Examination of the Lymphatic System

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• Examination of the Lymphatic System

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The Lymphatic SystemFunction

• An integral part of the immune system
• Provides defense against microorganisms by
  producing antibodies and performing phagocytosis

• Plays an unwanted role in providing at least one
  pathway for the spread of malignancy

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The Lymphatic SystemAnatomy

• Composed of
• lymph fluid
• collecting ducts
• lymph nodes
• spleen
• thymus
• tonsils
• adenoids
• Peyer patches

• Lymphatic tissue is also present in
• stomach
• bone marrow
• lungs

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The Lymphatic SystemAnatomy Physiology

• Lymph nodes
• usually occur in groups
• condition of nodes provides clues to the presence
  of infection or malignancy
• Lymphocytes
• arise from precursor cells in nodes, tonsils,
  adenoids, spleen bone marrow
• central to the bodys response to antigenic
  substances

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The Lymphatic SystemAnatomy Physiology

• Thymus
• located in superior mediastinum and into lower
  neck
• little or no demonstrated function in adults
• serves in forming protective immune function
  during fetal infant development
• Spleen
• located between the stomach and diaphragm
• forms and stores RBCs in early life
• macrophages in the spleen filter blood

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The Lymphatic SystemAnatomy Physiology

• Tonsils Adenoids
• tonsils are between palatine arches of pharynx
  near base of tongue . . . composed of lymphoid
  tissue and covered with mucous membrane
• adenoids (pharyngeal tonsils) are near
  nasopharyngeal border . . . may obstruct
  passageway if they enlarge in response to
  frequent bacterial or viral invasion
• Peyer Patches
• elevated areas of lymph tissue on the small
  intestine serving the intestinal tract

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Lymphatic System

• A separate vessel system.
• The two main functions are to transport excess
  fluid from the interstitial spaces to the
  circulatory system and to protect the body
  against infectious organisms.

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Components of the Lymph System

• Lymph Fluid pale yellow moves from the plasma
  through the capillary walls and becomes
  interstitial fluid.
• Lymph Nodes scattered through the body and
  contain dense patches of lymphocytes and
  macrophages.
• Lymph Organs the spleen and the thymus.

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Lymph System

• Lymphatic capillaries
• Lymphatic ducts
• Lymph Nodes
• System carries fluids from the interstitial
  spaces to the blood
• Proteins, fat from GI, and hormones return to
  blood
• Returns excess interstitial fluid to blood

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Lymphatic Circulation
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The Lymphatic SystemAnatomy Variations

• Infants Children
• infants response to infection is immature during
  first months of life
• lymphoid tissue increases to twice an adult mass
  between 6-9 years and regresses to adult levels
  by puberty
• tonsils are larger during childhood
• lymph node distribution is the same in children
  adults

• Older Adults
• the number and size of lymph nodes decreases with
  age
• some lymphoid elements are lost
• nodes are more fibrotic and fatty than in younger
  person, resulting in an impaired ability to
  resist infection

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The Lymphatic SystemHistory Review

• Present Problem
• bleeding
• enlarged nodes
• swelling of extremity
• medications
• Past Medical History
• chest x-rays
• TB and other skin tests
• transfusions
• chronic illness
• cardiac, renal, malignancy, HIV
• surgery
• recurrent infections

• Family History
• malignancy
• anemia
• recent infections
• TB
• agammaglobulinemia, other immune disorders
• hemophilia

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History

• Acute vs Chronic
• Localised (3/4) vs Generalised (1/4)
• Only 17 of generalized Lymphadenopathy
  identified
• Unilateral vs Bilateral

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HIV InfectionRisk Factors

• Adolescents and Adults
• Sexual contact with HIV partner
• Men with homosexual or bisexual activities
• Heterosexual contact with homosexual or bisexual
  men
• Multiple and indiscriminate sexual contacts
• IV drug use
• Hemophilia
• Blood transfusion
• Work related (very rare)

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HIV InfectionRisk Factors

• Infants and Children
• Mother either with or at risk for HIV infection
• Hemophilia
• Blood transfusion
• Sexual abuse

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History Variations

• Infants and Children
• recurrent infections
• poor growth, FTT
• loss of interest in playing or eating
• immunization history
• maternal HIV infection
• hemophilia
• illness in siblings

• Pregnant Women
• weeks gestation, EDC
• exposure to rubella and other infections
• presence of children in household
• Older Adults
• present or recent infection or trauma distal to
  nodes
• delayed healing

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Examination of theLymphatic System

• Utilizes inspection and palpation
• Generally examined region by region during the
  examination of the other body systems
• Always ask patients if they are aware of any
  lumps

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Lymph Nodes Accessible to Examination

• Head and Neck
• preauricular
• postauricular
• occipital
• tonsillar
• submandibular
• submental
• superficial anterior cervical
• deep cervical
• posterior cervical
• supraclavicular
• infraclavicular

• The Arms
• axillary
• anterior axillary (pectoral)
• lateral (brachial)
• mid axillary (central)
• posterior (subscapular)
• epitrochlear
• The Legs
• superficial superior inguinal
• superficial inferior inguinal
• popliteal (occasionally)

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Examination of theLymphatic System

• Inspect
• any visible nodes for
• edema
• erythema
• red streaks

• Palpate
• the superficial nodes
• compare side to side for
• size
• consistency
• mobility
• discrete borders or matted
• tenderness
• warmth

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Examination of theLymphatic System

• If an enlarged lymph node is found, examine
• P Primary site
• A All associated nodes
• L Liver
• S Spleen

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Age Related Variations

• Infants and Children
• commonly find small, discreet, firm, movable
  nodes in occipital, postauricular, cervical and
  inguinal chains . . .
• should not be warm or tender
• shape usually ovoid or globular
• often referred to as shotty nodes
• may find enlarged postauricular and occipital
  nodes in children lt 2 years old
• cervical and submandibular node enlargement is
  less frequent in children lt 1 year old and much
  more frequent in older children
• palatine tonsils may be enlarged

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EVALUATION OF Lymphatic System

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Objectives

• Student should be able to
• describe location, size, consistency, and other
  attributes of lymphadenopathy
• identify common clinical scenarios involving
  lymphadenopathy

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Overview

• This is a short lecture!
• A major goal is to synthesize the lymphatic
  system as a wholelymph node regions have been
  discussed individually by specific sitei.e.,
  head, neck, and abdomen, but not put together for
  systemic illness such as lymphoma.

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Lymphatic System
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The Lymphatic System
Palpable superficial lymph nodes
Occipital Posterior auricular Preauricular Tonsill
ar Submaxillary Submental Superficial
cervial Deep cervical Supraclavicular Axillary Lat
eral Subscapular Pectoral Epitrochlear Inguinal
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Lymph Node Examination

• Head/neck
• Axillary
• Epitroclear
• Inguinal/femoral

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Physical Examination

• Head and Neck LN
• Axillary LN
• Inguinal LN

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Lymph node regions
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Head and Neck Nodes

• Preauricular
• Posterior auricular
• Occipital
• Tonsillar
• Submandibular
• Submental
• Superficial cervical
• Posterior cervical
• Deep cervical
• Supraclavicular

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Lymph nodes of the head and neck, and the regions
that they drain
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ALLCervical Lymphadenopathy
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Right neck mass
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Lymphoma
Row of enlarged lymph nodes
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Lymphadenopathy in children
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TB abscess as part of immune reconstitution
syndrome
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Axillary

• A pectoral (anterior)
• L lateral
• P posterior
• C central
• Ap apical

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Axillary lymphatics and the structures that they
drain
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Describe
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Inguinal/ Femoral

• Horizontal group
• Vertical group

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Inguinal lymphatics and the structures that they
drain
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Chest X-Ray
Normal
Patient

• Hilar Lymphadenopathy
• Is a common feature of
• Sarcoidosis
• TB
• Coccidiomycosis
• Histoplasmosis

Interstitial Infiltrates Bilateral hilar
lymphadenopathy
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Lymphadenopathy

• Bilateral symmetric hilar and right paratracheal
  mediastinal adenopathy is the most common pattern
  of lymphadenopathy in sarcoidosis.
• Unilateral hilar lymphadenopathy is more common
  in TB, neoplasm and primary pulmonary fungal
  infection
• Frequently, the hila are prominent but not
  definitely abnormal. Even if the hila are
  enlarged, it may not be possible to determine if
  this is due to enlarged lymph nodes or enlarged
  pulmonary vessels.
• The lateral radiograph can often resolve
  uncertainties.

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Mediastinal Lymphadenopathy - ALL
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Descriptors of Lymphadenopathy

• Locationobvious
• Mobility
• Size
• Texture
• Shape
• Tender/non-tender
• Associated erythema or warmthsigns of
  inflammation

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Spleen

• Left upper quadrant
• Palpation most specific for detecting enlarged
  spleen (89-99 specificity)
• Spleen palpable to umbilicus is suggestive of
  hematologic pathology
• Percussion is non-sensitive (dullness in Traubes
  space) but can be specific in non-obese patients

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Organomegaly
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Splenomegaly
Spleen
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Case

• 28 yo man presents with c/o fevers, night sweats
  and 30 pound weight loss. He develops pruritis
  when he showers. He also has noted some enlarged
  glands in his neck and armpits. On lymphatic
  exam he has the following

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Case

• painless lymphadenopathy in anterior axilla and
  anterior cervical as well as supraclavicular
  areas bilaterally.
• Lymph nodes are not tender, freely mobile and no
  associated inflammation. They are ovoid
  (grape-shaped) and measure 2 x 3 cm. There is no
  splenomegaly by palpation or percussion.

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Differential Diagnosis

• Lymphoma
• Infection
• Cancermetastatic
• Granulomatous disease