Department of Oral and Maxillofacial Surgery

Dr H M Desai Oral Cancer Treatment Center

Faculty of Dental Science
Dharmsinh Desai University, Nadiad-387001

Lymphatic drainage of head

and neck
GUIDED BY:-
DR.HIREN PATEL
DR.HAREN PANDYA
DR.HITESH DIWAN
DR.BIJAL BHAVSAR
DR.URVI SHAH
DR HIRAK PATEL
DR.PALAK MEHTA
DR. DHAVAL PATEL
• By- Dr KHADIJA VASI
 Introduction

It is the part of the immune system

comprising of a network of vessels
called lymphatic vessels that carry a
clear fluid called lymph.
It goes in a unidirectional pathway

 Human anatomy - B.D.Chaurasia 3rd edition

 DEVELOPMENT

• Develop at 5th
week of
embryonic life
 • 6 Primary lymph sacs are
formed
1) 2 jugular lymph sacs
2) 2 iliac sacs
3) Retroperitoneal sacs
( Unpaired)
4) Cisterna chyli (Unpaired)

 Human anatomy - B.D.Chaurasia 3rd edition

Components of lymphatic system

• Lymph
• Lymph Capillaries
• Lymphatic Vessels
• Lymphatic Trunk
• Lymphatic Organs
 LYMPHOID ORGANS
ORGANS

PRIMARY (CENTRAL) BONE MARROW

LYMPHOID ORGAN THYMUS

SECONDARY ( PERIPHERAL) LYMPH NODE

LYMPHOID ORGAN SPLEEN
TONSILS
LYMPHATIC FLOW
Superficial lymph nodes

1. Occipital
2. Mastoid
3. Pre-auricular
4. Mandibular and buccal
5. Submental
6. Submandibular
7. Facial
8. Superficial cervical
LYMPH NODE LOCATION DRAINING AREA EFFERENTS
SUBMENTAL (3-4 nodes) b/w the anterior 1) Tissue below the chin To submandibular
belly of digastric 2) Central part of lower lip nodes
3) Adjoining gum
4) Anterior part of floor of
mouth
5) Tip of tongue

SUBMANDIBULAR ( 3 in number) Beneath the deep 1) Centre of forehead Mostly to jugulo-

cervical fascia on 2) Nose with frontal, omohyoid
the surface of maxillary, ethmoidal air Partly to jugulodigastric
submandibular sinus
salivary gland 3) Upper canthus of eye
4) Upper lip and anterior part
of cheek with underlying
gum and teeth
5) Outer part of lower lip with
lower gum and teeth
including incisors
6) Anterior 2/3 of tongue
including the lip and floor
of mouth
7) Efferents from submental
nodes
LYMPH NODE LOCATION DRAINING AREA EFFERENTS

Facial Buccal lies on the Part of cheek and lower eyelid Upper group of deep cervical
Buccal & Mandibular buccinator. nodes

Postauricular(Mastoid) On the mastoid process 1) Strip of scalp just above and Lower group of deep cervical
superficial to the SCM and behind auricle nodes
deep to the auricular 2) Upper half of medial surface
posterior and margin of auricle
3) The posterior wall of external
acoustic meatus
LYMPH NODE LOCATION DRAINING AREA EFFERENTS

Occipital Nodes Apex of posterior triangle 1) Occipital region of scalp Supraclavicular muscles of the
superficial to the attachment lower group pf deep cervical
of trapezius. nodes

Anterior Cervical Nodes Along the anterior jugular vein 1) Skin of anterior part of neck Deep cervical nodes on both
below the hyoid bone the sides

Superficial Cervical Nodes Along the external jugular vein 1) Lobule of the auricle Upper and lower deep cervical
superficial to SCM 2) The floor of the external nodes
acoustic meatus
3) Skin over lower parotid
region
4) Angle of jaw
LYMPH NODE LOCATION DRAINING AREA EFFERENTS

Prelaryngeal and Pretracheal Lie deep to the investing fascia 1) Drain larynx Deep cervical nodes
Lymph nodes the prelaryngeal nodes on the 2) Trachea
cricothyroid membrane and 3) Isthmus of thyroid
pretracheal infront of trachea 4) Afferent from anterior
below the isthmus of thyroid cervical nodes
gland.

Paratracheal Nodes Sides of trachea and 1) Esophagus Deep cervical nodes

esophagus along with 2) Trachea
recurrent laryngeal nerves 3) Larynx

Retropharyngeal Nodes In front of the prevertebral 1) Pharynx Upper deep cervical nodes
fascia and behind the 2) Auditory tube
buccopharyngeal fascia 3) Soft palate
covering the posterior wall of 4) Posterior part of hard
pharynx. palate
5) nose
LYMPH NODE LOCATION DRAINING AREA EFFERENTS

Jugulodigastric Below the posterior belly of 1) tonsil From jugular lymph trunk
digastric , between the angle
of mandible and anterior
border of SCM in the triangle
bounded by the posterior
belly of digastric , facial vein &
internal jugular vein.
Jugulomohyoid Above the intermediate 1) Tongue From jugular lymph trunk
tendon of omohyoid under 2) Indirectly from submental ,
cover of posterior border of submandibular upper deep
SCM cervical nodes

Supraclavicular Extend from nodes around 1) Axilla Jugular Lymph trunk

the inferior part of Internal 2) Thorax
Jugular Vein behind the SCM 3) Abdomen
muscle into the 4) Pelvis
supraclavicular region.
The deep cervical lymph nodes
lie on the internal jugular vein.
These nodes often become
adherent to the vein in
malignancy or in tuberculosis.
Cervical lymph nodes are a
common site of metastases
for malignant tumors.
 It can get enlarged in cases of
lymphoma, sarcoidosis, and
certain types of viral infection

Oral anatomy – Sicher & DuBruls

WALDEYER’S RING

The ring comprises lingual, palatine,

tubal and nasopharyngeal tonsils.
It helps protect the body against
inhaled and ingested pathogens

Oral anatomy – Sicher & DuBruls

DRAINAGE OF SKIN OF THE HEAD AND
NECK
• The scalp drains into the occipital, mastoid
and parotid nodes.
• The cheeks drain into the parotid, buccal
and submandibular nodes.
• The skin of the neck drains into the cervical
nodes.

Oral anatomy – Sicher & DuBruls

 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.

Oral anatomy – Sicher & DuBruls

 DRAINAGE OF EXTERNAL NOSE
• Lymphatic drainage of external nose is primarily to the submandibular
group of nodes although lymph from the root of the nose drains to
superficial parotid nodes.

Oral anatomy – Sicher & DuBruls

 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.

Oral anatomy – Sicher & DuBruls

 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.

Oral anatomy – Sicher & DuBruls

 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.
Oral anatomy – Sicher & DuBruls
EXAMINATION OF LYMPH
NODES
 EXAMINATION OF LYMPH NODES
History: 1) Age
2)Duration
3) Group Affected First
4)Pain
5)Fever
6) Loss of appetite and weight
7) Family history
8) Past history
Evaluation of cervical nodes

Soft, tender, and inflamed lymph nodes

suggest an acute inflammatory process,
which is most likely to be infective.
 Firm multinodular large-volume rubbery
nodes often suggest a diagnosis of
lymphoma
Enlarged lymph nodes that have an
irregular shape and a rubbery, hard
consistency may be infiltrated by
malignant cells.

Oral anatomy – Sicher & DuBruls

APPLIED ANATOMY-SUBMANDIBULAR
NODES
The submandibular lymph nodes are
clinically very important because of their
wide area of drainage
 very commonly enlarged
Needs to be taken care while surgery on
submandibular gland because of location
of mandibular branch of facial nerve this
facial artery.

Oral anatomy – Sicher & DuBruls

Marginal mandibular nerve

• Most commonly encountered injury

during the dissection of level 1b
• Landmarks :
1. 1cm anterior and inferior to the angle of
the mandible
2. Mandibular notch
3. Deep to the fascia of submandibular
gland
4. Superficial to facial vein

Oral anatomy – Sicher & DuBruls

Virchow’s node

• Virchow’s node is a supraclavicular

node, located in the left supraclavicular
fossa (located immediately superior to the
clavicle). It receives lymph drainage from
the abdominal cavity.
• The finding of an enlarged Virchow’s
node is referred to as Troisier’s sign –
and indicates of the presence of cancer in
the abdomen, specifically gastric cancer,
that has spread through the lymph vessels.

Oral anatomy – Sicher & DuBruls

INVESTIGATIONS
 INVESTIGATIONS
• CBC
• SEROLOGY
• CHEST X RAY
• LYMPH NODE BIOPSY
• FNAC
• USG
• MRI
• CT
 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.
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.
 ULTRASONOGRAPHY
• Normal cervical nodes appear sonographically
as somewhat flattened hypoechoic structures
with varying amounts of hilar fat.
• USG 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.
• A L/S ratio of 20 has a sensitivity and a
specificity of 95% for distinguishing benign and
malignant nodes in patients with head and neck
cancer.
 ULTRASONOGRAPHY
• Malignant infiltration alters the USG features of the lymph nodes,
resulting in enlarged nodes that are usually rounded and show
peripheral or mixed vascularity.
 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 35 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.
 MAGNETIC RESONANCE IMAGING
(MRI)
• Standard protocols for MRI of the cervical lymph nodes include a
selection of T- 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.
• Th1-weighted images depict lymph nodes as being of intermediate
signal intensity, similar to muscle, whilst T2-weighted images show
them as hyperintense signal.
 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.
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.
 Lymph node classification
• Level 1a- Submental lymph nodes
• Level 1b- Submandibular lymph nodes
• Level 2- Upper jugular group
• Level 3- Middle jugular group
• Level 4- Lower jugular group
• Level 5a&b- Posterior triangle group
• Level 6- Anterior compartment nodes
• Level 7- Superior mediastinum nodes
Nodal drainage
• Nodal Drainage Patterns by Head and Neck Site
• Oral Cavity: I-III
• Oropharynx: II-IV
• Nasopharynx: II-IV
• Hypopharynx: II-IV
• Larynx: II-IV
Radical neck dissection
• It entails removal of ipsilateral nodal groups extending from the
lower border of the mandible superiorly to the clavicle inferiorly
and from the lateral border of sternohyoid muscle, hyoid bone,
and contralateral anterior belly of digastric muscle medially to
the anterior border of trapezius muscle laterally. Thus, nodal
groups of level I–V are removed, while the anterior
compartment (central, level VI), suboccipital, peri-parotid
(except for the infra-parotid LNs lying in the submandibular
triangle), retropharyngeal, and buccinators LNs are not. It also
includes the removal of spinal accessory nerve (SAN), IJV, and
SCM.
 Modified radical neck dissection

• Modified radical neck

dissection (MRND) is defined
as the excision of all lymph
nodes routinely removed
in a radical neck
dissection with preservation
of one or more nonlymphatic
structures (SAN, IJV, SCM)
Selective neck dissection
• Selective neck dissection is an operative procedure designed
to remove cervical lymph nodes at risk for involvement by
metastatic disease and is characterized by the preservation of
one or more lymph node groups that are routinely removed in
radical neck dissections.
SOHND

• The supraomohyoid neck dissection is a

selective cervical node dissection that
removes the contents of the submental
and submandibular triangles (lymph
node level I), the jugulodigastric and
jugulo-omohyoid lymph node groups,
and the lymph node-bearing tissues
located anterior to the cutaneous
branches of the cervical plexus and
above the omohyoid muscle (lymph
node levels II and III).
 Gray’s anatomy 39th edition
 Human anatomy - B.D.Chaurasia
3rd edition
 Oral anatomy – Sicher & DuBruls
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