Cervical (neck) lymph node enlargement

Lymph nodes in the head and neck form groups. These groups are responsible for draining lymphatic fluid from
different areas (Regions) in the head and neck.
Epidemiology and statistics
Only one study provides reliable population-based estimates. Findings from this Dutch study revealed a 0.6 percent
annual incidence of unexplained lymphadenopathy in the general population.[1]
Causes of cervical (neck) lymph node enlargement
Localized cervical lymphadenopathy (disease of the lymph nodes) presents with lymph node enlargement that is
restricted to the cervical (neck) area. If lymph nodes in other areas (e.g., the arm pits) are also enlarged in
addition to those in the neck, then the condition should be evaluated as a case of generalized lymphadenopathy.
Submandibular lymph node

Location: Along the underside of the jaw on either side.

Common causes of enlargement: Infections of head, neck, sinuses, ears, eyes, scalp, pharynx.

Lymphatic drainage: Tongue, submaxillary gland, lips and mouth, conjunctivae.

Submental lymph node

Location: Located just below the chin.

Common causes of enlargement: Mononucleosis syndromes, Epstein-Barr virus, cytomegalovirus,

toxoplasmosis, dental pathology such as periodontitis.

Lymphatic drainage: Lower lip, floor of mouth, teeth, submental salivary gland, tip of tongue, skin of
cheek.

Jugular lymph node

Location: Nodes that lie both on top of and beneath the sternocleidomastoid muscles (SCM) on either
side of the neck, from the angle of the jaw to the top of the clavicle.
Lymphatic drainage: Tongue, tonsil, pinna, parotid

Common causes of enlargement: Pharyngitis organisms, rubella

Posterior cervical lymph node

Location: Extend in a line posterior to the sternocleidomastoid muscles but in front of the trapezius, from
the level of the mastoid bone to the clavicle (on the side of the neck near to the back).
Lymphatic drainage: Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes

Common causes of enlargement: Tuberculosis, lymphoma, head and neck malignancy

Suboccipital lymph node

Location: Located at the junction between the back of the head and neck.

Common causes of enlargement: Local infection

Lymphatic drainage: Scalp and head

Postauricular lymph node

Location: Located behind the ears.

Common causes of enlargement: Local infection

Lymphatic drainage: External auditory meatus, pinna, scalp

Preauricular lymph node

Location: Located in front of the ears.

Common causes of enlargement: External auditory canal infection.

Lymphatic drainage: Eyelids and conjunctivae, temporal region, pinna

Right supraclavicular lymph node

Location: Located on the right side in the hollow above the clavicle, just lateral to where it joins the
sternum.
Lymphatic drainage: Mediastinum, lungs, esophagus

Common causes of enlargement: Lung, retroperitoneal or gastrointestinal cancer

Left supraclavicular lymph node

Location: Located on the left side in the hollow above the clavicle, just lateral to where it joins the
sternum.
Lymphatic drainage: Thorax, abdomen via thoracic duct.
Common causes of enlargement: Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal
infection.

Clinical features of abnormal lymph node enlargement

Abnormal lymph node enlargement tends to commonly result from infection / immune response, cancer and less
commonly due to infiltration of macrophages filled with metabolite deposits (e.g., storage disorders).
Infected Lymph nodes tend to be firm, tender, enlarged and warm. Inflammation can spread to the overlying skin,
causing it to appear reddened.
Lymph nodes harboring malignant disease tend to be firm, non-tender, matted (i.e., stuck to each other), fixed
(i.e., not freely mobile but rather stuck down to underlying tissue), and increase in size over time.
Sometimes, following infection lymph nodes occasionally remain permanently enlarged, though they should be
non-tender, small (less the 1 cm), have a rubbery consistency and none of the characteristics described for
malignancy or for infection. These are also known as 'Shotty Lymph nodes'.
Size and clinical significance
Nodes are generally considered to be normal if they are up to 1 cm in diameter; however, some authors suggest
that epitrochlear nodes larger than 0.5 cm or inguinal nodes larger than 1.5 cm should be considered abnormal
[2,3].
Little information exists to suggest that a specific diagnosis can be based on node size. However, in one series [4]
of 213 adults with unexplained lymphadenopathy, no patient with a lymph node smaller than 1 cm2 had cancer,
while cancer was present in 8 percent of those with nodes from 1 cm2 to 2.25 cm2 in size, and in 38 percent of

those with nodes larger than 2.25 cm2. These studies were performed in referral centers, and conclusions may not
apply in primary care settings.
In children, lymph nodes larger than 2 cm in diameter (along with an abnormal chest radiograph and the absence
of ear, nose and throat symptoms) were predictive of granulomatous diseases (ie, tuberculosis, cat-scratch disease
or sarcoidosis) or cancer (predominantly lymphomas) [5].
An increase in nodal size on serial examinations is significant. Hence nodes that continue to grow in size are
important and those that regress in size tend to be more reassuring.
Pain/Tenderness
Pain/Tenderness. When a lymph node rapidly increases in size, its capsule stretches and causes pain. Pain is
usually the result of an inflammatory process or suppuration, but pain may also result from hemorrhage into the
necrotic center of a malignant node. The presence or absence of tenderness does not reliably differentiate benign
from malignant nodes.[1]
Consistency
Stony-hard nodes are typically a sign of cancer, usually metastatic. Very firm, rubbery nodes suggest lymphoma.
Softer nodes are the result of infections or inflammatory conditions. Suppurant nodes may be fluctuant. The term
"shotty" refers to small nodes that feel like buckshot under the skin, as found in the cervical nodes of children with
viral illnesses.
Matting
A group of nodes that feels connected and seems to move as a unit is said to be "matted." Nodes that are matted
can be either benign (e.g., tuberculosis, sarcoidosis or lymphogranuloma venereum) or malignant (e.g., metastatic
carcinoma or lymphomas).
Constitutional symptoms
Constitutional symptoms such as fever, weight loss, fatigue or night sweats could suggest disorders such as
tuberculosis, lymphoma, collagen vascular diseases, unrecognized infection or malignancy. The presence of fever is
commonly associated with infections.
Diagnosis
Palpation
In the case of cervical lymph node enlargement palpation has a low sensitivity and specificity 60-70%.
Supraclavicular lymph node palpation: In one study examining the presence of supraclavicular lymph node
enlargement in nonsmall cell lung cancer patients - Nodes had to have a diameter of 22.3 mm or greater to be
palpated in 50% of cases.[6]
Ultrasonography
Ultrasound is a useful imaging modality in assessment of cervical lymph nodes. Distribution of nodes, grey scale
and power Doppler sonographic features are useful to identify the cause of cervical lymphadenopathy. Useful grey
scale features include size, shape, status of echogenic hilus, echogenicity, micronodular appearance, intranodal
necrosis and calcification. Adjacent soft tissue edema and matting are particularly useful to identify tuberculosis.
Useful power Doppler features include vascular pattern and displacement of vascularity.
Ultrasonography can be combined with fine needle aspiration cytology in which a sample of cells from the lymph
node is aspirated using a needle and examined under the microscope.
Ultrasound is a useful imaging modality in evaluation of cervical lymphadenopathy because of its high sensitivity
(98%) and specificity (95%) when combined with fine-needle aspiration cytology (FNAC).[7]
CT scan

CT scans can detect the presence of enlarged cervical lymph nodes with a short-axis diameter of 5 mm or greater.
- Supraclavicular lymph node: In one study examining the presence of supraclavicular lymph node enlargement in
nonsmall cell lung cancer patients - The sensitivities of US and CT did not differ significantly.[8]
Is it cancer?
Incidence
Findings from a Dutch study revealed that only 10 percent of patients with unexplained adenopathy required
referral to a subspecialist, 3 percent required a biopsy and only 1 percent had a malignancy.[1]
Age
In primary care settings, patients 40 years of age and older with unexplained lymphadenopathy have about a 4
percent risk of cancer versus a 0.4 percent risk in patients younger than age 40.[1]
The supraclavicular lymph node
Right supraclavicular lymph node enlargement
The right supraclavicular lymph node is located on the right side in the hollow above the clavicle, just lateral to
where it joins the sternum. It drains the mediastinum, lungs, esophagus. Common causes of enlargement include
lung, retroperitoneal or gastrointestinal cancer.
Left supraclavicular lymph node enlargement
The left supraclavicular lymph node is located on the left side in the hollow above the clavicle, just lateral to where
it joins the sternum. It drains the thorax, abdomen via thoracic duct. Common causes of enlargement include
lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection.
Supraclavicular lymphadenopathy has the highest risk of malignancy, estimated as 90 percent in patients older
than 40 years and 25 percent in those younger than age 40 [1]. This refers to a clinically significant lymph node
enlargement. Little information exists to suggest that a specific diagnosis can be based on node size.
However, nodes are generally considered to be normal if they are up to 1 cm in diameter [2,3].
How to proceed
If the lymph node enlargement is unexplained, it may need to undergo a period of observation for 3 to 4 weeks
possibly with the addition of empirical antibiotics.
If it persists after a period of observation then the patient should seek medical attention which may require further
investigations using ultrasonography and fine needle aspiration cytology or an excisional biopsy