LYMOH DRAINAGE OF FACE AND NECK EXPLAINED BY OMFS

Lymoh drainage of face and neck

1. LYMPHATIC
DRAINAGE OF |
HEAD & NECK

DR. SWAT! SAHU
ORAL & MAXILLOFACIAL SURGERY

4
A
I |
i
Fo

2. INDEX

e
o
o
o
©

Introduction
Functions and development lo

Lymphatic drainage and lymph nodes of head and neck

Examination of lymph nodes

Investigations

Clinical implications

3. MPHATIC

o Lymphatic system is the part
of the immune system Lymph Capillaries in the Tissue Spaces
comprising a network of
vessels called lymphatic vessels
that carry a clear fluid called

lymph (from Latin lympha

water"). It goes in a

unidirectional pathway

(Toward Heart).

4. DEVELOPMENT

© Develop at the end of 5 wk of
embryonic life

© Lymphatic vessels develop from lymph
sacs which arise from developing veins

and are derived from mesoderm

© lymph sac to appear paired jugular
lymph sacs at junction of internal

jugular & subclavian veins

5. Six primary lymph sacs are formed
2 Jugular sacs (right and left)

+ 2iliac sae (right and left)

" Retroperitonial sac (Unpaired)

Cisterna ehyli (unpaired)

6. JUGULAR LYMPH SACS
Retains one connection with its Jugular vein
à Spreads lymphatic capillary plexuses to Thorax ,

imbs., head &neck.

uppe:
2 Left one develops into superior portion ofthöracie duct.

RETROPERITONEAL LYMPH SAC

3 Itis unpaired and develops from primitive
vena cava & mesonephric veins.

u Spreads capillary plexuses & lymphatic vessels to
abdominal viscera & diaphragm

& Develops connections with cisterna chyli 4 loses connections with neighboring veins

7. CISTERNA CHYLI

D Develops inferior to diaphragm on posterior
abdominal wall,

A Gives rise to inferior portion of thoracic
duet,

POSTERIOR LYMPH SACS

& Develops from iliac veins.

G Gives capillary plexuses & lymphatic vessels
toahdominal wall, pelvic region & lower
limbs,

A Join cisterna chyli & loose connections with

adjacent veins

8. Lymph vessels grow aut from the lymph sacs, along

the major veins,

a Except forthe upper portion of the cisterna chyli,
which persists, the lymph sacs are transformed into
groups af lymph nodes during early fetal life, at

about 3 months,

9. A PALATINE TONSILS - second pair of pharyngeal pauches

3 TUBAL (PHARYNGOTYMPANIC) TONSILS - aggregations of
lymph nodules around the openings of theauditory tubes

3 PHARYNGEAL TONSILS (adenoids) - aggregation of lymph
nodules in the nasopharyngeal wall

3 LINGUAL TONSILS - aggregations of lymph nodules in the

root of the tongue

10. FUNCTIONS OF LYMPHATIC SYSTEM

Fluid Lipid
Immunity
recovery absorption

11. FLUID RECOVERY

Each day, we lose an excess of a to 4 L of
waterand one-quarterto one-half of the
plasma protein, The lymphatic system

absorbs this excess fluid and returns it to

the bloodstream by way of the lymphatic

vessels,

12. IMMUNITY

As the lymphatic system recovers excess tissue fluid,
it also picks up foreign cells and chemicals from the
tissues. On its way back to the bloodstream, the fluid
passes through lymph nodes, where immune cells

stand guard against foreign matter.

13. LIPID ABSORPTION

In the small intestine, special lymphatic vessels
called Jacteals absorb dietary lipids that are not

absorbed by the blood capillaries,

14. COMPONENTS OF LYMPHATIC SYSTEM

iymphatic
organs

Se EG nphecytas and
which mocrophoges “in which these
transport cells ore
he a
the lymph Lymphatic rs.
tissue

pu

15. LYMPH

© Transudative fluid.

© Transparent & slightly yellowish liquid.
o Alkaline in nature.

© Derived from tissue fluid,

o When blood passes through tissues

9/10 of fluid - venous end

ito of fluid - lymph capillaries

16. COMPOSITION OF LYMPH

17. Tubularvessels transport back lymph to the blood ultimately replacing the volume lost from

the blood during the formation of the interstitial fluid.

Lymphatic
ducts

Lymphatic
trunks

Lymphatic
capillaries
and vessels

Richard L.Drake,GRAY'S Anatomy for
students;2005,19"" edition,333-335-

18. Fitroblast in loose
connective lisse

Fu
drone

©

Lymphatic capillaries are found around the cells of the body (asare blood capillaries)
u Blind ended.

o

Slightly larger in diameter and more permeable than blood capillaries. Have unique one-way flow.

à Permeable to components of interstitial Muid,

A.C:Guyton & JL, Hall; 1.0 of Medical Physiology"

edition 00693-1094.

19. Starling’s hypothesis

MATION OF LYMPH

Prosaures promote
Net Naar (ration
pra (NFP) = (MP + IFOP)

20. It absorbs and transports
nutrients,fattyacids and
fats as chyle from the GIT.

Removal of interstitial
fluid from tissues.
Return of protein, water
& electrolyte .

Transports immune cells to &
from lymph nodes into the
bones Transports APC ta lymph
nodes where immunological
response is stimulated.

21. C VESSELS

© Resemble veins in structure

Have thinner walls

o
© Elastic tissue not muscular

6 Contain lots of valves to prevent backflow
a

In skin lie in subcutaneous tissue and follows

same route as veins,

In viscera-follow arteries and form plexuses

around them.

A.C.Guyton & JE. Hall; T.B of Medical
Physiology;u" edition;2006/192-194.

22. o Formed by the union of collecting
vessels and drains large areas of the

body
ig

o Named after the areas they drain:
‘ lumbar tounks
2 bronchomediastinal trunks
A subclavian lymphatic trunk
4 jugular trunks: (all exist as pains)
3 asingle intestinal trunk,

o All eventually drain into two main
lymphatic ducts

23. RATE OF LYMPH FLOW

à Toral estimated lymph flaw is 130 ml / hr

D About 100 ml flows through Thoracic duct in resting man per hour

A Approx 20 ml flow into circulation through other channels

= 3-4 liters / day

24. FLOW OF LYMPH

Lymph takes the following route from the tissues back
to the bloodstream:

|
A Subclavian
veins

Ol v

® a. lymphatic Bts

> lal

lymphatic hus, there ia continual eyeing of Maid rom Medio 21,5 Fat ha Ban he aay and
Ly mpleati Systems. Bo capullo (nd to she tt spares:
capillaries tissue fluid to lymph and back to the blood. Ware Bahnen. Bien Caps oer fl the Sin space
[si

27. © Smallest lymphatic vessels

© They begin in the tissue spaces as blind-ended sacs.

© These capillaries form plexuses which collect lymph from the interstitial space mark the
beginning of lymphatic system

28. © They are lined by a single layer of
endothelial cells,

© These are attached to CT by anchoring
filaments,

‘The edge of one endothelial cell
overlaps the adjacent cell,

© Overlapping edge is free to Map inward
minute valve.

© Permits passage of high molecular weight
substance,

29. LYMPHATIC VESSELS

© Lymph capillaries merge to form lymphatic vessels.
e Resemble veins but
© Thin walls (Diameter - 0.2 - 0.3 mm)

© More valves (formed from folds of tunica intima)

© Lymph Nodesare located at

interval along its course

Have 3 coats (Tunica intima, Tunica media, Tunica

adventitia)

BEADED in appearance (semilunar valves).

Collagenous fibers attaches the endothelium to the outer

tissues ( fibrous sheath of muscle)

30. STRUCTURE OF LYMPH NODE

31. LYMPHOID CELLS

© Lymphocytes - main cells involved in immune CECI
i
| response
| T cells & B cells protect body against antigens E.

+

Antiusios
T cells - manage immune response by attacking +
& destroying foreign cells + secretion
B cells - produce plasma cells (daughter cells) ,
which secrete antibodies into blood,
Plasma tell

© Antibodies immobilize antigens until they can
be destroyed by phogocytes or by other means.

32. © Macrophages - phagocytize foreign substances

& help activate T cells

A ut bo
© Dendritic cells - spiny-looking cells with
e

functions similar to macrophages

e Reticular cells - fibroblast like cells thar produce

estroma, or network, that supports other cell types

in Iymphoid’organs.

33. LYMPHOID ORGANS
PRIMARY LYMPHATIC ORGANS :-

© Lymphatic (lymphoid) organs contain large numbers of lymphocytes, a type of white blend cell that
playsa pivotal role in immunity,

© The primary lymphatic organs are Red bone marrow and
‘Thymus gland

© Lymphocytes originate and/or mature in these organs.

34. BONE MARROW

© Bone marrow contains two types of cells multipotent stem cells

6 NON - LYMPHOID STEM CELLS differentiate in bone marrow,
Eg. Erythrocytes, granulocytes. monocytes & platelets.

0 LYMPHOID STEM CELLS differentiate in bone marrow & then migrate to lymphoid
tissue.

Eg. DK Tlymphocytes.

35. Figure 23,2 The iymphatic orga. Left The red bone mariow and Eyes lanl ae the primary iymphatie organs. Might ya minder
and the spine, as well as ülher Iymohalie nrpams such as the tantlis, are secandary Wmgihatic apar.

36. THE SECONDARY LYMPHATIC ORGANS
© thespleen,
© the lymph nodes and
o other organs, such as the tonsils.

All the secondary organs are the places where lymphocytes encounter and bind with antigens,
after which they proliferate and become actively engaged cells.

37. LYMPH NODES OF HEAD AND NECK

38. © All lymph vessels of the head and neck drain into the deep cervical nodes, either
directly from the tissues or indirectly via nodes in outlying groups.

o Lymph is returned to the systemic mas circulation via either the right lymphatic

duct or the thoracic duct,

39. A

CLASSIFICATION OF LYMPH NODES IN
| HEAD AND NECK REGION

SUPERFICIAL DEEP LYMPH
| LYMPH NODES NODES
À D ON 4

40. > The superficial cervical lymph nudes lleabave the
Investing layer atthe deep fascia,

+ They consist of fewsmall nodes that He superficial to

the external iugularand anterior jugularweins
© Superficial lymph nodes are -
+ Sutmental

+ Sdmandibralas

+ thecal
Panta

Pestausicular

Suquerticial vursiral

41. © Lie on mylohyoid musele in the submental triangle

© 3104 in number

© Afferents~ come from the chin, middle part of lower lip, anterior
gingiva, anterior floor of mouth and tip of tongue.

© Efferents «they goto submandibular and jugulo-omohyoid nodes.

42. a Lie in diagastrie triangle superficial ta submandibular gland

© They are 3 in number
© Afferents : Centre of forchead, medial angle of the eye, cheek and angle of mouth, upper tip, lateral part of
lower lip, frontal,maxillary and cchmoidal sinuses, nasal vestibule and anterior part of nasal cavity, gingiva,

soft palate, anterior part of tongue, sublingual salivary glands and submental |

Efferents; Mainly in jugulo-omohyoid and partly in jugulo-diagastric.

43. © Afferents: Upper part of forehead and temporal bone, lateral part of scalp, eyelid, lateral surface of auricle,
anterior wall of external acoustic meatus, parotid gland infratemporal fosa, nasopharynx, posterior part uf
nose,

cal group,

44. © Lie superficial to sternocieidomastoid and mastoid
process and deep to auricularis posterior.

© Afferents come from the scalp, posterior surface of
pinna and skin of mastoid,

© Efferents drain Into upper deep cervical lymph nodes:

45. © They Hear the apex of the posterior
triangle, superficial to trapezius and in close

relation with occipital artery,

| © Afferents come from posterior occipital

region of scalp, skin of upper neck.

© Efferents drain inte supraclavicular nodes:

46. L LYMPH N

© On the surface of buccinator muscle in relation to

facial vein
al O Afferent — lower eye lid, part of cheek , buecinator

muscle, facial vein

© Efferent - Submandibular lymph node

47. ANTERIOR CERVICAL LYMPH NODES

ANTERIOR JUGULAR CHAIN JUXTAVISCERAL CHAIN
It lies along anterior jugular vein and oPrelaryngeal node
drains the skin of anterior neck, (Delphian node)-situated infront of conus |

elasticus
oPretracheal_node

infront of trachea above the thyroid isthmus.
oParuracheal Node

on each side of trachea along recurrent

laryngeal nerve (glands of recurrent chain).

48. SUPERFICIAL

It lies superficial to SCM along external jugular veir are
© Afferents- lobule of auricle + \/ | |
Flooraf external acoustic: meatus: = à
Angle of jaw a ESA
Lower part of parotid land 2 a

posterior triangle of neck

© Efferents drains into upper and lower deep cervical group of lymph nodes,

49. It consists of three chains,
à Internal jugular
à Spinal accessory

D Transverse cervical

50. INTERNAL JUGULAR CHAIN

© Lymph nodes of internal jugularchain lie anterior

lateral and posterio! il jugular veir

© SUPERIOR DEEP CE

de,waldeyer's ring,a:

cavity, oropharynx, hypaphary

larynx and parotid

© MIDDLE GROUP drains oral cavity Hyoid
oropharyx,hypopharynx, larynx and thyroi Po Miipavid
EN 4

© INFERIOR DEEP CERVICAL NODES (jugulo- \ shutiage
ohyoid) group- drains larynx, chyroid and L rares
prop

Tramverse cervical gro

51. © Situated below the posterior belly of diagastric

© In telangulararca bounded by posterior belly of
diagastrie, facial vein and internal jugular vein,

© Afferents- Posterior third of tongue, palatine

tonsil.

© Efferents-Drain into inferior group of deep:
cervical or directly into jugular trunks

52. WALDEVER'S TONSILLAR RING(or pharyngeal
Iymphoid ring) is an anatomical term describing
the Lymphoid tissue ring located in the pharynx and to
the back of the oral cavity.

ho was named afler the nineteenth
century german anatomist heinrich withelm gort/ried vom
waldeyor-hortz.

The ring consists of (from superior ta inferior)
Pharyragcal. tonsil (also: known as ‘adenoid’ when
infected)

Tubal tonsil (where Eustachian tube opens in the
asopharynal

Palatine tonsils (commonly called "the tonsiós” in the

*Pharyngeal Tonsil
*Tubal Tonsil
«Palatine Tonsil
«Lingual Tonsil

Inner Ring

—— Submenzal Nodes

Quter Ring

53. © At the entrance to the pharynx there is a considerable
amount of lymphoid tissue,

© Grouped in the circular fashion. Aetrophanngeal
rode ‘Nasopharyngeal Tonal
© Formed superiorly by the pharyngeal tonsil, inferiorly by Ale ers —
the lingual tonsil and laterally by the palatine tonsil and
the tubal tonsil, This is known as internal ring of Aero + sn Tere,
waldeyer . = * Lngual Ton
Subemandibular modes + fubmental podes.

© lt drain into pericervical chain and upper deep cervical
nodes which together constitute the external ring of
waldeyer.

54. © Inframastoid nodes lying below the tip of mastoid

process under cover of SCM

© Receive lympl from pharyngeal tonsilstadenoids)

55. Lies above inferior belly of omohyoid where it crosses the

internal jugular vein,

Extend to subclavian triangle
Related to subclavian vessels and brachial plexus.

© Afferents- directly from tongue, indirectly through
superficial nodes:
Efferents - Inferior deep cervical lymph nodes

56. SPINAL ACCESSORY CHAIN

© Lies along the spinal accessory nerve

57. TRANSVERSE CERVICAL CHAIN

group

netion of internal jugular vein al Javian wir Tranverse cervical group"

58. [LYMPH NO

A. Retropharangeal
8. Infrahyoid
© Prelaryngeal

D. Pretracheal

E Paratracheal

59. ON
| |

RETROPHARYNGEAL LYMPH NODES

© Located between pharynx 8 atlas,

© Afferents
Pharynx ,
Auditery tube,

Soft palate.

posterior part of hard palate,
Nose,

60. O Afferents - Neighbouring

structures, thyroid gland

O Efferents - Deep cervical
lymph nodes

61. * Afferent - Anterior cervical
nodes

* Efferent - Deep cervical lymph
nodes

62. DRAINAGE OF SKIN OF THE HEAD AND NECK

© Thescalp drains into the occipital, mastoid and parotid nodes.

© Lower eye lid and anterior cheek drains into buceal nodes,
© Thecheeks drain into the parotid, buccal and submandibular nodes. 4

4 © Theupperlips and sides of the lower lips drain into the submandibular nodes,
© While the middle third of the lower lip drains into the submental nodes.

© Theskin of the neck drains into the cervical nodes,

63. © The Gingiva drain into the submandibular, submental and upper deep cervical lymph
nodes,

© The palate drains via lymph vessels that pass through the pharyngeal wall to the upper deep
cervical nodes.

© Anterior part of mouth floor drain into submental and upper deep cervical while posterior
part intosubmandibular and upper deep cervical,

64. DRAINAGE OF EXTERNAL NOSE

Lymphatic drainage of external nose is primarily to the submandibular group of

nodesalthough lymph from the root of the nose drains to superficial parotid nodes.

65. © Lymph vessels from the anterior region of the nasal cavity pass superficially to join those di
external nasal skin, and end in che submandibular nodes.

ing the

© The rest of the nasal cavity, paranasal sinuses, nasopharynx and pharyngeal end of the
1 pharyngotympanic tube, all drain to. the upper deep cervical nodes either directly or through the '

retropharyngeal nodes.

hn

© The posterior nasal floor drains to the parotid nodes.

66. © The lymphatic drainage of the tongue can be divided into
3 main regions: Marginal, Central and Dorsal.

© The anterior region of the tongue drains into marginal
and central vessels, and the posterior part of the tongue
behind the cireumvallate papillae drains into the dorsal
lymph vessels,

© The more central regions drain bilaterally into sub-
mental and sub-mandibular nodes.

67. LYMPHATIC DRAINAGE OF TEETH

© The lymph vessels from the teeth usually run directly into the ipsilateral submandibular lymph
nodes.

1 9 Lymph from the mandibular incisors, however, drains into the submental lymph nodes,

© Occasionally, lymph from the molars may pass directly into the jugulo-digastric group of nodes,

68. EXAMINATION OF
LYMPH NODES

69. HISTORY

o
o
o
o
o
o
o
o
o

Age

Duration

Group first affected

Pain

Fever

Primary focus

Loss of appetite & wt.Loss
Pressure effects

Past history

Family history

70. | pe

AGE:

Tuberculosis and syphilis , primary malignant lymphomas affect young age.

Acute lymphadenitis can oceurat any age,

Secondary malignant lymphomas - old age

DURATION:

Short (acute lympahadenitis)

Long (chronic lymphadenitis, tuberculosis)

GROUP AFFECTED FIRST : Eg: cervical group affects first in Hodgkin's disease . tuberculosis

ete where as inguinal lymphnode affects first in filariasis,

71. PRIMARY FOCUS: when ever lymph node enlarged, it is usual practice to look for primary focus

in drainage area of lymph nodes, This should be dane in acute and chronic septic
lymphadenitis,

PAIN: Acute and chronic infection are painful where as painless in syphilis , primary malignant
lymphomas and secondary carcinoma.

FEVER:

Evening rise of temperature is characteristic feature of TB.

Periodic fever in filaria (once in month)
Pel-ebstein fever - Hodkins disease

72. © LOSS OF APPETITE & WEIGHT: incase of malignant lymphadenopathis.

© PRESSURE EFFECTS: Eg. Dysphagia may occur when oesophagus is pressured,

© PAST HISTORY:

+ Enlargement of suboccipital group of lymph nades may be enlarged in secondary

stage of syphilis.

+ A patient who presents with enlarged cervical group of lymph nodes may give a

past history of tuberculosis,

© FAMILY HISTORY : Sometimes history of tuberculosis in families

73. INSPECTION

Son ás (à Presence of a swelling,
bp , number, position, size,
L surface

m
Skin over the
swelling
Pressure effects |

74. NUMBER

Single or multiple, A few conditions are known to produce generalised involvement
of lymph nodes like Hodgkin's disease, Tuberculosis, Lymphosarcoma, sarcoidosis.

POSITION

© cervical group eg . Tb,
© Epitrochlear and occipital eg Secondary syphilis.

75. SKIN OVER THE SWELLING

© In acute lymphadenitis skin becomes inflammed with redness, oedema,
brawny induration.
© Skin over Tuberculous lymphadenitis and cold abscess remains “cold” in

true sense till they reach a point of bursting when skin becomes red and

glossy.

o Over rapidly growing lymphosarcoma skin becomes tense, shining , with

dilated subcutaneous veins.

76. ile

PRESSURE EFFECTS

© Careful inspection must be made of whole body to detect any pressure effect due to

enlargement of lymphnodes.
© Dedema & swelling of upper limb- enlargement of axillary lymph nodes.

© Dedema $ swelling of lower limb- enlargement of inguinal lymph nodes.

© Swelling & venous engorgement of face and neck may occur due to pressure effect of
lymph nodes at the root of the neck.

a Hypaglossal nerve may be involved from enlarged upper group of cervical lymph nodes

due to Hodgkin's disease or secondary carcinoma.

77. PALPATION

Fixity © © Number and situation
| \/ |
a.

consistency @ = () Local temperature

IN

Surface and
hs o © Tenderness

78. NUMBER

LOCAL RISE IN TEMPERATURE

‘TENDERNESS

CONSISTENCY - Enlarged lymph nodes should be carefully palpated with palmar aspects of 7 fingers. While

rolling the fingess against the swelling slight pressure is maintained to know the actual consistency.
Enlarged lymph nodes may be;

+ Soft (Muctuating)

+ Elastic & rubbery (hodgkin's disease)
2 Firm, discrete and shotty (syphilis)

+ Stony hard (secondary carcinoma)

79. _

MATTING

© A group of lymph nodes that feels connected and move as a unit is

known as matted.

o Eg. Acute lymphadenitis, Metastatic Carcinoma, Tuberculosis

80. FIXITY TO SURROUNDING STRUCTURES

© Theenlarged lymphnode should be carefully palpated to know if they are fixed to;

Y Skin

y The deep fascia

+ The muscles

+ Thevessels

x The nerves

Eg: Any primary malignant growth of lymph nodes like lymphosarcoma ,
reticulosarcoma , histosarcoma or secondary carcinoma fixed to surrouding structures-

first to deep fascia & underlying muscle followed by adjoining structures and ultimately

overlying skin.

81. UBMENTAL NODES

> They are palpated under the chin

> The clinician can stand behind the patient to
palpate.

+ The patient is instructed to bend his/her neck |

cles and fascia in |

ghely forward so that the mi

that regions relax

> Fingers of both hands can be placed just below

the chin, under the lower border of mandible and

the lymph nodes should be tried to be cupped with

fingers.

82. Are palpated at the lower border of the mandible
approximately at the angle of the mandible.

The patient is instructed to passively flex the neck
towards the side that is being examined. This maneuver
helps relaxing the muscles and fascia of neck, thereby
allowing easy examination.

The fingers of the palpating hand should be kept
together to prevent the nodes from slipping in between
them.

The palmar aspect of the fingers is pushed on to the
soft tissue below the mandible near the midline, then
the clinician should then move the fingers laterally to
draw the nodes outwards and trap them against the

lower border of the mandible.

83. © They are palpated anterior tothe tragus
of the ear,

84. POSTAURICULAR LYMPH NODES

Are palpated behind the ear, on the
mastoid process

85. OCCIPITAL LYMPH NODES

Palpated at the base\lower border of skull

86. I

CAL LYMPH NODES

© Nodes that lie both on top of and
beneath the sternocleidomastoid

muscles (SCM) on either side of the

neck, from the angle of the jaw to the

top of the clavicle.

87. POSTERIOR CERVICAL LYMPH NODES

o Extend ina line posterior to the
SCMs but in front of the
trapezius, from the level of the

mastoid bone to the clavicle.

88. SUPRACLAVICULAR (SCALENE NODES)

© Rall your fingers gently behind the clavicles
Instruct the patient to cough .

© Occasionally an enlarged lymph node may
Pop up

89. INVESTIGATIONS

90. The laboratory investigation of patients with lymphadenopathy must be
tuilored to elucidate the etiology suspected from the patients history and

Physical findings

91. COMPLETE BLOOD COUNT, CBC

Provide useful data for the diagnosis of
© acute or chronic leukemias,
| o EBV or CMV mononucleosis,

o lymphoma with a leukemic component,

© pyogenic infections, or

© immune eytopenias in illnesses such as SL!

92. SEROLOGICAL STUDIES

may demonstrate

9 antibodies specific to components of EBV, CMV, HIV, and other
viruses;

o Toxoplasma gondii;
© Brucella;
© antinuclear and anti-DNA antibody in case of SLE.

93. 5
CHEST X-RAY

© Usually negative

E o The presence of a pulmonary infiltrate or mediastinal

lymphadenopathy would suggest tuberculosis, histoplasmosis,

sarcoidosis, lymphoma, primary lung cancer, or metastatic cancer

94. EE
LYMPH NODE BIOPSY

need insertos
© The indications for biopsy are imprecise, yet it is a valuable diagnostic tool. Bremen

© The decision to biopsy may be made early in a patient's evaluation ordelayed for up to two
weeks,
© Prompt biopsy should occur if the patient's history and physical findings suggest a

malignancy,

95. FINE NEEDLE ASPIRATION CYTOLOGY
(ENAC)

© lt should not be performed as the first diagnostic procedure.

© Fine-needle aspiration should be reserved for thyroid nodules and for
confirmation of relapse in patients whose primary diagnosis is known.

96. ULTRASONOGRAPHY

Na newhat

mal cervical nodes appear sonographically as

fattened hypoechoic structures with varying amounts of hitar

fat

US appearance of normal lymph node, Image shows flattened
hypoechoic cigar-shaped structure (arrow).

1

d to determine the long IL) axis, short (S) axis, and a ratio

of long to short axis in cervical nodes

An L/S ratio of <2.0

asensitivity and a sı

ificity

for distir

zuishing benign and malignant nodes in patients

with head and neck cancer

97. © Malignant infiltration alters the US features of the lymph nodes, resulting in enlarged
nodes that are usually rounded and show peripheral or mixed vascularity,
© Using these features, US has been shown to have an accuracy of 89%- 94% in

malignant from benign cervical lymph nodes

98. COMPUTED TOMOGRAPHY (CT)

© CT remains the most widely used modality for neck imaging.

© The CT examination is performed in the axial plane with contiguous sections of 3 + 5 mm
whilst a bolus of intravenous contrast media is administered,

© CT criteria for assessing lymph node metastasis are based on size, shape, the presence of

central necrosis and the appearance of a cluster of nodes in the expected lymph drainage

pathway for the tumour,

99. ‘The most effective size criteria for indicating metastatic involvement are now defined as minimum.
axial diameters in excess of u mm in the jugulodigastric region and in excess of 10 mm elsewhere.

Using these sizes a sensitivity af 42% and specificity of 99% per node were produced,

‘With the use of spiral CT, itis possible to reconstruct the image in any plane with good quality,

allowing more accurate calculation of the maximal axial and longitudinal dimensions and thus

assessment of nodal shape.

100. MAGNETIC RESONANCE IMAGING (MRI)

© Standard protocols for MRI of the cervical lymph nodes include a selection of Tı- and fast
spin echo Tz- weighted axial, coronal and sagittal images.

© STIR sequences allow a combination of Ti- and Ta-weighting with fat suppression, and

malignant nodes are clearly demonstrated as high signal.

© Ti-weighted images depict lymph nodes as being of intermediate signal intensity, similar

to muscle, whilst Ta-weighted images show them as hyperintense signal.

101. (a) Ti weighted and (b) Tz weighted sagittal MRI scans demonstrate a large

pathological deep cervical lymph node (level rwo/ three) which is of

intermediate signal on Ti and high signal on Ta

102. POSITRON EMMISION TOMOGRAPHY

© Most head and neck PET imaging is performed with the radiolabelled glucose analogue
FDG which has increased uptake in viable malignant tumour due to enhanced glycolysis.
© The result can be expressed as a standardised uptake value (SUV), with those values

greater than two being considered abnormal.

o PET scanning provides functional rather than anatomical imaging.

103. (A) Axial CT scan shows mixed soft tissue and fluid in left pleural space. Prevascular and

axillary lymph nodes were interpreted as normal. (B) Axial dual PET/CT scan shows
increased uptake in soft-tissue mass as well as small prevascular and axillary lymph

nodes, indicating recurrent dis

se with metastatic nodal spread.

104. ADVANCED IMAGING TECHNIQUES

@ Planar lympho-scintigraphy
© Hybrid SPECT/CT imaging

© Dynamic contrast - enhanced MR imaging,

© Ultra-small super-paramagnetic iron oxide (USPIO) enhanced MRI
© Gadolinium enhanced MRI

105. 5 NEL

|| * Thesentinal node is the first node encountered by tumor cells.

+ So the sentinal node (SLN) is defined as the lymph node which is in a direct drainage pathway
from the primary tumor .

+ The other node receive lymph from SLN

106. SSS

GOOD MORNING

107. ONCOLOGIC €]

* The lymph nodes describe the neck dissection, the neck is divided into 6 areas
called Levels.

* The levels are identified by Roman numeral, increasing towards the chest. A j
further Level VIE to denote lymph node groups in the superior mediastinum is Ea
no longer used.

= Instead, lymph nodes in other non-neck regions are referred to by the name of
their specific nodal groups.

108. Subgroups

7

VI
Vil

Submental
Submandibular

Upper jugular (Anterior to XI
Upper aur putes to x)

Middle jugular

Lower jugular (Clavicular)
crea (eves )

Posterior triangle (XI)
Posterior triangle (Transverse
cervical)

Central compartment
Superior mediastinal nodes

Robbins KT, Clayman G,Levine PA,et al. Neck dissection classification update: Revisions

proposed by the American head &neck society,& American Academy of otolaryngology-head
&neck surgeryArch Otolaryngol Head Neck Surg 2203; 128: 751-758.

110. LEVEL |

© Level | includes the submandilularand submental nodes. lt extends
| from the inferior border of the mandiblo superiorly to the hyoid

inferiorly, and is bounded by the digastric muscle. It may be
ssubtividded:

© Level! a: The submental group. Lies between the anterior bellies of the
digastric muscles. Bounded superiarly by the symphysis.and inferiorly
by the lipids

9 Level be The submandibular group. Bounded by the body of the
mandible superioely, the posterior belly af the digastric muscle
inferiorly, the-stylohyoid muscle posteriorly, and the anterior belly of
the digastri

terierly It includes the pre-and posteascular modes that

are related to the facial artery,

Da

=

|
N
aa

111. o Lymph nodes contained within level Lare at highest risk in oral

cancers invelving the skin of the chin, lower lip, tip of the tongue, and

floor of the mouth.

112. LEVEL Il

Level Il contains the upperjugular lymph nodes ¿hat surround the uppe
third of the internal jugular vein and the spinal accessory nerve. It
includes the jugulodigastric node (also

known as the principle node of Kurtewer) which ls the most common
node containing metastases in oral cancer. It is also frequently
subdivided based on the course of the spinal accessory nerve.

© Level Il a: Bounded superiorly by the skull base, inferiorly by the
hyoid bone radiographically and the carotid bifureation surgically,
anteriotly by the stylohygid muscle and posteriorly by a vertical plat
defined by the spinal accessory nerve.

113. A

© Level Il b: Bounded superiorly by the skull base, inferiorly by the hyoid
| bone radiographically and the carotid bifurcation surgically, anteriorly by
a vertical plane defined by the spinal accessory nerve and posteriorly by
the lateral aspect of the sternocleidomastoid muscle.

Nodal tissue within level IH receives efferent lymphatics the parotid,
submandibular, submental, and retropharyngeal nodal groups. It also is at
for metastases from cancers arising in many oral and extra-oral sites,
including, the nasal cavity, pharynx, middle ear, tongue, hard and soft palate,
and tonsils.

114. LEVEL Ill

© Level Ill encompasses node-bearing tissue surrounding the
middle third af the internal jugular vein. It is bounded
superiorly by the inferior border of level 11 (hyoid
radiographically and carotid bifureation surgically), inferiorly
by the omohyoid muscle surgically and the cricoid cartilage
radiographically, anteriorly by the sternahyoid muscle and

posteriorly by the lateral border of the stemocteidomastoid

muscle.

© Level I contains the dominant amehyoid node and receives
lymphatic drainage from level Il and level Y. In addition, it can
receive efferent lymphatics from the retropharynieal,
pretracheal, tongue base, and tonsils.

115. LEVEL IV

Level IV contains the nodal tissue surrounding tive inferior third of
the internal jogularvein, Itextends from the inferior bosdes of level
ao the clavicle. Ameriotly, it is bounded by the Lateral border af the
sternobyoid mmaiele; and posterinely, by the lateral border of the
sernocicidomastoid muscle.

© lt cotairs a variable number af odos that teceive efferent flaw
primarily from level [11 and IV. The reteopharyngeal, prerracheal,

hypapharyngeat, laryngeal and thyrosd lymphatics also make a
contribution,

© Only rarely is level IV involved with metastatic cancer from the oral
cavity without involvement af one of the higher levels.

116. LEVEL V

© Level Y makes up the posterior triangle,

© Similar to levels | and II, level Y may be
subdivided,

© Level V a: Begins at the apex formed by the
intersection of the sternocleidomastoid and the
trapezius, The inferior border is established by a
horizontal line defined by the lower edge of the

cricoid cartilage. Medially, the posterior edge of

the sternocleidomastoid forms the anterior edge

and the anterior border of the trapezius forms the

117. © Level V b: Begins at a line defined by the inferior edge
of the cricoid cartilage and extends to the clavicle. It

shares the same medial and lateral borders as level Va,

© Level V receives efferent flow from the occipital and
post auricular nodes. Its importance in primary oral
cavity cancers is limited except when lymph flow is
redirected by metastases in the higher levels.

© Oropharyngeal cancers, however, such as tongue base

and tonsillar primaries can spread to level V nodes,

118. LEVEL VI

The anterior compartment lymph node group is

of minimal importance in primaries originating
in the oral cavity. It is made up of the lymph node
bearing tissue occupying the visceral space. It
begins at the hyoid bone, extends inferior to the
suprasternal notch, and laterally is bound by the

common carotid arteries.

119. LEVEL VII

© The superior mediastinal nodes.

© They lie between the carotid arteries below the level of the top of the manubrium

120. TNM STAGING

TX-prii

| asses!

To-No der
tumour

then 2 cm

em in

T4-Tumour invade the adjacent

structure,

© NX- Regional lymph node that
can not be assessed

o No -No regional lymph node
metastasis,

© Ni-Metastasis in single
ipsilateral lymph node 3 cm or
less in greatest dimension.

© N2-Metastasis in single
ipsilateral lymph node more
then 3 em but not more then
6cm in gretest dimension .

121. ' Denolx PF, Schwartz D: Regeles
generales de classification des.
cancers el de presentation des

resutants therapeutics. Acad Chir
(Paris), 1959, vol 85 pg 416.

© N2a-Metastasis in single ipsilateral
lymph node more then 3cm but not
more then Gcm in greatest
dimension,

© Nzb-Metastasis in multiple
ipsilateral lymph node more then 6
cm in greatest dimension .

© Nac-Metastasis in bilateral or
contra lateral lymph node more
then 6em in greatest dimension

123. ESS

© 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.

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

125. 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

126. €. Fungal
-Histoplasmosis
-Coccidioidomycosis
D, Parasitic
-Toxoplasmosis
-Filiriasis
E. Chlamydial
-Lymphogranuloma venerum
- Trachoma

127. 2.Immunologic disease

A. Rheumatoid arthritis
B.Systemic lupus erythematous
C.Sjogren syndrome

D.Drug hypersensitivity

E.Mixed connective tissue disease

128. a.Hematological

-Hodgkin disease

on hodgkin disease
-Hairy cell leukamia
-T-cell lymphoma
-Multiple myeloma

B.Metastasis

-From primary site

129. 4-Lipid storage disease

“Gaucher's dise

shiemannspick d

5.Endocrine disease
-Hyperthyroidism
Adrenal insufficiency

-Thyroiditis

6.Other disorder

Sarcoidosis

-Lymphomatoid granulomatosis
3 i (Child wih Raras disease
a -Histocytasis x (red eyes, dry racks ips, red tongue) e
“Kikuchi distase

+Kawasaki dir

131. MANAGEMENT

COMPREHENSIVE NECK DISSECTION

1. Classical radical neck dissection

= Extended radical neck dissection

+ Modified radical neck dissection
TYPE=1
TYPE = 11
TYPE - 111

132. RADICAL NECK DISSECTION

* Refers to the removal of all ipsilateral cervical
lymph node groups extending from the inferior
border of the mandible to the clavicle, from the
lateral border of the sternohyoid muscle, hyoid
bone, and contralateral anterior belly of the
digastric muscle medially, to the anterior border

of the trapezius,

133. + dncfudod are levels EV

«This entails the removal of three important,

non-lymphalic siructures. the internal jugular
jugular vein. the sternocleidomastokl muscle,
muscle, and the spinal accessory ner

Other siructuros excised
+ Stornocieidomastold muscle

+ Internal jugular vein

+ Spinal accessory nerve

e Shtvmanctitedar salivary olan

134. Refers to removal of the same lymph node = 7 >

levels (1-4) as the radical neck dissection, D
but with preservation of the spinal accessory
nerve, the internal jugular vein, or the sternocleidomastoi

Muscle,

GE ren nodes: diamacte:

+ Level I
| = Level Ht

= Level IV
“Level ¥
OlNer structures excised
- Stern

= desterrado vein

+ Submandimular salvmey plane |

OO dorar Tobe poa hem

135. Subdividing the modified neck dissection into three types:

Y ‘Type | preserves the spinal accessory nerve;

¥ Type Il preserves the spinal accessory nerve and the sternocleidomastoid muscle; and

¥ Type Ill preserves the spinal accessory nerve, the sternocleidomastoid muscle, and the
internal jugular vein;

137. MRND Type Ill

MRND Type Il

£

138. aE
SELECTIVE NECK DISSECTION

* Refers to the preservation of one or more lymph node groups normally removed in a radical
neck dissection,
+ Inthe 1991 classification scheme, there were several "named" selective neck dissections, For
| example, the supraomohyoid neck dissection removed the lymph nodes from levels I-I11. Me.
* The subsequent proposed modification in 2001 sought to eliminate these named dissections. '
* The committee proposed chat selective neck dissections be named for the cancer that the

surgeon was treating and to name the node groups removed.
* Forexample, a selective neck dissection for most oral cavity cancers would encompass those
node groups most at risk (levels 111) and be referred to as a SND (1-11)

140. The term extended neck dissection refers to

the removal of one or more additional lymph

node groups, non-lymphatic structures or

both, not encompassed by a radical neck dissection,
for example, mediastinal nodes or

non-lymphatic structures, such as the carotid

artery and hypoglossal nerve.

141. REFERENCES

© Richard L.Drake,GRAY'S Anatomy for students;2005,13" edition, 333-335.

e E. LLOYD DuBRUL, Shicher's Oral anatomy; 8"" edition; 2000, pg n6.221-226,
© A.C.Guyton & JE, Hall; T.B of Medical Physiology;n" edition;2006:192-194.

© Eugene N. Myers etal,; CANCER of Head & Neck,4'' editian,2009,49-66,

© Michael Miloro, Peterson's Principles of OMPS, 2% edi.,vol.1,617-630

© Neclima A. Malik, TB.of OMFS, 3" edition,530.

142. THANK YOU