Lymphatic Disorders

 

Lymphadenopathy

Inspection

Number Multiple
Site
Shape
Size
Surface
Skin and color Inflammatory signs Acute lymphadenitis
Infiltrative signs Advanced malignancy
Sinus TB
Special signs Transmitted pulsations Para-aortic LN
Move with deglutition Para-tracheal LN

Palpation

Relations to the surroundings

Mobility

Relation to skin
Relation to muscles
Relation to nerves
Relation to arteries
Relation to veins
Other swellings Generalized lymphadenopathy
Temperature
Tenderness
Edge Well defined Scattered

Discrete

Ill defined Matted

Amalgamated

Reducibility
Solid, fluid or gas

Consistence

Fluctuation

Hard Advanced lymphoma
Firm TB

Chronic lymphadenitis

Cystic Cold abscess
Percussion Sternum for  :  Mediastinal masses

Tenderness in leukaemia

Auscultation Despine sign in case of mediastinal lymph nodes
After examination we will be able to answer these questions
  • Anatomical diagnosis
  • Localized or generalized
  • Aetipathologicaly (Infective, Neoplastic, Others )
  • Functional ( Pressure manifestations, Metastasis )

Lymphedema (Lower limb)

Inspection

  1. Grossly swollen legs
  2. Preserved skin creases
  3. Buffalo hump (dorsum of the foot) 
  4. Square toes

Palpation

  1. Non pitting edema
  2. Inguinal lymph nodes

TAKING HISTORY FROM A PATIENT WITH A LYMPHADENOPATHY

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Lumps (lymphadenopathy)
  • Pressure symptoms (according to the site of lymphadenopathy)
    • Neck lymphadenopathy
Dyspnea Trachea or larynx
Dysphagia Oesophagus
Hoarseness Recurrent laryngeal nerve
Horner’s syndrome Sympathetic chain
Fainting attacks Carotid artery compression
Face oedema IJV compression
  • Abdominal lymphadenopathy
Abdominal pain
Jaundice Nodes in porta hepatis
Leg edema Compression of iliac veins or IVC by iliac or para-aortic LN
Renal pain Ureteric compression
  • Chest lymphadenopathy

Chest pain

Cough

Dyspnea

  • Axillary lymphadenopathy
  • Oedema of the affected limb
Vein compression
  • Tingling
  • Numbness
Nerve compression
  • Ischemia
  • Gangrene
Artery compression
TAKING HISTORY FROM A PATIENT WITH A LYMPHEDEMA

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Swollen limb (lymphoedema)
  • Pain
  • Fever
Hectic abscess formation
Night fever TB
Pel Ebstien fever Hodgkin’s lymphoma
  • History suggesting the cause
    • If localized lymphadenopathy
      • Ask about the drainage area for (Infection – Malignancy)
    • If generalized lymphadenopathy
      • TB manifestations (Night sweat – Night fever – Loss of weight – Loss of appetite)
      • Leukaemia manifestations (Bleeding tendency – Bone aches)
      • Lymphoma manifestation (Pruritus – metastasis manifestation)
    • Secondary lymphoedema
      • Post-traumatic
        • Injuries as circumferential scars of the limbs
        • Operations as block dissection of regional lymph nodes
        • Burns at the site of lymph nodes
        • Irradiation of regional lymph nodes
      • Post-inflammatory
        • Non-specific infection
          • Recurrent non-specific lymphangitis
          • Recurrent cellulitis due to evident focus of infection
            • Interdigital infection
            • Chronic leg ulcer
          • Post-erysipelas lymphoedema
        • Specific infection (Filarial – TB)
      • Neoplastic
Differential diagnosis of swollen lower limb (lymphoedema)
  • Edema
    • Local causes
      • Venous (DVT – 1ry varicose veins – 2ry varicose veins)
      • Lymphatic obstruction) (Post traumatic – Post inflammatory – Neoplastic – Primary)
      • Arterial (Arterio-venous fistula – Post-revascularization)
      • Traumatic
      • Inflammatory
    • General causes
      • Cardiac – Hepatic – Renal – Nutritional – Allergic – Hypoalbuminaemia (Hepatic – Renal – Nutritional – Bowel – Trauma to thoracic duct)
  • Not edema
    • Local gigantism – Hemi hypertrophy – Tumor – Lipidaema in females (Cyclic – Non cyclic)
Types of primary lymphoedema

Congenita

Praecox

Tarda

Incidence 10% 80% 10%
Age At or within 1 year of birth Usually adolescence After 35 years
Sex M>F F>M M=F
Site Commonly bilateral and involve the whole leg Commonly unilateral and below the knee Usually unilateral