Lymph Ad en Op a Thy

8/6/2019 Lymph Ad en Op a Thy

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Distinguish between normal and pathological glands Size.

Normal glands in adults are seldom greater than 0.5 cm diameter.

Consistency.Normal glands feel soft, rubbery or 'shotty'. In contrast, in Hodgkin's

disease they are characteristically 'rubbery',in tuberculosis they may be 'matted' and in metastatic cancer they feel

'craggy'. Calcified glands feel stony hard.

Tenderness.Tenderness is usually a feature of acute viral or bacterial infection.

With tender cervical lymphadenopathy,common sources include infectious mononucleosis, dental sepsis and

tonsillitis. Fixation.Fixation of glands to deep structures or skin usually indicates

malignancy.


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Examination sequence General principles ? Inspect for any visible lymphadenopathy.

? Palpate one side at a time using the fingers of one hand. ? Compare with the glands on the contralateral side. ? Assess: ? site ? size

? consistency. ? Record the measurements of the main glands. ?Note any tenderness. ? Determine if the gland is fixed to: ? surrounding and deep structures

? Examine the cervical and axillary glands with the patientsitting.

? Examine for the inguinal and popliteal glands with thepatient lying down.


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Cervical glands

?From behind, examine the submental,

submandibular, preauricular, tonsillar,

supraclavicular and deep cervical glands in theanterior triangle of the neck

? Palpate deeply for the scalene nodes ?From the front of the patient, examine the

posterior triangles, up the back of the neck andthe posterior auricular and occipital nodes


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Axillary glands

?From in front of the patient, support the arm

on the side under examination.

Palpate the right axilla with your left hand andvice versa .

Gently place your finger tips into the vault ofthe axilla and then draw them downwardsfeeling the medial, anterior and posterioraxillary walls in turn. Make sure your nails are

short to avoid causing your patient discomfort.


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Epitrochlear glands

? Support the patient's right wrist with your

left hand, grasp the patient's partially flexedelbow with your right hand and use yourthumb to feel for the epitrochlear gland.

Examine the left epitrochlear gland with your

left thumb


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Inguinal glands

? Palpate over the horizontal chain, which liesjust below the inguinal ligament, and then overthe vertical chain along the line of thesaphenous vein .

Popliteal glands Use both hands to examine the popliteal fossa

with the knee flexed and limb muscles relaxed.


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Common abnormalities

If you find localized lymphadenopathy,

examine the areas which drain to that site.Most often infection causes

localized tender lymphadenopathy(lymphadenitis), e.g. in acute tonsillitis the

submandibular lymph glands are involved. Ifthe lymphadenopathy is non-tender, look for amalignant cause, tuberculosis or features ofHIV infection. Generalized lymphadenopathyoccurs in a number of conditions.

Look for enlargement of the liver and spleenand for other haematological features, e.g.purpura or petechiae.


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Important common causes of lymphadenopathy

Generalized

Viral Epstein-Barr virus (glandular fever orBurkitt'slymphoma), cytomegalovirus, HIV

Bacterial Brucellosis, syphilis

Protozoal Toxoplasmosis

Malignancy Lymphoma, acute or chroniclymphocytic leukaemia

Inflammatory Rheumatoid arthritis, systemiclupus erythematosus, sarcoidosis

Localized Infective Acute or chronic, bacterial or viral

Malignancy Secondary metastases, lymphoma(Hodgkin's or non-Hodgkin's lymphoma)


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CAUSES OF LYMPHADENOPATHY

Infection Bacterial (e.g., all pyogenic bacteria, cat-scratch disease, syphilis,tularemia) Mycobacterial (e.g., tuberculosis, leprosy) Fungal (e.g., histoplasmosis,coccidioidomycosis) Chlamydial (e.g., lymphogranuloma venereum) Parasitic (e.g.,toxoplasmosis, trypanosomiasis, filariasis) Viral (e.g., Epstein-Barr virus, cytomegalovirus,rubella, hepatitis, human immunodeficiency virus)

Benign disorder of the immune system (e.g., rheumatoid arthritis, systemic lupuserythematosus, serum sickness, drug reactions such as to phenytoin, Castleman's disease,sinus histiocytosis with massive lymphadenopathy, Langerhans cell histiocytosis,

Kawasaki's syndrome, Kimura's disease) Malignant disorders of the immune system (e.g., chronic and acute myeloid and lymphoid

leukemia, non-Hodgkin's lymphoma, Hodgkin's disease, angioimmunoblastic-like T-celllymphoma, Waldenstrm's macroglobulinemia, multiple myeloma with amyloidosis,malignant histiocytosis)

Other malignancies (e.g., breast carcinoma, lung carcinoma, melanoma, head and neckcancer, gastrointestinal malignancies, germ cell tumors, Kaposi's sarcoma) Storage diseases(e.g., Gaucher's disease, Niemann-Pick disease)

Endocrinopathies (e.g., hyperthyroidism, adrenal insufficiency, thyroiditis)

Miscellaneous (e.g., sarcoidosis, amyloidosis, dermatopathic lymphadenitis)


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FACTORSTO CONSIDER IN THEDIAGNOSISOF LYMPHADENOPATHY

Associated systemic symptoms

Patient's age

History of infection, trauma, medications, travelexperience, previous malignancy, etc.

Location: cervical, supraclavicular, epitrochlear,axillary, intrathoracic (hilar vs. mediastinal),intra-abdominal (retroperitoneal vs. mesentericvs. other), iliac, inguinal, femoral

Localized vs.disseminated

Tenderness/inflammation Size

Consistency


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METHODSOF LYMPHNODE EVALUATION

Physical examination

Imaging Chest radiography Lymphangiography

Ultrasonography

Computed tomography

Magnetic resonance imaging

Positron emission tomography Sampling

Needle aspiration

Cutting needle biopsy Excisional biopsy

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Lymph Ad en Op a Thy