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Cervical (neck) lymph node enlargement

Lymph nodes in the head and neck form groups. These groups are responsible for draining lymphatic fluid from different areas (Regions) in the head and neck.

Epidemiology and statistics

Only one study provides reliable population-based estimates. Findings from this Dutch study revealed a 0.6 percent annual incidence of unexplained lymphadenopathy in the general population.[1]

Causes of cervical (neck) lymph node enlargement

Localized cervical lymphadenopathy (disease of the lymph nodes) presents with lymph node enlargement that is restricted to the cervical (neck) area. If lymph nodes in other areas (e.g., the arm pits) are also enlarged in addition to those in the neck, then the condition should be evaluated as a case of generalized lymphadenopathy.

Submandibular lymph node

• Location: Along the underside of the jaw on either side.
• Lymphatic drainage: Tongue, submaxillary gland, lips and mouth, conjunctivae.
• Common causes of enlargement: Infections of head, neck, sinuses, ears, eyes, scalp, pharynx.

Submental lymph node

• Location: Located just below the chin.
• Lymphatic drainage: Lower lip, floor of mouth, teeth, submental salivary gland, tip of tongue, skin of cheek.
• Common causes of enlargement: Mononucleosis syndromes, Epstein-Barr virus, cytomegalovirus, toxoplasmosis, dental pathology such as periodontitis.

Jugular lymph node

• Location: Nodes that lie both on top of and beneath the sternocleidomastoid muscles (SCM) on either side of the neck, from the angle of the jaw to the top of the clavicle.
• Lymphatic drainage: Tongue, tonsil, pinna, parotid
• Common causes of enlargement: Pharyngitis organisms, rubella

Posterior cervical lymph node

• Location: Extend in a line posterior to the sternocleidomastoid muscles but in front of the trapezius, from the level of the mastoid bone to the clavicle (on the side of the neck near to the back).
• Lymphatic drainage: Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes
• Common causes of enlargement: Tuberculosis, lymphoma, head and neck malignancy

Suboccipital lymph node

• Location: Located at the junction between the back of the head and neck.
• Lymphatic drainage: Scalp and head
• Common causes of enlargement: Local infection

Postauricular lymph node

• Location: Located behind the ears.
• Lymphatic drainage: External auditory meatus, pinna, scalp
• Common causes of enlargement: Local infection

Preauricular lymph node

• Location: Located in front of the ears.
• Lymphatic drainage: Eyelids and conjunctivae, temporal region, pinna
• Common causes of enlargement: External auditory canal infection.

Right supraclavicular lymph node

• Location: Located on the right side in the hollow above the clavicle, just lateral to where it joins the sternum.
• Lymphatic drainage: Mediastinum, lungs, esophagus
• Common causes of enlargement: Lung, retroperitoneal or gastrointestinal cancer

Left supraclavicular lymph node

• Location: Located on the left side in the hollow above the clavicle, just lateral to where it joins the sternum.
• Lymphatic drainage: Thorax, abdomen via thoracic duct.
• Common causes of enlargement: Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection.

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Clinical features of abnormal lymph node enlargement

Abnormal lymph node enlargement tends to commonly result from infection / immune response, cancer and less commonly due to infiltration of macrophages filled with metabolite deposits (e.g., storage disorders).

Infected Lymph nodes tend to be firm, tender, enlarged and warm. Inflammation can spread to the overlying skin, causing it to appear reddened.

Lymph nodes harboring malignant disease tend to be firm, non-tender, matted (i.e., stuck to each other), fixed (i.e., not freely mobile but rather stuck down to underlying tissue), and increase in size over time.

Sometimes, following infection lymph nodes occasionally remain permanently enlarged, though they should be non-tender, small (less the 1 cm), have a rubbery consistency and none of the characteristics described for malignancy or for infection. These are also known as 'Shotty Lymph nodes'.

Size and clinical significance

Nodes are generally considered to be normal if they are up to 1 cm in diameter; however, some authors suggest that epitrochlear nodes larger than 0.5 cm or inguinal nodes larger than 1.5 cm should be considered abnormal [2,3].

Little information exists to suggest that a specific diagnosis can be based on node size. However, in one series [4] of 213 adults with unexplained lymphadenopathy, no patient with a lymph node smaller than 1 cm2 had cancer, while cancer was present in 8 percent of those with nodes from 1 cm2 to 2.25 cm2 in size, and in 38 percent of those with nodes larger than 2.25 cm2. These studies were performed in referral centers, and conclusions may not apply in primary care settings.

In children, lymph nodes larger than 2 cm in diameter (along with an abnormal chest radiograph and the absence of ear, nose and throat symptoms) were predictive of granulomatous diseases (ie, tuberculosis, cat-scratch disease or sarcoidosis) or cancer (predominantly lymphomas) [5].

An increase in nodal size on serial examinations is significant. Hence nodes that continue to grow in size are important and those that regress in size tend to be more reassuring.

Pain/Tenderness

Pain/Tenderness. When a lymph node rapidly increases in size, its capsule stretches and causes pain. Pain is usually the result of an inflammatory process or suppuration, but pain may also result from hemorrhage into the necrotic center of a malignant node. The presence or absence of tenderness does not reliably differentiate benign from malignant nodes.[1]

Consistency

Matting

Constitutional symptoms

Diagnosis

Palpation

In the case of cervical lymph node enlargement palpation has a low sensitivity and specificity 60-70%.

Supraclavicular lymph node palpation: In one study examining the presence of supraclavicular lymph node enlargement in nonsmall cell lung cancer patients - Nodes had to have a diameter of 22.3 mm or greater to be palpated in 50% of cases.[6]

Ultrasonography

Ultrasound is a useful imaging modality in assessment of cervical lymph nodes. Distribution of nodes, grey scale and power Doppler sonographic features are useful to identify the cause of cervical lymphadenopathy. Useful grey scale features include size, shape, status of echogenic hilus, echogenicity, micronodular appearance, intranodal necrosis and calcification. Adjacent soft tissue edema and matting are particularly useful to identify tuberculosis. Useful power Doppler features include vascular pattern and displacement of vascularity.

Ultrasound is a useful imaging modality in evaluation of cervical lymphadenopathy because of its high sensitivity (98%) and specificity (95%) when combined with fine-needle aspiration cytology (FNAC).[7]

CT scan

CT scans can detect the presence of enlarged cervical lymph nodes with a short-axis diameter of 5 mm or greater.

- Supraclavicular lymph node: In one study examining the presence of supraclavicular lymph node enlargement in nonsmall cell lung cancer patients - The sensitivities of US and CT did not differ significantly.[8]

Is it cancer?

Incidence

Findings from a Dutch study revealed that only 10 percent of patients with unexplained adenopathy required referral to a subspecialist, 3 percent required a biopsy and only 1 percent had a malignancy.[1]

Age

In primary care settings, patients 40 years of age and older with unexplained lymphadenopathy have about a 4 percent risk of cancer versus a 0.4 percent risk in patients younger than age 40.[1]

The supraclavicular lymph node

Right supraclavicular lymph node enlargement

The right supraclavicular lymph node is located on the right side in the hollow above the clavicle, just lateral to where it joins the sternum. It drains the mediastinum, lungs, esophagus. Common causes of enlargement include lung, retroperitoneal or gastrointestinal cancer.

Left supraclavicular lymph node enlargement

The left supraclavicular lymph node is located on the left side in the hollow above the clavicle, just lateral to where it joins the sternum. It drains the thorax, abdomen via thoracic duct. Common causes of enlargement include lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection.

Supraclavicular lymphadenopathy has the highest risk of malignancy, estimated as 90 percent in patients older than 40 years and 25 percent in those younger than age 40 [1]. This refers to a clinically significant lymph node enlargement. Little information exists to suggest that a specific diagnosis can be based on node size.

However, nodes are generally considered to be normal if they are up to 1 cm in diameter [2,3].

How to proceed

If the lymph node enlargement is unexplained, it may need to undergo a period of observation for 3 to 4 weeks possibly with the addition of empirical antibiotics.

If it persists after a period of observation then the patient should seek medical attention which may require further investigations using ultrasonography and fine needle aspiration cytology or an excisional biopsy.

References

1. Fijten GH, Blijham GH. Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians' workup. J Fam Pract 1988;27: 373-6.

3. Morland B. Lymphadenopathy. Arch Dis Child 1995; 73:476-9.

5. Slap GB, Brooks JS, Schwartz JS. When to perform biopsies of enlarged peripheral lymph nodes in young patients. JAMA 1984;252:1321-6.

6. Hans van Overhagen, MD, PhD, Koen Brakel, MD, PhD, Mark W. Heijenbrok, MD, Jan H. L. M. van Kasteren, MD, Cees N. F. van de Moosdijk, MD, Albert C. Roldaan, MD, PhD, Ad P. van Gils, MD, PhD and Bettina E. Hansen, MSc. Metastases in Supraclavicular Lymph Nodes in Lung Cancer: Assessment with Palpation, US, and CT. Radiology 2004;232:75-80.

7. Baatenburg de Jong RJ, Rongen RJ, Verwoerd CD, van Overhagen H, Lameris JS, Knegt P. Ultrasound-guided fine-needle aspiration biopsy of neck nodes. Arch Otolaryngol Head Neck Surg 1991;117:402-4.

8. Hans van Overhagen, MD, PhD, Koen Brakel, MD, PhD, Mark W. Heijenbrok, MD, Jan H. L. M. van Kasteren, MD, Cees N. F. van de Moosdijk, MD, Albert C. Roldaan, MD, PhD, Ad P. van Gils, MD, PhD and Bettina E. Hansen, MSc. Metastases in Supraclavicular Lymph Nodes in Lung Cancer: Assessment with Palpation, US, and CT. Radiology 2004;232:75-80.

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