y y y y y y y y y y y y y

INTRODUCTION LYMPH & ITS FLOW LYMPHATIC PATHWAY COLLECTING DUCTS THORACIC and RIGHT LYMPHATIC DUCT IMPORTANCE / FUNCTIONS OF LYMPHATIC SYSTEM GENERAL ANATOMY LYMPHATIC DRAINAGE OF SOME REGIONS OF HEAD & NECK CONNECTIONS OF LYMPHATIC SYSTEM WITH BLOOD STREAM EXAMINATION CAUSES OF ENLARGEMENT OF LYMPH NODES APPLIED ANATOMY OF LYMPHATICS OF HEAD & NECK CONCLUSION REFERENCES

Before taking up the lymphatics of the head and neck it is desirable to consider certain facts about the lymphatic system in general. When circulating blood reaches the capillaries part of its fluid content passes through them into the surrounding tissue as tissue fluid. Most of this tissue fluid re-enters the capillaries at their venous ends. Some of it is however is returned to the circulation through a separate set of lymphatic vessels. These vessels begin as lymphatic capillaries which drain into larger lymph vessels. Along the course of these lymph vessels there are groups of lymph nodes. These nodes consists predominantly of lymphoid tissue.

y The lymph vessels

and lymphatic

nodes together constitute

the

lymphatic system.
y

The lymphatic system includes other organs consisting predominantly of lymphoid tissue, namely spleen, thymus, bone marrow , tonsil & other aggregates of lymphoid tissue present in relation to the alimentary tract

It is a clear fluid that is driven through hydrostatic pressure from interstitial spaces into the lymphatic capillaries.

Flow of lymph :
y Once lymph enters a lymphatic vessel, valves prevent it from

flowing backwards.
y Lymph can only move towards a collecting duct due to the valves. y As it moves through vessels, it is filtered periodically by lymph

nodes.

Fluid in the interstitial space Lymphatic vessel Lymph node Lymphatic vessel Lymphatic trunk Collecting duct Subclavian vein (where it reenters the blood stream)

Lymphatic trunk joins with one of these two ducts :

y Thoracic duct y Right lymphatic duct y Thoracic duct :  Larger and longer collecting duct.  Receives lymph from lower limbs, abdominal regions, left upper

limb, left side of head, thorax, neck.  Empties into the left sub clavian vein near the junction of the left jugular vein.

y Right lymphatic duct :  Collects lymph from right side of head and neck, right upper limb,

right thorax.
 Empties into the right subclavian vein near the junction of

jugular vein.

y Transport of fluid. y Removal of unwanted material by phagocytosis. y Production of blood cells. y Immune responses against foreign proteins including bacteria. y All of the processes of tissue nutrition and repair are dependent upon

lymph.
y Through lymph vessels, metastasis frequently occurs, especially of

malignant tumor cells.

y Thermal antibody production. y Provides centers for lymphocytic production and a pool of stem

cells potentially capable of transforming into antibody producing B-lymphocytes and mature T-lymphocytes.

y i. ii. iii. y i. ii. iii. iv. v.

LYMPHATIC CHANNEL Lymph capillaries The collecting vessels Terminal collecting trunks LYMPHOID ORGANS Lymph nodes Tonsils Peyers patches Thymus spleen

Lymph Capillaries :
y Made up of endothelium y Forms a rich network y Closed system y Lies in the superficial part of the dermis y Deeper lymph vessels have numerous valves

The Collecting Lymph Vessels :

y Thin walled y Transparent y Strong and complex structures y Have three coats: outer, middle, inner

There are some general features that distinguish lymphatics from veins: y Greater number y Much thinner walls y less sinus course y Marked variation in caliber y Greater number of valves

The Terminal Collecting Lymphatic trunks : The lymph from the entire body is channeled into a small group of large terminal collecting lymphatic trunks , which return it to the venous stream at the confluence of the internal jugular and subclavian veins but thoracic duct on the left side, and the right lymphatic duct on the right side.

Lymph Node : y There are nearly 700 lymph nodes is body.

y They begin to develop in fetal life after lymphatic plexus is

developed.
y They are well formed by 2 years. y Reach greatest development at puberty.

y They are small, oval/ reniform bodies (0.1 to 2.5 cm long) situated

in the cause of lymph vessels, so that lymph passes through them on its way to blood.
y They are most numerous in the thoracic mediastinum on posterior

abdominal wall, in abdominal mesenteries and in pelvis, neck and proximal ends of limbs.

y Superficial lymph nodes y Deep lymph nodes y Superficial lymph nodes :

 The  The

nodes of the occipital group lie along the attachment of the trapezium to the occipital bone .(head) nodes of the retroauricular group lie superficial to the upper attachment of the sternocleidomastoid muscle .(head)

 The parotid lymph nodes are in 2 groups.

Superficial-> lie over parotid gland Deep-> embedded in the gland

The nodes of the submandibular group lie over the submandibular gland whereas some are embedded within the gland The submental nodes lie below the chin overlying the mylohyoid muscle, b/w the anterior bellies of the right and left digastric muscles.(neck) The buccal nodes lie along the facial vein.(head) The superficial cervical nodes lie along the external jugular vein superficial to the sternocleidomastoid muscle.(neck) The anterior vein.(neck) cervical nodes lie along the anterior jugular

y Deep cervical lymph nodes : y Lymph from superficial nodes drain to deep cervical lymph nodes

(internal jugular vein)

y Most of deep cervical nodes lie deep to the sternocleidomastoid

muscle. muscle.
y They are divided into two parts :

- Superior group - Inferior group

Superior group :
y Behind by the internal jugular vein. y Above

and in front digastric muscle.

by

the

posterior

belly

of

the

y Below and in front by the facial vein.

These are called jugulodigastric nodes.

Inferior group : y One node of this group lies just above the intermediate tendon of omohyoid muscle. This is jugulomohyoid node.
y Deeper tissues of head and neck drain into deep cervical nodes.

In fetal life and through post natal life, lymphocytes arise from the central lymphoid organs of the bone marrow and Thymus where the initial differentiation of B and T-lymphocytes takes place. Blood stream - to the lymph nodes - other peripheral lymphoid organs proliferate New lymphocytes. enters circulatory system Peripheral organs Sites of inflammation Other tissues. - T-lymphocytes go to thalamus - B-lymphocytes go to the lymph nodes.

Tonsils : y Multiple groups of large lymphatic nodules.

y Location mucous membrane of the oral and pharyngeal

cavities.
y Palatine tonsils

-Posterior-lateral walls of the oropharynx y Pharyngeal tonsil -Posterior wall of nasopharynx y Lingual tonsils y Base of tongue

Peyers patch : y These are aggregated lymphoid nodules, named after a swiss anatomist Johann conard peyer.
y They are aggregations of lymphoid tissue that are usually found in the

lowest portion of small intestine ileum in humans, as such, they differentiate ileum from duodenum and jejunum. Location and Appearance : y Observed as elongated thickenings of intestinal epithelium measuring a few cm in length. length.
y About 30 are found in humans. humans.

y Microscopically, they are oval, round lymphoid follicles (similar to lymph

nodes) located in lamina propria layer of mucosa and extending into submucosa of ileum. Functions : y Pathogenic microorganisms and other antigens entering the intestinal tract encounter macrophages, dendritic cells, B lymphocytes, Tlymphocytes, found in the peyers patch and other gut associated lymphoid tissue (GALT).
y Peyers patches are covered by special epithelium that contains

specialized cells called microfold cells (M cells), which sample antigen directly from the lumen and deliver it to antigen presenting cells.

y B cells and memory cells are stimulated upon encountering

antigen in Peyers patches. Pathology : y It has been associated with susceptibility to transmissible spongiform encephelopathies also known as Prions disease.

Thymus : y Located posterior to the upper sternum (breast bone); upper chest. bone); chest.
y Large during infancy and childhood. childhood. y Shrinks after puberty. puberty. y In elderly tissue is gradually replaced by adipose (fat) and

connective tissues. tissues.

y By 70 years it is one tenth the size that it was when a person is 10

years of age. age.

Thymus Physiology : y Thymus contains immature cells called Thymocytes.

y These can be inactive. However, when needed, they can mature

into T cells (T- lymphocytes).

y T- cells are important in immunity. y Thymus epithelial cells also secrete hormones called thymosis,

stimulate T- cells to mature as they migrate to other tissues.

Spleen : y Largest lymphatic organ.

y Located in the upper abdomen to the left of the stomach (on left side). y Sort of like a large lymph node except instead of inner space having

lymph, it has blood. Spleen has two types of tissues :

y White pulp y Red pulp

White pulp : y Like splattered islands around the space. y Contains many lymphocytes. Red pulp : y Contains many R.B.Cs, plus lymphocytes and macrophages. Functions : y Filters blood. y Stores blood.

SCALP :
Lymph vessels from the scalp end in the occipital , retroauricular and superficial parotid nodes. The part of the forehead just above the root of the nose drains into the submandibular nodes.

FACE: FACE: y The forehead, y The lateral parts of the eyelids y The whole of the conjunctiva and y The lateral part of the cheek drain into the superficial and deep parotid lymph nodes. The central part of face including : y The lower part of the forehead. y The medial parts of the eyelids, nose, medial parts of the cheeks.

y The upper lip and lateral parts of the lower lip drain into the

submandibular lymph nodes. Some of these vessels pass through the buccal nodes. y The median part of the lower lip y The chin and y The floor of mouth drain into the submental nodes and through them into the submandibular nodes.

NASAL CAVITY : y Most of the nasal cavity, the paranasal sinuses and the nasopharynx drain directly into the deep cervical lymph nodes.
y Lymphatics from the upper part of the nasal cavity reach the

skin, covering the nose and drain into the submandibular nodes.
y Lymphatics of the nasopharynx drain into the retropharanyngeal

nodes.

PALATE : Lymph from the y Hard palate, y Soft palate and y Nasopharynx drain into the retropharyngeal nodes and through them directly to the deep cervical lymph nodes

FLOOR OF MOUTH , GUMS, TEETH. TEETH. y Submandibular nodes and through them into the deep cervical nodes.
y Some to the submental nodes (anterior part of floor of mouth). y Some from the mouth go directly to deep cervical lymph nodes.

Tongue : y Tip of the tongue drains bilaterally to the submental nodes.

y The right and left halves of rest of anterior 2/3rd of tongue drain

unilaterally to the submandibular nodes; a few central lymphatics drain bilaterally to the same nodes.
y Since most of the lymph from the tongue drains into the jugulo-

omohyoid node; this is known as the lymph node of the tongue.

Lymphatic drainage of the neck Lymph from areas near the occipital nodes, the superficial cervical nodes, the submandibular nodes and the anterior cervical nodes drains first into these nodes and through them to the deep cervical nodes.
y y y y

Anterior cervical nodes Infrahyoid nodes Prelaryngeal nodes Pretracheal nodes

y Deeper tissues in the neck drain (directly into) -> deep cervical

nodes
y Pharynx y Trachea y Esophagus

LARYNX :

Lymph vessels are in 2 sets :

y y

Those above the vocal folds and those below them

The vessels of the upper part pierce the thyrohyoid membrane to reach the upper deep cervical nodes. These lymphatics travel along the superior laryngeal vessels.

Some of the vessels from the lower part of the larynx pass through the cricovocal membrane , to reach the prelaryngeal and pretracheal nodes. From here they pass to the deep cervical nodes. Some vessels pass below the cricoid cartilage and reach the lower deep cervical nodes directly.

THYROID GLAND :
The lymph vessels of the thyroid gland communicate freely with the tracheal plexus. They pass to the prelaryngeal nodes just above the isthmus to the pretracheal and paratracheal nodes, some may drain into the brachiocephalic lymph nodes, which are related to the thymus in the superior mediastinum. Laterally the gland is drained by vessels which accompany the superior thyroid vein to the deep cervical lymph nodes. Some lymph vessels from the thyroid gland may enter directly into the thoraxic duct .

Connections of the lymphatic system with the blood stream By the means of the thoracic duct and the veins at the root of the neck.

Examination of Lymphatic system y Age of patient y Duration y Which group was 1st affected y Pain. y Fever. y Primary Focus y Past History y Family History

y Inspection: Swelling

Position Skin over swelling

y Palpation: y Number y Situation y Local temperature y Tenderness y Surface (Smooth / lobulated) y Margin y Consistency

y y y y y

Lymph nodes in other parts of the body Spleen, liver, iliac lymph nodes Lungs Parotid and lacrimal glands Blood

y y y y y y

Tests: Tests: Aspiration Mantoux test Biopsy Radiograph Mediastinal scanning. y The thalamus and bone marrow are PRIMARY lymphoid organs. y The SECONDARY lymphoid organs include lymph nodes, spleen, lymphoid tissue.

y Inflammation: ->Acute lymphadenitis

Chronic lymphadenitis Hyperplasia Granulomatous lymphadenitis. Bacterial origin eg: Tuberculosis. Viral origin eg: Catscratch disease Parasite eg: filariasis Fungal eg: blastomycosi
y Neoplastic:

- Benign - rare. - Malignant - Primary malignant lymphoma y Diffuse y Nodular

y Classification based on cell type: type:

Malignant lymphoma.
 Undifferentiated type  Histocytic type  Lymphocyte type (Poorly differentiated)  Lymphocyte type (well differentiated)  Hodgkins type

Lymphocytic predominance. Nodular sclerosis. Mixed cellularity. Lymphocytes.

Lymphatic spread of tumors: 3 pathways for metastasis: y seeding within body cavities y lymphocyte spread. y Haematogenous spread.

y Lymph nodes of a healthy individual are soft non palpable

structures. However infection, inflammation and carcinomatous involvement of areas drained by lymph nodes cause these structures to become swollen hard, painful and palpable.
y Diseased states of the oral cavity will most probably be reflected

in the sub mental and submandibular lymph nodes.

y In the process of lymph drainage, the fluid passes through a series

of lymph nodes before emptying into the thoracic or right lymphatic ducts, it becomes evident that each lymph node group is a barrier where the disease agent is being combated

y The first such site is known as a primary node, which drains into a

secondary node that may be drained by a tertiary node. The more nodes that are interposed in the disease agents route of spread before reaching the major lymphatic channels, the better the chance of successfully combating the disease.

y The arrangement of the lymphatics in the neck are such that

there is every possibility of a checking or blocking of the lymph flow through vertebrae or muscular tension.

y The relation of the nodes to the nerves and blood vessels is

significant. If sufficiently enlarged they may produce pressure sufficient to create undue stimulation on nerves passing through the neck resulting in accelerated heart action or bronchial and gastric irritation.

y The enlargement of nodules may interfere with salivary secretions

through pressure and produce a flushed face.

Infections of Lymphatic System Glandular Fever Syndrome :

y The condition characterized by fever, the presence of atypical

lymphocytes in the peripheral blood, sore throat (often with exudate), splenomegaly, lymphadenopathy (local or generalized), liver dysfunction, malaise and sometimes a rash. y The infectious components of GFS comprise the Epstein Barr Virus (EBV) which specifically causes the condition of Infectious Mononucleosis, Cytomegalovirus (CMV), and the protozoan Toxoplasma gondii

Filarial infections involving the lymphatic system : y Filarial parasites (filaroids) are long hair-like tissue-dwelling nematodes.
y All except the Guinea worm Dracunculus medinensis (which uses a

copepod) employ insects as intermediate hosts.

y They all have a similar life cycle that includes an obligatory

maturation stage in a blood-sucking insect or a copepod, and a reproductive stage in the tissues or blood of a definitive host.

y Adult male and female worms live in the lymphatics, skin, or other

tissues.
y Microfilariae (which are specialized embryos not larvae) are

produced by the female worm, circulate in the blood, or invade the skin, and are ingested by the vector where larval development, but not multiplication occurs.

Microfilaria in thick blood film stained with Giemsa stain and showing the nuclear column

Lymphatic Filariasis : y Lymphatic filariasis is a mosquito-borne parasitic disease that is caused by three species of tissue dwelling filaroids :
 Wuchereria bancrofti

responsible for 90% of the cases and is found throughout the tropics and in some sub-tropical areas world-wide.

 Brugia timori - is found only in Timor and its adjacent islands.

All three species cause similar disease. y B . malayi - also found in monkeys, cats and other small animals but it is not known how important this is in the epidemiology of human disease.

Chronic filarial pathology : y Overall, hydrocele is the most common form of chronic filariasis . y Hydrocele can reduce work capacity, impair sexual activity. and cause severe psycho-social problems in affected males. y The most feared complications of lymphatic filariasis are chronic lymphedema and elephantiasis.

Elephantitis

Acute filarial disease : y Acute filarial attacks can occur in both amicrofilaraemics and microfilaraemics. y They can be extremely painful and debilitating. y In some cases filarial infection markers such as filarial antigen and antifilarial antibody are absent. y Two distinct syndromes cause acute attacks. The first is called acute dermatolymphangioadenitis (ADLA) and the second is acute filarial lymphangitis (AFL)

Tropical Pulmonary Eosinophilia (TPE) (TPE) y It is the result of a hypersensitivity response to filarial antigens.
y There is marked eosinophilia, extreme levels of serum IgE, and

high titres of antifilarial IgG and IgE.

y Nocturnal coughing and asthma. y Pulmonary infiltration gives rise to a characteristic xray picture

called "snow flake" lung.

Other manifestations of lymphatic filariasis : y Chyluria, the passing of milky-coloured urine, is caused by leakage of lymph into the urinary tract is seen from time to time and is exacerbated by a high-fat diet and exercise. y Rheumatic features and mono-arthritis of a knee or ankle joint. y Lymphatic filarasis is seldom seen in in casual travellers. Those who remain for longer periods in areas where transmission is intense are certainly at risk.

y There are two mechanisms

Permeation Metastasis y Permeation: in which the cancer cells invade lymphatic vessels and by growth in continuity along their lamina reach regional lymph nodes. y Metastasis : In which cancer cells grow into lymphatic vessels and as emboli drift along the lymph stream to regional lymph nodes.
y Mechanism: Tumors, when dividing rapidly often produce cells that

are not tightly contained in the original cell mass. These loose cells may then travel in the lymphatic vessels to nodes where they may establish a secondary site of tumor growth.

y Majority of the lymph nodes in the body are situated in the head

and neck, therefore many diseases of the lymphoid tissue are present primarily in this region. One is able to prognosticate the possible or probable involvement of certain lymph nodes if the site of a tumor or infection is known and conversely knowledge of the regional nodes permits the diagnosis of an obscure site of a pathologic process if a lymph node or a group of lymph nodes is found diseased.
y Knowledge of the regional co-ordination of lymph nodes is of

paramount importance in diagnosis and therapy of infections and malignant tumors.

y It is said that the blood feeds the lymph and the lymph feeds the cells

.Every cell is bathed in lymph. Every cell depends upon the lymph for nourishment. Every cell is afforded drainage by means of the lymph.
y Many systemic diseases are often present with involvement of the

lymphatic system. Different kinds of disease present with different manifestation of lymph nodes. Therefore thorough examination of lymph nodes should be mandatory.

y Textbook of Medical Physiology ; Guyton and Hall ; 10th edition. y B.D.Chaurasias Human Anatomy ; 6th edition. y Textbook of Physiology ; A.K.Jain; 2nd edition. y Wayne Melrose and John M. Goldsmid. Infections of

the

lymphatic system. Primer of Tropical Medicinetem.2005 y K.sembulingam, Prema Sembulingam. Essentials of Medical Physiology, 2nd edition