Cervico-facial adenopathies Course in Oral Pathology and Surgery
Plan
I-Introduction
II. Reminder
III- Positive diagnosis
IV- Differential diagnosis
V – Etiological diagnosis
A- Adenopathies of infectious origin:
A-1 bacterial infection
1- Tuberculosis:
2– Syphilis
3- Tularemia
4- Cat scratch disease = benign inoculation lymphoreticulosis
5- Adenitis due to atypical mycobacteria:
6- Actinomycosis:
7- OTHERS:
A.2- Adenopathies of viral origin
1- Infectious mononucleosis: (IM)
2- Acquired immunodeficiency syndrome (AIDS)
3- Herpes
5- Measles
A.3– Adenopathies of parasitic origin
1- Toxoplasmosis
2- Leishmaniasis
B/ Adenopathies of inflammatory or immuno-allergic origin
1 – Sarcoidosis or Besnier-Boek-Schaumann disease
2 – Adenopathies reactive to drugs
C. Adenopathies of tumor origin
C.1 – Malignant hematological adenopathies
1 – Hodgkin’s lymphoma
2 – Non-Hodgkin’s Lymphoma
3 – Leukemia
4 – Primary macroglobulinemia = Waldenström’s disease
C.2 – Metastatic adenopathies from squamous cell carcinoma
VI-Conclusion:
.
I-Introduction:
The discovery of cervicofacial adenopathies is a frequent clinical situation, whether reported by the patient himself, noted during a clinical examination, or motivated by other symptoms. Their etiologies are very varied. Cervical adenopathies are easy to diagnose if the initial assessment is rigorously conducted. The priority is to eliminate a malignant pathology (hematological disease or metastatic adenopathy) requiring rapid management.
The diagnostic difficulty of adenopathy is to determine the lymph node nature of this nodule and its origin.
Definition :
Adenopathy is the presence of an enlargement of a lymph node (or lymph node) greater than one centimeter in the major axis. It is the pathological state of a lymph node of inflammatory or tumoral origin with an increase in its volume greater than 1 cm.
II. Reminder
- Lymph: It is formed from interstitial fluid. Its composition corresponds to that of blood plasma, and our body produces 2 to 3 liters of lymph daily.
- Lymph nodes, ganglia or lymph nodes :
These are kidney-shaped organs located at the branching of the lymphatic vessels.
The lymph node has three regions ( Fig 1)
- The cortical zone (B lymphocytes)
- The paracortical or deep cortical zone (T lymphocytes and antigen-presenting cells)
- The medullary zone (macrophages and plasma cells)
Cervico-facial adenopathies Course in Oral Pathology and Surgery
The human body contains approximately 500 to 1000 lymph nodes arranged in clusters or chains; 0.1 to 10 mm in diameter.
The lymph node performs several functions:
• Lymph filtration: ability to stop foreign bodies.
• Non-specific defense: phagocytosis of foreign bodies by macrophages.
• Humorally mediated immunity: LBs produce circulating antibodies.
• Cell-mediated immunity: provided by LTs.
- Anatomical reminder
1-1. Pericervical lymph node circle (Poirier and Cuneo circle):
The pericervical lymph node collar (Poirier and Cuneo) surrounds the upper part of the neck at its junction with the head.
It includes six groups distributed from back to front, in ganglia: occipital, mastoid, parotid, submaxillary, genial, submental,
- Cervical lymphatic triangle: Rouviere’s triangle (fig 2)
- Made up of three vertical chains: internal jugular chain, spinal chain, transverse cervical chain
Cervico-facial adenopathies Course in Oral Pathology and Surgery
III- Positive diagnosis:
1 – The anamnesis:
– Interrogation:
It allows us to specify the patient’s history, the modalities of appearance of the adenopathy and the possible existence of associated ear, nose and throat (ENT) signs.
– Background:
The backgrounds are:
• notion of a known systemic disease;
• surgical history, in particular prior excision of a skin tumor of the face or scalp;
• alcohol and tobacco poisoning;
• stay abroad;
• socio-professional environment (contact with animals);
• status of vaccinations, particularly BCG.
2 – Clinical examination:
A- Local examination: It allows to note:
Upon inspection:
– the location of the adenopathy, and the number. Some adenomegaly may be visible upon inspection
– its volume, and the condition of the surrounding skin (inflammation, fistula, ulceration).
– its unilateral or bilateral character
Palpation: must be careful, head flexed forward to obtain good cervical muscle relaxation.
We must then specify:
– the seat
– the volume, measured with a tape measure
– whether it is painful or not;
– mobility in relation to the superficial skin plane and the deep planes (muscular or vascular)
– firm consistency, even hard and woody, elastic or soft, with a fluctuating collected appearance.
B- Local-regional examination:
- Must look for a potential cutaneous-mucosal microbial entry point (skin redness, ulceration, folliculitis, trace of insect or needle bite, cat scratch, etc.).
- The skin of the face, neck and scalp is carefully examined.
- The oral cavity is examined under good lighting, using two tongue depressors in order to properly smooth the mucous membranes, and to carry out a dental assessment (caries, etc.).
Thorough ENT examination
C-General examination: In order to look for polyadenopathy of general cause, it is necessary
perform a palpation of all lymph node areas (axillary, inguinal, etc.) and a
Abdominal palpation for hepatosplenomegaly. Mediastinal adenopathies are assessed by chest X-ray.
3 – Additional examinations:
Paraclinical examinations are essential to confirm a diagnosis, but they are requested based on the orientations of the clinical examination.
A- Biological examinations:
Basic tests are the sedimentation rate, CRP (C protein reaction) and the blood count with leukocyte formula to detect an infectious process or blood disease.
There are many serological reactions or tests. In decreasing order of incidence of diseases, we can cite the reaction of:
- Paul and Bunnell-Davidsohn for infectious mononucleosis (IM)
- The Sabin-Feldman reaction for toxoplasmosis,
- The TPHA-VDRL reaction for syphilis and the Wright reaction for brucellosis.
- Intradermal reaction (IDR) to tuberculin at 10 units for tuberculosis.
- Elisa confirmed by Western Blot for (HIV)
B- Bacteriological tests:
By lymph node puncture of the pus, a direct examination and culture can be performed, after having ruled out a process at the expense of the salivary tissue, because in this case, puncture is prohibited.
C- Histological examinations:
🡺 Fine needle aspiration cytology, but the diagnosis can be imprecise or falsely negative and is mainly of orientation value.
Sometimes contraindicated because of the risk of lymph node spread in the event of neoplastic adenopathy.
- Conventional cytomorphology: it is essentially based on May-Grünwald-Giemsa (MGG) staining carried out without delay on well-dried, air-dried and not previously fixed smears.
- Cytofluorometry study: it allows for a better understanding of the functional state of the constitutional elements of pathological tissues.
🡺 Histopathological examination by biopsy: adenectomy.
D- Medical imaging:
– Standard X-ray : namely, a panoramic X-ray and retroalveolar X-rays in order to eliminate an oral-dental entry point, look for lymph node calcifications or salivary lithiasis.
– Chest X-ray: This examination looks in particular for opacity suggestive of a lung tumor or a calcified lesion in the case of a tuberculous focus.
Ultrasound : which can detect subclinical adenopathies.
- Typically, benign lymph nodes are oval and malignant lymph nodes are rounded.
- Malignant adenopathies: are hypoechoic and sometimes even present posterior reinforcement.
– MRI , which is an important aid in the diagnosis of nerve tumors and salivary tumors. It is more effective than CT scans for studying the relationships between adenopathy and neighboring structures.
– Computed tomography (CT) with injection:
Allows assessment of the relationships between large adenopathies and adjacent structures, particularly vascular and laryngeal, in search of pathological invasion.
- Normal lymph nodes typically have a diameter of less than 10 or 15 mm at the level
cervical. They are, generally speaking, very homogeneous, enhanced in a diffuse and moderate way by the injection of contrast product.
Criteria for metastatic adenopathy:
- Heterogeneous character
- Signs of capsular rupture with periganglionic infiltration.
The problem of diagnosing an adenopathy is to determine the lymph node nature of this nodule, this is why the differential diagnosis is topographical
IV- Differential diagnosis:
1- At the level of the submental region:
– Median dermoid cyst.
– Thyroglossal duct cyst: mobile median lesion during swallowing due to adhesion to the hyoid bone.
– Suprashyoid frog or tumor process of the sublingual gland.
2-At the level of the submandibular region:
– Pathology of the submandibular gland, infectious or tumoral
– Cellulitis of dental origin: acute inflammatory swelling, most often associated with the mandibular rim, in a general infectious context.
3-At the level of the laterocervical region:
Parotid pathologies;
Congenital laterocervical cysts;
Vascular tumors.
Parotid swellings
V – Etiological diagnosis:
- Adenopathies of local origin:
Evoked in view of the inflammatory and painful nature of the adenopathy and the existence of an infectious or inflammatory focus in the drainage area.
- Acute adenitis: occurs following angina, dental infection, gingivo-buccal lesions
treatment: suppression of the etiology
- Adenophlegmon: is the prerogative of children, generally before the age of three.
constitutes a real inflammatory closet.
treatment: ATB, sometimes incision + drainage
- Adenopathies of general causes :
A- Adenopathies of infectious origin:
A-1 bacterial infection:
1- Tuberculosis:
It is an infection by Mycobacterium tuberculosis hominis
The interrogation allows us to identify the notion of counting.
Tuberculous adenopathy: This most often involves several firm, painless lymph nodes of unequal size without periadenitis, developing into a cold abscess with softening and fistulization, oozing lumpy pus.
– The diagnostic elements are:
- The IDR at 10 units which can be negative
- Samples taken from lymph node puncture, sputum, gastric tubing.
- Culture on LOWENSTEIN medium is specific but requires a minimum of 03 weeks.
- The telethorax from the front and side is systematic but normal in 50% of cases.
- Histology (after adenectomy) found epitheloid cell follicles with caseous necrosis.
Cervico-facial adenopathies Course in Oral Pathology and Surgery
2– SYPHILIS
It is a sexually transmitted infection, caused by a spirochete: Treponema pallidium .
Epidemiological investigation is essential for questioning and the search for contaminating unprotected reports.
The definitive diagnosis is bacteriological:
Serological test by:
– TPHA: Treponema Pallidium Haemagglutination Assay .
– VDRL: Venereal Disease Research Laboratory.
– FTA-abs: Fluorescent Treponema Antibody- absorption (direct immunofluorescence)
– Histological study of the lymph node puncture product.
3- TULAREMIA:
It is exceptional due to a germ called Pasteurella tularensis transmissible by rodents and game (hunters’ and butchers’ disease).
It is accompanied by adenitis with periadenitis. It is associated with ocular and pulmonary lesions.
Diagnosis: Tularine IDR
4- CAT SCRATCH DISEASE = BENIGN INOCULATION LYMPHORETICULOSIS:
- The most suspected germ is Rochalimae henselae , which certain animals (cat, dog, rabbit, monkey) carry.
- Contamination occurs through biting, scratching or simple licking.
- After incubation for two to three weeks, one or more adenopathies appear, painful at first, mobile with fever and asthenia.
- After fistulization of the adenopathy, the pus is greenish to yellow and apparently sterile when cultured on standard media.
Diagnosis: based on: REILLY specific Ag positive IDR
5- Adenitis due to atypical mycobacteria:
They occur mainly in very young children (65% before 3 years old).
Clinic:
- Cervical adenopathy is cold, isolated, firm and mobile, it evolves in 1 to 2 months towards suppuration and fistulization, with preservation of the general condition and absence of pulmonary image.
Diagnosis is based on: Puncture which brings back clear pus, absence of common germs and presence of numerous BAAR (acid-fast bacilli).
6- Actinomycosis:
- The entry point is intraoral: dental care, oral trauma, salivary lithiasis, poor oral hygiene.
- After a few weeks, adenopathy appears, subangulomandibular, woody, adherent, evolving towards abscessation, in an apyretic context. Fistulization lets out a thick pus containing characteristic yellow actinomycotic grains, called “sulfur grains”.
- The diagnosis is based on:
– Culture in a special medium enriched with strict anaerobes
– On direct examination of the pus, yellow grains and palisade filaments are characteristic.
7- Others
- Pasteurellosis vector animals are cats and dogs. The gateway is
a painful, oozing wound. Painful lymphadenopathy develops over several weeks without softening or fistulization.
- The diagnosis is based on: isolation of the germ from a portal of entry
– Cytopuncture of the germ
– The IDR at the REILLY AGM.
- Brucellosis: Due to the ingestion of fresh milk, fresh cheese (goat, cow)
Undulant fever with sudoralgia; painless cervical lymphadenopathy and splenomegaly.
Diagnosis is based on WRIGHT serodiagnosis and meletin IDR.
A.2- Adenopathies of viral origin
1- Infectious mononucleosis: (IM)
Due to EPSTEIN-BARR Herpes virus.
The disease affects adolescents or young adults (15 to 25 years old) through saliva contamination.
It begins with erythematopultaceous or ulceronecrotic angina or even
pseudomembranous. General signs include fever, malaise, asthenia and myalgia. Diagnosis is based on:
- FNS: hyperleukocytosis, monocytosis.
- The MNI test confirmed by the PAUL-BUNNELL-DAVIDSON reaction
2- Acquired immunodeficiency syndrome (AIDS):
Clinic:
- HIV patients may develop lymphadenopathy in all lymph node areas, including cervical lymph nodes.
- These adenopathies are firm, painless and mobile, persisting in at least two lymph node areas, often with a diameter greater than 1 cm.
Diagnosis:
Specific anti-HIV serological tests (ELISA test confirmed by Western Blot)
3- Herpes
Adenopathies are present during primary infection
These include bilateral upper cervical adenopathies, fever and dysphagia related to erosive mucosal lesions.
4- Rubella
- Cervical adenopathies are present early, preferentially at the retro-auricular and sub-occipital level. The lymph nodes are small, very mobile and not very painful on palpation.
- Diagnosis is based on clinical findings and possible titration of antibody levels at 10-day intervals.
Nb: the disease is to be feared in the first months of pregnancy.
5- Measles
- The lymph nodes are small and mobile, coexisting with the KOPLICK sign at the STENON ostium.
A.3– ADENOPATHIES OF PARASITIC ORIGIN:
1- TOXOPLASMOSIS:
The causative agent is Toxoplasma gondii. Contamination occurs through:
– contact with cat droppings
– ingestion of contaminated meat
– ingestion of raw or contaminated vegetables
Primary infection manifests itself by: an inconsistent flu syndrome, occipital and spinal adenopathies (multiple, painless and mobile) which persist for 6 to 12 months.
The diagnosis is based on the context and the IGM serology present from the first week. The IGM rate is at its maximum after 1 to 2 months. The sample must be taken 15 days apart.
Cervico-facial adenopathies Course in Oral Pathology and Surgery
2- LEISHMANIASIS:
It is a disease transmitted by insects: the Simuliidae. The manifestations are cutaneous, mucous or visceral.
The initial phase is manifested by a long-term fever with generalized, firm, painless and mobile adenopathies. All cervical territories may be affected; followed by a deterioration in the general condition and splenomegaly.
Diagnosis is based on the search for LEISHMAN-DONOVAN bodies.
. B/ adenopathies of inflammatory or immuno-allergic origin:
1 – Sarcoidosis or Besnier-Boek-Schaumann disease:
It is a chronic, systemic disease whose etiology and pathogenesis remain unknown.
The location is mediastinal-pulmonary in 80% of cases. Cervical adenopathies are supraclavicular, retroauricular, firm, mobile, painless and small, never progressing to the stage of suppuration.
The diagnosis is based on clinical, histological, biological and radiological arguments (tuberculoid granuloma without caseous necrosis, negative tuberculin IDR).
2 – Adenopathies reactive to drugs:
- The drugs incriminated are: hydantoins, iodine products, phenylbutazone, penicillin, L-dopa, anti-Parkinson drugs, carbamazepine, retinoids.
- Adenopathies most often regress when the offending treatment is stopped and recur if it is resumed.
C/ ADENOPATHIES OF TUMOR ORIGIN:
C.1 – HEMATOLOGICAL MALIGNANT ADENOPATHIES:
Hematological malignant adenopathies are generally mobile, firm or elastic, painless and without inflammatory appearance.
1 – HODGKIN LYMPHOMA:
It begins with one or more low and superficial cervical adenopathies, unilateral, more or less firm, painless, without periadenitis and without accompanying signs.
The evolution is towards bilateral cervical dissemination and general dissemination.
Histological examination of the lymph node puncture product found the REED-STERNBERG cell
2 – NON-HODGKIN’S LYMPHOMA:
Affects men aged 50 to 70 and is accompanied by extra-lymph node manifestations in 20 to 40% of cases.
Adenopathy is an early clinical sign. They are elastic, mobile, multiple, and can form a larger lymph node mass than in Hodgkin’s lymphoma. It has the appearance of a smooth, firm swelling, covered with normal or purplish mucosa. There are general signs such as asthenia, fever, weight loss, night sweats, and splenomegaly.
The diagnosis is based on histological examination .
3 – LEUKEMIA:
The clinic is dominated by hemorrhagic disorders, asthenia, fever, infections. The diagnosis is based on histological examination and bone marrow biopsy.
- Chronic lymphocytic leukemia: subject over 50 years old, large, firm, elastic, mobile, bilateral and symmetrical adenopathies, cervical and supraclavicular
- Acute lymphoblastic leukemia: Less symmetrical adenopathies
- Myeloid leukemia: Lymphadenopathy is rare.
4 – Primary macroglobulinemia = Waldenström’s disease:
Affects men over 50 years of age. It is accompanied by cervical adenopathies in 50% of cases; firm, painless, without inflammatory signs, associated with asthenia and hepatosplenomegaly.
Diagnosis is based on the presence of a monoclonal IGM peak on serum protein immunoelectrophoresis; a sign of monoclonal malignant B-cell proliferation.
C.2 – Metastatic adenopathies from squamous cell carcinoma:
This diagnosis should be considered in a man over 50 years old who is an alcoholic or smoker and has poor oral hygiene.
Metastatic malignant adenopathies are most often related to squamous cell carcinoma of the upper aerodigestive tract (UADT) or more or less differentiated squamous epithelioma.
VI-Conclusion :
Cervicofacial adenopathies represent a pathology that should not be neglected. Any cervicofacial adenopathy that has been developing for more than a month requires diagnostic and therapeutic management. The comparison of clinical data, biological explorations, or even histological examination after cytopuncture or adenectomy can clarify the diagnosis.
END
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