E2332. Sonographic Evaluation of Nodal Neck Bumps: A Comprehensive Review and Guide
  1. Lillian Niakan; Baylor Scott & White
  2. Ricardo Garza-Gongora; Baylor Scott & White
  3. Krista Birkemeier; Baylor Scott & White
  4. Rodney Hajdik; Baylor Scott & White
Head and neck anatomy including the lymphatic system are complex and its pathology can be devastating to patients. Sonography is commonly requested to assess patients with neck lumps and bumps. When cervical lymph nodes are encountered, ultrasound is an important implement to evaluate nodes for signs of disease, follow-up of disease, and treatment planning. Lymph node size is commonly utilized as the primary focus to determine whether a node is likely pathologic. However, the morphologic nodal features are typically more predictive of pathology.

Educational Goals / Teaching Points
Our presentation will commence with details of lymph node anatomy and lymphatic drainage boundaries. We will then focus on the nodal size cutoffs and sonographic morphologic features predictive of pathologic lymph nodes. The impact of accurate imaging and reporting on patient care and treatment planning will be explained. Finally, the exhibit will review the pertinent factors needed in perioperative radiology reports.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
A lymph node is composed of a cortex and a hilum, with normal and most reactive nodes displaying a predictable oblong shape, hypoechogenic cortex and a central hyperechogenic hilum on ultrasound. Pathologic nodes are commonly stereotyped when their short axis dimensions reach or exceed one centimeter. However, nodal cortical morphology has proven to be a more reliable indicator of disease independent of size. Important morphologic characteristics include the loss of the expected fatty hilum, cortical thickening, heterogeneity, or hypervascularity. Additionally, a rounded shape, irregular margin and/or nodal clustering are important indicators of malignancy. Through knowledge of neck anatomy and appropriate sonographic landmarks, an investigator may identify the lymphatic drainage borders. The seven nodal levels are readily identified on ultrasound via osteochondral and muscular landmarks. An understanding of these nodal levels and assigning a pathologic node to the correct zone is vital for predicting the origin of disease.

A thorough understanding of neck anatomy, imaging findings associated with nodal pathology, and accurate reporting are imperative to patient care. An interpreter should place a heightened emphasis on nodal morphologic characteristics in addition to size and correctly assigning a node level during reporting. In doing so, we may dramatically affect patient outcomes when a pathologic or normal/reactive node is encountered during a routine neck bump sonographic evaluation.