Physical Examination of The Lymphatic System: Russell C Hendershot DO, MS, FAAFP
Physical Examination of The Lymphatic System: Russell C Hendershot DO, MS, FAAFP
Physical Examination of The Lymphatic System: Russell C Hendershot DO, MS, FAAFP
OBJECTIVES
Determine the routine history for a patient with lymphadenopathy Define appropriate questions Demonstrate an appropriate regional and general examination of the lymphatic system Synthesize how to incorporate such examination within the confines of problem focused examination
LYMPH DISTRIBUTION
lymph fluid and collecting ducts tissues : lymph nodes, spleen, thymus, tonsils, adenoids, and Peyer patches. (the mucosa of the stomach and appendix, bone marrow, and lungs) Except for the placenta and the brain, every tissue supplied by blood vessels has lymphatic vessels.
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.
LYMPHATIC TRAVELS
The drainage point for the right upper body is a lymphatic trunk that empties into the right subclavian vein. The thoracic duct, the major vessel of the lymphatic system, drains lymph from the rest of the body into the left subclavian vein.
The Arms Axillary Epitrochlear (cubital) The Legs Superficial superior inguinal Superficial inferior inguinal Occasionally, popliteal
THYMUS
The thymus is located in the superior mediastinum, extending upward into the lower neck. In early life the thymus is essential to the development of the protective immune function. It is the site for production of T-lymphocytes, the effector cells for cell-mediated immunity reactions and the controlling agent for the humoral immune responses generated by Blymphocytes. In the adult, however, it has little or no demonstrated function.
SPLEEN
The spleen is situated in the left upper quadrant of the abdominal cavity between the stomach and the diaphragm. A highly vascular organ, it is composed of two systems: (1) the white pulp, made up of lymphatic nodules and diffuse lymphatic tissue, and (2) the red pulp, made up of venous sinusoids.
The palatine tonsils are commonly referred to as "the tonsils." Small / diamond-shaped, they are set between the palatine arches on either side of the pharynx just beyond the base of the tongue. The pharyngeal tonsils, or adenoids, are located at the nasopharyngeal border; the lingual tonsils are located near the base of the tongue. They enlarge gradually from birth to about seven years of age and then shrink.
PEYER PATCHES
Peyer patches are small, raised areas of lymph tissue on the mucosa of the small intestine.
Lymph nodes usually occur in groups. Superficial nodes are located in subcutaneous connective tissues deeper nodes lie beneath the fascia of muscles and within the various body cavities. The nodes are numerous and tiny, but some of them may have diameters as large as 0.5 to 1 cm.
CLINICAL PEARLS
The lymph nodes have the same distribution in children that they do in adults. The finding of small 12- to 13-mm, discrete, palpable, mobile nodes in the neonate is not unusual. Before 2 years of age, inguinal, occipital, and postauricular nodes are common; after 2 years of age, they are more likely to have significance. Cervical and submandibular nodes are uncommon during the first 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 a cause for concern OLDER ADULTS The number of lymph nodes may diminish and size may decrease with advanced age; some of the lymphoid elements are lost. The nodes of older patients are more likely to be fibrotic and fatty than those of the young, a contributing factor in an impaired ability to resist infection
CLINICAL PEARLS
INFANTS AND CHILDREN. The mass of lymphoid tissue is relatively plentiful in infants; increases during childhood, especially between 6 and 9 years of age; then regresses to adult levels by puberty The umbilical cord should drop off by 1 to 2 weeks after birth. If it hangs on much longer than that, there may be a congenital defect of the immune system. The thymus is at its largest relative to the rest of the body shortly after birth, but reaches its greatest absolute weight at puberty. Then it involutes, replacing much of its tissue with fat and becoming a rudimentary organ in the adult. The palatine tonsils, like much lymphoid tissue, are much larger during early childhood than after puberty. An enlargement of the tonsils in children is not necessarily an indication of problems.
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 brown to 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
Allopurinol (Zyloprim) Atenolol (Tenormin) Captopril (Capozide) Carbamazepine (Tegretol) Cephalosporins Gold Hydralazine (Apresoline) Penicillin Phenytoin (Dilantin) Primidone (Mysoline) Pyrimethamine (Daraprim) Quinidine Sulfonamides Sulindac (Clinoril)
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
HISTORY CONTD
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
HISTORY
PREGNANT WOMEN Weeks of gestation Exposure to rubella and other infections Presence of children and pets in household
OLDER ADULTS Presence of an autoimmune disease Present or recent infection or trauma distal to nodes Delayed healing
INFANTS AND CHILDREN Recurrent infections: tonsillitis, adenoiditis, bacterial infections, oral candidiasis, chronic diarrhea Present or recent infections, trauma distal to nodes Poor growth, failure to thrive Loss of interest in play or eating Immunization history Maternal HIV infection Hemophilia Illness in siblings
The lymphatic system is examined by inspection and palpation, usually region by region during examination of the other body systems, and by palpating the liver and spleen
PHYSICAL EXAM
Seven distinct regions drain into the great veins near the base of the neck Adult 400-500 LNs 30 arm/axilla; 20 leg; 6070 head/neck; remaining deep in thorax and abdomen and NOT palpable Only deep nodes that are palpable are the deep cervical (carotid, SCM )and axillary.
Use pads of the fingers 2-4 to lightly palpate Generally not able to feel If nodes are palpated explore adjacent areas for signs of infection shotty nodes ; grouped, small, movable, discrete, less than a centimeter in diameter that move under your fingers
Enlarged nodes characterized according to : location, size, shape, consistency, tenderness, movability or fixation and discreteness. Lymph nodes that are enlarged and juxtaposed so that they feel like a large mass rather than discrete nodes are described as "matted."
Problem: large, fixed, matted, inflamed or tender Note any vascularity, heat, pulsations (vessel)or transillumination(cyst)
Tenderness inflammation; may be from necrosis and bleeding Cancerous nodes usually not tender, vary in size, discrete to matted, may be hard, and asymetrical Bacterial infections warm, tender, matted * drainage may determine site of infection; ie otitis pre-auricular, retropharyngeal, deep cervical nodes
S Size S Shape S Surface characteristics (e.g., erythema, warmth) S Site S Symptoms (e.g., pain, pruritus) S Softness; fluctuation S Squeezability (e.g., hemangiomata) S Spread (e.g., lymph nodes in related areas) S Sensations (e.g., thrill of A-V fistula)
CLINICAL PEARL Immunizations given in the upper arm may cause axillary node enlargement, particularly BCG and smallpox vaccination
Lightly palpate the entire neck for nodes. The anterior border of the sternocleidomastoid muscle is the dividing line for the anterior and posterior triangles of the neck. The cervical nodes deep to the sternocleidomastoid (The deep cervical nodes may be difficult to feel if you press too vigorously; probe gently with your thumb and fingers around the muscle.)
Bending the patient's head slightly forward or to side The occipital nodes at the base of the skull The postauricular nodes located superficially over the mastoid process The preauricular nodes just in front of the ear The parotid and retropharyngeal (tonsillar) nodes at the angle of the mandible
On occasion, postauricular nodes affected by ear infection (particularly external otitis) may be surrounded by some cellulitis; this may cause the ears to protrude.
The submandibular nodes halfway between the angle and the tip of the mandible The submental nodes in the midline behind the tip of the mandible The superficial cervical nodes at the sternocleidomastoid muscle The posterior cervical nodes along the anterior border of the trapezius muscle
DEEP CERVICAL
The cervical nodes deep to the sternocleidomastoid Deep cervical nodes are named for clinical significance 1/ jugulodigastric at level of hyoid becomes inflammed withpharyngitis (tonsillar node) 2/ jugulo-omohyoid where omohyoid crosses jugular vein; drains tongue 3/ supraclavicular just behind clavicle underneath or posterior to SCM
(The deep cervical nodes may be difficult to feel if you press too vigorously; probe gently with your thumb and fingers around the muscle.)
Head and Neck; atypical mycobacteria, cat-scratch disease, toxoplasmosis, sarcoidosis, , Kawasakis syndrome Cervical Infections: pharyngitis, dental abscess, otitis media and otitis externa, infectious mononucleosis, toxoplasmosis, cytomegalovirus, hepatitis, adenovirus, rubella Malignancies: Hodgkin's disease, non-Hodgkin's lymphoma, squamous cell carcinoma of the head and neck Kikuchi disease
The supraclavicular areas, probing deeply in the angle formed by the clavicle and the sternocleidomastoid muscle Supraclavicular nodes are commonly the sites of metastatic disease. A Virchow node in the left supraclavicular region may be the result of either abdominal or thoracic malignancy. Mediastinal collecting ducts from the lungs go to both sides of the neck, and supraclavicular nodes may be palpated on both sides. May be detected more easily by having patient valsava EBM/BIOPSY: 54-87% metastatic Supradiaphragmatic-lung or breast; Infradiaphragmatic; carcinomas and metastisis 75% to L. and 25 % to R. 50% unaware of diagnosis at biopsy
EPITROCHLEAR NODES
Anteromedial surface of arms 2-3 cm above medical epicondyle of humerous Drain ulnar side of forearm and hand Exam with shaking hand technique Usually enlarged with generalized LA EBM- are palpable in up to 30% with sarcoid, lymphoma, CLL and 50% with mononucleosis HIV sensitivity 84% and specificity 81% in Zimbabwe
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
Supraclavicular and prelaryngeal Virchow node: abdominal and thoracic neoplasm Delphian node: thyroid and laryngeal disease Infections: mycobacterial (e.g., scrofula), fungal Axillary Infections: staphylococcal and streptococcal arm infections, catscratch fever, tularemia, sporotrichosis Malignancies: breast carcinoma, Hodgkin's disease, nonHodgkin's lymphoma, melanoma Epitrochlear Lymphoproliferative disorders Connective tissue diseases and sarcoidosis Dermatologic diseases "Historical" associations: syphilis, leprosy, leishmaniasis, rubella
INGUINAL NODES
Horizontal group just below inguinal ligament drains external genitalia, perineum, lower abdomen Vertical group near great saphenous vein drains leg
INGUINAL
Inguinal Benign reactive (especially in shoeless walkers) Malignancies: Hodgkin's disease, non-Hodgkin's lymphoma, melanoma, squamous cell carcinoma of the penis and vulva, anal cancer Infections: cellulitis, venereal disease Hilar Unilateral Infections: bacterial pneumonia, mycobacterial diseases, fungal infections, tularemia, psittacosis, pertussis Other granulomatous diseases Malignancies: bronchogenic carcinoma, metastatic breast cancer and gastrointestinal cancers, non-Hodgkin lymphoma, Hodgkin disease Bilateral Granulomatous diseases: sarcoidosis, berylliosis, etc. Bilateral infections Malignancies: non-Hodgkin's lymphoma, Hodgkin's disease, metastatic carcinoma Calcified: tuberculosis, histoplasmosis, silicosis
LYMPHATICS
Mesentery; attachment of small intestine, 1 inch above and to left of umbilicus to the point just anterior to the ASIS Vessels , lymphatics and nerves travel in mesentery Lymphatic and venous structures easily compressed Interstitial fluid from colon ultimately drains via thoracic duct Proper lymphatic drainage requires good motion of abdominal diaphragm, pelvic diaphragm, thoracic inlet
Mesenteric attachment
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 anterioraxillary line. An enlarged spleen may be palpated with finger tips of R. hand.
May also try with pt in RLR position with aid of gravity. Similar hand position
Spleen enlarges in diagonal manner toward umbilicus, this is starting position moving toward LUQ
PALPATION (SPLEEN)
Splenomegaly: seen with infection, hyperplasia, congestion and neoplasia. Spleen is not palpated under normal conditions
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 hand pushes in and up ,pulls up with L. Feel liver edge at R. hand & start low so liver edge not missed.
Downloaded from: StudentConsult (on 2 March 2008 07:24 PM) 2005 Elsevier
Reduced probablity: lympth node tenderness, size < 4cm, age < 40
Unhelpful findings: rash, regional distribution, fever, palpable spleen and or liver; generalized adenopathy
CLINICAL PEARLS
Generalized lymphadenopathy - two or more groups of regional LNs ; usually cervical and inguinal or cervical and axillary Implies systemic disorder lymphoma, leukemia, HIV, sarcoidosis, CTD
Ulceroglandular syndromefever, ulceration of arm/leg, regional adenopathy Parinauds syndrome oculoglandular fever ; conjunctivitis with ipsilateral preauricular and submandibular adenopathy Causes : tularemia, rickettsial infections, HSV; also in OCF cat scratch disease, viral, tularemia
SPECIAL NODES
SUMMARY OF EXAMINATION
The lymphatic system is examined region by region during the examination of the other body systems (i.e., head and neck, breast and axillary, genitalia, and extremities). Inspect the visible nodes and surrounding area for the following characteristics
Palpate the superficial lymph nodes and compare side to side for the following
If you discover lymphadenopathy, consider the associated drainage region to suggest possible sources for a presenting problem
Left supraclavicular node Thorax, abdomen via thoracic duct Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection Axillary Arm, thoracic wall, breast Infections, catscratch disease, lymphoma, breast cancer, silicone implants, brucellosis, melanoma Epitrochlear Ulnar aspect of forearm and hand Infections, lymphoma, sarcoidosis, tularemia, secondary syphilis Inguinal Penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal Infections of the leg or foot, STDs (e.g., herpes simplex virus, gonococcal infection, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum), lymphoma, pelvic malignancy, bubonic plague
Submandibular Tongue, submaxillary gland, lips and mouth, conjunctivae Infections of head, neck, sinuses, ears, eyes, scalp, pharynx Submental Lower lip, floor of mouth, tip of tongue, skin of cheek Mononucleosis syndromes, Epstein-Barr virus, cytomegalovirus, toxoplasmosis Jugular Tongue, tonsil, pinna, parotid Pharyngitis organisms, rubella Posterior cervical Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes Tuberculosis, lymphoma, head and neck malignancy Suboccipital Scalp and head Local infection Postauricular External auditory meatus, pinna, scalp Local infection Preauricular Eyelids and conjunctivae, temporal region, pinna External auditory canal Right supraclavicular node Mediastinum, lungs, esophagus Lung, retroperitoneal or gastrointestinal cancer Left supraclavicular node Thorax, abdomen via thoracic duct Lymphoma, thoracic or retroperitoneal cancer, bacterial or fungal infection