Where are the cervical lymph nodes located. What is the significance of different lymph node levels. How do lymph nodes relate to cancer metastasis. What are the key anatomical landmarks for identifying cervical lymph nodes.

Cervical Lymph Node Anatomy: An Overview

The cervical lymph nodes play a crucial role in the immune system and are of significant importance in the diagnosis and management of various head and neck pathologies. Understanding their anatomy, location, and function is essential for healthcare professionals dealing with head and neck disorders.

The cervical lymph node map is divided into several levels, each corresponding to specific anatomical regions and associated with particular primary tumor sites. This classification system, proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery, defines 10 node groups with clear anatomical boundaries.

Key Anatomical Landmarks

To accurately identify and locate cervical lymph nodes, it’s essential to be familiar with the following anatomical landmarks:

• Hyoid bone
• Cricoid cartilage
• Carotid arteries
• Sternocleidomastoid muscle
• Manubrium of sternum

These structures serve as reference points for defining the boundaries of different lymph node levels and are crucial for both imaging interpretation and surgical planning.

Level I: Submental and Submandibular Lymph Nodes

Level I lymph nodes are divided into two subgroups: Ia (submental) and Ib (submandibular). These nodes are often the first to be affected in cancers of the oral cavity, anterior nasal cavity, and soft tissues of the mid-face.

Level Ia: Submental Nodes

The submental nodes are located in a median region between the anterior belly of the digastric muscles. They primarily drain the anterior floor of the mouth, anterior tongue, and lower lip.

Level Ib: Submandibular Nodes

Submandibular nodes are found in the space bounded by the inner aspect of the mandible laterally and the digastric muscle medially. These nodes extend from the symphysis menti anteriorly to the submandibular gland posteriorly. They receive drainage from the oral cavity, anterior nasal cavity, soft tissues of the mid-face, and the submandibular gland itself.

What is the clinical significance of Level I lymph nodes? Level I nodes are often the first echelon of lymphatic drainage for oral cavity cancers. Their involvement can significantly impact staging and treatment decisions in head and neck oncology.

Level II: Upper Jugular Lymph Nodes

Level II lymph nodes, also known as upper jugular nodes, are of paramount importance in head and neck oncology due to their extensive drainage network. These nodes receive lymphatics from various structures, including:

• Face
• Parotid gland
• Submandibular and submental nodes
• Retropharyngeal nodes
• Nasal cavity
• Pharynx
• Larynx
• External auditory canal
• Middle ear
• Sublingual and submandibular glands

Level IIa vs. Level IIb

Level II is further subdivided into IIa and IIb, separated by an imaginary line drawn at the posterior edge of the internal jugular vein. This distinction is clinically relevant as it helps in more precise localization of metastases and guides surgical management.

How do Level IIa and IIb differ in terms of metastatic risk? While both sublevels are at risk for metastases from various head and neck cancers, Level IIb is more commonly associated with primary tumors of the oropharynx or nasopharynx. In contrast, Level IIa may harbor metastases from a broader range of primary sites, including the oral cavity, larynx, and hypopharynx.

Level III: Mid Jugular Lymph Nodes

Level III lymph nodes, or mid jugular nodes, serve as a critical junction in the cervical lymphatic system. They receive efferent lymphatics from:

• Level II nodes
• Level V nodes
• Retropharyngeal nodes
• Pretracheal nodes
• Recurrent laryngeal nodes

Additionally, Level III nodes directly collect lymphatics from several important anatomical structures:

• Base of the tongue
• Tonsils
• Larynx
• Hypopharynx
• Thyroid gland

Anatomical Boundaries

The inferior border of the cricoid cartilage serves as a crucial landmark, delineating the boundary between Level III and Level IVA. This anatomical distinction is essential for accurate staging and treatment planning in head and neck oncology.

What types of cancers commonly metastasize to Level III nodes? Level III nodes are at risk of harboring metastases from cancers of the oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx. Their central location in the neck makes them a common site for both early and advanced metastatic disease.

Level IV: Lower Jugular and Medial Supraclavicular Lymph Nodes

Level IV lymph nodes are further subdivided into IVa and IVb, with the boundary set approximately 2 cm cranial to the sternoclavicular joint. This distinction is crucial for understanding the patterns of lymphatic spread and optimizing surgical approaches.

Level IVa: Lower Jugular Nodes

Level IVa nodes are particularly significant in the context of certain head and neck cancers. They are at increased risk of harboring metastases from:

• Hypopharyngeal cancers
• Laryngeal cancers
• Thyroid cancers
• Cervical esophageal cancers

Interestingly, metastases from the anterior oral cavity may occasionally manifest in Level IVa nodes with minimal or no involvement of more proximal nodal levels. This phenomenon, known as “skip metastasis,” highlights the importance of thorough evaluation of all cervical node levels in head and neck cancer patients.

Level IVb: Medial Supraclavicular Nodes

Level IVb nodes share similar risk factors with Level IVa but are more commonly associated with cancers of the lower aerodigestive tract. The primary tumor sites that tend to metastasize to Level IVb include:

• Hypopharynx
• Subglottic larynx
• Trachea
• Thyroid gland
• Cervical esophagus

Why is the distinction between Level IVa and IVb clinically relevant? The subdivision of Level IV allows for more precise localization of metastases, which can impact surgical planning and radiation therapy fields. Moreover, involvement of Level IVb nodes often indicates more advanced disease and may influence prognosis and treatment decisions.

Level V: Posterior Triangle and Supraclavicular Lymph Nodes

Level V encompasses the lymph nodes of the posterior triangle group, a critical area in cervical lymph node anatomy. This level is further subdivided into Va and Vb, each with distinct anatomical boundaries and clinical implications.

Anatomical Boundaries of Level V

The posterior triangle is defined by the following anatomical landmarks:

• Anterior border: Posterior edge of the sternocleidomastoid muscle
• Posterior border: Anterior edge of the trapezius muscle
• Inferior border: Clavicle

Level Va: Upper Posterior Triangle Nodes

Level Va includes the lymph nodes located above the horizontal plane defined by the inferior border of the cricoid cartilage. These nodes are particularly important in the context of head and neck cancers, as they can be involved in metastases from various primary sites.

Level Vb: Lower Posterior Triangle and Supraclavicular Nodes

Level Vb comprises the lymph nodes below the horizontal plane of the inferior border of the cricoid cartilage, extending to the clavicle. This sublevel includes the supraclavicular nodes, which have significant implications in both head and neck oncology and systemic malignancies.

What is the significance of Level V nodes in cancer staging? Level V node involvement often indicates more extensive lymphatic spread and can significantly impact cancer staging, prognosis, and treatment planning. For instance, supraclavicular node metastases (Level Vb) are generally considered distant metastases (M1) in many cancer staging systems, reflecting their prognostic importance.

Retropharyngeal and Parapharyngeal Lymph Nodes

While not explicitly included in the traditional cervical lymph node levels, the retropharyngeal and parapharyngeal lymph nodes play crucial roles in the lymphatic drainage of the head and neck region. Understanding their anatomy and significance is essential for comprehensive evaluation of head and neck pathologies.

Retropharyngeal Lymph Nodes

Retropharyngeal lymph nodes are located in the retropharyngeal space, posterior to the pharyngeal constrictors and anterior to the prevertebral fascia. They are further classified into two groups:

1. Medial retropharyngeal nodes (nodes of Rouvière)
2. Lateral retropharyngeal nodes

These nodes are particularly important in the context of nasopharyngeal carcinoma and other malignancies of the posterior upper aerodigestive tract. Their involvement can significantly impact staging and treatment planning.

Parapharyngeal Lymph Nodes

Parapharyngeal lymph nodes are situated in the parapharyngeal space, a complex anatomical region bounded by multiple fascial planes. These nodes can be involved in various head and neck pathologies, including:

• Oropharyngeal cancers
• Nasopharyngeal cancers
• Salivary gland tumors

How do retropharyngeal and parapharyngeal nodes influence clinical decision-making? The involvement of these nodes often indicates more advanced disease and may necessitate modifications in surgical approach or radiation therapy planning. Their deep location also poses challenges for both imaging evaluation and surgical access, highlighting the importance of advanced imaging techniques and specialized surgical expertise in managing cases with suspected involvement of these nodal groups.

Clinical Implications and Imaging Considerations

Understanding the cervical lymph node anatomy is crucial for various clinical applications, including cancer staging, surgical planning, and radiation therapy design. The precise mapping of lymph node levels allows for more accurate assessment of disease extent and facilitates effective communication among healthcare professionals.

Imaging Modalities

Several imaging modalities play essential roles in evaluating cervical lymph nodes:

• Computed Tomography (CT): Provides excellent anatomical detail and is widely used for initial staging and follow-up.
• Magnetic Resonance Imaging (MRI): Offers superior soft tissue contrast, particularly useful for evaluating retropharyngeal and parapharyngeal spaces.
• Ultrasound: Valuable for real-time assessment and guided biopsies of superficial lymph nodes.
• Positron Emission Tomography (PET): Combined with CT, it provides functional information and can detect metabolically active metastases.

Importance in Cancer Staging

The TNM staging system for head and neck cancers heavily relies on the accurate assessment of cervical lymph node involvement. The number, size, and level of involved nodes significantly impact staging and, consequently, treatment decisions and prognosis.

How does lymph node involvement affect treatment planning? The presence and extent of lymph node metastases often dictate the need for more aggressive treatments, such as extended neck dissections or intensified chemoradiation protocols. Moreover, the specific levels involved can guide the extent of surgical resection and the design of radiation therapy fields.

Emerging Technologies and Future Directions

Advancements in imaging and molecular diagnostics are continually refining our ability to assess cervical lymph nodes. Some promising areas include:

• Advanced MRI techniques (e.g., diffusion-weighted imaging, dynamic contrast-enhanced MRI)
• Molecular imaging using novel PET tracers
• Artificial intelligence-assisted image analysis for improved detection and characterization of nodal metastases

These developments hold the potential to further enhance the accuracy of lymph node evaluation, potentially leading to more personalized and effective treatment strategies for patients with head and neck pathologies.

The Radiology Assistant : Cervical Lymph Node Map

modified from Robbins

Aurelia Fairise and Robin Smithuis

Institut de Cancérologie de Lorraine in Nancy, France and the Alrijne hospital in Leiderdorp, the Netherlands

Publicationdate 2022-07-11

This article is based on the nomenclature proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery.

10 node groups are defined with a concise description of their main anatomic boundaries, the normal structures juxtaposed to these nodes, and the main tumor sites at risk for harboring metastases in those levels [1]. 

Overview

In this cervical lymph node map the levels were extended to 10.

Some of these are being divided into sub-levels to correspond more completely with the TNM atlas.

Borders

Important landmarks are:

• Hyoid bone
• Cricoid
• Carotids
• Sternocleidomastoid muscle
• Manubrium of sternum

Axial CT

Axial CT slices in correlation to overview illustration.

Axial CT slices in more detail.
Enlarge images by clicking on them.

Levels

I – Submental and submandibular

Nodes in level I are at risk of developing metastases from cancers of the oral cavity, anterior nasal cavity and the soft tissues of the mid-face and the submandibular gland.

Level Ia 
is a median region located between the anterior belly of the digastric muscles, which contains the submental nodes.

Level Ib 
contains the submandibular nodes located in the space between the inner side of the mandible laterally and the digastric muscle medially, from the symphysis menti anteriorly to the submandibular gland posteriorly.

II – Upper jugular

Level II receives lymphatics from the face, the parotid gland, and the submandibular, submental and retropharyngeal nodes.
Level II also directly receives the collecting lymphatics from the nasal cavity, the pharynx, the larynx, the external auditory canal, the middle ear, and the sublingual and submandibular glands [1]. 

Level II can be divided into level IIa and level IIb by drawing a line at the posterior edge of the internal jugular vein.

The nodes in level IIa and IIb are at risk of harboring metastases from cancers of the nasal and oral cavity, nasopharynx, oropharynx, hypopharynx, larynx and major salivary glands.

Level IIb is more likely associated with primary tumors of the oropharynx or nasopharynx, and less frequently with tumors of the oral cavity, larynx or hypopharynx [1].

III – Mid jugular

Level III receives efferent lymphatics from levels II and V, and some efferent lymphatics from the retropharyngeal, pretracheal and recurrent laryngeal nodes.
It collects the lymphatics from the base of the tongue, tonsils, larynx, hypopharynx and thyroid gland.

The inferior border of the cricoid is the border between level III and IVA.

Nodes in level III are at risk of harboring metastases from cancers of the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx.

IV – Lower jugular and medial supraclavicular

The border between level IVa and IVb is set arbitrarily 2 cm cranial to the sterno-clavicular joint.

Level IVa
These nodes are at risk for harboring metastases from cancers of the hypopharynx, larynx, thyroid and cervical esophagus.
Rarely metastases from the anterior oral cavity may manifest in this location with minimal or no proximal nodal disease.

Level IVb
These nodes are at risk for harboring metastases from cancers of the hypopharynx, subglottic larynx, trachea, thyroid and cervical esophagus.

V – Posterior triangle and Supraclavicular

Level V contains the nodes of the posterior triangle group located posteriorly to the sternocleidomastoid muscle around the lower part of the spinal accessory nerve and the transverse cervical vessels.

Nodes in level V are most often associated with primary cancers of the nasopharynx, the oropharynx, the cutaneous structures of the posterior scalp, and the thyroid gland.

Level Vc – Supraclavicular

This level contains the lateral supraclavicular nodes located in the continuation of the posterior triangle nodes (level Va and Vb) from the cervical transverse vessels down to a limit set arbitrarily 2 cm cranial to the sternal manubrium.
It corresponds partly to the area known as the supraclavicular fossa.

Level Vc receives efferent lymphatics from the posterior triangle nodes (level Va and Vb) and is more commonly associated with nasopharyngeal tumors [1]. 

Transverse cervical artery
Scroll through the images for the anatomy of the transverse cervical artery.

VI – Anterior cervical

This level contains the superficial anterior jugular nodes (level VIa) and the deeper prelaryngeal, pretracheal, paratracheal and recurrent laryngeal nerve nodes (level VIb).

Level VIa
This level contains the superficially located anterior jugular nodes.

Level VIb
This level is contained between the medial borders of the common carotid arteries.
The nodes in this area are:

• pre-laryngeal nodes in front of the larynx and cricoid
• pre-tracheal nodes in front of the trachea 
• paratracheal nodes also called recurrent laryngeal nerve nodes

Delphian lymph node

The Delphian lymph node derived its name from the oracle of Delphi, whose prophecy would be a death secondary to laryngeal cancer.

It is a pretracheal node in level VIa located anterior to the cricoid and in between the cricothyroid muscles.

The recurrent laryngeal nerves branch off the vagus, the left at the aortic arch, and the right at the right subclavian artery.

The left laryngeal nerve can be compressed by subaortic lymph node metastases in the aorto-pulmonary window as seen in patients with lung cancer.

VII – Retropharyngeal and retrostyloid

Retropharyngeal nodes receive lymphatics from the mucosa of the nasopharynx, the Eustachian tube and the soft palate. 

These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate).

Level VIIa – retropharyngeal

These nodes lie within the retropharyngeal space, extending cranially from the upper edge of the first cervical vertebrae (massa lateralis) to the cranial edge of the body of the hyoid bone caudally (figure).

This space is bounded anteriorly by the pharyngeal constrictor muscles and posteriorly by the longus capitis and longus colli muscles.
Laterally, the retropharyngeal nodes are limited by the medial edge of the internal carotid artery.

Retropharyngeal nodes receive efferent lymphatics from the mucosa of the nasopharynx, the Eustachian tube and the soft palate.
These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate).

Level VIIb – retrostyloid

The retro-styloid nodes are the cranial continuation of the level II nodes.
They are located in the fatty space around the jugulo-carotid vessels up to the base of skull at the jugular foramen. 

Click to enlarge

The retro-styloid space is delineated by the internal carotid artery medially, by the styloid process and the deep parotid lobe laterally, by the vertebral body of C1 and the base of skull posteriorly and by the pre-styloid para-pharyngeal space anteriorly.

VIII – Parotid

This level contains the parotid node group, which includes the subcutaneous pre-auricular nodes, the superficial and deep intraparotid nodes and the subparotid nodes. 

These nodes extend from the zygomatic arch and the external auditory canal down to the mandible.

They extend from the subcutaneous tissue laterally to the styloid process medially, and from the posterior edge of the masseter and the pterygoid muscles anteriorly to the anterior edge of the sternocleidomastoid muscle and the posterior belly of the digastric muscle posteriorly [1].

Click to enlarge

The parotid group receive lymphatic from the frontal and temporal skin, the eyelids, the conjunctiva, the auricle, the external acoustic meatus, the tympanum, the nasal cavities, the root of the nose, the nasopharynx, and the Eustachian tube.  

They are at risk of harboring metastases from cancers of the frontal and temporal skin, orbit, external auditory canal, nasal cavities and parotid gland.

IX – Buccofacial

Level IX contains the malar and bucco-facial node group, which includes inconsistent superficial lymph nodes around the facial vessels on the external surface of the buccinator muscle.
These nodes extend from the caudal edge of the orbit (cranially) down to the caudal edge of the mandible (caudally) where they reached level Ib. 

They lay on the buccinators muscle (medially) in the sub-cutaneous tissue, from the anterior edge of the masseter muscle and the Bichat’s fat pad (posteriorly) to the anterior sub-cutaneous tissue of the face.

The bucco-facial nodes receive efferent vessels from the nose, the eyelids, and the cheek. 

They are at risk of harboring metastases from cancers of the skin of the face, the nose, the maxillary sinus (infiltrating the soft tissue of the cheek) and the buccal mucosa.

X – Retroauricular and occipital

Level Xa contains the retroauricular (also called mastoid) and subauricular nodes, which includes superficial nodes lying on the mastoid process from the cranial edge of the external auditory canal cranially to the tip of the mastoid caudally. 

Level Xb contains the occipital lymph nodes, which are the cranial and superficial continuation of the level Va nodes up to the cranial protuberance. They lie from the posterior edge of the sternocleidomastoid muscle to the anterior (lateral) edge of the trapezius muscle.

Lymph node metastases in level X are from skin cancers of the retro-auricular area (Xa) and skin cancers of the occipital area (Xb).

Click on the image below to get more information about Medical Action Myanmar, a medical organization run by Nini Tun and Frank Smithuis, who happens to be the brother of Robin Smithuis.

1. Delineation of the neck node levels for head and neck tumors: A 2013 update. DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI, RTOG, TROG consensus guidelines

   DAHANCA, EORTC, HKNPCSG,NCIC CTG, NCRI, RTOG, TROG consensus guidelines.
   by V Grégoire et al.
   Radiother Oncol 2014 ;110:172–81.

2. Integrating radiological criteria into the classification of cervical lymph node disease.
   by Robbins KT.
   Arch Otolaryngol Head Neck Surg 1999 ;125:385–7.

3. International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration.

   by El-Sherief AH, Lau CT, Wu CC, Drake RL, Abbott GF, Rice TW.
   Radiographics. 2014 Oct;34(6):1680-91.

The Adult Neck Mass | AAFP

ERIC SCHWETSCHENAU, M.D., AND DANIEL J. KELLEY, M.D.

Family physicians frequently encounter neck masses in adult patients. A careful medical history should be obtained, and a thorough physical examination should be performed. The patient’s age and the location, size, and duration of the mass are important pieces of information. Inflammatory and infectious causes of neck masses, such as cervical adenitis and cat-scratch disease, are common in young adults. Congenital masses, such as branchial anomalies and thyroglossal duct cysts, must be considered in the differential diagnosis. Neoplasms (benign and malignant) are more likely to be present in older adults. Fine-needle aspiration and biopsy and contrast-enhanced computed tomographic scanning are the best techniques for evaluating these masses. An otolaryngology consultation for endoscopy and possible excisional biopsy should be obtained when a neck mass persists beyond four to six weeks after a single course of a broad-spectrum antibiotic.

When an adult patient presents with a neck mass, malignancy is the greatest concern. Although differentiating benign and malignant masses can be difficult, a methodical approach will usually result in an accurate diagnosis and appropriate treatment. This article reviews the differential diagnosis of neck masses in adults and provides a framework for clinical decision-making.

Normal Anatomy

Accurate diagnosis of a neck mass requires a knowledge of normal structures. With practice and experience, normal variations in anatomy can be distinguished from true pathology without the need for additional diagnostic testing or subspecialist consultation.

The hyoid bone, thyroid cartilage, and cricoid cartilages are located within the central portion of the neck. The thyroid gland is usually palpable in the midline below the thyroid cartilage. Carotid arteries are pulsatile and can be quite prominent if atherosclerotic disease is present. The sternocleidomastoid muscles should be palpated along their entirety, with careful attention given to deep jugular lymph nodes.

The parotid glands are located in the preauricular area on each side in the lateral neck. The tail of each parotid gland extends below the angle of the mandible, inferior to the ear-lobe. The submandibular glands are located within a triangle bounded by the sternocleidomastoid muscle, the posterior belly of the digastric muscle, and the body of the mandible. In older patients, these glands may become ptotic and appear more prominent.

Lymph nodes are located throughout the head and neck region and are the most common sites of neck masses. Fixed, firm, or matted lymph nodes and nodes larger than 1. 5 cm require further evaluation.

History

A careful medical history can provide important clues to the diagnosis of a neck mass.¹ The patient’s age and the size and duration of the mass are the most significant predictors of neoplasia.¹ The patient’s age is most important, because the risk of malignancy becomes greater with increasing age.²

The occurrence of symptoms and their duration must also be determined. Acute symptoms, such as fever, sore throat, and cough, suggest adenopathy resulting from an upper respiratory tract infection. Chronic symptoms of sore throat, dysphagia, change in voice quality, or hoarseness are often associated with anatomic or functional alterations in the pharynx or larynx.

Recent travel, trauma to the head and neck, insect bites, or exposure to pets or farm animals suggests an inflammatory or infectious cause for a neck mass. A history of smoking, heavy alcohol use, or previous radiation treatment increases the likelihood of malignancy.

A review of associated medical conditions and previous treatments is useful in narrowing the differential diagnosis and formulating an appropriate treatment plan.

Physical Examination

The skin on the head and neck should be inspected for premalignant or malignant lesions resulting from chronic sun exposure. The otologic examination may show a sinus or fistula associated with a branchial anomaly. Evidence of chronic sinusitis or pharyngitis suggests reactive adenopathy as the most likely cause of a neck mass.

The physician should pay particular attention to mucosal surfaces. For examination of the mucosa, dentures or other dental appliances may need to be removed. Palpation of the tongue, including the base of the tongue, can reveal occult lesions. Attention should be paid to ulcerations, submucosal swelling, or asymmetry, particularly in the tonsillar fossa.

Examination of the larynx and pharynx is accomplished by indirect or flexible laryngoscopy. Palpation during swallowing or during a Valsalva’s maneuver may identify pathology within the larynx and thyroid gland. Rotation of the head in both flexion and extension aids examination of the posterior triangle of the neck.

For initial assessment and serial examination, the size of the mass may be measured using calipers or a tape measure.

Differential Diagnosis

CONGENITAL ANOMALIES

Although congenital anomalies of the neck are more common in children, they also should be considered in the differential diagnosis of neck masses in adults.

Lateral Neck

Branchial anomalies are the most common congenital masses in the lateral neck. These masses, which include cysts, sinuses, and fistulae, may be present anywhere along the sternocleidomastoid muscle.³ The masses are typically soft, slow-growing, and painless. A history of infection, spontaneous discharge, and previous incision and drainage is not uncommon.

Computed tomographic (CT) scanning can usually demonstrate cystic masses medial to the sternocleidomastoid muscle at the level of the hyoid bone in the neck. Treatment is complete surgical excision, with preparation and examination of frozen sections to exclude malignancy. Fine-needle aspiration and biopsy should be performed before excision because of the possibility of cystic metastases from squamous cell carcinoma within Waldeyer’s tonsillar ring.⁴

Other congenital anomalies of the lateral neck include cystic hygromas (lymphangiomas) and dermoids.

Central Neck

The thyroglossal duct cyst is the most common congenital anomaly of the central portion of the neck (Figure 1). This anomaly is caused by a tract of thyroid tissue along the pathway of embryologic migration of the thyroid gland from the base of the tongue to the neck. The thyroglossal duct cyst is intimately related to the central portion of the hyoid bone and usually elevates along with the larynx during swallowing. It may contain the patient’s only thyroid tissue.⁵ Thyroid carcinoma has been reported within thyroglossal duct cysts.

With regard to thyroglossal duct cysts, the extent of preoperative assessment is controversial and ranges from physical examination to serologic testing and diagnostic imaging.^6,7 If serum thyroid function test results are abnormal, thyroid scanning should be performed to determine the amount of thyroid tissue in the neck. Some investigators advocate routine ultrasonography or nuclear scanning to avoid permanent hypothyroidism. As with branchial cysts, a history of infection, spontaneous discharge, and previous incision and drainage is not uncommon.

The treatment of choice is the Sistrunk procedure, which involves complete excision of the thyroglossal duct cyst, including the central portion of the hyoid bone. If necessary, excision extends to the base of the tongue.

Other congenital midline neck masses include thymic rests and dermoids.

INFLAMMATORY AND INFECTIOUS CONDITIONS

Inflammation

Lymph node groups in the neck include the submandibular nodes within the submandibular triangle, the jugular chain of nodes located along the internal jugular vein, and the posterior-triangle nodes located between the sternocleidomastoid and trapezius musculature.

Inflammatory lymphadenopathy is typically self-limited and resolves spontaneously over a period of weeks. Chronic sialadenitis as a result of salivary stones or duct stenosis can result in gland hypertrophy and fibrosis.⁸ Chronic inflammation may result in a mass within the submandibular or parotid glands. Treatment is usually conservative unless pain is severe enough to justify surgical excision.

Cervical adenitis is probably the most common cause of an inflammatory mass in the neck. This condition is characterized by painful enlargement of normal lymph nodes in response to infection or inflammation.⁹

Infection

Both bacterial and viral infections can cause neck masses. Occasionally, the lymph node becomes necrotic, and an abscess forms. Staphylococcus and Streptococcus species are the organisms most commonly cultured from neck abscesses.¹⁰ In many instances, however, the infection is polymicrobial. A neck abscess usually requires intravenous antibiotic therapy, and surgical drainage may be necessary.

Typical and atypical mycobacterial infections are less common infectious causes of neck masses. Mycobacterial infection generally presents as a single enlarged node that is rarely tender or painful. Tuberculous infection generally presents in older patients with a history of tuberculosis exposure and a positive purified protein derivative (PPD) tuberculin skin test. Therapy with antituberculous antibiotics for six to 12 months is the treatment of choice.¹¹

Atypical mycobacterial infection is usually found in children with a nonreactive PPD skin test and no exposure history. Left untreated, the lymph node may drain spontaneously, leading to a chronic fistula. Surgical removal with curettage is the standard treatment. Antibiotic therapy is generally reserved for recurrent disease.¹²

In recent years, the incidence of typical mycobacterial infections has increased in adults who test positive for the human immunodeficiency virus (HIV) and in children who test negative for the virus. ^13,14 HIV infection should be considered in any adult with cervical adenopathy, and appropriate serologic testing is indicated. HIV-positive adult patients with a nontuberculous mycobacterial infection involving cervical lymph nodes are typically treated with clarithromycin (Biaxin). Surgical intervention is reserved for use in patients with resistant or unresponsive disease.¹⁵

Cat-scratch disease is another less common cause of neck masses. Accurate diagnosis may be difficult because the adenopathy can appear days to months after the original injury. The etiologic agent in cat-scratch disease (Bartonella henselae) was recently identified.¹⁶ In general, only one lymph node is enlarged, and the node returns to normal size without treatment.

Toxoplasmosis sometimes causes neck masses. This infection generally presents as a single enlarged node in the posterior triangle.¹⁷ The clinical course is benign, and antibiotic therapy is not needed. ¹⁸

Infectious mononucleosis usually presents with acute pharyngitis, cervical adenopathy, and an elevated Epstein-Barr virus titer.

Fungal infections such as actinomycosis can also cause neck masses.

TRAUMA

Neck masses resulting from trauma have a characteristic history and physical findings. Although new or organized hematomas generally resolve, they may persist as firm masses because of fibrosis.

Pseudoaneurysm or an arteriovenous fistula of a major arterial vessel in the neck is rare and is usually associated with the shearing effects of major blunt-force trauma, such as occurs in an automobile accident.¹⁹ If the injury is not recognized at the time of initial trauma, the patient may present later with a pulsatile, soft, fixed mass over which a thrill or bruit can generally be auscultated.

METABOLIC, IDIOPATHIC, AND AUTOIMMUNE CONDITIONS

Metabolic disorders are rare causes of neck masses. Gout and tumoral calcium pyrophosphate dihydrate deposition disease have been reported to present as neck masses. ^20,21

Idiopathic conditions, such as inflammatory pseudotumor, Kimura’s disease, and Castleman’s disease, can also present with a neck mass.^22–24 A neck mass may also be the presenting symptom of sarcoidosis.²⁵

Kimura’s disease is an uncommon chronic inflammatory condition involving subcutaneous tissue. The etiology is unknown. The disease presents as a tumor-like lesion with a predilection for the head and neck region.

Castleman’s disease is a benign lympho-proliferative disorder that most frequently involves the mediastinal lymph nodes. It typically presents in the head and neck as cervical adenopathy of unknown etiology. Multiple biopsies showing florid lymphoid hyperplasia are frequently required to establish the diagnosis.

NEOPLASM

Benign Masses

Lipomas, hemangiomas, neuromas, and fibromas are benign neoplasms that occur in the neck. They are all characterized by slow growth and lack of invasion. Lipomas are soft masses that are isodense with a fat signal on magnetic resonance imaging. Hemangiomas typically occur with cutaneous manifestations and are relatively easy to recognize. Neuromas may arise from nerves in the neck and rarely present with sensory or motor deficits. Most of these benign masses are diagnosed at the time of surgical excision.²⁶

Malignant Masses

Retrospective studies of open biopsies have shown high rates of malignancy for neck masses in adults.²⁷ A malignant neoplasm in the neck can arise as a primary tumor or as metastasis from the upper aerodigestive tract or a distant site.

Thyroid cancer, salivary gland cancer, lymphomas, and sarcomas are examples of primary malignancies.²⁸ The most common presentation for thyroid or salivary gland cancer is an asymptomatic nodule within the gland. Further diagnostic evaluation and management of the nodule is always indicated.²⁹

Risk factors for mucosal head and neck cancer (oral cavity, larynx, pharynx) include chronic sun exposure, tobacco and alcohol use, poor dentition, industrial or environmental exposures, and family history. ³⁰ Symptoms include a nonhealing ulcer within the oral cavity or oropharynx, persistent sore throat, dysphagia, change in voice, and recent weight loss.

Metastatic disease to lymph nodes of the neck from a head-and-neck primary site usually follows well-defined patterns^31,32(Figure 2). For example, cancers of the oral cavity typically metastasize to the submandibular triangle (Figure 3), whereas cancers from most other sites in the head and neck spread to the lateral neck. Patients with palpable lymphadenopathy in the supraclavicular fossa should be evaluated for malignancy below the clavicles (e.g., lung cancer).

Management

Many inflammatory lymph nodes resolve with no treatment, although close observation is required. A single course of therapy with a broad-spectrum antibiotic and reassessment in one to two weeks is a reasonable treatment choice when a patient with a neck mass has signs and symptoms of an inflammatory process (i. e., fever, painful mass, erythema) or a history of recent infection.

Thyroid and salivary gland nodules should undergo fine-needle aspiration and biopsy. This diagnostic procedure should also be performed when a neck mass persists beyond four to six weeks. In experienced hands, the sensitivity and specificity of fine-needle aspiration and biopsy exceed 90 percent.³³

Local recurrences have been reported following stereotactic core-needle biopsy of solid tumors, including breast, liver, colon, pancreas, and lung cancers.^34,35 The use of large-diameter needles has been associated with the seeding of head and neck carcinomas.^36,37 However, no cases of seeding or dissemination have been reported with the use of fine-needle aspiration, and the risk of tumor seeding of the biopsy site is considered to be exceedingly low. Fine-needle aspiration and biopsy are typically indicated when no cause for a neck mass is found on the initial evaluation.³⁸

Contrast-enhanced CT scanning is the best imaging technique for evaluating a neck mass. This modality should be used whenever the diagnosis is unclear. Assessment of a neck mass also requires a recent chest radiograph. Routine serologic tests can exclude metabolic disorders and other uncommon causes of neck masses in the vast majority of patients.

Cytopathologic differentiation of benign and malignant adenopathy can be difficult. Cytologic or radiographic evidence of conditions other than reactive lymphadenopathy warrants consultation with an otolaryngologist for endoscopic evaluation, with possible excisional biopsy or neck dissection.

Biopsy should be considered for neck masses with progressive growth, location within the supraclavicular fossa, or size greater than 3 cm. Biopsy also should be considered if a patient with a neck mass develops symptoms associated with lymphoma. Frozen-section examination of the mass followed by neck dissection should be performed if the mass proves to be metastatic carcinoma.

An algorithm for the evaluation and management of a neck mass in an adult patient is provided in Figure 4.

Lymphadenitis of the face and neck / Lipetsk city dental clinic №1

What are the lymph nodes on the face and where are they located

Lymph nodes on the face act as a kind of lymph filters from toxic substances. This defensive reaction is especially important on the face. Location of lymph nodes:

Behind both auricles on the head On the neck under the ears slightly shifted forward Under the jaw from below Under the beard Under the eyes

Causes of inflammation of the lymph nodes of the face

Facial lymph nodes play the role of “guards” of the body as a whole. And they are sensitive to the invasion of any infection or the beginning of an inflammatory process in the human body.

Inflammation of the lymph nodes on the face can be the result of such troubles as:

Infectious disease (cold, flu, rhinitis, sinusitis, tonsillitis) Tuberculosis Dental problems (periodontal disease, caries) Decreased immunity Skin diseases on the face Allergy Otitis Periodontitis

Inflammation of the lymphatic knots on the face often occur as a result of hypothermia of a person.

Lymphadenitis of the facial node

Inflammation of the lymph nodes on the face indicates that there is an infection in the human body and red blood cells “rushed into battle.” And it is worth not only treating the lymph nodes on the face, but conducting a complete diagnosis of the state of health to detect the underlying problem.

The main cause of lymphadenitis of the facial nodes are skin diseases: acne, acne.

Location of lymph nodes

Lymphadenitis of the parotid and behind the ear nodes

Thickening of the lymph nodes on the face near the ears is a companion of inflammatory processes that occur in the ear or salivary gland, or diseases of the throat.

In children, there is a thickening of the parotid and behind the ear nodes on the face with rubella, chickenpox. Such allergic reactions to vaccination are not uncommon. For a more accurate diagnosis, you should consult a surgeon.

Enlarged nodes in the lower part of the face

Lymph nodes in the lower part of the face can become inflamed for various reasons:

Dental problems (inflammation of the gums, caries) Sialoadenitis

With these diseases, there is an intensive removal of erythrocyte decay products from inflammation sites. Lymph nodes in the lower body do not have time to filter the lymph. This causes stagnation in the node and, as a result, its inflammation.

Lymphadenitis of the facial area symptoms

Inflammation of the lymph nodes on the face occurs with prolonged stagnation of lymph in the node itself. Main symptoms:

Skin thickening in this area Redness and itching Painful sensations when pressed Increased body temperature

Cases of purulent inflammation of the lymph nodes on the face are not uncommon. With such a complication, pus accumulates in the node itself. The final recovery of the patient occurs after the extraction of purulent accumulations. It can rupture on its own or be removed with minor surgery.

Remember! Inflammatory processes of the lymph nodes on the face are not an entirely innocent disease. It can lead to serious complications:

Meningitis Encephalitis

It is strictly forbidden to self-treat inflammation of the lymph nodes on the face.

Types of lymphadenitis

Lymphadenitis of the facial nodes is:

Acute Chronic Nonspecific lymphadenitis

The acute form of diseases of the lymph nodes on the face is characterized by the rapid onset of painful symptoms:

Thickening of the focus Redness of the skin Accumulation of pus Increased body temperature Painful sensations when pressed 04 Specific lymphadenitis on the face appears as concomitant manifestations of such diseases as:

AIDS Syphilis Tuberculosis

Nonspecific lymphadenitis manifests itself after various infectious bacteria enter the lymph:

Streptococcus Staphylococcus Various toxins

If pus accumulates in a lymph node on the face, it is purulent lymphadenitis.

Diagnosis

As noted above, lymphadenitis is one of the body’s signals that inflammatory processes are occurring in the human body. And it is worth making a full diagnosis to find the root cause. After all, eliminating the symptoms does not get rid of the main problem.

During the examination, the doctor pays special attention to the location of the inflamed lymph nodes. If they are near the ear, this may indicate otitis media. Purulent inflammation of the node on the face is most often the result of subcutaneous abscesses.

Purulent inflamed lymph nodes on the face in most cases are treated with surgery. But it is not uncommon that the abscess is torn. It is very good if the content comes out. It happens that pus gets inside. Then surgery is simply a must with a more thorough approach. Need general anesthesia and a long process of cleaning the affected area of ​​the face.

Prevention

Avoiding inflammation in the lymph node is quite easy:

Follow the strengthening of the immune system. This will help to avoid colds, viral diseases. Elementary hygiene of the oral cavity and ears will save you from stagnation of lymph in these areas of the face. Don’t skip the mandatory vaccination schedule. Try to avoid exposure to allergens on the body. Simple rules will relieve you of pain during lymphadenitis and strengthen the body.

MRI of the lymph nodes of the soft tissues of the neck

MRI Center – MRI of the lymph nodes

Neck soft tissue examination

A key part of the peripheral immune system consists of the lymph nodes. When metabolic / autoimmune pathologies occur, neoplasms occur, infection appears, lymph nodes increase in size. This process belongs to the general medical signs.

Such changes entail a variety of procedures and therapeutic examinations. The best way to examine this organ is tomography of the lymph nodes.

Price of MRI of lymph nodes in Moscow

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Survey	Promotion price! Find out the end date of the promotion by calling the medical center
Neck soft tissue MRI (lymph nodes)	5 600

Why MRI of lymph nodes is necessary

MRI of the lymph nodes is the most advanced diagnostic method that reveals inconsistencies in the body. The display is based on a magnetic field combined with radio frequency pulses.

The positive aspect of this research method is its harmlessness and information content. During the examination, patients are spared from contact with highly radioactive substances, as well as from the perception of harmful radiation. The image quality factor makes it possible to recognize even the slightest modifications in the depicted organ.

Using only MRI of the lymph nodes, doctors can make a qualitative assessment of the state of the entire lymphatic system, as well as its individual elements

Indications for MRI of the lymph nodes

Lymph nodes in the human body perform the work of filtering of natural origin. Lymph flows through these filters, and they also trap all kinds of cells of the wrong composition.

MRI of the lymph nodes is usually done if:

• Immunity is impaired due to various diseases.
• There is an assumption of infectious diseases. This includes special diseases (tuberculosis or HIV).
• Symptoms are present that suggest the presence of metastases or tumors in the lymph nodes.

An appointment for MRI of the lymph nodes is issued if the patient has:

• As a result of infection, the lymph nodes have changed in size.
• If the size of the lymph nodes has changed for unknown reasons.
• Lymph nodes are enlarged on one side.
• The patient has already recovered, and the lymph nodes continue to grow.
• Lymph nodes have become larger. At the same time, the patient’s body temperature is elevated, the patient feels pain, there is a violation of swallowing functions.

For more effective diagnosis, the patient may be offered an MRI with contrast. This research method consists of introducing a contrast agent into the body by injection. This drug accumulates in the organ being examined.

Soft tissues of the neck

MRI of the soft tissues of the neck

From an anatomical point of view, the neck area is subject to the greatest load. It contains many organs that fit tightly to each other in a limited space. These organs belong to different systems such as nervous, circulatory, digestive, endocrine, lymphatic. Therefore, with the help of MRI of the soft tissues of the neck organs, it is possible to examine various changes in the structures (larynx, lymph nodes, thyroid gland, salivary glands).

Neck MRI is prescribed if there are suspicions of diseases of the vascular system, endocrine anomalies, when the salivary glands or the thyroid gland are inflamed. Also, tomography helps to identify tumors and metastases in the neck.

Where to get an MRI of lymph nodes in Moscow

If you need to diagnose lymph nodes, please contact our medical center, located near the metro station.