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Cervical lymphadenopathy

Approach

• Standard for neck examination
• Inspection, protrusion of tongue, swallowing, palpation

Examination

1. Inspection
   • Site of the lump - midline, supraclavicular fossa
   • Other features on inspection of any lump - size, skin change, scars
2. Palpation
   • Check all the node groups
   • Examine lymph nodes as for any other lump
   • Consistency - rubbery, firm
   • Number - solitary, multiple
   • Fixation - skin tethering in TB or malignancy
3. Percussion
4. Auscultation 

Completion (things you'd also like to do)

1. Examine other sites of primary infection / neoplasia
   • ENT
   • Thorax
   • Breast (in female obviously)
   • Any site of infection or neoplasia above the umbilicus
2. Examination of ear, nose and throat
   • Middle ear
   • Thyroid gland
3. Examine the rest of the lymphoreticular system 

Important History

1. Symptoms from the lump
   • duration
   • pain
   • lumps elsewhere
2. Local symptoms
   • Intraoral diseases
   • Ear diseases
3. General symptoms / systemic features
4. Social history
   • Ethnic origin (high risk areas - TB in Indian subcontinent)
   • Foreign travel
   • Contact with animals
   • Risk factors for HIV

Causes of Lymphadenopathy

1. Infection
   • Bacterial: dental abscess, TB
   • Viral: CMV, EBV (infectious mononucleosis), HIV
   • Protozoal: toxoplasmosis
2. Inflammation
   • Autoimmune diseases
3. Tumours
   • Primary
   • Secondary
   • Lymphoma / leukaemia
4. Sarcoidosis 

Management / Investigations

1. Blood tests
   • FBC, ESR
   • TFTs, Serum ACE (raised in sarcoidosis)
   • Serological: Monospot / Paul-Brunnell test for EBV
2. Radiological tests
   • UISS
   • CT
   • MRI
3. Tissue diagnosis
   • FNAC

Management routes depending in FNA results

1. Inflammatory
   • ?TB - do not perform open lymph node excision (as may cause chronic sinus formation) - treat as for TB
   • Other inflammatory disorder - open lymph node excision biopsy
2. Malignant
   • ?SCC: do not perform open lymph node excision (spoils field for subsequent block dissection, reduced survival)
   • ?Adenocarcinoma: continue to open lymph node excision + look for primary (breast, intra-abdominal - pancreas, stomach)
   • ?Lymphoma: continue to open lymph node excision biopsy as whole node is required for detailed histology and tumour marker studies

Managment options in cervical lymphadenopathy

1. Open lymph node excision biopsy
   • GA
   • Beware biopsy in posterior triangle due to risk of damaging the spinal accessory nerve - leads to shoulder/arm pain + paralysis of trapezius and winging of scapula
2. Block dissection of neck
   • Removal of sternocleidomastoid, jugular vein, accessory nerve
   • Limited dissection now in favour (supra-omohyoid only in oral and oropharyngeal cancer; lateral only in hypophyaryngeal and pharyngeal tumours in conjunction with radiotherapy)
3. Radical neck dissection
   • Clear all lymphatic tissue from mandible above to clavicle below from midline to anterior border of trapezius
   • Incisions include "wineglass" and "standard Y" and "McFee" incision

Stages of Peripheral Tuberculous Lymphadenopathy

• Stage 1: Enlarged, mobile, discreet nodes
• Stage 2: Large rubbery "matted" nodes adherent to local tissue due to periadenitis
• Stage 3: Central softening due to abscess formation
• Stage 4: "Collar stud" abscess
• Stage 5: Sinus tract formation