LYMPHATIC SYSTEM

ANATOMY AND PHYSIOLOGY

- essential to system’s role in immunologic and metabolic processes
- major factor in maintenance of fluid balance
- production of lymphocytes and antibodies
- defend against invasion of microorganisms and other particles with filtration
and phagocytosis (ingestion and
digestion by cells of solid substances)
- plays unwanted role in providing at least one pathway for spread of
malignancy
- drainage point for right upper body empties into right subclavian vein
- has no built-in pumping mechanisms and depends on cardiovascular system
for this action
- usually occur in groups or chains

DEVELOPMENTAL VARIATIONS
A. INFANTS AND CHILDREN
- immune system and lymphoid system develop at about 20 weeks
gestation
- enlargement of tonsils in children is not necessarily an indication of
problems
- before 2 yrs. old, inguinal, occipital and post-auricular nodes are
common
- after 2, more likely to have significance
- supraclavicular nodes are not usually found - - presence is associated
with high incidence of
malignancy - - always a cause for concern
- lymphatic system reaches adult competency during childhood

B. PREGNANT WOMEN
- complex changes occur in immune system that are not fully understood
- shift from cell-mediated immunity to antibody production/humoral
immunity results in increased
susceptibility to certain infectious diseases
- can lead to remission of autoimmune/inflammatory diseases

C. OLDER ADULTS
- number of lymph nodes may diminish and size may decrease with
advanced age
- nodes are more likely to be fibrotic and fatty - - contributing factor in
impaired ability to resist infection

I. SUBJECTIVE ASSESSMENT
A. LYMPHATIC
1. History of Present Illness
- bleeding = site, character, associated symptoms
- enlarged nodes (bumps, kernels, swollen glands) = character,
associated symptoms,
 predisposing factors (infection, surgery, trauma)
- swelling of extremity = unilateral, bilateral, intermittent, constant,
predisposing factors,
associated symptoms, efforts at treatment and their effect

2. Past Medical History

- chronic illness, tuberculosis, blood transfusions, surgery, recurrent
infections

3. Family History
- malignancy, anemia, recent infections, tuberculosis, hemophilia

4. Developmental Variations
a. Infants and Children
- recurrent infections = tonsillitis, adenoiditis, bacterial
infections
- poor growth, failure to thrive
- immunization history
- maternal HIV infection
b. Pregnant Women
- exposure to rubella and other infections
- presence of autoimmune disease
c. Older Adults
- present or recent infection or trauma
- delayed healing

II. OBJECTIVE ASSESSMENT

A. LYMPH NODES
1. Inspection and Palpation (can start as soon as you see patient) of
Superficial Lymph Nodes
- always ask patient if he/she is aware of any lumps
- inspect for apparent nodes, edema, erythema, red streaks, and
skin lesions
- palpate for superficial nodes
- try to detect any hidden enlargement, noting consistency,
mobility, tenderness, size,
and warmth
- easily palpable lymph nodes generally are not found in
healthy adults
- superficial nodes are accessible to palpation but not large or
firm are common
- when node seems fixed in setting, there is greater cause for
concern
- explore for signs of possible infection or malignancy
- enlarged lymph nodes are characterized according to
location, size, shape,
consistency, tenderness, movability or juxtaposed to
surrounding tissues
 - nodes that are enlarged and juxtaposed feel like large mass
rather than discrete and
are described as matted
- note if there is tenderness on touch or rebound
- nodes that are large, fixed or matted, inflamed or tender
indicate a problem
- tenderness is almost always indicative of inflammation
(cancerous nodes are not
usually tender)
- note degree of discoloration or redness
- note any unusual increase in vascularity heat or pulsations
- with bacterial infection, nodes may become warm or tender
to the touch, matted and
much less discrete
- nodes to which a malignancy has spread are not usually tender
- vary greatly in size
- are sometimes discrete, matted and firmly fixed, tend to be
harder than expected
- masses anterior to sternocleidomastoid muscle are benign
- those posterior may be malignant
- in tuberculosis, nodes are usually “cold” (actually body
temperature), soft, matted, and often
not tender or painful

2. Head and Neck

- lightly palpate entire neck for nodes
- bending pt’s head slightly forward or to side will ease taut tissues
- feel for nodes on the head in following sequence:
• occipital nodes at base of skull
• postauricular nodes
• preauricular nose just in front of ear
• parotid and retropharyngeal (tonsillar) nodes at angle of
mandible
• submandibular (submaxillary) nodes halfway between angle
and tip of mandible
• submental nodes in midline behind tip of mandible
- then move down neck as follows:
• superficial, anterior cervical nodes
• posterior cervical nodes
• cervical nodes
• supraclavicular areas
- detection should always be considered a cause for concern
- supraclavicular nodes are commonly the sites of metastatic
disease because they are
located at the end of the upper “drainage” system

3. Developmental Variations
a. Infants and Children
 - commonly find small, firm, discrete, and movable nodes
that are neither warm nor
tender located in occipital, postauricular, cervical, and
inguinal chains
- not unusual to find enlarged postauricular and occipital
nodes in children younger
than 2
- if nodes have grown rapidly and are suspiciously large,
mildly painful, or fixed to
contiguous tissues and relatively immovable,
investigate further
- excessive enlargement may obstruct nasopharynx,
increasing risk of sleep apnea
and on rare occasions, pulmonary hypertension

mumps = characterized by somewhat painful swelling of

parotid glands unilaterally or
bilaterally, and occasionally by swelling and tenderness
of salivary glands
along mandible
- swelling can obscure angle of jaw and may appear on
inspection
- cervical adenitis does not ordinarily obscure angle of
jaw

III. COMMON ABNORMALITIES

A. ACUTE LYMPHANGITIS- inflammation of one or more lymphatic vessels
- characterized by pain, feeling of malaise and illness, and possibly fever
- red streak following course of lymphatic collecting duct
- appears as tracing of rather fine lines streaking up extremity
- slightly indurated and palpable
- look distal for sites of infection, particularly interdigitally

B. ACUTE SUPPURATIVE LYMPHADENITIS – node is usually quite firm and tender

- overlying tissue becomes edematous and skin appears erythematous,
usually within 72 hours
- mycobacterial adenitis is characterized by inflammation without warmth
that may or may not be
slightly tender
- causes include group a beta-hemolytic streptococci and coagulase-
positive staphylococci

C. NON-HODGKIN LYMPHOMA – malignant neoplasms of lymphatic system and

reticuloendothelial tissues are well
defined and solid
- occur most often in lymph nodes, spleen, and other sites where
lymphoreticular cells are found
- may be localized in posterior cervical or may become matted, crossing
into anterior
D. HODGKIN DISEASE - malignant lymphoma that occurs in the young of all races,
generally in late adolescence
and young adulthood
- males are twice as likely to develop
- commonly painless enlargement of cervical nodes, generally
asymmetric and inexorably progressive
- occasionally, pressure will produce symptoms that prompt pt to seek
medical care
- nodes are sometimes matted and generally feel very firm, almost
rubbery
- occasionally enlarged with size fluctuating

E. EPSTEIN-BARR VIRUS MONONUCLEOSIS – infectious mononucleosis that occurs at

almost any age but is most
common in adolescents and young adults
- symptoms include pharyngitis and, usually, fever, fatigue, and malaise
- splenomegaly, hepatomegaly and/or a rash may be noted
- may be generalized but more commonly felt in anterior and posterior
cervical chains
- vary in firmness and generally discrete and occasionally a bit tender

F. STREPTOCOCCAL PHARYNGITIS – fairly common

- symptoms include sore throat and often a runny nose with
accompanying headache, fatigue, and
abdominal pain
- anterior cervical nodes are commonly felt - - tending to be somewhat
firm, discrete and quite often
tender
- diagnosis is not ensured without a throat culture

G. HERPES SIMPLEX – can cause discrete labial and gingival ulcers, high fever, and
enlargement of anterior
cervical and submandibular nodes
- firm, quite discrete, movable, and tender
- fever is often high
- frequency of condition and symptoms are generally sufficient to
establish diagnosis

H. CAT SCRATCH DISEASE – most common cause of chronic lymphadenopathy in

children
- diagnosis can be made in presence of nodal enlargement lasting longer
than 3 wks, accompanied by
primary lesion of skin or eye and following an interaction with a cat,
a cat scratch, or cat lick
on break in skin
- may be a papule or pustule that may or may not subside over a short
period of time
- tender nodes are commonly found in the area of the head, neck, and
axillae
- nodes can be very large
 - lymphadenopathy can last for 2 – 4 mos. or even longer, making more
serious malignant disease

I. AIDS – acquired immune deficiency syndrome characterized by dysfunction of

cell-mediated immunity
- manifested as development of recurrent, often severe, opportunistic
infections
- initial symptoms include lymphadenopathy, fatigue, fever, and weight
loss
- in children, a prolonged clinical latent period, but initial signs may
include
neurodevelopmental problems with loss of developmental
milestones, a parotid
enlargement simulating mumps, anemia and
thrombocytopenia, chronic diarrhea, and
recurrent infections
- CD4+ T-lymphocyte count of less than 14% is significant marker for HIV-
related immunosuppression

J. HIV SEROPOSITIVITY – HIV antibodies not yet developed sequelae of recurrent

infections and neoplastic
disease
- warning signs and symptoms may include severe fatigue, malaise,
weakness, persistent unexplained
weight loss, persistent lymphadenopathy, feveres, arthralgias, and
persistent diarrhea

K. LYMPHEDEMA – congenital lymphedema is hypoplasia and maldevelopment of

lymphatic system, resulting in
swelling and often grotesque distortion of extremities
- acquired lymphedema results from trauma to ducts of regional lymph
nodes (particularly axillary and
inguinal) after surgery or metastasis
- obstruction and infection block lymphatic ducts
- does not pit, and overlying skin will eventually thicken and feel tougher
than usual
- congenital is usually apparent at birth and most often involves the legs

L. ELEPHANTIASIS – massive accumulation of lymphedema throughout body that

results from widespread
inflammation and obstruction of lymphatics by filarial worms, Wuchereria
bancrofti or Brugia malayi
- adequate drainage is prevented and pt is more susceptible to infection,
cellulites, and fibrosis