arterial venous & lymphatic drainage of head and neck.
Arterial drinage of head and neck
ARTERIAL VENOUS & LYMPHATIC DRAINAGE OF HEAD AND NECK
Presented by,
K. Manoj Kumar,1st year PG
Under the guidance of
Dr . Mehaboob shaik MDS MOMS,RCPS(U.K)
ARTERIAL SYSTEM
Development.
Description between arteries and veins.
Classification of arteries in head and neck.
Vital structures associated.
Applied anatomy.
AORTIC ARCHES
As the pharyngeal arches form during the 4th and 5th weeks, they
are supplied by arteries called aortic arches from the aortic
sac
The aortic arches arise from the aortic sac and terminate in the
dorsal aorta of the ipsilateral side
Though six pairs of aortic arches usually develop
All are not present at the same time
By the time the sixth pair of aortic arches has formed, the
first two pairs disappear
During the eighth week, the aortic arch pattern is transformed
to final fetal arterial arrangement
DEVELOPMENT OF ARTERIAL SYSTEM
1st pair of aortic arch.
2nd pair of aortic arch.
3rd pair of aortic arch.
4th pair of aortic arch.
5th pair
6th pair of aortic arch
Maxillary arteries and external carotid.
Stapedial arteries.
Common carotid and internal carotid.
Subclavian artery.
No vasculature.
Proximal part-pulmonary artery and distal part-ductus
arteriosus.
Derivatives
Aortic arches
ArteriesVeinsOxygen Concentration:Arteries carry oxygenated
blood (with the exception of thepulmonary arteryand umbilical
artery).Veins carry deoxygenated blood (with the exception of
pulmonary veins and umbilical vein).Types:Pulmonary and systemic
arteries.Superficial veins, deep veins, pulmonary veins and
systemic veinsDirection of Blood Flow:From the heart to various
parts of the body.From various parts of the body to the
heart.Anatomy:Thick, elastic muscle layer that can handle high
pressure of the blood flowing through the arteries.Thin, elastic
muscle layer with semilunar valves that prevent the blood from
flowing in the opposite direction.Overview:Arteries are red blood
vessels that carry blood away from the heart. resistance
vesselsVeins areblue bloodvessels that carry blood towards the
heart. capacitance vesselsRigid walls:more rigidcollapsibleThickest
layer:Tunica mediaTunica adventitiaLocation:Deeper in the
bodyCloser to the skinValves:Aren't present (except for semi-lunar
valves)Are present,
DIFFERENCES BETWEEN ARTERIES AND VEINS
CLASSIFICATION
Arch of aorta
Left sub clavian artery
Brachiocephalic artery
Right subclavian
Right common carotid
Left common carotid
External C A
Internal CA
Ext C A
Int C A
EXTERNAL CAROTID ARTERY
COURSE & DISTRIBUTION:
The external carotid artery, arises opposite the upper border of
the thyroid cartilage, and taking a slightly curved course, ascends
upwards and forwards, and then inclines backwards, to the space b/w
the neck of the condyle of the lower jaw, and the external meatus,
where it divides into the temporal $ internal maxillary
arteries.
BRANCHES
RINEE KHANNA
ANTERIOR
Superior thyroid
Lingual
facial
POSTERIOR
Occipital
Posterior auricular
Medial
Ascending pharyngeal
TERMINAL
Superficial Temporal
Internal maxillary
In the neck, both arteries runs upward within the carotid
sheath.
Contents of carotid sheath-
- Common carotid artery (medially)
- Internal jugular vein (laterally)
- Vagus nerve between the artery
& vein (posterially)
At the level of the upper border of thyroid cartilage the artery
dividing into the external and internal carotid arteries.
CAROTID SINUS
The termination of CCA or beginning of the internal carotid
artery shows a slight dilatation known as carotid sinus.
Acts as a baroreceptor
(pressure receptor)
& regulates blood pressure.
CAROTID BODY
Small, oval reddish brown structure situated behind the
bifurcation of CCA.
Receive nerve supply from glossopharyngeal & vagus
nerve.
Act as a chemoreceptor & responds to change in the O2 &
CO2 content of blood.
EXTERNAL CAROTID ARTERY & ITS BRANCHES
SUPERIOR THYROID ARTERY
COURSE:
It arises from the anterior aspect of ECA close to its origin.
It runs downwards and forwards deep to the infrahyoid muscles to
the upper pole of thyroid gland.
BRANCHES :
Infra hyoid branch
Superior laryngeal
Cricothyoid
Anterior thyroid
Sternomastoid
COURSE:
It arises from anterior aspect of ECA forms a typical loop which
is crossed by XII nerve. Its 2nd part lies deep to the hyoglossus.
The 3rd part runs along the ant. Border of hyoglossus $ 4th part
runs forwards under the surface of tongue.
DISTRIBUTION:
It is chief artery of muscular tongue. It supplies various
muscles, papillae n taste buds. also gives branches to tonsils.
LINGUAL ARTERY
FACIAL ARTERY
It is chief artery of face
It arises from the ECA just above the tip of the greater cornu
of the hyoid bone
Two parts of facial artery-
1. Cervical part- runs upwards in the neck
2. Facial part- on the face
CERVICAL PART-
It runs upwards on the pharynx deep to the posterior belly of
the digastric & to the ramus of mandible
It grooves the posterior border of submandibular gland
BRANCHES OF CERVICAL PART
1. Ascending palatine-
- supplies the tonsil & root of the tongue
2. Tonsillar-
- supplies the tonsils
3. Submental-
- supplies the submental triangle & sublingual salivary
gland.
4.Glandular branches-
- supplies submandibular salivary gland & lymph nodes
FACIAL PART
Course-
It enters the face by winding around the base of the mandible,
by piercing the deep cervical fascia at the antero-inferior angle
of the masseter muscle.
First it runs upwards & forwards to a point half an inch
lateral to the angle of the mouth.
Then it ascensds by the side of the nose up to the medial angle
of the eye, where it terminates by supplying the lacrimal sac &
by anastomosing with the dorsal nasal branch of the ophthalmic
artery.
The facial artery is very tortuous.( Tortuosity of the artery
prevents its walls from being unduly stretched during movement of
mandible,lips & the cheeks)
Facial artery
Ophthalmic Artery
BRANCHES OF FACIAL PART
Inferior labial
- supplies lower lip
Superior labial-
- supplies the upper lip & the anteroinferior part of the
nasal septum.
Lateral nasal-
- supplies to the ala & dorsum of the nose.
At the medial angle of the eye terminal branches of the facial
artery anastomosis with branches of the ophthalmic artery (it is
the site for anastomosis between the branches of ECA & ICA)
LITTLES AREA
The anteroinferior part of septum contains anastomoses between
the superior labial branch of the facial artery and sphenopalatine
artery.
Occipital artery-
Arises from the posterior aspect of the ECA.
Opposite the origin of facial artery
Supplies the occipital belly of occipitofrontalis & skin
& pericranium associated with the scalp.
5. Posterior auricular artery-
Arises from the posterior aspect of ECA just above the posterior
belly of digastric.
Supplies back of the auricle, the skin over the mastoid process
& over the back of the scalp.
6. Ascending pharyngeal artery-
Arises from the medial side of ECA.
Supplies the side wall of the pharynx, tonsil, medial wall of
the middle ear & the auditory tube.
7. MAXILLARY ARTERY
The maxillary artery, larger of the two terminal branches of the
external carotid artery.
3 parts
1. Mandibular- runs horizontally between neck of mandible &
sphenomandibular ligament.
2. Pterygoid- superficial or deep to the lower head of the
lateral pterygoid.
3. Pterygopalatine- between the two heads of the lateral
pterygoid through pterygomaxillary fissure
First portion
Thefirst or mandibular portionpasses horizontally forward,
between the neck of the mandible and the sphenomandibular ligament,
where it lies parallel to and a little below theauriculotemporal
nerve; it crosses theinferior alveolar nerve, and runs along the
lower border of thelateral pterygoid muscle.
Branches include:
Deep auricular artery
Anterior tympanic artery
Middle meningeal artery
Inferior alveolar arterywhich gives off itsmylohyoid branchjust
prior to entering themandibular foramen
Accessory meningeal artery
Second portion
Thesecond or pterygoid portionruns obliquely forward and upward
under cover of the ramus of the mandible and insertion of
thetemporalis, on the superficial (very frequently on the deep)
surface of thelateral pterygoid muscle; it then passes between the
two heads of origin of this muscle and enters the fossa.
Branches include:
Masseteric artery
Pterygoid branches
Deep temporal arteries(anterior and posterior)
Buccal artery
Third portion
Thethird or pterygopalatine portionlies in thepterygopalatine
fossain relation with thepterygopalatine ganglion. This is
considered the terminal branch of the maxillary artery.
Branches include:
Sphenopalatine artery(Nasopalatine artery is the terminal branch
of the Maxillary artery)
Descending palatine artery
Infraorbital artery
Posterior superior alveolar artery
Artery of pterygoid canal
Pharyngeal artery
Middle superior alveolar (a branch of the infraorbital
artery)
Anterior superior alveolar arteries(a branch of the infraorbital
artery)
TRANSVERSE FACIAL ARTERY
Branch of superficial temporal artery.
After emerging from the parotid gland, it runs forward over the
masseter between the parotid duct & zygomatic arch.
Accompanied by the upper buccal branch of facial nerve.
It supplies the parotid gland & its duct ,the masseter &
overlying skin.
3. INTERNAL CAROTID ARTERY
The ICA begins in the neck as one of the terminal branches of
CCA (at the level of upper border of the thyroid cartilage).
It divided into 4 parts-
1. Cervical part- in the neck it gives no branches.
2. Petrous part- in the petrous part of temporal bone gives 2
branches-
a) Corticotympanic branch
b) Pterygoid branch
3. Cavernous part- within the cavernous sinus.
a) Cavernous branches to the trigeminal ganglion
b) Superior & inferior hypophyseal branches
4. Cerebral part- lies at the base of the brain after emerging
from the cavernous sinus.
Ophthalmic
Anterior cerebral
Middle cerebral
Posterior communicating
Anterior choroidal
S shaped figure called as carotid siphon of angiograms
APPLIED ANATOMY..LIGATION OF ECA
Indications-
Bleeding from Oral Malignancies.
Slipping of Superior pedicle of Thyroid Gland.
Arterio Venous Malformation of Scalp.
Anaesthesia- General AnaesthesiaPosition- Supine with neck
extended to opposite side
Incision-Oblique incision along the anterior border of Sterno
Mastoid over the middle third.
Procedure-
1.Skin and Platysma are cut along the line of incision
2.Anterior border of Sternomastoid is retracted posteriorly
3.Internal Jugular Vein (IJV) is identified
4.Common carotid Artery is found medial to IJV
5.Bifurcation of the Common carotid artery defined
6.External Carotid Artery (ECA) is identified by its
branches
7.Internal Carotid Artery (ICA) has no branch in the neck
8.Safeguard the Hypoglossal Nerve which crosses ICA and ECA just
above hyoid bone.
To expose the carotid bifurcation, periarterial dissection of
the surrounding tissues is continued superiorly. During the
exposure of the carotid bifurcation and the carotid sinus,
bradycardia may occur. Recognizing any significant alterations in
heart rate and rhythm at this point in the procedure is critical
because many patients with carotid artery stenosis have coexisting
coronary artery disease.
If sinus bradycardia occurs, 1-2 mL of 1% lidocaine may be
administered topically between the ICA and the ECA to block nerve
conduction to the carotid sinus. Some surgeons routinely administer
lidocaine at the time of bifurcation exposure to prevent sinus
bradycardia.
Under normal circumstances, all
internal carotid artery blood flow is directed
intracranially,
and flow through the collateral pathways is from
intracranial
vessels to the external carotid artery branches,
normally
the external carotid arteries do not contribute significantly
to
intracranial or ocular blood flow. In the case of internal
carotid artery occlusion, the direction of flow in the
collateral
pathways reverses, and flow courses from the external ca
rotid branches to the intracranial branches of the internal
carotid artery,
Thus, with occlusion of the internal carotid
artery, the external carotid artery may become an important
source of blood flow to the brain..
VENOUS DRAINAGE OF HEAD AND NECK
Veins
Systemic veins
Pulmonary Veins
-Right Pulmonary vein
-Left Pulmonary vein
Head & Neck
Abdomen & Thorax
Upper limb
Lower limb
Classification of veins
Head & neck
External group
Internal jugular
External jugular
Anterior jugular
Oblique jugular
Posterior external jugular
Internal group
Venous sinuses
Emissary veins
Diploic veins
Superficial
External jugular Facial
Superficial temporal
Deep
Pterygoid plexus
Internal jugular
Supra orbital vein
Supra trochlear vein
Facial vein
Common facial vein
Retromandibular vein
Superficial temporal vein
Maxillary vein
Posterior auricular vein
Applied anatomy:
Facial vein is common source of bleeding following surgery
involving posterior vestibule lateral to mandible
Infection from face can spread in a retrograde direction and
cause thrombosis of the cavernous sinus. This is specially occur in
presence of infection in upper lip and lower part of nose. Called
dangerous area of the face.
Dangerous area of the face.
Lingual vein
Thelingual veinsbegin on the dorsum, sides, and under surface of
thetongue, and, passing backward along the course of thelingual
artery, end in theinternal jugular vein.
Drains tongue and
sublingual region
Three branches
Dorsal lingual veins
Deep lingual veins
Sublingual vein
Superficial temporal vein
It begins on the side andvertex of the skull in aplexuswhich
communicates with thefrontal vein andsupraorbital vein, with the
corresponding vein of the opposite side, and with theposterior
auricular veinandoccipital vein.
From this network frontal and parietal branches arise, and unite
above thezygomatic archto form the trunk of the vein, which is
joined by the middle temporal veinemerging from thetemporalis
muscle.
Maxillary vein
It begins in the infratemporal fossa
It collects blood from the pterygoid
Plexus
Through the pterygoid plexus It
receives the middle meningeal,
posterior superior alveolar, inferior
alveolar and other veins from the
nose and palate (areas served by
The maxillary artery)
After that it merges with the
superficial temporal vein to form
the retromandibular vein
Posterior auricular vein
Theposterior auricular veinbegins upon the side of the head, in
aplexus which communicates with the tributaries of theoccipital
veinand superficial temporal veins.
It descends behind theauricula, and joins the posterior division
of theposterior facial veinto form theexternal jugular.
Anterior jugular vein
start below the chin, pass beneath the platysma to the
suprasternal notch.
Pierce the deep fascia and is connected to the other side by an
anastomosing vein the jugular arch
angle laterally to pass deep to sternocleidomastoid and open in
the external
Tributaries:
Skin
Superficial tissues of neck
Applied anatomy:
Special care required to
preserve the vein during
surgical treatment
of wry neck
Veins of the Head and neck
Internal jugular vein:
It receive blood from the brain, face and the neck.
It emerges through the jugular foramen,as a continuation of the
sigmoid sinus descend down in the neck, first behind then lateral
to the internal carotid artery inside the carotid sheath
Terminate beneath the triangular interval between the sternal
and the clavicular head of the sternocleidomastoid muscle joining
the subclavian vein to form the brachiocephalic vein
Relations:
Superficially
Sternocleidomastoid
Posterior belly of digastric
Superior belly of omohyoid
Parotid gland
Styloid process
Accessory vein
Posterior auricular artery
Occipital artery
Sternocleidomastoid artery
Lower root of ansa cervicalis
Infrahyoid muscle
Anterior jugular vein
Deep cervical lymph nodes
Internal carotid artery
9th, 10th,11th & 12th nerve
Posteriorlly
Rectus capitis lateralis
Transverse process of atlas
Levator scapulae
Scaleneus medius
Cervical plaxus
Scalenus anterior
Phrenic nerve
Thyrocervical trunk
Inferior thyroid artery
Medially
Internal carotid artery
Common carotid artery
Vagus nerve
Tributaries
Inferior petrosal sinus
Pharyngeal veins
Common facial vein
Lingual vein
Superior thyroid vein
Kocher vein
Occipital vein
Thoracic duct (left)
lymphatic duct (right)
Communications
With external jugular by oblique jugular
With cavernous sinus by inferior petrosal sinus
Special characteristics of the blood flow
1
2
Superficial cerebral veins
Superior sagittal sinus
Right transverse sinus
Right sigmoid sinus
Right IJV
Deep cerebral vein
Great cerebral vein
Straight sinus
Left transverse sinus
Left sigmoid sinus
Left IJV
APPLIED ANATOMY:
Infection from middle ear spreads to IJV
Surgical removal of deep cervical nodes can puncture IJV
Easy accessibility between two heads of sternocleidomastoid
muscle for introduction of cannula
Thrombophlebitis can occur by spread of infection in caverous
sinus
Systolic thrill felt over the vein in mitral stenosis
During CCF dilatation of vein occur
Queckenstedts test to find out block in CSF cerculation the test
is perform during lumbar puncture
Jugular venous pulse (JVP)
Determine activity of
atrium
Seen better then felt
Preferable over EJV
Elevation of JVP indicative
of cardiac failure
Hepato Jugular reflex
Elicited by deep compression
of right lobe of liver
Facial vein anastomose with infraorbital vein and mental
vein.Joins the:Pterygoid plexus through deep facial vein Cavernous
sinus through superior ophthalmic vein
Anastomosis of facial vein
INTRACRANIAL VENOUS CONNECTION
The facial vein has numerous connections with venous channels
passing into deeper regions of the head.
1. Near the medial corner of the orbit it comminicates with
ophthalmic veins.
2. In the area of the cheek it communicates with veins passing
into the infra orbital foramen.
3. It communicates with veins passing into deeper regions of the
face (i.e. the deep facial vein connecting with the pterygoid
plexus of veins).
Pterygoid plexus
Inferior ophthalmic vein
Facial vein
Cavernous sinus
Intracranial Venous sinus
Formation:
Venous spaces between the osteal and meningeal layers of
duramater
Formed by reduplication of meningeal layer
Features:
Lined by endothelium
Receive blood from
Brain
Orbit
Internal ear
CSF
Valveless
Bidirectional flow
Classification
Posterosuperior group
Anteroinferior group
Unpaired
a) Superior sagittal
b) Inferior sagittal
c) Straight
d) Occipital
Paired
a) Transverse
b) Sigmoid
c) Petrosquamous
Unpaired
a) Anterior intercavernous
b) Posterior intercavernous
c) Basilar
Paired
a) Cavernous
b) Superior petrosal
c) Inferior petrosal
d) Sphenoparietal
e) Middle meningeal
Confluence of sinus:
The point where the superior sagittal sinus, straight sinus and
occipital sinus unite called Confluence of sinus
Located on the right side of the internal occipital
protuberance
Cavernous sinus
Paired sinus, large venous space situated in MCF
Extent: petrous part of temporal bone to SOF
Relation:
MediallyPituitary glandSphenoidal sinusLaterally Temporal lobe with
uncusSuperiorly Optic tract, optic chiasma,Olfactory tract,ICA
InferiorlyForamen lacerum , junction of body & greater wing of
sphenoid boneAnteriorly Superior orbital fissure & apex of
orbitPosteriorlyPetrous part of temporal bone
Structure passing through sinusStructures in lateral wall of
sinusICA VI cranial nerve III cranial nerveIV cranial nerveV 1 and
V2 division of V cranial nerve
Applied anatomy:
Arterio venous aneurysm occurs due to rupture of internal
carotid artery
Symptoms:
Loud systolic thrill
Exophthalmos
Conjunctivitis
Thrombosis of the sinus resulting in meningitis due to
infections in dangerous area of face , nasal cavity and PNS
Symptoms:
pain in eye
Oedema of eye lids , cornea and root of nose
Exophthalmos
Definition:
The lymphatic system is the part of the immune system comprising
a network of conduits called lymphatic vessels that carry a clear
fluid called lymph (from Latin lympha "water") in a unidirectional
pathway.
The widely and extensively dispersed vessel system collects
tissue fluids from all regions of the body to eventually convey
them towards the heart.
EMBRY0LOGY OF LYMPHATIC SYSTEM
Lymph sacs -appear between 2nd to 6th week of IUL.
7th week -jugular channel spread to connect with subclavin lymph
sacs.
9th week - thoracic duct is continuous channel draining into IJ
-subclavin vein junction.
12th week- all process are complete.
5th month -valves begins to start.
CELL ZONES
Zone 1
Extreme periphery
Loosely packed cells
lymphocytes, macrophages
Zone 2
More densely packed
small lymphocytes and
macrophages
Zone 3.
Germinal center
Large lymphoblasts
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VALVES
Except initial lymphatic sinus or capillaries every lymph
vessels has valves.
Valves may be
Bicuspid
Tricuspid
Quadricuspid
Functions:
It is responsible for the removal of interstitial fluid from
tissues i.e. act as "drains
to collect the excess fluid and return it to the venous blood
just before it reaches the heart preventing massive edema (which
can cause tissue destruction: pressure necrosis).
Returns back to circulation, the protiens that may have escaped
into interstitial spaces.
Lymphatic tissue is a specilized connective tissue - reticular
connective, that contains large quantities of lymphocytes(filter
fluids prior to adding it to circulation).
It transports immune cells to and from the lymph nodes in to the
bones
The lymph transports antigen-presenting cells (APCs), such as
dendritic cells, to the lymph nodes where an immune response is
stimulated.
works with the circulatory system to deliver nutrients, oxygen,
and hormones from the blood to the cells that make up the tissues
of the body.
It absorbs and transports fatty acids and fats as chyle to the
circulatory system
SHAPE OF LYMPH NODE
Inguinal lymph nodes large and round
Outer iliac lymph nodes longish mass
Inner iliac lymph node small and round
Head and neck lymph node- oval or kidney or spindle shaped
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A sound knowledge of the regional lymph nodes of the head and
neck is very important for dentists because it is a reliable guide
towards the origin of problem, and because of the possible
involvement of
the lymphatic system in the
spread of infection or the spread
of malignant tumour cells
(metastasis).
Role in dental practice
Role in dental practice
Clinical significance:
Diagnostic value
Aid in prediction of treatment outcome (modification of
treatment plan/course)
Prediction of disease history and therefore prognosis.
Lymph vessels can also transmit other substances such as
injected material or neoplastic cells.
Classification of nodes
in head and neck region
Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
The lymph nodes in the head and neck region can be grouped
into:
Superficial nodes
Deep nodes.
Classification of nodes
in head and neck region
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.
The superficial lymph nodes
The superficial lymph nodes
Submental
Submandibular
Buccal
Parotid (pre-auricular)
Mastoid (retro auricular/ post-auricular)
Occipital
Superficial cervical
Anterior cervical.
Superficial cervical nodes
The Deep lymph nodes:
Upper deep cervical
Lower deep cervical
Waldyers ring
Nodes of midline
The upper deep cervical (Jugulo-digastric group: lie along the
upper part of internal jugular vein deep to the sternomastoid.
The lower deep cervical (jugulo-omohyoid gp): arranged along the
lower part of IJV also deep to the SMm.
Deep cervical nodes
The waldyers ring is formed by: lingual, palatine, tubal, and
pharyngeal tonsils.
Midline nodes are termed in correspondence to the anatomical
area where they exist:
Infrahyoid
Prelaryngeal
Pretracheal
Paratracheal
Efferents of lower deep cervicals then collect into larger lymph
vessel called the jugular lymph trunk.
This trunk joins another two lymph trunks lymph (subclavian and
brachiocephalic trunks) to form the so called the lymph ducts
(right or left).
This duct finally opens into the angle between internal jugular
and subclavian veins to drain its contents back to venous
circulation.
The right and left lymph ducts are NOT of equal size.
The left lymph duct (also called the Thoracic duct )
which is considered the largest lymphatic vessel in the
body.
It collects most of the lymph in the body (except that from the
right arm and the right side of the chest, neck and head, which is
collected by the right lymphatic duct).
Thoracic duct
Composition of lymph- clear colour less fluid formed by 96%
water and 4% solids
Solids- may be inorganic , organic and cellular content.
Inorganic
- Na
-Ca
- K
- Cl
- HCo3
Organic-
- proteins (albumin, globulin, fibrinogen, prothrombin, other
clotting factors antibodies, enzymes)
-lipids in the form of chylomicrons and lipo protiens
-carbohydrates- glucose
-non protein nitrogenous substances like urea and creatinine
Cellular contents-
lymphocytes
monocytes
Macrophages
Plasma cells
It begins down as low as level of L2
(at the cisterna chyli) and extends upward to drain into the
region near the junction of the left subclavian and internal
jugular veins, with tributaries from the cervical, subclavian and
mediastinal trunks.
Thoracic duct
The skin of the head and neck drains :
The scalp drains into the occipital, mastoid and parotid
nodes.
Lower eye lid and anterior cheek drains into buccal LNs.
The cheeks drain into the parotid, buccal and submandibular
nodes.
The upper lips and sides of the lower lips drain into the
submandibular nodes.
While the middle third of the lower lip drains into the
submental nodes
The skin of the neck drains into the cervical nodes.
The drainage of the oral structures
The gingivae 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.
Teeth drain into the submandibular and deep cervical lymph
nodes.
Anterior part of mouth floor drain into submental and upper deep
cervical while posterior part into submandibular and upper deep
cervical.
Levels of Lymph nodes (SLOAN KETTERING CANCER CENTER, NY)
I
II
III
IV
VI
v
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PALPABLE LYMPHNODES AND PROBABLE ASSOCIATED CONDITIONS
Tender, Mobile, enlarged Acute infection
Non-tender, Mobile, Enlarged Chronic infection
Matted, Non tender Tuberculosis
Fixed, Enlarged Carcinoma
Rubbery, Enlarged Lymphomas
Level I
Submental triangle
(Ia)
Anterior digastric
Hyoid
Mylohyoid
Submandibular triangle (Ib)
Anterior and
posterior digastric
Mandible.
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
Upper Jugular Nodes
Anterior limit -Lateral border of sternohyoid
Posterior limit-Posterior border of SCM
Skull base
Hyoid bone (clinical landmark)
Carotid bifurcation (surgical landmark)
Level IIa anterior to XI
Level IIb posterior to XI
Oropharynx > oral cavity and laryngeal mets
Level II
Oral Cavity
Nasal Cavity
Nasopharynx
Oropharynx
Larynx
Hypopharynx
Parotid
Level III
Middle jugular nodes
Anterior limit -Lateral border of
sternohyoid
Posterior limit-Posterior border of SCM
Inferior border of level II
Cricoid cartilage lower
border (clinical landmark)
Omohyoid muscle (surgical
landmark)
Level IV
Lower jugular nodes
Anterior limit-Lateral border
of sternohyoid
Posterior limit-Posterior
border of SCM
Cricoid cartilage lower
border (clinical landmark)
Omohyoid muscle
(surgical landmark)
Junction with IJV
Clavicle
Level V
Posterior triangle of neck
Posterior border of SCM
Clavicle
Anterior border of
trapezius
VaSpinal accessory
nodes
Vb Transverse cervical
artery nodes
Radiologic landmark
Inferior border of Cricoid
Supraclavicular nodes
Level V
Nasopharynx
Oropharynx
Posterior neck and scalp
Level VI
Anterior compartment
Hyoid
Suprasternal notch
Medial border of carotid
sheath
Perithyroidal lymph nodes
Paratracheal lymph nodes
Precricoid (Delphian)
lymph node
Level VI
Thyroid
Larynx (glottic and subglottic) Pyriform sinus apex
Cervical esophagus
Staging
Nx: Regional lymph nodes cannot be assessed.
N0: No regional lymph node metastases.
N1: Single ipsilateral lymph node,
