Lymphatic & venous system of head and neck /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


LYMPHATIC &
VENOUS SYSTEM
OF HEAD AND
NECK
Moderator
Dr David Tauro

Presenter
Dr Mahantesh.S

CONTENTS
Development of
lymphatic system
 Lymph fluid
 Lymph node
 Lymphatic vessels
 Functions of
lymphatic system


Classification

Diagnosis of
Lymphadenopathy
Conclusion
 References


WHY
LYMPHATIC
SYSTEM

?


LYMPHATIC SYSTEM


This system was
described after the other
parts of vascular system
are already known.



The reason for this
delay is their delicate
and transparent
appearance.


EMBRY0LOGY OF
LYMPHATIC SYSTEM









Lymph sacs -appear between 2 nd to 6 th
week of IUL.
7 th week - jugular channel spread to
connect with subclavin lymph sacs.
9 th week - thoracic duct is continuous
channel draining into IJ -subclavin vein
junction.
12 th week- all process are complete.
5 th month - valves begins to start.

DEVELOPMENT OF LYMPH
NODE




Jugular, lymph

saccules and
Peritoneal lymph
saccules
Invasion of
neighboring
Mesenchymal cells
so called lymph
sinuses evolve intra
nodally.

LYMPHATIC SYSTEM
contents
Cells,
Organs
Vessel
Lymph fluid .
lymphoid organ

Primary /
central
Thymus and
bone marrow

Secondary /
peripheral
Spleen, tonsil and
lymph node

LYMPH FLUID
Definition
Transparent,colorless,or slightly yellow
watery fluid with specific gravity of 1.015.
Same as blood plasma but more dilute

CONTENTS
•Proteins
•Fats
•Cells
•Interstitial fluid


Lymph Fluid
Central

Intermediate


Peripheral

FORMATION OF LYMPH
FLUID





FORMATION
- Diffusion
- Osmosis
Terminal capillaries in
the Interstitium
0.003ml/100kg/min
tissues
2-3liters/day
produced

FACTORS AFFECTING
THE LYMPH
FORMATION


Environmental temperature



Body movement


VELOCITY OF LYMPH
FLOW


Depends on
– Intrinsic Factors
– Extrinsic Factors



Velocity is generally 3.1cm /min


EXTRINSIC

INTRINSIC
Intraluminal pressure
Lymphatic pump

Interstial pressure
Movement


Muscular
Arterial
respiration

Conditions where lymph
production increase
(pathologically)






Inflammation
Venous stasis
Mechanical insufficiency of vessels and
valves
Drugs –Serotonin,Prostaglandins,TXA2,
Nor-adrenaline

LYMPH
NODE


These are the raison d,etre of the
lymphatic system



Local aggregation of lymphoid tissue.



Lympha  colorless – yellow fluid
(lymphocytes)



Nodus knot

LYMPH NODE







800 L nodes in body
300 are present in head
and neck
1 st defense station of the
body.
Localized mainly in fatty
tissues & interposed
between lymphatic flow

SHAPE OF LYMPH
NODE


Inguinal lymph nodes – large and round



Outer iliac lymph nodes – longish mass



Inner iliac lymph node – small and round



Head and neck lymph node- oval or
kidney or spindle shaped

LYMPH NODE


Size
– 1- 30 um in diameter this depends
mainly on primary function



Absorption -0.07ml/l node


CELL ZONES
Zone 1
Extreme periphery
Loosely packed cells
lymphocytes,
macrophages
Zone 2
More densely packed
small lymphocytes and
macrophages
Zone 3.

Germinal center

STRUCTURAL CHANGES:
– Expansion of B and T lymphocytes
– Cortical region enlargement
– Increase in no of macrophages in sinus ,
medullary sinus

FUNCTIONAL CHANGES


Reduced filtering capacity



Immune cells No. increase


FUNCTION OF LYMPH
NODE


Biologic filtering



Production of lymphocytes in context
of immune reactions.


1. Biologic filtering
Afferent vessels

Capsule
Marginal sinus
Marginal Zones

Medullary cords
Medullary sinus
Efferent vessels


Hilus

2.Immune reaction
Antigen  Margninal sinus
Bound to Macrophages & Reticular cells

Adjacent T-helper cells  Present Ag to Immunocompetent
lymphocytes -- Mantle zone ( B-Lymphocytes)
Activated B cells
Immunoblast

IMMUNOBLAST

Move towards germinal centre
Differentiate

Immunocytes & Plasma
cells

5-7 days, Plasma cells  Medullary cords  Ab into the
medulla

Para cortical zone (T-lymphocytes)

Suppressor T cells

Helper T cells


LYMPHATIC VESSELS


Anatomically similar to veins



Are thin-walled , serve as drainage
channels



Initially lymph vessels are Finger-shaped
and blind.



they drain intercellular spaces and serous
sacs.

LYMPHATIC VESSELS


Abundant interlacing anastomoses



Interruption of the continuity by lymph
nodes.



Drainage channels from many parts not
drained by the venous system

LYMPHATIC VESSELS


Wide vascular lumen. 30-50um .



Lymph capillaries dose not contains valves.
valves are there in valvular precollectors .



Diameter larger than 10um only can spread
or metastasis can take place.


STRUCTURE OF
LYMPHATIC VESSEL
Initial lymph vessel
Endothelial cells that
are
Surrounded by an
incomplete and
interrupted basal
membrane
These cells overlap like
roof tiles

Lymphatic collectors
Intima consists of endothelial cells
Collagen fibers and single muscle cells.
Media contains bundles of smooth
muscles surrounded By collagen fibers.
Adventitia –longitudinal bundles of
connective tissue,elastic fibers&
Single smooth muscle cells


FUNCTIONS OF
ENDOTHELIAL CELLS




Intense protein
synthesis
Increase cellular
transportation


VALVES


Except initial lymphatic sinus or capillaries
every lymph vessels has valves.



Valves may be
– Bicuspid
– Tricuspid
– Quadricuspid

FUNCTIONS OF LYMPH
VESSELS


Transitional function of fluid between
intercellular spaces and veins.



Immunity



Fats and proteins

LYMPHATIC SYSTEM OF
HEAD AND NECK
REGION


LS of aero digestive mucosa consists of



Narrow –meshed ,superficial vascular
system



Wide – meshed ,deeply situated vascular
system

LYMPHATIC DRAINAGE OF HEAD
AND NECK
SUPERFICIAL
CERVICAL

DEEP
CERVICAL

Outer circle (Pericervical
collar)
Inner circle (upper part of
respiratory and alimentary
passages)
Surrounds IJV
Spinal Accessory
Base of skull- Neck


SUPERFICIAL CERVICAL NODES (Inner circle)
Pre-laryngeal Deep cervical
Anterior
Deep cervical
fascia(beneath) cervical nodes
nodes
Pre-tracheal

Trachea

Para-tracheal

Oesophagus
and trachea

Retropharyngeal

Retropharyngeal
space

Larynx,trachea Deep cervical
,oesophagus
nodes
and thyroid
gland
Pharynx,
palatine
tonsil,sphenoid
sinus


Upper deep
cervical nodes

DEEP CERVICAL LYMPH NODES
Jugulodigastric
nodes

Triangular
region(digastr
ic, facial vein
and IJV)

Palatine tonsil
and
tongue(post.1/
3rd)

Juguloomohyoid
nodes

On IJV above
intermediate
tendon of
omohyoid

Tongue,subJugular lymph
mental,subtrunk
mandibular
and upper deep
cervical


Upper deep
cervicaljug
ular trunk

SUB-MENTAL

SUB-MANDIBULAR

PAROTID NODES

UPPER DEEP CERVICAL CHAIN OF NODES

LOWER DEEP CERVICAL CHAIN OF NODES


3rd Molars
Tongue (base)
Tonsillar area
Soft palate

LOWER DEEP CERVICAL
Left lower body

Right upper body

(bilaterally)

RIGHT LYMPHATIC
DUCT

Right Brachiocephalic

THORACIC DUCT

vein

Left Brachiocephalic

Subclavian vein


vein

Levels of Lymph nodes

(SLOAN

–KETTERING CANCER CENTER, NY )

I
II
VI

III

v

IV

CLINICAL
CONSIDERATIONS


Normal lymph nodes not palpable


LYMPHADENOPATHY


EXAMINATION


How long swelling has been present?



Is it painful ?



Does it vary with size?


GENERAL PRINCIPLES
Inspection
Palpation
Compare with contra lateral side.
Site
Size
Consistency
Tenderness
Fixation

Consistency/Texture


Stony hard

 Metastatic cancer



Firm, Rubbery

 Lymphoma



Soft

 Infection Inflammatory



Shotty

 Viral infection

PALPABLE LYMPHNODES AND
PROBABLE
ASSOCIATED CONDITIONS


Tender, Mobile, enlarged  Acute infection



Non-tender, Mobile, Enlarged  Chronic
infection



Matted, Non tender  Tuberculosis



Fixed, Enlarged  Carcinoma



Rubbery, Enlarged  Lymphomas

Matted:Group of nodes – Connected – as a unit

Benign / Malignant
Benign

Malignant

TB

Metastatic carcinoma

Sarcoidosis

Lymphomas

Lymphogranuloma
venereum


Key Points in Diagnosing
Lymphadenopathy





In the absence of obvious infection consider it
as metastatic tumor until otherwise proven.
FNAC - useful investigation.
Open biopsy- recurrence, survival, further
examination is difficult, fungation. nerve
damage may occur.


AGE


<16yrsinfection,congenital, neoplasia.



16-40yrs- inflammation, neoplasia



>40yrs- neoplastic.

CERVICAL
LYMPHADENOPATHY

Classification

Localised

Generalised

2 or more non contiguous area

Involve one area


-

-

-

CAUSES FOR
CERVICAL
LYMPHADENOPATHY

Local

Infection-dental infections, tonsillitis, skin sepsis,
TB node.
Neoplasia-lymphoma or metastatic.

General

URTI, infectious mononucleosis, toxoplasmosis,
cat-scratch fever, HIV
Sarcodosis, Hodgkin's and non-Hodgkin's
lymphoma.
Congenital- cystic hygroma.

CONCLUSION


REFERENCES










Text book of surgical anatomy – Mag Craker
Text book of general anatomy 39 th ed – Grants
Clinical oriented anatomy –Moore
Head &neck emergencys-Mike parry
Text book of head &neck anatomy 2 nd ed –
Holleinsheid
Atlas of general histology – De Floire
Text book of Human histology- Inderbir Singh
Metastases of head and neck – R. Kim Davis
Text book medicine-Davidson

Thank
you


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

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