1. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Chapter 9 Lymphatic System

2. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Lymphatic System The lymphatic system is examined region by region during the examination of the other body systems and by palpating the spleen, an integral part of the system. Sometimes you may examine the entire lymphatic system at once, exploring all the areas in which the nodes are accessible. 2

3. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Lymphatic System Inspect the visible nodes and surrounding area for the following characteristics: –Edema –Erythema –Red streaks Palpate the superficial lymph nodes and compare side to side for the following: –Size –Consistency –Mobility –Discrete borders or matting –Tenderness –Warmth 3

4. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology Lymphatic system consists of: –Lymph fluid/collecting ducts –Lymph nodes –Spleen –Thymus –Tonsils and adenoids –Peyer patches Lymph tissue located in multiple body systems, including the mucosa of the stomach, appendix, bone marrow, and lungs –Exceptions: placenta and CNS 4

5. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology (Cont.) 5 Figure 9-01. Lymphatic System (Lymphoreticular System).

6. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Immune System Function –Protects body from antigenic substances –Removes damaged cells –Partial barrier to malignant cell maturation When it functions well, the individual is immunocompetent –Tissue rejection of transplanted organs When it fails, immunoincompetence can lead to a variety of illnesses –Allergic –Immunodeficient –Autoimmune 6

7. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Immunologic and Metabolic Processes Movement of lymph fluid in a closed circuit Production of lymphocytes Production of antibodies Phagocytosis Absorption of fat and fat-soluble substances Manufacture of blood when primary sources compromised 7

8. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Lymph Composition –Clear fluid –Mostly white blood cells (WBCs) –Occasional red blood cells (RBCs) –Proteins Drainage –Moves from bloodstream to interstitial spaces No built-in pumping mechanism –Collected by tubules/ducts –Carried to lymph nodes –Moved to venous system Subclavian veins –Closed but porous circulation 8

9. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Lymph Nodes Discrete structures surrounded by a capsule composed of connective tissue and a few elastic fibrils Usually occur in groups Receive lymph from the collecting ducts Usually occur in groups Receive lymph from the collecting ducts 9

10. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Lymphocytes Central to body response to antigens B-lymphocytes produce antibodies T-lymphocytes have important role in controlling immune responses brought about by B- lymphocytes Two types of immunity –Humoral –Cellular Increased presence in blood indicates systemic response to most viral and some bacterial infections 10

11. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Thymus Located in the superior mediastinum, extending upward into the lower neck Primary function in infancy and childhood –Little or no demonstrated function in adult Essential to the development of the protective immune function Site for T-cell production 11

12. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Spleen Situated in the left upper quadrant of the abdominal cavity Blood-forming organ early in life Site for red corpuscle storage Contains blood-filtering macrophages Immune response to bloodborne antigens; usually has its origins in the spleen 12

13. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Tonsils and Adenoids Palatine tonsils –Commonly referred to as the “tonsils” Pharyngeal tonsils –Commonly referred to as the “adenoids” Lingual tonsils –Located at the base of the tongue Defensive responses to inhaled and intranasal antigens are activated in these tissues 13

14. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants and Children Antibody production is immature at birth. Thymus is at its largest relative to the rest of the body shortly after birth. Tonsils are larger in early childhood. Lymph node distribution is same as in adults. Lymphatic system gradually reaches adult competency during childhood. 14

15. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Pregnant Women Pregnancy is a state of altered immune function –Implantation and fetal development Enhancement of certain immune mechanisms and suppression of others Leukocyte count increases Embryo is an in utero foreign body. –Mother’s hormones and the products of the fetal trophoblast create a unique environment. 15

16. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Older Adults Number of lymph nodes may diminish. Size of lymph nodes may decrease. Some of the lymphoid elements are lost. Nodes of older patients are more likely to be fibrotic and fatty. –Impaired ability to resist infection 16

17. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. History of Present Illness Enlarged node(s) –Character –Associated local symptoms –Associated systemic symptoms –Predisposing factors –Medications 17

18. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. History of Present Illness (Cont.) Swelling of extremity –Unilateral or bilateral, intermittent, duration –Predisposing factors –Associated symptoms –Efforts at treatment and effect 18

19. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Past Medical History Chest radiographs Tuberculosis and other skin testing Blood transfusions Chronic illness Surgery Recurrent infections Autoimmune disorders Allergies 19

20. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Family History Malignancy Anemia Recent infections Tuberculosis Immune disorders Hemophilia 20

21. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Personal and Social History Travel, especially to Asia, Africa, the Western Pacific, India, the Philippines Use of recreational drugs, especially injected Use of alcohol Sexual history (risk factors for HIV exposure) 21

22. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants and Children Recurrent infections Present or recent infections or trauma distal to nodes Poor growth, failure to thrive Loss of interest in play or eating Immunization history Maternal HIV infection Hemophilia 22

23. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Pregnant Women Weeks of gestation Exposure to rubella and other infections Presence of pets in household –Exposure to cat feces or litter 23

24. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Older Adults Presence of an autoimmune disease Present or recent infection or trauma distal to nodes Delayed healing 24

25. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Equipment Centimeter ruler Marking (skin) pencil 25

26. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Inspection Lymph nodes –Lymphadenopathy Edema –Lymphedema Erythema Red streaks –Lymphagenitis Skin lesions 26

27. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Palpation Detect and note –Enlargement –Consistency –Mobility –Tenderness –Size –Warmth 27

28. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Palpation (Cont.) Node characteristics –The harder the node, the more likely the malignancy –The more tender the node, the more likely inflammation –Nodes do not pulsate; arteries do –A palpable supraclavicular node on the left is a clue to abdominal or thoracic malignancy Virchow node 28

29. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Head and Neck Head sequence –Occipital nodes at skull base –Postauricular nodes over mastoid –Preauricular node in front of ear –Parotid/tonsillar nodes at mandible angle –Submandibular nodes between angle and tip of mandible –Submental nodes behind mandible tip 29

30. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Head and Neck (Cont.) Neck sequence –Superficial cervical nodes at sternocleidomastoid –Posterior cervical nodes along anterior trapezius –Cervical nodes deep to sternocleidomastoid –Supraclavicular areas in angle of clavicle and sternocleidomastoid 30

31. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Other Areas Axillae Epitrochlear lymph nodes Inguinal and popliteal lymph nodes Spleen 31

32. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants and Children Technique of examination is similar for all ages. Enlarged lymph nodes are common. –Enlarged postauricular/occipital not unusual in children younger than age 2 –Enlarged cervical/submandibular less frequent in children younger than age 1, much more frequent in children older than age 1 –Enlarged tonsils common, not necessarily abnormal Enlargement may not be associated with illness. 32

33. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities Acute lymphangitis –Inflammation of one or more lymphatic vessels Acute suppurative lymphadenitis –Infection and inflammation of a lymph node –May affect a single or localized group of nodes 33

34. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Cont.) Lymphedema –Edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage 34

35. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Cont.) Lymphatic filariasis (elephantiasis) –Massive accumulation of lymphedema throughout the body –Most common cause of secondary lymphedema worldwide Epstein-Barr virus mononucleosis –Infectious mononucleosis 35

36. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Cont.) Non-Hodgkin lymphoma (NHL) –Malignant neoplasm of the lymphatic system and the reticuloendothelial tissues Hodgkin disease –Malignant lymphoma Herpes simplex (HSV) –Infection by human herpes virus 1 (HSV-1) or human herpes virus 2 (HSV-2) 36

37. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Cont.) Cat scratch disease –Among the most common causes of subacute or chronic lymphadenitis in children AIDS (acquired immune deficiency syndrome) –Dysfunction of cell-mediated immunity Latex allergy type I reaction –True allergic reaction caused by protein antibodies 37