Lymph node examination
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Lymph Node Examination
Anatomy and Normal Characteristics
Lymph nodes are round or bean-shaped secondary lymphoid structures that typically measure less than 1 cm in diameter. They are located along lymphatic vessels and filter lymphatic fluid, intercepting microorganisms and antigens. Each node has a hilum where blood vessels enter and leave. Lymphatic fluid enters via afferent lymphatics into the subcapsular sinus and exits via a single efferent lymphatic at the hilum. They contain B cells, T cells, macrophages, and dendritic cells.
- Goldman-Cecil Medicine, p. 1771
Approach to Examination
1. History First
A thorough history is the first and most important step. Key elements include:
| Domain | Key Points |
|---|---|
| History of illness | Duration, rate of growth, tenderness, associated symptoms (fever, night sweats, weight loss, sore throat, pruritus) |
| Exposures | Recent travel, tick/insect bites, sick contacts, animal contact (cats → cat-scratch disease; rabbits → tularemia), undercooked meat (toxoplasmosis) |
| Past medical history | Autoimmune disease, immunosuppressive therapy, recent vaccinations (COVID-19 vaccine → unilateral axillary adenopathy) |
| Medications | Phenytoin, carbamazepine, allopurinol, hydralazine, isoniazid can all cause reactive lymphadenopathy |
| Social/sexual history | HIV risk, occupation, smoking/alcohol |
| Family history | Hematologic malignancies, autoimmune disease |
- Goldman-Cecil Medicine, p. 1774 (Table 154-1)
2. Inspection
- Note any visible swelling, overlying skin changes (erythema, warmth, violaceous discoloration suggesting sialoadenitis/malignancy)
- Ask the patient to point to any lump they have noticed
- Note whether the mass moves with swallowing or tongue protrusion (suggests thyroglossal duct cyst rather than a lymph node)
- Ask about tenderness before palpating
3. Palpation Technique
-
Palpate bilaterally and in a sequential/systematic manner, comparing both sides
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For the neck: examine all five palpable node levels (I-V), plus parotid, pre-auricular, and post-auricular nodes
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Ask whether a lump is tender before pressing
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If a node is clinically obvious, determine: solitary vs. multiple, then proceed to assess size, consistency, transillumination, and mobility
-
Scott-Brown's Otorhinolaryngology, p. 376
4. Key Parameters to Assess
Size
-
Nodes < 1.0 cm² (1 cm × 1 cm) are almost always benign/reactive
-
A diameter > 2 cm in younger patients is a discriminant for predicting malignant or granulomatous disease on biopsy
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A size of 2.25 cm² (1.5 × 1.5 cm) is the best cut-off for distinguishing malignant/granulomatous from reactive causes
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Supraclavicular, epitrochlear, and popliteal nodes are considered abnormal even when subcentimeter
-
Harrison's Principles of Internal Medicine 22E, p. 2085
Consistency / Texture
The texture of lymph nodes can be described as: soft, firm, rubbery, hard, discrete, matted, tender, movable, or fixed
| Finding | Interpretation |
|---|---|
| Tender, warm, soft | Acute infection/inflammation (capsule stretched by rapid enlargement) |
| Large, discrete, symmetric, rubbery, firm, mobile, nontender | Lymphoma |
| Hard, nontender, fixed/matted to surrounding tissue | Metastatic solid tumour |
| Soft, mobile | Hematologic malignancy (e.g., leukemia) |
| Fluctuant | Abscess (bacterial lymphadenitis, e.g., Staph. aureus) |
Note: some malignancies (e.g., acute leukemia) can cause rapid enlargement with pain, so pain alone does not exclude malignancy.
- Harrison's Principles, p. 2087; Goldman-Cecil Medicine, p. 1774
Distribution: Localized vs. Generalized
| Pattern | Common Causes |
|---|---|
| Generalized lymphadenopathy | Infectious mononucleosis (EBV), CMV, HIV, SLE, lymphoma, leukemia, sarcoidosis, toxoplasmosis |
| Localized (regional) | Infection or malignancy draining to that region |
Location-Specific Clues
| Site | Typical Cause |
|---|---|
| Submandibular/cervical | Reactive to URTI, dental/oral infection; in adults - head & neck carcinoma, lymphoma |
| Pre-auricular | Conjunctival infections, cat-scratch disease |
| Occipital/posterior auricular | Scalp infection, rubella |
| Supraclavicular (always abnormal) | Lymphoma; lung, breast, GI cancers; TB, sarcoidosis, toxoplasmosis |
| Left supraclavicular (Virchow's node) | Metastatic GI cancer (especially gastric) |
| Axillary | Upper limb injury/infection; melanoma, lymphoma; breast cancer (women) |
| Epitrochlear | Infections of ipsilateral hand/forearm; lymphoma, sarcoidosis |
| Inguinal | Lower limb infections/trauma; STDs (lymphogranuloma venereum, syphilis, genital herpes, chancroid); lymphoma; metastases from rectum, genitalia, lower limb |
| Popliteal | Always abnormal; infections of distal lower limb |
- Harrison's Principles, p. 2081-2082; Goldman-Cecil Medicine, p. 3814
Mobility
- Mobile nodes: generally reactive or lymphomatous
- Fixed/tethered to skin or deep tissues: suggests malignant infiltration with extracapsular spread
Transillumination
- A node that transilluminates suggests a cystic or lymphomatous lesion (e.g., cystic hygroma/lymphangioma)
5. Associated Physical Findings to Seek
A complete examination must also assess:
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Splenomegaly - when co-existing with lymphadenopathy, implies a systemic illness (infectious mononucleosis, lymphoma, leukemia, SLE, sarcoidosis, toxoplasmosis)
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Hepatomegaly
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Tonsillar enlargement (Burkitt lymphoma, EBV)
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Parotid enlargement (Sjögren syndrome)
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Rash (T-cell lymphoma, SLE, viral illness)
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Joint findings (autoimmune disorders)
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Breast mass (with axillary adenopathy)
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Testicular mass (with para-aortic adenopathy)
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Wasting/cachexia (malignancy)
-
Goldman-Cecil Medicine, p. 1774 (Table 154-3)
6. Acute vs. Subacute vs. Chronic: A Practical Framework
| Time course | Laterality | Likely cause |
|---|---|---|
| Acute | Bilateral | Viral infection |
| Acute | Unilateral | Bacterial infection |
| Subacute/Chronic (> 4-6 weeks) | Any | Granulomatous bacteria (TB, NTM), cat-scratch disease, malignancy, congenital lesion |
| Progressive growth | Any | Malignancy until proven otherwise |
| Fluctuating size | Any | Infectious/inflammatory |
- Tintinalli's Emergency Medicine, p. 1312
7. Investigation (when indicated)
| Test | Indication |
|---|---|
| CBC with differential + ESR | Baseline; look for atypical lymphocytes (EBV), cytopenias (leukemia) |
| Monospot / EBV serology | Cervical adenopathy + sore throat + splenomegaly |
| Chest X-ray | Mediastinal mass, hilar enlargement, pulmonary infiltrate |
| Ultrasound ± FNAC | First-line imaging; guided FNAC for suspicious nodes |
| CT/MRI with contrast | Cross-sectional assessment of extent, surrounding structures |
| PET-CT | Only when lymphoma or other malignancy already suspected |
| Needle aspiration | Infectious cause suspected |
| Excisional biopsy (preferred) | Malignancy suspected; gives full architecture |
| Core biopsy | When excisional biopsy is unsafe |
- Goldman-Cecil Medicine, p. 1755 (Table 154-3); Scott-Brown's Otorhinolaryngology, p. 387
Summary: Red Flags Requiring Urgent Investigation
- Node > 2 cm or rapidly enlarging
- Hard, fixed, or matted nodes (especially supraclavicular)
- Supraclavicular or epitrochlear adenopathy at any size
- Painless progressive lymphadenopathy
- Associated B symptoms: fever, drenching night sweats, > 10% weight loss
- Accompanying splenomegaly or hepatomegaly
- Node persisting > 6 weeks without explanation
- Virchow's node (left supraclavicular) - always investigate for GI primary
Sources: Harrison's Principles of Internal Medicine 22E | Goldman-Cecil Medicine | Scott-Brown's Otorhinolaryngology Head & Neck Surgery | Tintinalli's Emergency Medicine | S Das - A Manual on Clinical Surgery
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