In addition, this group also drains the external structures of the medial face including the lips, chin, cheeks, and medial aspects of the conjunctivae. Enlargement of these nodes should prompt careful inspection of the contents of the mouth. The anterior nodes, including the tonsillar, submaxillary, and submental nodes, are most commonly involved as they drain the tonsils and other structures in the pharyngeal area, including the teeth and gums.

The sternocleidomastoid muscle divides the cervical nodes into anterior and posterior sections, each with different drainage areas and resultant clinical importance. Conjunctivitis and anterior auricular adenopathy (the oculoglandular syndrome) is classically associated with Francisella tularensis via direct inoculation of the conjunctival sac but may also be seen with conjunctival infection from Neisseria gonorrhoeae, Bartonella henselae (cat scratch disease), and epidemic keratoconjunctivitis. The anterior auricular nodes drain the eyelids, palpebral conjunctivae, external auditory meatus, and pinna of the ear. In children, secondarily infected wounds from insect bites and ringworm (dermatophyte infection) are common causes. Adenopathy of these groups may be associated with primary infectious lesions in these areas (usually from staphylococcal and streptococcal infections) but can be a common feature of acute viral illnesses as well. The occipital and posterior auricular nodes drain large areas of the scalp and face.

The lymph nodes of the head and neck are collectively called cervical nodes and occipital and auricular nodes and are more accurately subdivided into several anatomic and clinical areas (see Figure 28.2). It is important to bear in mind and examine carefully the areas of drainage of each nodal group, as this will often reveal the primary site of infection or other pathology. In patients with unexplained localized lymphadenopathy and a reassuring clinical picture, a 3- to 4-week period of observation may be appropriate before considering biopsy. At times, the peripheral lesion may be subtle or inapparent. It is usually associated with a primary lesion. Infectious local adenopathy may be acute or chronic. Basic knowledge of the anatomy and areas drained by these lymph nodes can help in narrowing the differential diagnosis (see Table 28.1). Anatomically and clinically, the node-bearing areas are divided into five major groups, namely (1) the head and neck area, (2) the axilla, (3) the inguinal area, (4) the mediastinal-hilar areas, and (5) the retroperitoneal and para-aortic areas. Lymphadenopathy is considered localized if no more than two contiguous lymph node groups are involved. The presence or absence of tenderness does not reliably differentiate benign from malignant nodes. Pain and tenderness is usually the result of an inflammatory process or suppuration within the nodes but may also represent hemorrhage into the necrotic center of a malignant node. A group of nodes that feel connected and seem to move as a unit is said to be matted and can be either benign (e.g., tuberculosis, sarcoidosis, lymphogranuloma venereum, and human immunodeficiency virus ) or malignant (e.g., metastatic carcinoma and lymphoma). 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. Softer nodes are the result of infectious or inflammatory conditions and when suppuration is present, these nodes may tend to be fluctuant. Very firm, rubbery nodes suggest lymphoma. Stony-hard nodes are usually a sign of malignancy.

A thorough examination must include the location of lymphadenopathy including an evaluation of all accessible lymph node-bearing areas, the size and consistency of palpated nodes, whether they are discrete or matted and whether tenderness is present and, if so, at what level of severity.Īs a general rule, a node larger than 1 cm should be considered abnormal. Important elements of the history should also include the presence or absence of pain, occupational and animal exposures, geographic residence, travel history, sexual and drug use behavior, trauma and presence or absence of systemic symptoms, and/or history of underlying disease.

Shotty lymph nodes