Saraswathi Gopal K and Prakash vijayan B. / American Journal of Oral Medicine and Radiology. 2017;4(1):33-42.

ISSN - 2394-7721
American Journal of Oral Medicine
and Radiology
www.mcmed.us/journal/ajomr Research Article

CLINICAL EVALUATION AND ULTRASONOGRAPHIC

CHARACTERIZATION OF CERVICOFACIAL LYMPH NODES
B. Prakash vijayan1, K. Saraswathi Gopal2* and B. G. Harsha Vardhan3
1
PG Student, 2Professor and Head, 3Professor, Department of Oral Medicine and Radiology, Meenakshi Ammal Dental
College and Hospital, Chennai, Tamilnadu, India.

ABSTRACT
Patient presenting with lymphadenopathy is a common clinical scenario in a dental practice. Greyscale
ultrasonography has diverse applications in the field of medicine since 1972. Ultrasonography has gained wide acceptance
as a diagnostic aid in the evaluation of cervicofacial lymphadenopathy in various conditions. Cervicofacial
lymphadenopathy of the neck is commonly noticed following tooth related infections, oral ulcers and generalized infections.
Only presence of a lymphadenopathy can be evaluated clinically. But its contributing reason cannot be always ascertained.
Ultrasonography is an imaging method which is safe, painless, does not involve radiation, and is economical. Aim: The
present study was devised with an aim of comparing the clinical and ultrasonographic features of cervicofacial
lymphadenopathy. Materials and Methods: The subjects for the study were selected from the patients who visited the
outpatient section of Oral Medicine and Radiology department with clinically palpable lymph nodes. Seventy patients were
included in the study and they were divided into 3 groups; group I (subjects with odontogenic infections), group II (subjects
with non odontogenic oral conditions) and group III (subjects with head and neck carcinomas). A detailed case history was
recorded and a thorough clinical examination was carried out for all subjects. The cervicofacial lymph nodes were palpated
and examined. Ultrasonographic examination of cervicofacial lymph nodes was carried out and recorded. The
ultrasonographic features such as number, size, shape, short axis/long axis ratio, border sharpness, hilum, echogenicity,
distribution of the internal echoes & intranodal necrosis. The results were tabulated and statistical analysis was done. The
statistical analysis was done using chi square test. Result and Conclusion: Most of the subjects considered for the study
showed cervicofacial lymphadenopathy associated with odontogenic causes, non-odontogenic causes and head and neck
malignancies. The lymph nodes showed varied clinical features. The results obtained for each parameter in the study were
highly significant with a p value of <0.000. This study proves that a significant difference is present in the ultrasonographic
features between the benign (odontogenic & non-odontogenic) and malignant lymph nodes.

Key words:- Lymph nodes, Ultrasound, Cervicofacial lymph nodes, Odontogenic, Non-odontogenic, Head and neck
malignancy.

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DOI:
http://dx.doi.org/10.21276/ajomr.2017.4.1.7

Received:09.03.17 Revised:18.03.17 Accepted:21.03.17

INTRODUCTION
Corresponding Author Orofacial region is a common anatomic site for
the development of lymphadenopathy [1]. Characterizing
K. Saraswathi Gopal the lymphadenopathy prior to definitive diagnosis has
Email: - [email protected] advantages, which includes segregation of malignant and
benign lesions associated with the lymphadenopathy in

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 Saraswathi Gopal K and Prakash vijayan B. / American Journal of Oral Medicine and Radiology. 2017;4(1):33-42.

whom surgical intervention can be planned accordingly years. Individuals were clinically evaluated and only if
[2]. diagnosed to be a case of cervical lymphadenopathy, they
Although CT and MRI are indispensable tools were subjected to ultrasound analysis. The study was
for diagnosis, are expensive and not universally available approved by the Ethics Research Committee. The
[3]. CT exposes the subject to large doses of radiation patients were divided into 3 groups.
especially, if repeated follow-up examinations are to be
performed. Artifact produced by bone and metal degrade GROUP 1 GROUP 2 GROUP 3
images around the face and have poor contrast between
the various soft tissues.
USG reigns as a relatively inexpensive, easily Subjects with Subjects with non- Subjects with
reproducible, non-invasive diagnostic tool that could be odontogenic odontogenic Head and neck
repeated several times without any untoward effects and infections - 25 oral conditions 25 carcinoma 20
is immune to metal artifacts such as dental restorations subjects. subjects. subjects.
[4]. Diagnostic ultrasound employs a transducer (probe)
which generates a narrow focus beam. High frequency Imaging Unit used for the study was The LOGIQ* P6
electrical pulses cause mechanical oscillation of ultrasound system by GE Healthcare
piezoelectric crystals producing ultrasound which is a
longitudinal mechanical wave form. This beam is Inclusion criteria
reflected from the tissue, and sent back to the same Patients within the age range of 18 60 years of age.
transducer, which converts the echoes to an image that Patients with clinical signs, symptoms or history of
can be visualized and recorded [5]. cervical lymphadenopathy associated with odontogenic
Ultrasonography has been widely used in the infections, non-odontogenic lesions and head and neck
medical field since 1972 as a diagnostic and therapeutic malignancy.
tool [6]. It could be valuable for the characterization of
various swellings such as inflammatory swellings due to Exclusion Criteria
dental or skin infections, diseases of salivary glands, Patients who have already been treated for
lymph node reactions, cysts, tumors etc. in soft tissues of odontogenic infections, non-odontogenic lesions and
neck and cranio-facial region. malignancy.
Despite the major role played by Patient who failed to give consent for the study
ultrasonography as a diagnostic and therapeutic tool in
diverse fields of medicine, most of the dentists are METHOD
oblivious of its utility. High resolution real time Ethical Committee clearance was obtained from
ultrasonography enhances the possibility for distinction Institutional Review Board of Mennakshi Ammal Dental
between benign and malignant lymphadenopathy [7]. College. All subjects were evaluated with a formulated
Ultrasonography is increasingly being recognized as a case history format. This consisted of all parameters to be
noninvasive tool for evaluation of cervical lymph nodes. evaluated clinically and also contained the
The sonographic appearance of normal nodes differs ultrasonographic parameters to be recorded related to
from those of abnormal nodes. Sonographic features, lymph nodes. 70 patients fulfilling the above criteria
which help to identify abnormal nodes are shape, absent were informed about the study being conducted and their
hilus, intranodal necrosis, calcification, matting, consent was obtained.
peripheral hallow and a prominent vascularity. A normal All subjects were examined and oriented with a
node should be discoid with a hilus, sharp margins, pillow under the shoulder to keep the neck in an extended
absence of matting, calcification, necrosis or soft tissue position. The lymph nodes were scanned with the
edema [8]. LOGIQ P6 ultrasound system (GE Healthcare).
Differentiation between tubercular, metastatic
and lymphomatous cervical lymph nodes is extremely RESULTS
important from the therapeutic view point. It is also In this study of clinical evaluation and
important to make the correct diagnosis at the earliest, ultrasonographic characterization of cervical lymph
because a delayed diagnosis leads to upstaging of nodes, the grey scale sonographic features considered for
malignancy making a curable lesion incurable [9]. analysis of cervical lymphadenopathy were as follows:

MATERIALS AND METHOD 1. Number of nodes

A Cross-sectional study was conducted at the 2. Size of the lymph nodes: assessed by measuring
Department of Oral Medicine and Radiology, Meenakshi maximal transverse diameter;
Ammal Dental College and Hospital, Chennai. The Study 3. Shape of the lymph nodes: classified as round and
population consisted of 70 Subjects above the age of 18

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4. oval BORDER SHARPNESS OF THE NODES:

5. Border sharpness: classified as sharp and un-sharp 71.4% of the study group had sharp borders
6. Echogenic hilum; classified as present and absent (35.7 in odontogenic group & 35.7 in non-odontogenic
7. Internal echogenicity: classified as hypo- or group) and 28.6% (malignancy group) of the study group
hyperechoic; had un-sharp borders. The results were statistically highly
8. Internal distribution of echoes: classified as significant with a p value <0.01. (Table 5 & Graph 4)
homogenous or heterogenous
9. Nodal necrosis was assessed and recorded whether HILUM OF THE NODES:
present or absent. 71.4% of the study group showed presence of
hilum (35.7 in odontogenic group & 35.7 in non-
NUMBER OF NODES: odontogenic group) and 28.6% (malignancy group) of the
In our study, clinically 88, 88 and 103 lymph study group showed absence of hilum. The results were
nodes were palpable in the odontogenic, non-odontogenic statistically highly significant with a p value <0.01.
and malignancy groups respectively. Ultrasonography (Table 6 & Graph 5)
revealed presence of 435, 589 and 505 nodes
respectively. (Table 1 & Graph 1). Mean and standard ECHOGENICITY OF THE NODES:
deviation was calculated for the number of nodes 71.4% of the study group had hypoechoic nodes
detected in the study. (Table 2). (35.7 in odontogenic group & 35.7 in non-odontogenic
group) and 28.6% (malignancy group) of the study group
SIZE OF THE NODES: had hyperechoic nodes. The results were statistically
Out of the 435 nodes evaluated ultra highly significant with a p value <0.01. (Table 7 & Graph
sonographically in the odontogenic group the largest 6)
node had a size of 0.69 cm2 and smallest measured 0.17
cm2. In the case of non-odontogenic group where in 589 DISTRIBUTION OF INTERNAL ECHOES OF THE
nodes were evaluated, the largest node was 1 cm2 and the NODES:
smallest node was 0.18 cm2. Malignancy group revealed 71.4% of the study group had homogenous
presence of 505 lymph nodes ultrasonographically out of distribution of internal echoes (35.7 in odontogenic group
which the largest measured 1.14 cm2 and the smallest & 35.7 in non-odontogenic group) and 28.6% (mali
measured 0.25 cm2. (Table 3 & Graph 2) gnancy group) of the study group had heterogeneous
distribution of internal echoes. The results were
SHAPE OF THE NODES: statistically highly significant with a p value <0.01.
Of the 25 subjects in odontogenic group 13 (Table 8 & Graph 7)
showed presence of oval shaped nodes and 12 showed
round shaped nodes. In non-odontogenic group, out of NECROSIS OF THE NODES:
the 25 subjects 18 showed presence of oval shaped nodes 71.4% of the study group showed absence of
and 7 showed round shaped nodes. All 20 patients in the nodal necrosis (35.7 in odontogenic group & 35.7 in non-
malignancy group showed round shaped nodes. The odontogenic group) and 28.6 (malignancy group) of the
results were statistically highly significant with a p value study group showed presence of nodal necrosis. The
<0.01. (Table 4 & Graph 3) results were statistically highly significant with a p value
<0.01. (Table 9 & Graph 8).

Table 1. Distribution of lymph nodes detected on clinical and ultrasonographic examination

Groups Clinically detected nodes Ultrasonographically detected nodes
Odontogenic 88 435
Non-Odontogenic 88 589
Malignancy 103 505

Table 2. Mean of the number of nodes detected

Ultrasonographically Detected Nodes
Clinically Palpable Nodes
MEAN SD MEAN SD
Odontogenic 3.4 1.41 17.4 7.53
Non-Odontogenic 3.44 1.21 23.56 6.85
Malignancy 4.85 1.68 25.25 7.95

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Table 3. Size of the nodes in the study group

Groups Smallest (cm2) Largest (cm2)
Odontogenic 0.17 0.69
Non-odontogenic 0.18 1
Malignancy 0.25 1.14

Table 4. Distribution of study subjects based on shape of nodes

Odontogenic Non- Malignancy Total Pearson P
Odontogenic Chi Value
Square
Oval 13 18 0 31 24.283 0.000
Round 12 7 20 39
Total 25 25 20 70

Table 5. Distribution of study subjects based on border sharpness

Odontogenic Non- Malignancy Total Pearson P Value
Odontogenic Chi
Square
Sharp 25 25 0 50 70.000 0.000
Unsharp 0 0 20 20
Total 25 25 20 70

Table 6. Distribution of study subjects based on presence or absence of hilum

Odontogenic Non- Malignancy Total Pearson P Value
Odontogenic Chi
Square
Present 25 25 0 50 70.000 0.000
Absent 0 0 20 20
Total 25 25 20 70

Table 7. Distribution of study subjects based on echogenicity

Odontogenic Non- Malignancy Total Pearson P
Odontogenic Chi Value
Square
Hypoechoic 25 25 0 50 70.000 0.000
Hyperechoic 0 0 20 20
Total 25 25 20 70

Table 8. Distribution of study subjects based on internal echos

Odontogenic Non- Malignancy Total Pearson P
Odontogenic Chi Value
Square
Homogenous 25 25 0 50 70.000 0.000
Heterogenous 0 0 20 20
Total 25 25 20 70

Table 9. Distribution of study subjects based on nodal necrosis

Odontogenic Non- Malignancy Total Pearson P Value
Odontogenic Chi
Square
Absent 25 25 0 50 70.000 0.000
Present 0 0 20 20
Total 25 25 20 70

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Graph 1. Distribution of Lymph Nodes Detected on Graph 2. Size of the lymph nodes
Clinical and Ultrasonographic examination

Graph 3. Shape of nodes observed in the study groups Graph 4. Border sharpness observed in the study group

Graph 5. Presence or absence of hilum observed in the Graph 6. Echogenicity observed in the study group
study group

Graph 7. Distribution of internal echoes in the study Graph 8. Presence or absence ofAnodal necrosis in the
group study group

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Figure 1. A - Lymph node less than 1 cm2 Figure 1. B - Lymph node more than 1 cm2

Figure 2. A - Round shaped lymph nodes Figure 2. B - Oval shaped lymph node

Figure 3. A - Lymph node exhibiting unsharp border Figure 3. B - Lymph node exhibiting sharp border

Figure 4. B - Lymph node exhibiting destruction of

Figure 4. A - Lymph node exhibiting preserved hilum hilum

Figure 5. A - Hyperechoic lymph node Figure 5 B - Hypoechoic lymph node

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Figure 6. A - Heterogenous distribution of echoes Figure 6. B - Homogenous distribution of echoes

Figure 7. Lymph node exhibiting necrosis

DISCUSSION Normal and reactive lymph nodes are usually

Lymph nodes are vital immunologic organs found in submandibular, parotid, upper cervical, and
distributed widely throughout the body and linked by posterior triangle regions. On gray-scale sonography,
lymphatic vessels [11]. Cervical lymphadenopathy is a normal and reactive nodes tend to be hypoechoic
common presenting symptom and sign for a variety of compared with adjacent muscles and oval except for
diseases, ranging from subtle infections to life submandibular and parotid nodes, which are usually
threatening Head & Neck malignancies. It is well round, and have an echogenic hilus. The upper limit in
accepted that clinical examination alone cannot be minimal axial diameter of normal and reactive nodes is 9
considered as a diagnostic tool to justify the involvement mm for subdigastric and submandibular nodes and 8 mm
of cervical lymph nodes especially deep or small nodes. for other cervical nodes.
Cervical nodal involvement in head and neck Metastatic nodes are usually hypoechoic, round,
malignancies influences therapeutic decision. The role of and without echogenic hilus. Coagulation necrosis, which
ultrasound in the assessment of cervical appears as a demarcated echogenic focus may be found
lymphadenopathy is well established. in metastatic nodes. Lymph nodes with cystic necrosis
Imaging techniques play a very important role in are suggestive of malignancy and intranodal cystic
diagnosing head and neck pathologies especially those necrosis is common in metastatic nodes of squamous cell
involving deeper soft tissues. Lymphadenopathy is one carcinomas. A proven metastatic lymph node with ill-
such condition where critical evaluation becomes defined borders may suggest extracapsular spread and
mandatory not only to assess the severity of the disease patients may have a poor prognosis [1].
but also to determine disease prognosis and proper In the present study, it was observed that
treatment planning. Clinical examination of cervical ultrasonographic features like number, size, shape, border
lymph nodes is important in such patients but mostly sharpness, hilum, echogenicity, distribution of internal
remains difficult owing to their diverse location and echoes and intra nodal necrosis were significant in
multiple numbers. Ultrasound has higher sensitivity differentiating benign lymph nodes in odontogenic
(96.8%) than palpation (73.3%) for detection of cervical infections, non-odontogenic conditions and malignant
lymph nodes. CT and MRI can be used for evaluation of lymph nodes in head and neck cancer.
lymph nodes, but they are less sensitive than ultrasound
in detecting nodes <5mm in diameter, whereas ultrasound Number of lymph nodes:
can detect nodes even less than 2mm in diameter [9]. Clinical examination is subjective and highly
Gray-scale sonography is widely used in the inaccurate in the assessment of cervical
evaluation of the number, size, site, shape, borders, lymphadenopathy. Ultrasonogram is superior to clinical
matting, adjacent soft-tissue edema, and internal examination as it can detect 21% of nodes undetected by
architectures of cervical lymph nodes. clinical examination.

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In our study, clinically 88, 88 and 103 lymph nodes acoustic impedance between intra nodal region and
were palpable in the odontogenic, non-odontogenic and surrounding tissues. An unsharp border may be found in
malignancy groups respectively. Ultrasonography tuberculosis lymph nodes, and again this is related to the
revealed presence of 435, 589 and 505 nodes associated oedema and inflammation of the surrounding
respectively. This result is in accordance with those of soft tissues. Malignant lymph nodes in advanced stages
Ophellia D'Souza et al. (1993) & Venkatesh Jayaraman may also show an ill- defined border, indicating
et al. (2013) [16,17]. extracapsular spread and this has shown to reduce the
survival rate of the subjects by 50% [1, 10, 11, 13, 18, 19,
Size of lymph nodes: 22].
Nodal size is useful in clinical practice, in
subjects with known malignancy. When the size of Present study results showed that, 71.4% of the study
lymph nodes increases on serial ultrasonographic group had sharp borders (35.7 in odontogenic group &
examination it is said to be highly suspicious for 35.7 in non- odontogenic group) and 28.6% (Malignancy
metastasis. A progressive change of nodal size is also group) of the study group had un-sharp borders. The
useful to monitor the treatment response of the subjects results were statistically highly significant with a p value
with malignancy [11, 13, 20, 21]. <0.01. This is in accordance with the results of Ahuja et
al. (2008); Papakonstantinou et al. (2009) [10,18].
In the present study, out of the 435 nodes evaluated
ultrasonographically in the odontogenic group the largest Hilum of the nodes:
node had a size of 0.69 cm2 and smallest measured 0.17 The echogenic hilus is mainly the result of
cm2. In the case of non-odontogenic group where in 589 multiple medullary sinuses, each of which acts as an
nodes were evaluated, the largest node was 1 cm2 and the acoustic interface, which partially reflects the ultrasound
smallest node was 0.18 cm2. Malignancy group revealed waves and produces an echogenic structure. Fatty
presence of 505 lymph nodes ultrasonographically out of infiltration makes the hilus more obvious in
which the largest measured 1.14 cm2 and the smallest ultrasononography. On ultrasonographic examination the
measured 0.25 cm2. This result is in accordance with that echogenic hilus appears as a hyperechoic linear structure
obtained by Papakonstantinou et al. (2009) [18]. and is continuous with the adjacent fat. Neck lymph node
with a maximum transverse diameter greater than 5mm
Shape of the nodes shows an echogenic hilus. The incidence of echogenic
Normal and reactive lymph nodes are usually oval in hilus increases with age which is probably related to the
shape whereas malignant lymph nodes and tuberculous increased fatty deposition in the lymph nodes of elderly
lymph nodes tend to be round. Although pathologic individuals [6, 9,11-19,21,22].
lymph nodes are usually round occasionally normal
submandibular and parotid lymph nodes can also be Our study results proved that, 71.4% of the study group
round in shape [13, 16, 18, 20, 22] showed presence of hilum (35.7 in odontogenic group &
35.7 in non- odontogenic group) and 28.6% (Malignancy
In the current study results, Of the 25 subjects in group) of the study group showed absence of hilum. The
odontogenic group 13 showed presence of oval shaped results were statistically highly significant with a p value
nodes and 12 showed round shaped nodes. In non- <0.01. The results were in accordance with the results of
odontogenic group, out of the 25 subjects 18 showed Vassallo et al. (1992, Sophie Leboulleux et al. (2007),
presence of oval shaped nodes and 7 showed round Gary J. Whitman et al. (2011), Reshma VJ et al. (2014),
shaped nodes. All 20 patients in the malignancy group Mohamed Hefeda et al. (2014) & Sindhoori Komma et
showed round shaped nodes. The results were statistically al. (2014).
highly significant with a p value <0.01. The results of our
study are in accordance with Andrej Lyshchik et al. Echogenicity of nodes:
(2007), Papakonstantinou et al. (2009), Gary J. Whitman Malignant lymph nodes are predominantly
et al. (2011), Venkatesh Jayaraman et al. (2013), Reshma hypoechoic when compared to adjacent soft tissues
VJ et al. (2014) & Ionela Genes et al. (2014) [11,13, except in case of metastatic lymph nodes of papillary
16,18,22]. carcinoma of thyroid which are commonly hyperechoic.
In malignant diseases, the process involves infiltration of
Border sharpness of nodes: the nodes by malignant cells which is more likely to
Normal lymph nodes have unsharp borders. This result in early distortion of internal nodal architecture
is related to the associated oedema and inflammation of showing as heterogeneity on ultrasound. Tuberculous
surrounding soft tissues. Malignant lymph nodes on the lymph nodes tend to be hypoechoic which is related to
other hand tend to have sharp borders, due to the fact that intranodal cystic necrosis [9,16,17,20,22].
tumour infiltration causes an increase in the difference of

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In our study, 71.4% of the study group had hypoechoic Komma et al. (2014) & Ionela Genes et al. (2014)
nodes (35.7 in odontogenic group & 35.7 in non- [1,19,22,19,20].
odontogenic group) and 28.6% (Malignancy group) of
the study group had hyperechoic nodes. The results were CONCLUSION
statistically highly significant with a p value <0.01. The Gray-scale sonography is an efficient and
results are in accordance with those of Ying and Ahuja et reliable tool in classifying regional lymph nodes.
al. (2003), Reshma et al. (2014) & Ionela Genes et al. However, it is not routinely being used as a preliminary
(2014) [1,20,22]. diagnostic modality in head and neck region. Its
application in the recent past has shown promising
Distribution of internal echoes: results. It is simple, inexpensive, non-invasive and easily
According to the results of our study, 71.4% of the reproducible with minimal patient discomfort. Being a
study group had homogenous distribution of internal chairside and outpatient procedure, it can be used by
echoes (35.7 in odontogenic group & 35.7 in non- dentists for the evaluation of cervical lymphadenopathy.
odontogenic group) and 28.6% (Malignancy group) of Evaluating the metastases in lymph nodes of the neck has
the study group had heterogeneous distribution of a major role in determining the prognosis and treatment
internal echoes. The results were statistically highly of head and neck cancer.
significant with a p value <0.01. This is in accordance Present study depicted that features specific for
with the results of Reshma VJ et al. (2014) [22]. benign lymphadenopathy are oval/round shape, sharp
borders, presence of echogenic hilum, hypoechoic nodes,
Nodal necrosis: homogenous distribution of internal echoes and absence
Lymph nodes with intranodal necrosis, regardless of their of nodal necrosis. Whereas those suggestive of malignant
size are pathologic. Necrosis may manifest itself as a spread are round in shape, un-sharp borders, absence of
true cystic area within the lymph node (cystic necrosis) echogenic hilum, hyperechoic nodes, heterogenous
or present as an area of hyperechogenicity within a distribution of internal echoes and presence of nodal
lymph node (coagulation necrosis) [1,9,16-19,22]. necrosis Clinical examination is effective only in
evaluating the superficial lymph nodes. Whereas
We in our study concluded that, 71.4% of the study ultrasound helps in detecting and characterizing the deep-
group showed absence of nodal necrosis (35.7 in seated lymph nodes.
odontogenic group & 35.7 in non-odontogenic group) Future studies with inclusion of parameters such
and 28.6% (Malignancy group) of the study group as determining the correlation of ultrasonographic
showed presence of nodal necrosis. The results were features of lymph nodes with clinical staging and
statistically highly significant with a p value <0.01. This histopathological grading of lymph node metastasis can
is in accordance with the results of Ophellia D'Souza1 et be carried out to firmly establish the significance of
al. (1999), Anil T. Ahuja et al. (2005). Reshma VJ et al. ultrasound in detection and characterization of cervical
(2014), Papakonstantinou et al. (2009), Sindhoori lymph nodes.

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Cite this article:

Prakash vijayan B, Saraswathi Gopal K, Harsha vardhan BG. Clinical evaluation and ultrasonographic characterization of
Cervicofacial lymph nodes. American Journal of Oral Medicine and Radiology, 4(1), 2017, 33-42.
DOI: http://dx.doi.org/10.21276/ajomr.2017.4.1.7

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