Suppurative lymphadenitis is a form of acute inflammation of the lymph nodes of a nonspecific or specific etiology, accompanied by the formation of purulent exudate. It is characterized by an increase, compaction, soreness of the affected area, redness of the skin, the appearance of a symptom of fluctuation, fever and other signs of intoxication of the body. Diagnosis is carried out using clinical examination, laboratory and instrumental techniques (ultrasound, CT of lymph nodes, puncture). Complex treatment – surgical autopsy and rehabilitation of the lesion, drug therapy, physiotherapy.
Among the pathology of soft tissues, acute lymphadenitis is given one of the first places. The occurrence of purulent forms is 20-35% of the total number of inflammatory diseases of the maxillofacial region. Up to 46.5% of children are admitted to inpatient treatment with a complicated course of lymphadenitis, which is due to the structural and functional immaturity of the lymphatic system and diagnostic errors. The non-specific process is characterized by autumn-winter and spring seasonality. The spread of a number of specific lymphadenitis (with plague, tularemia, tick-borne encephalitis) has a clear geography (Far East, Central Asia, China, Africa).
The most significant pathogen (94% of cases) is Staphylococcus aureus (golden, epidermal) – in the form of a monoculture or in combination with streptococci, E. coli, anaerobes. The etiological characteristics of the disease are constantly changing, which is associated with the emergence of new strains, increasing resistance to antibiotics. A more detailed examination of the contents of the lymph nodes allows you to identify viruses (Epstein-Barr, cytomegalovirus), chlamydia. Specific variants occur with the participation of mycobacteria, pale treponema, toxoplasma, fungal flora.
Suppurative lymphadenitis almost always has a secondary character, arising as a result of the spread of infectious agents from the primary focus through the lymphatic or blood vessels. The source of the inflammatory reaction is pathological conditions of various localization:
- Infections of the dental apparatus. Odontogenic disorders, as the most frequent etiological factor, account for 47% of non-specific forms of pathology. In dental practice, the defeat of the submandibular and chin area is the result of alveolitis, periodontitis, periostitis and osteomyelitis of the jaw.
- Diseases of ENT organs. They are the second most common cause – tonsilogenic and otogenic processes account for a quarter of cases. Cervical and submandibular lymph nodes become inflamed in patients with angina (lacunar, complicated by paratonsillitis, pericaryngeal abscess), pharyngitis, adenoiditis. Abscessing conditions are also accompanied by otitis media, mastoiditis, acute sinusitis.
- Pathology of the skin and soft tissues. In dermatology, lymphadenitis occurs as a result of microbial eczema, pyoderma (furuncle, carbuncle, ectima), infiltrative-suppurative trichophytia, erysipelas. Surgeons are faced with purulent lesion of nodes in infected wounds, abscesses and phlegmon, panaritia. This reaction is characteristic of thrombophlebitis, osteomyelitis (if there is a breakthrough of pus with the formation of fistulas).
- Diseases of the genitourinary tract. Purulent inguinal lymphadenitis most often indicates sexually transmitted diseases. It is included in the symptoms of inflammatory pathology of the pelvic organs (chlamydia, ureaplasmosis, gonorrhea), genitals and perineal skin (vulvitis, balanitis, herpes).
In children, purulent inflammation is associated with acute respiratory viral infections, scarlet fever, and mononucleosis. In a number of patients, the cause is a specific infection: tuberculosis, syphilis, toxoplasmosis. Lymph nodes are affected against the background of tularemia, plague, actinomycosis and a number of other diseases. Compared with infectious ones, the role of traumatic factors is insignificant – if microbes penetrate directly into the node through an open wound, then primary lymphadenitis is detected. The risk of abscess formation increases in people with a weakening of the general reactivity of the body (hypothermia, frequent and prolonged stress, immunodeficiency, chronic diseases).
Inflammation is evidence of the barrier (protective) function of the nodes. At first, the process has a reactive or serous character, accompanied by edema, vascular fullness, and lymph retention. Further development of the infection leads to the penetration of the pathogen into the lymphoid structures. Proliferation of cellular elements is observed: the number of lymphocytes (mostly immature), neutrophils and macrophages increases. Microbes and exotoxins stimulate the chemotaxis of leukocytes and their death (including phagocytosis), which is accompanied by the formation of pus. Usually morphological changes are limited to the capsule, but there is a risk of destructive forms involving surrounding areas under the influence of proteolytic enzymes.
The classification of acute suppurative lymphadenitis used in practical surgery is designed to reflect the nature of the pathological condition in the clinical diagnosis. In order to obtain comprehensive information about the ongoing changes, the following criteria are taken into account:
- Etiology. By origin, there are secondary (infectious) and primary (traumatic) processes. Microbial forms, in turn, are nonspecific and specific. The latter are represented by tuberculous, syphilitic, fungal variants.
- The path of penetration. Depending on the location of the infectious focus, lymphadenitis is divided into odontogenic (the result of damage to the dental system) and non-odontogenic. The latter include stomatogenic, otogenic, tonsilogenic, rhinogenic, dermatogenic (affecting, respectively, the oral mucosa, ear, tonsils, nose, skin).
- Prevalence. Taking into account the spread, suppurative lymphadenitis can be isolated (local), regional (several nodes in one or adjacent areas are involved) and generalized (3 or more groups are affected). The pathological condition can cover various zones: cervical, submandibular, axillary, inguinal, etc.
- The degree of enlargement of lymph nodes. Assessing the inflammatory reaction of lymphoid formations, it is customary to distinguish several degrees of their increase: from 0.5 to 1.5 cm in diameter (the first); 1.5–2.5 cm (the second); up to 3.5 cm or more (the third).
The disease goes through several clinical and morphological stages of development. First, simple (serous) lymphadenitis occurs, then the inflammation becomes purulent (abscessing). Without adequate treatment, adenophlegmon develops.
The purulent process is a continuation of serous, which is observed with a decrease in the body’s resistance, untimely treatment, delayed diagnosis or incorrectly selected therapy. The disease is manifested by a violation of general well-being with an increase in temperature to febrile numbers (39 ° C), chills, malaise, body aches, decreased appetite. The child’s intoxication is also indicated by pallor, dryness of the skin and mucous membranes, lethargy, adynamia, sleep disorder.
Examination of the affected area reveals swelling without clear boundaries, leading to visible asymmetry. The skin over the inflamed focus is hyperemic, tense, does not gather into a fold. Palpation nodes are painful, acquire a dense elastic consistency, become limited mobility due to periadenitis. The melting of tissues (abscessing) is determined by the phenomenon of fluctuation in the center of the swelling – the oscillation of the exudate during jerky movements. Lymph nodes are usually not soldered to the skin and surrounding tissues.
In some cases, among the local changes, it is possible to identify signs of inflammatory lesions of lymphatic vessels (lymphangitis). Then you can notice that a dense painful weight is coming to the enlarged node from the entrance gate of the infection, determined from the outside by linear redness (a narrow strip on the skin). An active inflammatory reaction in the area of primary disorders complements the clinical picture with a number of concomitant symptoms (from the oral cavity, throat, urogenital tract, etc.).
If acute inflammation is not interrupted in time, then the capsule melts with a breakthrough of pus into the surrounding fiber. In this case, a diffuse process called adenophlegmon is observed. Localization in the cervical region is accompanied by a rapid flow with a rapid spread of pus through the interfacial spaces. The breakthrough of the exudate into other anatomical zones (organs, cavities) leads to the formation of fistulas, abscesses, mediastinitis. Infection can spread to venous vessels (thrombophlebitis) or enter the bloodstream with the development of septicopiemia.
A preliminary diagnosis is established on the basis of clinical data – a survey (complaints, anamnesis of the disease), examination and palpation of lymphoid formations. The area of the probable location of the primary infection is also subject to physical examination. To clarify the cause and nature of violations, a complex of laboratory and instrumental methods is needed:
- Blood test. Common signs indicating inflammatory changes in the body are leukocytosis and increased ESR. According to their level and other indicators (the shift of the leukocyte formula to the left, the toxic granularity of granulocytes), it is possible to judge the severity of infectious disorders. Bacterial pathology, according to the results of a clinical blood test, is manifested by neutrophilosis, and viral – lymphomonocytosis.
- Ultrasonography. Ultrasound of lymph nodes makes it possible to determine the size, shape, structure, contours, depth of occurrence, relationship with nearby tissues, the presence of complications. According to ultrasound Dopplerometry, suppurative lymphadenitis is accompanied by an increase in size, compaction and thickening of the capsule of nodes, heterogeneity of the structure with anechoic areas, the presence of zones with a complete absence of blood flow.
- CT of the affected areas. It is the most accurate visualization method in clinical practice. Computed tomography allows you to specify the size, location of inflamed structures, the presence of abscess, the spread of pus. Determines the primary changes in the lungs and other organs.
- Puncture of lymph nodes. The detection of signs of abscess formation causes the need for diagnostic puncture of lymph nodes. The resulting exudate is subject to microscopic and bacteriological examination to determine sensitivity to antimicrobial drugs. To exclude specific disorders, a piece of tissue taken by puncture or fine needle biopsy is sent for histological analysis.
For a more detailed study, ultrasound of lymphatic vessels, lymphography, lymphoscintigraphy are prescribed. Diagnosis of suppurative lymphadenitis caused by specific flora requires the use of additional techniques. Tuberculosis infection is confirmed by tuberculin tests (Mantoux, Koch, Pirke), and syphilis is confirmed by serological reactions (RW, ELISA).
The diagnosis is carried out by a purulent surgeon with the involvement of doctors of related specialties. Taking into account the localization of the primary process, it may be necessary to consult a dentist, an otolaryngologist, a dermatologist, etc. If a specific etiology is suspected, the patient should visit an infectious disease specialist, a phthisiologist, a venereologist. Differential diagnosis is carried out with chronic forms, lymphadenopathies with lymphocytic leukemia and lymphogranulomatosis, metastases of malignant tumors. Suppurated atheroma, abscesses and phlegmon should be excluded.
Effective treatment is achieved only with a complex effect on pathology using surgical and conservative methods. Abscessing or the presence of adenophlegmon is an indication for opening the focus, evacuation of pus, washing and drainage of the wound. Necrotized tissues and destroyed nodes are removed. The operation is performed by a surgeon in a hospital under local anesthesia.
In the postoperative period, the patient needs bed rest with limited movement in the affected area and an easily digestible diet. Antibacterial and detoxification therapy, nonsteroidal anti-inflammatory, desensitizing agents are prescribed. Bandages are carried out with hyperosmolar and antimicrobial ointments, the skin is treated with antiseptics. The recovery period involves the use of certain physiotherapy procedures (UHF, electrophoresis, electroplating and magnetotherapy).
Prognosis and prevention
Timely and comprehensive correction of abscessing lymphadenitis makes the prognosis favorable – complete recovery occurs with the restoration of the function of the affected segment. It is possible to prevent the development of suppurative lymphadenitis with active treatment of serous inflammation, which protects against further spread of the process and complications. Primary prevention measures include rehabilitation of chronic foci of infection (caries, tonsillitis), rational therapy of acute conditions, injury prevention, and healthy lifestyle.