CLINICAL WORK UP OF A PATIENT WITH LYMPH NODE ENLARGEMENT Dr.Anil Haripriya The lymph nodes are major components of the lymphatic system placed in small groups or chains at strategic locations where they drain the lymphatic vessels of various anatomic regions. They are composed of dense accumulation of lymphoid tissues. A normal lymph node is ovoid, round or bean shaped and vary in size from 2 mm to 20mm in longitudinal diameter. The location of each group of lymph nodes in the mammalian body is relatively constant receiving lymph from a specific region by multiple afferent lymphatic vessels which enter on its convex border. The efferent lymphatic vessels along with blood vessels are situated in the hilum. The drainage of lymph involves not only the mechanical filtration of the foreign Protein, viral and bacterial particles present in the lymph but also the
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Clinical Work Up Of A Patient With Lymph adenopathy. by anil haripriya
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CLINICAL WORK UP OF A PATIENT WITH
LYMPH NODE ENLARGEMENT
Dr.Anil Haripriya
The lymph nodes are major components of the lymphatic system placed
in small groups or chains at strategic locations where they drain the lymphatic
vessels of various anatomic regions. They are composed of dense
accumulation of lymphoid tissues. A normal lymph node is ovoid, round or bean
shaped and vary in size from 2 mm to 20mm in longitudinal diameter. The
location of each group of lymph nodes in the mammalian body is relatively
constant receiving lymph from a specific region by multiple afferent lymphatic
vessels which enter on its convex border. The efferent lymphatic vessels along
with blood vessels are situated in the hilum.
The drainage of lymph involves not only the mechanical filtration of the
foreign Protein, viral and bacterial particles present in the lymph but also the
recognition and processing of antigens. The lymph nodes exhibit a complex
architecture in which a variety of cell populations are arranged in distinct
interfacing compartments. This provides a favorable environment in which the
various cellular components can process antigens, interact, and generate the
immune response. Afferent lymph, containing lymphocytes, macrophages, and
antigens, enters the lymph node via the subcapsular space and drains through
paracortical and medullary areas into medullary sinuses that converge to form
efferent lymphatic vessels through which lymph exits. B cells from bone marrow
and T cells from the thymus enter lymph nodes from the circulation by binding to
specific receptors on cells of post capillary high endothelial venules. After
activation by antigen and clonal expansion, sensitized T and B cells and
antibody secreting plasma cells leave the node in efferent lymph and rejoin the
peripheral blood circulation via the thoracic duct.
Removal of macro molecules and excessive fluid from the interstitium also
takes place through lymphatics. Large molecules that escape into the tissue
fluid have considerable difficulty in re-entering the vascular
compartment. Proteins such as albumin, globulins, and fibrinogen that enter
the interstitial fluid are usually returned to the plasma through the lymphatics
and it passes through a lymph node where the foreign bodies are removed.
LYMPH NODE GROUPS:
It is estimated that 500 to 600 lymph nodes exist in humans. These
nodes are located in groups along the course of the lymphatic vessels, whose
contents pass through the regional nodes to the main drainage systems of the
thoracic duct and right lymphatic ducts. In good health lymph nodes are usually
not palpable.
It is important to understand the basic functional anatomy of the lymphatic
system to understand pathogenesis of lymph node enlargement. Major lymph
node groups of the body may be classified into superficial and deep lymph
nodes. Broadly all lymph node groups which are within the reach of an examiner
without assistance of investigative radiographic techniques form the superficial
group; involvement of which is easy to diagnose and manage. It is the deep
group which poses problems for diagnosis and management.
Fig. 1 : Functional architecture of the lymph node
MAJOR LYMPH NODE GROUPS:
SUPERFICIAL LYMPH NODE GROUPS
DEEP LYMPH NODE GROUPS
1.Superficial Cervical lymph nodes:
1. Deep Cervical lymph nodes
2. Supra clavicular lymph nodes 2. Intra thoracic lymph nodes (Mediastinal)
3. Extra thoracic lymph nodes (axillary group)
3. Para-aortic Lymph node
4. Inguinal lymph nodes
4. Peri portal lymph nodes
5. Epitrochlear lymph nodes 5. Iliac lymph nodes
6. Mesenteric group of nodes. (Lymph nodes along the named vessels. eg. Superior and inferior mesenteric)
Other unnamed lymph nodes
LYMPH NODES OF THE HEAD AND NECK
Approximately 75 nodes are present on each side of the neck, most of
which are in the deep jugular and spinal accessory chains. Cervical group of
lymph nodes are divided into superficial and deep group.
Superficial group of lymph nodes are arranged in circular chain and consist of
(a) Occipital - one or two nodes situated midway between the mastoid
process and the external occipital protuberance. They drain the back of the
scalp.
(b) Post auricular nodes: Situated on the mastoid process behind the
pinna. They drain the temporal region of the scalp, back of the pinna, and
external auditory meatus.
(c) Pre-auricular nodes: Situated immediately in front of the tragus, the
situation is so definite that a swelling not exactly in front of the tragus cannot
arise from this node. The node lies superficial to the parotid fascia. It drains
the outer surface of the pinna and side of the scalp.
(d) Parotid nodes: These nodes are situated both in the substance of the
parotid salivary gland and deep to it i.e. between it and the side wall of the
Pharynx. The deeper nodes drain (a) the nasopharynx (b) the back of the
nose. The more superficial receive lymph from (a) the eyelids, (b) front of
the scalp. (c) external auditary meatus (d) lymparic cavity.
(e) Submental nodes receives drainage from the skin of the chin, the
midportion of the lower lip, the tip of the tongue, the anterior oral cavity, and
the nasal vestibule.
(f) Submandibular: nodes receive drainage from the submental area, the
lower nasal cavity, the upper lip, the lateral lower lip, the anterior oral cavity,
and the skin of the midface. The submandibular nodes drain into the
superior deep jugular vein.
(g) Facial nodes: consists of superficial and deep groups.
Superficial group consists of
(a) Infraorbital: just below the orbit
(b) Buccinator: on the muscle of this name lateral to the angle of the
mouth.
(c) Supramandibular: on the mandible in front of the masseter around the
facial artery.
These nodes receive lymph from conjunctiva and eyelids, nose and the
neck.
Deep Group: These lie around the maxillary vessels in relation to the
external pterygoid muscle. They drain (a) the temporal tossa (b)
infratemporal fossa (c) back of the nose (d) pharynx.
(h) Superficial Cervical nodes: These lie on the outer surface of the
sternomastoid around the external Jugular vein. They drain the parotid
region and lower part of the ear.
(i) Anterior cervical nodes: These lie near the middle line of the neck in front
of the larynx and trachea. They consist of superficial and deep set of
nodes.
Superficial Set: Lie in relation to the anterior Jugular vein and drain the skin
of the neck.
Deep Set consists of:
(a) The infra hyoid nodes: These lie on the thyrohyoid membrane and
drain the front of the larynx.
(b) The prelaryngeal nodes: These lie on the cricothyroid ligament and
drain the larynx. Their afferents pass through a small foramen in the
middle of the cricothyroid ligament. These nodes are often the first to
become enlarged in the cancer of larynx. These nodes assist in the
drainage of the thyroid.
(c) The pre tracheal nodes: These lie in relation to the inferior thyroid
veins in front of the trachea and drain the thyroid and trachea.
Efferents of the circular chain: The deep cervical chain receives ultimately all
the nodes enumerated above. It receives the efferents directly from all these
node groups except the facial and sub mental. The efferents from these two
groups pass first to the submandibular nodes.
CERVICAL LYMPH NODES.
Vertical chain of the deep cervical nodes:
This consists of a number of large nodes lying in relation to the carotid
sheath. A few members of this group occupy an outlying position behind the
pharynx and are called the retropharyngeal nodes. They drain the back of the
nose and pharynx and the auditory tube.
The vertical chain of deep cervical nodes, lies alongside the pharynx,
trachea, and oesophagus and extends from the base of skull to the root of the
neck. They are arbitrarily divided into superior deep cervical and inferior deep
cervical groups by the point of bifurcation of the common carotid (or,
alternatively, by the Omohyoid). The nodes of both groups are in very intimate
relationship with the internal jugular vein. Some of the nodes of the inferior
group project beyond the posterior border of the sternomastoid into the posterior
triangle of the neck (Supraclavicular). The Spinal accessory nodes are located
along the spinal accessory nerves and receive drainage from the parietal and
occipital regions of the scalp and the nape of the neck and from the upper
retropharyngeal and parapharyngeal nodes draining the nasopharynx,
oropharynx and paranasal sinuses. The upper spinal accessory nodes drain
into the upper jugular nodes and into the lower spinal accessory nodes, which in
turn drain into the supraclavicular nodes.
There are a few small nodes of deep cervical group which lie in the groove
between the trachea and oesophagus alongside the recurrent nerve. They are
called paratracheal nodes and assist in the drainage of the thyroid.
Two of the deep cervical group are named Jugulodigastric, which is the
main node draining the tonsils and is situated just below the angle of mandible in
the angle between the internal jugular and common fascial vein. JUGULO-
OMOHYOID node is situated on the common carotid just above the point where
the anterior belly of the Omohyoid crosses the vessel. It plays a very important
part in the lymph drainage of the tongue, receiving some vessels from the apex
which take a circuitons route to reach the neck. The anterior Scalene
(Virchow’s) nodes received drainage from the thoracic duct and are located at
the junction of the thoracic duct and left subclavian vein. They usually are the
site of metastasis from Infraclavicular primary cancers. The supraclavicular
nodes receive drainage from the spinal accessory nodes and from infraclavicular
primary cancers.
The deep cervical nodes receive the lymph from the entire head and neck
either directly or indirectly from the nodes of the circular chain. The lymph from
the deep cervical chain i.e. all the lymph from that half of the head and neck, is
collected into one trunk, the jugular lymph trunk, which leaves the inferior deep
cervical nodes. On the right side this trunk enters the junction of the
subclavian vein and the internal jugular vein. On the left side the trunk enters
the thoracic duct.
Level of Nodes in Neck Dissection:
The terminology for the classification for neck dissections has been very
confusing, this is especially important when discussing the results of treatment
of neck disease because there are so many variations of neck dissections. In
an effort to make the terminology more uniform. Suen and Goepert in 1987
proposed a classification of neck dissections based on specific nodal groups
removed. Their recommended terminology for the nodal group was based on a
modification of the Memorial Stoan-Kettering Cancer Centre classification.
This classification assigns five level of distribution to the different nodal groups.
Level I is subdivided into Level I-A (submental triangle nodes) and Level I-B
(submandibular nodes).
Level II includes two subgroups, Level II-A (Jugular nodes including the
subdigastric area down to the carotid bifurcation, and the nodes surrounding the
spinal accessory nerve from the jugular foramen to the posterior border of the
sternocleidomastoid muscle) and Level II-B the (lymph nodes in the upper
posterior cervical triangle above the entrance of the spinal accessory nerve into
the triangle).
Level III indicates the jugular nodes between the carotid bifurcation and the level
of the carotid sheath where the omohyoid muscle crosses this structure and the
posterior margin of SCM muscle.
Level IV includes sub group IV-A (Jugular nodes between the omohyoid muscle
and the level of the clavicle and to the Posterior border of the sterno
cleidomastoid muscle) Level IV-B (the lymph nodes in the supra clavicular
space lateral to the posterior border of the SCM muscle and candal to the
omohyoid muscle.
Level V includes the nodes in the posterior cervical triangle created by the
posterior edge of the sterno cleidomastoid muscle, the level of the entrance of
the spinal accessory nerve, the trapezius muscle, and the posterior belly of the
omohyoid muscle.
AXILLARY LYMPH NODES:
The major and primary route of drainage of lymphatics from the breast is
by axillary pathway. There are five set of lymph nodes in the axilla namely the
anterior, posterior, lateral, central and apical set. There are about 35 to
50 lymph nodes in each axilla.
Anterior set situated along the lateral thoracic veins under the anterior axillary
fold. They lie mainly on the 3rd rib. The axillary tail of Spence is in actual
contact with those nodes and therefore cancer involving this process may be
misdiagnosed as an enlarged node.
Posterior set lie along the posterior axillary fold in relationship to the subscapular
vessels.
Lateral Set: lie along the upper part of the humerus in relation to the axillary
vein.
Central Set: is situated in the fat of the upper part of the axilla. The
intercostobrachial nerve passes outwards amongst these nodes. Enlargement
of these nodes, such as occurs in cancer, may, by pressure on the nerve,
cause pain in the distribution of the nerve along the inner border of the arm.
Occasionally the central lymph node is involved in carcinoma stomach via
Perigastric and para oesophageal to mediastinal and from mediastinal to central
node and it is termed as Irish node.
Apical Set: These are also called the infraclavicular nodes. They are very
important and constant in position being bounded below by the first intercostal
space, behind by the axillary vein, infront by the costocoracoid
membrane. These nodes lie very deeply, but can be palpated by pushing the
fingers of one hand into the axillary apex from below, and the fingers of the other
hand behind the clavicle from above.
They are of great importance because they receive one vessel directly
from the upper part of the breast and ultimately most of the lymph from the
breast. A single trunk leaves the apical group on each side of the subclavian
vein, and enters the junction of the jugular and subclavian vein, or may join the
thoracic duct on the left.
These nodes can conveniently be subdivided into three main groups
according to their relationship with the pectoralis minor muscle, nodes at level 1
lie below the muscle, level 2 lymph glands lie behind it, and those of level 3 are
in the apex of axilla above the muscle. The majority of lymph drains from nodes
at level 1 sequentially to those at level 2 and 3.
INGUINAL LYMPH NODES:
The lymph nodes of the lower limb are divided into superficial and deep
group. The superficial lymph nodes are readily palpable in the groin and are
subdivided into proximal set just below and parallel to the inguinal ligament
(horizontal chain) and a distal group arranged along the upper end of long
saphenous vein (vertical chain). Deep inguinal lymph nodes lie in the femoral
triangle along side the upper part of the femoral vein. One of these deep
inguinal node lies in femoral canal called node of Cloquet.
LYMPH NODE ENLARGEMENT:
Lymph node enlargement may occur because of proliferation of cells of
the lymphocyte and monocyte-macrophage systems usually in response to
antigenic stimulus or infiltration by inflammatory cells in infections involving
lymph nodes (lymphadenitis), In situ proliferation of malignant lymphocytes or
macrophages, infiltration of nodes by metastatic malignant cells or infiltration of
lymph nodes by metabolite laden macrophages in lipid storage diseases.
In normal immune responses, antigen stimulation of macrophages and
lymphocytes in lymph nodes expert profound influences on lymphocytic
traffic. One of the earliest effects of the antigen is to increase the blood flow
through the affected node, which may reach 10 to 25 times of normal
levels. Lymphocytes accumulate in antigen stimulated nodes by increase in
traffic through the node, decreased egress of lymphocyte from antigen
stimulated nodes, and proliferation of responding T and B cells. A lymph node
may thus reach 15 times its normal size 5 to 10 days after antigen stimulation.
DISEASES ASSOCIATED WITH LYMPHADENOPATHY:
In childhood, the lymphoid system grows rapidly. Possibly as a result of
antigenic stimulation, and lymph node enlargement in some parts of the body is
an almost universal finding. Thus nearly all children under 12 years have
palpable cervical, axillary and inguinal nodes. In adults inguinal node
enlargement is commonplace, presumably secondary to repeated
immunological or inflammatory stimuli generated by multiple minor injuries to the
lower extremity. Enlargement of other superficial nodes is unusual but
occasionally occurs for the same reason, such as repeated hand injuries in
manual labourers.
History and Examination:
Enlargement of lymph nodes require investigation when there are one or
more new nodes present equal to or greater than 1 cm in diameter, and not
known to arise from a previously recognised cause. However, this is not a rigid
criterion and under certain circumstances new multiple or single smaller lymph
nodes may warrant investigation. While taking history of the patient with lymph
node enlargement following points are particularly noted:
1. Age : Hodgkin’s disease, tuberculosis, syphilisare disease of the
young, whereas secondary involvement of lymph node occurs in old age
2. Duration: In acute lymphadenitis is short, whereas it is long in chronic
lymphadenitis like tuberculosis etc.
3. Which group was first affected? In case of generalised involvement of
the lymph nodes the physician should know which group was first
affected as it may give some clue to the diagnosis for example cervical
group is first affected in many cases of Hodgkin’s lymphoma.
4. Pain: lymph nodes are painful in both acute and chronic
lymphadenitis but are painless in syphillis, lymphosarcoma, secondary
carcinoma etc.
5. Fever: evening rise in temperature is a characteristic feature of
tuberculosis. In filaria periodic fever is very common. In Hodgkin’s
disease intermittent bouts of recurrent fever is quite peculiar. So called
Pel-Ebstain type of fever.
6. Primary focus: whenever the lymph nodes are enlarged, it is usual
practice to look for the primary focus in the drainage area of the lymph
nodes for the reason of lymph node enlargement.
On examination : The following Important factors should be considered in
assessing the significance of enlarged lymph nodes
1. The Node location: The location of enlarged lymph nodes may
suggest important clues to diagnosis. Enlarged posterior cervical lymph
nodes are frequently present in scalp infections, Toxoplasmosis, and rubella,
where as anterior auricular, nodes suggest infections of the eyelids and
conjunctiva, Lymphomas commonly involve cervical lymph nodes and can
occasionally involve posterior auricular and occipital nodes as
well. Enlarged suppurative cervical nodes are seen in mycobacterial
lymphadenitis. Unilateral jugular or mandibular lymph node enlargement
suggests lymphoma or non lymphoid head and neck
malignancy. Supraclavicular and Scalene lymph node enlargement is always
significant and frequently results from metastasis from intrathoracic or
gastrointestinal malignancies or from lymphoma. Virchow’s node is an
enlarged left supraclavicular lymph node infiltrated with metastatic tumor
usually from the gastrointestinal tract. Unilateral axillary adenopathy can be
seen with breast carcinoma, infections of the upper extremity and cat scratch
disease. Unilateral epitrochlear node enlargement is usually due to hand
infections, bilateral epitrochlear node enlargement is seen in Sarcoidosis and
secondary Syphillis. Bilateral inguinal adenopathy can be seen in variety of
venereal infections, however, lymphogranuloma venereum and syphilis are
associated with unilateral inguinal adenopathy. Progressive
inguinal lymphnode enlargement without obvious infection suggests
malignant disease. Femoral node enlargement has been reported to occur in
Pasteurella Pestis infection and lymphomas.
Enlargement of deeply situated lymph nodes may present by indirect
evidence. Certain symptoms should raise the suspicion of hilar or
mediastinal node enlargement. These patients may present with cough or
wheezing due to airway compression, recurrent laryngeal nerve compression
with hoarseness, paralysis of diaphragm, dysphagia with oesophageal
compression and swelling of the neck, face, or arm due to superior vena
cava or subclavian vein compression. Enlarged retroperitoneal lymph nodes
may present as oedema of lower limbs. Intra abdominal lymph nodes may
sometimes be palpable in thin subjects.
2. The physical characteristics of the peripheral lymph nodes are
important. Nodes of lymphomas tend to be rubbery and firm and discrete but
occasionally they are matted. Tuberculous lymph node are matted and
tender. Nodes involved with metastatic carcinoma are usually hard and may
be fixed to underlying tissue. In acute infections, nodes are tender,
asymmetrically enlarged, matted together and the overlying skin may be
erythematous.
3. The clinical setting is also important in assessing lymphadenopathy. In a
young college student with fever and recent onset of lymph node
enlargement, infectious mono nucleosis syndromes are important to
consider. In homosexuals, hemophiliacs, and intravenous drug abusers with
systemic lymphadenopathy, the acquired immunodeficiency syndrome
(AIDS) should be considered. In all case of lymphadenopathy Liver and
Spleen should be palpated for enlargement and nodularity.
Good physical examination techniques for palpation and assessment of
lymph nodes are essential for providing useful information on which
diagnostic and therapeutic decisions can be based. For serial evaluation of
nodes, the documentation of each node with regard to size, location,
consistency soft and mobility at each examination is critical. For cervical
nodes the examiner may stand behind or in front of the seated patient to
palpate the the neck and to examine in sequence the sites of various groups
of nodes.
Central axillary nodes are located near the middle of the thoracic wall of
the axilla, lateral axillary nodes are located near the upper part of the
humerus along the axillary vein and are best felt by having the patients arm
elevated. Subscapular nodes can be felt under the anterior edge of the
latissmus dorsi muscle and pectoral nodes are beneath the lateral edge of
the pectoralis major muscle. Infraclavicular nodes can be felt under the distal
end of clavicle and may require bimannual palpation.
Epitrochlear nodes are located approximately 3 cm proximal to the
medial humeral epicondyle. Palpation of epitrochlear nodes is best
accomplished by paplation of epitrochlear node area in an anterior to
posterior direction.
Enlarged abdominal lymph nodes can be difficult to palpate and
may be felt if the patient has shallow abdominal cavity. Pelvic nodes are best
evaluated with deep palpation of the lower abdomen by rolling the extended