This maneuver should be repeated several times in order to examine the lateral group, the medial group, and the pectoral group of axillary nodes. Fingers are brought down slowly, exerting gentle pressure against the thorax. The examiner's fingers should be slightly cuffed and should reach as high into the apex of the axilla as possible. The examiner's right hand is used to examine the patient's left axilla, and the left hand for the right axilla, as shown in Figure 149.2A. The patient's arm, supported by one of the examiner's hands, should be held in a slightly flexed position and adducted. The patient may be either sitting or supine. The patient should then be examined for axillary adenopathy. Although a chest x-ray or computerized tomography is often needed to verify this type of lymphadenopathy, dullness to percussion over the manubrium is sometimes suggestive of an anterior mediastinal mass or mediastinal nodes. If supraclavicular adenopathy is noted, the patient should also be closely examined for hilar and mediastinal adenopathy. Supraclavicular nodes are sometimes deep seated, and it is often helpful to have the patient perform a Valsalva maneuver in order to push the cupola of the lung upward, thereby bringing these deep-seated nodes to a more accessible position for palpation. Left-sided supraclavicular nodes, which carry the eponym 'Virchow's nodes,' are close to the thoracic duct and often signal intra-abdominal tumors, particularly from the stomach, ovaries, testes, or kidneys. Right-sided supraclavicular nodes drain parts of the lung and mediastinum and are signals of intrathoracic lesions, particularly in the lung and esophagus. When it is not part of generalized lymphadenopathy, it is suggestive of a primary malignancy in either the abdomen or the chest. Supraclavicular adenopathy is almost always abnormal. However, a unilateral cervical mass that is firm and nontender should always raise the question of an undetected nasopharyngeal carcinoma. Bilateral cervical adenopathy is also prominent in tuberculosis, coccidioidomycosis, infectious mononucleosis, toxoplasmosis, sarcoid, lymphomas, and leukemias.

Oropharyngeal and dental infections can also cause cervical adenopathy. For example, posterior auricular adenopathy suggests rubella, whereas unilateral anterior auricular adenopathy is associated with lesions of the conjunctiva and eyelids with the resultant oculoglandular syndrome seen in trachoma, tularemia, cat-scratch fever, tuberculosis, syphilis, epidemic keratoconjunctivitis, and outbreaks of adenovirus type 3 pharyngoconjunctival fever. In the absence of generalized adenopathy, enlargement of specific cervical lymph node groups can be helpful diagnostically. Starting from the top of the neck and going down, all of the various cervical lymph node chains should be evaluated including the preauricular, posterior auricular, occipital, superior cervical, posterior cervical, submaxillary, submental, inferior deep cervical, and supraclavicular, as noted in Figure 149.1. The examiner's right hand explores the left side of the patient's neck and then the left hand of the examiner explores the right side of the patient's neck. For an examination of lymph nodes of the neck, the patient either sits or stands facing the examiner.

Palpate in a systematic fashion, encompassing all accessible lymph nodes. Begin with a visual inspection of the area, looking for asymmetry or erythema. All major lymph node chains should be evaluated in a systematic fashion. The extent and location of lymphadenopathy are important in determining and providing diagnostic clues to the cause of lymphadenopathy. Matted nodes or nodes fixed to underlying structures should raise the question of malignancy or infection freely movable nodes are more likely to occur in benign conditions. Tender nodes are suggestive of an inflammatory process. Enlarged lymph nodes that have an irregular shape and a rubbery, hard consistency may be infiltrated by malignant cells. Lymph nodes that are smooth and relatively soft, but slightly enlarged, may be normal and reveal only hyperplasia when biopsied. Particular attention should be directed to the size, shape, and consistency of enlarged nodes. In searching for lymph nodes, one must be gentle otherwise, lymph nodes that are only minimally enlarged or embedded in tissue may not be apparent.

Shotty lymph nodes after surgery