Lymph node examination

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Lymph node examination

Study Guide

Clinical Skills Teaching & Learning Centre

Written by: Clinical Skills Lecturing Team

Reviewed by: Mr Adam Donne – Consultant Paediatric Otolaryngologist Professor John Wilding - Endocrinology System lead

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2 September 2020 September 2020

Glossary

Chyle Lymphatic fluid. Milky white in colour

Glands The colloquial name for lymph nodes

Lymphatic duct The right lymphatic duct drains the lymph from

the right upper limb, right side of thorax and right halves of head and neck

Lymphadenopathy One or more inflamed lymph node groups

Sentinel lymph nodes The first lymph node to become involved or noted. i.e. in diseases of the breast, the anterior axillary node is usually the first to be noted.

Thoracic duct Drains the rest of the body

Virchow’s lymph node & Troisier’s sign The names are used interchangeably.

Technically Virchow’s node is a swollen lymph node in the medial aspect of the left

suprascapular area and Troisier’s sign is when there is an appreciable mass of Virchow’s lymph node. They both indicate metastatic disease of the upper abdomen and thorax amongst other conditions.

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Learning Objectives

Year 1

 To have an awareness of role of the lymphatic system and the purpose of a lymph node examination

Year 2

 To revise the anatomy and physiology of the lymphatic system.  To link the anatomy and physiology to examination of lymph nodes.  To be able to perform a lymph node examination.

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Introduction

The lymphatic system

The vessels of the lymphatic system are capillaries that are closely intertwined with the blood vessels. Fluids composed of fatty acids and waste products leak out of the blood vessels into the interstitial spaces and are absorbed by the lymphatic vessels and transported as chyle (lymphatic fluid) towards the two main lymph ducts in the body. On route to these two ducts, the vessels pass through filters otherwise referred to as nodes. The function of these nodes is to filter and remove waste from the lymph fluid before the “cleaned” fluid moves onwards to the two main lymphatic ducts.

Role of the lymphatic system

“The lymphatic system role involves the following:

 Movement of lymph fluid within the cardiovascular system, a major factor in the maintenance of fluid balance. Without lymphatic drainage, fluid would build up in interstitial spaces because more fluid leaves capillaries than veins can absorb

 Filtration of fluid before it is returned to the bloodstream, filtering out substances that could be harmful to the body, and filtering microorganisms from the blood

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7  Phagocytosis—the ingestion and digestion by cells of solid substances such as other

cells, bacteria, and bits of dead tissue or foreign particles - is a specific function of cells in lymph nodes

 Production of lymphocytes within the lymph nodes, tonsils, adenoids, spleen, and bone marrow

 Production of antibodies

 Absorption of fat and fat-soluble substances from the intestinal tract” (Seidels’s Guide to Physical Examination 2019)

Lymph nodes

Lymph nodes are not normally palpable but become enlarged as part of inflammatory, infected or malignant reaction, causing the lymph nodes to swell and become tender when enlarged. There are over 500 lymph nodes in the body but the majority are deep lying and impalpable. When examining a patient we focus on the areas where lymph nodes are superficial and may be palpable if enlarged. Dependent on which system of the body is being examined, for

example: respiratory, gastrointestinal etc. The superficial lymph nodes that drain that area may be palpable are examined for routinely. Prominently these are the nodes situated around the head and neck, the axilla and the groin.

Lymphadenopathy (enlargement of lymph nodes)

Infection/Inflammation

The nodes may become enlarged, commonly the size and shape of a coffee bean (they may be significantly larger), they may be visible on inspection, but they appear the same as the

surrounding skin. On palpation they should feel smooth and pliable (slightly mobile) although firm they should not feel as hard as stone. Note-the term ‘rubbery’ is normally reserved for a

node thought to be affected by lymphoma. It should not be used for an infected or inflamed node. They should feel pliable (slightly mobile) although firm they should not feel as hard as stone. As the patient recovers, the size of the node diminishes, becoming small and soft, before becoming impalpable, this may take months.

Malignancy

A malignant lymph node will normally be hard in consistency more stone like and may be fixed (adhered to surrounding structures), they are not normally tender to the touch like those

responding to an infective or inflammatory process and their surface may be nodular on palpation.

Hyperplasia

Following enlargement of the lymph nodes a number of cells will have increased in size or number. Deposition of collagen occurs 6 weeks after the initial inflammatory process causing

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8 the lymph node to be permanently palpable. 50% of 12-month-old children, for example, have a palpable lymph node due to hyperplasia. Hyperplasic lymph nodes should be less than 1.5 centimetres in adults. They should be investigated if larger, increase in side or become nodular. Examination of the lymphatic system, requires knowledge of the superficial lymph nodes and what tissues drain to those nodes. The clinician will need to inspect the area initially and then palpate, there is no reason for percussion or auscultation in this examination.

See figure 2 as an example of an enlarged posterior cervical lymph node, figure 3 an enlarged anterior cervical or possibly a jugulodigastric lymph node and Figure 4 an enlarge

supraclavicular and cervical lymph node enlargement. The positions of which will be discussed in the surface anatomy section below along with anatomical drawings figure 5 and 6.

Indications

Performing a full examination of the entire lymphatic system in itself is unusual, but may be required if the patient presents with generalised lymphadenopathy (enlargement of at least two unrelated lymph node groups), in this case examination of the spleen would also be included to establish if this too is enlarged. If a patient presents with a lump situated where lymph glands lie the clinician may take a history and examine the swelling and close by lymph nodes. However, an examination of the associated lymph nodes is an essential element of any specific clinical examination of a specific system, remember cancerous enlarged lymph nodes are not painful and may have not been noticed by the patient. A lymph node examination consists of inspection and palpation.

Which lymph nodes should be examined when examining a system?  Breast Examination: Axillary, supra and infra clavicular.

 Gastrointestinal (Abdominal) Intestinal Examination: Deep and Superficial cervical, supra and infra clavicular, axillary and Inguinal. Head and neck also should be considered if upper GI tract is involved.

 Respiratory Examination: Head and neck (except occipital & deep cervical), axillary, supra and infra clavicular.

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9  Male / Female Genitalia Examination: Deep and superficial inguinal

Surface Anatomy (superficial palpable lymph nodes)

Lymph nodes of the head and neck (figures 5&6)

Figures 5/6

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10 o Submental in the midline behind the tip of the mandible

o Submandibular midway and along the inner surface of the inferior margin of the mandible o Jugulodigastric at the angle of the jaw

o Pre-auricular in front of the ear anterior to the tragus o Post-auricular over the mastoid process (behind the ear) o Occipital back of the head at the base of the skull

o Posterior cervical run along the anterior border of the trapezius muscle o Superficial cervical along the body of the sternocleidomastoid

o Deep cervical deep to the lateral border of the sternocleidomastoid. They are difficult to feel, press more firmly along the body of the sternocleidomastoid.

o Supra clavicular lie on top of the clavicle at the lateral border of the sternocleidomastoid medially.

o Infraclavicular lie along the inferior border of the clavicle

Axillary lymph nodes

The axillary nodes drain from the breast, the superficial surface of the chest wall and the upper limb. They range in number from around 20 to 40 and are organised into groups or chains within the axilla.

There are 5 groups of nodes in the axilla, they are called the; Anterior (on the underside of the anterior axillary fold), Posterior (on the underside of the posterior axillary fold), Lateral (in the axilla on the arm), Medial (in the axilla against the chest wall extending towards the ribs and upper breast) & Apical (central upper area of the axilla).

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Epitrochlear nodes

The inguinal and popliteal lymph nodes (see figure 9)

The inguinal lymph nodes lie beneath the inguinal ligament in the femoral triangle The popliteal are in the popliteal fossa (hollow in the back of the knee)

Figure 9

Epitrochlear are on the medial aspect of the upper arm above (proximal the antecubital fossa, 3 finger breaths above between the biceps and triceps muscles). These nodes drain the hand and fore arm and are associated with infections in these areas, but may enlarge as part of general lymphadenopathy. Drainage onwards from the epitrochlear nodes extends to the axillary nodes so are not routinely examined for. Figure 8

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History

Information from the clinical history is invaluable in the diagnostic management of the patient with lymphadenopathy. The age of the patient is also quite important. Dramatic enlargement of lymph and other lymphoid tissue such as the adenoids and tonsils is often a normal response to a variety of relatively weak antigenic stimuli such as mild viral and bacterial infections or

vaccinations in infants and children, whereas in adults these antigens will not elicit a generalised response. Karph M (1990)

Lymphadenopathy can be due to allergies, drug reactions and chronic or acute dermatological conditions. An allergic reaction to a cat scratch, an Elastoplast or a dermatological response in one area can give rise to lymphadenopathy in one area, emphasising the importance of a detailed history from the patient.

If the patient has noticed a swelling you suspect may be lymph in origin, consider asking the patient the following, all of which will help form a diagnosis:

 How long it has been there?  Has it got any larger?

 Is it tender to the touch?

 Have they recently been unwell?  Had night sweats?

 Suffered from generalized malaise recently?  Noticed any unintentional weight loss?

Please see your online resources for the history taking guide, which can be found in the “fundamentals” section.

If you can palpate enlarged node or nodes, think what area drains to that node, this may lead to alternate examinations, for example, enlarged Jugulodigastric nodes may lead the clinician to do a throat examination, multiple nodes of the head and neck may warrant a full ENT (ear, nose and throat) examination. The table below helps demonstrate the reasoning behind these

choices.

Drainage to the lymph nodes

Group Drains from

Submental  Tip of the tongue

 Floor of the mouth underneath the tip of the tongue Table 1

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 Incisor teeth and associated gums  Centre part of the lower lip  Skin over the chin

Submandibular This covers a wide area including:  Front of the scalp

 Nose and adjacent cheek

 Upper lip and lower lip (except the centre)  Frontal, ethmoid and maxillary sinuses  Upper and lower gums (except the incisors)  Anterior 2/3 of the tongue except the lip  Floor of the mouth and vestibule

Jugulodigastric  tonsils and back of the pharynx Pre-auricular (parotid)  Strip of scalp above the parotid

 Lateral surface of the auricle

 Anterior wall of external auditory meatus  Lateral part of the eyelids

 Some from the middle ear

Post-auricular (Mastoid)  Strip of scalp above the auricle

 Posterior wall of the external auditory meatus

Occipital  Scalp

Posterior cervical  Upper respiratory system (Sinuses) Superficial cervical  Skin over the angle of the jaw

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Deep cervical  Neighbouring structures and all other groups above Supraclavicular  Chest and stomach

Infraclavicular  Superficial vessels from the lateral side of the hand,

forearm and arm

Axillary  Breast, chest wall, upper abdomen superficial tissues from

umbilicus up) and upper limb

Epitrochlear  Upper limb

Inguinal  Lower limb, abdomen (superficial tissues from umbilicus

down) and genitals

Popliteal  Lower limb

Below are images of some of the triangles of the neck (figure 10). These triangles refer to the muscles, nerves, arteries, veins and lymph nodes contained within them and are particularly important when considering surgical treatment. Knowing the triangles also enables clinicians to work out the likely area a primary disease process has drained from. For example, the posterior triangle is at greatest risk for harbouring metastasis from cancers arising in the nasopharynx, oropharynx and skin of the scalp and neck. Describing which anatomical triangle a node has been found or better still drawing its position in the history and describing how the swelling feels on examination may ascertain if the cause is for example an infection or not. It should be noted that other tests will be required to confirm what pathology you are dealing with. For example, a biopsy of an enlarged node may be taken for histological examination.

Preparation

Figure 10 Anterior Triangle contains: Submental Submandibular Jugulodigastric Posterior Triangle contains: Superficial cervical Deep cervical Superior clavicular

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Patient safety

• Introduce yourself

• Check the patient’s identity and allergies

• Explain what you want to do

• Gain informed consent

• Consider an appropriate chaperone

• Adequate exposure maintaining dignity

• Position the patient appropriately – consider moving and handling

• Wear Personal Protective Equipment as required.

• Wash your hands before and after you touch the patient (as per WHO guidelines)

On first meeting a patient introduce yourself and confirm that you have the correct patient with the name and date of birth. If available please check this with the name band and written documentation and the NHS/ hospital number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure the procedure is explained to the patient in terms that they understand, gain informed consent and ensure that you are supervised, with a chaperone available as appropriate. Don personal protective equipment as required, especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO (2019)

http://www.who.int/infection-prevention/tools/hand-hygiene/en/. Please ensure you have clean short finger nails; lymph nodes can be difficult to palpate when enlargement is minimal and may require a degree of pressure.

Equipment

Hand wash

Couch or chair depending on lymph node groups you are examining Cover to maintain patient’s dignity if a level of exposure is required Good light source particularly if inspecting the axilla or groin

Tape measure to accurately record a lymph node of significant size

Inspection

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General Inspection

Does the patient look unwell, pale, sweaty, gaunt or in obvious discomfort? Lymph nodes can enlarge as part of an infective process and the patient may have a pyrexia or have lost a great deal of weight if there is metastatic spread to the lymph nodes.

Specific inspection

Inspection of the nodes is very important, if a swelling is large enough it may be visible, check the skin does it seem the same as surrounding tissue, does it appear red/inflamed, is it notably nodular in appearance. A level of undress to clearly inspect is key, as well as good lighting, for example removing their top for axillary or clavicular nodes, a headdress for cervical or occipital or their trousers for inguinal or popliteal. You may also need the patient to lift their arm to inspect the axilla, lift their hair to inspect the occipital region or neck or lie supine to inspect the inguinal region. Consider their mobility, they may need assistance.

Palpation

Use the palmar aspect of 2 – 3 finger tips to palpate for the lymph nodes.

The finger tips are used to gently palpate the nodes in a circular motion to assess for characteristics, e.g. position, size and tenderness. See fig10 & 11.

Palpation should be against a firm surface i.e. deeper tissues or structures. Where tissues are soft, the non-examining hand can be used as a support. This is often the case in axillary node examination.

The deep cervical lymph nodes require more pressure than the moderate pressure applied to the superficial nodes.

Some small lymph nodes may be normal and palpable in a thin person’s neck.

Familiarising yourself is key to recognising the normal, for example, try the palpation technique on your wrist (figure 13), note how the underlying structures feel, if there was a coffee bean like swelling you would notice it, when examining structures that are muscular this may make palpation more difficult. Getting the patient to drop their head down slightly will relax the

muscles of the neck when palpating the cervical lymph nodes, supporting the weight of the arm will help relax the arm muscles and make axillary palpation easier.

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Palpation of the lymph nodes of the head and neck (figure 14)

These nodes can be examined by standing either behind the patient or from in front. Warn your patient if you are opting to stand behind them.

Be familiar with the anatomy of the head and neck as this will aid you in locating the associated lymph nodes.

You may choose to palpate lymph nodes unilaterally (one hand at a time, until you are more proficient. The reason behind this is to ensure you palpate each node correctly and do not miss anything. Whether you are palpating simultaneously or unilaterally, ensure you compare and contrast each group of nodes to note any changes or differences.

The cervical lymph nodes are frequently enlarged in response to upper respiratory tract infections, especially during the Flu season. As these nodes are close to the baroreceptors of the neck examining these nodes unilaterally is certainly advisable until you become more proficient.

Palpation of the lymph nodes of the axilla (figure 15)

Figure 14

Figure 15

Supporting the patient’s arm, by the patient resting their flexed arms across yours reduces the muscle bulk and increases the likely hood of identifying these nodes.

Feeling lymph nodes against a firm surface help to identify them. The examiner may choose to use there none dominant hand to support the anterior and posterior axillary fold as how in figure 12, to achieve a firm surface.

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Palpation of the epitrochlear lymph nodes

Palpation of the inguinal lymph nodes (figure 17 & 18)

These nodes are palpated as part of a genital or groin examination. They can also be palpated in connection with lower limb and abdominal examinations. With patient usually lying flat, palpate just beneath the inguinal ligament for swellings. Only the superficial nodes will be palpable if enlarged, these drain to the deep nodes which are impalpable.

There are 3-4 groups of epitrochlear nodes. The normal /

abnormal aspects of these nodes are poorly understood as most clinicians examine the axillary nodes as the primary point for upper limb pathologies. However if a patient presents with generalised lymph adenopathy or noticed a swelling just above the medial aspect of the elbow they should be checked.

Ask the patient to flex their elbow support the weight of the

patients arm by holding at the patient’s wrist. Your examining hand should grasp just above the back of the patients elbow with fingers palpating the medial aspect of the upper arm just above the

antecubital fossa for swellings. See figure 16.

Figure 16

Figure 17

Figure 18

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Palpation of the popliteal lymph nodes

Drain from the lower limbs and then onwards towards the inguinal lymph nodes, unless general lymph adenopathy or the patient presents with a lump. They are divided between deep and superficial groups that are located in the popliteal fossa (hollow behind the knee) and number between six to seven groups. To examine for enlarged nodes ask the patient to expose the knee area, with knee slightly flexed place fingers at the back of the knee in the popliteal fossa, ask the patient to relax their leg to reduce muscle bulk to make palpation more likely. This is best done with patient lying as in figure 19.

Documentation

Whichever clinical examination you are undertaking you will need to document your findings in full. You must document your clinical findings regardless of whether these are negative or positive findings. When recording your findings, you must include the patient identifiers, date + time, your signature and print your name and designation at the end of the entry.

For example, if the patient had presented with an ear infection, document which associated lymph nodes were, and were not, enlarged and which ear/side of the patient the nodes were palpated.

However, if the patient presents with a swelling you suspect is an enlarged lymph node in isolation from any other symptoms, describe the lymph node in more detail. Please see the swelling study guide in ‘’fundamentals’’ in your online resources. Describe what the swelling looked like on inspection, same as surrounding skin, red etc. Was it tender to the touch, mobile, what size and shape it was, was the consistency, hard, soft or firm and was the surface smooth or nodular.

Giving as much detail on your findings will help a clinician to work out what additional

examinations may be required, what test may need to be organised and help form a diagnosis. Clinically. For example, if you palpate an enlarged lymph node in the medial aspect of the left supraclavicular fossa, it may be referred to as a Virchow’s lymph node. This can be suggestive of upper abdominal carcinoma or carcinomas associated with the thorax, either on it or in it. Virchow’s node is also called Troisier’s sign and is a rare finding but if you describe the node you palpated as nodular (lump) fixed (not mobile) this diagnosis is more likely. Virchow’s node is significant as this node drains into the left subclavian vein from the head, neck and the thoracic duct, thereby gaining rapid access to the rest of the body increasing the likely hood of

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Be sure to report any abnormal findings to your

supervisor

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Bibliography & Further Reading

WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/ [accessed 08/07/19]

References

Seidel’s Guide to Physical Examination, 9th_{Edition, Ball J W, Daines J E,Flynn J A, Barry S}

and Stewart R W, Elsevier Inc. 2019

Karpf M. Lymphadenopathy. In: Walker HK, Hall WD, Hurst JW, editors, Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd_{edition. Boston: Butterworths; 1990.}

Chapter 149.

Picture Credits

Figure 1: Lymph nodes of the body, Seidel's Guide to Physical Examination, Ball, Jane W.,

Figure 2: Enlarged posterior cervical lymph node, Abrahams' and McMinn's Clinical Atlas of Human Anatomy, Abrahams, Peter H., MB BS, FRCS (Ed), FRCR, DO (Hon) FHEA; Spratt, Jonathan D., MA (Cantab), FRCS (Eng), FRCR...Show all. Published January 1, 2020. Pages 365-376. © 2020………8

Figure 3: Superficial or jugulodigastric lymph node, Abrahams' and McMinn's Clinical Atlas of Human Anatomy, Abrahams, Peter H., MB BS, FRCS (Ed), FRCR, DO (Hon) FHEA,, Chapter 1, 1-85, © 2020, Elsevier Limited. All rights reserved……….8

Figure 4: Supraclavicular and cervical lymph node, General patient examination and differential diagnosis, Drake, William M., Hutchison's Clinical Methods, 2, 15-29, © 2018 Elsevier Ltd. All rights reserved………8

Figure 5: Lymph nodes of the neck, CSTLC……….9

Figure 6: Lymph nodes of the head and neck, CSTLC………...………9

Figure 7: lymph nodes of the axilla, CSTLC………10

Figure 11: Palmar aspect of fingers, CSTLC……….………16

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22 Figure 13: Palpation technique, Co-authored L Lee (2020)

https://www.wikihow.com/Check-Lymph-Nodes………...….…....16

Figure 14: Palpation of the neck, CSTLC………17

Figure 15: Palpation of the axilla, CSTLC………...………17

Figure 16: Palpation of the epitrochlear, CSTLC………18

Figure 17: Inguinal lymph nodes, Gray's Anatomy for Students. Drake, Richard L., PhD, FAAA; Vogl, A. Wayne, PhD, FAAA...Show all. Published January 1, 2020. Pages 823-1121.e4. © 2020. Anterior and posterior triangles of the neck……….…18

Figure 18: Inguinal lymph node drainage, Essential Surgery: Problems, Diagnosis and Management, Quick, Clive R.G., MBBS(London), FDS, FRCS(England), MS(London), MA(Cantab); Biers, Suzanne M., BSc, MBBS, MD, FRCS...Show all. © 2020……….18

Lymph node examination