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\begin{document}

\title{Dental origin Cervical lymphadenopathy: A Rare Case Report.}



\author[1]{sghaier Jihed}%
\author[2]{afef slim}%
\author[1]{Habib Hamdi}%
\affil[1]{Université de Monastir Faculté de Médecine Dentaire de Monastir}%
\affil[2]{University of Monastir Faculty of Dental Medicine of Monastir}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\textbf{Sghaier Jihed}1\textbf{, Afef Slim}2 \textbf{and Habib
Hamdi}3\emph{Department of Medicine and Oral Surgery, University Dental
Clinic, Monastir, Tunisia}

\subsection*{Abstract}

{\label{abstract}}

Cervical lymphadenopathy, an intricately multifactorial condition, is
one of the foremost prevalent presentations dental clinics encounter.
Consequently, oral surgeons should possess extensive knowledge regarding
the etiology of cervical lymphadenopathy. The present article describes
a case of a 60-year-old female who reported to the Department of oral
medicine and oral surgery at the University Dental Clinic of Monastir-
Tunisia with a complaint of painless swelling of 5 days duration on the
right side of her neck, specifically in the jugular-carotid region. The
oral examination revealed an infected right maxillary third molar,
confirmed on the radiograph. Considering the possibility of neck
swelling caused by reactive lymphadenitis secondary to an infected
molar, removing the third molar on the right side was performed under
antibiotic coverage, which was uneventful. The ultrasound examination,
as well as the opinion of the otorhinolaryngologist, confirms the
inflammatory origin and absence of signs of malignancy. The patient
remained free of the presenting symptoms 28 days later. As well as
complete regression of the swelling. The article aims to spotlight the
oral physician's crucial position withinside the early identity of neck
swellings, which could bring about well-timed care.

\section*{Introduction}

{\label{introduction}}

Lymphadenopathy is a common clinical finding for patients seeking dental
treatment. It might be local, limited, or general\textsuperscript{1}.
Cervical lymphadenopathy is thought to be caused by malignancies,
infections, autoimmune diseases, iatrogenic, and other miscellaneous
conditions\textsuperscript{2,3}. More than half of the patients examined
on a daily basis are likely to exhibit enlarged lymph nodes in the head
and neck area. The etiology of cervical lymphadenoplasia is varied, so
treatment differs from patient to patient \textsuperscript{4}. 1E-mail:
sghaier.jihed25@gmail.com 2E-mail: afef.1604@yahoo.fr 3E-mail:
doc\_hamdi@yahoo.fr

1

Most cervical lymphadenopathy is caused by a benign infectious etiology;
nevertheless, doctors should look for a precipitating reason and examine
additional nodal sites to rule out generalized lymphadenopathy.

\subsection*{Case Presentation}

{\label{case-presentation}}

A 60-year-old female reported to the Department of oral medicine and
oral surgery at the University Dental Clinic of Monastir-Tunisia with a
complaint of painless swelling of 5 days duration on the right side of
the neck, specifically in the jugular-carotid region, with an
inflammatory aspect. The patient had diabetes and dyslipidemia and was
being regularly treated and followed up by her primary care physician.
No history of weight loss or difficulty in swallowing or breathing.
There were no dysphagia, dysphonia, laryngeal dyspnea, or night sweats.
He reported no relevant history, treatment, known allergy, alcohol or
nicotine intoxication, or toxin consumption. Family history showed no
recent infections. The patient presented swelling on the upper part of
the right side of the neck, measuring approximately 5 \selectlanguage{ngerman}\emph{×} 3 cm in
size. On palpation, the swelling was mildly tender, firm, nodular, and
mobile with smooth intact overlying skin without any signs of
inflammation or infection. Examination of the contralateral side was
unremarkable. Patient consent was obtained for taking a photograph and
using it for study and publication purposes {[}Figure 1{]}. {[}Figure 1
about here.{]} Intraoral examination revealed poor oral hygiene with the
presence of local factors and signs of periodontitis. However, most
notably, the right maxillary third molar is decayed and necrotic (fig2).
{[}Figure 2 about here.{]} Panoramic radiograph revealed decayed right
maxillary third molars, generalized horizontal bone loss, and
endodontically treated 31, 32,33,43,45,46 with crowns {[}Figure 3{]}.
{[}Figure 3 about here.{]} Thus, a differential diagnosis of cervical
lymphadenopathy due to locoregional infection, toxoplasmosis, and
tuberculosis was given by history and clinical examination. Results of
the blood investigations included a raised C-reactive Protein (CRP) of
8.1 mg/l and raised Erythrocyte Sedimentation Rate (ESR) of 35 mm 1st
hour and 73 mm 2nd hour. Tuberculin skin test (TST) was negative after
exposure to smear-positive tuberculosis. An ultrasound scan of the neck
showed a right-sided, ovoid, well-defined adenopathy of group III,
heterogeneous, hypoechoic, with preserved fatty hilum and
non-vascularized on color Doppler, measuring 19x9 mm. It is associated
with infiltration and hyperemia of the surrounding soft tissues on color
Doppler. No signs of necrosis and no visible calcification (fig4).
{[}Figure 4 about here.{]} All the investigations were suggestive of
benign Reactive adenitis of dental origin. Then, the Extraction of the
third molar of the right side was performed under antibiotic coverage
with a combination of amoxicillin and clavulanic acid (1000 mg twice a
day). Swelling completely resolved within the first 10 days of the
therapy. But treatment continued as per the protocol. After 20 days of
follow-up, she was perfectly all right (fig5). {[}Figure 5 about
here.{]}

\section*{Discussion}

{\label{discussion}}

Painful neck swelling is a common presenting symptom in adults. Before
assessing a neck mass, a comprehensive history of the lesion (location,
migration, temporal course, and accompanying symptoms) is
collected\textsuperscript{5}. While infections are the most common cause
of neck masses, neoplasms are the most common cause of persistent neck
masses in adults. Malignant neoplasms exceed all other causes of adult
neck mass\textsuperscript{6}. In general, lymphadenopathy has two
mechanisms: hyperplasia and infiltration. The former happens in reaction
to immune or infectious stimuli, whereas the latter happens as a result
of infiltration by diverse cell types, such as cancer cells, lipid
cells, or glycoprotein-laden macrophages\textsuperscript{7}.
Lymphadenitis is the pathologic expression of lymph node inflammation.
When enlarged lymph nodes are found, a reason can sometimes be
discovered by taking a comprehensive medical history, doing a complete
physical examination, carefully selecting laboratory testing, and, if
required, performing a lymph node biopsy\textsuperscript{7}.
Lymphadenopathy can be caused by medication responses, infections,
immunologic diseases, cancer, and a variety of other conditions with
unknown causes \textsuperscript{8}. A study conducted between January
1997 and January 2001 investigated the underlying causes of cervical
lymphadenopathy in 454 patients who presented with masses in the head
and neck region. 61 individuals (13.4\%) were diagnosed with cat-scratch
disease, 54 (11.9\%) exhibited primary lymphadenopathy caused by
different infectious agents, and 41 (9.0\%) presented with
lymphadenopathy associated with primary infections in other organs. In
171 cases (37.7\%), the cause of cervical lymph node enlargement
remained unidentified\textsuperscript{9,10}. Iqbal et al. showed that
70.45\% of cervical lymphadenopathy is due to tuberculosis, 13.63\% due
to reactive lymphadenitis, 11.36\% of cases due to metastases, 4.54\%
cases due to lymphoma, and 2.27\% of cases due to chronic nonspecific
lymphadenitis\textsuperscript{11}. The diagnosis of cervical
lymphadenopathy (CLA) etiology should follow a systematic approach,
commencing with a comprehensive assessment of the patient's medical
history, thorough physical examination, and, if deemed necessary,
further investigative procedures.\textsuperscript{12}. Complete history
taking and physical examination are mandatory for diagnosis; laboratory
tests, imaging diagnostic methods, and tissue samplings are the next
steps\textsuperscript{13}. The importance of patient history varies
significantly. It can either lead directly to the reason and propose an
explanation, or it might be nondiagnostic \textsuperscript{14}. The
initial goal in determining CLA type is to identify whether it is
localized or generalized. The size, consistency, and mobility of the LNs
should also be evaluated since they may indicate a malignant
character\textsuperscript{12}. In cases of localized cervical
lymphadenopathy, a thorough evaluation of the draining sites
corresponding to the affected levels should be conducted to identify
potential sources of infection or malignant disease. If the patient's
history and physical examination successfully identify an infection
source, further testing may not be required, and treatment can be
initiated. However, monitoring for an appropriate response is essential
and follow-up care should be ensured\textsuperscript{13}. The following
factors should be considered during history taking\textsuperscript{13}:

\begin{itemize}
\tightlist
\item
  Age: The probability of malignant nature is higher in older age
  populations \textsuperscript{14}.
\item
  Symptoms of infection: Fever, dental pain, ulcers, or discharge.
\item
  Localized symptoms of malignancy: Hoarseness of voice, dysphagia,
  stridor, ulcers, and pain should be sought.
\item
  Generalized symptoms of malignancy: Weight Loss
\item
  Symptoms of the collagenic disease: Arthralgia or myalgia.
\item
  Medical history: Allergies to certain drugs are common causes of
  lymphadenopathy (e.g., phenytoin).
\item
  Occupational and epidemiological exposures: History of high-risk
  behavior, recent traveling to high-risk regions, or exposure to pets
  or speci\selectlanguage{english}fic occupational hazards can all suggest a speci\selectlanguage{english}fic underlying
  etiology.
\end{itemize}

Physical examination is another component of the patient's clinical
evaluation. A complete physical examination involves a thorough
inspection of the skin, neck, ears, eyes, nose, and throat. Examine the
oral mucosa, tongue, periodontium, and teeth as well
\textsuperscript{15}. Size is an essential criterion for
lymphadenopathy; Lymph nodes bigger than 1 centimeter in adults or
children are not considered normal. Notably, in adults, palpable nodes
smaller than 1 cm in the groin are typically regarded as normal
\textsuperscript{15}. Furthermore, a fixed, immobile node is a classic
indicator of malignancy. Tenderness or inflammation above the lymph node
indicates an inflammatory condition \textsuperscript{16}. Location of
enlarged lymph nodes may lead to a source of infection: Submandibular
and submental lymphadenopathy is most often caused by oral or dental
infections; cat-scratch disease and non-Hodgkin's
lymphoma\textsuperscript{16}. Pre-auricular and auricular nodes are
often enlarged in the presence of ocular disease, rubella, or
cat-scratch disease \textsuperscript{16}. When supraclavicular nodes are
enlarged, there is a strong suspicion of malignant disease, particularly
lymphoma or metastatic disease\textsuperscript{16}. When general
lymphadenopathy is evident, more diagnostic assessment is required,
which may involve a biopsy and laboratory testing. Ordering a complete
blood count (CBC) with differential might be beneficial for~a
practitioner in detecting cases caused by infectious mononucleosis,
leukemia, or lymphoma. Neutrophil leukocytosis is often seen in severe
infections \textsuperscript{18}. IgM toxoplasma antibody is the
diagnostic serologic test for the acute phase infection of toxoplasmosis
\textsuperscript{19}. Lymphocytosis can be seen in leukemia, autoimmune
disorders, Epstein-Barr virus, cytomegalovirus, and
Tuberculosis\textsuperscript{20}. Full blood count with hemogram, ESR,
CRP, and LDH are helpful in diagnosing malignancies and autoimmune
processes \textsuperscript{21}. Ultrasonography (US) plays a crucial
role in assessing the consistency of enlarged lymph nodes. It serves as
a primary diagnostic tool when the clinical examination alone is
insufficient to determine the nature of the lymph nodes. The primary
objective of the ultrasonographic examination is to differentiate
between reactive, tuberculous, lymphomatous, and metastatic etiologies
of the lymph nodes\textsuperscript{13}. Other means of adjunctive
evaluation may include lymph node aspiration, fine-needle aspiration
biopsy (FNAB), or excisional biopsy\textsuperscript{17}. Infections
arising in the teeth and oral tissues can migrate to the head and neck
region via the lymphatic system. This is made possible by the
lymphatics, which connect a number of nodes and allow germs to circulate
in the~lymph fluid \textsuperscript{22}. The route of dental infection
traveling through the nodes varies according to the teeth involved
\textsuperscript{23}. The primary nodes for the maxillary third molars
and the associated tissues, as in our case, are the superior deep
cervical nodes. The superior deep cervical nodes empty into either the
inferior deep cervical nodes or directly into the jugular trunk and then
into the vascular system \textsuperscript{23}. Oral infection
accompanied by evidence of systemic spread like lymphadenopathy requires
antibiotic therapy. The type of antibiotic chosen and its dosing regimen
is dependent upon the severity of the infection and the predominant type
of causative bacteria\textsuperscript{24}. Clindamycin or a combination
of amoxicillin and clavulanic acid should be used to treat patients who
have cervical lymphadenopathy and periodontal or dental disease since
these antibiotics offer coverage for anaerobic oral bacteria
\textsuperscript{25}. Depending on the clinical response of the present
treatment, antimicrobial therapy~may need to be adjusted after a causal
agent is discovered \textsuperscript{25}. Failure of regression of
lymphadenopathy after 4 to 6 weeks might be an indication for a
diagnostic biopsy \textsuperscript{26}.

\section*{Conclusion}

{\label{conclusion}}

This case study emphasizes the significance of appropriate examination,
particularly of lymph nodes, and the use of many diagnostic modalities
for accurate disease diagnosis. As oral healthcare professionals, we are
responsible for safeguarding our patients' oral and overall health.
Therefore, we must identify early signs of systemic diseases and deliver
appropriate patient care.

\section*{Consent (where ever
applicable)}

{\label{consent-where-ever-applicable}}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

Acknowledgements

Authors are grateful to the patients for their collaborations.

Competing interests

Authors have declared that no competing interests exist.

Authors' Contributions

All authors have read and agreed to the final version of this manuscript
and have equally contributed to its content and to the management of the
cases.

Consent (where ever applicable)

As per international standard or university standard, patient written
consent has been collected and preserved by the authors.

Ethical approval

As per international standard or university standard written ethical
approval has been collected and preserved by the authors.

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FIGURE 1: Showing swelling on the right side of the neck FIGURE 2:
intraoral view showing signs of decayed right third molar and signs of
periodontitis. FIGURE 3: Orthopantomography depicting decayed right
maxillary

third molars and generalized bone loss

\par\null

FIGURE 4: A: Grayscale ultrasound showing enlarged lymph node. B: Color
Doppler ultrasound\selectlanguage{english}
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FIGURE 5: Complete regression of the swelling after 20 days.\selectlanguage{english}
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