Examination technique and description rules
Examination of the lymphatic system begins with a visual inspection. Sometimes the enlargement of the nodes is so pronounced that it leads to visible deformation of body contours in the neck, inguinal, or axillary regions. Special attention is paid to the skin: the presence of scars (traces of healed fistulas) or fresh fistulous tracts with discharge of pus or fluid requires the immediate exclusion of tuberculosis (scrofuloderma).
The main method is palpation. It is performed with the fingertips using gentle circular movements. The fundamental principle is the mandatory and synchronous examination of symmetrical areas of the body.
For accurate clinical evaluation, each detected node is described using a standardized algorithm comprising 7 parameters:
- Number: single nodes or multiple.
- Localization: precise anatomical name of the affected group.
- Shape: for example, round.
- Size: indicated by the physician strictly in millimeters.
- Consistency: soft, elastic, or firm.
- Mobility: freely movable or not.
- Tenderness: reaction upon palpation is evaluated.
Mattedness of nodes into conglomerates (clusters) or their fusion with surrounding tissues and skin is recorded separately.
Topography of head and neck nodes
Palpation is performed systematically, moving strictly from top to bottom:
- Occipital nodes: palpable on the back of the neck at the transition to the occiput, at the attachment site of the trapezius muscle (m. trapezius) to the occipital bone.
- Parotid nodes: located anterior to the tragus of the auricle (tragus).
- Submental nodes: examined in the triangle of the same name behind the body of the mandible.
- Submandibular nodes: divided into anterior and posterior. Anterior lie anterior to the submandibular salivary gland (clinically often incorrectly referred to as "submaxillary"). Posterior lie posterior to the salivary gland at the angle of the mandible (sometimes mistakenly called "tonsillar").
Next, proceed to examine the neck. Superficial cervical nodes are palpated anterior to the sternocleidomastoid muscle (m. sternocleidomastoideus).
Topography of trunk and limb nodes
Continuing downward, the physician examines the lymph nodes of the shoulder girdle, chest, and limbs:
- Cervicosupraclavicular zone: supraclavicular nodes are sought in the supraclavicular fossae, in the space between the heads of m. sternocleidomastoideus. Subclavicular nodes are examined below the clavicle along the projection of the subclavian vein.
- Chest: pectoral nodes are localized under the pectoralis major muscles. Axillary nodes are palpated deep in the axillary fossae (fossa axillaris).
- Upper extremities: epitrochlear nodes are located on the anterior surface of the forearm (level of the medial epicondyle of the humerus) along the course of the basilic vein (v. basilica).
- Lower trunk: inguinal nodes are palpated in the inguinal regions, with the inguinal crease serving as a landmark.
Clinical significance and differential diagnosis
Lymphadenopathy helps localize the pathological process or suspect a systemic disease. A local reaction of the submandibular and submental nodes often indicates pathology of the palatine tonsils (tonsillitis) or odontogenic infections. Acute inflammations (acute pharyngitis, purulent mastitis) also cause enlargement of regional lymph nodes.
Generalized enlargement is an alarming sign. It can be an early and sole manifestation of HIV infection. Other causes include hemoblastoses, lymphoproliferative diseases (Hodgkin's lymphoma), systemic connective tissue disorders, and infections (e.g., brucellosis). In case of unclear etiology, the patient is indicated for node biopsy for morphological verification.
Metastatic involvement is of great importance. A classic symptom of advanced gastric cancer is Virchow's node (Virchow's node). This is one or more painless nodes in the left supraclavicular region, located in the angle between the upper edge of the clavicle and the outer edge of m. sternocleidomastoideus.
Briefly: answers to topical questions
In what strict sequence is the palpation of all lymph node groups of the head and neck performed?
Palpation of the lymph nodes of the head and neck is performed in a strict sequence from top to bottom:
- Occipital nodes
- Parotid nodes
- Submandibular nodes (anterior and posterior)
- Submental nodes
- Superficial cervical nodes
What does the mattedness of lymph nodes into conglomerates (clusters) clinically indicate?
The mattedness of lymph nodes into conglomerates (clusters) is a sign that must be recorded when describing lymphadenopathy. In sources, it is described in:
- Metastatic lymph node involvement: nodes are enlarged, round, firm, sometimes nodular, fused with surrounding tissues and other nodes into conglomerates, painless.
- Tuberculous lymphadenitis: periadenitis is characteristic; affected nodes form a conglomerate, are matted together, and vary in size. A slow enlargement of several nodes with the formation of firm, nodular "clusters" is also described.
What causes and diseases most frequently lead to generalized lymphadenopathy?
Generalized lymphadenopathy is indicated in sources for:
- HIV infection: generalized lymphadenopathy is characteristic at the early stage, often as the only clinical manifestation; generalized lymphadenopathy is also indicated in the early symptomatic stage.
- Leukemias: generalized lymph node enlargement is characteristic of leukemias, especially chronic lymphocytic leukemia.
- Lymphogranulomatosis (Hodgkin's lymphoma): generalized lymph node enlargement is characteristic of lymphogranulomatosis.
Prolonged unexplained generalized lymphadenopathy persisting for more than 1 month is an indication for targeted screening for HIV.
To memorize the 7 parameters of a node description, use the acronym: Cat Fed Roused, Chasing Some Mice Around (Count, Form, Size, Consistency, tenderness/Pain, Mobility, Adhesions).
Class and exam questions
How to differentiate Virchow's node metastasis from conventional inflammatory lymphadenitis?
Virchow's node is a metastasis of gastric cancer. Unlike inflammation, it is painless and has a strict localization: the left supraclavicular fossa, the angle between the clavicle and the edge of the sternocleidomastoid muscle.
Is it acceptable to describe lymph node size using comparisons ("pea-sized", "cherry-sized")?
No, this is unacceptable. The size of a lymph node is always measured and indicated by the physician strictly in millimeters to ensure data objectivity.
What does the presence of scars or fistulas on the skin over a lymph node indicate?
Fresh fistulas with purulent discharge or old scars over the cervical lymph nodes require the immediate exclusion of a specific lesion—tuberculosis (scrofuloderma).
Is it necessary to palpate the epitrochlear nodes if the patient has no complaints?
Mandatorily. Normally, epitrochlear lymph nodes are not palpable. Their accidental detection is an important marker of systemic lymphadenopathy.
What else to study on this topic
- Indications and technique of lymph node biopsy
- Differential diagnosis in generalized lymphadenopathy
- Clinical presentation and diagnosis of Hodgkin lymphoma (lymphogranulomatosis)
- Specific lymph node changes in early stages of HIV infection
- Scrofuloderma: pathogenesis and manifestations of lymph node tuberculosis
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