Lymph Nodes

It showed its first signs in men and women alike by means of swelling in the groin or under the armpits, some of which grew to the size of an apple or an egg, and these were called buboes.

—G. BOCCACCIO, THE DECAMERON, INTRODUCTION

POINTS TO REMEMBER:

Lymph nodes serve as sentinels of disease, as they do their job of defending the body against invaders or rogue cells (cancers). The search for lymph nodes is one of the most important parts of the physical examination, especially in patients with suspected infection or cancer.
If you palpate carefully with proper technique, you will find many more nodes than others generally do.
Along with precise location, determine the tenderness, size, consistency, and mobility of nodes.

The lymph nodes were discovered not by a physician but by a Swedish zoologist and botanist named Olof Rudbeck (1630-1702). They were confirmed by the Danish physician Bartholin, whose son discovered the glands known by that name (see Chapter 22).

The search for lymph nodes is easily one of the most important parts of the physical examination, especially in patients with a fever of unknown origin, weight loss, or known or suspected carcinoma. For example, on reviewing the oncology records in his practice, Dr David Clarkson of Alabama found that 21% of his cancer patients had measurable nodes.

Physicians must specifically look for lymph nodes using proper techniques; otherwise, they will miss them. In a study of the ability of primary care physicians to recognize physical findings associated with acquired immunodeficiency syndrome (AIDS), only 17% of 133 physicians detected diffuse lymphadenopathy in a patient complaining of fatigue, fever, and arthralgia (Paauw et al., 1995).

Dimensions

Although this chapter emphasizes the locations of lymph nodes and some techniques for finding them, there are four dimensions that must be described for any lymph node that is detected: (a) size, (b) tenderness, (c) consistency, and (d) matting. This is especially important for persons using this text, who will tend to find more lymph nodes than others do.

The clinical setting and the age of the patient are also important. Children are more likely than adults to respond with lymphoid hyperplasia to minor stimuli. In patients under age 30, lymphadenopathy is due to benign causes in 80% of cases. In patients over age 50, the cause of lymphadenopathy is benign in only 40% (Haynes, 1994) of cases.

As a general rule, lymph nodes bigger than the terminal phalanx of your little finger are significant. However, the benign chronic lymphadenopathy of intravenous drug users can occasionally cause larger nodes (Sapira, 1968), and a small node may be highly significant if it occurs in an unusual location (e.g., in the preauricular area). In cancer patients, the precise measurement of lymph nodes is an important index of response to treatment.

Plastic calipers should be purchased for measuring nodes. They can also be used to measure other lumps, as in the breast.
Tenderness usually indicates inflammation. Tender nodes are usually of clinical importance.
Nodes that are stony hard are felt in metastatic neoplasia. Nodes that are not stony hard but very firm like the rubber of a pencil tip eraser are often due to Hodgkin disease or other lymphomas.

The adjective “shotty” (not “shoddy”) refers to small nodes that feel like buckshot under the skin. The size of the shot may be large, but all the nodes feel firm and disconnected (not matted) and are generally of the same size.
Matted nodes feel as if they are connected, and when one is moved, the others seem to move with it. Such nodes are found in metastatic neoplasms and sometimes in primary lymphatic malignancy. However, matting also occurs in nonneoplastic conditions such as chronic inflammation and occasional sarcoidosis.

Lymph Node Groups

Axillary Nodes

Normally, lymph nodes cannot be palpated in the axilla. However, with the following method, it is occasionally possible to find very small nodes, whose normality is indicated by their small size, lack of tenderness, and lack of matting (if multiple).

A Method

To examine the patient’s left axilla, position your right hand so that your fingers are in the roof of the axilla and your palm is turned naturally toward the patient. With your other hand, passively abduct the patient’s arm, advancing your examining fingers superiorly. Then, to relax the skin folds and give you the best opportunity to palpate the roof of the axilla, bring the patient’s arm back down toward his side. Continue by pressing your fingers superiorly and medially. Next, work your fingertips down the medial wall of the axilla, trying to catch any lymph nodes in the fat pad and, lastly,
those beneath the fat pad and against the chest wall. Examine the other side in a mirror-image fashion.

Unilateral axillary adenopathy may be seen in infections of the upper extremity, breast cancer, cat-scratch disease, lymphoma, and brucellosis.

Epitrochlear Nodes

A Method

To feel the epitrochlear nodes at the patient’s right epitrochlear area, grasp the patient’s right hand with your right hand and place the palm of your left hand around the distal insertion of the triceps, as if you were a politician shaking hands (Fig. 8-1). The fingers of your left hand will now curl medially, pointing anteriorly (back at you). With your little finger on the medial epicondyle of the humerus, the remainder of your fingers should fall in or near a groove at the brachialis muscle. This is where the epitrochlear nodes will be if they are enlarged (or, rarely, normally palpable, as in a very thin person). Another reason for calling this a politician’s handshake is that it is sometimes necessary to use your hand-grasping hand to pump the arm (extend and flex the elbow joint) 10 or 15 degrees so as to maximize the exposure of the subcutaneous anatomy to the palpating fingers. An incorrect method is shown in Fig. 8-2.

Reverse the procedure for examining the epitrochlear nodes on the other side.

In the absence of dermatitis or other inflammation of the hands or forearms, the presence of epitrochlear nodes is an extremely valuable clue to systemic diseases, such as sarcoid. Bilateral epitrochlear nodes are also seen in tularemia and secondary syphilis.

Teaching Hint

The best persons in whom to search for epitrochlear nodes are intravenous drug abusers. (Drug abuse is, of course, a systemic disease; patients may also have inflammation at injection sites.)

I was told that the type of handshake described above was invented by Sir William Osler when he was regius professor of medicine at Oxford. Supposedly, he would shake hands in this way with young men who came to call on his daughter, in order to search for epitrochlear nodes sometimes found in the systemic lymphadenopathy of syphilis. Additionally, from this position the palpating fingers can slip a short distance to feel for the bounding Corrigan pulse of luetic aortic insufficiency at the brachial artery.

Question: What is wrong with this story? (See Appendix 8.1 for the answer.)

FIGURE 8-1 Palpating for epitrochlear nodes. The examiner’s right hand is shaking hands with the patient’s right hand, while the examiner’s left hand (shown) palpates correctly.

FIGURE 8-2 No matter how often Dr Vesalius dissects the arm, he will continue to miss the epitrochlear nodes unless he moves his hand higher and more posteriorly. See text and legend to Fig. 8-1 for the correct method for palpating for epitrochlear nodes. (From Medicine and the artist [Ars medica], with permission of the Philadelphia Museum of Art.)

Cervical Nodes

A Method for Posterior Cervical Nodes

Standing in front of the patient, put your fingers over the posterior cervical area and move quickly from top to bottom, searching for easily palpable nodes (Fig. 8-3). If you cannot see the nodes, this does not usually work.
Then, start again at the skull, putting your fingers in the groove behind the sternocleidomastoid and in front of the trapezius. Work your way down the groove, palpating deeply with almost a scratching motion. Once you have felt such lymph nodes in a patient, you will unconsciously adopt this type of motion from then on.

In the US at the present time, posterior cervical lymphadenopathy is very often due to dandruff (seborrheic dermatitis). It also occurs in scalp infections, toxoplasmosis, and rubella.

Anterior cervical nodes are found in front of the sternocleidomastoid. Search for them just after checking for submandibular nodes.

FIGURE 8-3 Sites of posterior cervical nodes are shown by stars. Arrow indicates the vertebra prominens (see Chapter 16). (Detail of Guilliano de Medici by Michelangelo.)

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