lymph nodes of head and neck

1. LYMPHATICS OF HEAD &
NECK
Dr.Karishma mishra

2. INTRODUCTION
• The lymphatic system represents an
accessory route through which fluid
flows from the interstitial spaces into
blood.

3. PHYSIOLOGYANDANATOMYOFLYMPHATICS
• The lymphatic system consists of :
1. Fluid, known as lymph
2. Vessels that transport lymph
3. Organs that contain lymphoid tissue
(eg, lymph nodes, spleen, and
thymus)

5. Mechanism of lymphatic flow:-
•Lymph flows under forces similar to those that
govern venous return
•Lymph flows at even lower pressure and speed
than venous blood; it is moved primarily by
rhythmic contractions of the lymphatic vessels
themselves, which contract when stretched by
lymph.

6. • Since lymphatic vessels are often wrapped with an artery in
a common sheath, arterial pulsation may also rhythmically
squeeze the lymphatic vessels and contribute to lymph flow.
• Finally, at the point where the collecting ducts join the
subclavian veins, the rapidly flowing bloodstream draws the
lymph into it.
• Considering these mechanisms of lymph flow, it should be
apparent that physical exercise significantly increases
the rate of lymphatic return.

7. Lymphatics ultimately deliver lymph into 2
main channels
Right lymphatic
duct
•Drains right side of
head & neck, right
arm, right thorax
•Empties into the
right subclavian
vein
Thoracic duct
•Drains the rest of
the body
•Empties into the
left subclavian
vein

10. Only 2 areas in head and neck have no direct
lymphatics:
a)orbit- is virtually devoid of lymphatics.
b) muscles- do not have lymphatics
Their lymph drains in fascial planes between
muscles and around the blood vessels that
supply them.

11. LYMPH NODES OF HEAD &
NECK
SUPERFICIAL/Terminal/
Peripheral
groups/Regional
Outer
circle
Inner
circle
DEEP/Outl
ying
groups
Deep cervical
lymph nodes

12. Outer
Circle:
• Sub-mental nodes
• Sub-mandibular nodes
• Buccal nodes
• Preauricular
• Postauriculal
• Occipital
• Anterior cervical
• Superficial cervical
Inner Circle:
1.Prelaryngeal and pretracheal 2.Paratracheal
3.Retropharyngeal

13. Submental lymph nodes
•chin & hyoid bone
•anterior bellies of
digastric muscles in
submental triangles.
Recieves lymph from
A. Tip of tongue
B. Floor beneath tongue
C. Lower incisors
D. Central part of lower
lip
E. Skin over chin

14. Submandibular lymph nodes
• Situated on
a)superficial surface of
submandibular salivary
gland.
b)Beneath investing layer of
deep cervical facia.
• They are divided into:
• Anterior group :submental vein close to
chin.
• Middle group : around facial vein&
facial artery above submandibular
salivary gland.
• Posterior group : behind facial vein.

15. Recieves lymph from:
•Front of scalp.
•Anterior part of nasal cavity,
palate & adjacent cheek.
•Upper & lower lip except
central part.
•Frontal, maxillary, ethmoidal
air sinuses.
•Upper& lower teeth except
lower incisors.
•Anterior 2/3rd of tongue.
•Floor of mouth, vestibule.

16. Buccal lymph nodes
• Situated over buccinator
muscle close to facial vein.
• Recieves lymph from
Eyelids, cheek, mid portion of
face

17. OCCIPITAL NODES
• Situated at the apex of
posterior triangle of neck
• Recieves lymph from back of
scalp
• Drains into deep cervical
lymph nodes

18. MASTOID / RETROAURICULAR
LYMPH
NODES
•Situated over lateral
surface of mastoid
process of temporal
bone
•Recieves lymph from
a) Strip of scalp
above auricle.
b) Posterior wall of
external auditory
meatus
Drains into
deep cervical lymph

19. PAROTID LYMPH NODES
• Situated on/ within parotid
gland.
• Receives lymph from:
a) Scalp above parotid
salivary gland.
B)lateral surface of
auricle.
C)anterior wall of external
auditory meatus
D) lateral wall of
external auditory
meatus.
E)lateral wall of eyelid

20. Retropharyngeal lymph nodes
•Situated in retropharyngeal space between
pharyngeal wall & prevertebral fascia .
•Receives lymph from: soft palate, nasal part of
pharynx, auditory tube, upper part of cervical
vertebral column.
•Drains into deep cervical lymph nodes.

21. Laryngeal lymph
nodes
•Situated in front of
larynx on cricothyroid
ligament.
•Recieves lymph from
larynx, trachea, isthmus
of thyroid.
•Drains into deep
cervical lymph
nodes.

22. Tracheal lymph nodes
•Situated
Pretracheal in front
of trachea.
Paratracheal lateral
to trachea.
•Recieves lymph :
Oesophagus, trachea,
larynx.
•Drains into deep
cervical lymph
nodes

23. CLINICALSIGNIFICANCE
• The most common area that drains into these nodes is
skin, and thus the most common tumors to
metastasize to them are melanoma and squamous cell
carcinoma.

24. Cervical lymph
nodes
• Distributed along the internal & external jugular
veins.
• Acc. To their relation to deep fascia of neck,
they are divided into superficial & deep
groups
• Superficial nodes restricted to upper region of
neck& found in angle between mandibular ramus
& SCM muscle.
• Receive lymph from
• Ear lobe
• Adjacent part of skin
• Secondary to preauricular & postauricular

25. • Deep cervical nodes divided into superior & inferior group
• It follows the internal jugular vein so called as JUGULAR
CHAIN

26. Jugulo digastric lymph nodes
• Situated at the level of greator horn of hyoid bone.
• Recieves lymph from tonsil and tongue.
Juglo-omohyoid nodes
• Situated related to the intermediate tendon of omohyoid muscle.
• Recieves lymph from posterior 1/3rd of tongue.
• In general deep cervical nodes receive lymph from regional lymph
nodes and drain into jugular lymph trunk

27. SUPERIOR DEEP CERVICAL NODES
INFERIOR DEEP CERVICAL/ SUPRACLAVICULAR
NODES.
THORACIC DUCT(Left
side) LYMPHATIC DUCT
(Right Side)
VENOUS ANGLE (on either side), where internal
jugular & subclavian veins unite.
Thus the lymph enters the system of superior vena
cava

28. WALDEYERRING
• 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.

30. •Waldeyer’s outer ring comprises of lymph
nodes in neck and cervical lymph nodes(
occipital, post auricular, pre auricular, parotid,
facial, lingual, submental and sub mandibular)

31. Adenoids
• Enlarge during 3-4 years(
respiratory infection _
bacterial)
• Contribute to recurrent sinusitis
and middle ear infection
• Nasal obstruction , snoring,
loss of sleep, change in voice,
adenoid faces( elongated
face,pinched nostrils, open
mouth, high arch palate,
shortened upper lip)Narrowing
of naso pharyngeal airway

32. Memorial SloanKettering group Classification –1981

33. Submentalnodes-1A
• Anterior belly of
digastric
on either side
• Base-hyoid bone
• Apex-symphysis
of mandible
• Lies on the mylohyoid

34. Submandibular-1b
• Anterior belly of
the
digastric anteriorly
• Posterior belly of
digastric posteriorly
• Body of
mandible
superiorly

35. Upper jugular group level2A/2b
• Along the upper 1/3 of the
internal jugular vein and
upper
½ of the spinal accessory N
• Skull base superiorly
• Carotid bifurcation below
/ hyoid bone
• Posterior border of
SCM laterally
• Posterior belly of
digastric medially

36. Level3 middle jugular group-jugulo
omohyoid
• Around the middle third of
the IJV
• Carotid bifurcation
superiorly
• Posterior border of Scm
laterally
• Lateral border of
sternohyoid medially

37. Level4-lower jugular
• Around the lower third of
the IJV
• Omohyoid –surgical land
mark
• Cricoid arch clinical
landmark
• Clavicle inferiorly
• Posterior border of the
SCM posteriorly
• Lateral border of
the sternohyoid
medially

38. Level5 A/5b
• Lymph nodes of the
posterior triangle
• Anterior border of
the trapezius
laterally
• Posterior border of
scm medially
• Clavicle inferiorly

39. • Sub-divided into level 5a
and 5b by the horizontal
plane marking the inferior
border of the cricoid arch
• 5a-spinal accessory nodes
• 5b-nodes accompanying
the transverse cervical
vessels

40. Level6-central compartment
• Nodes that surround the
midline
visceral structures
• Hyoid bone superiorly
• Suprasternal notch inferiorly
• CCA laterally
• This level includes
pretracheal,
paratracheal, prelaryngeal

41. EXAMINATIONOFLYMPHATICSYSTEM
LOCAL
EXAMINATION
a) Inspection:
• Swelling-
1. Number
2. Position
3. Size
4. Shape
5. Surface
• Skin over the
swelling

42. Palpation of lymphnodes

43. EXAMINATION OF LYMPH
NODES
1. Lymph nodes should be examined from patient’s behind.
2. Examination is done by asking patient to flex his neck
slightly to reduce tension of muscles
3. To palpate, use the pads of all four fingertips.
4. Examine both sides of head simultaneously while applying
steady gentle pressure.

44. Palpation
1. Rise in local temperature
2. Tenderness
3. Situation and extent
4. Size and shape
5. Surface
6. Margin
7. Consistency (Soft, elastic and rubbery, firm, hard and stony
hard)
8. Nodes separate or matted together
9. Fixity to surrounding structures(skin,
muscle,nerve,vessel,bone or any viscus)

45. ANTERIOR/POSTERIOR CERVICAL
LYMPH NODES
• They lie anterior & posterior to sternomastoid muscle.
• Tip of fingers are used to palpate anterior nodes, medial
to sternomastoid muscle and posterior nodes behind the
muscle while patient’s head tipped slightly forwards.

46. SUBMANDIBUL
AR NODES
• Palpated from
behind the patient
with patient chin
tipped slightly
towards the chest.

47. SUBMENTAL
NODES
• Roll the fingers below
the chin(in the
midline) with
patient’s head tilted
forwards

48. PAROTID
NODES/PREAURICULAR
NODES
• Roll the finger in front of
ear against the maxilla

49. POSTAURICULAR/
MASTOID NODES
• Roll the finger behind
the ear

50. Occipital
nodes
• Palpated behind the ear
at the base of skull

51. Supraclavicular lymph
nodes
• While patient’s head is tipped
forward, the index finger of
the examiner is placed in
the triangle and the area is
palpated with a rotary
motion.

52. PALPATI
ON
• Soft and
fluctuating
• Firm ,discrete
• Stony hard
• Matted
CONDITIO
NS
Hodgkins
lymphoma
Syphili
s
Secondary carcinoma
TB , Acute
lymphadenitis,
metastatic carcinoma

53. Applied anatomy

54. CYSTICHYGROMA
.
• A cystic hygroma/cystic lymphangioma, is an often congenital
multiloculated lymphatic lesion that can arise anywhere, but is
classically found in the left posterior triangle of the neck and
armpits. This is the most common form of lymphangioma .
• Cystic hygromas are benign, but can be disfiguring. It is a
condition which usually affects children

55. TONSILLITIS

56. PERITONSILLARABCESS
• Acutely infected tonsil may undergo abscess formation ,mass in
lateral pharynx, interfering with swallowing and breathing. Shows
symptoms of fever pain and trismus.
• Treatment surgical drainage of abscess with or without
tonsillectomy and iv antibiotics

57. CAUSES OF LYMPH NODE
ENLARGEMENT
Sub mandibular Nodes
• Sinusitis
• Tonsillitis
• Conjunctivitis
• Pharyngitis
Sub mental Nodes
• Periodontitis
• Mononucleosis
(Epstein-Barr Virus)
• Cytomegalovirus
• Toxoplasmosis

58. Deep cervical nodes
• Pharyngitis
• Rubella
• Tuberculosis
• Lymphoma
• Head and neck cancer
Occipital nodes
• Local infection
• Secondary Syphillis
• Neoplasm
Postauricular nodes
• Otitis Externa
• Secondary Syphilis
• Rubella

59. Pre auricular nodes
• Local infection
• Erysipelas
• Herpes Zoster
• Rubella
• Trachoma
• Viral Conjunctivitis
• Cat Scratch Disease
• Syphilis
• Tuberculosis

60. Causes of Generalised Lymphadenopathy
I- Infectious
* Viruses:
-Infectious mononucleosis
-Cytomegalo virus (C.M.V.)
* Bacteria:
- brucellosis
- T .B.
*Spirochetes:
* Protozoa
- kala azar
-toxoplasmosis.

61. 2- Leukemias: especially chronic lymphocytic leukamia (C.L.L.)
3- a- Hodgkin’s disease (H.D.)
b-Non- Hodgkin’s lymphoma (N.H.L)
4 Allergy
5 Sarcoidosis

62. Cervical
lymphadenopathy
•Shaw (1976)has stated that enlargement of cervical node of whatever
size is abnormal.

63. CHARACTERS OF L.N. ENLARGEMENT IN SOME DISEASES
1 Streptococcal infection of tonsils:
Uni or Bilateral *
Tender & unmatted
Usually submandibular but may extend to lower cervical group.
2 Scarlet Fever
Sore Throat
Marked enlargement of submandibular L.N.
Other cervical L.N. (bilateral, tender, discrete, suppuration is common
3-Diphtheria
Enlarged submandibular L.N. usually bilateral,
tender, not matted.

64. 4-German Measle:
•OccipitaI L.N.
always present
enlargement are nearly
infectious
•Closely resembles that of
mononucleosis
5-Infectious Mononucleosis:
Bilateral L.N. enlargement, firm, discrete, mobile.
Appear first in posterior cervical area, adjacent to cervical spines later ,
submandibular L.N. will be enlarged

65. 6- T.B.:
* The chiefly affected group is upper cervical group
• Generalized L.N. enlargement is exceptional.
* Unilateral or Bilateral.
* Often firm, matted, painful,
• May become adherent to skin or deep structures.

66. 7.Syphilis:
Primary
L.N draining a chancre - Rocky
hard, uni Or bilateral, not tender.
Secondary
•Generalized L.N.
enlargement
•Especially posterior triangle
of the neck
•(shotty, discrete, painless).

67. 8.Hodgkins Disease.:
* lower cervical group then later on generalized L.N.
enlargement.
•Glands are:
a. moderately enlarged, not tender.
b. Firm, rubbery in consistency.
c. Discrete, mobile however as a result of later
extension outside the capsule glands become matted or
fixed.
Non Hodgkins Lymphoma:
*Also the cervical group is firstly affected
*Hard in consistency
•Tend to become fused and fixed to deep
structures
•May give pressure manifestations.

68. 10- CARCINOMATOUS L.N.:
*Firm, but some times hard.
*A stoney hard nodes fixed to underlying tissues are nearly
always neoplastic in nature
*Carcinomatous L.N. may be freely mobile

69. LYMPHANGITIS
• Acute inflammation elicited when bacterial infections spread into
and through the lymphatics
• Most common agents are group A β-hemolytic streptococci
• Affected lymphatics are dilated
• Filled with an exudate of neutrophils and monocytes
• Infiltrates can extend through the vessel wall into the
perilymphatic tissues
• In severe cases, produce cellulitis or focal abscesses.

70. Clinicall
y, • Red, painful subcutaneous streaks (the inflamed lymphatics)
• Painful enlargement of the draining lymph nodes (acute
lymphadenitis).
• If bacteria are not contained within the lymph nodes, subsequent
passage into the venous circulation can result in bacteremia or
sepsis.

71. Lymphoma
• Cancer of the lymphatic system
• Lymphoma is differentiated by
the type of cell that multiplies
and how the cancer presents
itself
• Two main groups:
• Hodkgin’s lymphoma
• Non Hodgkins lymphoma

72. LYMPHOEDEMA
• Condition in which swelling of
tissue in the extremities occurs
due to obstruction of the
lymphatics & accumulation of
lymph.
• Etiology
• Primary lymphoedema
• Secondary lymphoedema

73. PRIMARY/CONGENITAL
LYMPHEDEMA
Diffuse swelling of the part of the body, result from
dilation of primordial lymphatic channels or congenital
hypoplasia of
lymphatic vessels.

74. Secondary or obstructive lymphedema
• Represents the accumulation of interstitial fluid
behind a blockage of a previously normal lymphatic
• Can result from Malignant tumors obstructing either
the
lymphatic channels or the regional lymph nodes
• Surgical procedures that remove regional
groups of lymph nodes (e.g., axillary lymph
nodes in radical mastectomy) Postirradiation
fibrosis, Filariasis, Post inflammatory
thrombosis and scarring

75. Symptom
s:
• Feeling of tightness in the
extremity
• Swollen extremity
• Visible skin changes (tautness,
pitting)

76. L
Y
MPHANGIOMA
• Benign hamartomatous tumor of lymphatic channels
• With a marked predilection for the head and neck
region, at submandibular and parotid area .

77. NODEMETASTASIS
Whytumour cellentermorereadilythanvascular system?
• Lymphatic system arises by budding from the
venous system.
• Blood capillaries have narrow endothelial
junction
and do not resorb larger molecules and cells.
• Lymphatic capillaries have relatively open
endothelial junction that permits larger
molecules and cells to be absorbed and
passed.

79. NECK DISSECTION
1.RADICAL NECK DISSECTION
2.MODIFIED RADICAL NECK DISSECTION –MRND TYPE 1,2,3
3.SELECTIVE NECK DISSECTION

80. Selective NeckDissection
• Cervical lymphadenectomy with preservation of one
or more lymph node groups
• Four common subtypes:
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection

81. TNM classification
NX- Regional lymph node that
can not be assessed
N0 -No regional lymph node
metastasis.
N1-Metastasis in single
ipsilateral lymph node 3 cm or
less in greatest dimension.
N2-Metastasis in single
ipsilateral lymph node more
then 3 cm but not more then
6cm in gretest dimension
N2a-Metastasis in single ipsilateral
lymph node more then 3cm but not
more then 6cm in greatest
dimension.
N2b –Metastasis in multiple
ipsilateral lymph node less then 6
cm in greatest dimension .
N2c-Metastasis in bilateral or
contra lateral lymph node less
then 6cm in greatest dimension N3- more than 6cm

82. THANK
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