Lymph Nodes of Head and Neck Region

8/10/2019 Lymph Nodes of Head and Neck Region

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LYMPH NODES OF THE HEAD AND NECK

GUIDED BY: PRESENTED BY:

Dr. Girish Dr. Preyas Joshi

Dr. Mayank agrawal 2nd YEAR P.G

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INTRODUCTION

DEVELOPMENT

LYMPHATIC DRAINAGE APPLIED ASPECT

REFERENCE


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LYMPHA

The Lympha is an ancientRoman deity of fresh water.

She is one of twelve

agricultural deities listed as

leadersofRoman farmers,

because "without water all

agriculture is dry and poor."

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BODY FLUIDS

Body fluid, bodily fluids, or biofluids are liquids originating from insidethe bodies of living people. They include fluids that

are excreted or secreted from the body.

Approximately 60-65% of body water is contained within the cells

(in intracellular fluid) with the other 35-40% of body water contained

outside the cells (in extracellular fluid).

This fluid component outside of the cells includes the fluid between the cells

(interstitial fluid), lymph and blood.

There are approximately 6 to 10 liters of lymph in the body, compared to 3.5

to 5 liters of blood.

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WHAT IS LYMPH?

Lymph is a clear to yellowish watery fluid that is

found throughout the body.

It circulates through body tissues picking up fats,

bacteria, and other unwanted materials, and filtering

them out through the lymphatic system.

This fluid contains white blood cells, known

as lymphocytes, along with a small concentration of

red blood cells and proteins. 5


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Most of the items(water,proteins,gases,nutrients,hormones,wastes & leukocytes) are

dissolved in the blood plasma.

Therefore, if we could get fluid out of the capillary, we could get these dissolved

materials out, too.

capillaries can leak out material at the junctions between endothelial cells. These

spaces are rather small, keeping larger things (RBCs) inside, while letting the fluid

(plasma) out.

The capillaries are porous enough that the plasma within them is in contact with the

fluid outside of them (extracellular fluid/interstitial fluid).

whether they will do so or not depends on the pressures on the fluids.

EXCHANGE ACROSS CAPILLARIES


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LYMPHATIC SYSTEM

The lymphatic systemis part of the circulatory system,

comprising a network of lymphatic vessels that carry aclear fluid called lymph directionally towards the heart.

Unlike the cardiovascular system the lymphatic systemis not a closed system. The circulatory system

processes an average of 20 litres of blood per daythrough capillary filtration which removes plasma whileleaving the blood cells.

Roughly 17 litres of the filtered plasma get reabsorbed

directly into the blood vessels, while the remaining 3litres are left behind in the interstitial fluid. One of themain functions of the lymph system is to provide anaccessory route for these excess 3 litres per day to getreturned to the blood.

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IMPORTANCE OF LYMPH

Lymph is the fluid that circulates throughout the lymphatic

system. The lymph is formed when the interstitial fluid (the

fluid which lies in the interstices of all body tissues) iscollected through lymph capillaries. It is then transported

through lymph vessels to lymph nodes before emptying

ultimately into the right or the left subclavian vein, where it

mixes back with blood.

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Since the lymph is derived from the interstitial fluid,

its composition continually changes as the blood and

the surrounding cells continually exchange substances

with the interstitial fluid. Lymph returns protein andexcess interstitial fluid to the circulation. Lymph may

pick up bacteria and bring them to lymph nodes where

they are destroyed. Lymph also transports fats from

the digestive system.

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STRUCTURE OF LYMPH NODES

A lymph node is an oval-shaped organ of the lymphaticsystem.

It is distributed widely throughout the body and linked

by lymphatic vessels. Lymph nodes are major sites of B- and T- immunity cells.

Lymph nodes act as filters or traps for foreign particles and

are important in the proper functioning of the immune

system.

They are packed tightly with the white blood

cells called lymphocytes and macrophages.


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Each lymph node is surrounded by a fibrous capsule.

The substance of the lymph node is divided into the outer cortex and

the inner medulla.

The cortex is continuous around the medulla except at the hilum,

where the medulla comes in direct contact with the hilum(part of an

organ where structures such as blood vessels and nerves enters).

C O S O O S


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FUNCTIONS OF THE LYMPH NODES

They produce and supply lymphocytes to the blood

They make screening of lymph by means of phagocytic activity

They serve a great defense role against bacterial infection

They temporarily stop spread of cancer cells as these cells have to

penetrate through lymph vessels to the lymph nodes from where they

spread in the body.

They act as a mechanical filters to resist entrance of poisonous

substances into circulation

They carry out immunological responses and they help in elaboration

of antibodies and in the development of immunity

Lymph nodes produce gamma globulin 16


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EMBRYOLOGY OF LYMPH NODES

Lymphatic sacs form in the fifth week of embryo. The first signs of the

lymphatic system are seen in the form of two paired and two unpaired

endothelial sacs. Traditionally these sacs have been considered to be

outgrowth from veins. However, they are now regarded to be

predominantly independent formations from mesenchyme that

connect with the venous system secondarily.

L h l f h h d k d


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THE PRIMARY LYMPH SACS IN A 42-DAY-OLD HUMAN EMBRYO

The first primordial lymph sacs to appear are the paired jugular sacs in the neck.

The next sac to appear is unpaired and located at the mesenteric root in the retroperitoneal

space.

The final paired sacs are two posterior (iliac) sacs.

One so-called cisterna chyli dorsal to the retroperitoneal lymph sac. 18

Lymph vessels of the head, neck, and

arms grows out from the jugular sacs.

Lymph vessels of the gut grows out

from the retroperitoneal and cisternal

sacs.

Lymph vessels of the lower trunk and

legs grows out from the iliac sacs.

CLASSIFICATION OF LYMPH NODES IN THE HEAD AND NECK REGION


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CLASSIFICATION OF LYMPH NODES IN THE HEAD AND NECK REGION

The lymph nodes in the head and neck region can be grouped into:

Superficial nodes

Deep nodes


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THE SUPERFICIAL LYMPH NODES

The superficial cervical lymph

nodes lie above the investing layerof the deep fascia.

They consist of a few small nodes

that lie superficial to the external

jugular and anterior jugular veins.

1. Submental

2. Submandibular

3. Buccal

4. Parotid (pre-auricular)

5. Mastoid (retro auricular/ post auricular)

6. Occipital

7. Superficial lateral cervical

8. Superficial anterior cervical.

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THE DEEP LYMPH NODES

1. Upper deep cervical: Jugulo-digastric group: lie along the upper part of internal

jugular vein deep to the sternomastoid.

2. Lower deep cervical:jugulo-omohyoid group: arranged along the lower part of

IJV also deep to the sternomastoid.

3. Waldyersring: The waldyersring is formed by: lingual, palatine, tubal, andpharyngeal tonsils.

4. Nodes of midline: Midline nodes are termed in correspondence to the anatomicalarea where they exist:

a) Infrahyoid

b) Prelaryngeal

c) Pretracheal

d) Paratracheal


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Waldyersring


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LYMPHATIC DRAINAGE OF THE SUPERFICIAL NODES

SUBMENTAL LYMPH NODES: The submental nodes are situated

between the anterior bellies of the Digastric. Their afferents drain the central

portions of the lower lip and floor of the mouth and the apex of the tongue;

Their efferents pass partly to the submandibular lymph nodes and partly to a

gland of the deep cervical group situated on the internal jugular vein at the level

of the cricoid cartilage.

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SUBMANDIBULAR LYMPH NODES:

The afferents of the submandibular glands drain the cheek, the side of

the nose, the upper lip, the lateral part of the lower lip, the gums, and the

anterior part of the margin of the tongue.

The submandibular lymph nodes, three to six in number, are placed beneath

the body of the mandible in the submaxillary triangle, and rest on the

superficial surface of the submandibular gland.

Efferent vessels from the facial and submental glands also enter the

submaxillary glands. Their efferent vessels pass to the superior deep cervical

glands.


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PAROTID (PRE AURICULAR) :


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PAROTID (PRE -AURICULAR) :

DEEP PAROTID LYMPH NODES:

The afferents of the subparotid glands drain the nasal part of the pharynx and the

posterior parts of the nasal cavities.

Their efferents pass to the superior

deep cervical glands.

SUPERFICIAL PAROTID LYMPH NODES:Their afferent vessels drain the root of the nose, the eyelids, the frontotemporal region,

the external acoustic meatus and the tympanic cavity, possibly also the posterior parts of

the palate and the floor of the nasal cavity.

The efferents of these glands pass to the superior deep cervical glands.


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POSTERIOR AURICUALR LYMPH NODES/MASTOID

LYMPH NODES/RETROAURICULAR LYMPH NODES:

Usually two in number, located just beneath the ear, on the mastoid insertion of

the sternocleidomastoid muscle, beneath the posterior auricular muscle.

Mastoid lymph nodes receives lymph from the posterior part of the temporoparietal

region, the upper part of the cranial surface of the visible ear and the back of the ear

canal. The lymph then passes to the superior deep cervical glands.


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OCCIPITAL LYMPH NODES :

The occipital lymph nodes, one to three in number, are located on the back of the head

close to the margin of the Trapezius and resting on the insertion of the Semispinalis

capitis.

Their afferent vessels drain the occipital region of the scalp, while their efferents pass to

the superior deep cervical glands.
http://en.wikipedia.org/wiki/Semispinalis_capitishttp://en.wikipedia.org/wiki/Semispinalis_capitis


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SUPERFI CIAL CERVICAL LYMPH NODES :

They can be broken down into:

Superficial anterior cervical lymph nodes: The superficial anterior cervical

lymph nodes are found in proximity to the anterior jugular vein.

Superficial lateral cervical lymph nodes: proximal to the external jugular vein.


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LYMPHATIC DRAINAGE OF THE DEEP LYMPH NODES

UPPER/SUPERIOR DEEP CERVICAL (JUGULO-DIGASTRIC):

The jugulodigastric lymph node is a large node found in the proximity of where the

posterior belly of the digastric muscle crosses the internal jugular vein. it receives

lymphatic drainage from the pharynx, palatine tonsil, and tongue.

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A A AC A A AC A O


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PRETRACHEAL: The pretracheal group consists of nodes between the isthmus of the

thyroid gland down to the level of the innominate vein.Varying from 2-12 in number, these

nodes drain the region of the thyroid gland and the trachea and receive afferent flow from the

prelaryngeal group. The pretracheal efferents empty in the internal jugular group and the

anterior superior mediastinal nodes.

PARATRACHEAL NODE: lie near the recurrent laryngeal nerve and drain the thyroid

lobes, parathyroid glands, subglottic larynx, trachea, and upper esophagus. The efferent

vessels travel to the lower jugular group or directly toward the junction of the internal jugular

vein and the subclavian vein.

PARATRACHEAL AND PRETRACHEAL LYMPH NODE:


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INFRAHYOID LYMPH NODE:

deep anterior cervical lymph nodes located between the levels of the hyoid bone

and thyroid cartilage.

PRE-LARYNGEAL LYMPH NODE:

Lie on conus elasticus and cricovocal membrane.They drain the anterior cervical

nodes, which in turn drain the skin of the anterior aspect of neck.


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WALDEYERS LYMPHATIC RING

In relation to the oropharyngeal isthmus, there are several aggregation of lymphoid

tissue that constitute waldeyers lymphatic ring. The most important aggregation

are the right and left palatine tonsils usually referred to simply as the tonsils.

Posteriorly and above there is the pharyngeal tonsil; laterally and above there are

the tubal tonsils, and inferiorly there is the lingual tonsil over the posterior part of

the dorsum of the tongue.

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METASTASIS

The development of secondary malignant growths at a distance from a primary

site of cancer.

Some cancer cells acquire the ability to penetrate the walls

of lymphatic and/or blood vessels, after which they are able to circulate

through the bloodstream (circulating tumor cells) to other sites and tissues in

the body.

After the tumor cells come to rest at another site, they re-penetrate the vessel

or walls and continue to multiply, eventually forming another clinically

detectable tumor. This new tumor is known as a metastatic (or secondary)

tumor.

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APPLI ED ANATOMY OF LYMPH NODES


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LYMPHATIC SPREAD OF METASTASIS

Lymphatic spread allows the transport of tumor cells to lymph

nodes and ultimately, to other parts of the body. This is the most

common route of metastasis for carcinomas. In contrast, it is

uncommon for a sarcoma to metastasize via this route. It is worth

noting that the lymphatic system does eventually drain into the

venous system, and therefore these metastatic cells can

eventually spread through the haematogenous route.

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TNM CLASSIFICATION

The latest classification has been created by the

American Joint Committee on Cancer(AJCC) and the American

Academy of Otolaryngology- Head and Neck Surgery.

The TNM(Tumor, Node, Metastasis) system devised by 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).

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R E G I O N A L L Y M P H N O D E S ( N )


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( )

Description:

NX = Regional lymph nodes cannot be assessed.

N0 = No regional lymph node metastasis.

N1 = Metastases in 13 regional lymph nodes.

N1a = Metastasis in 1 regional lymph node.

N1b = Metastases in 23 regional lymph nodes.

N2 = Metastases in 4 regional lymph nodes.

N2a = Metastases in 46 regional lymph nodes

N2b = Metastases in 7 regional lymph nodes.

EXAMI NATIO N OF THE LYMPHATIC SYSTE M


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EXAMI NATIO N OF THE LYMPHATIC SYSTE M(WHEN EXAMINING ONE AREA, ALWAYS COMPARE TO THE OTHER SIDE)

INSPECTION

Swelling

Number

Position

Size Shape

Surface

Skin over the swelling

PALPATION Rise in local temperature

Tenderness(Usually implies acuteinflammation or infection)

Situation andextent(localised/generalised)

Size and shape(Large nodes are usuallyabnormal,greater than 1 cm)

Surface

Margin

Consistency(Hard nodes suggestcarcinoma, soft may be normal

and rubbery nodes may be dueto lymphoma)

Nodes are separated/matted

Fixity to surrounding structures(Nodesthat are fixed to underlying structures aremore likely to be due to carcinoma)

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HOW TO PALPATE THE LYMPH NODES OF

HEAD AND NECK REGION

Lymph nodes should be examined frompatientsbehind.

Ask the patient to flex his neck slightly so as to reduce the tension of

muscles.

To palpate, use the pads of all four fingertips.

Using a gentle circular motion with your finger pads palpate

each lymph node.

It is a good idea to palpate both sides at the same time, comparing the

two sides symmetrically.


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CRITERIA FOR NORMAL LYMPH NODES

Normal cervical nodes should be less than one centimeter, movable, discrete, soft, and nontender.

ABNORMAL FINDINGS

If any nodes are palpable, enlarged, greater than 1 cm, and tender.


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PALPATION CONDITIONS


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Enlarged, tender and fixed lymph

nodes.

Discrete/matted.

Painless, firm, discrete and shotty

glands which do not suppurate.

elastic and rubbery, discrete and

movable with little tendency towards

matting, softening or suppuration.

nodes are enlarged, irregular, Hard

in consistency and fixed to all

structures including the skin.

Acute Lymphadenitis

Tuberculous Lymphadenitis

Syphilitic Lymphadenitis

Hodgkins Disease

Secondary Carcinoma


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LYMPHANGIOMA


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It is a benign tumour of lymphatic vessels.

Lymphangioma is a benign tumor of lymphatic vessels

Classiication (watson & McCarthy) Simple lymphangioma

Cavernous (most common)

Cellular

Diffuse systemic

Cystic hygroma

Clinical feature: age of onset is below 15 years.

Intra orally it commonly occurs on the tongue, but also seen on the palate, buccalmucosa, gingiva and lip.

Treatment: surgical excision

MALIGNANT LYMPHOMA


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It is derived from the basic cells of lymphoid tissue, the

lymphocytes, and histiocytes, in any of their developmental

stages.

Malignant lymphoma is following type:

I. Non Hodgkins lymphoma

II. Hodgkins lymphoma

III. Burkittslymphoma

NON HODGKINS LYMPHOMA


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NON-HODGKINS LYMPHOMA

The non-Hodgkins lymphoma involves lymph nodes and lymphoid

organs as well as extranodal organs and tissue.

Clinical features:

I. Affects persons of all age, from infants to the elderly and occurs in

both sexes.

II. Onset of symptoms may be acute or insidious and include

lymphadenopathy, abdominal and mediastinal enlargement.

III. Fever

IV. Night sweat

V. Weight loss

Treatment: Best treated by radiation or chemotherapy or both. 57

HODGKINS LYMPHOMA


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HODGKIN S LYMPHOMA

It is primarily one of lymph nodes and lymphoid organs. Lymph nodes

of the head and neck, particularly the cervical nodes, are often theinitial site of the involvement.

Clinical feature:

I. Bimodal age incidence peak, one in young adults and the second inthe fifth decade.

II. Painless enlargement of one or more cervical lymph nodes, and nodeusually firm and rubbery in consistency, and the overlying skin isnormal.

III. Pain may develop in the abdomen and back, owing to splendidenlargement and pressure of enlarged nodes or involvement of the

vertebrae.IV. Generalized weakness is sometimes as early feature.

V. Weight loss, cough, anorexia, itching of the skin.

Treatment: radiation therapy and combination of chemotherapy.

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BURKETTS LYMPHOMA


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In 1958-1959, Burkettsreported on a type of malignant

lymphoma seen with undue frequency, particularly

involving the jaws, in native children of Kampala,Uganda, in central East Africa. It also known as

AFRICAN JAW LYMPHOMA

Clinical feature:

It occurs between 2 and 14 years of age. In contrast to most non-Hodgkins lymphomas, it

particularly involves extra nodal tissue.

Begins as rapidly growing tumour mass of the jaws,

destroying the bone and causing loosening of the teethwith extension commonly to involve the maxillary,

ethmoid and sphenoid sinuses as well as orbit.

Treatment: fatal at one time but now being treated by

cytotoxic drug. 59


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T h e r e d s t r e a k e x t e n d s f r o m t h e a n k l e t o t h e g r o i n a n d f o l l o w s

l y m p h a t i c c h a n n e l s .

TREATMENT


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TREATMENT:

Patients in stable social situations who appear nontoxemic and who are

older than 3 years, afebrile, and well hydrated may be treated initially

with oral antibiotics in an outpatient setting.Ensure close follow-up.

Analgesics can be used to control pain, and anti-inflammatory

medications can help to reduce inflammation and swelling. Hot, moist

compresses also help to reduce inflammation and pain.

If possible, elevate and immobilize affected areas to reduce swelling,

pain, and the spread of infection. An abscess may require surgical

drainage.

CONCLUSION


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CONCLUSION

The lymphatic system, which is a subset of the circulatory system,also acts as a highway, transporting white blood cells to and from the

lymph nodes into the bones, and antigen-presenting cells to the lymph

nodes. It helps rid the body of toxins, waste and other unwanted

materials.

When bacteria are recognized in the lymph fluid, the lymph nodes

make more infection-fighting white blood cells, which can cause

swelling. The swollen nodes can sometimes be felt in the neck,

underarms and groin.

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REFERENCES


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REFERENCES

Grays anatomy by Henry Gray, Peter L. Williams

B D Chaurasia's Human Anatomy: Vol.3 Head and Neck, Brain (5 thedition)

Shafer's textbook of oral pathology (6thedition)

Human embryology by inderbir singh (6thedition)

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Lymph Nodes of Head and Neck Region