contents of ppt include introduction, embryology, lymphatic organs and tissues, classification of lymph nodes, tnm staging, diseases of lymph nodes, classification of lymph node, inspection and palpation of lymph nodes, composition of lymph, function of lymphatic system and lymph nodes

1. LYMPHATIC DRAINAGE OF HEAD,
NECK AND FACE
PRESENTED BY-
DR. MIMANSA DAFTARY
JR - 1
GUIDED BY-
DR. NEELIMA GEHLOT
HOD DEPT OF OMFS

2. CONTENTS
• INTRODUCTION
• EMBROYOLOGY
• COMPONENTS OF LYMPHATIC SYSTEM
• FUNCTIONS
• CELLS IN LYMPHATIC SYSTEM
• LYMPHATIC DRAINAGE OF HEAD, NECK, FACE
• DISEASES OF LYMPH NODES
• EXAMINATION AND INVESTIGATIONS OF LYMPH NODES

3. INTRODUCTION
 The lymphatic system is an endothelium-lined network of blind-ended
capillaries that collects excess fluid draining from cells and tissues
throughout body and returning it to blood stream which then recirculates it
to maintain overall fluid balance.
 It is the part of the immune system comprising of lymphatic vessels in a
unidirectional pathway.
 It’s a passive system and requires no pump

5. EMBRYOLOGY
 The lymphatic system begins to develop at the end of week 5 of intrauterine life from lateral plate of mesoderm.
 The first signs of the lymphatic system are seen in the form of a number of endothelium-lined lymph sacs.
 Traditionally, these sacs have been considered to be derived by sprouting from venous endothelium, the so-
called centrifugal theory. The second, the so-called centripetal theory, suggested that lymphatic
endothelium differentiates in situ from primitive mesenchyme, and secondarily acquires connection with
the vascular system

6. Local dilations of the lymphatic channel takes place and 6
primary lymph sacs occurs.
Two jugular lymph sacs
- near the junction of
subclavian and anterior cardinals veins
(future internal jugular vein)
Two iliac lymph sacs
- at the junction of iliac
and posterior cardinal vein
One retro peritoneal lymph sac
- near the root of the mesentery on
the posterior abdominal wall
One cisterna chyli
- dorsal to the retro peritoneal sac

7. Lymphatic vessels are formed either by extension
from the sacs or may form de novo, and extend
into various tissues. Ultimately all the sacs except
the cisterna chyli are invaded by connective tissue
and lymphocytes, and are converted into groups
of lymph nodes
The thoracic duct is the larger of the two and
responsible for lymph drainage from the
entire body except for the right sides of the
head and neck, the right side of the thorax,
and the right upper extremity which are
drained by the right lymphatic duct.

8. COMPONENTS OF LYMPHATIC SYSTEM
 Consists of the
1. Lymph
2. lymph vessels
3. Lymph nodes
4. Central lymphoid tissues
5. Peripheral lymphoid tissues
6. Circulating lymphocytes
• the
recovered
fluid
Lymph
• which
transport
the lymph
Lymphatic
vessels • lymphocytes
and
macrophages
Lymphatic
tissue
• in which these
cells are
especially
concentrated
lymphatic
organs

9.  It is usually a clear, colourless fluid, similar to the blood
plasma with protein content less when compared to blood
plasma.
 There are cells present in Lymph called as Lymphocytes.
Most of these cells are added to Lymph when it passes
through Lymph Nodes, but some are derived from tissues
drained by nodes
 large molecules of fat ( chylomicrons) are absorbed from the
intestines which enter the lymph vessels (after a fatty meal)
causing the lymph to be milky ( and is then called as CHYLE)
LYMPH

10. 96% water 4%solids
 PROTEINS : 2 to 6 % of solids.( Depending upon the part of
body from which it is collected)
Albumin, globulin, clotting factors (fibrinogen, prothrombin) ,
all antibodies and enzymes.
 LIPIDS : 5-15 % - mainly chylomicrons and lipoproteins.
 CARBOHYDRATES : 132 mg per 100 ml (Mainly glucose).
Non protein nitrogenous substances : Urea, A.A & Creatinine.
 ELECTROLYTES : sodium, calcium, potassium, Chloride &
bicarbonate.
 CELLULAR CONTENT : mainly lymphocytes 1000-2000 per
cu mm
 RATE OF LYMPH FLOW
-Total estimated lymph flow is 120 ml / hr
-3 – 4 liters / day

12. LYMPHATIC VESSELS
LYMPHATIC CAPILLARIES-
 Smallest lymphatic vessels
 They begin in the tissue spaces as blind-ended
sacs called capillary bulbs.
 The edge of one endothelial cell overlaps the
adjacent cell.
 Permits passage of high molecular weight
substance(higher permeability), like colloidal
materials, fat droplets, particulate matter such as
bacteria

13. MECHANISM OF LYMPH FLOW
Lymph flows under forces similar to those
that govern venous return, except that the
lymphatic system has no pump like the heart.
Lymph flows at even lower pressure and
speed than venous blood; it is moved
primarily by rhythmic contractions of the
lymphatic vessels themselves.
Skeletal muscle pump
Also like the medium veins, lymphatic
vessels have valves that prevent lymph from
flowing backward.

14. Arterial pulsation
A thoracic (respiratory) pump
Negative pressure of blood stream.
 Considering these mechanisms of lymph flow, it is apparent that physical exercise
significantly increases the rate of lymphatic return.

15. LYMPH NODE
 Are numerous small bean shaped structures
scattered along the course of lymphatic vessels
 Each lymph node consists of a connective tissue
framework , numerous lymphocytes and other cells.
 The node has the concavity constituting a hilum
through which blood vessels enter and leave the
node. Several lymph vessels enter the node on its
convex aspect. Usually a single lymph vessel leaves
the node through its hilum

17. Lymphnodeservesfewfunctions
 Lymphopoesis
 Filter bacteria and toxin substance from lymph.
 alert the immune system to pathogens.
 Site for final stage of maturation of lymphocytes & monocytes that have migrated from
bone marrow

18. LYMPHATIC TRUNK
 Large lymph vessel that forms from the convergence of
many efferent lymph vessels.
 Four paired with a right and left half, and one unpaired
trunk:
• Jugular lymph trunks (NECK) - Cervical lymph nodes
of the neck.
• Subclavian lymph trunks ( below clavicle) -Apical
lymph nodes around the armpit, which carry lymph from
the arms.
• Bronchomediastinal lymph trunks (chest) - Lungs, heart,
trachea, mediastinal, and mammary glands.
• Lumbar lymph trunks - Legs, pelvic region, and
kidneys.
Intestinal lymph trunk is the unpaired lymph trunk that
receives chyle (lymph mixed with fats) from the intestines.
Chyle typically has a high fatty acid content.

19. LYMPHATIC DUCTS
 THORACIC OR LEFT
LYMPHATIC DUCT
Thoracic duct Joins the venous system at the
junction of Left Sub clavian & Left internal
jugular veins & drains lymph via Lt
subclavian vein.
 RIGHT LYMPHATIC DUCT
Rt lymphatic duct joins the venous system at
the junction of Rt Sub clavian & Rt internal
jugular veins

20. LYMPHATIC CELLS, TISSUES AND ORGANS
T LYMPHOCYTES
B LYMPHOCYTES
MACROPHAGES
DENTRITIC CELLS
RETICULAR CELLS
MUCOSA ASSOCIATED LYMPHATIC TISSUE
 LYMPHATIC NODULES
PEYERS PATCHES

21. T LYMPHOCYTES -These are so-named
because they develop for a time in the thymus
and later depend on thymic hormones.(When
activated T cells differentiated to Activated T
cells which are sensitive to particular antigens)
B LYMPHOCYTTES -These are named after
an organ in birds (the bursa of Fabricius) in
which they were first discovered. (When
activated, B cells differentiate into plasma cells,
which produce circulating antibodies.)
MACROPHAGES – APC(Antigen Presenting
Cells)

22.  Dentritic cells –These are also APC present in epidermis, mucous membrane and
lymphatic organs and helps in defence(In skin they are often called as langerhans
cells)
 Reticular cells. They are branched cells that forms Connective tissue framework
(stroma) of the lymphatic organs
 Mucosa associated lymphatic tissue. It is particularly prevalent in body passages
that are open to the exterior—the respiratory, digestive, urinary, and reproductive
tracts—where it is called Mucosa-associated lymphatic tissue (MALT).
 lymphatic nodules (follicles). In some places, lymphocytes and other cells
congregate in dense mass.
 Peyers patches.
- Lymphatic nodules also form clusters called peyers patches
- are found in the ileum.

23.  Primary lymphatic organs
Contain large numbers of lymphocytes,
Lymphocytes originate and/or mature in
these organs. They are the
- red bone marrow and
- the thymus gland.
 Secondary lymphatic organs
Places where lymphocytes encounter and
bind with antigens, after which they proliferate
and become actively engaged cells. They are
- spleen
-the lymph nodes and
-other organs, such as the tonsils, Peyer
patches, and the appendix.

24. TONSILS
Tonsils are clusters of lymphatic tissue
under the mucous membranes that line
the nose, mouth, and pharynx. They are
classified as MUCOSA ASSOCIATED
LYMPHOID TISSUE(MALT)

26. FUNCTIONS OF LYMPHATIC SYSTEM
 To collect and transport tissue fluids from the intercellular spaces in all the tissues of
the body, back to the veins in the blood system;it plays an important role in returning
plasma proteins to the bloodstream
 Transport Digested and absorbed fat from the villi in the small intestine to the
bloodstream via the lymph vessels.
 Manufacture new lymphpocytes in the lymph nodes
 Lymph nodes play an important role in the defence mechanism of the body. They
filter out micro-organisms (such as bacteria) and foreign substances such as toxins, etc
 Transports large molecular compounds (such as enzymes and hormones) from
their manufactured sites to the bloodstream.

27. LYMPHATIC DRAINAGE OF HEAD NECK AND FACE
SUPERFICIAL GROUP
• Occipital
• Mastoid
• Preauricular
• Parotid
• Buccal
• Submental
• Submandibular
• Superficial cervical
DEEP GROUP
• Prelaryngeal
• Pretracheal
• paratracheal,
• retropharyngeal
• Jugulo-digastric
• Jugulo-omohyoid
• supraclavicular nodes.

28. Alternatively, they are also classified as

30. Occipital lymph nodes
 At the apex of the posterior triangle,
Superficial to trapezius
 AFFERENT: Back of scalp
 EFFERENT: Deep cervical lymph nodes

31. Retro auricular (mastoid) lymph nodes
 Situated on lateral surface of mastoid
process of temporal bone.
 AFFERENT: posterior part of the
temporoparietal region, the upper part
of the cranial surface of the auricula or
pinna, and the back of the external
acoustic meatus
 EFFERENT: Deep cervical nodes

32. Parotid lymph nodes
 Superficial parotid lymph nodes
 Deep parotid lymph nodes
 Afferent of superficial parotid nodes
• Strip of scalp above the parotid gland
• Lateral surface of auricle
• Anterior wall of external auditory meatus
• Lateral part of the eyelid
 Afferent of deep parotid nodes
- Middle ear
 Efferent
-Deep cervical nodes

33. BUCCAL LYMPH NODES
Location: Over the Buccinator
muscle over the Facial vein
Drains from: Eyelids, cheeks, mid
portion of face; rarely
gingiva and palate
Drains into: Submandibular lymph
nodes

34. Submandibular lymph node
Rest on the superficial surface of the submandibular gland
beneath investing layer of deep cervical fascia
AFFERENT: Front of scalp
Nose and adjacent cheek
Upper lip
Lower lip(except the the central part)
Frontal, maxillary, ethmoidal air sinus
Upper and lower teeth(except lower incisor)
Anterior 2/3rd of tongue except tip
Floor of the mouth, vestibule, gums
 EFFERENT: Deep cervical lymphnodes

35. Sub mental lymph nodes
 Situated between anterior belly of digastric muscle and
hyoid bone.
 AFFERENT: Tip of tongue
Floor of mouth beneath the tip of tongue
Incisor teeth and associated gum
Centre part of lower lip
Skin over chin
 EFFERENT: Submandibular node
Deep cervical lymph nodes
(Jugulo-omohyoid nodes)

36. ANTERIOR SUPERFICIAL CERVICAL LYMPH NODES
Location: Lies along the anterior
jugular vein
Drains from: Anterior part of neck
below the hyoid bone
Drains into: Deep cervical lymph
nodes

37. LATERAL SUPERFICIAL CERVICAL LYMPH NODES
Location: Lies along the external
jugular vein superficial to the
sternocleidomastoid
Drains from: a. Lobules of auricle
b. Floor of external acoustic meatus
c. Skin of the lower parotid region
d. Angle of the jaw
Drains into: Upper and lower deep
cervical nodes

38. Retropharyngeal lymph nodes
Located between pharynx & atlas.
AFFERENT :
• a. Nasopharynx
• b. Posterior ethmoidal and sphenoidal
sinuses
• c. Pharyngeal end of auditory tube
• d. Soft palate
• e. Posterior part of hard palate
EFFERENT: Deep cervical nodes

39. Paratracheal lymph nodes
• Location: Along the sides of
trachea and esophagus along the
external laryngeal
 AFFERENT: Trachea
Oesophagus
Larynx
 EFFERENT: Deep cervical lymph
node

40. Infrahyoid, prelaryngeal, pretracheal lymph node
• Location: Prelaryngeal nodes lie
in the cricothyroid membrane
• Pretracheal nodes lie anterior to
trachea below the isthmus
 AFFERENT: Larynx, trachea and isthmus of
thyroid
 EFFERENT: Deep cervical lymph nodes

41. Superior deep cervical lymph nodes
 Also called as Jugulodigastric lymph nodes
 Located - below posterior belly of digastric
between angle of the mandible & ant border of
Sternocleidomastoid
 AFFERENT: Tongue, tonsil
 EFFERENT: Lower deep Cervical Lymph nodes
and jugular trunk

42.  Also called as Jugular omohyoid lymph
nodes
 Located: Angle between the internal jugular
vein and superior belly of omohyoid
 AFFERENT: – Tongue & Superficial and
superior deep cervical nodes.
 EFFERENT: Jugular trunk
Inferior deep cervical lymph nodes

43. Lymphatic drainage of face
 Scalp- Preauricular and postauricular
nodes
 Malar and nasal cavity area-
Retropharyngeal, Superior deep
cervical
 External ear- Retropharyngeal,
preauricular
 Lacrimal gland- Superficial parotid
 Middle ear- Deep parotid

44. LYMPHATIC DRAINAGE OF TONGUE

45. Lymphatic drainage of para nasal sinuses
• Frontal Sinus Submandibular Nodes
• Maxillary Sinus Submandibular Nodes
• Ethmoidal Sinuses Submandibular Nodes
• Sphenoidal Nodes Retropharyngeal Nodes

46. LEVELS OF LYMPH NODES
•Developed by Memorial Sloan-
Kettering Cancer Center in 1981.
•Ease and uniformity in describing
regional nodal involvement in cancer
of the head and neck
•Single most important prognostic
factor in head & neck cancer, lymph
node involvement reduces overall
survival rate by 50%

47.  LEVEL Ia: Submental group
 LEVEL Ib: Submandibular group
 LEVEL IIa and b: Jugulodigastric
 LEVEL III: mid jugular
 LEVEL IV: jugulo-omohyoid &
Supraclavicular
 LEVEL Va and b: Posterior triangle
 LEVEL VI: Central compartment group
 LEVEL VII: Superior mediastinal group

48. HISTORY
1. Age
2. Duration
3. Which Group First
Affected
4. Pain
5. Fever
6. Primary Focus
7. Loss Of Appetite
And Weight
8. Pressure Effects
9. Past History
10. Family History
LOCAL
EXAMINATION
Inspection
Palpation
GENERAL
EXAMINATION
1. Examination Of
Lymph Nodes Of
Other Parts Of Body
2. Always Examine
Spleen, Liver,
Mesentric, Iliac Lymph
Nodes
3. Examine Lungs For
T.B And Secondary
Metastasis
Examination of lymph node

49. INSPECTION
The person’s head, face and neck should be observed for any
asymmetry, enlargement or erythematous appearance in the
area of lymph nodes

50. Swelling is palpated noting:
1. Number
2. Position
3. Local temperature
4. Tenderness
5. Surface
6. Margins
7. Consistency
8. Fixity to skin and surrounding
structures.
PALPATION

51. Palpable lymph nodes and associated conditions
Tender – acute lymphadenitis
Matted – TB
Elastic and rubbery: Hodgkin’s disease
Firm, discrete and shotty: Syphilis
Stony hard: malignancy
Variable consistency : Lymphosarcoma
( soft, firm and hard depending on the rate of growth)

55. DISEASES OF LYMPHATIC ORIGIN

56. • LYMPHEDEMA – Lymphedema is swelling of extrimities due to
build-up of lymph fluid in capillaries or node.
• LYMPHADENOPATHY- Is any Abnormal enlargement of lymph
nodes.
• LYMPHADENITIS – Refers specifically to lymphadenopathies
caused by inflammatory process
• LYMPHANGITIS - is acute inflammation of vessel due to infection

57. Benign neoplasm of lymphatics
3 types
• 1) Simple and capillary lymphangioma
• 2) Cavernous lymphangioma
• 3) Cystic hygroma
Lymphangioma

58. CYSTIC HYGROMA
Also known as MACROCYSTIC LYMPHATIC
MALFORMATION has large stretched vessels
and cyst filled with lymph, blood from
internal bleeding or both

59. Malignant neoplasms of cells of lymphoid tissue and are of two types.
Hodgkin's lymphoma
Incidence of disease has bimodal peaks.
One is young adults between 15 and 35 years and other peak after 5th decade of life. M>F.
Etiology : possible infection with Epstein barr virus
Lymphoma

60. Clinical features :
• Painless progressive and generalized lymph node enlargement in the
cervical or supraclavicular.
• May or may not be associated with malaise, fever, weight loss or
pruritis.
• Nodes are firm and rubbery and overlying skin is normal
Management : radiotherapy and chemotherapy

61. Non hodgkins lymphoma :
• More common than hodgkin's lymphoma.
• Seen in people older than 50 years
• Site: In head and neck region most common area is Waldeyer's
Ring.
Etiology: considered as clonal proliferation of immune cells.
Mainly B-lymphocyte in origin
Clinical features :Superficial lymphadenopathy Constituent
symptoms like fever, night sweats > weight loss.
Management : low grade lymphoma regress with radiotherapy.
Extensive ones require combination of chemotherapy and
radiotherapy.

62. • abnormal enlargement of lymph nodes
• Lymphadenopathy reflects disease involving the reticuloendothelial system,
secondary to an increase in normal lymphocytes and macrophages in
response to an antigen.
• Most lymphadenopathy in children is due to benign, self-limited disease such
as viral infections.
• Other, less common etiologies responsible for adenopathy include nodal
accumulation of inflammatory cells in response to an infection in the node
(lymphadenitis), neoplastic lymphocytes or macrophages (lymphoma), or
metabolite-laden macrophages in storage diseases (Gaucher disease).
LYMPHADENOPATHY

63. GENERALISED LYMPHADENOPATHY
• It has been defined as involvement of three or more non-contiguous lymph
node areas.
• Generalized lymphadenopathy is frequently associated with nonmalignant
disorders such as
1) Infections
Viral- EBV; Hepatitis A, B, C; CMV; Rubella; Measels
Bacterial – TB; Syphilis; Septicemia
2) Autoimmune – SLE; Juvenile Rheumatoid Arthritis; drug interactions-
Phenytoin.
3) Some of the Neoplastic diseases causing lymphadenopathy are
Hodgkins and non-Hodgkins Lymphoma; acute Leukemia.

64. LOCALISED LYMPHADENOPATHY
• implies involvement of a single anatomic area.
• The site of localized or regional adenopathy may provide a useful clue about
the cause.
• e.g. Occipital adenopathy often reflects an infection of the scalp, and
preauricular adenopathy accompanies conjunctival infections and cat-scratch
disease. Submental & Submandibular Lymphadenopathy after dental
infections and abscess.

65. Signal nodes/ seat of the devil/
supraclavicular adenopathy
Enlarged, hard L.N. in the
left supraclavicular fossa:
Troisier’s sign
Associated with metastasis
from SCC of the head and
neck, primary lung cancer,
esophageal cancer,
cancer in the abdomen
and pelvic region
VIRCHOW’S NODE

66. SENTINAL LYMPH NODE
The sentinel nodes are the first few lymph
nodes to which cancer spreads.
In sentinel node biopsy, a tracer material is
used to help the surgeon find the sentinel
nodes during surgery.
The sentinel nodes are removed and tested in a
lab. If the sentinel nodes are free of cancer,
then cancer probably hasn't spread.
ECHELON LYMPH NODE
those nodes receiving lymphatic drainage
directly from the SLNs. For patients with
positive-SLNs, SELNs can be biopsy and
assessed.

67. The following studies should be considered for chronic lymphadenopathy (>3 wk):
• CBC count, including a careful evaluation of the peripheral blood smear
• Lactate dehydrogenase (LDH) and uric acid
• Chest radiography
• Tuberculosis skin test (TST) and interferon-gamma release assay (eg, Quantiferon
Gold)
• Evaluation of hepatic and renal function and a urine analysis are useful in
identifying underlying systemic disorders that may be associated with
lymphadenopathy. When evaluating specific regional adenopathy, lymph node
aspirate for culture may be important if lymphadenitis is clinically suspected.
INVESTIGATIONS

68. • Ultra sonography
• CT scan
• MRI
• Positron emission tomography
• Lymphangiography/ Lymph node angiogram
• Fine Needle Aspiration Cytology
• biopsy
INVESTIGATION FOR LYMPH NODES

69. • Ultrasonography may be helpful in documenting the extent of lymph node
involvement and any changes in the lymph nodes
• Normal lymph nodes- flattened hypoechoic structure
• Malignancy- shows rounded lymph nodes with peripheral or mixed
vascularity.

70. COMPUTED TOMOGRAPHY
• Reflect tissue density
• Good in demonstrating bone detail
• Exact localization and extend of
cervical tumors can be asessed

71. MAGNETIC RESONANCE
• Tissue characterization
• Imaging modality of choice for
oropharyngeal cancers
• Improved contrast resolution than
a CT
• Abnormal tumor tissue- high
signal
• Normal tissue- low signal

72. fna of a cervical lymph node showing cluster
of cells with pleomorphism, hyperchromasia
and irregular borders
FINE NEEDLE ASPIRATION CYTOLOGY
(FNAC):
• Early detection and effective management of
head and neck cancer
• For patients with cervical lymphadenopathy

73. ULTRASOUND-DIRECTED FNAC
• Tumor is aspirated under vision.
• Small and localized tumor in the deeper
cervical levels ,where it cannot be
assessed by palpation
• Lymph nodes of size of 3–4 mm in
diameter, or lymphomas situated very
close to vessels
• Cellular aspiration was obtained from a
solid or cystic part of the lymph node
can be assessed.

74. BIOPSY
• Most accurate diagnostic procedure for the assessment of cervical lymph
node enlargement
• Risk to vital structures- influenced by the location and nature of node to the
structures
Indications:
• Clinical and/or cytologic suspicion of a malignancy
• Persisting enlarged lymph nodes indicating presence or absence of
malignancy
• Suspicion of a specific lymph node disease. eg ,tuberculosis
• Suspicion of a cervical lymph node recurrence after surgical and/or
radiotherapy

75. CLINICAL STAGING OF LYMPH NODES

77. The lymphatic system and its organ are
widespread throughout the body. Because the
vessels of this system are wide spread it
becomes an easy portal for the spread of
cancer and other diseases, which is why the
disorders and diseases of this system can be so
devastating.
Conclusion: