Cervical Lymphadenopathy

Related Subjects: |Neck Swellings by Triangle |Thyroglossal cyst |Head and Neck Cancers |Triangles of the neck |Cervical Lymphadenopathy

Lymphadenopathy is enlargement of lymphoid tissue containing the B and T cells responsible for filtering foreign antigens. Cervical lymphadenopathy refers to enlargement of lymph nodes in the neck. It is extremely common in primary care and ENT practice. Most cases are benign and reactive 🦠, but in adults-particularly smokers-a persistent neck node must be considered malignant until proven otherwise ⚠️. In adults, a persistent neck lump >3 weeks requires urgent 2-week-wait referral (suspected head & neck cancer pathway).

📍 Anatomy & Lymph Node Levels

• Level I: Submental (IA) & submandibular (IB) – drain oral cavity, lips.
• Level II: Upper jugular – tonsil, pharynx, parotid.
• Level III: Mid-jugular – larynx, hypopharynx.
• Level IV: Lower jugular – thyroid, oesophagus.
• Level V: Posterior triangle – scalp, nasopharynx.
• Level VI: Anterior compartment – thyroid, larynx.

1️⃣ Tender + mobile → likely infection. 2️⃣ Rubbery + B symptoms → think lymphoma. 3️⃣ Hard + fixed in adult smoker → metastatic SCC until proven otherwise. 4️⃣ Supraclavicular node → urgent investigation. Node level gives important diagnostic clues - e.g. supraclavicular (Virchow’s node) may indicate abdominal malignancy.

Causes

• Malignancy: head and neck cancer, lymphoma, leukaemia, metastatic disease
• Infection: bacterial (e.g., Streptococcus, Staphylococcus, TB (scrofula), viral (e.g., URTI, Herpes simplex, Herpes zoster, EBV, HIV), other (e.g., Lyme disease, toxoplasmosis)
• Autoimmune: rheumatoid arthritis (RA), Sjogren syndrome, systemic lupus erythematosus (SLE)
• Miscellaneous: amyloidosis, sarcoidosis
• Iatrogenic: medications (e.g., phenytoin, allopurinol, atenolol, hydralazine, penicillin, cephalosporins)

Likely benign or inflammatory: acute enlargement, painful, soft, mobile, no progression, generalised (Infection and Autoimmune, and Lymphoma sections). Likely malignant: slow growing, painless, unilateral, hard, fixed, progressive enlargement, localised (left supraclavicular node, a.k.a., Virchow’s node=likely gastric cancer)

📊 Causes of Cervical Lymphadenopathy

🩺 Clinical Assessment

• History: Duration, pain, fever, weight loss, night sweats 🌙, recent infection, travel, TB exposure, smoking.
• Examination: Size (>1 cm concerning in adults), consistency, fixation, overlying skin changes.
• Examine full ENT tract (oral cavity, tonsils, base of tongue) 👄.
• Check for hepatosplenomegaly (lymphoma).

🔬 Investigations

• Blood tests: FBC (lymphocytosis?), CRP, ESR, LDH (lymphoma), HIV test if indicated. anaemia, leucocytosis, neutropenia in leukaemia, positive viral serology
• EBV serology: If infectious mononucleosis suspected.
• Ultrasound neck: First-line imaging - assesses morphology (hilum, necrosis).
• FNAC (Fine Needle Aspiration): For suspected malignancy.
• Core/excision biopsy: Gold standard for lymphoma.
• CXR: TB, sarcoidosis, lymphoma. hilar lymphadenopathy, nodules, cavitating lesions, lung mass
• CT neck/chest: If metastatic disease suspected.

🧠 Ultrasound Red Flags

• Loss of fatty hilum
• Round shape (short-to-long axis ratio >0.5)
• Irregular margins
• Central necrosis
• Peripheral vascularity

💊 Management

• Reactive nodes: Observation (often resolve in 2–4 weeks).
• Bacterial infection: Antibiotics (e.g. flucloxacillin or amoxicillin).
• TB: Standard anti-TB therapy.
• Lymphoma: Haematology referral → chemo ± radiotherapy.
• Metastatic SCC: MDT management (surgery ± chemoradiotherapy).

🚨 Red Flag Features

• Hard, fixed node
• Supraclavicular location
• Rapid growth
• Associated hoarseness or dysphagia
• Unexplained weight loss
• Persistent >3 weeks in adult ⚠️

👶 Paediatric Considerations

• Most common cause = reactive viral infection 🦠.
• Nodes <2 cm, mobile, bilateral often benign.
• Supraclavicular node in child → always investigate.