LYMPHATIC DRAINAGE OF HEAD & NECK | ANATOMY PPT

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LYMPHATIC DRAINAGE OF HEAD & NECK | ANATOMY PPT

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LYMPHATIC DRAINAGE OF HEAD & NECK

 CONTENTS

Introduction

History of lymphatic system

Development of lymphatic system

Lymph

Lymph node

Lymph nodes of head and neck

Examination on neck nodes

Cervical lymphadenopathy

Refrences

INTRODUCTION

Lymphatic system consist of fluid called LYMPH

DEFINITION:Transparent, slightly yellowish liquid of alkaline reaction found in lymphatic vessel and derived from tissue fluid

Lymphatic system is absent in:

-C.N.S.

-Cornea

-Superficial layer of skin

-bones

-alveoli of lung

 

 

HISTORY OF LYMPH DISCOVERY AND LYMPHATIC DRAINAGE

In 1650,John Paquet-cysterna chyli

In 1962,Gaspard Asseli -milky veins

Olauf Rudbeck-first person to describe the lymphatic system

Alexander of winiwater-protocol for draining lymphedenomas

F.D.Millard -diagnostic importance by palpating lymphatic gland

Emil Vodder -technoque of lymphatic dranaige

Brono Chilky-rhythm of lymphatic flow

 

DEVELOPMENT

Starts at 5th week of intrauterine life.

First signs of lymphatic system are seen in the form of a number of endothelium lined lymph sacs

 

 

 

 

SIX PRIMARY LYMPH SACS ARE FORMED.

2 Jugular sacs (right and left)

At the junction of subclavian and anterior cardinal veins.

 

2 iliac sac (right and left)

At the junction of the iliac and posterior cardinal vein.

 

Retroperitonial sac (Unpaired)

Near the root of the mesentery.

 

Cisterna chyli (unpaired)

Dorsal to retroperitonial sac

 

All the sacs except the cisterna chyli are invaded by connective tissue and lymphocytes and are converted into lymph nodes

COMPOSITION OF THE LYMPH

 

Rate of lymph flow:

About 120ml of lymph flows into blood

 

 

Rate of flow of lymph along the human thoracic duct is from 1-1.5ml/min.

Regulation of the lymph flow mainly depends upon :

  • ØInterstitial pressure
  • ØAtrial pulsation
  • ØIntrathorasic pressure
  • ØMuscular massage

 

FORMATION OF LYMPH

Lymph is formed from tissue fluid,anything that increases amount of tissue fluid, will increase the rate of lymph formation

 

Various mechanisms:

  • ØFilteration from plasma normally exceeds resorption leading to net formation of tissue fluid
  • ØIncrease in interstitial fluid hydrostatic pressure favouring the movement of tissue fluid into lymphatic capillary forming lymph

 

FUNCTIONS OF THE LYMPH

Nutritive

Drainage

Transmission of proteins

Absorption of fats

Defensive

LYMPH MOVEMENT

It takes place with the help of:

  • ØContractile skeletal muscle
  • ØPresence of valve
  • ØContraction of smooth muscle in large     lymphatic trunk
  • ØPressure change in muscle during breathing

 

LYMPHATIC PATHWAYS

FLOW CHART

 

Before Lymph is  returned to the blood stream, it passes through at least one lymph node and often through several

The Lymph vessels that carry lymph to a lymph node are referred to as afferent & those that transport it away from a node are called efferent vessels

 

 

 

STRUCTURE OF LYMPH NODE

Lymph nodes are oval-shaped of bean-shaped structures

Some are as small as a pinhead and others as large as a lima bean

Each lymph node is enclosed by a fibrous capsule

Once lymph enters the node, it “percolates” slowly through the spaces known as sinuses before draining into a single efferent  draining vessel.

One-way valves in both the afferent and efferent vessels keep lymph flowing in one direction

 

 

 

Fibrous septa or trabeculae extend from the covering capsule toward the center of the node.

Cortical nodules found within the sinuses along the outer region of the node are separated from each other by these trabeculae.

Each cortical nodule is composed of packed lymphocytes that surround a less dense area called a germinal center.

When an infection is present, germinal centers form and the node begins to release lymphocytes.

 

Lymphocytes begin their final stages of maturation within the germinal center of the nodule and then are pushed to the more densely packed outer layers as they mature to become antibody-producing plasma cells.

The center or medulla of a lymph node is composed of sinuses and cords.

Both the cortical and medullary sinuses are lined with specialized reticuloendothelial cells (fixed macrophages) which are capable of phagocytosis

 

 

LYMPHNODE OF HEAD AND NECK

CLASSIFICATION

Upper horizontal chain of nodes:

Submental

Submandibular

Parotid

Postauricular

Occipital

41

SUBMENTAL NODES

Lie on mylohyoid muscle in the submental triangle

2 to 8 in number

Drainage –afferents come from the chin, middle part of lower lip, anterior gums, anterior floor of mouth and tip of tongue.

Efferents  -they go to submandibular and internal jugular chain

 

 

SUBMANDIBULAR NODES

They lie in submandibular triangle in relation to submandibular gland.

Afferents come from lateral part of the lower lip, upper lip, cheek,nasal vestibule and anterior part of nasal cavity,  gums,teeth medial canthus, soft palate, anterior pillar, anterior part of tongue, submandibular and sublingual salivary glands and floor of mouth

Efferents go to  internal jugular chain

 

 

PAROTID NODES

They lie in relation to the parotid salivary gland.

Afferents come from the scalp,pinna, external auditory canal,face,buccal mucosa.

Efferents go to internal jugular or external jugular chain

 

 

POST AURICULAR NODES

Also called as mastoid nodes

They lie behind the the pinna over the mastoid.

Afferents come from the scalp, posterior surface of pinna and skin of mastoid.

Efferents drain into internal jugular chain

 

 

OCCIPITAL NODES

They lie at the apex of the posterior triangle

Afferents come from scalp, skin of upper neck.

Efferents drain into upper accessory chain of nodes

 

 

 

Lateral cervical nodes

They include nodes, superficial and deep to sternocleidomastoid muscle and in the posterior triangle.

Superficial external jugular group

Deep group

i. Internal jugular chain (upper,middle and lower groups)

ii. Spinal accessory chain

iii. Transverse cervical chain

 

 

LATERAL CERVICAL NODES

a) Superficial group – it lies along external jugular vein and drains into internal jugular and transverse cervical nodes

 

b)Deep group

It consists of three chains, the internal jugular, spinal accessory and transverse cervical

 

 

Internal jugular chain

Lymph nodes of internal jugular chain lie anterior, lateral and posterior to internal jugular vein.

Upper group (jugulodigastric node) – drains oral cavity, orpharynx, nasopharynx,hypopharynx, larynx and parotid.

Middle group drains hypopharynx, larynx, throid, oral cavity, oropharynx.

Lower jugular group drains larynx, thyroid and cervical oesophagus

 

Spinal accessory  chain

Lies along the spinal accessory nerve. Spinal accessory chain drains the scalp, skin of the neck, the nasopharynx, occipital and postauricular nodes.

Efferents from this chain drain into transverse cervical chain

 

Transverse cervical chain (supraclavicular nodes)

It lies horizontally, along the trasverse cervical vessels, in thelower part of the posterior triangle.

The medial nodes of the group are called scalene nodes.

Afferents to those nodes come from the accessory chain and also infraclavicular structures,e.g. breast, lung, stomach, colon, ovary and testis

 

 

 

Anterior cervical nodes

Anterior jugular chain

Juxtavisceral chain

i. Prelaryngeal

ii. Pretracheal

iii. Paratracheal

 

 

ANTERIOR CERVICAL NODES

They lie between the two carotids and below the level of hyoid bone and consist of two chains:

(a) Anterior jugular chian

It lies along anterior jugular vein and drains the skin of anterior neck.

(b) Juxtavisceral chain

It consists of prelaryngeal,pretracheal and paratracheal nodes

•      Prelaryngeal node (Delphian node)-lies on cricothyroid membrane and drains subgottic region of larynx and pyriform sinuses

•      Pretracheal nodes lie in front of the trachea, and drain thyroid gland and the trachea.Efferents from these nodes go to paratracheal, lower internal jugular and anterior mediastinal nodes

•      Paratracheal Nodes – drain the thyroid lobes, subglottic larynx, tracha and cervical oesophagus

 

 

40

 

CLASSIFICATION OF NECK NODES ACCORDING TO LEVELS

Level I

Submental (IA)

Submandibular (IB)

Level II

Upper jugular

Level III

middle jugular

Level IV

Lower jugular

Level V

Posterior triangle group(Spinal accessory and transverse cervical chains)

Level VI

Prelaryngeal

Pretracheal

Paratracheal

Level VII

Nodes of upper mediastinum

 

 

 

Level I  includes :

IA Submental nodes, which lie in the submental triangle i.e. between  right  and  left  anterior bellies of diagastric muscles  and  the  hyoid bone.

IB Submandibular ones, lying  between anterior and  posterior bellies of diagastric muscle and the body of  mandible

 

 

 

 

 

Level II – Upper Jugular Nodes

They are located along the upper third of jugular vein I.e. between the skull base above, and the level of hyoid bone (or bifurcation of carotid artery) below

 

 

 

Level III – Middle Jugular Nodes

They are located along the middle third of jugular vein, from the level of hyoid bone above, to the level of upper border of cricoid cartilage

 

 

 

Level IV – Lower Jugular Nodes

They are located along the lower third of jugular vein; from upper border of cricoid cartilage to the clavicle

 

 

 

Level V – Posterior Cervical Group

They are located in the posterior triangle i.e. between posterior border of sternocleidomastoid(anteriorly), anterior border of trapezius (posteriorly), and the clavicle below. They include lymph nodes of spinal accessary chain,transverse cervical nodes and supraclavicular nodes

 

 

 

Level VI – Anterior Compartment Nodes

They are located between the medial borders of sternocleidomastoid muscles (or carotid sheaths) on each side, hyoid bone above and superasternal notch below. They include prelaryngeal,pretracheal, paratracheal nodes

 

 

 

Level VII

They are located below the suprasternal notch and include nodes of the upper mediastinum

EXAMINATION OF NECK NODES

Examination of neck nodes is important, particularly in head and neck malignancies and a systematic approach should be followed.

Neck nodes are better palpated while standing at the back of the patient.

Neck is slightly flexed to achieve relaxation of muscles

 

 

 

When a node or nodes are palpable, look for the following points:

(i) Location of nodes

(ii) Number of nodes

(iii) Size – Abnormal Nodes

Greater than 1.5 c.m. in jugulo digastric area (level 1,2,3)

Greater than 1 c.m. elsewhere.

(iv) Consistency. Metastatic nodes are hard;lymphoma nodes are    firm  and rubbery; hyperplastic nodes are soft. Nodes of metastatic melanoma are also soft.

(v) Discrete or matted nodes.

(vi) Tenderness. Inflammatory nodes are tender.

(vii) Fixity to overlying skin or deeper structures. Mobility  should be  checked both in the vertical and horizontal planes

 

The nodes are examined in the following manner so that none is missed.

a) Upper horizontal chain.

b) External jugular chain

c) Internal jugular chain

d) Spinal accessory chain

e) Transverse cervical chain

f) Anterior jugular chain

g) Juxtavisceral chain

 

Submental Nodes

Roll the fingers below the chin with patient’s head tilted forwards

 

Submandibular Nodes

Roll your fingers against inner surface of Mandible with patient’s head gently tilted towards one side

 

Parotid (Preauricular) Nodes

Roll your finger in front of the ear, against the maxilla

 

Post auricular (Mastoid Nodes)

Roll the fingers behind the ear

 

Occipital Nodes

 

Internal jugular chain

Examine the upper, middle and lower groups. Many of them lie deep to sternomastoid muscle which may need to be displaced posteriorly

 

Transverse Cervical  Nodes

Supraclavicular (Scalene Nodes)

Roll your fingers gently behind the clavicles. Instruct the patient to cough or to bear down like they are having a bowel movement. Occasionally an enlarged lymph node may pop up

CERVICAL LYMPHADENOPATHY

 
LYMPHADENITIS AND LYMPHADENOPATHY

Lymphadenitis is an infection in the lymph nodes. Lymph nodes are glands that are part of the immune system. They help the body fight infection by filtering germs. They become enlarged when infection is present.

Lymphadenopathy is usually a normal response of the lymph nodes to an infection elsewhere in the body.

 

Cervical lymphadenopathy may be either an important clue to an underlying disease process or a specific clinical syndrome

CAUSES OF LYMPHADENOPATHY

1.Infectious disease

A.Viral

-Infectious mononucleosis

-Infectious hepatitis

-Herpes simplex

-Rubella

-Measle

-Hiv

B.Bacterial

-Cat scratch disease

-Brucellosis

-Tuberculosis

-Atypical mycobacterial infection

-Primary and secondary syphilis

-Diptheria

C. Fungal

-Histoplasmosis

-Coccidioidomycosis

D.Parasitic

-Toxoplasmosis

-Filiriasis

E.Chlamydial

-Lymphogranuloma venerum

– Trachoma

 

2.Immunologic disease

A.Rheumatoid arthritis

B.Systemic lupus erythematous

C.Sjogren syndrome

D.Drug hypersensitivity

E.Mixed connective tissue disease

 

3.Malignant disease

a.Hematological

-Hodgkin disease

-Non hodgkin disease

-Hairy cell leukamia

-T-cell lymphoma

-Multiple myeloma

B.Metastasis

-From primary site

 

 

 

4.Lipid storage disease

-Gaucher’s disease

-niemann-pick disease

 

5.Endocrine disease

-Hyperthyroidism

-Adrenal insufficiency

-Thyroiditis

 

6.Other disorder

-Sarcoidosis

-Lymphomatoid granulomatosis

-Kawasaki disease

-Histocytosis x

-Kikuchi disease

CLINICAL EVALUTION

1.Location

A.Anatomical site

B.Presence of single or multiple nodes

C.Presence of localized or disseminated nodes

D.Palpable nodes are unilateral or bilateral

2.Consistency

A.Firm

B.Soft

C.Rubbery

D.Rock hard

E.Movable

F.Fixed

3.Size

A.<1 cm or >1cm

B.If nodes are bilateral,check for symmetry

4.Symptoms

A.Symptomatic

B.Tender

C.Painful

D.Associated with systemic symptoms or not

 

Structures that can be mistaken for enlarged lymph nodes include cystic hygromas, branchial cleft cysts, thyroglossal duct cysts, dental abscesses, dermoid cysts, and tumors of thyroid or neural tissue

CLINICAL STAGING OF CERVICAL NODE

Nx : Regional LN cannot be assessed

 

No :no regional LN metastasis

 

N1 :metastasis in a single ipsilateral LN

<3cm In greatest dimension

 

N2a :metastsis in single ipsilateral LN

>3cm but <6cm in greatest dimension

 

N2b :metastasis in the multiple ipsilateral LN

>6cm in greatest dimension

 

N2c :metastasis in a  bilateral or contralateral LN

none >6 cm  in greatest dimension

 

N3  :metastasis in lymphnode

>6cm In greatest dimensiom

SYMPTOMS

 

Tenderness, redness or warmth in the area of the lymph node

Fever

Lymph node enlargement

Difficulty in swallowing or breathing

 

TREATMENT

Acetaminophen or ibuprofen may be given for pain

Antibiotics if the cause is due to bacteria. Viral infections do not need antibiotics.

Referral to a dentist if a tooth is abscessed

 

Antibiotic Therapy of Cervical
Lymphadenopathy

Suspected Staphylococcus aureus or Group A Beta-hemolytic Streptococcus Infection

For children who do not appear toxic and have no apparent abscess or cellulitis, Oral empiric therapy with cephalexin, oxacillin, or clindamycin

For ill-appearing children who have abscess formation or cellulitis,node aspiration and intravenous therapy with cefazolin, nafcillin or oxacillin, or clindamycin

Suspected Infection With Anaerobic Bacteria

For children who have cervical lymphadenitis associated with periodontal disease, node aspiration and therapy with penicillin or clindamycin

 

Suspected Nontuberculous Mycobacteria Infection

Surgical excision of the infected lymph node without antibiotic therapy

For patients in whom surgery is not feasible, a macrolide-containing multidrug antimycobacterial regimen

Cat-scratch Disease

Following needle aspiration and PCR diagnosis of Bartonella infection, no antimicrobial therapy in patients who have uncomplicated lymphadenopathy.

Surgical removal of nodes  infected with Bartonella frequently results in persistent drainage and poor wound healing. Repeated node aspiration for management of suppurative lymphadenopathy caused by Bartonella infection

REFERENCES

C.J.Romanes Cunnighams manual of practical anatomy 15th edition

I.B.SinghText book of anatomy 3rd edition

Singh,Pal.Human embryology 7th edition

B D Chaurasia.Human Anatomy 4th edition vol3

Anand.Human Anatomy for Dental Students 1st edition

Anil Ghom.Textbook of Oral Medicine 1st edition

Shafer.Textbook of Oral Pathology 5th edition

Infectitious diseases Cervical Lymphadenopathy Pediatrics in Review Vol. 21 No. 12 December 2000

 

THANK YOU

 

 

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