|Year : 2019 | Volume
| Issue : 2 | Page : 29-33
The pattern of presentation of head and neck swellings in a tertiary health centre
Benjamin Fomete1, Rowlan Agbara2, Modupe O A. Samaila3, Dahiru G Waziri3, Daniel O Osunde4
1 Department of Maxillofacial Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
2 Dental and Maxillofacial Surgery, Jos University Teaching Hospital, Jos, Plateau, Nigeria
3 Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
4 Dental and Maxillofacial Surgery, University of Calabar Teaching Hospital, Calabar, Cross River, Nigeria
|Date of Submission||16-Oct-2019|
|Date of Acceptance||08-Apr-2020|
|Date of Web Publication||08-Aug-2020|
Dr. Benjamin Fomete
Department of Maxillofacial Surgery, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Background: Swellings of the head and neck region could present as lymphadenopathy. Lymphomas are among the diseases associated with lymphadenopathy and commonly affected lymph nodes are cervical nodes in the head and neck region. The present study aimed at analyzing the causes of head and neck swellings in a tertiary health facility specialized clinic.
Patients and Method: An analysis of patients with head and neck swellings carried out retrospectively between 2006 and 2014 in a tertiary health clinic. Relevant data were retrieved on patients' biodata, clinical details, and definitive histopathological reports from the clinic and departmental records. Data were analyzed using SPSS version 23.
Results: There were more males (65.6%) than female and the first decade of life was the most affected. The most common pathological site was the cervical nodes (44.8%) followed by the mandible. There were more neoplastic lesions with Burkitt's lymphoma been the commonest followed by diffuse large cell lymphoma.
Conclusion: Swellings and lymphadenopathies of the head and neck do occur in our environment with lymphoma accounting for the majority of them.
Keywords: Cervical lymphadenopathy, head and neck tumors, lymphoma, neck swellings
|How to cite this article:|
Fomete B, Agbara R, Samaila MO, Waziri DG, Osunde DO. The pattern of presentation of head and neck swellings in a tertiary health centre. Arch Int Surg 2019;9:29-33
|How to cite this URL:|
Fomete B, Agbara R, Samaila MO, Waziri DG, Osunde DO. The pattern of presentation of head and neck swellings in a tertiary health centre. Arch Int Surg [serial online] 2019 [cited 2021 Mar 6];9:29-33. Available from: https://www.archintsurg.org/text.asp?2019/9/2/29/291746
| Introduction|| |
Palpable swellings in the head and neck region are usually associated with lymph node enlargement. This lymphadenopathy is often a harbinger of underlying pathology from varying causes ranging from reactive to infective and neoplastic. A single node or a group of lymph nodes can be affected in a localized or generalized pattern depending on the underlying cause. The most common neoplastic cause of lymphadenopathy is lymphoma, a malignant disease of lymphocytes broadly classified into Hodgkin and non-Hodgkin lymphoma based on defined criteria which have undergone several changes over the years.,
This is closely followed by metastatic diseases that require identification of primary cancer in the body while the reactive and infective causes include viral, bacteria, parasitic, and fungal infections., Other causes of head and neck swellings include soft tissue masses and bony lesions.
The cervical group of lymph nodes is often enlarged in the diseases affecting the head and neck regions, though oral cavity and intracranial tumors are rarely associated with lymphadenopathy. Of the diseases associated with lymphadenopathy; lymphoma, the third most common cancer globally with alarmingly increasing incidence accounts for a significant percentage of cervical lymphadenopathy, and approximately 2% of head and neck malignancies though a significant percentage of lymphomas are extranodal diseases. These extranodal diseases may manifest as soft-tissue masses.
There is a paucity of literature on the pattern of distribution of diseases of the head and neck presenting with swelling and or lymphadenopathy in general thus, this study aimed at analyzing the causes of head and neck swellings in a tertiary health facility specialized clinic.
| Patients and Method|| |
A retrospective analysis of patients who presented with swellings or lymphadenopathy affecting the head and neck group of lymph nodes at the oral and maxillofacial clinic of the Ahmadu Bello University Teaching Hospital, Zaria over 9 years (2006–2014). Relevant data were retrieved on patients' biodata, clinical details, and definitive histopathological reports from the clinic and departmental records. Data were analyzed using SPSS version 23 Illinois, U.S.A.
| Results|| |
A total of 96 patients out of 1116 patients with head and neck swellings and lymphadenopathy who presented to the oral and maxillofacial clinic had either lymph node biopsy or incisional biopsy for definitive histopathological diagnosis. There were 63(%) males and 33(%) females with a male to female ratio of 2:1. Their ages ranged from 4 to 70 years with a mean of 25.8 (SD ± 17.79) years. The peak age of presentation was in the first three decades of life where over 50% of cases were seen. There was no statistically significant age difference in the sexes, P = 0.513.
The age category 1–10 years were the most frequently involved accounting for 26 (27.1%) cases; this was closely followed by the 11–20 years (n = 21; 21.9%). The 21–30 years and the 31–40 years age groups were equally represented by 15 (15.6%) of the cases each [Table 1].
Neoplastic lesions were the commonest causes of lymphadenopathy and accounted for 76% (n = 73) of the cases while reactive hyperplasia and infective causes accounted for 14.6% (n = 14) and 9.4% (n = 9), respectively. The neoplastic lesions were mainly lymphomas with metastatic tumors accounting for a paltry 9.4% (n = 9) of these.
Of the lymphomas, non-Hodgkin's lymphoma represented 95.3% and Hodgkin's lymphoma accounted for 4.7%. Burkitt's lymphoma was the most common non-Hodgkin's lymphoma histological variant and accounted for 26% (n = 25) cases. Diffuse large cell lymphoma and diffuse small cell lymphoma accounted for 17.7% (n = 17) and 13.5% (n = 13), respectively.
The non-neoplastic lesions included reactive hyperplasia (n = 14; 14.6%) and infective diseases comprising of tuberculosis (6.25%) and nonspecific chronic granulomatous inflammation (3.1%) [Table 2].
|Table 2: Gender distribution of underlying diseases associated with lymphadenopathy|
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Of the nine nodal metastatic lesions, 5 (5.2%) of the cases were squamous cell carcinoma, 2 (2.1%) were papillary adenocarcinoma, and 1 (1.0%) each of melanoma and follicular carcinoma of the thyroid gland.
The distribution of the lesions according to gender is shown in [Table 2]. Burkitt's lymphoma, diffuse large cell lymphoma, and metastatic lesions had a predilection for the male gender which was statistically significant (P = 0.046). Burkitt's lymphoma was twice as common in males (M/F ratio, 2:1), and metastatic lesions had 7 and 2 occurrences in males than females, respectively [Table 2].
The cervical group of nodes were the most commonly involved and accounted for 44.8% (n = 43), though side was unspecified in 22.9% (n = 22). Others included submandibular (n = 13), submental (n = 2), parotid (n = 3), retroauricular (n = 2), and preauricular (n = 1).
The mandible and maxillae were the common extranodal site with 13 and 12 cases, respectively while the cheek had 11 cases [Table 3]. The distribution of lesions according to site was not statistically significant (X2 = 333.513; P = 0.152).
The distribution of lesions according to age was significant (Likelihood Ratio: X2 = 167.068; df = 126; 0.021). Burkitt's lymphoma was frequently seen among the 1–10 years age group and was represented by 18 (18.8%) cases. The distribution of other lesions is shown in [Table 4].
| Discussion|| |
The study involved 63 (65.6%) males and 33 (34.4%) females who presented to our clinic with head and neck swelling or lymphadenopathy. The male preponderance in this study is contrary to studies by Sra et al. who had a female preponderance of 62.5% and Al-Tawfiq et al., study in Eastern Saudi who also reported a female preponderance of 53.7%. The male preponderance in this study may be attributed to sociocultural factors in our setting where the health-seeking behavior of the females is largely dependent on male relatives bringing them to a health facility.
The ages ranged from 4 to 70 years, with a mean (SD) of 25.8 (17.79) years. The difference between the mean ages of males and females was not significant (P = 0.513). The age category 1–10 years were the most frequently involved and accounted for 27.1% cases while the study by Sra et al. reported the 61–80 years as the commonest with 37.5% cases. The reason could allude to the higher frequency of Burkitt lymphoma, a predominantly childhood tumor.
Neoplastic lesion represented 76% while benign lesion represented 24%. A similar distribution pattern was documented by Sato et al. with 43/58 lymph nodes and Oh et al. Whereas, Tsuji et al. in Japan reported a frequency of 42% for malignant lesions. Al-Tawfiq et al. in eastern Saudi reported more benign cases comparatively. In Southwest Nigeria, Aramide et al. documented more malignant cases with a frequency distribution of 52.5%. The lymph node enlargement was 8.2% which is similar to the findings of Sra et al. Our findings are similar because these studies also reported more malignant cases that predominantly affected lymph nodes.
In this study, lymphomas (66.7%) constituted the bulk of lesions with non-Hodgkin lymphoma being the highest in number. This agrees with documented literature.,, Burkitt's lymphoma was the most common lesion in this study and was followed by diffuse large cell lymphoma. However, in the series by Sra et al., tuberculosis and reactive node were the commonest lesions with 35% and 34% cases, respectively whereas, reactive hyperplasia and tuberculosis constituted 14.6% and 6.2%, respectively in our study.
Burkitt's lymphoma is an aggressive tumor and the majority of cases in this study were found in the first decade of life (18/25; 72%). This agrees with previous studies in Nigeria. In this study, males were twice more affected in a ratio of 2.125:1(M: F). Amusa et al. and Ogweng et al. also found that males were dominant with a ratio of 2.5:1 and 1.8:1, respectively. In Stocks et al. study, they constituted 2.7%.
Diffuse large cell lymphoma (17.7%) was the second most common type of non-Hodgkin's [Figure 1] lymphoma followed by diffuse small cell with 13.5% while in Jos Nigeria, the diffuse small cell was the commonest with 70% frequency rate though more males than females (2.6:1) were affected. Armitage et al., also reported diffuse large cell lymphoma as the most common type of non-Hodgkin's lymphoma with a frequency distribution of 35%.
|Figure 1: Male patient with maxillary extra nodal swelling (Diffused B cell lymphoma)|
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Hodgkin lymphoma constituted 3.1% in this study. Our finding is lower than the average 10% or more from several reports by Sra et al., Hashemi-Bahremani et al., and Yakubu et al. The observed male dominance is also documented in Jos Nigeria.
Metastatic carcinoma [Figure 2] represented 9.4% with a male preponderance. This frequency rate is lower than the 21.7% recorded in Southwest Nigeria by Aramide et al. Of the nine metastatic lesions to the lymph node, 5 (5.2%) of the cases were squamous cell carcinoma, 2 (2.1%) were papillary adenocarcinoma, and 1 (1.0%) each of melanoma and follicular carcinoma of the thyroid gland.
A tuberculous lymphadenitis is a major form of extrapulmonary tuberculosis manifestation. Tuberculosis constituted 6.2% in this study and is considerably lower than the 63.8% in India by Jha et al. Our lower frequency may be attributed to the successful tuberculosis prevention campaign in the country and access to treatment by affected individuals. The almost equal gender distribution of tuberculosis infection is also comparable with other studies by Jha et al. and Aramide et al.
Reactive hyperplasia represented 14.6% and is comparatively lower than the 26.7% recorded by Aramide et al. Reactive hyperplasia was most common in the first two decades of life, this is not surprising as age group at the two extremes of life are prone to flu, cold, and upper respiratory tract infection from sub-optimal immune responses.
The cervical nodes [Figure 1] were the most commonly involved and accounted for 38.5% of all cases while the mandible was the most common extranodal site with 13.5% cases. This is in agreement with Sra et al. and Stock et al., who independently reported the cervical site as the most common. A study by Yakubu et al. in Jos, Nigeria, demonstrated that the maxilla [Figure 2] is the most common site with 36% frequency rate followed by cervical nodes in Jos, though in Taiwan, the tonsils accounted for 31.4% and were the most common site followed by the sinus and nasal cavity which accounted for 16.3% cases. Similarly, Picard et al., reported the tonsils as the most common site in 27% cases.
In conclusion, swellings and lymphadenopathy of the head and neck do occur in our environment and malignant lesions were the commonest cause with a predominant male disposition. Among the malignant lesions, lymphomas dominated.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Aramide KO, Ajani MA, Okolo CA. Cervical lymphadenopathy in Ibadan, Nigeria. Ann Ib Postgrad Med 2017;15:41-4.
Stein H, Pileri SA, Weiss LM, Poppema S, Gascoyne RD, Jaffa ES. Hodgkin lymphomas In: Swerdlow SH, Pileri SA, Stein H, Thiele J, editor. World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th
ed. Lyon: IARC; 2017. p. 424-8.
Aster J, Kumar V. White cells, Lymph nodes, spleen and thymus. In: Cotran RS, Kumar V, Collins T, editors. Robins Pathologically Basis of Disease. 6th
ed. Philadelphia: WB Saunders; 1999. p. 652-5.
Samaila M, Oluwole MP. Extrapulmonary tuberculosis: Fine needle aspiration cytology diagnosis. Niger J Clin Pract 2011;14:297-9.
] [Full text]
Samaila MO, Abdullahi K. Cutaneous manifestations of deep mycoplasma: An experience in a tropical pathology laboratory. Indian J Dermatol 2011;56:282-6.
] [Full text]
David OS, Isa MS, Azuh PC, Samaila MOA, Shehu MS, Abdullahi A. Lymphadenopathy Kaposi's sarcoma in an immunocompetent adult. J Coll Physicians Surg Pak 2012;22:1-4.
Amusa YB, Adediran IA, Akinpelu AO, Famurewa OC, Olateju SO, Adegbeingbe OD, et al
. Burkitt's lymphoma of the head and neck region in a Nigerian tertiary Hospital. WAJM 2005;24:139-42.
Walter C, Ziebart T, Sagheb K, Rahimi-Nedjat RK, Manz A, Hess G. Malignant lymphomas in the head and neck region – a retrospective, single-center study over 41 years. Int J Med Sci 2015;12:141-5.
Bernardes Silva TD, Ferreira CBT, Leite GB, de Menezes Pontes JR, Antunes HS. Oral manifestations of lymphoma: A systematic review. Ecancermedicalscience 2016;10:665. doi: 10.3332/ecancer. 2016.665.
Picard A, Cardinne C, Denoux Y, Wagne I, Chabole F, Bach CA. Extra nodale lymphoma of the head and neck: A 67 case series. Eur Ann Otolaryngol Head Neck Disea 2015;132:71-5.
Sra N, Verma SK, Singh D, Bal MS. Incidence of lymphomas in the head and neck region. Indian J Otolaryngol Head Neck Surg 2003;55:303-5.
Al-Tawfiq JA, Raslan W. The analysis of pathological findings for cervical lymph node biopsies in Eastern Saudi. J Infect Pub Health 2012;5:140-4.
Sato N, Kawabe R, Fujita K, Omura S. Differential diagnosis of cervical lymphadenopathy with intranodal color Doppler flow signals in patients with oral squamous cell carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:482-8.
Oh KH, Woo JS, Cho JG, Back SK, Jung KY, Kwon SY. Efficacy of ultrasound-guided core needle gun biopsy in diagnosing cervical lymphadenopathy. Eur Ann Otolaryngol Head Neck Disea 2016;133:401-4.
Tsuji T, Satoh K, Nakano H, Nishide Y, Uemura Y, Tanaka S, et al
. Predictors for the necessity for lymph node biopsy of cervical lymphadenopathy. J Cranio-Maxfac Surg 2015;43:2200-4.
Yakubu M, Ahmadu BU, Yerima TS, Simon P, Hezekiah IA, Pwavimbo AJ. Prevalence and clinical manifestation of lymphomas in North Eastern Nigeria. Indian J Cancer 2015;52:551-5.
] [Full text]
Ogwang MD, Bhatia K, Biggar RJ, and Mbulaiteye SM. Incidence and geographic distribution of endemic Burkitt lymphoma in northern Uganda revisited. Int J Cancer 2008;123:2658-63.
Stock K, Brandstetter M, Keller U, Knopf A. Clinical presentation and characteristics of lymphoma in the head and neck region. Head Face Med 2019;15:1-8.
Armitage JO. My treatment approach to patients with diffused large B cell lymphoma. Mayo Clin Proc 2012;87:161-71.
Hashemi-Bahremani M, Parwaresch MR, Tabrizchi H, Gupta RK, Raffii MR. Lymphomas in Iran. Arch Iranian Med 2007;10:343-8.
Jha BC, Dass A, Nagarkar NM, Gupta R, Singhal S. Cervical tuberculous lymphadenopathy: Changing clinical pattern and concepts in management. Postgrad Med J 2001;77:185-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]