The lymphatic system consists of lymph, lymphatic vessels, lymph nodes, the spleen, thymus, and bone marrow. It develops from lymph sacs that arise from veins. The main functions are restoration of interstitial fluid, absorption and transport of fats, and defense against pathogens. Lymph contains nutrients, waste, and immune cells. It is transported through a network of vessels and ducts and emptied into subclavian veins. Lymph nodes filter lymph and activate immune cells to fight infection. The spleen, thymus, and bone marrow also participate in immune responses.

1. LYMPHATICS OF
HEAD & NECK
PRESETED BY:
Dr.Apala Baduni

2. WILLIAM HARVEY
ALEXANDER OF
WINIWARTER
HIPPOCRATES
RUFUS OF EPHESUS
THOMAS
BARTHOLIN
HISTORY

3.  The lymphatic system represents an accessory route
through which fluid flows from the interstitial spaces
into blood
 It is an essential part of body’s immune system.
Introduction

4. EMBRYOLOGY
 Lymphatic vessels hemangioblastic stem cells
 First signs 5th week

5.  Begins to develop by end of
fifth week IU
Develop from lymph sacs that
arise from developing veins,
derived from mesoderm.
 Six primary lymph sacs are
formed.
 The first lymph sacs to
appear are paired jugular
lymph sacs .
Development of lymphatic system:

6. Capillary plexuses enlarge.
Form lymphatic vessels .
Each jugular lymph sac
retains at least one
connection with its jugular
vein.
Left one develops into the
superior portion of the
thoracic duct.

7. 8th wk of IU-Retroperitoneal lymph sacs forms.
9th wk of IU cisterna chili develops-lower part of the thoracic
duct develops from left jugular sac.
Later stages-lymph sacs are invaded by lymphocytes.
Transformed into group of lymph nodes

8. Development of Spleen & Thymus
 The spleen develops from mesenchymal cells
between layers of the dorsal mesentery of the
stomach.
 The thymus arises as an outgrowth of the third
pharyngeal pouch.

9.  The lymph nodes develop in the early fetal
period through a septation of the lymph sacs by
mesenchymal cells.
The spaces thus delimited become the sinus of the adult
lymph nodes.

10. PHYSIOLOGY AND ANATOMY

11.  The lymphatic system consists of the following
 Fluid, known as lymph
 Vessels that transport lymph
 Organs that contain lymphoid tissue (eg,
lymph nodes, spleen, and thymus)

12. MAIN FUNCTIONS
 Restoration of excess interstitial fluid and proteins to
the blood
 Absorption of fats and fat-soluble vitamins from the
digestive system and transport of these elements to
the venous circulation
 Defense against invading organisms

13. Components Of Lymphatic System
Organ Function
Lymph Contains nutrients, oxygen, hormones, and fatty acids,
as well as toxins and cellular waste products, that are
transported to and from cellular tissues
Lymphatic vessels Transport lymph from peripheral tissues to the veins of
the cardiovascular system
Lymph nodes •Monitors the composition of lymph,
•the location of pathogen engulfment
•eradication, the immunologic response, and the
regulation site
Spleen Monitors the composition of blood components, the
location of pathogen engulfment and eradication, the
immunologic response, and the regulation site
Thymus Serves as the site of T-lymphocyte maturation,
development, and control

14. LYMPH
 Lymph blood plasma.
 It is pushed out through the capillary wall by pressure exerted
by the heart or by osmotic pressure at the cellular level.
 Lymph contains
As the lymph passes through the lymph nodes, lymphocytes and
monocytes enter it.
Nutrients
Oxygen
Hormones
Toxins
Cellular Waste

15. Water (96%)
Solids (4 %) Organic
substances
Proteins
(2 – 6 % of solids)
Lipids
(5– 15% of solids)
Carbohydrates
Amino acids
Albumin
Globulin
Fibrinogen
Prothrombin
Other clotting factors
Antibodies
Enzymes
Chylomicrons
Lipoproteins
Glucose(120 mg%)
Allaminoacidspresentsinplasma
Composition of lymph

16. In Other
nitrogenous
substances
organic
substances In low conc.
than in plasma
Urea
Creatinine
Sodium
Potassium
Calcium
In higher
conc. than in
plasma
Chlorides
Bicarbonates
Cellular contents Lymphocytes 1000 -2000 cells
per cu mm
Other cells Monocytes
Macrophages
Plasma cells

17. Components of lymphatic system
 Lymph
 Lymphatic Vessels
 Lymphatic Capillaries
 Lymphatic Vessels
 Lymphatic Trunks
 Lymphatic Ducts

18. All tissues of body have special lymph channels to drain
excess fluid directly from interstitial spaces except :
 superficial portion of skin,
 CNS
 endomysium of muscles,
 bones
They have minute interstitial channels called prelymphatics .
Fluid eventually empties into lymphatic vessels , or in case of
brain into CSF & then directly back into blood.

19. Lymphatics ultimately deliver lymph into 2
main channels
Right lymphatic
duct
Drains right side of
head & neck, right
arm, right thorax
Empties into the
right
subclavian vein
Thoracic duct
Drains the rest
of the body
Empties into
the
left subclavian
vein

20. Only 2 areas in head and neck have no direct lymphatics:
 a) orbit- is virtually devoid of lymphatics.
 b) muscles- do not have lymphatics
Their lymph drains in fascial planes between muscles and around
the blood vessels that supply them.
 LYMPH VESSELS ARE NOT PRESENT IN :
 CNS
 Bones
 Alveoli of lungs

22. LYMPHATIC VESSELS
 .Lymphatic capillaries –
Blind-ended tubes
Thin endothelial walls.
Overlapping pattern
The lymphatic capillaries coalesce
to form larger meshlike networks of
tubes that are located deeper in the
body
Lymphatic vessels

23. The lymphatic vessels
2 lymphatic ducts
Lymphatic vessels have 1-way valves to prevent any
backflow
The right
lymphatic duct
Drains the
upper right
quadrant
The thoracic
duct
Which drains the
remaining
lymphatic
tributaries

24. RATE OF FLOW
 About 120 ml lymph flows into blood per hour
 100 ml/hr – Thoracic duct
 20 ml/hr - Rt. Lymphatic duct

25. Lymphatic Organs
PRIMARY ORGANS
 Red bone marrow
 Thymus gland
SECONDARY ORGANS
 Lymph nodes
 Lymph nodules
 Spleen

26. central
central
peripheral
peripheral

27. Thymus
 In the thymus, t lymphocytes dont respond to pathogens and foreign
organisms.
 After maturation
 They enter the blood and go to other lymphatic organs where they
help provide defense.
Bilobed lymphoid organ
Superior mediastinum of the thorax, posterior to the
sternum
Function
Processing and maturation of t lymphocytes.
Produces thymosin, a hormone that helps stimulate
maturation of t lymphocytes in other lymphatic organs

28. SPLEEN
 It is surrounded by a connective tissue capsule that extends inward to
divide the organ into lobules
 Red pulp venous sinuses filled with blood and cords of
lymphocytes and macrophages
 White pulp lymphatic tissue consisting of lymphocytes around
the arteries.
 Lymphocytes are densely packed within the cortex of the spleen.
•Largest lymphatic organ
•Convex lymphoid structure located Below
the diaphragm and behind The stomach.
•Cells
•small blood vessels
•tissue known as red and white pulp.

29. FUNCTIONS
 Reservoir of lymphocytes
 It filters blood
 It plays an important role in red blood cell and iron metabolism
through macrophage phagocytosis of old and damaged red blood cells
 It recycles iron by sending it to the liver
 It serves as a storage reservoir for blood
 It contains T lymphocytes and B lymphocytes for immunologic
response

30. Mucosa Associated Lymphoid Tissue
MALT
Non encapsulated lymphoid tissue
 2 major components of MALT:
 BALT (Bronchial Associated Lymphoid Tissue)
 GALT (Gut Associated Lymphoid Tissue) GALT
 Peyer’s patches
 Appendix – also known as belly tonsil / intestinal tonsil
 Minor components of MALT
 Nose-associated lymphoid tissue (NALT)
 Vulvovaginal-associated lymphoid tissue (VALT)
 Skin associated lymphoid tissue (SALT) is not mucosal but has
the same characteristics of the MALT

31. Tonsils
 Aggregates of lymph node tissue located under the epithelial lining of the
oral and pharyngeal areas.
 The predominance of lymphocytes and macrophages in these tonsillar
tissues offers protection against harmful pathogens and substances that may
enter through the oral cavity or airway
• The palatine tonsils (on the sides of the oropharynx)
• The pharyngeal tonsils (on the roof of the nasopharynx; also known
as adenoids)
•Lingual tonsils (on the base of the posterior surface of the tongue).

32. Type Epithelium Capsule Crypts Location
Adenoids (also
termed "pharyngeal
tonsils")
Ciliated
pseudostratified
columnar (respirator
y epithelium)
Incompletely
encapsulated
No Roof of pharynx
Tubal tonsils
Ciliated
pseudostratified
columnar
(respiratory
epithelium)
Partially
encapsulated
Roof of pharynx
Palatine tonsils
Non-keratinized
stratified squamous
Incompletely
encapsulated
Long, branched
Sides
of oropharynx betwe
en palatoglossal
and
palatopharyngeal
arches
Lingual tonsils
Non-keratinized
stratified squamous
Incompletely
encapsulated
Long, unbranched
Behind terminal
sulcus (tongue)

33. Lymphatic Organs – Lymph Nodes
 Oval, bean shaped structures scattered throughout body along
lymph vessels
 May be deep or superficial
 Concentrated along the respiratory tree and GI tract, in the
mammary glands, axillae, and groin
 Filter lymph fluid to trap foreign organisms, cell debris, and tumor
cells

34. Lymphatic Organs – Lymph Nodes
 Covered by a fibrous connective tissue capsule
 Trabeculae extend from cortex to medulla
 Stroma – the internal supportive connective tissue network of reticular fibers

35. Structure of a Lymph Node
 outer cortex - filled with lymph follicles
 outer edge of follicle contains more T cells
 inner germinal center is the site of B-cell
proliferation
 inner medulla - medullary cords of
lymphocytes, macrophages, plasma cells
(activated B cells)
Cortex
Medulla

36. Structure of a Lymph Node
 Medullary cords extend from
the cortex and contain B cells,
T cells, and plasma cells
 Throughout the node are
lymph sinuses crisscrossed by
reticular fibers
 Macrophages reside on these
fibers where they phagocytize
foreign matter

37. follicles with
germinal centers
Histology of Lymph Nodes

38. Circulation in the Lymph Nodes
 Lymph enters via a number of afferent
lymphatic vessels
 It then enters a large subcapsular sinus
and travels into a number of smaller
sinuses
 It meanders through these sinuses and
exits the node at the hilus via efferent
vessels
 The node acts as a “settling tank,”
because there are fewer efferent vessels,
lymph stagnates somewhat in the node
 This allows lymphocytes and
macrophages time to carry out their
protective functions
Only lymph nodes filter lymph!

39.  Fluid enters cortex through
afferent vessels
 Filter and trap damaged cells,
microorganisms, foreign
substances, tumor cells by
reticular fibers
 Macrophages phagocytize
some, lymphocytes destroy
some by immune defenses
 Exits medulla by efferent
vessels at hilus
Lymph Flow Through Lymph Nodes

40. Blood Flow Through Lymph Nodes
 Blood vessels enter
and exit at the hilus
 This blood provides
nutrition for the
node’s tissues
 route for leukocytes to
enter into or exit from
the lymphatic tissue
of the node

41. Superficial lymph nodes
 Sub-mental nodes
 Sub-mandibular nodes
 Buccal nodes
 Preauricular
 Postauriculal
 Occipital
 Anterior cervical
 Superficial cervical

42.  Deep lymph nodes
1. Prelaryngeal and pretracheal
2. Paratracheal
3. Retropharyngeal

43. OCCIPITAL NODES
 Situated at the apex of
posterior triangle of
neck
 Recieves lymph from
back of scalp
 Drains into deep
cervical lymph nodes

44. MASTOID /
RETROAURICULAR
LYMPH NODES
 Situated over lateral surface of
mastoid process of temporal
bone
 Recieves lymph from
a) Strip of scalp above auricle.
b) Posterior wall of external
auditory meatus
 Drains into
deep cervical lymph nodes

45. PAROTID LYMPH
NODES
 Situated on/ within
parotid gland.
 Receives lymph from
a) Strip of scalp above
parotid salivary
gland.
B) lateral surface of
auricle.
C) anterior wall of
external auditory
meatus
D) lateral wall of
external auditory
meatus.
E)lateral wall of eyelid
Drains into deep cervical nodes

46. Regional to:
 Anterior temporal
region
 Lateral part of
forehead
 Eyelids
 posterior part of
cheek
 part of external ear
 parotid gland
 PREAURICULAR/
POSTAURICULAR
 INFRA
AURICULAR /
SUPERFICIAL &
DEEP CERVICAL
NODES

47. CLINICAL SIGNIFICANCE
 The most common area that drains into
these nodes is skin, and thus the most
common tumors to metastasize to them are
melanoma and squamous cell carcinoma.

48. Buccal lymph nodes
 Situated over
buccinator muscle
close to facial vein.
 Recieves lymph from
Eyelids, cheek, mid
portion of face Rarely
gums & palate
Drains into submandibular
lymph nodes

49. Regional to:
 Skin on the anterior
surface of face
Secondary to:
 Deeper part of face
 Mucous memberane
of lips & cheek.
 Occasionally even
from upper/lower
teeth & adjacent
gingiva.

50. Submandibular lymph
nodes
 Situated on
a) superficial surface of
submandibular salivary
gland.
b) Beneath investing layer
of deep cervical facia.

51.  They are divided into:
 Anterior group :submental vein close to chin.
 Middle group : around facial vein& facial
artery above submandibular salivary gland.
 Posterior group : behind facial vein.

52. Recieves lymph from:
 Front of scalp.
 Anterior part of nasal cavity, palate & adjacent cheek.
 Upper & lower lip except central part.
 Frontal, maxillary, ethmoidal air sinuses.
 Upper& lower teeth except lower incisors.
 Anterior 2/3rd of tongue.
 Floor of mouth, vestibule.
Drains into deep cervical nodes.

53. Submental lymph nodes
 Lies b/w chin & hyoid
bone
 b/w anterior bellies of
digastric muscles in
submental triangles.
Recieves lymph from
A. Tip of tongue
B. floor beneath tongue
C. lower incisors
D. central part of lower lip
E. skin over chin Drains into submandibular &
deep cervical nodes

54.  Regional to
 Middle part of lower lip
 Skin of chin
 tip of tongue
 lower incisors & gingiva
 Secondary lymph nodes of this region are in part
submandibular & in part superior deep cervical
lymph nodes

55. Cervical lymph nodes
 Distributed along the internal & external jugular veins.
 Acc. To their relation to deep fascia of neck, they are
divided into superficial & deep groups
 Superficial nodes restricted to upper region of neck&
found in angle b/w mandibular ramus & SCM muscle.
 Receive lymph from
 ear lobe
 adjacent part of skin.
 secondary to preauricular & postauricular lymph nodes.

57.  Deep cervical nodes divided into upper & lower group
 The superior & inferior deep cervical nodes that are situated in
front of SCM muscle: c/a anterior/ medial deep cervical
nodes.
 It follows the internal jugular vein so c/a JUGULAR CHAIN
 Those situated in posterior triangles of neck behind SCM
muscle are c/a posterior/ lateral deep cervical nodes.
 They are in close relation to accassory nerve, known as
ACCESSORY CHAIN

58. Primary to :
 Base of tongue
 Sublingual
region
 Posterior part
of palate
They are secondary and tertiary
nodes into which the lymph of
auricular, submental,
submandibular & accessory nodes
of face empty.
They are also secondary to nuchal
nodes, deep lymph nodes of neck,
retropharyngeal, infrahyoid,
pretracheal, paratracheal lymph
nodes.

59. Jugulo digastric lymph nodes
 Situated at the level of greator horn of hyoid bone.
 Recieves lymph from tonsil and tongue.
Juglo-omohyoid nodes
 Situated related to the intermediate tendon of
omohyoid muscle.
 Recieves lymph from posterior 1/3rd of tongue.
 In general deep cervical nodes receive lymph from
regional lymph nodes and drain into jugular
lymph trunk

60. SUPERIOR DEEP CERVICAL NODES
INFERIOR DEEP CERVICAL/ SUPRACLAVICULAR
NODES.
THORASIC DUCT(left side)
LYMPHATIC DUCT (RIGHT SIDE)
VENOUS ANGLE (on either side), where internal jugular &
subclavian veins unite.
Thus the lymph enters the system of superior vena cava

61. Retropharyngeal lymph nodes
 Situated in retropharyngeal space b/w pharyngeal wall
& prevertebral fascia .
 Recieves lymph from: soft palate,nasal part of
pharynx, auditory tube, upper part of cervical vertebral
column.
 Drains into deep cervical lymph nodes.

62. Laryngeal lymph nodes
 Situated in front of larynx
on cricothyroid ligament.
 Recieves lymph from
larynx, trachea, isthmus of
thyroid.
 Drains into deep cervical
lymph nodes.

63. Tracheal lymph nodes
 Situated
Pretracheal in front of trachea.
Paratracheal lateral to trachea.
 Recieves lymph :
Oesophagus, trachea, larynx.
 Drains into deep cervical
lymph nodes

64. WALDEYER 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.

65. Tonsils

66. Dr. owais pg Ist yr ENT
SMHS
Grading the Size of Tonsils
Grading system:
A. 0 – tonsils in fossa
B. +1 – tonsils less than 25%
C. +2 – tonsils less than 50%
D. +3 – tonsils less than 75%
E. +4 – tonsils greater than 75%

67. Anatomy
Blood supply - Tonsils
 Facial a.
 Lingual a. Dorsal lingual
 Ascending pharyngeal ECA
 Greater palatine branch of maxillary artery
Tonsillar branch Tonsil (main branch)
Ascending palatine Tonsil

68. Anatomy
Blood supply – Adenoids
 Ascending palatine branch of facial a.
 Ascending pharyngeal a.
 Pharyngeal branch of IMAX.
 Ascending cervical branch of thyrocervical trunk.

69. LYMPHATIC DRAINAGE OF TONGUE
 Rich network of lymphtics
Enormous swelling
Carcinma of tongue:
Affected side is removed Surgically .With deep cervical node
Carcinoma of posterior one- third is more dangerous due to bilateral
lymphatic spread

70.  Tip of tongue drains bilaterally 
sub-mental nodes
 Right & left halves of remaining
halves of anterior 2/3rd drain
unilaterally  submandibular
nodes.
 Posterior 1/3rd drains bilaterally
juglo-digastric nodes.

71. APPLIED ANATOMY
The latest classification has been created by the
American Joint Committee on Cancer and
the American Academy of Otolaryngology -
Head and Neck Surgery.

72. Staging
 The TNM system devised by the AJCC is
designed to stratify cancer patients into
different stages based on the characteristics of
the primary tumor (T), regional lymph node
metastasis (N), and distant metastasis (M).

73. Regional Lymph Nodes (N)
Node Description
 NX Regional lymph nodes cannot be assessed
 N0 No regional lymph node metastasis
 N1 Metastasis in a single ipsilateral lymph node, 3 cm or less
in greatest dimension
 N2 Metastasis in a single ipsilateral lymph node, more than 3
cm but not more than 6 cm in greatest dimension; or in
multiple ipsilateral lymph nodes, none more than 6 cm in
greatest dimension; or in bilateral or contralateral lymph
nodes, none more than 6 cm in greatest dimension

74.  N2a Metastasis in a single ipsilateral lymph node more than 3
cm but not more than 6 cm in greatest dimension
 N2b Metastasis in multiple ipsilateral lymph nodes, none more
than 6 cm in greatest dimension
 N2c Metastasis in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
 N3 Metastasis in a lymph node more than 6 cm in greatest
dimension

75.  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

76.  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
posterior 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

77.  Level III - all nodes between
hyoid bone and cricoid
cartilage 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
muscleand posterolateral to
anterior scalene muscle and
lateral to common carotid
artery

78.  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

79.  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
between medial margins of
common carotid arteries
bilaterally, extending
inferiorly to level of
innominate vein

80. Face and Scalp Anterior Facial, Ib
Lateral Parotid
Posterior Occipital, V
Eyelids Medial Ib
Lateral Parotid, II
Chin Ia, Ib, II
External Ear Anterior Parotid, II
Posterior Post auricular, II, V
Middle Ear Parotid, II
Floor of mouth Anterior Ia, Ib, IIa > IIb
Lower incisors Ia, Ib, IIa > IIb
Lateral Ib, IIa > IIb, III
Teeth except incisors Ib, IIa > IIb, III
Nasal Cavity Anterior Ib
Posterior Retropharyngeal, II, V
Common Nodal Drainage Patterns

81. Nasal Cavity Posterior Retropharyngeal, II, V
Nasopharynx Retropharyngeal, II, III, V
Oropharynx IIb > IIa, III, IV, V
Larynx Supraglottic IIa > IIb, III, IV
Subglottic VI, IV
Cervical
esophagus IV, VI
Thyroid VI, IV, V, Mediastinal
Tongue Tip Ia, Ib, IIa > IIb, III, IV
Lateral Ib, IIa > IIb, III, IV
Common Nodal Drainage Patterns

82. METASTASIS
 Spread of tumor in such a way by invasion that
discontinuous secondary tumor masses are formed at the
site of lodgement.
 Routes of metasis:
1 Lymphatic spread
2 Haematogenous spread
3 Spread along body cavities and natural passages
( transcoelomic fluid, CSF)

83.  carcinomas metastatise by lymphatic route
 sarcomas by haematogenous route.
 The wall of lymphatics is readily invaded by cancer
cells & forms a continuous growth in lymphatic
channels c/a lymphatic permeation, or may detach to
form tumor emboli to be carried along to the next
lymph node.
 Tumor emboli enter the lymph node at it’s convex
surface & are lodged in subcapsular sinus.

85. SPREAD OF ORAL CANCER VIA LYMPH
NODES
 Mucosal lip cancers represent approximately 2 to 42% of oral cavity
cancers.
 10% of lower lip cancers and 20% of cancers in the upper lip and
commissure are found to metastasize to the nodes.
 Metastasis from the lower lip is to the submental, submandibular,
and perifacial nodes (level I more commonlythan level II).
 Preauricular, periparotid,and submandibular nodes drain cancers
of the upper lip and commissure (level II more commonly than level
I).

86.  Bilateral neck metastasis may develop if the lower lip lesion is
near or has crossed the midline;
 however, the upper lip rarely exhibits crossover between right-
and left-side lymphatics.
 Carcinoma of the buccal mucosa represents 2 to 10% of all
SCC of the oral cavity
 lymphatic drainage from the buccal mucosa is level I followed
by level II.
 Cervical metastases are observed in 10 to 27% of presenting
patients.

87.  Alveolar ridge or gingival carcinoma represents 2 to 18% of oral
cancers and occurs predominantly on the mandibular alveolus.
 Lymph node metastasis tends to occur more frequently in
mandibular ridge tumors than in maxillary tumors.
 Nodal drainage is principally to levels I and II for both the
maxillary and mandibular lesions and is found in 24 to 28% of
patients at diagnosis.

88.  Tumors of the retromolar trigone represent 2 to 6% of all oral
cavity carcinomas.
 Lymphatic drainage from this area is predominantly to the
submandibular nodes (level IB)
 and the upper jugulo-digastricnodes (level II).
 Lesions of this region tend to be more aggressive in nature
with regard to developing cervical metastasis, because 27 to
56% of individuals present with metastatic disease.

89.  There is a paucity of lymphatics to the hard palate.
 Approximately 10 to 25% of individuals present with
evidence of metastasis, generally to levels I and II.
 Hard palate lesions may also metastasize to retropharyngeal
nodes
 or nodes that are not palpable on a clinical examination or
readily removable with a traditional neck dissection.

90.  Lymphatic drainage of the oral tongue is principally to level II,
followed by levels III
 Carcinoma of the lateral border generally metastasizes
ipsilaterally
 but SCC of the tip or body of the tongue may exhibit bilateral
metastases.
 Approximately 40% of patients have evidence of clinical node
metastasis at the time of diagnosis.

91. Sentinel Lymph Node History
 1955  First echelon node
 1960  “Sentinel node”
 1977  Demonstrated in penile cancer
 1992  Morton reintroduced concept in N0
melanoma
 Currently widely used in melanoma and breast cancer
therapy.

92. Sentinel lymph node concept
 Tumor spreads via lymphatics to a primary node.
 Examination of primary echelon nodes for tumor direct the
need for surgical management of the nodal basins.

93. Sentinel lymph node concept
 Difficulties of lymphatic mapping in head and neck
(O’Brien).
1. It is difficult to visualize lymphatic channels using
lymphoscintigraphy because of proximity to the injection site.
2. The radiotracer travels fast in the lymphatic vessels.
3. If more than one node is visible, it can be difficult to
distinguish first echelon nodes from second-echelon nodes.
4. The SLN may be small and not easily accessible (eg, in the
parotid gland).

94.  see if cancer has spread from the primary tumour to the lymph
nodes
 This information is used to determine the stage (the extent
of cancer in the body).
 help plan treatment
 reduce the chance of lymphedema (buildup of lymph fluid)
developing
 SLNB reduces, but does not completely eliminate, the risk
of lymphedema.

95. Senital node biopsy
 The surgeon injects a radioactive substance (radiotracer), a blue dye or both into the
tissue around the tumour or into the area from where the tumour was removed.
 The radiotracer is injected anywhere from 1–16 hours before the surgical
procedure.
 It takes about 5 minutes for the blue dye to reach the sentinel nodes, so the dye
is often injected in the operating room just before the surgery.
 The dye or radioactive substance is taken up by the lymph vessels. It travels along
the lymph vessels draining the area around the cancer to the sentinel lymph node(s).

96.  A special scanning device detects the radioactivity in the sentinel lymph
node(s), or the surgeon looks for the lymph node(s) stained blue.
 Sometimes, the sentinel lymph node cannot be identified.
 If the sentinel lymph node is positive or if it cannot be identified, then more
lymph nodes will need to be removed.
 The surgeon makes a small cut (incision) over the node(s).
 The radioactive or blue lymph node(s) is removed and sent to the laboratory to
be examined under a microscope by a pathologist (a doctor who specializes in
the causes and nature of disease).

97. EXAMINATION OF LYMPHATI C SYSTEM
 LOCAL EXAMINATION
 Inspection
 Swelling
1. Number
2. Position
3. Size
4. Shape
5. Surface
 Skin over the swelling

98. Palpation
1. Rise in local temperature
2. Tenderness
3. Situation and extent
4. Size and shape
5. Surface
6. Margin
7. Consistency (Soft, elastic and rubbery, firm, hard and stony hard)
8. Nodes separate or matted together- periadenitis
9. Fixity to surrounding structures(skin, muscle,nerve,vessel,bone or
any viscus)

99.  Look for the primary focus in the drainage area
 Examine the lymph vessels

100.  Acute lymphangitis- lymph vessels show reddened, tender, indurated
streaks ascending to the regional lymph nodes from the point of
infection
 Carcinoma- multiple hard subcutaneous nodules in path b/w primary
focus and lymph nodes
 Lymphedema-stasis of lymph(lymphatic obstruction)
swelling of affected limb
Early- pitting is seen
Late – fibrosis, prolonged pressure to pit
Finally extreme fibrosis- no pitting

101. EXAMINATION OF LYMPH NODES
1. Lymph nodes should be examined from patient’s behind.
2. Examination is done by asking patient to flex his neck
slightly to reduce tension of muscles
3. To palpate, use the pads of all four fingertips.
4. Examine both sides of head simultaneously while applying
steady gentle pressure.

102. ANTERIOR/POSTERIOR CERVICAL LYMPH
NODES
 They lie anterior & posterior to sternomastoid muscle.
 Tip of fingers are used to palpate anterior nodes, medial to
sternomastoid muscle and posterior nodes behind the muscle
while patient,s head tipped slightly forwards.

103. SUBMANDIBULAR
NODES
 Palpated from behind
the patient, with
patient,s chin tipped
slightly towards the
chest.

104. SUBMENTAL NODES
 Roll the fingers below
the chin(in the midline)
with patient’s head
tilted forwards

105. PAROTID
NODES/PREAURICULAR
NODES
 Roll the finger in front of ear ,
against the maxilla

106. POSTAURICULAR/
MASTOID NODES
 Roll the finger behind the
ear

107. Occipital nodes
 Palpated behind the ear at
the base of skull

108. Supraclavicular lymph
nodes
 While patient’s head is tipped
forward, the index finger of
the examiner is placed in the
triangle and the area is
palpated with a rotary motion.

109. PALPATION
 Soft and fluctuating
 Firm ,discreet ,shotty
 Stony hard
 matted
CONDITIONS
Hodgkins lymphoma
Syphilis
Secondary carcinoma
TB , Acute lymphadenitis,
metasttic carcimoma

110. Laboratory Studies
 Directed by the history and physical examination, overall clinical assessment
 CBC count, peripheral blood smear.
 Evaluation of hepatic and renal function, urine underlying systemic
disorders
 Skin testing for tuberculosis is usually indicated.
 Specific regional adenopathy, lymph node aspirate for culture may be
important if lymphadenitis is clinically suspected.
 Titers for specific microorganisms-generalized adenopathy is present.
 These may include epstein-barr virus, cytomegalovirus (cmv), b henselae,
toxoplasma species, and human immunodeficiency virus (hiv).

111. Imaging Studies
 Chest radiography -primary screening tool
 Elucidating mediastinal adenopathy and underlying diseases affecting
the lungs
 .
 Supraclavicular adenopathy,-CT scanning of the chest, abdomen, or
both.
 Positron-emission tomography (PET) scanning is not helpful as a
screening tool as benign and malignant conditions may cause intense
uptake
•Tuberculosis,
• Coccidioidomycosis,
•Lymphomas,
•Neuroblastoma,
•Histiocytoses,
•Gaucher disease

112.  PET scanning is helpful in the evaluation of lymphomas once a
clinical or tissue-based diagnosis is made.
 scanning is helpful in the evaluation of lymphomas.
 Ultrasonography -evaluating the changes in the lymph nodes and
in evaluating the extent of lymph node involvement in patients
with lymphadenopathy

113.  Patients with matted nodes were more likely to
develop distant metastases, whereas patients
with normal nodes were more likely to develop
a local recurrence

114. Sensitivity %
(range)
Specificity %
(range)
Palpation 35 (30-40) 35 (27-42)
CT 45 (17-86) 11 (3-21)
US 46 (42-50) 21 (11-33)
MRI 42 (20-70) 14 (5-26)
Accuracy of diagnostic methods in detecting occult cervical metastases.
A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of
sentinel node biopsy and positron emission tomography

115. BIOPSY
 If the size, location, or character of the lymphadenopathy suggests
malignancy and laboratory testing is inconclusive, a lymph node biopsy is
immediately indicated.
 Best performed on regional lymph nodes suggestive of metastasis using a
fine-bore needle to aspirate cells for cytologic examination.
 Ultrasound-guided fine-needle aspiration cytology is now favored.
 Fine needle aspiration -small samples with limited ability to perform flow
cytometry and chromosomal analysis
 So some prefer excisional biopsy.

116. CAUSES OF ENLARGEMENT OF LYMPH
NODES
INFLAMMTORY
 (a) Acute Lymphadenitis
 (b) Chronic Lymphadenitis
 (c) Granulomatous Lymphadenitis
NEOPLASTIC
 (a) Benign – almost non-existent
 (b) Malignant
 1. Primary
 (i) Giant follicle lymphoma
 (ii) Lymphosarcoma
 (iii) Reticular cell sarcoma
 (iv) Hodgkin’s disease.
 ) Granulomatous Lymphadenitis

117.  2. Secondary
 Malignant melanoma
Autoimmune Disorders
 (i) Juvenile rheumatoid arthritis
 (ii) Other collagen diseases such as Systemic lupus
erythomatosus, Polyarteritis nodosa and scleroderma.

118. CAUSES OF LYMPH NODE ENLARGEMENT
Sub mandibular Nodes
 Sinusitis
 Tonsillitis
 Conjunctivitis
 Pharyngitis
Sub mental Nodes
• Periodontitis
• Mononucleosis
(Epstein-Barr Virus)
• Cytomegalovirus
• Toxoplasmosis

119. Deep cervical nodes
 Pharyngitis
 Rubella
 Tuberculosis
 Lymphoma
 Head and neck cancer
Occipital nodes
• Local infection
• Secondary Syphillis
• Neoplasm
Postauricular nodes
• Otitis Externa
• Secondary Syphilis
• Rubella

120. Preauricular nodes
 Local infection
 Erysipelas
 Herpes Zoster
 Rubella
 Trachoma
 Viral Conjunctivitis
 Cat Scratch Disease
 Syphilis
 Tuberculosis

121. 1-lymph node draining a septic foicus* cervical : tonsilitis, scarlet
fever, scalp infection.
* periauricular: otitis media.
Causes of localised lymphadenopathy
2-carcinomatous.
* virchow’s: stomach
* cervical: thyroid, tongue, parotid.
3- Systemic Infections
Viruses: - Viral hepatitis Rt. supraclavecular L.N
- German measles (cervical LN)
Bacteria:
T.B
Generalized L.N. may start as localized L.N. as in Hodgkin’s
disease

122. Causes of Generalised Lymphadenopathy
I- Infectious
* Viruses:
a-Infectious mononucleosis
b-Cytomegalo virus (C.M.V.)
* Bacteria: a- brucellosis
b- T .B.
*Spirochetes:
* Protozoa
a- kala azar
b-toxoplasmosis.

123. Causes of Generalised Lymphadenopathy
2- leukemias: especially chronic lymphocytic leukamia
(C.L.L.)
3- : a- Hodgkin’s disease (H.D.)
b-Non- Hodgkin’s lymphoma (N.H.L)
4- Collagenosis: a-rheumatoid artheritis.
b- Felty’s syndrome.
.
5-Allergy
6- Sarcoidosis
7- Lipoidosis
8-Miscellaneous

124. Characters of L.N. Enlargement in Some Diseases
1- Streptococcal infection of tonsils:
2- Scarlet Fever
Sore throat.
3-Diphtheria
Uni or Bilateral * Tender & unmatted
*Usually submandibular but may extend to lower
cervical group.
marked enlargement of submandibular L.N.
*Other cervical L.N. (bilateral, tender, discrete,
suppuration is common
Enlarged submandibular L.N. usually bilateral,
tender, not matted.

125. 4-German Measle:
•OccipitaI L.N. enlargement are nearly always present, closely
resembles that of infectious mononucleosis.
5-Infectious Mononucleosis:
* Sore throat, Fever, sometimes headache, myalgia.
* Palatal petechiae often, are present
* Mild splenomegally in 50% of cases
*Lymphocytosis in 75% of cases with some atypical lymphocytes.
Bilateral L.N. enlargement, firm, discrete, mobile.
* Appear first in posterior cervical area, adjacent to
cervical spines, few days later , submandibular L.N. will
be enlarged

126. 6- T.B.:
* The chiefly affected group is upper cervical group, generalized
L.N. enlargement is exceptional.
* Unilateral or Bilateral.
* Often firm, matted, painful, may become adherent to skin or deep
structures.
* Cystic areas may occur due to caseation and later on cold abscess
formation.
* Overlying skin may break down giving T.B. ulcers or sinuses.

127. Syphilis:
Primary
L.N draining a chancre
-Rocky hard, uni Or bilateral, not tender.
Secondary
-Generalized L.N. enlargement especially posterior
triangle of the neck or epitrochlear gp
(slightly enlarged, shotty, discrete, painless).

128. 8- LYMPHOMATOUS L. N:
•May be associated with constitutional symptoms.(anorexia, fever,
weight loss, sweating, ….. etc).
•Pel Ebstein fever: may be observed in H.D., it is a period of fever
lasting for few days or weeks alternating with longer or shorter
apyrexial periods .
• L.N. usually discrete at start & not tender (but may become tender
during febrile periods).
•L.N. may increase in size during pyrexial periods and decrease in size
during apyrexial periods

129. a-H.D.:
* may be confined to one group at first esp. lower cervical group then
later on generalized L.N. enlargement.
•Glands are:
a- moderately enlarged, not tender.
b- Firm, rubbery in consistency.
c- Discrete, mobile however as a result of later extension
outside the capsule glands become matted or fixed
b-N.H .L:
*Also the cervical group is firstly affected
*Rapid rate of growth results in large number of variable sized nodes
which are hard in consistency, tend to become fused and fixed to deep
structures & may give pressure manifestations.

130. 9- LEUKAEMIC L. N:
*May be associated with general manifestations (fever, malaise,
anorexia, headache, Hemorhagic tendency)
a- Acute Leukaemia:
*Late, slightly or moderately enlarged
*Soft, discrete esp. cervical L.N. due to oral sepsis
*May be tender bone.
b-C.L.L:
* May affect cervica1 L.N. but mostly all superficial L.N. are
enlarged.
*The glands usually are (firm, not tender, not matted, usually
moderately enlarged, but in advanced stages may be markedly
enlarged)
c-C.M.L.:
*Rare to be manifested by L.N. enlargement.

131. 10- CARCINOMATOUS L.N.:
*Firm, but some times hard.
*A stoney hard nodes fixed to underlying tissues are nearly
always neoplastic in nature, however the reverse is not true.
*Carcinomatous L.N. may be freely mobile

132. lymphangioma
 Lymphangioma is a benign hamartomatous tumor of lymphatic
channels, with a marked predilection for the head and neck
region, at submandibular and parotid area .

134. CONCLUSION
 Lymphatic system is a closed system of lymph
channels through which lymph flows.
 It is an one way system.
 The entire lymph from the head and neck drains
ultimately into deep cervical nodes either directly
or through peripheral nodes.
 In CNS- lymph is replaced by CSF
 It is essential to have appropriate knowledge of
tumor metastases for most appropriate treatment.