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GSL Medical College, Rajmundry, Andhra Pradesh

ISSN: International Journal of Medical Science and Advanced Clinical Research (IJMACR) Available Online at: Volume 1, Issue 6, November - December , Page No. : Evaluation
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ISSN: International Journal of Medical Science and Advanced Clinical Research (IJMACR) Available Online at: Volume 1, Issue 6, November - December , Page No. : Evaluation of Cervical Lymphadenopathy in Lesions of Ear, Nose and Throat- An Observational Clinical Trial Dr. Rohit Stephen Mede 1, Dr. M. A. Amjad Khan 2*, Dr. Priyadershini Rangari 3 1,2 M.B.B.S.,M.S. (E.N.T.), 1 Rohit, E.N.T., hospital, Bottuguda, Nalgonda, Telangana 2* GSL Medical College, Rajmundry, Andhra Pradesh 3 Assistant Professor, Department of Dentistry, Sri Shankaracharya Medical College, Bhilai, Durg, (Chhattisgarh). Corresponding Author: Dr. M. A. Amjad Khan, GSL Medical College, Rajmundry, Andhra Pradesh, India. Type of Publication: Original Research Paper Conflicts of Interest: Nil Abstract Background: Cervical lymphadenopathy is a common Conclusion: By this study it is evident that there is clear pattern of relationship between organ-specific drainage clinical condition. It may be primary regional and incidence of cervical metastasis. lymphadenopathy but mostly it may be secondary to either infective lesion in areas that drain to neck or due to metastasis from the malignant lesions of the areas which drain into cervical lymphnodes of different levels. Objectives: This study was performed to evaluate the clinical behavior, management and outcome of cervical lymphnodes and to determine the distribution of primary site in upper aero digestive tract in cases of cervical lymph node metastasis. Methods: Patients visiting the ENT OPD and/or admitted This study helps in planning and dealing occult metastasis tumors and other lesions of oral cavity, pharynx by following echelon lymphnodes for the corresponding primary sites. Keywords: Lymph Nodes, Cervical Lymphadenopathy, Endoscopy, FNAC, Metastasis, Ultrasound. Introduction There are around eight hundred lymph nodes in our body out of which not less than three hundred are cited in the neck. Enlargement of cervical lymph nodes is a common in the IPD for Cervical Lymphadenopathy was taken up clinical condition encountered by the clinicians. for study with the help of relevant history, thorough clinical examination of nose, paranasal sinuses, oral cavity and pharynx. Appropriate investigations including FNAC (Fine Needle Aspiration Cytology), Ultrasound of the neck, endoscopy etc. was performed for each patient. Results: Out of 40 cases presenting with cervical lymphadenopathy, 29 of the patients presented at stage IVA i.e., 72.5%, 4 cases at stage III i.e., 10%, 2 cases at stage IVB i.e., 5%. Remaining out of 5 cases, 3 cases were CAT-I i.e., 7.5%, 2 cases were stage IA and IIIB of Hodgkin s and Non-Hodgkin s lymphoma respectively Enlargement of the lymph nodes more than 1cm 1 indicates a clinical manifestation of regional or systemic disease and serves as an excellent clue to the underlying disease 2. Cervical lymphadenopathy, a common clinical problem, often presents as a diagnostic dilemma. It is crucial to establish a definite diagnosis as early in the course of evaluation as possible in order to institute a meaningful treatment. In view of rich lymphatic drainage, majority of patients with malignancies of upper aero digestive tract presents with regional dissemination of disease to cervical lymph nodes. i.e., 5%. Page 47 Corresponding Author: Dr. M. A. Amjad Khan, Volume -1 Issue -6, Page No In the absence of detectable metastasis, cervical metastasis is currently regarded as the single most significant independent adverse prognostic factor influencing disease free and overall survival. The number of lymph nodes and the level in the neck involved and the size of the metastasis, the presence of macroscopic or microscopic extra capsular spread of the metastatic tumor and the soft tissue deposits have all been shown to influence the planning of therapy and also significantly affect the prognosis. 3 The surgical procedure employed in the management of cervical lymphnodes metastasis have evolved over the years from radical neck dissection 4 to different types of selective neck dissections 5 in recent years. Radical neck dissection offers comprehensive anatomical clearance of all cervical lymphnodes groups in the neck but also causes significant complications. The data on pattern of nodal metastasis would then provide the basis for advocating limited neck dissection and planning future prospective trials to evaluate the role of limited neck dissection in the management of carcinoma of upper aero digestive tract. Cervical lymphadenopathy could be an external manifestation of underlying severe and significant disease. Tumors in the oral cavity and pharynx have a higher incidence of metastatic disease at presentation. It could be only presenting symptom of an underlying severe disease. Any form of affections of cervical lymphadenopathy should not be ignored and should be considered as a strong and significant clinical input which ultimately leads to detection of several clinically silent diseases. It helps in early diagnosis, early treatment and good prognosis. 8, 9 This study was performed to evaluate the clinical behavior, management and outcome of cervical lymphnodes and to determine the distribution of primary site in upper aero digestive tract in cases of cervical lymph node metastasis. Materials and Methods This study was conducted on the patients visiting the ENT OPD and/or admitted in the IPD for Cervical Lymphadenopathy during December 2013 to July 2015, for evaluation at GSL Medical College and Hospital, Rajmundry. Written informed consent was taken from each patient. A pre designed Performa was used to record relevant information like patient data, history, clinical findings and investigation report from individual cases. Detail local examination of neck for organ-specific drainage neck node was done for its site, size, number and its apparent relation to surrounding structure. A detailed examination of ear, nose and throat was done to detect primary lesion and investigations like endoscopy, FNAC, Ultrasound, etc. FNAC for neck node and biopsy of primary lesion was done for histopathological confirmation and to classify primary tumor based on grades of differentiation into well, moderate and poor differentiation. All the malignancies of nose, oral cavity, pharynx including nasopharynx, oropharynx, hypopharynx and larynx were staged according to American Joint Committee on Cancer (AJCC/UICC 2002 TNM classification). Inclusion Criteria: Cases of cervical lymphadenopathy, with or without previous history of any medical or surgical treatment for the same and cases which were regular for post treatment follow-up. Exclusion Criteria: Cases which did not come for regular follow-up and who did not complete or receive any medical or surgical treatment. Statistical analysis was performed by using MS Excel and SPSS software trial version 20.0 Descriptive statistical data was presented as mean ± standard deviation and percentages. Chi-square test was Page48 performed to assess the association among various categorical variables. Results This study consisted of total 40 patients, out of which 16 were female i.e.,40% and 24 were males i.e., 60%. (Table 1) In the present study, patients in the age group of years are 9 i.e., 22.5 % of cases, 20 in the age group of years i.e.,50% and the remaining 11 in the age group of years i.e., 27.5%. (Table 2) Majority of the patients in our study were agricultural labour (40%) and daily labour (10%). Rest of them was semi skilled labors like carpenter (5%), electrician (5%), chef (2.5%), tailor (2.5%), driver (2.5%) and ex-serviceman (2.5%). Remaining 30% of the study population was house wives. (Table 3) In the present study, majority of patients belong to low socio-economic status group i.e., 82.5%% of cases, 17.5% in the group belong to middle socioeconomic status group. (Table 4) Patient presenting with the primary lesion like neck swelling (42.5%) (Table 5, 6) 40% Patients were presented with dysphasia. (Table 7), 10% Patients complained of Dyspnoea. (Table 8) 17 cases presented with right sided cervical lymphadenopathy, 8 cases with left sided cervical lymphadenopathy and bilateral involvement of cervical lymphadenopathy was seen in 15 cases, which accounts to 42.5%, 20%, 37.5% respectively.(table 9) 22 cases were firm, 16 cases were hard and 2 cases were firm and matted in appearance whose percentage were 55%, 40% and 5% respectively.(table 10) Lymph nodes were mobile in 31 cases i.e., 77.5% and fixed lymphadenopathy was seen in 9 cases i.e., 22.5%.(table 11) Distribution of Neck Metastasis according to Grading of Tumor, in which 9 cases were well differentiated i.e.,22.5%, 22 cases were moderately differentiated i.e.,62.5%, 1 case is poorly differentiated i.e., 2.5% as shown in table 12. T- Stage distribution, 16 (45.7%) cases in T2, 17 (48.6%) cases in T3 and 2 (5.7%) cases in T4 respectively and 5 cases not included in TNM staging. In present study most of the cases were in T3 stage. (Table 13) N-stage Distribution, 5 (14.3%) cases in N1, 1 (2.8%) case in N2a, 12 (34.2%) cases in N2b, 15 (42.9%) cases in N2c and 2 (5.7%) cases in N3.Remaining 5 cases were not included in TNM staging. (Table 14) Consistency of lymph nodes: 22 cases were firm, 16 cases were hard and 2 cases were firm and matted in appearance whose percentage were 55%, 40% and 5% respectively. (Table 15) Biopsy reports were consistent with FNAC reports in our study. Accuracy of FNAC in respect to biopsy is statistically significant in our study.(table 16) Out of 40 cases presenting with cervical lymphadenopathy, 29 of the patients presented at stage IVA i.e., 72.5%, 4 cases at stage III i.e., 10%, 2 cases at stage IVB i.e., 5%. Remaining out of 5 cases, 3 cases were CAT-I i.e., 7.5%, 2 cases were stage IA and IIIB of Hodgkin s and Non- Hodgkin s lymphoma respectively i.e., 5%. (Table 17) All the primary lesions diagnosed as Squamous Cell carcinoma on Histopathology report received Radiotherapy and Chemotherapy treatment. Tuberculous lymphadenitis was treated with Anti-Tuberculous treatment. Hodgkin s and Non-Hodgkin s Lymphoma was treated with chemotherapy.(table 18) Out of 40 cases presenting with cervical lymphadenopathy, 29 of the patients presented at stage IVA i.e., 72.5%, 4 cases at stage III i.e., 10%, 2 cases at stage IVB i.e., 5%. Remaining out of 5 cases, 3 cases were CAT-I i.e., 7.5%, 2 cases were stage IA and IIIB of Hodgkin s and Non- Hodgkin s lymphoma respectively i.e., 5%. (Table 19, 20) Discussion The major presenting symptoms of the patients in this study were primary growth (42.5%), neck swellings (42.5 %), dysphasia (40%), dyspnoea (10%), change in voice Page49 (25%) and other symptoms being trismus, burning sensation in oral cavity and pain in the oral cavity, referred nostalgia and fever. In this study, involvement of lymph node pattern observed is, 17 (42.5%) cases presented with Right sided Cervical Lymphadenopathy, 8(20%) cases with Left sided Cervical Lymphadenopathy and Bilateral involvement of Cervical Lymphadenopathy were seen in 15(37.5%) cases, compared to the study of Meera Bai in 2004 which shows left side involvement to be more common. Left side of the neck was involved in 25 cases (50%) right side in 21 cases (42%) and bilateral involvement was seen in 4 cases (8%) in her study. In this study, most common level of lymphnodes involved on Left side is Level-II followed by Level-IB and Level- III. Level of lymphnodes most commonly involved on Right side is Level-II followed by Level-IB. Consistency of lymph nodes: 22(55%) cases are firm, 16(40%) cases are hard and 2(5%) cases were firm and matted in appearance. Mobility of lymph nodes in our study was mobile in 31 cases i.e., 77.5% and fixed in 9 cases i.e., 22.5%. Cervical lymph node metastases according to primary site differentiation are as follows: 9 cases were Well Differentiated Squamous Cell Carcinoma i.e., 22.5%, 25 cases are Moderately Differentiated Squamous Cell Carcinoma i.e., 62.5%, 1 case is Poorly Differentiated Squamous Cell Carcinoma i.e., 2.5%. In this study incidentally all the Histopathology reports found to be Squamous Cell Carcinoma even though all histological types of carcinoma were aimed in our study. In a similar study conducted by Hemant et al 35, maximum number of tumor type are Moderately Differentiated. Remaining cases were 3 of tuberculous lymphadenitis i.e., 7.5%, 1 of Hodgkin's Lymphoma i.e. 2.5% and 1 of Non-Hodgkin s Lymphoma i.e., 2.5%. As per TNM staging system, in this study following observations were made regarding the tumor size and T staging is 40% in T2, 42.5% in T3 and 5% in T4 respectively and remaining 5 cases i.e., 12.5% were not included in TNM staging. In present study most of the cases were in T3 stage. As per TNM staging system, in this study following observations were made regarding the node size and N staging is 12.5% in N1, 2.5% in N2a, 30% in N2b, 37.5% in N2c and 5% in N3. Remaining 5 cases i.e., 12.5% were not included in TNM staging. Most of the cases presented in our study at a later stage that is N2 in contrast to the study conducted by Li XM et al., Michel F et al 36 and Kris Moe et al 37 which showed majority of nodal metastasis at early stage i.e., N1. In this study, out of 40 cases presenting with cervical lymphadenopathy, 29 patients presented at stage IVA i.e., 72.5%, 2 cases at stage IV i.e., 5%, 4 cases at stage III i.e., 10%. Remaining out of 5 cases, 3 cases were CAT-I i.e., 7.5%, 2 cases were stage IA and IIIB of Hodgkin s and Non-Hodgkin s lymphoma respectively i.e., 5%. All the 40 cases were subjected to FNAC, 3 cases were tuberculous lymphadenitis, 2 cases were Hodgkin s Lymphoma and Non-Hodgkin s Lymphoma one each and the remaining 35 cases were secondary metastases. The clinical diagnosis made among 40 cases of this study was consistent with FNAC result. The diagnostic accuracy of FNAC in our study was comparable to study of Debra R et al 38 and Sarada A.K et al 39 (100%). Oral Cavity: In this study, 17 cases were presented with oral carcinomas i.e., 42.5%. Out of 17 cases, females are 9 i.e., 53% and males are 8 i.e., 47%. Primary lesion of oral carcinomas located in majority of the cases was from anterior 2/3 rd of tongue (35.2%) and palate (35.2%). Remaining cases, primary site location is at buccal Page50 mucosa (23.5%) and floor of mouth (5%). Few other similar studies reported that, Oral SCC affects the tongue in 20%-40% of cases and the floor of the mouth in 15% - 20% of the cases, and together these sites account for 41, 42 about 50% of all cases of oral SCC. the gingivae, palate, retromolar area and the buccal and labial mucosa are oral sites less frequently affected. 43 In our study in patients of carcinoma of the oral cavity, metastasis is mostly to level me, II and III. The same was described by Shah J.P. 44 and Candela F.C. 45 that nodal involvement usually occurs at level I, II, III in carcinoma of oral cavity. Posterior parts of oral cavity either drain directly into the upper deep cervical nodes (level II/III) or indirectly via the submandibular nodes in level IB. More anterior parts of the oral cavity and tongue also drain to the submental nodes (level Ia) or indirectly to the jugulo-omohyoid nodes (level III/IV) low in the neck. This is in accordance to our study where the lesions from the primary growth drain into the specific lymphnodes. Oropharynx: Oropharyngeal squamous carcinomas is said to represent percent of all head and neck tumors. There is an increasing prevalence of oral cavity and Oropharyngeal cancers in the last decade, particularly in men aged years. 46 The frequency distribution of the primary site carcinoma in the oropharynx is tonsil or faucial pillar 45%, posterior tongue 40%, soft palate 15% and posterior Oropharyngeal wall 5%. 47 The condition is more common in men, with a sex ratio of 4:1. Each level of neck may be palpate systemically. It must be remembered that the majority of lymphnodes metastasis 48, 49 will be located in levels II, III and IV. In this study, 4 cases were presented with ore-pharyngeal carcinomas i.e., 10% and all were 4. In 3 (75%) cases the Primary lesion of cervical lymph node metastasis was from base of tongue and in 1 (25%) case it is from left tonsillar area. In this study 2 cases are Moderately Differentiated Squamous Cell Carcinomas and 1 case is Well Differentiated Squamous Cell Carcinoma and 1 is Poorly Differentiated Squamous Cell Carcinoma. In a study conducted by Vartanian et al, 50 in total of 80% with Oropharyngeal carcinoma, the primary tumor sites were common in tonsils, base of tongue, vallecula and soft palate in decreasing order. In our present study, the commonest site of Oropharyngeal carcinoma with neck metastasis is base of tongue. In Oropharyngeal malignancy, metastasis is mainly to level II and III. This is in accordance to organ specific drainage of the oropharynx where the lesion from the oropharynx drain into the upper and middle deep cervical lymphnodes again either directly or via the retropharyngeal or submandibular nodes. Hypopharyngeal Carcinomas: The hypopharynx is an uncommon site of tumors, the majority being malignant and accounts for less than 10% of all squamous cell carcinomas overall. The distribution macroscopically of Hypopharyngeal cancer varies geographically, with tumors of the pyriform sinus being the most common subside in North America and Europe, and post cricoids lesions more common in Northern Europe and UK. The mean age at presentation is 60 years. Pyriform sinus and posterior pharyngeal wall carcinomas demonstrate a male dominance. Post cricoids lesions unlike other sites show a female preponderance. 51 the majority of the tumors present as ulcers and are widely infiltrative. They have tendency to extend submucosal and also to metastasize to the local lymph nodes. Cervical lymphadenopathy is frequent at the time of presentation and is most often detected at level Ila and III. In this study, 6 cases were presented with Hypopharyngeal carcinomas i.e., 15%. Out Page51 of 6 cases, males are 4 i.e., 66.7% and females are 2 I.e., 33.3%. In majority of the cases the primary lesion was found to be post cricoids region 4 cases (66.7%). Out of remaining two cases, one each from pyriform fosse (16.6%) and posterior pharyngeal wall (16.6%). Laryngeal Carcinoma: Laryngeal cancer represents one of the most common head and neck malignancies, accounting approximately for 20% of all cases. The vast majority of tumors are squamous cell carcinomas. 44, 44 Up to 40% of patients present with advanced disease. Due to the important physiologic functions of the larynx, advanced laryngeal lesions are associated with significant morbidity and mortality for the patient and increased financial costs for society 34, 45 In this study, 7 cases were presented with Carcinoma Larynx i.e., 17.5%. Out of 7 cases, males are 6 i.e., 85.7% and one female patient i.e., 14.3%. The primary lesion for cervical node metastasis was found to be supra-glottis area. 5 patients complained of change in voice, 4 of them presented with neck swellings and 3 of them presented with dysphasia. Six out of seven cases attended, presented at a stage IVA and one case presented at a stage III. Supraglottis drain through vessels which accompany the superior laryngeal pedicle via the thyroid membrane to reach the upper deep cervical nodes (levels II/III). In our study, supraglottic lesions metastasis is mainly to level I, II and III. In study conducted by Akmansu et al, 38 neck metastasis according to tumor localization were follows 26.5% glottis and 66.7% in Tran s glottis. But in our study all cases of primary localization is in supraglottis. Nasopharyngeal Carcinoma: Nasopharyngeal Carcinoma is caused by the interaction of genetic susceptibility, environmental factors (e.g., exposure to chemical carcinogens), and infection with Epstein-Barr virus. High antibody titers to Epstein-
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