The discovery of cervical lymphadenopathy is common in general practice.Most of the time it is a trivial diagnosis of reactive lymphadenopathy to an infectious complication. However, the patient and doctor fear the malignant causes, either primitive: lymphoma or hodgkin, or secondary: metastatic lymphadenopathy. The question is centered on the initial assessment, to be carried out before the biopsy, which one must decide the moment, neither too late nor too early.
Specify the seat, the size in cm, the consistency, the mobile character or adherent to the deep plane, painful or painless, single or multiple.
All these characters can point to a cause that can be caricatured as:
– Small, hard and painless ganglia → neoplasia;
– Large, painful pasted ganglions → infection.
The diagnosis of lymphadenopathy is easy when it is multiple lymphadenopathy. When dealing with a single mass, discuss:
– According to the consistency:
• soft → lipoma,
• hard → ossifying fibroma,
• swinging and expansive → tumor of the carotid glomus;
– According to the seat:
• dysembryoplastic cyst: lower pole of the parotid,
• maxillary gland (lithiasis);
– Common lymphadenopathy of the good immunological responder, known to the patient for a long time and whose dimensions are less than 2 cm.
In difficult cases, the ultrasound can confirm the lymph node nature of the palpated mass and provides information on its shape, its homogeneity (cyst, abscess), its vascularity.
The orientation of the etiological diagnosis requires:
An attentive interrogation:
MODE OF OCCURRENCE:
– Acute or progressive installation.
– Circumstances of discovery:
• Dental infection;
• Oral aphtosis;
• Skin damage.
– Are there any compressive signs: dysphagia, dysphonia, cough?
– Are there any general signs: fever, sweating, weight loss?
PATIENT LIFE MODEL:
– Age, tobacco +++, treatments?
– Occupation +++
– Cats (cat’s claws, toxoplasmosis)? Hunter (tularemia)? Fish?
RECENT OR OLD CONTAGE:
– Tuberculosis in the family.
– Contact with young children? Rubella….
– Sexual life at risk? Syphilis, HIV.
A complete clinical examination +++
Especially of all ganglionic areas, search for splenomegaly.
Ear (external auditory canal), oral cavity (palpation), scalp (melanoma, insect sting), skin (scratches, boils …).
SYSTEMATIC CONSULTATION BY AN OTOLARYNGOLOGIST:
Search for a cause in the draining territories of cervical lymphadenopathy (not to mention the skin and scalp lining for spinal lymphadenopathy).
Simple biological examinations:
– Blood count with reticulocytosis and careful study of the smear, +++ looking:
• leukocytosis by neutrophil polynucleosis;
• eosinophilia, hyperlymphocytosis, mononucleosis.
– Inflammatory assessment: VS, electrophoresis of proteins.
– Pulmonary radiography.
– Hepatic assessment: TGO, TGP, alkaline phosphatase, gamma GT.
– MNI test, Dye test, Wright.
– IDR at Tuberculin.
A NON-SPECIFIC INFECTIOUS LYMPHADENOPATHY:
Secondary to an ENT localization, often with a trailing appearance: teeth, bacterial angina, even tonsillar phlegmon, furuncle of the external auditory canal, wasp stings …
A SPECIFIC BENIGN LYMPHADENOPATHY:
– Infectious mononucleosis (IM): adolescents, inflammatory nature of lymphadenopathy, acute clinical appearance, initial angina.
NFS: mononucleotic syndrome.
– Rubella: contagion with children, multiple lymphadenopathy and posterior +++;
NFS: mononucleotic syndrome + plasmocytosis.
– Primary HIV infestation or AIDS related complex:
Young man: torpid dragging lymphadenopathy.
Be wary of the inaugural lymphomas ++++.
– Toxoplasmosis: contagion with cats, insidious clinical course (chronic … 2 years).
NFS: mononucleosic syndrome + hypereosinophilia.
– Cat scratch disease = or benign lymphoreticulosis of inoculation.
Contage? Chancre of inoculation gone? Fistulization of lymphadenopathy.
– Tuberculosis ganglionnaire: transplanted, family story.
Character of lymphadenopathy evolving towards fistulization.
– Brucellosis: farmers, multiple lymphadenopathy especially axillary, farms little painful, sudoro-algic temperature.
– Tularemia: contact with game, painful nature of lymphadenopathy, progressing to fistulization.
Inoculation point? Conjunctivitis often associated. Serology.
• primitive = single lymphadenopathy, oral inoculation canker = amygdala, unilateral necrotic lymphadenopathy.
• secondary = multiple lymphadenopathy, associated roseola.
A NON-INFECTIOUS INFLAMMATORY LYMPHADENOPATHY:
• Low cervical seat, chest X-ray, associated mediastinal lymphadenopathy;
• Diagnosis confirmed by biopsy.
– Rheumatoid arthritis: diagnosis mentioned in the clinical context. Do not biopsy.
– Whipple’s disease: associated digestive disorders.
– Immunological lymphadenopathy: toxic +++.
– Kikuchi (necrotizing lymphadenitis): young woman, fever, cervical dragging lymphadenopathy.
Diagnosis confirmed by biopsy.
Primary malignant etiologies: hematologic diseases
– Asymmetrical character of lymphadenopathy, evolution by relapses: lymphadenopathy which regresses is not always benign +++.
– Fever + pruritus + inflammatory syndrome.
– Mediastinal lymphadenopathy.
– Negative IDR.
→ Rapid biopsy +++
NON HODGKIN’S LYMPHOMA:
Same table, but:
– growth + fast
– polyadenopathy or very large lymphadenopathy.
Importance of biopsy quality with freezing +++++.
→ Rapid biopsy +++
THE CHRONIC LYMPHOID EUCEMIA:
Diagnosis mentioned after 50 years in front of:
Symmetrical polyadenopathy associated with splenomegaly;
– diagnosis confirmed by NFS + phenotype of peripheral lymphocytes.
→ Unnecessary biopsy +++ except to rule out Richter syndrome on a faster growing asymmetric ganglionic mass.
– Adenopathy rarely revealing.
– Diagnosis carried by NFS.
Secondary malignant etiologies: lymph node metastases
A METASTATIC MALIGNANT LYMPHADENOPATHY:
“Small lesion – large lymphadenopathy”
– Digestive cancers: ganglion of Troisier
– Mediastinal cancers: right supracicular lymph node
– ENT cancers:
• mobile language: Küttner’s ganglion;
• base of the tongue: low jugular;
• amygdala: high jugulocarotidian;
• cavum: occipital;
• ear, larynx: spinal.
Do not forget the palpation of the thyroid.
REALIZE A GOOD ENT EXAMINATION +++ BY MISFURING :
Folds of the tubal orifice;
– Reliefs of the amygdaloglossal sulcus;
– the piriform sinus.