lymph node examination

Question 1

overview

Answer 1

Head and neck nodes
Axillary nodes
Epitrochlear nodes
Para-aortic nodes
Inguinal and leg nodes

Question 2

General points to note:

Answer 2

Size: anything >1cm is abnormal
Consistency: hardness suggests Ca, rubbery consistency points to lymphoma
Tenderness: implies infection
Fixation: suggests malignancy
Overlying skin: tethering is a feature of malignancy, inflammation suggests infection

Remember to palpate the spleen and liver as part of the lymphatic system, and examine the drainage areas of any enlarged nodes. Assess any lumps as usual

Question 3

Head and neck nodes

Answer 3

Head and neck nodes

Start by examining the nodes encircling the lower face and neck. Sit the patient forward. You can examine these nodes from the front or the back, and both d=sides can be examined simultaneously.

Palpate the nodes in sequence:
- submental group in the midline behind the tip of the mandible
- submandibular nodes midway and along the inner surface of the inferior margin of the
mandible
- tonsillar node at the angle of the jaw
- pre-auricular nodes immediately in front of the ear
- post-auricular nodes over the mastoid process
- occipital nodes at the base of the skull posteriorly

• vertical neck nodes. It may be helpful to flex the neck slightly to relax the strap muscles. Feelfor the superficial cervical nodes along the body of the sternocleidomastoid. The posterior cervical nodes run along the anterior body of trapezius. The deep cervical chain is difficult to feel, as they are deep to the long axis of sternocleidomasoid; explore for these nodes by palpating firmly through the muscle.
• supraclavicular nodes - lie in the area bound by the clavicle inferiorly and the lateral borer of
  sternocleidomastoid medially.
• infraclavicular nodes – lie just beneath the clavicle

Question 4

Axillary nodes

Answer 4

Axillary nodes

The axillary nodes can be palpated from the front with the patient either lying or sitting. Take the
patient’s L arm with your R hand and explore with your L hand and vice versa.

• Slightly cup your examining hand and palpate into the apex of the axilla for the apical group of
  nodes – small nodes may only be felt by rotating the fingertips against the chest wall.
• Feel for the anterior group of nodes along the posterior border of the anterior axillary fold, the
  central group against the lateral chest wall, and the posterior group along the posterior axillary
  fold.
• Check for supra and infra clavicular nodes and also the epitrochlear nodes.

Question 5

Epitrochlear nodes

Answer 5

Passively flex the patient’s relaxed elbow to a right angle. Support this position with one hand whilst
feeling with your fingers for the epitrochlear nodes, which lie in a groove above and posterior to the
medial condyle of the humerus.

Question 6

Para-aortic nodes

Answer 6

A deep central mass can be due to enlarged para-aortic nodes.

Question 7

Inguinal and leg nodes

Answer 7

Examine these nodes with the patient lying down. The superficial nodes run in two chains:

• Palpate horizontal chain – runs just below the line of the inguinal ligament
• Palpate vertical chain – runs along the long saphenous vein
  Relax the popliteal fossa by passive flexion – explore the fossa for enlarged popliteal nodes by
  wrapping the hands around either side of the knee and exploring the fossa with the fingers of both
  hands.