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 collected5. 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 mass6. 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 macrophages7. 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 biopsy7. Lymphadenopathy can be caused by medication responses, infections, immunologic diseases, cancer, and a variety of other conditions with unknown causes 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 unidentified9,10. 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 lymphadenitis11. 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.12. Complete history taking and physical examination are mandatory for diagnosis; laboratory tests, imaging diagnostic methods, and tissue samplings are the next steps13. The importance of patient history varies significantly. It can either lead directly to the reason and propose an explanation, or it might be nondiagnostic 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 character12. 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 ensured13. The following factors should be considered during history taking13:
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 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 15. Furthermore, a fixed, immobile node is a classic indicator of malignancy. Tenderness or inflammation above the lymph node indicates an inflammatory condition 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 lymphoma16. Pre-auricular and auricular nodes are often enlarged in the presence of ocular disease, rubella, or cat-scratch disease 16. When supraclavicular nodes are enlarged, there is a strong suspicion of malignant disease, particularly lymphoma or metastatic disease16. 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 18. IgM toxoplasma antibody is the diagnostic serologic test for the acute phase infection of toxoplasmosis 19. Lymphocytosis can be seen in leukemia, autoimmune disorders, Epstein-Barr virus, cytomegalovirus, and Tuberculosis20. Full blood count with hemogram, ESR, CRP, and LDH are helpful in diagnosing malignancies and autoimmune processes 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 nodes13. Other means of adjunctive evaluation may include lymph node aspiration, fine-needle aspiration biopsy (FNAB), or excisional biopsy17. 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 22. The route of dental infection traveling through the nodes varies according to the teeth involved 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 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 bacteria24. 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 25. Depending on the clinical response of the present treatment, antimicrobial therapy may need to be adjusted after a causal agent is discovered 25. Failure of regression of lymphadenopathy after 4 to 6 weeks might be an indication for a diagnostic biopsy 26.