Avatar universal

Swollen Submandibular Lymph Nodes

Okay, so I had some ultrasounds and a CT done on my neck about a year ago. The ultrasound showed some abnormal lymph nodes, with the biggest being about 9mm. The CT showed absolutely nothing so my doctor just dropped the case as palpable benign lymph nodes (I made a post about this a little over a year ago). Well now I can feel more lymph nodes (one on the side of my neck, a few more in the submandibular/sub mental region, and one on the opposite lower side of my neck), all about a centimeter size. The original nodes are still there and don't seem to have grown. I have to get another ultrasound done and most likely a FNA. My new doctor did blood work and doesn't seem too concerned and doesn't think it's cancerous based on that, she is just doing the FNA just in case. From what I've read, Lymphoma usually doesn't make an appearance in blood work, even if I've had it for almost two years.

To summarize:
- I'm a 20 year old female, I first found the the nodes when I was 18.
- it has taken about a year for 3 or 4 more nodes to pop up.
- Indolent lymphomas are extremely rare for someone my age so I don't THINK it could be that.
- Is it normal for Hodgkin's to grow this slowly?
- I have impacted wisdom teeth and swollen gums from when I had braces, so maybe that could be causing this?

Unfortunately, I'm a huge hypochondriac, so these tiny little lumps in my neck are causing me all sorts of problems.
17 Responses
Avatar universal
Also to add: The nodes feel hard-ish(?) but are super mobile. And the ultrasound noted some hypervascularity.
1081992 tn?1389903637
"I have impacted wisdom teeth and swollen gums from when I had braces, so maybe that could be causing this?"

Yes, that's most likely. However, that doesn't quite explain why there is that odd cascading behavior - and that behavior probably explains ordering the FNA.

Can you post the sono report? There are some key things to look for, to mostly rule out cancer.

"Unfortunately, I'm a huge hypochondriac..."
My own belief is that people who are prone to worry also likely have very reactive immune systems.
Avatar universal
Here is is very first ultrasound report. When they did the follow up there were no significant changes, and then the CT scan showed nothing significant.

I went to the doctor in
February due a swollen lymph node in my neck. I told her that I had first noticed it in January and that it has neither increased or decreased in size from what I could tell. She didn't seem TOO concerned about it, but ordered an ultrasound for me anyways. I went to get an ultrasound the next day and these were the results:

Ovoid left submandibular lymph node (level IB) noted, measuring 10 x 5 x 9 mm (transverse, AP and CC dimension respectively). Internal architecture is heterogeneous with lack of normal hilar morphology. Intralesional hypervascularity noted with a
centralized feeding vessel. Adjacent smaller hypoechoic lymph node noted measuring 7 x 5 x 5 mm. This also demonstrates lack of normal hilar morphology. Visualized regional musculature demonstrates a normal sonographic appearance.

Ovoid hypervascular node at the left submandibular region, suspect inflammatory (reactive) lymph node. However given abnormal architecture and hypervascularity, malignant node or other neoplasm remain considerations. Consider followup ultrasound in 2-3
months for revaluation. "

Hi, the sono report tells most everything you need to know at this point. The presence of the hilum almost always means no-cancer. But the absence of the hilum doesn't necessarily mean cancer. E.g., fierce inflammation can also efface the hilum.

Normally, one would think of hypervascularity as being bad. But in your case, that seems confined to where the hilum would be, so the hypervascularity is probably not from cancer. It's also has on;y that one single blood vessel, which likely means means the node is reactive - as opposed to distributed vessels which are bad.

The size and shape are okay. Your nodes might be staying enlarged because of fibrosis/scarring.

Have you been tested for tuberculosis? There is a resurgence which is likely due to immigration.

Your biopsy will likely show no-cancer. Be aware of false positive CNAs, but still you likely don't have cancer anyway. The next step is that you should want to discover the "why me?" of what is going on - if not an unusual infection then a hyper immune system.

I will dig up a nice, detailed ref for sono in suspected nodes if you like.

should read--> false negative CNAs
Avatar universal
I had the TB skin test done when I was around 16 or 17 years old for a nursing class at my high school and it was negative. Of course, I could have had it again. I don't think it was tested for in the recent blood work.
1081992 tn?1389903637
Another possibility for nodes that seem permanently enlarged and also hard yet mobile would be some granulomatous disease. Yes, I'd very much think that your 'tonsil stones' as you described last year are related.

From "A clinicopathologic series of 22 cases of tonsillar granulomas":
"a number [of cases] may not develop an identifiable etiology, with the granulomas probably representing an exaggerated immune response to chronic tonsillitis."

You might have something similar to but yet different from Kikuchi disease or Rosai-Dorfman  disease. But your nodes don't have necrosis in the center, while they are too small for Rosai-Dorfman. The histiocytes could be in the tonsils and also in the nodes, surrounding and walling off some common infection.

Did you start off in the very beginning with a fever?

As you are learning, you should eventually feel as if your head will explode from too much information. Then you'll know you are proceeding correctly :)
1081992 tn?1389903637
Are you of Japanese descent? Then Kikuchi would be more likely, even though your nodes are not necrotic.
Avatar universal
Not  Japanese descent. And I don't think I had a fever. I get tons of sinus infections and am constantly treated with antibiotics with no luck with decrease in lymph node size.

Can chronic tonsillitis be fairly asymptomatic?
"constantly treated with antibiotics"
Did they at least do a culture to try to identify any bacteria? How do thy know it's not a virus or allergy or even a runaway immune reaction?
It is becoming well established that overuse of antibiotics will likely result in your beneficial gut flora getting wiped out. which allows bad bacteria to take hold. "Leaky gut" can have very many harmful effects via a dysfuncitonal immune system. (This is not just some trendy nonsense, as are many health topics that become popular.)

"Can chronic tonsillitis be fairly asymptomatic?"
It might be more of a sign than a cause.
This gallery might be useful: http://www.sayahh.com/photo-gallery.html
Avatar universal
No, they just diagnose by doing the typical examination.

The nodes that are swollen are the submandibular, sub mental, and superficial cervical on the left and then the posterior cervical on the right. Do those usually swell up with sinus?

I have really bad nasal allergies. And acne. They suspect the nasal allergies to be causing the sinus infections.
" Do those usually swell up with sinus?"
With sinus and throat, probably.

"They suspect the nasal allergies to be causing the sinus infections."
and also very probably the nodes.

I'd want to know if FNAC is sufficient to detect granulomas/histiocytes. Maybe a resectional biopsy is needed, I don't know.
Avatar universal
Will the FNA at least be able to tell me if there is any sort of malignancy? Is an FNA accurate as far as finding out how serious of a situation I am in? I won't really need specifics, but I'm currently in the process of transferring schools and moving so this is a really inconvenient time to be investigating this (I know, disease is never convenient).
The problem with FNA is that the needle might not hit the right spots to find bad cells, just by chance. This is called a "false negative" result.

For Hodgkin Lymphoma, the false negative rate is around 20%. The rate for a granulomatous disease seems to be around 30%.

Avatar universal

Okay, had a new U/S done. Obviously my nodes have grown and multiplied. The radiologist said since they are so thin, a FNA would be pointless, so I just have another follow up ultrasound in 6 months. I might get a second opinion from an ENT soon.

Bilateral multiple nonspecific neck lymph nodes are visualized some of which measure slightly enlarged right neck greater than the left.
Majority are within normal limits for size.
At the upper neck there is a 2.1 x 0.5 x 2.3 cm mildly enlarged lymph node which does however maintain its normal shape and visualization of central fat
Mid right neck 1.2 x 0.3 x 1 cm mildly enlarged lymph node which does maintain its normal shape and visualization of central fat.
At least 5 lymph nodes are demonstrated only one of which is mildly enlarged measuring 1.9 x 0.5 x 1.7 cm. The remaining 4 lymph nodes less than a centimeter and sonographically unremarkable.
All lymph nodes visualized maintain normal reniform shape and central fat echogenicity.
That further tends (a lot) against cancer - because cancer almost always gets rounded but your nodes aren't doing that.

I'm guessing that the clue here is that your nodes have grown so much in the long axis but not in the short axis. The ratio of L/S should be at least 2, but yours are all the way up to 4. That seems quite unusual and I don't know what condition would cause that. Maybe granulomas.

I just had a thought: maybe after your move you can ask about a *guided* FNA, and have them sample at the ends where the growth is occurring.
Maybe. I can't find anything about lymph nodes only growing on the long axis. It's weird.
Yep, it is weird. Maybe that can help differentiate between granuloma versus merely reactive nodes.

I found this: "The measurements of the long axis were significantly higher when granulomatous scar tissue was observed in the lymph nodes. The incidence of granulomatous diseases can affect the reference value adopted for the size of the lymph node."

For the 1st time, I'd actually like to see the sono image. If the elongation occurs symmetrically at both ends, that might just be due to you, to your genetics. But if it occurs at only one end, maybe that's because of what is entering the node via afferent vessels there.

In any event, whatever is causing the  gums/sinuses/tonsils is probably being carried by Antigen Presenting Cells (APCs) to the nodes, and the APCs might be secreting (or causing to be secreted) some kind of growth factor. That's a theory, anyway.

1081992 tn?1389903637
This is important: if you haven't already been tested for an immunodeficiency disease, then you should be. I was assuming you have had your immunoglobulin levels (antibodies) tested because of your history of frequent infections. If not, you should be and something like CVIDS can account for all of your troubles, including sinus infections, lymphadenopathy and possible granulomas. It's just a blood test.


Thank you! I'll look into it.
Avatar universal
My doctor called and basically just reiterated my ultrasound report to me. She wants to do a follow up U/S in December or January and see if there are any changes. If there are, I think she may want to do a CT Scan. Ill also ask about the immunoglobulin test, because she didn't test for that last time.
Okay, good luck during the waiting period. But if the nodes get significantly bigger or more numerous in the meantime, you should tell the doctor.

I'd also suggest that you learn about "leaky gut" from antibiotics, since the treatment is something that you can do yourself - if you determine that you actually do have it.

Good luck.
Avatar universal
So, I was overlooking my blood work, and a hemoglobin test was conducted. Along with a mono test. Basically all autoimmune diseases I think were covered in my blood tests and they all came back fine. I messaged my doctor and requested to go ahead with the CT scan now. Should I be worried?
A CT gives a lot of radiation, especially if done over a large area looking for enlarged nodes. If you haven't gotten worse, then there doesn't seem to be any need now.

But the immunoglobulin test is cheap and not harmful.
Well, I have found two small swollen nodes behind my right ear. Not very big, smaller than a pea, but palpable.
1081992 tn?1389903637
I would want the immunoglobulin test.

Did you have a recent CBC?
Yes, I had one about a month ago.
1081992 tn?1389903637
AFAIK, if your CBC is normal, that would tend away from active infection and tend toward granuloma.
Avatar universal

LYMPH NODES: No lymphadenopathy. There are small bilateral cervical chain lymph nodes which are morphologically normal and do not meet size criteria for pathologic enlargement. Largest node on the right is a level 2A node that measures 7 mm short axis (2, 38). Similarly largest node on the left is a 2A node measuring 6 mm short axis (2, 37). No abnormal nodal enhancement. The nasopharyngeal adenoids and tonsillar pillar regions appear unremarkable.

So, what do you think?
This is from a new scan?

There's still no reason to be alarmed about lymphoma.

You still have something going on which is not normal, probably infection. That could be granuloma. It also could involve "biofilm" which makes bacteria safe from antibiotics.

But overall, what stands out is that any radiologist should have all previous scan results in front of them when they make a report on a new scan, because your case requires making  comparisons of the nodes over time. There seems to be just a small increase in the short axis, which I don't think is anything to worry about.
Avatar universal
Yes, this is a new scan.

Thank you.

Can infections go unnoticed in blood work?
The immune system can't detect bacteria hidden in a biofilm, and antibiotics can't penetrate that, either.

The immune system likely can't detect bacteria walled off in granulomas, either.
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