Venous and lymphatic drainage of head and neck.pptx

Venous and lymphatic drainage of head and neck

1. VENOUS AND LYMPHATIC DRAINAGE OF HEAD AND NECK Made by : Dr Pratik Agrawal ( R1) Guided by : Dr Navin Shah ( Professor And HOD, Oral & Maxillofacial Surgery)

2. INDEX: Venous drainage of the head region Venous drainage of the facial region Venous drainage of the neck region Clinical/applied anatomy of venous drainage Lymphatic drainage of the head and facial region Lymphatic drainage of the neck region Clinical/applied anatomy lymphatic drainage.

3. Venous drainage of the Head region: Superficial Temporal Vein Middle Temporal vein Posterior Auricular Vein Occipital Vein

4. 1.Superficial Temporal Vein: Path/course: begins on the side and vertex of the skull, communicates with the Supratrochlear vein(frontal vein) and supraorbital vein, posterior auricular vein and occipital vein. From this network frontal and parietal branches arise, and unite above the zygomatic arch to form the trunk of the vein, which is joined by the middle temporal vein emerging from the temporalis muscle. It then crosses the posterior root of the zygomatic arch, enters the substance of the parotid gland, and unites with the maxillary vein to form the retromandibular vein.

5. Tributaries: The superficial temporal vein receives in its course the following: some parotid veins articular veins from the temporomandibular joint anterior auricular veins from the auricle the transverse facial vein from the side of the face

6. 2.Middle Temporal Vein: Path/Course: The middle temporal vein lies beneath the superficial layer of the deep temporal fascia and is distributed in the superficial temporal fat pad between the superficial and deep layers of the deep temporal fascia. The vein connects the supraorbital vein through the zygomatic temporal vein near the zygomatic process of the frontal bone. As the vein passes back to the proximal side, it pierces and runs several millimeters over the surface of the superficial layer of the deep temporal fascia. Finally, the vein joins the superficial temporal vein approximately 1 cm below the upper aspect of the zygomatic root.

7. SURGICAL ANATOMY: The caliber of the middle temporal vein is significantly greater than that of the superficial temporal vein. The vein can be safely used as a recipient vessel in case of free-tissue transfer.

8. 3.Posterior Auricular Vein: Path/Course: The posterior auricular vein begins from the parieto-occipital venous network, which communicates with the occipital and superficial temporal veins. It descends behind the auricle to join the posterior branch of the retro-mandibular vein to form the external jugular vein. Tributaries: It collects the blood from the stylo-mastoid vein and some tributaries from the cranial surface of the auricle and also often receives a mastoid emissary vein from the sigmoid sinus.

9. SURGICAL ANATOMY: Inadvertent injury of the mastoid emissary vein poses a significant problem not only because of difficulty with hemostasis but also because of its bidirectional flow and close proximity to the sigmoid sinus.

10. 4.Occipital Vein: Path/course: The vein begins as a plexus in the posterior scalp at the external occipital protuberance. It pierces the cranial attachment of the trapezius muscle, turns into a venous plexus in the suboccipital triangle , and joins the deep cervical and vertebral veins. It finally joins the posterior auricular vein. Occasionally , it accompanies the occipital artery and ends in the internal jugular vein. The parietal and mastoid emissary veins link it with the superior sagittal and transverse sinuses.

11. Venous drainage of facial region: The main venous drainage pathway of the face is primarily the facial vein. In the middle of the face, the hemiloop -like vein surrounds the orbit . This vein can be contributed to by the supraorbital , angular, or facial veins, depending on its location.

12. Fresh cadaver specimen with white contrast medium inside the veins. The hemiloop-like vein surrounds the orbit. The vein can be formed by the supraorbital, angular, or facial injected into veins, depending on its location.

13. 1.Supraorbital Vein: Path/course: The supraorbital vein passes medially above the orbital rim under the orbicularis oculi muscle to connect to the angular vein in the medial canthal area. A branch of the supraorbital vein also connects to the superior ophthalmic vein at the supraorbital notch or foramen. Laterally , it connects to the zygomatico-temporal vein arising from the middle temporal vein near the zygomatic process of the frontal bone. There , it also connects with radicles of the superficial temporal veins.

14. Surgical anatomy: The zygomatico-temporal vein is known as a sentinel vein . The vein is located in a 10-mm zone above which the temporal branch of the facial nerve passes .

15. 2.Supratrochlear Vein: Path/course: Basically, one or two large veins arise from the medial canthal area and run toward the forehead . The supratrochlear vein connects to the tributaries of the superficial temporal veins to form a large venous network in the forehead. Both the deep veins from the peri-cranial layer and the superficial veins from the galea frontalis layer empty into the vein. The supratrochlear vein finally joins the angular or nasal root vein near the medial canthus.

16. 3.Nasal Root Vein: Path/course: Arising superficially from the angular vein, the nasal root vein pierces the procerus muscle and anastomoses with its contralateral counterpart to form a large communicating vein under the skin of the nasal root . The nasal root vein is convex toward the nasal tip. It is a bridge of the bilateral hemiloop-like veins. Several tributaries from the external nose connect to the nasal root vein

17. 4.Angular Vein: Path/course: The angular vein is formed by the union of the supratrochlear and supraorbital veins . It runs inferiorly across the medial margin of the medial canthal tendon approximately 8 mm from the medial canthus of the eye. It becomes the facial vein at its junction with the superior labial vein. The two major veins arise from it, namely, the transverse nasal root vein ( superficial) and a branch to form the inferior root of the superior ophthalmic vein (deep). Several tributaries from the external nose and lower eyelid also connect to the angular vein.

18. 5.Superior Ophthalmic Vein: Path/course: The superior ophthalmic vein is formed at the supero-medial margin of the orbit immediately posterior to the trochlea by the union of two contributing roots, namely, a superior root from the supraorbital vein and an inferior root from a branch of the angular vein. It runs with the ophthalmic artery and links the facial and intracranial veins. It traverses the superior orbital fissure to end in the cavernous sinus . The superior ophthalmic vein has venous valves; the blood flows toward the cavernous sinus.

19. 6.Inferior Ophthalmic Vein: Path/course: The inferior ophthalmic venous plexus is formed by veins with abundant interconnections. It originates in a network of minute veins in the anterior region of the orbital floor and receives veins from the inferior rectus muscle, inferior oblique muscle, lacrimal sac, and eyelids. It usually joins the superior ophthalmic vein . Rarely , the vein can drain directly into the cavernous sinus. It connects with the pterygoid venous plexus by a small branch that passes through the inferior orbital fissure .

20. 7.Facial Vein: Path/course: The facial vein is the main venous drainage pathway of the face. It starts from the angular vein and descends obliquely near the side of the nasolabial fold. The facial vein and artery lie in close proximity at the level of the lower edge of the mandible. Thereafter, however , the artery takes a tortuous course among the facial muscles, whereas the vein has a direct path from the angular vein to the lower mandibular border. From its origin it runs obliquely downward and backward, beneath the zygomaticus major muscle and zygomatic head of the quadratus labii superioris, descends along the anterior border and then on the superficial surface of the masseter, crosses over the body of the mandible, and passes obliquely backward, beneath the platysma and cervical fascia, superficial to the submandibular gland, the digastricus and stylohyoideus muscles . The facial vein is joined by the anterior division of the retromandibular vein near the mandibular angle and finally drains directly or indirectly into the internal jugular vein.

21. Cranial to the mandible , th e deep facial vein from the pterygoid venous plexus and the inferior palpebral, superior and inferior labial, Buccinator, parotid , and Masseteric veins join the facial vein. Caudal to the mandible, the submental, tonsillar, external palatine , and submandibular veins join the facial vein . The facial vein has valves, particularly around the level of the mandible. The distribution of venous valves indicates that the blood flow is caudal toward the internal jugular vein in the lower part of the facial vein and normally toward the cavernous sinus in the superior ophthalmic vein . COMMUNICATION: The vein communicates with the superior ophthalmic veins and through them with the cavernous sinus.

22. 8.Pterygoid Venous Plexus: Path/course: The pterygoid plexus is a venous plexus of considerable size and is situated between the temporalis muscle and the lateral pterygoid muscle, and partly between the two pterygoid muscle. It receives the tributaries from the following : 1. Sphenopalatine 2. Middle meningeal 3. Deep temporal (anterior & posterior) 4. Pterygoid 5. Masseteric 6. Buccinator 7. Alveolar 8. some palatine veins (palatine vein which divides into the greater and lesser palatine veins 9. A branch which communicates with the ophthalmic vein through the inferior orbital fissure 10. Infraorbital vein

23. RELATIONS: This plexus communicates freely with the anterior facial vein, it also communicates with the cavernous sinus, by branches through the foramen ovale, and foramen lacerum. Due to its communication with the cavernous sinus, infection of the superficial face may spread to the cavernous sinus, causing cavernous sinus thrombosis. Complications may include edema of the eyelids, conjunctivae of the eyes, and subsequent paralysis of cranial nerves which course through the cavernous sinus. The pterygoid plexus of veins becomes the maxillary vein. The maxillary vein and the superficial temporal vein later join to become the retromandibular vein. The posterior branch of the retromandibular vein and posterior auricular vein then form the external jugular vein, which empties into the subclavian vein.

24. SURGICAL ANATOMY: In reduction malar- plasty , which is common in Asian patients, osteotomy should be performed cautiously and not too deep in reaching the periosteum of the posterior side of the maxillary sinus to avoid injuring the deep facial vein, which lies just behind the posterior side of the maxillary sinus.

25. 9.Maxillary Vein: Path/course: The maxillary vein consists of a short trunk that serves as the main drainage pathway of the pterygoid venous plexus. It passes backward between the sphenomandibular ligament and neck of the mandible with the mandibular segment of the maxillary Artery. It forms the retromandibular vein by connecting with the superficial temporal vein . The Maxillary vein runs alongside the first part of maxillary artery. It has its origin in the pterygoid plexus of veins which is present in the infratemporal fossa. The veins corresponding to the branches of the maxillary artery drain into this plexus. The plexus is connected to the facial vein through the deep facial vein. It is connected to the cavernous sinus by a number of emissary veins. The plexus is drained by the maxillary vein which ends by joining the superficial temporal vein to form the retromandibular vein.

26. 10.Retromandibular Vein: Path/course: The Retromandibular vein lies behind the ramus of the mandible. It is formed by union of the superficial temporal and maxillary vein. It is embedded in the parotid gland. Within the gland the vein is superficial to the external carotid artery and deep to the facial nerve. Descending within the substance of the gland the vein divides into anterior and posterior branches. The anterior branch joins the facial vein. The posterior branch joins the posterior auricular vein to form the external jugular vein.

27. Venous Drainage of neck region

28. 1. THE INTERNAL JUGULAR VEIN: Chief vein of the head and neck, Paired vein Location and course: On either side the upper end of the vein lies in the jugular foramen on the base of the skull. Here the vein becomes continuous with the sigmoid sinus. The lower end of the vein lies behind the sternal end of the clavicle where the IJV joins the subclavian to form the corresponding brachiocephalic vein. The IJV lies alongside the Internal Carotid and Common carotid Artery being enclosed with them in the Carotid Sheath .

29. The vagus nerve is also enclosed within the carotid sheath which lies posteriomedial to the vein. The upper end of the vein is enlarged to form the superior bulb which occupies the jugular fosssa on the base of the skull, similarly the lower end is enlarged to form the inferior bulb.

30. Tributaries of Internal jugular vein: IN HEAD: - INFERIOR PETROSAL SINUS - SIGMOID SINUS IN NECK: - THE FACIAL VEIN - LINGUAL VEIN - PTERYGOID PLEXUS - SUPERIOR AND MIDDLE THYROID VEINS

31. SURFACE ANATOMY: Internal jugular vein is marked by a broad line by joining these two points: A)1 st point on the neck medial to the lobule of the ear B) 2 nd point on the medial end of the clavicle. The lower bulb of the vein lies beneath the lesser supraclavicular fossa between the sternal and clavicular heads of the sternocleidomastoid muscle.

32. LINGUAL VEIN: COURSE/LOCATION: The lingual veins begin on the dorsum, and under surface of the tongue, and, passing backward , end in the internal jugular vein. The vena comitans of the hypoglossal nerve ( ranine vein ), begins below the tip of the tongue, and join the lingual vein; generally, however, it passes backward on the hyoglossus, and joins the common facial vein.

33. TRIBUTARIES OF LINGUAL VEIN Sublingual vein : it accompanies the sublingual artery in the floor of the mouth, lateral to the hypoglossal nerve it may join the deep lingula vein to form the lingual vein. Deep lingual vein : 1.drains the tip of the tongue and joins the sublingual vein 2.it runs posteriorly near the median plane often visible through the mucosa on the underside of the tongue, to each side of the frenulum. Dorsal lingual veins : drains the dorsum and the sides of the tongue Suprahyoid vein

34. The SUPERIOR THYROID VEIN: COURSE/LOCATION : The superior thyroid vein beings in the substance and on the surface of the thyroid gland, and ends in the upper part of the internal jugular vein. DRAINAGE : It receives blood from the superior laryngeal and cricothyroid veins. Recieves blood from the upper part of the thyroid gland and larynx and empties in to the IJV

35. THE MIDDLE THYROID VEIN: The middle thyroid vein drains the lower part of the thyroid gland and after being joined by some veins from the larynx and trachea, ends in the lower part of the internal jugular vein. It crosses the common carotid artery to enter the internal jugular vein Clinical Feature : This vein is subjected for dissection as a part of surgical procedure of the thyroid galnd

36. 2. The External Jugular Vein: The external jugular vein is formed by union of the posterior division of the Retromandibular vein with the posterior auricular vein. The origin lies within the lower part of the parotid gland or just below it. The level corresponds to the angle of the mandible. From here the vein runs downwards and somewhat backwards and ends by joining the subclavian vein. The termination lies behind the middle of the clavicle, near the lateral margin of the scalnenus anterior muscle. The greater part of the vein is superficial being covered by skin, superficial fascia and platysma. As a result the vein can be clearly seen in the living.

37. It pierces the deep fascia near its termination to reach the subclavian vein. The vein crosses the sternocleidomastoid obliquely running downwards and backwards across it. SURFACE ANATOMY : The vein can be visible through the skin and can be made more prominent by blowing with the mouth and nostrils closed. It can be marked, if not visible by joining these points, A) 1 st point a little above and behind the angle of mandible. B) 2 nd on the clavicle just lateral to the posterior border of the Sternocleidomastoid muscle.

38. 3 . The Anterior jugular vein: The anterior jugular vein runs down the front of the neck a short distance from the midline. It begins near the hyoid bone and extends downwards to a point a little above the sternoclavicular joint. Here the vein turns laterally deep to the sternocleidomastoid, but superficial to the sternohyoid and sternothyroid muscles and ends by joining the lower end of the external jugular vein. Just above the sternum the right and left anterior jugular vein are unified by a transverse vein called the Jugular arch.

39. 4 .Subclavian Vein: Path/course: The subclavian vein is a continuation of the axillary vein that runs from the outer border of the first rib to the medial border of the anterior scalene muscle. From here, it connects with the internal jugular vein to form the brachiocephalic vein. The vein follows the subclavian artery and is separated from the artery by the insertion of the anterior scalene muscle. Hence, the vein lies anterior to the muscle, whereas the artery lies posterior to the muscle. The thoracic duct drains into the left subclavian vein near its junction with the left internal jugular vein (i.e ., venous angle), and the right lymphatic duct drains into the junction of the right internal jugular and right subclavian veins.

40. SURFACE ANATOMY: Subclavian vein is represented by a broad line along the clavicle extending from a little medial to its midpoint to the medial end of the bone.

41. CLINICAL/APPLIED ANATOMY: The facial veins and its deep connecting veins are devoid of valves, making an uninterrupted passage of blood to cavernous sinus. Squeezing the pustules or pimples in the area of the upper lip or side of nose or even the cheeks may cause infection which may be carried to the cavernous sinus leading to its thrombosis. So the cheeks are included in the dangerous area of the face.

42. 2 . External jugular vein is clinically important. The distension of the vein is visible in raised venous pressure due to congestive heart failure. The height of the column above the clavicle provides a rough guide to the increase in the venous pressure which is called as jugular venous pressure.

43. 3 . The vein can be cannulated by direct puncture in the interval between sternal and clavicular heads of sternocleidomastoid muscle. 4.In congestive cardiac failure or any other diseases where venous pressure is raised, the internal jugular vein is markedly dilated and engorged. 5. T hroat infections commonly spread to the middle ear through the auditory tube and cause otitis media. The pus from the middle ear can erode the floor and spread downwards, causing thrombosis of the sigmoid sinus and internal jugular vein.

44. Lymphatic Drainage of head and neck

45. The Lymphatic drainage of the Head and facial region: The lymph glands of the head and facial region are arranged in the following groups: 1. Occipital 2. Posterior Auricular 3. Parotid 4. Buccal 5. F acial 6. Deep Facial 7. Anterior Auricular 8. Lingual 9. Retropharyngeal .

46. 1.The occipital group: one to three in number LOCATION : on back of the head close to the margin of the Trapezius and resting on the insertion of the Semispinalis capitis muscle. AFFERENT VESSELS drain the occipital region of the scalp EFFERENT VESSELS pass to the superior deep cervical glands They are usually palpated at the base or lower border of the skull.

47. 2.The posterior auricular group (mastoid group): usually two in number They are situated on the mastoid insertion of the Sternocleidomastoid muscle beneath the posterior auricular muscle. Their afferent vessels drain the: posterior part of the temporo - parietal region, the upper part of the cranial surface of the auricle or pinna, and the back of the external acoustic meatus. T heir efferent vessels pass to the superior deep cervical glands . They are palpated behind the ear on the mastoid process.

48. 3.The Anterior auricular nodes (superficial parotid or preauricular lymph nodes ): Usually are one to three in number lies immediately in front of the tragus. Their afferents drain the lateral surface of the auricle and the skin of the adjacent part of the temporal region T heir efferent pass to the superior deep cervical glands. They are palpated anterior to the tragus of the ear.

49. 4. The Parotid group : form two groups in relation with the parotid salivary gland (1) group imbedded in the substance of the gland . ( 2) group of subparotid glands - small glands are found in the subcutaneous tissue over the parotid gland. - Their afferent vessels drain the root of the nose, the eyelids, the frontotemporal region , the external acoustic meatus and the tympanic cavity, possibly also the posterior parts of the palate and the floor of the nasal cavity - The efferents of these glands pass to the superior deep cervical glands. - The afferents of the subparotid glands drain the nasal part of the pharynx and the posterior parts of the nasal cavities .

50. 5. F acial group: They comprises of three groups: ( a ) I nfraorbital or maxillary : - scattered over the infraorbital region from the groove between the nose and cheek to the zygomatic arch . ( b ) Buccinator: - one or more placed on the Buccinator muscle opposite the angle of the mouth. ( c ) supramandibular: - on the outer surface of the mandible, in front of the Masseter and in contact with the external maxillary artery and anterior facial vein. - Their afferent vessels drain the eyelids, the conjunctiva, and the skin and mucous membrane of the nose and cheek. - Their efferents pass to the submandibular glands.

51. 6.The D eep facial nodes : They are placed beneath the ramus of the mandible, on the outer surface of the lateral pterygoid muscle, in relation to the internal maxillary artery. Their afferent vessels drain the temporal and infratemporal fossa and the nasal part of the pharynx T heir efferents pass to the superior deep cervical glands. 7.The lingual lymph nodes : They are two or three small nodules lying on the Hyoglossus and under the Genioglossus. They form merely glandule substance in the course of the lymphatic vessels of the tongue.

52. 8.Retropharyngeal group : They are one to three in number, lie in the buccopharyngeal fascia, behind the upper part of the pharynx and in front of the arch of the atlas, being separated, however, from the latter by the Longus capitis muscle. Their afferents drain the nasal cavities, the nasal part of the pharynx, and the auditory tubes. T heir efferents pass to the superior deep cervical glands . 9. Buccal Group of lymph nodes: They lie on the buccinator muscle and drains into the submandibular group of nodes.

53. The Lymphatic drainage of the Neck region ( American academy of otolaryngology) : Classification of the Lymph Nodes in neck region are: Level 1 : Submental (1a), submandibular (1b) Boundaries : The body of the mandible, stylo-hyoid muscle, anterior belly of the digastric muscle Levels 2, 3, and 4 : The upper, middle, and lower jugular nodes Level 2 is divided into 2a and 2b by the spinal accessory nerve . Level 3 nodes boundaries: The hyoid bone and a horizontal plane defined by the inferior border of the cricoid cartilage, sternohyoid muscle, and posterior border of the sternocleidomastoid muscle. Level 4 refers to the group of nodes related to the lower third of the jugular vein. Boundaries : Inferior border of the cricoid cartilage, clavicle, sternohyoid muscle, and posterior border of the sternocleidomastoid muscle .

54. Level 5 nodes are located in the posterior triangle of the neck. Boundaries : The posterior border of the sternocleidomastoid, anterior border of the trapezius muscle and clavicle . This level is subdivided by a plane defined by the inferior border of the cricoid cartilage into level 5a superiorly and level 5b inferiorly. Level 6 nodes are in the anterior, or central, compartment of the neck. Boundaries : Carotid arteries , hyoid bone, suprasternal notch. Lymph nodes in this compartment are located in the trache-oesophageal groove (paratracheal nodes), in front of the trachea (pretracheal nodes), around the thyroid gland (Para-thyroidal nodes ), and on the cricothyroid membrane ( pre-cricoid lymph nodes or Delphian nodes)

55. 1.Submental or suprahyoid group (1a): They are situated between the anterior bellies of the Digastric. Their afferents drain the central portions of the lower lip and floor of the mouth and the apex of the tongue. Their efferents pass partly to the submandibular glands and partly to a gland of the deep cervical group

56. 2 . Submandibular group( 1b): three to six in number, are placed beneath the body of the mandible in the submandibular triangle, and rest on the superficial surface of the submandibular salivary gland. The afferents of the submandibular glands drain the medial palpebral commissure, the cheek, the side of the nose, the upper lip, the lateral part of the lower lip, the gums, and the anterior part of the margin of the tongue; efferent vessels from the facial and submental glands also enter the submandibular glands. Their efferent vessels pass to the superior deep cervical glands.

57. 3 .Superficial cervical group : lie in close relationship with the external jugular vein as it emerges from the parotid gland, and, therefore, superficial to the Sternocleidomastoid muscle. Their afferent drain the lower parts of the auricle and parotid region, while their efferent pass around the anterior margin of the Sternocleidomastoid muscle to join the superior deep cervical glands

58. 4 .The anterior cervical group: form an irregular and inconstant group on the front of the larynx and trachea. They may be divided into ( a ) a superficial set: placed on the anterior jugular vein . ( b ) a deeper set which is further subdivided into prelaryngeal, on the middle cricothyroid ligament, and pretracheal, on the front of the trachea. This deeper set drains the lower part of the larynx, the thyroid gland, and the upper part of the trachea . I ts efferents pass to the lowest of the superior deep cervical glands. They are palpated on and beneath the sternocleidomastoid muscle on either side of the neck, from the angle of the jaw to the top of the clavicle.

59. 5 .The deep cervical glands: They form a chain along the carotid sheath, lying by the side of the pharynx, esophagus, and trachea, and extending from the base of the skull to the root of the neck. They are usually described in two groups: ( 1) The superior deep cervical glands lying under the Sternocleidomastoid muscle in close relation with the accessory nerve and the internal jugular vein . ( 2) The inferior deep cervical glands extending beyond the posterior margin of the Sternocleidomastoid muscle into the supraclavicular triangle, where they are closely related to the brachial plexus and subclavian vein .

60. All lymph nodes drain directly or indirectly to the deep cervical group of nodes -Some of deep cervical nodes form a circular collar at the junction of the head and neck - Is collected by the jugular lymph trunk a-on the left side usually joins the thoracic duct b-on the right side either joins the right lymphatic duct or empties independently at the junction of the IJV and subclavian vein

61. 6.Posterior cervical Group of lymph nodes: They extend in a line posterior to the sternocleidomastoid muscle but in front of the trapezius, from the level of the mastoid bone to the clavicle.

62. Lymphatic vessels of the scalp are divisible into 3 parts: ( a ) those of the frontal region, which terminate in the anterior auricular and parotid glands ; ( b ) those of the temporo-parietal region, which end in the parotid and posterior auricular glands; and ( c ) those of the occipital region, which terminate partly in the occipital nodes and partly in a trunk which runs down along the posterior border of the Sternocleidomastoid muscle to end in the inferior deep cervical glands.

63. lymphatic vessels of the auricle and external acoustic meatus are also divisible into three groups: ( a ) an anterior, from the lateral surface of the auricle and anterior wall of the meatus to the anterior auricular glands. ( b ) a posterior, from the margin of the auricle, the upper part of its cranial surface, the internal surface and posterior wall of the meatus to the posterior auricle and superior deep cervical glands; ( c ) an inferior, from the floor of the meatus and from the lobule of the auricle to the superficial and superior deep cervical glands

64. Lymphatics of face: lymphatic vessels of the face are more numerous than those of the scalp. Those from eyelids and conjunctiva terminate partly in the submandibular but mainly in parotid glands . The vessels from posterior part of the cheek also pass to the parotid glands, while those from anterior portion of the cheek, side of the nose, upper lip, and lateral portions of lower lip end in the submandibular glands. The deeper vessels from the temporal and infra-temporal fossa pass to deep facial and superior deep cervical glands. Both superficial and deep vessels of the central part of the lower lip run to submental glands.

65. Lymphatic Vessels of the Nasal Cavities : Those from the anterior parts of the nasal cavities communicate with the vessels of the integument of the nose and end in the submandibular glands. T hose from the posterior two-thirds of the nasal cavities and from the accessory air sinuses passes partly to the retropharyngeal and partly to the superior deep cervical glands.

66. Lymphatic vessels of mouth: The vessels of the gingiva pass to the submandibular glands; those of the hard palate are continuous in front with those of the upper gingiva but passes backward to pierce the Constrictor pharyngis superior and end in the superior deep cervical and subparotid glands; T hose of the soft palate passes backward and laterally and end partly in the retropharyngeal and subparotid, and partly in the superior deep cervical glands. The vessels of the anterior part of the floor of the mouth pass either directly to the inferior glands of the superior deep cervical group, or indirectly through the submental glands. F rom the rest of the floor of the mouth the vessels pass to the submandibular and superior deep cervical glands.

67. Waldeyer’s lymphatic ring: It is basically lymphoid tissue that surrounds the opening into the respiratory and digestive system forming a ring. The lateral part of the ring is formed by the palatine tonsils and tubal tonsils{ lymphoid tissue around the opening of the auditory tube in the lateral wall of the pharynx}. The pharyngeal tonsil in the roof the nasopharynx forms the upper part, and the lingual tonsil on the posterior one third of the tongue forms the lower part.

68. lymphatics of tongue: They drained chiefly into the deep cervical glands lying between the posterior belly of the Digastric and the superior belly of the Omohyoid. ( 1)apical, from the tip of the tongue to the suprahyoid glands and principal gland of the tongue. (2) lateral, from the margin of the tongue—some of these pierce the Mylohyoid to end in the submandibular glands, others pass down on the Hyoglossus to the superior deep cervical glands. (3) basal, from the region of the circum vallate papillae to the superior deep cervical gland (4) median, a few of which perforate the Mylohyoid to reach the submandibular glands .

69. Jugulo-digastric node: Is a large and constant member of the superior group of the deep cervical nodes. Lies at the point where the posterior belly of the digastric muscle crosses the IJV. Drains the posterior third of the tongue and the palatine tonsil. Jugulo-omohyoid nodes Is a large and constant member of the inferior group of the deep cervical nodes. Lies above the intermediate tendon of the omohyoid muscle, as it crosses the IJV. Drains the anterior 2/3 of the tongue , larynx and thyroid

70. The lymphatic vessels of thyroid gland consist of two sets, an upper part, which accompanies the superior thyroid artery and enters the superior deep cervical glands, and a lower part, which runs partly to the pretracheal glands and partly to the small paratracheal glands which accompany the recurrent nerves. These latter glands receive also the lymphatic vessels from the cervical portion of the trachea.

71. The lymphatic vessels of the skin and muscles of the neck From the upper part of the pharynx the lymphatic vessels pass to the retropharyngeal, from the lower part to the deep cervical glands .. The vessels of the upper set pierces the hyothyroid membrane and join the superior deep cervical glands . Of the lower set, some pierce the conus elasticus and join the pretracheal and prelaryngeal glands. O thers run between the cricoid and first tracheal ring and enter the inferior deep cervical glands.

72. Clinical / Applied anatomy Block dissection of neck is sometimes envisaged for removal of all cervical lymph nodes to arrest metastasis from carcinoma in region of mouth and lips. When the radical block dissection is combined with resection of area of lesion(oral cavity or mandible) it is called commendo operation. The presence of rich network of lymphatics and of loose areolar tissue is responsible for enormous swelling of tongue in acute glossitis Carcinoma of tongue is quite common. Affected side of tongue is removed surgically . All the deep cervical lymph nodes are removed surgically ; block dissection of neck is done because recurrence of malignancy occurs in lymph nodes Carcinoma of posterior one third of tongue is more common due to bilateral lymphatic spread. Deep cervical lymph nodes lie along internal jugular vein.These become adherent in malignancy to the vein . so,during operation along with lymph nodes ,vein is also removed.

73. Carcinoma of tongue is quite common. Affected side of tongue is removed surgically. All the deep cervical lymph nodes are removed surgically; block dissection of neck is done because recurrence of malignancy occurs in lymph nodes Carcinoma of posterior one third of tongue is more common due to bilateral lymphatic spread. Deep cervical lymph nodes lie along internal jugular vein. these become adherent in malignancy to the vein. so,during operation along with lymph nodes ,vein is also removed.

74. neck infections in front of prevertebral fascia in retropharyngeal space usually arise from suppuration i.e formation of pus in retropharyngeal lymph nodes .. parotid abscess may be formed by suppuration of parotid lymph nodes draining in infected area. The most common swelling in the posterior triangle is due to enlargement of the supraclavicular lymph nodes . ( V irchows lymph node) While doing biopsy one must be careful in preserving the accessory nerve which may get entangled amongst enlarged lymph nodes. Submandibular lymph nodes lie both within and outside the submandibular salivary glands. The gland is to be removed if lymph nodes are affected in any diseases especially carcinoma of tongue.

75. Chronic infection of the palatine tonsil causes enlargement of jugulo-digastric lymph nodes which adhere to the internal jugular vein. The left supraclavicular nodes are called the Virchow's lymph nodes. Cancer from stomach and testis may metastasize into these lymph nodes, which may become palpable.

76. Troiser’s sign

77. Hypertrophy or enlargement of the pharyngeal tonsil or adenoids may obstruct the posterior nasal aperture and may interfere with nasal respiration and speech leading to mouth breathing. These tonsils usually regress by puberty. Hypertrophy of the tubal tonsil may occlude the auditory or pharyngotympanic tube leading to middle ear problems.

78. REFERNCES: B.D CHAURASIA CUNNINGHAMS REED AND SHEPERD NETTERS CLINICAL ANATOMY INDERBIR SINGH GRAY’S ANATOMY Anatomy for plastic Surgery of the face , head and neck