Cervical lymphadenopathy is a frequent clinical finding encountered in surgical, medical and ENT practice. It may result from benign self-limiting infections, tuberculosis, chronic inflammatory lesions, lymphoma or metastatic malignancy. Because clinical presentation may overlap between benign and malignant causes, systematic evaluation is essential. Lymphadenopathy is recognized as a common abnormal physical finding and may be caused by neoplastic, inflammatory or infectious etiologies.

In regions with a high tuberculosis burden, tubercular lymphadenitis remains an important cause of cervical lymph node enlargement. Tuberculosis continues to be a major global public health problem, and the WHO Global Tuberculosis Report 2023 provides an updated assessment of tuberculosis burden, diagnosis and treatment progress worldwide.

Cervical tubercular lymphadenitis commonly presents as chronic lymph node enlargement and may occur with or without constitutional symptoms. The present study also shows that constitutional symptoms were absent in a majority of tubercular cases, emphasizing that clinical symptoms alone cannot reliably exclude tuberculosis.

Fine-needle aspiration cytology is widely used as an initial diagnostic investigation for cervical lymphadenopathy because it is simple, minimally invasive, rapid and cost-effective. However, FNAC may be inconclusive or may show non-specific findings in some cases. Histopathological examination remains important when FNAC is inconclusive, when lymphoma is suspected, or when clinical findings and cytology do not correlate.

Recent evidence continues to support FNAC as an important diagnostic tool for tuberculous lymphadenitis, although molecular tests such as GeneXpert/Xpert MTB/RIF and Xpert Ultra may improve microbiological confirmation in extrapulmonary tuberculosis. WHO consolidated TB diagnostic guidelines state that Xpert MTB/RIF may be used in lymph node aspirate or lymph node biopsy specimens as an initial diagnostic test in suspected extrapulmonary TB, and Xpert Ultra may also be used in lymph node aspirate and biopsy specimens.

The present study was conducted to evaluate the clinicopathological spectrum of cervical lymphadenopathy, with special reference to tubercular lymphadenitis, and to compare FNAC findings with histopathological diagnosis.

Aim

To study the clinicopathological profile of cervical lymphadenopathy with special reference to tubercular lymphadenitis.

Objectives

• To evaluate the clinical and histopathological spectrum of cervical lymphadenopathy among patients presenting with cervical lymph node enlargement.
• To assess the diagnostic utility of FNAC in comparison with histopathological examination for major causes of cervical lymphadenopathy.

Study Design

This was a prospective observational study.

Place of Study

Department of ENT, Dr. Patnam Mahender Reddy Institute of Medical Sciences, Chevella, Rangareddy District, Telangana.

Study Period

October 2024 to March 2025.

Study Population

The study included patients presenting with cervical lymph node enlargement during the study period.

Sample Size

A total of 100 consecutive patients with cervical lymphadenopathy were included.

Inclusion Criteria

Patients aged more than 12 years presenting with cervical lymph node enlargement were included.

Exclusion Criteria

Patients below 12 years of age and patients in whom FNAC and/or biopsy of the lymph node could not be performed were excluded.

Clinical Evaluation

After obtaining institutional ethical approval and written informed consent, detailed clinical history was recorded, including duration of swelling, constitutional symptoms and history of contact with tuberculosis. A complete general physical examination and local examination of cervical lymph nodes were performed. Relevant investigations included FNAC, lymph node biopsy, contrast radiological investigations and endoscopy wherever indicated. The  source methodology describes FNAC, biopsy, radiological investigations and relevant endoscopic evaluation as part of the diagnostic work-up.

Cytological and Histopathological Evaluation

All cases underwent FNAC. Excisional biopsy was performed in all cases, and histopathological examination was considered the final diagnostic standard.

Treatment Approach

Medical treatment was used predominantly for tubercular lymphadenitis and infective lymph node swellings. Cases confirmed as tubercular lymphadenitis were treated according to standard antitubercular treatment regimens. Abscesses were drained surgically, and sinus tracts were excised where required. Neoplastic lesions were referred for oncology evaluation and managed according to site-specific protocols.

Statistical Analysis

Data were expressed as frequencies and percentages. FNAC findings were compared with histopathological diagnosis. Sensitivity and specificity were calculated for major diagnostic categories using histopathology as the reference standard.

Patient Flow and Diagnostic Evaluation

A total of 100 patients presenting with cervical lymphadenopathy were included in the study. All patients underwent detailed clinical evaluation and fine-needle aspiration cytology. Excisional biopsy with histopathological examination was performed in all 100 cases and was considered the final diagnostic standard. FNAC yielded a diagnostic result in 94 cases [94.0%], while 6 cases [6.0%] were inconclusive.

Table 1. Patient Flow and Diagnostic Evaluation, n = 100

All patients underwent histopathological confirmation. FNAC was diagnostic in most cases, but 6% required histopathological confirmation because of inconclusive cytology.

Age and Sex Profile

The majority of patients were young, with 73 patients [73.0%] in the 12–40 years age group. The maximum number of cases was seen in the 21–30 years age group, comprising 36 cases [36.0%]. The second and third decades together accounted for 59 cases [59.0%]. The male-to-female ratio was 1.22:1.

Table 2. Age-Related Distribution, n = 100

Cervical lymphadenopathy was most common among young adults, particularly in the 21–30-year age group.

Constitutional Symptoms

Constitutional symptoms were present in 42 patients [42.0%] and absent in 58 patients [58.0%]. Symptoms were present in 16 of 51 tubercular lymphadenitis cases [31.4%], 19 of 31 chronic non-specific/reactive lymphadenitis cases [61.3%], 2 of 8 malignant secondaries [25.0%], and 5 of 10 lymphoma cases [50.0%].

Table 3. Constitutional Symptoms According to Histopathological Diagnosis, n = 100

Constitutional symptoms were present in less than half of all cases. They were not specific for tubercular lymphadenitis, as only 31.4% of tubercular cases had constitutional symptoms.

Histopathological Diagnosis

Histopathological examination showed that 51 cases [51.0%] were tubercular lymphadenitis, 16 cases [16.0%] were reactive lymphadenitis, 15 cases [15.0%] were chronic non-specific lymphadenitis, 8 cases [8.0%] were malignant secondaries, and 10 cases [10.0%] were lymphomas. Overall, 82 cases [82.0%] were non-neoplastic and 18 cases [18.0%] were neoplastic.

Table 4. Histopathological Distribution of Cervical Lymphadenopathy, n = 100

Tubercular lymphadenitis was the most common histopathological diagnosis.

Table 5. Broad Diagnostic Category, n = 100

             Non-neoplastic causes predominated, with tuberculosis forming the largest subgroup.

FNAC Diagnosis Compared with Histopathology

FNAC diagnosed tubercular lymphadenitis in 41 cases, chronic non-specific lymphadenitis in 22 cases, reactive lymphadenitis in 15 cases, malignant secondaries in 7 cases, Hodgkin’s lymphoma in 2 cases, and Non-Hodgkin’s lymphoma in 7 cases. Histopathology confirmed tubercular lymphadenitis in 51 cases, chronic non-specific lymphadenitis in 15 cases, reactive lymphadenitis in 16 cases, malignant secondaries in 8 cases, Hodgkin’s lymphoma in 2 cases, and Non-Hodgkin’s lymphoma in 8 cases.

Table 6. FNAC Diagnosis Compared with Histopathological Diagnosis, n = 100

FNAC diagnostic categories total 94 because 6 FNAC reports were inconclusive.

FNAC showed good diagnostic agreement with histopathology, particularly for neoplastic lesions. However, some tubercular lymphadenitis cases were reported as chronic non-specific lymphadenitis on FNAC, emphasizing the need for histopathological confirmation where clinical suspicion persists.

Tubercular Lymphadenitis Profile

Tubercular lymphadenitis was diagnosed in 51 cases [51.0%]. The posterior triangle was the most commonly involved cervical lymph node group, seen in 31.3% of tubercular cases, followed by the upper deep jugular group in 21.5%. Multiple-site involvement was observed in about 30.0% of tubercular cases. Discrete lymph nodes were seen in 37 of 51 cases [72.6%], while matted lymph nodes were observed in 14 cases [27.4%]. Caseation was present in 24 cases [47.0%].

Table 7. Clinicopathological Features of Tubercular Lymphadenitis, n = 51

Tubercular lymphadenitis most commonly presented as discrete unilateral cervical lymphadenopathy. Caseation was seen in nearly half of the tubercular cases.

Lymphoma Profile

Among the 10 histopathologically confirmed lymphoma cases, 8 cases [80.0%] were Non-Hodgkin’s lymphoma and 2 cases [20.0%] were Hodgkin’s lymphoma. Multiple-site involvement was present in 9 of 10 cases [90.0%], constitutional symptoms in 5 of 10 cases [50.0%], generalized nodal involvement in 3 of 10 cases [30.0%], axillary involvement in 2 of 10 cases [20.0%], and inguinal involvement in 1 of 10 cases [10.0%].

Table 8. Lymphoma Profile, n = 10

Non-Hodgkin’s lymphoma was more common than Hodgkin’s lymphoma. Most lymphoma cases had multiple-site involvement.

Malignant Secondaries

Malignant secondaries were diagnosed in 8 cases [8.0%]. The primary site was larynx in 2 cases, thyroid in 2 cases, and parotid in 1 case. In 3 cases, the primary site remained unknown despite diagnostic evaluation.

Table 9. Distribution of Primary Site in Malignant Secondaries, n = 8

Larynx and thyroid were the commonest identified primary sites. Three cases were classified as carcinoma of unknown primary.

FNAC Diagnostic Performance

FNAC showed 80.4% sensitivity and 100.0% specificity for tubercular lymphadenitis. For chronic non-specific lymphadenitis, sensitivity was 73.3% and specificity was 87.0%. For malignant secondaries, sensitivity was 87.5% and specificity was 100.0%. For lymphoma, sensitivity was 90.0% and specificity was 100.0%.

Table 10. Sensitivity and Specificity of FNAC Compared with Histopathology

FNAC showed high specificity across major diagnostic groups, indicating that positive FNAC findings were reliable. However, lower sensitivity for tubercular lymphadenitis and chronic non-specific lymphadenitis indicates that histopathology remains important in inconclusive or clinically discordant cases.

Follow-Up of Tubercular Lymphadenitis

Of the 51 tubercular lymphadenitis cases, 6 cases did not attend regular follow-up. Among the remaining 45 followed-up cases, 35 cases [77.8%] showed uneventful resolution. Fresh nodes developed in 4 cases [8.9%], which later resolved with continuation of treatment. Abscess requiring drainage occurred in 2 cases [4.4%], and 4 cases [8.9%] had residual lymph nodes at the end of therapy.

Table 11. Follow-Up Outcome in Tubercular Lymphadenitis, n = 45

Most followed-up cases of tubercular lymphadenitis resolved with medical treatment. Surgery had a limited adjunctive role in cases presenting with abscess or sinus.

The present prospective observational study evaluated 100 patients with cervical lymphadenopathy. Histopathology showed that most cases were non-neoplastic [82.0%], while neoplastic lesions accounted for 18.0%. Tubercular lymphadenitis was the most common diagnosis, accounting for 51.0% of all cases. This finding is consistent with the continued importance of tuberculosis as a cause of lymph node enlargement in high-burden settings.

The majority of patients in the present study were young, with 73.0% in the 12–40-year age group. The highest number of cases was in the 21–30-year age group [36.0%]. This age pattern supports the observation that cervical lymphadenopathy, particularly tubercular lymphadenitis, commonly affects younger patients in endemic regions.

Constitutional symptoms were present in only 42.0% of all cases. Among tubercular lymphadenitis cases, symptoms were present in 31.4%, while 68.6% had no constitutional symptoms. This shows that absence of fever, weight loss or other constitutional symptoms does not exclude tubercular lymphadenitis. Therefore, pathological confirmation remains necessary when clinical suspicion persists.

Histopathology identified tubercular lymphadenitis in 51.0%, reactive lymphadenitis in 16.0%, chronic non-specific lymphadenitis in 15.0%, malignant secondaries in 8.0%, and lymphoma in 10.0%. The predominance of non-neoplastic causes is comparable with earlier clinicopathological studies from India and similar settings, where tuberculosis and reactive/inflammatory conditions frequently form the major diagnostic groups.

The present study found FNAC sensitivity and specificity of 80.4% and 100.0%, respectively, for tubercular lymphadenitis. This is close to Adhikari et al., who reported FNAC sensitivity of 80.0% and specificity of 100.0% for tubercular lymphadenopathy.

For chronic non-specific lymphadenitis, FNAC sensitivity and specificity were 73.3% and 87.0%, respectively. For malignant secondaries, sensitivity and specificity were 87.5% and 100.0%, while for lymphoma they were 90.0% and 100.0%. These findings indicate that FNAC had high specificity across major diagnostic groups, but sensitivity varied by lesion type.

A recent prospective clinicopathological study of cervical lymphadenopathy reported FNAC sensitivity and specificity of 75.5% and 98% for tuberculosis, 64% and 100% for lymphoma, 80% and 100% for metastatic secondaries, and 79% and 86% for reactive lymphadenitis. Compared with that study, the present study showed similar specificity and slightly higher sensitivity for lymphoma, but the same conclusion applies: FNAC is useful as a frontline test but does not replace histopathology.

The present study found that FNAC diagnosed tuberculosis in 41 of 51 histopathologically confirmed tubercular cases. The remaining tubercular cases were mainly diagnosed as chronic non-specific lymphadenitis on FNAC. This highlights the limitation of cytology when granulomatous or necrotic features are not adequately represented in aspirated material.

Recent studies evaluating tuberculosis lymphadenitis have emphasized that FNAC is useful but may be strengthened by adjunctive tests. Kumbi et al. reported FNAC sensitivity of 83.3% and specificity of 94.8% for TB lymphadenitis, and recommended GeneXpert testing on FNA material to reduce missed smear-negative cases.

Molecular diagnostic methods are increasingly relevant in suspected extrapulmonary TB. Xpert MTB/RIF Ultra has shown variable performance by specimen site; in one Scientific Reports study, lymph node aspirate/biopsy specimens showed Xpert Ultra sensitivity of 87.5% but lower specificity of 51.08% compared with culture. These data support a combined diagnostic approach rather than reliance on a single test.

The tubercular lymphadenitis subgroup in the present study showed discrete lymph nodes in 72.6%, matting in 27.4%, caseation in 47.0%, unilateral cervical involvement in 80.3%, and bilateral involvement in 19.7%. Posterior triangle involvement was commonest [31.3%], followed by upper deep jugular group [21.5%]. These findings are consistent with the classical clinical pattern of cervical tubercular lymphadenitis.

Among lymphoma cases, Non-Hodgkin’s lymphoma was more common [80.0%] than Hodgkin’s lymphoma [20.0%]. Multiple-site involvement was observed in 90.0% of lymphoma cases, supporting the need for careful systemic examination and histopathological confirmation when lymphoma is suspected.

Malignant secondaries accounted for 8.0% of cases. Primary sites included larynx, thyroid and parotid, while three cases remained carcinoma of unknown primary. This finding reinforces the importance of ENT evaluation, imaging and endoscopy in adult cervical lymphadenopathy, especially when metastatic disease is suspected.

Follow-up among tubercular lymphadenitis cases showed that 35 of 45 followed-up cases [77.8%] resolved uneventfully. Fresh nodes developed in 4 cases [8.9%], abscess requiring drainage occurred in 2 cases [4.4%], and residual lymph nodes persisted in 4 cases [8.9%]. These findings support medical treatment as the mainstay of tubercular lymphadenitis management, with surgery reserved for diagnostic biopsy, abscess drainage, sinus excision or persistent nodes.

Overall, the present study confirms that cervical lymphadenopathy requires a structured clinical, cytological and histopathological approach. FNAC is a valuable frontline investigation, but histopathological examination remains the most dependable confirmatory tool, especially in inconclusive FNAC, suspected lymphoma and clinically discordant cases.,

Comparison with Previous Studies

Cervical lymphadenopathy is a common clinical condition with a broad etiological spectrum. In the present study, non-neoplastic lesions predominated, and tubercular lymphadenitis was the most common diagnosis. Constitutional symptoms were not reliable indicators of tubercular etiology, as most tubercular cases did not show constitutional symptoms. FNAC was a useful frontline investigation with high specificity, but histopathological examination remained the most dependable diagnostic tool. Tubercular lymphadenitis responded well to medical treatment in most followed-up cases, while surgery had a limited adjunctive role for biopsy, abscess drainage, sinus excision and persistent nodes.

Limitations

This was a single-centre observational study. Molecular tests such as GeneXpert/Xpert MTB/RIF, mycobacterial culture and drug-resistance testing were not included in the result dataset. Long-term follow-up was available only for tubercular lymphadenitis cases, and 6 tubercular cases were lost to regular follow-up.

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