LYMPHATIC DRAINAGE OF HEAD AND NECK

All the lymph from the region of head and neck drains into deep cervical lymph nodes. The efferents from these nodes form the jugular trunk. On the right side, jugular trunk drains into right lymphatic duct. On the left side, jugular trunk drains into thoracic duct.

2. ONT It ENT: | Ss

exe

» INTRODUCTION

» EMBRYOLOGY

» LYMPHATIC SYSTEM

» LYMPHATIC DRAINAGE OF HEAD & NECK
» LEVELS OF LYMPHNODES

» APPLIED ASPECTS

» CONCLUSION

» REFERENCE

3. LA

L 4

LA

v

The blood and lymphatic systems are the two
major circulatory systems in our body.

One way system- lymph flows only towards
the heart.

The lymphatic system is ubiquitous and exists
in all tissues where blood vessels are also
found

placenta being an exception. Corea does not
contain lymphatics

4. EMBRYOLOGY

> Lymphatic vessels arise as sac-like outgrowths from the endothelium of
veins.

» Six primary lymph sacs =

» two jugular, at the junction of the subclavian and anterior cardinal
veins

> two iliac.
> one retroperitoneal.
> one cisterna chyli.

5. Jugulor sac

Superior vena cava

Superficial ipmphatics

Jugular lymph sac

Subelavian lymph sac

lymph node

Deep lymphatics Cisterna chyli

Thorecis duct

Retroperitonea!
lymph sac

Superficial 3 $ Cisterna chyli
Imphaties

Posterior lymph sac

Posterior sac

6. > Numerous channels connect the sacs with each other and drain lymph
from the limbs, body wall, head, and neck.

» Two main channels, the right and left thoracic ducts, join the jugular sacs
with the cisterna chyli, and soon an anastomosis forms between these
ducts.

» The thoracic duct develops from the distal portion of the right thoracic
duct , the anastomosis, and the cranial portion of the left thoracic duct.

> The right lymphatic duct is derived from the cranial portion of the right
thoracic duct.

» Both ducts maintain their original connections with the venous system and
empty into the junction of the internal jugular and subclavian veins.

7. | Y\ ADHATIF SVSTEN
V

3

4

6

JH | - EN
IT MAIIL OTOILEWI

LYMPH

LYMPH CAPILLARIES
LYMPH VESSELS

LYMPH DUCTS

LYMPH NODES

LYMPH TISSUES & ORGANS

8. Functions of lymphatic system

. Returns Fluid from Tissues to Blood.

Hemopoiesis.

Returns large molecules to blood.
Body Defence/lmmunity.

Absorb and Transport Fats.

9. LYMPHATIC ORGANS

Adenoids
Tonsils

Lymph nodes
Spleen

Peyer's patches
Appendix
Lymph nodes

Primary Organs | Secondary Organs |

10. LYMPH

» Transparent, colourless, or slightly yellow, watery
fluid.

» Resembles blood plasma ,but fewer proteins.
» Varies in composition based on site of origin
> Bone marrow , thymus , spleen- more WBC s
> Intestine- fat.

11. COMPOSITION

12. LYMPHATIC CAPILLARIES

j Loose connective
» Lies close to blood vessels. cope Anh,
» Lined by single layer of endothelial cells. capillaries

» Permeable solvents &cells.

13. VMDU
LYMPHATIC VE

> lymphatic capillaries merge with others to
form larger lymphatic vessels.

» Resembles veins in structure.
» One way Valves,

» has lymph nodes at intervals along its
course

14. LYMPH NODES

» Lymph glands

» oval to bean shaped bodies present
along lymphatic vessels.

15. Afferent lymphatic vessel

Valve

Capsule
Cortex 3 Subcapsular sinus

Hilum

( }— Effarent lymphatic vessel

As
a
— Medullary cords

Fig. 43.1: Transverse section through a lymph node

16. Right jugular trunk
Right lymphatic duct —_ “$
Right subelavian trunk —=>

Right subclavian vein
Right bronchomediaatinal
trunk

Brachlocephalic veins

Superior vena cava
Azygos vein
Cisterna chyli ———,

Right lumbar —
trunk

== Left jugular trunk

— Internal jugular veins

Loft subclavian trunk

Loft subelavian vein

Left bronchomediastinal
trunk

Entrance of thoracic duct
Into left subclavian vein

Esophagus
— Trachea

Ribs

17. > lymphatic trunks merge together to
form two major Lymphatic Ducts

18. RIGHT LYMPHATIC DUCT

(ductus lymphaticus dexter)

» Lymphatic trunk on the right side unite to form right lymphatic duct.

» courses along the medial border of the Scalenus anterior at the root of the
neck

> Opens at the junction of right subclavian & right internal jugular vein.
» Drains upper right quadrant of the body.

> orifice is guarded by 2 semilunar valves, prevent the passage of venous
blood into the duct.

19. > Largest.
> Drains the rest of the body (3/4 )

> Drains all of the body below
diaphragm ‚left hand ‚left side of
head ,neck and thorax

> Drains into left subclavian vein.

20. Drainage
of right
lymphatic
duct

|

Drainage of

/ thoracic

duct (left

À lymphatic

duct)

21. Right internal jugular vein

Right lymphatic duct

Right brachiocephalic vein 4

Bronchomediastinal trunk

Superior vena cava

Left internal jugular vein

Bronchomediastinal trunk

* Left brachiocephalic vain

22. FLOW OF LYMPH

BLOOD » | INTERSTITIAL E
VESSELS y FLUID 4 CAPILLARIES
m
y
SUBCLAVIAN € 4 LYMPHATIC | / À LYMPH
VEIN DUCTS N VESSELS

23. Peripheral (outlying) lymph nodes

Occipital | Occipital

|
‘60 66
Postauricular——¿0) o — postauricular
0
@— Preauricular
'0
Y 60 =
: Ss .% ¿7
0 Submental 3 Submandibular odo
| \ 0

Outer circle

Preauricular —@ÿ
0

Submandibular ‘©

Terminal ©

Internal Terminal

jugular vein
Inner circle

24. DEEP CERVICAL LYMPH NODES

» Lymph from head and neck drains into the
deep cervical lymph nodes

> lie along and around the IJV ‚deep to the
SCM

» divided into two groups by the intermediate
tendon of omohyoid.

25. Deep cervical
(jugular) node ~ 4

26. » lie above the omohyoid muscle.

> present in a triangle formed by the internal
jugular vein, posterior belly of digastric and
facial vein

» receive lymph primarily from palatine tonsils

» The superior group drains into the inferior
group

27. > lie along the internal jugular
vein below the omohyoid.

» node receives lymph primarily
from the tongue (node of
tongue),

Jugulo-digastric

28. a. Superficial cervical lymph nodes.

b. Lymph nodes related to head& neck.
c. Palatine tonsils

d. Tongue

e. Larynx above the vocal folds

oler deg
coa lado

» Form the right and left jugular lymph

trınke

29. 1. Infrahyoid.

2. Pre laryngeal nodes

3. Pre tracheal nodes.

4. Paratracheal.

5. Retropharyngeal nodes.

30. Preyertabral fascia

Cervical part of vertebrs

Buccopharyngeal
fascia

31. Infrahyoid nodes: in front of thyrohyoid membrane.

Pre laryngeal nodes: in front of the cricothyroid membrane.

Pre tracheal lymph nodes: in front of trachea below the isthmus of
thyroid gland.

Paratracheal nodes: on either side of trachea and esophagus along the
recurrent laryngeal nerves.

Retropharyngeal lymph node: posterior to pharynx and in front of
prevertebral fascia in the retropharyngeal space

32. Ciimi RA
Supraclavicular nodes

» lower part of posterior triangle

» Left supraclavicular lymph nodes is called
VIRCHOW'S nodes.

» Swelling of left Supraclavicular nodes due
cancer of stomach, colon.

33. SUPERFICIAL CERVICAL LYMPH
NODES

4.
> 4 in number
> In submental triangle

> Afferents from : tip of tongue , floor of
mouth, chin, central part of lower lip.

> Efferent from : submandibular node &
jugulo omohyoid node

34. > 3 in number
> In submandibular triangle.

> AFFERENTS :- centre of
forehead, medial angle of
eye, side of nose, cheek,
angle of mouth, anterior 2/3"
of tongue, gums, submental
lymph nodes , frontal &
maxillary sinuses

> EFFERENT: Deep cervical
lvmnh notes

35. » Superficial group lie over the gland

> Deep group within the gland

> AFFERENTS :-

1, Forehead,

2. Temporal region

3. Auricle, lateral surface

4. External acoustic meatus, anterior wall
5. Eyelids, lateral half

> EFFERENT :- Deep cervical nodes

36. > Situated at the apex of occipital
triangle along the occipital artery

> AFFERENT :- Posterior part of
scalp

> EFFERENT :- Supraclavicular
nodes.

37. > Lie on the buccinator
muscle , along the facial
vein.

> upward extension of
submandibular nodes

> AFFERENT - part of cheek
& lower eyelid

» Efferent :- deep cervical
nodes

38. > submucosal ring of aggregated masses of lymphoid tissue called tonsils, which surround
the commencement of air and food passages.

39. lymph from lymphoid
tissue of this ring
drains into
pericervical chain and
deep cervical chain,
which constitutes the
external ring of
Waldeyer.

Retropharyngeal lymph nodes

Jugulodigastric
— Pharyngeal

lymph node
tonsil

1— Tubal tonsil

N

+— Palatine tonsil

Ome fs
MU
“DO

Upper deep
cervical lymph
nodes

— Lingual

tonsil

1 F
Submandibular lymph nodes LE Submental lymph nodes

40. PALATINE TONSIL

> In tonsillar fossae

> b/w palatoglossal
&palatopharyngeal arches

> Efferent pass to jugulodigastric
node

> No afferents

41. Pharyngobasilar fascia

Paratonsillar vein
Ramus of mandible —#
Medial pterygoid | Mf Tonsillar fossa

Glossopharyngeal nerve — Palatine tonsil

Tongue
Facial artery

Styloglossus
Submandibular salivary gland

Suspensory ligament of tonsil

42. CLINICAL ANATOMY

> Tonsils are larger in children, regress after puberty. | k 5 “x ,
TONSILLITIS eS a A
> inflammation of tonsils. ‘

> Two types - acute & chronic

> Acute -viral & bacterial

» Chronic - complication of acute

> Clinical features recurrent sore throat, halitosis , cough , difficulty in breathing

43. PERITONSILLAR ABSCESS/QUINSY

» When tonsillar infection spreads to tonsillar bed.
» Radiating pain to ear & side of neck

» Spasm of pterygoid muscles- trismus

» Swelling of soft palate

44. TREATMENT- TONSILLECTOMY

> Ptin supine position with head extended ; sand bag under shoulder
> Mouth gag is used to open and fix the jaw including the tongue.
Packing of larynx to prevent aspiration.

Tonsils grasped with tonsil holding forceps and stretched medially.
Mucosa incised over upper pole, anterior pillar& posterior pillar

ww V

Bluntly dissect tonsil from its bed
> Lower pole is separated with a snare

> Bleeding vessel is ligated/cauterised

45. » Bleeding from tonsillar fossa after tonsillectomy: occurs due to
damage of paratonsillar vein, blood clots should be removed in order to
check bleeding. If not removed, they interfere with the retraction of the
vessel walls by preventing the contraction of the surrounding muscles.

» Postoperative edema of tonsillar bed after tonsillectomy can affect the
glossopharyngeal nerve.

46. LYMPHATIC DRAINAGE OF FACE

> SUB MENTAL NODES
> SUB MANDIBULAR NODES
» PAROTID LYMPH NODES

LYMPHATIC DRAINAGE OF THE SCALP

> OCCIPITAL
» MASTOID
> PAROTID

47. LYMPHATIC DRAINAGE OF ORBIT
PAROTID
SUBMANDIBULAR

LYMPHATIC DRAINAGE OF EAR
PAROTID
MASTOID

48. LYMPHATIC DRAINAGE OF TEETH

» MANDIBULAR INCISORS- SUBMENTAL
+ OTHERS- SUBMANDIBULAR LYMPH NODES

LYMPHATIC DRAINAGE OF NASAL CAVITY
» ANTERIOR HALF - SUBMANDIBULAR LYMPH NODES

» POSTERIOR HALF - RETROPHARYNGEAL LYMPH
NODES.

49. LYMPHATIC DRAINAGE OF TONGUE

1, Apical vessels: tip and inferior surface of the
tongue into submental lymph nodes. Paeptan gel nes

2. Marginal vessels: marginal portions of the
anterior two-third of the tongue—unilaterally into
submandibular lymph nodes.

3. Central v : central portion of the
anterior two-third of the tongue into the deep
cervical lymph nodes.

4, Basal vessels: root of the tongue and
posterior one-third of the tongue bilaterally into
upper deep cervical lymph nodes,

50. LEVELS OF LYMPH NODES

(Americ ‘an head and neck society & the American academy of otolaryngology)

IA- submental lymph nodes

IB- submandibular lymph nodes

II A &ll B -upper jugular lymph nodes

Ill- middle jugular lymph nodes

IV- lower jugular lymph nodes

VA&VB -posterior triangle lymph nodes

VI- anterior ( Central) compartment lymph nodes
VIl- superior mediastinal

52. LEVEL | LYMPH NODES

| A- between the anterior belly of the digastric muscles and hyoid bone.

| A- bounded by the anterior and posterior bellies of the digastric muscle
and the inferior border of the body of the mandible.

lymph nodes adjacent to the submandibular salivary gland and along the
facial artery are included in this group.

53. LEVEL Il LYMPH NODES

> Upper jugular
> around the upper portion of the internal jugular vein and the
upper part of the spinal accessory nerve.

» extending from the base of the skull up to the bifurcation of the
carotid artery or the hyoid bone.

> Lymph nodes anterior to the spinal accessory nerve are
designated level IIA, and those posterior to it are designated
level IIB.

54. LEVEL III LYMPH NODES

> Mid jugular group, which includes lymph nodes around the
middle third of the internal jugular vein from the hyoid bone up
to the inferior border of cricoid cartilage.

LEVEL IV LYMPH NODES

includes lymph nodes around the lower third of the internal
jugular vein from the inferior border of cricoid cartilage up to the
clavicle

55. LEVEL V

» Posterior triangle group
» Lower portion of spinal accessory nerve

> bounded by the triangle formed by the clavicle, the posterior border of the
sternocleidomastoid muscle, and the anterior border of the trapezius muscle.

> divided into two levels by a plane at the level of the inferior border of the cricoid
cartilage.

» Level V Ais superior to this plane, and level VB is inferior to it.

56. LEVEL VI

» Central compartment
» Hyoid bone to suprasternal notch,
» And between carotid sheaths.

LEVEL VII

» superior mediastinal group

> lymph nodes in the anterosuperior mediastinum and tracheoesophageal
groove

> extending from the suprasternal notch to innominate artery.

57. EXAMINATION OF LYMPHNODES

LOOK FOR

1. LOCATION

2, SIZE

3. CONSISTENCY
4, NUMBER

58. ORDER OF EXAMINATION

1. UPPER HORIZONTAL CHAIN
2. EXTERNAL JUGULAR CHAIN

En

INTERNAL JUGULAR CHAIN

4. SPINAL ACCESSORY CHAIN

5. TRANSVERSE CERVICL CHAIN
6. ANTERIOR JUGULAR CHAIN

7. JUXTAVISCERAL CHAIN

59. Submental Nodes
Roll the fingers below the chin with patient's
head tilted forwards

60. Submandibular Nodes
Roll your fingers against inner surface of
Mandible with patient's head va tilted

towards one side

61. Parotid (Preauricular) Nodes
Roll your finger in front of the ear, against the
maxilla

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

63. Occipital Nodes

64. Internal jugular chain

Examine the upper, middle and lower groups.
Many of them lie deep to sternomastoid
muscle which may need to be displaced
posteriorly }

65. Transverse Cervical Nodes
Supraclavicular (Scalene Nodes)
Roll your fingers gently behind the clavicles. Instruct
the patient to cough orto bear down like they are
having a bowel movement. Occasionally an enlarged
lymph node may pop up

66. PATTERNS OF NECK METASTASIS

» For primary tumors in the oral cavity, the regional lymph nodes at highest
risk for early dissemination by metastatic cancer are limited to levels |, Il,
and Ill

Primary site
Oral cavity

First echelon

lymph nodes

. Levell
. Level Il
. Level Ill

67. » For tumors on the lateral aspect of the oropharynx, hypopharynx, and
larynx first-echelon lymph nodes at highest risk are levels II, Ill, and IV on

Primary sites
Larynx

Pharynx

First echelon
lymph nodes
. Level ll
. Level Ill
. Level lV

68. Primary site
Thyroid

First echelon

lymph nodes

Perithyroid nodes
Tracheoesophageal groove
Level VI

69. Primary site

Parotid

First echelon
lymph nodes
, Preauricular
. Periparotid £ intraparotid
, Level ll
, Level Ill
Upper accessory chain

70. Primary sites

Submandibular gland
Sublingual gland

First echelon

lymph nodes
Level |
Level Il
Level Ill

71. Cutaneous malignant tumors of the scalp

» Aline joining the helix of one ear to the helix of the opposite ear in a
coronal plane separates the watershed areas of the scalp.

» Tumors anterior to this line in general metastasize to preauricular,
periparotid,& levels | to IV.

» Posterior to this line metastasize to the suboccipital and postauricular &
posterior triangle of the neck and the deep jugular chain (levels II to V).

72. CLINICAL
STAGING OF
CERVICAL
LYMPH NODES is ee os

(N STAGING)

73. Neck Dissection Classification

A. Radical Neck Dissection

» standard basic procedure for cervical lymphadenectomy
» removal of all ipsilateral cervical lymph node groups

» Levels | through V

LA

spinal accessory nerve, internal jugular vein, and sternocleidomastoid

v

inferior border of the mandible superiorly to the clavicle inferiorly

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 muscle laterally.

LA

74. RND + preservation of one or
more non lymphatic structures
(SAN , JV & SCM).

75. C. Selective Neck Dissection

preservation of one or more of the lymph nodes
Anterior Neck Dissection—Includes Level VI.

Supra omohyoid Neck Dissaction—Includes Levels IA € IB, Level IIA or Levels IIA & 118, and
Level Ill

Lateral Neck Dissection—Includes Level IA or Levels IIA & JIB, Level Ill, and Level IV
Posterolateral Neck Dissection—Includes Levels Il, Ill, IV, & V

D. Extended Radical Neck Dissection

RND + removal of one or more additional lymph node groups or non lymphatic structures

76. es of Swollen Cervical

Scalp infections

Tonsillitis

77. LYMPHATIC DISORDERS

ibe
» caused by Streptococcus pyogenes

» spreads to the draining lymphatics and
lymph nodes (lymphadenitis) where an
abscess may form.

» progress to bacteraemia or septicaemia.

> t/t- intravenous antibiotics

as abnormal limb swelling secondary to
defective lymphatic drainage.

78. 3. LYMPHOMAS

Neoplastic condition

> Types - Hodgkin & non
Hodgkin lymphoma.

> HODGKIN'S LYMPHOMA -
most common

> NON HODGKIN LYMPHOMA —
more aggressive

» Inner waldeyer's ring involved.

» Poor prognosis.

79. 4. BURKITT'S LYMPHOMA

» EBV -aetiology F
> Common in jaw -either upper/lower
> Treatment-radiotherapy & chemotherapy

5. TUBERCULOUS LYMPHADENITIS

-Mycobacterium tuberculosis
-cold abscess

1
Common in jugulodigastric(54%) & posterior triangle |
lymph nodes | À Ml |

80. LYMPHADENOPATHY-INVESTIGATIONS

» BLOOD EXAMINATION
» FNAC
» BIOPSY
> IMAGING -
1, ULTRASOUND
2. CT
3, MRI
4, PET
5, NANOPARTICLE MRI
6 LYMPHANGIOGRAPHY

81. ULTRASOUND

> NORMAL = FLATTENED MALIGNANT LYMPHNODES -
HYPOECHOICH STRUCTURE WITH ENLARGED NODES, ROUNDED WITH
VARYING AMOUNT OF FAT = CIGAR PERIPHERAL /MIXED VASCULARITY

SHAPED ‚HYPERECHOICH &SEPTATION

82. CT SCAN

LYMPHADENOPATHY
NORMAL
» <icminsize

» Smooth,well defined homogenous

83. MRI SCAN

*
MS, | LYMPHADENOPATHY
#

BER
+ ay |
4 SN

NORMAL

84. POSITRON EMISSION TOMOGRAPHY

85. MR LYMPHANGIOGRAM

Contrast dye will then be injected into the vessel, making the vessels more visible

under imaging.

86. LYMPHOSCINTIGRAPHY

> injecting tiny amounts of radioactive
particles (Technetium-99m sulfur-
colloid) at the site of the primary i
cancer \

» identify the first sentinel lymph nodes

87. CONCLUSION

Situation of lymph nodes in neck, their areas of
drainage are of clinical importance since
removal of lymph nodes in neck is the
management of cancers in head and neck
region.

88. REFERENCE

Gray's Anatomy For Students, 4" Edition , Richard L. Drake, A Wayne Vogl, Adam W. M.
Mitchell.

Textbook Of Anatomy Head, Neck And Brain ,2"° Edition , Vishram Singh.
Human Anatomy - Head And Neck, 7" Edition Vol 3, B D Chaurasia.
Anand's Human Anatomy for Dental Students, 3rd Edition-Mahindra Kumar Anand

Quick Reference Guide To TNM Staging Of Head And Neck Cancer And Neck
Dissection Classification — 4" Edition, American Academy Of Otolaryngology - Head And
Neck Surgery Foundation.

SRB's Manual Of Surgery Third Edition- Sriram Bhat M
Oral Anatomy , 38° Edition - Harry Sicher.

i, Human physiology for bds 5" edition AK Jain,

Jatin Shah's Head And Neck Surgery And Oncology 4th Edition -Jatin P. Shah, Snehal
G. Patel, Bhuvanesh Singh.

Fn, ar tte ey sr RSS a ore TA US

89. — u;

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