Palpate the infraclavicular nodes on the underside of the clavicle.

Some lung and abdominal cancers metastasize to these nodes, so they may be discovered during the examination.

Palpate the supraclavicular nodes deep within the angle formed by the sternomastoid muscle and clavicle.Palpate the posterior cervical nodes between the anterior edge of the trapezius and posterior edge of the sternomastoid.Deep cervical nodes, beneath the sternomastoid muscle, are rarely palpable. Palpate the anterior and superficial cervical nodes in front of and overlying the sternomastoid muscle, respectively.Note that submandibular nodes need to be distinguished from the underlying submandibular gland, which is larger and lobulated. Palpate the tonsillar nodes located at the angle of mandible, the submandibular nodes midway between the angle and tip, and the submental nodes a few centimeters from the tip.Palpate the occipital nodes posteriorly at the base of the skull.Palpate the preauricular, posterior auricular, and mastoid nodes in front of the ear, behind the ear, and superficial to the mastoid process, respectively.In many cases, the nodes are not palpable. For each of the following steps, plan to palpate the head and neck nodes ( Figure 2) with both hands, one on each side.With the patient's neck flexed slightly forward, inspect for noticeably visible node enlargement.It is best to use the pads of the index and middle fingers to note the size, shape, number, pliability, texture, mobility, and tenderness of nodes bilaterally.įigure 2. In addition to lymphoma, diffuse lymphadenopathy may be an indication of generalized infectious or inflammatory disorders such as HIV, mononucleosis, or sarcoidosis.īecause lymph nodes are distributed throughout the body, their evaluation usually takes place as part of the regional examinations of the head and neck, breast and axillae, upper extremities, external genitalia, and/or lower extremities. Lymphoma, a primary cancer intrinsic to the lymphatic system, may be present anywhere in the body as single or multiple enlarged lymph nodes, which may become big enough to see on inspection, and are generally hard and non-tender on palpation. If the cancer invades the outer capsules, nodes may become fixed to the surrounding soft tissue or matted together. Unlike infections, malignant cells invading lymph nodes may cause them to feel irregular and firm (even rock hard) but remain non-tender. Many metastatic cancers spread to regional lymph nodes first. In rare cases, the intensity of the inflammatory reaction may cause the nodes to adhere to the surrounding soft tissue, fixing them in place. This may be accompanied by the appearance of red streaks and systemic symptoms such as fever, chills, and malaise. An infected wound or cellulitis may also result in lymphangitis or lymphadenitis, a condition in which the infection spreads along the chain of lymph channels and nodes. Regional lymph nodes draining the area of a localized infection typically remain invisible but may become enlarged and tender on palpation. For example, a soft, tender lymph node palpable near the angle of the mandible may indicate an infected tonsil, whereas a firm, enlarged, non-tender lymph node palpable in the axilla of a female patient may be a sign of breast cancer. Nodes may become enlarged, fixed, firm, and/or tender depending on the pathology present.

Lymphadenopathy usually indicates an infection or, less commonly, a cancer in the area of lymph drainage. However, larger nodes (>1 cm) in the neck, axillae, and inguinal areas are often detectable as soft, smooth, movable, non-tender, bean-shaped masses imbedded in subcutaneous tissue. Lymph nodes are normally invisible, and smaller nodes are also non-palpable. Only nodes near the surface can be inspected or palpated. Most lymph channels and nodes reside deep within the body and, therefore, are not accessible to physical exam ( Figure 1). As the collected fluid passes through lymphatic channels on its way back to the systemic circulation, it encounters multiple nodes consisting of highly concentrated clusters of lymphocytes. The lymphatic system has two main functions: to return extracellular fluid back to the venous circulation and to expose antigenic substances to the immune system. Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

Lymph nodes base of back neck