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