Examination of the lymph nodes.
A thorough clinical examination should usually include both the systematic
inspection and palpation of the clinically relevant lymph node stations.
The most important stations are: the head and neck area, the axilla, and the
inguinal area. Consequently, the lymph nodes are usually
examined from cranial to caudal. Around one-third of all lymph nodes are
located in the head and neck area where they can be found superficially and are
therefore easily palpable. The following lymph nodes should be included in every
palpation: sub-occipital, retro- and pre-auricular, submandibular,
sub-mental, posterior triangle of the neck, and those within the area of the
internal jugular vein, which lie deep within the neck and may be palpated
ventral or dorsal to the sternocleidomastoid muscle.
Additionally, the supraclavicular lymph nodes should be palpated as well, since
enlargement of these lymph nodes is often associated with malignancies.
Abdominal tumors that metastasize by the lymphatic system, such as gastric cancer,
will often result in an enlarged Virchow node in the left supraclavicular fossa.
Carefully palpate the individual lymph node stations.
To facilitate differentiation between lymph nodes and muscles, the area that is
palpated should be as relaxed as possible.
Every palpable lymph node is considered enlarged.
If there is enlargement, pay attention to consistency, tenderness, mobility, the
number of enlarged lymph nodes, and any erythema in the affected area.
Multiple fused lymph nodes are referred to as conglomerates and are highly
suspicious for malignancy.
After palpating the head and neck, continue by examining the axillary
lymph nodes, which can be divided into different groups as well.
The pictorial or anterior group is located in the anterior axillary fold
and is responsible for the majority of lymphatic drainage of the chest and
chest wall.
The subscapular or posterior lymph node group is palpable deep within the
posterior axillary fold. It drains parts of the arms and the chest wall.
The brachial or lateral lymph nodes drain the majority of the arms and can
be palpated in the area of the proximal humerus.
All of the lymph node groups just mentioned then drain into the central
group, which is palpable at the base of the axilla. The sub clavicular or apical
group represents the last lymph node station before the lymphatic vessels
drain into the venous system. This group should be examined together with the
cervical or axillary lymph nodes. In this patient the examiner starts by palpating
the pectoral group behind the lateral aspect of the pectoralis major muscle.
Afterwards, he palpates the central group, followed by the posterior group in the
area of the posterior axillary fold and the brachial group of the upper arm.
Distinguishing between lymph nodes and surrounding muscles is best achieved
when the arm is relaxed and lowered.
Afterwards, the superficial lymph nodes of the inguinal area should be palpated.
They are divided into a horizontal and a vertical group.
The horizontal group lies below the inguinal ligament and can therefore be
palpated parallel to its course. This group is responsible for draining
parts of the external genitalia, trunk, and lower back.
The vertical group is located adjacent to the great proximal saphenous vein and
drains lymphatic fluid from the lower extremity.
Examination of the inguinal lymph nodes is best performed with the patient lying
down.
As a lymphatic organ, the spleen should always be a part of the lymph node
assessment since splenomegaly can hint at a systemic inflammatory or malignant
illness.
The spleen is generally not palpable in healthy adults. A pathologically enlarged
spleen is palpated under the left costal margin during inspiration, as the
inferior edge descends to the examiners fingertips. If an enlarged spleen is
already suspected, palpation should begin further down.
The examination may be facilitated by gently lifting the left flank of the
patient ventrally.