Brief introduction of lymphatic system and Clinical examinations of lymphnode.

1. Presented by:
Dr. Nisha Naaz Siddiqui
Department of Surgery
National Institute of Unani Medicine
Under guidance
Prof. Shah Alam Sir
National Institute of Unani Medicine
Bengaluru Karnataka
‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. What we are examine..??
• Small capsulated bean shaped or oval shaped,
lymphoid tissue.
• Varying in size 1-1.5 cm
• Located along the channel of lymphatic
vessels
• They are scattered throughout the body, both
superficially and deep, and usually in clusters.
A LYMPHNODE

3. BRIEF INTRODUCTION OF LYMPHATIC SYSTEM
• Lymphoid tissue is a specialized form of reticular connective tissue
that contains large numbers of lymphocytes makes the lymphatic
system.
• Lymphatic system begins to develops during 6th week of IUL as LYMPH
SAC adjacent to jugular vein.
• Lymphatic system has 3 important components-
1. LYMPHATIC CAPPILARIES
2. LYMPHATIC VESSELS
3. LYMPHNODES
Obviously lymph

4. Cont.
• Lymphatic system is a closed system of lymph channels or lymph vessels,
through which lymph flows. It is a one-way system.
• Lymphatic system arises from tissue spaces as a meshwork of delicate vessels.
These vessels are called lymph capillaries.
• Lymph capillaries start from tissue spaces as enlarged blind-ended terminals
called capillary bulbs.These bulbs contain valves, to insure one way flow.
• Capillaries unite to form large lymphatic vessels. Lymphatic vessels become
larger and larger by joining of many tributaries along their course.
• Larger lymph vessels ultimately form the right lymphatic duct and thoracic
duct.
• LYMPH most components of blood plasma filter through blood capillary walls to
form interstitial fluid. After interstitial fluid passes into lymphatic vessels, it is
called lymph (LIMF = clear fluid)

5. Fig. 1 Lymphatic Capillary bed and its structure

6. Lymphatic Trunks and lymphatic Ducts
• As lymphatic vessels exit lymph nodes , they unite to form lymph trunks.
• The principal trunks are the
I. Lumbar trunk (drain lymph from the lower limbs, the wall and viscera of the
pelvis, the kidneys, the adrenal glands, and the abdominal wall. )
II. Intestinal trunk (drains lymph from the stomach, intestines, pancreas, spleen, and
part of the liver)
III. Bronchomediastinal trunk(drain lymph from the thoracic wall, lung, and heart)
IV. Subclavian trunk (drain the upper limbs)
V. Jugular trunks (drain the head and neck)
The lymph passage from the lymph trunks to the venous system.

7. Right Jugular trunks
Right Subclavian trunk
Right Bronchomediastinal trunk
Left Jugular trunks
Left Subclavian trunk
Left Bronchomediastinal trunk
Right & left Lumbar trunk
intestinal trunk
As a result of these pathways, lymph from the upper right quadrant of the body returns to the superior vena
cava from the right brachiocephalic vein, while all the lymph form the left upper side of the body and the
entire body below the diaphragm returns to the superior vena cava via the left brachiocephalic vein.
RIGHT
LYMPHATIC
DUCT
LEFT
LYMPHATIC
DUCT
OR
THORACIC DUCT

8. Drainage area of lymphatic

9. Functions of the Lymphatic System
The lymphatic system has three primary
functions:
1. Drains excess interstitial fluid.
2. Transports dietary lipids
3. Carries out immune responses

10. Why I’m not here…
Superficial layers of skin
Alveoli of lungs
Bones
Cornea Central nervous system

11. MICROANATOMY OF LYMPHNODE
• Lymph nodes are 1–25 mm long with an
indentation called hilum on one side.
• Enclosed in a fibrous capsule that extends into the
interior.
• The capsular extensions, called trabeculae, divide
the node into compartments:
1. Cortex
- Outer cortex
- Inner cortex (Paracortex)
2. Medulla

12. Cortex of lymph node consists of
primary and secondary lymphoid
follicles (germinal center).
Paracortex contains T lymphocytes
and dendritic cells.
Medulla contains B and T
lymphocytes, Plasma cells and
macrophages.
Blood vessels of lymph node pass
through medulla

13. Fig. Interior of lymphnode
Route of lymph flow
through a lymph node:
Afferent lymphatic vessel
Subcapsular sinus
Trabecular sinus
Medullary sinus
Efferent lymphatic vessel

14. There are around 600-800 lymph nodes in a human body
of which
• Around 300 are only in neck
• Around 100 in thorax
• Around 50-60 in axilla
• Around 250 in abdomen and pelvis
• Around 50 in groin
Hey..! I'm secondary lymphoid organ

15. Functions of lymph node
• They act as immunological filters.
• They filter out the antigen or microbes before allowing lymph
to return into circulation.
• Acts as defense barriers; Bacteria and other toxic substances
are destroyed by macrophages.

16. Examination of lymphnode
• The purpose of the examination is to assess whether a patient has
evidence of lymphadenopathy or lymphoma.
• Patient may come with the complaint of painful or painless swelling.
• History of presenting illness, past history, personal history and family
history should be properly asked.
• Detailed general examination is very essential.
Important point to remember
Fever
Weight loss
First node involved
Family H/O
Cough/hemoptysis/chest pain
Abdominal mass
Anemia/icterus

17. Local examination
• It is important to examine in a systematic manner.
• Normally lymphnodes are non palpable (except submandibular and
axillary LN in some healthy individuals)
• For any palpable lymph node, it’s important to assess the following
characteristics to narrow the differential diagnosis:
1. Number
2. Site
3. Size
4. Shape and Extent
5. Surface
6. Margin

18. 7. Skin over swelling
8. Tenderness
9. Consistency
10. Mobility
11. Fixity to overlying skin or underlying structures
12. Fluctuation test
13. Transillumination test
14. Examination of Drainage area

19. • Important in staging metastatic nodal status (N stage)
• Nodes are generally considered to be normal if they are up to 1 cm in diameter; however,
some authors suggest that epitrochlear nodes larger than 0.5 cm or inguinal nodes larger
than 1.5 cm should be considered abnormal
SIZE
• Hodgkin’s disease and tuberculosis affect cervical group of lymph nodes in the beginning
• Filariasis and lymphogranuloma inguinale affect inguinal group of lymph nodes
• Secondary stage of syphilis involves the epitrochlear and occipital groups
POSITION
• Smooth in lymphoma and tuberculosis
• Irregular in secondaries
SURFACE

20. TENDER
• Present in acute lymphadenitis, advanced/late stage secondaries.
• Enlarged nodes due to tuberculosis, syphilis andsarcoidosis are usually
nontender.
SKIN OVER
SWELLING
• Red, inflamed, oedematous in acute lymphadenitis.
• Tense, shiny with often dilated veins in lymphoma.
• Skin ulceration, skin adherent to swelling underneath, fungation is
common in secondaries in lymph nodes. Eg. Peau d’orange
• Scar, sinus, ulcer may suggest tuberculosis or malignancy.
(Scar often indicates previous bursting of cold abscess or a previous
operation)

21. • Whether single or multiple groups
• Generalized involvement of lymph nodes: hodgkin’s disease,
tuberculosis, lymphosarcoma, lymphatic leukaemia, brucellosis
sarcoidosis
NUMBER
• Soft (fluctuating) or elastic and rubbery - hodgkin's disease
• Firm, discrete and shotty- syphilis
• Stony hard - secondary carcinoma
• Variable consistency - soft, firm and hard in places depending on the rate
of the growth – lymphosarcoma
CONSISTENCY
MATTED OR NOT
• If there be periadenitis, the adjoining nodes become matted.
• Often matted in tuberculosis, acute lymphadenitis and metastatic
carcinoma.

22. • Any primary malignant growth of lymphnode is often fixed to the
surrounding
FIXITY TO
SURROUNDING
STRUCTURE
• Fluctuation test is important when it is soft or tensely cystic.
• Fluctuation is observed in cold abscess
FLUCTUATION
• Negative in most of lymphnode enlargement
• Only cystic hygroma and acquired lymph cyst is brilliantly transilluminate
TRANSILLUMIN
ATION

23. Lymphnode should be palpated using the most sensitive part of
your hands; FINGERTIPS
In general, lymph nodes greater than 1 cm in diameter are considered to be abnormal

24. Cervical group of Lymph node
They are arranged as 2 horizontal ring
and 2 vertical chains on either side of
neck.
• Upper horizontal group of cervical
lymphnode
• Lateral group of cervical lymphnode
• Anterior cervical nodes

25. • Cervical lymphnodes receive lymphatics from head, face,
mouth, pharynx and neck.
• All the lymph from the region of head and neck drains
directly or indirectly into a vertical chain of deep cervical
lymph nodes
• The efferents from these nodes form the jugular trunk.
• On the right side, jugular trunk drains into right lymphatic
duct.
• On the left side, jugular trunk drains into thoracic duct.

26. Waldeyer’s Ring (Waldeyer’s-Pirogov Ring)
• Outer waldeyer’s ring
• Occipital
• Postauricular
• Preauricular
• Submandibular
• Submental
• Inner waldeyer’s ring
• Adenoids or nasopharyngeal tonsils
• Tubal tonsils
• Palatine tonsils
• Lingual tonsils

27. Waldeyer’s Ring

28. AA0-HMS 1998 classification aka Robbin’s classification further
divides the CERVICAL LYMPHNODE into 7 group for convenience
1. Level Ia: Submental LN
Level Ib: Submandibular LN
2. Level II: Upper Jugular Group LN
3. Level III: Middle Jugular Group LN
4. Level IV: Lower Jugular Group LN
5. Level Va and Vb: Posterior Triangle Group(supraclavicular)
6. Level VI: Anterior Compartment Group (Pretracheal &
Prelaryngeal)
7. Level VII: Mediastinal group of LN

30. VIRCHOW’S LYMPHNODE
• Left supraclavicular LN lying between two
heads of sternocleidomastoid is called the
Virchow’s lymphnode.
• It receive lymphatics from left side of upper
limb, left side of chest and viscera of abdomen
including both testes.
• This may be involved in metastasis from
carcinoma of stomach, testicular tumor,
carcinoma of esophagus and bronchogenic
carcinoma.
Virchow’s node or troisier’s node

31. How to palpate cervical lymph Node
• The cervical lymph nodes may be palpated both from front and the back the
clinician stands behind the patient.
• The neck is slightly flexed and turned to the side of examination.
• The different groups of lymph nodes levels i to vi are then palpated
systematically with one hand.

32. Palpation of level I
• Level IA lymph nodes are palpated at the submental triangle with the
pulp of the fingers directed upwards with the neck slightly flex and
turned to the same side.
• Similarly level IB nodes are palpated at the submandibular triangle.
Level IA Level IB

33. Palpation of level II, III, IV
• Level II, III and III nodes are palpated along the line of internal jugular
vein with the pulp of the fingers.
Level II
Along the upper third of
internal jugular vein
Level II Level III
Along the middle third of
internal jugular vein
Along the lower third of internal
jugular vein

34. Palpation of level V
• Level v nodes are palpated at the posterior triangle with the pulp of the
fingers
Palpate along the anterior border of
trapezius muscle
palpate along the posterior border of
sternocleidomastoid muscle

35. Palpation of supraclavicular LN
• The supraclavicular nodes (Level v) are palpated with the pulp of the fingers kept at the
supraclavicular fossa and asking the patient to shrug the shoulder up.
Palpate the supraclavicular fossa for supraclavicular lymph nodes

36. Examination of Tonsils (Waldeyer’s ring)

37. Common causes of cervical lymphodenopathy

39. Axillary group of Lymph node
Axillary group of lymph node drains
• Upper limb
• Breast
• Chest wall
• Trunk from clavicle to umbilicus

40. Surgical classification of axillary lymph node or
BERG’S LEVEL
Axillary lymph nodes are divided into three levels
in relation to pectoralis minor muscle
Berg’s levels—
Level I:Below the pectoralis minor
Level II: Behind the pectoralis minor
Level III: Above the pectoralis minor

41. Anatomical classification of Axillary group of Lymphnode
There are five axillary lymph node groups, namely
• Anterior (pectoral)
• Posterior (subscapular)
• Lateral (humeral)
• Central
• Apical nodes
The apical nodes are the final common pathway for all of the axillary
lymph nodes.

42. Anterior (pectoral) lymph nodes
• Location: situated behind the anterior axillary fold
• Receives: lymph from skin and muscles of the
supraumbilical anterolateral body wall, breast
• Drains into: central and apical nodes
Lateral (humeral) lymph nodes
• Location: Posteromedial to axillary vein (Lies against the
shaft of the humerus)
• Receives: lymph from most of the upper limb
• Drains into: central, apical and deep cervical nodes

43. Posterior (subscapular) lymph nodes
• Location: along subscapular vessels on inferior margin of the posterior
axillary fold
• Receives: lymph from skin and muscles of the posterior and inferior
body wall
• Drains into: Central and Apical nodes
Central lymph nodes
• Location: fat of the axilla or over the lateral thoracic wall.
• Receives: lateral, anterior and posterior lymph node groups
• Drains into: Apical nodes

44. Apical (terminal) lymph nodes
• Location: Posterior and superior to pectoralis minor, towards the axillary
vein
• Receives: Lymph from cephalic vein nodes, upper peripheral breast, the
above mentioned central nodes
• Drains into: Subclavian trunk
(may drain into jugulosubclavian venous trunk, subclavian vein, jugular
lymphatic trunk, right lymphatic duct (left into thoracic duct), inferior deep
cervical nodes)

45. How To Examine Axillary Lymphnode
• Patient is in sitting posture facing the clinician, and proper exposure is done.
• The Anterior, Central, Apical and the Lateral group of lymph nodes are palpated
from the front.
• The Posterior or Subscapular group are palpated from the back of the patient.
• The right axilla is palpated with the left hand except the lateral and the posterior
group which are palpated with the corresponding hand.

46. Palpation of The Anterior Group of Axillary Node
Lift the hand and place the fingers
behind the anterior axillary fold
Bring the hand down over the
forearm of the clinician and palpate along the
anterior axillary fold

47. Palpation of Central Group of Lymph Nodes
• Lift the right hand of the patient and place the left hand of the clinician in the center of the axilla.
• Bring the right hand down to rest on the left forearm of the clinician and the right hand of the
clinician now steadies the opposite shoulder. The central group of lymph node is now palpated with
the fingers against the lateral chest wall over the 2nd, 3rd and 4th rib in the axilla
Left hand of the clinician placed in
the center of the axilla
The central group of lymph nodes
are palpated against the 2nd, 3rd and 4th rib

48. Palpation of Apical group of Lymph nodes
• The Apical group of lymph nodes is palpated by pushing the finger up in the apex of the
axilla and keeping the right hand over the ipsilateral supraclavicular fossa
Palpation of the apical group of
lymph nodes

49. Palpation of Lateral Group of Axillary Lymph Nodes
• Palpated on the right side with the right hand of the clinician against the shaft of
humerus between two axillary folds.
The clinician steadies the right
shoulder with the left hand and right hand
palpate the lateral group
Hand of the clinician in the lateral wall of the axilla
Inbetween the anterior and posterior axillary fold

50. Posterior or subscapular lymph node palpation
• The clinician stands on the back of the patient.
• For right side, the right hand is supported by the left hand of the clinician and the right
hand of the clinician palpate the posterior group of lymph nodes along the posterior
fold of the axilla along the subscapularis muscle.

51. Some possible causes of axillary lymphnode

52. Inguinal Group of Lymph Nodes
Inguinal LN are divided into 2 group
1. Superficial inguinal lymphnode
2. Deep inguinal lymphnode
• Superficial inguinal lymph nodes are form a chain
immediately below the inguinal ligament. They lie deep to
the fascia of Camper.
• Deep inguinal lymph nodes 2-3 in number. They lies deep
to fascia lata medial to the femoral vein. The superior most
node of this group is called as CLOQUET’S lymphnode or
Rosenmuller's node.

53. Superficial Inguinal Lymphnode
Superficial
inguinal lymph
node
Horizontal
group
Superomedial
Superolateral
Vertical group Inferior

54. Superficial inguinal LN
• Inferior – Receive drainage from lower legs
• Superolateral – receive drainage from the side buttocks and the lower abdominal
wall.
• Superomedial – received drainage from the perineum and genitals.
Deep inguinal LN- received afferents from
• Superficial inguinal lymph node
• Popliteal lymph nodes
• Glans penis or clitoris
• Deep lymphatics from lower limb

55. How to examine inguinal lymphnode
• Subject should be in supine position and exposed from midthigh to
nipple line with hip slightly flexed to relax muscles and fascia.
• They are palpated in relation to inguinal ligament with the pulp of
the finger
• Palpate immediately inferior to the inguinal ligament (which runs
between the anterior superior iliac spine and pubic tubercle) to
assess the horizontal group of superficial inguinal lymph nodes.
• Position your fingers approximately 3cm lateral to the pubic
tubercle and then palpate vertically downwards over the
saphenous opening

57. To Conclude……… Let’s Begin

58. QUESTION & ANSWER SESSION

59. THANKYOU