Lymphatics

GOOD
MORNING
www.indiandentalacademy.com

LYMPHATIC DRAINAGE OF HEAD
AND NECK

Contents
• Introduction
• Development of lymphatic system
• Lymphatic system
1) lymph
2) lymphatic channels
3) lymphoid organs
4) lymph nodes
• Topography of lymph nodes
• Regional distribution of lymph nodes

• Lymphatic drainage of the body
• Lymphatic drainage of head and neck
1) classification of cervical lymph nodes
2) lymph nodes of head and neck
3) lymphatic drainage of individual organs of head &
neck
• Diseases of lymphatic system
a) Disease of lymphatics
b) Disease of lymph nodes
• Investigations
• Conclusion www.indiandentalacademy.com

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 . www.indiandentalacademy.com

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.

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

• 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

Lymphatic system
• Accessory route by which the
fluid can flow from the
interstitial spaces into blood.
• Lymphatic system mainly
consists of
1) Lymphatic channels
a)lymphatic capillaries
b)lymphatic vessels
2) Lymph
3 )Lymph nodes
4) Lymphoid organs and tissues

FUNCTIONS
1. Draining interstitial fluid
2. Transporting dietary lipids
3. Protecting against invasion
• Immune responses : 2 types
a) Cytotoxic (T lymphocytes)
b) Antibody secreting (B lymphocytes)

Lymph
• Definition: transparent, slightly yellowish liquid of alkaline
reaction found in lymphatic vessels and derived from
tissue fluid
• Physiology of lymph circulation:
1)Filtration-Starling’s theory
2)Diffusion-Papenhemier(1953)

Filtration-starlings theory
• The movement of fluid back & forth across capillaries is
governed by balance b/w the BP in capillary, which
tends to force fluid outwards (into tissues) & osmotic
pressure of plasma proteins which tends to suck it back.
• At arterial end the BP is high- there is tendency for
filtration to occur outward into tissues.
• At the venous end the BP is low- the osmotic pressure
of plasma proteins tend to absorb the fluid back into
capillary.
• The tension of tissues is an additional factor which
oppose entry of fluid into tissue or its return into
capillary.
• The small excess of fluid filtered out results in lymphatic
fluid, which is eventually reabsorbed by the lymphatic
system.

Diffusion
• Means of exchange of molecules
• Smaller molecules diffuse out into tissues
• Larger molecules are inhibited from diffusing
• Few larger molecular proteins squeezes out
• This along with water constitutes lymphatic fluid

• Composition:
a)albumin
1) Protein b)globulin
c)fibrinogen
2) fats
3) Carbohydrates
4) Enzymes and antibodies
Electrolytes-Na,k,ca,mg,etc
5) solutes
Non electrolyte-amino acids
6) cells

Formation and sequence of fluid flow
ARTERIES
(BLOOD
PLASMA)
BLOOD
CAPILLARIES
(BLOOD PLASMA)
LYMPHATIC VESSELS
(LYMPH)
INTERSTITIAL
SPACES
(INTERSTITIAL FLUID)
LYMPHATIC
CAPILLARIES
(LYMPH)
LYMPHATIC DUCTS
(LYMPH)
SUBCLAVIAN VEINS
(BLOOD PLASMA).

Lymphatic circulation

• The flow of lymph from tissue spaces large lymphatic
ducts subclavian veins
• maintained primarily by the
1)contraction of skeletal muscles (milking action).
2)One-way valves.
3)Breathing movements
4)smooth muscle contraction

Rate of lymph flow:
• About 100ml/hr lymph flows through thoracic duct of
a resting human.
• Approximately 20ml/hr flows into circulation.
• The total estimated lymph flow is about 120ml/hr

Functions of lymph
• Return of plasma proteins into blood
• Carries hormones into blood
• Carries lymphocyte and antibodies into blood
• Collects waste products of tissue fluid like dead blood
cells and cancer cells
• Absorbs fats from intestine
• Absorbs dissolved proteins between cells

LYMPHATIC CHANNELS
• lymphatic capillaries.
• Begin as closed-ended
vessels.
• They do not have well
developed basal lamina
• The number, size and
richness of capillary
plexuses differ in different
regions and organs
• Larger molecules can pass
through the capillarieswww.indiandentalacademy.com

Found throughout the body, except in
1. Avascular tissues
2 CNS
3 Splenic pulp
4 Bone marrow
However, these tissues contain minor interstitial channels
called pre-lymphatics.

• They are lined by a single
layer of endothelial cells
• These are attached by
Anchoring filaments(5-
10nm)
• Partly composed of fine
collagen fibrils

• unique structure that permits
interstitial fluid to flow into them
but not out
Endothelial cells that make up
the wall of a lymphatic capillary
overlap
• When pressure is greater in
interstitial fluid than lymph, the
cells separate slightly, fluid
enters the lymphatic capillary
and vice versa

• specialized lymphatic
capillary called lacteal
• Lacteals transport lipids
absorbed from small
intestine into lymphatic
vessels and ultimately into
blood.
• Fluid within lacteals is called
chyle

• Clinical consideration:
• During edema, excess
interstitial fluid accumulates
• This swelling pulls
anchoring filaments, making
the openings between cells
even larger.
• so that more fluid can flow
into the lymphatic capillary.

• In large lymphatics, valves
exist every few millimeters
and in smaller lymphatics
much closer than this.
• The post capillary venules
are lined by tall cuboidal
endothelial cells.
• Allow movement of
lymphocytes from blood
stream.
Lymphatic vessels

• In skin, vessels lie in
subcutaneous tissue and
generally follow veins
• In viscera, vessels
generally follow arteries
forming plexuses around
them.

LYMPH TRUNKS AND DUCTS
• Lymph passes
• Lymphatic capillaries
• Lymphatic vessels
• Lymph nodes.
• lymph nodes unite to form lymph trunkwww.indiandentalacademy.com

• Principal trunks
1. Lumbar,
2. Intestinal,
3. Bronchomediastinal,
4. Subclavian, and
5. Jugular trunks
i. Thoracic (left lymphatic) duct
ii. Right lymphatic duct.
• From these ducts, lymph passes into venous blood.

• The cisterna chyli receives
lymph from right and left
lumbar trunks .
• lumbar trunks drain lymph
from the lower limbs, wall and
viscera of the pelvis, kidneys,
adrenal (suprarenal) glands.
• The intestinal trunk drains
lymph from the stomach,
intestines, pancreas, spleen,
and part of the liver.

• left jugular trunk drains
lymph from left side of the
head and neck .
• left subclavian trunk
drains lymph from left
upper limb.
• left bronchomediastinal
drains lymph from left
side of the deeper parts
of the anterior thoracic
wall,

THORACIC (LEFT LYMPHATIC) DUCT
• 38-45 cm (15-18 in.) in length
• Begins as a dilation called the cisterna
chyli, anterior to the second lumbar
vertebra.
• Main collecting duct of lymphatic system.
• Receives lymph from left side of the head,
neck & chest, left upper limb, & entire body
inferior to the ribs

RIGHT LYMPHATIC DUCT
• 1.25 cm (1/2 in.) long
• Drains lymph from the upper right
side of the body
• Collects lymph from right jugular
trunk, which drains right side of the
head and neck.
• Right broncho-mediastinal trunk,
which drains the right side of the
thorax, right lung, right side of the
heart.

central
central
peripheral
peripheral

Thymus Gland
• Usually a bilobed lymphatic
organ
• located in mediastinum,
posterior to sternum and
between the lungs.
• An enveloping layer of
connective tissue holds two
thymic lobes closely together
• Connective tissue consists of
capsule, trabeculae, lobules.

• Each lobule consists of a
deeply 1) cortex
2) medulla
• The cortex is composed
of tightly packed
lymphocytes.
• Pre-T cells migrate (via
the blood) from red bone
marrow to thymus,.

• The medulla consists mostly of epithelial cells and more
widely scattered lymphocytes.
• The epithelial cells produce thymic hormones,
1) Thymosin
2) Thymin
• Medulla contains characteristic Thymic (Hassall's)
corpuscles, which are remnants of dying cells.

DEVELOPMENT, STRUCTUREAND
FUNCTIONS OFLYMPHNODE

Lymph Nodes
• Oval or bean-shaped structures
• Located along the length of lymphatic
vessels
• Range from I to 25 mm in length.
• Scattered throughout body, usually in
groups.
• Heavily concentrated in areas such as
mammary glands, axillae, and groin.

A) aggregation of
lymphatic tissue
B) sinuses
formation
C) Trabeculae
formation
D) Definitive
morphology
Development

Structure of lymph node consists of three different
regions;
• Cortex (Outer region)
• Paracortex (Region between cortex and medulla)
• Medulla (Internal region)

CORTEX
Highly cellular region
• Cells are densely packed and
may form isolated lymphoid
follicles.
• The follicular center composed
of cells which are larger, less
deeply staining and are
Germinal Centers.

• Lymphocyte migrate outward
into the mantle zone
surrounding germinal centers.
• The cells pass from follicles
into sinuses, which convey
them across the medulla to the
hilar efferent vessel.

PARACORTEX / DEEP CORTEX
• Region between cortex and medulla consists of
mainly ‘T’ cells and is called Thymus - dependent
zone of lymph node.
• If the ‘T’ cells become activated, proliferation ,the
size of the para cortex increases (may invade
medulla region).

• High endothelial venules
(HEV’s) allow blood borne
lymphocytes to leave the
vasculature and enter the
node.
• ‘B’ cells migrate to the
cortex and ‘T’ cells remain
in the para cortex.
• The HEV’s are special –
lined by simple cuboidal.

MEDULLA
• Represent a network of minute
lymphatic channels.
• Lymphocytes are much less
densely packed,
.
• Blood vessels in medulla region
allow lymphocytes and plasma
cells to enter or exit the lymph
node.

MICROSCOPIC STRUCTURE OF
LYMPH NODE
• Lymph node
mainly consist
of
• Capsule
• Trabeculae
• Reticulum
• Lymphatic
vasculature
• Lymphatic
vessels
• cells

1. Capsule & Trabeculae
(Type I collagen)
• Composed mainly of
collagen fibers, a few
fibroblasts and elastin
fibers,
• From capsule,trabeculae
tissue extend radially
into the nodes interior
.
• At hilum, dense fibrous
tissue may extend into
the medulla with an
efferent lymphatic vessel
embedded in it.
trabeculae
capsule

2. Reticulum (Type III collagen) / Stroma
• It is a network of fine collagen (reticulin) fibers.
• Filters lymph by slowing down the flow of lymph fluid .
• The fibers are identifiable with reticulin stains, which
show how their bundles branch and interconnect forming
a very dense network

.
• providing attachment for
various cells, mostly
macrophages lymphocytes.
• Reticular connective tissue
forms the stroma of the
cortical nodules, medullary
cords and all sinuses.

Arteries
(Hilus)Node
enter
Medullary cords
Cortex (arterioles)
give off
Lymphatic tissue
(capillaries)
3.Lymphatic vasculature

4. Cells
• Most of the cells reticulum are ‘B’ and ‘T’ lymphocytes
but macrophages also occur,
• Distribution of lymphocytes varies in different regions.
• In the cortex cells are densely packed and may form
isolated lymphoid follicles.
• whereas in the medulla lymphocytes are much less
densely packed.

• Immuno fluorescent staining
shows that they occupy
distinct territories.
1. Immature ‘B’ cells occur in the
more peripheral parts of
follicles, whereas.
2. Mature ‘B’ cells (plasmacytes)
exist mainly in medullary cords
and sinuses while some are also
peripheral to the cortical follicles.

Other types of cells in Lymph Nodes
• The different types of “non lymphocytic” cells
• STEINMAN et al 1974 and other authors, endothelial
cells, fibroblasts, typical macrophages.
.
• cells lining blood vessel walls (smooth miocytes,
pericytes) also occur.
• NOPAJAROONSRI et al 1971 have used the term
“Littoral cell” to describe the endothelial cells lining the
nodal sinuses.
• They were also referred to as “endothelial macrophages”

Zone 1 - is a region of loosely packed cells, predominantly small
lymphocytes, macrophages and occasional plasmacytes.
Zone 2 - is a denser region internal to zone 1,composed mainly of
small lymphocytes and macrophages
.
Zone 3 - comprises the germinal centers of follicles, its cells include large
lymphoblast, dendritic cells and macrophages.
Cell Zones in Lymph Nodes -NOPAJAROONSRI et al 1971

FUNCTIONS OF LYMPH NODES
1. They produce and supply lymphocytes to the blood and
has a supportive function.
.
• Basically they are two types of lymphocytes
- T lymphocyte-Cell mediated immunity
-B lymphocyte-Humoral immunity

2. Lymph node act as mechanical filter to resist entrance
of poisonous substances into the circulation
• Cellular debris and antigens carried by incoming lymph
are removed by macrophages and follicular dendritic
cells.
• They enter the lymph and flow through the lymphatic
vessels to the lymph nodes.

3. They serve a great defensive role against bacterial
infections.
• The immune system recognizes the foreign bodies and
develops antibodies against these.
• The entire process is called opsonization.

5 Production of red blood cells
4 They temporarily stop the spread of cancer cells
6. Lymph nodes produce γ – globulin.
•‘B’ lymphocytes present in the lymph nodes release
immunoglobulin which is a type of γ – globulin.
7. They help in elaboration of antibodies in the development of
immunity
.

Spleen
• The oval spleen is the
largest single mass of
lymphatic tissue in the
body.
• About 12 cm (5 in.) in
length.
• Situated in the left hypo-
chondriac region
between stomach and
diaphragm lateral to the
liver.
. www.indiandentalacademy.com

• A capsule of dense connective tissue
surrounds the spleen.
• The capsule, in turn, is covered by a
serous membrane, the visceral
peritoneum.
• The capsule plus trabeculae, reticular
fibers, and fibroblasts constitute the
stroma of the spleen.
• The parenchyma of the spleen
consists of two different kinds of
tissue called white & red pulp.
Microscopic structure

• The white pulp of the spleen functions in immunity as a
site of B cell proliferation into antibody-producing plasma
cells.
• Red pulp carries out the main function of the spleen, i.e
phagocytosis of bacteria and worn-out or damaged red
blood cells and platelets
• During early fetal development, the spleen also
participates in blood cell formation.

• Clinical consideration: RUPTURED SPLEEN
• The spleen is the organ most often damaged in
cases of abdominal trauma..
• Prompt removal of the spleen, called a splenectomy,
is needed to prevent the patient from bleeding to
death.
• Other structures, particularly red bone marrow and
the liver, can take over functions normally carried out
by the spleen

Lymphatic Nodules
• Lymphatic nodules are oval-shaped concentrations of
lymphatic tissue.
• Although they are not surrounded by a capsule, most
lymphatic nodules are solitary, small, and discrete.

• They are scattered
throughout the lamina
propria lining
1)gastrointestinal tract,
2)respiratory airways,
3)urinary tract,
4)reproductive tract
.
• This lymphatic tissue is
referred to as mucosa-
associated lymphoid
tissue (MALT).

• Some lymphatic nodules occur in multiple, large aggregations
in specific parts of the body.
• Tonsils in the pharyngeal region are aggregated lymphatic
follicles
• Peyer's patches in the ileum of the small intestine.
• Aggregations of lymphatic nodules also occur in Appendix.

GOOD MORNING

WALDEYER’S LYMPHATIC RING
• In relation to oropharyngeal
isthmus, there are several
aggregations of lymphoid tissue
that constitute Waldeyer’s
lymphatic ring.
• The most important
aggregations are
1) The right and left palatine
tonsils.
2) The pharyngeal tonsil.
3) Tubal tonsils
4) Lingual tonsil www.indiandentalacademy.com

TOPOGRAPHY OF LYMPH NODES
• SUPERFICIAL / DEEP
• RELATED VASCULATURE
-BUCCAL NODES
-CERVICAL NODES
-CLAVICULAR NODES
-INGUINAL NODES

- EXTERNAL ILIAC
- INTERNAL ILIAC
• RELATIONS TO VISCERA: parotid, pulmonary,
• GENERAL LOCATIONS
LEG- popliteal,inguinal
ARM- axillary
HEAD AND NECK-cervical lymph nodes

Number And Regional Distribution
• A normal young adult body contains some 400-450
lymph nodes
Head and neck - 60-70
Arms/superficial thorax – 40
Legs/superficial buttocks- 30
Thorax –100
Abdomen/pelvis –230

LYMPHATIC DRAINAGE OF THE
HEAD AND NECK
• The lymphatics of the head and neck are distributed
in a systematic fashion
• The lymphatics that drain the superficial structure of
the head and neck follow the venous channels
• The deeper structures are associated with the
arteries that supply these structures

LYMPHATIC DRAINAGE OF HEAD AND NECK
Classification:
Superficial cervical
Outer circle (Pericervical
collar)
Inner circle (upper part of
respiratory and alimentary
passages)
Deep cervical
Surrounds IJV
Base of skull- Neck

parotid
Sub mental
Submandibular
occipitalmastoid
Lower deep cervical
Jugulo-omohyoid
Buccal
Superficial cervical
Upper deep cervical
prelaryngeal
pre tracheal

I
II
VI
III
V
IV
Level I: Sub-mental
Sub-mandibular
Level II: Cranial J N
Level III: Medial J N
Level IV: Caudal J N
Level V: Posterior
triangle
Level VI: Anterior
compartment
Level VII: Tracheo-
Oesophageal & Superior
Mediastinal nodes
Surgical point of classification

Image based nodal classification
Level I:
Level IA: Sub-mental
Level IB: Sub-mandibular
Level II: Cranial J N
Level IIA:
Level IIB
Level III: Medial J N
Level IV: Caudal J N
Level V: Posterior triangle
Level VA
Level VBwww.indiandentalacademy.com

Level VI: upper visceral nodes
Level VII: Tracheo-Oesophageal &
Superior Mediastinal nodes

DEEP CERVICAL LYMPHATIC
NODES
. Are alongside the carotid sheath
. They form superior and inferior
groups.

1.SUPERIOR DEEP CERVICAL LYMPH NODES:
• Adjoin upper internal jugular vein.
• Most are deep to
sternocleidomastoid
• Jugulo- digastric.
• Efferents from the upper deep
cervical nodes drain to the
lower group or directly into the jugular.

2 INFERIOR DEEP CERVICAL
LYMPH NODES:
• Are partly deep to the
sternocleidomastoid
• Some are closely related to
brachial plexus and subclavian
vessels.
• One node is on, or just above the
intermediate tendon of omohyoid,
the jugulo-omohyoid node
• Efferents from this lower group
join the jugular lymph trunk.www.indiandentalacademy.com

A. LYMPHATIC DRAINAGE OF THE SUPERFICIAL
TISSUES OF THE HEAD AND NECK
• Groups concerned are:
1. In the head:
• Occipital, retro-auricular (mastoid), parotid, buccal
(facial)
2) In the neck
Submandibular, Submental, anterior cervical, superficial
cervical.

1. IN THE HEAD:
a) OCCIPITAL:
• They lie in the apex of the posterior triangle
superficial to the attachment of the trapezius.
• They drain the occipital part of the scalp and upper
part of the back of the neck to the upper deep
cervical lymph nodes

b) RETROAURICULAR:
• These nodes lie on the
mastoid process superficial
to the sternomastoid.
• They drain a strip of scalp
just above and behind the
auricle
• The posterior wall of the
external acoustic meatus.
• Their efferents pass to the
posterosuperior group of
deep cervical nodes.

c. PAROTID:
• The parotid lymph
nodes lie partly in the
superficial fascia and
partly deep to the deep
fascia
• They drain temple, side
of the scalp, lateral
surface of the auricle,
external acoustic
meatus
• Efferents from these
nodes pass to the upper
group of deep cervical
nodes www.indiandentalacademy.com

d) BUCCAL:
• The buccal node lies on the
buccinator.
• They drain part of the cheek
and lower eyelid.
anterosuperior group of deep
cervical nodes.

2 IN THE NECK:
a) SUBMANDIBULAR:
• Wide area of
drainage;
• The nodes lie beneath
the deep cervical
fascia on the surface
of submandibular
salivary gland.

• They drain centre of forehead,
the nose inner canthus of the
eye, upper lip and anterior part
of the cheek
• outer part of the lower lip with
the lower gum and teeth the
anterior 2/3rds of the tongue
and floor of the mouth
• The efferents from the
submandibular lymph nodes
pass mostly to the jugulo-
omohyoid nodes and partly to
the jugulo-digastric node

b) SUBMENTAL:
• 2-4 small submental
lymph nodes are situated
in the superficial fascia
• They drain superficial
tissue below the chin,
central part of the lower
lip, floor of the mouth, tip
of the tongue
submandibular nodes.www.indiandentalacademy.com

c. ANTERIOR CERVICAL
NODES
• Lie along the anterior jugular
vein.
• Drain skin of the anterior part
of the neck
• Efferents pass to the deep
cervical nodes

d) SUPERFICIAL CERVICAL NODES
• Lie along the external jugular vein superficial to
sternomastoid.
• Drain the lobule of auricle, floor of external
acoustic meatus
• The skin over the lower parotid region and the
angle of the jaw.
• Efferent drain into deep cervical group of lymph
nodes

B) LYMPHATIC DRAINAGE OF
DEEP TISSUES OF HEAD AND
NECK
a) RETROPHARYNGEAL NODES:
• Lie in front of the prevertebral
fascia and behind the
buccopharyngeal fascia
• Extend laterally in front of the
lateral mass of the atlas.
• Drain the pharynx, the auditory
tube, the soft palate.
• Efferents pass to the upper deep
cervical nodes.

b) PARATRACHEAL NODES:
• They lie on the sides of the
trachea and esophagus
• They receive lymph from the
oesophagus, the trachea
and the larynx.
• Efferent drain into lower
jugular group ,anterior
mediastinal lymph nodes

C) PRELARYNGEAL AND
PRETRACHEAL NODES:
• Lie deep to the investing fascia,
the prelaryngeal nodes on the
cricothyroid membrane .
-Drain:
upper node supra glottic larynx
lower nodes infra glottic larynx
• The pretracheal nodes in front of
the trachea below the isthmus of
the thyroid gland.
-Drain: region of thyroid gland and
trachea

d) LINGUAL NODES:
• Are small and inconstant
• Situated on the external surface of hyoglossus and
also between the genioglossi.
• They drain into the upper deep cervical nodes.

Lateral cervical lymph nodes
• They are divided into two groups
1)Superficial
2)Deep
a)Spinal accessory chain
b)Transverse cervical chain
c)internal jugular groupwww.indiandentalacademy.com

Internal jugular
Drains:
Entire nasal fossa
Pharynx and tonsils
External and middle ear, eustachian tube
Tongue, hard and soft palate

Transverse cervical
group
• These nodes receives
drainage from the spinal
accessory group
• collecting trunks from the
skin of upper chest and
lower lateral neck
• Efferent drains into:
-into internal jugular
subclavian junction

TO SUMMARISE:
Lymphatic drainage of scalp and ear
• Anterior part of scalp pre-auricular lymph nodes
• Posterior part of scalp post-auricular (mastoid) and
occipital lymph nodes
• External acoustic meatus, middle ear and auditory tube
deep parotid lymph nodes
Lymphatic drainage of face
• Upper part Parotid Lymph nodes
• Middle part. Submandibular lymph nodes
• Lower part Submental lymph nodes

Lymphatic drainage of deep tissue of head and neck
• Head and neck tissues to deep fascia
Deep cervical lymph nodes
• Nasopharynx, pharyngotympanic membrane.
Retropharyngeal
• Trachea, oesophagus, thyroid
Paratracheal

Lymphatic drainage of mouth, teeth, tonsil,
tongue
• Gingiva Submandibular lymph nodes
• Hard palate Superficial deep cervical and
retropharyngeal
• Soft palate Retropharyngeal
• Floor of the mouth Submental (deep cervical)
• Teeth Submandibular and deep cervical
• Tonsil Jugulodigastric nodes

• Tongue
• Anterior 2/3rds
submandibular and
deep cervical
• Tip Submental
(deep cervical)
• Posterior 1/3rd
Jugulodigastric lymph
nodes.

Lymphatic drainage of nasal cavity and
paranasal sinus:
• mucous membrane of nasal cavity and anterior part
Submandibular and deep cervical lymph nodes
• Posterior part Deep cervical
• Frontal and maxillary sinus Submandibular
• Sphenoid and ethmoid Retropharyngeal

CLINICAL CONSIDERATIONS:
The disease of lymphatics broadly
classified into :
• Diseases of lymphatics:
1.Acute lymphangitis
2.Chronic lymphangitis
3.Neoplasms of lymphatics:
a. Benign neoplasms
1.CysticHygroma[Hydrocele]
2.lymphangioma

b.Malignant neoplasms:
i. Lymphangiosarcoma
ii. lymphoedema

• Diseases of lymph nodes:
1.Inflammatory
-Acute lymphadenitis
-Chronic lymphadenitis
-Granulomatous lymphadenitis
a.Bacterial origin
b.Viral origin
c.Fungal origin
2. Neoplastic:-Benign:- almost non existing
-Malignant
a. primary
b.secondary
3.Lymphatic leukaemias

CAUSES OF LYMPHADENOPATHY
1 INFECTIVE:
• Bacterial: Streptococcal, TB, brucellosis
• Viral: Epstein-Barr, HIV
• Protozoal: toxoplasmosis
• Fungal: histoplasmosis, coccidiodomycosis
2 NEOPLASTIC:
• Primary: leukaemias, lymphomas
• Secondary: eg. Lung, breast, thyroid, stomach

3 CONNECTIVE TISSUE DISORDERS:
• Rheumatoid arthritis
• SLE
4 SARCOIDOSIS
5 AMYLOIDOSIS

INVESTIGATIONS
1. CLINICAL EXAMINATION
2. BLOOD
3. ASPIRATION
4. BIOPSY
5. RADIOLOGICAL EXAMINATION
6. LYMPHANGIOGRAPHY
7. LAPROSCOPY
8. IMAGING

1. CLINICAL EXAMINATION OF THE LYMPH
NODES
• It is important to note that a normal lymph node
cannot be felt.
• “If a node is palpable, it must be abnormal”
• Most lymph nodes should be examined by
extraoral, bimanual, palpation from behind the
patient.

General Principles
• Inspection
• Palpation
• Compare with contra lateral side
• Assess
1) Number
2) Site
3) Size
4) Consistency
5) Tenderness
6) Fixation www.indiandentalacademy.com

EXAMINATION OF LYMPHNODES:
Pre-auricular lymph nodes

Examination of submandibular lymph nodes:
•Submandibular-, patients head
tipped to the side being examined.
•Operator stands behind the patient.

Examination of submental lymph nodes:
Submental- Tip the head
forward and try to roll the
node against the inner
aspect of the mandible

Palpation of Posterior Cervical Nodes:
• Dorsal pads of the
fingertips are used to
palpate along the
anterior surface of the
trapezius muscle
• Then moved slowly in a
circular motion toward
the posterior surface of
the SCM muscle

Palpation for Supraclavicular Lymph
Nodes
• The examiners free
hand is used to flex the
patient’s head forward
to relax the soft tissues
of the anterior neck
• The fingers are hooked
over the clavicle lateral
to the SCM muscle

• If a node is palpable, record the following
a) Site
b) Size
c) Texture- soft (infective),
rubbery hard (Hodgkin’s),
stony hard (secondary carcinoma)
d) Tenderness to palpation (infection)

e) Fixation ; surrounding tissues (may suggest
metastatic cancer).
f) Coalescence ; (eg. Tuberculosis)
g) Number of nodes; (multiple-glandular fever,
leukaemia, etc.)
• If more than one node is found, refer for
examination of the rest of the body for generalized
lymphadenopathy and blood tests.

PALPABLE NODE CHARACTERISTICS:
• Acute infection- large, soft, painful, mobile, discrete,
rapid onset.
• Chronic infection large, firm, less tender, mobile
• Lymphoma rubbery hard, matted, painless,
multiple
• Metastatic cancer stony hard, fixed to the
underlying tissues, painless
• Syphilis (primary) Firm discrete shotty
• Tuberculosis-
• Stage I: Lymph nodes enlarged without matting
• Stage II: Lymph nodes enlarged with matting
• Stage III: Cold abscesswww.indiandentalacademy.com

CLINICAL CONSIDERATIONS
• Most common swelling in the posterior triangle:
enlargement of the Supraclavicular lymph nodes.
• A swelling in this region may also be caused by a
lipoma, cystic hygroma (lymphangioma), pharyngeal
pouch
• Supraclavicular lymph nodes are generally enlarged
in tuberculosis, Hodgkins diseasewww.indiandentalacademy.com

• The left Supraclavicular nodes (Virchows or scalene
nodes) are also involved in malignant growths eg.
Stomach, testis and other abdominal organs.
• They are therefore known as “signal node”.
• Scalene node biopsy is very helpful in the early
diagnosis of such malignancies. This is to be co-
related with the vast territory drained by the thoracic
duct

• The TNM classification of tumours relies on proper
clinical examination.
• Palpable nodes are denoted by ‘N’ and are classified
into various groups based on their size named as
N0 N1 N2 N3 Nx

• Hodgkins :
• Most common
presentation is painless
and progressive
enlargement of lymph
node
.
• Clinical staging of
Hodgkins disease is
done depending on the
involvement of single or
multiple lymph node.

• The 4 stages of Hodgkin’s lymphoma:
• I- confined to one lymph node site
• II- in more than one site, either all above or all below
the diaphragm
• III- nodes involved above and below diaphragm
• IV- spread beyond lymphatic system, eg.liver.

2 BLOOD
Routine examination of blood is essential for
• leukocytosis: particularly polymorphs (acute
lymphadenitis)
• lymphocytosis: tuberculosis, lymphatic leukaemia
• eosinophilia: seen in filariasis
• raised ESR: seen in TB, secondary carcinoma and
primary malignant lymphadenopathy
• Complement fixation test should be performed for
lymphogranuloma inguinale and syphilis.

3) ASPIRATION- of the abscess is essential for
diagnosis be it a cold abscess or lymphogranuloma
inguinale
4) BIOPSY- This is probably the most important
special investigation.

5) RADIOLOGICAL EXAMINATION:
• In case of enlarged cervical lymph nodes,.
• To detect pulmonary tuberculosis or bronchogenic
carcinoma as the cause of enlargement of cervical
lymph nodes.
• Calcified tuberculous lymph nodes may easily be
seen in x-ray film,

6 LYMPHANGIOGRAPHY:
• This test is of immense value in finding out the
causes of lymphoedema
• lymph node enlargement and sites of lymph node
metastases in various carcinoma and malignant
melanoma.
• In malignant melanoma, sometimes radio-active
phosphorous is added to the radio-opaque dye for
lymphangiography
.
• This will destroy the malignant cells in the lymph
nodes. This process is called endo lymphatic
therapy.

7) LAPROSCOPY: This seems to be the last court of
appeal in Hodgkins disease.
This is required to know the clinical staging of the
disease by wedge biopsy of the liver.

8) IMAGING:
a) CT:
• Size: Axial plane, 3-5mm sections whilst bolus of IV
contrast media is administered.
• metastasis– based on size, shape, presence of
central necrosis, appearance of cluster of nodes in
expected lymph drainage pathway.

b) MRI
• Std protocol for cervical lymph nodes include a
selection of axial, coronal and sagittal images.
• Conventional MRI has the disadvantage of
discriminating abnormal lymph nodes only on the
basis of morphology.
• Hence recently, both IV ultra small
superparamagnetic iron oxide particles and
magnetization transfer imaging have been
evaluated for this purpose

c) ULTRASOUND
• Rapidly demonstrates all 3 nodal dimensions.
• Deeper lymph nodes, eg. Retropharyngeal region
cannot be assessed.
• Optimal size: diameters of 9mm for level II nodes
and 8mm for remaining levels.
• Combined with FNAC guidance increases the
specificity of ultrasound

d) POSITRON EMISSION TOMOGRAPHY
• Performed with radiolabelled glucose analogue
• Which has increased uptake in viable malignant
tumor due to enhanced glycolysis
• provides functional rather than anatomical imaging
• PET is able to measure tumour metabolism
• Offers potential to evaluate tumour proliferation

Lymphatics

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