Lymphatics of head and neck

complete description of lymphatic drainage of head and neck
detailed function of lymph supply

1. LYMPHATIC DRAINAGE
OF
HEAD AND NECK

2. •Lymphatic system is a closed system of
lymph channels or vessels through which
lymph flows.
•The well-being of every individual
depends on the health of the lymphatic
system.
INTRODUCTION

3. 1.All of the processes of tissue nutrition and repair are dependent upon
the lymph
2.Since the blood does not come into direct contact with the tissue cells
one of the main function of blood circulation is to supply and renew
the lymph to all tissues . As has been briefly said “the blood feeds the
lymph and the lymph feeds the cells.”
3.The excretion of the cells , the waste products of metabolism are
carried by the lymph back into the blood stream for elimination.
4.Through the lymph vessels metastasis frequently occurs especially of
malignant tumor cells.
5.Provides considerable protection against various forms of infection
Importance of the lymphatics

4. •Lymph sacs -appear between 2
nd
to 6
th
week of
IUL.
•7
th
week -jugular channel spread to connect with
subclavin lymph sacs.
•9
th
week - thoracic duct is continuous channel
draining into IJ -subclavin vein junction.
•12
th
week- all process are complete.
•5
th
month -valves begins to start.
EMBRY0LOGY OF LYMPHATIC SYSTEM

5. 1.Filtration of lymph
2.Return of leaked fluid
to c.v. system
3.“Education” and
production of immune
system lymphocytes
4.Transport of digested
lipids from small
intestinal lacteals
Major Functions of Lymphatic System

6. It consists of:
(1) Complex capillary networks which collect the lymph
in the various organs and tissues;
(2) Collecting vessels which conduct the lymph from
the capillaries to:
(3) Lymph trunks and ducts: They empty the lymph
into the large veins of the neck, where the lymph is poured
into the blood stream; and
(4) Lymph nodes which are interspaced in the
pathways of the collecting vessels filtering the lymph as it
passes through them and contributing lymphocytes to it.
(5) Extra nodal (lymphoid) tissues.
THE LYMPHATIC SYSTEM

7. 1mm to 25 mm
Bean-shaped with hilus, cortex
and medulla
Several afferent vessels, one
efferent vessel
Function: filter
Popular term “lymph gland” is
misnomer.
Contain lots of Lymphocytes,
Macrophages and Plasma Cells
Clinical application: Swollen lymph
nodes
Fig 23.9
Lymph Nodes

8. •800 L nodes in body
•300 are present in head
and neck
•1
st
defense station of the
body.
•Localized mainly in fatty
tissues & interposed
between lymphatic flow

9. •Afferent lymphatic vessels carry lymph into the nodes
where waste products and some of the fluid are filtered
out
•Lymphocytes, which are specialized white blood cells
located within the lymph node, kill pathogens that may be
present. Lymph nodes also trap cancer cells and slow the
spread of the cancer until they are overwhelmed by it.
•Efferent lymphatic vessels carry lymph out of the node to
continue its return to the circulatory system.
•Cancer cells that have left their original site travel first to
nearby lymph nodes. For this reason lymph nodes play
an important role in the detection and treatment of cancer
Lymph Nodes

10. 1. Biologic filtering
Capsule

Hilus
Afferent vessels
Marginal sinus
Marginal Zones
Medullary cords
Medullary sinus
Efferent vessels

11. CELL ZONES
Zone 1
Extreme periphery
Loosely packed cells
lymphocytes,
macrophages
Zone 2
More densely packed
small lymphocytes and
macrophages
Zone 3.
Germinal center
Large lymphoblasts

12. Includes, vessels, fluid, and nodes or
nonsecreting "glands".
Lymphatic vessels convey fluid from
the periphery to the veins.
The fluid, lymph (=clear water), is what
seeps out of the blood at the
peripheral capillaries. Composition
is similar to plasma without as
much protein
Lymphatic organs or tissues ("glands")
are filtering areas and arenas of
lymphocyte maturation and
competency.
Accessory to cardiovascular system,
thus there are two drainage
systems.
Overview of the Lymphatic System

13. •mesh-like network of tiny tubes that are distributed
throughout the tissue spaces
•located just under the skin.
•branch and interconnect freely so that they extend into
almost all tissues.
LYMPHATIC CAPILLARIES

14. •Lymph capillaries are blind-ended tubes with no opening to
allow the lymph easy access. The end of the capillary is
only one-cell in thickness and these cells are arranged in a
slightly overlapping pattern – like the shingles on a roof.
•Pressure from the fluid surrounding the capillary forces
these cells to separate for a moment. This allows fluid to
enter, but not to leave, the capillary.

15. •There are one-way valves within the lymphatic
capillaries.
•These valves ensure the continued flow of the
lymph away from the tissues.
•They are present in all tissues of the body
except in the central nervous system, bones,
cartilages, teeth, nails, hair, eye ball, and bone
marrow

16. •Because of this structural arrangement, lymphatic
capillaries are more permeable than blood capillaries
and all components of the interstitial fluid, including
proteins as well as micro-organisms (bacteria and
viruses), can enter these vessels and transported
throughout the lymphatic system.
•Similarly, these vessels may transport cancer cells and
promote their spread to other tissues or organs
(metastasis).
•The intestinal villi contain specialized lymphatic
capillaries called lacteals; they transport the recently
absorbed fats (chyle) away from the digestive tract.
Chyle is a milky-like fluid (lacte = milk).

17. Lymph capillaries
converge to become
collecting vessels
and end up as either
Thoracic duct or
right lymphatic duct
Thoracic (left lymphatic) duct
Left subclavian vein
Right
lymphatic
duct
Right
subclavian
vein
Cysterna Chyli

18. •Anatomically similar to veins
•Are thin-walled , serve as drainage channels
•Initially lymph vessels are Finger-shaped and
blind.
•they drain intercellular spaces and serous sacs.
LYMPHATIC VESSELS

19. •Abundant interlacing anastomoses
•Interruption of the continuity by lymph
nodes.
•Drainage channels from many parts not
drained by the venous system
LYMPHATIC VESSELS

20. •Deeper within the body the lymphatic vessels
become progressively larger and are located
near the veins.
• Like veins, the lymphatic vessels have valves to
prevent any backward flow. Angions are the
segments created by the space between two
sets of valves. Smooth muscles in the walls of
the lymphatic vessels cause the angions to
contract sequentially to aid the flow of lymph
toward the thoracic region.
LYMPHATIC VESSELS

21. Lymphatic Vessels (collecting vessels)

•Lymphatic vessels differ from the veins in that:
–The layers are usually thinner than those of the veins.
–In the lymphatic vessels the valves are more numerous and
placed at much shorter intervals than in the veins.
–These vessels anastomose more than the veins.

22. •Superficial collecting vessels accompany the superficial veins.
•Deep collecting vessels like those of the trunk and the digestive
system, accompany the deep arteries (vena commitante).
•If blocked lymphedema develops, e.g. following surgery or radiation.
Lymphedema is a common complication of such operation. Later,
however, new lymph vessels will develop and edema will be relieved.
•Anatomy of lymphatic drainage is consistent.
• Cancerous metastases from organs follow typical pattern of spread.
•In the cases of lymphangitis (inflammation of the lymphatic vessels),
the course of the superficial congested lymphatic vessels appears
through the skin in the form of fine red lines (congested vasa
vasorum, i.e. blood vessels that supply the lymphatic vessels.).

23. Fluid that accumulates in the spaces between the cells of loose
connective tissue is called interstitial fluid, or tissue fluid.
 Under normal conditions, more liquid tend to leave the capillaries of
cardiovascular system than enters them forming the tissue fluid.
 Plasma proteins do not easily pass through the walls of capillaries;
however, as the liquid portion of the blood moves into the intercellular
space, it carries a small amount of plasma proteins with it.

Usually these smaller molecules do not move back with water and
other dissolved substances into the venule ends of the capillaries.
If the tissue fluid (and plasma proteins) is allowed to accumulate, the
tissues swell, producing a condition called edema (oedema).
Lymph

24. –Lymph, found only in the closed lymphatic vessels, is
a transparent, colorless, or slightly yellow, watery
fluid. Lymph coming from the digestive system is
milky in appearance (chyle).
–2-3 liters of lymph are present in the body.

25. FORMATION OF LYMPH FLUID
•FORMATION
- Diffusion
- Osmosis
Terminal capillaries in
the Interstitium
•0.003ml/100kg/min
tissues
•2-3liters/day
produced

26. •organized into two separate and very unequal drainage areas.
• These are the right and left drainage areas and normally lymph
does not drain across the invisible lines that separate these areas.
•Structures within each area carry lymph to its destination, which is to
return to the circulatory system.
DRAINAGE AREAS

27. The Right Drainage Area removes lymph from
the:
•Right side of the head and neck
•Right arm
•Upper right quadrant of the body.
•Lymph from this area flows into the right
lymphatic duct. This duct returns the lymph
to the circulatory system by draining into the
right subclavian vein.

28. The Left Drainage Area removes lymph from
the:
•Left side of the head and neck
•Left arm and the left upper quadrant
•Lower trunk
•Both legs

29. •The terminus is the area at the base of the
neck where the lymphatic ducts return the
lymph to the circulatory system.
•Here the subclavian veins, which are
located just under the collar bones,
receive the lymph and it once again
circulates throughout the body as plasma.

30. •The cisterna chyli temporarily stores lymph
as it moves upward from the lower areas
of the body.
• The thoracic duct carries lymph upward to
the left lymphatic duct.
•The left lymphatic duct returns the lymph
to the circulatory system by draining into
the left subclavian vein.

31. LYMPHATIC DRAINAGE OF HEAD
AND NECK
DEEP
CERVICAL
Surrounds IJV
Spinal Accessory
Base of skull- Neck
SUPERFICIAL
CERVICAL
Outer circle (Pericervical
collar)
Inner circle (upper part of
respiratory and alimentary
passages)

32. LOWER DEEP CERVICAL
Left lower body
(bilaterally)
THORACIC DUCT
Right Brachiocephalic vein
Right upper body
RIGHT LYMPHATIC
DUCT
Left Brachiocephalic vein
Subclavian vein

34. Organized into 2 groups:
–A terminal (collecting) group : deep cervical group
•is related to the carotid sheath
•All lymph vessels from the head and neck drain directly
to this group or indirectly via the
–Intermediary, outlying groups
•The jugular trunk　
–is formed by efferents of the deep cervical group
–drains on the right into the right lymphatic duct or at
the junction between the internal jugular and
subclavian vein.
–drains on the left into the thoracic duct or joins the
internal jugular or subclavian vein.
LYMPHATIC DRAINAGE OF THE HEAD AND NECK

35. 1) Superior deep cervical nodes
•found next to the upper portion of the internal jugular vein.
•and most lie deep to the sternocleidomastoid muscle.
•drain to the lower inferior group or directly to the jugular trunk.
•The jugulodigastric group : for lymphatic drainage of the tongue ; in
a triangle bordered by the posterior belly of the digastric muscle, the
facial and internal jugular veins.
•2) Inferior deep cervical lymph nodes are related to:
•the deep surface of the SCM muscle
•the lower portion of the internal jugular vein
•the brachial plexus and subclavian vessels
•Jugulo-omohyoid node ( at the level of the intermediate tendon of the
omohyoid ) : lymphatic drainage of the tongue.
• Inferior deep cervical lymph nodes drain into the jugular lymph trunk.
The deep cervical lymphatic nodes

37. •2 types of drainage exist:

–Drainage by vessels afferent to local groups
of nodes which in turn drain to the deep
cervical nodes.
–Direct drainage to deep cervical nodes.
LYMPHATIC SYSTEM OF SUPERFICIAL HEAD & NECK

38. 1) In the head:
–occipital
–retroarticular (mastoid)
–parotid
–buccal (facial)
2) In the neck:
–submandibular
–submental
–anterior cervical
–superficial cervical
SUPERFICIAL LYMPHATIC DRAINAGE

40. •Submandibular nodes receive drainage from the frontal region
above the root of the nose.
•Superficial parotid nodes (anterior to tragus, superficial and deep to
parotid fascia) receive drainage from :
–rest of the forehead,
–temporal region,
–upper half of the lateral auricular aspect
–anterior wall of the external acoustic meatus
•lateral vessels from the eyelids and skin of the zygomatic region
•Efferent vessels drain to the upper deep cervical nodes
Lymphatic drainage of scalp and ear

41. •Upper deep cervical nodes and
retroauricular nodes receive drainage
from:
–a strip of scalp above the auricle
–the upper half of the cranial aspect and
margin of the auricle
–the posterior wall of the external acoustic
meatus

43. •The retroauricular nodes are found:
–superficial to the mastoid attachment of the
sternocleidomastoid muscle
–deep to the auricularis posterior
–They drain to the upper deep cervical nodes

•Superficial cervical or upper deep cervical nodes receive
drainage from :
–auricular lobule
–floor of the auditory meatus
–skin over the mandibular angle
–skin over the lower parotid region

44. •Superficial cervical nodes:
–are distributed along the external jugular vein superficial
to sternocleidomastoid
–have efferents:
•going around the anterior border of the
sternocleidomastoid to the upper deep cervical nodes
•following the external jugular vein to the lower deep
cervical nodes in the subclavian triangle.

•The occipital scalp is drained:
–partly to the occipital nodes.
–partly by a vessel along the posterior border of
sternocleidomastoid to the lower deep cervical nodes.
•The occipital nodes are mainly found superficial to the
upper attachment of trapezius and occasionally in the
superior angle of the posterior triangle of the neck

45. •Lymph vessels draining the eyelid and conjunctiva:
–start in a subcutaneous and deep plexus around the tarsal plates.
–divided into lateral and medial vessels
•Lymph vessels from eyelids and conjunctiva are organized
into:
•1) Lateral vessels :
–drain the whole thickness of both eyelids (except for the medial
parts)
–drain all of the conjunctiva
–run to the superficial parotid nodes and deep nodes embedded in
the parotid gland.
–also receive lymph from the middle ear.
•2) Medial vessels:
–drain the whole thickness of the medial parts of the lids.
–drain the caruncular lacrimalis.
–run to the submandibular nodes.
Lymphatic drainage of the face

46. Submandibular nodes
–drain directly the:
•external nose
•cheeks
•upper lip and lateral
part of the lower lips
•the mucosa of lips and
cheeks
•A few buccal nodes
may be present near
the facial vein and they
also drain to the
submandibular nodes.

47. •The skin over the root of the nose and central forehead drains partly
to the parotid nodes and partly to the submandibular nodes.
•The lateral part of the cheek drains to the parotid nodes.
•Submental nodes
–are located on the mylohyoid, between the anterior bellies of the
digastric muscles.
–receive bilateral afferents.
–have efferents running to the submandibular and jugulo-
omohyoid nodes.

49. •Superficial vessels run:
–around the sternocleidomastoid, to the superior or
inferior deep cervical nodes.
–over the sternocleidomastoid and the posterior
triangle, to the superficial cervical and occipital nodes.
•Superior region of the anterior triangle drains to the
submandibular and submental nodes.
•Anterior cervical skin below the hyoid bone drains to the
anterior cervical lymph nodes near the anterior jugular
veins.
•Efferents go to the deep cervical nodes bilaterally
(infrahyoid, prelaryngeal and pretracheal groups).
•An anterior cervical node may often be found in the
suprasternal space
Lymphatic drainage of the neck

51. •Deep nodes are organized into
–Superior deep cervical nodes
–Inferior deep cervical nodes
–Retropharyngeal nodes
–Paratracheal nodes
–Infrahyoid, prelaryngeal and pretracheal nodes.
–Lingual nodes.
•The retropharyngeal nodes: .
–lie between the pharyngeal and prevertebral fasciae.
–receive afferents from the nasopharynx, Eustachian
tube and joints between the occipital bone, C1 and C2
vertebrae.
–drain to the upper deep cervical nodes.
LYMPHATIC SYSTEM OF DEEP HEAD AND NECK

53. Paratracheal nodes
–drain to the upper and lower deep cervical nodes.
Infrahyoid nodes:
–drain afferents from the anterior cervical nodes.
–drain to the deep cervical nodes.
Lingual nodes
–form an inconstant group.
–drain to the upper cervical nodes.

54. –The anterior region of the nasal cavity drains superficially to the
submandibular nodes.
–Rest of nasal cavity, paranasal sinuses, nasopharynx and
pharyngeal end of the auditory tube drain via the
retrophrayngeal nodes or directly to the upper deep cervical
nodes.
–the posterior nasal floor drains to the parotid nodes.
LYMPHATIC DRAINAGE OF NASAL CAVITY AND NASOPHARYNX

55. LYMPHATIC DRAINAGE OF PALATE

56. –The mucosa of the tympanic membrane and
the antrum drain to the parotid or upper deep
cervical lymph nodes.
–The tympanic end of the auditory tube drain to
the deep cervical lymph nodes.
LYMPHATIC DRAINAGE OF THE MIDDLE EAR

57. •1) Superior vessels run with the superior
laryngeal vessels to the upper deep cervical
nodes.
•2) Inferior vessels run:
–between the cricoid cartilage and the first
tracheal ring to the inferior deep cervical
nodes.
–or through the cricothyroid ligament to the
pretracheal and prelaryngeal nodes.
LYMPHATIC DRAINAGE OF THE MIDDLE EAR

58. •A dense network of lymphatic vessels (tracheal plexus) is present in
the tracheal wall.
•This tracheal plexus drains to:
–the pretracheal nodes
–the paratracheal nodes
•or directly to the inferior deep cervical nodes
LYMPHATIC DRAINAGE OF THE TRACHEA

59. –Lymphatic vessels from the thyroid gland communicate with the:
•prelaryngeal nodes pretracheal nodes,
•paratracheal nodes,
•brachiocephalic nodes
•deep cervical nodes
• directly to the thoracic duct
LYMPHATIC DRAINAGE OF THE THYROID GLAND

60. –Gingiva drain to the submandibular nodes.
–Soft and hard palate drain to the superior deep
cervical nodes and the retropharyngeal nodes.
–Anterior part of the floor of the mouth drains via the
submental nodes or directly to the superior deep
cervical nodes.
–Rest of the floor of the mouth drains to the
submandibular and superior deep cervical nodes.
LYMPHATIC DRAINAGE OF THE MOUTH

61. •Lymphatics from the teeth pass to the
submandibular and deep cervical nodes.
•The lymphatic drainage of the tonsil drains
to the superior deep cervical nodes:
–most to the jugulodigastric node.
•some to the small nodes on the lateral
aspect of the internal jugular vein
LYMPHATIC DRAINAGE OF THE TEETH
LYMPHATIC DRAINAGE OF THE TONSIL

62. –Anterior 2/3 of the tongue drains into the marginal
and central vessels.
–Posterior 1/3 of the tongue drains into the dorsal
lymph vessels.
•Marginal vessels of the tongue
–arise from the tip of the tongue
and frenulum.
–drain bilaterally to the:
•submental nodes,
•jugulo-omohyoid node,
•anterior or middle
Submandibular node,
•jugulo-digastric nodes.
LYMPHATIC DRAINAGE OF THE TONGUE

63. •Central vessels of the tongue follow the lingual vein to drain to:
–deep cervical nodes (jugulodigastric and juguloomohyoid
nodes).
–submandibular nodes.
•Dorsal vessels of the tongue
–join with the marginal vessels
–drain into the jugulodigastric node or juguloomohyoid node

64. –passes:
•through the
retropharyngeal or
paratracheal nodes
•or directly to the deep
cervical nodes.
•The epiglottis drains
to the infrahyoid
nodes.
LYMPHATIC DRAINAGE OF THE PHARYNX AND CERVICAL PART OF THE ESOPHAGUS

65. The lymph nodes of the head and neck are
distributed in 3 regions
•A ring of superficial lymphoid tissue found at the entrance of the oral
pharynx
•Aggregated in specific areas to form masses called tonsils:
•a) Palatine tonsil - an ovoid mass between palatoglossal and
palatopharyngeal arches on the lateral wall of oral pharynx. It
occupies the tonsillar fossa.
•b) Lingual tonsil - applies to nodules on dorsum of posterior 1/3
tongue.
•c) Tubal tonsil - a nodule next to the opening of the auditory tube.
•d) Pharyngeal tonsil - a rounded prominence at junction of the roof
and posterior wall of the nasopharynx.
•When enlarged, tonsils are called ‘adenoids’ and may hamper nasal
breathing (subject breathes through mouth).
WALDEYER’s RING

66. •Ring of superficial nodes at
junction of head and neck.
•Drain the face and scalp and
are distributed in 6 groups:
a) Occipital nodes
– located posteriorly between inion
and mastoid process;
–Drain the back of the scalp.
–Enlarged in presence of scalp
infection.
b) Retroauricular (mastoid)
–Located behind the ear
–Drain the adjacent scalp,
upper/medial quadrant of the ear
and posterior wall of external
acoustic meatus (EAM)
CIRCULAR CHAIN (PERICERVICAL COLLAR )

67. c) Parotid nodes
•Located deep to the gland .
•Divided into superficial and deep.
•Superficial nodes drain upper/lateral quadrant of
the ear, anterior wall of EAM, tympanic cavity,
temporal region, lateral part of face, eyelids and
forehead.
•Deep nodes drain nasopharynx and posterior ½
of nasal cavity.
d) Buccal nodes
• located on the buccinator below the orbit,
along the facial vein.
• they drain the cheeks.

68. Consists of two groups of lymph nodes in the
neck: Superficial cervical and Deep cervical.
•A) SUPERFICIAL CERVICAL NODES
•1. Alongside external jugular vein: They
receive lymphatics from lower medial and lateral
quadrants of the ear and lymphatics from the
parotid nodes (superficial group)
•2. In the midline in front of the larynx and
trachea lie prelaryngeal and pretracheal nodes
also referred to as anterior cervical nodes;
they drain the larynx and trachea.
VERTICAL CHAIN

69. •Superior deep cervical nodes
–found next to the upper
portion of the IJV
–most lie deep to the SCM
muscle.
–drain to the lower inferior
group or directly to the
jugular trunk.
• Jugulodigastric group
– for lymphatic drainage of
the tongue
–triangle bordered by the
posterior belly of the
digastric muscle, the facial
and internal jugular veins.

Deep Cervical Nodes

70. •Inferior deep cervical
lymph nodes
–deep surface of the
SCM muscle
–lower portion of the
internal jugular vein
–brachial plexus and
subclavian vessels

•The jugulo-omohyoid
node
– lymphatic drainage
of the tongue.
Deep Cervical Nodes

71. Structure Location Regions drained
accessory
nodes
posterior
triangle of the
neck, arranged
along the
accessory n.
occipital region
and posterior
scalp
anterior
auricular nodes
subcutaneous
connective
tissue anterior
to the ear
anterior part of
the parietal
region of the
scalp; anterior
surface of the
ear and external
acoustic meatus

72. anterior jugular
nodes
along the
anterior jugular
vein
skin and mm. of
the anterior
infrahyoid
region of the
neck
auricular nodes,
anterior
subcutaneous
connective
tissue anterior
to the ear
anterior part of
the parietal
region of the
scalp; anterior
surface of the
ear and external
acoustic meatus

73. cervical nodes,
deep
in and around
carotid sheath
posterior and
lateral to the
internal jugular
v.
head and neck
cervical nodes,
superficial
in superficial
fascia and
along
superficial
vessels of the
head & neck
head & neck

74. deep cervical
nodes
in and around
carotid sheath
posterior and
lateral to the
internal jugular
v.
head and neck
deep cervical
nodes, inferior
around the
internal jugular
v., inferior to the
crossing of the
omohyoid m.
head and neck

75. deep cervical
nodes, superior
around the
internal jugular
v., superior to
the crossing of
the omohyoid
m.
head and the
superior part of
the neck
external jugular
nodes
along the
external jugular
v.
inferior part of
the ear and the
parotid region

76. facial nodesalong the
course of the
facial a. and v.
eyelids, nose,
cheek and lips
inferior deep
cervical nodes
around the
internal jugular
v., inferior to the
crossing of the
omohyoid m.
head and neck

77. jugular
lymphatic trunk
carotid sheath
in root of neck
head & neck
jugular nodes,
anterior
along the
anterior jugular
vein
skin and mm. of
the anterior
infrahyoid
region of the
neck

78. jugular nodes,
external
along the
external jugular
v
inferior part of
the ear and the
parotid region
jugulodigastric
node
anterolateral to
internal jugular
v. where it is
crossed by
posterior belly
of the digastric
oral cavity,
tongue, palatine
tonsil

79. juguloomohyoid
node
lateral to internal
jugular v. where it
is crossed by
superior belly of
omohyoid
submental region
and tip of tongue;
head & neck
above this level
occipital nodes superior nuchal
line, along the
course of the
occipital a. and v.
occipital part of the
scalp and the
superior neck
parotid nodes,
deep
on the lateral side
of the pharyngeal
wall, deep to the
parotid gland
external acoustic
meatus, auditory
tube, middle ear

80. parotid nodes,
superficial
superficial to the
parotid gland and
also deep to the
parotid fascia
anterior surface of
the ear and
external acoustic
meatus; temporal
and frontal
regions; eyelids,
lacrimal gland
cheek and nose
retroauricular
nodes
posterior to the
ear
scalp overlying
the posterior
parietal region;
skin of the
posterior surface
of the ear

81. retropharyngeal
node
posterior to
pharynx in the
retropharyngeal
space
nasal fossae,
paranasal
sinuses, hard
palate, soft
palate, middle
ear, oropharynx
right lymphatic
duct
root of neck on
the right side
right half of the
head and neck;
right upper limb;
right side of the
chest

82. submandibular
nodes
along the inferior
border of the
submandibular
gland
anterior part of
tongue, lower lip,
floor of the
mouth, nose,
cheeks, chin,
gums and lower
incisor teeth,
lower surface of
palate
submental nodes under the
mandible on the
mylohyoid m.
of the tongue,
lower lip, floor tip
of the mouth,
chin, gums and
lower incisor teet

83. submandibular
nodes
along the inferior
border of the
submandibular
gland
anterior part of
tongue, lower lip,
floor of the
mouth, nose,
cheeks, chin,
gums and lower
incisor teeth,
lower surface of
palate
submental nodes under the
mandible on the
mylohyoid m.
of the tongue,
lower lip, floor tip
of the mouth,
chin, gums and
lower incisor teet

84. superficial cervical
nodes
in superficial
fascia and along
superficial vessels
of the head &
neck
head & neck
superficial parotid
nodes
superficial to the
parotid gland and
also deep to the
parotid fascia
anterior surface of
the ear and
external acoustic
meatus; temporal
and frontal
regions; eyelids,
lacrimal gland
cheek and nose

85. superior deep
cervical nodes
around the internal
jugular v., superior
to the crossing of
the omohyoid m.
head and the
superior part of the
neck
supraclavicular
nodes
in and around
carotid sheath
below level of
omohyoid
head and neck

86. tonsil, lingualsuperior surface of
the root of the
tongue
"guards" the
entrance of the
oropharynx
tonsil, palatine lateral wall of the
oropharynx
between the
palatoglossal and
palatopharyngeal
arches
guards" the
entrance of the
oropharynx

87. tonsil, pharyngeal roof and posterior
wall of the
nasopharynx
"guards" the
entrance to the
nasopharynx
tonsil, tubal pharyngeal recess guards" the
entrance to the
nasopharynx

88. tonsil, pharyngeal roof and posterior
wall of the
nasopharynx
"guards" the
entrance to the
nasopharynx
tonsil, tubal pharyngeal recess guards" the
entrance to the
nasopharynx

89. superficial chains.
The lymphatics of the neck are arranged into deep and

90. The superficial tissues drain into superficial nodes as shown in this diagram.

91. •The viscera have deep nodes associated with them as shown in this
diagram.

92. The deep jugular nodes lie on the internal jugular vein as shown in this
diagram

93. SUB-MANDIBULAR
UPPER DEEP CERVICAL CHAIN OF NODES
SUB-MENTAL
3rd Molars
Tongue (base)
Tonsillar area
Soft palate
PAROTID NODES
LOWER DEEP CERVICAL CHAIN OF NODES

94. The sentinel lymph node is the hypothetical first
lymph node or group of nodes reached by
metastasizing cancer cells from a tumor.
The spread of some forms of cancer usually
follows an orderly progression, spreading first
to regional lymph nodes, and so on, since the
flow of lymph is unidirectional.
SENTINEL LYMPH NODE

95. •The concept of the sentinel lymph node is
important because of the advent of the
sentinel lymph node biopsy technique,
also known as the sentinel node
procedure. This technique is used in the
staging of certain types of cancer to see if
they have spread to any lymph nodes,
since lymph node metastasis is one of the
most important prognostic signs.

96. Levels of Lymph nodes (SLOAN –
KETTERING CANCER CENTER, NY )
I
II
III
IV
VI v

97. Simplified Nodal Classification
•Level 1: Submandibular, submental.
•Level 2: Internal jugular from skull base to
carotid bifurcation.
•Level 3: Internal jugular below carotid bifurcation
to omohyoid.
•Level 4: Internal jugular below omohyoid.
•Level 5: Posterior triangle.
•Level 6: Adjacent to thyroid.
•Level 7: Tracheal esophageal groove and
superior mediastinum

99. Subgroups
•IaSubmental
•IbSubmandibular
•IIaUpper jugular (Anterior to SAN)
•IIb Upper jugular (Posterior to SAN)
•IIIMiddle jugular
•IVaLower jugular (behind Clavicular head)
•IVbLower jugular (behind Sternal head)
•VaPosterior triangle (SAN group)
•VbPosterior triangle (Transverse
cervical artery group,supraclavicular group)
•VIAnterior(Central)
compartment(paratracheal,perithyroid grp)
•VII Suprasternal group

100. Modified AJCC (Harnsberger) Nodal
Staging
–N0: Less than 1.5 centimeters, no central necrosis.
–N1: Single ipsilateral node 15-29 millimeters or less than 15
millimeters with central necrosis.
–N2: Ipsilateral 3-6 centimeters.
–N2A: Single.
–N2B: Multiple.
–N3: Greater than 6 centimeters.
–N3A: Ipsilateral.
–N3B: Bilateral.
–N3C: Contralateral.
–N3D: Extracapsular.
•Extracapsular spread carries a grave prognosis and may
be the best indicator of treatment failure

101. Face and ScalpAnterior Facial, Ib
Lateral Parotid
Posterior Occipital, V
Eyelids Medial Ib
Lateral Parotid, II
Chin Ia, Ib, II
External EarAnterior Parotid, II
Posterior Post auricular, II, V
Middle Ear Parotid, II
Floor of mouthAnterior Ia, Ib, IIa > IIb
Lower incisors Ia, Ib, IIa > IIb
Lateral Ib, IIa > IIb, III
Teeth except incisorsIb, IIa > IIb, III
Nasal CavityAnterior Ib
Posterior Retropharyngeal, II, V
Common Nodal Drainage Patterns

102. Nasal Cavity PosteriorRetropharyngeal, II, V
Nasopharynx Retropharyngeal, II, III, V
Oropharynx IIb > IIa, III, IV, V
Larynx SupraglotticIIa > IIb, III, IV
SubglotticVI, IV
Cervical
esophagus IV, VI
Thyroid VI, IV, V, Mediastinal
Tongue Tip Ia, Ib, IIa > IIb, III, IV
Lateral Ib, IIa > IIb, III, IV
Common Nodal Drainage Patterns

103. •Stony hard  Metastatic cancer
•Firm, Rubbery  Lymphoma
•Soft  Infection Inflammatory
•Shotty  Viral infection
Consistency/Texture

104. PALPABLE LYMPHNODES AND
PROBABLE
ASSOCIATED CONDITIONS
•Tender, Mobile, enlarged  Acute infection
•Non-tender, Mobile, Enlarged  Chronic
infection
•Matted, Non tender  Tuberculosis
•Fixed, Enlarged  Carcinoma
•Rubbery, Enlarged  Lymphomas

105. Benign
TB
Sarcoidosis
Lymphogranuloma
venereum
Malignant
Metastatic carcinoma
Lymphomas
Matted:-
Group of nodes – Connected – as a unit
Benign / Malignant

106. •Inflammation
•Venous stasis
•Mechanical insufficiency of vessels and
valves
•Drugs –Serotonin,Prostaglandins,TXA2,
Nor-adrenaline
Conditions where lymph production increase
(pathologically)

107. •GRAY’S ANATOMY 39
th
EDITION.
•MASTERY OF SURGERY VOL.1(4
TH
EDITION).BY
ROBERT J.BAKER.
•PRINCIPLES OF ANATOMY AND PHYSIOLOGY 8 th
EDITION.
•SICHER AND DuBRUL’S ANATOMY 8
th
EDITION.
•HUMAN ANATOMY.B.D CHAURASIA 4
th
EDITION.
•TEXT BOOK OF ANATOMY ,COLOUR ATLAS 2
nd

EDITION,INDERBIR SINGH.
•INTERNET SOURCE.
REFERENCES