Transcript Examination of the Lymphatic System

Examination of the
Lymphatic System
The Lymphatic System:
Function
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An integral part of
the immune system
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Provides defense
against
microorganisms by
producing antibodies
and performing
phagocytosis
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Plays an unwanted
role in providing at
least one pathway
for the spread of
malignancy
The Lymphatic System:
Anatomy
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Composed of:
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lymph fluid
collecting ducts
lymph nodes
spleen
thymus
tonsils
adenoids
Peyer patches
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Lymphatic tissue is
also present in:
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stomach
bone marrow
lungs
The Lymphatic System:
Anatomy & Physiology
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Lymph nodes
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usually occur in groups
condition of nodes provides clues to the
presence of infection or malignancy
Lymphocytes
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arise from precursor cells in nodes, tonsils,
adenoids, spleen & bone marrow
central to the body’s response to antigenic
substances
The Lymphatic System:
Anatomy & Physiology
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Thymus
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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
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located between the stomach and diaphragm
forms and stores RBCs in early life
macrophages in the spleen filter blood
The Lymphatic System:
Anatomy & Physiology
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Tonsils & Adenoids
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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
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elevated areas of lymph tissue on the small
intestine serving the intestinal tract
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
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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
Lymphatic Circulation
The Lymphatic System:
Anatomy Variations
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Infants & Children
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infant’s 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
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Older Adults
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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
The Lymphatic System:
History Review
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Present Problem
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bleeding
enlarged nodes
swelling of extremity
medications
Past Medical History
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chest x-rays
TB and other skin tests
transfusions
chronic illness
– cardiac, renal, malignancy, HIV
surgery
recurrent infections
Family History
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malignancy
anemia
recent infections
TB
agammaglobulinemia, other
immune disorders
hemophilia
History
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Acute vs Chronic
Localised (3/4) vs
Generalised (1/4)
» Only 17% of
generalized
Lymphadenopathy
identified
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Unilateral vs
Bilateral
HIV Infection:
Risk Factors
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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)
HIV Infection:
Risk Factors
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Infants and Children
» Mother either with or at risk for HIV infection
» Hemophilia
» Blood transfusion
» Sexual abuse
History Variations
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Infants and Children
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recurrent infections
poor growth, FTT
loss of interest in playing
or eating
immunization history
maternal HIV infection
hemophilia
illness in siblings
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Pregnant Women
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weeks gestation, EDC
exposure to rubella and
other infections
presence of children in
household
Older Adults
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present or recent infection
or trauma distal to nodes
delayed healing
Examination of the
Lymphatic 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
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Head and Neck
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preauricular
postauricular
occipital
tonsillar
submandibular
submental
superficial anterior cervical
deep cervical
posterior cervical
supraclavicular
infraclavicular
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The Arms
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axillary
– anterior axillary (pectoral)
– lateral (brachial)
– mid axillary (central)
– posterior (subscapular)
epitrochlear
The Legs
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superficial superior inguinal
superficial inferior inguinal
popliteal (occasionally)
Examination of the
Lymphatic System
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Inspect
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any visible nodes for:
– edema
– erythema
– red streaks
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Palpate
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the superficial nodes
compare side to side for:
– size
– consistency
– mobility
– discrete borders or
matted
– tenderness
– warmth
Examination of the
Lymphatic System
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If an enlarged lymph node is found,
examine:
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»L
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Primary site
All associated nodes
Liver
Spleen
Age Related Variations
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Infants and Children
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commonly find small, discreet, firm, movable nodes in
occipital, postauricular, cervical and inguinal chains . . .
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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 < 2 years old
cervical and submandibular node enlargement is less
frequent in children < 1 year old and much more frequent
in older children
palatine tonsils may be enlarged
EVALUATION OF Lymphatic
System
Objectives
Student should be able to …
 describe location, size, consistency, and
other attributes of lymphadenopathy
 identify common clinical scenarios involving
lymphadenopathy
Overview
This is a short lecture!
 A major goal is to synthesize the
lymphatic system as a whole…lymph
node regions have been discussed
individually by specific site…i.e., head,
neck, and abdomen, but not put together
for systemic illness such as lymphoma.
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Lymphatic
System
The Lymphatic
System:
Palpable superficial lymph nodes
Occipital
Posterior auricular
Preauricular
Tonsillar
Submaxillary
Submental
Superficial cervial
Deep cervical
Supraclavicular
Axillary
Lateral
Subscapular
Pectoral
Epitrochlear
Inguinal
Lymph Node Examination
Head/neck
 Axillary
 Epitroclear
 Inguinal/femoral
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Physical Examination
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Head and Neck LN
Axillary LN
Inguinal LN
Lymph node regions
Head and
Neck Nodes
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Preauricular
Posterior auricular
Occipital
Tonsillar
Submandibular
Submental
Superficial cervical
Posterior cervical
Deep cervical
Supraclavicular
Lymph nodes of the head and neck,
and the regions that they drain
ALL:Cervical Lymphadenopathy
Right neck mass
Lymphoma
Row of
enlarged
lymph nodes
Lymphadenopathy in children
TB abscess
as part of immune reconstitution syndrome
Axillary
A pectoral
(anterior)
 L lateral
 P posterior
 C central
 Ap apical
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Axillary lymphatics and the
structures that they drain
Describe
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Inguinal/
Femoral
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Horizontal
group
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Vertical
group
Inguinal lymphatics and the
structures that they drain
Chest X-Ray
Normal
Hilar Lymphadenopathy
Is a common feature of:
1. Sarcoidosis
2. TB
3. Coccidiomycosis
4. Histoplasmosis
Patient
Interstitial Infiltrates – Bilateral hilar lymphadenopathy
Lymphadenopathy
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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.
Mediastinal Lymphadenopathy - ALL
Descriptors of
Lymphadenopathy
Location…obvious
 Mobility
 Size
 Texture
 Shape
 Tender/non-tender
 Associated erythema or warmth…signs
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
Traube’s space) but can be specific in
non-obese patients
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Organomegaly
Splenomegaly
Spleen
Case
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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:
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
 Cancer—metastatic
 Granulomatous disease
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