OCUPACIÓN Y NIVEL DE CONOCIMIENTOS
AMA DE CASA DESOCUPADA OCUPADA
• There are about 800 lymph nodes in the body.
• Approximately 300 lymph nodes lie in the neck.
• The lymphatics of head and neck drain in cervical lymph nodes.
• Lymph nodes in neck are arranged in two groups:
i. Superficial group: These are present superficial to deep cervical fascia and are very few in number.
ii. Deep group: These are present deep-to-deep cervical fascia. They are further divided into two groups:
a. Circular chain: It consists of—
Submental Submandibular Preauricular Postauricular Occipital
b. Vertical chain: These glands lie in intimate relation to internal jugular vein and are deep to sternomastoid muscle. These are:
Jugulodigastric nodes: These lie below posterior belly of digastric muscle as it crosses internal jugular vein. These nodes drain nasopharynx, oropharynx, tonsils, posterior 1/3rdof tongue, upper larynx and pyriform fossae. These are the commonest site of involvement due to disease in these areas.
Jugulo-omohyoid nodes: These lie behind the mid part of internal jugular vein where it is crossed by anterior belly of omohyoid muscle. These nodes drain tongue, thyroid and mediastinal structures.
Supraclavicular nodes: These lie around inferior part of internal jugular vein and extend in the supraclavicular region. These nodes drain thyroid, esophagus, lungs and breast.
Virchow’s lymph nodes: These are left supraclavicular group of lymph nodes lying between the two heads of sternomastoid muscle. These lymph nodes are enlarged due to metastasis from abdominal malignancies (stomach, colon, pancreas) and testicular tumors due to retrograde spread from thoracic duct (Troisier’s sign).
Pretracheal and Paratracheal lymph nodes:
Present around trachea and drain trachea and thyroid.
Adenoid tissue: This is lymphoid tissue present at the entrance of pharynx in a circular fashion and is known as Waldeyer’s lymphatic ring (Fig. 13.1). It is formed by:
Superiorly—adenoids in the roof of pharynx.
Fig. 13.1: Waldeyer’s lymphatic ring
Sanjay Marwah
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Textbook of Surgery for Dental StudentsInferiorly—lingual tonsils, i.e. lymphoid tissue at base of tongue.
Laterally—tonsils on side wall of pharynx.
• For neck dissection operations for lymph nodes, various levels of lymph node groups have been described for ease of identification of involved lymph nodes (Box 13.1A, Fig. 13.2).
Box 13.1A: Levels of lymph nodes in the neck Level I Submental and submandibular group.
Level II Upper jugular group (Jugulodigastric) Level III Mid jugular group (Jugulo-omohyoid) Level IV Lower jugular group
Level V Posterior triangle group
Level VI Anterior compartment group (Prelaryngeal, Pretracheal, Paratracheal)
Clinical Examination of Lymph Nodes and Lymphatic System
History
• History of swelling: Ask following details
Duration of swelling: It is short in infective lymphadenitis (days) and long in metastatic lymph node deposits (few weeks or months) and tubercular lymphadenitis (months or years).
Progress of swelling: It is slow in tuberculosis and rapid in malignant deposits. Rapid increase in size in a day or two with pain and fever is suggestive of suppuration and abscess formation. There may be history of regression in size with antibiotic treatment in infective pathology while malignant deposits increase progressively.
Pain in swelling: Acute throbbing pain occurs in suppurative lymphadenitis. The lymph node enlargement in tuberculosis and malignancy is painless.
Fig. 13.2: Levels of lymph nodes in the neck
Other similar swellings: These may appear at multiple sites (neck, axilla, groin) in generalized lymphadenopathy (lymphoma, tuberculosis).
• History of fever:
High grade fever of short duration occurs in acute infections.
Low grade fever with evening rise of temperature occurs in tuberculosis.
Remittent bouts of intermittent fever occur in lymphoma.
There is usually no fever in metastatic lymph nodes.
• Weight loss: If more than 10% of body weight is lost in six months time, it is considered as significant weight loss. It is seen in lymphoma, tuberculosis, malignancy.
• Loss of appetite: It is also seen in malignancy and tuberculosis.
• History regarding site of primary pathology:
Cervical lymph nodes appearing after dental sepsis are due to infective pathology.
Cervical lymph nodes appearing after non-healing ulcer in the tongue, hypersalivation, and disarticulation is suggestive of metastatic lymph nodes from carcinoma tongue.
• Past history: Ask about history of tuberculosis, exposure to sexually transmitted diseases (especially HIV) in the past.
• Family history: Ask about history of tuberculosis in family members.
General Physical Examination
• Anemia
• Jaundice
• Sternal tenderness (leukemia)
• Dilated veins in neck and chest (superior vena cava compression due to enlarged mediastinal nodes in lymphoma).
• Unilateral limb edema (arm edema in axillary nodes and pedal edema in inguinal nodes enlargement).
Local Examination
• In a patient presenting with cervical lymph node enlargement, remove clothing to expose neck, axillae and chest/breast.
• Inspection is done from the front to see the groups of enlarged lymph nodes. Look for associated lesion, e.g. tumors, sinuses, scars in head and neck region.
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• Palpation is best done by standing behind the patient (Figs 13.3A and B). Palpate all groups as depicted in Figure 13.4 and record findings (Box 13.1B).
• Flexion of neck helps in better palpation of submandibular nodes and vertical chain nodes.
• If any of the nodes are found enlarged, the corres-ponding drainage area is examined, i.e. scalp, ears, eyes, nose, oral cavity, face, neck, chest, etc.
(Figs 13.5A to D).
• Oral cavity should be examined thoroughly using torch for illumination, tongue depressor for exposure and a gloved hand for intraoral palpation.
• Examine the other lymph node areas, e.g. axilla, groin, abdomen.
• Examine the abdomen for:
Hepatosplenomegaly (in lymphoma)
Any abdominal malignancy especially if left supraclavicular lymph nodes (Virchow’s) are enlarged.
• Examine the testes for any tumor.
• Per-rectal and vaginal examination for any pelvic malignancy.
CASE SUMMARY
30 years old male presented with painful swelling in right submandibular region for the last 2 months. The diagnosis of cervical lymphadenitis was made and it responded to antibiotic treatment. However the swelling recurred after one month and developed an abscess as well (Fig. 13.5A). The case was referred for surgical opinion and oral cavity examination Fig. 13.3A: Method of palpating submandibular
lymph nodes
Fig. 13.3B: Method of palpating supraclavicular lymph nodes
Fig. 13.4: Various groups of cervical lymph nodes
Box 13.1B: Findings on palpation of lymph nodes
• Site: More than two anatomical sites—generalized lymphadenopathy
• Number
• Size
• Surface
• Consistency:
– Soft in acute infections
– Firm in chronic infections (tuberculosis) – Hard in malignancy
– Rubbery in lymphoma
• Fixity to skin: Fixed in malignancy, cold abscess
• Mobility on underlying structures:
– Mobile in chronic infection – Fixed in infiltrating malignancy
• Matting: Tubercular lymphadenitis
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Textbook of Surgery for Dental StudentsPatient presents with fever, sore throat and enlarged tender lymph nodes.
Simple infection is treated with antibiotics (amoxycillin).
In case of abscess formation, it may require needle aspiration or incision and drainage.
Chronic Nonspecific Lymphadenitis
It is due to chronic infection in the drainage area, e.g.
dental sepsis, recurrent tonsillitis, pediculosis capitis. It is also seen in cases of inadequate antibiotic treatment of infection in the drainage area. Upper deep cervical Fig. 13.5A: Cervical lymphadenitis with overlying abscess
Fig. 13.5B: Oral cavity examination of the patient revealed dental sepsis as a cause of cervical lymphadenitis
Fig. 13.5C: Multiple hard lymph nodes in the neck of an old man
Fig. 13.5D: Examination of oral cavity of the old man revealed growth base of the tongue
revealed severe dental sepsis (Fig. 13.5B). Once dental sepsis was treated, the abscess as well as cervical lymphadenitis resolved completely.
Learning point—In patient presenting with cervical lymphadenitis, always examine the drainage area (head and neck) including oral cavity to look for the site of primary lesion.
Causes of Cervical Lymphadenopathy (Box 13.2) Acute Suppurative Lymphadenitis
It is usually caused by bacterial infection. Common organisms are group A streptococci or staphylococci.
Infection starts in throat and spreads to involve cervical lymph nodes.
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lymph nodes are affected and involvement may be bilateral.
The lymph nodes are firm, mildly tender but not matted. FNAC of the cervical lymph node shows sinus histiocytosis or follicular hyperplasia. It helps in ruling out specific causes of lymphadenopathy.
Treatment is to treat the underlying cause and attend to the general health of the patient.
Tuberculous Lymphadenitis
Details given in Chapter 4: Specific Infections.
Glandular Fever (Infectious mononucleosis)
It is an acute viral infection caused by Epstein-Barr virus.
It usually affects teenagers.
Patient presents with fever, fatigue and sore throat.
There is generalized lymphadenopathy, hepatospleno-megaly and skin rash.
The monospot test detects RBC agglutination by antibodies to EB virus.
Treatment is symptomatic.
Toxoplasmosis
It is caused by a protozoan, Toxoplasma gondii. It is transmitted by undercooked meat.
Patient presents with fever, myalgia and lymph-adenopathy.
Cat Scratch Disease
There is history of contact with cats. Local inflammation occurs at site of injury. Two weeks later, regional lymph nodes become enlarged and acutely tender.
Lymph nodes often get suppurated containing sterile pus. The abscess subsides after drainage. It is a self-limiting disease. Antibiotics may be given in complex cases.
Secondary Deposits in Lymph Nodes
Any malignant tumor in head and neck region can metastasize to cervical lymph nodes. It is commonly seen in elderly individuals, usually males. However, metastasis from papillary carcinoma thyroid is seen in young adults.
The patient presents with painless enlargement of neck nodes.
There may be associated symptoms of primary lesion, e.g. sore throat, hoarseness, dysphagia, non-healing ulcer in oral cavity, cough, hemoptysis, etc.
The enlarged lymph nodes are stony hard, non-tender, mobile or fixed.
In elderly patients, greater cornu of hyoid bone is ossified and can be mistaken for a metastatic lymph node. However, on deglutition, the hyoid bone moves upwards.
Look for the evidence of primary growth in head and neck region.
If no primary growth is apparent, a specific search is made in oral cavity, nasopharynx, hypopharynx (nasopharyngoscopy), larynx (indirect laryngoscopy), external auditory canal, lung fields, breasts, chest wall and upper limbs. Various sites of occult primary lesion in metastatic lymph nodes are:
Pyriform sinus Base of tongue Vallecula Nasopharynx Thyroid
In case of enlargement of Virchow’s lymph node, look for abdominal malignancy (Troisier’s sign) and testicular tumor.
When there is no evidence of primary lesion even after investigations, it is described as metastasis of unknown origin (MUO) (Fig. 13.6).
Staging of metastatic cervical lymph nodes: TNM classification of oral cancers (See Chapter 14: Diseases of Oral Cavity).
Box 13.2: Causes of cervical lymphadenopathy Infective
• Acute suppurative lymphadenitis
• Chronic nonspecific lymphadenitis
• Tuberculous lymphadenitis
• Glandular fever
• Toxoplasmosis
• Cat scratch fever Malignancy
• Secondary deposits
• Primary—Hodgkin’s lymphoma
• Non-Hodgkin’s lymphoma
• Burkitt’s lymphoma
• Chronic lymphocytic leukemia Autoimmune disease
• Systemic lupus erythematosus
• Juvenile rheumatoid arthritis.
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Textbook of Surgery for Dental StudentsInvestigations
• Complete hemogram.
• Triple endoscopy: Direct laryngoscopy, broncho-scopy and esophagobroncho-scopy to look for any primary lesion.
• Chest X-ray: To look for primary or secondaries in the lungs, mediastinal lymph node enlargement.
• X-ray paranasal sinuses: For a tumor overlying the palate.
• CT scan: It is useful in detecting a small sized primary tumor, picks up small clinically impalpable lymph nodes and indicates extracapsular spread.
• Biopsy of primary tumor.
• If primary is occult, blind biopsies are taken from nasopharynx, pyriform sinus, base of tongue, tonsillar bed and esophagus.
• FNAC of enlarged cervical lymph node. Its accuracy is 98%. It can diagnose squamous cell carcinoma, adenocarcinoma and undifferentiated carcinoma.
• Lymph node biopsy: When aspiration cytology is inconclusive.
Operative Steps of Lymph Node Biopsy
The part is cleaned and draped. Local anesthesia is given by infiltrating 2% xylocaine. Skin incision is given directly over the lymph node along the skin crease. Skin, platysma and deep fascia are incised in line of incision.
The lymph node is dissected out from surrounding tissues while holding it with Bebcock forceps. In case,
there is a big matted lymph node mass adherent to vessels, a wedge biopsy of the mass is taken. Hemostasis is achieved. The fascia is closed with continuous chromic catgut sutures and the skin is closed with interrupted silk sutures or skin staples.
Treatment
• Surgical removal of primary lesion with en block dissection of lymph nodes.
• Radiotherapy to primary lesion as well as to lymph nodes.
• After radiotherapy, if primary tumor resolves and there are residual lymph nodes in neck, the nodes are removed by block dissection.
Metastatic Nodes—Secondary to Unknown Primary Tumor
The underlying pathology is diagnosed by FNAC or biopsy of involved lymph nodes.
• If histological diagnosis is squamous cell carcinoma and nodes are localized, consideration is given to block dissection of neck.
• If metastatic tumor is undifferentiated and nodes are large and multiple, primary site is presumed to be pharynx. Radiotherapy is given to pharynx along with nodes.
• Occasionally, it may be metastatic carcinoma from thyroid. It needs to be treated as thyroid carcinoma (Chapter 23: The Thyroid Gland).
• Sometimes it is metastatic adenocarcinoma suggestive of advanced abdominal malignancy.
Role of Chemotherapy
It is used in advanced head and neck cancers and aim is local control of disease.
Cisplatinum and 5FU are the agents used.
Types of Neck Dissection Radical Neck Dissection (Crile)
It involves resection of all lymph node groups from level I to level VI. The structures closely associated to lymph nodes are also removed. These are:
• Sternomastoid muscle
• Internal Jugular vein
• Accessory nerve Fig. 13.6: Multiple hard lymph nodes in the neck with no
evidence of primary tumor—MUO
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The main drawback of this surgery is cosmetic deformity and frozen shoulder due to paralysis of trapezius muscle (supplied by accessory nerve).
Modified Radical Neck Dissection
All cervical lymph nodes from level I to level VI are removed. However, one or more of the following three structures are preserved:
• Sternomastoid muscle
• Internal jugular vein
• Accessory nerve Selective Neck Dissection
One or more of the major lymph node groups are preserved. Also sternomastoid muscle, internal jugular vein and accessory nerve are preserved, e.g. in supraomohyoid neck dissection, level I, II and III group of lymph nodes are removed. It is indicated in carcinoma of lower lip and floor of mouth. Its advantage is that both sides of neck can be operated at one operation.
Complications of neck dissection are given in Box 13.3.
Box 13.3: Complications of neck dissection Immediate
• Hemorrhage
• Pneumothorax
• Raised intracranial pressure Late
• Infection
• Chylous fistula
• Flap necrosis
• Carotid artery rupture
• Frozen shoulder
Hodgkin’s Lymphoma
• It is a malignant tumor of lymphoreticular system arising mostly in lymph nodes and rarely in extra nodal sites (liver, spleen, etc.)
• It has bimodal age distribution (children and middle age people are mostly affected), more common in males (Box 13.4).
• It usually starts as painless enlargement of lymph nodes in left supraclavicular region (Fig. 13.7).
• Spread occurs to other lymph nodes in downstream lymphatic drainage in a systematic fashion.
• Grossly lymph nodes are pink-grey and cut surface is homogenous and smooth.
• Microscopically, characteristic Reed-Sternberg cells are seen. These are giant cells containing two large mirror image nuclei that may overlap (pennies on a plate appearance). In addition, histiocytes, plasma cells, eosinophils, lymphocytes, neutrophils may be seen. “Cellular pleomorphism” is a striking feature of Hodgkin’s lymphoma.
• Depending upon type of cells, Hodgkin’s lymphoma is divided into four types (Rye classification):
1. Lymphocytic predominant: Plenty of mature lymphocytes and a few RS cells. It has excellent prognosis.
2. Nodular sclerosis: Multiple thick bands of collagen tissue seen. It has good prognosis.
3. Mixed cellularity: Mixed cell population seen. It has poor prognosis.
4. Lymphocytic depleted: Very few lymphocytes and large number of RS cells seen. It is aggressive disease with poor prognosis.
Clinical Features
• Painless progressive enlargement of cervical lymph nodes.
• Following systemic symptoms may be present:
a. Unexplained fever with night sweats. Sometimes fever is seen in cyclical pattern (Pel-Ebstein Fig.13.7: Large discrete rubbery lymph nodes
in neck—Hodgkin’s lymphoma
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Textbook of Surgery for Dental Studentsfever), i.e. fever for 5-7 days alternating with period of normal temperature of similar duration.
b. Unexplained weight loss: 10% weight loss in six months duration is considered as significant.
c. Pruritis.
d. Bone pains: More after taking alcohol (seen in metastasis). Secondary deposits usually occur in lumbar vertebrae. These are osteosclerotic and pathological fracture rarely occurs.
• Sometimes patient presents with features of venous compression due to enlarged lymph nodes:
Dyspnea, hoarseness of voice, engorged neck veins due to superior vena cava compression.
Edema both legs due to inferior vena cava compression.
• On local examination, cervical lymph nodes are nontender, smooth, rubbery and discrete (non-matted). Sometimes in late stages, matting of lymph nodes may be seen.
• On general examination, there can be:
Anemia.
Jaundice.
Enlargement of other groups of lymph nodes.
Hepatosplenomegaly.
Pleural effusion.
Edema feet.
Red scaly patches of skin due to cutaneous involvement (Mycosis Fungoides).
Clinical Staging (Ann Arbor staging) The aim of staging is:
• to determine extent of disease.
• to plan treatment.
• to assess the prognosis.
Stage I Confined to one lymph node site.
Stage II Involvement of more than one site, either all above or below the diaphragm.
Stage III Nodes involved above and below diaphragm.
Stage IV Involvement of extralymphatic sites, e.g.
liver, bone, etc.
All stages are further subdivided into group A or B on the basis of absence (A) or presence (B) of the systemic symptoms such as weight loss, fever and night sweats.
Investigations
• Complete blood count with ESR to rule out leukemia.
• Renal function tests—blood urea, serum creati-nine.
• Liver function tests.
• Chest X-ray to demonstrate enlarged mediastinal nodes and pleural effusion.
• Abdominal ultrasound to look for
Hepatosplenomegaly.
para-aortic lymph node enlargement.
• CT scan of the abdomen for better delineation of structures seen on ultrasound. Even small sized lymph nodes are picked up on CT scan.
• Intravenous pyelography (IVP): To look for comp-ression and back pressure effect (hydronephrosis) on kidneys due to enlarged para-aortic lymph nodes.
However, if CECT abdomen is done, it clearly outlines kidneys and IVP is not required.
• Bone scan: If bony metastasis is suspected.
• Bone marrow biopsy may be required in case of hematological abnormality to look for bone marrow involvement.
• FNAC: It can give diagnosis of lymphoma. But histological pattern cannot be identified on FNAC.
• Lymph node biopsy: Excision biopsy is best for estab-lishing the diagnosis and accurate histological grading.
• Lower limb lymphangiography: It can demonstrate pelvic and retroperitoneal nodes. A foamy or reticular appearance is characteristic of lymphoma.
However, it is not done these days because of its invasive nature and availability of USG and CT scan.
• Staging laparotomy: It is also not done these days because of availability of CT scan and MRI that can detect early lesions. Earlier, it was done in clinical stage I, II and III of lymphoma. It helped in accurate staging of disease.
Steps
Splenectomy (helps in downstaging the disease).
Liver biopsy.
Para-aortic lymph node biopsy.
Mesenteric lymph node biopsy.
Iliac crest marrow biopsy
Oopharopaxy (in females).
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Disadvantages
Invasive procedure.
Operative morbidity in form of pneumonitis, abdominal sepsis, wound infections, OPSI (overwhelming post-splenectomy infection).
Treatment
• Radiotherapy (RT) and chemotherapy (CT) are the two modes of treatment given according to stage of
• Radiotherapy (RT) and chemotherapy (CT) are the two modes of treatment given according to stage of