the examination of the lymph nodes for
abnormalities is an essential part of
the physical exam we have hundreds of
lymph nodes throughout our body most of
them we cannot feel or palpate because
they are small or deep and they cannot
be felt but to our surprise if you do a
radical dissection of the neck or the
axilla or the pelvis we finally find 10
15 or 20 lymph nodes in that operation
which were never appreciated lymph nodes
are virtually always abnormal in the
sense that they arose some from some
preceding process usually an infection
early in life and then they maintained
their small size for life in the
examination of lymph nodes to determine
serious problems there are a number of
characteristics that are important the
most important of course is their size
because lymph nodes are generally
thought to be virtually normal or
insignificant when they are 2
centimeters over less at least that's
the criteria that radiologists use in
examining the abdomen that's more or
less true than the other parts of the
body there are some parts of the body
such as the armpits or the XLE which
lymph glands may reach the size of 3
centimeters or even more and not be a
concern occasionally on CT scan you will
see that those lymph nodes contain fat
in the center and they are rather C
shaped but their size under the act in
the axilla can be larger than in other
locations whereas in other locations
even one centimeter or a smaller than
node is of great concern such as in the
supraclavicular fossa where lymph nodes
are not usually the residual level
infection and indicate more serious
problems other than size the next
important
iteration is how they feel when you
palpate them are they soft hard
something in between which we call
rubbery each of those need something
slightly different normal or
insignificant lymph nodes are usually
soft very hard lymph nodes are a much
more concern if their group stone-hard
or mean then we more often think of a
malignancy occasionally an old infection
a particularly a granulomas infection
can leave you with hard lymph nodes
intermediate consistency er we call
rubbery and rubbery lymph nodes are
often a sign of lymphoma which is a
primary tumor of course of a lymph node
system the other important
characteristic is whether they are
tender or non tender tender lymph nodes
as you palpate them are almost always a
sign of infection and malignancies that
involve the lymph nodes are usually not
tender with the occasional exception
when they grow very rapidly and that's
not common the other important
consideration is the age of the patient
youngsters children from ages 2 to 12
very frequently have lymph nodes
especially in the neck posterior
cervical mid cervical occasionally and
other peripheral sites which are due to
frequent viral or other bacterial
infections that they get in the nose and
throat and as a normal part of
maturation of the patient and of the
immune system as one gets older then you
may not want to feel them for nodes that
are acceptable in children so the
examination which I am about to show you
it's just part of the consideration
and I'd be glad to go ahead no thank you
so to begin with I always have my
patient seated and that's the best way
to feel lymph glands from the waist up
and often we do that
symmetrically because low flows are
usually not symmetrical in their
enlargements especially abnormal lymph
nodes so we often use two hands and we
start in the posterior occipital region
and occasionally you feel lymph glands
this gentleman has a very hard lump in
the back of his head which is not a
lymph node and you have to distinguish
loan from a lymph node but up here he
has about a two centimeter firm bony
protuberance it is not a lymph node and
it's nothing of concern as you come down
you just out pay with your fingers until
you get to the posterior auricular area
and lymph nodes can be felt there
usually they are abnormal even when
they're quite small in this location and
you use your fingers gently and then you
come down to the general neck area
there's another
that's important with the pre Rick your
lymph nodes and you feel with your
fingers gently symmetrically and you
don't usually feel pre auricular lymph
nodes even small ones would be of
concern may mean an infection may mean
something were generalized as you come
down then to the mandibor the the angle
of the mandible the parotid gland may be
felt in this location in this gentleman
we don't feel the parotid gland but they
would be symmetrical and they overlap
that angle and they are not lymph nodes
and then you come down along the
sternocleidomastoid muscle and you
palpate for jugular lymph nodes and you
go up and down gently if you can then
all the way down to the clavicle and
these would be the jugular lymph nodes
of cervical lymph nodes and what's very
important to distinguish is that there
are submandibular salivary glands which
are symmetrical usually maybe slightly
different one side from the other and
this gentleman has salivary gland right
here which is about 1/2 centimeters and
small and he has a smaller one on this
side but they are symmetrical they are
not concerned and they are not lymph
nodes in my judgment the other thing you
have to be aware of is that the carotid
arteries are here and very often you
will feel the carotid artery or carotid
bulb and interpret that as a swollen
lymph nodes but lymph nodes you're not
pulsate and they when they pulsate that
means is obviously a carotid artery and
they are in this location
now this gentleman has a very small
implant on the right side your posterior
cervical region right here it's probably
no more than three millimeters it's flat
lymph nodes that are normal are usually
flat and ovoid lymph nodes that are not
are more abnormal or spherical and that
you can sort of tell by your palpation
you come down and the most important
area to feel is the supraclavicular
fossa now sometimes it's a little better
to just bend the neck forward to relax
this area and you take your fingers and
you push right down over the clavicle
and see if you can roll your fingers
over any nodules now these are most
important because they are not usually
found normally after infections and if
they are enlarged they often indicate
some process which is deeper in the body
and the most important one is on the
left side and as you probably have
rather remember the left super-goof node
is called the sentinel lymph node or
rear coughs node because it was an
indication that there was serious
trouble in the abdomen now why in the
left supercooling fossa would that
indicate abdominal disease or you recall
that the lymphatics of the abdomen drain
to the cisterna chyli and then go up to
thoracic duct and they dump into the
left side left jugular vein and if there
is malignancy in this location and it is
spread to a lymph node very frequently
the first sign of that disease is a
swollen and far left circular bicular
lymph node and you shouldn't feel a
lymph node in this location at least
normally that doesn't mean that they're
always bad but that it should raise your
suspicion
the right side occasionally the thoracic
duct will split and send some lymph and
cells to the right side
but the intrathoracic lymphatic strained
to the right super particular fossa so
this is another very important place to
feel and then you continue to feel
around and make sure that it's
symmetrical be sure to distinguish that
the muscles from the carotid vessels the
hyoid bone is here and should be
confused with lymph nodes it's firm and
to push on one side it goes to the other
and many young medical students or
doctors will confuse the hyoid bone and
the larynx hyoid bone is higher let's go
me and it moves