Lymph node enlargement

An important diagnostic sign, often a symptom of a pathological process, is enlarged lymph nodes. In some cases, this is the first and only sign of disease, which is why the doctor must examine all groups of lymph nodes and enter information about them into medical records.

Normally, lymph nodes are painless, mobile, elastic in consistency, their size varies from a few millimeters to 1-1.5 cm. The maximum size is for lymph nodes located along the lymphatic vessels that collect lymph from areas subject to the greatest antigen irritation (inguinal, cervical, axillary), caused by abrasions, injuries, inflammatory processes in the mouth and nasopharynx.

To assess the condition of the lymph nodes during a clinical examination, the patient's complaints about their soreness and swelling are taken into account, attention is paid to the localization of lymphadenopathy, the clarity of the contours and size of the lymph nodes, changes in the color of the skin above them, consistency, mobility or adhesion to each other and surrounding tissues. Examination and palpation of the lymph nodes are carried out in the following order: occipital, pre- and postauricular, anterior and posterior cervical, submandibular, supra- and subclavian, axillary, elbow, inguinal, popliteal.

The lymph nodes, together with the spleen, tonsils and lymphoid tissue, are secondary (peripheral) organs of the immune system. The lymph nodes contain lymphocytes and macrophages; the sinus of the cortex of the lymph nodes is filled with phagocytes, which provide the first stage of the immune response to infections. Antigenic irritation is accompanied by the proliferation of T- and B-lymphocytes in the lymph nodes. The transformation of B-lymphocytes into plasma cells that secrete immunoglobulins (antibodies). In addition, the lymph nodes are a biological filter that prevents various foreign agents from entering the lymph and blood, including microorganisms, their metabolic products and toxins. This is why many infectious diseases naturally cause lymphadenopathy to varying degrees. which is usually combined with other symptoms characteristic of infections: fever, intoxication, hepatosplenomegaly, rash, etc.

Enlargement of regional lymph nodes, such as the cervical and other areas, is sometimes the main complaint of patients, leading them to the doctor. In this case, enlarged lymph nodes can be noticeable, as they deform the corresponding part of the body. However, the main method of examining lymph nodes is palpation. Palpation of the lymph nodes is performed with soft movements of the fingertips, comparing symmetrical areas of the head, neck, forehead.

During palpation, the following characteristics of the lymph nodes are assessed:

• Quantity.
• Form.
• Size.
• Consistency.
• Painfulness.
• Mobility.
• Adhesion to surrounding tissues (if there are several lymph nodes, also to each other).

It is advisable to palpate the lymph nodes in a certain order: occipital, parotid, submandibular (anterior and posterior), submental, superficial cervical, supraclavicular, subclavian, thoracic, axillary, elbow, inguinal.

• The occipital lymph nodes should be palpated at the site of attachment of the trapezius muscle in the area where the back of the neck transitions to the back of the head.
• The parotid lymph nodes are palpated anterior to the tragus of the auricle.
• The anterior submandibular lymph nodes (in clinical practice, they are not entirely correctly referred to as submandibular) should be palpated anterior to the submandibular salivary gland.
• The posterior submandibular lymph nodes (in clinical practice they are not quite correctly called tonsillar) are located behind the submandibular gland near the angle of the lower jaw.
• The submental lymph nodes are palpated in the submental triangle of the neck (behind the body of the lower jaw). Enlargement of the submandibular and submental lymph nodes often occurs as a local reaction to inflammatory processes in the palatine tonsils and teeth.
• The superficial cervical lymph nodes lie anterior to the sternocleidomastoid muscle.
• The supraclavicular lymph nodes are located in the supraclavicular fossa between the legs of the sternocleidomastoid muscle.
• The subclavian lymph nodes should be palpated under the clavicle along the subclavian vein.
• The pectoral lymph nodes are located under the pectoralis major muscles.
• The axillary lymph nodes are palpated in the axillary fossa.
• The superficial ulnar lymph nodes are located on the anterior surface of the forearm at the level of the medial epicondyle of the arm along the medial saphenous vein of the arm. A palpable ulnar lymph node is usually a sign of systemic lymphadenopathy.
• The inguinal lymph nodes should be palpated in the inguinal areas along the inguinal fold. The size of the detected enlarged lymph node is expressed in millimeters. Sometimes in the area of a dense lymph node, cicatricial formations can be found - traces of former fistula tracts or fresh fistulas with the separation of pus, other fluid, which, naturally, must be specially examined (for example, to detect tuberculosis). In some cases, the lymph nodes are detected already during a general examination.

The characteristic, for example, of the submandibular group of lymph nodes will sound like this: a single submandibular lymph node is palpated, round in shape, 7 mm in size, soft in consistency, mobile, painless, not fused with surrounding tissues.

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Causes of enlarged lymph nodes

The most significant enlargement of lymph nodes occurs in the following conditions.

• Various acute inflammatory diseases, such as acute pharyngitis, acute purulent, mastitis.
• Early stage of HIV infection: in many cases, generalized lymphadenopathy is the only clinical sign of the disease.
• Blood diseases - primarily hemoblastoses.
• Lymphoproliferative diseases - lymphogranulomatosis.
• Systemic connective tissue diseases.
• Tumors with metastases to the lymph nodes. A classic example is the so-called Virchow's metastasis (one or more enlarged but painless lymph nodes palpated between the upper edge of the clavicle and the outer edge of the sternocleidomastoid muscle) - a common sign of metastasis of gastric cancer. Unfortunately, the detection of Virchow's metastasis in gastric cancer indicates an advanced stage of the tumor process.
• Some infectious diseases, such as brucellosis.

To clarify the cause of enlarged lymph nodes, in addition to general clinical and laboratory studies, a biopsy of the node is performed for its morphological examination.

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Diagnosis of enlarged lymph nodes

To diagnose a patient with lymphadenopathy, the following factors must be taken into account.

• Age of the patient (infectious mononucleosis, adenovirus infection, rubella most often occur in children and young people).
• Information about previous illnesses (frequent tonsillitis and acute respiratory infections, inflammatory processes in the oropharynx explain the enlargement of the lymph nodes of the cervical group), pay special attention to tuberculosis. Lymphadenopathy in the anamnesis.
• Other symptoms (fever, splenomegaly, skin rash, lung damage, etc.).
• Epidemiological history (contact with animals, stay in regions endemic for certain infections, promiscuous sexual relations, etc.).

Examination of patients with lymphadenopathy is carried out in stages. Sometimes the results of determining peripheral blood parameters are sufficient: for the diagnosis of infectious mononucleosis (lymphomonocytosis, atypical mononuclear cells), chronic lymphocytic leukemia (absolute lymphocytosis), acute lymphoblastic leukemia, lymphogranulomatosis (absolute lymphopenia, eosinophilia). Routine methods also include ultrasound of the abdominal cavity and pelvic organs, X-ray examination of the chest organs, and blood serum testing for antibodies to pathogens of some of the above-mentioned infectious diseases. If necessary, a puncture and/or biopsy of the lymph node with bacteriological and histological examination of the biopsy is performed. determination of specific tumor markers.

Differential diagnostics

Differential diagnostics when detecting lymphadenopathy includes a wide range of both infectious and somatic diseases.

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Principles of treatment of patients with lymphadenopathy

• It is necessary to establish the cause of lymphadenopathy as early as possible and only then prescribe appropriate therapy.
• Antibacterial drugs should only be used for bacterial infections, including rickettsiosis.
• In case of lymphadenopathy of unknown etiology, it is recommended to avoid the administration of glucocorticoids.
• In case of suppuration of the lymph nodes (tularemia, benign lymphoreticulosis, staphylococcal, streptococcal lymphadenitis), surgical intervention is indicated.