LYMPHATIC DRAINAGE OF HEAD & NECK

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CONTENTS

Introduction History of lymphatic system Development of lymphatic system Lymph Lymph node Lymph nodes of head and neck Examination on neck nodes Cervical lymphadenopathy Refrences

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INTRODUCTION

Lymphatic system consist of fluid called LYMPH

DEFINITION:Transparent, slightly yellowish liquid of alkaline reaction found in lymphatic vessel and derived from tissue fluid

Lymphatic system is absent in: -C.N.S. -Cornea -Superficial layer of skin -bones -alveoli of lung

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HISTORY OF LYMPH DISCOVERY AND LYMPHATIC DRAINAGE

In 1650,John Paquet-cysterna chyli In 1962,Gaspard Asseli -milky veinsOlauf Rudbeck-first person to describe

the lymphatic systemAlexander of winiwater-protocol for

draining lymphedenomasF.D.Millard -diagnostic importance by

palpating lymphatic glandEmil Vodder -technoque of lymphatic

dranaigeBrono Chilky-rhythm of lymphatic flow

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DEVELOPMENT

Starts at 5th week of intrauterine life. First signs of lymphatic system are

seen in the form of a number of endothelium lined lymph sacs

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SIX PRIMARY LYMPH SACS ARE FORMED.2 Jugular sacs (right and left) At the junction of subclavian and anterior cardinal veins.

2 iliac sac (right and left) At the junction of the iliac and posterior cardinal vein.

Retroperitonial sac (Unpaired) Near the root of the mesentery.

Cisterna chyli (unpaired) Dorsal to retroperitonial sac

All the sacs except the cisterna chyli are invaded by connective tissue and lymphocytes and are converted into lymph nodes

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COMPOSITION OF THE LYMPH

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Rate of lymph flow: About 120ml of lymph flows into

blood

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Rate of flow of lymph along the human thoracic duct is from 1-1.5ml/min.

Regulation of the lymph flow mainly depends upon :

Interstitial pressureAtrial pulsation Intrathorasic pressureMuscular massage

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FORMATION OF LYMPH

Lymph is formed from tissue fluid,anything that increases amount of tissue fluid, will increase the rate of lymph formation

Various mechanisms: Filteration from plasma normally exceeds

resorption leading to net formation of tissue fluid

Increase in interstitial fluid hydrostatic pressure favouring the movement of tissue fluid into lymphatic capillary forming lymph

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FUNCTIONS OF THE LYMPH

Nutritive Drainage Transmission of proteins Absorption of fats Defensive

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LYMPH MOVEMENT

It takes place with the help of:Contractile skeletal musclePresence of valve Contraction of smooth muscle in

large lymphatic trunkPressure change in muscle during

breathing

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LYMPHATIC PATHWAYS FLOW CHART

LYMPHATIC CAPPILLARY

LYMPHATIC VESSEL

LYMPHATIC NODE

LYMPHATIC VESSEL

LYMPHATIC TRUNK

SUBCLAVIAN VEIN

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Before Lymph is returned to the blood stream, it passes through at least one lymph node and often through several

The Lymph vessels that carry lymph to a lymph node are referred to as afferent & those that transport it away from a node are called efferent vessels

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STRUCTURE OF LYMPH NODE Lymph nodes are oval-shaped of bean-shaped

structures Some are as small as a pinhead and others as

large as a lima bean Each lymph node is enclosed by a fibrous capsule Once lymph enters the node, it "percolates"

slowly through the spaces known as sinuses before draining into a single efferent draining vessel.

One-way valves in both the afferent and efferent vessels keep lymph flowing in one direction

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Fibrous septa or trabeculae extend from the covering capsule toward the center of the node.

Cortical nodules found within the sinuses along the outer region of the node are separated from each other by these trabeculae.

Each cortical nodule is composed of packed lymphocytes that surround a less dense area called a germinal center.

When an infection is present, germinal centers form and the node begins to release lymphocytes.

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Lymphocytes begin their final stages of maturation within the germinal center of the nodule and then are pushed to the more densely packed outer layers as they mature to become antibody-producing plasma cells.

The center or medulla of a lymph node is composed of sinuses and cords.

Both the cortical and medullary sinuses are lined with specialized reticuloendothelial cells (fixed macrophages) which are capable of phagocytosis

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LYMPHNODE OF HEAD AND NECK

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CLASSIFICATION

Upper horizontal chain of nodes:

Submental SubmandibularParotidPostauricularOccipital

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SUBMENTAL NODES

Lie on mylohyoid muscle in the submental triangle

2 to 8 in number Drainage –afferents come from the

chin, middle part of lower lip, anterior gums, anterior floor of mouth and tip of tongue.

Efferents -they go to submandibular and internal jugular chain

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SUBMANDIBULAR NODES

They lie in submandibular triangle in relation to submandibular gland.

Afferents come from lateral part of the lower lip, upper lip, cheek,nasal vestibule and anterior part of nasal cavity, gums,teeth medial canthus, soft palate, anterior pillar, anterior part of tongue, submandibular and sublingual salivary glands and floor of mouth

Efferents go to internal jugular chain

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PAROTID NODES

They lie in relation to the parotid salivary gland.

Afferents come from the scalp,pinna, external auditory canal,face,buccal mucosa.

Efferents go to internal jugular or external jugular chain

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POST AURICULAR NODES

Also called as mastoid nodes They lie behind the the pinna over

the mastoid. Afferents come from the scalp,

posterior surface of pinna and skin of mastoid.

Efferents drain into internal jugular chain

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OCCIPITAL NODES

They lie at the apex of the posterior triangle

Afferents come from scalp, skin of upper neck.

Efferents drain into upper accessory chain of nodes

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 Lateral cervical nodes They include nodes, superficial and deep

to sternocleidomastoid muscle and in the posterior triangle.

Superficial external jugular group Deep group i. Internal jugular chain (upper,middle

and lower groups) ii. Spinal accessory chain iii. Transverse cervical chain

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LATERAL CERVICAL NODES

a) Superficial group – it lies along external jugular vein and drains into internal jugular and transverse cervical nodes

b)Deep groupIt consists of three chains, the internal

jugular, spinal accessory and transverse cervical

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Internal jugular chain Lymph nodes of internal jugular chain lie

anterior, lateral and posterior to internal jugular vein.

Upper group (jugulodigastric node) – drains oral cavity, orpharynx, nasopharynx,hypopharynx, larynx and parotid.

Middle group drains hypopharynx, larynx, throid, oral cavity, oropharynx.

Lower jugular group drains larynx, thyroid and cervical oesophagus

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Spinal accessory chain Lies along the spinal accessory

nerve. Spinal accessory chain drains the scalp, skin of the neck, the nasopharynx, occipital and postauricular nodes.

Efferents from this chain drain into transverse cervical chain

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Transverse cervical chain (supraclavicular nodes)

It lies horizontally, along the trasverse cervical vessels, in thelower part of the posterior triangle.

The medial nodes of the group are called scalene nodes.

Afferents to those nodes come from the accessory chain and also infraclavicular structures,e.g. breast, lung, stomach, colon, ovary and testis

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Anterior cervical nodesAnterior jugular chain Juxtavisceral chain i. Prelaryngeal ii. Pretracheal iii. Paratracheal

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ANTERIOR CERVICAL NODES

They lie between the two carotids and below the level of hyoid bone and consist of two chains:

(a) Anterior jugular chian It lies along anterior jugular vein and drains the skin of anterior

neck.(b) Juxtavisceral chain It consists of prelaryngeal,pretracheal and paratracheal nodes(i) Prelaryngeal node (Delphian node)-lies on cricothyroid

membrane and drains subgottic region of larynx and pyriform sinuses

(ii) Pretracheal nodes lie in front of the trachea, and drain thyroid gland and the trachea.Efferents from these nodes go to paratracheal, lower internal jugular and anterior mediastinal nodes

(iii) Paratracheal Nodes – drain the thyroid lobes, subglottic larynx, tracha and cervical oesophagus

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CLASSIFICATION OF NECK NODES ACCORDING TO LEVELS

Level ISubmental (IA)Submandibular (IB) Level IIUpper jugular Level IIImiddle jugular Level IVLower jugular Level VPosterior triangle group(Spinal accessory and transverse cervical chains) Level VIPrelaryngealPretrachealParatracheal Level VIINodes of upper mediastinum

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Level I includes : IA Submental nodes, which lie in the

submental triangle i.e. between right and left anterior bellies of diagastric muscles and the hyoid bone.

IB Submandibular ones, lying between anterior and posterior bellies of diagastric muscle and the body of mandible

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Level II – Upper Jugular Nodes They are located along the upper

third of jugular vein I.e. between the skull base above, and the level of hyoid bone (or bifurcation of carotid artery) below

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Level III – Middle Jugular Nodes They are located along the middle

third of jugular vein, from the level of hyoid bone above, to the level of upper border of cricoid cartilage

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Level IV – Lower Jugular Nodes They are located along the lower

third of jugular vein; from upper border of cricoid cartilage to the clavicle

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Level V – Posterior Cervical Group They are located in the posterior

triangle i.e. between posterior border of sternocleidomastoid(anteriorly), anterior border of trapezius (posteriorly), and the clavicle below. They include lymph nodes of spinal accessary chain,transverse cervical nodes and supraclavicular nodes

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Level VI – Anterior Compartment Nodes

They are located between the medial borders of sternocleidomastoid muscles (or carotid sheaths) on each side, hyoid bone above and superasternal notch below. They include prelaryngeal,pretracheal, paratracheal nodes

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Level VII They are located below the

suprasternal notch and include nodes of the upper mediastinum

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EXAMINATION OF NECK NODES

Examination of neck nodes is important, particularly in head and neck malignancies and a systematic approach should be followed.

Neck nodes are better palpated while standing at the back of the patient.

Neck is slightly flexed to achieve relaxation of muscles

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When a node or nodes are palpable, look for the following points:

(i) Location of nodes(ii) Number of nodes(iii) Size – Abnormal NodesGreater than 1.5 c.m. in jugulo digastric area (level 1,2,3)Greater than 1 c.m. elsewhere.(iv) Consistency. Metastatic nodes are hard;lymphoma

nodes are firm and rubbery; hyperplastic nodes are soft. Nodes of metastatic melanoma are also soft.

(v) Discrete or matted nodes.(vi) Tenderness. Inflammatory nodes are tender.(vii) Fixity to overlying skin or deeper structures. Mobility

should be checked both in the vertical and horizontal planes

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The nodes are examined in the following manner so that none is missed.

a) Upper horizontal chain.b) External jugular chainc) Internal jugular chaind) Spinal accessory chaine) Transverse cervical chainf) Anterior jugular chaing) Juxtavisceral chain

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Submental Nodes Roll the fingers below the chin with

patient’s head tilted forwards

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Submandibular Nodes Roll your fingers against inner

surface of Mandible with patient's head gently tilted towards one side

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Parotid (Preauricular) Nodes Roll your finger in front of the ear,

against the maxilla

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Post auricular (Mastoid Nodes) Roll the fingers behind the ear

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Occipital Nodes

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Internal jugular chain Examine the upper, middle and

lower groups. Many of them lie deep to sternomastoid muscle which may need to be displaced posteriorly

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Transverse Cervical Nodes Supraclavicular (Scalene Nodes) Roll your fingers gently behind the clavicles.

Instruct the patient to cough or to bear down like they are having a bowel movement. Occasionally an enlarged lymph node may pop up

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CERVICAL LYMPHADENOPATHY

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LYMPHADENITIS AND LYMPHADENOPATHY

Lymphadenitis is an infection in the lymph nodes. Lymph nodes are glands that are part of the immune system. They help the body fight infection by filtering germs. They become enlarged when infection is present.

Lymphadenopathy is usually a normal response of the lymph nodes to an infection elsewhere in the body.

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Cervical lymphadenopathy may be either an important clue to an underlying disease process or a specific clinical syndrome

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CAUSES OF LYMPHADENOPATHY

1.Infectious disease A.Viral -Infectious mononucleosis -Infectious hepatitis -Herpes simplex -Rubella -Measle -Hiv B.Bacterial -Cat scratch disease -Brucellosis -Tuberculosis -Atypical mycobacterial infection -Primary and secondary syphilis -Diptheria C. Fungal -Histoplasmosis -Coccidioidomycosis D.Parasitic -Toxoplasmosis -Filiriasis E.Chlamydial -Lymphogranuloma venerum - Trachoma

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2.Immunologic disease A.Rheumatoid arthritis B.Systemic lupus erythematous C.Sjogren syndrome D.Drug hypersensitivity E.Mixed connective tissue disease

3.Malignant disease a.Hematological -Hodgkin disease -Non hodgkin disease -Hairy cell leukamia -T-cell lymphoma -Multiple myeloma B.Metastasis -From primary site

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4.Lipid storage disease -Gaucher’s disease -niemann-pick disease

5.Endocrine disease -Hyperthyroidism -Adrenal insufficiency -Thyroiditis

6.Other disorder -Sarcoidosis -Lymphomatoid granulomatosis -Kawasaki disease -Histocytosis x -Kikuchi disease

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CLINICAL EVALUTION

1.Location A.Anatomical site B.Presence of single or multiple nodes C.Presence of localized or disseminated nodes D.Palpable nodes are unilateral or bilateral2.Consistency A.Firm B.Soft C.Rubbery D.Rock hard E.Movable F.Fixed3.Size A.<1 cm or >1cm B.If nodes are bilateral,check for symmetry4.Symptoms A.Symptomatic B.Tender C.Painful D.Associated with systemic symptoms or not

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Structures that can be mistaken for enlarged lymph nodes include cystic hygromas, branchial cleft cysts, thyroglossal duct cysts, dental abscesses, dermoid cysts, and tumors of thyroid or neural tissue

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CLINICAL STAGING OF CERVICAL NODE

Nx : Regional LN cannot be assessed

No :no regional LN metastasis

N1 :metastasis in a single ipsilateral LN <3cm In greatest dimension

N2a :metastsis in single ipsilateral LN >3cm but <6cm in greatest dimension

N2b :metastasis in the multiple ipsilateral LN >6cm in greatest dimension

N2c :metastasis in a bilateral or contralateral LN none >6 cm in greatest dimension

N3 :metastasis in lymphnode >6cm In greatest dimensiom

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SYMPTOMS

Tenderness, redness or warmth in

the area of the lymph node Fever Lymph node enlargement Difficulty in swallowing or breathing

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TREATMENT

Acetaminophen or ibuprofen may be given for pain

Antibiotics if the cause is due to bacteria. Viral infections do not need antibiotics.

Referral to a dentist if a tooth is abscessed

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Antibiotic Therapy of CervicalLymphadenopathy

Suspected Staphylococcus aureus or Group A Beta-hemolytic Streptococcus Infection

For children who do not appear toxic and have no apparent abscess or cellulitis, Oral empiric therapy with cephalexin, oxacillin, or clindamycin

For ill-appearing children who have abscess formation or cellulitis,node aspiration and intravenous therapy with cefazolin, nafcillin or oxacillin, or clindamycin

Suspected Infection With Anaerobic Bacteria For children who have cervical lymphadenitis

associated with periodontal disease, node aspiration and therapy with penicillin or clindamycin

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Suspected Nontuberculous Mycobacteria Infection Surgical excision of the infected lymph node without

antibiotic therapy For patients in whom surgery is not feasible, a macrolide-

containing multidrug antimycobacterial regimenCat-scratch Disease Following needle aspiration and PCR diagnosis of

Bartonella infection, no antimicrobial therapy in patients who have uncomplicated lymphadenopathy.

Surgical removal of nodes infected with Bartonella frequently results in persistent drainage and poor wound healing. Repeated node aspiration for management of suppurative lymphadenopathy caused by Bartonella infection

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REFERENCES

C.J.Romanes Cunnighams manual of practical anatomy 15th edition

I.B.SinghText book of anatomy 3rd edition Singh,Pal.Human embryology 7th edition B D Chaurasia.Human Anatomy 4th edition

vol3 Anand.Human Anatomy for Dental Students

1st edition Anil Ghom.Textbook of Oral Medicine 1st

edition Shafer.Textbook of Oral Pathology 5th edition Infectitious diseases Cervical

Lymphadenopathy Pediatrics in Review Vol. 21 No. 12 December 2000

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