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LYMPHATIC DRAINAGE OF HEAD & NECK
History of lymphatic system
Examination on neck nodes
DEFINITION:Transparent, slightly yellowish liquid of alkaline reaction found in lymphatic vessel and derived from tissue fluid
Lymphatic system is absent in:
-Superficial layer of skin
-alveoli of lung
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
Emil Vodder -technoque of lymphatic dranaige
Brono Chilky-rhythm of lymphatic flow
Starts at 5th week of intrauterine life.
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
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
- 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
Transmission of proteins
Absorption of fats
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
STRUCTURE OF LYMPH NODE
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
Upper horizontal chain of 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
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
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
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
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
It consists of three chains, the internal jugular, spinal accessory and transverse cervical
Internal jugular chain
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
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.
Anterior cervical nodes
Anterior jugular chain
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
CLASSIFICATION OF NECK NODES ACCORDING TO LEVELS
Posterior triangle group(Spinal accessory and transverse cervical chains)
Nodes of upper mediastinum
Level I includes :
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
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.
(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
Roll the fingers below the chin with patient’s head tilted forwards
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
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
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.
Cervical lymphadenopathy may be either an important clue to an underlying disease process or a specific clinical syndrome
CAUSES OF LYMPHADENOPATHY
-Cat scratch disease
-Atypical mycobacterial infection
-Primary and secondary syphilis
B.Systemic lupus erythematous
E.Mixed connective tissue disease
-Non hodgkin disease
-Hairy cell leukamia
-From primary site
4.Lipid storage disease
B.Presence of single or multiple nodes
C.Presence of localized or disseminated nodes
D.Palpable nodes are unilateral or bilateral
A.<1 cm or >1cm
B.If nodes are bilateral,check for symmetry
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
Tenderness, redness or warmth in the area of the lymph node
Lymph node enlargement
Difficulty in swallowing or breathing
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
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
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
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