Lymph nodes in the head and neck can be examined and classified into different levels. There are about 300 lymph nodes in the head and neck region organized into two circles - the outer and inner circles. The outer circle includes submental, submandibular, preauricular and occipital nodes. The inner circle includes prelaryngeal, pretracheal, paratracheal and retropharyngeal nodes. Lymph nodes are further classified into 6 levels from I to VI based on their location for cancer staging and treatment planning. Lymph nodes examine antigen filtration and immune response initiation making examination important for clinical assessment.

1. GOOD MORNING 1

2. EXAMINATION OF LYMPH NODES OF HEAD AND
NECK AND ITS APPLIED ASPECT
GUIDED BY:
Dr. Neeraj Chauhan
Dr. Abhishek Gupta
Presented by:
Dr. Arshdeep Kaur
MDS-1st year
Dept. of Public Health Dentistry
Bhabha College Of Dental
Sciences and Research Centre 2

3. Contents
 Introduction
 Anatomy of lymph nodes
 Function of lymph nodes
 Classification of lymph nodes
 Draining areas
 Examination of lymph nodes
 Applied aspect
3

4. INTRODUCTION
• Lymphatic system is the part of the immune system
comprising a network of lymphatic vessels that carry
a clear fluid called lymph (from Latin lympha
“water”) in a unidirectional pathway
• Lymphatic system is absent in CNS, cornea,
superficial layer of skin, bones, alveoli of lung.
• Lymphatic system is essential drainage system which
is essential to venous system.
4

5. • Most tissue fluid formed at the arterial 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”
5

6. RELATION OF LYMPH SYSTEM TO BLOOD SYSTEM
6

7. COMPONENTS OF LYMPHATIC SYSTEM
• Lymph vessels
Bone marrow
• Central lymphoid organs
Thymus
lymph nodes
• Peripheral lymphoid organs Spleen
Tonsils
• Circulating lymphocytes
7

8. LYMPH NODES
 Lymph nodes are peripheral lymphoid organs
connected to the circulation by a afferent & efferent
lymphatics.
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
longitudinal diameter.
There are about 800 lymph nodes in the body and
around 300 are located in head and neck.
8

9.  Lymph nodes usually occur in groups.
 Superficial lymph nodes are located in subcutaneous
connective tissue.
 Deeper nodes lie beneath the fascia and muscles.
Superficial lymphnodes are gateways for assessing
health of entire lymphatic system.
9

10. STRUCTURE OF LYMPH NODE
10

11. Path of lymph flow through a lymph node
Afferent lymphatics carry [afferent to bring to] lymph to the
lymph node from peripheral tissues. The afferent lymphatics
penetrate the capsule of the lymph node on the side opposite
to hilum.
The afferent vessels deliver lymph to the subcapsular space, a
meshwork of reticular fibers, macrophages, and dendritic cells.
Dendritic cells are involved in the initiation of immune
response.
Lymph next flow into the outer cortex , which contains B cells
with germinal centers that resemble those of lymphoid nodule.
11

12. Lymph then flows through lymph sinuses in the deep cortex,
which is dominated by T cells.
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 continues into the medullary sinus at the core of the
lymph node. This region contain B cells and plasma cells.
12

13. FUNCTIONS OF LYMPH NODES:
• Lymph nodes play an important role in the defense
mechanism of the body. They filter out micro-
organisms (such as bacteria) and foreign substances
such as toxins, etc.
• Major functions are:
I. Lymphopoiesis
II. Filtration of lymph
III. Processing of antigens
13

14. • 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.
14

15. Lymph nodes are classified into
Peripheral nodes Deep cervical nodes
1. Jugulo-digastric node
2. Jugulo-omohyoid node
1. Pretracheal
2. Paratracheal
3. Retropharyngeal
4. Waldeyer’s ring
1. Submental
2. Submandibular
3. Preauricular
4. Postauricular
5. Occipital
6. Anterior cervical
7. Superficial
cervical nodes
Deep
Inner circle
of cervical
nodes
Superficial
Outer
circle of
cervical
nodes
15

16. 16

17. • All the lymph from the region of head and neck
drains into deep cervical lymph nodes.
• Efferents from deep cervical lymph nodes form the
jugular trunk which on right side drains into right
lymphatic duct and on left side into thoracic duct,
which empty into the junction of the subclavian and
internal jugular veins on that respective sides
17

18. OUTER CIRCLE
• Formed by lymph node groups, which form the
pericervical or cervical collar at the juction of head
and neck.
• Extends from chin in front to the occiput behind.
• They include submental, submandibular, superficial
parotid (preauricular), mastoid (postauricular) in
relation with sternocleidomastoid muscle, occipital
nodes present in relation with trapezius muscle.
18

19. 19

20. INNER CIRCLE
• Lymph node groups which lie deep to the
investing layer of deep cervical fascia.
• Lymph nodes of the inner circle consists of
Prelaryngeal
Pretracheal
Paratracheal
Retropharyngeal
Lingual and Infrahyoid nodes
20

21. 21

22. WALDEYER’S LYMPHATIC RING
• Deep to inner circle,
there is a
submucosal ring of
aggregated masses
of lymphoid tissue
called tonsils, which
surround the
commencement of
air and food
passages.
• These together
constitute the
Waldeyer’s
lymphatic ring. 22

23. WALDEYER’S RING
The tonsils and adenoids form a ring of
lymphoid tissues
23

24. TERMINAL LYMPH NODES
• These are deep cervical lymph nodes that lie
along and around the internal jugular vein,
some within the carotid sheath & some on the
surface of the sheath, under cover of
sternocleidomastoid.
• Divided into upper and lower group
24

25. • Superior group of deep cervical lymph nodes: lie
along the upper part of internal jugular vein, they
lie above the omohyoid.
• Jugulodigastric node-subgroup of nodes that lies in a
triangle bounded behind by the internal jugular vein,
above by posterior belly of digastric and below by
the facial vein.
25

26. • The inferior deep cervical lymph nodes lie along the
lower part of internal jugular vein.
• Jugulo-omohyoid node-just above the intermediate
tendon of the omohyoid muscle.
• Tongue drains into jugulo-omohyoid nodes.
• A few nodes of the deep cervical group also extend
in front of Scalenus anterior muscle.
• Enlargement of the left scalene node is a common
finding in carcinoma of stomach (Virchow's node).
• Efferents from the lower deep cervical group drain
into the jugular lymph trunk.
26

27. 27

28. 28

29. 29

30. 30

31.  Original classifiaction 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.
31

32. 32

33. 33

34.  The lymph nodes in the neck have historically been
divided into at least six anatomic neck lymph node
levels for the purpose of head and neck cancer
staging and therapy planning.
Level I: submental and submandibular
superiorly: mylohyoid muscle and mandible
inferiorly: inferior border of the hyoid bone
anteriorly: platysma muscle
posteriorly: posterior border of the submandibular
gland
There are two sublevels:
level Ia (submental nodes): anteromedial between
the anterior bellies of both digastric muscles
level Ib (submandibular nodes): posterolateral to the
anterior belly of the digastric muscles 34

35. • Level II: upper internal jugular (deep cervical) chain
• superiorly: base of the skull at the jugular fossa
• inferiorly: inferior border of the hyoid bone
• anteriorly: posterior border of the submandibular
gland
• posterolaterally: posterior border of
the sternocleidomastoid muscle
• medially: medial border of the internal carotid artery
• ​There are two sublevels:
• level IIa: inseparable from or anterior to the
posterior edge of the internal jugular vein;
includes jugulodigastric nodal group
• level IIb: posterior to and separable by a fat plane
from the internal jugular vein
35

36. • Level III: middle internal jugular (deep cervical)
chain
• superiorly: inferior border of the hyoid bone
• inferiorly: inferior border of the cricoid cartilage
• anteriorly: anterior border of the
sternocleidomastoid muscle
• posterolaterally: posterior border of the
sternocleidomastoid muscle
• medially: medial border of the common carotid
artery
36

37. • Level IV: lower internal jugular (deep cervical) chain
• superiorly: inferior border of the cricoid cartilage
• inferiorly: level of the clavicle
• anteriorly: anterior border of the
sternocleidomastoid muscle
• posterolaterally: oblique line drawn through the
posterolateral edge of the sternocleidomastoid
muscle and the lateral edge of the anterior scalene
muscle 2
• medially: medial border of the common carotid
artery
• includes medial supraclavicular
nodes including Virchow node
37

38. • Level V: posterior triangle
• superiorly: skull base at the apex of the convergence
of sternocleidomastoid and trapezius muscles
• inferiorly: level of the clavicle
• anteromedially: posterior border of the
sternocleidomastoid muscle
• posterolaterally: anterior border of the trapezius
muscle
• ​There are two sublevels:
• level Va: superior half, superior to inferior border of
the cricoid cartilage (posterior to levels II and III);
includes spinal accessory nodes
• level Vb: inferior half, inferior to inferior border of
the cricoid cartilage (posterior to level IV); includes
lateral supraclavicular nodes 1
38

39. • Level VI: central (anterior) compartment
• superiorly: inferior border of hyoid bone
• inferiorly: superior border
of manubrium (suprasternal notch)
• anteriorly: platysma muscle
• posteriorly: trachea (medially) and prevertebral
space (laterally)
• laterally: medial borders of both common carotid
arteries (medial to levels III and IV)
• includes anterior jugular, pretracheal, paratracheal,
prelaryngeal/precricoid (Delphian), and perithyroidal
nodes
39

40. • Termination
• All the levels above eventually drain to the jugular
trunk of their respective side and then to the right
lymphatic duct or the thoracic duct (left).
40

41. 41

42. NODES
SUBMENTAL
NODES
LOCATION
Under the
chin in
submental
triangle on
the surface
of mylohyoid
muscle.
DRAINING
AREA
Lower lip,
the chin, tip
of tongue
and anterior
floor of
mouth.
EFFERENT’S
Submandibul
--ar nodes or
jugulo-
omohyoid
group.
42

43. NODES
Sub mandibular
LOCATION
Lie within the
submandibular
region scattered
over the surface
of
submandibular
salivary gland.
An extension of
the
submandibular
group lie on the
cheek
superiorly
called the
buccal group.
DRAINING AREA
• Submental
nodes
• Cheek
• Nose
• Upper lip
• Maxillary
teeth
• Vestibule
• Gingiva
• Posterior
floor of the
mouth
• tongue
EFFERENT’S
Drain into
nodes of deep
cervical chain
43

44. NODES
Parotid nodes
Retro auricular
nodes
LOCATION
Lie superficial
to the capsule
of parotid
gland
Lie over the
mastoid
process
DRAINING
AREA
• The eyelid
• Temple
• Prominence
of cheeks
and
• The auricle
• The scalp
• The auricle
EFFERENT’S
• Deep
parotid
nodes
• Superficial
cervical
nodes
• Deep
cervical
nodes
44

45. NODES
Occipital
LOCATION
Lie just below
the superior
nuchal lines at
the trapezius
muscle and in
proximity with
occipital
artery.
DRAINING
AREA
From scalp
EFFERENT’S
Drain to deep
cervical nodes
45

46. NODES
SUPERFICIAL
CERVICAL
JUGULO-
DIGASTRIC
LOCATION
3-4 nodes lie
along the
external
jugular vein
and are
situated
superficial to
upper part of
sternocleido
mastoid.
Below the
posterior belly
of digastric
DRAINING
AREA
• Floor of
external
acoustic
meatus
• Lobule of
the ear
• Angle of the
jaw
• Palatal
tonsils
• Posterior
1/3rd of
tongue
EFFERENT’S
Lower deep
cervical nodes
Lower group
of deep
cervical nodes
46

47. NODES
JUGULO –
OMOHYOID
SUPRA
CLAVICULAR
NODES
LOCATION
On the internal
jugular vein, just
below the
intermediate
tendon of
omohyoid.
Supra clavicular
triangle
DRAINING AREA
• Directly from
the tongue and
indirectly from
submental,
submandibular,
upper deep
cervical nodes.
• Axillary
• Thorax
• Abdomen
• Pelvis
EFFERENT’S
Thoracic duct
Thoracic duct
47

48. NODES
RETRO
PHARYNGEAL
(1-3)
LOCATION
Retropharyng
eal space
DRAINING
AREA
• Posterior
nasal cavity
• Paranasal
sinuses
• Hard and
soft palate
• Nasophary-
-nx
• Oropharynx
• Auditory
tube
EFFERENT’S
Superior deep
cervical nodes
48

49. LYMPHADENOPATHY:
• Lymph nodes which are abnormal in size, number or
consistency and is often used as a synonym for
swollen or enlarged lymph nodes.
Classified as generalized or localised
 Generalized: 2 or more non contiguous area
 Localised – involve one area
49

50. Causes of enlargement of lymph
nodes
Inflammatory Neoplastic
Acute or chronic Carcinoma
Lymphadenitis Sarcoma
Infection
Tuberculosis
Filariasis
Secondary syphilis
Infectious mononucleosis
50

51. Haematological Immunological
Hodgkins lymphoma Aids
Non-hodgkins lymphoma Drug reaction
Chronic lymphatic leukemia Systemic lupus
Erythromatosus
Rhematoid arthritis
51

52. Clinical examination:
• History – Age
Duration
Group first affected
Pain
Fever
Primary focus
Loss of appetite & weight loss
Pressure effects
Past history
Family history
52

53. Local examination
• Inspection – number, position, size, overlying
skin swelling, pressure effects.
• Palpation – consistency, matted or not, fixity
to surrounded structures, drainage area.
General examination:
Lymph nodes in other parts of the body.
53

54. AGE: Tuberculosis, Syphilis and primary malignant
lymphomas affect young age.
DURATION: Short (acute lymphadenitis)
GROUP AFFECTED FIRST: In case of Hodgkin’s
lymphoma and tuberculosis cervical group is affected
first, whereas in filariasis inguinal LN’s are affected
earlier.
PAIN: Acute and chronic infections are painful but in
case of syphilis, primary malignant lymphomas and
secondary carcinomas, infection is painless.
FEVER: evening rise of temperature is characteristic
feature of TB, whereas in case of filaria fever is periodic
( once in month).
54

55. • PRIMARY FOCUS: In acute and chronic septic
lymphadenitis. It is usual practice to look for primary
focus in drainage area.
• LOSS OF APPETITE & WEIGHT: Incase of malignant
lymphadenopathies.
• PRESSURE EFFECTS: e.g. Dysphagia may occur when
esophagus is pressurized.
• PAST HISTORY: enlargement of epitrochlear and
suboccipital group of lymphnodes may be enlarged
in secondary stage of syphilis.
• FAMILY HISTORY: sometimes history of TB in families.
55

56. • INSPECTION:
• NUMBER: single or mutiple, there is generalized
involvement of LN’s in hodgkin’s lymphoma, TB,
Lymphosarcoma, sarcoidosis.
• POSITION: Cervical group is involved in case of TB,
epitrochlear and occipital in case of secondary syphilis.
• SKIN OVER THE SWELLING:
 In acute lymphadenitis skin becomes inflammed with
redness, oedema, brawny induration.
 Skin over tuberculous lymphadenitis and cold abscess
remains “cold” till they reach a point of bursting when
skin becomes red and glossy.
 Over rapidly growig lymphosarcoma skin becomes tense,
shining with dilated subcutaneous veins.
56

57. • PRESSURE EFFECTS:
• Careful inspection of whole body must be made to detect any
pressure effect due to enlargement of LN’s.
• Edema and swelling of upper limb – enlargement of axillary LN’s.
• Edema and swelling of lower limb - enlargement of inguinal LN’s
• Swelling & venous engorgement of face and neck may occur due
to pressure effect of lymph nodes at the root of the neck.
• Hypoglossal nerve may be involved from enlarged upper group
of cervical LN’s due to Hodgkin’s disease or secondary
carcinoma.
57

58. PALPATION
 NUMBER
LOCAL RISE IN TEMPERATURE
TENDERNESS
CONSISTENCY – Enlarged LN’S 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.
58

59. Enlarged lymph nodes may be:
• Soft
• 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.
E.g. Acute lymphadenitis
Metastatic carcinoma
Tuberculosis
59

60. FIXITY TO SURROUNDING STRUCTURE:
The enlarged lymph node should be carefully palpated to
know if they are fixed to:
• Skin
• 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 surrounding structures-first to deep fascia
& underlying muscle followed by adjoining structures and
ultimately overlying skin.
60

61. DRAINING AREA
• Cervical LN’s receive
lymphatics from –
head, face, mouth,
pharynx and neck.
• Left supra-clavicular
LN’s (virchows)
receives lymphatics
from upper limb, left
side of chest and also
viscera of abdomen
61

62. ANATOMY OF CERVICAL LYMPHATIC CHAINS
1. Superficial temporal artery
2. Masseter muscle
3. Facial artery
4. Submental
5. Submandibular gland
6. Superficial & deep parotid
7. Posterior auricular
8. Occipital
9. Anterior belly of digastric muscle
10. Posterior belly of digastric muscle
11. Jugulodigastric
12. Sternomastoid muscle
13. Deep cervical lymph chain
14. Omohyoid muscle
15. Jugulo-omohyoid
16. Superficial cervical lymph chain
17. External Jugular Vein
18. Internal Jugular vein
19. Prelaryngeal
20. Pretracheal
21. Supraclavicular
22. Subclavian vein 62

63. METHOD OF PALPATION
• a, b, c, d, e :
examination of
lymphatic
groups around
skull base
• Examined in
their circle
around the
base of the
skull
63

64. • The deep
cervical lymph
chain, lies
around the IJV,
• The chain
passes deep to
the
sternomastoid
muscle & in the
lower neck,
extends
laterally into
the
supraclavicular
region.
64

65. • Although the vast majority of cervical
lymphadenopathy is related to head & neck,
the scalene nodes are an exception. This gp.
Of supraclavicular nodes is situated behind
the lower end of the sternomastoid muscle.
They are a common site for metastases from
breast, lung, gastrointestinal & genitourinary
malignances, particularly on the left side.
• The scalene nodes can easily be missed if you
don’t palpate deep to the sternomastoid.
65

66. • To assess whether a
mass is deep, fixed to,
or superficial to the
sternomastoid muscle,
ask the subject to turn
their chin away from
the side being
examined, pressing
against your hand.
This allows the
demonstration of
mobility of superficial
or deep masses in
relation to the tensed
muscle
66

67. • Palpate the superficial
lymph chain along the
length of the EJV
completing the
examination by
palpation along the
borders of the trachea &
larynx for nodes along
the anterior jugular
vein.
• Occasionally nodes are
encountered on the
isthmus of the thyroid
gland & over the larynx;
these small “delphium”
nodes are related to
thyroid & other
superficial malignances.
67

68. INVESTIGATIONS
 Complete Blood Count
 Chest Radiography
 Serological investigation
 Nodal Biopsy
 Fine needle aspiration cytology
 C.T. Scan
 M.R.I
68

69. 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 imaging (MRI) allow
reliable detection of cervical lymph nodes.
However, the differentiation between benign
and malignant lymph nodes remains
challenging.
69

70. • Alternative imaging modalities such as single
photon emission computed tomography (SPECT)
and positron emission tomography (PET) can help
to differentiate between benign and malignant
LN’s.
• In a recent meta-analysis, ultrasound and US-
guided fine needle aspiration cytology (USgFNAC)
have been shown to be valuable tools in
characterizing cervical LN’s.
• Sentinel node biopsy has greater accuracy in
determining lymph node status for carcinoma
than commonly used imaging methods.
70

71.  Lymphography:
valuable tool for detection of lymphatic fistulas
and lymphatic leakage
 Lymphangioscintigraphy
Tc-99m – intradermally, and after 1 minute and
again after 10-30 minutes
71

72. APPLIED ASPECTS
• Lymphatics are primarily meant for coarse
drainage including cell debris & micro-organisms,
from the tissue spaces to the regional lymph
nodes, where the foreign & noxious material is
filtered off by the phagocytic activity of
macrophages for its final disposal by the
appropriate immune responses within the nodes.
• Thus the lymphatic system is the first line of
defence of our body.
72

73. • The arrangement of lymphatics of head and
neck is in such a manner that there is every
possibility of checking or blocking of lymph
flow.
• While draining from an infected area, the
lymphatics & lymph nodes carrying infected
debris may become inflamed, resulting in
lymphangitis & lymphadenitis.
• Enlarged lymph nodes may interfere with
salivary secretions and can cause dry mouth.
73

74. • Lymphatics provide most convenient route of
spread of cancerous 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 operative procedures.
74

75. CONCLUSION
• The location of the lymph node may help to
determine the site of malignancy.
• Diffuse, bilateral involvement suggests a
systemic malignancy (e.g. lymphoma) while
those limited to a specific anatomic region are
more likely associated with a local problem
75

76. REFERANCES
• Human anatomy head and neck – BD Chourasia
4/e
• Loachim’s lymph node pathology – Harry L.
loachim, 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
76