Complete overview of lymphatic drainage of head and neck in detail.

1. Presented By:
Dr. Anil Kumar Godara
114 March 2019

2. CONTENTS:
 Introduction
 Historical perspectives
 Embryonic Development of Lymphatic System
 Lymphatic System Structures
 Lymph and it’s circulation
 Functions of Lymphatic System
 Lymphatic tissues of the oral cavity and pharynx
 Bone Marrow
 Spleen
 Thymus
2

3.  Classification of the Lymph Node
 Disease of Lymphatic System
 Examination of the Lymph Node
 Lymphadenectomy
 Lymphatic Malformations
 Conclusion
 References
3

4. Introduction
 All Body tissues are bathed in tissue fluid consisting of the
diffusible constituent of blood & waste material from cell.
Some tissue fluid returns to capillaries at their venous end,
the reminder defuses through the more permeable wall of
lymph capillaries forming the lymph.
 Cardiovascular & lymphatic system both supplies fluid flow
into the body, but both are different type of fluid.
 Lymphatic system does not having closed circuit & central
pump like heart.
4

5. Historical perspectives
 Ancient Greeks like Hippocrates and Aristotle
described them as white fluid.
 ERASISTRATUS in Alexandria was first to describe
around 2000 years ago.
 GASPARO ASELLI an Italian anatomist rediscovered
lymphatic vessels in 1622.
 VAN HOOK of Leyden in 1652 demonstrated the
presence of cisterna chyli and thoracic duct in
humans. 5

6.  WILLIAM HUNTER in the late 18th century was the
first to describe the functions of lymphatic system.
 STARLINGS work on hydrostatics and hydrodynamics
forces across the capillaries controlling the
movement of fluid described the dynamics of lymph
formation.
 OLOF RUDBECK of Swedish university described that
lymphatic system constitute a circulatory system
separate from blood circulation and was accepted by
Royal Society of London in 1751.
6

7. Embryonic Development Of Lymphatic
System
 Begins to develop by end of fifth
week IU
 Develop from lymph sacs that
arise from developing veins,
derived from mesoderm.
 Six primary lymph sacs are
formed.
 The first lymph sacs to appear
are paired jugular lymph sacs .

8.  Capillary plexuses enlarge
 Form lymphatic vessels
 Each jugular lymph sac
retains at least one connection
with its jugular vein.
 Left one developing into the
superior portion of the thoracic
duct.

9. 8th week of IU-Retroperitoneal lymph
sacs forms.
9th week of IU cisterna chyli develops-
lower part of the thoracic duct
develops from left jugular sac.
Later stages-lymph sacs are divided by
CT, which invaded by lymphocytes.
Transformed into group of lymph nodes

10.  The jugular (paired) - first to appear,
at the junction of the subclavian vein
with the primitive jugular
 The posterior lymph-sacs (paired) -
at the junction of the iliac vein with
the cardinal
 The retroperitoneal (unpaired) - in
the root of the mesentery near the
suprarenal glands
 The cisterna chyli (unpaired) -
opposite the third and fourth lumbar
vertebrae.

11.  The spleen develops from mesenchymal cells
between layers of the dorsal mesentery of the
stomach.
 The thymus gland arises as an outgrowth of the third
pharyngeal pouch.
11

12. WHY A LYMPHATIC SYSTEM?
Water, small proteins, white blood cells can
escape cardiovascular system.
Must have way to return them to
cardiovascular system, or there will be fluid
buildup outside in tissues.
12

13. 13
The major components of the
lymphatic system include:
1) Lymph
2) lymphatic vessels
3) lymphatic organs that
contain lymphoid tissues.
Lymphatic System Structures

14. Organization
 The conducting system
and the lymphoid tissue.
 The conducting system
carries the lymph
 consists of tubular vessels
,the lymph capillaries, the
lymph vessels, and the
right and left thoracic
ducts.
14

15.  The lymphoid tissue-
involved in immune
responses and consists of
lymphocytes
 Lymphoid tissue-
organized as lymph
nodes or mucosa-
associated lymphoid
tissue (MALT)
15

16. Lymphatic Capillaries.
 single layer of thin flat
endothelial cells
 arranged in a slightly
overlapping pattern
 fastened to nearby
tissues by an anchoring
filament
 blind ends or cul-de-sacs
are especially common
 two layers: a superficial
and a deep.
16

17.  Absent-nervous system,
the meninges, the eyeball
(except the conjunctiva),
the orbit, the internal ear,
within striated muscle.
17

18. LACTEALS
• Specialized lymph capillaries associated with
absorptive surfaces of small intestine.
• One of the ways fat is incorporated in body fluids.
• Absorb fat from small intestine for distribution
throughout the body.
• All the fat droplets make the lymph appear "milky,"
thus the name lacteal.
18

19. LYMPHATIC VESSELS
 Unlike blood vessels, only carry
fluid away from the tissues
 valves as well as smooth muscle
walls.
 the afferent lymph vessel
 Exceedingly delicate, transparent
coats
 Valves-knotted or beaded
appearance prevent the backflow
of blood
19

20. LYMPHATIC VALVES
 thin layers of fibrous tissue
covered on both surfaces by
endothelium.
 Semi-lunar
 Usually two such valves, of equal
size, are found opposite one
another.
 placed at much shorter intervals
 Found more frequently in the
lymphatic vessels of the neck
and upper extremity
 knotted or beaded
appearance when distended.
20

21. 21

22. Lymphangion
 A lymphangion is the functional
unit of a lymph vessel that lies
between two semilunar (half
moon-shaped) valves.
 Uni- directional valves form
segments that respond to filling
with contraction of smooth
muscle in the vessel walls,
moving fluid to the next segment
enhanced by the active muscle
pump.
22

23. Lymphoid tissue
 Primary- thymus and the
bone marrow
 Secondary- lymph nodes,
and the lymphoid follicles
in tonsils, Peyer's patches,
spleen, adenoids, skin,
etc. that are associated
with the mucosa-
associated lymphoid
tissue
23

24. 24

25. LYMPH
 transparent, colorless, or slightly
yellow, watery fluid of specific gravity
about 1.015; closely resembles the
blood plasma.
 Derived from blood plasma as fluids
pass through capillary walls at the
arterial end.
 Two views are at present held as to
the mode by which the lymph is
formed: one being by the physical
processes of filtration, diffusion, and
osmosis, and the other, that in
addition to these physical processes
the endothelial cells have an active
secretory function
25

26. Formation of interstitial fluid from blood
26

27. CIRCULATION OF LYMPH
(How do you do it with no pump?)
Contraction of smooth muscle in larger
vessels.
Squeezing action of skeletal muscles.
Dumps into venous system; the connection
"pulls" the lymph along.
27

28. propulsion of lymph through lymph
vessel
28

29. Functions of Lymphatic System
29
 The lymphatic system is a circulatory system that drains fluid
from the blood vessels.
 Lymph vessels are the site of fluid drainage and pump lymph
fluid using smooth muscle and skeletal muscle action. The
larger vessels contain valves to prevent backflow and pump
towards the heart to return lymph fluid to the bloodstream by
the subclavian veins.
 A lymph node is an organized collection of lymphoid tissue
through which the lymph passes on its way to returning to the
blood. Lymph nodes are located at intervals along the
lymphatic system.
 Lymphoid tissue contains lymphocytes and other specialized
cells and tissues that have immune system functions.

30. 30

31. 31
• The lymphatic system is a linear network of lymphatic vessels
and secondary lymphoid organs. It is the site of many immune
system functions as well as its own functions.
• It is responsible for the removal of interstitial fluid from
tissues into lymph fluid, which is filtered and brought back
into the bloodstream through the subclavian veins near the
heart.
• Edema accumulates in tissues during inflammation or when
lymph drainage is impaired.
• It absorbs and transports fatty acids and fats as chylomicrons
from the digestive system.
• It transports white blood cells and dendritic cells to lymph
nodes where adaptive immune responses are often triggered.
• Tumors can spread through lymphatic transport.

32. THE LYMPHATIC TISSUES OF THE ORAL
CAVITY & PHARYNX
 Clusters of lymphatic tissue
just under the mucous
membranes that line the
nose, mouth, and pharynx
 Lymphocytes and
macrophages in the tonsils
provide protection against
harmful substances and
pathogens that may enter
the body through the nose
or mouth.
32

33. Pharyngeal tonsil
 The adenoid, also known
as a pharyngeal tonsil or
nasopharyngeal tonsil, is
the superior-most of the
tonsils.
 It is a mass of lymphatic
tissue located behind the
nasal cavity, in the roof of
the nasopharynx, where
the nose blends into the
throat.
33

34. Palatine tonsils
 The palatine tonsil is
one of the mucosa-
associated lymphoid
tissues (MALT), located
at the entrance to the
upper respiratory and
gastrointestinal tracts to
protect the body from
the entry of exogenous
material through
mucosal sites.
34

35. Lingual tonsils
 The lingual tonsils are two
small mounds of lymphatic
tissue located at the back of the
base of the tongue, one on
either side.
 They are composed of
lymphatic tissue that functions
to assist the immune system in
the production of antibodies in
response to invading
pathogenic bacteria or viruses.
35

36. Tubal tonsil
 The tubal tonsil is very close to
the torus tubarius, which is why
this tonsil is sometimes also
called the tonsil of the torus
tubarius. Equating the torus
with its tonsil however might be
seen as incorrect or imprecise.
 It is located posterior to the
opening of the Eustachian
tube on the lateral wall of
the nasopharynx.
36

37. Waldeyer’s ring
37
• An interrupted circle of protective lymphoid tissue at the
upper ends of the respiratory and alimentary tracts.

38. Bone Marrow
 It is the site of stem cells that are ever
capable of dividing and producing
blood cells.
 Some of these cells become the
various types of white blood cells:
neutrophils, eosinophils, basophils,
lymphocytes and monocytes.
 In a child, most of the bone have red
bone marrow, but in an adult it is
limited to the sternum, vertebrae,
ribs, part of the pelvic girdle and
proximal heads of the humerus and
femur.
38

39.  The red bone marrow consist of a network of reticular
tissue fibers, which support the stem cells and their progeny.
 They are packed around thin walled sinuses filled with
venous blood. Differentiated blood cells enter the
bloodstream at these sinuses.
 Lymphocytes differentiate into the B lymphocytes and T
lymphocytes.
 Bone marrow is not only the source of B lymphocytes, but
also the place where B lymphocytes mature.
 T lymphocytes mature in the thymus.
39

40. Spleen
 Largest lymphatic organ
 Located between the stomach &
diaphragm
 Structure is similar to a node
 Capsule present
 But no afferent vessels or sinuses
 Histology
 Red pulp contains all the components
of circulating blood
 White pulp is similar to lymphatic
nodules
 Functions
 Filters blood
 Stores blood
40

41. •Highly vascularized.
•In spleen, BLOOD passes
resident macrophages and
lymphocytes.
•Not strictly a lymph filter, but
its interaction with blood can
stimulate production and action
of materials normally found in
lymph.
•Macrophages abundant: help to
scavenge spent red blood cells
and recycle hemoglobin.
•Antigens (nasty stuff) in blood
active lymphocytes in spleen for
antibody production.
SPLEEN 41

42. Thymus
 Location – behind the sternum
in the mediastinum
 The capsule divides it into 2
lobes
 Development
 Infant – conspicuous
 Puberty – maximum size
 Maturity – decreases in size
 Function
 Differentiation and
maturation of T cells
42

43. Adult
THYMUS
43

44. One-year
old
THYMUS
44

45. 45

46. 46

47. Main Channels of Lymphatics
47

48. LEFT THORACIC DUCT
Begins as a loosely dilated sac and
connections in the abdomen called the
CYSTERNA CHYLI.
Drains both legs, and left side of body.
Goes through thorax, receives
tributaries from: LEFT SUBCLAVIAN
TRUNK (from left arm) and LEFT
JUGULAR TRUNK (left side of head and
neck).
Dumps into venous circulation at junction between left subclavian vein and left
jugular vein. (Technically into left brachiocephalic vein.)
48

49. RIGHT LYMPHATIC
DUCT
Upper right quadrant is
drained by right
lymphatic duct.
dumps into venous
circulation at junction
between right subclavian
vein and right jugular
vein. (Technically into
right brachiocephalic
vein.)
49

50. 50

51. 51

52. Right drainage area landmarks
 Drains lymph from the right side of the head and
neck
 The right arm
 Upper right quadrant of the body.
 Lymph from this area flows into the right
lymphatic duct.
 This duct empties the lymph into the right
subclavian vein.
Left lymphatic drainage landmarks
 Drains lymph from the left side of the head and
neck
 The Left arm and the left upper quadrant
 The lower trunk and both legs
 The cisterna chyli temporarily stores lymph as it
moves upward from the lower areas of the body.
 The thoracic duct transports lymph upward to the
left lymphatic duct.
 The left lymphatic duct empties the lymph into the
left subclavian vein.
52

53. CLASSIFICATION OF LYMPH NODES
 300 of the estimated 800 lymph nodes in the body are situated in the
neck region.
 Most common classification -By Henri Rouvière (1938).
 based upon anatomical landmarks found in dissection.
 Defined both the location and drainage patterns of the cervical lymph
nodes.
 More recently, classification systems have been proposed organized
around what can be observed via diagnostic imaging.
 Commonly used systems have been devised by the American
Academy of Otolaryngology and the American Joint Committee on
Cancer
53

54. Anatomic classification of lymph
nodes of the head
(1) The Occipital:
 1-3 in number
 Placed on the back of the head
close to the margin of the trapezius
and resting on the insertion of the
semispinalis capitis.
 Their afferent vessels drain the
occipital region of the scalp
 Efferents pass to the superior deep
cervical glands.
54

55. (2) The Posterior Auricular:
 usually two in number.
 Situated on the mastoid insertion of
the sternocleidomastoid, beneath the
auricularis posterior.
 Their afferent vessels drain the
posterior part of the temporoparietal
region, the upper part of the cranial
surface of the auricular or pinna, and
the back of the external acoustic
meatus.
 Their efferent pass to the superior
deep cervical glands.
55

56. (3) The Anterior Auricular (superficial parotid or pre-auricular)
 one to three in number.
 lie immediately in front of the tragus
of the ear.
 Their afferent drain the lateral surface
of the auricle and the skin of the
adjacent part of the temporal region.
 Their efferent pass to the superior
deep cervical glands.
56

57. 57

58.  Form 2 groups in relation with parotid salivary
gland:
1) a group imbedded in the substance of
the gland.
2) a group of sub-parotid glands lying on
the lateral wall of pharynx.
 Occasionally small glands are found in the
subcutaneous tissue over the parotid gland.
 Their afferent vessels drain the root of the
nose, the eyelids, the frontotemporal region,
the external acoustic meatus and the
tympanic cavity, possibly also the posterior
parts of the palate and the floor of the nasal
cavity. 58
(4) The Parotid:

59.  The efferent of these glands pass to
the superior deep cervical glands.
 The afferent of the subparotid glands
drain the nasal part of the pharynx
and the posterior parts of the nasal
cavities; their efferent pass to the
superior deep cervical glands.
59

60. It comprise three groups:
 (a) Infraorbital or maxillary, scattered over the
infraorbital region from the groove between the
nose and cheek to the zygomatic arch.
 (b) Buccinator, one or more placed on the
buccinator opposite the angle of the mouth.
 (c) Supramandibular, on the outer surface of
the mandible, in front of the Masseter in contact
with the external maxillary artery and anterior
facial vein.
 Their efferent vessels drain the eyelids, the
conjunctiva, and the skin and mucous
membrane of the nose and cheek.
 Their efferent pass to the submandibular glands.
60
(5) The facial:

61. ( 6) The deep facial:
 Placed beneath the ramus of the mandible, on the outer
surface of the lateral pterygoid, in relation to the internal
maxillary artery.
 Their afferent vessels drain the temporal and infratemporal
fossae and the nasal part of the pharynx.
 Their efferent pass to the superior deep cervical glands.
(7) The Lingual:
 2-3 small nodules lying on the Hyoglossus and under the
Genioglossus.
 They form merely glandular substations in the course of the
lymphatic vessels of the tongue.
61

62. (8) The Retropharyngeal:
 1-3 in number
 Lie in the buccopharyngeal
fascia, behind the upper part of
the pharynx and in front of the
arch of the atlas and being
separated. However, from the
latter by the Longus capitis.
 Their afferent drain the nasal
cavities, the nasal part of the
pharynx, and the auditory tubes.
 Their efferent pass to the
superior deep cervical glands.
62

63. Anatomic classification of the lymph
nodes of the neck
(1) The Submandibular:
 These are paired group of lymph nodes.
 3-6 in number
 Placed beneath the body of the
mandible in the submandibular triangle,
and rest on the superficial surface of
the submandibular salivary gland.
 One gland, the middle gland of Stahr,
which lies on the external maxillary
artery as it turns over the mandible, is
the most constant of the series.
63

64. 64
(2) The Submental Or
Suprahyoid:
• Situated between the anterior
bellies of the Digastric.
• Their afferents drain the central
portions of the lower lip and floor of
the mouth and the apex of the
tongue;
• Their efferent pass partly to the sub-
mandibular glands and partly to a
gland of the deep cervical group
situated on the internal jugular vein
at the level of the cricoid cartilage.

65. - Sub divided into superficial and deep
groups according to the relation of the
nodes to the deep fascia of the neck.
(A) The Superficial Cervical
 Lie in close relationship with the external
jugular vein ,superficial to the
Sternocleidomastoid.
 Restricted to the upper region of the neck
and are found in the angle between the
ramus of the mandible and the
sternocleidomastoid muscle.
 Mostly lie adjacent to the inferior
auricular lymph nodes, and these two
groups are often inseparable.
65
(3) Cervical:

66.  Their afferents drain the lower
parts of the auricle and parotid
region
 Their efferent pass around the
anterior margin of the
Sternocleidomastoid muscle to
join the superior deep cervical
glands.
66

67. (B) The deep cervical (deep jugular
lymph nodes)
 Chain along the carotid sheath, lying by the side
of the pharynx, oesophagus, trachea, and
extending from the base of the skull to the root of
the neck.
 Accompany the internal jugular vein
 Subdivided by omohyoid-
(i) The Superior Deep Cervical
(ii) The Inferior Deep Cervical
(supraclavicular lymph nodes)
 subdivided into an anterior (medial), and a
posterior (lateral) group according to the relation
of the nodes to the sternocleidomastoid.
 medial group -jugular chain;
 lateral group -accessory chain.
67

68. (i) The Superior Deep Cervical:
68
• Lie under the Sternocleidomastoid in close
relation with the accessory nerve and the
internal jugular vein,
• The jugulo-digastric node at the level of the
greater cornu of hyoid bone
• Drain the occipital portion of the scalp, the
auricle, the back of the neck, a considerable
part of the tongue, the larynx, thyroid gland,
trachea, nasal part of the pharynx, nasal
cavities, palate and oesophagus.
• receive the efferent vessels from all the other
glands of the head and neck, except those
from the inferior deep cervical glands.

69. (ii) The Inferior Deep Cervical
(supraclavicular lymph nodes)
 Extend beyond the posterior margin of the
Sternocleidomastoid into the
supraclavicular triangle, where they are
closely related to the brachial plexus and
subclavian vein.
 Virchow's node (or signal node) is an
enlarged, hard left sided supraclavicular
nodes and considered a sign of metastatic
abdominal malignancy.
69

70.  Drain the back of the scalp and neck,
the superficial pectoral region, part of
the arm, and, occasionally, part of the
superior surface of the liver, In addition,
they receive vessels from the superior
deep cervical glands.
 Their efferent pass to the jugular trunk.
 A few minute paratracheal glands are
situated alongside the recurrent nerves
on the lateral aspects of the trachea and
oesophagus.
70

71. (4) The Anterior Cervical:
 Form an irregular and inconstant group in the front of the
larynx and trachea.
 May be divided into
(a) A superficial set- on the anterior jugular vein
(b) A deeper set-subdivided
(i) Prelaryngeal
(ii) Pretracheal
 Deeper set drains the lower part of the larynx, the thyroid
gland and the upper part of the trachea.
 Efferent pass to the lowest part of the superior deep cervical
glands.
71

72. The cervical lymph node groups
1.Sub-mental
2.Sub- mandibular
3. Pre-laryngeal
4. Thyroid
5. Pre-tracheal
6. Para-tracheal
7. Lateral jugular
8. Anterior jugular
9. Jugulo-digastric
10. Jugulo-omohyoid
11. Supraclavicular
(scalene)
72

73. NODAL CLASSIFICATION
 A drawback of Rouviere's classification was that the anatomic descriptions were not
easily correlated with surgical landmarks during a neck dissection. It was difficult to
directly translate to cross-sectional images(CT scan or MRI )
 For the purpose of standardizing clinical observations and surgical reports, the
Union for International cancer control (UICC ), the American Joint Committee on
Cancer (AJCC) and the American Academy of Otolaryngology- head and neck
surgery (AAO-HNS) adopted the classification of cervical lymph nodes into specific
groups, based on anatomic location.
 This classification was suggested by Suen & Geopfert (1987), based on the
classification used in the Memorial Sloan-Kettering Cancer Center.
 Provide a uniform, standardized nomenclature that could facilitate the reporting
and analysis of treatment result. Each lymph node group, or level, has specific
anatomic, clinical and radiologic boundaries. 73

74. LEVEL I
 Level I
 Sub-mental and submandibular
nodes
 Level I A – Sub-mental nodes,
between the medial margins of
the anterior bellies of the
digastric muscles.
 Level I B -Submandibular
nodes, lateral to level I A nodes
and anterior to the back of the
submandibular salivary gland.
74

75. LEVEL II
 Level II
 Upper jugular nodes, posterior to the
back of the submandibular salivary
gland, anterior to the back of the
sternocleidomastoid muscle and above
the level of the bottom of the body of
the hyoid bone.
 Level IIA. Level IIA nodes lie posterior
to the internal jugular vein and are
inseparable from the vein, or they are
nodes that lie anterior, medial, or lateral
to the vein.
 Level IIB. Level IIB nodes lie posterior to
the internal jugular vein and have a fat
plane separating the nodes and the
vein. 75

76. LEVEL III
 Level III
 Middle jugular node, bottom of
the body of the hyoid bone and
the level of the bottom of the
cricoid arch, anterior to the back
of the sternocleidomastoid
muscle.
76

77. LEVEL IV
 Level IV
 Low jugular nodes, between the
level of the bottom of the cricoid
arch and the level of the clavicle,
anterior to a line connecting the
back of the sternocleidomastoid
muscle and the posterolateral
margin of the anterior scalene
muscles; they are lateral to the
carotid arteries.
77

78. LEVEL V
 Level V
 Posterior triangle nodes, posterior to
the back of the sternocleidomastoid
muscle, and posterior to the line
described in level IV
 Level V A -Above the level of the
bottom of the cricoid arch
 Level V B -Between the level of the
bottom of the cricoid arch and the
level of the clavicle
78

79. LEVEL VI
 Level VI
 Upper visceral nodes, between the
carotid arteries from the level of the
bottom of the body of the hyoid
bone to the level of the top of the
manubrium
79

80. Level VII
 Level VII
 Superior mediastinal nodes,
between the carotid arteries
below the level of the top of
the manubrium and above
the innominate vein.
80

81. RETROPHARYNGEAL NODES (Nodes of
Rouviere)
 These nodes are often forgotten because they are not
apparent on clinical examination.
 Nodes behind the pharynx, medial to the internal
carotid artery, from the skull base down to the level of
the hyoid bone.
81

82. 82

83.  Lymphedema, also known
as lymphoedema and lymphatic edema, is a
condition of localized fluid retention and
tissue swelling caused by a
compromised lymphatic system, which
normally returns interstitial fluid to the
bloodstream.
 The condition is most frequently a
complication of cancer treatment or
parasitic infections, but it can also be seen
in a number of genetic disorders. Though
incurable and progressive, a number of
treatments can ameliorate symptoms.
Tissues with lymphedema are at high risk of
infection. 83
Diseases of the Lymphatic System
Lymphoedema

84. Lymphangitis
 Lymphangitis is an inflammation or
an infection of the lymphatic channels that
occurs as a result of infection at a site distal to
the channel. The most common cause of
lymphangitis in humans is Streptococcus
pyogenes (Group A strep), although it can also
be caused by the fungus Sporothrix schenckii.
 Lymphangitis is sometimes mistakenly called
"blood poisoning". In reality, "blood poisoning"
is synonymous with sepsis.
 Signs and symptoms include a deep reddening
of the skin, warmth, lymphadenitis
(inflammation of a lymphatic gland), and a
raised border around the affected area. The
person may also have chills and a high fever
along with moderate pain and swelling. 84

85. LYMPHADENOPATHY
 Lymphadenopathy or adenopathy is disease of
the lymph nodes, in which they are abnormal in
size, number, or consistency.
 Lymphadenopathy of an inflammatory type
( most common type)
is lymphadenitis, producing swollen or
enlarged lymph nodes. In clinical practice, the
distinction between lymphadenopathy and
lymphadenitis is rarely made and the words are
usually treated as synonymous. Inflammation
of the lymphatic vessels is known
as lymphangitis.
 Infectious lymphadenitides affecting lymph
nodes in the neck are often called scrofula.
85

86. The following broad etiologic categories lead to lymph
node enlargement
(1) Reactive:
 An immune response to infective agents like bacteria, virus or fungi.
 These can be acute infections- abcess (e.g. bacterial, or viral),
 chronic infections (tuberculous lymphadenitis, cat-scratch disease).
 Infectious mononucleosis is an acute viral infection, the hallmark of which is
marked enlargement of the cervical lymph nodes.
 It is also a symptom of cutaneous anthrax, measles and Human African
trypanosomiasis, the later giving lymphadenopathy in lymph nodes in the
neck.
 Toxoplasmosis, a parasitic disease, gives a generalized lymphadenopathy
86

87. (2) Tumoral :
 Primary lymphadenopathy involves localized neoplastic proliferation of
lymphocytes or macrophages as in the case of Hodgkin lymphoma, non-
Hodgkin lymphoma, and hairy cell leukemia. Lymphadenopathy is seen in all
or a few lymph nodes.
 Secondary lymphadenopathy is due to infiltration of neoplastic cells carried
to the node by lymphatic or blood circulation metastasis, Virchow's Node,
Neuroblastoma
(3) Autoimmune disorders:
 Certain autoimmune diseases like sarcoidosis, systemic lupus
erythematosus, rheumatoid arthritis cause generalized lymphadenopathy.
87

88. (4) Acquired Immunodeficiency Syndrome:
Generalized lymphadenopathy is an early sign of infection with human
immunodeficiency virus (HIV),
"Lymphadenopathy syndrome" has been used to describe the first
symptomatic stage of HIV progression, preceding AIDS-related complex and
full-blown AIDS
(5) Storage Disorders:
Gaucher disease, Histiocytosis X, Cystinosis, Niemann-Pick disease cause
infiltration of macrophages filled with metabolite deposits resulting in
lymphadenopathy.
(6) Bites from certain venomous snake species e.g. the black mamba,
kraits, Australian brown snakes, coral snakes, tiger snakes, and some of the
more toxic species of cobra cause lymphadenopathy.
(7) Certain drugs like phenytoin are known to cause lymphadenitis 88

89. EXAMINATION OF LYMPH NODES
 Location:
localised to one region or if there is generalized lymphadenopathy..
 Size: considered to be normal if they are up to 1 cm in diameter
 Pain/Tenderness: usually the result of an inflammatory process or
suppuration, may also result from haemorrhage into the necrotic centre of a
malignant node.
 Consistency:
Stony-hard nodes- sign of cancer, usually metastatic.
Very firm, rubbery - lymphoma.
Softer nodes - infections or inflammatory conditions.
Suppurant nodes may be fluctuant.
The term "shotty" refers to small nodes that feel like buckshot under the
skin, as found in the cervical nodes of children with viral illnesses.
89

90.  Matting: That feels connected and seems to move as a unit is
said to be "matted."
can be either benign as in case of tuberculosis or sarcoidosis;
or malignant as in cases of metastatic carcinoma or
lymphomas.
 Fixation: More likely to be due to carcinoma
 When examining one area, the examiner should always
compare it to the other side
90

91. METHOD OF EXAMINING LYMPH NODES OF HEAD &
NECK REGION
 POSITION OF THE EXAMINER AND PATIENT: The
recommended position of the examiner for evaluation of
cervical lymph nodes is from behind the patient. Ideally the
examination is best carried out by standing behind the seated
patient.
 INSPECTION: On inspecting the head & neck area, sometimes
the enlarged nodes may be visible.
91

92. PALPATION: The various facial and cervical lymph nodes are
palpated in the following manner:
 The Submental node which lies directly
under the chin can be palpated by rolling
the finger below and lingual to the chin,
against the mylohyoid muscle.
 The Submandibular nodes are located
below the angle of the jaw. These nodes
are bilateral and can be palpated by
pressing the tissue below the jaw against
the medial side of the mandible or by
bimanual palpation with one finger in the
mouth and the other externally pushing
up. The manipulation is facilitated if the
patient bends the head forwards and
towards the side being examined.
92

93.  The Parotid node can be palpated
posterior to the angle of the mandible.
For palpation of preauricular nodes,
finger should be rolled in front of the
tragus of the ear, against the maxilla.
The postauricular node can be
palpated behind the ear.
 Sub occipital lymph nodes are palpable
immediately behind the ear
93

94.  The anterior cervical group of nodes The
patient is asked to relax the shoulders and
the anterior cervical chain of nodes can
be palpated down the anterior border of
the sternocleidomastoid muscle
 The tonsillar (jugulodigastric) node can
be palpated at the angle of Mandible.
94

95.  The deep cervical lymph nodes should be
palpated, one side at a time. Gently bend
the patient's head forward and roll your
fingers over the deeper muscles along the
carotid arteries.
 The posterior cervical chain of nodes can be
palpated at the posterior border of the
sternocleidomastoid muscle and the
posterior triangle of the neck. Cervical
nodes are behind sternocleidomastoid and
in front of Trapezius.
 To feel the supaclavicular lymph nodes the
patient is asked to slightly shrug the
shoulders. 95

96. LYMPHADENECTOMY
 Consists of the surgical removal of one or more groups of
lymph nodes.
 Almost always performed as part of the surgical
management of cancer.
 Done because many types of cancer have a marked
tendency to produce lymph node metastasis early on in
their natural history.
96

97.  A lymphatic malformation is a mass in the head or neck that results from an
abnormal formation of lymphatic vessels. Lymphatic vessels are small
canals that lie near blood vessels and help to carry tissue fluids from within
the body to the lymph nodes and back to the bloodstream.
 There are two main types of lymphatic malformations:
 Lymphangioma. A group of lymphatic vessels that form a mass or lump. A
cavernous lymphangioma contains greatly enlarged lymphatic vessels.
 Cystic hygroma. A large cyst or pocket of lymphatic fluid that results from
blocked lymphatic vessels. A cystic hygroma may contain multiple cysts
connected to each other by the lymphatic vessels.
97
LYMPHATIC MALFORMATIONS

98.  Nearly all cystic hygromas occur in the neck, although some
lymphangiomas can occur in the mouth, cheek, and tissues
surrounding the ear, as well as other parts of the body.
 Lymphatic malformations are present at birth, but they are
sometimes not detected until the child is older. Some lymphatic
malformations can spread into surrounding tissues and affect the
proper development of the area. Lymphatic malformations may also
enlarge and become infected following an upper respiratory
infection.
 Lymphatic malformations are sometimes seen in children with
certain chromosome abnormalities and genetic conditions, including
Down syndrome and Turner syndrome.
98

99. Conclusion
 In conclusion, the lymphatic system and its organs
are widespread and scattered throughout the body.
It functions to service almost every region of the
body. Because the vessels of the lymphatic system
span the entire body it becomes an easy portal for
the spread of cancer and other diseases, which is why
disorders and diseases of this system can be so
devastating.
99

100. References
• B.D. Chaurasia’s Human Anatomy Volume III (Third edition)
• Altas of Human Anatomy, by Frank H Netter, 6th edition
• Anatoy of the Human Body, by Henry Gray. 20th edition
• Anatomy and physiology - The unity of form and function (Saladin K. - 2003 -
3rd ed. - McGraw-Hill)
• Understanding Human Anatomy and Physiology - Sylvia S. Mader
• Textbook of Head and Neck Anatomy (Hiatt - Gartner, 4th Ed.2010)
• Peter M. Som. Imaging-Based Nodal Classification for Evaluation of Neck
Metastatic Adenopathy. Arch Otolaryngol Head Neck Surg. 1999;125:388-396.
• Cunningham’s text book of anatomy; G.J.Romanes 12th edition
100

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