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  3. 3.  The lymphatic system represents an accessory route through which fluid flows from the interstitial spaces into blood  It is an essential part of body’s immune system. Introduction
  4. 4. EMBRYOLOGY  Lymphatic vessels hemangioblastic stem cells  First signs 5th week
  5. 5.  Begins to develop by end of fifth week IU Develop from lymph sacs that arise from developing veins, derived from mesoderm.  Six primary lymph sacs are formed.  The first lymph sacs to appear are paired jugular lymph sacs . Development of lymphatic system:
  6. 6. Capillary plexuses enlarge. Form lymphatic vessels . Each jugular lymph sac retains at least one connection with its jugular vein. Left one develops into the superior portion of the thoracic duct.
  7. 7. 8th wk of IU-Retroperitoneal lymph sacs forms. 9th wk of IU cisterna chili develops-lower part of the thoracic duct develops from left jugular sac. Later stages-lymph sacs are invaded by lymphocytes. Transformed into group of lymph nodes
  8. 8. Development of Spleen & Thymus  The spleen develops from mesenchymal cells between layers of the dorsal mesentery of the stomach.  The thymus arises as an outgrowth of the third pharyngeal pouch.
  9. 9.  The lymph nodes develop in the early fetal period through a septation of the lymph sacs by mesenchymal cells. The spaces thus delimited become the sinus of the adult lymph nodes.
  11. 11.  The lymphatic system consists of the following  Fluid, known as lymph  Vessels that transport lymph  Organs that contain lymphoid tissue (eg, lymph nodes, spleen, and thymus)
  12. 12. MAIN FUNCTIONS  Restoration of excess interstitial fluid and proteins to the blood  Absorption of fats and fat-soluble vitamins from the digestive system and transport of these elements to the venous circulation  Defense against invading organisms
  13. 13. Components Of Lymphatic System Organ Function Lymph Contains nutrients, oxygen, hormones, and fatty acids, as well as toxins and cellular waste products, that are transported to and from cellular tissues Lymphatic vessels Transport lymph from peripheral tissues to the veins of the cardiovascular system Lymph nodes •Monitors the composition of lymph, •the location of pathogen engulfment •eradication, the immunologic response, and the regulation site Spleen Monitors the composition of blood components, the location of pathogen engulfment and eradication, the immunologic response, and the regulation site Thymus Serves as the site of T-lymphocyte maturation, development, and control
  14. 14. LYMPH  Lymph blood plasma.  It is pushed out through the capillary wall by pressure exerted by the heart or by osmotic pressure at the cellular level.  Lymph contains As the lymph passes through the lymph nodes, lymphocytes and monocytes enter it. Nutrients Oxygen Hormones Toxins Cellular Waste
  15. 15. Water (96%) Solids (4 %) Organic substances Proteins (2 – 6 % of solids) Lipids (5– 15% of solids) Carbohydrates Amino acids Albumin Globulin Fibrinogen Prothrombin Other clotting factors Antibodies Enzymes Chylomicrons Lipoproteins Glucose(120 mg%) Allaminoacidspresentsinplasma Composition of lymph
  16. 16. In Other nitrogenous substances organic substances In low conc. than in plasma Urea Creatinine Sodium Potassium Calcium In higher conc. than in plasma Chlorides Bicarbonates Cellular contents Lymphocytes 1000 -2000 cells per cu mm Other cells Monocytes Macrophages Plasma cells
  17. 17. Components of lymphatic system  Lymph  Lymphatic Vessels  Lymphatic Capillaries  Lymphatic Vessels  Lymphatic Trunks  Lymphatic Ducts
  18. 18. All tissues of body have special lymph channels to drain excess fluid directly from interstitial spaces except :  superficial portion of skin,  CNS  endomysium of muscles,  bones They have minute interstitial channels called prelymphatics . Fluid eventually empties into lymphatic vessels , or in case of brain into CSF & then directly back into blood.
  19. 19. 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
  20. 20. 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.  LYMPH VESSELS ARE NOT PRESENT IN :  CNS  Bones  Alveoli of lungs
  21. 21. LYMPHATIC VESSELS  .Lymphatic capillaries – Blind-ended tubes Thin endothelial walls. Overlapping pattern The lymphatic capillaries coalesce to form larger meshlike networks of tubes that are located deeper in the body Lymphatic vessels
  22. 22. The lymphatic vessels 2 lymphatic ducts Lymphatic vessels have 1-way valves to prevent any backflow The right lymphatic duct Drains the upper right quadrant The thoracic duct Which drains the remaining lymphatic tributaries
  23. 23. RATE OF FLOW  About 120 ml lymph flows into blood per hour  100 ml/hr – Thoracic duct  20 ml/hr - Rt. Lymphatic duct
  24. 24. Lymphatic Organs PRIMARY ORGANS  Red bone marrow  Thymus gland SECONDARY ORGANS  Lymph nodes  Lymph nodules  Spleen
  25. 25. central central peripheral peripheral
  26. 26. Thymus  In the thymus, t lymphocytes dont respond to pathogens and foreign organisms.  After maturation  They enter the blood and go to other lymphatic organs where they help provide defense. Bilobed lymphoid organ Superior mediastinum of the thorax, posterior to the sternum Function Processing and maturation of t lymphocytes. Produces thymosin, a hormone that helps stimulate maturation of t lymphocytes in other lymphatic organs
  27. 27. SPLEEN  It is surrounded by a connective tissue capsule that extends inward to divide the organ into lobules  Red pulp venous sinuses filled with blood and cords of lymphocytes and macrophages  White pulp lymphatic tissue consisting of lymphocytes around the arteries.  Lymphocytes are densely packed within the cortex of the spleen. •Largest lymphatic organ •Convex lymphoid structure located Below the diaphragm and behind The stomach. •Cells •small blood vessels •tissue known as red and white pulp.
  28. 28. FUNCTIONS  Reservoir of lymphocytes  It filters blood  It plays an important role in red blood cell and iron metabolism through macrophage phagocytosis of old and damaged red blood cells  It recycles iron by sending it to the liver  It serves as a storage reservoir for blood  It contains T lymphocytes and B lymphocytes for immunologic response
  29. 29. Mucosa Associated Lymphoid Tissue MALT Non encapsulated lymphoid tissue  2 major components of MALT:  BALT (Bronchial Associated Lymphoid Tissue)  GALT (Gut Associated Lymphoid Tissue) GALT  Peyer’s patches  Appendix – also known as belly tonsil / intestinal tonsil  Minor components of MALT  Nose-associated lymphoid tissue (NALT)  Vulvovaginal-associated lymphoid tissue (VALT)  Skin associated lymphoid tissue (SALT) is not mucosal but has the same characteristics of the MALT
  30. 30. Tonsils  Aggregates of lymph node tissue located under the epithelial lining of the oral and pharyngeal areas.  The predominance of lymphocytes and macrophages in these tonsillar tissues offers protection against harmful pathogens and substances that may enter through the oral cavity or airway • The palatine tonsils (on the sides of the oropharynx) • The pharyngeal tonsils (on the roof of the nasopharynx; also known as adenoids) •Lingual tonsils (on the base of the posterior surface of the tongue).
  31. 31. Type Epithelium Capsule Crypts Location Adenoids (also termed "pharyngeal tonsils") Ciliated pseudostratified columnar (respirator y epithelium) Incompletely encapsulated No Roof of pharynx Tubal tonsils Ciliated pseudostratified columnar (respiratory epithelium) Partially encapsulated Roof of pharynx Palatine tonsils Non-keratinized stratified squamous Incompletely encapsulated Long, branched Sides of oropharynx betwe en palatoglossal and palatopharyngeal arches Lingual tonsils Non-keratinized stratified squamous Incompletely encapsulated Long, unbranched Behind terminal sulcus (tongue)
  32. 32. Lymphatic Organs – Lymph Nodes  Oval, bean shaped structures scattered throughout body along lymph vessels  May be deep or superficial  Concentrated along the respiratory tree and GI tract, in the mammary glands, axillae, and groin  Filter lymph fluid to trap foreign organisms, cell debris, and tumor cells
  33. 33. Lymphatic Organs – Lymph Nodes  Covered by a fibrous connective tissue capsule  Trabeculae extend from cortex to medulla  Stroma – the internal supportive connective tissue network of reticular fibers
  34. 34. Structure of a Lymph Node  outer cortex - filled with lymph follicles  outer edge of follicle contains more T cells  inner germinal center is the site of B-cell proliferation  inner medulla - medullary cords of lymphocytes, macrophages, plasma cells (activated B cells) Cortex Medulla
  35. 35. Structure of a Lymph Node  Medullary cords extend from the cortex and contain B cells, T cells, and plasma cells  Throughout the node are lymph sinuses crisscrossed by reticular fibers  Macrophages reside on these fibers where they phagocytize foreign matter
  36. 36. follicles with germinal centers Histology of Lymph Nodes
  37. 37. Circulation in the Lymph Nodes  Lymph enters via a number of afferent lymphatic vessels  It then enters a large subcapsular sinus and travels into a number of smaller sinuses  It meanders through these sinuses and exits the node at the hilus via efferent vessels  The node acts as a “settling tank,” because there are fewer efferent vessels, lymph stagnates somewhat in the node  This allows lymphocytes and macrophages time to carry out their protective functions Only lymph nodes filter lymph!
  38. 38.  Fluid enters cortex through afferent vessels  Filter and trap damaged cells, microorganisms, foreign substances, tumor cells by reticular fibers  Macrophages phagocytize some, lymphocytes destroy some by immune defenses  Exits medulla by efferent vessels at hilus Lymph Flow Through Lymph Nodes
  39. 39. Blood Flow Through Lymph Nodes  Blood vessels enter and exit at the hilus  This blood provides nutrition for the node’s tissues  route for leukocytes to enter into or exit from the lymphatic tissue of the node
  40. 40. Superficial lymph nodes  Sub-mental nodes  Sub-mandibular nodes  Buccal nodes  Preauricular  Postauriculal  Occipital  Anterior cervical  Superficial cervical
  41. 41.  Deep lymph nodes 1. Prelaryngeal and pretracheal 2. Paratracheal 3. Retropharyngeal
  42. 42. OCCIPITAL NODES  Situated at the apex of posterior triangle of neck  Recieves lymph from back of scalp  Drains into deep cervical lymph nodes
  43. 43. 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 nodes
  44. 44. PAROTID LYMPH NODES  Situated on/ within parotid gland.  Receives lymph from a) Strip of 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 Drains into deep cervical nodes
  45. 45. Regional to:  Anterior temporal region  Lateral part of forehead  Eyelids  posterior part of cheek  part of external ear  parotid gland  PREAURICULAR/ POSTAURICULAR  INFRA AURICULAR / SUPERFICIAL & DEEP CERVICAL NODES
  46. 46. CLINICAL SIGNIFICANCE  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.
  47. 47. Buccal lymph nodes  Situated over buccinator muscle close to facial vein.  Recieves lymph from Eyelids, cheek, mid portion of face Rarely gums & palate Drains into submandibular lymph nodes
  48. 48. Regional to:  Skin on the anterior surface of face Secondary to:  Deeper part of face  Mucous memberane of lips & cheek.  Occasionally even from upper/lower teeth & adjacent gingiva.
  49. 49. Submandibular lymph nodes  Situated on a) superficial surface of submandibular salivary gland. b) Beneath investing layer of deep cervical facia.
  50. 50.  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.
  51. 51. 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. Drains into deep cervical nodes.
  52. 52. Submental lymph nodes  Lies b/w chin & hyoid bone  b/w 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 Drains into submandibular & deep cervical nodes
  53. 53.  Regional to  Middle part of lower lip  Skin of chin  tip of tongue  lower incisors & gingiva  Secondary lymph nodes of this region are in part submandibular & in part superior deep cervical lymph nodes
  54. 54. 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 b/w mandibular ramus & SCM muscle.  Receive lymph from  ear lobe  adjacent part of skin.  secondary to preauricular & postauricular lymph nodes.
  55. 55.  Deep cervical nodes divided into upper & lower group  The superior & inferior deep cervical nodes that are situated in front of SCM muscle: c/a anterior/ medial deep cervical nodes.  It follows the internal jugular vein so c/a JUGULAR CHAIN  Those situated in posterior triangles of neck behind SCM muscle are c/a posterior/ lateral deep cervical nodes.  They are in close relation to accassory nerve, known as ACCESSORY CHAIN
  56. 56. Primary to :  Base of tongue  Sublingual region  Posterior part of palate They are secondary and tertiary nodes into which the lymph of auricular, submental, submandibular & accessory nodes of face empty. They are also secondary to nuchal nodes, deep lymph nodes of neck, retropharyngeal, infrahyoid, pretracheal, paratracheal lymph nodes.
  57. 57. 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
  58. 58. SUPERIOR DEEP CERVICAL NODES INFERIOR DEEP CERVICAL/ SUPRACLAVICULAR NODES. THORASIC 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
  59. 59. Retropharyngeal lymph nodes  Situated in retropharyngeal space b/w pharyngeal wall & prevertebral fascia .  Recieves lymph from: soft palate,nasal part of pharynx, auditory tube, upper part of cervical vertebral column.  Drains into deep cervical lymph nodes.
  60. 60. 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.
  61. 61. Tracheal lymph nodes  Situated Pretracheal in front of trachea. Paratracheal lateral to trachea.  Recieves lymph : Oesophagus, trachea, larynx.  Drains into deep cervical lymph nodes
  62. 62. WALDEYER 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.  Heinrich Wilhelm Gottfried von Waldeyer-Hartz.
  63. 63. Tonsils
  64. 64. Dr. owais pg Ist yr ENT SMHS Grading the Size of Tonsils Grading system: A. 0 – tonsils in fossa B. +1 – tonsils less than 25% C. +2 – tonsils less than 50% D. +3 – tonsils less than 75% E. +4 – tonsils greater than 75%
  65. 65. Anatomy Blood supply - Tonsils  Facial a.  Lingual a. Dorsal lingual  Ascending pharyngeal ECA  Greater palatine branch of maxillary artery Tonsillar branch Tonsil (main branch) Ascending palatine Tonsil
  66. 66. Anatomy Blood supply – Adenoids  Ascending palatine branch of facial a.  Ascending pharyngeal a.  Pharyngeal branch of IMAX.  Ascending cervical branch of thyrocervical trunk.
  67. 67. LYMPHATIC DRAINAGE OF TONGUE  Rich network of lymphtics Enormous swelling Carcinma of tongue: Affected side is removed Surgically .With deep cervical node Carcinoma of posterior one- third is more dangerous due to bilateral lymphatic spread
  68. 68.  Tip of tongue drains bilaterally  sub-mental nodes  Right & left halves of remaining halves of anterior 2/3rd drain unilaterally  submandibular nodes.  Posterior 1/3rd drains bilaterally juglo-digastric nodes.
  69. 69. APPLIED ANATOMY The latest classification has been created by the American Joint Committee on Cancer and the American Academy of Otolaryngology - Head and Neck Surgery.
  70. 70. Staging  The TNM system devised by the AJCC is designed to stratify cancer patients into different stages based on the characteristics of the primary tumor (T), regional lymph node metastasis (N), and distant metastasis (M).
  71. 71. Regional Lymph Nodes (N) Node Description  NX Regional lymph nodes cannot be assessed  N0 No regional lymph node metastasis  N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension  N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
  72. 72.  N2a Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension  N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension  N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension  N3 Metastasis in a lymph node more than 6 cm in greatest dimension
  73. 73.  Level I - all nodes above hyoid bone, below mylohyoid muscle, and anterior to posterior edge of submandibular gland Level IA - all nodes between medial margins of anterior digastric muscles, above hyoid bone, below mylohyoid muscle Level IB - all nodes below mylohyoid muscle, above hyoid bone, posterior and lateral to medial anterior digastric muscle and anterior to submandibular gland
  74. 74.  Level II - all nodes below skull base at jugular fossa to hyoid bone, anterior to posterior edge of sternocleidomastoid muscle and posterior to submandibular gland  Level IIA - all nodes that lie posterior to internal jugular vein and are inseperable from the vein or lie anterior, lateral or medial to the vein  Level IIB - all nodes that lie posterior to internal jugular vein and have a fat plane separating the nodes and the vein
  75. 75.  Level III - all nodes between hyoid bone and cricoid cartilage arch and anterior to posterior sternoclediomastoid muscle, and lateral to the internal carotid artery Level IV - all nodes between cricoid cartilage arch and clavicle, anterior to posterior sternocleidomastoid muscleand posterolateral to anterior scalene muscle and lateral to common carotid artery
  76. 76.  Level V - all nodes from skull base posterior down to posterior border of sternocleidomastoid muscle to level of clavicle, anterior to trapezius muscle  Level VA - all nodes between skull base and cricoid cartilage arch, behind posterior edge of sternocleidomastoid muscle  Level VB - all nodes between cricoid cartilage arch and clavicle, behind sternoclediomastoid muscle
  77. 77.  Level VI - all nodes inferior to hyoid bone and above top of manubrium, between medial margins of bilateral common carotid and internal carotid arteries Level VII - all nodes behind the manubrium between medial margins of common carotid arteries bilaterally, extending inferiorly to level of innominate vein
  78. 78. Face and Scalp Anterior Facial, Ib Lateral Parotid Posterior Occipital, V Eyelids Medial Ib Lateral Parotid, II Chin Ia, Ib, II External Ear Anterior Parotid, II Posterior Post auricular, II, V Middle Ear Parotid, II Floor of mouth Anterior Ia, Ib, IIa > IIb Lower incisors Ia, Ib, IIa > IIb Lateral Ib, IIa > IIb, III Teeth except incisors Ib, IIa > IIb, III Nasal Cavity Anterior Ib Posterior Retropharyngeal, II, V Common Nodal Drainage Patterns
  79. 79. Nasal Cavity Posterior Retropharyngeal, II, V Nasopharynx Retropharyngeal, II, III, V Oropharynx IIb > IIa, III, IV, V Larynx Supraglottic IIa > IIb, III, IV Subglottic VI, IV Cervical esophagus IV, VI Thyroid VI, IV, V, Mediastinal Tongue Tip Ia, Ib, IIa > IIb, III, IV Lateral Ib, IIa > IIb, III, IV Common Nodal Drainage Patterns
  80. 80. METASTASIS  Spread of tumor in such a way by invasion that discontinuous secondary tumor masses are formed at the site of lodgement.  Routes of metasis: 1 Lymphatic spread 2 Haematogenous spread 3 Spread along body cavities and natural passages ( transcoelomic fluid, CSF)
  81. 81.  carcinomas metastatise by lymphatic route  sarcomas by haematogenous route.  The wall of lymphatics is readily invaded by cancer cells & forms a continuous growth in lymphatic channels c/a lymphatic permeation, or may detach to form tumor emboli to be carried along to the next lymph node.  Tumor emboli enter the lymph node at it’s convex surface & are lodged in subcapsular sinus.
  82. 82. SPREAD OF ORAL CANCER VIA LYMPH NODES  Mucosal lip cancers represent approximately 2 to 42% of oral cavity cancers.  10% of lower lip cancers and 20% of cancers in the upper lip and commissure are found to metastasize to the nodes.  Metastasis from the lower lip is to the submental, submandibular, and perifacial nodes (level I more commonlythan level II).  Preauricular, periparotid,and submandibular nodes drain cancers of the upper lip and commissure (level II more commonly than level I).
  83. 83.  Bilateral neck metastasis may develop if the lower lip lesion is near or has crossed the midline;  however, the upper lip rarely exhibits crossover between right- and left-side lymphatics.  Carcinoma of the buccal mucosa represents 2 to 10% of all SCC of the oral cavity  lymphatic drainage from the buccal mucosa is level I followed by level II.  Cervical metastases are observed in 10 to 27% of presenting patients.
  84. 84.  Alveolar ridge or gingival carcinoma represents 2 to 18% of oral cancers and occurs predominantly on the mandibular alveolus.  Lymph node metastasis tends to occur more frequently in mandibular ridge tumors than in maxillary tumors.  Nodal drainage is principally to levels I and II for both the maxillary and mandibular lesions and is found in 24 to 28% of patients at diagnosis.
  85. 85.  Tumors of the retromolar trigone represent 2 to 6% of all oral cavity carcinomas.  Lymphatic drainage from this area is predominantly to the submandibular nodes (level IB)  and the upper jugulo-digastricnodes (level II).  Lesions of this region tend to be more aggressive in nature with regard to developing cervical metastasis, because 27 to 56% of individuals present with metastatic disease.
  86. 86.  There is a paucity of lymphatics to the hard palate.  Approximately 10 to 25% of individuals present with evidence of metastasis, generally to levels I and II.  Hard palate lesions may also metastasize to retropharyngeal nodes  or nodes that are not palpable on a clinical examination or readily removable with a traditional neck dissection.
  87. 87.  Lymphatic drainage of the oral tongue is principally to level II, followed by levels III  Carcinoma of the lateral border generally metastasizes ipsilaterally  but SCC of the tip or body of the tongue may exhibit bilateral metastases.  Approximately 40% of patients have evidence of clinical node metastasis at the time of diagnosis.
  88. 88. Sentinel Lymph Node History  1955  First echelon node  1960  “Sentinel node”  1977  Demonstrated in penile cancer  1992  Morton reintroduced concept in N0 melanoma  Currently widely used in melanoma and breast cancer therapy.
  89. 89. Sentinel lymph node concept  Tumor spreads via lymphatics to a primary node.  Examination of primary echelon nodes for tumor direct the need for surgical management of the nodal basins.
  90. 90. Sentinel lymph node concept  Difficulties of lymphatic mapping in head and neck (O’Brien). 1. It is difficult to visualize lymphatic channels using lymphoscintigraphy because of proximity to the injection site. 2. The radiotracer travels fast in the lymphatic vessels. 3. If more than one node is visible, it can be difficult to distinguish first echelon nodes from second-echelon nodes. 4. The SLN may be small and not easily accessible (eg, in the parotid gland).
  91. 91.  see if cancer has spread from the primary tumour to the lymph nodes  This information is used to determine the stage (the extent of cancer in the body).  help plan treatment  reduce the chance of lymphedema (buildup of lymph fluid) developing  SLNB reduces, but does not completely eliminate, the risk of lymphedema.
  92. 92. Senital node biopsy  The surgeon injects a radioactive substance (radiotracer), a blue dye or both into the tissue around the tumour or into the area from where the tumour was removed.  The radiotracer is injected anywhere from 1–16 hours before the surgical procedure.  It takes about 5 minutes for the blue dye to reach the sentinel nodes, so the dye is often injected in the operating room just before the surgery.  The dye or radioactive substance is taken up by the lymph vessels. It travels along the lymph vessels draining the area around the cancer to the sentinel lymph node(s).
  93. 93.  A special scanning device detects the radioactivity in the sentinel lymph node(s), or the surgeon looks for the lymph node(s) stained blue.  Sometimes, the sentinel lymph node cannot be identified.  If the sentinel lymph node is positive or if it cannot be identified, then more lymph nodes will need to be removed.  The surgeon makes a small cut (incision) over the node(s).  The radioactive or blue lymph node(s) is removed and sent to the laboratory to be examined under a microscope by a pathologist (a doctor who specializes in the causes and nature of disease).
  94. 94. EXAMINATION OF LYMPHATI C SYSTEM  LOCAL EXAMINATION  Inspection  Swelling 1. Number 2. Position 3. Size 4. Shape 5. Surface  Skin over the swelling
  95. 95. 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- periadenitis 9. Fixity to surrounding structures(skin, muscle,nerve,vessel,bone or any viscus)
  96. 96.  Look for the primary focus in the drainage area  Examine the lymph vessels
  97. 97.  Acute lymphangitis- lymph vessels show reddened, tender, indurated streaks ascending to the regional lymph nodes from the point of infection  Carcinoma- multiple hard subcutaneous nodules in path b/w primary focus and lymph nodes  Lymphedema-stasis of lymph(lymphatic obstruction) swelling of affected limb Early- pitting is seen Late – fibrosis, prolonged pressure to pit Finally extreme fibrosis- no pitting
  98. 98. 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.
  99. 99. 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.
  100. 100. SUBMANDIBULAR NODES  Palpated from behind the patient, with patient,s chin tipped slightly towards the chest.
  101. 101. SUBMENTAL NODES  Roll the fingers below the chin(in the midline) with patient’s head tilted forwards
  102. 102. PAROTID NODES/PREAURICULAR NODES  Roll the finger in front of ear , against the maxilla
  103. 103. POSTAURICULAR/ MASTOID NODES  Roll the finger behind the ear
  104. 104. Occipital nodes  Palpated behind the ear at the base of skull
  105. 105. 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.
  106. 106. PALPATION  Soft and fluctuating  Firm ,discreet ,shotty  Stony hard  matted CONDITIONS Hodgkins lymphoma Syphilis Secondary carcinoma TB , Acute lymphadenitis, metasttic carcimoma
  107. 107. Laboratory Studies  Directed by the history and physical examination, overall clinical assessment  CBC count, peripheral blood smear.  Evaluation of hepatic and renal function, urine underlying systemic disorders  Skin testing for tuberculosis is usually indicated.  Specific regional adenopathy, lymph node aspirate for culture may be important if lymphadenitis is clinically suspected.  Titers for specific microorganisms-generalized adenopathy is present.  These may include epstein-barr virus, cytomegalovirus (cmv), b henselae, toxoplasma species, and human immunodeficiency virus (hiv).
  108. 108. Imaging Studies  Chest radiography -primary screening tool  Elucidating mediastinal adenopathy and underlying diseases affecting the lungs  .  Supraclavicular adenopathy,-CT scanning of the chest, abdomen, or both.  Positron-emission tomography (PET) scanning is not helpful as a screening tool as benign and malignant conditions may cause intense uptake •Tuberculosis, • Coccidioidomycosis, •Lymphomas, •Neuroblastoma, •Histiocytoses, •Gaucher disease
  109. 109.  PET scanning is helpful in the evaluation of lymphomas once a clinical or tissue-based diagnosis is made.  scanning is helpful in the evaluation of lymphomas.  Ultrasonography -evaluating the changes in the lymph nodes and in evaluating the extent of lymph node involvement in patients with lymphadenopathy
  110. 110.  Patients with matted nodes were more likely to develop distant metastases, whereas patients with normal nodes were more likely to develop a local recurrence
  111. 111. Sensitivity % (range) Specificity % (range) Palpation 35 (30-40) 35 (27-42) CT 45 (17-86) 11 (3-21) US 46 (42-50) 21 (11-33) MRI 42 (20-70) 14 (5-26) Accuracy of diagnostic methods in detecting occult cervical metastases. A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography
  112. 112. BIOPSY  If the size, location, or character of the lymphadenopathy suggests malignancy and laboratory testing is inconclusive, a lymph node biopsy is immediately indicated.  Best performed on regional lymph nodes suggestive of metastasis using a fine-bore needle to aspirate cells for cytologic examination.  Ultrasound-guided fine-needle aspiration cytology is now favored.  Fine needle aspiration -small samples with limited ability to perform flow cytometry and chromosomal analysis  So some prefer excisional biopsy.
  113. 113. CAUSES OF ENLARGEMENT OF LYMPH NODES INFLAMMTORY  (a) Acute Lymphadenitis  (b) Chronic Lymphadenitis  (c) Granulomatous Lymphadenitis NEOPLASTIC  (a) Benign – almost non-existent  (b) Malignant  1. Primary  (i) Giant follicle lymphoma  (ii) Lymphosarcoma  (iii) Reticular cell sarcoma  (iv) Hodgkin’s disease.  ) Granulomatous Lymphadenitis
  114. 114.  2. Secondary  Malignant melanoma Autoimmune Disorders  (i) Juvenile rheumatoid arthritis  (ii) Other collagen diseases such as Systemic lupus erythomatosus, Polyarteritis nodosa and scleroderma.
  115. 115. CAUSES OF LYMPH NODE ENLARGEMENT Sub mandibular Nodes  Sinusitis  Tonsillitis  Conjunctivitis  Pharyngitis Sub mental Nodes • Periodontitis • Mononucleosis (Epstein-Barr Virus) • Cytomegalovirus • Toxoplasmosis
  116. 116. 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
  117. 117. Preauricular nodes  Local infection  Erysipelas  Herpes Zoster  Rubella  Trachoma  Viral Conjunctivitis  Cat Scratch Disease  Syphilis  Tuberculosis
  118. 118. 1-lymph node draining a septic foicus* cervical : tonsilitis, scarlet fever, scalp infection. * periauricular: otitis media. Causes of localised lymphadenopathy 2-carcinomatous. * virchow’s: stomach * cervical: thyroid, tongue, parotid. 3- Systemic Infections Viruses: - Viral hepatitis Rt. supraclavecular L.N - German measles (cervical LN) Bacteria: T.B Generalized L.N. may start as localized L.N. as in Hodgkin’s disease
  119. 119. Causes of Generalised Lymphadenopathy I- Infectious * Viruses: a-Infectious mononucleosis b-Cytomegalo virus (C.M.V.) * Bacteria: a- brucellosis b- T .B. *Spirochetes: * Protozoa a- kala azar b-toxoplasmosis.
  120. 120. Causes of Generalised Lymphadenopathy 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- Collagenosis: a-rheumatoid artheritis. b- Felty’s syndrome. . 5-Allergy 6- Sarcoidosis 7- Lipoidosis 8-Miscellaneous
  121. 121. Characters of L.N. Enlargement in Some Diseases 1- Streptococcal infection of tonsils: 2- Scarlet Fever Sore throat. 3-Diphtheria Uni or Bilateral * Tender & unmatted *Usually submandibular but may extend to lower cervical group. marked enlargement of submandibular L.N. *Other cervical L.N. (bilateral, tender, discrete, suppuration is common Enlarged submandibular L.N. usually bilateral, tender, not matted.
  122. 122. 4-German Measle: •OccipitaI L.N. enlargement are nearly always present, closely resembles that of infectious mononucleosis. 5-Infectious Mononucleosis: * Sore throat, Fever, sometimes headache, myalgia. * Palatal petechiae often, are present * Mild splenomegally in 50% of cases *Lymphocytosis in 75% of cases with some atypical lymphocytes. Bilateral L.N. enlargement, firm, discrete, mobile. * Appear first in posterior cervical area, adjacent to cervical spines, few days later , submandibular L.N. will be enlarged
  123. 123. 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. * Cystic areas may occur due to caseation and later on cold abscess formation. * Overlying skin may break down giving T.B. ulcers or sinuses.
  124. 124. 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 or epitrochlear gp (slightly enlarged, shotty, discrete, painless).
  125. 125. 8- LYMPHOMATOUS L. N: •May be associated with constitutional symptoms.(anorexia, fever, weight loss, sweating, ….. etc). •Pel Ebstein fever: may be observed in H.D., it is a period of fever lasting for few days or weeks alternating with longer or shorter apyrexial periods . • L.N. usually discrete at start & not tender (but may become tender during febrile periods). •L.N. may increase in size during pyrexial periods and decrease in size during apyrexial periods
  126. 126. a-H.D.: * may be confined to one group at first esp. 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 b-N.H .L: *Also the cervical group is firstly affected *Rapid rate of growth results in large number of variable sized nodes which are hard in consistency, tend to become fused and fixed to deep structures & may give pressure manifestations.
  127. 127. 9- LEUKAEMIC L. N: *May be associated with general manifestations (fever, malaise, anorexia, headache, Hemorhagic tendency) a- Acute Leukaemia: *Late, slightly or moderately enlarged *Soft, discrete esp. cervical L.N. due to oral sepsis *May be tender bone. b-C.L.L: * May affect cervica1 L.N. but mostly all superficial L.N. are enlarged. *The glands usually are (firm, not tender, not matted, usually moderately enlarged, but in advanced stages may be markedly enlarged) c-C.M.L.: *Rare to be manifested by L.N. enlargement.
  128. 128. 10- CARCINOMATOUS L.N.: *Firm, but some times hard. *A stoney hard nodes fixed to underlying tissues are nearly always neoplastic in nature, however the reverse is not true. *Carcinomatous L.N. may be freely mobile
  129. 129. lymphangioma  Lymphangioma is a benign hamartomatous tumor of lymphatic channels, with a marked predilection for the head and neck region, at submandibular and parotid area .
  130. 130. CONCLUSION  Lymphatic system is a closed system of lymph channels through which lymph flows.  It is an one way system.  The entire lymph from the head and neck drains ultimately into deep cervical nodes either directly or through peripheral nodes.  In CNS- lymph is replaced by CSF  It is essential to have appropriate knowledge of tumor metastases for most appropriate treatment.