The presentation elaborates on the lymphatic system involving lymph nodes, vessels and, lymph. The physiology and function of the lymphatic system have been discussed. Levels of cervical lymph nodes have been explained in detail along with 8th edition of TNM staging.

1. Lymphatic system of
Head and Neck
TNM staging 8th edition
Dr. Hussam A. Harb
Dept of OMFS,SRCDSR
PG 1st Year

2. Index
• History
• Introduction
• Lymph nodes of H&N
• Levels of cervical lymph nodes
• Lymphatic drainage
• Examination
• Diseases of lymphatic system
• TNM staging
• References

3. HISTORY
• In 1622, Aselli discovered lacteal vessels while
dissecting well-fed canines & found that the milk-
like liquid flowed from the cut edge of these
vessels.
• 1692- Nuck facilitated study lymphatics by
introducing mercury injection technique.
• Mascangi(1787) & Sappey(1874) were first to
detail the lymphatic system of H&N.
• Gerota’s method(1896) – introduction of Prussian
blue stain
Lymphatic system
Sappey
1874
Wei-Ren Pan 2013

4. INTRODUCTION
Lymphatic system is a closed system of lymph
channels or lymph vessels through which
lymph flows.
One-way system : Lymph flow from tissue
spaces towards the blood.
Lymphatic system

5. INTRODUCTION
Lymph nodes
• Lymph nodes are small (1-2 cm)
glandular structures located in the
course of lymph vessels.
• Each lymph node constitutes masses of
lymphatic tissue covered by a dense
connective tissue capsule
Greys anatomy

6. INTRODUCTION
Afferent lymphatic vessels
Lymph circulation
Lymph Node
Cortex – Paracortex - Medulla
Efferent lymphatic vessels
Guyton textbook
Borle textbook

7. INTRODUCTION
Lymph
• Clear fluid formed by 96% water & 4% solids.
• Derived from interstitial fluid that flows into the
lymphatics.
• Functions:
• Return proteins from tissue spaces into the blood
• Redistribution of fluid in the body
• Bacteria, toxins and other foreign bodies are
removed from tissues.
• Route for intestinal fat absorption
• Important role in immunity by transport of
lymphocytes
Guyton textbook

8. K. Sembulingam textbook of physiology

9. INTRODUCTION
Lymph organs
Primary lymphopoietic organs -
Bone marrow and Thymus
Lymphoid stem cells undergo spontaneous division
independent of antigenic stimulation.
Secondary lymphopoietic organs –
Lymph nodes, Spleen, GALT, MALT
Produce lymphocytes as a response to antigenic
stimulation

10. INTRODUCTION
Importance
• Infections as well as malignant tumors may spread via lymph
vessels.
• Knowledge of the regional lymph nodes enables to
• Prognosticate the involvement of certain lymph nodes if
the site of a tumor or an infection is known.
• Diagnose a site of a pathologic process if a lymph node
or a group of lymph nodes is found diseased.
Guyton textbook

11. INTRODUCTION
Importance
Status of cervical L.N. – Single most important prognostic factor in pts with SCC of H&N.
• Single node with metastatic cancer reduces survival by 50%
• Involvement of contralateral/bilateral node further reduce survival by 50%
J.P. Shah & K.N. Patel 2005

12. Lymph Nodes of Head & Neck
Arrangement
Posterior/lateral - accessary chain
Anterior/medial - Jugular chain
Horizontal rings-
Inner ring – nasopharynx, oropharynx
Outer ring - mandible, auricle, occiput
Vertical chain-

13. Lymph Nodes of Head & Neck
Arrangement : Horizontal rings
Outer/superficial ring-
1. Submental L.N.
2. Submandibular L.N.
3. Preauricular (parotid) L.N.
4. Post auricular (mastoid) L.N.
5. Occipital L.N.
Preauricular
Postauricular
Submental
Occipital
Submandibular
Greys anatomy

14. Lymph Nodes of Head & Neck
Inner ring / Waldeyer’s ring
Arrangement : Horizontal rings
Mucosa associated lymphoid tissue
1. Nasopharyngeal tonsil
2. Tubal tonsil
3. Palatine tonsil
4. Lingual tonsil

15. Pharyngeal tonsil
Tubal tonsil
Palatine tonsil
Lingual tonsil
Greys anatomy

16. Lymph Nodes of Head & Neck
Internal jugular chain
Arrangement : Vertical chain
Present along internal jugular vein & divided by
omohyoid muscle into
1. Upper group – Jugulo-digastric nodes
2. Lower group – Jugulo-omohyoid nodes
Greys anatomy

17. Greys anatomy

18. Lymph Nodes of Head & Neck
Arrangement : Vertical chain
Lymph nodes present along the course
of spinal accessory nerve
Accessory/posterior chain of lymph nodes

19. Greys anatomy

20. Lymph Nodes of Head & Neck
Arrangement
Lymph nodes present in between the jugular chains
1. Prelaryngeal
2. Prethyroid
3. Pretracheal
4. Paratracheal chain
5. Precricoid (delphian node)
Aka juxtavisceral nodes
Greys anatomy

21. Lymph Nodes Levels Classification:
• Level I - Submental & Submandibular group
• Level II - Upper jugular group
• Level III - Middle jugular group
• Level IV - Lower jugular group
• Level V - Posterior triangle group
• Level VI - Anterior compartment group
• Level VII - Superior mediastinal
• Supraclavicular
• Retropharyngeal
Som et al 1999

23. Lymph Nodes Levels Classification
Subdivision: (Digastric muscle)
• Level Ia : Submental lymph nodes
• Level IIb : Submandibular nodes
Level I - Submental and Submandibular group
Anatomy:
Bounded by the mylohoid superiorly and laterally,
by the hyoid bone inferiorly.

24. Lymph Nodes Levels Classification
Subdivision:
IIA nodes – anterior/medial/lateral/posterior to I.J.V.
IIB nodes – posterior to the I.J.V. separated by a fat plane
Level II - Upper jugular group
Anatomy:
Superiorly –Skull base
Inferiorly - caudal border of the hyoid bone
Anteriorly - posterior edge of the submandibular gland
Posteriorly - posterior edge of the SCM

25. Lymph Nodes Levels Classification
Level III - Middle jugular group
Anatomy:
Superiorly -caudal border of the hyoid bone
Inferiorly – bottom of cricoid arch
Anteriorly - anterior edge of the SCM
Posteriorly - posterior border of the SCM
Laterally - medial surface of the SCM
Medially - internal carotid artery and scalenus muscle

26. Lymph Nodes Levels Classification
Level IV - Lower jugular group
Anatomy:
Superiorly -lower margin of the cricoid cartilage
Inferiorly - clavicle
Posteriorly - posterior border of the SCM and
Scalene muscle
Medially - carotid artery
Virchow’s node

27. Lymph Nodes Levels Classification
Subdivision:
VA nodes – superior to cricoid cartilage
VB nodes – inferior to cricoid cartilage
Level V - Posterior triangle group
Anatomy:
Superiorly - skull base
Inferiorly - clavicle
Anteriorly - posterior to the back of SCM and anterior
scalene muscle
Posteriorly - anterior edge of the trapezius muscle

28. Lymph Nodes Levels Classification
Level VI - Anterior compartment group
Anatomy:
Superiorly - lower margin of the hyoid bone
Inferiorly - manubrium
Laterally - carotid arteries
Aka visceral or juxtavisceral nodes
Include:
Prelaryngeal L.N.
Prethyroid L.N.
pretracheal L.N.
Paratracheal chain L.N.
Precricoid L.N. (Delphian node)

29. Lymph Nodes Levels Classification
Level VII - Superior mediastinal nodes
Anatomy:
Superiorly - caudal to the superior margin
of the manubrium
Inferiorly - innominate vein
Laterally - carotid arteries

30. Lymph Nodes Levels Classification
Supraclavicular Nodes
They lie at or caudal to the level of clavicle
and lateral to the carotid arteries as seen
on axial scan
Retropharyngeal Nodes
Lie within 2 cm of skull base and medial to
internal carotid arteries

31. Level Ia
Level II
Level III
Level IV
Level V
Level VI
Right lymphatic
duct
Retroph.
nodes
Waldeyer’s ring
Jugular trunk
R. Subclavian vein
Thoracic duct/ left
lymphatic duct
L. Subclavian vein
Level Ib
Lymphatic drainage
Greys anatomy

32. Borle textbook

33. Neelima malik

34. Specific features on examination
Lymph nodes changes in diseased state
• Elastic and rubbery consistency –
Hodgkin's disease
• Firm, discrete and shotty consistency –
Syphilis
• Stony hard consistency –
Carcinoma
• Matted texture –
Tuberculosis, acute lymphadenitis and metastatic carcinoma
• Fixity to surrounding structures (immobile) –
Primary malignant growth of the lymph nodes/ secondary
carcinoma.

35. Diseases of lymphatic system
Normal :
The lymph nodes are bean-shaped / oval structures 1 to
2 cm in length and not palpable on examination.
Lymphadenitis :
Inflammation of lymph nodes
(Enlarged/palpable/tender)
Lymphangitis :
Inflammation of lymphatic system
Lymphedema :
accumulation of lymph within the
tissues

36. Diseases of lymphatic system
Lymphangioma :
Benign neoplasm of lymphatic
vessels and nodes
Cystic hygroma :
Variety of lymphangioma seen in
new born and young children
Malignancies :
Lymphosarcoma, Hodgkin
lymphoma, Non-Hodgkin
lymphoma, Lymphoid leukemia
S Das

37. Lymphatic system: route of metastasis
TNM classification (8th edition)
• Lymph nodes and vessels are a route of metastasis for malignant cancer.
• TNM staging of oral cancer considers
• LYMPH NODES: Number of metastatic nodes/ size of nodes/ ENE
• TUMOR: Size/ extent/ DOI
• METASTASIS: Present/ absent

38. TNM classification (8th edition) : Lymph nodes
• The predominant pattern of lymphatic spread resembles the shape of an ‘inverted cone’.
• Lateral to medial location – involvement of ipsilateral to bilateral/contralateral L.N.
• Anterior to posterior location – involvement of level I to II
• Skip metastasis – Rare; predominantly from tongue.
Pattern of spread
L.V. Vassiliou et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 711e718

39. L.V. Vassiliou et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 711e718
TNM classification (8th edition) : Lymph nodes
Pattern of spread

40. Tongue
Lateral view demonstrates ipsilateral commonly affected neck levels.
Front view demonstrates the rate of possible contralateral neck nodal involvement
L.V. Vassiliou et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 711e718
TNM classification (8th edition) : Lymph nodes
Pattern of spread

41. L.V. Vassiliou et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 711e718
TNM classification (8th edition) : Lymph nodes
Pattern of spread
Lateral view demonstrates ipsilateral commonly affected neck levels.
Front view demonstrates the rate of possible contralateral neck nodal involvement

42. TNM classification (8th edition) : Lymph nodes
Pattern of spread
Lateral view demonstrates ipsilateral commonly affected neck levels.
Front view demonstrates the rate of possible contralateral neck nodal involvement
L.V. Vassiliou et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 711e718

43. TNM classification (8th edition) : Lymph nodes
Extra Nodal Extension
• Added as a prognostic variable for regional lymph node metastases in addition to the number and
size of metastatic lymph nodes
• ENE is defined as extension of metastatic carcinoma from within a lymph node through the fibrous
capsule and into the surrounding connective tissue, regardless of the presence of stromal reaction.
• Metastatic carcinoma that stretches the capsule but does not breach it does not constitute ENE.
Lydiatt WM et al; CA Cancer J Clin. 2017

44. • Clinically- +ve if unambiguous ENE detected by physical examination and supported by radiological evidence.
(invasion of skin, infiltration of musculature/dense tethering to adjacent structures, or dysfunction of a cranial
nerve)
• Pathologically- +ve if,
• ENE minor: extension within 2 mm from the capsule
• ENE major: extension apparent to the pathologist’s naked eye/ more than 2 mm from capsule
microscopically
TNM classification (8th edition) : Lymph nodes
Extra Nodal Extension
Lydiatt WM et al; CA Cancer J Clin. 2017

45. TNM classification (8th edition) : Lymph nodes
Extra Nodal Extension
Lydiatt WM et al; CA Cancer J Clin. 2017
metastasis that stretches, but does not breach, the lymph node capsule should be classified as ENE-negative

46. TNM classification (8th edition) : Lymph nodes

47. TNM classification (8th edition) : Tumor
DOI/Size/Extent
Lydiatt WM et al; CA Cancer J Clin. 2017
• The propensity of OSCC to metastasize has been linked to its vertical growth.
• The vertical dimension of a tumor's growth can be measured by its thickness or its depth of
invasion (DOI)
• DOI is measured from the level of the basement membrane of the closest adjacent normal mucosa
to the deepest point of tumor invasion.
• The T category increases with every interval of 5 mm

48. TNM classification (8th edition) : Tumor
Depth of invasion
Lydiatt WM et al; CA Cancer J Clin. 2017
• Tumor thickness is different from DOI.
• Tumour thickness represents the vertical dimension of the tumour measured from the deepest
point of invasion to its mucosal surface.
• DOI is superior to tumor thickness, as the latter underestimates aggressive potential.

49. TNM classification (8th edition): Tumor
Depth of invasion
Lydiatt WM et al; CA Cancer J Clin. 2017
White bar- tumor thickness; Blue bar - depth of invasion

50. Yellow bar- tumor thickness;
Blue bar - depth of invasion
Lydiatt WM et al; CA Cancer J Clin. 2017

51. TNM classification (8th edition) : Tumor
Lydiatt WM et al; CA Cancer J Clin. 2017

52. TNM classification(8th edition) : Metastasis
Lydiatt WM et al; CA Cancer J Clin. 2017
• M refers to metastasis to distant organs (beyond regional lymph nodes)
• M0 – No distant metastasis
• M1 – Distant metastasis present

53. TNM classification: Staging

54. REFERENCES
Wei-Ren Pan, De-Guang Wang. Historical review of lymphatic studies in the head and neck. Journal of Lymphoedema, 2013, Vol 8, No 1
Som PM, Curtin HD, Mancuso AA. An imaging-based classification for the cervical nodes designed as an adjunct to recent clinically based nodal
classifications. Arch Otolaryngol Head Neck Surg. 1999 Apr;125(4):388-96. doi: 10.1001/archotol.125.4.388. PMID: 10208676.
Kulzer MH, Branstetter BF 4th.
Chapter 1 Neck Anatomy, Imaging-Based Level Nodal Classification and Impact of Primary Tumor Site on Patterns of Nodal Metastasis. Semin
Ultrasound CT MR. 2017 Oct;38(5):454-465. doi: 10.1053/j.sult.2017.05.002. Epub 2017 May 20. PMID: 29031363.
Borle textbook/Guyton textbook/B D Chaurasia textbook/Greys anatomy textbook/ K. Sebulingam /Neelima malik textbook
Lydiatt WM, Patel SG, O'Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, Loomis AM, Shah JP. Head and Neck cancers-major changes in the
American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017 Mar;67(2):122-137. doi:
10.3322/caac.21389. Epub 2017 Jan 27. PMID: 28128848.
Vassiliou LV, Acero J, Gulati A, Hölzle F, Hutchison IL, Prabhu S, Testelin S, Wolff KD, Kalavrezos N. Management of the clinically N0 neck in early-
stage oral squamous cell carcinoma (OSCC). An EACMFS position paper. J Craniomaxillofac Surg. 2020 Aug;48(8):711-718. doi:
10.1016/j.jcms.2020.06.004. Epub 2020 Jul 2. PMID: 32718880.
Crescenzi D, Laus M, Radici M, Croce A. TNM classification of the oral cavity carcinomas: some suggested modifications. Otolaryngol Pol.
2015;69(4):18-27. doi: 10.5604/00306657.1160919. PMID: 26388356.

55. Thank
You

56. Sentinel node biopsy
TNM classification and grading
• Identification and removal of first echelon L.N.
• Primary site area injected with radioactive labelled Tc-sulfur colloid.
• Radiograph taken to identify and locate the sentinel node.
• Isosulfan die blue dye injected in primary area prior to surgery.
• Gamma detection probe counterprobe used to identify node with highest colloid concentration.
• Node is removed for histological analysis.