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 VARIATIONSA. 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 ASSESSMENTA. 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 Variationsa. 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 ASSESSMENTA. 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 Variationsa. 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 ABNORMALITIESA. 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