Swollen Submandibular Lymph Nodes

[Anncorn314]

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.

[Ken_PA]

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.

http://www.immunedisease.com/about-pi/types-of-pi/common-variable-immunodeficiency-cvid.html

https://rarediseases.org/rare-diseases/common-variable-immune-deficiency/

[Anncorn314]

Thank you! I'll look into it.

[Anncorn314]

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.


FINDINGS:
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.
Right
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.
Left
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.

[Ken_PA]

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.

[Anncorn314]

Maybe. I can't find anything about lymph nodes only growing on the long axis. It's weird.

[Ken_PA]

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."
http://www.scielo.br/scielo.php?pid=s1806-37132007000200006&script=sci_arttext&tlng=en

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.

[Anncorn314]

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).

[Ken_PA]

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%.

http://www.sciencedirect.com/science/article/pii/S111003621100029X#t0005

[Anncorn314]

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.

[Ken_PA]

" 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.

[Anncorn314]

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?

[Ken_PA]

"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

[Ken_PA]

Are you of Japanese descent? Then Kikuchi would be more likely, even though your nodes are not necrotic.