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Examination of Lymphatic System
https://t.me/med1917
Microanatomy of Lymph Node
Lymph node contains three regions—cortex; paracortex and medulla. Cortex contains mainly follicles.
It may be rounded lymphocytic aggregations of primary
follicles or lymphocytic aggregation with germinal
centers of secondary follicles due to antigenic stimulation. It contains B lymphocytes, macrophages, dendritic reticulum cells. Germinal center is surrounded
by small B lymphocytes. Both cortex and medulla are
associated with humoral immunity. Proliferation of
germinal centers suggests active humoral immunity
with antibody production. Central medulla contains
mainly lymphatic sinuses, arteries and veins, plasma
cell and B lymphocytes. Paracortex is located in a zone
between cortex and medulla. It contains T lymphocytes,
related to cell mediated immunity. Post-capillary
venules with high endothelial cells and lymphocytes in
the wall are typical. In cell mediated immunity,
paracortex expansion occurs. Af ferent lymph vessels
enter the node through the capsule. It enters the
marginal sinus, communicates with intranodal sinus,
merging as efferent lymph vessels which enter the
hilum. Intranodal sinus lining is highly phagocytic
containing littoral cells and sinus lining histiocytes.
Main artery and veins pass through the hilum to enter
the medulla, paracortex and inner part of cortex.
Superficial cortex is supplied by direct capsular vessels.
Function
Most of the intravascular proteins are daily filtered
through lymphatics and return to circulation again.
Macromolecules and microbes are also filtered at the
nodal level as first immune system. From GIT fat is
absorbed directly through lymphatics. Lymph shows
centripetal flow. T ransport is mainly due to intrinsic
contractility of the lymphatic vessels which contain
valves for effective forward flow. To a lesser extent
only other factors like muscle contraction, arterial
pressure, thoracic pressure, respiratory movements
play role.
171
Tuberculous lymphadenitis occurs in young age
group. It is common in neck nodes. Hodgkin’s
lymphoma occurs in both young and elderly with
bimodal age occurrence. Malignant secondaries in
lymph nodes occur in old age. Non-specific adenitis,
HIV infected lymphadenopathy can occur in any age
group. Filarial lymphadenitis is common in any age
group especially in certain parts of India and other
developing countries. It commonly affects inguinal
lymph nodes. Primary lymphoedema occurs in younger
age group; secondary lymphoedema occurs in middle
aged and elderly (Figs 7.3 to 7.10).
Filarial lymphoedema is more common in tropical
countries. In India it is common in coastal areas. Orissa
is the most affected state in India.
Fig. 7.3: Bilateral axillary lymph nodes—lymphoma. Entire
lymphatic system has to be examined thoroughly.
History taking includes:
Name:
Address:
Age:
Sex:
Occupation:
Fig. 7.4: Tuberculous cold abscess neck.
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Fig. 7.5: Fungating secondaries in the neck.
SRB’s Clinical Surgery
Fig. 7.6: Filarial lymphoedema—elephantiasis left leg.
Also upper limb lymphoedema left side.
Fig. 7.7: Lymphoedema left lower limb after left sided
A
Figs 7.8A and B: Lymphoedema left sided in a male patient
due to studded advanced cancer in left axillary nodes
and chest wall. In photo B, female patient having lymphoedema right upper limb following mastectomy with axillary
clearance.
ilioinguinal block dissection.
B
Examination of Lymphatic System
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173
A B
Figs 7.9A to C: Right upper limb lymphoedema in a male who underwent reduction surgery for the same.
A
Figs 7.10A and B: Lymphoedema of scrotum and penis in two different patients.
A
C
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Lymphoedema, primary or secondary is more
common in females.
SRB’s Clinical Surgery
Chief Complaints
History of swelling and duration.
History of pain and duration.
History
History of Present Illness
Swelling
Swelling is the common presentation in lymphadenopathy. Which group enlarged first has to be noted. Its
progress, presence of pain, whether reduced in size has
to be noted. Enlarged lymph node if reduced in size after
some time means it is of inflammatory origin; there is
no spontaneous reduction in size in neoplastic
conditions. Number of swellings is also important.
Lymphoma may show multiple groups of nodal
enlargement. Site of the origin of first swelling is impor-
tant. If it is in the upper neck, then probably it may be
either due to tuberculosis or primary in the oral cavity/
pharynx/larynx. If it is in the lower neck then primary
may be in oesophagus/bronchus, etc. Acute lymphadenitis is of short duration with pain and fever (with
features of acute inflammation—redness, warmness,
pain, and loss of function at the site). Malignancy in the
lymph node either primary lymphoma or secondaries
(metastases) are also of short duration (in few weeks).
But initially it is painless. It is rapidly progressive and
later may become painful. Tuberculosis, syphilis,
brucellosis and sarcoidosis are of long duration and
commonly painless. In syphilis lymph node enlargement occurs in secondary syphilis. Syphilis, brucellosis, sarcoidosis are rare now . T uberculous lymphadenitis is still common condition in developing countries like India. Tuberculous lymphadenitis is much
more common in HIV infected or immunosuppressed
patients.
Pain
Acute lymphadenitis is painful. T uberculosis is painless. If there is secondary infection pain can occur.
Malignant lymphoma and secondaries in lymph node
are initially painless but can be painful once there
is fixity, necrosis, infiltration into deeper planes and
nerves or fungation or secondary infection.
Fever
Continuous high grade fever occurs in acute
lymphadenitis with suppuration. Evening rise of
temperature is seen in tuberculous disease. But many
patients with tuberculous lymphadenitis may not show
any fever (fever is not always seen in tuberculous
lymphadenitis). In Hodgkin’s lymphoma intermittent
fever (Pel-Ebstein fever) may be present which also
decides prognosis and staging. Pel-Ebstein fever is
also seen in brucellosis. Fever is not common in
secondaries but can occur due to sepsis, tumour
necrosis, and fungation.
Other Relevant History
History of cough, haemoptysis, chest pain in tuberculosis (tuberculous lymphadenitis may often be
associated with pulmonary tuberculosis); hoarseness
of voice due to pressure on recurrent laryngeal nerve
either by lymph nodes in tracheooesophageal groove
or by mediastinal nodes on left side compressing the
left recurrent laryngeal nerve; dysphagia due to
compression over oesophagus; swelling of face and
neck due to compression of superior vena cava by
superior mediastinal lymph nodes; stridor or dyspnoea
by pressure on the trachea or bronchus. If nodes are
secondaries, hoarseness/dyspnoea/dysphagia are may
be features of primary tumour in larynx/bronchus/
pharynx or oesophagus. Often tuberculous cervical
lymphadenitis may be associated with laryngeal
tuberculosis causing hoarseness of voice. Upper limb
oedema may be present in axillary node enlargement
due to compression. Inguinal lymph node enlargement
may cause lower limb lymphoedema or venous oedema
due to compression or lymphatic block or infiltration
by malignant lymph node. Retroperitoneal nodal
enlargement can cause compression/encasement of
IVC/iliac vessels causing oedema of lower limbs.
History of bleeding gums is common in leukaemia,
lymphomas, and blood dyscrasias.
History of loss of appetite and reduced weight is
important in lymphomas, advanced secondaries, AIDS,
etc.
History of trauma is often important in acute
lymphadenitis.
Examination of Lymphatic System
https://t.me/med1917
History of night sweats, rigors, pruritis, and bone
pain are important symptoms in lymphoma. Bone pain
may be observed in the sternum, ribs, vertebra, etc.
Jaundice may suggest liver secondaries; haemoptysis
and chest pain may suggest lung secondaries; bone
pain could be due to metastases.
Past History
Past history of any disease like tuberculosis, treatment
received, earlier investigations like chest X-ray , FNAC,
biopsy. Earlier treatment for malignancy with radiotherapy or chemotherapy should be asked for.
Personal History
History of smoking—its duration, number of cigarettes;
alcohol intake—duration, quantity; chewing pan—
duration, placing quid in the cheek; snuff abuse; dietary
habits; history of sexual contact in case of HIV
infection, syphilis, etc.
Family History
History suggestive of any disease or treatment taken
for any specific condition by the family members is
important. Tuberculosis can occur among many family
members. Lymphoma can run in families.
175
culosis, lymphatic leukaemia, sarcoidosis, brucellosis
etc; Size—It is important in staging metastatic nodal
status (N stage); Shape—Globular, hemispherical,
oval; extent from a bony part, Surface—Smooth in
lymphoma and tuberculosis, irregular in secondaries;
Margin—W ell-defined or ill-defined; Pulsation—As
transmitted pulsation due to compression over adjacent
major arteries like aorta/femoral/abdominal aorta;
Peristalsis—May be visible in mesenteric lymphadenitis causing subacute obstruction; Impulse on
coughing—may be present in swellings in relation
to cavities like thorax; Dilated veins over the
swelling—May be visible due to compression over
the major veins in the neck or SVC in the mediastinum;
oedema over the swelling or distal to it like in the
limbs may be seen; venous engorgement of face can
be seen in neck swelling (Fig. 7.11) . Tuberculosis and
Hodgkin’s lymphoma usually occurs in the neck lymph
nodes; filariasis and lymphogranuloma venereum
(LGV L1, 2, 3) occurs in groin lymph nodes.
Epitrochlear and suboccipital nodes are involved in
secondary syphilis. Epitrochlear nodes also can get
involved in Non-Hodgkin’s lymphoma.
General Examination
Detailed general examination is very essential.
Anaemia/oedema/jaundice/clubbing/lymphadenopathy should be noted. Radial pulse/blood pressure/
raise in temperature must be recorded. Attitude of the
patient/nutritional assessment by skin texture, subcutaneous fat, weight, body mass index/any other
relevant findings should be mentioned. Cachexia
signifies advanced malignancy or tuberculosis.
Increased pulse rate and fever suggests swelling with
inflammatory pathology.
Local Examination
Inspection
Swelling
Detailed inspection for swelling which is discussed
in swelling chapter should be done. Number—multiple
lymph nodal enlargement occurs in lymphoma, tuber-
Fig. 7.11: Dilated veins in the neck left sided with enlarged
lymph nodes. It could be lymphoma/secondaries with
mediastinal node enlargement compressing SVC.
Skin over the swelling is red, inflamed, oedematous
in acute lymphadenitis. It may be tense, shiny with
often dilated veins in lymphoma. Skin ulceration, skin
adherent to swelling underneath, fungation is common
in secondaries in lymph nodes. Scar, sinus, ulcer may
suggest tuberculosis or malignancy.
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SRB’s Clinical Surgery
Features suggestive of pressure effects should be
looked for:
Diffuse swelling of face and neck with dilated veins
in this region suggests compression over major veins
in neck or SVC obstruction in mediastinum. Axillary
lymph nodes when enlarged may cause upper limb
venous oedema. Neck nodes causing compression over
subclavian vein also cause similar effect. Compression
on hypoglossal nerve (causes deviation of tongue
towards the same side with hemiparesis of tongue
muscles of same side)/spinal accessory nerve palsy
(causes defective shrugging of shoulder against
resistance with wasting of trapezius muscle)/cervical
sympathetic nerve (causes Horner’s syndrome—
enophthalmos due to decreased aqueous humour and
pressure, miosis, anhydrosis, ptosis and loss of
ciliospinal reflex) can be evident in large fixed neck
nodes due to secondaries. Tracheal compression by
the neck nodes causes stridor. Lower limb oedema
may be evident in iliac or caval nodal enlargement
(Fig. 7.12).
Local Rise of Temperature
It is seen in acute lymphadenitis, and often in vascular
tumours like lymphoma. Lymph node secondaries may
show local rise in temperature when once infection
develops in it. Increase in vascularity also may add
for the cause (Fig. 7.13).
1. Tenderness over the swelling is present in acute
lymphadenitis, advanced/late stage secondaries.
Enlarged nodes due to tuberculosis, syphilis and
sarcoidosis are usually nontender.
2. Number, size, shape and extent should be
assessed by palpation. Symmetrical and consecutive group of lymph node involvement is seen in
Hodgkin’s lymphoma. Asymmetrical involvement of lymph nodes is common in NHL. It is
better to measure the swelling in two dimensions.
Margin is assessed whether it is well-defined or
ill-defined. Often some part of the margin may
be clear and in such occasion the margin which
is not clear should be mentioned. In the neck if
lower margin is not clear then it is considered that
it may be extending into the superior mediastinum.
4. Surface should be felt whether it is smooth or
nodular . It may be smooth in lymphoma, nodular
Fig. 7.12: Related neurological involvement (nerve infiltration
by malignant tumour) causing altered sensory and motor
functions. Example hypoglossal nerve involvement by neck
secondaries can cause deviation of tongue towards same
side.
Palpation
Normal lymph nodes are usually not palpable.
Fig. 7.13: Warmness should be looked for in lymph
node enlargement.
Examination of Lymphatic System
https://t.me/med1917
in secondaries, typically matted in tuberculous
lymphadenitis (due to periadenitis in caseating
tuberculous lymphadenitis). Lymph nodes may be
adherent to each other in lymphoma and secondaries. Discrete lymph nodes are often observed
in lymphoma and hyperplastic tuberculous lymphadenitis. Discrete lymph nodes are also observed
in lymphatic leukaemia, sarcoidosis, brucellosis,
HIV infection and syphilis.
4. Consistency is very important finding to decide
the pathology of the lymph node. It may be soft
and fluctuant in cold abscess, suppurated lymph
node or where there is tumour necrosis usually
over summit (here remaining part of the swelling
may be hard). In Hodgkin’s lymphoma it has
typical India rubber consistency with firm and
elastic nature. In Non-Hodgkin’s lymphoma it
may be soft/firm/hard or variable in consistency.
Shotty discrete lymph nodes are observed in
syphilis.
5. Mobility of swelling should be checked in two
perpendicular directions. Once it is checked
muscle in relation to it should be contracted and
mobility should be checked to find out the fixity.
6. Fixity of swelling can occur to overlying skin;
adjacent muscle either superficial or deep; deep
fascia; bone in the deeper plane; vessels and
nerves. Swelling is non-mobile when nodes are
fixed to bone in deeper plane. Swelling when
adherent to the muscle show mobility, but mobility reduces when the muscle is contracted. Skin
fixity is checked by moving the skin over the
swelling or by pinching the skin (Fig. 7.14).
7. Fluctuation test is important when it is soft or
tensely cystic. Fluctuation is observed in cold
abscess (tuberculosis), when there is suppuration
in lymph node with abscess formation, and when
there is tumour necrosis. It is done with fingers
after fixing the swelling or by Paget’s method of
eliciting the fluctuation (Fig. 7.15).
8. Plane of the swelling should be assessed.
Whether it lies superficial/deep to deep fascia;
deep to muscle should be assessed. It is done by
stretching the deep fascia or by contracting the
muscle underneath against resistance.
9. Involvement of neurovascular bundle should be
assessed. Carotid and superficial temporal artery
177
Fig. 7.14: Skin over the swelling is adherent to node
underneath or not should be checked by pinching the skin.
Fig. 7.15: First mobility of the node/swelling is checked in
relaxed position. Muscle underneath is then contracted
against resistance to check the change in mobility. If node
is adherent to muscle, mobility will be restricted.
pulsation in neck nodal mass; femoral artery or
distal arteries of the lower limb in groin nodes;
radial artery pulsation in axillary nodes should be
checked. Infiltration to adjacent nerve should be
assessed by checking altered sensory and motor
function (Figs 7.16 and 7.17).
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Fig. 7.16: Palpation of carotid pulse. Neurovascular
bundle should be examined in nodal enlargement.
SRB’s Clinical Surgery
by placing two fingers on the swelling. In
transmitted pulsation fingers move only
perpendicular (as raised without separating apart
and away) over the surface but not apart. In
expansile pulsation (due to arterial disease like
aneurysm) fingers deviate apart (raised and
separated) properly. Para-aortic nodes show
transmitted pulsation due to close proximity to the
aorta. The pulsation is checked in supine position
and later confirmed in lateral and knee elbow
position. In transmitted pulsation (nodal mass),
pulsation reduces or disappears in changed
positions whereas expansile aortic pulsation will
remain same as before.
Drainage Area
Drainage area of lymph nodes should be examined.
It suggests the origin of the disease in the lymph node
(secondaries from carcinoma or melanoma/tuberculosis/lymphadenitis) from a primary focus in the
drainage area.
Fig. 7.17: Pulse distal to the node should be examined for
compression at the nodal level. Palpation of superficial
temporal artery is done in neck node enlargement.
10. Transillumination test is negative in most of the
lymph nodal enlargement. Only cystic hygroma
in infants and acquired lymph cyst in any age
group are brilliantly transilluminant.
11. Transmitted pulsation may be evident in large
node sitting on the major artery . It is confirmed
Lymph Nodes in the Groin
They are divided into superficial and deep. Deep is
called as Cloquet’s node. It drains from glans penis
or clitoris. Superficial lymph nodes are divided into
vertical and horizontal groups. Vertical drains from
lower limb. Horizontal chains are divided into medial
and lateral. In carcinoma penis inguinal nodes are
divided into five zones (zones of Rouviere) by a vertical
and horizontal line centering at saphenous opening.
Zone 1-superolateral; zone 2-superomedial; zone
3-inferomedial; zone 4-inferolateral; zone 5 is central.
Superomedial zone 2 contains sentinel sapheno-
epigastric node of Cabanas. They are palpated in
supine position in relation to inguinal ligament in
relaxed position (Fig. 7.18). Inguinal lymph nodes
drain (from umbilicus to toes) entire lower limb,
perineum, penis, scrotum, vulva, anus, buttock, lower
anal canal, lower urethra, vagina, skin over lower
abdomen below the umbilicus.
Axillary Lymph Nodes
They drain entire upper limb, trunks, breast, and chest
wall from the clavicle to umbilicus. Axillary lymph
nodes are divided into three levels in relation to
Examination of Lymphatic System
https://t.me/med1917
Fig. 7.18: Inguinal lymph node palpation.
pectoralis minor muscle. Berg’s levels—Level I:
Below the pectoralis minor; Level II: behind the
pectoralis minor; Level III: above the pectoralis minor.
179
which cause axillary lymph node enlargement are carcinoma breast; tuberculosis; lymphoma; lymphadenitis;
any inflammatory or neoplastic pathology in upper
limb, trunk, above umbilicus. While palpating number,
size, surface, discrete or adherent, tenderness, consistency, mobility , fixity should be assessed. For staging
in carcinoma breast (N staging), fixity/mobility of
nodes, whether discrete or not are important features
to be assessed. Which groups are enlarged is not
important for staging. Palpable nodes are commonly
significant in carcinoma breast; but non-palpable
situation does not confirm the absence of metastases.
50% of clinically impalpable axillary nodes show
histologically positive features after axillary dissection
in carcinoma breast (Fig. 7.20).
Examination of Axillary Lymph Nodes
Patient will be in sitting position in a stool. Right axilla
is palpated using left hand and vice versa. Both axillae
should be examined always (Fig. 7.19). Conditions
Fig. 7.19: Axilla should be inspected with arm raised
above in sitting position.
Fig. 7.20: Carcinoma breast with secondaries in
axillary nodes.
Palpation of Axillary Lymph Nodes
Anterior group (pectoral group) is situated behind
the anterior axillary fold. The patient’s arm is raised
from her/his side and extended fingers of the right
hand (for left axillary node) is passed into the axilla
and insinuated beneath the pectoralis major. Pulp of
the fingers is directed forwards and arm of the patient
is lowered to rest relaxed over the forearm of the
examiner’s right hand. Pectoral nodes are palpated
between thumb in front and fingers behind the muscle
(Figs 7.21A and B).
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SRB’s Clinical Surgery
A
Figs 7.21A and B: Examination of pectoral nodes.
A B
Figs 7.22A and B: Examination of medial/central group of lymph nodes.
Central group (medial group) is over the lateral
thoracic wall. The patient’s arm is raised from side
and extended fingers of the right hand of the examiner
are passed high up to the apex of left axilla of the
patient. Palm and fingers are directed towards the
lateral thoracic wall. Patient’s arm is relaxed down
and forerarm rests and relaxed on the examiner’s
forearm. Non-examining hand (left hand) of the
examiner is placed on the right shoulder of the patient
to steady and control the examination. Hand and fingers
in the axilla are still pushed high up; hand is cupped
with fingers sliding and moving over the lateral thoracic
B
wall to feel the slipping of the lymph nodes between
fingers (Figs 7.22A and B).
Lateral/brachial axillary nodes are situated over the
axillary vein. After placing the hand and fingers high
in axilla, palm and fingers are directed laterally over
the humerus beneath the insertion of the pectoralis
major over third part of axillary vessels. Opposite hand
of the examiner depresses the patient’s shoulder for
better assess.
Subscapular lymph nodes are located in the posterior
axillary fold in relation to latissimus dorsi muscle. It
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