AN OVERVIEW OF
Dept.Of Oral and Maxillofacial Surgery,
Vishnu Dental College,
HEAD AND NECK
• Development of lymphatic system
• Lymphatic system
• Lymphatic Channels
• Lymph node
• Lymphoid organs
• Lymph nodes of head and neck
• Diseases of lymphatic system
• Ancient greeks Hippocrates and Aristotle described lymph
as white fluid.
• Gasparo aselli an italian anatomist
discovered lymphatic vessels in 1622.
• Van hook in 1652 demonstrated the presence of cisterna
chyli and thoracic duct in humans.
• William hunter in the late 18th century
was the first to describe the functions
of lymphatic system.
• Olof Rudbeck of swedish university
described that lymphatic system
constitute a circulatory system separate
from blood circulation and this fact was
accepted by Royal society of London.
• Develop at the end of 5th wk of
• Lymphatic vessels develop
from lymph sacs which arise
from developing veins and are
derived from mesoderm
• 1st lymph sac to appear paired
jugular lymph sacs at junction
of internal jugular & subclavian
• JUGULAR LYMPH SACS
• Retains one connection with its
• Spreads lymphatic capillary plexuses
to Thorax , upper limbs , head &neck.
• Left one develops into superior
portion of thoracic duct.
• RETROPERITONEAL LYMPH SAC
• It is unpaired and develops from primitive vena cava & mesonephric
• Spreads capillary plexuses & lymphatic vessels to abdominal viscera &
• Develops connections with cisterna chyli & loses connections with
• develops inferior to diaphragm on
post abdominal wall.
• gives rise to inferior portion of
POSTERIOR LYMPH SACS
• Develops from iliac veins.
• Gives capillary plexuses & lymphatic
vessels to abdominal wall , pelvic
region & lower limbs.
• Join cisterna chyli & loose
connections with adjacent veins
• Lymph vessels grow out from the
lymph sacs, along the major
• Except for the upper portion of
the cisterna chyli, which persists,
the lymph sacs are transformed
into groups of lymph nodes during
early fetal life, at about 3 months.
• PALATINE TONSILS – second pair of pharyngeal
• TUBAL (PHARYNGOTYMPANIC) TONSILS -
aggregations of lymph nodules around the openings of
the auditory tubes
• PHARYNGEAL TONSILS (adenoids) - aggregation of
lymph nodules in the nasopharyngeal wall
• LINGUAL TONSILS - aggregations of lymph nodules in
the root of the tongue
• LYMPH NODULES also are seen in the mucosa of the
digestive tract and respiratory tract
• SPLEEN - aggregation of mesenchymal cells in the
dorsal mesentery of the stomach
• Lymphatic comes from the Latin word lymphaticus, meaning
"connected to water," as lymph is clear.
• Network of vessels & lymph nodes which are located in all
major tissues of body.
• Lymphatic system is absent in CNS, Cornea, Superficial
layer of skin, Bones, Alveoli of lung.
• CONSIST OF
– Lymphatic Channels
– Lymph Nodes
– Lymph Organs
• Transudative fluid.
• Transparent & slightly yellowish
• Alkaline in nature.
• Derived from tissue fluid.
• When blood passes through
9/10 of fluid - venous end
1/10 of fluid - lymph capillaries
• “CHYLE” - Lymph from small
COMPOSITION OF LYMPH
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
LIPIDS : 5-15 % - mainly chylomicrons and lipoproteins.
CARBOHYDRATES : Sugar - 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
96% water 4% solids
RATE OF LYMPH FLOW
• Total estimated lymph flow is 120 ml / hr
• About 100 ml flows through Thoracic duct in resting man per hour
• Approx 20 ml flow into circulation through other channels
• 3 – 4 liters / day
• Lymph carries protein and large particulate matter away from the
• End products of digestion are absorbed mainly by lymph channels.
• Important role in redistribution of fluid in the body.
• Bacteria, toxins and other foreign bodies are removed from the
• Maintenance of structural and functional integrity of tissue.
• In immune response of the body.
• Production and maturation of lymphocytes.
FUNCTIONS OF LYMPHATIC SYSTEM
• Smallest lymphatic vessels
• They begin in the tissue spaces as blind-ended sacs.
• These capillaries form plexuses which collect lymph from
the interstitial space mark the beginning of lymphatic
• They are lined by a single layer
of endothelial cells.
• These are attached to C.T by
• The edge of one endothelial cell
overlaps the adjacent cell.
• Overlapping edge is free to flap
inward minute valve.
• Permits passage of high
molecular weight substance.
• Lymph capillaries merge to form lymphatic
• Resemble veins but
– Thin walls (Diameter - 0.2 – 0.3 mm)
– More valves (formed from folds of
– Lymph Nodes are located at
interval along its course
Have 3 coats (Tunica intima, Tunica media,
BEADED in appearance (semilunar valves).
Collagenous fibers attaches the endothelium
to the outer tissues ( fibrous sheath of
RIGHT LYMPHATIC DUCT
THORACIC / LEFT LYMPHATIC DUCT
• 38 – 45 cm long
• Begins as a dilation called cisterna chyli
anterior to 2nd lumber vertebra.
• Main duct for return of lymph to blood
• Receives lymph from left side of head, neck,
Left upper limb, chest & entire body inferior
• Joins the venous system at the junction of Left
Sub clavian & Left internal jugular veins &
drains lymph via Lt subclavian vein.
Origin, course, relations, and
• Arises in the abdomen from cisterna chyli under cover
• Enters the thorax through the aortic opening.
• It continues upward through the posterior mediastinum, on
the left, first with the aortic arch and then with the
• It enters the root of the neck, where it arches laterally
behind the left carotid sheath, to terminate in the upper
end of the left innominate vein, in the angle of junction of
the internal jugular and subclavian veins.
• Chyle leak.
• Virchows or scalene nodes or signal nodes – supra
RIGHT LYMPHATIC DUCT
• 1.2 cm long
• 3 lymphatic trunks drain into Rt lymphatic duct
– Rt Jugular trunk-drains Rt side of head & neck
– Rt subclavian trunk-Rt upper limb
– Rt bronchomediastinal trunk-Rt side of thorax, Rt lung,
Rt side of heart , & part of liver
• Rt lymphatic duct joins the venous system at the junction of Rt Sub clavian
& Rt internal jugular veins
Primary or Central
lymphocytes are produced and undergo development and
are supplied to secondary organs.
• Bone marrow
Secondary or peripheral organs :
lymphocytes are activated to participate in specific immune
• Lymph nodes
• Bone marrow contains two types of cells multipotent stem cells
• NON – LYMPHOID STEM CELLS differentiate in bone marrow.
• Erythrocytes , granulocytes , monocytes & platelets.
• LYMPHOID STEM CELLS differentiate in bone marrow & then
migrate to lymphoid tissue.
• B & T lymphocytes.
• T- lymphocytes ( 75-80 %)
- based on coreceptor divided into
T - helper cells (with CD 4 coreceptors)
T - cytotoxic cells(with CD 8 coreceptors)
• B- lymphocytes
• Primary organ of Lymphatic System.
• Unpaired organ.
• Consists of 2 pyramidal lobes.
• Delicate & finely lobulated surface.
• Located in mediastinum.
• Upwards - into neck as far as lower edge of thyroid gland
• Downwards - as far as fourth costal cartilage
• Largest at puberty and weighs 35 to 40 gms - Pinkish grey.
• Gradually atrophies in old age- yellowish in colour ( fat).
FUNCTIONS OF THYMUS
- Thymus contains lobes divided into lobules.
- Each lobule – cortex ( immature T lymphocytes, Macrophages)
– medulla ( T lymphocytes, thymic corpuscels)
1) Processing the “T’’ Lymphocytes
2) Endocrine functions Of Thymus
They Secretes Hormones namely
C) Thymic Humoral Factor
• Located in left hypochondrium,
directly below diaphragm, above
left kidney & descending colon
& behind fundus of stomach.
Roughly ovoid shape
Varies in size in diff individuals
Same individuals differs in size from time to time
Hypertrophy in infections
Atrophies in old age
Surrounded by fibrous capsule
Its extensions run inwardly roughly dividing the organ into
WHITE PULP and RED PULP ( Splenic cords & sinusoids).
FUNCTIONS OF SPLEEN
• DEFENSE : as the blood passes through sinusoids of spleen,
microorganism from the blood are destroyed
• HEMOTOPOIESIS : monocytes & lymphocytes complete
development in spleen
• Worn – out RBC & platelets are destroyed
• Acts as a RESERVOIR of blood (200-350 ml )
• Main source of circulating antibody in the body.
• Egg shaped masses of lymphatic tissue
not surrounded by capsule.
• They are scattered through out the GIT,
urinary & reproductive tracts and
respiratory airways and are referred to as
Mucosa – Associated Lymphatic tissue ( MALT )
• Many lymphatic nodules are small & solitary
• Peyers patches
• Some occur in multiple aggregation in specific parts of body
In relation to oropharyngeal
isthmus , they are several
aggregates of lymphoid
• Rt & Lf palatine tonsil
• Pharyngeal tonsil
• Tubal tonsil
• Lingual tonsil
• Tonsil are located under mucous
membrane and back of throat
• There are depression of surface epithelium
around which aggregate of lymph nodule
are grouped called CRYPTS.
• Intratonsillar crypt
• Peritonsillar abscess begins in this cleft
• It is a collection of pus between fibrous
capsule of the tonsil usually at its upper
pole and the superior constrictor muscle
• Hyperplasia is the most common abnormality
of the lingual tonsil.
• Lingual tonsils sit on the base of the tongue and extend to
the vallecula and do not have a capsule.
• Can be visualized by indirect mirror or flexible
• Clinically, infection is marked by erythema and
enlargement of tonsillar tissue.
• Although the lymphoid tissue in Waldeyer's ring tends to
decrease with advancing age, the lingual tonsil may
increase in size. Important cause of lingual tonsil
hypertrophy is the occurrence of compensatory
hyperplasia following adenotonsillectomy.
• Pathological hypertrophy of nasopharyngeal tonsils.
• Mostly between 3 to 5 years of age.
• Nasal obstruction ( mouth breathing, snoring, nasal tone,
difficulty while suckling and eating)
• Adenoid facies
( elongated, flat, expressionless,
without nasolabial folds,
open mouth, dry lips, high palate,
• Mucopurulent anterior and posterior nasal
• Sleep disturbances (snoring, night enuresis due
to hypercapnia )
• Feeding problems ( indigestion, loss of appetite )
• Decreased mental performance
• Recurrent ear problems
• Respiratory problems
• A normal young adult body contains some 400-450
•Head and neck -- 60-70
• Arms/superficial thorax – 40
• Legs/superficial buttocks – 30
•Thorax – 100
•Abdomen/pelvis – 230
• Small oval or bean shaped
• Range from 10 to 20 mm in
• Positioned along the course
of lymph vessel.
• Slight depression called
(blood vessels enter & leave
MICROSCOPIC STRUCTURE OF LYMPH NODES
Each lymph node is enclosed by a
It consist of Capsule, Cortex,
Fibrous septa or trabeculae extend
from covering capsule toward
centre of node.
Cortical nodule packed
lymphocytes surrounded by
less dense area Germinal
Cortical nodules within cortex
separated from each other
MEDULLA is composed of
Sinuses & Medullary Cords
CELL ZONES IN LYMPH NODES
ZONE 1 - is a region of loosely
packed cells, predominantly small
lymphocytes, macrophages and
occasional plasma cells.
ZONE 2 - is a denser region internal
to zone 1,composed mainly of small
lymphocytes and macrophages
ZONE 3 - comprises the germinal
centers of follicles, its cells include
large lymphoblast, dendritic cells
FUNCTIONS OF LYMPH NODES
As lymph passes through lymph Node reticuloendothelial cells
remove microorganisms & other injurious particles
Site for final stage of maturation of lymphocytes & monocytes that
have migrated from bone marrow
CLASSIFICATION OF LYMPH NODES
HORIZONTAL CHAIN - Outer circle
- Inner circle
level 1 consist of sub mental,
level 2 consist of upper jugular nodes
level 3 consist of middle jugular group
level 4 lower jugular group
level 5 posterior triangle group
level 6 anterior compartment group
level 7 superior mediastinal group
level 8 supraclavicular nodes
level 9 retropharyngeal nodes
Base of skull
Bifurcation of carotid
or hyoid bone
Inferior border of cricoid
cartilage or omohyoid muscle
The Lymphatic Drainage of the Tissue of the Head and Neck
1. The superficial tissues
2. The deeper structures and viscera
The two layers are separated by deep cervical fascia.
1. Lymphatic Drainage of the Superficial Tissues of the Head and Neck
Regional lymph nodesSuperficial tissues
Deep cervical nodes
Lymph nodes of Head
of superficial tissues
- Buccal (facial)
- Anterior cervical
Occipital lymph nodes
Afferent – Back of scalp
Efferent – Deep cervical lymph nodes
At the apex of posterior triangle,
superficial to trapezius
Retroauricular (mastoid) Lymph Nodes
Afferent - Strip of scalp above auricle
- Posterior external auditory
Efferent - Deep cervical nodes
superficial to sternocleidomastoid
and mastoid process and deep to
auricularis posterior muscle
Parotid Lymph Nodes
- Superficial parotid nodes
- Deep parotid nodes
Afferent of superficial parotid nodes
- Strip of scalp above the parotid salivary gland
- Lateral surface of auricle
- Anterior wall of external auditory meatus
- Lateral part of the eyelid
Afferent of deep parotid nodes
- Middle ear
- Deep cervical nodes
5 to 6 in number
Buccal Lymph Nodes
Afferent – lower eye lid, part of cheek
buccinator muscle, facial vein
Efferent - Submandibular lymph node
On the surface of buccinator muscle in
Relation to facial vein
Submandibular Lymph Nodes
Afferent - Front of scalp
- Nose and adjacent cheek
- Upper lip
- Lower lip ( except center part )
- Frontal, maxillary, ethmoidal air sinus
- Upper and lower teeth ( except lower incisor )
- Anterior 2/3 of tongue ( except tip)
- Floor of mouth, vestibule, gums
- Deep cervical lymph nodesEfferent
Submental Lymph Nodes
Afferent - Tip of tongue
- Floor of mouth beneath the tip of tongue
- Incisor teeth and associated gum
- Center part of lower lip
- Skin over chiin
Efferent – Submandibular node
- Deep cervical lymph nodes
Superficial Cervical Lymph Nodes
Afferent - Skin over the angle of jaw
- Skin over apex of parotid
salivary gland and lobule of ear
Efferent - Deep cervical lymph nodes
2. Lymphatic Drainage of the Deeper Tissues of Head and Neck
Deeper tissues of head and neck
Regional lymph nodes Deep cervical lymph nodes
Superior Deep Cervical Lymph Nodes
-Jugulodigastric lymph nodes
-Located - below posterior belly of
digastric , between angle of the mandible
& ant border of sternocleidomastoid
-One larger node and few small nodes
Afferent – Tongue, tonsil
Efferent - Lower deep cervical lymph
nodes and Jugular trunk
Inferiordeepcervical lymph nodes
Located - angle between the Int J V
and superior belly of omohyoid
Afferent – Tongue & Superficial and
superior deep cervical nodes.
Efferent - Jugular trunk
LYMPHATIC DRAINAGE OF FACE
– Upper part Parotid Lymph nodes
– Middle part Submandibular lymph nodes
– Lower part Submental lymph nodes
Gingiva Submandibular lymph nodes
Hard palate Superficial deep cervical
Soft palate Retropharyngeal
Floor of the mouth Submandibular and Submental
Teeth Submandibular and deep cervical
Tonsil Jugulodigastric nodes
LYMPHATIC DRAINAGE OF MOUTH,
Anterior 2/3rds Submandibular & deep cervical
Posterior 1/3rd Jugulodigastric lymph nodes
LYMPHATIC DRAINAGE OF TONGUE
DISEASES OF LYMPHATIC SYSTEM
• Diseases of Lymphatics
• Diseases of Lymph Nodes
DISORDERS OF LYMPHATICS
• Caused --- Haemolytic sreptococci,
• Infection occurs - distal limb - spreads
to regional lymph. N
• Lymph N - enlarged , tender & later
abscess may occur
– Treatment --- conservative
Penicillin --- drug of choice
• Caused -repeated
attack of Acute
LYMPHANGITIS inflammation of peripheral lymphatics
•Appear as red streaks progressing towards regional lymph N
• Condition in which swelling of tissue in the extremities occurs
due to obstruction of the lymphatics & accumulation of lymph
– Primary lymphoedema
– Secondary lymphoedema
• According to the distribution of edematous fluid:
(a) Local edema:(brain edema, pulmonary edema, etc).
(b) Generalized edema:(cardiac edema, renal edema).
• According to the causes of edema:
a) cardiac edema
b) renal edema
c) hepatic edema
d) idiopathic edema
• According to the gravity of edema:
a) recessive (non-pitting) edema;
b) frank (pitting) edema.
• Frank (pitting) edema:
• 99% of interstitial fluid is fixed to collagen,
mucopolysaccharide and hyaluronic acid (gel),
(connective tissue), which called fixed water.
• 1% of interstitial fluid is free water (moving
Mechanism of edema caused
by increased CHP
capillary hydrostatic pressure(CHP)↑
effect hydrostatic pressure(EHP)↑
effective filtration pressure(EFP)↑
interstitial fluid ↑.
Mechanism of decreased COP leading to edema
plasma colloidal OP↓
Effective filtration pressure ↑
Interstitial fluid ↑
Mechanism of leading to edema in increased
permeability of capillary wall
permeability of capillary wall ↑
protein and fluid leak to interstitial
tissue COP↑ plasma COP ↓
effective filtration pressure↑
interstitial fluid ↑
mechanism of lymph edema
obstructed lymphatic vessels
backflow of protein in interstitial
fluid is blocked,
the interstitial COP will increase
effective COP decrease
effective FP increase
more fluid accumulates in interstitial space.
3. Characteristics of edema
(1) Properties of edematous fluid
Edematous causes protein appearance specific
fluid concentration gravity
transudate ↑effective filtration 1～2g % clear low
exudates ↑permeability of 4g % muddy high
lymph obstruction of 4～5 % chyliform higher
• Lymphoedema Congenita
– Oedma present at birth
– Occurs ---- 10 % of cases
• Lymphoedema Parecox
– Starts at adolescents ( 15 – 25 age )
– Occurs ---- 75 % of cases
• Lymphoedema Tarda
– Occurs after 35 yrs
– Seen in 15 % of pts
Developmental error of lymphatic system
• Caused - Neoplastic / inflammatory process
• Surgical excision / Radiotherapy
• Parasitic infection with Filariasis
DISORDERS OF LYMPH NODES
• Lymphadenities ---- due to primary inflammatory reactions
• Lymphadenopathy ---- due to primary immune reactions
– All kinds of acute inflammation
– Common causes
• Microbiological infections
• Foreign body in wound
– Nodes ---- enlarged , tender , may be fluctuant , over lying skin is
– Commonly called --- Reactive lymphoid hyperplasia
– Cause --- repeated attacks of acute lymphadenities
lymph from malignant tumours
EXAMINATION OF LYMPHNODES
• Normal lymph node --- Non palpable
• Inspection :
– Swelling --- Number, position ,size
– Skin over swelling ---
• Acute lymphadenites --- inflamed , red , edema
• Chronic lymphadenites --- no change
• T B & Cold abscess --- skin is cold
• Lymphosarcoma --- tense , shining with dilated
– Number, size , tenderness , local temp , surface margins ,
consistency , fixation to underlying tissues
• Acute infection --- large, soft, painful, mobile,
• Chronic infection --- large, firm, less tender, mobile
• Lymphoma --- rubbery hard, matted, painless and multiple
• Metastatic cancer --- stony hard, fixed to the underlying tissues,
• Syphilis --- Firm discrete shotty
• Tuberculosis- Stage I: Lymph nodes enlarged without matting
Stage II: Lymph nodes enlarged with matting
Stage III: Cold abscess
LYMPH NODE EXAMINATION
• Pt relaxed & unstrained position with out head support
• Depending on site
– Bilateral ---- behind pt
– Unilateral ---- front of pt
• Palpation is done by placing flat surface of finger tips at same
position on both sides
• Commencing with most superior nodes & working down to the
• valuable tool for detection of lymphatic fistulas
and lymphatic leakage
• Tc-99m albumin –intradermally, and after 1 minute
and again after 10–30 minutes,
• High-resolution scintiscan camera
• Computed Tomography
• MRI (MR lymphography)
• Fluorescein Microlymphangiography (isothiocynate)