Whenever I was sick as a kid, my mother always used to run her hands along my neck just underneath the jawline to feel for “swollen glands”. If I had swollen glands, it would mean that I got to stay home from school until they weren’t swollen any longer. I never really knew what “glands” she was feeling for, and didn’t know what made them swollen, I just knew that if I had them, then I got a day off from school with toast and chicken soup.
These “glands” that my mom was feeling for are actually lymph nodes, sometimes called lymph glands. We all have lymph nodes in our necks, a lot of them. Most of the time you can’t feel them, either because they are very small or they are in deep tissue. They can swell to the size of marbles or even bigger in some cases. The most common cause of enlarged lymph nodes, or lymphadenopathy, is infection. Respiratory infections, tonsillitis, dental infections, or even head lice, among others, can cause lymphadenopathy in the neck. Once the infection subsides either through treatment with antibiotics or resolves of its own accord, the lymph nodes will decrease in size.
Last week I saw a young patient who had an enlarged lymph node that was of this type. After performing the ultrasound and FNA, I was able to let him know that this most likely was a reactive lymph node, since it looked like a heterogeneous population of lymphocytes, with different cell types seen (Figure 1). Until that point he was planning to have surgery to remove it, but upon hearing my diagnosis it was clear that surgery was not necessary. The flow cytometry was confirmatory.
The less common and more suspicious causes of lymphadenopathy are cancers, lymphomas and leukemias. Lymphadenopathy usually develops more slowly in these cases, and it is usually painless. People who have suspicious lymphadenopathy are candidates for ultrasound guided fine needle aspiration biopsy (USFNA). We saw a patient who had painless lymphadenopathy and presented for USFNA. Physical examination revealed that she had two enlarged lymph nodes in the neck as well as one in the groin. Ultrasound examination of the neck nodes showed large round lymph nodes with no fatty hilum, which are suspicious findings (Figure 2). Fine Needle Aspiration biopsy (FNA) was performed in the two neck nodes, both of which had similar cytologic findings with a monotonous population of lymphocytes that appeared atypical (Figure 3). Immediate assessment of the specimens was performed, and it was determined that further testing was necessary. Because the patient was still in the office, we were able to procure a sample for flow cytometry testing, which is a test for lymphoma. The flow cytometry was run on site in our laboratory, and within a few hours we had a diagnosis of follicular lymphoma, which is a low grade lymphoma. We were able to call the patient’s physician with the diagnosis within 24 hours of seeing the patient, and she was able to receive treatment right away based on our diagnosis.
Bottom line is: most of the time, swollen glands are caused by infections, either bacterial or viral. No surgical intervention is necessary, as they will resolve on their own in due time. In cases where lymph nodes are enlarged due to malignancy, intervention is necessary because they will not resolve on their own. Not only is it important to differentiate these two very different clinical situations, it is also relatively easy to do so with ultrasound guided FNA biopsy.