Name the level, measure the short axis, then the features that matter more than size: loss of the fatty hilum, rounded shape, necrosis, cystic change, calcification, peripheral vascularity and extranodal extension.
Orient first
- Size thresholds are level-dependent and insensitive; morphology beats size.
- Necrosis in a node is metastatic until proven otherwise (in endemic regions, tuberculosis is the main alternative).
- Cystic nodes in level II in a young adult: HPV-related oropharyngeal or thyroid papillary metastasis.
Acquire the study
- Linear probe ≥ 10 MHz; transverse and longitudinal planes of each level; colour Doppler.
The manoeuvre
- Level I–VI; short-axis diameter in mm and short-to-long axis ratio (> 0.5 rounded).
- Echogenic fatty hilum present vs absent.
- Colour Doppler: hilar (benign) vs peripheral or chaotic (malignant) vascularity.
- Cystic change, microcalcification (thyroid papillary), matting and surrounding oedema (TB).
What confirms it
- Abnormal morphology with cytology or histology.
What licenses you to exclude it
- Oval nodes with a preserved fatty hilum and hilar flow are reactive in most cases.
The classic misread
- Calling a normal submandibular node abnormal because of size alone.