Lymph Examination 2013

7/27/2019 Lymph Examination 2013

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PHYSICAL EXAMINATION OF

THE LYMPHATIC SYSTEMRussell C Hendershot DO, MS, FAAFP


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Determine the routine history for a patient with

lymphadenopathy

Define appropriate questions

Demonstrate an appropriate regional and generalexamination of the lymphatic system

Synthesize how to incorporate such examination

within the confines of problem focused examination

OBJECTIVES


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LYMPH DISTRIBUTION

lymph fluid andcollecting ducts

tissues : lymph nodes,spleen, thymus, tonsils,

adenoids, and Peyerpatches. (the mucosa ofthe stomach andappendix, bone marrow,and lungs)

Except for the placentaand the brain, everytissue supplied by bloodvessels has lymphaticvessels.


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FUNCTIONS

Production of lymphocytes ( lymph nodes, tonsils,

adenoids, spleen, and bone marrow)

Production of antibodies

Phagocytosis,Absorption of fat and fat-soluble substances from

the intestinal tract

Manufacture of blood (when the primary sources

are pathophysiologically compromised ) spread of malignancy.


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LYMPHATIC TRAVELS

The drainage point for

the right upper body is

a lymphatic trunk that

empties into the right

subclavian vein. Thethoracic duct, the major

vessel of the lymphatic

system, drains lymph

from the rest of thebody into the left

subclavian vein.


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NODES MOST ACCESSIBLETO INSPECTION

AND PALPATION

Parotid and retropharyngeal (tonsillar)

Submandibular

Submental

Sublingual (facial)

Superficial anterior cervical

Superficial posterior cervical Preauricular and postauricular

Sternocleidomastoid

Occipital

Supraclavicular

The Arms Axillary Epitrochlear (cubital)

The Legs Superficial superior inguinal

Superficial inferior inguinal

Occasionally, popliteal


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THYMUS

The thymus is located in thesuperior mediastinum,extending upward into thelower neck. In early life thethymus is essential to thedevelopment of the

protective immune function.It is the site for production ofT-lymphocytes, the effectorcells for cell-mediatedimmunity reactions and thecontrolling agent for thehumoral immune responsesgenerated by B-lymphocytes. In the adult,however, it has little or nodemonstrated function.


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SPLEEN

The spleen is situated inthe left upper quadrant ofthe abdominal cavitybetween the stomachand the diaphragm. A

highly vascular organ, itis composed of twosystems: (1) the whitepulp, made up oflymphatic nodules anddiffuse lymphatic tissue,

and (2) the red pulp,made up of venoussinusoids.


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TONSILS AND ADENOIDS

The palatine tonsils arecommonly referred to as"the tonsils." Small /diamond-shaped, they areset between the palatinearches on either side ofthe pharynx just beyond

the base of the tongue. The pharyngeal tonsils, or

adenoids, are located atthe nasopharyngealborder;

the lingual tonsils arelocated near the base of

the tongue. They enlargegradually from birth toabout seven years of ageand then shrink.


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CLINICALPEARLS : GENERALIZATIONS

Lymph nodes usuallyoccur in groups.

Superficial nodes arelocated in subcutaneousconnective tissues

deeper nodes lie beneaththe fascia of muscles andwithin the various bodycavities.

The nodes are numerousand tiny, but some ofthem may havediameters as large as 0.5to 1 cm.


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CLINICALPEARLS

The lymph nodes have the same distribution in children that theydo in adults.

The finding of small 12- to 13-mm, discrete, palpable, mobilenodes in the neonate is not unusual. Before 2 years of age,inguinal, occipital, and postauricular nodes are common; after 2years of age, they are more likely to have significance.

Cervical and submandibular nodes are uncommon during thefirst year and much more common in older children.Supraclavicular nodes are not usually found; their presence,associated with a high incidence of malignancy, is always acause for concern

OLDER ADULTSThe number of lymph nodes may diminish andsize may decrease with advanced age; some of the lymphoidelements are lost. The nodes of older patients are more likely tobe fibrotic and fatty than those of the young, a contributing factorin an impaired ability to resist infection


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CLINICAL PEARLS

INFANTSAND CHILDREN. The mass of lymphoid tissue isrelatively plentiful in infants; increases during childhood,especially between 6 and 9 years of age; then regresses toadult levels by puberty

The umbilical cordshould drop off by 1 to 2 weeks after birth.

If it hangs on much longer than that, there may be acongenital defect of the immune system.

The thymus is at its largest relative to the rest of the bodyshortly after birth, but reaches its greatest absolute weight atpuberty. Then it involutes, replacing much of its tissue with fatand becoming a rudimentary organ in the adult.

Thepalatine tonsils, like much lymphoid tissue, are muchlarger during early childhood than after puberty. Anenlargement of the tonsils in children is not necessarily anindication of problems.


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LYMPHADENOPATHY

HISTORY OF PRESENT ILLNESS

Bleeding Site: nose, mouth, gums, rectal (blood in stools; black, tarry stools), skin

petechiae, easy bruising, blood in vomitus

Character: onset, frequency, duration, amount, color (bright red or brownto coffee-colored)

Associated symptoms: pallor, dizziness, headache, shortness of breath

Enlarged nodes Character: onset, location, duration, number, tenderness

Associated symptoms: pain, fever, redness, warmth, red streaks, itching(some tumors cause pruritus)

Predisposing factors: infection, surgery, trauma

Swelling of extremity Unilateral or bilateral, intermittent or constant, duration

Predisposing factors: cardiac or renal disorder, surgery, infection, trauma,venous insufficiency

Associated symptoms: warmth, redness or discoloration, ulceration

Efforts at treatment and their effect: support stockings, elevation

Medications: chemotherapy, antibiotics

Complementary and alternative therapies, if any


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MEDICATIONS THAT MAY CAUSE

LYMPHADENOPATHY

Allopurinol (Zyloprim)Atenolol (Tenormin)Captopril (Capozide)Carbamazepine (Tegretol)Cephalosporins

GoldHydralazine (Apresoline)

PenicillinPhenytoin (Dilantin)Primidone (Mysoline)Pyrimethamine (Daraprim)

QuinidineSulfonamidesSulindac (Clinoril)

Diphenylhydantoin,

aspirin,

barbiturates,

tetracycline,

iodide, mesantoin,


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PAST MEDICAL HISTORY

Chest x-rays

Tuberculosis and other skin testing

Blood transfusions, use of blood products ; hemophilia

Chronic illness: cardiac, renal, malignancy, HIV infection

Surgery: trauma to regional lymph nodes; organ

transplant

Recurrent infections

Autoimmune disorder

HIV risk factors in all patients: sexual practices, IV drug use,

blood transfusion, work history, needle exposure, birth hx


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HISTORYCONTD

Travel hx TB, trypanosomiasis, scrub typhus,

leishmaniais, tularemia, plague, anthrax

Soc hx etoh, tobacco, ultraviolet exposure;

metastatic carcinoma

Occ hx - silicon or beryllium

Sex hx HIV risk factors; AIDS (kaposis sarcoma;

non-Hodgkins lymphoma

Fam hx breast cancer, melenoma, Malignancy,Anemia ,Recent/recurrent infections , Tuberculosis ,

Agammaglobulinemia, severe combined immune

deficiency, other immune disorders ,Hemophilia


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HISTORY

INFANTSANDCHILDREN

Recurrent infections:tonsillitis, adenoiditis,bacterial infections, oralcandidiasis, chronic diarrhea

Present or recent infections,

trauma distal to nodes Poor growth, failure to thrive

Loss of interest in play oreating

Immunization history

Maternal HIV infection Hemophilia

Illness in siblings

PREGNANTWOMEN

Weeks of gestation

Exposure to rubella and otherinfections

Presence of children and

pets in household

OLDERADULTS

Presence of an autoimmunedisease

Present or recent infection or

trauma distal to nodes Delayed healing


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ROS FEATURESASSOCIATEDWITHENLARGED

NODESANDDISEASE

Mononucleosisfatigue, malaise, fever,cervicallymphadenopathy;

possible enlargementof spleen

Hodkins Lymphomafever night sweats,weight loss, B

symptoms,Autoimmune disease -

arthralgias, muscleaches, rash


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PHYSICAL EXAMINATION OF LYMPHATIC

SYSTEM

Complete lymphatic

exam ; r/o generalized

lymphadenopathy

Skin look for

suspicious lesions or

trauma

Spleen any

enlargement is rare

and usually notpalpable

The lymphatic system

is examined by

inspection and

palpation, usually

region by region duringexamination of the

other body systems,

and by palpating the

liver and spleen

PALS;PPrimary site, A All associated nodes

L Liver , SSpleen, ,


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PHYSICAL EXAM

Seven distinct regionsdrain into the great veinsnear the base of the neck

Adult 400-500 LNs

30 arm/axilla; 20 leg; 60-70 head/neck; remainingdeep in thorax andabdomen and NOTpalpable

Only deep nodes that arepalpable are the deepcervical (carotid, SCM)and axillary.


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PHYSICAL EXAMINATION OF LYMPHATIC

SYSTEM

Use pads of the fingers2-4 to lightly palpate

Generally not able to feel

If nodes are palpated

explore adjacent areasfor signs of infection

shotty nodes ; grouped,small, movable, discrete,

less than a centimeter indiameter that move underyour fingers


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CLINICAL PEARL; NODES

Enlarged nodes

characterized according

to : location, size, shape,

consistency, tenderness,

movability or fixation anddiscreteness.

Lymph nodes that are

enlarged and juxtaposed

so that they feel like a

large mass rather thandiscrete nodes are

described as "matted."

Problem: large, fixed,

matted, inflamed or

tender

Note any vascularity,heat, pulsations

(vessel)or

transillumination(cyst)


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CLINICAL PEARLS ; NODES

Tenderness inflammation;may be from necrosis andbleeding

Cancerous nodes usuallynot tender, vary in size,

discrete to matted, may behard, and asymetrical

Bacterial infections warm,tender, matted

*drainage may determine

site of infection; ie otitis

pre-auricular,retropharyngeal, deepcervical nodes


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REMINDERSABOUTNODES

CLINICAL PEARLS

The harder the node and the more discrete, the

more likely it is a malignancy.

The more tender a node, the more likely it is aninflammation.

Nodes do not pulsate; arteries do.

A palpable supraclavicular node on the left is a re

clue to thoracic or abdominal malignancy. Slow nodal enlargement over weeks and months

suggests a benign process; rapid enlargement

without inflammation suggests malignancy


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FEATURESOFA LUMP, HOWTODESCRIBEIT

S Size

SShape

SSurface characteristics(e.g., erythema, warmth)

SSite

SSymptoms (e.g., pain,pruritus)

SSoftness; fluctuation

SSqueezability (e.g.,hemangiomata)

SSpread (e.g., lymphnodes in related areas)

SSensations (e.g., thrill ofA-V fistula)

CLINICAL PEARL

Immunizations given in theupper arm may causeaxillary node enlargement,particularly BCG and

smallpox vaccination


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DIFFERENTIAL DIAGNOSIS

CONDITIONS SIMULATING LYMPH NODE

ENLARGEMENT

15 % of patients referred have extranodal cause of enlargement

Lipomas and epidermoid cysts - skin

Lymphangioma (transilluminates; hemangiomas do not)

Cystic hygroma (thin-walled, contains clear lymph fluid)

Hemangioma (tends to feel spongy; appears reddish-blue, with color depending on size and

extent of angiomatous involvement; Valsalva maneuver may enlarge the mass) Branchial cleft cyst (sometimes accompanied by a tiny orifice in the neck on a line extending to

the ear along the sternocleidomastoid muscle; may fluctuate in size when inflamed)

Thyroglossal duct cyst (midline in the neck; may retract when tongue is protruded)

Granular cell tumor

Laryngocele

Esophageal diverticulum

Thyroid goiter Graves disease

Hashimoto thyroiditis

Parotid swelling (e.g., from mumps )


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EXAMINATIONOFHEADANDNECK

Lightly palpate the entireneck for nodes. The anteriorborder of thesternocleidomastoid muscleis the dividing line for the

anterior and posteriortriangles of the neck.

The cervical nodes deep tothe sternocleidomastoid(The deep cervical nodesmay be difficult to feel if you

press too vigorously; probegently with your thumb andfingers around the muscle.)


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EXAMINATIONOFNODESOFTHEHEAD

Bending the patient'shead slightly forward orto side

The occipital nodes at thebase of the skull

The postauricular nodeslocated superficially overthe mastoid process

The preauricular nodesjust in front of the ear

The parotid andretropharyngeal (tonsillar)nodes at the angle of themandible

On occasion, postauricular nodes affected by ear infection (particularly external otitis)

may be surrounded by some cellulitis; this may cause the ears to protrude.


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EXAMINATIONOFNODESOFTHEHEAD

The submandibular nodeshalfway between the angleand the tip of the mandible

The submental nodes in themidline behind the tip of themandible

The superficial cervical nodesat the sternocleidomastoidmuscle

The posterior cervical nodesalong the anterior border ofthe trapezius muscle

EBM 50% of pts withnegative exam havemetatasis laproscopicaly


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DEEP CERVICAL

The cervical nodes deep tothe sternocleidomastoid

Deep cervical nodes arenamed for clinicalsignificance

1/ jugulodigastric at level ofhyoid becomes inflammedwithpharyngitis (tonsillarnode)

2/jugulo-omohyoid whereomohyoid crosses jugularvein; drains tongue

3/ supraclavicularjustbehind clavicle underneathor posterior to SCM

(The deep cervical nodes may be difficult to feel if you press too vigorously; probegently with your thumb and fingers around the muscle.)


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HEADAND NECK

Head and Neck; atypicalmycobacteria, cat-scratchdisease, toxoplasmosis,sarcoidosis, , Kawasakissyndrome

Cervical Infections:pharyngitis, dental abscess,otitis media and otitisexterna, infectiousmononucleosis,toxoplasmosis,cytomegalovirus, hepatitis,

adenovirus, rubellaMalignancies: Hodgkin'sdisease, non-Hodgkin'slymphoma, squamous cellcarcinoma of the head andneck Kikuchi disease


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EXAMINATIONOFNODESOFTHEHEADAND

NECK

The supraclavicular areas, probing deeplyin the angle formed by the clavicle and thesternocleidomastoid muscle

Supraclavicular nodes are commonly thesites of metastatic disease. A Virchow nodein the left supraclavicular region may be theresult of eitherabdominal or thoracicmalignancy. Mediastinal collecting ductsfrom the lungs go to both sides of the neck,

and supraclavicular nodes may be palpatedon both sides.

May be detected more easily by havingpatient valsava

EBM/BIOPSY: 54-87% metastatic

Supradiaphragmatic-lung or breast;

Infradiaphragmatic; carcinomas andmetastisis 75% to L. and 25 % to R.

50% unaware of diagnosis at biopsy


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EPITROCHLEARNODES

Anteromedial surface of arms2-3 cm above medicalepicondyle of humerous

Drain ulnar side of forearmand hand

Exam with shaking hand

technique Usually enlarged with

generalized LA

EBM- are palpable in up to30% with sarcoid, lymphoma,

CLL and 50% withmononucleosis

HIV sensitivity 84% andspecificity 81% in Zimbabwe


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AXILLARY NODES

Drain ispsilateral arm,

breast, chest wall

Abduct and elevate

patients arm

EBM up to 33% of

patients with negative

exam have metastasis

discovered at surgery


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Supraclavicular and prelaryngealVirchow node: abdominal andthoracic neoplasm Delphian node:thyroid and laryngeal diseaseInfections: mycobacterial (e.g.,scrofula), fungal

Axillary Infections: staphylococcaland streptococcal arm infections, cat-

scratch fever, tularemia,sporotrichosis Malignancies: breastcarcinoma, Hodgkin's disease, non-Hodgkin's lymphoma, melanoma

EpitrochlearLymphoproliferativedisorders Connective tissue diseasesand sarcoidosis Dermatologicdiseases "Historical" associations:

syphilis, leprosy, leishmaniasis,rubella


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INGUINAL NODES

Horizontal group just

below inguinal ligament

drains external

genitalia, perineum,

lower abdomen Vertical group near

great saphenous vein

drains leg


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INGUINAL

Inguinal Benign reactive (especially inshoeless walkers) Malignancies: Hodgkin'sdisease, non-Hodgkin's lymphoma,melanoma, squamous cell carcinoma of thepenis and vulva, anal cancer Infections:cellulitis, venereal disease

HilarUnilateral Infections: bacterialpneumonia, mycobacterial diseases, fungalinfections, tularemia, psittacosis, pertussis

Other granulomatous diseasesMalignancies: bronchogenic carcinoma,metastatic breast cancer andgastrointestinal cancers, non-Hodgkinlymphoma, Hodgkin disease BilateralGranulomatous diseases: sarcoidosis,berylliosis, etc. Bilateral infectionsMalignancies: non-Hodgkin's lymphoma,Hodgkin's disease, metastatic carcinomaCalcified: tuberculosis, histoplasmosis,

silicosis


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LYMPHATICS Mesentery; attachment of small

intestine, 1 inch above and to leftof umbilicus to the point justanterior to the ASIS

Vessels , lymphatics and nervestravel in mesentery

Lymphatic and venous structureseasily compressed

Interstitial fluid from colonultimately drains via thoracic duct

Proper lymphatic drainagerequires good motion of abdominaldiaphragm, pelvic diaphragm,thoracic inlet

Mesenteric

attachment


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PALPATION (SPLEEN)

Stand on R. side of pt. and with L.

hand elevate rib cage while

pushing upward and inward with R.

hand (inspiration) toward anterior-

axillary line. An enlarged spleen

may be palpated with finger tips ofR. hand.

May also try with pt in RLR position

with aid of gravity. Similar hand

position

Spleen enlarges in diagonal

manner toward umbilicus, this isstarting position moving toward

LUQ


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PALPATION (SPLEEN)

Splenomegaly: seen withinfection, hyperplasia,

congestion and neoplasia.

Spleen is not palpated undernormal conditions


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Figure 17-23 Technique for liver palpation.

Downloaded from: StudentConsult (on 2 March 2008 07:24 PM)

2005 Elsevier

PALPATION (LIVER)

Stand on R. side of pt., L. hand

underneath pt between 12th rib

and iliac crest; R. hand in RUQ

lateral to rectus muscle and

below area of liver dullness. Pt

takes deep breath as R handpushes in and up ,pulls up with

L. Feel liver edge at R. hand &

start low so liver edge not

missed.


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celiac

Superiormesenteric

Inferior

mesenteric


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EBM FINDINGS; PHYSICALSIGNSANDSYMPTOMS

Pruritis associated

with lymphoma (98%

specificity)

Increased risk of

serious disease ; fixednodes, size > 9 cm,

weight loss, hard

texture, supraclavicular

adenopathy, age > 40

Reduced probablity:

lympth node

tenderness, size

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Lymph Examination 2013

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