1. Examination of the Lymphatic System

2. The Lymphatic System: Function l An integral part of the immune system l Provides defense against microorganisms by producing antibodies and performing phagocytosis l Plays an unwanted role in providing at least one pathway for the spread of malignancy

3. The Lymphatic System: Anatomy l Composed of: » lymph fluid » collecting ducts » lymph nodes » spleen » thymus » tonsils » adenoids » Peyer patches l Lymphatic tissue is also present in: » stomach » bone marrow » lungs

4. The Lymphatic System: Anatomy & Physiology l Lymph nodes – usually occur in groups – condition of nodes provides clues to the presence of infection or malignancy l Lymphocytes – arise from precursor cells in nodes, tonsils, adenoids, spleen & bone marrow – central to the body’s response to antigenic substances

5. The Lymphatic System: Anatomy & Physiology l Thymus – located in superior mediastinum and into lower neck – little or no demonstrated function in adults – serves in forming protective immune function during fetal & infant development l Spleen – located between the stomach and diaphragm – forms and stores RBCs in early life – macrophages in the spleen filter blood

6. The Lymphatic System: Anatomy & Physiology l Tonsils & Adenoids – tonsils are between palatine arches of pharynx near base of tongue... composed of lymphoid tissue and covered with mucous membrane – adenoids (pharyngeal tonsils) are near nasopharyngeal border... may obstruct passageway if they enlarge in response to frequent bacterial or viral invasion l Peyer Patches – elevated areas of lymph tissue on the small intestine serving the intestinal tract

7. Lymphatic System l A separate vessel system. l The two main functions are to transport excess fluid from the interstitial spaces to the circulatory system and to protect the body against infectious organisms.

8. Components of the Lymph System l Lymph Fluid: pale yellow; moves from the plasma through the capillary walls and becomes interstitial fluid. l Lymph Nodes: scattered through the body and contain dense patches of lymphocytes and macrophages. l Lymph Organs: the spleen and the thymus.

9. Lymph System l Lymphatic capillaries l Lymphatic ducts l Lymph Nodes l System carries fluids from the interstitial spaces to the blood l Proteins, fat from GI, and hormones return to blood l Returns excess interstitial fluid to blood

10. Lymphatic Circulation

11. The Lymphatic System: Anatomy Variations l Infants & Children » infant’s response to infection is immature during first months of life » lymphoid tissue increases to twice an adult mass between 6-9 years and regresses to adult levels by puberty » tonsils are larger during childhood » lymph node distribution is the same in children & adults l Older Adults » the number and size of lymph nodes decreases with age » some lymphoid elements are lost » nodes are more fibrotic and fatty than in younger person, resulting in an impaired ability to resist infection

12. The Lymphatic System: History Review l Present Problem » bleeding » enlarged nodes » swelling of extremity » medications l Past Medical History » chest x-rays » TB and other skin tests » transfusions » chronic illness – cardiac, renal, malignancy, HIV » surgery » recurrent infections l Family History » malignancy » anemia » recent infections » TB » agammaglobulinemia, other immune disorders » hemophilia

13. History l Acute vs Chronic l Localised (3/4) vs Generalised (1/4) »Only 17% of generalized Lymphadenopathy identified l Unilateral vs Bilateral

14. HIV Infection: Risk Factors l Adolescents and Adults »Sexual contact with HIV+ partner »Men with homosexual or bisexual activities »Heterosexual contact with homosexual or bisexual men »Multiple and indiscriminate sexual contacts »IV drug use »Hemophilia »Blood transfusion »Work related (very rare)

15. HIV Infection: Risk Factors l Infants and Children »Mother either with or at risk for HIV infection »Hemophilia »Blood transfusion »Sexual abuse

16. History Variations l Infants and Children » recurrent infections » poor growth, FTT » loss of interest in playing or eating » immunization history » maternal HIV infection » hemophilia » illness in siblings l Pregnant Women » weeks gestation, EDC » exposure to rubella and other infections » presence of children in household l Older Adults » present or recent infection or trauma distal to nodes » delayed healing

17. Examination of the Lymphatic System l Utilizes inspection and palpation l Generally examined region by region during the examination of the other body systems l Always ask patients if they are aware of any “lumps”

18. Lymph Nodes Accessible to Examination l Head and Neck » preauricular » postauricular » occipital » tonsillar » submandibular » submental » superficial anterior cervical » deep cervical » posterior cervical » supraclavicular » infraclavicular l The Arms » axillary – anterior axillary (pectoral) – lateral (brachial) – mid axillary (central) – posterior (subscapular) » epitrochlear l The Legs » superficial superior inguinal » superficial inferior inguinal » popliteal (occasionally)

19. Examination of the Lymphatic System l Inspect » any visible nodes for: – edema – erythema – red streaks l Palpate » the superficial nodes » compare side to side for: – size – consistency – mobility – discrete borders or matted – tenderness – warmth

20. Examination of the Lymphatic System l If an enlarged lymph node is found, examine: »P Primary site »A All associated nodes »L Liver »S Spleen

21. Age Related Variations l Infants and Children » commonly find small, discreet, firm, movable nodes in occipital, postauricular, cervical and inguinal chains... – should not be warm or tender – shape usually ovoid or globular – often referred to as “shotty nodes” » may find enlarged postauricular and occipital nodes in children < 2 years old » cervical and submandibular node enlargement is less frequent in children < 1 year old and much more frequent in older children » palatine tonsils may be enlarged

22. EVALUATION OF Lymphatic System

23. Objectives Student should be able to … l describe location, size, consistency, and other attributes of lymphadenopathy l identify common clinical scenarios involving lymphadenopathy

24. Overview l This is a short lecture! l A major goal is to synthesize the lymphatic system as a whole…lymph node regions have been discussed individually by specific site…i.e., head, neck, and abdomen, but not put together for systemic illness such as lymphoma.

25. Lymphatic System

26. The Lymphatic System: Palpable superficial lymph nodes Occipital Posterior auricular Preauricular Tonsillar Submaxillary Submental Superficial cervial Deep cervical Supraclavicular Axillary Lateral Subscapular Pectoral Epitrochlear Inguinal

27. Lymph Node Examination l Head/neck l Axillary l Epitroclear l Inguinal/femoral

28. Physical Examination l Head and Neck LN l Axillary LN l Inguinal LN

29. Lymph node regions

30. Head and Neck Nodes l Preauricular l Posterior auricular l Occipital l Tonsillar l Submandibular l Submental l Superficial cervical l Posterior cervical l Deep cervical l Supraclavicular

31. Lymph nodes of the head and neck, and the regions that they drain

32. ALL:Cervical Lymphadenopathy

33. Right neck mass

34. Lymphoma Row of enlarged lymph nodes

35. Lymphadenopathy in children

36. TB abscess as part of immune reconstitution syndrome

37. Axillary l A pectoral (anterior) l L lateral l P posterior l C central l Ap apical

38. Axillary lymphatics and the structures that they drain

39. Describe

40. l

41. Inguinal/ Femoral l Horizontal group l Vertical group

42. Inguinal lymphatics and the structures that they drain

43. Chest X-Ray NormalPatient Hilar Lymphadenopathy Is a common feature of: 1.Sarcoidosis 2.TB 3.Coccidiomycosis 4.Histoplasmosis Interstitial Infiltrates – Bilateral hilar lymphadenopathy

44. Lymphadenopathy l Bilateral symmetric hilar and right paratracheal mediastinal adenopathy is the most common pattern of lymphadenopathy in sarcoidosis. l Unilateral hilar lymphadenopathy is more common in TB, neoplasm and primary pulmonary fungal infection l Frequently, the hila are prominent but not definitely abnormal. Even if the hila are enlarged, it may not be possible to determine if this is due to enlarged lymph nodes or enlarged pulmonary vessels. l The lateral radiograph can often resolve uncertainties.

45. Mediastinal Lymphadenopathy - ALL

46. Descriptors of Lymphadenopathy l Location…obvious l Mobility l Size l Texture l Shape l Tender/non-tender l Associated erythema or warmth…signs of inflammation

47. Spleen l Left upper quadrant l Palpation most specific for detecting enlarged spleen (89-99% specificity) l Spleen palpable to umbilicus is suggestive of hematologic pathology l Percussion is non-sensitive (dullness in Traube’s space) but can be specific in non-obese patients

48. Organomegaly

49. Splenomegaly Spleen

50. Case l 28 yo man presents with c/o fevers, night sweats and 30 pound weight loss. He develops pruritis when he showers. He also has noted some enlarged “glands” in his neck and armpits. On lymphatic exam he has the following:

51. Case l painless lymphadenopathy in anterior axilla and anterior cervical as well as supraclavicular areas bilaterally. l Lymph nodes are not tender, freely mobile and no associated inflammation. They are ovoid (grape-shaped) and measure 2 x 3 cm. There is no splenomegaly by palpation or percussion.

52. Differential Diagnosis l Lymphoma l Infection l Cancer—metastatic l Granulomatous disease