CONTENTS

Introduction

History

Development of lymphatic system

Lymphatic capillaries,

Lymphatic vessels,

Lymphoid tissues,

Lymphoid organs, and

Lymph fluid

Physiology and Pathophysiology

Detailed anatomy of head & neck lymphatics

Clinical approach of patient with cervical lymphadenopathy

Clinical significance – of lymphatics and lymphnodes

Summary of Lymphatics of the HeadandNeck & Applied

anatomy

References

Introduction
 The world is not always kind to the human body. Accidental collisions and
interactions with objects in our environment produce bumps, cuts, and burns. The effects
of an injury may be compounded by assorted viruses, bacteria, and other microorganisms
that thrive in our environment. Some of these microorganisms normally live on the
surface of and inside our bodies, but all have the potential to cause us great harm.
Remaining alive and healthy involves a massive, combined effort involving many
different organs and systems. In this ongoing struggle, the lymphatic system plays the
primary role.
The lymphatic system consists of a network of lymphatic vessels, lymph, the fluid
connective tissue transported in these vessels, and lymphoid tissues and lymphoid organs,
which monitor and alter composition of the lymph. Lymphatic vessels originate in
peripheral tissues and deliver lymph to the venous system. Lymph consists of (1)
interstitial fluid, a fluid that resembles blood plasma, but with a lower concentration of
proteins, (2) lymphocytes, cells responsible for the immune response, and (3)
macrophages of various types. Lymphatic vessels often begin within or pass through
lymphoid tissues and lymphoid organs, structures that contain large numbers of
lymphocytes, macrophages, and (in many cases) lymphoid stem cells.

History

This system was described after the other parts of vascular system were already
known. The reason for this delay is the delicate and transparent appearance of lymphatic
channels & fluid.
Gaspare Asellius, professor of anatomy and Surgery in Pavia, Italy in
1622, is credited to be the first person to describe a second channel
system of fluid flow – the lymph vessels, which he called – ‘venae
albae et lacteae’ in animals apart from the cardiovascular system, but
he did not manage to identify human lymph vessels.
 Johann Vesling from Padua first published illustrations of Human lymph vessels
1628. In 1784 John Hunter proposed the anatomy and basic function of lymphatics and
Virchow in 1860 suggested the concept of lymph nodes as barriers to cancer.
Halstead described the principle of excision of lymph nodes with primary tumour.
Crile in 1906 developed a surgical procedure for treating neck metastasis. This
still remains the “gold standard “ in the management of cervical nodes.
Bocca with Pignetoro (1967) described the anatomy of aponeurotic system in the
neck. This provided a rationale for Functional Neck Dissection (preserving the spinal
accessory nerve, internal jugular vein and sternocleidomastoid muscle).
Development of Lymphatic System
The lymphatic system begins to develop at the end of the sixth week; about 2
weeks after the primordia of the cardiovascular system are recognizable.

Lymphatic vessels develop in a manner similar to that of blood vessels and make
connections with the venous system. The early lymphatic capillaries join each other to
form a network of lymphatics.
Development of Lymph Sacs and Lymphatic Ducts

There are six primary lymph sacs at the end of the embryonic period

 Two jugular lymph sacs near the junction of the subclavian veins with the anterior
cardinal veins (the future internal jugular veins)
 Two iliac lymph sacs near the junction of the iliac veins with the posterior cardinal
veins
 One retroperitoneal lymph sac in the root of the mesentery on the posterior
abdominal wall
 One chyle cistern (L. cisterna chyli) located dorsal to the retroperitoneal lymph sac
 Above image is of the left side of an 8-week embryo showing the primary lymph
sacs.
Lymphatic vessels soon join the lymph sacs and pass along main veins to the
head, neck, and upper limbs from the jugular lymph sacs; to the lower trunk and lower
limbs from the iliac lymph sacs; and to the primordial gut from the retroperitoneal lymph
sac and the chyle cistern (cisterna chyli). 'Two large channels (right and left thoracic
ducts) connect the jugular lymph sacs with the cistern. Soon a large anastomosis forms
between these channels.

Thoracic Duct

The thoracic duct develops from

 The caudal part of the right thoracic duct

 The anastomosis between the thoracic ducts and the cranial part of the left thoracic
duct.

Because there are initially there are two thoracic ducts that is - right and left
thoracic ducts, there are many variations in the origin, course, and termination of the
 adult thoracic duct which is formed by joining of all of the left thoracic duct and the
inferior part of the right thoracic duct i.e. except its cranial part.
The right lymphatic duct is derived from the cranial part of the right thoracic
duct.
The thoracic duct and right lymphatic duct connect with the venous system at the
angle between the internal jugular and subclavian veins. The superior part of the
embryonic chyle cistern persists.

The above image on left side shows ventral view of the lymphatic system at 9
weeks, showing the paired thoracic ducts. The image on right shows the system in late
fetal period, illustrating formation of the thoracic duct and right lymphatic duct.

Development of Lymph Nodes

Except for the superior part of the chyle cistern, the lymph sacs are transformed
into groups of lymph nodes during the early fetal period. Mesenchymal cells invade each
lymph sac and break up its cavity into a network of lymphatic channels - the primordia of
the lymph sinuses. Other mesenchymal cells give rise to the capsule and connective tissue
framework of the lymph node.

Development of Lymphocytes

The lymphocytes are derived originally from stem cells in the yolk sac
mesenchyme and later from the liver and spleen. The lymphocytes eventually enter the
bone marrow, where they divide to form lymphoblasts. The lymphocytes that appear in
lymph nodes before birth are derived from the thymus, a derivative of the third pair of
pharyngeal pouches. Small lymphocytes leave the thymus and circulate to other lymphoid
organs. Later some mesenchymal cells in the lymph nodes differentiate into lymphocytes.
Lymph nodules do not appear in the lymph nodes until just before and/or after birth.

Development of Spleen and Tonsils

The spleen develops from an aggregation of mesenchymal cells in the dorsal

mesentery of the stomach. The palatine tonsils develop from the second pair of
pharyngeal pouches. The tubal tonsils develop from aggregations of lymph nodules
around the pharyngeal openings of the pharyngotympanic (auditory, eustachian) tubes.
The pharyngeal tonsils (adenoids) develop from an aggregation of lymph nodules in the
wall of the nasopharynx. The lingual tonsil develops from an aggregation of lymph
nodules in the root of the tongue. Lymph nodules also develop in the mucosa of the
respiratory and digestive systems.

Anomalies of Lymphatic System

Congenital anomalies of the lymphatic system are uncommon. There may be

diffuse swelling of a part of the body - congenital lymphedema. This condition may
result from dilation of primordial lymphatic channels or from congenital hypoplasia of
lymphatic vessels. More rarely, diffuse cystic dilation of lymphatic channels involves
widespread portions of the body. In cystic hygroma, large swellings usually appear in
the inferolateral part of the neck and consist of large single or multilocular, fluid-filled
cavities. Hygromas may be present at birth, but they often enlarge and become evident
during infancy. Most hygromas appear to be derived from abnormal transformation of the
jugular lymph sacs. Hygromas are believed to arise from parts of a jugular lymph sac that
are pinched off, or, from lymphatic spaces that fail to establish connections with the main
lymphatic channels.
The Lymphatic System
 The lymphatic system is a unidirectional series of channels from the tissues to the
heart through the venous system. It collects the extracellular fluid from the tissues to
ultimately emptying into the subclavian veins.
The lymphatic system consists of
1) lymphatic capillaries,
2) lymphatic vessels,
3) lymphoid tissues,
4) lymphoid organs, and
5) lymph fluid

Lymphatic Capillaries

The lymphatic network begins with the lymphatic capillaries, or terminal

lymphatics, which form a complex network within peripheral tissues. Lymphatic
capillaries differ from vascular capillaries in several ways:
1) They are larger both in diameter and in sectional view;
2) They have thinner walls because their endothelial cells lack a continuous
basement membrane;
3) They often have a flat or irregular outline, in part because the walls are too thin to
hold their shape when the already low lymph pressure disappears entirely; and
4) Their endothelium overlap instead of being tightly bound to one another.

The region of endothelial cell overlap acts as a one-way valve, permitting passage
of interstitial fluid into the lymphatic capillary but preventing its escape. The endothelial
cells are often fenestrated, and with pores in the cells and gaps between cells there is little
in the interstitial fluid that cannot find its way into a lymphatic capillary.
 The gaps between endothelial cells are large enough that the lymphatic capillaries
absorb not only interstitial fluid and dissolved solutes but any viruses or other abnormal
items, such as cell debris or bacteria that are present in damaged or infected tissues. As a
result, a lymphatic capillary contains chemical and physical evidence about the health of
the surrounding tissues.

Lymphatic capillaries are present in almost every tissue and, organ in the body.
Prominent lymphatic capillaries in the small intestine, called lacteals, transport lipids
absorbed by the digestive tract. Lymphatic capillaries are absent in areas that lack a blood
supply, such as the matrix of cartilage and the cornea of the eye, and there are no
lymphatics, in either the bone marrow or the central nervous system.

Lymphatic Vessels

The collecting system that ultimately returns its contents to the blood stream is
composed of lymphatic vessels. Most of the lymphatic vessels flow into the thoracic duct
which empties into the junction of the left internal jugular vein with the left subclavian
vein.

The thoracic duct carries all the lymph except that from the right head, right neck,
right thorax, right arm, right lung, and right side of the heart. It is a thin-walled tube
extending from the lumbar vertebrae to the root of the neck. It is situated close to the
spine as it courses superiorly.
Lymph not drained by the thoracic duct is drained by the right lymphatic duct. The right
lymphatic duct empties into the junction of the right subclavian vein with the right
internal jugular vein. It is a short vessel, approximately 1 to 1.5 cm long.
From the lymphatic capillaries, lymph flows into larger lymphatic vessels that
lead toward the lymphatic trunks in the abdomino-pelvic and thoracic cavities. The larger
lymphatics are comparable to veins both in the layers in their walls and in the presence of
internal valves. The valves are quite close together, and at each valve the lymphatic
vessel bulges noticeably. This configuration gives large lymphatics a beaded appearance.
Pressures within the lymphatic system are minimal; in fact, interstitial fluid pressure is
lower than that of the venous system. The valves prevent the backflow of lymph within
lymph vessels, especially those of the limbs. The larger lymphatic vessels have layers of
smooth muscle in their walls.

Rhythmic contractions of these vessels propel lymph toward the lymphatic ducts.
Skeletal muscle contraction and respiratory movements work together to help move
lymph through the lymphatic vessels. Contractions of skeletal muscles in the limbs
compress the lymphatics and squeeze lymph toward the trunk; a comparable mechanism
assists venous return. With each inhalation, pressure decreases inside the thoracic cavity,
and lymph is pulled from smaller lymphatic vessels into the lymphatic ducts.

If a lymphatic vessel is compressed or blocked or its valves are damaged, lymph

drainage slows or ceases in the affected area. When fluid continues to leave the vascular
capillaries in that region but the lymphatic system is no longer able to remove it, the
interstitial fluid volume and pressure gradually increase. The affected tissues become
distended and swollen, and this condition is called lymphedema.
Lymphatic vessels are often found in association with blood vessels. There are
gross differences in relative size, general appearance, and branching pattern that
distinguish lymphatic vessels from arteries and veins. There are also characteristic color
differences that are apparent on examining living tissues. Arteries are usually a bright
red, veins a dark red, and lymphatics a pale golden color.

Major Lymph-Collecting Vessels

Two sets of lymphatic vessels, the superficial lymphatics and the deep
lymphatics, collect lymph from the lymphatic capillaries. Superficial lymphatics travel
with superficial veins and are found in:

 . The subcutaneous layer next to the skin.

  . The loose connective tissues of the mucous membranes lining the digestive,
respiratory, urinary, and reproductive tracts.
 . The loose connective tissues of the serous membranes lining the pleural,
pericardial, and peritoneal cavities.

Deep lymphatics are large lymph vessels that accompany the deep arteries and
veins. These lymphatic vessels collect lymph from skeletal muscles and other organs of
the neck, limbs, and trunk, as well as visceral organs in the thoracic and abdomino-pelvic
cavities.
Within the trunk, superficial and deep lymphatics converge to form larger vessels
called lymphatic trunks. The lymphatic trunks include

1) lumbar trunks,
2) intestinal trunks,
3) bronchomediastinal trunks,
4) subclavian trunks, and
5) jugular trunks
 The lymphatic trunks in turn empty into two large collecting vessels, the
lymphatic ducts, which deliver lymph to the venous circulation.

The Thoracic Duct

The thoracic duct collects lymph from both sides of the body inferior to the
diaphragm and from the left side of the body superior to the diaphragm. The thoracic duct
begins inferior to the diaphragm at the level of vertebra L2. The base of the thoracic duct
is an expanded, saclike chamber, the cisterna chili. The cisterna chyli receives lymph
from the inferior region of the abdomen, pelvis, and lower limbs through the right and
left lumbar trunks and the intestinal trunk.
The inferior segment of the thoracic duct lies anterior to the vertebral column.
From its origin anterior to the second lumbar vertebra, it penetrates the diaphragm with
the aorta, at an opening known as the aortic hiatus, -and ascends along the left side of the
vertebral column to the level of the left clavicle. After collecting lymph from the left
bronchomediastinal trunk, the left subclavian trunk, and the left jugular trunk, it empties
into the left subclavian vein near the base of the left internal jugular vein. Lymph
collected from the left side of the head, neck, and thorax as well as lymph from the entire
body inferior to the diaphragm reenters the venous system in this way
 .

The Right Lymphatic Duct

The relatively small right lymphatic duct collects lymph from the right side of the
body superior to the diaphragm. The right lymphatic duct receives lymph from smaller
lymphatic vessels that converge in the region of the right clavicle. This duct empties into
the venous system at or near the junction of the right internal jugular vein and right
subclavian vein.
LYMPHOID TISSUES

Lymphoid tissues are connective tissues dominated by lymphocytes. In a

lymphoid nodule, the lymphocytes are densely packed within the loose connective tissue
of the mucous membranes lining the respiratory, digestive, urinary, and reproductive
tracts. Typical lymphoid nodules average around a millimeter in diameter, but the
boundaries are indistinct because no fibrous capsule surrounds them. They often have a
pale, central zone, called a germinal center, which contains activated dividing
lymphocytes.
 The digestive tract has an extensive array of lymphoid nodules collectively known
as the gut-associated lymphatic tissue (GALT). Large nodules in the wall of the
pharynx are called tonsils. The lymphocytes aggregated in tonsils gather and remove
pathogens that enter the pharynx in either inspired air or food.

There are usually five tonsils:

 A single pharyngeal tonsil, often called the adenoids, located in the posterior
superior wall of the nasopharynx;
 A pair of palatine tonsils, located at the posterior margin of the oral cavity along
the boundary of the pharynx to the soft palate; and
 A pair of lingual tonsils, which are not visible, because they are located at the base
of the tongue.

Clusters of lymphoid nodules in the mucosal lining of the small intestine are
known as aggregate lymphoid nodules, or Peyer's patches. In addition, the walls of the
appendix, a blind pouch that originates near the junction between the small and large
intestines, contain a mass of fused lymphoid nodules.
The lymphocytes within these lymphoid nodules are not always able to destroy
bacterial or viral invaders that have crossed the epithelium of the digestive tract. An
infection may then develop; familiar examples include tonsillitis and appendicitis.
LYMPHOID ORGANS
Lymphoid organs are separated from surrounding tissues by a fibrous connective
tissue capsule.

These organs are classified in two groups:

 Primary or central which include Thymus and bone marrow

 Secondary or peripheral which include Spleen, tonsil and lymph node

The Thymus

The thymus lies posterior to the sternum, in the anterior portion of the
mediastinum. It has a nodular consistency and a pinkish coloration. The thymus reaches
its greatest size (relative to body size) in the first year or two after birth, and its maximum
absolute size during puberty, when it weighs between 30 and 40 g. Thereafter the thymus
gradually decreases in size and the functional cells are replaced by connective tissue
fibers. This degenerative process is called involution.
Below is a diagram to show the thoracic contents (mainly the thymus) in an infant
and an adult, illustrating the complete degeneration of thymus.
 The capsule that covers the thymus divides it into two thymic lobes. Fibrous
partitions, or septae, extend from the capsule to divide the lobes into lobules averaging 2
mm in width. Each lobule consists of a dense outer cortex and a somewhat diffuse, paler
central medulla. The cortex contains lymphoid stem cells that divide rapidly, producing
daughter cells that mature into T cells and migrate into the medulla. During the
maturation process, any T cells that are sensitive to normal tissue antigens are destroyed.
The surviving T cells eventually enter one of the specialized blood vessels in that region.
While they are within the thymus, T cells do not participate in the immune response; they
remain inactive until they enter the general circulation. The capillaries of the thymus
resemble those of the CNS in that they do not permit free exchange between the
interstitial fluid and the circulation. This blood-thymus barrier prevents premature
stimulation of the developing T cells by circulating antigens.
Epithelial cells are scattered among the lymphocytes of the thymus. These cells
are responsible for the production of thymic hormones that promote the differentiation of
functional T cells. In the medulla, these cells cluster together in concentric layers,
forming distinctive structures known as Hassall's corpuscles, whose function remains
unknown.

The Spleen
 The spleen is the largest lymphoid organ in the body. It is around 12 cm (5 in.)
long and weighs an average of up to 160 g. The spleen lies along the curving lateral
border of the stomach, extending between the ninth and eleventh ribs on the left side. It is
attached to the lateral border of the stomach by a broad mesenterial band, the
gastrosplenic ligament.
On gross dissection the spleen has a deep red color because of the blood it
contains. The spleen performs functions for the blood comparable to those performed by
the lymph nodes for lymph.
The functions of the spleen include
1) the removal of abnormal blood cells and other blood components through phago-
cytosis,
2) the storage of iron from recycled red blood cells, and
3) the initiation of immune responses by B cells and T cells in response to antigens
in the circulating blood.

SURFACES OF THE SPLEEN

 The spleen has a soft consistency, and its shape primarily reflects its association
with the structures around it. It lies wedged between the stomach, the left kidney, and the
muscular diaphragm. The diaphragmatic surface is smooth and convex, conforming to
the shape of the diaphragm and body wall. The visceral surface contains indentations
that follow the shapes of the stomach (the gastric area) and kidney (the renal area).
Splenic blood vessels and lymphatics communicate with the spleen on the visceral
surface at the hilus, a groove marking the border between the gastric and renal areas. The
splenic artery, splenic vein, and the lymphatics draining the spleen are attached at the
hilus.

LYMPH NODES
Lymph nodes are small, oval lymphoid organs ranging in diameter from 1 to 25
mm (up to around 1 in.). The general pattern of lymph node distribution in the body can
be seen in the diagram below.
 Each lymph node is covered by a dense fibrous connective tissue capsule. Fibrous
extensions from the capsule extend partway into the interior of the node. These fibrous
partitions are called trabeculae.
The shape of a typical lymph node resembles that of a lima bean. Blood vessels
and nerves attach to the lymph node at the indentation, or hilus. Two sets of lymphatic
vessels are connected to each lymph node: afferent lymphatics and efferent lymphatics.
The afferent lymphatic vessels, which bring lymph to the node from peripheral tissues,
penetrate the capsule on the side opposite the hilus.

Lymph then flows slowly through the lymph node within a network of sinuses,
which are open passageways with incomplete walls. Upon arriving at the node, lymph
first enters the subcapsular sinus that contains a meshwork of branching reticular fibers,
macrophages, and dendritic cells. Dendritic cells collect antigens from the lymph and
present them in their cell membranes. T cells encountering these bound antigens become
activated, thus initiating an immune response.
 After passing through the subcapsular sinus, lymph flows through the outer
cortex of the node. The outer cortex contains aggregated B cells with germinal centers
similar to those of lymphoid nodules.

Lymph flow continues through lymph sinuses in the deep cortex (paracortical
area). Here, circulating lymphocytes leave the bloodstream and enter the lymph node by
crossing the walls of blood vessels within the deep cortex. The deep cortical area is domi-
nated by T cells.
After flowing through the sinuses of the deep cortex, lymph continues into the
core, or medulla, of the lymph node. The medulla contains B cells and plasma cells
organized into elongate masses known as medullary cords. Lymph enters the efferent
lymphatics at the hilus after passing through a network of sinuses in the medulla.

The lymph nodes function like a kitchen water filter: They filter and purify lymph
before it reaches the venous system. As lymph flows through ~ lymph node, at least 99%
of the antigens present in the arriving lymph will be removed.
 Fixed macrophages in the walls of the lymphatic sinuses engulf debris or
pathogens in the lymph as it flows past. Antigens removed in this way are then processed
by the macrophages and "presented" to nearby T cells. Other antigens stick to the
surfaces of dendritic cells, where they can stimulate T cell activity.
The largest lymph nodes are found where peripheral lymphatics connect with the
trunk, in regions such as the base of the neck, the axillae, and the groin. These nodes are
often called lymph glands. "Swollen glands" usually indicate inflammation or infection of
peripheral structures. Dense collections of lymph nodes also exist within the mesenteries
of the gut, near the trachea and passageways leading to the lungs, and in association with
the thoracic duct.

Distribution of Lymphoid Tissues and Lymph Nodes

Lymphoid tissues and lymph nodes are distributed in areas particularly
susceptible to injury or invasion. If we wanted to protect a house against intrusion, we
might guard all doors and windows and perhaps keep a pitbull indoors. The distribution
of lymphoid tissues and lymph nodes is based on a similar strategy.
1. The cervical lymph nodes monitor lymph originating in the head and neck.
2. The axillary lymph nodes filter lymph arriving at the trunk from the upper limbs.
In women, the axillary nodes also drain lymph from the mammary glands.
3. The popliteal lymph nodes filter lymph arriving at the thigh from the leg, and the
inguinal lymph nodes monitor lymph arriving at the trunk from the lower limbs.
4. The thoracic lymph nodes receive lymph from the lungs, respiratory
passageways, and mediastinal structures.
5. The abdominal lymph nodes filter lymph arriving from the urinary and
reproductive systems.
6. The lymphatic tissue of Peyer's patches, the intestinal lymph nodes, and the
mesenterial lymph nodes receive lymph originating from the digestive tract.

LYMPH FLUID
By definition, lymph is the fluid found only in the closed lymphatic vessels. It is a
transparent, colorless, watery fluid (with specific gravity of 1.015) closely resembling
blood plasma. Lymph is more dilute than plasma and lacks some of the protein and other
elements found in plasma.

CONTENTS
• Cells (mainly Lymphocytes)
• Proteins
• Fats
• Interstitial fluid

LYMPHOCYTES
Lymphocytes are the primary cells of the lymphatic system, and they are
responsible for specific immunity. They respond to the presence of:
• invading, organisms, such as bacteria or viruses;
• abnormal body cells, such as virus-infected cells or cancer cells; and
• Foreign proteins, such as the toxins released by some bacteria.
Lymphocytes attempt to eliminate these threats or render them harmless
by a combination of physical and chemical attack. They travel throughout the body,
circulating in the bloodstream, then moving through peripheral tissues and eventually
returning to the bloodstream through the lymphatic system. The time spent within the
lymphatic system varies; a lymphocyte may remain within a lymph node or other
lymphatic organ for hours, days, or even years. When in peripheral tissues, lymphocytes
may encounter invading pathogens or foreign proteins; while in the lymphatic system,
they may be exposed to pathogens or proteins carried by lymph. Regardless of the source,
lymphocytes respond by initiating an immune response.

Physiology and Pathophysiology

Formation & Flow of Lymph
The formation of lymph fluid into the lymphatic vasculature occurs mainly by two
physiological processes:
1. Diffusion
2. Osmosis
 These processes occur in the terminal capillaries present in the interstitium.
• Lymph is produced at the rate of 0.003ml/100kg/minin the tissues
• 2-3liters/day of lymph fluid is produced
• Velocity of lymph flow depends on
• Intrinsic Factors
• Extrinsic Factors
• Velocity is generally 3.1cm /min

INTRINSIC EXTRINSIC

Intraluminal pressure Interstitial pressure

Temperature
Muscular
Lymphatic pump Movement
Arterial
Respiration

Almost all tissues of the body have lymph channels that drain excess fluid directly
from the interstitial spaces. The exceptions include the superficial portions of the skin,
the central nervous system, the endomysium of muscles, and the bones.
Even these tissues have minute interstitial channels called prelymphatics through
which interstitial fluid can flow; this fluid eventually empties either into lymphatic
vessels or, in the case of the brain, into the cerebrospinal fluid and then directly back into
the blood. .
Essentially all the lymph from the lower part of the body eventually flows up the
thoracic duct and empties into the venous system at the juncture of the left internal
jugular vein and subclavian vein.
Lymph from the left side of the head, the left arm, and parts of the chest region
also enters the thoracic duct before it empties into the veins.
Lymph from the right side of the neck and head, the right arm, and parts of the right
thorax enters the right lymph duct, which then empties into the venous system at the
juncture of the right subclavian vein and internal jugular vein.
Most of the fluid filtering from the blood capillaries flows among the cells and
finally is reabsorbed back into the venous ends of the blood capillaries; but on the
average, about 1/10th of the fluid instead enters the lymphatic capillaries and returns to
the blood through the lymphatic system rather than through the venous capillaries. The
total quantity of this lymph is normally only 2 to 3 liters each day.
The fluid that returns to the circulation by way of the lymphatics is extremely

important because substances of high molecular weight, such as proteins, cannot be ab-
sorbed from the tissues in any other way, although they can enter the lymphatic
capillaries almost unimpeded. The reason for this is a special structure of the lymphatic

Anchoring filaments
capillaries, demonstrated in the figure below.

This figure shows the endothelial cells of the lymphatic capillary attached by
anchoring filaments to the surrounding connective tissue. At the junctions of adjacent
endothelial cells, the edge of one endothelial cell overlaps the edge of the adjacent cell in
such a way that the overlapping edge is free to flap inward, thus forming a minute valve
that opens to the interior of the capillary. Interstitial fluid, along with its suspended
particles, can push the valve open and flow directly into the lymphatic capillary. But this
fluid has difficulty leaving the capillary once it has entered because any backflow closes
the flap valve. Thus, the lymphatics have valves at the very tips of the terminal lymphatic
capillaries as well as valves along their larger vessels up to the point where they empty
into the blood circulation.
Lymph is derived from interstitial fluid that flows into the lymphatics. Therefore,
lymph as it first enters the terminal lymphatics has almost the same composition as the
interstitial fluid.
The protein concentration in the interstitial fluid of most tissues averages about 2
g/dl, and the protein concentration of lymph flowing from these tissues is near this value.
Conversely, lymph formed in the liver has a protein concentration as high as 6 g/dl, and
lymph formed in the intestines has a protein concentration as high as 3 to 4 g/dl. Because
about two thirds of all lymph normally is derived from the liver and intestines, the
thoracic duct lymph, which is a mixture of lymph from all areas of the body, usually has
a protein concentration of 3 to 5 g/dl.
The lymphatic system is also one of the major routes for absorption of nutrients
from the gastrointestinal tract, being responsible principally for the absorption of fats.
Indeed, after a fatty meal, thoracic duct lymph sometimes contains as much as 1 to 2 per
cent fat.
Finally, even large particles, such as bacteria, can push their way between the
endothelial cells of the lymphatic capillaries and in this way enter the lymph. As the
lymph passes through the lymph nodes, these particles are removed and destroyed.
The diagram below shows the action of smooth muscles & the one-way
valves on the continuous unidirectional flow of lymph in an attempt to recover the total
circulating fluid volume along with other components.
Dynamics of Capillary Exchange

Starling Equilibrium for Capillary Exchange

E. H. Starling pointed out a century ago that under normal conditions, a state of
near-equilibrium exists at the capillary membrane. That is, the amount of fluid filtering
outward from the arterial ends of capillaries equals almost exactly the fluid returned to
the circulation by absorption. The slight disequilibrium that does occur, accounts for the
small amount of fluid that is eventually returned by way of the lymphatics.
The following chart shows the principles of the Starling equilibrium. For this
chart, the pressures in the arterial and venous capillaries are averaged to calculate the
mean functional capillary pressure for the entire length of the capillary. This calculates to
be 17.3 mm Hg.

mmHg
Mean forces tending to move fluid outward
Mean capillary pressure 17.3
Negative interstitial free fluid pressure 3.0
Interstitial fluid colloid osmotic pressure 8.0
TOTAL OUTWARD FORCE 28.3
Mean force tending to move fluid inward
Plasma colloid osmotic pressure 28.0
TOTAL INWARD FORCE 28.0
Summation of mean forces
Outward 28.3
Inward 28.0
NET OUTWARD FORCE 0.3

Thus, for the total capillary circulation, we find a near-equilibrium between the
total outward forces, 28.3 mm Hg, and the total inward force, 28.0 mm Hg. This slight
imbalance of forces, 0.3 mm Hg, causes slightly more filtration of fluid into the
interstitial spaces than reabsorption. This slight excess of filtration is called the net
filtration, and it is the fluid that must be returned to the circulation through the
lymphatics. The normal rate of net filtration in the entire body is only about 2 ml/min.

Effect of Abnormal Imbalance of Forces at the Capillary Membrane

If the mean capillary pressure rises above 17 mm Hg, the net force tending to
cause filtration of fluid into the tissue spaces rises. Thus, a 20-mm Hg rise in mean
capillary pressure causes an increase in the net filtration pressure from 0.3 mm Hg to 20.3
mm Hg, which results in 68 times as much net filtration of fluid into the interstitial spaces
as normally occurs. To prevent accumulation of excess fluid in the spaces would require
68 times the normal flow of fluid into the lymphatic system, an amount that is usually 2
to 3 times too much for the lymphatics to carry away. As a result, fluid would begin to
accumulate in the interstitial spaces and edema would result.
Conversely, if the capillary pressure falls very low, net reabsorption of fluid into the
capillaries would occur instead of net filtration, and the blood volume would increase at
the expense of the interstitial fluid volume.

Hence
• Whether fluids leave or enter capillaries depends on net balance of pressures
 – net outward pressure of 10 mm Hg at arterial end of a capillary bed
– net inward pressure of 9 mm Hg at venous end of a capillary bed
• About 85% of the filtered fluid is returned to the capillary
– escaping fluid and plasma proteins are collected by lymphatic capillaries
(3 liters/day)
Following is a self explanatory diagram to illustrate the dynamics of capillary
exchange -

Starling’s law of the capillaries is that the volume of fluid & solutes reabsorbed is
almost as large as the volume filtered
Detailed Anatomy
HEAD & NECK LYMPHATICS
Lymph nodes in the head and neck are organized into 2 groups:
1. A terminal (collecting)group : deep cervical group
• is related to the carotid sheath
 • All lymph vessels from the head and neck drain directly to this group or
indirectly via the
2. Intermediary, outlying groups

The jugular trunks are formed by efferents of the deep cervical group
• drains on the right into the right lymphatic duct or at the junction between the
internal jugular and subclavian vein.
• drains on the left into the thoracic duct or joins the internal jugular or subclavian
vein.
The deep cervical lymphatic nodes:

1) Superior deep cervical nodes

 which can be found next to the upper portion of the internal jugular
vein.
 and most lie deep to the sternocleidomastoid muscle.
 drain to the lower inferior group or directly to the jugular
The jugulodigastric group: for lymphatic drainage of the tongue ; in a triangle
bordered by the posterior belly of the digastric muscle, the facial and internal jugular
veins.

2) Inferior deep cervical lymph nodes are related to:

 the deep surface of the SCM muscle
 the lower portion of the internal jugular vein
 the brachial plexus and subclavian vessels
 Superficial Lymphatic Drainage Deep Lymphatic Drainage

The jugulo-omohyoid node (at the level of the intermediate tendon of the
omohyoid): lymphatic drainage of the tongue.
The inferior deep cervical lymph nodes drain into the jugular lymph trunk.
LYMPHATIC SYSTEM OF SUPERFICIAL HEAD & NECK
2 types of drainage exist:
 Drainage by vessels afferent to local groups of nodes which in turn drain
to the deep cervical nodes.
 Direct drainage to deep cervical nodes.
Superficial drainage groups
1) In the head:
 occipital
 retro auricular (mastoid)
 parotid
 buccal (facial)
2) In the neck:
 submandibular
 submental
 anterior cervical
 superficial cervical
Lymphatic drainage of scalp and ear
Submandibular nodes receive drainage from the frontal region above the root of the nose.
Superficial parotid nodes (anterior to tragus, superficial and deep to parotid fascia)
receive drainage from:
 rest of the forehead,
 temporal region,
 upper half of the lateral auricular aspect
 anterior wall of the external acoustic meatus
 lateral vessels from the eyelids and skin of the zygomatic region
Efferent vessels drain to the upper deep cervical nodes.
Upper deep cervical nodes and retroauricular nodes receive drainage from:
 a strip of scalp above the auricle
 the upper half of the cranial aspect and margin of the auricle
 the posterior wall of the external acoustic meatus
The retroauricular nodes are found:
 superficial to the mastoid attachment of the sternocleidomastoid muscle
 deep to the auricularis posterior
 They drain to the upper deep cervical nodes
Superficial cervical or upper deep cervical nodes receive drainage from :
 auricular lobule
 floor of the auditory meatus
 skin over the mandibular angle
 skin over the lower parotid region
Superficial cervical nodes:
o are distributed along the external jugular vein superficial to
sternocleidomastoid
o have efferents:
 going around the anterior border of the sternocleidomastoid to the
upper deep cervical nodes
 following the external jugular vein to the lower deep cervical
nodes in the subclavian triangle.
The occipital scalp is drained:
 partly to the occipital nodes.
 partly by a vessel along the posterior border of sternocleidomastoid to the
lower deep cervical nodes.
The occipital nodes are mainly found superficial to the upper attachment of trapezius and
occasionally in the superior angle of the posterior triangle of the neck.

Lymphatic drainage of the face

Lymph vessels draining the eyelid and conjunctiva:
 start in a subcutaneous and deep plexus around the tarsal plates.
 divided into lateral and medial vessels
Lymph vessels from eyelids and conjunctiva are organized into:
1) Lateral vessels :
 drain the whole thickness of both eyelids (except for the medial parts)
 drain all of the conjunctiva
 run to the superficial parotid nodes and deep nodes embedded in the
parotid gland.
 also receive lymph from the middle ear.
2) Medial vessels:
 drain the whole thickness of the medial parts of the lids.
 drain the caruncular lacrimalis.
 run to the submandibular nodes.
Submandibular nodes
 lie deep to the cervical fascia, in the submandibular triangle.
 are usually 3 in number:
 one at the anterior pole of the submandibular gland.
 two on either side of the facial artery as it reaches the mandible.
 Other nodes may be embedded in the submandibular gland or deep
to it.
 drain a wide area from the :
 submental nodes
 buccal nodes
 lingual nodes
 drain to the upper and lower deep cervical nodes.
 drain directly the:
 external nose
 cheeks
 upper lip and lateral part of the lower lips
 the mucosa of lips and cheeks
 A few buccal nodes may be present near the facial vein and they
also drain to the submandibular nodes.
The skin over the root of the nose and central forehead drains partly to the parotid nodes
and partly to the submandibular nodes.
The lateral part of the cheek drains to the parotid nodes.
Submental nodes
 are located on the mylohyoid, between the anterior bellies of the digastric
muscles.
 receive bilateral afferents.
 have efferents running to the submandibular and jugulo-omohyoid nodes.
Lymphatic drainage of the neck
Superficial vessels run:
 around the sternocleidomastoid, to the superior or inferior deep cervical
nodes.
 over the sternocleidomastoid and the posterior triangle, to the superficial
cervical and occipital nodes.
The superior region of the anterior triangle drains to the submandibular and submental
nodes.
The anterior cervical skin below the hyoid bone drains to the anterior cervical lymph
nodes near the anterior jugular veins.
Efferents go to the deep cervical nodes bilaterally (infrahyoid, prelaryngeal and
pretracheal groups).
An anterior cervical node may often be found in the suprasternal space

LYMPHATIC SYSTEM OF DEEP HEAD AND NECK

Deep nodes are organized into

 Superior deep cervical nodes
 Inferior deep cervical nodes
 Retropharyngeal nodes
 Paratracheal nodes
 Infrahyoid, prelaryngeal and pretracheal nodes.
 Lingual nodes.
The retropharyngeal nodes:
 are formed by a median and 2 lateral groups. The lateral group is found
bilaterally, anterior to the lateral process of the atlas, along the border of
the longus capitis muscle.
 lie between the pharyngeal and prevertebral fasciae.
 receive afferents from the nasopharynx, eustachian tube and joints
between the occipital bone, C1 and C2 vertebrae.
 drain to the upper deep cervical nodes.

Paratracheal nodes
 lie on either side of the trachea and esophagus, along the recurrent
laryngeal nerves.
 drain to the upper and lower deep cervical nodes.

Infrahoid, prelaryngeal and pretracheal nodes are located deep to the cervical
fascia.
 infrahyoid nodes are anterior to the thyrohyoid membrane.
 prelaryngeal nodes are on the conus elasticus and cricothryoid ligament.
 pretracheal nodes are anterior to the trachea near the inferior thyroid veins.
The infrahyoid nodes:
 drain afferents from the anterior cervical nodes.
 drain to the deep cervical nodes.
Lingual nodes
 form an inconstant group.
 are found on the external surface of the hyoglossus, and between the
genioglossi.
 drain to the upper cervical nodes.

Lymphatic drainage of nasal cavity and nasopharynx

 The anterior region of the nasal cavity drains superficially to the
submandibular nodes.
  rest of nasal cavity, paranasal sinuses, nasopharynx and pharyngeal end of
the auditory tube drain via the retrophrayngeal nodes or directly to the
upper deep cervical nodes.
 the posterior nasal floor drains to the parotid nodes.

Lymphatic drainage of the middle ear

 The mucosa of the tympanic membrane and the antrum drain to the parotid
or upper deep cervical lymph nodes.
 The tympanic end of the auditory tube drain to the deep cervical lymph
nodes.

Lymphatic drainage of the larynx (Laryngeal lymphatic vessels)

 form superior and inferior groups, at the level of the vocal fold,
 anastomose on the posterior wall.
1) Superior vessels run with the superior laryngeal vessels to the upper deep cervical
nodes.
2) Inferior vessels run:
 between the cricoid cartilage and the first tracheal ring to the inferior deep
cervical nodes.
 or through the cricothyroid ligament to the pretracheal and prelaryngeal
nodes.
 Lymphatic
drainage of
the trachea

A dense
network of
lymphatic
vessels
(tracheal
plexus) is
present in the tracheal wall.
This tracheal plexus drains to:
 the pretracheal nodes
 the paratracheal nodes
 or directly to the inferior deep cervical nodes.

Lymphatic drainage of the thyroid gland

Lymphatic vessels from the thyroid gland communicate with the:
 prelaryngeal nodes (above thyroid isthmus) via the tracheal plexus,
 pretracheal nodes,
 paratracheal nodes,
 brachiocephalic nodes (in superior mediastinum),
 deep cervical nodes via the superior thyroid vessels,
 and directly to the thoracic duct.

Lymphatic drainage of the mouth

 Gingiva drain to the submandibular nodes.
 Soft and hard palate drain to the superior deep cervical nodes and the
retropharyngeal nodes.
  Anterior part of the floor of the mouth drains via the submental nodes or
directly to the superior deep cervical nodes.
 Rest of the floor of the mouth drains to the submandibular and superior
deep cervical nodes.

Lymphatic drainage of the teeth

Lymphatics from the teeth pass to the submandibular and deep cervical nodes.

Lymphatic drainage of the tonsil

The lymphatic drainage of the tonsil drains to the superior deep cervical nodes:
 most to the jugulodigastric node.
 some to the small nodes on the lateral aspect of the internal jugular vein.
Lymphatic drainage of the tongue
The lingual mucosal plexus is continuous with the intramuscular plexus.
 The anterior 2/3 of the tongue drains into the marginal and central
vessels.
 The posterior 1/3 of the tongue drains into the dorsal lymph vessels.
Marginal vessels of the tongue
 arise from the tip of the tongue and frenulum.
 drain bilaterally to the:
 submental nodes,
 jugulo-omohyoid node,
 anterior or middle submandibular node,
 jugulo-digastric nodes.

Central vessels of the tongue follow the lingual vein to drain to:
 deep cervical nodes (jugulodigastric and juguloomohyoid nodes).
 submandibular nodes.

Dorsal vessels of the tongue

 join with the marginal vessels
 drain into the jugulodigastric node or juguloomohyoid node
Lymphatic drainage of the pharynx and cervical part of the esophagus
Passes:
 through the retropharyngeal or paratracheal nodes
 or directly to the deep cervical nodes.
The epiglottis drains to the infrahyoid nodes.
 Lymphatics of the Head and Neck – Summary

Afferents
Structure Location Efferents to Regions drained Notes
from
Accessory Posterior Occipital Transverse Occipital region Accessory nodes also
nodes triangle of the nodes, cervical chain and posterior scalp collect lymph from the
neck, arranged retroauricular of nodes nape of the neck and
along the nodes the region overlying
accessory n. the supraspinatous
fossa
Anterior subcutaneous lymphatic superior parotid anterior part of the anterior auricular
auricular connective vessels from nodes; superior parietal region of nodes are 1 or 2 in
nodes tissue anterior to the side of the deep cervical the scalp; anterior number
the ear head nodes surface of the ear
and external
acoustic meatus

Anterior along the lymphatic inferior deep skin and mm. of anterior jugular nodes
jugular nodes anterior jugular vessels from cervical nodes the anterior are located between
vein the anterior infrahyoid region the superficial layer of
inferior part of of the neck deep cervical fascia
the neck and the infrahyoid
mm.
Anterior along the course lymphatic bronchomediast thymus, anterior anterior mediastinal
mediastinal of the vessels from inal trunk respiratory nodes are from 2 to 5
nodes brachiocephalic the anterior diaphragm, in number
vessels and aorta mediastinum pericardium, part
and middle of the heart
mediastinum
Auricular subcutaneous lymphatic superior parotid anterior part of the anterior auricular
nodes, connective vessels from nodes; superior parietal region of nodes are 1 or 2 in
anterior tissue anterior to the side of the deep cervical the scalp; anterior number
the ear head nodes surface of the ear
and external
acoustic meatus
Broncho- along the course union of left: thoracic thoracic wall and right broncho-
mediastinal of the brachio- efferents from duct; right: viscera; medial mediastinal trunk
trunk cephalic v. the paratracheal right lymphatic part of the receives lymph from
nodes, duct mammary gland the lower lobe of the
parasternal left lung;
nodes and broncho-mediastinal
anterior trunk may drain
mediastinal directly into the
nodes venous system on
either side

Broncho- hilum of the pulmonary tracheobronchi lung Broncho-pulmonary

pulmonary lung nodes al nodes nodes are also known
nodes as: hilar nodes

Cervical in and around lymphatic jugular trunk head and neck superior and inferior
nodes, deep carotid sheath vessels and subdivisions of deep
posterior and numerous node cervical nodes are
lateral to the groups from the delineated by the
internal jugular head and neck crossing of the
v. omohyoid m.

Cervical in superficial lymphatic varies by head & neck several groups are
nodes, fascia and along vessels from group; ultimate designated by
superficial superficial superficial destination is location:
vessels of the structures in the jugular occipital,
head & neck head & neck trunk retroauricular,
anterior auricular,
superficial parotid,
facial, submental,
 submandibular,
external jugular,
anterior jugular

Deep in and around lymphatic jugular trunk head and neck superior and inferior
cervical carotid sheath vessels and subdivisions of deep
nodes posterior and numerous node cervical nodes are
lateral to the groups from the delineated by the
internal jugular head and neck crossing of the
v. omohyoid m.

Deep around the superior deep jugular trunk head and neck inferior deep cervical
cervical internal jugular cervical nodes; nodes are in direct
nodes, v., inferior to the numerous node continuity with the
inferior crossing of the groups of the superior deep cervical
omohyoid m. neck chain of nodes

Deep around the numerous node inferior deep head and the the superior deep
cervical internal jugular groups of the cervical nodes superior part of the cervical node group
nodes, v., superior to head and upper neck has many large nodes;
superior the crossing of neck, including the jugulodigastric and
the omohyoid m. retropharyngeal juguloomohyoid nodes
nodes and deep are members of this
parotid nodes group

External along the lymphatic superior deep inferior part of the there are one or two
jugular nodes external jugular vessels from cervical nodes ear and the parotid nodes in this group
v. the side of the region
head
Facial nodes along the course lymphatic submandibular eyelids, nose, facial nodes are
of the facial a. vessels from nodes cheek and lips grouped inferior to the
and v. the face orbit; at the angle of
the mouth and over the
mandible

Hilar nodes at hilum of lung pulmonary tracheobronchi lung also known as:
nodes al nodes bronchopulmonary
nodes
Inferior deep around the superior deep jugular trunk head and neck inferior deep cervical
cervical internal jugular cervical nodes; nodes are in direct
nodes v., inferior to the numerous node continuity with the
crossing of the groups of the superior deep cervical
omohyoid m. neck chain of nodes

Inferior inferior to bronchopulmon right superior lower lobes of the left inferior
tracheobronc tracheal ary nodes, left tracheobronchi lungs; middle tracheobronchial
hial nodes bifurcation side inferior al nodes mediastinum; nodes drain to the
tracheobronchi posterior right side
al nodes drain mediastinum
into right
inferior
tracheobronchi
al nodes
Infraclavicul along the lymphatic apical axillary skin and infraclavicular nodes
ar nodes cephalic v. in the vessels from nodes superficial fascia may become inflamed
deltopectoral the superficial of the upper limb during infections of
groove upper limb the superficial tissues
of the upper limb
Jugular carotid sheath in deep cervical Left thoracic head & neck jugular trunk carries
lymphatic root of neck nodes duct near its most of the lymph
trunk termination; Rt from the head and
lymphatic duct neck
or junction of
Rt subclavian
and Rt internal
jugular vv.
Jugular along the lymphatic inferior deep skin and mm. of anterior jugular nodes
nodes, anterior jugular vessels from cervical nodes the anterior are located between
anterior vein the anterior infrahyoid region the superficial layer of
inferior part of of the neck deep cervical fascia
the neck and the infrahyoid
mm.
Jugular along the lymphatic superior deep inferior part of the there are one or two
nodes, external jugular vessels from cervical nodes ear and the parotid nodes in this group
external v. the side of the region
head

Jugulo- anterolateral to superior deep inferior deep oral cavity, tongue, a member of the
digastric internal jugular cervical nodes cervical nodes palatine tonsil superior deep cervical
node v. where it is node group; important
 crossed by node to palpate during
posterior belly physical exam
of the digastric

Jugulo- lateral to internal superior deep inferior deep submental region an important node to
omohyoid jugular v. where cervical nodes cervical nodes and tip of tongue; examine in cases of
node it is crossed by head & neck above oral cancer caused by
superior belly of this level use of tobacco
omohyoid products

Juxta- adjacent to the cervical viscera superior deep esophagus, larynx, four groups of
visceral cervical viscera cervical nodes, trachea and thyroid juxtavisceral nodes are
nodes inferior deep gland recognized:
cervical nodes infrahyoid,
prelaryngeal,
pretracheal and
paratracheal

Occipital superior nuchal lymphatic accessory occipital part of occipital nodes are 2
nodes line, along the vessels from nodes the scalp and the or 3 nodes located
course of the the posterior superior neck between the
occipital a. and head and neck attachments of the
v. sternocleido-mastoid
m. and the trapezius
m.
Parasternal lateral border of anterior phrenic larger medial side of the parasternal nodes
nodes sternum, along nodes, lymphatic mammary gland; constitute an important
the course of the lymphatic vessels in the medial part of the drainage pattern in
internal thoracic vessels from root of the anterior chest wall cases of cancer of the
vessels the anterior neck and muscles mammary gland; one
thoracic wall or two parasternal
nodes may be found in
the anterior end of
intercostal spaces 1-6;
also known as: sternal
nodes

Para-tracheal coursing along superior Broncho- lungs, trachea, paratracheal nodes are
nodes the lateral tracheo- mediastinal upper esophagus, an important group of
surface of the bronchial nodes trunk the part of the nodes in cases of
trachea and larynx below the pulmonry infection or
esophagus vocal folds lung cancer; also
 known as: tracheal
nodes

Parotid on the lateral lymphatic superior deep external acoustic deep parotid nodes are
nodes, deep side of the vessels from cervical nodes meatus, auditory part of the deep
pharyngeal wall, the ear tube, middle ear cervical chain of nodes
deep to the
parotid gland

Parotid superficial to the anterior superior deep anterior surface of superficial parotid
nodes, parotid gland auricular nodes cervical nodes the ear and nodes are up to 10 in
superficial and also deep to external acoustic number and may be
the parotid meatus; temporal located superficial or
fascia and frontal deep to the parotid
regions; eyelids, fascia
lacrimal gland
cheek and nose
Pulmonary within the lung lymphatic Broncho- lung parenchyma, pulmonary nodes are
nodes parenchyma vessels from pulmonary bronchial tree located along the
the parenchyma (hilar) nodes within the lungs larger bronchi of the
of the lung lung

Retro- posterior to the lymphatic superior deep scalp overlying the retroauricular nodes
auricular ear vessels from cervical nodes posterior parietal are 1 or 2 nodes
nodes the ear and side region; skin of the located at the insertion
of the head posterior surface of of the sternocleido-
the ear mastoid m.

Retropharyn posterior to lymphatic superior deep nasal fossae, retropharyngeal

geal nodes pharynx in the vessels from cervical paranasal sinuses, nodes are one or two
retropharyngea the nasal and nodes hard palate, soft in number; they are
l space pharyngeal palate, middle part of the deep
regions ear, oropharynx cervical chain of
nodes

Right root of neck on formed by the junction of right half of the right lymphatic duct
lymphatic the right side union of right the right head and neck; has a valve near its
duct jugular trunk, subclavian v. right upper limb; termination; the
right and right right side of the three trunks that
subclavian internal chest form right lymphatic
 trunk, and the jugular v. duct may drain
right broncho- separately into the
mediastinal venous system
trunk
Subclavian along the apical axillary drains into the upper limb, most subclavian lymphatic
trunk course of the nodes; infra- junction of of breast, trunk occasionally
subclavian v. clavicular the internal anterolateral drains into the
nodes jugular v. and chest wall thoracic duct on the
the left side; into the
subclavian v. right lymphatic duct
on the right side
Sub- along the submental superior deep anterior part of submandibular nodes
mandibular inferior border nodes; facial cervical tongue, lower lip, may be within the
nodes of the nodes; nodes; floor of the sheath of the
submandibular lymphatic jugulo- mouth, nose, submandibular
gland vessels from omohyoid cheeks, chin, gland; this group
the node gums and lower consists of from 3 to
submandibula incisor teeth, 6 nodes
r and lower surface of
sublingual palate
regions

Submental under the lymphatic submandibula tip of the tongue, submental nodes are
nodes mandible on vessels from r nodes, lower lip, floor of important nodes to
the mylohyoid the lower face jugulo- the mouth, chin, examine in cases of
m. and chin omohyoid gums and lower oral cancer caused
node incisor teeth by the use of tobacco
products

Superficial in superficial lymphatic varies by head & neck several groups are
cervical fascia and vessels from group; designated by
nodes along superficial ultimate location: occipital,
superficial structures in destination is retroauricular,
vessels of the head & neck the jugular anterior auricular,
head & neck trunk superficial parotid,
facial, submental,
submandibular,
external jugular,
anterior jugular
Superficial superficial to anterior superior deep anterior surface superficial parotid
parotid the parotid auricular cervical of the ear and nodes are up to 10 in
nodes gland and also nodes nodes external acoustic number and may be
deep to the meatus; temporal located superficial or
parotid fascia and frontal deep to the parotid
regions; eyelids, fascia
lacrimal gland
cheek and nose

Superior around the numerous inferior deep head and the the superior deep
deep internal jugular node groups cervical superior part of cervical node group
cervical v., superior to of the head nodes the neck has many large
nodes the crossing of and upper nodes; the
the omohyoid neck, jugulodigastric and
m. including juguloomohyoid
retropharynge nodes are members
al nodes and of this group
deep parotid
nodes
Superior superolateral to Broncho- paratracheal lungs, middle inferior tracheo-
tracheo- the tracheal pulmonary (tracheal) mediastinum, bronchial nodes
bronchial bifurcation (hilar) nodes nodes posterior drain lymph from the
nodes mediastinum lower lobe of the left
lung to the right
superior
tracheobronchial
nodes

Supra- in and around superior deep efferents form head and neck also known as:
clavicular carotid sheath cervical , the jugular inferior deep cervical
nodes below level of transverse lymphatic nodes
omohyoid cervical & trunk
spinal
accessory
nodes

Thoracic between the formed by the junction of all of the body thoracic duct is the
duct esophagus union of the the left and limbs below largest lymphatic
anteriorly and lumbar lymph subclavian v. the respiratory vessel; it passes
 the thoracic trunks, and the left diaphragm; the through the aortic
vertebral sometimes internal left side of the hiatus on the right
bodies dilated to jugular v. chest, left upper side of aorta; it
posteriorly form a limb and the left swings to the left
cisterna chyli side of the head side of the
and neck above esophagus at the T4-
the diaphragm T5 intervertebral
disc (at the level of
the sternal angle)

Tonsil, superior lymphatic superior deep "guards" the lingual tonsil is part
lingual surface of the vessels of the cervical entrance of the of the tonsillar ring
root of the tongue nodes oropharynx (of Waldeyer)
tongue

Tonsil, lateral wall of lymphatic superior deep "guards" the palatine tonsil is part
palatine the oropharynx vessels of the cervical entrance of the of the tonsillar ring
between the posterior nodes, oropharynx (of Waldeyer)
palatoglossal tongue and especially the
and palatoglossal/ jugulodigastri
palatopharynge palatopharyng c node
al arches eal arch
region

Tonsil, roof and lymphatic superior deep "guards" the pharyngeal tonsil is
pharyngeal posterior wall vessels of the cervical entrance to the part of the tonsillar
of the wall of the nodes nasopharynx ring (of Waldeyer);
nasopharynx pharynx also known as:
adenoids

Tonsil, tubal pharyngeal lymphatic superior deep "guards" the tubal tonsil is located
recess vessels of the cervical entrance to the at the pharyngeal
torus tubarius nodes nasopharynx orifice of the
and auditory auditory tube; it is
tube greater significance
in restricting
infection spread
between oral cavity
& middle ear
Tracheal coursing along superior bronchomedia lungs, trachea, tracheal nodes are an
nodes the lateral tracheobronch stinal trunk upper esophagus, important group of
surface of the ial nodes the part of the nodes in cases of
trachea and larynx below the pulmonary infection
esophagus vocal folds or lung cancer; also
known as:
paratracheal nodes

Tracheobro along the lymphatic bronchomedia lungs, visceral tracheobronchial

nchial nodes trachea, around vessels from stinal lymph pleura, bronchi, nodes may be
the tracheal the lung trunk thoracic part of divided into five
bifurcation and trachea, left side groups: paratracheal
primary of heart, (tracheal), superior
bronchi esophagus, tracheobronchial,
posterior inferior
mediastinum tracheobronchial,
bronchopulmonary
(hilar), pulmonary
Tracheobro inferior to bronchopulmo right superior lower lobes of left inferior
nchial tracheal nary nodes, tracheobronch the lungs; middle tracheobronchial
nodes, bifurcation left side ial nodes mediastinum; nodes drain to the
inferior inferior posterior right side
tracheobronch mediastinum
ial nodes drain
into right
inferior
tracheobronch
ial nodes

Tracheobro superolateral to bronchopulmo paratracheal lungs, middle inferior

nchial the tracheal nary (hilar) (tracheal) mediastinum, tracheobronchial
nodes, bifurcation nodes nodes posterior nodes drain lymph
superior mediastinum from the lower lobe
of the left lung to the
right superior
tracheobronchial
nodes

Transverse along the accessory variable: lateral part of the transverse cervical
cervical course of the chain of jugular neck, anterior nodes are
nodes transverse nodes, lymphatic thoracic wall, approximately 10 in
cervical blood sometimes the trunk, right mammary gland number and may
vessels apical axillary lymphatic drain directly into
nodes trunk or the internal jugular
thoracic duct v. or subclavian v.

APPLIED ANATOMY

Lymph Node Levels/Nodal regions

  For ease and uniformity of description, nodal regions have been subdivided into
levels with corresponding clinical descriptions. This system was established by the
Sloan-Kettering Memorial Group and is as follows:
 
Level I: Lymph node groups – submental and submandibular

Level Ia*: Submental triangle

Boundaries – anterior bellies of the digastric muscle and the hyoid bone

Level Ib*: Submandibular triangle

 Boundaries – body of the mandible, anterior and posterior belly of the
digastric muscle

Note: includes the submandibular gland, pre- and post glandular lymph nodes and
pre- and post vascular (relative to facial vein and artery) lymph nodes, but does not
include perifacial lymph nodes

Level II: Lymph node groups – upper jugular

Boundaries –
1) anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of the Sternocleidomastoid muscle
3) superior – skull base
4) inferior – level of the hyoid bone (clinical landmark)
or carotid bifurcation (surgical landmark)

Level IIa* and IIb* are arbitrarily designated anatomically by splitting level II with
the spinal accessory nerve.
 
Level III: Lymph node groups – middle jugular
Boundaries –
1) anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of the sternocleidomastoid muscle
 3) superior – hyoid bone (clinical landmark) or carotid bifurcation (surgical
landmark)
4) inferior – cricothyroid notch (clinical landmark) or omohyoid
muscle (surgical landmark) 
Level IV: Lymph node groups – lower jugular
Boundaries –
1) anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of the sternocleidomastoid muscle
3) superior – cricothyroid notch (clinical landmark) or omohyoid muscle (surgical
landmark)
4) inferior – clavicle

Level IVa* denotes the lymph nodes that lie along the internal jugular vein but
immediately deep to the sternal head of the SCM.

Level IVb* denotes the lymph nodes that lie deep to the clavicular head of the SCM
 
Level V: Lymph node groups – posterior triangle
Boundaries –
1) anterior – posterior border of the sternocleidomastoid muscle
2) posterior – anterior border of the trapezius muscle
3) inferior - clavicle
 
Level Va* denotes those lymphatic structures in the upper part of level V that follow the
spinal accessory nerve. Level Vb* refers to those nodes that lie along the transverse
cervical artery. Anatomically, the division between these two subzones is the inferior
belly of the omohyoid muscle.
 
Level VI: Lymph node groups – [prelaryngeal (Delphian), pretracheal, paratracheal, and
precricoid (Delphian) lymph nodes] - also known as the anterior compartment
Boundaries –
 1) lateral – carotid sheath
2) superior – hyoid bone
3) inferior – suprasternal notch

Level VII: Lymph node groups – Upper mediastinal

Boundaries –
1) lateral – carotid arteries
2) superior – suprasternal notch
3) inferior – aortic arch
 
Supraclavicular zone or fossa: relevant to nasopharyngeal carcinoma
Boundaries –
1) superior margin of the sternal end of the clavicle
2) superior margin of the lateral end of the clavicle
3) the point where the neck meets the shoulder
 
* Note: The subzones Ia, Ib, IIa, IIb, IVa, IVb, Va, and Vb were not part of the original
description of the levels of the neck. They have been suggested by Suen and Goepfert
(1987) to further subdivide areas of differing lymphatic drainage within certain levels.
Depending on the site of the primary tumor, these subzones may have biological
significance and can guide decision-making in determining which nodal levels should be
addressed surgically. For example, level Ia is more likely to contain metastatic disease
associated with primary lesions arising in the, lower lip, floor of mouth, and ventral
tongue, whereas lesions arising from other oral cavity subsites are more likely to spread
directly to level Ib, II, and III. Level II is divided into subzones anatomically by the
spinal accessory nerve, however, subzones Level IIa and IIb have biologic implications
as well. Primary lesions from the oropharynx and nasopharynx are more likely to involve
level IIb. Therefore it is important to mobilize the spinal accessory nerve and remove the
fibrofatty components containing lymph nodes from this compartment. Obviously level
IIb should also be dissected when there are clinically positive lymph nodes in level IIa
however, it may not be necessary to dissect level IIb when performing elective neck
dissections for carcinomas arising from the oral cavity, larynx, and hypopharynx.
Similarly Level IV may be subdivided into subzones. Clinically positive
lymphadenopathy in Level IVa may signify a higher risk of spread to level VI whereas
lymph nodes in Level IVb may be more likely to spread to level V. Level Va denotes
those lymphatic structures coursing along with the spinal accessory nerve as it exits the
posterior border of the SCM and enters the anterior border of the trapezius muscle.
Tumors arising in the oropharynx, nasopharynx, and cutaneous structures of the posterior
scalp and neck are more likely to involve these lymph nodes. Level Vb refers to those
lymph nodes lying along the transverse cervical artery and are anatomically separated
from Level Va by the inferior belly of the omohyoid muscle. These notes have a high
risk of involvement in metastatic thyroid cancers.
 
Staging
 
The “N” or nodal classification for cervical metastasis is consistent for all
mucosal sites except the nasopharynx. Thyroid and nasopharyngeal carcinomas have
unique nodal classifications that are based upon tumor behavior and prognosis. The
staging systems for cervical metastases have been established by the American Joint
Committee on Cancer most recently updated in 1997. These systems are based on the
best possible estimate of the extent of disease before first treatment. Clinical information
including physical exam and imaging modalities are used to contribute to this estimate.

Regional Lymph Nodes (N)

 
Lip, oral cavity, oropharynx, hypopharynx, larynx, trachea, paranasal sinuses,
major salivary glands,
 
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Single ipsilateral lymph node 3-6 cm
N2
N2a Single ipsilateral lymph node 3-6 cm
N2b Multiple ipsilateral nodes < 6 cm
N2c Bilateral lymph nodes < 6 cm
N3 Any node > 6 cm
 
Nasopharynx
 
NX nodes cannot be assessed
N0 no regional lymph node metastasis
N1 Unilateral metastasis in lymph nodes < 6 cm above the supraclavicular fossa
N2 Bilateral metastasis in lymph nodes < 6 cm above the supraclavicular fossa
N3 Metastasis in a lymph node(s)
N3a > 6 cm
N3b extension to the supraclavicular fossa
Thyroid
 
NX Regional lymph noses cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
N1a Metastasis in ipsilateral cervical lymph node(s)
N1b Metastasis in bilateral, midline, or contralateral cervical or mediastinal lymph
node(s)
 
Classification
 
In 1991, the Committee for Head and Neck Surgery and Oncology of the
American Academy of Otolaryngology/Head and Neck Surgery developed a system for
the classification of neck dissections. Other individual authors prior to and since this
time have proposed other classification systems, however, the Academy’s system remains
the most widely accepted and has been endorsed by the American Society for Head and
Neck Surgery. It is based on the following concepts:
 
1) Radical neck dissection is the standard basic procedure for cervical
lymphadenectomy against which all other modifications are compared.
2) Modifications of the radical neck dissection which include the preservation of any
non-lymphatic structures are referred to as modified radical neck dissection
(MRND)
3) Any neck dissection that preserves one or more groups or levels of lymph nodes is
referred to as a selective neck dissection.
4) An extended neck dissection refers to the removal of additional lymph node
groups or non-lymphatic structures relative to the radical neck dissection.
 
The following are the four major types and subtypes of neck dissections proposed
by the Academy:
 
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
3) Selective neck dissection (SND):
a. supra-omohyoid type
b. lateral type
c. posterolateral type
d. anterior compartment type
4) Extended radical neck dissection
In 1989 Medina suggested that the term “comprehensive neck dissection” be used
whenever all the lymph nodes contained in levels I through V have been removed. The
radical neck dissection and the modified radical neck dissection would, therefore, be
included under this title. He then recommended three subtypes of modified radical neck
dissection. This additional nomenclature has the disadvantage of adding further
complexity to the classification system, however it may be more conducive to consider
adding such refinements to the Academy’s system now that most head and neck surgeons
are familiar with its structure and concepts. Medina’s classification is as follows:
 
1) Comprehensive neck dissection
Radical neck dissection
Modified radical neck dissection
Type I (XI preserved)
Type II (XI, IJV preserved)
Type III (XI, IJV, and SCM preserved)

2) Selective neck dissection (a-d as above)

 
In 1994, Spiro suggested changes to the Academy’s classification of neck
dissections. He recommended that the term “radical neck dissection” be used for any
neck dissection in which four or more lymph node levels are removed, and that the term
“modified radical neck dissection” be included under the heading of RND. Additionally
they included two other types of neck dissection: selective and limited. He believed that
his system more accurately reflected the time and effort involved and provided a “more
equitable basis for reimbursement”. The following table describes Spiro’s “three-tiered”
classification:
 
Radical (4 or 5 node levels resected)
Conventional radical neck dissection
Modified radical neck dissection
Extended radical neck dissection
Modified and extended radical neck dissection
Selective (3 node levels resected)
Supraomohyoid neck dissection
Jugular dissection (Levels II-IV)
Any other 3 node levels resected
Limited (no more than 2 node levels resected)
Paratracheal node dissection
Mediastinal node dissection
Any other 1 or 2 node levels resected

The Academies system for classification of neck dissection as compared to others

has the advantage of being simple, logical, based on historical terminology, and most
importantly, represents a consensus of opinions by the two organizations at the time it
was developed. Therefore, it has become the most widely accepted and utilized system
throughout the world. It is not perfect, however. Not all neck dissections fit perfectly
into the classification. Thus, there will be continued discussion and debate concerning
the nomenclature used in these situations.
Radical neck dissection
 
Definition
 
The radical neck dissection is the gold standard for oncologic treatment of lymph
node metastasis in the neck. It involves removal of all lymphatics from levels I-V. In
addition, removal of nonlymphatic structures including the spinal accessory nerve, the
sternocleidomastoid muscle and the internal jugular vein is carried out. It does not
include removal of the postauricular and suboccipital nodes, periparotid nodes except for
a few nodes located in the tail of the parotid gland, the perifacial and buccinator nodes,
the retropharyngeal nodes, and the paratracheal nodes.
 

Indications for R.N.D

 
Decision to perform a radical neck dissection is not always straight forward, and
often is determined at the time of surgery. A RND is indicated in patients with extensive
cervical lymph node metastasis and/or extension beyond the capsule with invasion into
the spinal accessory nerve, IJV, and SCM. Many surgeons will elect to perform a RND if
there is extensive disease surrounding the spinal accessory nerve without gross evidence
of invasion. Others would elect to perform a MRND. The bottom line is the one should
not risk inadequate oncologic resection for the sake of preserving these any of these non
lymphatic structures.
To summarize:
1. Presence of clinically positive N2a, N2b & N3 nodes
Treatment of N1 neck is still a controversy.
2. Extra nodal spread (including skin involvement)
3. Recurrence after treatment

Contra indications for R.N.D

1. Uncontrolled primary lesion

2. Involvement of internal / common carotid artery
3. Presence of distant metastasis.
4. Poor anesthetic risk patient.

CLASSIFICATION OF NECK DISSECTIONS

Malignancies from head & neck region spread in a predictable manner to the
cervical nodes.
 The levels commonly involved in oral cancers are Level 1, II and III.
This has lead to the development of several modifications of the neck dissection. This is
especially helpful in avoiding unnecessary radical neck dissections.
Helpful classification of neck dissection (by MSKCC) is

1. Comprehensive Neck dissection:

Level I to V all the group of nodes are excised.

a) Classical R.N.D.
b) Extended radical resection of additional nodes/skin/nerves
c) MRND - I - Preserves the accessory nerve
d) MRND -II - Preserves accessory nerve, stern mastoid muscle and IJV
e) MRND - III - Preserves IJV, stern mastoid muscle and accessory nerve
 2. Selective neck dissection:
a) Suprahyoid - level I, II & III (Staging of primary oral cavity lesion)
b) Anterior lateral neck - Level II & III - hypo pharynx and larynx
c) Central compartment - adjacent to thyroid & trachea oesophageal
groove (Ca thyroid)
d) Poster lateral - Level II, III & IV involvement - squamous Ca of
posterior scalp.

Modified Radical Neck Dissection 

Definition
Modified radical neck dissection involves excision of the same lymph node
bearing tissues from one side of the neck as is performed in a RND with the preservation
of one or more nonlymphatic structure including the spinal accessory nerve, the IJV, or
the SCM. As mentioned before, Medina subclassifies the MRND into Types I-III.
MRND is analogous to the “functional neck dissection” described by Bocca, however
they differ in that Bocca originally did not remove the submandibular gland.
 
Indications
 
MRND is indicated in patients with gross nodal metastasis to the neck that does
not directly infiltrate or adhere to the non-lymphatic structures previously mentioned.
Bilateral MRND is indicated when there is contralateral nodal involvement with the
above mentioned specifications.

Selective Neck Dissection: Supraomohyoid Type (Level I-III)

 
Definition
The supraomohyoid neck dissection (SOHND) is the most commonly performed
selective neck dissection for the treatment of the N0 neck. It involves the en bloc
removal of cervical lymph node groups I-III. The posterior limit of this dissection is
marked by the cutaneous branches of the cervical plexus and the posterior border of the
SCM. The inferior limit is the superior belly of the omohyoid muscle where it crosses
the IJV.
 
Indications
SOHND is indicated in patients with primary tumors arising from the oral cavity
without clinical or radiologic evidence of cervical metastasis but who have a high
probability of occult lymphatic disease. The oral cavity includes the area between the
vermillion border of the lips and the junction of the of the hard and soft palate superiorly
and the circumvallate papillae of the tongue inferiorly. Subsites in the oral cavity include
the lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone, hard palate,
and anterior two thirds of the tongue, and floor of mouth. Indications
SOHND is indicated in patients with primary tumors arising from the oral cavity
without clinical or radiologic evidence of cervical metastasis but who have a high
probability of occult lymphatic disease
 
Bilateral SOHND is indicated in patients who have carcinomas of the anterior
tongue or oral tongue and floor of mouth that approach or cross the midline.
SOHND is indicated along with parotidectomy in patients with squamous cell
carcinoma, Merkel cell carcinoma, or selected stage I melanomas (thickness between 1.5
and 3.99mm) in the cheek and zygomatic regions of the face.
   
Selective Neck Dissection: Lateral Type (Levels II-IV)
 
Definition
The lateral type neck dissection refers to the en bloc removal of the jugular lymph
nodes including Levels II-IV.
 
Indications
The primary indications for the lateral type neck dissection include removal of
nodal disease associated with carcinomas arising in the oropharynx, hypopharynx, and
larynx.
The boundaries of the oropharynx are: anteriorly at the junction of the hard and
soft palate and circumvallate papillae of the tongue base, superiorly at an imaginary line
draw from the hard palate to the posterior oropharyngeal wall, and inferiorly at the
pharyngoepiglottic folds. Structures contained in the oropharynx are the tonsils, tonsillar
fossa, tonsillar pillars, tongue base and a portion of the posterior pharyngeal wall.
  The hypopharynx extends from the hyoid bone superiorly to the cricoid cartilage
inferiorly and includes three subsites: the pyriform sinus, the postcricoid region, and the
posterior hypopharyngeal wall.

The supraglottic larynx is bounded superiorly by the valleculae and extends

inferiorly to the apex of the ventricle. It includes the epiglottis, the aryepiglottic folds,
arytenoids, false vocal cords, and the superior aspect of the ventricle.

The boundaries of the larynx include the apex of the ventricle superiorly to a
horizontal plane passing 1 cm below this point and includes the true vocal cords and the
anterior and posterior commissures.

 
Selective Neck Dissection: Posterolateral Type (Levels II-IV, suboccipital and
postauricular)
 
Definition
The posterolateral type neck dissection involves the en bloc excision of lymph
bearing tissues in Levels II-IV and additional node groups including the suboccipital and
postauricular nodes
Indications
This type of neck dissection is primarily used to treat the neck in patients with
cutaneous malignancies (primarily squamous cell carcinoma, melanoma, and other skin
tumors with metastatic potential, such as the Merkel cell carcinomas) and soft tissue
sarcomas.
  
Selective Neck Dissection: Anterior Compartment Type (Level VI)
 
Definition
  The anterior compartment neck dissection involves the en bloc removal of lymph
structures in Level VI. The lymph node groups excised are the perithyroidal nodes,
pretracheal, precricoid (Delphian), and paratracheal nodes located along each recurrent
laryngeal nerve. The superior limit of the dissection is the hyoid bone and the inferior
extent is the suprasternal notch. Laterally the dissection is carried out to the carotid
sheath.
 
Indications

The anterior neck dissection is performed in the following situations: 1)

selected cases of differentiated thyroid carcinoma,
2) parathyroid carcinoma
3) subglottic carcinoma
4) glottic carcinomas with subglottic extension,
5) cervical esophagus.
 Robbins (1998) also recommends this neck dissection in some patients with
hypopharyngeal carcinoma as paratracheal nodes are at high risk for occult disease in
these tumors.

Extended Neck Dissection

 
Definition
Extended neck dissection refers to any of the above listed dissections involving
the removal of additional lymphatic groups or nonlymphatic structures (vascular, neural,
or muscular) beyond what is normally included in that procedure.
 
Indications
Extended neck dissections are usually performed when MRND or RND is
planned for N+ necks. The decision to extend the neck dissection may either be made
preoperatively based on findings on CT or MR or intraoperatively based on findings of
tumor invasion of surrounding structures. The most significant example is when cervical
disease involves the carotid artery. Some authors feel that resection of the carotid artery
is futile because of the poor prognosis of these patients and the significant risk incurred
by undergoing this procedure. Others advocate resection with or without reconstruction
determined by preoperative tolerance to carotid artery balloon occlusion.
Other examples where extended neck dissections are indicated include performing level
VI neck dissection for carcinoma involving the subglottis and removal of retropharyngeal
lymph nodes in one or both sides when the primary tumor originates in the pharyngeal
walls.
CLINICAL APPROACH

COMPLETE MEDICAL HISTORY –

This information reveal important facts regarding the etiology of enlarged lymphnodes.
 Duration
 Exposures: animal exposure
 Associated symptoms: constitutional symptoms
 Past medical history : history of malignancy, drugs, infection

Review symptoms of malignancy

 Hoarseness
 Paraesthesia
 Hemoptysis
 Hematuria
 Occult blood in stool
 Abdominal pain
 Symptoms of skin rash: rubella, measles, syphilis, infectious mononucleosis

Social and family history

 Patients age, occupation,
 Exposure to pets,dietary habits,
 sexual orientation
 physical examination-
 Evaluation of skin ,nose,neck,eyes, ears ,throat.

Check for dental, other oral, pharyngeal or skin causes in the area.
 Clinical examination-
 understanding of head and neck surface anatomy
  Identify the node and its draining area
 Examine the other side of head and neck region.

Clinical Evaluation of the affected lymph node

 Inspection
 Palpation
 Compare with contra lateral side

ASSESS
 Number of lymph node enlarged
 Location

 Degree of enlargement
 Unilateral / bilateral involvement

Tenderness: Tenderness indicates inflammation / infection or both of the adjacent

tissues.
 Tenderness is also a feature of secondary infection within a tumor or a cyst.

Consistency: A normal lymph node, if palpable will be firm in consistency.

 Softer lymph nodes- Infections / inflammation
 Shotty nodes - viral illnesses.
 Suppurant lymph nodes - fluctuant.
 Stony hard nodes - metastatic cancer.
 Very firm, rubbery nodes - lymphoma
 Matted lymph nodes -.tuberculosis
Degree of mobility:
 If the mobility decreases it indicates fixation.
 . Fixity is also a feature of malignancy.
.

Fluctuation:
Lymph nodes may exhibit fluctuations due to pooling in the later stage of inflammation
or infection.
 Acute infection - large, soft, painful, mobile, discrete, rapid onset.
 Chronic infection - large, firm, less tender, mobile
 Lymphoma - rubbery hard, matted, painless, multiple
 Metastatic cancer - Stony hard, fixed to the underlying tissues, painless
 Syphilis (primary) - Firm discrete shotty
 Tuberculosis-
 Stage I: Lymph nodes enlarged without matting
 Stage II: Lymph nodes enlarged with matting
 Stage III: Cold abscess

PALPATION OF THE LYMPHNODES

 Use the pads of all four fingertips
 Examine both sides of the head simultaneously
 Applying steady, gentle pressure
 Evaluated in a systematic fashion
PRE AURICULAR LYMPHNODES
 Stand behind the patient ,Gently tilt the head to the opposite side of node being
palpated ,Roll your finger in front of the ear, against the bone.

POST AURICULAR LYMPHNODES

Stand behind the patient ,Gently tilt the head to the opposite side of node being palpated,
Roll your finger behind the auricle , against the mastoid process.

SUBMANDIBULAR LYMPHNODES
Stand behind the patient ,Gently tilt the head to the same side of node being palpated
,Roll your fingers against inner surface of mandible applying pressure against the bone.

SUBMENTAL LYMPHNODES
Stand behind the patient ,Gently tilt the head in front .Roll your fingers against inner
surface of symphysis applying pressure against the bone.

SUPERFICIAL CERVICAL LYMPHNODES-

Stand behind the patien,Palpate using four fingers above the sternocleidomastoid muscle
using rolling motion

DEEP CERVICAL LYMPHNODES-

They are located deep to the sternocleidomastoid muscle and are often
inaccessible,Palpate by standing behind the patient and hooking thumb and fingers
around either side of the muscle.

POSTERIOR CERVICAL LYMPHNODES

Stand behind the patient ,Palpate along the anterior edge of the trapezius.

SUPRA CLAVICULAR LYMPHNODES

Stand behind the patient and gently with both hands roll fingers behind the clavicle.

CONCLUSION
Lymphatics relate very diversely with the human body and are indicators of
the mildest to the most deadliest of diseases …

Millions die every year following tumor metastasis and through pathologies
related to the lymphatic system.

A thorough knowledge of the lymphatic drainage , and use of the most

modern available investigations can help us trace the diseased nodes and
treat those in most need.

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Bricker.

 Text book of oralmedicine,oral diagnosis and oralradiology –

Ravikiran ongole.

 Chaurasia: human anatomy 4th ed.

 A manual on clinical surgery –s.Das

 Textbook of oral pathology – Shafer 4th edi

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 Mesta Parisi et al.Cervical lymphadenopathy in the dental patient:

A Review of clinical apporoach . Quintessience international.

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Peadiatrics 2002.

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histological appearance of T- zone dysplasia with hyperplastic
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 Sakai o, etal. Radiologic evaluation of the neck: lymphnode

pathology Radiol Clinic North Amer 20oo.

 Recurrent neck disease in oral cancer: Godden et al, JOMS 60: 748-
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 M. Sathiya and K. Muthuchelian, “Significance of Immunologic

Markers in the Diagnosis of Lymphoma” Academic Journal of
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 Long. “Lymphatic Flow in the Head and Neck.” Principles and

Practice of Pediatric Infectious Diseases, 2nd edition. 2003