European Journal of Cardiovascular Medicine

Cervical lymphadenopathy is an abnormal enlargement of lymph nodes (LNs) in the head and neck usually >1 cm and in most cases are benign and self-limited, however, the differential diagnosis is broad¹. The neck consists of nearly 2/3rd of the total lymph nodes of the body. The enlargement of these lymph nodes is quite significant in that there are so many etiological agents and is an index spread of infections and malignancy ². Acute infective lymphadenopathy is usually self-limiting and settles with antibiotic therapy but abscess formation may occur which may require aspiration or Incision and Drainage³ Cervical lymphadenopathy is most commonly localized to inflammatory processes in the neck or nearby areas. For instance, throat infection, the common cold, dental decay, ear infection, bronchitis, conjunctivitis, and infections of the salivary glands are all causative factors. These infections can be of viral or bacterial origin. Certain cancers of the head and neck regions can also cause localized cervical lymphadenopathy. Such cancers usually involve the skin and underlying soft tissue, nose, Para nasal sinuses, mouth, tthroat, vocal cords, salivary glands, and thyroid glands. 

In some cases, lymphadenopathy can be generalized due to a systemic disease affecting organs far away from the neck. Generalized cervical lymphadenopathy is often seen in chronic infections, cancerous conditions, autoimmune disorders, and some other miscellaneous conditions. Chronic infections such as AIDS or acquired immunodeficiency syndrome, infectious mononucleosis, and pulmonary tuberculosis often present with cervical lymphadenopathy⁴. Tubercular lymphadenitis is one of the most common causes of enlarged cervical lymph nodes in India. It is differentiated by Fine Needle Aspiration Cytology (FNAC) which is one of the most reliable; less expensive and basic diagnostic procedure⁵ for the definitive and conclusive diagnosis immune system reciprocates in the form of enlarged lymph nodes depending on their drainage⁶. Neck masses are a common concern in infants, children as well as in adults⁷. Certain cancers—such as Hodgkin’s and Non-Hodgkin’s lymphoma, acute lymphoblastic leukemia, and acute myeloblastic leukemia can also result in generalized cervical lymphadenopathy. 

Autoimmune diseases may also result in cervical lymphadenopathy. Systemic lupus erythematosus, also known as lupus, is an inflammatory autoimmune disorder that often results in the swelling of lymph nodes throughout the body. Similarly, rheumatoid arthritis is a chronic inflammatory condition that typically affects the joints but can also lead to the inflammation of tissues throughout the body, and the consequent swelling of lymph nodes. Sarcoidosis is characterized by the growth of abnormal inflammatory cell masses, and commonly targets the lymph nodes. Kawasaki disease, a rare inflammatory disease in children, usually presents with cervical lymphadenopathy⁴.

The cervical region's enlargement can make diagnosis difficult. So the purpose of our study is to systematically identify the many pathogenic conditions presenting with enlarged lymph nodes in the neck, as well as the scenario of  different ways of presentation of these disorders both clinically and pathologically with the help of FNAC and Ultrasonography diagnostic techniques there by better management services could be rendered to the affected individuals in our set up.

Machilipatnam, Andhra Pradesh. A one year observational study was conducted during the period from October 2022 to September 2023. According to the hospital censes the prevalence of Cervical Lymphadenopathy cases attending Surgery OPD  was found to be 50% and the sample size was calculated by using the formula N=4PQ/L² where P=50%, Q=100-P that is 50% and L=20% allowable error in ‘P’ that is 10 therefore N=100. All the cases of clinically diagnosed and  as per standard case definitions attending the OPD during the above period up to reach the required sample size was included in the study after duly following the inclusion and exclusion criteria as indicated below. Inclusion criteria: 1. Patients aged above 12 years of age of both gender presenting with cervical lymphadenopathy. 2. Patients presenting with cervical lymph node enlargement as an incidental finding on clinical examination and as well as radiological investigation. Exclusion Criteria : 1.Patients less than 12 years of age of both gender  2. Patients with Generalised Lymphadenopathy. Objectives: 1.To know the socio-demographic profiles of the study subjects 2. To study the clinical scenario and the outcome of the Cervical Lymphadenopathy.

After receiving the Ethical committee clearance from the institution the study was began and the required data was collected by using a pretested proforma pertaining to their socio-demographic profiles, histopathological examinationof Lymphadenopathy, distribution of presenting complaint, distribution of primary cancerous site with neck secondaries and treatment & outcome of the study subjects etc. and all the cases (study subjects) of the study were managed and followed 

on Out Patient basis. In order to make a provisional diagnosis, each patient underwent a clinical examination and the necessary investigations like Fine Needle Aspiration Cytology, USG (MyLabX6 L4-15 Probe) and routine blood as well. Radiological examination of the chest was done to find primary lesion of lung. Lymph node biopsy specimen was sent to pathologist for expert opinion. Also ENT opinion, contrast radiological investigation, X-ray and endoscopy etc. were carried out in relevant cases.

Finally the collected data was analyzed by using appropriate statistical tools like percentages, proportions, measures of central tendency, measures of dispersion, standard error of mean and tests of significance etc. with the help of computer software. The study results were compared and discussed in the light of published material of various similar studies belongs to different authors and there by conclusions and recommendations were framed.

Table 1: Age & sex wise distribution of Study Subjects

                                    Mean = 53.8, Mean + 2SD = 44.12 – 63.48,    P < 0.01

• It was observed that the majority about 35% of cases were belongs to the age group 41-50 years followed by 23.5% between 21-30 years, 16.6% between both 31-40 years & 51years and above  and 8.5% between 12-20 years of age group with the mean 53.8 years.
• And regarding the sex males were more in number significantly when compared to females that was 1.7:1

   Table 2: Histopathological Categorization of Lymphadenopathies

• Regarding histopathological diagnosis and categorisation , majority of the cases were Tuberculosis lymphadenopathy (43.5%) followed by Secondaries ( 28.3%) Reactive lymphadenopathy (23.3%), Hodgkin´s lymphoma (3.3%) and Non-Hodgkin´s lymphoma (1.6%)

Table 3: Distribution of Presenting Complaints

• Related to distribution of presenting complaint almost all the cases were visited the hospital with the complaint h/o neck swelling and among the other symptoms fever was the common one (33.3%) followed by cough (30%), decreased appetite (26.6%), weight loss, pain (20%), painful swallowing (3.3%) and voice change (1.6%).

Table 4: Distribution of Primary Cancerous site with neck secondaries

• With reference to Primary cancerous sites with neck secondaries, Oral cavity occupies major position (23.5%) followed by Larinx (11.7%), Stomach (11.7%), Esophagus (5.8%) and Thyroid (5.8%) respectively and regarding histopathology Squamous cell carcinoma was the commonest one observed.

Table 5 : Treatment and Outcome Of the Study sssubjects.

The overall recovery rate was 65% and the complete recovery (100%) was observed among Tubercular cervical lymphadenitis and Reactive lymphadenitis and the maximum number of cases missed for the followup was observed in Secondaries neck and mortality was observed in Secondaries neck and Hodgkin`s lymphoma

The discussion was made mostly based on clinico-epidemiological aspects of the study observations regarding the presenting symptoms, clinical behaviour, signs, investigations and management on 60 study subjects of enlarged cervical lymph nodes attending department of General Surgery OPD of Government General Hospital during the study period.There were about 40 (60%) non-neoplastic lesions and 20 (30%) neoplastic lesions were observed in our study out of 60 cervical lymphadenopathy cases which was in correlation to Avijeeth and Vikramramamurthy et al study⁸ where the non-neoplastic and neoplastic cases were 76% and 24% respectively. But in other study by Shafullah and Syed Humayun Shah et al⁹ the non-cancerous and cancerous lesions were 90.6% and 9.4% respectively.

In this study the sex ratio between male and female was found to be 1.7:1 which was onpar with the finding of  Bedi RS et al¹⁰ study where the ratio was 1.7:1 and in other studies like Ammari FF et al¹¹ (1:2), Dworski et al¹² (1.1.38), Dandapat MC et al¹³ (1:1.2), Purohit SD et al¹⁴ (1.4:1) and Santosh Kumar et al¹⁵ (1:1) reported. And regarding age distribution it was observed that the majority about 35% of cases were belongs to the age group 41-50 years followed by 23.5% between 21-30 years, 16.6% between both 31-40 years & 51years and above  and 8.5% between 12-20 years of age group with the Mean = 53.8, Mean + 2SD = 44.12 – 63.48,    P < 0.01

Regarding histopathological diagnosis and categorisation, majority of the cases were Tuberculous lymphadenopathy (43.5%) followed by Secondaries (28.3%) Reactive lymphadenopathy (23.3%), Hodgkin´s lymphoma (3.3%) and Non-Hodgkin´s lymphoma (1.6%) which was correlated with  the figures of Shafullah et al study ⁹,  Avijeeth et al⁸ study and Santosh Kumar et al¹⁵ study where as in another study done by Jha BC et al¹⁶ who examined 94 cases where Tuberculous 

lymphadenopathy being found in 63.8% cases followed by Reactive lymphadenopathy (9.6%), Malignant secondaries (20.7%). And also about 19.3% of our study subjects had the h/o contact with an active tuberculosis case. So it is understood that Tb lymohadenopathy is the commonest one being observed in our setup.  And also in our present study, Non-Hodgkin’s lesion vs Hodgkin’s lesion ratio is 1:2 where as in study by Peh SC and Sham et al¹⁷ it was 9:1 and by Raymond Alexandrian et al study¹⁸ it was 5:1.

Related to distribution of presenting complaint almost all the cases in our study were visited the hospital with the complaint h/o neck swelling and among the other symptoms fever was the common one (33.3%) followed by cough (30%), decreased appetite (26.6%), weight loss, pain (20%), painful swallowing (3.3%) and voice change (1.6%) which was similar with the finding of Avijeeth et al study⁸ . In this present study about 16.5% of cases showed multiple matted lymph nodes as Tuberculous lymphadenopathy where as 38% of cases showed single discrete lymph nodes but in a study by Jha BC et al¹⁶ showed matting in 38.3% of cases which was comparable to our study result. With reference to Primary cancerous sites with neck secondaries, Oral cavity occupies major position (23.5%) followed by Larinx, Stomach, Esophagus and Thyroid and regarding histopathology Squamous cell carcinoma was the commonest one observed in this study. According to studies by Linderman et al¹⁹,the lungs and pancreas were the most typical primary sites in cases of malignant secondary but in our study it was oral cavity and in the study of Osama Gaber et al ²⁰ ,primary was diagnosed in 86.7% whereas in the current study it was 71.5% and also in the current study primary from larynx and gastric antrum were 11.7% cases each and about 5.8% of cases each from esophagus & thyroid. Due to availability of limited resources in hospital the primary was unable to trace in the majority of the patients.

And regarding the treatment & outcome, the overall recovery rate was 65% and the complete recovery (100%) was observed among Tubercular cervical lymphadenitis and Reactive lymphadenitis and the maximum number of cases missed for the followup was observed in Secondaries neck and mortality was observed in Secondaries neck and Hodgkin`s lymphoma. Similar results were observed in Jha BC et al¹⁶ study. Antibiotics and local therapy were effective in managing the reactive lymphadenopathy. The lymphomas and malignant secondaries were reffered to higher oncologic facilities for proper diagnosis, standard stazing & treatments like radiotherapy, chemotherapy and skilled oncologic surgeries and finally after reaching the diagnosis, treatment was instituted appropriately. Medical management was done for TB lymphadenitis and LN. All patients received the requisite counseling and were urged to follow up with the surgical outpatient department.

 LIMITATIONS

The study was a hospital based and conducted in a small group of patients. And availabilty of limited resources to trace the Primary malignant lesion etc.

As the majority of the cases belongs to between 41-50 years which is economically productive age group , it is important to identify & treat the cases early to prevent complications and prolonging the life. Next to swelling as the majority of the cases were presented with the chief complains of fever followed by cough, decreased appatite and weight loss etc.will alert the examining doctor to compulsary check for cervical lymphnodes for early evaluation and necessary action.

In this study the majority of the Cervical lymphadenopathy cases were due to Tuberculosis followed by secondaries neck and Reactive non-specific conditions, a simple investigation like FNAC plays an important role towards early diagnosis and treatment of these cases so as to improve the survival rate of these patients. And also the disease Tuuberculosis is 100% curable with Fixed Drug Combinations (FDCs) under National Tuberculosis Elimination Programme ( NTEP), it is a best treatment option for the majority of cases with free of cost available at all the Government Health Care facilities and in our study except secondaries neck most of the cases are medically manageable.

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