Lymph node and spleen examination

This page teaches the lymph node and spleen examination as one joined system, the lymphoreticular examination. Lymph nodes are filters along lymphatic channels and there are chains that can be felt at the bedside: cervical, supraclavicular, axillary, epitrochlear and inguinal, plus others in the head and neck such as occipital and posterior auricular. The spleen (and, because lymphoma and leukaemia spill beyond one organ, the liver) sits in the same assessment. The examination answers four questions: are any nodes enlarged or abnormal, what do their features suggest (reactive, infective, malignant or metastatic), is there hepatosplenomegaly, and is the picture focal or generalised. It also sets up the next decision, which blood tests, imaging and (sometimes) biopsy are needed and how quickly. ^[1]

Do this examination in a warm, private room with the patient adequately exposed and a chaperone present. It is usually done as a screen (for example, any unwell patient, any suspected haematological problem, or any suspected metastatic cancer) or as a focused test (for example, a patient with a lump in the neck or with fever, night sweats and weight loss). Palpable neck nodes were found in 38 to 45% of children in one estimate, so the normal examination is common and must be described with confidence rather than dismissed. ^[2]

Regional lymphadenopathy means enlargement in one node group or in contiguous groups draining an area; generalised lymphadenopathy is enlargement of more than 2 noncontiguous lymph node groups and points to systemic disease. ^[2]

Introduce yourself, confirm the patient's name and date of birth, and explain the examination in plain language: "I am going to look at and feel the glands in your neck, armpits and groins, and feel your tummy. It should not hurt; please tell me if it does." Offer a chaperone for both male and female patients and record that it was offered and accepted or declined. Ask permission before exposing any region, and ask the patient to keep underclothes on until each region is reached. Wash your hands before and after and wear gloves where there is infection, broken skin or suspected tuberculosis.

Raise the head of the bed to a 45-degree angle for inspection and for the position in which many chains are examined, with the patient sitting for the neck and lying at 45 degrees for the axillae. ^[1] The abdomen is examined with the patient lying flat with arms by the sides and legs uncrossed. Adequately expose each area in turn and re-cover it when finished. Ask the patient where they have pain or swelling before you start and leave painful areas until last.

Warm your hands. For the neck, ask the patient to tilt the chin slightly down to relax the sternocleidomastoid muscles and to rest the hands in the lap. When palpating the anterior cervical chain, be careful not to compress the carotid arteries, which can compromise cerebral blood flow; it is usually safest to examine one side at a time there. ^[1] Stop at once for pain, distress or unexpected tenderness.

Examine in the same order every time, so that no group is missed. The sequence below moves from inspection to palpation, from head and neck to the limbs, and ends with the abdomen and a summary. ^[1]

The detailed steps are these.

1. Set the scene and look generally. Stand at the end of the bed and inspect the patient at rest for pallor, cachexia, bruising, petechiae and abdominal distension, and for clinical signs of underlying disease. ^[1] Note objects and equipment around the bed (sputum pot, inhalers, drug chart, fluid balance) that give context. If the nodes are being examined because of a suspected lymphoma or leukaemia, a thorough lymphoreticular examination is essential, because lymphoma and leukaemia commonly cause hepatosplenomegaly. ^[1]

2. Cervical nodes. Seat the patient upright and examine from behind if possible. Ask the patient to tilt the chin slightly downwards and rest the hands in the lap. ^[1] Inspect for visible lymphadenopathy or neck irregularity. Use the pads of the second, third and fourth fingers to press and roll each node in turn over the surrounding tissue, comparing sides with both hands so that asymmetry in size, consistency and mobility is noticed. Use a systematic chain, such as: submental, then submandibular, then tonsillar and parotid, pre-auricular, post-auricular, superficial cervical, deep cervical (behind the sternocleidomastoid), posterior cervical, occipital, and finally supraclavicular. ^[1] Do not slide the fingertips over the skin; that "piano-playing" technique misses deep nodes and causes false reassurance. ^[1] Note overlying skin changes such as erythema and warmth. The cervical chains drain the tongue, external ear, parotid, larynx, thyroid and trachea, and submaxillary and submental nodes drain the teeth, tongue, gums and buccal mucosa; occipital nodes drain the posterior scalp and pre-auricular nodes the conjunctivae, cheek, eyelids and temporal scalp; mediastinal drainage is reflected in supraclavicular nodes. ^[2] For any node, record site, size, shape (regular or irregular borders), consistency (soft, rubbery or hard), tenderness, mobility and fixity to surrounding structures, number and overlying skin changes.

3. Axillary nodes. Ask about shoulder pain before moving the arm. Inspect each axilla for scars, masses or skin changes. ^[1] Examine with the patient lying at 45 degrees. For the right axilla, hold the patient's right forearm in your right hand, let the arm relax completely and support its weight, and palpate with the left hand; reverse this for the left axilla. ^[1] Cover the five groups in turn: pectoral (anterior, behind the lateral edge of pectoralis major), central (medial, against the thoracic wall at the apex of the axilla), subscapular (posterior, inside the lateral edge of latissimus dorsi), humeral (lateral, the inner aspect of the arm) and apical (reaching up into the apex, warning the patient that it may be uncomfortable), then repeat on the other side. ^[1] Axillary enlargement is often the presenting finding in breast or melanoma metastasis, so a breast examination may be warranted when unilateral nodal enlargement is found. ^[1]

4. Epitrochlear nodes. Hold the wrist of the side being examined with the corresponding hand (right to right) and use the other hand to grasp behind the olecranon, with the thumb reaching across the crease of the elbow to palpate the inner aspect of the arm just above the medial epicondyle of the humerus. ^[1] Epitrochlear nodes are rare but obvious when enlarged, and can accompany conditions causing generalised lymphadenopathy or metastatic melanoma of the arm. ^[1]

5. Inguinal nodes. Inguinal examination is often omitted in OSCEs but should be understood. Ask the patient to lower trousers and underwear, lie flat, and inspect for swellings or irregularity. Palpate directly inferior to the inguinal ligament, which runs between the anterior superior iliac spine and the pubic tubercle, for the horizontal group of superficial inguinal nodes, then place fingers about 3 cm lateral to the pubic tubercle and palpate vertically downwards over the saphenous opening and proximal great saphenous vein for the vertical group. ^[1] Inguinal nodes are often palpable in healthy people, particularly children, and are usually no larger than 1 to 1.5 cm in diameter. ^[2]

6. Abdomen. Hepatomegaly and splenomegaly may be caused by lymphoma and leukaemia, so a thorough abdominal examination is essential in any suspected lymphoreticular problem. ^[1] Position the patient lying flat with arms by the sides and legs uncrossed. Inspect for abdominal distension (which may be caused by gross hepatosplenomegaly), bruising, petechiae and striae from rapid growth or overstretching. ^[1] Perform light and deep palpation of the nine regions, mapping tenderness, guarding, rebound and masses. For the liver, begin palpation in the right iliac fossa at the edge of the superior iliac spine with the flat (radial) edge of the hand, ask the patient to take a deep breath and feel for the step as the liver edge passes below the hand, and move 1 to 2 cm superiorly at a time towards the right costal margin. ^[1] In healthy people the liver edge may become palpable typically 1 to 2 cm below the costal margin; extension greater than 2 cm suggests hepatomegaly. ^[1] For the spleen, palpate similarly from the right iliac fossa with the fingers aligned with the left costal margin; a step may be felt as the splenic edge passes below the hand during inspiration and the splenic notch may be noted. ^[1] In healthy people the spleen should not be palpable; a palpable spleen at the edge of the left costal margin suggests splenomegaly, and for the spleen to be palpable at this location it would need to be about three times its normal size. ^[1] Cross-check by percussion and by turning the patient onto the right side for the spleen, which brings it forward.

7. Completion. Thank the patient, cover, dispose of gloves and apron, and wash your hands. Summarise the findings, then decide on further assessments and investigations (full blood count and film, imaging such as chest X-ray, ultrasound or CT, and biopsy of any suspicious node). ^[1]

A lymph node's features matter more than its presence. Benign or reactive nodes are typically less than 1 cm, smooth, rounded, mobile and either non-tender (benign) or tender (reactive, with infective symptoms such as fever). ^[1] Nodes associated with haematological malignancy are typically widespread, enlarged and rubbery; nodes associated with metastatic cancer are regional, hard or firm, irregular and frequently tethered to local structures. ^[1] A node that is tender, erythematous and warm suggests acute bacterial infection or lymphadenitis; an indolent, non-tender, matted group suggests chronic granulomatous or neoplastic disease.

Red flags for malignancy or urgent disease include: a node that is hard or firm, irregular in outline, fixed or matted to surrounding tissues, or markedly enlarged (well above the 1 cm typical of benign nodes on the source above); supraclavicular (especially isolated and in adults) or infraclavicular enlargement; generalised lymphadenopathy; associated B symptoms (fever, night sweats, weight loss, pruritus); breathlessness, suggesting mediastinal disease; hepatosplenomegaly; petechiae, bruising or abnormal blood counts; and persistent enlargement without an obvious local source. Mediastinal nodes cannot be palpated directly, so their enlargement is suspected from cough, wheeze, dysphagia, haemoptysis or atelectasis, or from supraclavicular findings. ^[2] Supraclavicular adenopathy is often associated with mediastinal adenopathy, and mediastinal masses are predominantly tumours or cysts. ^[2]

Most cervical lymphadenopathy in children is reactive to infection, and an obvious source in the upper respiratory, dental, scalp or skin territory can be watched after treating it. NICE advises, for suspected cancer recognition and referral, that the following should prompt urgent action:

• Generalised lymphadenopathy or hepatosplenomegaly are among the features that should make a clinician consider a very urgent full blood count to assess for leukaemia in adults, and hepatosplenomegaly or petechiae should make a clinician refer children and young people for immediate specialist assessment. ^[3]
• Unexplained lymphadenopathy or splenomegaly in adults should prompt consideration of a suspected cancer pathway referral for non-Hodgkin lymphoma, taking into account associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. ^[3]
• Unexplained lymphadenopathy in adults should prompt consideration of a suspected cancer pathway referral for Hodgkin lymphoma, taking into account associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcohol-induced lymph node pain. ^[3]
• For children and young people, unexplained lymphadenopathy or splenomegaly should prompt consideration of referral for specialist assessment within 48 hours for non-Hodgkin lymphoma, and unexplained lymphadenopathy should prompt consideration of referral within 48 hours for Hodgkin lymphoma, with the same associated symptoms. ^[3]
• Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy appears in NICE guidance on assessing for lung cancer with an urgent chest X-ray in people aged 40 or over. ^[3]
• Persistent, unexplained lumps in the neck are included among the features prompting consideration of a suspected cancer pathway referral for laryngeal or oral cancer. ^[3]

These are prompts to think and to act locally, not automatic diagnoses; always apply local pathways and guidelines, and seek senior advice. First-line tests for unexplained lymphadenopathy include a full blood count with blood film, inflammatory markers, liver function, Epstein-Barr virus and cytomegalovirus serology, human immunodeficiency virus testing and a chest X-ray, with ultrasound of an abnormal node and biopsy when features are suspicious or the node persists despite a plausible benign cause.

Start with the finding that matters most, then the rest in the order you examined, then the negatives that change the differential, then a one or two sentence summary with alternatives. Lead with the important finding rather than the first one you found, and state numbers (centimetres, how many groups, which side) rather than labels such as "large". Use the form "consistent with / suggesting", not a premature diagnosis. End with what you would do next only if it follows from the findings you have actually made. ^[1]

A useful order is this: general state (well, cachectic, jaundiced); which groups are involved and which are not; the features of the nodes (size, consistency, tenderness, mobility); hepatosplenomegaly or its absence; summary and differential; next steps. State the negatives that settle the differential (no supraclavicular nodes, no splenomegaly, no B symptoms, nodes tender and mobile) and do not list every normal finding.

In the notes, write short lines in the same order as the spoken presentation, one finding per line: "No cervical, axillary or inguinal lymphadenopathy. Liver 1 cm below right costal margin, soft. Spleen not palpable. No ascites. In summary, normal lymphoreticular examination." Do not copy prose into the notes, and do not add a diagnosis that the findings do not support.

All patient details below are invented and illustrative; they are not real patients.

Normal lymphoreticular examination, 24-year-old man, pre-employment. Spoken: "On examination the patient is comfortable and not pale or cachectic. There is no cervical, axillary, epitrochlear or inguinal lymphadenopathy. The abdomen is soft, the liver is just palpable 1 cm below the right costal margin and soft, and the spleen is not palpable. There is no ascites. In summary, the lymphoreticular examination is normal."

Reactive cervical lymphadenopathy, 19-year-old woman, sore throat. Spoken: "On examination the patient is pink and afebrile, with tender 1 cm smooth mobile anterior cervical nodes bilaterally and a normal pharynx. There is no axillary, epitrochlear or inguinal lymphadenopathy. The abdomen is soft, the liver is not palpable and the spleen is not palpable. In summary, localised tender mobile cervical nodes consistent with reactive lymphadenopathy from an upper respiratory tract infection; differential includes infectious mononucleosis, so I would check a full blood count if symptoms persist."

Suspected haematological malignancy, 64-year-old man, weight loss. Spoken: "On examination the patient is thin and pale but afebrile. There are widespread rubbery lymph nodes in the cervical, axillary and inguinal groups, the largest about 3 cm, non-tender and tethered; there is no erythema. The spleen is palpable 5 cm below the left costal margin and the liver edge is 4 cm below the right costal margin, firm. There is no ascites. In summary, generalised lymphadenopathy with hepatosplenomegaly, most consistent with a haematological malignancy; key alternatives are advanced infection or autoimmune disease, and I would arrange an urgent full blood count and film, imaging and lymph node biopsy."

Localised metastatic disease, 58-year-old woman, breast lump. Spoken: "On examination the patient is not cachectic. There is a 2 cm firm irregular mobile right axillary node, with no nodes elsewhere; the breast examination is abnormal. The abdomen is soft and there is no hepatosplenomegaly. In summary, regional axillary lymphadenopathy in a group draining the breast, consistent with metastatic spread; I would complete a breast examination and arrange imaging."

• Forgetting groups entirely, especially the supraclavicular, occipital, axillary and inguinal nodes; a chest or breast problem is missed when the axilla is not felt. ^[1]
• Sliding the fingertips along the skin instead of pressing and rolling the nodes; this finds nothing or finds only the skin. ^[1]
• Palpating painful areas first, so the patient tenses for the rest of the examination.
• Palpating the anterior cervical chain too firmly or compressing both sides at once, risking carotid compression.
• Calling a node "enlarged" without measuring and recording site, size, consistency, tenderness and mobility.
• Missing hepatosplenomegaly by palpating too gently, by not starting low enough in the right iliac fossa, or by forgetting to inspect for distension and striae.
• Calling liver enlargement without remembering that a normal liver edge can sit 1 to 2 cm below the costal margin. ^[1]
• Calling the spleen enlarged without noting that it must be about three times its normal size before it becomes palpable. ^[1]
• Not distinguishing reactive (tender, mobile, small) from suspicious (hard, fixed, large) nodes.
• Omitting B symptoms, the primary examination and the other node groups once one abnormality is found.
• Over-stating a diagnosis from the examination alone; the examination narrows the differential, it does not replace blood tests, imaging and histology.

• The lymph node and spleen examination is a single lymphoreticular assessment, usually done with the patient sitting for the neck, lying at 45 degrees for the axilla, and lying flat for the abdomen. ^[1]
• Raise the head of the bed to 45 degrees and ask the patient to tilt the chin down to relax the neck muscles. ^[1]
• Cervical palpation uses the pads of the second to fourth fingers to press and roll; examine the chains in a fixed order including the often-missed occipital and supraclavicular groups. ^[1]
• Benign or reactive nodes are typically less than 1 cm, smooth, rounded, mobile and tender when reactive; malignant nodes are hard or firm, irregular and often fixed. ^[1]
• A palpable spleen at the left costal margin implies splenomegaly of about three times normal size; a normal liver edge may sit 1 to 2 cm below the right costal margin and an edge greater than 2 cm below suggests hepatomegaly. ^[1]
• Inguinal nodes are often felt in healthy people and are usually no larger than 1 to 1.5 cm in diameter. ^[2]
• Occipital nodes are palpable in about 5% of healthy children and pre-auricular nodes are rarely palpable in healthy children. ^[2]
• Generalised lymphadenopathy is enlargement of more than 2 noncontiguous node groups and indicates systemic disease. ^[2]
• Supraclavicular lymphadenopathy, particularly on the left, can reflect intra-abdominal disease and always merits explanation. ^[2]
• Mediastinal node enlargement cannot be felt and is inferred from respiratory or swallowing symptoms or from supraclavicular findings. ^[2]
• Unexplained lymphadenopathy or splenomegaly (especially with B symptoms) should prompt urgent or suspected-cancer pathway referral and blood tests, as advised by NICE. ^[3]
• Presentation leads with the finding that determines management, gives numbers, lists the negatives that change the differential, and ends with a summary and alternatives.