Describe the causes and assessment of cervical lymphadenopathy.

Causes and Assessment

• Cervical lymphadenopathy is enlargement of the cervical lymph nodes.
• It is extremely common and reactive, but is also the commonest presentation of head and neck malignancy and of lymphoma — so the task is to separate the many benign cases from the few that matter.
• The neck contains 300 of the body’s 800 lymph nodes.
• The causes divide usefully into four groups:

Investigation and Management

• The investigation follows the same order as for any neck lump, and the order is what protects the patient
• Full history and complete ENT examination including nasendoscopy, and examination of the scalp, skin, thyroid and all node groups
• Ultrasound with FNAC as the first-line test
• Where FNAC shows squamous carcinoma — the diagnosis of metastasis is made and the search for the primary begins: CT of neck and chest, pet-CT, and examination under anaesthesia with panendoscopy and directed biopsy, including ipsilateral tonsillectomy and tongue base biopsy where no primary is seen
• Where FNAC suggests lymphoma — a core or excision biopsy is required.
• Where FNAC suggests tuberculosis — send material for ZIEHL-neelsen staining, culture and GeneXpert, and treat with antitubercular chemotherapy
• Where FNAC is inadequate or non-diagnostic — repeat it under ultrasound guidance before considering anything more invasive; a first inadequate sample is common and is not an indication for open biopsy
• Management of a reactive node — treat the underlying infection, reassure, and review at 4 to 6 weeks, with clear instructions to return sooner if it enlarges
• A trial of antibiotics is reasonable where infection is likely, but must not be repeated indefinitely — a node that fails to resolve after one adequate course requires investigation, not a second course. Serial courses of antibiotics for a persistent node are the commonest cause of delayed cancer diagnosis in the neck
• IN children — the great majority are reactive and need only observation; but a persistent, enlarging, or supraclavicular node, or one with systemic symptoms, needs investigation for lymphoma, tuberculosis or atypical mycobacteria
• Atypical mycobacterial adenitis in a child is treated by complete surgical excision.
• Counsel and follow up, since a proportion of apparently benign nodes declare themselves later
• One course of antibiotics is a trial and a second is a delay, which is the commonest reason neck cancer is diagnosed late
• A node persisting beyond three to six weeks requires investigation rather than continued observation
• Supraclavicular nodes are malignant in a high proportion, and should never be watched
• Lymphoma needs architecture, so cytology suggests it but a core or excision biopsy classifies it
• Rubbery, multiple and bilateral in a young patient with B symptoms suggests lymphoma rather than metastasis
• Posterior triangle nodes in a young adult suggest glandular fever, alongside fatigue and splenomegaly
• Nodes painful after alcohol suggest Hodgkin disease, which is rare but striking and worth asking about
• Excise atypical mycobacterial nodes completely; incision and drainage produces a chronic discharging sinus
• A violaceous painless node in a young child suggests atypical mycobacteria rather than ordinary infection
• Repeat an inadequate FNAC under ultrasound before considering anything more invasive
• Send material for GeneXpert where tuberculosis is possible, which gives a rapid answer and rifampicin resistance together
• The neck holds a large share of the body nodes, which is why it is such a frequent site of clinical disease
• Reactive nodes are small, tender and mobile, and resolve over weeks with the infection that caused them
• Check HIV serology where nodes are generalised, particularly in a young adult with constitutional symptoms
• Papillary thyroid carcinoma may present with a cystic node, which is easily mistaken for a branchial cyst in a young adult
• Perform tonsillectomy and tongue base biopsy where squamous carcinoma is found and no primary is visible
• Send a thyroglobulin washout from an aspirated cystic node where thyroid carcinoma is suspected