Lymphatic Drainage of Head and Neck

LYMPHATIC DRAINAGE OF HEAD AND NECK
GUIDED BY:
DR. PANKAJ KUKREJA PRESENTED BY:
(PROFRESSOR & HEAD) DR. NASIM
ORAL & MAXILLOFACIAL SURGERY PG I YEAR
ORAL & MAXILLOFACIAL SURGERY
CONTENTS
Introduction
Development of lymphatic system
Functions of lymphatic system
 Components of lymphatic system
Lymphatic drainage of head and neck
Applied Aspects
Conclusion
References
INTRODUCTION
THE LYMPHATIC SYSTEM consists of:

Complex capillary networks which collect the lymph in the various organs and
tissues;
Elaborate system of collecting vessels which collect the lymph from the
capillaries to the large veins of the neck at the junction of the internal jugular
and subclavian veins, where the lymph is poured into the blood stream; and
Lymph nodes which are interspaced in the pathways of the collecting vessels
filtering the lymph as it passes through them and contributing lymphocytes to it.
Lymphatic system consist of fluid called LYMPH
 Transparent, slightly yellowish liquid of alkaline nature found in lymphatic
vessel and derived from tissue fluid.
Lymphatic system is absent in:
i. C.N.S.
ii. Cornea
iii. Superficial layer of skin
iv. Bones
v. alveoli of lung
DEVELOPMENT OF LYMPHATIC SYSTEM
 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.
 Six primary lymph sacs are formed.
i. 2 Jugular sacs (right and left): At the junction of subclavian and
anterior cardinal veins.
ii. 2 iliac sac (right and left): At the junction of the iliac and posterior
cardinal vein.
iii. Retroperitonial sac (Unpaired): Near the root of the mesentery.
iv. Cisterna chyli (unpaired): Dorsal to retroperitonial sac.
FUNCTIONS OF LYMPHATIC SYSTEM
Transport of tissue fluid formed in the capillary bed.
The removal of cell debris and foreign matter (e.g. bacteria) by mononuclear phagocytic series cells.
Prevention of bacterial and foreign material from entering the blood stream.
Production of lymphocytes and control of the immune responses.
Digested fat are absorbed and then transported from the villi in the small intestine to the bloodstream via the lacteals and lymph vessel.
COMPONENTS OF LYMPHATIC SYSTEM
Lymph, the recovered fluid;
Lymphatic vessels, which transport the lymph;
Lymphatic tissue, composed of aggregates of lymphocytes and
macrophages that populate many organs of the body; and
Lymphatic organs, in which these cells are especially concentrated and
which are set off from surrounding organs by connective tissue capsules.
Parotid Lymph Nodes
Submandibular Lymph Nodes
Submental Lymph Nodes
Occipital nodes
Postauricular (mastoid) nodes
Buccal (facial) nodes
Retropharyngeal Lymph Nodes
Drains :
• Nasopharynx
• Posterior nasal cavity
• Paranasal sinuses
• Posterior oropharynx
• Hypopharynx
Pretracheal Lymph Nodes
Drain
 Lower larynx
 Hypopharynx
 Cervical esophagus
 Upper trachea
 Thyroid
Spinal accessory Lymph Nodes
Drain :
• Scalp (parietal & occipital

region
 Nape of neck
 Upper retropharyngeal
 Parapharyngeal nodes
SUPERFICIAL CERVICAL LYMPH NODES
DEEP CERVICAL LYMPH NODE
(SUPERIOR JUGULAR)
Primary drainage sites
• Soft palate
• Tongue(Post. & base)
• Tonsils
• Supraglottic larynx
• Pyriform sinus
Secondary drainage sites

• Parotid node
• Submandibular
• Retropharyngeal
• Spinal accessory
• Superficial cervical
DEEP
CERVICAL
LYMPH NODES
MIDDLE JUGULAR

• Supraglottic larynx
• Lower pyriform sinus
• Post. Cricoid area
Secondary drainage sites

• Superior jugular
• Lower retropharyngeal
INFERIOR JUGULAR

• Trachea
• Thyroid
• Cervical esophagus
Secondary drainge sites

• Superior jugular
• Middle jugular
• Paratracheal
Waldeyer’s Lymphatic Ring
 Posterior part of mouth and pharynx contains an accumulation
of lymphatic tissues-
 Pharyngeal tonsil
 Palatine tonsil
 Lingual tonsil
 Tubal tonsil
 The ring collects lymphatics and drains into

retropharyngeal lymph nodes→jugulo-digastric lymph
nodes.
LYMPHATIC DRAINAGE OF TONGUE
 Tip
Submental nodes
 Anterior 2/3 lateral border
Ipsilateral Submandibular node
 Anterior 2/3 centrally
Submandibular nodes on both sides
 Posterior 1/3
Jugulo-omohyoid nodes
FINAL NODES TO BE INVOLVED ARE

Jugulo-omohyoid and deep cervical nodes
IMAGING BASED NODAL CLASSIFICATION
 1998 modification of the 1991 AAO-HNS (American Academy of

Otolaryngology – Head and Neck Surgery) classification
TNM CLASSIFICATION OF REGIONAL
NODE
 Nx - nodes can not be assessed
 N0 – No lymph node metastasis
 N1 – metastasis in single ipsilateral node 3cm or less.
 N2a – single ipsilateral node >3cm but <6cm
 N2b – multiple ipsilateral nodes <6cm
 N2c – bilateral / contralateral nodes <6cm
 N3 – metastasis in node >6cm
LYMPHADENOPATHY
 Enlargement of lymph nodes
 Soft , flat submandibular nodes ( 1 cm) are often palpable in healthy children
and young adults.
 Classifies into
• Generalised lymphadenopathy
• Localised or regional lymphadenopathy
GENERALISED
LYMPHADENOPATHY
 Frequently associated with nonmalignant disorders such as
•Infective mononucleosis,EBV, CMV,AIDS ,SLE
•Mixed connective tissue disease
•Acute and chronic lymphocytic leukemias and malignant lymphomas also
produce generalised adenopathy in adults
Localized or regional
lymphadenopathy
 Involvement of single anatomic area
 Site of adenopathy may provide useful clue about the cause.
•Eg : Occipital adenopathy reflects an infection of scalp, preauricular
adenopathy accompanies conjuctival infections and cat scratch disease
CLINICAL ASSESSMENT
 Careful medical history
 Physical examination
 Laboratory tests
 An excisional lymph node biopsy
MEDICAL HISTORY
 Symptoms such as sore throat, cough ,fever, night sweats, fatigue , weight
loss or pain in the nodes should be sought.
 Patient, age, sex, occupation, exposure to pets , use of drugs are
important.
 Children and young adults usually have benign disorders that account for the
observed lymphadenopathy ex. Viral or bacterial URI infections.
 After age50, incidence of malignant disorders increase and that of benign
disorders decreases.
EVALUATION
 Neck should be carefully palpated, with specific attention to location, size,
firmness, and mobility of each node.
 Direct attention should be given to nodes that appear fixed to
underlying neurovascular structures or visceral organs or that
demonstrate skin infiltration.
 Clinical palpation of the neck demonstrates a larger variation of findings among
various examiners.
Following characteristics should be noted and described:
 Size
 Pain / tenderness
 Consistency
 Matting
 Location
SIZE
 Nodes are generally considered to be normal if they are up to 1 cm in

diameter.
 Nodes < 1 cm sq are almost always secondary to benign , nonspecific
reactive causes.
 Diameter > 2 cm sq reveals great chance of malignant or granulomatous
disease.
PAIN / TENDERNESS
 When a lymph node rapidly increases in size, its capsule stretches and
causes pain.
 Pain is usually the result of an inflammatory process or suppuration, but
may also result from hemorrhage into the necrotic center of a malignant
node.
 The presence or absence of tenderness does not reliably differentiate
benign from malignant nodes.
CONSISTENCY
 Stony-hard nodes are typically a sign of malignancy, usually metastatic.
 Very firm, rubbery nodes suggest lymphoma.
 Softer nodes are the result of infections or inflammatory conditions.
 Suppurative nodes may be fluctuant.
LOCATION
 The anatomic location is sometimes helpful in narrowing the differential
diagnosis
MATTING
 A group of nodes that feels connected and seems to move as a unit is said
to be "matted.“
 Nodes that are matted can be either :
• Benign (e.g., tuberculosis, sarcoidosis or lymphogranuloma Venereum)
• Malignant (e.g., metastatic carcinoma or lymphomas)
TEXTURE
 Lymph node described as soft, firm, rubbery, hard, discrete, matted.
 On palpation
• Stony hard- carcinoma
• Rubbery – hodgkin lymphoma
• Cystic/soft- cold abscess
• Matted – tuberculosis
• Firm - syphilis
Palpation of lymph nodes
 Lymph node and chain palpation starts with parotid and
preauricular area which may also be palpated bimanually.
 Palpating with light finger pressure against underlying firm tissues(bone or
muscle) or bimanually.
 Head and neck lymph examination continues down the mandible to
the submandibular region ,palpation proceeds forward to the submental
nodes
LABORATORY INVESTIGATION
 Complete blood count ,CBC provide useful data for diagnosis of disease ex.
Leukemias, EVB or CMV mononucleosis , lymphomas ,SLE
 SEROLOGICAL STUDIES –
• Antibodies specific to EVB, CMV ,HIV Brucella
• Toxoplasma gondii SLE
 CHEST XRAY
• Presence of a pulmonary infiltrate or mediastinal lymphadenopathy suggest
tuberculosis, histoplasmosis, sarcoidosis, lung cancer or metastatic cancer
 FNAC
• Should be performed as the first diagnostic
Procedure
 Lymph node biopsy
RADIOLOGICAL INVESTIGATIONS
 Ultrasound
 CT scan
 MRI
 Positron emission tomography and single-photon emission computed
tomography
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.
REFERENCES
 Anatomy of the Human Body, by Henry Gray (1918)
 Sicher and Du BRUL`S oral anatomy. 8th edition
 BD Chaurasia Human Anatomy 4th edition : volume 3

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What are the components of the lymphatic system?

What are the functions of the lymphatic system?

LYMPHATIC DRAINAGE OF HEAD AND NECK

THE LYMPHATIC SYSTEM consists of:

 Starts at 5th week of intrauterine life.

• Scalp (parietal & occipital

Secondary drainage sites

Primary drainage sites

Secondary drainage sites

Primary drainage sites

Secondary drainge sites

 The ring collects lymphatics and drains into

FINAL NODES TO BE INVOLVED ARE

 1998 modification of the 1991 AAO-HNS (American Academy of

 Nodes are generally considered to be normal if they are up to 1 cm in

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