The document discusses the lymphatic system and lymph nodes. It describes the anatomy and functions of the lymphatic system. This includes how lymph is formed, the components of the lymphatic system, and the roles of lymph nodes. It then details the specific lymph nodes of the head and neck region, including their locations, drainage patterns, and methods for examination. Finally, it covers clinical aspects such as lymphadenopathy and the involvement of lymph nodes in carcinoma and metastasis.

1. Guided By: Dr Madan N
Presented By: Sanskriti Shah

2. 1. Introduction
2. Components of the Lymphatic System
3. Development
4. Anatomy
5. Drainage of various lymph nodes
6. Examination of lymph nodes
7. Clinical aspects
8. Applied aspects
9. Role of lymph nodes in Carcinoma
10. References

3. • The lymphatic system is a closed
network in which lymph flows
from the tissue spaces towards
blood.
• It is a one-way system.
• It is responsible for defense attack
to any microorganisms that gain
entry into the body.

4. The lymphatic system comprises of :-
1. Lymph
2. Lymphatic vessels
3. Lymphatic tissue
4. Lymph Organs

5. • Lymph is formed from interstitial fluid, due to the permeability of lymph
capillaries.
• The composition of lymph is more or less similar to the interstitial fluid
including the protein content.

6. • When blood passes via blood
capillaries in the tissues, 9/10th
of fluid passes into venous end
of capillaries from the arterial
end.
• The remaining 1/10th of the
fluid passes into lymph
capillaries, which have more
permeability than blood

8. The functions of lymph are –
1. Redistribution of fluid inside the body
2. Transfer proteins back to the blood
3. To remove bacteria, viruses and toxins from blood and
various tissue spaces.
4. To maintain the structural and functional integrity of
tissues.
5. Helps in intestinal fat absorption.
6. Plays a role in immunity by transporting lymphocytes.

9. • Also known as Defense Barriers.
• Lymph ultimately drains into lymph nodes.
• They serve as filters which filter bacteria and toxic
substances from the lymph.

11. 1. Cortex- It consists of primary and secondary lymphoid follicles.
2. Paracortex- It lies between the coretx and medulla. It contains T lymphocytes.
3. Medulla- It contains both B and T lymphocytes and macrophages.
Blood vessels are found here.
4. Afferent Vessels- They enter the lymph nodes.
5. Efferent Vessels- They exit the lymph nodes.
ANATOMY OF LYMPH NODES

12. DRAINAGE OF LYMPHATIC SYSTEM

13. The lymph nodes of head and neck are
broadly classified into two groups :
1. Horizontal group
2. Vertical group

15. They are also classified as
1. Superficial nodes
2. Deep nodes

16. Superficial lymph nodes:
1. Submental
2. Submandibular
3. Buccal
4. Preauricular
5. Postauricular
6. Occipital
7. Anterior cervical
8. Superficial cervical
Deep lymph nodes:
1. Prelaryngeal & Pretracheal
2. Paratracheal
3. Retropharyngeal
4. Deep cervical

17. Submental lymph nodes
Location: Between anterior
bellies of digastric muscle in
submental triangle
Drains from:
a. Tip of tongue
b. Floor of tongue
c. Lower incisors
d. Central part of lower lip
e. Skin of chin
Drains into: Submandibular and
deep cervical nodes

18. Submandibular lymph nodes
Location:
a. Superficial surface
of submandibular salivary
gland
b. Beneath investing layer of
deep cervical fascia
Drains from:
a. Front of scalp
b. Anterior part of nasal cavity, palate and gingiva
c. Cheeks
d. Upper lip
e. Lower lip except the central part
f. Frontal, anterior and posterior ethmoidal and maxillary sinus
g. Upper teeth
h. Lower teeth except the incisors
i. Anterior 2/3rd of tongue
Drains into: Deep cervical nodes

19. Buccal lymph nodes
Location: Over the Bucciantor
muscle over the Facial vein
Drains from: Eyelids, cheeks,
mid portion of face; rarely
gingiva and palate
Drains into: Submandibular
lymph nodes

20. Parotid lymph nodes
Location: On/within the parotid
gland
Drains from: a. Strip of scalp above
parotid gland
b. Lateral surface of auricle.
c. Anterior and lateral wall of external
auditory meatus
d. Lateral wall of eyelid
Drains into: Upper deep cervical
nodes

21. Mastoid/Retroauricular nodes
Location: Lateral surface of mastoid
process of temporal bone
Drains from: a. Strip of scalp over
the auricle
b. Posterior wall of external auditory
meatus
Drains into: Deep cervical nodes.

22. Occipital nodes
Location: At the apex of
posterior triangle of neck
Drain from: Back of scalp
Drain into: Posteroinferior
group of deep cervical nodes

23. Anterior superficial cervical lymph nodes
Location: Lies along the anterior jugular vein
Drains from: Anterior part of neck
below the hyoid bone
Drains into: Deep cervical lymph
nodes

24. Lateral Superficial Cervical Lymph Nodes
Location: Lies
along the external
jugular vein
superficial to the
sternocleidomastoid
Drains from: a. Lobules of auricle
b. Floor of external acoustic meatus
c. Skin of the lower parotid region
d. Angle of the jaw
Drains into: Upper and lower deep
cervical nodes

25. Prelaryngeal and Pretracheal lymph nodes
Location: Prelaryngeal nodes lie
in the cricothyroid membrane
Pretracheal nodes lie anterior
to trachea below the isthmus
of thyroid gland
Drains from: Larynx, trachea,
Isthmus of thyroid
Drains into: Deep cervical nodes

26. Paratracheal lymph nodes
Location: Along the sides of
trachea and oesophagus
along the external laryngeal
nerve
Drains from: Oesophagus,
trachea, larynx
Drains into: Deep cervical
nodes

27. Retropharyngeal lymph nodes
Location: Between buccopharyngeal
and prevertebral fascia.
Drains from: a. Nasopharynx
b. Posterior etmoidal and sphenoidal
sinuses
c. Pharyngeal end of auditory tube
d. Soft palate
e. Posterior part of hard palate
Drains into: Deep cervical nodes

28. Jugulo-digastric nodes
Location: Lies below the
posterior belly of digastric
between angle of mandible
and anterior border of
Sternocleidomastoid
Drains from: It is the main
node draining the tonsils.
DEEP CERVICAL

29. Jugulo-omohyoid lymph nodes
Location: Lies above the
omohyoid just above the
sternocleidomastoid
Drains from: It is the main
lymph node of the tongue

30. Extra nodal Lymphoid tissue
Waldeyer’s 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.
Heinrich Wilhelm Gottfried von Waldeyer-Hartz.

32. INSPECTION
The person’s head, face and neck should be observed for any asymmetry,
enlargement or erythematous appearance in the area of lymph nodes.
PALPATION AND EXAMINATION
All lymph nodes have to be duly palpated to observe number, change in
consistency, size and shape
EXAMINATION OF LYMPH NODES

33. Submental lymph nodes
Examination: Roll the fingers below the chin with patient’s
head tilted forwards and bent so that the muscles and fascia
in that region relaxes.

34. Submandibular lymph nodes
Examination: Roll your fingers in the inferior and inner surface of the
mandible with patient’s head slightly tilted to the ipsilateral side

35. Parotid lymph nodes
Examination: Roll your fingers in front of the ear; against
the maxilla.

36. Mastoid/Retroauricular nodes
Examination: Roll the fingers behind the ear, on the
mastoid process

37. Occipital nodes
Examination: Palpated at the base of lower border of the skull

38. Examination of cervical lymph nodes

41. Levels of Lymph Nodes
Ooncologic classification

43. Level I - all nodes above hyoid
bone, below mylohyoid muscle,
and anterior to posterior edge of
submandibular gland
Level IA - all nodes between
medial margins of anterior
digastric muscles, above hyoid
bone, below mylohyoid muscle
Level IB - all nodes below
mylohyoid muscle, above hyoid
bone, posterior and lateral to
medial anterior digastric
muscle and anterior to
submandibular gland

44. 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
Anterior to internal jugular
vein and are inseperable 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
vein

45. Level III - all nodes between hyoid bone
and cricoidcartilage arch and anterior to
posterior
sternoclediomastoid muscle and lateral to
the internal carotid artery
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

46. 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
sternocleidomastoid muscle
Level VB - all nodes between cricoid
cartilage arch and clavicle, behind
sternoclediomastoid muscle

47. 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 sterni, between medial
margins of common carotid arteries
bilaterally, extending
inferiorly to level of innominate vein

48. TNM staging first reported by Pierre Denoix in 1940s
Adapted by the International Union Against Cancer (UICC) in
1968 for 23 body sites
Consistent for all mucosal sites except the nasophaynx and
hypopharynx
Thyroid, hypopharynx and nasophaynx have different staging
based on tumour behaviour and prognosis
TNM Staging

51. LYMPHANGITIS
Acute inflammation of
vessels due to infection
Thin red streaks are seen
extending from an infected
region up the arms and leg

52. LYMPHADENITIS
Infection of lymph node because of infectious organism.
It Can be
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

53. Chronic lymphadenitis:-
- Nonspecific etiology – recurrent dental infection, recurrent
tonsillitis
- Increased number of immunoblasts, plasma cells, histiocytes
and fibrosis
-Painless

54. LYMPHOEDEMA
• Swelling of tissues of extremities due to obstruction of lymph
capillaries or nodes.
• It can either be congenital (Milroy’s disease) or acquired.
• Commonly it is a complication of cancer
treatment or parasitic infections

56. LYMPHADENOPATHY:
Enlargement of one or more lymph nodes either by
infection or neoplasms.

57. It may be acute or chronic.
It can also be classified as:
1. Localized: When only one group of lymph node is enlarged.
For example: Mumps
2. Generalized: When three or more than three groups of lymph nodes are
enlarged
For example: Infectious mononucleosis, Systemic lupus erythematosus
Its etiological factors are:
1. Infectious
2. Immunologic
3. Malignant

58. Change in consistency
a. Soft: Infections / inflammation
b. Discrete and shotty: Syphilis
c. Shotty - Children with viral illnesses.
d. Stony hard - Metastatic cancer.
e. Firm, rubbery - Lymphoma
f. Matted - Tuberculosis

59. HODGKINS LYMPHOMA
• Bimodal
• Peak age between 15-34 years
• Painless enlargement of one or more cervical lymph nodes
• Nodes are firm and rubbery and overlying skin is normal
• Weight loss, fever, night sweats

60. 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 involving submental,
submandibular, postauricular,
occipital.
• Systemic symptoms like Weight
loss,fever,night sweats
• Etiology-environmental factors,
immunocompromised patients
• Genetic abnormalities

61. 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,
enalrged cervical lymphnodes, abdominal
masses and ascites
• Endemic and sporadic forms

62. Lymph nodes contribute in the metastasis
of carcinoma.
Their change in size and shape can lead to
staging and grading of the tumour.

63. Routes of metastasis:
1 Lymphatic spread
2 Haematogenous spread
3 Spread along body cavities, natural passages
( transcoelomic fluid, CSF)

64. 1st nodal station reached by lymphatic drainage of
an organ: 1st echelon nodal group
1st echelon L.N. connect to each other through
post-lymphnodal collecting ducts and finally drain
to more central efferent L.N. or directly into the
venous system through the main lymphatic trunk
Echelon Lymph Nodes

65. Virchow’s Nodes
Signal nodes/ seat of the devil/
supraclavicular adenopathy
Enlarged, hard L.N. in the
left supraclavicular fossa:
Troisier’s sign
Associated with metastasis
from SCC of the head and
neck, primary lung cancer,
esophageal cancer,
cancer in the abdomen
and pelvic region

66. REFERENCES
• Richard L.Drake,GRAY’S Anatomy for students
• BD Chaurasia
• SRB
• Manipal manual of surgery - shenoy
• E. LLOYD DuBRUL, Shicher’s Oral anatomy
• A.C.Guyton & J.E. Hall; T.B of Medical Physiology
• Eugene N. Myers et al.; CANCER of Head & Neck
• Michael Miloro, Peterson’s Principles of OMFS

67. THANK YOU