EXAMINATION OF LYMPH NODE

1. 1

2. EXAMINATION OF LYMPH
NODES AND APPLIED ASPECTS
2

3. CONTENT
 Introduction
 Classification
 History
 Local Examination
 Applied aspects
 Investigations
 Conclusion
 References
3

4. INTRODUCTION
Lymph nodes
 Are small glandular structures located in the centre of
lymph vessels
 Also called lymph glands
 Filter bacteria and toxic substances
Lymph
 Is a clear colourless fluid
 Formed by (96% )water and solids
 Some blood cells may also be present
4

5. Rate of lymph flow
 120ml lymph flows into blood
 Out of which 100ml/hr flows through thoracic duct and
20 ml/ hr flows through the right lymphatic duct
Lymphatic system
 Closed system of lymph channels / vessels through which
the lymph flows
 One way system
 Lymph flows from tissue spaces toward the blood
5

7. FUNCTIONS:
They are centre of production of both B and T
lymphocytes.
Filter bacteria and other particulate matter from lymph
to prevent their entry into systemic circulation.
Antibodies produced by B-lymphocytes are carried to
the circulation and indirectly help in mounting an
immune response.
It supplies nutrition and oxygenation where blood
cannot reach.
Drainage: it helps in maintaining volume and tissue
fluid composition constant by returning excess
metabolic protein that escapes the circulation.

9. CLASSIFICATION
I. Upper Horizontal chain of
lymph nodes
 Submental
 Submandibular
 Parotid
 Post auricular
 Occipital
II. Anterior cervical chain
 Anterior jugular
 Juxta visceral chain
 Prelaryngeal
 Pretracheal
 Paratracheal
III. Lateral cervical nodes
 Superficial cervical
 Deep chain
 Internal jugular
 Spinal accessory
 Transverse cervical chain
9

11. LYMPH NODES OF HEAD AND NECK REGION
Arranged in two rings
Outer & superficial circle
 Occipital
 Retroauricular
 Preauricular
 Superficial cervical
 Jugulodigastric
 Jugulo omohyoid
11
Inner & deep circle
 Pretracheal
 Paratracheal
 Retropharyngeal
 Supra clavicular

12. ACCORDING TO LEVEL
Level –I : Submental & submandibular
Level –II : Upper jugular
Level –III : Middle Jugular
Level –IV : Lower Jugular
Level –V : Posterior traingle group
Level –VI : Prelaryngeal & pretracheal
Level –VII : Nodes of upper mediastinum
(Textbook of oral carcinoma by Jatin shah)
12

13. Waldeyer’s lymphatic ring
 It is present at the entrance of pharynx
 Superior- palatine tonsil & adenoids.
 Inferior- lingual tonsil situated at posterior
part of dorsum of tongue
 Lateral-tubular tonsil referred to as tonsil
situated at the isthmus one on each side
 Posteiorly- pharyngeal tonsil
 Drainage- main lymph node of tonsil situated in the angle
between the internal jugular vein & common facial vein just
below the angle of jaw.
13

14. DRAINAGE OF LYMPHATIC SYSTEM
 Larger lymph vessels
ultimately from right
lymphatic duct & thoracic
duct
 Right lymphatic duct opens
into right subclavian vein
& thoracic opens into left
subclavian vein
 Thoracic duct drains lymph
from more than 2/3 rd of
the tissue spaces in the
body
14

15. Lymphatic drainage of the structures of head & neck
Structure Draining Lymph
node
Drains further into
Maxilla
Upper jaw including
teeth, gingiva &
palate
Lateral Part of hard
palate
Submandibular
Retropharyngeal
Deep cervical nodes
Mandible
Anterior part of
mandible, gingiva,
incisors & the chin
Lower jaw,
remaining teeth &
gingiva
Submental
Submandibular
Deep cervical or to
submandibular
Deep cervical lypmh
nodes
15

16. Structure Draining Lymph node Drains further into
Tongue
 Tip of the tongue
Anterior 2/3rd
Lateral portions
midline
Posterior 1/3rd
Bilaterally to submental
nodes
Unilaterally to submandibular
nodes
Bilaterally to submandibular
nodes
Bilaterally to jugulo-omohyoid
nodes
Lypmh from all regions of
tongue eventually drains
into deep cervicalis &
jugular lymphnodes
Lips
Upper lip
Some areas of upper
lip
Middle parts of lower
Lateral part of lower
lip
Submandibular nodes
Superficial cervical nodes
Submental lymph nodes
Submandibular nodes
Upper internal jugular
nodes
Deep cervical
Directly to deep cervical or
to submandibular & then
to deep cervicall
Upper internal jugular
nodes
16

17. Structure Draining Lymph node Drains further into
Floor of the mouth
Anterior part of floor
Remaining areas of the
floor of the month
Cheeks & Buccal
mucosa
Submental nodes
Submental nodes
Submandibular, parotid &
sometimes directly to
superficial upper deep
cervical lymph nodes
Directly to deep cervicalior
to submandibular & then
todeep cervical
Deep cervical
Deep cervical lymph
nodes
Salivary glands
Parotid
Submandibular
Sublingual Anterior part
Sublingual Posterior part
Parotid
Submandibular
Submandibular
Upper deep cervical lymph
nodes
Deep cervical lymph
nodes
17

18. Structure Draining Lymph node Drains further into
Tonsils, nose
 External & anterior part
of nose
Root of the nose &
adjacent parts of upper
eyelid
Posterior part of nasal
cavity
Jugulodigastric nodes
Submandibular nodes
Parotid nodes
Upper deep cervical &
retropharyngeal group of
lymph nodes
Deep cervical lymph
nodes
Paranasal sinuses
Maxillary sinus
Frontal & ethmoidal sinus
Shenoidal sinus
Submandibular
lymphnodes
Retropharyngeal
lymphnode
18

19. Structure Draining Lymph node Drains further into
Eyes
• Eyelids and conjunctiva
• Orbits and its contents
• Lacrimal gland
Parotid and
submandibular lymph
nodes
Preauricular lymphnodes
Submandibular
lymphnodes
Deep cervical lymph
nodes
Deep cervical lymph
nodes
Deep cervical lymph
nodes
Ear
• External ear (auricle)
• Middle ear
• Lateral surface of ear
Preauricular lymphnodes
Mastoid lymphnodes
Parotid &
Retropharyngeal
Parotid lymphnodes
Chain of nodes along
external jugular vein
Deep cervical
Scalp
Anterior portion of the
scalp
Remaining portion of the
scalp
Submandibular
lymphnodes
Occipital, parotid & post
auricular lymphnodes
Deep cervical lymph
nodes
Deep cervical lymph
nodes 19

20. HISTORY
The following points are noted while taking the history of
patient
1.Age
 Young age – TB, syphilis, Primary malignant lymphoma
 Old age – Secondary malignant lymphadenopathy
2.Duration
 Short – Acute lymphadenitis
 Long – Chronic lymphadenitis
3.Which group was affected first?
 Cervical LN – TB , Hodgkins disease
 Inguinal – Filiariasis
 In case of generalized involvement of the lymph node,the
clinician should know which group of lymph node was first
affected 20

21. 4.Pain
Painful – Acute & chronic lymphadenitis
Painless – Syphilis, Secondary carcinoma
5.Fever
Evening rise in temperature is characteristic feature of –
Tuberculosis
Periodic fever – Filiaria
Intermittent bouts of remittent fever(Pel-Ebstain fever) –
Hodgkins disease
21

22. 6.Primary focus
 Whenever the lymph nodes are enlarged it is the usual practice to look
for the primary focus in the drainage area of lymph node
 This should be done particularly in acute and chronic lymphadenitis
 An insignificant abrasion or inflammation in the drainage area lead to
lymphadenitis
Loss of appetite & weight
 Malignant lymphadenopathies
Pressure effects
 Pressure effect may be due to enlarged lymph node
 Swelling of face & neck due to lymphatic & venous obstruction
 Dyshagia when oesophagus is pressured
 Dyspnoea in case of enlargement of mediastinal group of lymph node
22

23. Past history
 Enquire into in case of Tb, syphilis , Secondary Ca.
 A patient with enlarged cervical lymph node may give
history of previous lung tuberculosis if specifically asked
Family history
 Sometimes tuberculosis runs in families and should be asked
for.
 Lymphosarcoma and other lymphomas have also shown a
tendency to run in families.
23

24. PHYSICAL EXAMINATION
 General survey
Malnutrition, cachexia, anaemia and loss of weight are
often seen in cases of tuberculous lymphadenitis,primary and
secondary malignant lymphadenopathies
24

25. INSPECTION
Inspect the normal anatomic locations of
lymph nodes for enlargements
Number
 Single
 Multiple –Hodgkins disease, TB, Lymphosarcoma, Sarcoidosis,
Brucellosis, Lypmhatic leukaemia
Position
 E.x : Hodgkins Disease & Tuberculosis - cervical LN
Filiariasis – Inguinal group
25

26. Skin over the swelling :
 Redness , oedema – acute lymphadenitis
 No such changes – chronic lymphadenitis
 Tense , shining, dilated subcutaneous veins – Lymphosarcoma
 Scar – previous bursting of cold abscess
Pressure effects
 Dysnoea
 Dysphagea
26

27. PALPATION
27
 Best palpated with the clinician standing behind the patient
who is seated on the dental chair.
 Ideally done commencing from the most superior lymph
nodes and then working down
 Is done to assess for tenderness, consistency, size and fixity.
 Normal lymph nodes not palpable

28. 28
Palpation
 Number
 Situation
 Tenderness
 Temperature
 Surface
With the palmar surface of fingers, the clinician should
palpate the surface of the swelling in entirety.
Smooth – cyst
Lobular with smooth bumps – lipoma
Nodular – mass of matted lymph nodes
Irregular and rough - carcinoma

29. • Consistency:
Soft
Elastic & rubbery – Hodgkins disease
Firm discrete & shotty – Syphilis
Stony hard - Secondary carcinoma
Variable( soft, firm , hard) - Lymphosarcoma

30.  Matted / not :
Matted -Tuberculosis
 Fixity to underlying structures
E.x: Lymphosarcoma, Secondary carcinoma, reticulosarcoma
 Drainage area
Whenever a patient comes with enlarged lymph nodes it
should be a routine practice to examine its draining area.
General examination
 Lymphnodes in other part of body
 Examine the lungs for tuberculosis & secondary metastasis
 Syphlitic stigmas
 Parotid & lacrimal glands ( Sarcoidosis)
30

31.  Submental Nodes
Roll the fingers below the chin with patient’s head
tilted forwards

32.  Submandibular Nodes
Roll the fingers against inner surface of Mandible
with patient's head gently tilted towards one side

33.  Parotid (Preauricular) Nodes
Roll the finger in front of the ear, against the maxilla

34.  Post auricular (Mastoid Nodes)
Roll the fingers behind the ear

35.  Occipital Nodes
Roll the fingers below the occipital protruberance

36.  Internal jugular chain
The tips of fingers are used to palpate the nodes in
anterior triangle. The patient’s head is tipped slightly
forward and the area medial to sternomastoid muscle is
pressed with examiner’s fingertips. The fingers are rotated
along the entire length of the muscle.

37.  Transverse Cervical Nodes
Supraclavicular (Scalene Nodes)
These nodes are felt by tipping the patient’s
head forward to relax the muscles in the neck.
Roll the fingers gently behind the clavicles. Instruct
the patient to cough. Occasionally an enlarged
lymph node may pop up

38. Posterior Cervical nodes
 Stand behind the patient
 Palpate along the anterior edge of the trapezius.

39. Applied aspects
 When a patient has a disease process such as cancer or
infection active in a region, the region’s lymph nodes
respond.
 The resultant increase in size and change in
consistency of the lymphoid tissue is considered
lymphadenopathy
 Lymphadenopathy results from an increase in both the
size of each individual lymphocyte and the overall cell
count in the lymphoid tissue.
 With more larger lymphocytes and increased numbers,
the lymphoid tissue can better fight the disease
process.

40.  changes in consistency allow the node to be palpated
during the extraoral examination along the even firmer
backdrop of underlying bones and muscles such as the
sternocleidomastoid muscle (SCM) or the clinician’s
hands.
 This change in lymph node consistency can range
from firm to bony hard.
 Nodes can remain mobile or free from the surrounding
tissue during a disease. However, they can also
become attached or fixed to the surrounding tissue
such as skin, bone, or muscle, as the disease process
progresses to involve the regional tissue.

41.  When the nodes are involved with lymphadenopathy,
the node can also feel tender to the patient when
palpated.
 This tenderness is due to pressure on the area nerves
resulting from the nodes’ enlargement.
 A dental professional needs to examine the patient
carefully for any palpable lymph nodes of the head and
neck during an extraoral examination and record
whether any are present
 The lymph nodes that are palpable due to
lymphadenopathy may help determine where a disease
process such as infection or cancer is active

42.  The examination also may help determine whether the
disease process has become widespread and involves a
larger region and thus more secondary lymph nodes
and related tissue.

43.  VIRCHOW'S NODES
Named after a German pathologist “Rudolf Virchow”.
These are the left supraclavicular lymph nodes called
as “SIGNAL NODES” because enlargement of these
nodes indicate metastasis from the malignant tumor
from distant organs eg:- stomach, oesophagus, testis,
breast. Enlargement of these nodes called as
TROISIER'S SIGN.

44. CLINICAL STAGING OF CERVICAL
NODE

46. LYMPHADENOPATHY
 Definition: Lymphadenopathy is the enlargement
of one or more lymph nodes. Lymphadenopathy
is classically described as a node larger than 1 cm
and varies by lymphatic region.
 Lymph node enlargement typically results from
one of three mechanisms.
 Proliferation in response to a regional / a systemic
antigenic challenge
 Metastatic invasion by malignant cells
 Neoplastic transformation of primary nodular tissue.

47. Definitions
 Pathologic Lymph Node
 >2cm in children is considered abnormal
 Acute Lymphadenopathy
 < 2 weeks duration
 Subacute Lymphadenopathy
 2-6 weeks duration
 Chronic Lymphadenopathy
 > 6 weeks duration

48.  Localized lymphadenopathy is defined as involving
only one anatomical region and is usually due to
infection, malignancy or recent immunization.
 Generalized lymphadenopathy is said to be present
when two or more noncontiguous areas are affected.
The etiologies include systemic processes such as
hypersensitivity and metabolic disease.
 Distinguishing between two is important in
formulating a differential diagnosis.
 3/4 of patients will present with localized
lymphadenopathy
 1/4 with generalized lymphadenopathy.

52. Investigations
 Blood examination
 Leucocytosis – acute lymphadenitis
 Eosinophilia – filiariasis
 Raised ESR- TB, secondary carcinoma
 Kahn test - Syphilis
 Aspiration ( cold abscess – acid fast bacilli)
 Mantoux test (specific for tuberculosis)
 Gordon’s biological test ( hodgkins disese)
52

53.  Radiological examination (chest X ray)
 Lymphangiography
 Mediastinal scanning ( Gallium 67)
 Laparatomy
 USG
 MRI
 CT scan
 Fine needle aspiration biopsy

54. US
Ultrasound assessment of cervical lymph nodes has the benefits of rapidly and
cheaply demonstrating all three nodal dimensions without the need for ionizing
radiation or intravenous contrast medium.
Deeper lymph nodes, as in the retropharyngeal region cannot be assessed by
ultrasound. The optimal size to define pathological lymph nodes ultrasound are
minimum diameters of 9 mm for level two nodes and 8 mm for the remaining levels
which offer a sensitivity of 74% and specificity of 78%.
US image of a deep cervical (level four) lymph
node in a patient with a nasopharyngeal SCC.
The nodal hilum is hyperechoic relative to the
hypoechoic peripheral cortex. The increased size
(14 mm) and the eccentric cortical widening are
indicators of malignant involvement

55. Grayscale sonogram showing
oval lymph node with
intact hilum.
The Colour doppler ultrasonographic
evaluation was found to be highly significant
with a sensitivity of 92.90% and a specificity
of 84.21%, after comparing the CDUS findings
with histopathologic findings in diagnosing
cervical lymphadenopathy in oral cancer
patients.

56. Fine Needle Aspirate
 Convenient, less invasive, quicker turn-around
time
 Most patients with a benign diagnosis on FNA
biopsy do not undergo a surgical biopsy

57. LYMPHANGIOGRAPHY
Lymphography is a medical imaging technique in
which a radiocontrast agent is injected, and then an
X-ray picture is taken to visualize structures of the
lymphatic system, including lymph nodes, lymph
ducts, lymphatic tissues, lymph capillaries and
lymph vessels.
.
The pedal
lymphangiogram in
Indian patient with
filariasis.

58. viral

59. Upper respiratory infections
 Acute bilateral cervical lymphadenopathy is commonly caused
by viruses and bacteria that infect the upper respiratory tract in
both adults and children.
 Symptoms suggestive of upper respiratory infections include
cough, sinus congestion, rhinorrhea, and occasionally fever and
malaise.
 Cervical lymph nodes may be bilateral, acutely swollen and
tender, and may persist for weeks after the resolution of other
symptoms. Nodes may be palpable in the anterior triangle of the
neck.

60. Viral infections
 Cervical adenopathy is a common feature of many viral
infections.
 Systemic viral infections may cause acute syndromes such as
hand, foot and mouth disease, chickenpox, measles, and rubella.
 These viruses include Epstein Barr virus(EBV), human
immunodeficiency virus (HIV),cytomegalovirus (CMV), and
human herpes virus 6 (HHV-6) infections.
 cervical lymphadenopathy of both anterior and posterior nodes.
Enlarged lymph nodes resulting from these viral infections are
firm and tender, and characteristically not warm or erythematous.
 Infectious mononucleosis often presents with posterior and
anterior cervical adenopathy

61. BACTERIAL

62. TUBERCULOSIS
 Primary tuberculosis: Occurs in previously unexposed people
and almost always involves the lungs.
 Secondary tuberculosis Active disease usually develops later in
life from a reactivation of organisms in a previously infected
person. This reactivation is typically associated with compromise
host defense
 Diffuse dissemination through the vascular system may occur and
has been termed miliary tuberculosis.

63.  Tubercular lymphadenitis(Scrofula)
 Discreate
 Matted appearance
 Cold abscess
 Sinus

64. TULARAEMIA (rabbit fever):
Ulceroglandular tularaemia is the most prevalent form
of the disease. The primary ulcer is localized in the
mouth, and lymph nodes of the neck region are
enlarged.

65. FUNGAL

66. Histoplasmosis, Penicilliosis,
Cryptococcosis)
Presenting Signs and Symptoms
 Clinical Symptoms may evolve
• Fever
• Lymphadenopathy
• Often skin/oral lesions
 Biopsy for histology and culture of skin lesions
or lymph nodes often reveals the diagnosis

67. IMMUNOLOGICAL

68. Rhuematoid arthritis
 Lymphadenopathy may present as a clinical sign of
rheumatoid arthritis. Classical studies by Motulsky et
al have indicated that upto 75% of patients with
rheumatoid arthritis may present with enlarged lymph
nodes.
 Enlarged nodes are associated with active disease and
are often localized near an inflamed joint, although
generalized lymphadenopathy is also quite common.

69. SLE
 SLE-associated lymphadenopathy is largely reactive,
however, malignancy should be considered in
persistent cases.
 Lymph node histology reveals a diffuse hyperplasia
with small lymphocytes, plasma cells, and prominent
immunoblasts.

70. Sjögren’s syndrome
 Lymphadenopathy occurring in the head and neck
region may be present in up to 20% of patients with
Sjögren’s syndrome.
 Lymph node histology in patients with Sjögren’s
syndrome is characterized by paracortical hyperplasia
with prominent vascular proliferation and many
lymphoid follicles with germinal centers.

71. MALIGNANT DISEASES

72. HODGKINS LYMPHOMA
 Hodgkins Lymphoma is a malignant lymphatic disease.
Involving lymph node spleen and liver
 Etiology: Unknown. Probably due to viral infections,
environmental exposures and genetically determined host
response.
 The incidence of Hodgkin’s lymphoma is lower than that of
Non-Hodgkins lymphoma

73.  Clinical feature
 Age: the second and fifth decades.
 Sex: Male cases predominate
 Begins in the lymph node . The most common sites of initial
presentation are the cervical and supraclavicular lymph nodes (70-
75%).
 The usual presenting sign is the identification by the patient of a
persistently enlarging, non-tender discrete mass or masses in one
lymph node region. In the early stages the involved lymph nodes
are often movable as the condition progresses, the node become
more matted and fixed to the surrounding tissues. If it is untreated,
the condition spreads to other lymph node group and eventually
involves the spleen and other extra lymphatic tissues such as bone,
liver and lungs.

75. NON HODGKINS LYMPHOMA
 It initially arises within lymph nodes and tends to grow as solid masses.
It arises mainly from B lymphocytes, less commonly from T
lymphocytes and rarely from histiocytes.
 PATHOGENESIS:
 Epstein Barr virus
 Helicobacter pylori

76.  CLINICAL FEATURES
 Age: primarily in adults
 Constitutional symptoms include fever, weight loss, night sweats.
 Site: Common site is lymph nodes. GIT, spleen, skin, bone
marrow, nose and paranasal sinuses.
 Non-tender, slowly enlarging mass of lymph nodes such as the
cervical, axillary or inguinal lymph nodes is common. Initially the
lymph nodes are freely movable, later the number and size of
lymph nodes increase and become fixed to adjacent structures or
matted together. Gradually the process involves other lymph node
groups and invasion of adjoining normal tissue occurs.
 Seventy-seven percentages of primary head and neck NHL arise in
waldeyers ring. More than half of theses occur in the palatine
tonsil. NHL of waldeyers ring accounts for about 5% of extranodal
NHL overall.

77.  Less frequently, the salivary glands, larynx, thyroid or conjunctiva
may give rise to clinically indolent MALT lymphomas, a subtype of
marginal zone of lymphomas. Renal obstruction, neurological
impairment, liver or skin infiltration and bone marrow involvement
commonly occur during the course of the disease.
 Lymphomas of oral cavity usually appear as extranodal soft tissue
lesion. The lesion appears as non-tender swelling with boggy
consistency.

78. BURKITTS LYMPHOMA (African Jaw
Lymphoma)
 Burkitts lymphoma, a Non Hodgkins lymphoma is
a malignancy of B-lymphocytic origin that
represents an undifferentiated Lymphoma.
 Etiology: EBvirus.The virus may be a prime
etiologic agent, a carcinogen or just an innocent
passenger.

79.  Clinical Features
 Age: young children (7 yrs of age)
 Sex: male predilection
 Site: 50% - 70% in jaws. Posterior segments of the jaws are common.
 Maxilla is commonly involved than mandible
 noted for the African tumor.
 In non-endemic non-African form, it tends to involve the lymphnodes and
lymphoid tissues particularly bone marrow, more often the visceral involvement is
more common . The tumor expands rapidly and may double in size every 1-3
days, making it the fastest growing human cancer.

80. conclusion
 The documentation and history concerning palpable lymph nodes will
assist in the diagnosis, treatment, and outcome of a disease process that
may be present in the patient.
 Therefore a dental professional must understand the relationship
between node location and node drainage patterns throughout the head
and neck.
 The dental professional needs to remember that these lymph nodes
drain not only intraoral dental structures such as the teeth but also other
structures of the head and neck such as the eyes, ears, nasal cavity, and
deeper areas of the pharynx.
 A patient may need a medical referral when lymph nodes are palpable
due to a disease process in these other structures.

81. REFERENCES
 S. Das., “A manual of clinical surgery”,8th edition
 BURKET’S ORAL MEDICINE 12th edition
 ILLUSTRATED ANATOMY OF THE HEAD AND NECK
(4th Edition) – Margaret J. fehrenbach & Susan W. Herring.
 GRAY’S ANATOMY 3rd edition
 CLINICAL MANUAL FOR ORAL MEDICINE &
RADIOLOGY –Ravikiran ongole & Praveen BN.
 P Ernesta , G Michael . Cervical lymphadenopathy in the
dental patient: A review of clinical approach.
QUINTESSENCE INTERNATIONAL VOLUME 36 ,
NUMBER 6, JUNE 2005.pg.no 423-436
 ORAL DIAGNOSIS,ORAL MEDICINE AND
TREATMENT PLANNING 2nd edition Bricker,Langlais
&Miller.
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