LN HEAD AND NECK.pptx

Elaborative description of lymph nodes head and neck

1. GOOD MORNING 1

2. EXAMINATION OF LYMPH NODES OF HEAD AND NECK AND ITS APPLIED ASPECT GUIDED BY: Dr. Neeraj Chauhan Dr. Abhishek Gupta Presented by: Dr. Arshdeep Kaur MDS-1 st year Dept. of Public Health Dentistry Bhabha College Of Dental Sciences and Research C entre 2

3. Contents Introduction Anatomy of lymph nodes Function of lymph nodes Classification of lymph nodes Draining areas Examination of lymph nodes Applied aspect 3

4. INTRODUCTION Lymphatic system is the part of the immune system comprising a network of lymphatic vessels that carry a clear fluid called lymph (from Latin lympha “water”) in a unidirectional pathway Lymphatic system is absent in CNS, cornea, superficial layer of skin, bones, alveoli of lung. Lymphatic system is essential drainage system which is essential to venous system. 4

5. Most tissue fluid formed at the arterial end of capillaries is absorbed back into the blood by venous end capillaries and rest of tissue fluid (10-20%) is absorbed by lymphatics. Larger particles like proteins and particulate matter can be removed from the tissue fluid only by the lymphatics. Therefore lymphatic system may be regarded as drainage system of “coarse type” & venous system as “fine type” 5

6. RELATION OF LYMPH SYSTEM TO BLOOD SYSTEM 6

7. COMPONENTS OF LYMPHATIC SYSTEM Lymph vessels Bone marrow Central lymphoid organs Thymus lymph nodes Peripheral lymphoid organs Spleen Tonsils Circulating lymphocytes 7

8. LYMPH NODES Lymph nodes are peripheral lymphoid organs connected to the circulation by a afferent & efferent lymphatics. These are ovoid or bean shaped nodular formation composed of dense accumulation of lymphoid tissue, vary in size from 2 to 20mm & average of 15mm in longitudinal diameter. There are about 800 lymph nodes in the body and around 300 are located in head and neck. 8

9. Lymph nodes usually occur in groups. Superficial lymph nodes are located in subcutaneous connective tissue. Deeper nodes lie beneath the fascia and muscles. Superficial lymphnodes are gateways for assessing health of entire lymphatic system. 9

10. STRUCTURE OF LYMPH NODE 10

11. Path of lymph flow through a lymph node Afferent lymphatics carry [afferent to bring to] lymph to the lymph node from peripheral tissues. The afferent lymphatics penetrate the capsule of the lymph node on the side opposite to hilum. The afferent vessels deliver lymph to the subcapsular space, a meshwork of reticular fibers, macrophages, and dendritic cells. Dendritic cells are involved in the initiation of immune response. Lymph next flow into the outer cortex , which contains B cells with germinal centers that resemble those of lymphoid nodule. 11

12. Lymph then flows through lymph sinuses in the deep cortex, which is dominated by T cells. Efferent lymphatics [efferent to bring out] leave the lymph node at the hilum. These vessels collect lymph from the medullary sinus and carry it towards the venous circulation. Lymph continues into the medullary sinus at the core of the lymph node. This region contain B cells and plasma cells. 12

13. FUNCTIONS OF LYMPH NODES: Lymph nodes play an important role in the defense mechanism of the body. They filter out micro-organisms (such as bacteria) and foreign substances such as toxins, etc. Major functions are: Lymphopoiesis Filtration of lymph Processing of antigens 13

14. Multiplication of B cells and T cells from preexisting lymphocytes in response to antigens. Antibodies produced are carried to circulation indirectly helping to mount an immune response. 14

15. Lymph nodes are classified into Peripheral nodes Deep cervical nodes Jugulo -digastric node Jugulo-omohyoid node Pretracheal Paratracheal Retropharyngeal Waldeyer’s ring Submental Submandibular Preauricular Postauricular Occipital Anterior cervical Superficial cervical nodes Deep Inner circle of cervical nodes Superficial Outer circle of cervical nodes 15

16. 16

17. All the lymph from the region of head and neck drains into deep cervical lymph nodes. Efferents from deep cervical lymph nodes form the jugular trunk which on right side drains into right lymphatic duct and on left side into thoracic duct, which empty into the junction of the subclavian and internal jugular veins on that respective sides 17

18. OUTER CIRCLE Formed by lymph node groups, which form the pericervical or cervical collar at the juction of head and neck. Extends from chin in front to the occiput behind. They include submental, submandibular, superficial parotid ( preauricular ), mastoid ( postauricular ) in relation with sternocleidomastoid muscle, occipital nodes present in relation with trapezius muscle. 18

19. 19

20. INNER CIRCLE Lymph node groups which lie deep to the investing layer of deep cervical fascia. Lymph nodes of the inner circle consists of Prelaryngeal Pretracheal Paratracheal Retropharyngeal Lingual and Infrahyoid nodes 20

21. 21

22. WALDEYER’S LYMPHATIC RING Deep to inner circle, there is a submucosal ring of aggregated masses of lymphoid tissue called tonsils, which surround the commencement of air and food passages. These together constitute the Waldeyer’s lymphatic ring. 22

23. WALDEYER’S RING The tonsils and adenoids form a ring of lymphoid tissues 23

24. TERMINAL LYMPH NODES These are deep cervical lymph nodes that lie along and around the internal jugular vein, some within the carotid sheath & some on the surface of the sheath, under cover of sternocleidomastoid. Divided into upper and lower group 24

25. Superior group of deep cervical lymph nodes: lie along the upper part of internal jugular vein, they lie above the omohyoid . Jugulodigastric node-subgroup of nodes that lies in a triangle bounded behind by the internal jugular vein, above by posterior belly of digastric and below by the facial vein. 25

26. The inferior deep cervical lymph nodes lie along the lower part of internal jugular vein. Jugulo-omohyoid node -just above the intermediate tendon of the omohyoid muscle. Tongue drains into jugulo-omohyoid nodes. A few nodes of the deep cervical group also extend in front of Scalenus anterior muscle. Enlargement of the left scalene node is a common finding in carcinoma of stomach (Virchow's node). Efferents from the lower deep cervical group drain into the jugular lymph trunk. 26

27. 27

28. 28

29. 29

30. 30

31. Original classifiaction system of cervical lymph nodes was developed by Rouviere in 1938. In 1981, Shah recommended that cervical lymph nodes be classified in a simpler fashion based on levels. The latest classification has been created by the American Joint Committee on Cancer and the American Academy of Otolaryngology-Head and Neck Surgery. 31

32. 32

33. 33

34.   The lymph nodes  in the neck have historically been divided into at least six anatomic  neck lymph node levels  for the purpose of head and neck cancer staging and therapy planning. Level I: submental and submandibular superiorly :  mylohyoid muscle  and  mandible inferiorly: inferior border of the  hyoid bone anteriorly:  platysma muscle posteriorly: posterior border of the  submandibular gland ​ There are two sublevels: level Ia   (submental nodes): anteromedial between the anterior bellies of both  digastric muscles level Ib   (submandibular nodes): posterolateral to the anterior belly of the digastric muscles 34

35. Level II: upper internal jugular (deep cervical) chain superiorly:  base of the skull  at the  jugular fossa inferiorly: inferior border of the hyoid bone anteriorly: posterior border of the submandibular gland posterolaterally : posterior border of the  sternocleidomastoid muscle medially: medial border of the  internal carotid artery ​There are two sublevels: level IIa :  inseparable from or anterior to the posterior edge of the  internal jugular vein ; includes  jugulodigastric nodal group level IIb :  posterior to and separable by a fat plane from the internal jugular vein 35

36. Level III: middle internal jugular (deep cervical) chain superiorly: inferior border of the hyoid bone inferiorly: inferior border of the  cricoid cartilage anteriorly: anterior border of the sternocleidomastoid muscle posterolaterally : posterior border of the sternocleidomastoid muscle medially: medial border of the  common carotid artery 36

37. Level IV: lower internal jugular (deep cervical) chain superiorly: inferior border of the cricoid cartilage inferiorly: level of the  clavicle anteriorly: anterior border of the sternocleidomastoid muscle posterolaterally : oblique line drawn through the posterolateral edge of the sternocleidomastoid muscle and the lateral edge of the  anterior scalene muscle   2 medially: medial border of the common carotid artery includes medial  supraclavicular nodes  including  Virchow node   37

38. Level V: posterior triangle superiorly: skull base at the apex of the convergence of sternocleidomastoid and trapezius muscles inferiorly: level of the clavicle anteromedially : posterior border of the sternocleidomastoid muscle posterolaterally : anterior border of the  trapezius muscle ​There are two sublevels: level Va :  superior half, superior to inferior border of the cricoid cartilage (posterior to levels II and III); includes  spinal accessory  nodes level Vb :  inferior half, inferior to inferior border of the cricoid cartilage (posterior to level IV); includes lateral  supraclavicular nodes   1 38

39. Level VI: central (anterior) compartment superiorly: inferior border of  hyoid bone inferiorly: superior border of  manubrium  (suprasternal notch) anteriorly:  platysma muscle   posteriorly: trachea (medially) and prevertebral space (laterally)  laterally: medial borders of both common carotid arteries (medial to levels III and IV) includes anterior jugular, pretracheal , paratracheal , prelaryngeal / precricoid ( Delphian ), and perithyroidal nodes 39

40. Termination All the levels above eventually drain to the  jugular trunk  of their respective side and then to the  right lymphatic duct  or the  thoracic duct  ( left) . 40

41. 41

42. NODES SUBMENTAL NODES LOCATION Under the chin in submental triangle on the surface of mylohyoid muscle. DRAINING AREA Lower lip, the chin, tip of tongue and anterior floor of mouth. EFFERENT’S Submandibul -- ar nodes or jugulo-omohyoid group. 42

43. NODES Sub mandibular LOCATION Lie within the submandibular region scattered over the surface of submandibular salivary gland. An extension of the submandibular group lie on the cheek superiorly called the buccal group. DRAINING AREA Submental nodes Cheek Nose Upper lip Maxillary teeth Vestibule Gingiva Posterior floor of the mouth tongue EFFERENT’S Drain into nodes of deep cervical chain 43

44. NODES Parotid nodes Retro auricular nodes LOCATION Lie superficial to the capsule of parotid gland Lie over the mastoid process DRAINING AREA The eyelid Temple Prominence of cheeks and The auricle The scalp The auricle EFFERENT’S Deep parotid nodes Superficial cervical nodes Deep cervical nodes 44

45. NODES Occipital LOCATION Lie just below the superior nuchal lines at the trapezius muscle and in proximity with occipital artery. DRAINING AREA From scalp EFFERENT’S Drain to deep cervical nodes 45

46. NODES SUPERFICIAL CERVICAL JUGULO-DIGASTRIC LOCATION 3-4 nodes lie along the external jugular vein and are situated superficial to upper part of sternocleido mastoid. Below the posterior belly of digastric DRAINING AREA Floor of external acoustic meatus Lobule of the ear Angle of the jaw Palatal tonsils Posterior 1/3 rd of tongue EFFERENT’S Lower deep cervical nodes Lower group of deep cervical nodes 46

47. NODES JUGULO –OMOHYOID SUPRA CLAVICULAR NODES LOCATION On the internal jugular vein, just below the intermediate tendon of omohyoid . Supra clavicular triangle DRAINING AREA Directly from the tongue and indirectly from submental, submandibular,upper deep cervical nodes. Axillary Thorax Abdomen Pelvis EFFERENT’S Thoracic duct Thoracic duct 47

48. NODES RETRO PHARYNGEAL (1-3) LOCATION Retropharyngeal space DRAINING AREA Posterior nasal cavity Paranasal sinuses Hard and soft palate Nasophary - - nx Oropharynx Auditory tube EFFERENT’S Superior deep cervical nodes 48

49. LYMPHADENOPATHY: Lymph nodes which are abnormal in size, number or consistency and is often used as a synonym for swollen or enlarged lymph nodes. Classified as generalized or localised Generalized: 2 or more non contiguous area Localised – involve one area 49

50. Causes of enlargement of lymph nodes Inflammatory Neoplastic Acute or chronic Carcinoma Lymphadenitis Sarcoma Infection Tuberculosis Filariasis Secondary syphilis Infectious mononucleosis 50

51. Haematological Immunological Hodgkins lymphoma Aids Non- hodgkins lymphoma Drug reaction Chronic lymphatic leukemia Systemic lupus Erythromatosus Rhematoid arthritis 51

52. Clinical examination: History – Age Duration Group first affected Pain Fever Primary focus Loss of appetite & weight loss Pressure effects Past history Family history 52

53. Local examination Inspection – number, position, size, overlying skin swelling, pressure effects. Palpation – consistency, matted or not, fixity to surrounded structures, drainage area. General examination : Lymph nodes in other parts of the body. 53

54. AGE: Tuberculosis, Syphilis and primary malignant lymphomas affect young age. DURATION: Short (acute lymphadenitis) GROUP AFFECTED FIRST: In case of Hodgkin’s lymphoma and tuberculosis cervical group is affected first, whereas in filariasis inguinal LN’s are affected earlier. PAIN: Acute and chronic infections are painful but in case of syphilis, primary malignant lymphomas and secondary carcinomas, infection is painless. FEVER: evening rise of temperature is characteristic feature of TB, whereas in case of filaria fever is periodic ( once in month). 54

55. PRIMARY FOCUS : In acute and chronic septic lymphadenitis. It is usual practice to look for primary focus in drainage area. LOSS OF APPETITE & WEIGHT: Incase of malignant lymphadenopathies. PRESSURE EFFECTS: e.g. Dysphagia may occur when esophagus is pressurized. PAST HISTORY: enlargement of epitrochlear and suboccipital group of lymphnodes may be enlarged in secondary stage of syphilis. FAMILY HISTORY: sometimes history of TB in families . 55

56. INSPECTION: NUMBER: single or mutiple , there is generalized involvement of LN’s in hodgkin’s lymphoma, TB, Lymphosarcoma , sarcoidosis. POSITION: Cervical group is involved in case of TB, epitrochlear and occipital in case of secondary syphilis. SKIN OVER THE SWELLING: In acute lymphadenitis skin becomes inflammed with redness, oedema , brawny induration. Skin over tuberculous lymphadenitis and cold abscess remains “cold” till they reach a point of bursting when skin becomes red and glossy. Over rapidly growig lymphosarcoma skin becomes tense, shining with dilated subcutaneous veins. 56

57. PRESSURE EFFECTS: Careful inspection of whole body must be made to detect any pressure effect due to enlargement of LN’s. Edema and swelling of upper limb – enlargement of axillary LN’s. Edema and swelling of lower limb - enlargement of inguinal LN’s Swelling & venous engorgement of face and neck may occur due to pressure effect of lymph nodes at the root of the neck. Hypoglossal nerve may be involved from enlarged upper group of cervical LN’s due to Hodgkin’s disease or secondary carcinoma. 57

58. PALPATION NUMBER LOCAL RISE IN TEMPERATURE TENDERNESS CONSISTENCY – Enlarged LN’S should be carefully palpated with palmar aspects of 3 fingers. While rolling the fingers against the swelling slight pressure is maintained to know the actual consistency. 58

59. Enlarged lymph nodes may be: Soft Elastic & rubbery ( hodgkin’s disease) Firm, discrete and shotty (syphilis) Stony hard (Secondary Carcinoma) Matted or Not: A group of lymph nodes that feels connected and move as a unit is known as matted. E.g. Acute lymphadenitis Metastatic carcinoma Tuberculosis 59

60. FIXITY TO SURROUNDING STRUCTURE: The enlarged lymph node should be carefully palpated to know if they are fixed to: Skin The deep fascia The muscles The vessels The nerves Eg : Any primary malignant growth of lymph nodes like lymphosarcoma , reticulosarcoma , histosarcoma or secondary carcinoma fixed to surrounding structures-first to deep fascia & underlying muscle followed by adjoining structures and ultimately overlying skin. 60

61. DRAINING AREA Cervical LN’s receive lymphatics from – head, face, mouth, pharynx and neck. Left supra-clavicular LN’s ( virchows ) receives lymphatics from upper limb, left side of chest and also viscera of abdomen 61

62. ANATOMY OF CERVICAL LYMPHATIC CHAINS Superficial temporal artery Masseter muscle Facial artery Submental Submandibular gland Superficial & deep parotid Posterior auricular Occipital Anterior belly of digastric muscle Posterior belly of digastric muscle Jugulodigastric Sternomastoid muscle Deep cervical lymph chain Omohyoid muscle Jugulo-omohyoid Superficial cervical lymph chain External Jugular Vein Internal Jugular vein Prelaryngeal Pretracheal Supraclavicular Subclavian vein 62

63. METHOD OF PALPATION a, b, c, d, e : examination of lymphatic groups around skull base Examined in their circle around the base of the skull 63

64. The deep cervical lymph chain, lies around the IJV, The chain passes deep to the sternomastoid muscle & in the lower neck, extends laterally into the supraclavicular region. 64

65. Although the vast majority of cervical lymphadenopathy is related to head & neck, the scalene nodes are an exception. This gp . Of supraclavicular nodes is situated behind the lower end of the sternomastoid muscle. They are a common site for metastases from breast, lung, gastrointestinal & genitourinary malignances, particularly on the left side. The scalene nodes can easily be missed if you don’t palpate deep to the sternomastoid . 65

66. To assess whether a mass is deep, fixed to, or superficial to the sternomastoid muscle, ask the subject to turn their chin away from the side being examined, pressing against your hand. This allows the demonstration of mobility of superficial or deep masses in relation to the tensed muscle 66

67. Palpate the superficial lymph chain along the length of the EJV completing the examination by palpation along the borders of the trachea & larynx for nodes along the anterior jugular vein. Occasionally nodes are encountered on the isthmus of the thyroid gland & over the larynx; these small “ delphium ” nodes are related to thyroid & other superficial malignances. 67

68. INVESTIGATIONS Complete Blood Count Chest Radiography Serological investigation Nodal Biopsy Fine needle aspiration cytology C.T. Scan M.R.I 68

69. fine-needle aspiration, excisional biopsy remains the initial diagnostic procedure of choice. Modern cross-sectional imaging modalities such as ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) allow reliable detection of cervical lymph nodes. However, the differentiation between benign and malignant lymph nodes remains challenging. 69

70. Alternative imaging modalities such as single photon emission computed tomography (SPECT) and positron emission tomography (PET) can help to differentiate between benign and malignant LN’s. In a recent meta-analysis, ultrasound and US-guided fine needle aspiration cytology ( USgFNAC ) have been shown to be valuable tools in characterizing cervical LN’s. Sentinel node biopsy has greater accuracy in determining lymph node status for carcinoma than commonly used imaging methods. 70

71. Lymphography : valuable tool for detection of lymphatic fistulas and lymphatic leakage Lymphangioscintigraphy Tc-99m – intradermally , and after 1 minute and again after 10-30 minutes 71

72. APPLIED ASPECTS Lymphatics are primarily meant for coarse drainage including cell debris & micro-organisms, from the tissue spaces to the regional lymph nodes, where the foreign & noxious material is filtered off by the phagocytic activity of macrophages for its final disposal by the appropriate immune responses within the nodes. Thus the lymphatic system is the first line of defence of our body. 72

73. The arrangement of lymphatics of head and neck is in such a manner that there is every possibility of checking or blocking of lymph flow. While draining from an infected area, the lymphatics & lymph nodes carrying infected debris may become inflamed, resulting in lymphangitis & lymphadenitis. Enlarged lymph nodes may interfere with salivary secretions and can cause dry mouth. 73

74. Lymphatics provide most convenient route of spread of cancerous cells. Helpful in diagnosis of primary site of cancer. Helps in predicting the prognosis & classifying the stage of cancer. Helps the surgeon in doing block dissections during operative procedures. 74

75. CONCLUSION The location of the lymph node may help to determine the site of malignancy. Diffuse, bilateral involvement suggests a systemic malignancy (e.g. lymphoma) while those limited to a specific anatomic region are more likely associated with a local problem 75

76. REFERANCES Human anatomy head and neck – BD Chourasia 4/e Loachim’s lymph node pathology – Harry L. loachim , Jeffery .4/E A manual on clinical surgery – S.Das 6/E Applied anatomy of lymphatics – D.O Millard Text book of head and neck anatomy – Hiatt, Gartner 4/E Principles and practice of radiation oncology – Edward halperin , Carlos perez 5/E 76