The document discusses the lymphatic drainage of the head and neck region. It begins by describing the development, functions, and components of the lymphatic system. It then details the specific lymphatic drainage pathways and lymph nodes of the head and neck region. There are both superficial and deep lymph nodes that drain different areas and connect via lymphatic vessels and trunks to eventually drain into the right lymphatic duct or thoracic duct and return lymph to systemic circulation.

1. LYMPHATIC
DRAINAGE OF
HEAD & NECK
DR. SWATI SAHU
ORAL & MAXILLOFACIAL SURGERY1

2. Introduction1
Functions and development2
Lymphatic drainage and lymph nodes of head and neck3
Examination of lymph nodes4
Investigations5
Clinical implications6
INDEX
2

3. 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).
3

4.  Develop at the end of 5th wk 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
DEVELOPMENT
4

5. 5
Six primary lymph sacs are formed –
• 2 Jugular sacs (right and left)
• 2 iliac sac (right and left)
• Retroperitonial sac (Unpaired)
• Cisterna chyli (unpaired)

6. 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 neighboring veins
6

7. 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
7

8.  Lymph vessels grow out from the lymph sacs, along
the major veins.
 Except for the upper portion of the cisterna chyli,
which persists, the lymph sacs are transformed into
groups of lymph nodes during early fetal life, at
about 3 months.
8

9.  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
9

10. The lymphatic system has threefunctions:
FUNCTIONS OF LYMPHATIC SYSTEM
10

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.
11

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.
12

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

14. COMPONENTS OF LYMPHATIC SYSTEM
14

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
15

16. LYMPH
WATER (96%) OTHERS (4%)
SOLIDS CELLULAR
PROTEINS
LIPIDS
CARBOHYDRATES
AMINOACIDS
NON-NITROGENOUS SUSTANCES
ELETCROLYTE(Na, K)
LYMPHOCYTE (T,B)
MONOCYTE,MACROPHAGES ,
PLASMA CELL
COMPOSITION OF LYMPH
16

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
Richard L.Drake,GRAY’S Anatomy for
students;2005,13th edition,333-335.

18.  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.
A.C.Guyton & J.E. Hall; T.B of Medical Physiology;11th
edition;2006;192-194.

19. Starling’s hypothesis
FORMATION OF LYMPH

20. FUNCTIONS OF LYMPH
Removal of interstitial
fluid from tissues.
Return of protein, water
& electrolyte .
It absorbs and transports
nutrients,fattyacids and
fats as chyle from the GIT.
Transports immune cells to &
from lymph nodes into the
bones,Transports APC to lymph
nodes where immunological
response is stimulated.

21. LYMPHATIC VESSELS
 Resemble veins in structure
 Have thinner walls
 Elastic tissue not muscular
 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.
A.C.Guyton & J.E. Hall; T.B of Medical
Physiology;11th edition;2006;192-194.

22. LYMPHATIC TRUNKS
 Formed by the union of collecting
vessels and drains large areas of the
body
 Named after the areas they drain:
1. lumbar trunks
2. bronchomediastinal trunks
3. subclavian lymphatic trunk
4. jugular trunks (all exist as pairs)
5. a single intestinal trunk.
 All eventually drain into two main
lymphatic ducts

23. RATE OF LYMPH FLOW
 Total estimated lymph flow is 120 ml / hr
 About 100 ml flows through Thoracic duct in resting man per hour
 Approx 20 ml flow into circulation through other channels
 3 – 4 liters / day

24. FLOW OF LYMPH
24
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 to lymph and back to the blood.

25. Thoracic duct
( left
lymphatic
duct)
All lymph trunks
eventually drain into
Right
lymphatic
duct

26. LYMPHATIC PATHWAYS

27. LYMPHATIC CAPILLARIES
 Smallest lymphatic vessels
 They begin in the tissue spaces as blind-ended sacs.
 These capillaries form plexuses which collect lymph from the interstitial space mark the
beginning of lymphatic system

28.  They are lined by a single layer of
endothelial cells.
 These are attached to C.T by anchoring
filaments.
 The edge of one endothelial cell
overlaps the adjacent cell.
 Overlapping edge is free to flap inward
minute valve.
 Permits passage of high molecular weight
substance.

29. LYMPHATIC VESSELS
 Lymph capillaries merge to form lymphatic vessels.
 Resemble veins but
 Thin walls (Diameter - 0.2 – 0.3 mm)
 More valves (formed from folds of tunica intima)
 Lymph Nodes are located at
interval along its course
Have 3 coats (Tunica intima, Tunica media, Tunica
adventitia)
BEADED in appearance (semilunar valves).
Collagenous fibers attaches the endothelium to the outer
tissues ( fibrous sheath of muscle)

30. STRUCTURE OF LYMPH NODE

31. 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 phogocytes or by other means.
31

32. 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.
32

33. 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

34. 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.

35. 37

36. THE SECONDARY LYMPHATIC ORGANS
 the spleen,
 the lymph nodesand
 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.
38

37. LYMPH NODES OF HEAD AND NECK

38.  A l l lymph vessels of the head and neck drain intothe deep cervical nodes, either
directly from the tissues or indirectly via nodes in outlying groups.
 Lymph is returned to the systemic venous circulation via either the right lymphatic
duct or the thoracic duct.
40

39. CLASSIFICATION OF LYMPH NODES IN
HEAD AND NECK REGION
41
SUPERFICIAL
LYMPH NODES
DEEP LYMPH
NODES

40. 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
 Postauricular
 Occipital
 Anterior cervical
 Superficial cervical
42

41.  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.
43
SUBMENTAL LYMPH NODES

42.  Lie in diagastric triangle superficial to submandibular gland
 They are 3 in number
 Afferents : 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.
 Efferents: Mainly in jugulo-omohyoid and partly in jugulo-diagastric.
44
SUBMANDIBULAR LYMPH NODES

43.  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.
 Efferents- Go into the upper deep cervical group.
45
PAROTID LYMPH NODES (PREAURICULAR)

44.  Lie superficial to sternocleidomastoid and mastoid
process and deep to auricularis posterior.
 Afferents come from the scalp, posterior surface of
pinna and skin of mastoid.
 Efferents drain into upper deep cervical lymph nodes
46
POSTAURICULAR LYMPH NODES

45.  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.
 Efferents drain into supraclavicular nodes
47
OCCIPITAL LYMPH NODES

46.  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
48
BUCCAL LYMPH NODES

47. ANTERIOR JUGULAR CHAIN
It lies along anterior jugular vein and
drains the skin of anterior neck.
49
ANTERIOR CERVICAL LYMPH NODES
JUXTAVISCERAL CHAIN
Prelaryngeal node
(Delphian node)-situated infront of conus
elasticus
Pretracheal node
infront of trachea,above the thyroid isthmus.
Paratracheal Node
on each side of trachea along recurrent
laryngeal nerve (glands of recurrent chain).

48. It lies superficial to SCM along external jugular vein
 Afferents- lobule of auricle
Floor of external acoustic meatus
Angle of jaw
Lower part of parotid gland
posterior triangle of neck
 Efferents drains into upper and lower deep cervical group of lymph nodes.
50
SUPERFICIAL CERVICAL LYMPH NODES

49. It consists of three chains,
 Internal jugular
 Spinal accessory
 Transverse cervical
51
DEEP CERVICAL LYMPH NODES

50.  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.
52
INTERNAL JUGULAR CHAIN

51.  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
53
JUGULO-DIGASTRIC GROUP OF LYMPH NODES

52.  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")
54
WALDEYER’S LYMPHATIC RING

53.  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 pericervical chain and upper deep cervical
nodes which together constitute the external ring of
waldeyer.
55

54.  Inframastoid nodes lying below the tip of mastoid
process under cover of SCM
 Receive lymph from pharyngeal tonsils(adenoids)
56
ADENOIDS

55.  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
57
JUGULO-OMOHYOID LYMPH NODES

56.  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
58
SPINAL ACCESSORY CHAIN

57.  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
59
TRANSVERSE CERVICAL CHAIN

58. A. Retropharangeal
B. Infrahyoid
C. Prelaryngeal
D. Pretracheal
E. Paratracheal
60
REGIONAL LYMPH NODES

59. RETROPHARYNGEAL LYMPH NODES
 Located between pharynx & atlas.
 Afferents
Pharynx ,
Auditory tube ,
Soft palate ,
posterior part of hard palate,
Nose.

60.  Afferents – Neighbouring
structures, thyroid gland
 Efferents – Deep cervical
lymph nodes
Paratracheal node
PARATRACHEAL LYMPH NODES

61. • Afferent – Anterior cervical
nodes
• Efferent – Deep cervical lymph
nodes
Infrahyoid node
Prelaryngeal node
Pretracheal node
INFRAHYOID, PRELARYNGEAL & PRETRACHEAL LYMPH NODES

62.  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 draininto the submandibular nodes.
 While the middle third of the lower lip drains intothe submental nodes.
 The skin of the neck drains into the cervical nodes.
64
DRAINAGE OF SKIN OF THE HEAD AND NECK

63.  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.
65
DRAINAGE OF ORAL STRUCTURES

64. Lymphatic drainage of external nose is primarily to the submandibular group of
nodesalthough lymph from the root of the nose drains to superficial parotid nodes.
66
DRAINAGE OF EXTERNAL NOSE

65.  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.
67
DRAINAGE OF NASAL CAVITY

66.  The lymphatic drainage of the tongue can be divided into
3 main regions: Marginal, Central and Dorsal.
 The anterior region of the tongue drains into marginal
and central vessels, and the posterior part of the tongue
behind the circumvallate papillae drains into the dorsal
lymph vessels.
 The more central regions drain bilaterally into sub-
mental and sub-mandibular nodes.
68
DRAINAGE OF TONGUE

67.  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.
69
LYMPHATIC DRAINAGE OF TEETH

68. EXAMINATION OF
LYMPH NODES

69. HISTORY
 Age
 Duration
 Group first affected
 Pain
 Fever
 Primary focus
 Loss of appetite & wt.Loss
 Pressure effects
 Past history
 Family history
71

70.  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.
72

71.  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
73

72.  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
74

73. INSPECTION
Presence of a swelling,
number, position, size,
surface
Skin over the
swelling
Pressure effects

74. 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.
76

75. 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.
77

76. 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.
78

77. PALPATION
Number and situation
Local temperature
Tenderness
Palpationconsistency
Surface and
margins
Fixity

78.  NUMBER
 LOCAL RISE IN TEMPERATURE
 TENDERNESS
 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;
 Soft (fluctuating)
 Elastic & rubbery (hodgkin’s disease)
 Firm, discrete and shotty (syphilis)
 Stony hard (secondary carcinoma)
80

79. MATTING
 A group of lymph nodes that feels connected and move as a unit is
known as matted.
 Eg. Acute lymphadenitis, Metastatic Carcinoma, Tuberculosis
81

80. 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.
82

81. 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.

82. 84
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 maneuver
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.

83.  They are palpated anterior tothe tragus
of the ear.
85
PAROTID LYMPH NODES

84. 86
POSTAURICULAR LYMPH NODES
Are palpated behind the ear, on the
mastoid process

85. Palpated at the baselower border of skull
87
OCCIPITAL LYMPH NODES

86.  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.
88
ANTERIOR CERVICAL LYMPH NODES

87.  Extend in a line posterior to the
SCMs but in front of the
trapezius, from the level of the
mastoid bone to the clavicle.
89
POSTERIOR CERVICAL LYMPH NODES

88. 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

89. INVESTIGATIONS

90. The laboratory investigation of patients with lymphadenopathy must be
tailored to elucidate the etiology suspected from the patient's history and
physical findings
92

91. 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

92. 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.
94

93. 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
95

94. 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.
96

95. 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.
97

96. 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).
 Used to determine the long (L) axis, short (S) axis, and a ratio
of long to short axis in cervical nodes.
 An L/S ratio of <2.0 has a sensitivity and a specificity of 95%
for distinguishing benign and malignant nodes in patients
with head and neck cancer.
98

97.  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
99

98. 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.
100

99.  The most effective size criteria for indicating metastatic involvement are now defined as minimum
axial diameters in excess of 11 mm in the jugulodigastric region and in excess of 10 mm elsewhere.
 Using these sizes a sensitivity of 42% and specificity of 99% per node were produced.
 With the use of spiral CT, it is possible to reconstruct the image in any plane with good quality,
allowing more accurate calculation of the maximal axial and longitudinal dimensions and thus
assessment of nodal shape.
101

100. MAGNETIC RESONANCE IMAGING (MRI)
 Standard protocols for MRI of the cervical lymph nodes include a selection of T1- and fast
spin echo T2- weighted axial, coronal and sagittal images.
 STIR sequences allow a combination of T1- and T2-weighting with fat suppression, and
malignant nodes are clearly demonstrated as high signal.
 T1-weighted images depict lymph nodes as being of intermediate signal intensity, similar
to muscle, whilst T2-weighted images show them as hyperintense signal.
102

101. 103
(a) T1 weighted and (b) T2 weighted sagittal MRI scans demonstrate a large
pathological deep cervical lymph node (level two/ three) which is of
intermediate signal on T1 and high signal on T2

102.  Most head and neck PET imaging is performed with the radiolabelled glucose analogue
FDG which has increased uptake in viable malignant tumour due to enhanced glycolysis.
 The result can be expressed as a standardised uptake value (SUV), with those values
greater than two being considered abnormal.
 PET scanning provides functional rather than anatomical imaging.
104
POSITRON EMMISION TOMOGRAPHY

103. 105
(A) Axial CT scan shows mixed soft tissue and fluid in left pleural space. Prevascular and
axillary lymph nodes were interpreted as normal. (B) Axial dual PET/CT scan shows
increased uptake in soft-tissue mass as well as small prevascular and axillary lymph
nodes, indicating recurrent disease with metastatic nodal spread.

104. ADVANCED IMAGING TECHNIQUES
 Planar lympho-scintigraphy
 Hybrid SPECT/CT imaging
 Dynamic contrast – enhanced MR imaging
 Ultra-small super-paramagnetic iron oxide (USPIO) enhanced MRI
 Gadolinium enhanced MRI
106

105. • The sentinal node is the first node encountered by tumor cells.
• So the sentinal node (SLN) is defined as the lymph node which is in a direct drainage pathway
from the primary tumor .
• The other node receive lymph from SLN
SENTINEL NODES

106. 108

107. • 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.
ONCOLOGIC CLASSIFICATION

108. 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
Robbins KT, Clayman G,Levine PA,et al. Neck dissection classification update: Revisions
proposed by the American head &neck society,& American Academy of otolaryngology-head
&neck surgery.Arch Otolaryngol Head Neck Surg 2202; 128: 751-758.

110. LEVEL I
 Level I includes the submandibular and submental nodes. It extends
from the inferior border of the mandible superiorly to the hyoid
inferiorly, and is bounded by the digastric muscle. It may be
subdivided:
 Level I a: The submental group. Lies between the anterior bellies of the
digastric muscles. Bounded superiorly by the symphysis and inferiorly
by the hyoid;
 Level I b: The submandibular group. Bounded by the body of the
mandible superiorly, the posterior belly of the digastric muscle
inferiorly, the stylohyoid muscle posteriorly, and the anterior belly of
the digastric anteriorly. It includes the pre- and postvascular nodes that
are related to the facial artery.
112

111.  Lymph nodes contained within level I are at highest risk in oral
cancers involving the skin of the chin, lower lip, tip of the tongue, and
floor of the mouth.
113

112. LEVEL II
Level II contains the upper jugular lymph nodes that surround the upper
third of the internal jugular vein and the spinal accessory nerve. It
includes the jugulodigastric node (also
known as the principle node of Kuttner) which is the most common
node containing metastases in oral cancer. It is also frequently
subdivided based on the course of the spinal accessory nerve.
 Level II a: Bounded superiorly by the skull base, inferiorly by the
hyoid bone radiographically and the carotid bifurcation surgically,
anteriorly by the stylohyoid muscle and posteriorly by a vertical plane
defined by the spinal accessory nerve.
114

113.  Level II b: Bounded superiorly by the skull base, inferiorly by the hyoid
bone radiographically and the carotid bifurcation surgically, anteriorly by
a vertical plane defined by the spinal accessory nerve and posteriorly by
the lateral aspect of the sternocleidomastoid muscle.
Nodal tissue within level II receives efferent lymphatics the parotid,
submandibular, submental, and retropharyngeal nodal groups. It also is at
for metastases from cancers arising in many oral and extra-oral sites,
including, the nasal cavity, pharynx, middle ear, tongue, hard and soft palate,
and tonsils.
115

114. LEVEL III
 Level III encompasses node-bearing tissue surrounding the
middle third of the internal jugular vein. It is bounded
superiorly by the inferior border of level II (hyoid
radiographically and carotid bifurcation surgically), inferiorly
by the omohyoid muscle surgically and the cricoid cartilage
radiographically, anteriorly by the sternohyoid muscle and
posteriorly by the lateral border of the sternocleidomastoid
muscle.
 Level III contains the dominant omohyoid node and receives
lymphatic drainage from level II and level V. In addition, it can
receive efferent lymphatics from the retropharyngeal,
pretracheal, tongue base, and tonsils.
116

115. LEVEL IV
 Level IV contains the nodal tissue surrounding the inferior third of
the internal jugular vein. It extends from the inferior border of level
III to the clavicle. Anteriorly, it is bounded by the lateral border of the
sternohyoid muscle; and posteriorly, by the lateral border of the
sternocleidomastoid muscle.
 It contains a variable number of nodes that receive efferent flow
primarily from levels III and IV. The retropharyngeal, pretracheal,
hypopharyngeal, laryngeal and thyroid lymphatics also make a
contribution.
 Only rarely is level IV involved with metastatic cancer from the oral
cavity without involvement of one of the higher levels.
117

116. LEVEL V
 Level V makes up the posterior triangle.
 Similar to levels I and II, level V may be
subdivided.
 Level V a: Begins at the apex formed by the
intersection of the sternocleidomastoid and the
trapezius. The inferior border is established by a
horizontal line defined by the lower edge of the
cricoid cartilage. Medially, the posterior edge of
the sternocleidomastoid forms the anterior edge
and the anterior border of the trapezius forms the
posterior (lateral) border.
118

117.  Level V b: Begins at a line defined by the inferior edge
of the cricoid cartilage and extends to the clavicle. It
shares the same medial and lateral borders as level Va.
 Level V receives efferent flow from the occipital and
post auricular nodes. Its importance in primary oral
cavity cancers is limited except when lymph flow is
redirected by metastases in the higher levels.
 Oropharyngeal cancers, however, such as tongue base
and tonsillar primaries can spread to level V nodes.
119

118. LEVEL VI
The anterior compartment lymph node group is
of minimal importance in primaries originating
in the oral cavity. It is made up of the lymph node
bearing tissue occupying the visceral space. It
begins at the hyoid bone, extends inferior to the
suprasternal notch, and laterally is bound by the
common carotid arteries.
120

119. LEVEL VII
 The superior mediastinal nodes.
 They lie between the carotid arteries below the level of the top of the manubrium
.
121

120. TNM STAGING
TUMOR (T) STAGE
TX-primary tumor cannot be
assessed
T0-No evidence of primary
tumour
T1-Tumour < 2cm in greatest
dimension
 T2-Tumour not more then 2 cm
but less then 4 cm in greatest
dimension
T3-tumour more then 4 cm in
greatest dimension
T4-Tumour invade the adjacent
structure.
REGIONAL LYMPH NODE (N)
STAGE
 NX- Regional lymph node that
can not be assessed
 N0 -No regional lymph node
metastasis.
 N1-Metastasis in single
ipsilateral lymph node 3 cm or
less in greatest dimension.
 N2-Metastasis in single
ipsilateral lymph node more
then 3 cm but not more then
6cm in gretest dimension .

121.  N2a-Metastasis in single ipsilateral
lymph node more then 3cm but not
more then 6cm in greatest
dimension.
 N2b –Metastasis in multiple
ipsilateral lymph node more then 6
cm in greatest dimension .
 N2c-Metastasis in bilateral or
contra lateral lymph node more
then 6cm in greatest dimension
DISTANT METASTASIS (M) : ALL
SITES
Mx-Distant metastasis can not be
assesed
Mo- No distant metastasis.
M1-Distant mestasis.
Denoix PF, Schwartz D: Regeles
generales de classification des
cancers et de presentation des
resutants therapeutics. Acad Chir
(Paris),1959,vol 85,pg 415.

122. CLINICAL IMPLICATIONS

123.  Lymphadenitis is an infection in the lymph nodes. Lymph nodes
are glands that are part of the immune system. They help the body
fight infection by filtering germs. They become enlarged when
infection is present.
 Lymphadenopathy is usually a normal response of the lymph
nodes to an infection elsewhere in the body.

124. Cervical lymphadenopathy may be either an important
clue to an underlying disease process or a specific
clinical syndrome

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

126. C. Fungal
-Histoplasmosis
-Coccidioidomycosis
D. Parasitic
-Toxoplasmosis
-Filiriasis
E. Chlamydial
-Lymphogranuloma venerum
- Trachoma

127. 2.Immunologic disease
A.Rheumatoid arthritis
B.Systemic lupus erythematous
C.Sjogren syndrome
D.Drug hypersensitivity
E.Mixed connective tissue disease

128. a.Hematological
-Hodgkin disease
-Non hodgkin disease
-Hairy cell leukamia
-T-cell lymphoma
-Multiple myeloma
B.Metastasis
-From primary site
3. Malignant disease

129. 4.Lipid storage disease
-Gaucher’s disease
-niemann-pick disease
5.Endocrine disease
-Hyperthyroidism
-Adrenal insufficiency
-Thyroiditis
6.Other disorder
-Sarcoidosis
-Lymphomatoid granulomatosis
-Kawasaki disease
-Histocytosis x
-Kikuchi disease

130. SURGICAL
IMPLICATIONS

131. 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

132. 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.

133. • 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.
135

134. 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.

135. 137
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;

136. MRND TYPE I

137. MRND Type II MRND Type III

138. SELECTIVE NECK DISSECTION
• Refers to the preservation of one or more lymph node groups normally removed in a radical
neck dissection.
• In the 1991 classification scheme, there were several ‘‘named’’ selective neck dissections. For
example, the supraomohyoid neck dissection removed the lymph nodes from levels I–III.
• The subsequent proposed modification in 2001 sought to eliminate these named dissections.
• The committee proposed that selective neck dissections be named for the cancer that the
surgeon was treating and to name the node groups removed.
• For example, a selective neck dissection for most oral cavity cancers would encompass those
node groups most at risk (levels I–III) and be referred to as a SND (I–III)

139. 141

140. EXTENDED NECK DISSECTION
142
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.

141. REFERENCES
 Richard L.Drake,GRAY’S Anatomy for students;2005,13th edition,333-335.
 E. LLOYD DuBRUL, Shicher’s Oral anatomy; 8th edition; 2000, pg no.221-226.
 A.C.Guyton & J.E. Hall; T.B of Medical Physiology;11th edition;2006;192-194.
 Eugene N. Myers et al.; CANCER of Head & Neck,4th edition,2009,49-66.
 Michael Miloro, Peterson’s Principles of OMFS, 2nd edi.,vol.1,617-630
 Neelima A. Malik, TB of OMFS, 3rd edition,530.

142. THANK YOU
144