INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
www.indiandentalacademy.com
LYMPHATIC &
VENOUS SYSTEM
OF HEAD AND
NECK
Moderator
Dr David Tauro

Presenter
Dr Mahantesh.S
www.indiandentalacademy.com
CONTENTS
Development of
lymphatic system
 Lymph fluid
 Lymph node
 Lymphatic vessels
 Functions of
lymphatic system

...
WHY
LYMPHATIC
SYSTEM

?

www.indiandentalacademy.com
LYMPHATIC SYSTEM


This system was
described after the other
parts of vascular system
are already known.



The reason f...
EMBRY0LOGY OF
LYMPHATIC SYSTEM









Lymph sacs -appear between 2 nd to 6 th
week of IUL.
7 th week - jugular chan...
DEVELOPMENT OF LYMPH
NODE




Jugular, lymph

saccules and
Peritoneal lymph
saccules
Invasion of
neighboring
Mesenchymal...
LYMPHATIC SYSTEM
contents
Cells,
Organs
Vessel
Lymph fluid .
lymphoid organ

Primary /
central
Thymus and
bone marrow

Sec...
LYMPH FLUID
Definition
Transparent,colorless,or slightly yellow
watery fluid with specific gravity of 1.015.
Same as blood...
Lymph Fluid
Central

Intermediate

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Peripheral
FORMATION OF LYMPH
FLUID





FORMATION
- Diffusion
- Osmosis
Terminal capillaries in
the Interstitium
0.003ml/100kg/mi...
FACTORS AFFECTING
THE LYMPH
FORMATION


Environmental temperature



Body movement

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VELOCITY OF LYMPH
FLOW


Depends on
– Intrinsic Factors
– Extrinsic Factors



Velocity is generally 3.1cm /min

www.ind...
EXTRINSIC

INTRINSIC
Intraluminal pressure
Lymphatic pump

Interstial pressure
Movement

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Musc...
Conditions where lymph
production increase
(pathologically)






Inflammation
Venous stasis
Mechanical insufficiency ...
LYMPH
NODE


These are the raison d,etre of the
lymphatic system



Local aggregation of lymphoid tissue.



Lympha  c...
LYMPH NODE







800 L nodes in body
300 are present in head
and neck
1 st defense station of the
body.
Localized mai...
SHAPE OF LYMPH
NODE


Inguinal lymph nodes – large and round



Outer iliac lymph nodes – longish mass



Inner iliac l...
LYMPH NODE


Size
– 1- 30 um in diameter this depends
mainly on primary function



Absorption -0.07ml/l node

www.india...
CELL ZONES
Zone 1
Extreme periphery
Loosely packed cells
lymphocytes,
macrophages
Zone 2
More densely packed
small lymphoc...
STRUCTURAL CHANGES:
– Expansion of B and T lymphocytes
– Cortical region enlargement
– Increase in no of macrophages in si...
FUNCTION OF LYMPH
NODE


Biologic filtering



Production of lymphocytes in context
of immune reactions.

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1. Biologic filtering
Afferent vessels

Capsule
Marginal sinus
Marginal Zones

Medullary cords
Medullary sinus
Efferent ve...
2.Immune reaction
Antigen  Margninal sinus
Bound to Macrophages & Reticular cells

Adjacent T-helper cells  Present Ag t...
IMMUNOBLAST

Move towards germinal centre
Differentiate

Immunocytes & Plasma
cells
www.indiandentalacademy.com
5-7 days, Plasma cells  Medullary cords  Ab into the
medulla

Para cortical zone (T-lymphocytes)

Suppressor T cells

He...
LYMPHATIC VESSELS


Anatomically similar to veins



Are thin-walled , serve as drainage
channels



Initially lymph v...
LYMPHATIC VESSELS


Abundant interlacing anastomoses



Interruption of the continuity by lymph
nodes. 



Drainage cha...
LYMPHATIC VESSELS


Wide vascular lumen. 30-50um .



Lymph capillaries dose not contains valves.
valves are there in va...
STRUCTURE OF
LYMPHATIC VESSEL
Initial lymph vessel
Endothelial cells that
are
Surrounded by an
incomplete and
interrupted ...
FUNCTIONS OF
ENDOTHELIAL CELLS




Intense protein
synthesis
Increase cellular
transportation

www.indiandentalacademy.c...
VALVES


Except initial lymphatic sinus or capillaries
every lymph vessels has valves.



Valves may be
– Bicuspid
– Tri...
www.indiandentalacademy.com
FUNCTIONS OF LYMPH
VESSELS


Transitional function of fluid between
intercellular spaces and veins.



Immunity



Fats...
LYMPHATIC SYSTEM OF
HEAD AND NECK
REGION


LS of aero digestive mucosa consists of



Narrow –meshed ,superficial vascul...
LYMPHATIC DRAINAGE OF HEAD
AND NECK
SUPERFICIAL
CERVICAL

DEEP
CERVICAL

Outer circle (Pericervical
collar)
Inner circle (...
www.indiandentalacademy.com
SUPERFICIAL CERVICAL NODES (Inner circle)
Pre-laryngeal Deep cervical
Anterior
Deep cervical
fascia(beneath) cervical node...
DEEP CERVICAL LYMPH NODES
Jugulodigastric
nodes

Triangular
region(digastr
ic, facial vein
and IJV)

Palatine tonsil
and
t...
www.indiandentalacademy.com
SUB-MENTAL

SUB-MANDIBULAR

PAROTID NODES

UPPER DEEP CERVICAL CHAIN OF NODES

LOWER DEEP CERVICAL CHAIN OF NODES

www.ind...
LOWER DEEP CERVICAL
Left lower body

Right upper body

(bilaterally)

RIGHT LYMPHATIC
DUCT

Right Brachiocephalic

THORACI...
Levels of Lymph nodes

(SLOAN

–KETTERING CANCER CENTER, NY )

I
II
VI

III

v

IV
www.indiandentalacademy.com
CLINICAL
CONSIDERATIONS


Normal lymph nodes not palpable

www.indiandentalacademy.com
LYMPHADENOPATHY

www.indiandentalacademy.com
EXAMINATION


How long swelling has been present?



Is it painful ?



Does it vary with size?

www.indiandentalacadem...
GENERAL PRINCIPLES
Inspection
Palpation
Compare with contra lateral side.
Site
Size
Consistency
Tenderness
Fixation
www.in...
Consistency/Texture


Stony hard

 Metastatic cancer



Firm, Rubbery

 Lymphoma



Soft

 Infection Inflammatory

...
PALPABLE LYMPHNODES AND
PROBABLE
ASSOCIATED CONDITIONS


Tender, Mobile, enlarged  Acute infection



Non-tender, Mobil...
Matted:Group of nodes – Connected – as a unit

Benign / Malignant
Benign

Malignant

TB

Metastatic carcinoma

Sarcoidosis...
Key Points in Diagnosing
Lymphadenopathy





In the absence of obvious infection consider it
as metastatic tumor until...
AGE


<16yrsinfection,congenital, neoplasia.



16-40yrs- inflammation, neoplasia



>40yrs- neoplastic.
www.indianden...
CERVICAL
LYMPHADENOPATHY

Classification

Localised

Generalised

2 or more non contiguous area
www.indiandentalacademy.co...

-

-

-

CAUSES FOR
CERVICAL
LYMPHADENOPATHY

Local

Infection-dental infections, tonsillitis, skin sepsis,
TB node.
Neo...
CONCLUSION

www.indiandentalacademy.com
REFERENCES










Text book of surgical anatomy – Mag Craker
Text book of general anatomy 39 th ed – Grants
Cl...
Thank
you

www.indiandentalacademy.com
CLINICAL STAGING


Scan and attach

www.indiandentalacademy.com
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Lymphatic & venous system of head and neck /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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Lymphatic & venous system of head and neck /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. www.indiandentalacademy.com
  3. 3. LYMPHATIC & VENOUS SYSTEM OF HEAD AND NECK Moderator Dr David Tauro Presenter Dr Mahantesh.S www.indiandentalacademy.com
  4. 4. CONTENTS Development of lymphatic system  Lymph fluid  Lymph node  Lymphatic vessels  Functions of lymphatic system  Classification Diagnosis of Lymphadenopathy Conclusion  References www.indiandentalacademy.com
  5. 5. WHY LYMPHATIC SYSTEM ? www.indiandentalacademy.com
  6. 6. LYMPHATIC SYSTEM  This system was described after the other parts of vascular system are already known.  The reason for this delay is their delicate and transparent appearance. www.indiandentalacademy.com
  7. 7. EMBRY0LOGY OF LYMPHATIC SYSTEM      Lymph sacs -appear between 2 nd to 6 th week of IUL. 7 th week - jugular channel spread to connect with subclavin lymph sacs. 9 th week - thoracic duct is continuous channel draining into IJ -subclavin vein junction. 12 th week- all process are complete. 5 th month - valves begins to start. www.indiandentalacademy.com
  8. 8. DEVELOPMENT OF LYMPH NODE   Jugular, lymph saccules and Peritoneal lymph saccules Invasion of neighboring Mesenchymal cells so called lymph sinuses evolve intra nodally. www.indiandentalacademy.com
  9. 9. LYMPHATIC SYSTEM contents Cells, Organs Vessel Lymph fluid . lymphoid organ Primary / central Thymus and bone marrow Secondary / peripheral Spleen, tonsil and lymph node www.indiandentalacademy.com
  10. 10. LYMPH FLUID Definition Transparent,colorless,or slightly yellow watery fluid with specific gravity of 1.015. Same as blood plasma but more dilute CONTENTS •Proteins •Fats •Cells •Interstitial fluid www.indiandentalacademy.com
  11. 11. Lymph Fluid Central Intermediate www.indiandentalacademy.com Peripheral
  12. 12. FORMATION OF LYMPH FLUID    FORMATION - Diffusion - Osmosis Terminal capillaries in the Interstitium 0.003ml/100kg/min tissues 2-3liters/day produced www.indiandentalacademy.com
  13. 13. FACTORS AFFECTING THE LYMPH FORMATION  Environmental temperature  Body movement www.indiandentalacademy.com
  14. 14. VELOCITY OF LYMPH FLOW  Depends on – Intrinsic Factors – Extrinsic Factors  Velocity is generally 3.1cm /min www.indiandentalacademy.com
  15. 15. EXTRINSIC INTRINSIC Intraluminal pressure Lymphatic pump Interstial pressure Movement www.indiandentalacademy.com Muscular Arterial respiration
  16. 16. Conditions where lymph production increase (pathologically)     Inflammation Venous stasis Mechanical insufficiency of vessels and valves Drugs –Serotonin,Prostaglandins,TXA2, Nor-adrenaline www.indiandentalacademy.com
  17. 17. LYMPH NODE  These are the raison d,etre of the lymphatic system  Local aggregation of lymphoid tissue.  Lympha  colorless – yellow fluid (lymphocytes)  Nodus knot www.indiandentalacademy.com
  18. 18. LYMPH NODE     800 L nodes in body 300 are present in head and neck 1 st defense station of the body. Localized mainly in fatty tissues & interposed between lymphatic flow www.indiandentalacademy.com
  19. 19. SHAPE OF LYMPH NODE  Inguinal lymph nodes – large and round  Outer iliac lymph nodes – longish mass  Inner iliac lymph node – small and round  Head and neck lymph node- oval or kidney or spindle shaped www.indiandentalacademy.com
  20. 20. LYMPH NODE  Size – 1- 30 um in diameter this depends mainly on primary function  Absorption -0.07ml/l node www.indiandentalacademy.com
  21. 21. CELL ZONES Zone 1 Extreme periphery Loosely packed cells lymphocytes, macrophages Zone 2 More densely packed small lymphocytes and macrophages Zone 3. www.indiandentalacademy.com Germinal center
  22. 22. STRUCTURAL CHANGES: – Expansion of B and T lymphocytes – Cortical region enlargement – Increase in no of macrophages in sinus , medullary sinus FUNCTIONAL CHANGES  Reduced filtering capacity  Immune cells No. increase www.indiandentalacademy.com
  23. 23. FUNCTION OF LYMPH NODE  Biologic filtering  Production of lymphocytes in context of immune reactions. www.indiandentalacademy.com
  24. 24. 1. Biologic filtering Afferent vessels Capsule Marginal sinus Marginal Zones Medullary cords Medullary sinus Efferent vessels www.indiandentalacademy.com Hilus
  25. 25. 2.Immune reaction Antigen  Margninal sinus Bound to Macrophages & Reticular cells Adjacent T-helper cells  Present Ag to Immunocompetent lymphocytes -- Mantle zone ( B-Lymphocytes) Activated B cells www.indiandentalacademy.com Immunoblast
  26. 26. IMMUNOBLAST Move towards germinal centre Differentiate Immunocytes & Plasma cells www.indiandentalacademy.com
  27. 27. 5-7 days, Plasma cells  Medullary cords  Ab into the medulla Para cortical zone (T-lymphocytes) Suppressor T cells Helper T cells www.indiandentalacademy.com
  28. 28. LYMPHATIC VESSELS  Anatomically similar to veins  Are thin-walled , serve as drainage channels  Initially lymph vessels are Finger-shaped and blind.  they drain intercellular spaces and serous sacs.  www.indiandentalacademy.com
  29. 29. LYMPHATIC VESSELS  Abundant interlacing anastomoses  Interruption of the continuity by lymph nodes.   Drainage channels from many parts not drained by the venous system www.indiandentalacademy.com
  30. 30. LYMPHATIC VESSELS  Wide vascular lumen. 30-50um .  Lymph capillaries dose not contains valves. valves are there in valvular precollectors .  Diameter larger than 10um only can spread or metastasis can take place. www.indiandentalacademy.com
  31. 31. STRUCTURE OF LYMPHATIC VESSEL Initial lymph vessel Endothelial cells that are Surrounded by an incomplete and interrupted basal membrane These cells overlap like roof tiles Lymphatic collectors Intima consists of endothelial cells Collagen fibers and single muscle cells. Media contains bundles of smooth muscles surrounded By collagen fibers. Adventitia –longitudinal bundles of connective tissue,elastic fibers& Single smooth muscle cells www.indiandentalacademy.com
  32. 32. FUNCTIONS OF ENDOTHELIAL CELLS   Intense protein synthesis Increase cellular transportation www.indiandentalacademy.com
  33. 33. VALVES  Except initial lymphatic sinus or capillaries every lymph vessels has valves.  Valves may be – Bicuspid – Tricuspid – Quadricuspid www.indiandentalacademy.com
  34. 34. www.indiandentalacademy.com
  35. 35. FUNCTIONS OF LYMPH VESSELS  Transitional function of fluid between intercellular spaces and veins.  Immunity  Fats and proteins www.indiandentalacademy.com
  36. 36. LYMPHATIC SYSTEM OF HEAD AND NECK REGION  LS of aero digestive mucosa consists of  Narrow –meshed ,superficial vascular system  Wide – meshed ,deeply situated vascular system www.indiandentalacademy.com
  37. 37. LYMPHATIC DRAINAGE OF HEAD AND NECK SUPERFICIAL CERVICAL DEEP CERVICAL Outer circle (Pericervical collar) Inner circle (upper part of respiratory and alimentary passages) Surrounds IJV Spinal Accessory Base of skull- Neck www.indiandentalacademy.com
  38. 38. www.indiandentalacademy.com
  39. 39. SUPERFICIAL CERVICAL NODES (Inner circle) Pre-laryngeal Deep cervical Anterior Deep cervical fascia(beneath) cervical nodes nodes Pre-tracheal Trachea Para-tracheal Oesophagus and trachea Retropharyngeal Retropharyngeal space Larynx,trachea Deep cervical ,oesophagus nodes and thyroid gland Pharynx, palatine tonsil,sphenoid sinus www.indiandentalacademy.com Upper deep cervical nodes
  40. 40. DEEP CERVICAL LYMPH NODES Jugulodigastric nodes Triangular region(digastr ic, facial vein and IJV) Palatine tonsil and tongue(post.1/ 3rd) Juguloomohyoid nodes On IJV above intermediate tendon of omohyoid Tongue,subJugular lymph mental,subtrunk mandibular and upper deep cervical www.indiandentalacademy.com Upper deep cervicaljug ular trunk
  41. 41. www.indiandentalacademy.com
  42. 42. SUB-MENTAL SUB-MANDIBULAR PAROTID NODES UPPER DEEP CERVICAL CHAIN OF NODES LOWER DEEP CERVICAL CHAIN OF NODES www.indiandentalacademy.com 3rd Molars Tongue (base) Tonsillar area Soft palate
  43. 43. LOWER DEEP CERVICAL Left lower body Right upper body (bilaterally) RIGHT LYMPHATIC DUCT Right Brachiocephalic THORACIC DUCT vein Left Brachiocephalic Subclavian vein www.indiandentalacademy.com vein
  44. 44. Levels of Lymph nodes (SLOAN –KETTERING CANCER CENTER, NY ) I II VI III v IV www.indiandentalacademy.com
  45. 45. CLINICAL CONSIDERATIONS  Normal lymph nodes not palpable www.indiandentalacademy.com
  46. 46. LYMPHADENOPATHY www.indiandentalacademy.com
  47. 47. EXAMINATION  How long swelling has been present?  Is it painful ?  Does it vary with size? www.indiandentalacademy.com
  48. 48. GENERAL PRINCIPLES Inspection Palpation Compare with contra lateral side. Site Size Consistency Tenderness Fixation www.indiandentalacademy.com
  49. 49. Consistency/Texture  Stony hard  Metastatic cancer  Firm, Rubbery  Lymphoma  Soft  Infection Inflammatory  Shotty  Viral infection www.indiandentalacademy.com
  50. 50. PALPABLE LYMPHNODES AND PROBABLE ASSOCIATED CONDITIONS  Tender, Mobile, enlarged  Acute infection  Non-tender, Mobile, Enlarged  Chronic infection  Matted, Non tender  Tuberculosis  Fixed, Enlarged  Carcinoma  Rubbery, Enlarged  Lymphomas www.indiandentalacademy.com
  51. 51. Matted:Group of nodes – Connected – as a unit Benign / Malignant Benign Malignant TB Metastatic carcinoma Sarcoidosis Lymphomas Lymphogranuloma venereum www.indiandentalacademy.com
  52. 52. Key Points in Diagnosing Lymphadenopathy    In the absence of obvious infection consider it as metastatic tumor until otherwise proven. FNAC - useful investigation. Open biopsy- recurrence, survival, further examination is difficult, fungation. nerve damage may occur. www.indiandentalacademy.com
  53. 53. AGE  <16yrsinfection,congenital, neoplasia.  16-40yrs- inflammation, neoplasia  >40yrs- neoplastic. www.indiandentalacademy.com
  54. 54. CERVICAL LYMPHADENOPATHY Classification Localised Generalised 2 or more non contiguous area www.indiandentalacademy.com Involve one area
  55. 55.  - - - CAUSES FOR CERVICAL LYMPHADENOPATHY Local Infection-dental infections, tonsillitis, skin sepsis, TB node. Neoplasia-lymphoma or metastatic. General URTI, infectious mononucleosis, toxoplasmosis, cat-scratch fever, HIV Sarcodosis, Hodgkin's and non-Hodgkin's lymphoma. Congenital- cystic hygroma. www.indiandentalacademy.com
  56. 56. CONCLUSION www.indiandentalacademy.com
  57. 57. REFERENCES          Text book of surgical anatomy – Mag Craker Text book of general anatomy 39 th ed – Grants Clinical oriented anatomy –Moore Head &neck emergencys-Mike parry Text book of head &neck anatomy 2 nd ed – Holleinsheid Atlas of general histology – De Floire Text book of Human histology- Inderbir Singh Metastases of head and neck – R. Kim Davis Text book medicine-Davidson www.indiandentalacademy.com
  58. 58. Thank you www.indiandentalacademy.com
  59. 59. CLINICAL STAGING  Scan and attach www.indiandentalacademy.com
  60. 60. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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