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Anatomy of the lymphatic system
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Anatomy of the lymphatic system

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• Gross anatomy: …

• Gross anatomy:
– Components of the lymphatic system: lymphatic plexuses, lymphatics, lymphoid tissue
– Plan of the lymphatic system: Superficial lymphatic vessels, deep lymphatic vessels, lymph nodes, lymph trunks, cysterna chyli, lymph ducts: right lymph duct and thoracic duct.
– Lymphatic drainage of the lower limb
• Superficial inguinal lymph nodes: arrangement and drainage area.
• Deep inguinal lymph nodes: arrangement and drainage area. The popliteal lymph nodes
– Lymphatic drainage of the upper limb
• Superficial and deep lymphatics. Supratrochlear and infraclavicular lymph nodes.
• Axillary lymph nodes: arrangement and drainage area.
– Plan of the lymphatic drainage of the head and neck: deep cervical lymph nodes, inner and outer circle of lymph nodes.
• Deep cervical lymph nodes: location of the upper and lower groups, jugulodigastric node, jugulo-omohyoid, supraclavicular lymph nodes. Drainage area and efferent vessels.
• The outer circle of lymph nodes: submental, submandibular, buccal, mandibular, parotid, mastoid, occipital: location, drainage area and efferent vessels.
• The inner circle of lymph nodes: pretracheal, paratracheal and retropharyndeal.
• The tonsils and Waldeyer’s ring.
– Lymphatic drainage of the thorax:
• Lymph nodes of the chest wall: Parasternal, intercostal, and phrenic
• Lymph nodes of the mediastinum: Nodes around the division of the trachea and the main bronchi, anterior and posterior mediastinal nodes.
– Plan of lymphatic drainage of the abdomen: lumbar and intestinal lymph trunks.
• Pre-aortic lymph nodes: mesenteric, celiac, superior and inferior mesenteric lymph nodes.
• Para-aortic lymph nodes.
• MALT & Peyer’s patches.
– Lymphatic drainage in the pelvis: External and internal iliac lymph nodes, lymph nodes in fascial sheaths, sacral and common iliac lymph nodes.
• Applied anatomy
• Functional and clinical importance of the lymphatic system; Virchow’s lymph nodes; Retropharyngeal abscess; Clinical applications of enlarged thoracic lymph nodes: involvement of left recurrent laryngeal nerve and phrenic nerve. Pressure on the esophagus. Carinal lymph nodes and bronchoscopy; Communications of lymphatics between thorax and abdomen.
• Radiographic anatomy:
– Lymphangiogrms.
• Surface anatomy of palpable lymph node groups: superficial inguinal, axillary, infraclavicular, outer circle of crevical lymph nodes, deep cervical lymph nodes.

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  • 1. Anatomy of the Lymphatic System Dr.Akram Jaffar, Ph.D.Dr. Akram Jaffar Dr. Akram Jaffar
  • 2. References and suggested reading • Moore KL et al. (2010): Clinically Orientated Anatomy. 6th Ed. Lippincott, Williams & Wilkins. Philadelphia. • Snell RS (2006): Clinical anatomy by systems. Lippincott Williams & Wilkins. Baltimore. • Young B, Lowe JS, Stevens A & Heath JW (2006): Wheater’s functional histology. 5th ed. Churchill Livingstone Elsevier. Philadelphia. pp: 263-273. • Lymphangiograhpy: http://www.answers.com/topic/lymphangiography?cat=healthDr. Akram Jaffar Dr. Akram Jaffar
  • 3. Objectives • Gross anatomy: – Components of the lymphatic system: lymphatic plexuses, lymphatics, lymphoid tissue – Plan of the lymphatic system: Superficial lymphatic vessels, deep lymphatic vessels, lymph nodes, lymph trunks, cysterna chyli, lymph ducts: right lymph duct and thoracic duct. – Lymphatic drainage of the lower limb • Superficial inguinal lymph nodes: arrangement and drainage area. • Deep inguinal lymph nodes: arrangement and drainage area. The popliteal lymph nodes – Lymphatic drainage of the upper limb • Superficial and deep lymphatics. Supratrochlear and infraclavicular lymph nodes. • Axillary lymph nodes: arrangement and drainage area. – Plan of the lymphatic drainage of the head and neck: deep cervical lymph nodes, inner and outer circle of lymph nodes. • Deep cervical lymph nodes: location of the upper and lower groups, jugulodigastric node, jugulo-omohyoid, supraclavicular lymph nodes. Drainage area and efferent vessels. • The outer circle of lymph nodes: submental, submandibular, buccal, mandibular, parotid, mastoid, occipital: location, drainage area and efferent vessels. • The inner circle of lymph nodes: pretracheal, paratracheal and retropharyndeal. • The tonsils and Waldeyer’s ring. – Lymphatic drainage of the thorax: • Lymph nodes of the chest wall: Parasternal, intercostal, and phrenic • Lymph nodes of the mediastinum: Nodes around the division of the trachea and the main bronchi, anterior and posterior mediastinal nodes. – Plan of lymphatic drainage of the abdomen: lumbar and intestinal lymph trunks. • Pre-aortic lymph nodes: mesenteric, celiac, superior and inferior mesenteric lymph nodes. • Para-aortic lymph nodes. • MALT & Peyer’s patches. – Lymphatic drainage in the pelvis: External and internal iliac lymph nodes, lymph nodes in fascial sheaths, sacral and common iliac lymph nodes. • Applied anatomy • Functional and clinical importance of the lymphatic system; Virchow’s lymph nodes; Retropharyngeal abscess; Clinical applications of enlarged thoracic lymph nodes: involvement of left recurrent laryngeal nerve and phrenic nerve. Pressure on the esophagus. Carinal lymph nodes and bronchoscopy; Communications of lymphatics between thorax and abdomen. • Radiographic anatomy:Dr. Akram Jaffar – Lymphangiogrms. • Surface anatomy of palpable lymph node groups: superficial inguinal, axillary, infraclavicular, outer circle of cervical lymph nodes, deep cervical lymph nodes. Dr. Akram Jaffar
  • 4. Components of the lymphatic system Widely distributed throughout most of the body but absent from CNS, eyeball, internal ear, cartilage and bone • Lymphatic plexuses: network of lymphatic capillaries. • Lymphatic vessels (lymphatics): thin walled vessels with abundant valves. Beaded appearance. – What are the factors influencing the lymph flow?. • Lymph nodes. • Lymphoid tissue: Sites that produce lymphocytes, such as that aggregated in the walls of the digestive tract; in the Lymphatic vessel valve spleen, thymus, and lymph nodes..Dr. Akram Jaffar Dr. Akram Jaffar
  • 5. Functional and clinical importance • Function – Assist the capillaries: • Returns some plasma proteins that leak into the extracellular spaces as well as cellular debris that cannot return through the wall of blood capillaries. – Essential for immonological defenses. • Clinical importance: – Obstruction  Lymphoedema. – Conduit for the spread of malignant disease and infection • Cells loosened from the primary tumor enter and travel via lymphatics. • The cells are filtered through and trapped by the lymph nodes. Which thus become secondary (metastatic) cancer sites. – May be the site of primary tumor.Dr. Akram Jaffar Dr. Akram Jaffar
  • 6. Plan of the lymphatic system • Superficial lymphatic vessels drain the skin and follow the venous drainage. • Superficial lymphatic vessels drain into deep lymphatic vessels that accompany the arteries and also receive the drainage of internal organs. • Both superficial and deep lymphatic vessels traverse lymph nodes as they course proximally. • The larger lymphatic vessels enter large collecting vessels called lymph trunks which unite to form either the right lymph duct or the thoracic duct. • The lymph ducts drain into the venous system. • Lymphatic vessels communicate freely with each other and with veins in many parts of the body. Consequently, ligation of a lymphatic trunk may have only a transient effect.Dr. Akram Jaffar Dr. Akram Jaffar
  • 7. Lymph ducts • Right lymph duct – Drains lymph from the body’s right upper quadrant (right side of the head, neck, right side of the thorax, and the right upper limb. – Enters the right venous angle (junction of the right internal jugular and right subclavian veins). • Thoracic duct – Drains lymph from the Internal remainder of the body. jugular v. Thoracic duct – Enters the left venous angle. Subclavian v.Dr. Akram Jaffar Dr. Akram Jaffar
  • 8. Cisterna chyli Venous angle • A dilated collecting sac. • Located in the abdomen in front of the bodies of the 1st and 2nd lumbar vertebrae. Thoracic duct • Drain lymphatic trunks of the lower part of the body. • Give rise to the thoracic duct which ascends through the aortic Cysterna chyli opening of the diaphragm into the thorax.Dr. Akram Jaffar Dr. Akram Jaffar
  • 9. Lymphatic drainage of the lower limb • Superficial inguinal lymph nodes: Inguinal lig. • Arrangement: Superficial Inguinal LN – T-shape: one row runs parallel to and (horizontal gp) below the inguinal ligament, while the Superficial other row is arranged vertically along Inguinal LN (vertical gp) the great saphenous vein. • Drainage area: – Superficial tissues (everything popliteal LN superficial to the deep fascia) – Lower limb (including the buttocks) except posterolateral part of the calf Great saphenous v (drains to popliteal lymph nodes) – Lower abdominal wall below the umbilicus. – External genitalia (excluding the testes). – Perineum, the lower part of anal canal and vagina – Cornu of the uterus by means of lymphatics that follow the roundDr. Akram Jaffar ligament. Dr. Akram Jaffar
  • 10. Lymphatic drainage of the lower limb External iliac LN • Deep inguinal lymph nodes: Three of four nodes. Lie medial to the femoral vein, one being in the Femoral a & v femoral canal. • Drainage area: Deep inguinal LN Femoral ring – Deep lymphatics that accompany the femoral vessels from the popliteal fossa – Glans penis (or clitoris). – Efferent lymphatics from the superficial inguinal nodes that pass through the cribriform Cribriform fascia fascia. • Efferent vessels from the deep inguinal lymph nodes pass through External iliac LN the femoral canal to enter the external iliac group of lymph nodes. Femoral ring Deep inguinal LNDr. Akram Jaffar Superficial Inguinal LN Dr. Akram Jaffar
  • 11. Inguinal lymphangiogram External iliac LN Deep inguinal LNDr. Akram Jaffar http://www.answers.com/topic/lymphangiography?cat=health Dr. Akram Jaffar
  • 12. Lymphatic drainage of the upper limb Infraclavicular LN • Superficial lymphatics Cephalic v. – From the thumb, index finger, and lateral part of the hand follow the cephalic vein  infraclavicular lymph nodes. – From the medial part of the hand Axillary LN follow the basilic vein  supratrochlear lymph node which lies just above the medial epicondyle of the humerus  lateral Supratrochlear LN group of axillary lymph nodes. • Deep lymphatics: follow the arteries  Basilic v. lateral group of axillary lymph nodes.Dr. Akram Jaffar Dr. Akram Jaffar
  • 13. Axillary lymph nodes apical gp • Arrangement: Central gp • Anterior or pectoral group lying deep Pectoralis to pectoralis major along the inferior Minor m. border of pectoralis minor muscle: Axillary v. drain most of the lymph of the breast. • Posterior or subscapular group, lie in front of subscapularis on the posterior wall of the axilla. • Lateral group lying along the axillary vein. • Central group lying in the axillary fat. • Apical group lying behind the clavicle at the apex of the axilla. • Drainage area – Breast. – Pectoral region. Anterior gp. – Upper part of the abdominal wall. – Upper part of the back. posterior gp. – Upper limb. lateral gp.Dr. Akram Jaffar Dr. Akram Jaffar
  • 14. Axillary lymphangiogram • Four days after the injection of lipoidol into a lymph vessel into the dorsum of the hand.Dr. Akram Jaffar Dr. Akram Jaffar
  • 15. Lymph drainage of the head & neck: General plan • Deep cervical lymph nodes: – Surround the whole length of the internal jugular vein. – Ultimately drain all the lymph from the head and neck. – Most of this lymph has already filtered through outlying nodes that are arranged in two ‘circles’. • The outer circle is made up of superficial nodes from chin to occiput. • The inner circle lies within it, surrounding the upper air and alimentary passages.Dr. Akram Jaffar Dr. Akram Jaffar
  • 16. Deep cervical nodes • The upper group • Situated in the angle between the lower border of the mandible and anterior border of Jugulo-digastric LN sternomastoid. • One is related to the posterior belly of digastric and is therefore called the jugulo-digastric node. – Often tender and enlarged in infections of the tonsil and is therefore called the tonsillar gland. Internal jugular v.Dr. Akram Jaffar Examination of upper deep cervical lymph nodes Dr. Akram Jaffar
  • 17. Deep cervical nodes • The lower group • Situated in the angle between the sternomastoid and the clavicle. • One lying deep to sternomastoid above the inferior belly of omohyoid and is called jugulo-omohyoid. – Associated with lymphatic drainage of the tongue, it is also called the lingual node. Internal jugular v. Jugulo-omohyoid LNDr. Akram Jaffar Dr. Akram Jaffar
  • 18. Deep cervical nodes • The lower group • Supraclavicular nodes: lie in the posterior triangle behind the posterior border of sternomastoid. • Efferents from the lower deep cervical group form the jugular lymph trunk, which joins the thoracic duct on the left side. Thoracic duct Examination of surpraclavicular lymph nodes supraclavicular LNDr. Akram Jaffar Dr. Akram Jaffar
  • 19. Supraclavicular lymph nodes • In tumors of the bronchus and some abdominal organs e.g. stomach, supraclavicular lymph nodes particularly on the left side may enlarge indicating spread. • Backflow of lymph from the thoracic duct can pass into the supraclavicular nodes. This is probably the reason why nodes on the left side are most commonly involved. Right lymph duct Jugular lymph trunk Subclavian lymph trunk Bronchomediastinal lymph trunk Virchow’s lymph nodeDr. Akram Jaffar Dr. Akram Jaffar
  • 20. The outer circle • Submental nodes • Lie beneath the chin. • Drain a wedge of tissue including the tip of the tongue, floor of the mouth, gum opposite the incisor teeth and the same extent of the lower lip. • Bilateral drainage. Submental LN • Drain into the submandibular group but few into the jugulo-omohyoid node. Submandibular LN Jugulo-omohyoid LNDr. Akram Jaffar Submental lymphadenopathy Dr. Akram Jaffar
  • 21. The outer circle • Submandibular nodes Jugulo-digastric LN • Lie on the surface of the submandibular salivary gland. • Drain from the submental nodes, face, anterior 2/3rd of the tongue (excluding tip), Submandibular floor of the mouth, anterior half of the nose, salivary gland frontal, maxillary and middle and anterior ethmoidal sinuses. • Drain into the jugulo-digastric node; a few drain into the jugulo-omohyoid node. Submental LN Submandibular LN Jugulo-omohyoid LN Internal jugular v. To submandibular nodes To submentalDr. Akram Jaffar nodes Dr. Akram Jaffar
  • 22. The outer circle Upper deep cervical group • Buccal node – Small node, which lies on the parotid LN buccinator muscle. • Mandibular node Buccal LN – Lie on the lower border of the mandible at the anterior border of masseter. • They drain part of the cheek and lower Mandiblar LN eyelids. To which nerve is it closely related? • Their efferents pass to the superior deep cervical nodes. • Pre-auricular (parotid) nodes • Lie on or within the parotid gland. • Dain the temple, vertex, eyelids, and orbits and the external acoustic meatus. • Efferents drain into the upper deep cervical lymph nodes.Dr. Akram Jaffar Dr. Akram Jaffar
  • 23. The outer circle Occipital LN • Retroauricular (mastoid) nodes Mastoid LN – Drain the scalp, auricle, and external auditory meatus. • Occipital nodes – Lie at the apex of the posterior triangle. – Drain the posterior part of the scalp. • Efferents drain into the lower deep cervical nodes. Lower deep cervical groupDr. Akram Jaffar Dr. Akram Jaffar
  • 24. The inner circle Retropharyngeal LN • Surround the larynx, trachea, and pharynx. • Pre-tracheal and paratracheal nodes drain the lower larynx and trachea and thyroid isthmus. Deep cervical LN • Retropharyngeal nodes drain the soft palate, posterior part of the hard palate and nose, and the pharynx. – Are involved in a retropharyngeal abscess. • Drain to the nearest group of deep cervical nodes. Pretracheal LNDr. Akram Jaffar Dr. Akram Jaffar
  • 25. Retropharyngeal abscess Retropharyngeal LN • Accumulates in the space between the prevertebral fascia and the buccopharyngeal membrane. • May compress the pharynx resulting into dysphagia and dysartheria. ? ?Dr. Akram Jaffar Retro-pharyngeal abscess Dr. Akram Jaffar
  • 26. The tonsils • Discontinuous ring (Waldeyers ring) of lymphatic tissue around the entrance of the mouth and nose into the pharynx. • Paired: – Palatine tonsil – Tubal tonsil • Unpaired – Pharyngeal tonsil – Lingual tonsilDr. Akram Jaffar Tonsillitis Dr. Akram Jaffar
  • 27. Lymphatic drainage of the thorax Thoracic duct Bronchomediastiinal trunk intercostal • Lymph nodes of the chest wall: – Parasternal – Intercostal – diaphragmatic (phrenic) parasternal • Lymph nodes of the mediastinum: – nodes around the division of the trachea and the main bronchi – posterior mediastinal nodes – anterior mediastinal nodes Anterior mediastiinal Nodes around Trachea & bronchi Posterior phrenic mediastiinalDr. Akram Jaffar Dr. Akram Jaffar
  • 28. Lymph nodes of the chest wall • Parasternal nodes parasternal – along the internal thoracic vessels at the anterior end of the intercostal spaces. – Most important afferents are from the medial half of the breast. Internal thoracic vesselsDr. Akram Jaffar Dr. Akram Jaffar
  • 29. Lymph nodes of the chest wall • Intercostal nodes – At the posterior ends of the intercostal spaces. intercostal • Diaphragmatic nodes – Around the periphery of the upper surface of the diaphragm. phrenicDr. Akram Jaffar Dr. Akram Jaffar
  • 30. Nodes around the division of the trachea and main bronchi tracheobronchial • Divided into pulmonary (in the lung itself), bronchopulmonary (along the large bronchi in the hilum) (hilar) and tracheobronchial (around the division of the trachea) nodes. • Efferents form the right and left bronchomediastinal lymph trunks. Bronchomediastiinal trunk Nodes around Trachea & bronchi bronchopulmonaryDr. Akram Jaffar pulmonary Dr. Akram Jaffar
  • 31. Nodes around the division of the trachea and main bronchi • On left side these nodes lie near the L. recurrent laryngeal n. recurrent laryngeal nerve, which may be pressed on by enlarged nodes  voice being affected. • Involvement of the phrenic nerve  Lymph nodes paralysis of the diaphragm. Phrenic n.Dr. Akram Jaffar Dr. Akram Jaffar
  • 32. Posterior mediastinal nodes • Lie posterior to the pericardium. Their afferents come from the esophagus and posterior part of the pericardium, and their efferents go to the thoracic duct. Enlargement of the posterior mediastinal nodes may indent the esophagus as seen radiologically in barium swallow. Esophagus Pericardium Posterior mediastiinalDr. Akram Jaffar Dr. Akram Jaffar
  • 33. Anterior mediastinal nodes • Lie in front of the brachiocephalic veins (brachiocephalic nodes). Their afferents come from the thymus, thyroid gland, and anterior part of the pericardium. Their efferents go to the bronchomediastinal trunk. Anterior Bronchomediastiinal mediastiinal trunkDr. Akram Jaffar Anterior mediastiinal Dr. Akram Jaffar
  • 34. Connections with the abdomen • The lower part of the anterior thoracic wall has lymphatic connections with the upper part of the anterior abdominal wall. • Cancer of the breast can spread along these connections to the abdominal cavity. • The upper surface of the diaphragm has lymphatic connections with its lower surface. These vessels provide another channel for the spread of cancer from the thorax to the abdomen.Dr. Akram Jaffar Dr. Akram Jaffar
  • 35. Thoracic duct lymphangiogramDr. Akram Jaffar Dr. Akram Jaffar
  • 36. Lymph node groups in the abdomen • Closely related to the main arteries – Pre-aortic: related to the three ventral branches of the aorta – Para-aortic: related to the lateral branchesDr. Akram Jaffar Dr. Akram Jaffar
  • 37. Coeliac nodes L.gastric LN splenic LN celiac LN • Around the stem of the coeliac trunk drain from groups related to the main arteries of the region – Left gastric, splenic, hepatic groups; in addition to the pyloric and right gastroepiploic groups related to the gastroduodenal branch of the hepatic artery pyloric LN gastroepiploic LNDr. Akram Jaffar Dr. Akram Jaffar
  • 38. Superior and inferior mesenteric lymph nodes • Drain the small and large intestines • Drain the intestines via lymph nodes close to intestinal wall and intermediate nodes in the mesentery Epicolic LN Paracolic LN Sup. mesenteric LN Inf. mesenteric LN Mesocolic LN mesenteric LNDr. Akram Jaffar Dr. Akram Jaffar
  • 39. Mucosa Associated Lymphoid Tissue • Non-encapsulated lymphoid tissue which is located in the mucosa and submucosa of the gastrointestinal, respiratory and urogenital tracts. • The mucosa-associated lymphoid tissue (MALT) takes the form of diffuse infiltrates or more discrete nodules: it provides immunologic protection against invasion by pathogens via vulnerable exposed absorptive surfaces.Dr. Akram Jaffar Dr. Akram Jaffar
  • 40. Peyer’s patches • Lymphoid nodules clusters located in the lamina propria of the ileum. • Most exhibit germinal centers, • May be large enough to produce visible bulge on the luminal surface and extend into the submucosa. • Contain B lymphocyes, T lymphocytes, macrophages, and plasma cells.Dr. Akram Jaffar Peyer’s patch Dr. Akram Jaffar
  • 41. Para-aortic nodes • Drain iliac nodes which receive from the pelvis and lower limb • Drain kidneys, suprarenals, and gonadsDr. Akram Jaffar Dr. Akram Jaffar
  • 42. Plan of the lymphatic drainage in the abdomen Thoracic duct coeliac Cisterna chyli Stomach Liver Spleen suprarenal Pancreas Para-aortic kidney Intestinal lymph trunk gonads intestines Common iliac Aorta Superior and inferior mesenteric External iliac Internal iliacDr. Akram Jaffar Lower limb Pelvis Dr. Akram Jaffar
  • 43. Lymphangiogrm Immediately after completion of injection of contrast Taken 24hrs after. Lymph nodes are completely opacified medium. Lymphatic vessels are filled Para-aortic LN Common iliac LN External iliac LNDr. Akram Jaffar Dr. Akram Jaffar
  • 44. Lymphatic drainage in the pelvis • Lymph nodes along the external, internal, and common iliac Internal vessels in addition to the sacral iliac LN vessels External • Lymph nodes between the layers of iliac LN the broad ligament and in the fascial sheath of the rectum and the urinary bladder. LN in fascial sheath Sacral LNDr. Akram Jaffar Dr. Akram Jaffar
  • 45. Lymphatic drainage in the pelvis • The external iliac lymph nodes: – Receive from the deep inguinal nodes, the deeper layer of the anterior abdominal wall below the umbilicus, urinary bladder and prostate or the uterus and upper vagina. – Efferents go to the common iliac lymph nodes. • The internal iliac lymph nodes – Receive from all pelvic viscera, deep part of the perineum, and the gluteal region. – Efferent vessels go to the common iliac lymph nodes. • The sacral nodes – Receive lymph from the rectum, bladder, prostate or cervix, and the posterior pelvic wall. – Efferents go to the internal and common iliac lymph nodes. • The common iliac lymph nodes – Receive from the external and internal iliac nodes, may receive lymph directly from pelvic viscera. – Efferent lymphatics go to para-aortic lymph nodes.Dr. Akram Jaffar Dr. Akram Jaffar