Palpation Technique
Use the pads of the second, third, and fourth fingers to gently press and roll the lymph nodes over the underlying tissue, assessing for the characteristics listed below:
Characteristics of Lymph Nodes
During palpation, it’s essential to assess the following characteristics of lymph nodes:
- Site: The location of the lymph node in relation to anatomical landmarks.
- Size: Normal lymph nodes are generally less than 1 cm in diameter; larger nodes may indicate pathology.
- Shape: Nodes should have regular, smooth borders.
- Consistency: Soft nodes are often insignificant, rubbery nodes may suggest lymphoma, and hard nodes can indicate malignancy.
- Tenderness: Tender nodes are commonly associated with infections.
- Mobility: Mobile nodes are usually benign, while immobile nodes may indicate malignancy.
- Overlying Skin Changes: Look for signs of erythema or other skin changes that could suggest underlying pathology.
Interpretation of Lymph Node Examination Findings
Interpreting the characteristics of lymph nodes is crucial in narrowing down potential diagnoses and guiding further clinical management. Below is a more detailed breakdown of the typical findings associated with benign, reactive, malignant, and metastatic lymph nodes.
Benign Lymph Nodes
- Size: Benign lymph nodes are usually small, typically measuring less than 1 cm in diameter. Their size does not generally change over time.
- Shape: These nodes are typically smooth and rounded, with well-defined borders that can be easily delineated during palpation.
- Consistency: Benign nodes feel soft to the touch, similar to the texture of a grape. Their softness indicates the absence of fibrosis or malignancy.
- Mobility: Benign lymph nodes are freely mobile, meaning they can be easily moved under the skin and are not attached to surrounding tissues.
- Tenderness: These nodes are generally non-tender, indicating that there is no active inflammation or infection.
Reactive Lymph Nodes
- Size: Reactive lymph nodes are often enlarged, typically exceeding 1 cm in diameter, as they respond to local or systemic infections or inflammatory conditions.
- Shape: The shape of reactive nodes is generally smooth and rounded, although they may be slightly irregular due to inflammatory swelling.
- Consistency: These nodes tend to be soft but can feel slightly rubbery, reflecting their reactive nature. The increased cellular activity within the node contributes to this rubbery texture.
- Mobility: Reactive nodes are mobile and are not fixed to surrounding structures, which distinguishes them from malignant nodes.
- Tenderness: Tenderness is a hallmark of reactive lymphadenopathy, often associated with signs of infection such as erythema or warmth over the node. The tenderness results from inflammation within the node.
Malignant Lymph Nodes
- Size: Malignant lymph nodes are often enlarged, and the size may progressively increase as the disease advances. These nodes are usually greater than 1 cm in diameter.
- Shape: The borders of malignant lymph nodes are often irregular, lacking the smooth, rounded contour seen in benign nodes. This irregularity reflects the invasive nature of cancer cells.
- Consistency: Malignant nodes typically feel hard and firm upon palpation, indicating the presence of fibrosis or direct invasion by malignant cells. The hardness is due to the fibrotic response of the tissue surrounding the invading cancer cells.
- Mobility: Unlike benign or reactive nodes, malignant lymph nodes may be immobile. This lack of mobility suggests the invasion of the cancer cells into nearby structures, making the node less mobile.
- Tenderness: Malignant nodes are generally non-tender, as the growth of cancer cells does not typically trigger the same inflammatory response seen in infections.
Metastatic Lymph Nodes
- Size: Metastatic lymph nodes are usually significantly enlarged as they become infiltrated by cancer cells from a primary tumor located in a nearby organ.
- Shape: The shape of metastatic nodes is often irregular, with poorly defined borders, reflecting the aggressive spread of cancerous cells.
- Consistency: Metastatic nodes are typically firm to hard, indicating a high level of cellularity and fibrosis within the node. This firmness can also be due to the scarring or fibrotic reaction that occurs in response to tumor invasion.
- Mobility: These nodes are often immobile – fixed to surrounding tissues, a characteristic feature of metastatic disease. The invasion of the surrounding tissue by cancer cells leads to a loss of the normal architecture and mobility of the node.
- Tenderness: Tenderness is not commonly associated with metastatic nodes, as the process of metastasis usually does not provoke an acute inflammatory response. However, tenderness may be present if there is associated inflammation or if the node is compressing surrounding nerves or tissues.
Examination of Lymph Nodes
Lymph nodes are located in specific regions, many of which can be palpated during a clinical examination. Each group of lymph nodes should be examined in a consistent, methodical manner to ensure no area is overlooked.
Cervical Lymph Nodes (Head and Neck)
The cervical lymph nodes are a primary focus during examination due to their frequent involvement in infections and systemic diseases. The examination is best performed with the patient seated upright, with their head slightly tilted downward to relax the neck muscles.
- Submental Nodes: Located under the chin, these nodes are palpated first.
- Submandibular Nodes: Found beneath the jawbone.
- Tonsillar Nodes: Located at the angle of the jaw.
- Parotid Nodes: Near the ear, associated with the parotid gland.
- Pre-auricular Nodes: In front of the ear.
- Post-auricular Nodes: Behind the ear.
- Superficial Cervical Nodes: Along the surface of the neck, near the sternocleidomastoid muscle.
- Deep Cervical Nodes: Situated deeper within the neck, often palpated behind the sternocleidomastoid.
- Posterior Cervical Nodes: Found along the back of the neck.
- Occipital Nodes: Located at the base of the skull.
- Supraclavicular Nodes: Positioned above the clavicle, these nodes can be indicative of significant pathology if enlarged, especially on the left side (Virchow’s node).
Axillary Lymph Nodes (Armpits)
The axillary lymph nodes, located in the armpits, are examined with the patient lying at a 45° angle. This position helps relax the axillary muscles, making palpation more effective.
Support the patient’s arm to allow their muscles to relax, and then systematically palpate the different groups of axillary nodes:
- Pectoral (Anterior) Nodes: Behind the lateral edge of the pectoralis major.
- Central (Medial) Nodes: Against the thoracic wall.
- Subscapular (Posterior) Nodes: Along the lateral edge of the latissimus dorsi.
- Humeral (Lateral) Nodes: Along the inner aspect of the arm.
- Apical Nodes: At the apex of the axilla; warn the patient that this may be uncomfortable.
Inguinal Lymph Nodes Examination (Groin)
The inguinal lymph nodes, located in the groin, are important indicators of various conditions, including infections of the lower limbs, sexually transmitted infections, and malignancies. These nodes are divided into two groups: the horizontal and vertical chains.
Positioning the Patient: Begin by asking the patient to lie flat on the examination table, ensuring the inguinal region is fully exposed. This position allows for a thorough and accurate examination of the lymph nodes.
Palpation of the inguinal lymph nodes is performed in two distinct areas:
- Horizontal Chain: Start by palpating immediately below the inguinal ligament, which runs between the anterior superior iliac spine and the pubic tubercle. This chain runs parallel to the ligament and is best palpated with the patient’s skin relaxed.
- Vertical Chain: To examine the vertical chain, position your fingers approximately 3 cm lateral to the pubic tubercle, along the line of the femoral artery. Palpate vertically downwards over the saphenous opening and the proximal portion of the great saphenous vein.