PEDIATRICS Vol. 105 No. 2 February 2000, pp. 467

Benign Enlargement of the Mandibulofacial Lymph Node

To the Editor.

Several patients have been seen in an office setting over the last 10 years, with a small mobile lump, located on the side of the face over the mandible. A prospective study was made over a 2-year period to document the phenomenon, because a search of the English medical literature failed to extract a single article that could provide a benign clinical cause for it.

In this series of 14 patients, 9 of whom were girls, the ages ranged from 2 to 15 years. The lumps were identified as lymph nodes, located subcutaneously over the mandible, anterior to the masseter muscle, and in close proximity to the facial artery. They were in the same location in all patients and were half to 1 cm in diameter. They were mobile and were grasped with some difficulty between the thumb and index finger.

Three patients had ipsilateral oral ulcers. In a fourth patient a gingival ulcer was reportedly present 2 weeks before presentation. A healing skin ulcer with mild edema of the lip was present on the same side as the node in a single patient. Two patients had a concomitant otitis media, and another 2 patients had signs of an upper respiratory tract infection. In all other patients, the lymph node enlargement was the only physical finding. Although bilateral enlargement was present in 2 patients, 8 of the remaining 12 had a right-sided node. An excisional biopsy was done on only 1 patient. This revealed lymphoid tissue with prominent germinal centers near the cortex, and mild sinus histiocytosis. On follow-up examinations of these patients over a 6-month period, the nodes were no longer palpable in all but 1 patient.

The lymph nodes of the head and neck have been variously described in the literature. The classic reference is Rouviere,¹ who divided them into 10 groups. One such group consists of the facial lymph nodes, which are very inconsistently present in the head and neck. They are believed to be present in only 10% of the population.¹

Although Rouviere further divided the facial nodes into 4 subsetsinferior maxillary, buccinator, infraorbital (nasolabial), and malar nodesa fifth subset (retrozygomatic nodes) was described by Tart et al.²

Our attention has been drawn to the inferior maxillary or mandibular lymph node. This node must be distinguished from the buccinator nodes, which are found deep in the muscles of facial expression and may be palpable by grasping the cheek with the thumb and index finger of the same hand.³ It must also be distinguished from the submandibular nodes, which are found between the mandible and the posterior bellies of the digastric muscles.

There is usually 1 inferior maxillary node, sometimes 2, and rarely 3.¹ This node is found near the inferior border of the mandible or along its lateral slope. The afferent lymphatics are from the infraorbital and buccinator lymph nodes, as well as from the lower lip and cheek. The node is rarely connected with the gingival lymphatics and very rarely with those of the hard and soft palates.^1,2 To avoid confusion as to location, we suggest the use of the term mandibulofacial lymph node.

In the absence of any cutaneous lesions in all but 1 of our patients and given the fact that 4 patients had associated oral lesions, we suggest that the lymph node most probably enlarges because of intraoral gingival mucosal lesions. In some of the other patients, it is conceivable that oral lesions had healed at the time the nodes were brought to our attention.

Facial lymph nodes are uncommonly involved in neoplastic disease, but involvement of the mandibulofacial lymph node is very rare.^2,4 In adults, disease of these nodal groups may be the sole manifestation of a lymphoma.⁴

These observations indicate that in a pediatric population, enlargement of the mandibulofacial lymph node is usually a benign finding, with no consequences. It is important that clinicians are made aware of this physical sign, so that unnecessary investigations may be avoided, and the patient and family should be reassured that the node is not malignant. Appropriate follow-up may be necessary in selected cases.

Errol C. Baptist, MD, FAAP and Martha H. Villalba, BA
University of Illinois
College of Medicine at Rockford
Rockford, IL 61107

REFERENCES

1. Rouviere H. Anatomie des Lymphatiques del'homme. Paris, France: Masson et Cie, 1932. Translated by: Tobias MJ: as: Anatomy of the Human Lymphatic System. Ann Arbor, MI: Edwards Bros. Inc; 1938:chap 2
2. Tart RP, Mukherji SK, Avino AJ, Facial lymph nodes: normal and abnormal CT appearances. Radiology. 1993; 188:695-700 [Abstract/Free Full Text]
3. Weidman B, Warman E Lymph nodes of the head and neck. J Oral Med. 1980; 35:39-43 [Medline]
4. Robbins J, Fitzhugh G, Constable W Involvement of the buccinator node in facial malignancy. Arch Otolaryngol. 1971; 94:356-358 [CrossRef][Medline]