The Intraoral and Extraoral Exam
Lymph Nodes

The major lymph nodes of the head and neck area should be palpated with the patient in an upright position. Findings which should be noted in the patient record include enlarged palpable nodes, fixed nodes, tender nodes and whether the palpable nodes are single or present in groups. Single or multiple non-tender, and fixed nodes are very suspicious for malignancy. Groups of tender nodes usually occur in conjunction with some type of acute infection. Occasionally nodes will remain enlarged and palpable after an infection. This is a relatively common occurrence especially within the submandibular group of lymph nodes. When examined, these nodes should be small (less than 1 cm), non-tender and mobile. Remember to correlate findings from the medical history and general appraisal of the patient to the observations made during the head and neck examination. For example, a previous history of cancer should cause the clinician to be more suspicious of newly appearing palpable nodes than if there is no history of cancer. If suspicious nodes are discovered, the patient should be referred to a physician for immediate evaluation. Figures 11 through 18 depict the examination techniques for the following lymph nodes.

• Occipital nodes (Figure 11) – Palpate the occipital nodes about one inch above and below the hairline.

• Auricular (Figures 12 and 13) – Palpate the pre and post auricular nodes bilaterally using the pads of the index, middle and ring fingers.

• Cervical Chain (Figures 14 and 15) – Palpate the nodes medial to the sternocleidomastoid muscle using a bidigital technique and the nodes posterior to the muscle with a bimanual technique.

• Supraclavicular (Figure 16) – These nodes are examined using digital compressions just superior to the clavicle.

• Submandibular (Figure 17) – Palpate the submandibular nodes by pulling or rolling the tissues under the chin up and over the inferior border of the mandible. Next ask the patient to firmly press the roof of the mouth with the tongue. This will allow you to assess the muscles and any pathology associated with the submandibular lymph node areas.

• Submental (Figure 18) – Use digital palpation to determine the presence of an abnormal submental lymph node.