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Examination of Lymphatic System
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181
Fig. 7.23: Examination of subscapular group of lymph
nodes.
is examined from behind. Examiner stands behind the
patient. Respective examiner’s hand is used for
palpation of respective side of the subscapular group
of lymph node. Hand and fingers are placed over the
anteroinferior aspect of the posterior axillary fold and
using other hand patient’ s arm is partially lifted. Nodes
are palpated between thumb and fingers (Fig. 7.23).
Apical group of lymph nodes are palpated using
examiner’s opposite hand. Fingers are pushed very high
up and another hand of the examiner is placed over the
same shoulder of the patient to depress downwards.
Cervical Lymph Nodes
Cervical lymph nodes drain from lymphatics of head,
neck, face, oral cavity , nasal cavity, paranasal sinuses,
pharynx, larynx and thyroid. Left supraclavicular nodes
receive from left upper limb, left side chest wall, left
breast, abdomen and both testes. Cervical lymph nodes
can be superficial or deep. Nodes are placed in different
levels—Level I to level VI. Level VII is mediastinal
node. Level I—submental and submandibular nodes;
level II is upper deep cervical; level III is middle deep
cervical; level IV is lower deep cervical; level V is
posterior triangle nodes; level VI is central nodes
(paratracheal and laryngeal). Level I and level II are
further divided into a and b. Ia is submental; Ib is
submandibular. Level Va above the spinal accessory
level; level Vb is below it (Figs 7.25 to 7.27).
A
B
Figs 7.24A and B: Inner Waldeyer’s ring should be examined
in lymphadenopathy. It is significant in tuberculosis and NHL.
Inner W aldeyer’ s ring—adenoids, tubal tonsils, faucial
tonsils, lingual tonsils also should be examined (Figs
7.24A and B).
Outer W aldeyer’ s ring—retropharyngeal lymph nodes;
jugulodigastric lymph nodes; submandibular lymph
nodes; submental nodes.
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A
C
Figs 7.25A to D: Palpation of submental and submandibular lymph nodes on both sides.
In generalised lymphadenopathy, all nodal groups
on both sides should be examined. Epitrochlear and
popliteal nodes should be examined. These nodes may
get enlarged in NHL. Epitrochlear node also may be
enlarged in syphilis. Epitrochlear nodes are examined
in sitting position with elbow partially flexed; 2 cm
above the medial epicondyle in the groove between
biceps and brachialis (Figs 7.28A and B). Popliteal
B
D
nodes are palpated ideally in prone position with knee
flexed to relax the popliteal fascia. It is felt in the
lower part of the popliteal fossa over the upper part
of flat tibial surface. Lungs should be examined for
pleural effusion. Para-aortic nodes, iliac nodes,
liver and spleen enlargement should be looked for
(Figs 7.29A and B). Examination of spine is also
mandatory.
Examination of Lymphatic System
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183
A
C
B
D
Figs 7.26A to E: Examination of level II, III, IV, V and supraclavicular nodes in the neck.
E
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Fig. 7.27: Opposite side neck also should be always
examined for any enlargement of lymph nodes.
SRB’s Clinical Surgery
A
A
B
Figs 7.28A and B: Epitrochlear lymph node
palpation—2 cm above the medial epicondyle.
B
Figs 7.29A and B: Iliac and para-aortic nodes should be
examined in generalised lymphadenopathy. Iliac nodes are
palpated above and medial to inguinal ligament. It is enlarged
in lymphoma, secondaries, etc. Para-aortic nodes are
palpated in epigastrium above the umbilicus. It is resonant,
non-mobile mass, vertically placed. It is felt on deep palpation.
Percussion
Sternal tenderness should be checked by direct method.
It is elicited in lymphoma and leukaemias. Change
in percussion note over the sternum (direct or indirect
method) suggests superior mediastinal lymph node
mass or other superior mediastinal tumors like retrosternal goitre, thymoma, and aneurysm. Percussion
over the abdomen to look for free fluid is essential.
Percussion in respiratory system is done to find out
pleural effusion (Figs 7.30A and B).
Examination of Lymphatic System
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185
liver, palpable spleen, para-aortic nodes, iliac nodes,
etc. (Figs 7.31A to E).
Spine is examined for tenderness, paraspinal
spasm, restricted spine movements and neurological
deficits. NHL can involve spine causing neurological
deficits (Figs 7.32A and B). There may be altered
sensation, altered muscle power in the lower limb with
urinary incontinence. It needs urgent radiotherapy/
steroid therapy/surgical decompression.
Investigations
Blood
In acute lymphadenitis leucocytosis with neutrophilia
is observed. Lymphocytosis is common in tuberculosis,
A
lymphomas, leukaemia. Peripheral smear may show
atypical lymphocytes in lymphatic leukaemia.
Nocturnal blood smear may show microfilaria in
peripheral smear of patient with filariasis. Specific
blood tests for lymphogranuloma venereum or syphilis
or HIV may be carried out. ESR is raised in tuberculosis
and malignancies. Liver function test is useful in
lymphoma to predict the possible involvement of liver.
It is also useful during treatment period in case of
tuberculosis to assess side effects. Hb% is significant
in tuberculosis, lymphoma and secondaries. Platelet
count is needed prior to therapy in case of lymphoma.
B
Figs 7.30A and B: Sternum should be percussed for
tenderness and note. Sternal tenderness is significant in
lymphoma and leukaemia. Normal note on percussion over
the sternum is resonant. It becomes dull if there is mass
lesion like lymph nodes in the superior mediastinum.
Percussion is done by direct method to check tenderness.
To find out the note either direct or indirect method may
be used.
Auscultation
Auscultation over the mass is done to find out any
bruit due to compression.
Systemic Examination
Respiratory system examination is done to look for
pleural effusion, or any altered breath sounds;
abdominal examination is done to look for palpable
FNAC/Aspiration
It is useful in tuberculosis, malignancy. Caseating
material with epithelioid cells is typical feature of
tuberculosis. Langhans giant cells, lymphocytes and
plasma cells are also found. Secondaries are diagnosed
by FNAC. FNAC is not much useful in lymphomas
as open biopsy is better to assess the type and to do
histochemistry.
Lymph Node Biopsy
It is very useful method of investigation in lymph node
enlargement especially in lymphomas. It is also useful
in tuberculosis. In metastatic lymph nodal disease,
if repeat FNAC is still not conclusive then only open
biopsy is done. Routine open biopsy of secondaries
in lymph node is avoided as spread can occur to further
level of nodes increasing the nodal staging of the
disease. Biopsy is done under general anaesthesia.
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A B
C
Figs 7.31A to E: Respiratory system is examined for effusion and altered breath sounds.
Abdomen should be examined for liver enlargement, palpable spleen, para-aortic nodes.
D
E
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187
A
Figs 7.32A and B: Spine should be examined in generalised lymphadenopathy for tenderness,
paraspinal spasm. It could be lymphoma, chronic lymphatic leukaemia, spine tuberculosis.
Proper selection of lymph node to be taken for biopsy
is essential so that possibility of negative result and
need for rebiopsy may be reduced. Large sized/hard
lymph node is more likely to be positive than small
and soft lymph node. Adequate incision, exposure,
retraction of deep fascia and soft tissues are needed.
Breaking of the capsule is avoided as much as possible.
Unnecessary handling of the node during dissection
is avoided. Lymph node is held with nontoothed
dissecting forceps. Ideally entire one lymph node is
removed for biopsy. But in adherent node it is often
difficult to remove the entire lymph node. Imprint films
may be taken for cytological study. In tuberculosis
cut section of node is yellowish, opaque with caseation
in the centre. Histologically it shows caseating necrosis,
epithelioid cells (modified histiocytes), Langhans
giant cells, fibrosis, and chronic inflammatory cells.
Cut section in lymphoma is fleshy, firm, elastic, grayish
with often areas of haemorrhage and necrosis.
Histologically (in HL) it shows cellular pleomorphism
with features of anaplasia, lymphocytes, lymphoblasts,
large multinucleated Reed-Sternber g giant cells with
owl eye nuclei. Stroma shows silver stained reticular
elements.
Radiological Examinations
Chest X-ray
Chest X-ray is significant to see pulmonary tuberculosis, pleural effusion, mediastinal lymph nodal
B
mass, calcified tubercular lymph node, primary bronchogenic carcinoma.
Relevant investigations for primary like endoscopies, blind biopsies, CT of the part is also done.
CT Chest
CT chest is more relevant than chest X-ray to detect
early lesions either malignancy or inflammatory
condition and also mediastinal nodes. 30% of lesions
in the lungs can be missed in chest X-ray but are well
detected by CT chest. CT abdomen is done when
needed in individual patient basis.
US Abdomen
US abdomen is done to see liver, spleen and paraaortic, mesenteric, iliac nodes especially in lymphomas. Dancing filaria may be evident if US is done
directly on the lymph node. US of specific area like
axilla/groin/neck is done to assess the size, extent,
relations of enlarged lymph nodes and also vascularity ,
and relation of major vessels in the region.
Lymphangiography
It is done in congenital lymphoedema to see aplasia/
hypoplasia/hyperplasia; lymphomas (shows reticular
pattern) to assess the response for treatment as dye
stays for long duration in the lymph node and so
node can be assessed by taking repeated X-rays of
the area. Patent blue dye or 1 ml isosulphan blue is
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injected subcutaneously in the web space of the foot.
Lymph vessels take up this dye and make it clearly
visible. Using operating microscope, after skin
incision, lymphatic vessel is identified and cannulated
with 30 G needle. Ultrafluid (ethiodised oil) lipiodol
is injected slowly using pressure pump at a rate of
1 ml in 8 minutes. Total of 7 ml of contrast agent
is injected. It takes 24 hours to pass through the
lymphatics and reach the lymph nodes—iliac and paraaortic nodes. X-rays are taken to visualise lymphatics
and lymph nodes. Lymphomas show foamy or reticular
pattern. Secondaries show irregular filling defects.
Lymphatic pattern/anomalies can be assessed properly
and classify lymphoedema as congenital hyperplasia
(10%); distal obliteration (80%); proximal obliteration
(10%)—Browse’s lymphangiographic classification
of lymphoedema. Disadvantages—Procedure is
invasive, technically difficult, time consuming, dye
may not reach the required area, extravasation of dye
can cause complications like sepsis, skin necrosis.
In melanoma radiopaque phosphorus is added to
the dye during lymphangiography which will destroy
malignant cells in lymph nodes and is called as
endolymphatic therapy.
Isotope Lymphoscintigraphy
It has got 90% sensitivity; 100% specificity. It is useful
to differentiate lymphoedema from other causes of
limb swelling. It is simple, safe, and reproducible and
there is low exposure to radioactivity (5 mCi). Radiolabeled human albumin or Technetium 99m labeled
sulphur colloid is injected into the web space. It
migrates in skin and subcutaneous lymphatics and is
monitored using whole body gamma camera. It gives
clear images of lymphatics, and nodes in the inguinal,
iliac, para-aortic region. Later it gives image of thoracic
duct also. Amount of radiotracer is assessed in the
inguinal nodes in 30 and 60 minutes. Normal uptake
is 0.6 to 1.6%. An uptake less than 0.3% in 30 minutes
is diagnostic of lymphoedema. In oedema due to venous
diseases, uptake is rapid and shows more than 2%
in 30 minutes in inguinal nodes. Thoracic duct, liver
and other lymphatic organs in the body can be
visualised. It is technically easier and faster.
Mediastinal Gallium 67 radioisotope scan can be
done to find out whether mediastinal nodes are involved
or not.
SRB’s Clinical Surgery
Laparoscopy/mediastinoscopy/thoracoscopy are
useful in difficult cases.
Bone marrow aspiration is essential once
lymphoma is confirmed to stage the disease and also
eventually to see the therapeutic response. It is also
important in lymphatic leukaemia.
CT/MRI spine to see spine involvement in case
of lymphoma.
Other Tests
Mantoux test/guinea pig inoculation test for tuberculosis; Gordon’s biological test for Hodgkin’s
lymphoma; Frei’s intradermal test for lymphogranuloma venereum. In Gordon’s test affected lymph node
emulsion is injected into the cerebrum of the rabbit
which initiates encephalitis in few days in case of
Hodgkin’s disease. In Frie’s test pus is collected from
an unruptured bubo. It is diluted using saline—1:10;
sterilised with 60 degree temperature. 0.1 ml of such
solution when injected intradermally will show a
reddish papule at the site of injection in case of positive
for lymphogranuloma inguinale (LGV- L1, 2, 3).
Pathology of Lymph Systems
Generalised Lymphadenopathy
Generalised lymphadenopathy means enlargement of
more than one non-contiguous group of lymph nodes
for a period of 3 months with each group showing
at least one node more than 1.0 cm in size.
Causes for generalised lymphadenopathy aretuberculosis; lymphoma either Hodgkin’s or NonHodgkin’s; lymphatic leukaemia; HIV infection;
autoimmune diseases as part of collagen disease;
secondary syphilis (secondary and primary syphilis;
not in tertiary syphilis); infectious mononucleosis;
sarcoidosis; brucellosis; toxoplasmosis, etc. Presently
tuberculosis, lymphoma, leukaemia are common
causes. Other causes can be present but rare. In
generalised lymphadenopathy, all groups of lymph
nodes should be carefully examined in detail—neck
nodes; axilla; groin nodes. Epitrochlear nodes,
popliteal nodes should also be examined. Nodes on
both sides should be examined. Respiratory system
and chest should be examined for change in breath
sounds, pleural effusion. Abdomen should be examined
Examination of Lymphatic System
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in the drainage area like in neck nodes following
tonsillitis, oral infection, scalp infection, nasal and
ear infection; in the axillary nodes following skin
infection, hidradenitis, trauma; in groin nodes following filarial adenitis with acute presentation, trauma
(bare foot walk, ulcers, abrasions, wounds), infective
focus in the lower limbs, perineal diseases. It is rapidly
enlarging swelling of sudden onset (lymph node) with
pain, fever, redness, tenderness, brawny oedema. Once
suppuration (pus formation) occurs, fluctuation
develops in the centre (Paget’s test is positive). Pitting
on pressure is appreciated in the periphery of swelling.
Primary focus in the drainage area may be evident.
If patient is immunosuppressed and diabetic septicaemia may often develop.
189
Fig. 7.33: Generalised lymphadenopathy in a patient
with Non-Hodgkin’s lymphoma.
for hepatomegaly , splenomegaly and ascites. Looking
for sternal tenderness, percussion note on the sternum,
and spine examination is must. Fever, itching, weight
loss, wasting, jaundice, neurological deficits are
important features to be noted (Fig. 7.33).
Causes of Lymph Node Enlargement
a. Inflammatory: Acute lymphadenitis; Chronic
lymphadenitis; Granulomatous lymphadenitis:
(a) Bacterial like tuberculosis, syphilis, tularaemia,
brucellosis, lymphogranuloma venereum, Cat
scratch fever. (b) V iral like HIV infection, infectious
mononucleosis. (c) Parasitic like filarial adenitis,
toxoplasmosis. (d) Fungal like blastomycosis,
histoplasmosis, coccidiodomycosis. (e) Other
causes like sarcoidosis.
b. Neoplastic: Lymphomas (HL and NHL); Secon-
daries in lymph node from most of the carcinomas,
some sarcomas, malignant melanoma.
c. Haematological: Chronic lymphatic leukaemia.
d. Immunological: Serum sickness, drug reactions,
rheumatoid arthritis, systemic lupus erythematosus,
scleroderma, polyarteritis nodosa.
Acute Lymphadenitis
It is acute bacterial infection of the lymph nodes. It
usually results following spread from an infective focus
Chronic Lymphadenitis
It is usually due to non-specific bacterial infection.
Lymph nodes are enlar ged, discrete or often adherent,
slightly tender and elastic. Focus may be from drainage
area like scalp, limbs, and perineum. It should be
differentiated from tuberculosis and lymphomas.
Reactive Hyperplasia of Lymph Nodes
It is enlargement of lymph node as hyperplastic
response to existing diseases in the drainage area like
carcinomas or recurrent infections. Lymph node is
enlarged, non-tender, firm, discrete and mobile. Hyper plasia occurs in germinal centre of the node. But
clinically it is difficult to differentiate it from secondaries from carcinoma. Histological study following
FNAC/biopsy or after radical dissection confirms the
reactive hyperplasia.
Tuberculous Lymphadenitis
It is common in neck nodes. Mediastinal, mesenteric,
axillary and inguinal nodes also can get involved. In
the neck, nodes are involved commonly through tonsils.
Upper deep cervical nodes (54%) are commonly
involved. Posterior triangle nodes are involved in 22%
cases. Often multiple, bilateral nodes may get involved.
Axillary nodes are often diseased through retrograde
spread from neck nodes of posterior triangle or through
blood or from apical lung disease across parietal pleura.
Infection also may be following blood spread from
primary pulmonary tuberculosis. Occasionally it may
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SRB’s Clinical Surgery
be part of miliary tuberculosis also. It is caused by
Mycobacterium tuberculosis. Infection is more
common in HIV , lymphoma, malnourished, immunosuppressed patients. Bacteria evoke inflammation and
cell mediated immunity in the paracortex. Disease
passes through five stages. Stage 1: S tage of infection
and lymphadenitis; Stage 2: Stage of periadenitis and
matting; Stage 3: Stage of caseating necrosis and cold
abscess formation; Stage 4: Stage of collar stud
abscess formation where caseating material passes
through deep fascia into subcutaneous tissue and gets
adherent to the skin; Stage 5: Stage of sinus formation.
Fibrosis and calcification can occur in this node.
Tuberculous lymphadenitis can occur in two types.
T ype 1: Caseating tuber culous lymphadenitis which
is 80% common. It causes caseation, matting due to
periadenitis, cold abscess and sinus formation. Here
body resistance is less and drug may not reach in
effective concentration into the area of caseation and
so resistance and residual disease is common to
develop. Type 2: Hyperplastic tuberculous lymphade-
nitis is 20% common. It is firm, nontender, discrete
node without central caseation. Cold abscess and sinus
will not occur. Host resistance is good and so shows
good and rapid response to drugs. Gross features of
caseating tuberculous lymphadenitis are firm, matted,
node with yellowish central caseation on cut section.
Histologically it contains epithelioid cells (are
modified histiocytes—diagnostic feature), Langhans
giant cells, macrophages and lymphocytes. Clinically,
presents as firm swelling, which is not warm, nontender,
matted, usually mobile, can be adherent to adjacent
muscles. Cold abscess is soft, nontender, smooth,
fluctuant, non-transilluminating, well localised, often
nonmobile swelling with free non-adherent skin over
the surface. Skin will be adherent at collar stud abscess
stage. Tonsils and lungs should be examined for
primary focus (Fig. 7.34). Secondaries, lymphoma,
chronic lymphadenitis, lymph cyst, HIV , branchial cyst
are differential diagnosis (Fig. 7.35).
Filarial Lymphadenitis
It is common in inguinal nodes. Firm, tender, enlarged
lymph nodes are common. Periodic fever and pain
is common. Thickening of spermatic cord (funiculitis),
thickened epididymis (epididymitis), thickened scrotum, filarial limb are common. Night blood sample
Fig. 7.34: Tonsil is the common focus of the
tuberculous lymphadenitis of cervical nodes.
Fig. 7.35: Tuberculous lymphadenitis
with sinus in the neck.
may show microfilaria in the circulation. Eosinophilia
is common. US of lymph node shows typical dancing
microfilaria. Biopsy reveals adult worm.
Lymphogranuloma Inguinale/Climatic Bubo/
Tropical Bubo
Lymphogranuloma inguinale/climatic bubo/tropical
bubo is a sexually transmitted disease due to
lymphogranuloma inguinale, a venereal spreading
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