Enlarged Lymph Nodes in Neck
Bernadette L. Koch, MD
DIFFERENTIAL DIAGNOSIS
Common
Reactive Lymph Nodes
Suppurative Lymph Nodes
Hodgkin Lymphoma, Lymph Nodes
Cat Scratch Disease
Non-Hodgkin Lymphoma, Lymph Nodes
Non-TB Mycobacterium, Lymph Nodes
Less Common
Metastatic Neuroblastoma
Post-Transplant Lymphoproliferative Disorder
Differentiated Thyroid Carcinoma, Nodal
Rare but Important
Systemic Metastases, Nodal
Langerhans Histiocytosis, Nodal
ESSENTIAL INFORMATION
Helpful Clues for Common Diagnoses
Reactive Lymph Nodes
Key facts
“Reactive” implies benign
Response to infection/inflammation, acute or chronic
Any H&N nodal group
Imaging
Enlarged well-defined oval-shaped nodes with variable contrast enhancement
± cellulitis: Common with bacterial infection
Cellulitis is usually absent in non-TB Mycobacterium (NTM)
± edema in adjacent muscles (myositis)
± necrosis: Bacterial, NTM, & cat scratch
Suppurative Lymph Nodes
Key facts
Pus within node = intranodal abscess
If untreated, rupture
soft tissue abscess
Imaging
If thick enhancing walls + central hypodensity, suspect drainable abscess (phlegmon may have similar appearance)
Associated cellulitis: Common in bacterial infection, absent in NTM
Associated nonsuppurative adenopathy
± thickening of muscles (myositis)
Hodgkin Lymphoma, Lymph Nodes
Key facts
B-cell origin; histology shows Reed-Sternberg cells
Most commonly involves cervical and mediastinal lymph nodes
Extranodal disease uncommon
Tumors are EBV positive in up to 50%
Imaging
Cannot distinguish Hodgkin lymphoma (HL) from non-Hodgkin lymphoma (NHL)
Round nodal masses with variable contrast enhancement, ± necrotic center
Single or multiple nodal chains
Calcification uncommon (unless treated)
FDG PET (or Ga-67) scans for staging and evaluating response to treatment
Cat Scratch Disease
Key facts
Usually self limited
Tender or painful regional lymphadenopathy
70-90 % present in fall or early winter
4/5 of patients are < 21 years old
Scratch or bite may precede development of adenopathy by 1-4 weeks
Bartonella henselae most common pathogen
Imaging
Homogeneous or necrotic lymphadenopathy
Non-Hodgkin Lymphoma, Lymph Nodes
Key facts
Extranodal disease more common in NHL than HL
Imaging
Cannot distinguish NHL from HL
Single dominant node or multiple enlarged nonnecrotic nodes
Non-nodal lymphatic disease: Palatine, lingual, or adenoid tonsils
Non-nodal extralymphatic: Paranasal sinus, skull base, and thyroid gland
Non-TB Mycobacterium, Lymph Nodes
Key facts
M. avium-intracellulare (MAI), M. scrofulaceum, M. kansasii
Usually nontender lymphadenopathy
Imaging
Necrotic lymphadenopathy common
Lack of surrounding cellulitis
Helpful Clues for Less Common Diagnoses
Metastatic Neuroblastoma
Key facts
Most cervical involvement with neuroblastoma is metastatic
Imaging
Large lymph nodes, rarely necrotic
± bilateral skull base metastasis common
± enhancing masses with aggressive bone erosion
Post-Transplant Lymphoproliferative Disorder
Key facts
Spectrum: Benign hyperplasia to lymphoma
Most common in patients who are EBV seronegative prior to transplant
More common after heart or lung than after kidney transplant
Children > > > > adults
Abdomen, chest, allograft, H&N, CNS
Imaging
Cervical lymphadenopathy
Adenotonsillar hypertrophy; may lead to upper airway obstruction
± sinusitis, otitis media
Differentiated Thyroid Carcinoma, Nodal
Key facts
Nodal spread common in papillary, distant spread common in follicular
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