Ahuja and Ying

Sonographic Evaluation of Cervical Lymph

Nodes
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Pictorial Essay
Anil T. Ahuja1
Michael Ying2
Sonographic Evaluation of Cervical
Ahuja AT, Yi

Lymph Nodes
OBJECTIVE. Sonography is a useful imaging tool in the evaluation of cervical lymph
nodes. Gray-scale sonography and color and power Doppler sonography are commonly used
in clinical practice. This article documents the common sonographic appearances of different
causes of cervical lymphadenopathy.
CONCLUSION. The sonographic appearances of normal nodes differ from those of ab-
normal nodes. Sonographic features that help to identify abnormal nodes include shape
(round), absent hilus, intranodal necrosis, reticulation, calcification, matting, soft-tissue
edema, and peripheral vascularity.

etastatic cervical lymph nodes vascular resistance of lymph nodes can also

M are common in patients with head

Received August 4, 2004; accepted after revision
September 30, 2004.
1Department of Diagnostic Radiology and Organ Imaging,
The Chinese University of Hong Kong, Prince of Wales
Hospital, Shatin, Hong Kong SAR, China.
2Department of Optometry and Radiography, The Hong Kong
Polytechnic University, Hung Hom, Kowloon, Hong Kong
SAR, China. Address correspondence to M. Ying.
AJR 2005;184:1691–1699
0361–803X/05/1845–1691
© American Roentgen Ray Society
and neck [1] and non–head and
neck [2] cancers. In patients with
squamous cell carcinoma in the head and
neck, the presence of a metastatic node re-
duces the 5-year survival rate to 50%, and
the presence of another metastatic node on
the contralateral side further reduces the 5-
year survival rate to 25% [3]. Therefore,
evaluation of cervical lymph nodes is impor-
tant in patients with cancers because it aids
in the assessment of patient prognosis and
helps in planning treatment. Cervical lymph
nodes are also common sites of involvement
of lymphoma; tuberculous lymphadenitis;
and other benign lymphadenitis such as
Kikuchi’s disease, Kimura’s disease, and
Rosai-Dorfman disease [4, 5].
Sonography is a useful imaging tool in
the assessment of cervical lymph nodes.
Gray-scale sonography is widely used in the
evaluation of the number, size, site, shape,
borders, matting, adjacent soft-tissue
edema, and internal architectures of cervical
lymph nodes. Although both color and
power Doppler sonography are routine, 3D
sonography is not commonly used to assess
the intranodal vascular distribution. With
the use of spectral Doppler sonography, the
be measured. The purpose of this article is to
briefly reiterate and illustrate the sono-
graphic features of normal and abnormal
cervical lymph nodes.
Normal and Reactive Lymph Nodes
In sonography examinations, cervical
lymph nodes are usually classified into
eight regions (Fig. 1). Normal and reactive
lymph nodes are usually found in subman-
dibular, parotid, upper cervical, and poste-
rior triangle regions. On gray-scale
sonography, normal and reactive nodes
tend to be hypoechoic compared with adja-
cent muscles and oval (short axis–to–long
axis ratio [S/L] < 0.5) except for subman-
dibular and parotid nodes, which are usu-
ally round (S/L ≥ 0.5), and to have an
echogenic hilus [6] (Fig. 2). The upper limit
in minimal axial diameter of normal and re-
active nodes is 9 mm for subdigastric and
submandibular nodes and 8 mm for other
cervical nodes [7].
On color Doppler, power Doppler, and
3D sonography, normal cervical nodes
show hilar vascularity or appear avascular,
and reactive nodes predominantly show hi-
lar vascularity [6] (Fig. 3). On spectral
Doppler sonography, normal and reactive

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Fig. 1.—Schematic diagram of neck shows classification of cervical lymph nodes in sonography examinations.

A B

Fig. 2.—Gray-scale sonograms of lymph nodes in healthy subjects.

A, Image of 45-year-old man shows normal intraparotid lymph node is hypoechoic and oval. Lymph node shows echogenic hilus (arrows), which is continuous with adjacent
soft tissues (arrowheads).
B, Image of 20-year-old man shows normal posterior triangle lymph node is hypoechoic, elliptic, and elongated (arrows). Arrowheads indicate echogenic hilus that is con-
tinuous with adjacent soft tissues.

nodes usually show low vascular resistance
(resistive index [RI] and pulsatility index
[PI]) [6] (Fig. 4). Inflammation causes va-
sodilatation, which increases blood flow
velocity in reactive lymph nodes. It may ex-
plain the low vascular resistance in reactive
lymph nodes given that high blood flow ve-
locity is always associated with a lower
vascular resistance.
Malignant Lymph Nodes
Malignant lymph nodes include meta-
static and lymphomatous nodes. On gray-
scale sonography, metastatic nodes are usu-
ally hypoechoic, round, and without
echogenic hilus (Fig. 5A). Coagulation ne-
crosis, which appears as a demarcated
echogenic focus, may be found in metastatic
nodes (Fig. 5A). Eccentric cortical hypertro-
phy is a useful sign to indicate focal tumor
infiltration (Fig. 5B). Lymph nodes with
cystic necrosis are suggestive of malig-
nancy, and intranodal cystic necrosis is com-
mon in metastatic nodes from squamous cell
carcinomas (Fig. 5C).
A proven metastatic lymph node with ill-
defined borders may suggest extracapsular
spread and patients may have a poor progno-

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A B

Fig. 3.—42-year-old man with palpable submandibular lymph nodes.

A, Color Doppler sonogram shows extensive vascularity originating in hilus and
branching radially toward periphery of lymph node (arrows). Subsequent fine-needle
aspiration cytology confirmed reactive node.
B, Power Doppler sonogram of same lymph node as in A shows hilar vascularity of
reactive lymph node (arrows).
C, Three-dimensional power Doppler sonogram of same lymph node as in A and B
shows hilar vascularity of reactive lymph node (arrows). More extensive vascularity
is shown on 3D power Doppler sonography than power Doppler sonography.

sis (Fig. 5D). Metastatic nodes from papil-
lary carcinoma of the thyroid may be
hyperechoic compared with adjacent mus-
cles and have punctate calcifications [8]
(Fig. 5E). In Hodgkin’s lymphoma and
non-Hodgkin’s lymphoma, lymph nodes
tend to be round, hypoechoic, and without
echogenic hilus and tend to show intranodal
reticulation [9] (Fig. 6).
On color Doppler, power Doppler, and 3D
sonography, metastatic and lymphomatous
nodes usually show peripheral (Fig. 7) or mixed
(Fig. 8) vascularity. On spectral Doppler sonog-
raphy, malignant lymph nodes tend to have high
RI and PI values [8] (Fig. 9). In metastatic
nodes, blood vessels within the nodes are com-
pressed by tumor cells, which grow and spread
and replace a large portion of the lymph node,
resulting in an increase in vascular resistance.
Gray-scale sonography has a sensitivity of
95% and a specificity of 83% in differentiating

A B
Fig. 4.—53-year-old man with confirmed reactive lymph nodes in neck.
A, Spectral Doppler sonogram shows low vascular resistance of lymph node with resistive index (RI) of 0.59 and pulsatility index (PI) of 0.94, which are lower than cutoff values
commonly used to differentiate benign and malignant nodes (RI, 0.7; PI, 1.5).
B, Longitudinal gray-scale sonogram of same lymph node as in A shows lymph node is hypoechoic and oval (arrows). Arrowheads indicate echogenic hilus where blood
vessels enter and leave lymph node.

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A B

C D

Fig. 5.—Gray-scale sonograms of patients with metastatic nodes.

A, Image of 63-year-old man with lung carcinoma and proven metastatic lymph
nodes in lower cervical and supraclavicular regions shows lower cervical node is
hypoechoic, round, and without echogenic hilus (arrows). Note intranodal coagula-
tion necrosis that appears as demarcated echogenic focus and is not continuous
with adjacent soft tissues (arrowheads).
B, Image of 60-year-old woman with carcinoma of breast and proven metastatic
nodes in supraclavicular region and internal jugular chain shows eccentric cortical
hypertrophy of upper cervical lymph node due to focal tumor infiltration (arrow-
heads).
C, Image of 70-year-old man with carcinoma of tongue and with bilateral metastatic
upper cervical lymph nodes shows one of metastatic upper cervical nodes is hypo-
echoic, round, and without echogenic hilus (arrows). Lymph node also shows multi-
ple areas of intranodal cystic necrosis (arrowheads).
D, Image of 25-year-old man with nasopharyngeal carcinoma and proven metastatic
nodes in posterior triangle shows metastatic node in posterior triangle with ill-
defined nodal borders (arrows), which indicates extracapsular spread.
E, Image of 44-year-old woman with papillary carcinoma of thyroid and associated
metastatic node in right upper cervical region shows metastatic node appears
hyperechoic (arrowheads) when compared with adjacent muscle and has intranodal
punctate calcification (arrow). These sonographic features are common in meta-
static nodes from papillary carcinoma of thyroid.
E

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Fig. 6.—68-year-old man with proven bilateral non-Hodgkin’s lymphomatous nodes in

submandibular region. High-resolution gray-scale sonogram shows lymphomatous node
appears hypoechoic, round, and without echogenic hilus and shows intranodal reticula-
tion—that is, micronodular appearance (arrows). (Reprinted with permission from [8])

A B

Fig. 7.—43-year-old woman with nasopharyngeal carcinoma and proven metastatic

nodes in posterior triangle.
A, Color Doppler sonogram shows metastatic node with peripheral vascularity
(arrows) that runs along periphery of nodes, with perforating branches into lymph
nodes.
B, Power Doppler sonogram of same lymph node as in A shows peripheral vascular-
ity (arrows) similar to that seen in A.
C, Three-dimensional power Doppler sonogram of same lymph node as in A and B
shows peripheral vascularity of lymph node (arrows) is better depicted on 3D power
Doppler sonography.
C

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A B
Fig. 8.—43-year-old man with proven non-Hodgkin’s lymphomatous nodes in posterior triangle.
A, Color Doppler sonogram shows lymphomatous node with both hilar (arrows) and peripheral (arrowhead) vascularity.
B, Power Doppler sonogram of same lymph node as in A shows hilar (arrows) and peripheral (arrowheads) vascularity similar to that seen in A.

Fig. 9.—41-year-old man with nasopharyngeal carcinoma and metastatic lymph

nodes in posterior triangle. Spectral Doppler sonogram shows high vascular resis-
tance of lymph node with resistive index (RI) of 0.85 and pulsatility index (PI) of 2.18,
which are higher than cutoff values commonly used to differentiate benign and
malignant nodes (RI, 0.7; PI, 1.5).

A B
Fig. 10.—Gray-scale sonograms of two patients with proven tuberculous lymphadenitis.
A, Image of 59-year-old woman shows two tuberculous nodes (arrows) matted together without normal intervening soft tissues. Note cystic necrosis within lymph nodes
(arrowheads), which is common in tuberculous lymphadenitis.
B, Image of 31-year-old woman shows hypoechoic and round tuberculous node in posterior triangle (arrows) with adjacent soft-tissue edema (arrowheads), which is common
in tuberculous lymphadenitis.

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A B

Fig. 11.—20-year-old man with proven tuberculous lymphadenitis.

A, Color Doppler sonogram shows tuberculous node in posterior triangle with hilar
vascularity (arrows) is being displaced by intranodal cystic necrosis (arrowheads).
B, Power Doppler sonogram of same lymph node as in A shows displaced hilar vas-
cularity (arrows) and intranodal cystic necrosis (arrowheads).
C, Three-dimensional power Doppler sonogram of same lymph node as in A and B
shows displaced vascularity (arrows); however, intranodal cystic necrosis (arrow-
heads) is not shown because 3D power Doppler sonography did not provide super-
imposed gray-scale image.
C

A B
Fig. 12.—30-year-old woman with palpable nodes in upper cervical region proven to be Kikuchi’s disease. (Reprinted with permission from [12])
A, Gray-scale sonogram of upper cervical node (small arrows) shows node is hypoechoic and elliptic and has echogenic hilus (arrowheads). Large arrows indicate common
carotid artery, and asterisk indicates internal jugular vein. Note gray-scale sonographic appearance of lymph nodes in Kikuchi’s disease is similar to that of reactive nodes.
B, Power Doppler sonogram of same lymph node as in A (arrows) reveals that lymph node involved with Kikuchi’s disease shows hilar vascularity (arrowheads) that is similar
to vascular pattern of reactive lymph nodes.

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A B

Fig. 13.—42-year-old man with palpable nodes in submandibular area that were subsequently proven to be Kimura’s disease.
A, Gray-scale sonogram shows submandibular lymph node (arrows) is hypoechoic, is round, and has echogenic hilus (arrowheads). Gray-scale sonographic appearance
is similar to that of reactive nodes except that lymph nodes in Kimura’s disease tend to be round and are located in the vicinity of the salivary glands.
B, Power Doppler sonogram of same lymph node as in A (arrows) shows extensive hilar vascularity (arrowheads), which is similar to vascular pattern of reactive lymph nodes.

A B

Fig. 14.—13-year-old boy with palpable nodes in submental and submandibular areas that were subsequently proven to be Rosai-Dorfman disease.
A, Gray-scale sonogram shows two submental nodes that are hypoechoic, round, and without echogenic hilus (arrows). Sonographic appearance is similar to that of malig-
nant nodes.
B, Power Doppler sonogram of same submental node as in A shows peripheral vascularity (arrows), which is similar to malignant lymph nodes.

metastatic and reactive nodes [10]. Color or
power Doppler sonography is essential and
useful to patients when gray-scale sonogra-
phy is equivocal. In one study, power Doppler
sonography aided in the diagnosis of 5% of
patients with metastatic nodes and 17% of pa-
tients with reactive nodes [10].
Tuberculous Lymph Nodes
On gray-scale sonography, tuberculous
nodes tend to be hypoechoic, round, and with-
out echogenic hilus and tend to show intranodal
cystic necrosis, nodal matting, and adjacent
soft-tissue edema [8] (Fig. 10). On color Dop-
pler, power Doppler, and 3D sonography, the
vascular distribution of tuberculous nodes is
varied and simulates benign and malignant
nodes. However, displacement of hilar vascu-
larity is common in tuberculous nodes and is
due to the high incidence of intranodal cystic ne-
crosis, which displaces the vessels, in tubercu-
lous nodes [11] (Fig. 11).
Unusual Lymphadenopathy
Diseases such as Kikuchi’s disease (histio-
cytic necrotizing lymphadenitis), Kimura’s
disease (eosinophilic hyperplastic lymphogranu-
loma), and Rosai-Dorfman disease (sinus histi-
ocytosis with massive lymphadenopathy) may
show benign and inflammatory lymphadenopa-
thy in the neck. Kikuchi’s disease is a self-lim-
iting and benign lymphadenitis in which
cervical nodes are usually affected. Kimura’s
disease is an autoimmune eosinophilic granulo-

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 Sonographic Evaluation of Cervical Lymph Nodes
matous disorder with generalized lymphaden-
opathy. Rosai-Dorfman disease is a rare
idiopathic benign histiocytic proliferation, and
massive lymphadenopathy is usually found in
the neck region with predominant sinusoidal
histiocyte infiltration.
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On sonography, lymph nodes involved with
Kikuchi’s and Kimura’s diseases have an ap-
pearance similar to that of reactive nodes,
which tend to be hypoechoic, and have an
echogenic hilus. In patients with Kikuchi’s dis-
ease, lymph nodes are usually oval (Fig. 12A),
whereas lymph nodes in patients with
Kimura’s disease are usually round (Fig. 13A).
On power Doppler sonography [12, 13], lymph
nodes in patients with Kikuchi’s disease and
Kimura’s disease tend to show hilar vascular-
ity [12, 13] (Figs. 12B and 13B). In patients
with Rosai-Dorfman disease, involved lymph
nodes appear similar to malignant nodes,
which are hypoechoic, round, and without
echogenic hilus (Fig. 14A). On power Doppler
sonography, involved lymph nodes in Rosai-
Dorfman disease also have an appearance sim-
ilar to that of malignant nodes and show pe-
ripheral or mixed vascularity [12] (Fig. 14B).
AJR:184, May 2005
Because the sonographic appearance of these
unusual lymphadenopathies is similar to that
of reactive or malignant nodes, the diagnosis is
still based on histology.
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