the examination of the lymph nodes for abnormalities is an essential part of the physical exam we have hundreds of lymph nodes throughout our body most of them we cannot feel or palpate because they are small or deep and they cannot be felt but to our surprise if you do a radical dissection of the neck or the axilla or the pelvis we finally find 10 15 or 20 lymph nodes in that operation which were never appreciated lymph nodes are virtually always abnormal in the sense that they arose some from some preceding process usually an infection early in life and then they maintained their small size for life in the examination of lymph nodes to determine serious problems there are a number of characteristics that are important the most important of course is their size because lymph nodes are generally thought to be virtually normal or insignificant when they are 2 centimeters over less at least that's the criteria that radiologists use in examining the abdomen that's more or less true than the other parts of the body there are some parts of the body such as the armpits or the XLE which lymph glands may reach the size of 3 centimeters or even more and not be a concern occasionally on CT scan you will see that those lymph nodes contain fat in the center and they are rather C shaped but their size under the act in the axilla can be larger than in other locations whereas in other locations even one centimeter or a smaller than node is of great concern such as in the supraclavicular fossa where lymph nodes are not usually the residual level infection and indicate more serious problems other than size the next important iteration is how they feel when you palpate them are they soft hard something in between which we call rubbery each of those need something slightly different normal or insignificant lymph nodes are usually soft very hard lymph nodes are a much more concern if their group stone-hard or mean then we more often think of a malignancy occasionally an old infection a particularly a granulomas infection can leave you with hard lymph nodes intermediate consistency er we call rubbery and rubbery lymph nodes are often a sign of lymphoma which is a primary tumor of course of a lymph node system the other important characteristic is whether they are tender or non tender tender lymph nodes as you palpate them are almost always a sign of infection and malignancies that involve the lymph nodes are usually not tender with the occasional exception when they grow very rapidly and that's not common the other important consideration is the age of the patient youngsters children from ages 2 to 12 very frequently have lymph nodes especially in the neck posterior cervical mid cervical occasionally and other peripheral sites which are due to frequent viral or other bacterial infections that they get in the nose and throat and as a normal part of maturation of the patient and of the immune system as one gets older then you may not want to feel them for nodes that are acceptable in children so the examination which I am about to show you it's just part of the consideration and I'd be glad to go ahead no thank you so to begin with I always have my patient seated and that's the best way to feel lymph glands from the waist up and often we do that symmetrically because low flows are usually not symmetrical in their enlargements especially abnormal lymph nodes so we often use two hands and we start in the posterior occipital region and occasionally you feel lymph glands this gentleman has a very hard lump in the back of his head which is not a lymph node and you have to distinguish loan from a lymph node but up here he has about a two centimeter firm bony protuberance it is not a lymph node and it's nothing of concern as you come down you just out pay with your fingers until you get to the posterior auricular area and lymph nodes can be felt there usually they are abnormal even when they're quite small in this location and you use your fingers gently and then you come down to the general neck area there's another that's important with the pre Rick your lymph nodes and you feel with your fingers gently symmetrically and you don't usually feel pre auricular lymph nodes even small ones would be of concern may mean an infection may mean something were generalized as you come down then to the mandibor the the angle of the mandible the parotid gland may be felt in this location in this gentleman we don't feel the parotid gland but they would be symmetrical and they overlap that angle and they are not lymph nodes and then you come down along the sternocleidomastoid muscle and you palpate for jugular lymph nodes and you go up and down gently if you can then all the way down to the clavicle and these would be the jugular lymph nodes of cervical lymph nodes and what's very important to distinguish is that there are submandibular salivary glands which are symmetrical usually maybe slightly different one side from the other and this gentleman has salivary gland right here which is about 1/2 centimeters and small and he has a smaller one on this side but they are symmetrical they are not concerned and they are not lymph nodes in my judgment the other thing you have to be aware of is that the carotid arteries are here and very often you will feel the carotid artery or carotid bulb and interpret that as a swollen lymph nodes but lymph nodes you're not pulsate and they when they pulsate that means is obviously a carotid artery and they are in this location now this gentleman has a very small implant on the right side your posterior cervical region right here it's probably no more than three millimeters it's flat lymph nodes that are normal are usually flat and ovoid lymph nodes that are not are more abnormal or spherical and that you can sort of tell by your palpation you come down and the most important area to feel is the supraclavicular fossa now sometimes it's a little better to just bend the neck forward to relax this area and you take your fingers and you push right down over the clavicle and see if you can roll your fingers over any nodules now these are most important because they are not usually found normally after infections and if they are enlarged they often indicate some process which is deeper in the body and the most important one is on the left side and as you probably have rather remember the left super-goof node is called the sentinel lymph node or rear coughs node because it was an indication that there was serious trouble in the abdomen now why in the left supercooling fossa would that indicate abdominal disease or you recall that the lymphatics of the abdomen drain to the cisterna chyli and then go up to thoracic duct and they dump into the left side left jugular vein and if there is malignancy in this location and it is spread to a lymph node very frequently the first sign of that disease is a swollen and far left circular bicular lymph node and you shouldn't feel a lymph node in this location at least normally that doesn't mean that they're always bad but that it should raise your suspicion the right side occasionally the thoracic duct will split and send some lymph and cells to the right side but the intrathoracic lymphatic strained to the right super particular fossa so this is another very important place to feel and then you continue to feel around and make sure that it's symmetrical be sure to distinguish that the muscles from the carotid vessels the hyoid bone is here and should be confused with lymph nodes it's firm and to push on one side it goes to the other and many young medical students or doctors will confuse the hyoid bone and the larynx hyoid bone is higher let's go me and it moves



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