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LYMPH NODE EXAMINATION
THE LYMPHATIC SYSTEM
·
Lymphatic
system is a closed system of channels called lymph channels or lymph vessels.
It is the one way system and the lymph flows through this from tissue system
towards blood.
Lymph
·
Lymph
is a transudate from blood & contains the same proteins as in plasma but in
smaller amounts.
·
It
mainly consists of lymphocytes.
Lymphatic vessels
·
Lymphatic
vessel includes lymph capillaries & larger lymph vessels.
Lymph capillaries are similar to blood capillaries,
but adapted to have much greater permeability.
they are found in most tissues of the body, except avascular tissues
like cornea, hair, nails etc.
Larger lymph vessels
·
They
have structure similar to that of veins.
·
Lymph
capillaries join together to form large lymph vessels.
·
THORACIC
DUCT is the largest lymph vessel in the body.
Lymph nodes
·
They
are bean shaped organs found in clusters along the lymphatic channels of the
body.
·
They
are mainly composed of lymphoid tissue.
Structure of
lymph node
·
Lymph
node consists of a connective tissue framework, with numerous lymphocytes and
other cells fill the interstices of the network.
·
Lymph
node is surrounded by a capsule made of collagen fibres. Numerous septa run
into the node from the capsule and divide it into lobules.
·
It
includes various cells,
mainly, Lymphocytes
Lymphoblast
Dividing Lymphoblast
Reticular Cells
Plasma Cells
Macrophages
Smooth Muscle Cells
Functions of lymphatic system
- Movement
and transportation of lymphocytes
- Production
of lymphocytes.
- Production
of antibodies.
- Phagocytosis
- Absorption
of fat and fat soluble substances.
Lymph nodes of head & neck region
Lymph nodes in the head and neck region are arranged into 2 rings
Ø
Outer
and superficial circle of lymph nodes
•
Occipital
nodes
•
Preauricular
nodes
•
Postauricular
nodes
•
Superficial
cervical nodes
•
Submental
nodes
•
Submandibular
nodes
•
Buccal
nodes
•
Jugulodigastric
nodes
•
Juguloomohyoid
nodes
Inner and deep circle of lymph nodes
•
Pretracheal
nodes
•
Paratracheal
nodes
•
Retropharyngeal
nodes
•
Supraclavicular
nodes
Levels of
lymph node
I Submental &
Submandibular
II Upper jugular nodes
III Middle jugular nodes
IV Lower jugular nodes
V Posterior cervical
region
VI Anterior compartment
nodes
VII Upper Mediastinal nodes
Position of Nodes
|
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 |
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Lymphatic drainage
Examination of lymph nodes in head and neck
region
Patient should be instructed to remove clothing around the face and neck
such as scarves and caps, the clavicular region should also be exposed.Neck
nodes are better palpable while standing at the back of the patient.
Neck is slightly flexed to achieve relaxation of the muscle.examination
Inspection
ü
Inspect
the normal anatomic locations of lymph nodes for any obvious enlargement.
ü
If
nodes are obviously enlarged describe the location, the approximate dimension
and number of nodes.
ü
Look
for any surface changes such as ulceration, or discharge from the site.
Palpation
ü
Lymph
nodes are palpated better by standing behind the patient who is seated on a
dental chair.
ü
Ideal
palpation is best started from the superior lymph nodes and then working down
to the clavicular region.
ü
Nodes
are better palpated to assess wheather they are tender or non tender , consistency
and size. Fixity of nodes are also accessed.
Pre auricular nodes (Parotid nodes)
They lie in relation to the parotid salivary gland
They drain from
·
scalp
·
Pinna
·
External
auditory meatus
·
Face
·
Buccal
mucosa
·
They
drain into internal jugular chain
Post auricular nodes
They lie behind the pinna over the mastoid
They drain
o
scalp
o
Posterior
surface of pinna
o
Skin
of mastoid
They drain into internal jugular chain
Palpated at the mastoid process
Occipital nodes
·
Occipital
nodes lie at the apex of occipital triangle
·
They
drain from scalp
Skin of upper neck
submental node
It lies on the mylohyoid muscle in the submental triangle.
2-8 in number
They drain
o
chin
o
middle
part of lower lip
o
Anterior
gums
o
Anterior
floor of mouth
o
Tip
of tongue
Submandibular lymph node
·
They
lie in the submandibular triangle in relation to the submandibular gland.
·
They
drain lateral part of lower lip
·
Upper
lip
·
Cheek
·
anterior
part of nasal cavity
·
Gums
·
Soft
palate
·
Anterior
part of tongue
·
Submandibular
salivary glands
·
Submental
salivary glands
·
Floor
of mouth
·
On
examination roll your finger against inner surface of mandible with patient’s
head gently shifted towards the other side
Superficial cervical group
They lie along external
jugular vein
Internal
jugular chain
·
They
lie anterior , lateral & posterior to the internal jugular vein.
·
Upper
group drains oral cavity, oropharynx , nasopharynx , larynx & parotid.
·
Middle
group drains oral cavity, oropharynx , larynx and thyroid
·
Lower
group drains larynx, thyroid & esophagus.
·
It
is deep to sternocleidomastoid it may be displaced posteriorly.
Examination of middle jugular lymph node
Examination of lower jugular nodes
Transverse cervical chain (supraclavicular
nodes)
·
It
lies horizontally along the transverse cervical vessels, in the lower part of
the posterior triangle.
·
Roll
your finger gently behind the clavicle. Instruct the patient to cough or bear
down as having a bowel movement. Occasionally an enlarged node may pop up.
Anterior cervical group
It includes
·
Paratracheal
lymph nodes
·
Pretracheal
lymph nodes
·
Prelaryngeal
lymph nodes
Protocol for lymph node examination
Lymph
node
Palpable non palpable
- Inspection
·
site
·
gross
enlargement
·
number
- Palpation
·
tenderness
·
tender
·
non
tender
·
number
·
discrete/matted
·
consistency
·
soft
·
firm
·
rubbery
·
stony
hard
·
fixity
to underlying structures
·
approximate
size (for TNM staging)
Causes
of lymph node enlargement
Inflammatory infective
Ø
Local
causes
·
bacterial
·
Viral
Ø
Systemic
causes
·
bacterial
·
Viral
·
Other
conditions
Inflammatory non infective causes
Ø
sarcoidosis
Ø
Crohn,s
disease
Ø
Connective
tissue diseases
Neoplastic causes
Ø
primary
·
leukemias
·
lymphomas
Ø
secondary
metastasis from sites in
the drainage area of the lymph node
- Other
causes
·
drugs
such as Phenytoin
Lymph nodes in
inflammatory conditions
Ø
Increase
in volume of lymph
Ø
Occurs
in young & adults in cases of lymphadenitis
Ø
Pain
in case of pyogenic lymphadenitis
Ø
Skin
over the lymph node appears red
Ø
At
times yellow due to pus
Acute inflammation
Ø
Enlarged,
tender and firm on palpation.
Ø
Becomes
fluctuant if pus formed within it.
Chronic inflammation
Ø
Painless
enlargement, unless secondarily infected
Ø
Firm
on palpation due to fibrotic changes
Ø
Coalesces
together & become adherent to the adjacent soft tissue & overlying skin
Lymph nodes in infections
Ø
Occurs
in adults ,viral etiology.
Ø
Short
duration in pyogenic infections , while long in TB.
Ø
Slow
growth ,fever with evening rise in temperature and weight loss is suggestive of
tuberculosis.
Ø
upper
deep cervical nodes are affected and is matted in case of TB.
Ø
Fever
with multiple enlarged nodes occur in infectious mononucleosis.
Ø
Firm
and mobile in chronic infections.
Lymph nodes in neoplasms
Ø
Young-acute
leukemia
Ø
Middle
aged-hodgkins lymphoma
Ø
In
case of multiple sites
begins first in
the neck nodes and then others-Hodgkins lymphoma
if enlargement
appears simultaneously - Non Hodgkins
lymphoma
Ø
Slow
growth , intermitent fever ,nodular, rubbery nodes is suggestive of lymphoma
Lymph nodes in metastasis
Ø
Malignant
tumours commonly metastasis through lymphatic system.
Ø
Usually
seen in old age.
Ø
Short
duration, rapid growth and absence of fever is suggestive of metastasis.
Ø
Nodes
become enlarged, non-tender and stony hard.
Ø
Mobile
in early stages but becomes matted later.
Ø
They
are fixed to the skin and also infiltrate to nerves.
BIBLIOGRAPHY
- MANIPAL
MANUAL OF SURGERY Rajgopal Shenoy
- CLINICAL
MANUAL FOR ORAL MEDICINE AND RADIOLOGY Ravikiran Ongole , Praveen B N
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