Lymphatic drainage of the head and neck drains to various lymph nodes in the head and neck region. The lymphatic system has clinical implications for conditions affecting the lymph nodes like lymphadenopathy, lymphadenitis, and metastasis. Palpation of lymph nodes in specific areas of the head and neck can provide information to evaluate lymphadenopathy and its potential causes.

1. LYMPHATIC DRAINAGE OF
HEAD AND NECK AND ITS
CLINICAL IMPLICATIONS
KARISHMA.S
I MDS
Pedodontics
R.V Dental college

2. CONTENT
S
 Introduction
 Embryological aspects
 Lymphatic system
 Anatomy- Lymphatic drainage
- Site Specific Lymphatic drainage
 Clinical implications- Palpation
- Lymphadenopathy
- Lymphadenitis
- Metastasis
 Conclusion
 references

3. LYMPH is a transparent, usually slightly yellow, often
opalescent liquid found within the lymphatic vessels, and
collected from tissues in all parts of the body and returned
to the blood via lymphatic system. Its cellular component
consists chiefly of lymphocytes.
( BY DORLAND MEDICAL DICTIONARY)
 One way system of lymph flow from tissue
spaces towards blood.
INTRODUCTION

4. EMBRYOLOGICAL ASPECT
 Lymphoid system begins to develop in
the end of 5th week of fetal life
 One view states that the lymphatics
develop as diverticulae of the
endothelium of veins ; whereas
another states that like other blood
vessels they develop from clefts in the
mesenchyme that connect with the
venous system secondarily.

5. ANATOMY OF LYMPHATIC VESSELS
 Lymphatic capillaries resemble veins in structure except in
They have -thinner walls
-more valves
-lymph nodes at intervals
 The walls of vessel is formed by thinner large endothelial cells
 White collagenous fibres are attached with the endothelium of the
lymph channels
 Semilunar valves are extremely numerous in lymphatics
 Vessels have the capacity for repair and regeneration

7. Lymphatic system
 Lymphatic vessels
 Lymph nodes
 Lymphatic trunks and
duct

8. ORGANIZATION OF LYMPHATIC SYSTEM
Lymphatic capillaries
Small lymph vessels
Large lymph vessels
Thoracic duct (left) and right
lymphatic duct
Right and left subclavian

9. RATE OF FLOW OF LYMPH
 0.5 -1 ml/min in thoracic duct
 within 24 hours 2-4 litres of
lymph is drained into the
lymphatic system
Mechanism of movement of lymph
 By rhythmic contraction of lymphatic vessels
 By transmitted pulsations for neighbouring arteries
 By the contraction of neighbouring muscles
 Negative intrathoracic pressure during inspiration

10. FACTORS AFFECTING LYMPH FORMATION
AND LYMPH FLOW
 Capillary hydrostatic pressure
 Capillary osmotic pressure
 Capillary surface area
 Capillary permeability
 Functional activity of organs
 Pressure gradient
 ECF volume

11. LYMPH NODES

12. COMPOSITION OF LYMPH
LYMPH
OTHERS (4%)
SOLIDS
PROTEINS
LIPIDS
CARBOHYDRATES
AMINOACIDS
NON-NITROGENOUS SUSTANCES
ELETROLYTE
CELLULAR
LYMPHOCYTE
MONOCYTE,MACROPHAGES ,
PLASMA CELL
Water (96%)

13. FUNCTIONS OF LYMPH
Transfer of proteins from tissue spaces into
blood(200gms/day).
Re-distribution of fluid in the body.
Defence-Removal of bacteria,toxins and other foreign
bodies.
Maintenance of structural and functional integrity of
tissue
Absorption and transport of long chain fatty acids and
cholesterol bt lacteals of intestine
Nutritive function
Immune function

14. CLASSIFICATION OF LYMPH NODES
ACCORDING TO THE ANATOMICAL POSITION
Circular groups ( arranged around base of skull ):
A. Outer circle
i. Submental group
ii. Submandibular group
iii. Buccal and facial group
iv. Preauricular (parotid) group
v. Postauricular (mastoid) group
vi. Occipital group
B. Inner circle
i.Retropharyngeal
ii.Pretracheal
iii.Paratacheal

15. MEMORIAL SLOAN KETTERING CANCER
CENTER 1981
•Level I -Submental and
Submandibular
•Level II- upper jugular
•Level III - Mid-jugular
•Level IV -Lower jugular
•Level V - Posterior triangle
(Spinal accessory)
•Level VI- Prelaryngeal (Delphian),
Pretracheal, Paratracheal
•Level VII - Upper mediastinal

16. Lymph nodes in
head and neck
SUPERFICIAL
GROUP
DEEP
GROUP
DEEPEST
GROUP
Lymphatic
drainage
Horizontal vertical

17. SUPERFICIAL GROUP
A)BUCCAL AND MANDIBULAR
NODES:
 Buccal-lies on buccinators
 Mandibular-lies at the lower border of
mandible near anterio inferior angle of
the masseter
 They drain part of cheek and lower eye
lids.
 Their efferents pass to the anterio
superior group of deep cervical nodes.

18. B)pre auricular
 One to three in number
 Lies immediately in front of tragus
 Drains infraorbital region,parotid
gland,temporal region,middle ear,eye
etc

19. C)Post auricular(mastoid) nodes:
 Lies on the mastoid process
superficial to SCM
 Drains a strip of scalp above and
behind the auricle,margin of
auricle,posterior wall of external
acoustic meatus
 Efferents pass to the posterior group
of deep cervical nodes

20. d)occipital nodes
 They lie at the apex of the
posterior triangle
 Drains occipital region of scalp
 Efferents drain into
posterioinferior group of deep
cervical nodes.

21. E)Anterior superficial cervical nodes
Lie along the anterior jugular vein
Suprasternal lymphnode is a member
of this group
Drains the anterior part of the neck
below the hyoid bone
Efferents pass to deep cervical lymph
nodes of both sides

22. F)lateral superficial cervical nodes
 Lie along the external jugular vein
superficial to SCM
 Drains lobules of auricle,floor of
external acoustic meatus,skin over
the lower parotid region and the
angle of jaw
 Efferents reach the upper and lower
deep cervical nodes

23. DEEP GROUP
Sub mental and submandibular
 Submental nodes lie deep to chin
-Drains lymph from tip of tongue and anterior part of floor of
mouth.
 Sub mandibular lie on the surface of submandibular salivary
gland
-Drains anterior 2/3 of tongue,gums and teeth of upper and lowe
arch and central areas of forehead,nose,sinuses
 Efferents pass mostly to the jugulo digastric and jugulo omohyoid
node which are situated along the internal jugular vein

24. Upper lateral group
 Jugulo digastric is a member of this
group
 Lies below posterior belly of digastric
b/w angle of mandible and anterior
border of SCM,in a triangle bounded
by facial vein,post.belly of digastric
and int. jugular vein.
 It is the main node draining the
TONSIL

25. Middle lateral group
 Drains thyroid and parathyroid glands
 Efferents from prelaryngeal,pretracheal and
paratracheal lymphnodes
Lower lateral group
Jugulo omohyoid is a member of the group
Lies just above the omohyoid under cover
of SCM
It is the main lymphnode of the TONGUE

26. Lymphnodes in posterior
triangle
 Present around the spinal root of
accessory nerve
 Efferents join to form jugular lymph
trunks one on each side

27. DEEPEST GROUP
Pre laryngeal and pretracheal nodes:
 Prelaryngeal nodes lie of cricothyroid
membrane
 Pre tracheal lie in front of trachea below
the isthmus of thyroid gland
 They drain the larynx,trachea and
isthmus of thyroid
 Efferents pass to nearby deep cervical
nodes

28. Paratracheal nodes
 Lie on the sides of trachea and
oesophagus along the reccurent
laryngeal nerves
 Receive lymph fron oesophagus,trachea
and larynx and pass it on to the deep
cervical nodes

29. Retropharyngeal lymph node
Lies between the buccopharyngeal and
prevertebral fascia, behind the constrictors
Drainage - Nasopharynx
- Paranasal sinuses
- Pharyngeal end of the auditory tube
- soft palate
- posterior part of hard palate
 Efferents to upper deep cervical lymph node

30. DRAINAGE OF LYMPHATICS
ORAL CAVITY
 Buccal mucosa – Buccal and mandibular
 Anterior hard palate- Submandibular and retropharyngeal
 Posterior hard and soft palate-Superior deep cervical and
retropharyngeal
 Tongue

31. HEAD AND NECK REGION
 Scalp- Superficial lymph nodes of head, accessory
 Malar and nasal cavity area- Malar, Nasolabial, Retropharyngeal,
Superior deep cervical
 External ear- Retro, Anterior auricular, Superficial parotid
 Lacrimal gland- Superficial parotid
 Middle ear- Deep parotid
 Paranasal sinuses- Retropharyngeal

32. LYMPHATIC ORGANS

33. CLASSIFICATIONOF
LYMPHOIDORGANS
Primary (central)
lymphoid organs
Bone marrow
Thymus
Secondary
(peripheral)
lymphoid organs
Lymph nodes
Spleen
Mucosa associated
lymphoid tissue

34. SPLEEN
 Located in the upper far left part of the
abdomen, to the left of the stomach.
 Commonly fist-shaped, purple, and about 4
inches long.
represents the haemic lymph node.
 Splenic artery divides into number of
branches before entering the spleen at the
hilus,each of these supplies a trabeculus

35. THYMUS
 Derived from the vertical portion of 4th pharyngeal
arch
 It is filled with lymphocytes which originate from
bone marrow derived,blood brone precursor cells
 In the thymus the t cell clonality is established,auto
reactive t cells are deleted and t cell sub population
MHC recognition is determined

36. MUCOSA ASSOCIATED LYMPHOID TISSUE
A diffuse system of small concentrations of lymphoid
tissue found in various mucosal sites of the body,
such as the gastrointestinal
tract, thyroid, breast, lung, salivary glands, eye,
and skin.
 MALT contains T cells,B cell,plasma
cells and macrophages,to encounter
antigens passing through the mucosal
epithelium.

37. TONSILS
 Masses of lymphoid tissue in a protective ring under
the mucous membrane in the mouth and back of
throat
 while its position in the upper respiratory tract
make it a likely first line of defense against inhaled
antigen
1.Palatine
2.Lingual
3.Pharyngeal
4.Tubal

38. CLINICAL EXAMINATION OF THE
LYMPHATIC SYSTEM
HISTORY
1)Age of the patient
a)Young children-viral infections,tuberculosis,acute leukaemia
b)Adolescent and teenagers-viral infections, bacterial
infections,lymphoreticular disease, glandular fever
c)Adults-TB lymphadenitis
d)Middle age –Hodgkins lymphoma
e)Old age-Malignancy
2)Duration of swelling
a)Short-Pyogenic infections
b)Long-Tuberculosis,secondary metastasis
3)Multiple swellings

39. 4)Speed of growth
5)Associated fever
6)Weight loss
7)Pain
GENERAL PHYSICAL EXAMINATION
LOCAL EXAMINATION
a)Inspection-
1)Location
2)Size
3)Surface
4)Skin over the swelling

40. B) PALPATION OF NODES
 Adequate access
 Use the pads of all four fingertips
 Examine both sides of the head simultaneously
 Applying steady, gentle pressure
 Evaluated in a systematic fashion
 Examination to check the consistency,matting,mobility
and fixity of the node

41. PRE AURICULAR POST AURICULAR

42. SUB MANDIBULAR NODE
Stand behind the patient.
-Gently tilt the head to the same
side of node being palpated.
-Roll your fingers against inner
surface of mandible applying
pressure against the bone.

43. SUB MENTAL NODE
Stand behind the patient.
-Gently tilt the head in front.
-Roll your fingers against inner
surface of symphysis applying
pressure against the bone

44. CERVICAL LYMPHNODES

45. SUPRACLAVICULAR NODES
Tell patient perform a Valsalva maneuver or cough in order to
push the cupola of the lung upward.
-Stand in front of the patient.
-Gently with both hands roll fingers behind the clavicles

46. Applied anatomy of lymphatic system
 The route of odontogenic infection varies acc. to the
teeth involved
 Submandibular nodes- all teeth except mandibular
incisors and maxillary 3rd molars
 Superior deep cervical nodes- maxillary 3rd molars
 Submental nodes- mandibular incisors

47. LYMPHADENOPATHY
The enlargement of one or more lymph nodes.
Lymphadenopathy is classically described as a node
larger than 1 cm and varies by lymphatic region.
CAUSES OF CERVICAL LYMPHADENOPATHY
A)Infections-bacterial,viral,parasitic,infective
B)Neoplasms
C)Miscellaneous-Sarcoidosis,Drug reactions, connective
tissue disorders

48.  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 does anterior cervical lymphadenopathy.
 Generalized lymphadenopathy is often caused by a viral infection, and less
frequently by malignancies, collagen vascular diseases, and medications.
ETIOLOGY:

49. Change in consistency
a. Softer lymph nodes: Infections / inflammation
b. Discrete and shotty: Syphilis
c. Shotty nodes - children with viral illnesses.
d. Stony hard nodes - metastatic cancer.
e. Very firm, rubbery nodes - lymphoma
f. Matted lymph nodes -E.g. tuberculosis
 Tonsillitis- tonsil serve as the first line of
defense.

50. Lymphadenitis
Inflammation of a lymph node because of the invasion of an
infectious organism.
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

51. 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

52. LYMPHOMA-A)HODGKINS LYMPHOMA
B)NON HODGKINS LYMPHOMA
C)BURKIT’S LYMPHOMA
D)INFECTIOUS
MONONUCLEOSIS

53. 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
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

54. 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

55. 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

56. INFECTIOUS MONONUCLEOSIS KAWASKI DISEASE

57. Metastasis
 Metastatic deposits in regional lymphnodes occur most commonly
from carcinomas and malignanat melanomas
 Sarcomas often disseminate via haemotogenous route but
uncommonly to regional lymphnodes
 Metastatic tumour cells from primary malignant tumours are
drained via lymphatics
 The pushing margins of metastatic tumours in stroma of
lymphnode is well demarcated characteristically
 Area of necrosis is common in
Metastatic tumors in lymphnodes
 Fixed, bony hard lymph nodes

58. Lab investigations
 Blood picture
 Serological studies
 Skin test – Montoux test
 Gordon’s biologic test
 Histopathology and cytology
-FNAC (Fine Needle Aspiration Cytology)
-Biopsy
-Ultrasonography
-CT scan
-MRI
Investigations for Cervical lymphadenopathy

59. MANAGEMENT OF DISEASES OF LYMPH NODES
 Treatment with antibiotics covering bacterial pathogens frequently
implicated in lymphadenitis, followed by re-evaluation in 2-4 weeks
is reasonable, if clinical findings suggest lymphadenitis. Benign
reactive adenopathy may be safely observed for months.
 If the size, location, or character of the lymphadenopathy suggests
malignancy, the need for laboratory studies and biopsy is more
urgent.
 Most clinicians treat children with cervical lymphadenopathy
conservatively. Antibiotics should be given only if a bacterial
infection is suspected

60. Role Of Biopsy In Pediatric Lymphadenopathy.
Hanif G1, Ali SI, Shahid A, Rehman F, Mirza U.
Saudi Med J 2009jun;30(6):798-806
OBJECTIVE: To determine the role of lymph node biopsy in the diagnosis of lymphadenopathy and to
find out the pattern of different diseases in relation to age, gender, and the site of lymph nodes
involved.
METHODS: This retrospective study was carried out at the Histopathology Department of the
Children's Hospital and The Institute of Child Health, Lahore, Pakistan, over a period of 9 years, from
January 1999 to December 2007. Tissue samples were collected from 898 children presenting with
lymphadenopathy, and the diagnosis was confirmed on histology and through various specific tests.
The clinical data of the patients were collected from computerized hospital records.
RESULTS: Among the total 898 consecutive lymph node biopsies, the most common pathology
encountered was reactive hyperplasia in 356 children (39.6%), followed by tuberculosis in 262 (29.1%)
and malignant lymphomas in 132 children (14.6%). The rest of the lesions include; 72 cases of
granulomatous lymphadenitis (8%), 13 of histiocytosis X (1.4%), 44 (4.9%) of metastatic tumors, 16 of
chronic inflammation (1.8%), and 3 cases of Kikuchi's disease (0.3%). The cause of lymphadenopathy
was found to be significantly associated with age, gender, and site of the lymph nodes involved.
CONCLUSION: Lymphadenopathy is a relatively common condition in the pediatric age group.
Although 39.6% of children had reactive hyperplasia of unknown etiology, 60.3% children presented
with a specific diagnosis

61. CONCLUSION

62. REFERENCES
 Human anatomy – vol 3, B.D. Chaurasia – 3rd edition
 Human histology-Inderbir Singh
 P.J. Mehta, Practical Medicine, 18th edition
 Essentials of medical physiology – k sembulingam
 General pathology – Walter Talbot
 Gray’s anatomy for students, Drake and Mitchell
 Textbook of medical physiology,Guyton,10th ed
 Oral pathology – Shafers – 5th edition
 Textbook of pathology – Harsh Mohan
 Harrison’s General Medicine, Patrick H. Henry, Dan L. Lango, 16th
edition.