination (📌 L S C T M):
  • Location: Level; supraclavicular (Virchow's) ⚠️.
  • Size: >1.5 cm abnormal; >2 cm red flag.
  • Consistency: Rubbery (lymphoma), hard (mets), fluctuant (abscess).
  • Tenderness: Inflammatory.
  • Mobility: Fixed/matted (TB, malignancy).
  • Check primary sites (ENT, scalp, chest).

⭐ Lymphomatous nodes: Typically non-tender, firm, rubbery; may be matted.

• Red Flags (prompt urgent workup):
  • Age >40
  • Duration >4-6 wks
  • Size >2 cm
  • Hard/fixed consistency
  • Supraclavicular location
  • B-symptoms (fever, night sweats, weight loss)
  • History of cancer

Investigations - Unmasking the Mass

• Initial Approach:
  • Ultrasound (USG) Neck:
    • Characterizes node: size, shape, hilum (absent/present), echotexture, vascularity.
    • Guides FNAC.
    • Malignant signs: Round, hypoechoic, absent hilum, calcification, necrosis, peripheral vascularity.
  • Fine Needle Aspiration Cytology (FNAC):

    ⭐ FNAC is the initial diagnostic test of choice for most palpable cervical lymph nodes.

    • High sensitivity & specificity.
• If FNAC Inconclusive/Suspicious:
  • Repeat FNAC.
  • Core Needle Biopsy (esp. lymphoma).
  • Excision Biopsy: Gold standard; for definitive diagnosis or lymphoma subtyping.
• Staging & Primary Search (if malignancy confirmed/suspected):
  • Contrast-Enhanced CT (CECT) Neck ± Chest.
  • MRI: Superior soft tissue detail.
  • PET-CT: Unknown primary, staging, recurrence.
  • Panendoscopy (Direct Laryngoscopy, Esophagoscopy, Bronchoscopy): For suspected SCC.
• Blood Tests: CBC, ESR, LDH; specific markers (e.g., viral serology, tumor markers if indicated).

High‑Yield Points - ⚡ Biggest Takeaways

• Persistent cervical lymphadenopathy (>2 weeks) mandates further investigation.
• Supraclavicular nodes, especially left (Virchow's), strongly indicate underlying malignancy (often GI).
• Posterior triangle nodes are frequently associated with nasopharyngeal carcinoma (NPC) or lymphoma.
• FNAC is the initial investigation of choice for most palpable cervical nodes.
• Tuberculosis (scrofula) is a key differential in India, presenting as matted nodes, possibly with a cold abscess.
• Metastatic Squamous Cell Carcinoma (SCC) is the most common malignant cause in adults.