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INDIAN DENTAL ACADEMY

Leader in continuing dental education
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LYMPHATIC &
VENOUS SYSTEM
OF HEAD AND NECK
Moderator
Dr David Tauro
Presenter
Dr Mahantesh.S
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 Development of
lymphatic system
 Lymph fluid
 Lymph node
 Lymphatic vessels
 Functions of
lymphatic system
Classification
Diagnosis of
Lymphadenopathy
Conclusion
 References
CONTENTS
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WHY LYMPHATIC
SYSTEM
?
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LYMPHATIC SYSTEM
 This system was
described after the
other parts of vascular
system are already
known.
 The reason for this
delay is their delicate
and transparent
appearance.
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EMBRY0LOGY OF
LYMPHATIC SYSTEM
 Lymph sacs -appear between 2
nd
to 6
th

week of IUL.
 7
th
week -jugular channel spread to
connect with subclavin lymph sacs.
 9
th
week - thoracic duct is continuous
channel draining into IJ -subclavin vein
junction.
 12
th
week- all process are complete.
 5
th
month -valves begins to start.
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DEVELOPMENT OF LYMPH NODE
 Jugular, lymph
saccules and
Peritoneal lymph
saccules
 Invasion of
neighboring
Mesenchymal cells
so called lymph
sinuses evolve intra
nodally.
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Primary /
central
Thymus and
bone marrow
Secondary /
peripheral
Spleen, tonsil and
lymph node
contents
Cells,
Organs
Vessel
Lymph fluid .
LYMPHATIC SYSTEM
lymphoid organ
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LYMPH FLUID
CONTENTS
•Proteins
•Fats
•Cells
•Interstitial fluid
Definition
Transparent,colorless,or slightly yellow
watery fluid with specific gravity of 1.015.
Same as blood plasma but more dilute
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Lymph Fluid
Peripheral
Intermediate
Central
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FORMATION OF LYMPH FLUID
 FORMATION
- Diffusion
- Osmosis
Terminal capillaries in
the Interstitium
 0.003ml/100kg/min
tissues
 2-3liters/day
produced
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FACTORS AFFECTING THE
LYMPH FORMATION
 Environmental temperature
 Body movement
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VELOCITY OF LYMPH FLOW
 Depends on
– Intrinsic Factors
– Extrinsic Factors
 Velocity is generally 3.1cm /min
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INTRINSIC
EXTRINSIC
Intraluminal pressure
Lymphatic pump
Interstial pressure

Movement

Muscular
Arterial
respiration
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Conditions where lymph
production increase
(pathologically)
 Inflammation
 Venous stasis
 Mechanical insufficiency of vessels and
valves
 Drugs –Serotonin,Prostaglandins,TXA2,
Nor-adrenaline
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 These are the raison d,etre of the
lymphatic system
 Local aggregation of lymphoid tissue.
 Lympha  colorless – yellow fluid
(lymphocytes)
 Nodus knot
LYMPH NODE
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 800 L nodes in body
 300 are present in head
and neck
 1
st
defense station of
the body.
 Localized mainly in fatty
tissues & interposed
between lymphatic flow
LYMPH NODE
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SHAPE OF LYMPH NODE
 Inguinal lymph nodes – large and round
 Outer iliac lymph nodes – longish mass
 Inner iliac lymph node – small and round
 Head and neck lymph node- oval or
kidney or spindle shaped
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 Size
– 1- 30 um in diameter this depends
mainly on primary function

 Absorption -0.07ml/l node

LYMPH NODE
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CELL ZONES
Zone 1
Extreme periphery
Loosely packed cells
lymphocytes,
macrophages
Zone 2
More densely packed
small lymphocytes and
macrophages
Zone 3.
Germinal center
Large lymphoblasts
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STRUCTURAL CHANGES:
–Expansion of B and T lymphocytes
–Cortical region enlargement
–Increase in no of macrophages in sinus ,
medullary sinus
FUNCTIONAL CHANGES
 Reduced filtering capacity
 Immune cells No. increase

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FUNCTION OF LYMPH NODE
 Biologic filtering
 Production of lymphocytes in context
of immune reactions.
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1. Biologic filtering

Capsule







Hilus
Afferent vessels
Marginal sinus
Marginal Zones
Medullary cords
Medullary sinus
Efferent vessels
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2.Immune reaction
Antigen  Margninal sinus
Bound to Macrophages & Reticular cells
Adjacent T-helper cells  Present Ag to Immunocompetent
lymphocytes -- Mantle zone ( B-Lymphocytes)
Activated B cells
Immunoblast

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IMMUNOBLAST
Move towards germinal centre
Immunocytes & Plasma
cells
Differentiate
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5-7 days, Plasma cells  Medullary cords  Ab into the
medulla
Para cortical zone (T-lymphocytes)
Helper T cells
Suppressor T cells
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LYMPHATIC VESSELS
 Anatomically similar to veins
 Are thin-walled , serve as drainage
channels
 Initially lymph vessels are Finger-shaped
and blind.
 they drain intercellular spaces and serous
sacs.
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LYMPHATIC VESSELS
 Abundant interlacing anastomoses
 Interruption of the continuity by lymph
nodes.
 Drainage channels from many parts not
drained by the venous system

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LYMPHATIC VESSELS
 Wide vascular lumen. 30-50um .
 Lymph capillaries dose not contains valves.
valves are there in valvular precollectors .
 Diameter larger than 10um only can spread
or metastasis can take place.
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STRUCTURE OF LYMPHATIC
VESSEL
Initial lymph vessel Lymphatic collectors
Endothelial cells that
are
Surrounded by an
incomplete and
interrupted basal
membrane
These cells overlap
like roof tiles
Intima consists of endothelial cells
Collagen fibers and single muscle cells.
Media contains bundles of smooth
muscles surrounded By collagen fibers.
Adventitia –longitudinal bundles of
connective tissue,elastic fibers&
Single smooth muscle cells

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FUNCTIONS OF ENDOTHELIAL
CELLS
 Intense protein
synthesis
 Increase cellular
transportation
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VALVES
 Except initial lymphatic sinus or capillaries
every lymph vessels has valves.
 Valves may be
– Bicuspid
– Tricuspid
– Quadricuspid
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FUNCTIONS OF LYMPH
VESSELS
 Transitional function of fluid between
intercellular spaces and veins.
 Immunity
 Fats and proteins
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LYMPHATIC SYSTEM OF
HEAD AND NECK REGION
 LS of aero digestive mucosa consists of
 Narrow –meshed ,superficial vascular
system
 Wide – meshed ,deeply situated vascular
system
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LYMPHATIC DRAINAGE OF HEAD
AND NECK
DEEP
CERVICAL
Surrounds IJV
Spinal Accessory
Base of skull- Neck
SUPERFICIAL
CERVICAL
Outer circle (Pericervical
collar)
Inner circle (upper part of
respiratory and alimentary
passages)
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SUPERFICIAL CERVICAL NODES (Inner circle)
Pre-laryngeal Deep cervical
fascia(beneath)
Anterior
cervical nodes
Deep cervical
nodes
Pre-tracheal

Para-tracheal
Trachea

Oesophagus
and trachea
Larynx,trachea
,oesophagus
and thyroid
gland
Deep cervical
nodes
Retro-
pharyngeal
Retro-
pharyngeal
space
Pharynx,
palatine
tonsil,sphenoid
sinus
Upper deep
cervical nodes
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DEEP CERVICAL LYMPH NODES
Jugulo-
digastric
nodes
Triangular
region(digastr
ic, facial vein
and IJV)
Palatine tonsil
and
tongue(post.1/
3
rd
)
Upper deep
cervicaljugu
lar trunk
Jugulo-
omohyoid
nodes
On IJV above
intermediate
tendon of
omohyoid
Tongue,sub-
mental,sub-
mandibular
and upper deep
cervical
Jugular lymph
trunk
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SUB-MANDIBULAR
UPPER DEEP CERVICAL CHAIN OF NODES
SUB-MENTAL
3rd Molars
Tongue (base)
Tonsillar area
Soft palate
PAROTID NODES
LOWER DEEP CERVICAL CHAIN OF NODES
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LOWER DEEP CERVICAL
Left lower body
(bilaterally)
THORACIC DUCT
Right Brachiocephalic vein
Right upper body
RIGHT LYMPHATIC
DUCT
Left Brachiocephalic vein
Subclavian vein
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Levels of Lymph nodes (SLOAN –
KETTERING CANCER CENTER, NY)


I
II
III
IV
VI
v
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CLINICAL CONSIDERATIONS
 Normal lymph nodes not palpable
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LYMPHADENOPATHY
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EXAMINATION
 How long swelling has been present?

 Is it painful ?

 Does it vary with size?
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GENERAL PRINCIPLES
Inspection
Palpation
Compare with contra lateral side.
Site
Size
Consistency
Tenderness
Fixation
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 Stony hard  Metastatic cancer
 Firm, Rubbery  Lymphoma
 Soft  Infection Inflammatory
 Shotty  Viral infection
Consistency/Texture

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PALPABLE LYMPHNODES AND PROBABLE
ASSOCIATED CONDITIONS
 Tender, Mobile, enlarged  Acute infection
 Non-tender, Mobile, Enlarged  Chronic
infection
 Matted, Non tender  Tuberculosis
 Fixed, Enlarged  Carcinoma
 Rubbery, Enlarged  Lymphomas
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Benign
TB
Sarcoidosis
Lymphogranuloma
venereum

Malignant
Metastatic carcinoma
Lymphomas
Matted:-
Group of nodes – Connected – as a unit

Benign / Malignant
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Key Points in Diagnosing
Lymphadenopathy
 In the absence of obvious infection consider it
as metastatic tumor until otherwise proven.
 FNAC - useful investigation.
 Open biopsy- recurrence, survival, further
examination is difficult, fungation. nerve
damage may occur.
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 <16yrsinfection,congenital, neoplasia.

 16-40yrs- inflammation, neoplasia

 >40yrs- neoplastic.
AGE
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Classification
Generalised
2 or more non contiguous area
Localised
Involve one area
CERVICAL
LYMPHADENOPATHY
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 Local
- Infection-dental infections, tonsillitis, skin sepsis,
TB node.
- Neoplasia-lymphoma or metastatic.
- General
URTI, infectious mononucleosis, toxoplasmosis,
cat-scratch fever, HIV
- Sarcodosis, Hodgkin's and non-Hodgkin's
lymphoma.
- Congenital- cystic hygroma.
CAUSES FOR CERVICAL
LYMPHADENOPATHY
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CONCLUSION
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REFERENCES
 Text book of surgical anatomy – Mag Craker
 Text book of general anatomy 39
th
ed – Grants
 Clinical oriented anatomy –Moore
 Head &neck emergencys-Mike parry
 Text book of head &neck anatomy 2
nd
ed –
Holleinsheid
 Atlas of general histology – De Floire
 Text book of Human histology- Inderbir Singh
 Metastases of head and neck – R. Kim Davis
 Text book medicine-Davidson www.indiandentalacademy.com
Thank
you

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CLINICAL STAGING
 Scan and attach
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