DR.CHAITHRASHREE

2. LYMPHATIC DRAINAGE OF HEAD AND NECK REGION

3. CONTENTS:
• Introduction
• Development of lymphatic system
• Functions of lymphatic system
• Components of lymphatic system
• Lymph nodes
• Lymphatic drainage of head and neck
• Applied Aspects
• Conclusion
• References

4. LYMPHATIC SYSTEM
• Lymphatic system is the part of
the immune system comprising
a network of vessels called
lymphatic vessels that carry a
clear fluid called lymph (from
Latin lympha "water").
• It goes in a unidirectional
pathway (Toward Heart).

5. DEVELOPMENT
• Develops at the end of 5th
week of embryonic life .
• 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 veins.

6. • Six primary lymph sacs are formed –
• 2 Jugular sacs (right and left)
• 2 iliac sac (right and left)
• Retro-peritonial sac (Unpaired)
• Cisterna chyli (unpaired)

7. • JUGULAR LYMPH SACS :
• Retains one connection with its Jugular vein .
• 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 veins.
• Spreads capillary plexuses & lymphatic vessels
to abdominal viscera & diaphragm.
• Develops connections with cisterna chyli & loses
connections with neighbouring veins.

8. • CISTERNA CHYLI :
• Develops inferior to diaphragm on
posterior abdominal wall.
• Gives rise to inferior portion of thoracic
duct.
• 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

9. FUNCTIONS OF LYMPHATIC SYSTEM
• To collect and transport tissue fluids from the intercellular spaces in all the tissues
of the body, back to the veins in the blood system.
• It plays an important role in returning plasma proteins to the bloodstream.
• Digested fats are absorbed and then transported from the villi in the small intestine
to the bloodstream via lymph vessels.
• New lymphocytes are manufactured in the lymph nodes;
• Antibodies and lymphocytes assist the body to build up an effective immunity to
infectious diseases.
• 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.
• It transports large molecular compounds (such as enzymes and hormones) from
their manufactured sites to the bloodstream.

10. • The lymphatic system has 3 functions:
FLUID
RECOVERY
IMMUNITY
LIPID
ABSORPTION

11. • FLUID RECOVERY:
 Each day, we lose an excess of 2
to 4 L of water and one-quarter
to one-half of the plasma protein.
 The lymphatic system absorbs
this excess fluid and returns it to
the bloodstream by way of the
lymphatic vessels

12. • IMMUNITY:
 As the lymphatic system
recovers excess tissue fluid, it
also picks up foreign cells and
chemicals from the tissues
 On its way back to the
bloodstream, the fluid passes
through lymph nodes, where
immune cells stand guard against
foreign matter.

13. • LIPID ABSORPTION:
 In the small intestine, special
lymphatic vessels called lacteals
absorb dietary lipids that are not
absorbed by the blood capillaries.

14. COMPONENTS OF LYMPHATIC SYSTEM

15. LYMPH
• Transudative fluid.
• Transparent & slightly
yellowish liquid.
• Alkaline in nature.
• Derived from tissue fluid.
• When blood passes through
tissues
9/10 of fluid - venous end
1/10 of fluid - lymph capillaries

16. COMPOSITION OF LYMPH
LYMPH

17. • Tubular vessels transport back lymph to the blood ultimately replacing
the volume lost from the blood during the formation of the interstitial
fluid.
Lymphatic
capillaries
and
vessels
Lymphatic
trunks
Lymphatic
ducts

18. FORMATION OF LYMPH:

20. HISTOLOGY OF LYMPHATIC SYSTEM
• The gaps between lymphatic endothelial cells are so large that bacteria
and other cells can enter along with the fluid.
• The overlapping edges of the endothelial cells act as valve like flaps
that can open and close.
• When tissue fluid pressure is high, it pushes the flaps inward (open)
and fluid flows into the lymphatic capillary.
• When pressure is higher in the lymphatic capillary than in the tissue
fluid, the flaps are pressed outward (closed).

21. • They have
• Tunica Interna with an endothelium and
valve,
• Tunica Media with elastic fibres and
smooth muscle, and
• Tunica Externa. Their walls are thinner and
their valves are more numerous than those
of the veins.

22. LYMPHATIC SYSTEM
• Lymphatic capillaries are
found around the cells of the
body (as are blood
capillaries).
• Blind ended.
• Slightly larger in diameter
and more permeable than
blood capillaries. Have
unique one-way flow.
• Permeable to components of
interstitial fluid

23. • LYMPHATIC VESSELS :
• Resemble veins in structure.
• Have thinner walls.
• Elastic tissue.
• Contain lots of valves to prevent
backflow.
• In skin- lie in subcutaneous tissue
and follows same route as veins.
• In viscera-follow arteries and
form plexuses around them.

24. • LYMPHATIC TRUNKS :
• Formed by the union of collecting vessels and drains large areas of
the body .
• Named after the areas they drain:
• lumbar trunks
• Broncho mediastinal trunks
• subclavian lymphatic trunk
• jugular trunks (all exist as pairs)
• single intestinal trunk.

25. RATE OF LYMPH FLOW:
• Total estimated lymph flow is 120 ml / hr .
• About 100 ml flows through Thoracic duct in resting man /hour .
• Approximately 20 ml flow into circulation through other channels .
• 3 – 4 litres / day

26. FLOW OF LYMPH
• Lymph takes the following route from the tissues back to the
bloodstream.
• Thus, there is a continual recycling of fluid from blood to tissue fluid
and to lymph and back to the blood.

27. All eventually drain
into two main
lymphatic ducts
RIGHT
LYMPHATIC
DUCT
LEFT
LYMPHATIC
DUCT
(THORASIC
DUCT)

28. STRUCTURE OF LYMPH NODE:
• A lymph node is an elongated or bean-shaped
structure, usually less than 3 cm long,
• often with an indentation called the hilum on
one side.
• It is enclosed in a fibrous capsule with
extensions (trabeculae) that incompletely
divide the interior of the node into
compartments
• The interior consists of a stroma of reticular
connective tissue (reticular fibers and
reticular cells) and a parenchyma of
lymphocytes and antigen- presenting cells

29. LYMPHOID CELLS:
• Lymphocytes - main cells involved in
immune response .
• T cells & B cells protect body against
antigens
• T cells –
• manage immune response by attacking &
destroying foreign cells
• B cells –
• produce plasma cells (daughter cells) , which
secrete antibodies into blood.
• Antibodies immobilize antigens until they can
be destroyed by phagocytes or by other means

30. OTHER LYMPHOID CELLS:
• Macrophages – phagocytize foreign
substances & help activate T cells.
• Dendritic cells – spiny-looking cells
with functions similar to macrophages
• Reticular cells – fibroblast like cells
that produce a stroma, or network, that
supports other cell types in lymphoid
organs.

31. LYMPHOID ORGANS:
• PRIMARY LYMPHATIC ORGANS :-
• Lymphatic (lymphoid) organs contain large numbers of lymphocytes,
a type of white blood cell that plays a pivotal role in immunity.
• The primary lymphatic organs are Red bone marrow and Thymus
gland
• Lymphocytes originate and/or mature in these organs.

33. BONE MARROW
• Bone marrow contains two types of cells multipotent stem cells .
• NON – LYMPHOID STEM CELLS
• differentiate in bone marrow.
• Eg. Erythrocytes , granulocytes , monocytes & platelets.
• LYMPHOID STEM CELLS
• differentiate in bone marrow & then migrate to lymphoid tissue. Eg. B
& T lymphocytes.

34. • THE SECONDARY LYMPHATIC
ORGANS :
• the spleen.
• the lymph nodes and
• other organs, such as the tonsils.
• All the secondary organs are the places
where lymphocytes encounter and bind with
antigens, after which they proliferate and
become actively engaged cells

35. • PALATINE TONSILS – second
pair of pharyngeal pouches
• 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

37. CLASSIFICATION OF LYMPH NODES IN
HEAD AND NECK REGION:
Superficial
lymph nodes
Deep lymph
nodes

38. LYMPH NODES OF HEAD AND NECK:

39. SUPERFICIAL LYMPH NODES
• The superficial cervical lymph nodes lie above the investing layer of the deep
fascia.
• They consist of a few small nodes that lie superficial to the external jugular and
anterior jugular veins.
• Superficial lymph nodes are –
 Submental
 Submandibular
 Buccal
Parotid
Post-auricular
 Occipital
 Anterior cervical
 Superficial cervical

40. SUBMENTAL LYMPH NODES
• Lie on mylohyoid muscle in the
submental triangle .
• 3 to 4 in number .
• Afferents – come from the chin, middle
part of lower lip, anterior gingiva ,
anterior floor of mouth and tip of
tongue.
• Efferents -they go to submandibular and
jugulo-omohyoid nodes

41. SUBMANDIBULAR LYMPH NODES
• Lie in digastric triangle superficial to
submandibular gland .
• They are 3 in number .
• Afferent : Centre of forehead, medial angle of the
eye, cheek and angle of mouth, upper lip, lateral
part of lower lip, frontal, maxillary and ethmoidal
sinuses, nasal vestibule and anterior part of nasal
cavity, gingiva, soft palate, anterior part of tongue,
sublingual salivary glands and submental lymph
nodes.
• Efferent: Mainly in jugulo-omohyoid and partly
in jugulo-diagastric.

42. PRE-AURICULAR LYMPH NODES
• Afferents- Upper part of forehead
and temporal bone, lateral part of
scalp, eyelid, lateral surface of
auricle, anterior wall of external
acoustic meatus, parotid gland,
infratemporal fossa, nasopharynx,
posterior part of nose.
• Efferent- Go into the upper deep
cervical group

43. POST-AURICULAR LYMPH NODES
• Lie superficial to
sternocleidomastoid and mastoid
process and deep to auricularis
posterior.
• Afferents -from the scalp,
posterior surface of pinna and skin
of mastoid.
• Efferent- drain into upper deep
cervical lymph nodes

44. OCCIPITAL LYMPH NODES
• They lie at the apex of the
posterior triangle, superficial
to trapezius and in close
relation with occipital artery.
• Afferents- come from
posterior occipital region of
scalp, skin of upper neck.
• Efferent- drain into
supraclavicular nodes

45. BUCCAL LYMPH NODES
• On the surface of buccinator
muscle in relation to facial
vein.
• Afferent – lower eye lid,
part of cheek , buccinator
muscle, facial vein
• Efferent - Submandibular
lymph node

46. ANTERIOR CERVICAL LYMPH NODES
• ANTERIOR CERVICAL
LYMPH NODES
• It lies along anterior jugular
vein and drains the skin of
anterior neck.

47. DEEP CERVICAL LYMPH NODES
• It consists of three chains, :
• Internal jugular
• Spinal accessory
• Transverse cervical

48. INTERNAL JUGULAR CHAIN
• Lymph nodes of internal jugular chain lie
anterior, lateral and posterior to internal
jugular vein.
• SUPERIOR DEEP CERVICAL
(jugulodigastric node, waldeyer’s ring,
adenoids) – drains oral cavity, oropharynx,
hypopharynx, nasopharynx, larynx and
parotid.
• MIDDLE GROUP drains oral cavity,
oropharyx,hypopharynx, larynx and thyroid.
• INFERIOR DEEP CERVICAL NODES
(jugulo- omohyoid) group- drains larynx,
thyroid and cervical oesophagus

49. JUGULO-DIGASTRIC GROUP OF LYMPH
NODES
• Situated below the posterior belly
of diagastric
• In triangular area bounded by
posterior belly of diagastric, facial
vein and internal jugular vein.
• Afferents- Posterior third of
tongue, palatine tonsil.
• Efferents-Drain into inferior
group of deep cervical or directly
into jugular trunks

50. WALDEYER’S LYMPHATIC 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.
• It was named after the nineteenth century German anatomist Heinrich
Wilhelm Gottfried von waldeyer-Hartz.
• The ring consists of (from superior to inferior)
Pharyngeal tonsil (also known as 'adenoids' when infected)
 Tubal tonsil (where Eustachian tube opens in the nasopharynx)
 Palatine tonsils (commonly called "the tonsils" in the vernacular, less
commonly termed "faucial tonsils")

51. • At the entrance to the pharynx there is a
considerable amount of lymphoid tissue.
• Grouped in the circular fashion.
• Formed superiorly by the pharyngeal
tonsil, inferiorly by the lingual tonsil and
laterally by the palatine tonsil and the
tubal tonsil. This is known as internal ring
of waldeyer .
• It drain into peri cervical chain and upper
deep cervical nodes which together
constitute the external ring of waldeyer.

52. ADENOIDS
• Inframastoid nodes
lying below the tip of
mastoid process
under cover of SCM
• Receive lymph from
pharyngeal
tonsils(adenoids)

53. JUGULO-OMOHYOID LYMPH NODES
• Lies above inferior belly of
omohyoid where it crosses the
internal jugular vein.
• Extend to subclavian triangle .
• Related to subclavian vessels and
brachial plexus.
• Afferents- directly from tongue,
indirectly through superficial
nodes
• Efferents – Inferior deep cervical
lymph nodes

54. SPINAL ACCESSORY CHAIN
• Lies along the spinal accessory nerve.
• Afferents- Spinal accessory chain
drains the scalp, skin of the neck, the
nasopharynx, occipital and
postauricular nodes.
• Efferents- From this chain, drain into
transverse cervical chain

55. TRANSVERSE CERVICAL CHAIN
• It lies horizontally, along the transverse cervical
vessels, in the lower part of the posterior triangle.
• The medial nodes of the group are called scalene
nodes.
• Afferents to those nodes come from the accessory
chain and also infraclavicular structures, e.g. breast,
lung, stomach, colon, ovary and testis.
• Efferents Jugular trunk or directly into thoracic duct
or right lymphatic duct or independently into
junction of internal jugular vein and subclavian vein

56. REGIONAL LYMPH NODES
• Retro-pharyngeal
• Infra-hyoid
• Pre-laryngeal
• Pre-tracheal
• Para-tracheal

57. RETROPHARYNGEAL LYMPH NODES
• Located between pharynx
& atlas.
• Afferents-
 Pharynx , Auditory tube ,
Soft palate , posterior part
of hard palate, Nose.

58. PARA-TRACHEAL LYMPH NODES
• Afferents –
Neighbouring
structures, thyroid
gland
• Efferents – Deep
cervical lymph
nodes &
Paratracheal node

59. INFRAHYOID, PRE-TRACHEALAND
PRE-LARYNGEAL LYMPH NODES
• Afferent – Anterior cervical
nodes
• Efferent – Deep cervical
lymph nodes Infrahyoid
node Prelaryngeal node
Pretracheal node

60. DRAINAGE OF THE SKIN OF HEAD AND
NECK REGION
• The scalp drains into the occipital, mastoid
and parotid nodes.
• Lower eye lid and anterior cheek drains
into buccal nodes.
• The cheeks drain into the parotid, buccal
and submandibular nodes.
• The upper lips and sides of the lower lips
drain into the submandibular nodes.
• While the middle third of the lower lip
drains into the submental nodes.
• The skin of the neck drains into the
cervical nodes.

61. DRAINAGE OF ORAL STRUCTURES
• The Gingiva drain into the submandibular, submental and upper deep
cervical lymph nodes.
• The palate drains via lymph vessels that pass through the pharyngeal
wall to the upper deep cervical nodes.
• Anterior part of mouth floor drain into submental and upper deep
cervical while posterior part into submandibular and upper deep
cervical.

62. DRAINAGE OF EXTERNAL NOSE
• Lymphatic drainage of external nose is primarily to the submandibular
group of nodes although lymph from the root of the nose drains to
superficial parotid nodes.

63. DRAINAGE OF NASAL CAVITY
• Lymph vessels from the anterior region of the nasal cavity pass
superficially to join those draining the external nasal skin, and end in
the submandibular nodes.
• The rest of the nasal cavity, paranasal sinuses, nasopharynx and
pharyngeal end of the pharyngotympanic tube, all drain to the upper
deep cervical nodes either directly or through the retropharyngeal
nodes.
• The posterior nasal floor drains to the parotid nodes.

64. DRAINAGE OF TONGUE
• The lymphatic drainage of the tongue
can be divided into 3 main regions:
Marginal, Central and Dorsal.
• Tip – submental nodes
• Anterior 2/3 laterally – ipsilateral
submandibular nodes
• Anterior 2/3 centrally – submandibular
nodes
• Posterior 1/3 – jugulo- omohyoid
• Ultimately drains into jugulo-
omohyoid and deep cervical nodes

65. LYMPHATIC DRAINAGE OF TEETH
• The lymph vessels from the teeth usually run directly into the
ipsilateral submandibular lymph nodes.
• Lymph from the mandibular incisors, however, drains into the
submental lymph nodes.
• Occasionally, lymph from the molars may pass directly into the
jugulo-digastric group of nodes

67. EXAMINATION OF LYMPH NODES
• HISTORY
• Age
• Duration
• Group first affected
• Pain
• Fever
• Primary focus
• Loss of appetite & wt.Loss
• Pressure effects
• Past history
• Family history

68. • AGE :
• Tuberculosis and syphilis -primary malignant lymphomas affect young age.
• Acute lymphadenitis can occur at any age.
• Secondary malignant lymphomas – old age
• DURATION:
• Short (acute lympahadenitis)
• Long (chronic lymphadenitis , tuberculosis)
• GROUP AFFECTED FIRST : Eg:
• cervical group affects first in Hodgkin’s disease , tuberculosis etc where as
inguinal lymphnode affects first in filariasis

69. • 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 lymphadenitis.
• PAIN:
• Acute and chronic infection are painful .
• where as painless in syphilis , primary malignant lymphomas and secondary
carcinoma.
• FEVER:
• Evening rise of temperature is characteristic feature of TB.
• Periodic fever in filaria (once in month)
• Pel-ebstein fever – Hodkins disease

70. • LOSS OF APPETITE & WEIGHT:
• incase of malignant lymphadenopathis.
• PRESSURE EFFECTS: Eg.
• Dysphagia may occur when oesophagus is pressured.
• PAST HISTORY :
• Enlargement of suboccipital group of lymph nodes may be enlarged in
secondary stage of syphilis.
• A patient who presents with enlarged cervical group of lymph nodes may give
a past history of tuberculosis.
• FAMILY HISTORY :
• Sometimes history of tuberculosis in families

71. •INSPECTION
• Presence of a swelling
• number
• Position
• size
• surface skin over the swelling
• Pressure effects

72. • NUMBER
• Single or multiple.
• A few conditions are known to produce generalised involvement of lymph
nodes like Hodgkin’s disease , Tuberculosis , 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 induration.
• 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.

73. • 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.
• Hypoglossal nerve may be involved from enlarged upper group of cervical
lymph nodes due to Hodgkin’s disease or secondary carcinoma.

74. • PALPATION
• Number and situation
• Local temperature
• Tenderness
• Palpation consistency
• Surface and margins
• Fixity

75. • 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;
• Soft (fluctuating)
• Elastic & rubbery (hodgkin’s disease)
• Firm, discrete and shotty (syphilis)
• Stony hard (secondary carcinoma)
• MATTING :
• A group of lymph nodes that feels connected and move as a unit is known as
matted.
• Eg. Acute lymphadenitis, Metastatic Carcinoma, Tuberculosis

76. • FIXITY TO SURROUNDING STRUCTURES :
• The enlarged lymphnode 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 surrouding structures- first to deep fascia &
underlying muscle followed by adjoining structures and ultimately
overlying skin

77. SUBMENTAL NODES
• 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.

78. SUBMANDIBULAR NODES
• 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 maneuverer helps relaxing the muscles and fascia of
neck, thereby allowing easy examination.
• The fingers of the palpating hand should be kept together to
prevent the nodes from slipping in between them.
• 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.

79. PAROTID LYMPH NODES
• They are palpated
anterior to the
tragus of the ear.

80. POSTAURICULAR LYMPH NODES
• Are palpated behind the ear,
on the mastoid process

81. OCCIPITAL LYMPH NODES
• Palpated at the base lower
border of skull.

82. ANTERIOR CERVICAL LYMPH NODES
• Nodes that lie both on top of
and beneath the
sternocleidomastoid muscles
(SCM) on either side of the
neck, from the angle of the
jaw to the top of the clavicle.

83. POSTERIOR CERVICAL LYMPH NODES
• Extend in a line posterior to
the SCMs but in front of the
trapezius, from the level of
the mastoid bone to the
clavicle.

84. TRANSVERSE CERVICAL NODES
SUPRACLAVICULAR (SCALENE
NODES)
• Roll your fingers gently
behind the clavicles.
Instruct the patient to
cough .
• Occasionally an enlarged
lymph node may pop up

85. CLINICAL ASPECTS
• When a lymph node is under challenge from a foreign antigen, it may
become swollen and painful to the touch— a condition called
lymphadenitis.
• Commonly palpated and accessible lymph nodes are - the cervical,
axillary, and inguinal. Lymph nodes are common sites of metastatic
cancer because cancer cells from almost any organ can break loose,
enter the lymphatic capillaries, and lodge in the nodes.
• Lymphadenopathy is a collective term for all lymph node diseases

86. LYMPHADENOPATHY
• Lymphadenopathy is usually an immune response of the
lymph nodes to an infection elsewhere in the body.
• TYPES
• Localized :
Localized or regional lymphadenopathy Implies involvement
of a single anatomic area. The site of localized or regional
adenopathy may provide a useful clue about the cause. e.g.
Occipital lymphadenopathy often reflects an infection of the
scalp, and preauricular lymphadenopathy accompanies
conjunctival infections.
• Generalized
Generalized lymphadenopathy: It has been defined as
involvement of three or more noncontiguous lymph node

87. 1.Infectious disease
A. Viral
-Infectious mononucleosis
-Infectious hepatitis
-Herpes simplex
-Rubella
-Measles
-HIV
B. Bacterial
-Cat scratch disease
-Brucellosis
-Tuberculosis
-Atypical mycobacterial infection
-Primary and secondary syphilis
-Diptheria

88. C. Fungal
-Histoplasmosis
-Coccidioidomycosis
D. Parasitic
-Toxoplasmosis
-Filariasis
E. Chlamydial
-Lymphogranuloma venerum
- Trachoma
2. Immunologic disease (generalized lymphadenopathy)
A. Rheumatoid arthritis
B. Systemic lupus erythematous
C. Sjogren syndrome
D. Drug hypersensitivity

89. 3. Malignant disease
a. Hematological
• -Hodgkin’s lymphoma
• -Non Hodgkin’s lymphoma
• -Hairy cell leukemia
• -T-cell lymphoma
• -Multiple myeloma
b. Metastasis -From primary site
4.Lipid storage disease
• -Gaucher’s disease
• -niemann-pick disease

90. 5.Endocrine disease
• -Hyperthyroidism
• -Adrenal insufficiency
• -Thyroiditis
6.Other disorder
• Sarcoidosis
• Lymphomatoid granulomatosis
• Kawasaki disease
• Histocytosis x

91. • Acute bilateral cervical lymphadenopathy-
• viral upper respiratory tract infection or streptococcal pharyngitis.
• Acute unilateral cervical lymphadenitis-
• streptococcal or staphylococcal infection in 40% to 80% of cases.
• The most common causes of subacute or chronic lymphadenitis are :
• cat scratch disease
• mycobacterial infection
• and tuberculosis.
• Supraclavicular or posterior cervical lymphadenopathy carries a much
higher risk for malignancies than anterior cervical lymphadenopathy.

92. • Lymphadenitis is an infection in the lymph nodes.
• Acute lymphadenitis:-
• Most common in children
• Enlarged painful / tender lymph nodes, redness of overlying skin, low grade
fever, malaise
• Accumulation of neutrophils, vascular dilatation and edema of the capsule
• Chronic lymphadenitis:-
• Nonspecific etiology
• Increased number of immunoblasts, plasma cells, histiocytes and fibrosis
• Painless
LYMPHADENITIS

93. DISEASES OF THE LYMPHATIC SYSTEM
ASSOCIATED WITH LYMPHATIC VESSELS
• A)Lymphedema:
• Swelling of tissues of extremities due to obstruction
of lymphatics and accumulation of lymph
• Congenital(milroys disease) and acquired
• B)Lymphangitis:
• Acute infection of vessels which is due to invasion by
an infectious organism
• Thin red streaks extending from an infected region up
the arms and leg

94. LYMPHOMA
A)HODGKINS LYMPHOMA
B) NON HODGKINS LYMPHOMA
C)BURKIT’S LYMPHOMA
D)INFECTIOUS MONONUCLEOSIS
HODGKINS LYMPHOMA
• Binodal
• Peaking age between 15-34 years
• Painless enlargement of one or more cervical lymphnodes
• Nodes are firm and rubbery and overlying skin is normal
• Weight loss,fever,night sweats

95. • NON HODGKINS LYMPHOMA
• Seen in older than 50 years
• B-cell NHL is more seen in children and young adults
• Lymphadenopathy is more common manifestation
• Systemic symptoms like Weight loss,fever,night sweats
• Etiology-environmental factors,EBV in burkitts, immunocompromised
patients
• Genetic abnormalities
• Burkitts lymphoma
• Type of non hodgkins lymphoma
• Mostly seen in tropical central Africa and is endemic to Africa
• It’s a high grade B-cell neoplasm
• Mostly soft tissue mass associated involving jaw and other facial
bones,enarged cervical lymphnodes,abdominal masses and ascites
• Endemic and sporadic forms

96. Ludwigs angina:
• Acute cellulitis beginning in submandibular space
• Commonly dental origin
• Main tooth involved are mand second and third molars
• Features-elevation of tongue,difficulty in swallowing and breathing
• Treated by maintaining a proper airway, anitibiotic therapy and extraction of
infected teeth

97. ONCOLOGICAL CLASSIFICATION
• The lymph nodes describe the neck dissection, the neck is divided into
6 areas called Levels.
• The levels are identified by Roman numeral, increasing towards the
chest. A further Level VII to denote lymph node groups in the superior
mediastinum is no longer used.
• Instead, lymph nodes in other non-neck regions are referred to by the
name of their specific nodal groups.

98. ONCOLOGIC CLASSIFICATION
• Ia Submental
• Ib Submandibular
• IIa Upper jugular (Anterior to XI)
• IIb Upper jugular (Posterior to XI)
• III Middle jugular
• IVa Lower jugular (Clavicular)
• IVb Lower jugular (Sternal)
• Va Posterior triangle (XI)
• Vb Posterior triangle (Transverse cervical)
• VI Central compartment
• VII Superior mediastinal nodes Subgroups

99. N – STAGING OF LYMPH NODES

100. INVESTIGATIONS
The laboratory investigation of patients with lymphadenopathy must be
tailored to elucidate the etiology suspected from the patient's history and
physical findings
COMPLETE BLOOD COUNT:
CBC Provide useful data for the diagnosis of
• acute or chronic leukemias,
• EBV or CMV mononucleosis,
• lymphoma with a leukemic component,
• pyogenic infections, or
• immune cytopenias in illnesses such as SLE. 93

101. • SEROLOGICAL STUDIES may demonstrate
• antibodies specific to components of EBV, CMV, HIV, and other viruses;
Toxoplasma gondii
• Brucella
• antinuclear and anti-DNA antibody in case of SLE
• CHEST X-RAY
• Usually negative
• The presence of a pulmonary infiltrate or mediastinal lymphadenopathy would
suggest tuberculosis, histoplasmosis, sarcoidosis, lymphoma, primary lung
cancer, or metastatic cancer

102. LYMPH NODE BIOPSY
• The indications for biopsy are imprecise, yet it is a valuable diagnostic tool.
• The decision to biopsy may be made early in a patient's evaluation or delayed
for up to two weeks.
• Prompt biopsy should occur if the patient's history and physical findings
suggest a malignancy.
• FINE NEEDLE ASPIRATION CYTOLOGY (FNAC)
• It should not be performed as the first diagnostic procedure.
• Fine-needle aspiration should be reserved for thyroid nodules and for
confirmation of relapse in patients whose primary diagnosis is known

103. • ULTRASONOGRAPHY :
• Normal cervical nodes appear sonographically as somewhat flattened
hypoechoic structures with varying amounts of hilar fat.
• US appearance of normal lymph node. Image shows flattened
hypoechoic cigar-shaped structure (arrow)
• Malignant infiltration alters the US features of the lymph nodes,
resulting in enlarged nodes that are usually rounded and show
peripheral or mixed vascularity.
• Using these features, US has been shown to have an accuracy of
89%– 94% in malignant from benign cervical lymph nodes

104. Criteria for US:
(1) A lymph node with definite internal echoes is defined as malignant.
(2) A lymph node with hilar but no definite internal echoes is defined as
benign.
(3) A lymph node with a L/S ratio of 3.5 or more is considered benign
(4)A lymph node measuring 10 mm or more in the short axis is defined
as malignant.
(5) A lymph node which can not be associated to categories 1 to 4 is
considered to be `questionable'

105. • COMPUTED TOMOGRAPHY (CT):
• CT remains the most widely used modality for neck imaging.
• The CT examination is performed in the axial plane with contiguous
sections of 3 ± 5 mm whilst a bolus of intravenous contrast media is
administered.
• CT criteria for assessing lymph node metastasis are based on size,
shape, the presence of central necrosis and the appearance of a cluster
of nodes in the expected lymph drainage pathway for the tumour

106. SURGICAL IMPLICATIONS
• COMPREHENSIVE NECK DISSECTION
• 1. Classical radical neck dissection
• 2. Extended radical neck dissection
• 3. Modified radical neck dissection
• TYPE – I
• TYPE – II
• TYPE - III MANAGEMENT

108. RADICAL NECK DISSECTION
• Refers to the removal of all ipsilateral cervical lymph node groups
extending from the inferior border of the mandible to the clavicle,
from the lateral border of the sternohyoid muscle, hyoid bone, and
contralateral anterior belly of the digastric muscle medially, to the
anterior border of the trapezius.
• Included are levels I– V.
• This entails the removal of three important, non-lymphatic structures:
• the internal jugular jugular vein,
• the sternocleidomastoid muscle, muscle,
• and the spinal accessory nerve.

109. MODIFIED RADICAL NECK
DISSECTION
• Refers to removal of the same lymph node levels (I–V) as the radical
neck dissection, but with preservation of the spinal accessory nerve,
the internal jugular vein, or the sternocleidomastoid Muscle.
• Subdividing the modified neck dissection into three types:
• Type I preserves the spinal accessory nerve;
• Type II preserves the spinal accessory nerve and the
sternocleidomastoid muscle; and
• Type III preserves the spinal accessory nerve, the sternocleidomastoid
muscle, and the internal jugular vein;

110. SELECTIVE NECK DISSECTION
• Refers to the preservation of one or more lymph node groups normally
removed in a radical neck dissection.

111. EXTENDED NECK DISSECTION
• The term extended neck dissection refers to the removal of one or
more additional lymph node groups, non-lymphatic structures or both,
not encompassed by a radical neck dissection.
• for example, mediastinal nodes or non-lymphatic structures, such as
the carotid artery and hypoglossal nerve.