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GOOD MORNING

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EXAMINATION OF LYMPH NODES OF HEAD AND NECK AND ITS APPLIED ASPECT

Presented by:

Dr. Ratna . SamudrawarPg 1 yearDepartment of Oral Medicine and RadiologyRungta College of Dental Sciences and Research

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CONTENTS: INTRODUCTION ANATOMY OF LYMPH NODES FUNCTION OF LYMPH NODES CLASSIFICATION OF LYMPH NODES DRAINING AREAS EXAMINATION OF LYMPH NODES APPLIED ASPECT

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INTRODUCTION:• Lymphatic system is essential drainage system which is accessory to venous system.

• Most tissue fluid formed at the aterial end of capillaries is absorbed back into the blood by venous end capillaries and rest of tissue fluid (10- 20%) is absorbed by lymphatics.

• Larger particles like proteins and particulate matter can be removed from the tissue fluid only by the lymphatics.

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• Therefore, lymphatic system may be regarded as drainage system of “coarse type” & venous system as “fine type”

• Tissue fluid flowing in the lymphatics are called lymph.( clear fluid)

• It passes through filters called (lymph nodes) placed in the course of lymphatics .

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Diagramatic relation of lymph system to blood system

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COMPONENTS OF LYMPHATIC SYSTEM

Lymph vessels

Central lymphoid organs Bone marrow

Thymus

Peripheral lymphoid organs

Lymph nodes

Spleen

Tonsils

Circulating lymphocytes

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LYMPH NODES: Lymph nodes are peripheral lymphoid organs

connected to the circulation by a afferent & efferent lymphatics.

These are ovoid or bean shaped nodular formation composed of dense accumulation of lymphoid tissue, vary in size from 2 to 20mm & average of 15mm in longitudinal diameter.

There are about 800 lymph nodes in the body and around 300 are located in head and neck.

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lymph nodes usually occur in groups.

Superficial lymph nodes are located in subcutaneous connective tissue .

Deeper nodes lie beneath the fascia & muscles.

Superficial lymphnodes are gateways for assessing health of entire lymphatic system.

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Structure of lymph node

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Path of lymph flow through a lymph node

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FUNCTIONS OF LYMPH NODES: play an important role in the defence mechanism of the

body. They filter out micro-organisms (such as bacteria) and foreign substances such as toxins, etc.

Major functions are :I. LymphopoiesisII. Filteration of lymphIII. Processing of antigens multiplication of B cells and T cells from preexisting lymphocytes in response to antigens. Antibodies produced are carried to circulation indirectly helping to mount an immune response.

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Lymph nodes are classified into :

Peripheral nodes Deep cervical nodes

Superficial (outer circle ) of cervical nodes.

Deep (inner circle) of cervical nodes

1. Submental2. Submandibular3. Preauricular 4. Postauricular5. Occipital6. Anterior

cervical7. Superficial

cervical nodes.

1.Pretracheal2.Paratracheal3.Retropharyngeal4.Waldeyer’s ring.

1. Jugulo-diagastric node2. Jugulo-omohyoid node

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Tonsil

Tongue

Submental nodes

Submandibular nodes

Omohyoid .M

Anterior cervical nodes

Parotid nodes

Jugulo-omohyoid nodes

Jugular lymph trunk

Mastoid nodes

Occipital nodes

Diagastric .m

Jugulo-digastric nodes

Superficial cervical nodes

Supra-clavicular node

Subclavian lymph trunk

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Deep (inner circle) of cervical nodes

Pre laryngealParatrachealPretracheal

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The tonsils and adenoids form a ring of lymphoid tissues

Adenoid

Palatine tonsil

Lingual tonsil

Tongue

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The original classification system of cervical lymph nodes was developed by Rouviere in 1938.

In 1981, Shah recommended that cervical lymph nodes be classified in a simpler fashion based on levels.

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

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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

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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 in seperable 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

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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 muscle and posterolateral to anterior scalene muscle and lateral to common carotid artery

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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

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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

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Submental nodes

Under the chin in submental triangle on the surface of mylohyoid muscle

Lower lip, the chin , tip of tongue and anterior floor of mouth.

Submandibular nodes or jugulo-omohyoid group

Nodes Location Draining area Efferent’s

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Sub mandibular

Lie within the submandibular region scattered over the surface of sub mandibular salivary gland. An extension of the submandibular group lie on the cheek superiorly called the buccal group

•Sub mental nodes•Cheek•Nose•Upper lip•Maxillary teeth •Vestibule•gingiva•Posterior floor of the mouth and the •Tongue

Drain into nodes of deep cervical chain

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Parotid nodes Lie superficial to the capsule of parotid gland

• the eye lid• temple• prominence of cheeks and • the auricle

• deep parotid nodes• Superficial cervical nodes

Retro auricular nodes

Lie over the mastoid process

• The Scalp• The Auricle

Deep cervical nodes

Occipital Lie just below the superior nuchal lines at the trapezius muscle and in proximity with occipital artery

From scalp Drain to deep cervical nodes

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Superficial cervical

3-4 nodes lie along the ext jugular vein and are situated superficial to upper part of sterno-cleido mastoid

• floor of ext acoustic meatus•Lobule of the ear • angle of the jaw

Lower deep cervical nodes

Jugulo-Digastric Below the posterior belly of digastric

•Palatal tonsils•Posterior 1/3rd of tongue

Lower group of Deep Cervical nodes

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Jugulo- omohyoid

On the Internal Jugular Vein, just below the intermediate tendon of Omohyoid

•Directly from the tongue and indirectly from submental, sub mandibular, upper deep Cervical nodes.

Thoracic duct

Supra clavicular nodes

Supra clavicular triangle

•Axillary•Thorax•Abdomen•Pelvis

Thoracic duct

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Retropharyngeal (1-3)

Retropharyngeal space

Posterior nasal cavityParanasal sinusesHard and soft palateNasopharynx, oropharynxAnditory tube

Superior deep cervical nodes

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Lymphadenopathy:

Classified :

Generalised - 2 or more non contiguous area Localised - involve one area

lymph nodes which are abnormal in size, number or consistency and is often used as a synonym for swollen or enlarged lymph nodes.

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Inflammatory Acute or chronic lymphadinitisInfection TuberculosisFilariarisSecondary syphilisInfectious mononucleosis

NeoplasticCarcinomaSarcoma

HaematologicalHodgkins diseaseNon-hodgkins lymphomaChronic lymphatic leukemia

ImmunologicalAidsDrug reactionSystemic lupus erythromatosusRheumatoid arthritis

Causes of Enlargement of Lymph Node

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Clinical examination :History – age duration group first affected pain fever primary focus loss of appetite & wt.loss pressure effects past history Family history

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Local examination:• Inspection- number, position, size , skin over

lying swelling , pressure effects.

• Palpation- inspectory findings, consistency, matted or not , fixity to surrounding structures, drainage area.

General examination:• Lymphnodes in other parts of the body.

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AGE : Tuberculosis and syphilis , primary malignant lymphomas affect young age .

DURATION: Short (acute lympahadenitis)

GROUP AFFECTED FIRST : Eg: cervical group affects first in Hodgkin’s disease , tuberculosis etc where as inguinal lymphnode affects first in filariasis.

PAIN: Acute and chronic infection are painful where as painless in syphilis , primary malignant lymphomas and secondary carcinoma.

FEVER:evening rise of temperature is characteristic feature of TB. Periodic fever in filaria (once in month).

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PRIMARY FOCUS: when ever lymph node enlarged, it is usual practice to look for primary focus in drainage area of lymph nodes. This should be done in acute and chronic septic lymphadenitis.

LOSS OF APPETITE & WT: incase of malignant lymphadenopathis.

PRESSURE EFFECTS: Eg. Dysphagia may occur when oesopahgus is pressured.

PAST HISTORY : enlargement of epitrochlear and soboccipital group of lymphnodes may be enlarged in secondary stage of syphilis.

FAMILY HISTORY : sometimes history of tb in families

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INSPECTION:NUMBER: single or multiple. A few conditions are known to

produce generalised invovlement of lymph nodes like hodgkin’s disease , Tb , Lymphosarcoma, sarcoidosis.

POSITION: cervical group eg . Tb , Epitrochlear and occipital eg Secondary syphilis.

SKIN OVER THE SWELLING: In acute lymphadenitis skin becomes inflammed with redness, oedema, brawny induration.

• Skin over Tuberculous lymphadenitis and cold abscess remains “cold” in true sense till they reach a point of bursting when skin becomes red and glossy.

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• Over rapidly growing lymphosarcoma skin becomes tense, shining , with dilated subcutaneous veins.

PRESSURE EFFECTS: Careful inspection must be made of whole body to detect any pressure effect due to enlargement of lymphnodes.

Oedema & swelling of upper limb- enlargement of axillary lymph nodes.

Oedema & swelling of lower limb- enlargement of inguinal lymph nodes.

Swelling & venous engorgement of face and neck may occur due to pressure effect of lymph nodes at the root of the neck.

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Hypoglyspossal nerve may be involved from enlarged upper group of cervical lymphnodes due to hodgkin’s disease or secondary carcinoma.

PALPATION:

NUMBER LOCAL RISE IN TEMPERATURE TENDERNESS

CONSISTENCY – Enlarged lymph nodes should be carefully palpated with palmar aspects of 3 fingers.While rolling the fingers against the swelling slight pressure is maintained to know the actual consistency.

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Enlarged lymph nodes may be; Soft Elastic & rubbery (hodgkin’s disease) Firm, discrete and shotty (syphilis) Stony hard (secondary carcinoma)

Matted or Not: A group of lymph nodes that feels connected and move as a unit is known as matted.

Eg. Acute lymphadenitis Metastatic Carcinoma Tuberculosis

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FIXITY TO SURROUNDING STRUCTURE:The enlarged lymphnode should be carefully palpated to know if they are fixed to;• Skin• The deep fascia• The muscles• The vessels • The nervesEg: Any primary malignant growth of lymph nodes like lymphosarcoma , reticulosarcoma , histosarcoma or secondary carcinoma fixed to surouding structures- first to deep fascia & underlying muscle followed by adjoining structures and ultimately overlying skin.

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DRAINING AREA:• Cervical lymph nodes receive lymphatics from – head,

face, mouth , pharynx and neck.• Left supra –clavicular lymphnodes( virchow’s) receives

lymphatics from upper limb, left sids of chest including the breast and also viscera of abdomen.

It is named after Rudolf Virchow (1821-1902), the German pathologist who first described the association. The presence of an enlarged Virchow's node is also referred to as Troisier's sign, named after Charles Emile Troisier, who also described this

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METHOD OF PALPATION:

Pre auricular lymph nodes- they are palpated anterior to the tragus of ear.

Post auricular lymph nodes-Are palpated behind the ear, on the mastoid process

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Occipital nodes- palpated at the base or lower border of skull

They are palpated under the chin

The clinician can stand behind the patient to palpate.

The patient is instructed to bend his/her neck slightly forward so that the muscles and fascia in that regions relax.

Fingers of both hands can be placed just below the chin, under the lower border of mandible and the lymph nodes should be tried to be cupped with fingers

Submental nodes

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Submandibular nodes

Are palpated at the lower border of the mandible approximately at the angle of the mandible.

The patient is instructed to passively flex the neck towards the side that is being examined. This maneuver helps relaxing the muscles and fascia of neck, thereby allowing easy examination.

The palmar aspect of the fingers is pushed on to the soft tissue below the mandible near the midline, then the clinician should then move the fingers laterally to draw the nodes outwards and trap them against the lower border of the mandible.

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Anterior Cervical: (both superficial and deep): Nodes that lie both on top of and beneath the sternocleidomastoid muscles (SCM) on either side of the neck, from the angle of the jaw to the top of the clavicle.

Posterior Cervical: Extend in a line posterior to the SCMs but in front of the trapezius, from the level of the mastoid bone to the clavicle.

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III

Complete Blood Count

Chest Radiography

Serological investigation

Nodal Biopsy

Fine Needle Aspiration cytology .

C. T. Scan

M.R.I

INVESTIGATIONS

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fine-needle aspiration, excisional biopsy remains the initial diagnostic procedure of choice.

Modern cross-sectional imaging modalities such as ultrasound (US), computed tomography (CT) and magnetic resonance (MR) imaging allow reliable detection of cervical lymph nodes. However, the differentiation between benign and malignant lymphnodes remains challenging

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Alternative imaging modalities such as single photonemission computed tomography (SPECT) and positron emission tomography (PET) can help to differentiate between benign and malignant lymph nodes.

In a recent meta-analysis, ultrasound and US-guided fine needle aspiration cytology (USgFNAC) have been shown to be valuable tools in characterizing cervical lymph nodes.

Sentinel node biopsy has greater accuracy indetermining lymph node status for cancer than current commonly used imaging methods.

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Lymphographyvaluable tool for detection of lymphatic fistulas and lymphatic leakage

Lymphangioscintigraphy Tc-99m –intradermally, and after 1 minute and again after 10–30 minutes,

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APPLIED ASPECTS

Lymphatics are primarily meant for coarse drainage including cell debris & microorganisms, from the tissue spaces to the regional lymph nodes, where the foreign & noxious material is filtered off by the phagocytic activity of the macrophage cells for its final disposal by the appropiate immune responses within the node.

Thus the lymphatic system forms first line of defense of body.

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The arrangement of lymphatics of head & neck such that there is every possibility of checking or blocking of lymph flow.

While draining from an infected area, the lymphatics & lymph nodes carrying infected debris may become inflammed , resulting in lymphangitis & lymphadenitis.

Enlargement of nodes may interfere with salivary secretions through pressure & cause dry mouth or decreased saliva

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Enlarged glands may block the capillaries & veins & produced flushed face ,this point may be demonstrated when patient has cold and nodes in neck & under the rami of inferior maxillary enlarged.

Lymphatics provide most convinient route of spread of cancer cells

Helpful in diagnosis of primary site of cancer

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Helps in predicting the prognosis & classifying the stage of cancer

Helps the surgeon in doing block dissections during operative procedures

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CONCLUSION

Knowledge of regional lymph nodes is important to prognosticate the probable involvement certain lymph nodes in case of known site of tumor or infection.

The knowledge of regional lymph nodes permits the diagnosis of an obscure site of a pathological process if a lymph node or group of lymph node is found diseased.

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Human anatomy head and neck – BD chourasia 4/E. Ioachim’s lymph node pathology – Harry L. Ioachim , Jeffery .4/E A manual on clinical surgery - S. Das 6/E Applied anatomy of lymphatics – D.O Millard Text book of head and neck anatomy – Hiatt, Gartner 4/E Principles and practice of radiation oncology – Edward halperin,

Carlos perez 5/E.

REFERENCES

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