Journal Reading

Imaging of Cervical
Lymphadenopathy in Children
and Young Adults
Dessyana Wulandari 1210070100023

Preseptor : dr. Dessy Wimelda, Sp. Rad

OBJECTIVE

This article describes the role of imaging in

evaluating cervical lymphadenopathy in patients
from birth to their mid-20s, illustrates imaging
features of normal and abnormal lymph nodes,
and highlights nodal imaging features and head
and neck findings that assist in diagnosis.
 Normal Lymph Nodes

Retropharyngeal No specific size

criteria for
Adults : 10 mm nodes has been lymphadenophaty in
proposed as 8 mm pediatric population

On MRI
On ultrasound: Nodes show low to
On CT intermediate signal on T1-
Normal or reactive lymph weighted images,
Nodes are iso- or
nodes are well defined and intermediate to high
hypoattenuating relative
reniform in shape,with fatty signal on T2-weighted
echogenic hila and a
to muscle and show
mild homogeneous images relative to muscle,
hypoechoic cortex relative and homogeneous
to muscle Enhancement
enhancement
 Reactive Lymph Nodes

Viral Infections
Cytomegalovirus, herpes 01
simplex virus, varicella, Bacterial
rubeola, rubella
02 Staphylococcus aureus and
group A Streptococcus.
Fungal Infections 03
Cryptococcosis,coccidiomycosis, Protozoal
and histoplasmosis 04 Toxoplasmosis
Fig. 1

7-year-old boy with normal lymph

node. Gray-scale ultrasound shows
circumscribed, ovoid node with cortical
hypoechogenicity (arrowhead) and
relatively hyperechoic hilum (arrow).
Fig.
2

18-year-old woman with normal lymph

nodes. Contrast-enhanced axial CT image
shows multiple ovoid, circumscribed left
level II nodes with fatty hila (arrow), which
are hypo- to isoattenuating relative to
muscle
Fig. 3
Axial T1-weighted MR
image shows ovoid right
level IIA node with low to
7,1% intermediate T1 signal
relative to muscle (arrow)

Axial T2-weighted
MR image shows
intermediate to
high T2 signal
within same node
(arrow)

A B
Fig 4

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A B

A. Gray-scale ultrasound shows increased cortical echogenicity (arrow) and

lack of echogenic hilum

B. Axial contrast-enhanced CT image in same patient shows enhancing,

round, enlarged level II node (arrowhead) with perinodal inflammatory
change. Note reactive retropharyngeal edema (arrow)
Reactive Lymph Nodes
On ultrasound
Commonly occur in children 1–4
Suppurative adenopathy include years old
anechoic regions, peripheral 03 01
vascularity, and possibly Enlarged nodes with perinodal
septations and posterior inflammatory change and may
acoustic enhancement progress to suppurative
02 adenopathy
On CT
suppurative nodes are
hypoattenuating centrally,
04 The peripheral enhancement on
with peripheral rim cross-sectional imaging in
enhancement and perinodal intranodal abscesses conforms to
06 the nodal border, whereas true
inflammatory change 05
MRI retropharyngeal abscesses show
Central T1 hypo- and T2 hyperintensity, retropharyngeal fluid with
with peripheral enhancement enhancement corresponding to the
borders of the retropharyngeal
space
Fig 5

6-year-old boy with

suppurative lymph node
due to Staphylococcus
aureus. Gray-scale color
Doppler ultrasound shows
enlarged cervical lymph
node with central
hypoechogenicity and
peripheral Doppler
vascularity
 Fig 6

6-year-old boy with intranodal abscess within

lateral retropharyngeal lymph node. Axial
contrast-enhanced CT image shows central
fluid attenuation and peripheral enhancement
within enlarged left lateral retropharyngeal
lymph node (arrow) with surrounding phlegmon
 Mycobacterium
Tuberculosis
Mycobacterial Infection
Acute Phase
Tuberculous granulomas may
Chronic Phase
produce nodal enlargement and
enhancement
01 Nodal calcification

Subacute Phase
 Characterized by
03
formation of suppurative
nodes and intranodal 02 Non Tuberculosis
abscesses

 On imaging and The most common findings include a

characterized by intranodal dominant centrally necrotic
abscess formation, which peripherally enhancing neck mass,
classically lacks perinodal 04 typically in the parotid or
inflammatory change submandibular region
 Cat-Scratch Disease

Regional lymphadenitis Related to cat

Most commonly The imaging findings in
secondary to Bartonella scratches or bites
(formerly Rochalimaea) affects children regional catscratch disease are
henselae infectiond and young adults lymphadenopathy variable, ranging from
identified enhancing to necrotic
approximately 3 weeks lymphadenopathy
after inoculation
Fig 7

18-year-old boy with tuberculous

adenitis. Axial contrast-enhanced
CT image shows multiple enlarged
02
bilateral level II lymph nodes with
central fluid attenuation and thick,
irregular peripheral enhancement
(arrows). Lack of perinodal fat
stranding is characteristic finding
of tuberculous adenitis
Fig. 8

2-year-old boy with

nontuberculous mycobacterial
infection. Axial contrast-
enhanced CT image shows
enlarged, hypoattenuating left
intraand periparotid, level V,
and lateral retropharyngeal
nodes with thick irregular
enhancement and septations
(arrows). Note perinodal
inflammatory change posteriorly
Viral
Infectious Mononucleosis
Infections Caused by Ebstein-Barr virus.
HIV

Children present with On imaging, findings are

pharyngitis, fatigue, and fevers typical of reactive viral-
infected nodes. Identification
Lymphadenopathy is of multiple, bilateral parotid
classically diffuse and lacks lymphoepithelial lesions
perinodal inflammatory (cysts) suggests underlying
change. Associated head HIV infection when seen in
and neck findings can aid in conjunction with generalized
diagnosis, particularly cervical lymphadenopathy
adenoid and palatine tonsil
enlargement
 Fig. 9

16-year-old boy with

infectious mononucleosis.
Axial contrast-enhanced
CT image shows enlarged
palatine tonsils bilaterally
(arrows) and enlarged left
level IIA lymph node
(arrowhead)
Lymphadenopathy Assosiated with Clinical Syndrome
 Age of onset is 6 months in Japan and between  Histiocytic necrotizing lymphadenitis,
13 and 24 months in North America is a self-limiting disease

 Diagnostic criteria include fever lasting at least  Patients present with cervical
5 days; cervical adenopathy lymphadenopathy, often with systemic
symptoms, including fever, fatigue, nausea,
 The presence of lymphadenopathy vomiting, diarrhea, and weight loss
may be confused with bacterial lymphadenitis

Kawasaki Disease Kikuchi –Fujimoto Disease

On ultrasound, nodal involvement consists of a On Imaging

coalescent nodal mass resembling a cluster of Unilateral cervical nodal involvement or
grapes formed by multiple hypoechoic nodes as asymmetric bilateral nodal involvement with
opposed to mildly enlarged or centrally cystic levels II, V, and III nodes most often involved.
vascular nodes in bacterial infection .Head and neck Homogeneous attenuation, enhancement,
findings of mucositis, including tonsillar enlargement and perinodal inflammatory change and
and retropharyngeal edema. some show intranodal necrosis.
 Figure 10
Additional image in same patient
shows multiple enlarged right
level II nodes, including
conglomerate adenopathy
(arrow) with periadenitis. Findings
are consistent with mucositis and
reactive lymphadenopathy

A B

Axial contrast-enhanced CT
image shows bilateral palatine
tonsil hypertrophy (arrows)
and retropharyngeal edema
(arrowhead)
Castleman Disease Kimura Disease

On Ultrasound On Ultrasound
Marked nodal enlargement Focal hypervascular hypoechoic
is present, typically with Doppler lesions within the subcutaneous tissues
hypervascularity are characteristic
On CT On CT
Contrast-enhanced CT depicts enhancing
Central lack of enhancement, subcutaneous masses, regional cervical
indicative of fibrosis, lymphadenopathy, and often focal or
within an enhancing nodal mass infiltrative salivary gland lesions

MRI MRI
Lesions are typically T1 hypointense Low to intermediate signal on T1-
relative to muscle and T2 hyperintense weighted images, intermediate to high
with linear, stellate T2 hypointensity signal on T2-weighted images relative to
centrally muscle, and enhancement after contrast
administration
 9-year-old boy with Castleman
Figure disease. Axial contrast-enhanced
fatsaturated T1-weighted MR
12
Figure image shows markedly enlarged,
Homogeneously enhancing,
13 nonnecrotic, intermediate-signal
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22-year-old woman with Kikuchi-

Fujimoto disease. Axial contrast-
enhanced CT shows
homogeneously enhancing mass in
right submandibular space (arrow)
with surrounding inflammatory
change
 Neoplasia
Color Dopplers

1
Sonographic
Malignant lymphadenopathy include nodal
enlargement, round shape, absent or
eccentric echogenic hilum, hypoechoic
parenchyma, and tendency of nodes to
2 Subcapsular vessels, displacement
of hilar vasculature, and absent
segments of nodal vessels, have
been suggested to be related to
tumor infiltration
aggregate into a mass .
.

3 Diffusion-weighted MRI has been reported to

differentiate between enlarged benign and malignant
lymph nodes on the basis of decreased apparent
diffusion coefficient values in some malignancies
 Figure 14 A

14-year-old boy with Kimura

disease involving right parotid
gland and intraparotid lymph
nodes.
A. Gray-scale color Doppler
ultrasound image shows
hypoechoic parotid mass B
(arrow) with increased
vascularity.

B. Axial STIR MR image

shows hyperintense right
parotid lesion (arrow)
Lymphoma

Hodgkin
In young adults, age of onset is in the mid to late 20s.
Cervical lymphadenopathy is the most common manifestation

Non Hodgkin
Extranodal

Imaging cannot reliably distinguish

between Hodgkin lymphoma and non-
Hodgkin lymphoma

Asociated head and neck findings to raise suspicion of

lymphoma and guide clinical management. Involved nodes
show the characteristic features of malignant adenopathy,
typically with homogeneous density and mild enhancement
Figure 15

21-year-old man
with Hodgkin
lymphoma. Axial
contrast-enhanced
CT image shows
multiple, markedly
enlarged
homogeneous left
level II lymph nodes
(arrow) without
necrosis or
periadenitis
Leukimia

1 Most common childhood malignancy

2 Cervical lymphadenopathy is a common

presentation of acute lymphocytic leukimia

3 On imaging is very similar to lymphoma

 Metastatic Disease
Approximately 25% of malignant childhood
tumors occur in the head and neck, and 01 Extracapsular tumor spread is
suggested by ill-defined nodal margins
cervical lymph nodes are common sites of
metastatic disease 02 and enhancement extending into the
perinodal soft tissues and is
Ultrasound, CT, and MRI depict associated with an increased risk of
central nodal necrosis with a lack of 03 distant metastasis and a poor prognosi
periadenitis 04
Nodes related to metastatic papillary thyroid range in appearance from mimicking reactive nodes to
enhancing, cystic, or necrotic nodes. Fine calcifications on CT or punctate hyperechogenicities on
ultrasound may be seen secondary to psammoma bodies in papillary thyroid metastases . MRI
features include T1 nodal hyperintensity, thought to be due to thyroglobulin or intranodal
Hemorrhage.
.
Figure 16
20-year-old man with nodal
metastasis due to oral tongue
cancer. Axial contrast-enhanced
CT shows large left level II node
(arrow) with intranodal and
irregular, peripheral
enhancement. Biopsy revealed
squamous cell carcinoma, and
primary tongue neoplasm was
subsequently identified on
physical examination
 A
Figure 17

26-year-old woman with cystic nodal metastases secondary to papillary thyroid cancer
A. Axial T2-weighted MR image shows enlarged hyperintense left level II/III node (arrow).
B. Coronal T1-weighted MR image shows hyperintensity within enlarged node (arrow), which
may be related tothyroglobulin content or hemorrhage
Conclution
Enlarged cervical lymph nodes are commonly eccountered in
the pediatric population, both clinically and imaging. Imaging
plays an important role, particularly when lymph nodes lack
benign features or fail to resolve with treatment. Imaging can
characterize nodal features including size, distribution,
internal architecture, vascularity, and enhancement.
Ultrasound is an excellent initial modality because of the lack
of ionizing radiation, and CT and MRI may add additional
detail regarding deep spaces of the neck and evaluation of
associated head and neck pathology.
Thank you