Dr. Ratna . Samudrawar
Pg 1 year
Department of Oral Medicine and Radiology
Rungta College of Dental Sciences and
ANATOMY OF LYMPH NODES
FUNCTION OF LYMPH NODES
CLASSIFICATION OF LYMPH NODES
EXAMINATION OF LYMPH NODES
• Lymphatic system is essential drainage system which is
accessory to venous system.
• Most tissue fluid formed at the aterial end of capillaries is
absorbed back into the blood by venous end capillaries
and rest of tissue fluid (10- 20%) is absorbed by lymphatics.
• Larger particles like proteins and particulate matter can be
removed from the tissue fluid only by the lymphatics.
• Therefore, lymphatic system may be regarded as
drainage system of “coarse type” & venous system
as “fine type”
• Tissue fluid flowing in the lymphatics are called
lymph.( clear fluid)
• It passes through filters called (lymph nodes)
placed in the course of lymphatics .
Diagramatic relation of lymph system
to blood system
COMPONENTS OF LYMPHATIC SYSTEM
Central lymphoid organs
Peripheral lymphoid organs
Lymph nodes are peripheral lymphoid organs
connected to the circulation by a afferent & efferent
These are ovoid or bean shaped nodular formation
composed of dense accumulation of lymphoid tissue,
vary in size from 2 to 20mm & average of 15mm in
There are about 800 lymph nodes in the body and
around 300 are located in head and neck.
lymph nodes usually occur in groups.
Superficial lymph nodes are located in subcutaneous
connective tissue .
Deeper nodes lie beneath the fascia & muscles.
Superficial lymphnodes are gateways for assessing
health of entire lymphatic system.
Lymph next flows into the outer cortex , which contains B cells with
germinal centres that resemble those of lymphoid nodule
The afferent vessels deliver lymph to the subscapular space , a mesh work
of reticular fibres, macrophages , and dentritic cells. Dendritic cells are
involved in the intitiation of immune response.
Afferent lymphatics[ afferent to bring to] carry lymph to the lymphnode
from peripheral tissues. The afferent lymphatics penetrate the capsule of
the lymph node on the side opposite to hilum
Path of lymph flow through a lymph node
Efferent lymphatics [efferent, to bring out] leave the lymph node at the
hilum. These vessels collect lymph from the medullary sinus and carry
it towards the venous circulation.
Lymph continous into the medullary sinus at the core of the lymph
node .This region contain B cells and plasma cells.
Lymph then flows through lymph sinuses in the deep cortex, which is
dominated by T cells.
FUNCTIONS OF 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.
Major functions are :
II. Filteration of lymph
III. Processing of antigens
multiplication of B cells and T cells from preexisting
lymphocytes in response to antigens.
Antibodies produced are carried to circulation indirectly
helping to mount an immune response.
Lymph nodes are classified into :
Peripheral nodes Deep cervical nodes
circle ) of cervical
circle) of cervical
1. Jugulo-diagastric node
2. Jugulo-omohyoid node
Deep (inner circle) of cervical nodes
The tonsils and adenoids
form a ring of lymphoid
The original classification system of cervical lymph nodes
was developed by Rouviere in 1938.
In 1981, Shah recommended that cervical lymph nodes be
classified in a simpler fashion based on levels.
The latest classification has been created by the American
Joint Committee on Cancer and the American Academy of
Otolaryngology - Head and Neck Surgery
Level I - all nodes above hyoid bone, below mylohyoid
muscle, and anterior to posterior edge of
Level IA - all nodes between medial margins of anterior
digastric muscles, above hyoid bone, below mylohyoid
Level IB - all nodes below mylohyoid muscle, above hyoid
bone, posterior and lateral to medial anterior digastric
muscle and anterior to submandibular gland
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 in seperable 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
Level III - all nodes between hyoid bone and cricoid
cartilage arch and anterior to posterior
sternoclediomastoid muscle, and lateral to the internal
Level IV - all nodes between cricoid cartilage arch and
clavicle, anterior to posterior sternocleidomastoid muscle
and posterolateral to anterior scalene muscle and lateral to
common carotid artery
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
Level VB - all nodes between cricoid cartilage arch and
clavicle, behind sternoclediomastoid muscle
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
Under the chin
triangle on the
Lower lip, the
chin , tip of
anterior floor of
nodes or jugulo-
Nodes Location Draining area Efferent’s
Lie within the
region scattered over
the surface of sub
An extension of the
group lie on the
called the buccal
of the mouth
Drain into nodes
of deep cervical
Parotid nodes Lie superficial
to the capsule
of parotid gland
• the eye lid
• prominence of
• the auricle
• deep parotid
Lie over the
• The Scalp
• The Auricle
Occipital Lie just below
nuchal lines at
muscle and in
From scalp Drain to deep
3-4 nodes lie
along the ext
jugular vein and
upper part of
• floor of ext
•Lobule of the
• angle of the
Jugulo-Digastric Below the
Lower group of
On the Internal
just below the
the tongue and
Hard and soft
Generalised - 2 or more non contiguous area
Localised - involve one area
lymph nodes which are abnormal in size, number or
consistency and is often used as a synonym for swollen or
enlarged lymph nodes.
Acute or chronic
Causes of Enlargement of Lymph Node
Clinical examination :
History – age
group first affected
loss of appetite & wt.loss
• Inspection- number, position, size , skin over
lying swelling , pressure effects.
• Palpation- inspectory findings, consistency,
matted or not , fixity to surrounding structures,
• Lymphnodes in other parts of the body.
AGE : Tuberculosis and syphilis , primary malignant
lymphomas affect young age .
DURATION: Short (acute lympahadenitis)
GROUP AFFECTED FIRST : Eg: cervical group affects first in
Hodgkin’s disease , tuberculosis etc where as inguinal
lymphnode affects first in filariasis.
PAIN: Acute and chronic infection are painful where as
painless in syphilis , primary malignant lymphomas and
FEVER:evening rise of temperature is characteristic feature of
TB. Periodic fever in filaria (once in month). 36
PRIMARY FOCUS: when ever lymph node enlarged, it is usual
practice to look for primary focus in drainage area of lymph
nodes. This should be done in acute and chronic septic
LOSS OF APPETITE & WT: incase of malignant
PRESSURE EFFECTS: Eg. Dysphagia may occur when
oesopahgus is pressured.
PAST HISTORY : enlargement of epitrochlear and soboccipital
group of lymphnodes may be enlarged in secondary stage of
FAMILY HISTORY : sometimes history of tb in families 37
NUMBER: single or multiple. A few conditions are known to
produce generalised invovlement of lymph nodes like
hodgkin’s disease , Tb , Lymphosarcoma, sarcoidosis.
POSITION: cervical group eg . Tb ,
Epitrochlear and occipital eg Secondary syphilis.
SKIN OVER THE SWELLING: In acute lymphadenitis skin
becomes inflammed with redness, oedema, brawny
• Skin over Tuberculous lymphadenitis and cold abscess
remains “cold” in true sense till they reach a point of
bursting when skin becomes red and glossy.
• Over rapidly growing lymphosarcoma skin becomes
tense, shining , with dilated subcutaneous veins.
PRESSURE EFFECTS: Careful inspection must be made of
whole body to detect any pressure effect due to
enlargement of lymphnodes.
Oedema & swelling of upper limb- enlargement of
axillary lymph nodes.
Oedema & swelling of lower limb- enlargement of
inguinal lymph nodes.
Swelling & venous engorgement of face and neck may
occur due to pressure effect of lymph nodes at the root
of the neck.
Hypoglyspossal nerve may be involved from enlarged upper
group of cervical lymphnodes due to hodgkin’s disease or
LOCAL RISE IN TEMPERATURE
CONSISTENCY – Enlarged lymph nodes should be carefully
palpated with palmar aspects of 3 fingers.While rolling the
fingers against the swelling slight pressure is maintained to
know the actual consistency.
Enlarged lymph nodes may be;
Elastic & rubbery (hodgkin’s disease)
Firm, discrete and shotty (syphilis)
Stony hard (secondary carcinoma)
Matted or Not: A group of lymph nodes that feels
connected and move as a unit is known as matted.
Eg. Acute lymphadenitis
FIXITY TO SURROUNDING STRUCTURE:
The enlarged lymphnode should be carefully palpated to
know if they are fixed to;
• The deep fascia
• The muscles
• The vessels
• The nerves
Eg: Any primary malignant growth of lymph nodes like
lymphosarcoma , reticulosarcoma , histosarcoma or
secondary carcinoma fixed to surouding structures- first to
deep fascia & underlying muscle followed by adjoining
structures and ultimately overlying skin.
• Cervical lymph nodes receive lymphatics from – head,
face, mouth , pharynx and neck.
• Left supra –clavicular lymphnodes( virchow’s) receives
lymphatics from upper limb, left sids of chest including
the breast and also viscera of abdomen.
It is named after Rudolf
Virchow (1821-1902), the
German pathologist who first
described the association.
The presence of an enlarged
Virchow's node is also
referred to as Troisier's sign,
named after Charles Emile
Troisier, who also described
METHOD OF PALPATION:
Pre auricular lymph
nodes- they are
palpated anterior to
the tragus of ear.
Post auricular lymph nodes-
Are palpated behind the
ear, on the mastoid
palpated at the base or
lower border of skull
They are palpated under the chin
The clinician can stand behind the
patient to palpate.
The patient is instructed to bend his/her
neck slightly forward so that the muscles
and fascia in that regions relax.
Fingers of both hands can be placed just
below the chin, under the lower border of
mandible and the lymph nodes should be
tried to be cupped with fingers
Are palpated at the lower border
of the mandible approximately at
the angle of the mandible.
The patient is instructed to
passively flex the neck towards the
side that is being examined. This
maneuver helps relaxing the muscles
and fascia of neck, thereby allowing
The palmar aspect of the fingers is pushed on to the soft tissue
below the mandible near the midline, then the clinician should then
move the fingers laterally to draw the nodes outwards and trap
them against the lower border of the mandible. 46
Anterior Cervical: (both
superficial and deep): Nodes that
lie both on top of and beneath the
(SCM) on either side of the neck,
from the angle of the jaw to the
top of the clavicle.
Posterior Cervical: Extend in a
line posterior to the SCMs
but in front of the trapezius,
from the level of the mastoid
bone to the clavicle.
Complete Blood Count
Fine Needle Aspiration cytology .
C. T. Scan
fine-needle aspiration, excisional biopsy remains the initial
diagnostic procedure of choice.
Modern cross-sectional imaging modalities such as
ultrasound (US), computed tomography (CT) and
magnetic resonance (MR) imaging allow reliable
detection of cervical lymph nodes. However, the
differentiation between benign and malignant lymph
nodes remains challenging
Alternative imaging modalities such as single photon
emission computed tomography (SPECT) and positron
emission tomography (PET) can help to differentiate
between benign and malignant lymph nodes.
In a recent meta-analysis, ultrasound and US-
guided fine needle aspiration cytology (USgFNAC)
have been shown to be valuable tools in
characterizing cervical lymph nodes.
Sentinel node biopsy has greater accuracy in
determining lymph node status for cancer than current
commonly used imaging methods.
valuable tool for detection of
lymphatic fistulas and lymphatic
Tc-99m –intradermally, and after 1
minute and again after 10–30
Lymphatics are primarily meant for coarse drainage
including cell debris & microorganisms, from the tissue
spaces to the regional lymph nodes, where the foreign &
noxious material is filtered off by the phagocytic activity
of the macrophage cells for its final disposal by the
appropiate immune responses within the node.
Thus the lymphatic system forms first line of defense
The arrangement of lymphatics of head & neck such
that there is every possibility of checking or blocking of
While draining from an infected area, the lymphatics &
lymph nodes carrying infected debris may become
inflammed , resulting in lymphangitis & lymphadenitis.
Enlargement of nodes may interfere with salivary
secretions through pressure & cause dry mouth or
Enlarged glands may block the capillaries & veins &
produced flushed face ,this point may be demonstrated
when patient has cold and nodes in neck & under the
rami of inferior maxillary enlarged.
Lymphatics provide most convinient route of spread
of cancer cells
Helpful in diagnosis of primary site of cancer
Helps in predicting the prognosis & classifying the
stage of cancer
Helps the surgeon in doing block dissections during
Knowledge of regional lymph nodes is important to
prognosticate the probable involvement certain lymph
nodes in case of known site of tumor or infection.
The knowledge of regional lymph nodes permits the
diagnosis of an obscure site of a pathological process if a
lymph node or group of lymph node is found diseased.
Human anatomy head and neck – BD chourasia 4/E.
Ioachim’s lymph node pathology – Harry L. Ioachim , Jeffery .4/E
A manual on clinical surgery - S. Das 6/E
Applied anatomy of lymphatics – D.O Millard
Text book of head and neck anatomy – Hiatt, Gartner 4/E
Principles and practice of radiation oncology – Edward halperin,
Carlos perez 5/E.