Adenopathies. Also known as lymphadenomegalies or lymphadenopathies; They are the increase in size or the alteration of the consistency of the lymph nodes. Its normal size is less than 1 cm, except for the inguinal nodes where the limit is 2 cm. In any other body location, nodes smaller than 0.5 cm can be palpated, corresponding to old infections.
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- 1 Lymphatic system
- 2 Most frequent causes or etiologies
- 3 Personal Background
- 4 Symptoms
- 5 Diagnosis
- 6 Complementary examinations
- 1 Basic tests for adenopathy without obvious cause
- 7 Differential Diagnostic Algorithm
- 8 Treatment
- 9 Source
The lymphatic system is made up of lymph, lymphatic ducts, and various organs, including lymph nodes. These are usually grouped and are very numerous. The superficial nodes are lodged in the subcutaneous connective tissue, while the deepest are located next to the fasciae of the muscles and inside the various body cavities.
Most frequent causes or etiologies
Lymph node growth may be due to: an increase in the number of benign macrophages and lymphocytes during response to antigens, infiltration by inflammatory cells in infections involving nodes, in situ proliferation of malignant macrophages or lymphocytes, infiltration by malignant neoplastic cells, or infiltration by metabolite-laden macrophages in lipid deposition diseases
- Recent surgery,
• addicted to parenteral drugs,
• sexual, homosexuality,
• taking drugs,
• habitual occupations,
• contact with animals or infectious contacts,
It is also very important to consider the clinical context in which it occurs, if there are infectious skin lesions or general symptoms, as has already been discussed in previous lines. It is very important to assess the evolution time of the adenopathy, if it is less than 15 days it is probably of infectious origin or malignant hematological disease, if it is longer than 1 month it may be of tuberculosis or neoplastic origin.
The presence of
• unexplained fever,
• night sweats and weight loss greater than 10% should be investigated ),
• skin lesions or rash,
• Hoster’s sign (nodes are painful when ingesting alcohol),
• heart murmurs,
• signs of hemorrhagic diathesis,
• signs of local infection in the drainage areas
• other signs that may orient towards the etiology.
Physical examination: All regions must be explored. For palpation of the superficial nodes, the palmar surface of the second, third and fourth fingers is gently used, detecting any inconspicuous size increase and observing its consistency, mobility, sensitivity to touch and heat.
If it is a large tumor, try to isolate it with the thumb and index finger. If they are smaller tumors, an attempt is made to palpate them by resting the tips of the fingers on the deep ganglion structures -particularizing in size, location, consistency and mobility in each examination.
On general examination: In the neck, the anterior border of the sternocleidomastoid constitutes the dividing line of the anterior and posterior cervical triangles and serves as a useful reference point to describe the location.
Tilting the patient’s head forward relaxes the tissues and improves accessibility. To explore the cervical nodes it is useful to stand behind the seated patient. (It is also interesting to feel the thyroid in the midline and observe its displacement when swallowing the patient). The otorhinolaryngological area will be especially valued in the presence of lymphadenopathies of the cervical region. They should be explored in sequence:
- Superficial behind the ear over the mastoid process
- Preauriculares, located immediately in front of the pinna, comparing those on both sides
- Parotid and retropharyngeal (tonsillar) of the mandibular angle
- Submaxillae located halfway between the angle and the mandibular vertex (bimanual palpation with some fingers located at the oral level and others externally is sometimes necessary). It is very common to confuse a submaxillary gland with a lymphadenopathy.
- Submentals in the midline and behind the vertex of the mandible. Then we feel by moving down the neck:
- Superficial cervicals along the sternocleidomastoid muscle
- Posterior cervicals along anterior border of trapezius
- Deep cervicals below the sternocleidomastoid, difficult to explore if done with a lot of pressure
- Supraclavicular, palpating deeply at the angle formed by the clavicle and sternocleidomastoid muscle, the Virchow node area. They are frequent sites of metastasis due to their location at the end of the thoracic lymphatic duct and other associated ducts. Palpable nodes can be found on either side of the neck because the mediastinal collecting ducts of the lungs run both ways.
Cervical palpation must be completed with a general lymph node examination. To palpate the axillary nodes, the patient’s forearm is grasped and the flat palm of the explorer hand is inserted into the axillary socket or, alternatively, the patient’s forearm is allowed to rest in the one of the hand that performs the exploration, describing movements circular with the tips of the fingers and the palm, noting the central axillary nodes – towards the middle of the chest wall of the armpit – and the lateral axillary nodes – under the anterior border of the latissimus dorsi muscle.
A systematic procedure should always be used to palpate other regions. For the epitrochlear nodes, hold the elbow with one hand while exploring the depression above and behind the medial condyle of the humerus, approximately 3 cm proximal to the humeral epitrochlea. For the ganglia in the inguinal and popliteal regions, the patient should be placed in the supine position, with the knees slightly flexed.
The superior superficial inguinal nodes (femoral) are very close to the surface above the inguinal ducts. The lower inguinal nodes are located in deeper areas of the groin. The ganglia in the inguinal region increase in size when there are lesions on the surface of the scrotum or penis.
The study of an adenopathy can be carried out according to the location of the nodes and the type of clinical symptoms present, which can reveal diagnostic data to guide further investigations. For example, the presence of cervical lymphadenopathy, especially if it is multiple, accompanied by lymph nodes in other territories, will guide us towards lymphoma or generalized infectious disease and, based on this orientation, we will request additional tests.
Sometimes the anamnesis, the physical examination and an analytical test make it possible to diagnose the disease, as occurs in most exanthematic diseases such as rubella or infectious mononucleosis. On other occasions other tests have to be used. The study must be individualized according to the clinical diagnostic orientation. If there are generalized lymphadenopathy, the study is similar to that of the localized one, also adding immunological analysis and serology to human immunodeficiency virus (HIV).
Basic tests for adenopathy without obvious cause
- Initials: CBC, peripheral blood smear, globular sedimentation rate (ESR), Biochemistry: liver function, kidney function, bilirubin, alkaline phosphatase, folic acid, iron, vitamin B12.
- Subsequent: -Microbiology: serologies (Epstein-Barr virus (EBV), cytomegalovirus, toxoplasmosis, HIV, hepatitis B virus (HBV), lus, rubella, brucella), cultures, bacilloscopy, Mantoux. -Immunology: rheumatoid factor, immunoglobulins , lymphocyte populations, antinuclear antibodies, anti-DNA antibodies.-Chest radiography, with which, among other pathologies, cysts, tuberculous calcifications, or radiopaque foreign bodies can be studied. -Abdominal ultrasound, can inform us about retroperitoneal nodes. -Toracic / abdominal CT, which allows assessing, for example, vascular alterations, hematomas, tumors and cysts, both in location and in
extension, as well as retroperitoneal and mesenteric adenopathies. It is very sensitive to detect lymphadenopathies between 1 and 2 cm in diameter. -67Ga scan and thyroid scan.
- If we do not reach the etiological diagnosis with all this battery of tests, we should consider performing -Fine needle aspiration (FNA) and / or lymph node biopsy. – FNA is an effective technique for the evaluation of superficial lymphadenopathy in the initial study, being a useful means of recognizing metastases and 10 specific lymphadenitis, but not in lymphoproliferative processes and other processes such as myeloproliferative syndromes. -The lymph node biopsy is diagnostic in 50-60% of cases, over 25% of nondiagnostic cases they will present a variable disease, usually a lymphoma, in a variable period of time, so a close follow-up of these patients and repeat the biopsy if necessary.
Differential Diagnostic Algorithm
Lymphadenopathy at the cervical level can be differentiated between inflammatory and non-inflammatory. Noninflammatory lymphadenopathy would include neoplastic lymph nodes. With respect to neoplastic tumors, 50% of them are lymph node tumors and 40% are metastases from other tumors. They are usually large and multiple lymphomas.
Regarding the location of the primary neoplastic region, it can be generalized that the retropharyngeal nodes usually correspond to a cavul neoplasm. Submaxillary and submandibular lymphadenopathies are related to the oral cavity and the tonsils. The lymphadenopathies in the superficial cervical region guide us towards laryngeal or pyriform sinus neoplasms.
Supraclavicular lymphadenopathies lead us to suspect an esophageal or bronchial location, or are metastases from supra or infraradiaphragmatic, pulmonary, breast, or prostate neoplasms.
Inflammatory lymphadenopathy can be acute or subacute / chronic. The acute ones are more frequently related to infectious processes of the upper aerodigestive tract, in the context of a feverish syndrome with elastic, rolling and painful nodes that can provoke the voluntary immobility of the neck. Usually, no complementary test is required to reach the diagnosis and its spontaneous evolution is towards healing in two or three weeks, with residual lymph node hypertrophy for a long time.
Within the subacute / chronicles we must highlight a series of entities:
- Cervical tuberculosis: normally it is a single, laterocervical adenopathy, frequently located at the level of the posterior cervical triangle or in the submandibular region, which can fistulize leaving a characteristic brownish scar called scrofula. Its diagnosis is by culture of the sample obtained by FNA or by study of the removed node.
- HIV: Initially, a syndrome composed of lymphadenopathies, fever and arthralgias that later became palpable and non-painful lymphadenopathy in two or more lymph node regions.
- XToxoplasmosis: in the acquired form, phases of symptoms similar to those of influenza appear with subfebrile temperatures and inflammatory occipital and / or submandibular lymphadenopathy.
- CoSarcoidosis: lymphadenopathy, especially mediastinal and supraclavicular lymphadenopathy associated with ocular disorders, lacrimal and salivary glands and other symptoms.
- TrasOthers: Tularemia, cat scratch disease, syphilis, brucellosis,
The treatment of lymphadenopathy will be that of the underlying disease. It is important to assess the presence of systemic disease. It is assumed that an adenopathy, depending on our diagnostic suspicion, should be evaluated again 15 days after its appearance along with the complementary tests and guide its study based on its evolution. The complications of lymphadenopathy are not very frequent, but they derive from the compression of neighboring structures, the degree of inflammation and their possibility of fistulizing fundamentally.