Where are lymph nodes located in the human body. How do lymph nodes function in the immune system. What causes lymph nodes to swell. What is the anatomy of a lymph node. How many lymph node groups are there in the body. What are portal lymph nodes. How do doctors use lymph nodes to diagnose infections.

The Intricate Anatomy of Lymph Nodes

Lymph nodes are small, bean-shaped structures that play a crucial role in our immune system. These remarkable organs, typically measuring 1-2 centimeters in size, can be found either in isolation or in groups throughout the body. To fully appreciate their function, it’s essential to understand their complex anatomy.

The structure of a lymph node consists of four primary layers:

1. Capsule: The outermost layer composed of connective tissue and fibers
2. Subscapular sinus: Responsible for transporting lymphatic fluid
3. Cortex: Contains lymphocytes, key players in immune response
4. Medulla: The innermost layer housing blood vessels and efferent lymphatic vessels

This layered structure allows lymph nodes to efficiently filter lymph and trap potentially harmful substances, making them an integral part of our body’s defense mechanism.

Mapping the Lymph Node Network: Key Locations in the Human Body

The human body houses an extensive network of lymph nodes, strategically positioned to ensure comprehensive coverage of all organs and tissues. This intricate system is divided into six primary regions:

• Head and neck
• Axillary (armpit area)
• Upper limb
• Iliac (abdominal region)
• Inguinal (groin area)
• Lower limb

Each region contains both superficial and deep nodes, working in harmony to filter lymph and protect the body from potential threats. For instance, the head and neck region boasts an array of nodes along the trapezius muscles, sternocleidomastoid muscle, and various facial areas. The axillary region, crucial for breast health, includes nodes in the mammary glands and along the clavicle and pectoral muscles.

Intrathoracic Nodes: A Closer Look

Within the axillary region, the intrathoracic nodes deserve special attention. These nodes are further divided into 14 stations surrounding the lungs and heart, each playing a specific role in monitoring and protecting these vital organs. From the supraclavicular nodes in Zone 1 to the peripheral nodes in Zones 12-14, this complex network ensures thorough surveillance of the thoracic cavity.

The Sentinel Guards: Lymph Nodes of the Neck

The neck region hosts several crucial groupings of lymph nodes, each responsible for draining specific areas:

• Post auricular (mastoid) nodes: Located behind the ears, draining the back of the neck, part of the external ear, and ear canal
• Occipital cervical nodes: Positioned at the junction of the back of the head and neck, draining surrounding areas
• Superficial cervical nodes: Found along the jugular vein, draining neck tissues
• Deep cervical nodes: Draining both superficial cervical nodes and all head and neck tissues

This comprehensive network ensures that potential threats in the head and neck region are swiftly identified and addressed by the immune system.

Portal Lymph Nodes: Guardians of the Liver

Portal lymph nodes play a unique role in the body’s lymphatic system. Located near the portal vein of the liver, these specialized nodes are part of a connected network that follows the hepatic artery to the celiac artery. Their primary function is to transport lymph to and from the liver, an organ that produces a significant amount of lymph used by the lymphatic system.

The importance of portal lymph nodes becomes evident when we consider the liver’s crucial role in detoxification and metabolism. By efficiently filtering lymph from this vital organ, portal lymph nodes help maintain liver health and overall bodily function.

The Multifaceted Functions of Lymph Nodes

Lymph nodes are more than just passive filters; they are active participants in the body’s defense against infections and diseases. Their primary function is to filter lymph fluid, which is carried throughout the body via the lymphatic system. This fluid contains extra fluids drained from cells and tissues, along with potential pathogens.

As lymph travels through the nodes, foreign bodies such as viruses and bacteria are trapped and destroyed by lymphocytes, a type of white blood cell. This process is crucial for maintaining our health and preventing the spread of infections.

The Swelling Phenomenon: When Lymph Nodes Go into Overdrive

When a lymph node is actively producing many lymphocytes to combat an infection, it can begin to swell. This swelling may even become visible through the skin, serving as a visible sign of the body’s immune response in action.

Swollen lymph nodes often appear during common infections like colds or flu. They can typically be felt along the jawline, under the arm, or in the groin area. Interestingly, the location of the swollen nodes often corresponds to the site of infection. For example, a flu infection might result in tender and swollen nodes in the neck region.

Lymph Nodes as Diagnostic Tools

Medical professionals often use lymph nodes as a diagnostic tool to assess a patient’s health. By palpating areas rich in lymph nodes, such as the neck and jawline, doctors can gather valuable information about potential infections or other health issues.

The presence of swollen or tender lymph nodes can provide clues about the nature and location of an infection. This simple yet effective diagnostic technique has been a cornerstone of physical examinations for centuries, highlighting the importance of understanding lymph node locations and their significance in human health.

Beyond Infection: Other Causes of Lymph Node Swelling

While infections are a common cause of lymph node swelling, they are not the only reason these structures may become enlarged. Other potential causes include:

• Autoimmune disorders: Conditions like lupus or rheumatoid arthritis can cause chronic lymph node swelling
• Cancer: Certain types of cancer, particularly lymphomas, can cause persistent lymph node enlargement
• Medications: Some drugs may cause lymph node swelling as a side effect
• Injury: Physical trauma to an area can result in temporary lymph node swelling

Understanding these various causes emphasizes the importance of professional medical evaluation when experiencing persistent or unexplained lymph node swelling.

When to Seek Medical Attention

While occasional, temporary lymph node swelling is often benign, certain situations warrant medical attention. Consider consulting a healthcare provider if you experience:

• Lymph node swelling that persists for more than two weeks
• Nodes that are painless, hard, or fixed in place
• Swelling accompanied by unexplained weight loss, fever, or night sweats
• Rapidly growing nodes

These symptoms could indicate more serious underlying conditions that require prompt medical evaluation and treatment.

The Lymphatic System: A Broader Perspective

While lymph nodes are crucial components of the lymphatic system, they are part of a larger network that includes lymphatic vessels, the spleen, and the thymus gland. This system works in tandem with the circulatory system to maintain fluid balance, absorb fats from the digestive system, and support immune function.

The lymphatic system’s role extends beyond fighting infections. It helps remove cellular waste, maintain fluid balance in tissues, and even plays a part in the body’s fat metabolism. Understanding the broader context of the lymphatic system highlights the interconnectedness of various bodily functions and the importance of maintaining overall lymphatic health.

Promoting Lymphatic Health

While the lymphatic system operates largely autonomously, there are ways to support its function:

• Regular exercise: Physical activity helps stimulate lymph flow
• Hydration: Adequate water intake supports overall lymphatic function
• Healthy diet: Consuming anti-inflammatory foods may benefit the lymphatic system
• Stress management: Chronic stress can impact immune function, including the lymphatic system

By adopting these healthy lifestyle habits, individuals can support their lymphatic system and, by extension, their overall health and well-being.

Advancing Our Understanding: Current Research in Lymphatic System Function

The field of lymphatic research is dynamic and ever-evolving. Recent studies have shed light on previously unknown aspects of lymph node function and the lymphatic system as a whole. Some exciting areas of current research include:

• The role of the lymphatic system in neurological health and cognitive function
• Potential therapeutic applications targeting the lymphatic system for various diseases
• The interplay between the lymphatic system and the gut microbiome
• Advanced imaging techniques for better visualization and understanding of lymphatic function

These ongoing investigations promise to deepen our understanding of the lymphatic system and may lead to novel therapeutic approaches for a wide range of health conditions.

The Future of Lymphatic Medicine

As our knowledge of the lymphatic system expands, so too does the potential for targeted therapies and interventions. Some promising areas of development include:

• Lymphatic-targeted drug delivery systems for more effective treatments
• Bioengineered lymph nodes for transplantation in cases of lymphatic system damage
• Advanced diagnostic tools for early detection of lymphatic system disorders
• Personalized treatment plans based on individual lymphatic system profiles

These advancements hold the promise of revolutionizing our approach to treating not only lymphatic disorders but also a wide range of conditions influenced by lymphatic function.

Lymph Nodes in Veterinary Medicine: A Comparative Perspective

The study of lymph nodes isn’t limited to human anatomy. In veterinary medicine, understanding lymph node location and function is equally crucial for diagnosing and treating various animal diseases. While the basic principles remain similar, there are some interesting differences in lymph node distribution and function across species.

For example:

• Dogs and cats have a more extensive network of mesenteric lymph nodes compared to humans, reflecting their different digestive systems
• Horses have a unique arrangement of submandibular lymph nodes that can make them prone to certain types of swelling
• Birds have a specialized lymphoid organ called the bursa of Fabricius, which is crucial for their immune system development

These comparative studies not only enhance our understanding of animal health but also provide valuable insights into the evolution and adaptability of the lymphatic system across different species.

One Health Approach: Lymphatic System Across Species

The concept of “One Health” recognizes the interconnectedness of human, animal, and environmental health. In this context, studying lymphatic systems across species can provide valuable insights into:

• Zoonotic diseases and their transmission patterns
• Evolutionary adaptations of the immune system
• Potential new approaches to treating lymphatic disorders in both humans and animals

This holistic approach to understanding lymphatic function across species may lead to breakthrough discoveries that benefit both human and veterinary medicine.

Lymph Nodes and Immunity: A Lifelong Partnership

The relationship between lymph nodes and our immune system is a lifelong one, evolving and adapting throughout our lives. From the development of the immune system in infancy to the changes that occur in old age, lymph nodes play a crucial role in maintaining our health and fighting off infections.

Key aspects of this lifelong partnership include:

• Childhood: Rapid development and maturation of the lymphatic system
• Adolescence: Hormonal changes influencing lymphatic function
• Adulthood: Maintenance and adaptation to various environmental challenges
• Old age: Potential decline in lymphatic function and immune response

Understanding these age-related changes can help healthcare providers tailor their approach to maintaining and supporting lymphatic health throughout a person’s lifetime.

Supporting Lymphatic Health Across the Lifespan

While the lymphatic system is remarkably resilient, there are ways to support its function at every stage of life:

• Childhood: Ensuring proper nutrition and vaccination to support immune system development
• Adolescence: Promoting healthy lifestyle habits that benefit overall lymphatic function
• Adulthood: Regular health check-ups and maintaining an active lifestyle
• Old age: Focusing on interventions that can help maintain lymphatic function and overall immune health

By adopting a lifespan approach to lymphatic health, individuals can work with healthcare providers to ensure optimal function of this crucial system throughout their lives.

Lymph Node Location, Diagram & Anatomy | What are the Lymph Nodes? – Video & Lesson Transcript

Lymph Node Anatomy

Lymph nodes range in size from 1-2 centimeters and are sometimes found alone, or in groups. These bean-shaped structures are composed of four main layers – the capsule, subscapular sinus, cortex, and medulla. The capsule is the outermost layer of the lymph node and is made of connective tissue and fibers. The subscapular sinus is the next layer, which functions in the transport of the lymphatic fluid. The cortex is a third layer that contains lymphocytes. The innermost layer is the medulla, which contains blood vessels and drains the lymph through the efferent lymphatic vessels.

Lymph Nodes Location

Lymph nodes are found throughout the body in a connected network to ensure that all organs and tissues have a connection to the lymphatic system. There are six primary regions of lymph nodes – head and neck, axillary, upper limb, iliac, inguinal, and lower limb. Superficial and deep nodes run along the base of the head and throughout the neck. Lymph nodes along the arm drain into axillary lymph nodes in the armpit area. Axillary lymph nodes in the chest can be found in mammary glands and along the clavicle and pectoral muscles. Iliac lymph nodes can be found throughout the abdomen following the iliac artery and vein. Inguinal lymph nodes are found in the groin area and are connected to nodes within the lower limb.

The intrathoracic nodes within the axillary region are further divided into 14 stations around the lungs and heart.

Lymph Nodes of the Neck

There are several groupings of lymph nodes in the head and neck. The post auricular, or mastoid, nodes are located behind the ears and drain the back of the neck, part of the external ear, and part of the ear canal. The occipital cervical nodes are located where the back of the head meets the neck and drain lymph from the surrounding areas. Superficial cervical nodes are located along the jugular vein and drain the tissues within the neck. There are also deep cervical nodes that drain the superficial cervical nodes as well as all of the tissues within the head and neck.

Portal Lymph Nodes

A portal lymph node can be found near the portal vein of the liver. The gallbladder, liver and surrounding areas have a connected network of lymph nodes that follow the hepatic artery to the celiac artery. These nodes assist with transporting lymph to and from the liver, which produces a significant amount of the lymph that is used by the lymphatic system.

Function of Lymph Nodes

Lymph nodes play an important role in the prevention of infection and diseases within the human body. The primary function of these structures is to filter lymph fluid, which is carried throughout the body using the lymphatic system. Lymph contains extra fluids that are drained from cells and tissues and travel throughout the lymphatic system via a network of lymphatic vessels. When lymphatic fluid travels through the lymph nodes, foreign bodies such as viruses and bacteria are trapped and then destroyed by lymphocytes, a type of white blood cell. When a lymph node is producing many lymphocytes, it can begin to swell and may even be visible through the skin.

Swollen Lymph Nodes

When infections occur, such as a cold or the flu, the lymph nodes may swell. The swollen nodes can sometimes be felt along the jaw line, under the arm, or in the groin area. Typically the swelling will be closest to the part of the body with the infection. For example, if you have the flu, the nodes of your neck may be tender and swollen. Doctors will often feel a patient’s neck and jawline to look for this swelling as an indication of infection. Lymph nodes will feel like round lumps under the skin.

Blood Supply in Lymphatic System

As the lymph travels through the lymphatic vessels, it makes its way back to the right and left lymphatic, or thoracic, ducts, which connect to the subclavian vein. The lymph fluid is returned to the blood stream and will continue circulation throughout the body. Because this fluid is available within a person’s blood, it can be checked for signs of infection or cancer.

Cancer in Lymph Nodes

Since the lymph nodes filter out harmful cells in the lymph fluid, they can be susceptible to cancer. When a cancer cell is detected, the lymph node will try to kill it like any other foreign substance. However, sometimes the cancer cells are able to replicate and infect the lymph nodes and surrounding areas. Often lymph nodes near the site of a cancerous tumor are checked to determine if the cancer has spread to other parts of the body.

Lesson Summary

Lymph nodes are small structures spread throughout the body that are integral to the function of the immune system. There are groupings of these nodes in the head and neck, armpit, abdomen, and groin. These are categorized into six different types:

• Head and Neck
• Upper Limb
• Axillary
• Iliac
• Inguinal
• Lower Limb

Lymph nodes are an important part of the lymphatic system, which circulates lymphatic fluid, or lymph, made up of extra fluid and foreign bodies from organs and tissues. When a foreign body such as a virus, bacteria, or cancer is trapped within the lymph node, it will produce lymphocytes to attack and destroy them.

Swollen lymph nodes are an indication of infection, and doctors may feel for this swelling when diagnosing a problem.

Lymph nodes are susceptible to cancer as they filter cancer cells from lymphatic fluid, and sometimes the cancer is able to replicate and create a tumor.

How to check your lymph nodes

What are the aims of this leaflet?

This leaflet has been written to help you to understand more about how to check your lymph nodes yourself. It tells you why you should be doing it, what lymph nodes should be checked, how often they should be checked and how to check them, and where you can find out more about this issue. 

What are lymph nodes?

The Lymphatic System

Lymph nodes are part of the lymphatic system, which is a network of tiny tubes that carry a colourless fluid called lymph through the skin and deeper parts of the body.  Lymph fluid contains immune cells (lymphocytes) nutrients and waste materials. 

Diagram 1. Position of lymph nodes

Lymphatic Vessels

It bathes the cells of the skin and internal organs and   drains into lymphatic vessels then larger ducts in the neck before joining the blood stream near the heart (see Figure 1).

Lymph Nodes

Lymph nodes (‘glands’) are small oval nodules and contain millions of infections fighting lymphocyte cells.  They are found at intervals along the lymphatic vessels like ‘beads on a string’ (see Diagram 1). The lymph nodes filter out harmful organisms and abnormal cells before the lymph reaches the blood stream. Lymph nodes can only be felt in certain areas:

• head and neck
• arms
• axilla (armpit)
• inguinal area (groin)
•  back of knees

Lymph node are usually too small to feel except in slim people when they can be felt as smooth pea-sized lumps in the groin. Another common exception is when people get a sore throat or an ear infection, which can make the neck lymph nodes enlarged, painful and tender.

Lymph nodes can also become enlarged if cancer cells lodge in them. In this case, they are usually painless.

Why should you be checking your lymph nodes?

You may have been diagnosed with a skin cancer that  can sometimes spread into the lymphatic system, for example melanoma or squamous cell carcinoma.

A doctor will usually examine the lymph nodes around the location of your skin cancer at check up visits.  e.g. if the skin cancer was on your leg then the lymph nodes behind your knee and in your groin, will be felt, or, if the skin cancer was on your face then the nodes around your ears and neck would be examined. The aim is to detect any enlargement of the lymph nodes at an early stage.

Some people are advised to check their lymph nodes between clinic appointments. If you are worried about enlarged lymph nodes, tell your doctor or nurse specialist straight away, rather than waiting until your next clinic appointment.

If you are unsure about anything in this leaflet please talk to your doctor or clinical nurse specialist, whocan show you how and which lymph nodes to check.

How often should I check my lymph nodes?

Doctors usually advise check your lymph nodes once a month. This can be done at the same time as you check your skin for new or changing moles, lumps and bumps.

Do not be alarmed if you feel a lymph node (especially if it is tender) as it may be due to an infection, but if it has not gone in a week, contact your doctor or clinical nurse specialist.

How do I check lymph nodes in the head and neck?

• With your fingertips and a gentle circular motion feel the lymph nodes illustrated
• Start with the nodes in front of the ear (no. 1 in Figure 2) then follow in order finishing just above the collar bone (no. 10 in Figure 2)
• Always check your nodes in this order
• Check both sides for comparison. If you have an enlarged lymph node it may feel firm and the size of a pea or grape.

                        Figure 2. Location of lymph nodes (green) around the jaw and neck

Examine in the order shown, starting at no. 1.

            Figure 3. How to Check lymph nodes in front of the ear

Figure 4. How to check lymph nodes in the neck

  To feel for nodes in the neck (no. 8 in Figure 2):

• Tilt your head towards the side you are examining, this helps to relax the muscle
• Now press your fingers under the muscle

                Figure 5. How to check lymph nodes above the collar bone

To check lymph nodes above the collar bone:

• Hunch your shoulders and bring your elbows forward to relax the skin
• Now feel the area illustrated in Figure 5

How to check lymph nodes in the armpit?

     Figure 6. How to check lymph nodes in the armpit; location of lymph nodes in the armpit

Remove top clothing down to the waist to get easy access to the armpits:

• Sit in a comfortable position
• Check each armpit in turn

To check the left side lift your arm slightly then place the fingers of your right hand high into the armpit and then lower your arm.

• Feel in the central area of the armpit

Now move your fingers firmly against the chest wall as follows:

• Along the front border of the armpit
• Along the back border of the armpit
• Feel along the inner border of the arm

Now check the other armpit in the same way.

How do I check lymph nodes in the groin?

There are two areas to feel in the groin (see figure 7) :

• orizontally along the groin crease   
• Vertically along the upper thigh

                                                                                                                            Check both sides

  Figure 7. Checking your lymph nodes in the groin

Where can I get more information about checking lymph nodes?

Wessex Cancer Trust

Bellis House, 11 Westwood Road
Southampton SO17 1DL
Tel: (023) 8067 2200
Fax: (023) 8067 2266
Web: www.wessexcancer.org
Email: [email protected]

For details of source materials used please contact the Clinical Standards Unit ([email protected]).

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel

BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED AUGUST 2011
REVIEW DATE NOVEMBER 2017
REVIEW DATE NOVEMBER 2020

UC San Diego’s Practical Guide to Clinical Medicine

Head and Neck Exam

Lymph Nodes:

The major lymph node groups are located along the anterior
and posterior aspects of the neck and on the underside of the jaw. If the nodes
are quite big, you may be able to see them bulging under the skin, particularly
if the enlargement is asymmetric (i.e. it will be more obvious if one side is
larger then the other). To palpate, use the pads of all four fingertips as these
are the most sensitive parts of your hands. Examine both sides of the head simultaneously,
walking your fingers down the area in question while applying steady, gentle
pressure. The major groups of lymph nodes as well as the structures that they
drain, are listed below. The description of drainage pathways are rough approximations
as there is frequently a fair amount of variability and overlap. Nodes are generally
examined in the following order:

Palpating Anterior Cervical Lymph Nodes

1. Anterior Cervical (both superficial and deep): Nodes that lie both on top of and
   beneath the sternocleidomastoid muscles
   (SCM) on either side of the neck, from the angle of the jaw to the top of the
   clavicle.
   This muscle allows the head to turn to the right and left. The right SCM turns the
   head to the left and vice versa.
   They can be easily identified by asking the patient to turn their head into your
   hand while you provide resistance.
   Drainage: The internal structures of the throat as well as part of the posterior
   pharynx, tonsils, and thyroid gland.

2. Posterior Cervical: Extend in a line posterior to the SCMs but in front of the trapezius,
   from the level of the mastoid bone to the clavicle. Drainage: The skin on the back of the
   head. Also frequently enlarged during upper respiratory infections (e.g. mononucleosis).
3. Tonsillar: Located just below the angle of the mandible. Drainage: The tonsilar and
   posterior pharyngeal regions.
4. Sub-Mandibular: Along the underside of the jaw on either side. Drainage: The structures in
   the floor of the mouth.
5. Sub-Mental: Just below the chin. Drainage: The teeth and intra-oral cavity.
6. Supra-clavicular: In the hollow above the clavicle, just lateral to where it joins the
   sternum. Drainage: Part of the throacic cavity, abdomen.

Lymph nodes of the head and neck

A number of other lymph node groups exist. However, palpation of these areas is limited to those
situations when a problem is identified in that specific region (e.g. the pre-auricular nodes,
located in front of the ears, may become inflamed during infections of the external canal of the
ear).

What are you feeling for? Lymph nodes are part of the immune system. As such, they are most
readily palpable when fighting infections. Infections can either originate from the organs that
they drain or primarily within the lymph node itself, referred to as lymphadenitis. Infected
lymph nodes tend to be:

• Firm, tender, enlarged and warm. Inflammation can spread to the overlying skin, causing it
  to appear reddened.

If an infection remains untreated, the center of the node may become necrotic, resulting in the
accumulation of fluid and debris within the structure. This is known as an abscess and feels a
bit
like a tensely filled balloon or grape (a.k.a. fluctuance). Knowledge of which nodes drain
specific
areas will help you search efficiently. Following infection, lymph nodes occasionally remain
permanently enlarged, though they should be non-tender, small (less the 1 cm), have a rubbery
consistency and none of the characteristics described above or below. It is common, for example,
to
find small, palpable nodes in the submandibular/tonsilar region of otherwise healthy
individuals.
This likely represents sequelae of past pharyngitis or dental infections.

Malignancies may also involve the lymph nodes, either primarily (e.g. lymphoma) or as a site of
metastasis. In either case, these nodes are generally:

• Firm, non-tender, matted (i.e. stuck to each other), fixed (i.e. not freely mobile but
  rather stuck down to
  underlying tissue), and increase in size over time.

The location of the lymph node may help to determine the site of malignancy. Diffuse,
bilateral involvement suggests a systemic malignancy (e.g. lymphoma) while those limited to
a specific anatomic region are more likely associated with a local problem. Enlargement of
nodes located only on the right side of the neck in the anterior cervical chain, for
example, would be consistent with a squamous cell carcinoma, frequently associated with an
intra-oral primary cancer.

Cervical Adenopathy:

Right anterior cervical adenopathy secondary to metastatic cancer.

Cervical Adenopathy:

Massive right side cervical adenopathy secondary to metastatic squamous cell cancer
originating from this patient’s oropharynx.

Diffuse upper airway infections (e.g. mononucleosis), systemic infections (e.g. tuberculosis) and
inflammatory processes (e.g. sarcoidosis) can all cause lymphadenopathy (i.e. lymph node
enlargement). HIV
infection can also cause adenopathy in any region of the body, including head/neck, axilla,
epitrochlear,
inguinal and other areas where there are lymph nodes. In these settings, the findings can be
symmetric or
asymmetric. Historical information as well findings elsewhere in the body are critical to making
these
diagnoses. Furthermore, it may take serial examinations over the course of weeks to determine
whether a node
is truly enlarging, suggestive of malignancy, or responding to therapy/the passage of time and
regressing in
size, as might occur with other inflammatory processes.”

The Ear

External structures: Briefly examine the outer structures, paying particular attention to any
skin
changes suggestive of cancer (e.g basal cell, melanoma, squamous cell), a common asymptomatic
abnormality affecting this sun exposed area. If the patient has pain, try to identify its
precise
location. Infection within the external canal (otitis externa), may cause discharge, and pain
when
the
ear lobe and tragus are manipulated.

Otoscope

Otoscopy: The otoscope allows you to examine the external canal, the structure that connects the
outside world with the middle ear, as well as the ear drum and a few inner ear structures. Proceed
as follows:

1. Put the otoscopic head on your oto-opthalmoscopic. It should easily twist
   into position.
2. Turn on the light source.
3. Place one of the disposable specula on the end of the scope.
4. Grasp the scope so that the handle is either pointed directly downward or
   angled up and towards the patient’s forehead. Either technique is acceptable.
   The scope should be in your right hand if you are examining the right ear.
5. Place the tip of the specula in the opening of the external canal. Do this
   under direct vision (i.e. not while looking through the scope).
6. Gently grasp the top of the left ear with your left hand and pull up and
   backwards. This straightens out the canal, allowing easier passage of the
   scope.
   

   Otoscopic Examination

7. Look through the viewing window with either eye. Slowly
   advance the scope, heading a bit towards the patient’s nose but without
   any up or down angle. Move in small increments. Try not to wiggle the scope
   too much as the external canal is quite sensitive. I find it helpful to
   extend the pinky and fourth fingers of my right hand and place them on the
   side of the patient’s head, which has a stabilizing effect. As you advance,
   pay attention to the appearance of the external canal. In the setting of
   infection, called otitis externa, the walls becomes red, swollen and may
   not accommodate the speculum. In the normal state there should be plenty
   of room. If wax, which appears brownish, irregular and mushy, obscures your
   view, stop and go to the other side. Do not try to extract it until/unless
   you have had specific training in this area! There are pharmacologic means
   of softening wax, which may then be easily irrigated from the canal.
   
   

   Otitis Externa:

   Swelling due to infection in the external
   canal of the left ear (picture on right) limits the space around
   the Q-Tip. Picture on left is of normal ear for comparison.

   
   

   After moving ahead a few centimeters, you should see the
   tympanic membrane (a.k.a. ear drum). Pay particular attention to:

   
   

   1. The color: When healthy, it has a grayish, translucent appearance.
   2. The structures behind it: The malleous, one of the bones of
      the middle ear, touches the drum. The drum is draped over this
      bone, which is visible through its top half, angled down and backwards.
      The part that is closest to the top of the drum is called the
      lateral process, and is generally most prominent. The tip at the
      bottom-most aspect is the umbo.
   3. The light reflex: Light originating from your scope will be
      reflected off the surface of the drum, making a triangle that
      is visible below the malleous.
      
      
   4. In the setting of infection within the middle ear (known
      as otitis media, the most common pathologic process affecting this area),
      the drum becomes diffusely red and the light reflex is lost. The malleous
      also appears less prominent and you may be able to see a line caused
      by fluid collecting behind the drum. This is called a middle ear effusion
      and can cause the drum to bulge outwards.

   5. There is a valve on your scope that allows the attachment
      of a small, compressible bulb. Place the bulb in the palm of the hand
      which is not holding the scope. With this device, you can squirt small
      puffs of air (known as pneumatic otoscopy) at the tympanic membrane.
      The normal membrane moves, which can be appreciated by the examiner.
      Effusions prevent this from occurring. Ask an experienced examiner to
      demonstrate as this is quite awkward at first and it’s difficult to
      appreciate the movement.

8. Move to the other side of the body and examine the left ear. Hand position is reversed.

Auditory Acuity: If the patient does not complain of hearing loss, this part of the exam is omitted.
A crude assessment can be performed by asking the patient to close their eyes while you place your
fingers a few centimeters from either ear. Rub the finger tips of first one hand and then the other.
Make note of any obvious differences in hearing. Alternatively, you can stand behind the patient and
whisper a few words in first one ear and then the other. Are they able to repeat the phrases back
correctly? Does this seem to be equal on either side? These tests obviously are not very objective.
Precise quantification requires sensitive equipment and is usually done by a trained audiologist.

Detecting Conductive v. Sensorineural Deficits: As with acuity, these tests would only be
performed if the patient complained of hearing loss. Transmission of sound can be broken into
two components:

1. Conduction: The passage of sound from outside to the level of the 8th cranial nerve. This
   includes transmission of sound through the external canal and middle ears.
2. Sensorineural: The transmission of sound through the 8th nerve to the brain.

Hearing loss can occur at either level. To determine which is affected, the following tests are
performed:

Weber: Grasp the 512 Hz tuning fork by its stem and get it to vibrate by either
striking the tines against your hand or by “snapping” the ends between
your thumb and middle finger. Then place the stem towards the back of the patient’s
head, on an imaginary line equidistant from either ear. The bones of the skull
will transmit this sound to the 8th nerve, which should then be appreciated
in both ears equally. Remind the patient that they are trying to detect sound,
not the buzzing vibratory sensation from the fork. If there is a conductive
deficit (e.g. wax in the external canal), the sound will be heard better in
that ear. This is because impaired conduction has prevented any competing sounds
from entering the ear via the normal route. You can create a transient conductive
hearing loss by putting a finger in one ear. Sound transmitted from the tuning
fork will then be heard louder on that side. In the setting of a sensorineural
abnormality (e.g. an acoustic neuroma, a tumor arising from the 8th CN), the
sound will be best heard in the normal ear. If sound is heard better in one
ear it is described as lateralizing to that side. Otherwise, the Weber test
is said to be mid-line.

Weber Test

Rinne: Strike the same tuning fork and place the stem on the mastoid bone, a bony prominence
located
just behind and below the ear. Bone conduction will allow the sound to be transmitted and
appreciated. Instruct the patient to let you know as soon as they can no longer hear the sound.
Then
place the tines of the still vibrating fork right next to, but not touching, the external canal.
They should again be able to hear the sound. This is because, when everything is functioning
normally, transmission of sound through air is always better then through bone. This will not be
the
case if there is a conductive hearing loss (e.g. fluid associated with an infection in the
middle
ear), which causes bone conduction to be greater then or equal to air. If there is a
sensorineural
abnormality (e.g. medication induced toxicity to the 8th CN), air conduction should still be
better
then bone as they will both be equally affected by the deficit.

Rinne Test

The Nose

In the absence of symptoms, this exam is generally omitted. First check to see if the
patient is able to breathe through either nostril effectively. Push on one nostril until it
is occluded and have them inhale. Then repeat on the other side. Air should move equally
well through each nares. To look in the nose, have the patient tilt their head back. Push up
slightly on the tip of the nose with the thumb of your left hand. Place the end of the
speculum (it’s OK to use the same one from the ear exam) into the nares under direct vision.
Now look through the viewing window, noting:

1. The color of the mucosa. It can become quite reddened in the setting of
   infection.
2. The presence of any discharge as well as its color (clear with allergic
   reactions; yellowish with infection).
3. The middle and inferior turbinates, which are shelf-like projections along
   the lateral wall. Any polypoid growths, which may be associated with allergies
   and obstructive symptoms?
4. The other nostril is examined in a similar manner.
5. Loss of smell (anosmia) is a relatively common problem, though often undiagnosed.
   In patients who make mention of this problem, olfaction can be crudely assessed
   using an alcohol pad sniff test as follows:
   1. Ask the patient to close their eyes so that they don’t get any visual
      cues.
   2. Occlude each nostril seqeuentially, making sure that they can move air
      adequately thru both.
   3. Occlude one nostril and then present an unknown item with distinctive aroma,
      asking the patient to inform you when they are able to detect its smell.

   
   A patient should be able to detect the odor of substances with distinctive aromas at a
   distance of 10 cm. Typically coffee, mint or wintergreen oil are used.
   

   Using coffee grounds to assess sense of smell.

Evaluation of Frontal and Maxillary Sinuses

Maxillary and Frontal Sinuses

The head and face contain
a number of sinuses, open cavities that communicate with the upper airway. They
function to warm and cleanse air before it travels down to the lungs. They may
also help to reduce the total weight of the skull. In normal health, these sinuses
cannot be appreciated on examination and cause no symptoms. Inflammatory states,
in particular those caused by allergy or infection, produce symptoms and findings
that may be detected during examination. Symptoms associated with sinusitis
include: nasal congestion, nasal discharge, facial pain, fever, and pain on
palpation of the maxillary teeth. The frontal and maxillary sinuses are the
two that can be indirectly examined. Examination for sinusitis should include
the following:

1. Examination of the nasal mucosa for colored discharge as described above.
   This is due to the fact that the maxillary sinuses drain into the nose via
   a passageway located under the middle turbinate.
2. Directly palpate and percuss the skin overlying the frontal and maxillary
   sinuses. Pain suggests underlying inflammation.
3. Dim the room lights. Place the lighted otoscope directly on the infraorbital
   rim (bone just below the eye). Ask the patient to open their mouth and look
   for light glowing through the mucosa of the upper mouth. In the setting of
   inflammation, the maxillary sinus becomes fluid filled and will not allow
   this transillumination. There are specially designed transilluminators that
   may work better for this task, but are not readily available.
   

   Transillumination of the right maxillary sinus

4. Using a tongue depessor, tap on the teeth which sit in the floor of the
   maxillary sinus. This may cause discomfort if the sinus is inflamed.

The Oro-Pharynx

Exposure and good lighting are critical. Head and Neck specialists have head lamps
that provide excellent illumination and allow them to use both hands to explore
the oral cavity. Most other physicians, however, use an otoscope or flashlight
for illumination. A tongue depressor assists with the exploration. The exam should
be performed in an orderly fashion as follows:

1. Have the patient stick out their tongue so that you can examine the posterior
   pharynx (i.e. the back of the throat). Ask the patient to say “Ah”, which
   elevates the soft palate, giving you a better view. If you are still unable
   to see, place the tongue blade � way back on the tongue and press down while
   the patient again says “Ah,” hopefully improving your view. This causes some
   people to gag, particularly when the blade is pushed onto the more proximal
   aspects of the tongue. It may occasionally be important to determine whether
   the gag reflex is functional (e.g. after a stroke that impairs CNs 9 or 10;
   or to determine if a patient with depressed level of consciousness is able
   to protect their airway from aspiration). This is done by touching a q-tip
   against the posterior pharynx, uvula or tongue. It is not necessary to do
   this during your routine exam as it can be quite noxious!
2. Note that the uvula hangs down from the roof of the mouth, directly in the
   mid-line. With an “Ah,” the uvula rises up. Deviation to one side may be caused
   by CN 9 palsy (the uvula deviates away from the affected side), a tumor or
   an infection.
   

   Cranial Nerve 9 Dysfunction:

   Patient has
   suffered stroke, causing
   loss of function of left CN 9. As a result, uvula is pulled towards the
   normally functioning (ie right) side.

3. The normal pharynx has a dull red color. In the setting of infection, it
   can become quite red, frequently covered with a yellow or white exudate (e.g.
   with Strep. Throat or other types of pharyngitis).
4. The tonsils lie in an alcove created by arches on either side of the mouth.
   The apex of these arches are located lateral to and on a line with the uvula.
   Normal tonsils range from barely apparent to quite prominent. When infected,
   they become red, are frequently covered by whitish/yellow discharge. In the
   setting of a peritonsilar abscess, the tonsils appear asymmetric and the uvula
   may be pushed away from the affected side. When this occurs, the tonsil may
   actually compromise the size of the oral cavity, making breathing quite difficult.

   Left Peritonsilar Abscess.

   Note deveiation of
   uvula towards right.

5. Look carefully along the upper and lower gum lines and at the mucosa in
   general, which can appear quite dry if the patient is dehydrated.
6. Examine the teeth to get a sense of general dentition, as dental health
   has wide implications including:
   • Nutrition (ability to eat)
   • Appearance
     • Self esteem
     • Employability
     • Social acceptance
   • Systemic disease (endocarditis, ? other)
   • Local problems:
   • Profound lack of access to dental care has resulted in MDs assuming
     responsibility for primary Dx and Rx of a number of dental conditions.
   • Dental Anatomy & Exam
     • 16 top teeth, 16 bottom teeth
     • Examine all the teeth and gums, using gloved hands, gauze, tongue
       depressor & lighting if abnormal
     • Make note of: General appearance, any absent teeth, broken teeth
       or obvious cavities; areas of pain, swelling, or infection
     • If abnormal areas are noted, try to precisely define the tooth/teeth
       involved as well as extent of the problem. For example, pain produced
       by tapping on a tooth is commonly caused by a root abscess.

   
   

   NIH
   Tooth
   Site

   
   

   
   
   
   Tooth Abscess: Tooth abscess involving left molar region. Associated
   inflammation of left face can clearly be seen.

7. Have the patient stick their tongue outside their mouth, which allows evaluation
   of CN 12. If there is nerve impairment, the tongue will deviate towards the
   affected side. Any obvious growths or abnormalities? Ask them to flip their
   tongue up so that you can look at the underside. If you see something abnormal,
   grasp the tongue with gauze so that you can get a better look.

   Left CN 12 Dysfunction:

   Stroke has resulted
   in L CN 12 Palsy.
   Tongue therefore deviates to the left.




8. Make note of any growths along the cheeks, hard palate (the roof of the
   mouth between the teeth), soft palate, or anywhere else. In particular, patients
   who smoke or chew tobacco are at risk for oral squamous cell cancer. Any areas
   which are painful or appear abnormal should also be palpated. Put on a pair
   of gloves to better explore these regions. What do they feel like? Are they
   hard? To what extent does a growth involve deeper structures? If the patient
   feels something that you cannot see, try to get someone else to hold the light
   source, freeing both your hands to explore the oral cavity with two tongue
   depressors.
9. The parotid glands are located in either cheek. Infection will cause pain
   and swelling in this area, which can be confirmed on palpation. The ducts
   which drain the parotids enter the mouth in line with the lower molars and
   are readily visible. When infected, you may be able to express pus from the
   ducts by gently palpating the gland.




Right parotid mass.

Note enlargement on right compared with left.

The Thyroid Exam

Prior to palpation, look at the thyroid region. If the gland is quite enlarged, you may
actually notice it protruding underneath the skin. To find the thyroid gland, first locate
the thyroid cartilage (a.k.a the Adams Apple), which is a mid-line bulge towards the top of
the anterior surface of the neck. It’s particularly prominent in thin males, sits atop the
tracheal rings, and can be seen best when the patient tilts their head backwards. Deviation
to one side or the other is usually associated with intra-thoracic pathology. For example,
air trapped in one pleural space (known as a pneumothorax) can generate enough pressure so
that it collapses the lung on that side, causing mediastinal structures, along with the
trachea, to be pushed towards the opposite chest. This deviation may be visible on
inspection and can be accentuated by gently placing your finger in the top of the thyroid
cartilage and noting its position relative to the midline. The thyroid gland lies
approximately 2-3 cm below the thyroid cartilage, on either side of the tracheal rings,
which may or may not be apparent on visual inspection. If you’re unsure, give the patient a
glass of water and have them swallow as you watch this region. Thyroid tissue, along with
all of the adjacent structures, will move up and down with swallowing. The normal thyroid is
not visible, so it’s not worth going through this swallowing exercise if you don’t see
anything on gross inspection.

Location of the Thyroid

Palpation: The thyroid can be examined while you stand in front of or behind the
patient. Exam from behind the patient is described below:

1. Stand behind the patient and place the middle three fingers of either hand
   along the mid-line of the neck, just below the chin. Gently walk them down
   until you reach the top of the thyroid cartilage, the first firm structure
   with which you come into contact. Use gentle pressure, otherwise this can
   be uncomfortable. Make sure that you tell your patients what you’re doing
   so they know you’re not trying to choke them! The cartilage has a small notch
   in its top and is approximately 1.5-2 cm in length. As you cannot actually
   see the area that you’re examining, it may be helpful to practice in front
   of a mirror. You can also try to identify and feel the structures from the
   front while looking at the area in question before performing the exam from
   behind.
2. Walk down the thyroid cartilage with your fingers until you come to the
   horizontal groove which separates it from the cricoid cartilage (the first
   tracheal ring). You should be able to feel a small indentation (it barely
   accepts the tip of your finger) between these 2 structures, directly in the
   mid-line. This is the crico-thyroid membrane, the site for emergent tracheal
   access in the event of upper airway obstruction.
3. Continue walking down until you reach the next well defined tracheal ring.
   Now slide the three fingers of both hands to either side of the rings. The
   thyroid gland extends from this point downwards for approximately 2-3 cm along
   each side. The two main lobes are connected by a small isthmus that reaches
   across mid-line and is almost never palpable. Apply very gentle pressure when
   you palpate as the normal thyroid tissue is not very prominent and easily
   compressible. If you’re unsure or wish confirmation, have the patient drink
   water as you palpate. The gland should slide beneath your fingers while it
   moves upward along with the cartilagenous rings. It takes a very soft, experienced
   touch in order to actually feel this structure, so don’t be disappointed if
   you can’t identify anything.
   

   Thyroid Examination

4. Pay attention to several things as you try to identify the thyroid: If enlarged
   (and this is a subjective sense that you will develop after many exams), is
   it symmetrically so? Unilateral vs. bilateral? Are there discrete nodules
   within either lobe? If the gland feels firm, is it attached to the adjacent
   structures (i.e. fixed to underlying tissue.. consistent with malignancy)
   or freely mobile (i.e. moves up and down with swallowing)? If there is concern
   re: malignancy, a careful lymph node exam (described above) is important as
   this is the most common site of spread.

Anatomy, Abdomen and Pelvis, Inguinal Lymph Node – StatPearls

Introduction

The inguinal lymph node can be subdivided into the superficial and deep lymph nodes and collectively drains the anal canal(below the pectinate line), the skin below the umbilicus, lower extremity, scrotum, vulva, glans penis, and clitoris. The lymph node’s primary function is to filter for harmful substances as lymphatic fluids travel through its cortex, paracortex, and medulla. Clinical signs of inguinal lymphadenopathy can help to clue physicians in possible diagnoses of sexually transmitted diseases such as syphilis, chancroid, and lymphogranuloma venereum. The lymph node can also serve to assist in the diagnosis of cancer. 

Structure and Function

Lymph nodes are small, round kidney-shaped structures that run with the lymphatic system. Lymph nodes play a vital role in the body’s ability to fight off infection. A tough fibrous connective tissue capsule encapsulates lymph nodes. The fibrous capsule extends into the lymph node to form trabeculae and divide each node into lobules. Different lymph node size has a different number of lobules. Each lobule divides into separate compartments; cortex, paracortex, and medulla—the cortex houses primary follicles, which are dormant B- cell lymphocytes. The paracortex houses T-cell lymphocytes. The medulla contains reticular cells and macrophages and communicates with efferent lymphatic vessels.[1] 

Lymph node has afferent vessels that carry lymphatic fluid to the lymph node. As the fluid travels through the lymph node, immune cells within the node filter for harmful substances such as bacteria, viruses, parasites, and other foreign material. If there is a presence of an antigen, B-cell lymphocyte in the follicles create antibodies that are specific to the antigen. Activated primary follicles form into secondary follicles called germinal centers and indicate the proliferation of B-lymphocytes and the production of antibodies. The antibodies tagged the antigen for destruction by other immune cells. T-cell lymphocytes are responsible for cell-mediated immunity. Macrophages phagocytize pathogens such as bacteria and viruses and destroy them.

Lymph nodes are located throughout the body and can be found deep within tissues and superficially and drain specific areas of the body. The inguinal lymph nodes are in the groin area and classify as superficial and deep. The superficial inguinal lymph nodes reside below the inguinal ligament and subdivide into the inferior, superolateral, and superomedial nodes. The superficial inguinal lymph nodes drain the anal canal(below the pectinate line), the skin below the umbilicus, lower extremity, scrotum, and vulva. The deep inguinal lymph nodes are within the femoral sheath medial to the femoral vein. The deep nodes receive drainage from the glans penis or clitoris, as well as the superficial lymph nodes. The superficial and deep inguinal lymph nodes both drain into the external iliac lymph nodes.

Embryology

The lymph node development starts from the 11 weeks of gestation as a mesenchymal condensation giving rise to the lymph node capsule and connective tissue. The T-cell lymphocytic region begins development during the 13 weeks. The B-cell lymphocytic region begins during the 14 weeks. From week 13 onward, monocytes and macrophages can be present with the lymph sac. During the 20 weeks, the follicle, paracortex, and medulla are discernable and continue to develop throughout gestation and after birth.[2][3]

The lymphatic system derives from the mesodermal embryological sheet.

Blood Supply and Lymphatics

Artery enter from the hilum, a depression on the concave side of the lymph node, on the concave side of the kidney-shaped structure. The artery passes through the medulla and into the cortex. Once in the cortex, the artery branches into arterioles and capillaries. The vein exits the lymph node from the hilum as well. The afferent lymphatic vessel enters the lymph node on the convex side of the node. The afferent vessels carry lymph through one-way valves and into the node where it is circulated through the sinuses. After the lymph fluid is filtered, it exits through the efferent lymphatic vessels from the hilum. The efferent vessels also have one-way valves to prevent the backflow of lymph fluids.[4] 

Nerves

The femoral nerve is in the Scarpa triangle or femoral triangle. Swollen lymph nodes can compress the nerve and cause a femoral neuropathy.

Surgical Considerations

The inguinal lymph node resides within the femoral triangle. The femoral triangle is bounded by the inguinal ligament, adductor longus muscle, and sartorius muscle. The fascia lata forms the roof of the femoral triangle. The floor of the femoral triangle forms from the iliopsoas and pectineus muscles. On surgery day, technetium-99m radiolabelled nano colloid is injected into the primary site of cancer. The location of the sentinel node is located using a handheld gamma camera. Blue dye is also often injected in the primary site of cancer to assist with visualization of the sentinel node after making the incision.[5] The incision is made parallel to the inguinal ligament, and the deep inguinal lymph node can be found medial to the femoral vein. 

A surgical approach in this area can give several adverse symptoms for the patient:

• Lymphocele

• Wound dehiscence

• Skin necrosis

• Seroma

• Ventral inguinal hernia

Clinical Significance

Lymphadenopathy

Swollen lymph nodes usually indicate infection from bacteria or viruses. Swollen inguinal lymph nodes could indicate an infection of areas of the lower body. One of the more concerning causes of inguinal lymphadenopathy is sexually transmitted infections. Sexually transmitted infections that commonly presents with inguinal lymphadenopathy are lymphogranuloma venereum, secondary syphilis, and chancroid caused by Chlamydia trachomatis(L1-L3), Treponema pallidum, and Haemophilus ducreyi, respectively.  

Lymphogranuloma venereum

Lymphogranuloma venereum is a disease of the genital area caused by the gram-negative bacteria Chlamydia trachomatis (serovars L1, L2, and L3). Lymphogranuloma venereum primarily affects the lymphatic system and has three stages. The secondary stage of lymphogranuloma venereum can present with unilateral or bilateral tender inguinal lymphadenopathy.[6] 

Syphilis

Syphilis is a bacterial infection caused by the spirochete Treponema pallidum. Clinical presentation of secondary syphilis can present with diffuse lymphadenopathy along with fever, skin rashes, and condylomata lata.[7] 

Chancroid

Chancroid is a rare sexually transmitted disease caused by a small gram-negative rod, Haemophilus ducreyi. Fifty percent of infected individuals present with tender inguinal lymphadenopathy along with ulcers with exudate.[8]

Lymphedema

Lymphedema is the swelling that typically occurs in the arm or leg due to the lymph vessels unable to drain lymph fluid sufficiently. Damage to the inguinal lymph node can present with lymphedema of the lower limb. Infection-related lymphedema is more common in developing countries in tropical and subtropical regions. Wuchereria bancrofti is a nematode known to commonly cause lymphedema of the leg. Transmitted by mosquito bites, Wuchereria bancrofti invade lymph nodes and causes inflammation and damage to the lymph node and lymphatic system.[9]     

In developed countries, lymphedema causes are commonly due to malignancy or treatment of malignancy. Treatment includes the excision of malignant lymph nodes for diagnosis and radiation treatment.[10]   

Cancer Diagnosis

Cancer can appear in the lymph node as the primary site of cancer or can spread there from another primary site. Cancer cells are able to migrate through the lymphatic system and end up in a lymph node that is draining the primary site. For carcinomas that disseminate through the lymphatic system, they commonly spread to the regional node before spreading to the next tier of nodes. These immediate regional nodes are called the sentinel lymph nodes. If the clinician suspects an individual of having cancer, a biopsy or dissection of the sentinel lymph node that is draining the site of interest can help to determine if cancer has metastasized. Upon finding a cancerous cell in the sentinel lymph node, this information can assist with staging cancer and direct mode of therapy.[11][12][13]

Common tumors that metastasize to the inguinal lymph node include squamous carcinoma of the vulva, penis, and anus.

Vulvar Cancer

The vulva is the area of skin surrounding the urethra and vagina. Vulvar cancer is more common in postmenopausal women and can present with lumps or bumps and itching. Other symptoms include tenderness, bleeding, and skin changes. The precise etiology of vulvar cancer is unknown, but some factors increase the risk of someone getting vulvar cancer. These risk factors include older age, exposure of human papillomavirus, smoking, a weakened immune system, and a skin condition involving the vulva.[14]  

Penile Cancer

Penile cancer is most common in Asia, Africa, South America. Penile cancer begins as a small lesion on the glans that varies on appearance. The lesion can appear as masses growing from skin or white or reddish-colored mass. Risk factors include uncircumcised and human papillomavirus infection. Other risk factors include a history of phimosis, balanitis, chronic inflammation, tobacco use, lichen sclerosis, and poor hygiene.[15] 

Anal Cancer

Anal cancer is cancer that occurs in the anal canal. Patients can present with anal bleeding, weight loss, a sensation of a mass, tenderness, and itching. Risk factors include older age and human papillomavirus infection.[16]  

Other Issues

Digeorge syndrome is due to a small deletion on chromosome 22, resulting in poor development in several organ systems. One of the problems commonly present in someone with DiGeorge is thymus gland dysfunction. The thymus gland is where T cells mature and help fight infection; thus, thymus gland dysfunction will result in T-cell deficiency. T-cell deficiency will result in the paracortex of lymph nodes not being well developed.[17] 

Lymphoid: The Histology Guide

What are lymph nodes?

These are about 100-200 100 bean shaped organs, which
are found along lymphatic vessels, and which filter micro-organisms etc from lymph.

This is a diagram of a lymph node, cut away to
show the organisation inside, into cortical and medullary regions.

Primary follicles: lymphoid follicles without a germinal centre.

Secondary follicles: lymphoid follicles with a germinal centre. These mostly contain B-cells.

The nodes are covered by a capsule of dense connective
tissue, and have capsular extensions, of connective tissue, called
the trabeculae, which provide support for blood
vessels entering into the nodes.
Lymph, containing micro-organisms, soluble antigens,
antigen presenting cells, and a few B-cells, enters the lymph node
via afferent lymphatic vessels which enter the
subcapsular sinus. It then runs through cortical
sinuses into medullary sinuses and leaves
through the efferent lymphatic vessels, at the
Hilium as efferent lymph. This
contains lots of T-lymphocytes, B-lymphocytes, plasma cells and
antibody.
All the blood sinuses are lined by a discontinuous
layer of simple squamous endothelium, and they also contain lymphocytes
and macrophages. Reticular fibres provide additional support to
the matrix/stroma.
The cortex is divided into an outer
and an inner cortex.

The outer cortex has lymphatic nodules that mostly
contain B-cells. Small lymphocytes sit in the spaces between the
reticular fibre meshwork in the cortex. (see the picture below).
The lighter staining areas are germinal centres,
where the B-cells proliferate into antibody secreting
plasma cells (see B-and T-lymphocytes).
Macrophages are also present in these regions,
together with dendritic cells, and some T-cells.
Both the macrophages, and the dendritic cells trap antigens and
present them on their surfaces to B-cells.

The inner cortex contains mostly T-cells.

The deep cortical, and medullary cords
contain B-cells and plasma cells.Plasma cells live for 3 days, and
make IgG type antibodies.

This diagram of a lymph node shows the pathways that lymphocytes can take, in and out of the lymph node.

Most of the lymphocytes enter the lymph nodes via blood vessels, and about 10% enter through the lymph.

The structure of the post-capillary venule, in the deep cortex
(paracortex) is unusual in that it is not lined by simple squamous
epithelium, but by a simple cuboidal epithelium. These are called
high endothelial venules (HEVs) (see the picture below). Lymphocytes
recognise and adhere to these endothelial cells, and squeeze through
them into the deep cortical regions of the nodes. This region of
the lymph has lots of T-cells, as well as the antigen presenting
dendritic cells.

T-cells entering here become activated in the cortex, between lymphoid follicles.

What do normal lymph nodes feel like?

What are lymph nodes?

Lymph nodes are small bean-shaped glands that help our bodies fight infection and cancer as part of the lymphatic system.

A fluid called lymph, (consisting of water, white blood cells, damaged cells, bacteria, proteins and fats) travels through the lymphatic system and the damaged cells and bacteria are filtered and removed by the lymph nodes.

Swelling of the lymph nodes (lymphadenopathy) is common when an infection is present. Lymph nodes may feel painful when they become swollen (lymphadenitis).

The most common cause of swollen lymph nodes is a mild infection. Less commonly, lymph nodes can swell due to cancer, HIV or tuberculosis.

Make an appointment with your doctor if you ever notice any unusual lumps or swellings in your lymph nodes.

Where are lymph nodes located?

Lymph nodes are located throughout the body, distributed along the tubes of the lymphatic system.

Places where you might be able to feel your swollen lymph nodes include your head and neck, under your chin, your arms, under your armpits, the area around your groin, and the back of your knees.

You will not be able to feel swollen lymph nodes that are located in deeper parts of your body, but you may experience other symptoms. For example, a swollen lymph node near the lung may cause a persistent cough.

What causes swollen lymph nodes?

Lymph nodes can become swollen for a number of reasons. The most common causes of swollen lymph nodes are upper respiratory infections (URI) and infections in parts of the body near lymph nodes.

Swollen lymph nodes can sometimes be a sign of something less common. For example, they may be a symptom of cancer, HIV or tuberculosis.

See your doctor if you are ever concerned about your lymph nodes.

How often should I check my lymph nodes?

It may be a good idea to check your lymph nodes around once per month. Areas that you might want to focus on include your head and neck, your underarms, and your groin.

The British Association of Dermatologists has a leaflet – How to check your lymph nodes – which demonstrates the correct way to examine your lymph nodes at home.

Visit your doctor if you ever notice any unusual lumps or bumps anywhere on your body.

What do normal lymph nodes feel like?

Healthy lymph nodes are typically pea-sized. You should not normally be able to feel them.

Lymph nodes that are just below the skin may be easier to feel when they become swollen as they will become larger.

You might experience other symptoms if a lymph node in a deeper part of your body becomes swollen, like a cough or swelling of a limb.

See your doctor if you ever suspect one of your lymph nodes has become swollen or if you notice any lumps or bumps on your body.

Swollen lymph nodes treatment

Treatment for swollen lymph nodes will depend on the cause. If your doctor determines the cause of swelling is an upper respiratory infection, it may be recommended that you wait for about a week to see if your lymph nodes recover on their own.

More serious conditions like cancer will need longer-term treatment.

Conclusion

Lymph nodes are located in many areas of your body, but most of the time you should not be able to feel them. Healthy lymph nodes are normally about the size of a pea, but numerous health conditions can cause them to swell and become larger.

You may want to check your lymph nodes once a month.

Swollen lymph nodes can be caused by a variety of conditions. Speak to your doctor if you ever notice any lumps, bumps or swellings on your body.

Article information

Last reviewed:

09 July 2019

Next review:

09 July 2022

Lesson 2. Lymph nodes and drainage patterns

LYMPH NODES: 
Eventually, all lymph vessels lead to lymph nodes. Lymph nodes can be as small as the head of a pin, or as big as an olive. There are 400-700 lymph nodes in the body, half of which are located in the abdomen, and many are in the neck.

The primary function of lymph nodes is to filter and purify the lymph. The lymph nodes produce various types of lymphocytes. Lymphocytes destroy harmful substances within the body, and are a big part of the immune system. The lymph nodes reabsorb about 40% of the liquid content of the lymph. This makes the lymph much thicker. Because of this thickening and the filtering process, the lymph nodes offer the greatest resistance to the flow of lymph. In fact the lymph nodes offer about 15 times more resistance than the vessels themselves. Lymphatic drainage can help overcome this resistance and get the lymph flowing.

EDEMA:
Each cell is nourished by the nutrients, oxygen and proteins that flow across the walls of capillaries into the interstitial fluid. There is a dynamic balance between the forces that help those nutrients to first exit the capillaries, and then get reabsorbed back into the blood stream. Proteins play a big part in this transfer because they have a tendency to draw water to themselves. This means that the proper amounts of protein on both sides of the capillary wall are vital to keep the tissues balanced. If there are too many proteins within the interstitial spaces, fluid will start to accumulate, causing edema. The lymph system’s role of removing proteins is vital to keeping edema down. If the lymph system becomes sluggish, or is damaged by surgical removal of lymph nodes, edema can develop. This type of edema is called lymphostatic edema- or a high protein edema. Lymphatic drainage can be helpful in reducing this type of edema because the cause is a reduced functioning of the lymph system.

Other causes of edema can be a chemical imbalance in the body caused by liver disease, diabetes, or a variety of other ailments. This type of edema is called lymphodynamic edema, and requires other forms of therapy due to the fact that it is a chemical imbalance. (Kasseroller, R., Compendium of Dr. Vodder’s Manual Lymph Drainage, Haug, Heidelberg, 1998)

this is an image of the nodes and drainage patterns of the lymphatic system

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Metastases to the lymph nodes of the abdominal cavity, retroperitoneal space and small pelvis

Lymph nodes of the abdominal cavity and retroperitoneal space and small pelvis – treatment of advanced cancer

If the tumor was not detected at an early stage, it begins to spread to other parts of the body.One of the most frequent targets of metastasis is the lymph nodes. Moreover, most malignant tumors of the abdominal cavity metastases to nearby parts of the lymphatic system.

And this means that, with a high degree of probability, the patient, simultaneously with the treatment of the primary tumor, will have to treat metastases in lymph nodes of the abdominal cavity, retroperitoneal space and small pelvis . In modern conditions, the treatment tactics provides for the simultaneous treatment of the primary tumor and metastases to the lymph nodes CyberKnife ( radiosurgery ), or surgical removal of affected lymph nodes (if surgical treatment of of the primary tumor was performed), as well as radiation therapy to affected lymph nodes, or those to which the tumor process could spread with a high degree of probability.Also, chemotherapy is widely used as a treatment for metastases (including in the lymph nodes).

Combined treatment of lymph node metastases

Traditionally, local spread of primary tumor cells to closely spaced lymph nodes is quite common. In the event that the choice of the method of radical treatment was chosen surgery , the patient was recommended removal of nearby lymph nodes . If the lymph nodes are affected by distant metastases (lymphogenous metastasis), their surgical treatment (second surgery) may be difficult due to the severity of the patient’s condition or the large volume of required intervention.

In case of the presence of multiple metastases, the patient is indicated for chemotherapy, and for the treatment of single metastases in the world practice, high-precision radiation therapy IMRT is widely used. Also, radiation therapy is combined with surgical treatment of the primary tumor, after which most of the world’s protocols provide for irradiation of the removed tumor bed and lymph nodes.

Metastases to the lymph nodes of the abdominal cavity and retroperitoneal space, IMRT radiation therapy plan on a modern linear accelerator

Treatment of metastases in the lymphatic system with CyberKnife

CyberKnife radiosurgical system is the most effective method of fighting cancer metastases

In many cases, in order to carry out the treatment of metastases to the lymph nodes, it is not necessary to use surgical intervention, which is associated with the need for anesthesia, damage to healthy tissues during access to the metastasis, as well as the recovery period during healing.Such a bloodless alternative to traditional surgery is stereotactic radiosurgery, implemented on the CyberKnife system.

There is no unequivocal recommendation that any lymph node metastasis should be treated with CyberKnife. In some cases, the treatment of metastases in the lymph nodes of the abdominal cavity, retroperitoneal space and small pelvis can be more effective with radical treatment on a high-precision linear accelerator (IMRT). Therefore, like any other treatment, CyberKnife radiosurgery for lymph node metastases is prescribed after an interdisciplinary consultation, at which doctors of various specializations consider all aspects of a particular case in order to determine the most effective treatment regimen.

If the patient is indicated for radiosurgery on CyberKnife, preliminary planning is carried out, during which, based on the data of CT and MRI diagnostics, a volumetric model of the relative position of the affected lymph node, surrounding healthy tissues, and the supply of ionizing radiation is inadmissible.

During each of the treatment sessions (fractions) CyberKnife, based on the treatment plan, will deliver many single beams of ionizing radiation, at the intersection of which a high dose zone will be formed, corresponding to the shape and volume of metastasis to the lymph node.In addition, the treatment of metastases on CyberKnife can be included in the fraction (session) for the treatment of the primary tumor or other metastases.

As a rule, the cost of treatment with CyberKnife is lower than with surgery, because no need for anesthesia and recovery period.

Diagnostics

Computed tomography (CT) does not always differentiate between metastases and unchanged lymph node tissue. Magnetic resonance imaging (MRI) has a slight advantage over CT, because MRI allows you to more accurately determine the stage of the tumor process in the pelvic organs.

What are metastases and where do they come from?

In a significant number of patients with the growth of a tumor that has not received sufficient or timely treatment, metastases – secondary tumor nodes – appear in nearby and distant organs. Treatment of metastases is easier when they have small volumes, but micrometastases and circulating tumor cells are often not detected by available diagnostic methods.

Metastases can occur in the form of single nodes (single metastases), but they can also be multiple.It depends on the characteristics of the tumor itself and the stage of its development.

There are the following ways of metastasis of cancer tumors: lymphogenous , hematogenous and mixed .

• lymphogenic – when tumor cells, having penetrated into the lymph node, pass with the lymph flow to the nearest (regional) or distant lymph nodes. Cancer tumors of internal organs: esophagus, stomach, colon, larynx, cervix often direct tumor cells in this way to the lymph nodes.
• hematogenous – when cancer cells, penetrating into a blood vessel, pass into other organs (lungs, liver, bones of the skeleton, etc.) with the blood flow. In this way, metastases from cancerous tumors of the lymphatic and hematopoietic tissue, sarcoma, hypernephroma, chorionepithelioma appear.

Lymph nodes of the abdominal cavity are subdivided into parietal and internal:

• parietal (parietal) nodes are concentrated in the lumbar region.Among them, the left lumbar lymph nodes are distinguished, which include lateral aortic, pre-aortic and post-aortic nodes, intermediate lumbar nodes located between the portal and inferior vena cava; and the right lumbar nodes, including the lateral caval, precaval, and postcaval lymph nodes.
• visceral nodes are arranged in several rows. Some of them are located on the path of the lymph from the organs along the large internal vessels and their branches, the rest are collected in the area of ​​the gates of the parenchymal organs and near the hollow organs.

Lymph from the stomach enters the left gastric nodes located in the lesser curvature of the stomach; left and right gastroepiploic nodes located in the region of the greater curvature of the stomach; hepatic nodes following along the hepatic vessels; pancreatic and splenic nodes located at the gate of the spleen; pyloric nodes heading along the gastro-duodenal artery; and in the cardiac nodes that form the lymphatic ring of the cardia.

With cancerous tumors in the abdominal cavity (stomach) and pelvic cavity (ovary), dissemination of the process along the peritoneum occurs in the form of small “dust” metastases with the development of hemorrhagic effusion – ascites.

Metastatic ovarian cancer can arise from any organ affected by cancer, but is most often observed with stomach cancer , from where tumor cells are carried either by the blood stream or retrogradely through the lymphatic tract ( Krukenberg tumor ). Metastatic ovarian cancer is characterized by rapid growth and more malignant course. Both ovaries are more often affected. The tumor early passes to the peritoneum of the small pelvis, forming multiple tuberous tumor nodes.

In the case of metastasis of ovarian cancers to various organs, in the first place are metastases in the peritoneum, in the second place – in the retroperitoneal lymph nodes, then – the greater omentum, iliac lymph nodes, liver, small omentum, second ovary, pleura and diaphragm, lymph nodes mesentery, mesentery of the intestinal tract, parametric tissue, inguinal lymph nodes, lungs, spleen, uterus, cervical lymph nodes, kidneys, adrenal glands, navel.

90,000 Lymphatic drainage on the face and neck.

Superficial lymph nodes of the head and neck – right side view in 3 turns.

There are parotid, behind the ear, submandibular and chin lymph nodes.

1. Chin lymph nodes (nodi lymphatici submentales).
2. Submandibular lymph nodes (nodi lymphatici submandibulares).
3. Facial buccal lymph nodes (nodi lymphatici faciales / buccinatorii /).
4. Mandibular lymph nodes (nodi lymphatici mandibulares).
5. Superficial cervical lymph nodes (nodi lymphatici cervicales superficiales).
6. Deep cervical lymph nodes (nodi lymphatici cervicales profundi).
7. Supraclavicular lymph nodes (nodi lymphatici supraclaviculares).
8. Occipital lymph nodes (nodi lymphatici occipitales).
9. Mastoid lymph nodes (nodi lymphatici mastoidei).
10. Parotid lymph nodes (nodi lymphatici parotidei).

• Parotid lymph nodes collect lymph from the forehead, the lateral corner of the eye, the region of the upper and lower eyelids, and the wing of the nose.
• In the submandibular lymph nodes, lymph swells from the lower eyelid, corner of the eye, cheek, nose, upper and lower lips.
• To the chin lymph nodes, the outflow goes from the lower lip and chin.
• Behind-the-ear lymph nodes collect lymph from the temporal, occipital, parietal regions.
• From the face area along the superficial and deep lymph nodes of the neck, lymph moves to the supraclavicular lymph nodes.

Pink zone – areas of lymphatic anastomoses, where bilateral or cross metastasis of tumors is possible.

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90,000 Hodgkin’s lymphoma in children and adolescents

Biopsy

To take a tissue sample from an enlarged lymph node, the surgeon performs a biopsy.Morphologists examine the tissue under a microscope and make a diagnosis.

The type of biopsy depends on the location of the suspected cancer.

• Excisional biopsy : Removal of the entire lymph node or tissue induration. This type of biopsy is preferred because the morphologist can see the pattern of the lymph node, making the diagnosis easier.
• Incisional biopsy : Removal of part of a lump, lymph node or tissue sample.
• Thick-needle biopsy : Removal of small pieces of tissue or part of a lymph node with a wide needle.
• Fine needle aspiration biopsy : Removal of tissue or part of a lymph node using a fine needle.

If Hodgkin’s lymphoma affects lymph nodes deep in the chest and it is not possible to take a sample from other more accessible lymph nodes, a biopsy can be performed using a mediastinoscope (a thin tubular instrument used to examine and take samples of tissue and lymph nodes in the area between the lungs).

Analysis of tissue obtained as a result of biopsy

A morphologist will examine the tissue under a microscope to find tumor cells. Classic Hodgkin’s lymphoma is characterized by the presence of Berezovsky-Sternberg-Reed cells. If abnormal cells are found, the morphologist will conduct additional examination (immunohistochemistry) of the tissue under a microscope, checking for the presence of specific markers present on the cancer cells. After a biopsy has confirmed the tumor, doctors will do additional tests to determine the stage of the disease.The stage determines whether the cancer has spread to other parts of the body and, if so, how much metastases have spread and how far they have spread.

Staging is slightly different for Hodgkin’s lymphoma, as lymph nodes throughout the body are interconnected, hence cancer is often found in multiple locations. The staging of Hodgkin’s lymphoma depends on the following factors:

• Number of affected areas of lymph nodes
• Signs and symptoms of illness in a patient
• Is the tumor massive
• Has the lymphoma spread outside the lymphatic system

ultrasound of lymph nodes in Tyumen

The Alfa-Health Center clinic has digital ultrasound diagnostic devices.An ultrasound examination allows you to detect diseases at an early stage. The clinic’s doctors will offer treatment and help you stay healthy.

Lymph nodes in the body perform an important function of protection from external agents: viruses, bacteria, fungi, poisons, etc. Through them, the blood passes and is purified. There are hundreds of nodes in the human body, and each has its own role.

Changes in the structure of the lymph node do not always indicate a disease of the lymphatic system.Organs are sensitive to pathological processes throughout the body. The system is hidden in the layers of surrounding tissues, therefore, ultrasound is prescribed to diagnose any disease. An ultrasound scan of the lymph nodes gives the doctor the information he needs.

Indications for ultrasound of lymph nodes

The procedure is prescribed for the following symptoms:

• The presence of purulent processes.
• Swollen lymph nodes, pain on palpation.
• Swelling and flushing of the skin.
• Oncological diseases of the circulatory and lymphatic system.
• Tumors, cysts in the immediate vicinity of the nodes.
• Suspected metastases.
• Asymmetric and mobile lymph nodes.

What the ultrasound shows

The diagnosis depends on the location of the altered node:

• Ultrasound of the lymph nodes of the neck is prescribed for cancer, actinomycosis, tuberculosis.The study is also necessary in the absence of positive dynamics after treatment of the underlying pathology. Cervical lymph nodes help diagnose infections. For example, non-suppurative lymphadenitis does not damage tissue. The knots on the neck remain straight and well-defined. Only magnification is determined.
• Ultrasound of the lymph nodes of the armpits is performed for mastitis, fibrosis, breast cancer, after removal of the breast. The examination is carried out as planned or as directed by a doctor if metastasis is suspected.Ultrasound of the axillary lymph nodes is also needed after toxoplasmosis has been treated and HIV-positive has been established. Viruses often persist in these structures.
• Ultrasound of the inguinal lymph nodes helps in the diagnosis of infectious diseases, inflammatory processes in the small pelvis. Puffiness may indicate the presence of syphilis, HIV. The inguinal structures as regional can be involved in the malignant process – this is evident from the high echogenicity. A patient with such indications is referred to an oncologist’s consultation, it is possible to prescribe an additional ultrasound of the peripheral lymph nodes.

Sign up for an ultrasound of the lymph nodes of the neck and other parts of the body in Tyumen

We conduct a study of the cervical, inguinal, peripheral lymph nodes, scan the armpits. The ultrasound protocol is handed out to the patient. If necessary, in the clinic “Alfa-Health Center” you can do an ultrasound of regional lymph nodes, take tests, make an appointment for a consultation with a narrow specialist. The phone number is listed on the website.

Lymph nodes – location, scheme

There are more than 150 groups of lymph nodes in the human body.These organs of the lymphatic system perform a particularly important function – they filter the lymph and prevent the multiplication of harmful microorganisms.

What do lymph nodes look like?

Lymph nodes are round or oval in shape. Their size ranges from 0.5 mm to 1 cm, but lymph nodes of more impressive sizes are found. These organs are light-colored – white or gray. In the human body, lymph nodes are located in small groups of 8-10 pcs. Lymph nodes are composed of connective tissue and represent a complex and interconnected structure.Due to its composition, lymph flows easily through the nodes and is cleansed in them. In the figure, you can see a diagram of the location of the lymph nodes on the human body.

Immunological cells of our body mature in the lymph nodes. Also, in these organs, white blood cells are activated to fight infection. If viruses or bacteria in large quantities have entered the human body, then intensive work is being done in the lymph node to combat them. The most complex natural processes are triggered, the production of white cells increases and all harmful microorganisms are destroyed.Thus, in the lymph nodes of a person, the development of complex diseases is prevented.

Layout of lymph nodes

The human body is a perfect biological system, which, when properly functioning, is capable of withstanding any external harmful influences. Each organ takes its place and performs its function, which ensures the healthy life of a person.

Basically, the location of the lymph nodes is concentrated in the groin, neck and armpits – the most rational places to fight various kinds of infections.Also, a fairly large number of lymph nodes are located in the abdominal cavity in the chest area. Lymph node capillaries penetrate many internal organs and tissues. Next, we will consider the location of the main groups of lymph nodes:

• location of the lymph nodes in the neck. The location of the cervical lymph nodes allows them to reliably protect the body from various types of tumors and inflammatory processes. Some of the cervical lymph nodes are located deep in the tissues, the other is more superficial.The location of the cervical and occipital lymph nodes is a chain that runs through all the tissues of the neck and occipital region. The photo shows a diagram of the location of the lymph nodes on the neck and in the head area.
• location of the lymph nodes in the groin. The location of the inguinal lymph nodes is concentrated near the large arteries and internal organs of the pelvis. Some of the groin nodes are located on the sides of the pubic bone under the skin. In the groin, the nodes are also placed in small groups. This arrangement of lymph nodes in the groin allows them to signal diseases of the pelvic and genital organs, and prevent the development of these diseases;
• Armpit lymph node location. The location of the axillary lymph nodes is concentrated in the cavity at the base of the arm in the tissue. Depending on the location, the axillary lymph nodes are divided into two groups: internal and superficial.

The location of all groups of lymph nodes is thought out by nature in such a way that each of these groups is responsible for the nearby organs. Therefore, according to the state of the lymph nodes, one can judge the presence of infections and inflammatory processes in different areas of our body. In their normal state, the lymph nodes do not cause any inconvenience and discomfort to a person, and inflammation and soreness are a serious cause for alarm.

Diagnosis of metastatic lesions of regional lymph nodes in stomach cancer. Part 1: CT Anatomy of Regional Lymph Nodes | Aghababyan

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