Lymphatics of head, neck & face / dental crown & bridge courses

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CONTENTS
 Introduction
 The Lymphatic System
 Structure Of Lymph node
 Blood supply
 Lymphatic trunks
 Drainage of head and neck
 Functions
 Importance
 Clinical application
 Clinical staging
 Clinical evaluation
 References

 All regions of head and neck with the exception of deep
orbit-contains a rich supply of lymphatics.
 Of the estimated 800 lymph nodes in the body-
approximately 300 are located in head and neck region
 (ophthalmic &plastic reconstructive surg
journal-jan feb 2007 vol 23 issu 1 page 32-36)
INTRODUCTIONINTRODUCTION

 The lymph nodes and the lymph vessels together
constitutes the lymphatic system.
 Lymph vessels form minute channels which carry lymph,
a clear fluid, to the lymph nodes
 In addition to lymph and the lymphatic vessels, the
system includes :-
• lymph nodes located along the paths of the collecting
vessels,
• isolated nodules of lymphatic tissue such as Peyer’s
patches in the intestinal wall, and

• specialized lymphatic organs such as the tonsils, thymus,
and spleen.
 Volume of lymph:-
The estimated amount of lymph is 1/3rd
to
1/6th
of total blood volume.

 It consists of:
1. Complex capillary networks
2. Collecting vessels
3. Lymph trunks and ducts
4. Lymph nodes
5. Extra nodal (lymphoid) tissues.
THE LYMPHATIC SYSTEM

 They are the smallest vessels of the network.
 They are microscopic and have a blind end (Cul-de-
sacs).
 Present in all tissues of the body except in the central
nervous system, bones, cartilages, teeth, nails, hair, eye
ball, and bone marrow.
 Their structures are similar to those of the blood
capillaries, i.e. lined by a single layer of flat endothelium
but they are more permeable because of fenestrated
"porous“ endothelium.
Lymphatic capillaries

Lymphatic capillaries

 Oval or bean-shaped bodies.
 Situated in the course of lymphatic vessels
 Inflamed (tender) nodes (called lymphadenitis) suggest
infection in the area of drainage.
 Each generally presents on one side a slight depression-
the hilus-through which the blood vessels enter and leave
the interior.
Structure Of Lymph node

Structure
Of
Lymph
node

 Efferent lymphatic vessel
also emerges from the
gland at this spot.
 Afferent vessels enter the
organ at different parts of
the periphery.
. They are usually in groups
and may be either
superficial or deep.

Structure of LN
1. Stroma:- 3parts;
a. Connective tissue capsule rich in collagen.
b. Trabeculae.
c. Reticular fibers.
They are composed of stroma
parenchyma

a. Cortex: formed of follicles. It is
sometimes called the zone
of B cells.
Two types of follicles are present:
i. Primary lymphoid follicles
without germinal
center.
i. Secondary lymphoid
follicles, many of which
have a pale spherical center
called germinal center.
2. Parenchyma: composed of the following zones;

b. Para cortical zone: contains T lymphocytes and
zone of T cells
c. Medulla: formed of columns (cords) of cells
mainly plasmocytes (the cells that produce
immunoglobulins) and APCs. (Antigen
Presenting Cells).

 Small arteries enter
the hilum, divide into
arterioles and then
into capillaries.
 The capillaries form
venules called post
capillary venules.
Blood supply of lymph nodesBlood supply of lymph nodes

 Lymph flows through thoracic duct and reenters the
general circulation at the rate of about 125ml/hour.
Flow of the LymphFlow of the Lymph

To mount the immune response in the body
Biological filter for lymph
Detect & defend against foreign antigen that
carried in lymph
Active phagocytosis for particulate material &
micro organism
Lymphocyte production-by multiplication of pre-
existing lymphocytes on antigenic stimulus.

 The factors which support the circulation of the lymph
are the same factors which support the venous return to
the heart:
1. Contraction of the skeletal muscles.
2. The pulsation of the nearby arteries can compress lymph
vessels and move the lymph within them.
3. The presence of the valves permitting the lymph to move
only in the direction of the blood stream.
4. Pressure changes due to the contraction of respiratory
muscles.
5. In addition, the rhythmic contractions of the smooth
muscles of the walls of the lymphatic ducts and trunks
aid the circulation.

The principal lymphatic trunks
are:
 Lumbar trunks: left and right,
drain the lower limbs, the pelvis
and the abdomen except the
digestive system.
 Intestinal trunk: drains the part of
the digestive system located
below the diaphragm. It receives
the chyle from the digestive tract.
 Broncho-mediastinal trunks: left
and right, drain the thorax.
 Jugular trunks: left and right,
drain head and neck.
 Subclavian trunks: left and right,
drain the upper limbs.
These trunks then join one of the two collecting ducts; the
thoracic duct or the right lymphatic duct.

1. The right lymphatic duct
receives the lymph from
the right side of the
head and neck through
the right jugular trunk;
2. From the right upper
extremity through the
right subclavian trunk;
3. From the right side of
the thorax, through the
right bronchomediastinal
trunk.
Tributaries ofTributaries of right lymphatic duct : (collecting duct): (collecting duct)

It drains the following areas:
 2 lower limbs, the pelvis and
the abdomen, the left half of
the head and neck the left half
of the thorax, and the left
upper limb.
 The thoracic duct conveys the
greater part of the lymph and
chyle into the blood.
The Thoracic Duct: (collecting duct)The Thoracic Duct: (collecting duct)

It is the
common trunk of
all the lymphatic
vessels of the
body, excepting
those on the
right side of the
head, neck, and
thorax, and right
upper extremity.

LOCATION BASED CLASSIFICATION
Given by Rouvière in 1938
Superficial lymph nodes Deep nodes
Pericervical collar Superior
a. Submental a. Jugulodiagastric
b. Submandibular b. internal ring of
waldeyer
c. Preauricular Inferior
d. Mastoid a. Juguloomohyoid
e. Occipital b. Paratracheal
Facial nodes c. Supraclavicular
Prelaryngeal nodes d. Retropharyngeal
Anterior cervical nodes
Infrahyoid lymph nodes
Superficial cervical lymph nodes

Inner circle of lymph nodes

Arrangement of outer circle of lymph nodes

Lymph nodes of neck

 The spleen
 The thymus
 The tonsils
 The mucous
membranes associated
lymphatic tissue
"MALT"
Extra-nodal lymphoid tissue (organs)Extra-nodal lymphoid tissue (organs)

All these organs have
 A stroma (capsule and trabeculae) made of fibrous
connective tissue called reticular connective tissue,
except the thymus which has a stroma made of epithelial
cells called thymocytes.
 A parenchyma made of cells mainly lymphocytes and
macrophages. These lymphocytes can be disseminated
or in clusters called follicles.
 All these organs protect against the microorganisms
(part of the immune system).
 All have efferent lymphatic vessels, but, only the lymph
nodes have afferent and efferent lymphatic vessels.

It is the largest lymphoid organ
 Position: It is located in the upper part on the left side of
the abdominal cavity, just below the diaphragm and in the
9th, 10th, 11th left coastal cartilages.
 Dimensions: ~ the size of a fist. Normally we cannot
palpate the spleen unless its size increases more than 2
times.
SpleenSpleen

 It is a prominent organ in infants
 Its size varies with age
 In its active stage, it is a bilobar glandular organ
 It is a ductless gland
ThymusThymus

 They are circular bands
(rings) of lymphoid tissue
around the entrance into
the pharynx where they are
located in the mucous
membrane.
 They are named according
to their location.
 With age they become
atrophied (during
adulthood).
TonsilsTonsils

 Are located on both sides at the posterior part of
the oral cavity, in the lateral wall of the oropharynx.
 They are the largest and are the most frequently
infected.
Lingual tonsils
 located at the posterior third of the base of the
tongue.
Pharyngeal tonsils (Adenoids)
 Are located in the posterior wall of the
nasopharynx.
Palatine tonsilsPalatine tonsils

 They surround the openings of the
Eustachian tubes in the nasopharynx.
 They are extensions of pharyngeal tonsils
around the opening of the auditory
(Eustachian) tube which is the channel
through which the tympanic cavity of the ear
communicates with nasopharynx.
Tubal tonsilsTubal tonsils

The mucous membranes associated lymphatic tissue
"MALT"
These are either dispersed lymphocytes or aggregates of
lymphocytes:
1.Gut associated lymphoid tissue (GALT).
 They are found in the mucus membrane of the gut
mainly that of the tonsils, the esophagus, peyer's
patches of the ileum and the small intestine, the
appendix, and the colon.
 They generate plasma cells that secrete antibodies in
large amounts in response to foreign bodies in the
intestine.
2. Similar clusters of tissue are found along the bronchi of
the respiratory system "BALT" (bronchus-associated
lymphoid tissue).

1. It acts as a "sponge" to reabsorb the fluid (lymph) from the
interstitial space in order to prevent edema formation.
2. Destruction of bacteria and removal of foreign particles from the
lymph by phagocytosis, mainly by macrophages that are present
in the lymph nodes.
3. Specific immune responses: In response to the presence of
bacteria or other foreign substances, lymphocytes and other
plasma cells participate in specific immune responses such as the
production of antibodies.
Functions of the lymphatic systemFunctions of the lymphatic system

CLINICAL APPLICATION
 Situation of lymph nodes in the neck, their areas of drainage are of
clinical importance since complete removal of all the lymphatics in the
neck is the only hope of permanent cure for cancers in different parts
of head and neck
 Submandibular nodes are under the superficial lamina of investing
layer of deep fascia in actual contact of salivary gland.In cancer,
therefore, removal of these lymph nodes necessitates the removal of
the submandibular salivary gland as well because of this intimate
relationship.
 Painful enlargement of the submandibular nodes is common because
infections of the regions they drain is common.

 Occipital nodes are enlarged in the early stage of German measles
 Tuberculous disease of the neck usually involves the upper deep
cervical nodes usually from tonsillar infection.They adhere very firmly to
the internal jugular vein which may be injured in the course of their
removal.
 Enlargement of jugulodigastric node is valuable in the diagnosis of
pharyngeal or tonsillar involvement
 Infection of retropharyngeal nodes may lead to retropharyngeal
abscess.
 Supraclavicular nodes may be enlarged in ascending infection from
axillary nodes.
 Enlargement of supraclavicular nodes in front of left scalenus anterior
muscle is common in malignant disease of stomach.These are known
as virchows gland.

CLINICAL STAGING OF CERVICAL LYMPH
NODES
 As per AJCC/UICC
 Nx-Regional lymph nodes can not be assessed.
 No-No regional lymph node metastasis.
 N1-Metastasis in a single ipsilateral lymph node,<3cm in
greatest dimension.
N2a-metastasis in a single ipsilateral lymph node,>3cm
but<6cm in greatest dimension.

N2b-metastasis in multiple ipsilateral lymph
nodes,none>6cm in greatest dimension.
N2c-metastasis in bilateral or contralateral lymph
nodes,none >6cm in greatest dimension.
 N3-metastasis in a lymph node >6cm in greatest dimension.

SIMPLIFIED NODAL CLASSIFICATION
A simple nomenclature was suggested by Memoria Sloan-
Kettering Cancer centre,New York
 Level I :- submandibular and submental nodes
 Level II:-upper cervical nodes
 Level III:-middle cervical nodes
 Level IV:-lower cervical nodes

 Leve lV:-posterior triangle nodes
 Level VI:-lymph nodes in tracheoesophageal grooves and
perithyroid region
 Level VII:-superior mediastinal nodes

Normal lymph nodes are not palpable.
Enlarged lymph nodes are easily located
Palpable nodes are primary & imp. sign of clinical
disease
Palpation of lymph nodes:-
Started with most sup.node working down to the
clavicle
Best done from behind the seated subject using both
hands together

Pt’s neck is flexed with 1 hand & his head is
positioned forward, downward & laterally, while
other hand is used for palpating
Fingers semiflexed & adducted & thumb in
partial opposition; fingers explore systemically;
submandibular Δ(thumb over
buccinator),retromandibular depression (thumb
over parotid),the upper attachment of
sternomastoid & occipital attachment of
trapezius.

submandibular nodes:- if extraoral palpation
is combining with the placing of the index finger of
the opp. hand along the floor of mouth to fix the
mylohyoid muscle, slightly enlarged may be
readily palpated.
Submental nodes:-by pressing the fingers
upward against the symphysis of the jaw.

Deep cervical nodes:-
Turn or flex the head towards the side of
examination to relax the sternomastoid muscle
& fasciae of the neck.
Palpate ant. & post. Border of muscle with
thumb & finger closed .
Repeat the procedure on other side.
Supraclavicular nodes:-
Above the clavicle, lateral to the attachment of
sternomastoid muscle.

Lymph node examination
Palpable Not palpable
Normal diseased
History Physical Examination
Local General Special
Examination Examination investigation

HISTORY :-
1. Age
2. Duration
3. which group was affected first
4. Pain
5. Fever
6. Past history
7. Family history

Local Examination:-
1.Inspection
a.Number
b.Size
c.Position
d.Surface
e.Skin over the swelling
2.Palpation
a. Situation
b. Local temperature
c. Approx. diameter in cms.
d. Tenderness
e. Surface
f. Margin

g.Consistency
h.Discrete or confluent
i. Fixity to the skin & surrounding structure
3.Examination of the drainage area
General examination
1.Lymph nodes in other parts of the body
2.Examination of the other visceral parts
of the body

 Blood examination
 FNAC
 Biopsy
 Imaging
Ultrasound
CT
MRI
PET
Nanoparticle enhanced MRI
Lymphangiography

Widely available & easy to use
Conventional ultrasound has a high sensitivity
for detecting enlarged lymph nodes, whereas its
specificity is moderate.
Normal cervical nodes appears as
Flattened hypoechoic structure with varying
amount of fat
May show vascularity but usually hypovascular

Malignant lymph nodes appears as
 enlarged nodes that are usually rounded
 show peripheral or mixed vascularity
Metastatic lymph node
 Thickened outer wall, internal echoes,nodularity &
septation
Accuracy of
89%-94% in
differentiating
malignant from
benign cervical
lymph node.

Cross sectional imaging technique requires
understanding of cross sectional anatomy of
nodes
High patients acceptance & short examination
time
Technique :-
patient supine in quiet respiration a pad
placed beneath the patient’s scapulae
produces mild hyperextension of the neck and
provides consistent images perpendicular to
the long axis of the neck.
Scans are obtained using 3–5 mm or thinner
slices.

Use of contrast facilitates differentiation of
vessels from lymph nodes and the
characterization of pathology.
 Normal lymph nodes:-
 <1c.m. In size
 Smooth & well defined border
 Uniform & homogenous density
 Benign node have central fatty hilum

To improve cross sectional imaging,dynamic gadolonium
contrast enhanced MRI is in use
Evaluates alteration in lymph node microcirculation
such as flow characteristics, blood volume,
microvascular permeability.
Acc.to Fischbein at al ,lower peak enhancement, lower
maximum slope, & slower washout slope in tumor-
involved lymph nodes seen compared with normal
lymph nodes.
As in malignant lymph node, there is a decreased
transfer of contrast material to the tissue and a
reduced volume of extracellular space.

Functional imaging techniques
Use of glucose analog 18F-FDG, which is
avidly taken up by cells with increased
rates of glycolysis
18F-FDG is phosphorylated to 18F-FDG-
6P, which is trapped in tumor cells that
are relatively deficient in glucose-6-
phosphatase during the time interval in
which images are acquired.

USPIO are node specific contrast agent used for
MR lymphography
Nanoparticles have improved detection of
lymph node metastases by MRI
2 MR scans performed 24 hr.apart.
1st
scan to see existence and location of the
lymph nodes.
2nd
to evaluate contrast enhancement of the
identified lymph nodes
recommended optimal dose of ferumoxtran-10
=2.6 mg Fe/kg

Fig E
Mechanism of
action.
Systemically injected
long circulating
particles gain access
to interstitium and are
drained ubiquitously
through lymphatic
vessels. Lymph flow
disturbances or
disturbances of nodal
architecture by
metastases lead to
abnormal accumulation
patterns, detectable by
MRI.

Once within the nodes, these
nanoparticles bind to macrophages,
producing a decrease in signal intensity
on T2- weighted images.
Tumor infiltrated part lacks of
ferumoxtran-10 uptake & retain their
high signal intensity after
administration of the contrast material.

 All of the processes of tissue nutrition and repair are
dependent on lymph
 Since the blood does not come in direct contact with tissue
cells(except in one organ-spleen)of the main function of
blood circulation is to supply and renew the lymph to all
tissues.
 “The blood feeds the lymph and the lymph feeds the cells”
 The excretion of the cells-the waste products of metabolism
are carried by the lymph back into the blood stream for
elimination.
 Through the lymph channels-metastasis frequently occurs –
esp of malignant tumor cells.
 Gives protection against various forms of infection.

 Henry Gray. Gray”s Anatomy:Lymphatic
drainage of head and neck;38th,
edi-churchill
livingstone,2000,pg no.1612
 B.D.Chaurasia”s.Human Anatomy Regional and
applied:Deep structure of neck;2nd
edi-CBS
publishers,pg no.161
 S.M Balaji.Textbook of oral and maxillofacial
surgery,Lymph node examination,Elsevier,
2008,pg.no.15

 N.Chakraborty D Chakraborty;Fundamentals of
human anatomy.Lymphatic drainage of head
and neck.Vol.III-2004,New central book
agency,pg.no87
 A.Halim;Regional and clinical anatomy for
dental.pg.no162
 Neelima Malik;Textbook of oral and
maxillofacial surgery,Lymph nodes level.2nd
edi
jaypee,pg.no.736

Das S.,A manual on clinical surgery, 4th
edition
Greenberg M.,Glick M.,Ship A.,Burket’s Oral Medicine
Torabi M.,Aquino S.,j.nuclear med 2004;45:1509-1518
Mukherji, et al. Neurographics , Vol. 2, Issue 2, Article 2

Ananthnarayan & Paniker,Textbook of Microbiology ,4th
edition
Das S.,A manual on clinical surgery, 4th
edition
Greenberg M.,Glick M.,Ship A.,Burket’s Oral Medicine
Torabi M.,Aquino S.,j.nuclear med 2004;45:1509-1518
Mukherji, et al. Neurographics , Vol. 2, Issue 2, Article 2
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