Lymphatics of head, neck, and face 2/ oral surgery courses

LYMPHATICS OF HEAD,
NECK, AND FACE-II
SEMINAR ON
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
LEADER IN CONTINUING DENTAL EDUCATION

REFERENCES
 Henry Gray. Gray”s Anatomy:Lymphatic drainage of head and
neck;38th, edi-churchill livingstone,2000,pg no.1612
 B.D.Chaurasia”s.Human Anatomy Regional and applied: Deep
structure of neck;2nd edi-CBS publishers,pg no.161
 S.M Balaji.Textbook of oral and maxillofacial surgery, Lymph
node examination,Elsevier,
2008,pg.no.15

 N.Chakraborty D Chakraborty;Fundamentals of human
anatomy.Lymphatic drainage of head and neck.Vol.III-
2004,New central book agency,pg.no87
 A.Halim;Regional and clinical anatomy for
dental.pg.no162
 Neelima Malik;Textbook of oral and maxillofacial
surgery,Lymph nodes level.2nd edi jaypee,pg.no.736

Das S.,A manual on clinical surgery, 4th edition
Greenberg M.,Glick M.,Ship A.,Burket’s Oral Medicine
Torabi M.,Aquino S.,j.nuclear med 2004;45:1509-1518
Mukherji, et al. Neurographics , Vol. 2, Issue 2, Article 2

LEARNING OBJECTIVES
By the end of seminar the learner must be able to :-
 Classification of lymph nodes
 Its clinical significance
 Method for evaluation of lymph nodes.
 Various diagnostic methods used for its detection

INTRODUCTION
 Lymphatic system consist of fluid called LYMPH
 DEFINITION: Transparent, slightly yellowish liquid of
alkaline reaction found in lymphatic vessel and derived
from tissue fluid.
 Lymphatic system is absent in:
-C.N.S.
-Cornea
-Superficial layer of skin
-bones
-alveoli of lung

CLASSIFICATION OF LYMPH NODES
LYMPH NODE OF
HEAD & NECK
HORIZONTAL
SUBMENTAL LN
SUBMANDIBULAR
LN
PAROTID LN
PREAURICULAR
LN
OCCIPITAL LN
VERTICAL
CENTRAL
PRELARYNGEAL LN
PRETRACHEAL LN
PARATRCHEAL LN
LATERAL
JUGULODIGASTRIC
LN
JUGULO-OMOHYOID
LN

ANATOMY OF CERVICAL LYMPH NODES
Classification
1. Upper horizontal chain of nodes.
a) Submental
b) Submandibular
c) Parotid
d) Postauricular
e) Occipital

2. Lateral cervical nodes.
 They include nodes, superficial
and deep to
sternocleidomastoid muscle
and in the posterior triangle.
a) Superficial external jugular
group
b) Deep group
 i. Internal jugular chain (upper,
middle and lower groups)
 ii. Spinal accessory chain
 iii. Transverse cervical chain

3. Anterior cervical nodes
a) Anterior jugular chain
b) Justavisceral chain
 i. Prelaryngeal
 ii. Pretracheal
 iii. Paratracheal

CLASSIFICATION OF NECK NODES ACCORDING
TO LEVELS
 Level I:
 Submental (IA)
 Submandibular (IB)
 Level II Upper jugular
 Level III middle jugular
 Level IV Lower jugular

 Level V
 Posterior triangle group
(Spinal accessory and
transverse cervical chains)
 Level VI
 Prelaryngeal
 Pretracheal
 Paratrachal
 Level VII
 Nodes of upper mediastinum

Level I includes :
 IA Submental nodes, which lie
in the submental triangle i.e.
between right and left anterior
bellies of diagastric muscles and
the hyoid bone.
 IB Submandibular ones, lying
between anterior and posterior
bellies of diagastric muscle and
the body of mandible.

Level II – Upper Jugular
Nodes
 They are located along the
upper third of jugular vein
i.e. between the skull base
above, and the level of
hyoid bone (or bifurcation
of carotid artery) below

Level III – Middle Jugular Nodes
 They are located along the middle third of jugular vein,
from the level of hyoid bone above, to the level of upper
border of cricoid cartilage.
Level IV – Lower Jugular Nodes
 They are located along the lower third of jugular vein;
from upper border of cricoid cartilage to the clavicle.

Level V – Posterior Cervical Group
 They are located in the posterior triangle i.e. between
posterior border of sternocleidomastoid (anteriorly),
anterior border of trapezius (posteriorly), and the clavicle
below.
 They include lymph nodes of spinal accessory chain,
transverse cervical nodes and supraclavicular nodes.

 Level VI – Anterior Compartment Nodes
 They are located between the medial borders of
sternocleidomastoid muscles (or carotid sheaths) on each side,
hyoid bone above and superasternal notch
below.
 They include prelaryngeal,pretracheal, paratracheal nodes.
 Level VII
 They are located below the suprasternal notch and include
nodes of the upper mediastinum.

Submental Nodes
 Lie on mylohyoid muscle in the
submental triangle 2 to 8 in
number
 Drainage – afferents come from
the chin, middle part of lower lip,
anterior gums, anterior floor of
mouth and tip of tongue.
 Efferents - they go to
submandibular and internal
jugular chain

 Submandibular –
 They lie in submandibular triangle in
relation to submandibular gland.
 Afferents come from lateral part of
the lower lip, upper lip, cheek,
nasal vestibule and anterior part of
nasal cavity, gums teeth medial
canthus, soft palate, anterior pillar
anterior part of tongue, submandibular
and sublingual salivary glands and
floor of mouth.
 Efferents go to internal jugular chain.

 Parotid nodes – they lie in
relation to the parotid salivary
gland.
 Afferents come from the
scalp, pinna,external auditory
canal,face ,buccal mucosa.
 Efferents go to internal
jugular or external jugular
chain.

 Post auricular nodes(mastoid
nodes) –
 They lie behind the the pinna
over the mastoid.
 Afferents come from the scalp,
posterior surface of pinna and
skin of mastoid.
 Efferents drain into internal
jugular chain

 Occipital Nodes
 They lie at the apex of the
posterior
triangle
 Afferents come from scalp, skin
of upper neck. Efferent drains
into upper accessory chain of
nodes

Lateral Cervical Nodes
 a) Superficial group –
it lies along external
jugular vein and drains
into internal jugular
and transverse cervical
nodes.

Deep Group of lymph nodes:-
 It consists of three chains, the internal jugular, spinal
accessory and transverse cervical.
Internal jugular chain
 Lymph nodes of internal jugular chain lie anterior, lateral
and posterior to internal jugular vein.
 Upper group (jugulodigastric node) – drains oral cavity,
orpharynx, nasopharynx,hypopharynx, larynx and
parotid.
 Middle group drains hypopharynx, larynx, throid, oral
cavity, oropharynx.
 Lower jugular group drains larynx, thyroid and cervical
oesophagus.

Spinal accessory chain
 Lies along the spinal
accessory nerve. 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.

Transverse cervical chain
(supraclavicular nodes)
 It lies horizontally, along the
trasverse cervical vessels, in the
lower part of the posterior
triangle. The medial nodes of the
group 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.

Anterior Cervical Nodes:-
They lie between the two carotids
and below the level of hyoid bone
and consist of two chains:
(a) Anterior jugular chian - It lies
along anterior jugular vein and
drains the skin of anterior neck

(b) Juxtavisceral chain –
It consists of prelaryngeal,pretracheal, and paratracheal
node.
(i) Prelaryngeal node (Delphian node):-
it lies on cricothyroid membrane and drains subgottic
region of larynx and pyriform sinuses.

(ii) Pretracheal nodes lie in front of the trachea, and
drain thyroid gland and the trachea.
Efferent from these nodes go to paratracheal,
lower internal jugular and anterior mediastinal
nodes.
(iii) Paratracheal Nodes – drain the thyroid lobes,
subglottic larynx, trachea and cervical oesophagus.

LEVEL I
 Ia
 Chin
 Lower lip
 Anterior floor of mouth
 Mandibular incisors
 Tip of tongue
 Ib
 Oral Cavity
 Floor of mouth
 Oral tongue
 Nasal cavity (anterior)
 Face

LEVEL II
 Oral Cavity
 Nasal Cavity
 Nasopharynx
 Oropharynx
 Larynx
 Hypopharynx
 Parotid

LEVEL III
 Oral cavity
 Nasopharynx
 Oropharynx
 Hypopharynx
 Larynx

LEVEL IV
 Hypopharynx
 Larynx
 Thyroid
 Cervical esophagus

LEVEL V
 Nasopharynx
 Oropharynx
 Posterior neck and scalp

LEVEL VI
 Thyroid
 Larynx
(glottic and subglottic)
 Pyriform sinus apex
 Cervical esophagus

Inner circle of lymph nodes

Arrangement of outer circle of lymph nodes

CLINICALAPPLICATION
 Situation of lymph nodes in the neck, their areas of drainage are
of clinical importance since complete removal of all the
lymphatics in the neck is the only hope of permanent cure for
cancers in different parts of head and neck
 Submandibular nodes are under the superficial lamina of
investing layer of deep fascia in actual contact of salivary gland.
In cancer, therefore, removal of these lymph nodes necessitates
the removal of the submandibular salivary gland as well because
of this intimate relationship.
 Painful enlargement of the submandibular nodes is common
because infections of the regions they drain is common.

 Occipital nodes are enlarged in the early stage of German measles
 Tuberculous disease of the neck usually involves the upper deep
cervical nodes usually from tonsillar infection.
 They adhere very firmly to the internal jugular vein which may
be injured in the course of their removal.
 Enlargement of jugulodigastric node is valuable in the diagnosis
of pharyngeal or tonsillar involvement

 Infection of retropharyngeal nodes may lead to
retropharyngeal abscess.
 Supraclavicular nodes may be enlarged in ascending
infection from axillary nodes.
 Enlargement of supraclavicular nodes in front of left scalenus
anterior muscle is common in malignant disease of stomach.
These are known as virchows gland.

CLINICAL STAGING OF CERVICAL
LYMPH NODES
 Nx-Regional lymph nodes can not be assessed.
 No-No regional lymph node metastasis.
 N1-Metastasis in a single ipsilateral lymph node,<3cm in
greatest dimension.
 N2a-metastasis in a single ipsilateral lymph node,>3cm but<6cm
in greatest dimension.

 N2b-metastasis in multiple ipsilateral lymph nodes,none>6cm in
greatest dimension.
 N2c-metastasis in bilateral or contralateral lymph nodes,none
>6cm in greatest dimension.
 N3-metastasis in a lymph node >6cm in greatest dimension.

CLINICAL EVALUATION
 Normal lymph nodes are not palpable.
 Enlarged lymph nodes are easily located
 Palpable nodes are primary & imp. sign of clinical disease
 Palpation of lymph nodes:-
 Started with most superior node working down to the
clavicle
 Best done from behind the seated subject using both hands
together

EXAMINATION OF NECK
NODES
 Examination of neck nodes is
important, particularly in head
and neck malignancies and a
systematic approach should be
followed.
 Neck nodes are better palpated
while standing at the back of
the patient.
 Neck is slightly flexed to
achieve relaxation of muscles

When a node or nodes are palpable, look for the following
points:
 (i) Location of nodes
 (ii) Number of nodes
 (iii) Size – Abnormal Nodes
 (iv) Consistency. Metastatic nodes are hard; lymphoma nodes
are firm and rubbery; hyperplastic nodes are soft. Nodes of
metastatic melanoma are also soft.

 (v) Discrete or matted nodes.
 (vi) Tenderness. Inflammatory nodes are tender.
 (vii) Fixity to overlying skin or deeper structures.
Mobility should be checked both in the vertical and
horizontal planes.

The nodes are examined in the following manner so that
none is missed.
 a) Upper horizontal chain.
 b) External jugular chain
 c) Internal jugular chain
 d) Spinal accessory chain
 e) Transverse cervical chain
 f) Anterior jugular chain
 g) Juxtavisceral chain.

SUBMENTAL NODES
Roll the fingers below the chin with patient’s head tilted
forwards

SUBMANDIBULAR NODES
Roll your fingers against inner surface of Mandible with patient's
head gently tilted towards one side

PARTOID NODES
Roll your finger in front of
the ear, against the maxilla.

POST AURICULAR (MASTOID NODES)
Roll the fingers
behind the ear

OCCIPITAL NODES

EXTERNAL JUGULAR CHAIN
It lies superficial to sternomastoid

INTERNAL JUGULAR CHAIN
Examine the upper,
middle and lower
groups.
Many of them lie deep
to sternomastoid
muscle which may need
to be displaced
posteriorly.

Supraclavicular (Scalene
Nodes)
Roll your fingers gently
behind the clavicles.
Instruct the patient to cough
or to bear down like they are
having a bowel movement.
Occasionally an enlarged
lymph node may pop up.
Transverse Cervical Nodes

HISTORY :-
1. Age
2. Duration
3. which group was affected first
4. Pain
5. Fever
6. Past history
7. Family history

Local Examination:-
1.Inspection
a.Number
b.Size
c.Position
d.Surface
e.Skin over the swelling

2.Palpation
 Situation
 Local temperature
 Approx. diameter in cms.
 Tenderness
 Surface
 Margin
 Consistency
 Discrete or confluent
 Fixity to the skin & surrounding structure

INVESTIGATIONS
 Blood examination
 FNAC
 Biopsy
 Imaging
Ultrasound
CT
MRI
PET
Nanoparticle enhanced MRI
Lymphangiography

ULTRASOUND
 Widely available & easy to use
 Conventional ultrasound has a
high sensitivity for detecting
enlarged lymph nodes, whereas
its specificity is moderate.
Normal cervical nodes appears as
Flattened hypoechoic structure
with varying amount of fat
May show vascularity but
usually hypovascular cigar
shaped normal lymph node

 Malignant lymph nodes appears as
enlarged nodes that are usually
rounded show peripheral or mixed
vascularity
 Metastatic lymph node
 Thickened outer wall, internal
echoes,nodularity & septation
• Accuracy of 89%-94% in
differentiating malignant from
benign cervical lymph node.

CT-SCAN
 Cross sectional imaging technique requires understanding
of cross sectional anatomy of nodes
 High patients acceptance & short examination time
Technique :-
 Patient supine in quiet respiration a pad placed beneath the
patient’s scapulae produces mild hyperextension of the
neck and provides consistent images perpendicular to the
long axis of the neck.
 Scans are obtained using 3–5 mm or thinner slices.

 Use of contrast facilitates differentiation of vessels from
lymph nodes and the characterization of pathology.
 Normal lymph nodes:-
 <1c.m. In size
 Smooth & well defined border
 Uniform & homogenous density
 Benign node have central fatty hilum

MRI
 To improve cross sectional imaging,dynamic gadolonium
contrast enhanced MRI is in use
 Evaluates alteration in lymph node microcirculation such
as flow characteristics, blood volume, microvascular
permeability.
 According to Fischbein at al ,lower peak enhancement,
lower maximum slope, & slower washout slope in tumor-
involved lymph nodes seen compared with normal lymph
nodes.
 As in malignant lymph node, there is a decreased transfer
of contrast material to the tissue and a reduced volume of
extracellular space.

CONCLUSION :-
 All of the processes of tissue nutrition and repair are dependent on
lymph.
 Since the blood does not come in direct contact with tissue
cells(except in one organ-spleen) the main function of blood
circulation is to supply and renew the lymph to all tissues.

The blood feeds the lymph and the lymph feeds the
cells”
The excretion of the cells-the waste products of
metabolism are carried by the lymph back into the blood
stream for elimination.
Through the lymph channels-metastasis frequently
occurs –especially of malignant tumor cells.
Gives protection against various forms of infection.

Ananthnarayan & Paniker,Textbook of
Microbiology ,4th edition
Das S.,A manual on clinical surgery, 4th edition
Greenberg M.,Glick M.,Ship A.,Burket’s Oral
Medicine
Torabi M.,Aquino S.,j.nuclear med 2004;45:1509-
1518
Mukherji, et al. Neurographics , Vol. 2, Issue 2,
Article 2
THANK YOU!

Lymphatics of head, neck, and face 2/ oral surgery courses

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