LYMPHATIC

DRAINAGE
OF HEAD &
NECK
DR. SWATI SAHU
1 ORAL & MAXILLOFACIAL
SURGERY
 2

INDEX
1 Introduction

2 Functions and development

3 Lymphatic drainage and lymph nodes of head and neck

4 Examination of lymph nodes

5 Investigation
s

6 Clinical implications
 3

LYMPHATIC SYSTEM
🞇 Lymphatic system is the
part of the immune system
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 5th wk of

embryonic life

🞇 Lymphatic vessels develop from lymph

sacs which arise from developing

veins and are derived from mesoderm

🞇 1st 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)

• 2 iliac sac (right and left)

• Retroperitonial sac (Unpaired)

• Cisterna chyli (unpaired)

 6

JUGULAR LYMPH SACS

 Retains one connection with its Jugular vein
 Spreads lymphatic capillary plexuses to Thorax ,

upper limbs , head &neck.

 Left one develops into superior portion of
thoracic duct.

RETROPERITONEAL LYMPH SAC

 It is unpaired and develops from

primitive vena cava & mesonephric veins.

 Spreads capillary plexuses & lymphatic
vessels to

abdominal viscera & diaphragm.

 Develops connections with cisterna chyli
& loses connections with neighboring
veins
 7

CISTERNA CHYLI
 Develops inferior to diaphragm on
posterior abdominal wall.
 Gives rise to inferior portion of thoracic
duct.

POSTERIOR LYMPH SACS

 Develops from iliac veins.
 Gives capillary plexuses & lymphatic
vessels to abdominal wall , pelvic region &
lower limbs.
 Join cisterna chyli & loose connections with
adjacent veins
 8

 Lymph vessels grow out from the lymph sacs, along

the major veins.

 Except for the upper portion of the cisterna chyli,

which persists, the lymph sacs are transformed into

groups of lymph nodes during early fetal life, at

about 3 months.
 9

 PALATINE TONSILS – second pair of pharyngeal pouches

 TUBAL (PHARYNGOTYMPANIC) TONSILS - aggregations of

lymph nodules around the openings of the auditory tubes

 PHARYNGEAL TONSILS (adenoids) - aggregation of lymph

nodules in the nasopharyngeal wall

 LINGUAL TONSILS - aggregations of lymph nodules in the

root of the tongue

 10

FUNCTIONS OF LYMPHATIC
SYSTEM
The lymphatic system has three
functions:
 11

FLUID RECOVERY
Each day, we lose an excess of 2 to 4 L of

water and one-quarter to 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 lacteals absorb dietary lipids that are

not absorbed by the blood capillaries.

 14

COMPONENTS OF LYMPHATIC SYSTEM

 15

LYMP
HTransudative fluid.
🞇

🞇 Transparent & slightly yellowish liquid.

🞇 Alkaline in nature.

🞇 Derived from tissue fluid.

🞇 When blood passes through tissues

9/10 of fluid - venous end

1/10 of fluid - lymph capillaries
 16

COMPOSITION OF LYMPH
LYMPH
WATER OTHERS (4%)
(96%)
SOLIDS CELLULAR

PROTEINS LYMPHOCYTE (T,B)

LIPIDS MONOCYTE,MACROPHAGES
,

CARBOHYDRATES PLASMA CELL

AMINOACIDS

NON-NITROGENOUS SUSTANCES

ELETCROLYTE(Na, K)
Tubular vessels transport back lymph to the blood ultimately replacing the volume lost
from the blood during the formation of the interstitial fluid.

Lymphatic Lymphatic
trunks ducts
Lymphatic
capillaries
and vessels

Richard L.Drake,GRAY’S Anatomy for

students;2005,13th edition,333-335.
 Lymphatic capillaries are found around the cells of the body (as are blood capillaries).
 Blind ended.
 Slightly larger in diameter and more permeable than blood capillaries. Have unique one-way flow.
 Permeable to components of interstitial fluid.

A.C.Guyton & J.E. Hall; T.B of Medical Physiology;11th

edition;2006;192-194.
FORMATION OF LYMPH

Starling’s hypothesis
FUNCTIONS OF LYMPH

It absorbs and transports

Removal of interstitial
nutrients,fattyacids and
fluid from tissues.
fats as chyle from the GIT.
Return of protein, water
& electrolyte .

Transports immune cells to &

from lymph nodes into the
bones,Transports APC to lymph
nodes where immunological
response is stimulated.
 LYMPHATIC
VESSELS
🞇 Resemble veins in structure

🞇 Have thinner walls

🞇 Elastic tissue not muscular

🞇 Contain lots of valves to prevent backflow

🞇 In skin- lie in subcutaneous tissue and

follows same route as veins.

🞇 In viscera-follow arteries and form plexuses

around them.

A.C.Guyton & J.E. Hall; T.B of Medical

Physiology;11th edition;2006;192-194.
 LYMPHATIC TRUNKS
🞇 Formed by the union of collecting
vessels and drains large areas of the
body

🞇 Named after the areas they

drain:
1. lumbar trunks
2. bronchomediastinal trunks
3. subclavian lymphatic trunk
4. jugular trunks (all exist as
pairs)
5. a single intestinal trunk.

🞇 All eventually drain into two main

lymphatic ducts
RATE OF LYMPH FLOW
 Total estimated lymph flow is 120 ml / hr
 About 100 ml flows through Thoracic duct in resting man per
hour
 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:

Thus, there is a continual recycling of fluid from blood

to
tissue fluid to lymph and back to the blood.
 All lymph trunks
eventually drain into

Right Thoracic duct

lymphatic ( left
duct lymphatic
duct)
LYMPHATIC PATHWAYS
LYMPHATIC CAPILLARIES

🞇 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
🞇 They are lined by a single layer
of endothelial cells.

🞇 These are attached to C.T by

anchoring filaments.

🞇 The edge of one endothelial cell

overlaps the adjacent cell.

🞇 Overlapping edge is free to flap inward

minute valve.

🞇 Permits passage of high molecular

weight
substance.
LYMPHATIC
VESSELS
🞇Lymph capillaries merge to form lymphatic vessels.

🞇 Resemble veins but

🞇 Thin walls (Diameter - 0.2 – 0.3 mm)

🞇 More valves (formed from folds of tunica

intima)

🞇 Lymph Nodes are 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)
STRUCTURE OF LYMPH NODE
 31

LYMPHOID CELLS
🞇 Lymphocytes - main cells involved in immune
response
T cells & B cells protect body against antigens
T cells - manage immune response by
attacking
& destroying foreign cells
B cells - produce plasma cells (daughter cells)
, which secrete antibodies into blood.

🞇 Antibodies immobilize antigens until

they can be destroyed by phogocytes or by
other means.
 32

OTHER LYMPHOID CELLS

🞇 Macrophages – phagocytize foreign substances

& help activate T cells

🞇 Dendritic cells – spiny-looking cells with

functions similar to macrophages

🞇 Reticular cells – fibroblast like cells that produce

a stroma, or network, that supports other cell types

in lymphoid organs.
 33

LYMPHOID ORGANS
PRIMARY LYMPHATIC ORGANS :-

🞇 Lymphatic (lymphoid) organs contain large numbers of lymphocytes, a type of white blood cell that
plays a pivotal role in immunity.

🞇 The primary lymphatic organs are Red bone marrow and

Thymus gland

🞇 Lymphocytes originate and/or mature in these organs.

 BONE MARROW
🞇 Bone marrow contains two types of cells multipotent stem cells

🞇 NON – LYMPHOID STEM CELLS differentiate in bone marrow.

Eg. Erythrocytes , granulocytes , monocytes & platelets.

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

Eg. B & T lymphocytes.

37
 38

THE SECONDARY LYMPHATIC ORGANS

🞇 the spleen,

🞇 the lymph nodes and

🞇 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.
LYMPH NODES OF HEAD AND NECK
 40

🞇A l l 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.

🞇 Ly m p h is returned to the systemic venous circulation via either the right lymphatic

duct or the thoracic duct.

 41

CLASSIFICATION OF LYMPH NODES IN

HEAD AND NECK REGION

SUPERFICIAL DEEP LYMPH

LYMPH NODES NODES
 42

SUPERFICIAL LYMPH
NODES
 The superficial cervical lymph nodes lie above t h e

investing layer of the deep fascia.

 They consist of a few small nodes t h a t lie superfi cial to

t h e external jugular and anterior jugular veins.

 Superficial lymph nodes are -

 Submental
 Submandibular
 Buccal
 Parotid
 Postauricular
 Occipital
 Anterior cervical
 Superficial cervical
 43

SUBMENTAL LYMPH NODES

🞇 Lie on mylohyoid muscle in the submental triangle

🞇 3 to 4 in number

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

🞇 Efferents -they go to submandibular and jugulo-omohyoid

nodes.
 44

SUBMANDIBULAR LYMPH NODES

🞇 Lie in diagastric triangle superficial to submandibular gland

🞇 They are 3 in number

🞇 Afferents : Centre of forehead, medial angle of the eye, cheek and angle of mouth, upper lip, lateral part of
lower lip, frontal,maxillary and ethmoidal sinuses, nasal vestibule and anterior part of nasal cavity, gingiva,
soft palate, anterior part of tongue, sublingual salivary glands and submental lymph nodes.

🞇 Efferents: Mainly in jugulo-omohyoid and partly in jugulo-diagastric.

 45

PAROTID LYMPH NODES (PREAURICULAR)

🞇 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 fossa,nasopharynx, posterior part of
nose.

🞇 Efferents- Go into the upper deep cervical group.

 46

POSTAURICULAR LYMPH NODES

🞇 Lie superficial to sternocleidomastoid 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
 47

OCCIPITAL LYMPH NODES

🞇 They lie at 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 into supraclavicular nodes

 48

BUCCAL LYMPH NODES

🞇 On the surface of buccinator muscle in relation to

facial vein

🞇 Afferent – lower eye lid, part of cheek , buccinator

muscle, facial vein

🞇 Efferent - Submandibular lymph node

 49

ANTERIOR CERVICAL LYMPH NODES

ANTERIOR JUGULAR CHAIN JUXTAVISCERAL CHAIN

It lies along anterior jugular vein 🞇Prelaryngeal node

and drains the skin of anterior neck. (Delphian node)-situated infront of conus
elasticus

🞇Pretracheal node

infront of trachea,above the thyroid

isthmus.

🞇Paratracheal Node

on each side of trachea along recurrent

laryngeal nerve (glands of recurrent chain).
 50

SUPERFICIAL CERVICAL LYMPH NODES

It lies superficial to SCM along external jugular vein

🞇 Afferents- lobule of auricle

Floor of external acoustic meatus

Angle of jaw

Lower part of parotid gland

posterior triangle of neck

🞇 Efferents drains into upper and

lower deep cervical group of lymph
nodes.
 51

DEEP CERVICAL LYMPH NODES

It consists of three
chains,

 Internal jugular

 Spinal accessory

 Transverse cervical
 52

INTERNAL JUGULAR CHAIN

🞇 Lymph nodes of internal jugular chain lie anterior,

lateral and posterior to internal jugular vein.
🞇 SUPERIOR DEEP CERVICAL (jugulodigastric
node,waldeyer’s ring,adenoids) – drains oral
cavity, oropharynx, hypopharynx, nasopharynx,
larynx and parotid.
🞇 MIDDLE GROUP drains oral cavity,
oropharyx,hypopharynx, larynx and thyroid.
🞇 INFERIOR DEEP CERVICAL NODES (jugulo-
omohyoid) group- drains larynx, thyroid and
cervical oesophagus.
 53

JUGULO-DIGASTRIC GROUP OF LYMPH NODES

🞇 Situated below the posterior belly of diagastric

🞇 In triangular area bounded by posterior belly

of diagastric, 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
 54

WALDEYER’S LYMPHATIC RING

🞇 WALDEYER’S TONSILLAR RING(or pharyngeal
lymphoid ring) is an anatomical term describing
the Lymphoid tissue ring located in the pharynx and to
the back of the oral cavity.

🞇 It was named after the nineteenth

century german anatomist heinrich wilhelm gottfried von
waldeyer-hartz.

🞇 The ring consists of (from superior to inferior)

 Pharyngeal tonsil (also known as 'adenoids'
when
infected)
 Tubal tonsil (where Eustachian tube opens in
the nasopharynx)
 Palatine tonsils (commonly called "the tonsils" in the
vernacular, less commonly termed "faucial tonsils")
 55

🞇 At the entrance to the pharynx there is a considerable

amount of lymphoid tissue.

🞇 Grouped in the circular fashion.

🞇 Formed superiorly by the pharyngeal tonsil, inferiorly by

the lingual tonsil and laterally by the palatine tonsil and
the tubal tonsil. This is known as internal ring of
waldeyer .

🞇 It drain into pericervical chain and upper deep cervical

nodes which together constitute the external ring of
waldeyer.
 56

ADENOIDS

🞇 Inframastoid nodes lying below the tip of mastoid

process under cover of SCM

🞇 Receive lymph from pharyngeal tonsils(adenoids)

 57

JUGULO-OMOHYOID LYMPH NODES

🞇 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

 58

SPINAL ACCESSORY CHAIN

🞇 Lies along the spinal accessory nerve.

🞇 Afferents- Spinal accessory chain drains the scalp,

skin of the neck, the nasopharynx, occipital and
postauricular nodes.

🞇 Efferents- From this chain, drain into transverse

cervical chain
 59

TRANSVERSE CERVICAL CHAIN

🞇 It lies horizontally, along the transverse cervical

vessels, in the lower part of the posterior triangle.

🞇 The medial nodes of the group are called

scalene nodes.

🞇 Afferents to those nodes come from the accessory

chain and also infraclavicular structures, e.g. breast,
lung, stomach, colon, ovary and testis.

🞇 Efferents Jugular trunk or directly into thoracic duct

or right lymphatic duct or independently into
junction of internal jugular vein and subclavian vein
 60

REGIONAL LYMPH NODES

A. Retropharangeal

B. Infrahyoid

C. Prelaryngeal

D. Pretracheal

E. Paratracheal
RETROPHARYNGEAL LYMPH NODES
🞇 Located between pharynx & atlas.

🞇 Afferents
Pharynx ,
Auditory tube ,
Soft palate ,
posterior part of hard
palate, Nose.
PARATRACHEAL LYMPH NODES

 Afferents – Neighbouring
structures, thyroid gland

 Efferents – Deep cervical

lymph nodes

Paratracheal
node
INFRAHYOID, PRELARYNGEAL & PRETRACHEAL LYMPH NODES

• Afferent – Anterior cervical

Infrahyoid nodes
node
Prelaryngeal node
• Efferent – Deep cervical lymph
Pretracheal node
nodes
 64

DRAINAGE OF SKIN OF THE HEAD AND NECK

🞇 The scalp drains into the occipital, mastoid and parotid nodes.

🞇 Lower eye lid and anterior cheek drains into buccal nodes.

🞇 The cheeks drain into the parotid, buccal and submandibular nodes.

🞇 The upper lips and sides of the lower lips drain into the submandibular
nodes.
🞇 While the middle third of the lower lip drains into the submental nodes.

🞇 The skin of the neck drains into the cervical nodes.

 65

DRAINAGE OF ORAL STRUCTURES

🞇 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 into submandibular and upper deep cervical.
 66

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.
 67

DRAINAGE OF NASAL CAVITY

🞇 Lymph vessels from the anterior region of the nasal cavity pass superficially to join those draining the
external nasal skin, and end in the submandibular nodes.

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

🞇 The posterior nasal floor drains to the parotid

nodes.
 68

DRAINAGE OF TONGUE

🞇 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 circumvallate papillae drains into the dorsal
lymph vessels.

🞇 The more central regions drain bilaterally into sub-

mental and sub-mandibular nodes.
 69

LYMPHATIC DRAINAGE OF TEETH

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

🞇 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.
EXAMINATION OF
LYMPH NODES
 71

HISTOR
Y
🞇 Age

🞇 Duration

🞇 Group first affected

🞇 Pain

🞇 Fever

🞇 Primary focus

🞇 Loss of appetite &

wt.Loss

🞇 Pressure effects

🞇 Past history

🞇 Family history
 72

🞇 AGE :

 Tuberculosis and syphilis , primary malignant lymphomas affect young age.

 Acute lymphadenitis can occur at 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 etc where as inguinal lymphnode affects first in filariasis.

 73

🞇 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 done 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

 74

🞇 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 nodes 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

INSPECTION
Presence of a swelling,
number, position, size,
surface

Skin over
the swelling

Pressure
effects
 76

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.
 77

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.

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

dilated subcutaneous veins.
 78

PRESSURE EFFECTS
🞇 Careful inspection must be made of whole body to detect any pressure effect due to

enlargement of lymphnodes.

🞇 Oedema & swelling of upper limb- enlargement of axillary lymph nodes.

🞇 Oedema & 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.

🞇 Hypoglossal nerve may be involved from enlarged upper group of cervical lymph nodes

due to Hodgkin’s disease or secondary carcinoma.

 PALPATION

Number and situation

Fixity

consistency Palpation Local temperature

Surface and
Tendernes
margins
s
 80

🞇 NUMBER

🞇 LOCAL RISE IN TEMPERATURE

🞇 TENDERNESS

🞇 CONSISTENCY – Enlarged lymph nodes should be carefully palpated with palmar aspects of 3 fingers.While

rolling the fingers against the swelling slight pressure is maintained to know the actual consistency.

Enlarged lymph nodes may be;

 Soft (fluctuating)

 Elastic & rubbery (hodgkin’s disease)

 Firm, discrete and shotty (syphilis)

 Stony hard (secondary carcinoma)

 81

MATTIN
G
🞇 A group of lymph nodes that feels connected and move as a unit is

known as matted.

🞇 Eg. Acute lymphadenitis, Metastatic Carcinoma, Tuberculosis

 82

FIXITY TO SURROUNDING STRUCTURES

🞇 The enlarged lymphnode should be carefully palpated to know if they are fixed to;
 Skin
 The deep fascia
 The muscles
 The vessels
 The nerves

Eg: Any primary malignant growth of lymph nodes like lymphosarcoma ,

reticulosarcoma , histosarcoma or secondary carcinoma fixed to surrouding structures-
first to deep fascia & underlying muscle followed by adjoining structures and ultimately
overlying skin.
SUBMENTAL 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

slightly forward so that the muscles and fascia in

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.
 84

SUBMANDIBULAR NODES
 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
 85

PAROTID LYMPH NODES

🞇 They are palpated anterior to the tragus

of the ear.
 86

POSTAURICULAR LYMPH NODES

Are palpated behind the ear, on

the mastoid process
 87

OCCIPITAL LYMPH NODES

Palpated at the base\lower border of

skull
 88

ANTERIOR CERVICAL 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.
 89

POSTERIOR CERVICAL LYMPH NODES

🞇 Extend in a line posterior to the

SCMs but in front of the
trapezius, from the level of the
mastoid bone to the clavicle.
 TRANSVERSE CERVICAL NODES

SUPRACLAVICULAR (SCALENE NODES)

🞇 Roll your fingers gently behind the clavicles.

Instruct the patient to cough .

🞇 Occasionally an enlarged lymph node may

pop up
INVESTIGATIONS
 92

The laboratory investigation of patients with lymphadenopathy must be

tailored to elucidate the etiology suspected from the patient's history and
physical findings
 93

COMPLETE BLOOD COUNT, CBC

Provide useful data for the diagnosis of
🞇 acute or chronic leukemias,
🞇 EBV or CMV mononucleosis,
🞇 lymphoma with a leukemic component,
🞇 pyogenic infections, or
🞇 immune cytopenias in illnesses such as SLE.
 94

SEROLOGICAL STUDIES
may demonstrate
🞇 antibodies specific to components of EBV, CMV, HIV, and other
viruses;
🞇 Toxoplasma gondii;
🞇 Brucella;
🞇 antinuclear and anti-DNA antibody in case of SLE.
 95

CHEST X-RAY
🞇 Usually negative

🞇 The presence of a pulmonary infiltrate or mediastinal

lymphadenopathy would suggest tuberculosis, histoplasmosis,
sarcoidosis, lymphoma, primary lung cancer, or metastatic cancer
 96

LYMPH NODE BIOPSY

🞇 The indications for biopsy are imprecise, yet it is a valuable diagnostic tool.

🞇 The decision to biopsy may be made early in a patient's evaluation or delayed for up to two

weeks.

🞇 Prompt biopsy should occur if the patient's history and physical findings suggest a

malignancy.
 97

FINE NEEDLE ASPIRATION CYTOLOGY

(FNAC)

🞇 It 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.
 98

ULTRASONOGRAPHY
🞇 Normal cervical nodes appear sonographically as somewhat

flattened hypoechoic structures with varying amounts of hilar

fat.

🞇 US appearance of normal lymph node. Image shows flattened

hypoechoic cigar-shaped structure (arrow).

🞇 Used to determine the long (L) axis, short (S) axis, and a ratio

of long to short axis in cervical nodes.

🞇 An L/S ratio of <2.0 has a sensitivity and a specificity of

95% for distinguishing benign and malignant nodes in

patients with head and neck cancer.

 99

🞇 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
 100

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.
 101

🞇 The most effective size criteria for indicating metastatic involvement are now defined as minimum

axial diameters in excess of 11 mm in the jugulodigastric region and in excess of 10 mm elsewhere.

🞇 Using these sizes a sensitivity of 42% and specificity of 99% per node were produced.

🞇 With the use of spiral CT, it is 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.

 102

MAGNETIC RESONANCE IMAGING (MRI)

🞇 Standard protocols for MRI of the cervical lymph nodes include a selection of T1- and fast

spin echo T2- weighted axial, coronal and sagittal images.

🞇 STIR sequences allow a combination of T1- and T2-weighting with fat suppression, and

malignant nodes are clearly demonstrated as high signal.

🞇 T1-weighted images depict lymph nodes as being of intermediate signal intensity, similar

to muscle, whilst T2-weighted images show them as hyperintense signal.

 103

(a) T1 weighted and (b) T2 weighted sagittal MRI scans demonstrate a

large
pathological deep cervical lymph node (level two/ three) which is of
intermediate signal on T1 and high signal on T2
 104

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.

🞇 PET scanning provides functional rather than anatomical imaging.

 105

(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 disease with metastatic nodal spread.
 106

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

 SENTINEL NODES
• The sentinal 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

108
 ONCOLOGIC CLASSIFICATION

• 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 further Level VII to denote lymph node groups in the superior
mediastinum is no longer used.

• Instead, lymph nodes in other non-neck regions are referred to by the name
of
their specific nodal groups.
Subgroups
Ia Submental
Submandibular
Ib
Upper jugular
II (Anterior to XI)
a Upper jugular
II (Posterior to XI)
b
Middle jugular
II
I Lower jugular (Clavicular)
Lower jugular (Sternal)
IVa
Posterior triangle (XI) Posterior
IV triangle (Transverse cervical)
VI
b
VI Central compartment
Robbins KT, Clayman G,Levine PA,et al.IVa Superior
Neck dissection mediastinal
classification nodes
update: Revisions
proposed by the American head &neck society,&
Vb American Academy of otolaryngology-head
&neck surgery.Arch Otolaryngol Head Neck Surg 2202; 128: 751-758.
 11
2

LEVEL
🞇 I
Level I includes the submandibular and submental nodes. It extends

from the inferior border of the mandible superiorly to the hyoid

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

subdivided:

🞇 Level I a: The submental group. Lies between the anterior bellies of

the digastric muscles. Bounded superiorly by the symphysis and

inferiorly by the hyoid;

🞇 Level I b: The submandibular group. Bounded by the body of the

mandible superiorly, the posterior belly of the digastric muscle

inferiorly, the stylohyoid muscle posteriorly, and the anterior belly of

the digastric anteriorly. It includes the pre- and postvascular nodes that

are related to the facial artery.

 113

🞇 Lymph nodes contained within level I are at highest risk in oral

cancers involving the skin of the chin, lower lip, tip of the tongue, and
floor of the mouth.
 11
4

LEVEL
II
Level II contains the upper jugular lymph nodes that surround the upper
third of the internal jugular vein and the spinal accessory nerve. It
includes the jugulodigastric node (also
known as the principle node of Kuttner) which is the most
common node containing metastases in oral cancer. It is also
frequently subdivided based on the course of the spinal accessory
nerve.

🞇 Level II a: Bounded superiorly by the skull base, inferiorly by the

hyoid bone radiographically and the carotid bifurcation surgically, e
anteriorly by the stylohyoid muscle and posteriorly by a vertical plan
defined by the spinal accessory nerve.
 115

🞇 LevelII 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 II 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.
 11
6

LEVEL
III
🞇 Level III encompasses node-bearing tissue surrounding the
middle third of the internal jugular vein. It is bounded
superiorly by the inferior border of level II (hyoid
radiographically and carotid bifurcation surgically), inferiorly
by the omohyoid muscle surgically and the cricoid cartilage
radiographically, anteriorly by the sternohyoid muscle and
posteriorly by the lateral border of the sternocleidomastoid
muscle.

🞇 Level III contains the dominant omohyoid node and receives

lymphatic drainage from level II and level V. In addition, it can
receive efferent lymphatics from the retropharyngeal,
pretracheal, tongue base, and tonsils.
 11
7

LEVEL
IV
🞇 Level IV contains the nodal tissue surrounding the inferior third of
the internal jugular vein. It extends from the inferior border of level
III to the clavicle. Anteriorly, it is bounded by the lateral border of the
sternohyoid muscle; and posteriorly, by the lateral border of the
sternocleidomastoid muscle.

🞇 It contains a variable number of nodes that receive efferent flow

primarily from levels III and IV. The retropharyngeal, pretracheal,
hypopharyngeal, laryngeal and thyroid lymphatics also make a
contribution.

🞇 Only rarely is level IV involved with metastatic cancer from the oral
cavity without involvement of one of the higher levels.
 11
8

LEVEL
V
Level V makes up the posterior triangle.
🞇

🞇 Similar to levels I and II, level V 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 posterior (lateral) border.
 119

🞇 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.
 120

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.
 121

LEVEL VII
🞇 The superior mediastinal nodes.

🞇 They lie between the carotid arteries below the level of the top of the manubrium
.
TNM STAGING
REGIONAL LYMPH NODE
TUMOR (T) STAGE (N) STAGE
TX-primary tumor cannot 🞇 NX- Regional lymph node that
be assessed can not be assessed
T0-No evidence of primary 🞇 N0 -No regional lymph node

tumour metastasis.
T1-Tumour < 2cm in greatest 🞇 N1-Metastasis in single

dimension ipsilateral lymph node 3 cm or

less in greatest dimension.
🞇 T2-Tumour not more then 2 cm
but less then 4 cm in greatest 🞇 N2-Metastasis in single

dimension ipsilateral lymph node more

then 3 cm but not more
T3-tumour more then 4 cm
then 6cm in gretest
in greatest dimension
dimension .
T4-Tumour invade the
adjacent
structure.
 Denoix PF, Schwartz D: Regeles
generales de classification des
cancers et de presentation des
resutants therapeutics. Acad Chir DISTANT METASTASIS (M) : ALL
(Paris),1959,vol 85,pg 415. SITES

🞇 N2a-Metastasis in single ipsilateral

lymph node more then 3cm but Mx-Distant metastasis can not be
assesed
not more then 6cm in greatest
Mo- No nt metastasis.
dimension.
dista M1- est asis.
🞇 N2b –Metastasis in multiple Distant m
ipsilateral lymph node more then 6
cm in greatest dimension .
🞇 N2c-Metastasis in bilateral or
contra lateral lymph node more
then 6cm in greatest
dimension
CLINICAL IMPLICATIONS
🞇 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.
Cervical lymphadenopathy may be either an important
clue to an underlying disease process or a specific clinical
syndrome
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
C. Fungal
-Histoplasmosis
-Coccidioidomycosis
D. Parasitic
-Toxoplasmosis
-Filiriasis
E. Chlamydial
-Lymphogranuloma
venerum
- Trachoma
2.Immunologic disease

A. Rheumatoid arthritis
B. Systemic lupus erythematous
C. Sjogren syndrome
D. Drug hypersensitivity
E.Mixed connective tissue disease
a.Hematological
-Hodgkin disease
-Non hodgkin disease
-Hairy cell leukamia
-T-cell lymphoma

-Multiple myeloma
B.Metastasis
-From primary
site
4. Lipid storage
disease
-Gaucher’s disease
-niemann-pick
disease

5. Endocrine disease
-Hyperthyroidism
-Adrenal
insufficiency
-Thyroiditis

6. Other disorder
-Sarcoidosis
-Lymphomatoid
granulomatosis
-Kawasaki
disease
-Histocytosis x
 SURGICAL
IMPLICATION
S
MANAGEMENT
COMPREHENSIVE NECK DISSECTION

1. Classical radical neck dissection

2. Extended radical neck dissection

3. Modified radical neck dissection

TYPE – I
TYPE – II
TYPE - III
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.
135

• Included are levels I– V.

• This entails the removal of three important,
non-lymphatic structures: the internal jugular
jugular vein, the sternocleidomastoid muscle,
muscle, and the spinal accessory nerve.
 MODIFIED RADICAL NECK DISSECTION
Refers to removal of the same lymph node
levels (I–V) as the radical neck dissection,
but with preservation of the spinal
accessory
nerve, the internal jugular vein, or the
sternocleidomastoid
Muscle.
 137

Subdividing the modified neck dissection into three types:

 Type I preserves the spinal accessory nerve;
 Type II preserves the spinal accessory nerve and the sternocleidomastoid muscle; and
 Type III preserves the spinal accessory nerve, the sternocleidomastoid muscle, and the
internal jugular vein;
MRND TYPE I
MRND Type II MRND Type III
SELECTIVE NECK DISSECTION
• Refers to the preservation of one or more lymph node groups normally removed in a
radical neck dissection.
• In the 1991 classification scheme, there were several ‘‘named’’ selective neck dissections. For
example, the supraomohyoid neck dissection removed the lymph nodes from levels I–III.
• The subsequent proposed modification in 2001 sought to eliminate these named
dissections.
• The committee proposed that selective neck dissections be named for the cancer that
the surgeon was treating and to name the node groups removed.
• For example, a selective neck dissection for most oral cavity cancers would encompass
those node groups most at risk (levels I–III) and be referred to as a SND (I–III)
141
 142

EXTENDED NECK DISSECTION

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.
REFERENCES
🞇 Richard L.Drake,GRAY’S Anatomy for students;2005,13th edition,333-335.

🞇 E. LLOYD DuBRUL, Shicher’s Oral anatomy; 8th edition; 2000, pg no.221-226.

🞇 A.C.Guyton & J.E. Hall; T.B of Medical Physiology;11th edition;2006;192-194.

🞇 Eugene N. Myers et al.; CANCER of Head & Neck,4th edition,2009,49-66.

🞇 Michael Miloro, Peterson’s Principles of OMFS, 2nd edi.,vol.1,617-630

🞇 Neelima A. Malik, TB of OMFS, 3rd edition,530.

 144

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YOU