LYMPHATIC DRAINAGE OF HEAD AND NECK

PRESENTED BY DR RUDRA DEO KUMAR

EMBRYOLOGICAL DEVELOPMENT

• The lymphatic system begins to develop at the end of week 5, approximately 2 weeks later than the cardiovascular system

• In week 6-9 local dilatations of the lymphatic channels and formation of 6 primary lymph sac occurs

Two jugular lymph sacs near the junction of the subclavian veins with the anterior cardinals(future internal jugular vein) Two iliac lymph sacs near the junction of iliac veins with the

posterior cardinal veins One retroperitonial lymph sac in the root of the mesentry on

the posterior abdominal wall One cysterna chyli dorsal to the retroperitoneal lymph sac, at

the level of the adrenal glands

Lymph vessel development

• It grows from the lymph sacs, along the major veins• the head, neck and arms from jugular sacs• the lower trunk and legs from the iliac sacs• the gut from the retroperitoneal and

cisternal sacs

TOPICS

• EMBRYOLOGY• FUNCTIONS OF LYMPHATIC SYSTEM• COMPONENTS OF LYMPHATIC SYSTEM• LYMPH NODES OF HEAD AND NECK• LYMPHADENOPATHY• APPLIED

• The cysterna chyli is connected to the jugular lymph sacs by 2 large channels, the right and left thoracic ducts• An anastomosis forms between the 2 ducts, thus the definitive thoracic duct is formed by the caudal portion of the right thoracic duct, the anastomosis, and the cranial portion of the left thoracic duct

• The right lymphatic duct is derived from the cranial part of the right thoracic duct

• Both right and left thoracic ducts join the venous system at the angle of the subclavian and internal jugular veins at the base of the neck

LYMPH NODE DEVELOPMENT• Lymph node development, at about 3 month

• Except for the anterior part of the sac that produces the cisterna chyli, all lymphatic capillary plexus become invaded by mesenchymal cells that proliferate and aggregate to form group of lymph nodes

• The lymph nodules and germinal centers of lymphocyte production do not appear in the nodes until just before or after birth

FUNCTIONS OF LYMPHATIC SYSTEM

• Transport of tissue fluid formed in the capillary bed

• The removal of cell debris and foreign matter (e.g. bacteria) by mononuclear phagocytic series cells

• Prevention of bacterial and foreign material from entering the blood stream

• Production of lymphocytes and control of the immune responses.

• Digested fat are absorbed and then transported from the villi in the small intestine to the bloodstream via the lacteals and lymph vessel

COMPONENTS OF LYMPHATIC SYSTEM

• Lymph , the recovered fluid• Lymphatic vessels, which transport the lymph• Lymphatic tissue, composed of aggregates of

lymphocytes and macrophage that populate many organs of body• Lymphatic organs, in which these cells are especially

concentrated and which are set off from surrounding organs by connective tissue capsule

LYMPH• Lymph means clear water and it is basically the colorless fluid and

protein that has been squeezed out of the blood.

• Fluid similar in composition to blood plasma.

• ISF forms at the arterial (coming from the heart) end of the capillaries because of higher pressure of blood

Fluid leaves capillaries by diffusion and filtration

• Most of it returns to its venous ends and venules; the rest (10—20%) enters the lymph capillaries as lymph

• proteins escaped• If lymph flow blocked = tissue swelling or edema

• Specialized lymphatic capillaries in villi of small intestine transport lipids - they are called LACTEALS, and the fluid is called CHYLE.• As it flows through the lymph nodes, however, it comes in

contact with blood and tends to accumulate more cells (particularly lymphocytes) and proteins

• Capillary networks collect the lymph in the various organs and tissues

• Collecting vessels which conduct the lymph from the capillaries to the large veins of the neck at the junction of the internal jugular and subclavian veins, where the lymph is poured into the blood stream

• Lymph nodes which are interspaced in the pathways of the collecting vessels filtering the lymph as it passes through them and contributing lymphocytes to it

LYMPHATIC TISSUE

• The lymphatic capillaries and collecting vessels are lined throughout by a continuous layer of endothelial cells, forming a closed system• The capillary plexuses are often in two layers:• A superficial and a deep• The superficial being of smaller caliber than the deep. • The capillaries are without valves

LYMPH VESSELS

• Delicate• Knotted/beaded appearance.• Valves are present, formed by overlap and are

opened by pressure of interstitial fluid• Valves are formed of thin layer of fibrous tissue

covered on both surfaces by endothelium.• Valves are most numerous near glands & more in

neck region.

Lymph node

• Bean shaped, with the concavity forming the hilum

• Covered by a connective tissue capsule, which extends inside the lymph node to form trabeculae • OUTER CORTEX and INNER MEDULLA• Lymphocytes are tightly packed as follicles in the cortex, which become germinal

centres once challenged by an antigen. • They are arranged in medullary cords in the medulla.

• Lymph enters the convex side of the lymph node through multiple afferent lymphatic vessels, while the efferent vessel leaves the node at the hilum.

LYMPH NODES OF HEAD AND NECK

LYMPH NODES OF HEAD AND NECK

SUPERFICIAL CERVICAL NODES OF FACE

a) Parotid

b) Submandibular

c) Submental

Parotid Lymph Nodes

a) PAROTID NODES

• Parotid gland• Skin of temporal region• Lateral part of forehead• Lateral part of eyelids• Posterior part of cheek• Part of outer ear

Submandibular Lymph Nodes

(b) Submandibular Nodes

• Central part of forehead• Nose• Sinuses (frontal, maxillary & ethmoid)• Inner canthus of eye• Upper lip & anterior part of cheek with underlying gums

and teeth• Outer part of lower lip with underlying gums and teeth• Anterior 2/3 of tongue excluding tip• Floor of mouth• Anterior part of hard palate

Submental Lymph Nodes

(c) Submental Nodes

• Middle part of lower lip• Skin of chin• Tip of tongue• Anterior Part of floor of mouth• Lower incisors and adjacent gums

Occipital nodes

Retroauricular (mastoid) nodes

Buccal (facial) nodes

Superficial cervical nodes

Retropharyngeal Lymph Nodes

Drains :• Nasopharynx• Posterior nasal cavity• Paranasal sinuses• Posterior oropharynx• Hypopharynx

Pretracheal Lymph Nodes

Drain Lower larynx Hypopharynx Cervical esophagus Upper trachea Thyroid

Spinal accessory Lymph Nodes

Drain :

Scalp (parietal & occipital region Nape of neck Upper retropharyngeal Parapharyngeal nodes

DEEP CERVICAL LYMPH NODE(SUPERIOR JUGULAR)Primary drainage sites• Soft palate• Tongue(Post. & base)• Tonsils• Supraglottic larynx• Pyriform sinus

Secondary drainage sites• Parotid node• Submandibular• Retropharyngeal• Spinal accessory• Superficial cervical

MIDDLE JUGULAR

Primary drainage sites• Supraglottic larynx• Lower pyriform sinus• Post. Cricoid area

Secondary drainage sites• Superior jugular• Lower retropharyngeal

INFERIOR JUGULAR

Primary drainage sites• Trachea• Thyroid• Cervical esophagus

Secondary drainge sites• Superior jugular• Middle jugular• Paratracheal

Waldeyer’s Lymphatic Ring

• Posterior part of mouth and pharynx contains an accumulation of lymphatic tissues-

Pharyngeal tonsil

Palatine tonsil

Lingual tonsil

Tubal tonsil

• The ring collects lymphatics and drains into retropharyngeal nodes→jugulo-digastric lymph nodes.

NASOPHARYNGEAL TONSIL

• ‘the adenoids’•consists of a collection of lymphoid tissue beneath the epithelium of the roof and posterior wall of this region.

THE PALATINE TONSILS

• lies in the tonsillar fossa between the palatoglossal and palatopharyngeal arches.• The floor of tonsillar fossa is formed by superior

constrictor of the pharynx separated from the tonsil by the tonsillar capsule.• From late puberty onwards this lymphoid tissue

undergoes progressive atrophy.• Lymph drainage is via lymphatics that pierce the

superior constrictor muscle and pass to jugulodigastric node.• Affected in tonsillitis.

LYMPHATIC DRAINAGE OF TONGUE Tip

Submental nodes

Anterior 2/3 lateral borderIpsilateral Submandibular node

ANTERIOR 2/3 CENTRALLYSubmandibular nodes on both sides

Posterior 1/3 Jugulo-omohyoid nodes

FINAL NODES TO BE INVOLVED ARE Jugulo-omohyoid and deep cervical nodes

LEVELS OF CERVICAL LYMPH NODES

TNM CLASSIFICATION OF REGIONAL NODENx - nodes can not be assessedN0 – No lymph node metastasisN1 – metastasis in single ipsilateral node 3cm or less.N2a – single ipsilateral node >3cm but <6cmN2b – multiple ipsilateral nodes <6cmN2c – bilateral / contralateral nodes <6cmN3 – metastasis in node >6cm

Evaluation of neck for cervical metastasis

PHYSICAL EXAMINATION

Classic method for patients with tumors in the head and neck.

The single most important factor in determining prognosis is whether nodal metastasis is present

Survival rates decrease by 50% when nodal metastases are present.

Presence of cervical adenopathy has been correlated with an increase in the rate of distant metastasis

LYMPHADENOPATHY

• Enlargement of lymph nodes• Soft , flat submandibular nodes ( 1 cm) are often

palpable in healthy children and young adults• Classifies into• Generalised lymphadenopathy• Localised or regional lymphadenopathy

GENERALISED LYMPHADENOPATHY• Frequently associated with nonmalignant disorders

such as • Infective mononucleosis,EBV, CMV,AIDS ,SLE• Mixed connective tissue disease• Acute and chronic lymphocytic leukemias and

malignant lymphomas also produce generalised adenopathy in adults

Localized or regional lymphadenopathy• Involvement of single anatomic area• Site of adenopathy may provide useful clue about

the cause• Eg . Occipital adenopathy reflects an infection of

scalp, preauricular adenopathy accompanies conjuctival infections and cat scratch disease

CLINICAL ASSESSMENT

• Careful medical history• Physical examination• Laboratory tests• An excisional lymph node biopsy

MEDICAL HISTORY

• Symptoms such as sore throat, cough ,fever, night sweats, fatigue , weight loss or pain in the nodes should be sought• Patient, age, sex, occupation, exposure to pets , use of

drugs are important• Children and young adults usually have benign disorders

that account for the observed lymphadenopathy ex. Viral or bacterial URI infections • After age 50, incidence of malignant disorders increase

and that of benign disorders decreases

EVALUATION

Neck should be carefully palpated, with specific attention to location, size, firmness, and mobility of each node.

Direct attention should be given to nodes that appear fixed to underlying neurovascular structures or visceral organs or that demonstrate skin infiltration

Clinical palpation of the neck demonstrates a large variation of findings among various examiners

Following characteristics should be noted and described:

Size Pain / tenderness Consistency Matting Location

SIZE:

Nodes are generally considered to be normal if they are up to 1 cm in diameter.Nodes < 1 cm sq are almost always secondary to benign , nonspecific reactive causesDiameter > 2 cm sq reveals great chance of malignant or granulomatous disease

PAIN / TENDERNESS

- When a lymph node rapidly increases in size, its capsule stretches and causes pain.

- Pain is usually the result of an inflammatory process or suppuration, but may also result from hemorrhage into the necrotic center of a malignant node.

- The presence or absence of tenderness does not reliably differentiate benign from malignant nodes.

CONSISTENCYStony-hard nodes are typically a sign of malignancy, usually metastatic.

Very firm, rubbery nodes suggest lymphoma.

Softer nodes are the result of infections or inflammatory conditions.

Suppurative nodes may be fluctuant.

LOCATION

• The anatomic location is sometimes helpful in narrowing the differential diagnosis

MATTING

A group of nodes that feels connected and seems to move as a unit is said to be "matted."

Nodes that are matted can be either :

Benign (e.g., tuberculosis, sarcoidosis or lymphogranuloma venereum) Malignant (e.g., metastatic carcinoma or lymphomas)

TEXTURE

• Lymph node described as soft, firm, rubbery, hard, discrete, matted

On palpation

• Stony hard- carcinoma• Rubbery – hodgkin lymphoma• Cystic/soft- cold abscess• Matted – tuberculosis• Firm - syphilis

Palpation of lymph nodes

• Lymph node and chain palpation starts with parotid and preauricular area which may also be palpated bimanually• Palpating with light finger pressure against underlying firm

tissues(bone or muscle) or bimanually• Head and neck lymph examination continues down the

mandible to the submandibular region ,palpation proceeds forward to the submental nodes

LABORATORY INVESTIGATION

• Complete blood count ,CBC provide useful data for diagnosis of disease ex. Leukemias, EVB or CMV mononucleosis , lymphomas ,SLE • SEROLOGICAL STUDIES – Antibodies specific to EVB, CMV ,HIV Brucella Toxoplasma gondii SLECHEST XRAYPresence of a pulmonary infiltrate or mediastinal lymphadenopathy suggest tuberculosis, histoplasmosis, sarcoidosis, lung cancer or metastatic cancer

• FNAC• Should be performed as the first diagnostic

procedure

• Lymph node biopsy• Prompt biopsy should occur if the patient’s history

and physical findings suggest a malignancy

• Ultrasound• CT scan• MRI• Positron emission tomography and single-photon

emission computed tomography

RADIOLOGICAL INVESTIGATIONS

TUBERCULOSIS• Basic pathology is a granulomatous inflammation with

tubercles which undergoes caseation necrosis and destruction of the lymph node• Tuberculous disease of the neck usually involves the upper

part of the deep cervical chain (from tonsillar infection). These infected nodes may adhere very firmly to the internal jugular vein, which may be wounded in the course of their excision• Spread of the infection to the adjacent nodes by

periadenitis result in the nodes getting adherent to each other, which gives the characteristic physical sign of early matting of the node

COLLAR STUD ABSCESS

• Node lies deep to the deep fascia as in the neck, the caseous node perforates through the deep fascia and the caseous matter escapes the superficial fascia resulting in the characteristic collar stud abscess.• condition most commonly affect children and young

adults but can occur at any age• The deep upper cervical lymph nodes are most commonly

affected followed by mediastinal, mesenteric, axillary and inguinal group of lymph nodes according to the order of frequency.

LYMPHANGITIS & LYMPHADINITIS• Secondary inflammation of lymphatic vessels & lymph

nodes respectively.• May occurs when lymphatic system is involved in chemical

or bacterial transport after severe injury or infection.• Lymphatic vessels , not usually evident, may become

apparent as red streaks in the skin & nodes may become painfully enlarged.• This is potentially dangerous because uncontrolled

infection may lead to septicaemia.

TONSILLECTOMY• May be carried out by dissection or by the guillotine

method; both depend on removing the lymphoid tissue and underlying fascial capsule from the loose areolar tissue clothing the superior constrictor in the floor of the tonsillar fossa. • Unless there have been repeated infections, the superior

constrictor lies separated from the palatine tonsil and its capsule by loose areolar tissue that prevents the pharyngeal wall being dragged into danger during tonsillectomy.• Similarly, the internal carotid artery, although only 1 inch

(2.5 cm) behind the tonsil, is never injured in this operation since it lies safely freed from the pharynx by fatty tissue around the carotid sheath.

QUINSY

• Suppuration in the peritonsillar tissue secondary to tonsillitis.• It is drained by an incision in the most prominent

part of the abscess where softening can be felt.

NECK DISSECTION Four major types and subtypes of neck dissections

proposed by the Academy of head and neck surgery

• Radical neck dissection (RND)• Modified radical neck dissection (MRND)• Selective neck dissection (SND): a. Supra-omohyoid type b. Lateral type c. Posterolateral type d. Anterior compartment type• Extended radical neck dissection

RADICAL NECK DISSECTION• Gold standard for oncologic treatment of lymph node

metastasis in the neck.• It involves removal of all lymphatics from levels I-V. • Removal of nonlymphatic structures including the spinal

accessory nerve, the sternocleidomastoid muscle and the internal jugular vein • 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

MODIFIED RADICAL NECK DISSECTION

• Modified radical neck dissection involves excision of the same lymph node bearing in RND with the preservation of one or more non lymphatic structure including the spinal accessory nerve, the IJV, or the SCM.• Medina subclassifies the MRND into

Types I-III

• MND type I entails preservation of 1/3, usually XIn

• MND type II entails preservation of 2/3, usually XIn and IJV

• MND type III all 3 structures are preserved.

• MND type II is most commonly done, and is oncologically acceptable in the absence of adherence of cervical nodal metastases to XIn or IJV.

SUPRAOMOHYOID NECK DISSECTION

• Supraomohyoid neck dissection (SOHND) is the most commonly performed selective neck dissection for the treatment of the N0 neck. • Involves the en bloc removal of cervical lymph node

groups I-III. • Posterior limit of this dissection is marked by the

cutaneous branches of the cervical plexus and SCM. • The inferior limit is the superior belly of the omohyoid

muscle where it crosses the IJV.

• 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 in thecheek and zygomatic regions of the face.

LATERAL TYPE NECK DISSECTION

• lateral type neck dissection refers to the en bloc removal of the jugular lymph nodes including Levels II-IV.

• primary indications for the lateral type neck dissection include removal of nodal disease associated with carcinomas arising in the oropharynx, hypopharynx, and larynx.

POSTEROLATERAL

• 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

ANTERIOR TYPE• 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

ANTERO LATERAL

Involves removal of lymph nodesof level I ,II,III,IV

EXTENDED NECK DISSECTION

• 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

Neck incisions

McGregor and McGregor (1986) described three types of incisions for this.

• The Hayes Martin incision• The tri-radiate incision or one of its modified

versions.• The MacFee incision

HAYES MARTIN INCISION

• Submandibular component is met by a vertical limb which below becomes continuous with an inverted Y in the supraclavicular region

• Four flaps are thus created, the base of each extending to the limit of the neck dissection on each side• Posterior flap, with no platysma at its base to signpost the

plane in which the flap is raised, is liable to have a less adequate blood supply

TRI-RADIATE INCISION

• Incision used the same submandibular component as the Hayes Martin incision, either straight or curved• Also uses a vertical incision in the same

line as Hayes Martin, i.e., a little behind the line of the carotid, but it continues this incision down over the clavicle 3-4 cm• Continuation allows better access to the antero and

postero-inferior angles

Modifications of tri-radiate incision

• SCHOBINGER (1969) the vertical limb instead of being straight should be curved posteriorly , in order to avoid lying directly over the carotids.

• Cramer and Culf 1969, suggested S shaped incision

CONLEY INCISION• Posterior curve and the anterior part

of the submandibular incision are both modified to run as a single curve, beginning in the submental region and ending by running downwards along the anterior border of trapezius to the level of the clavicle• The posterior part of the submandibular

incision then meets it at aright angle approximately below the lobule of the ear

MCFEE INCISION

• Avoids using a vertical limb. Two horizontal incisions are made one in the submandibular region and one in the supraclavicular region. • Between these two incisions a bipedicled flap

is raised, based anteriorly on the mid-line and posteriorly on the anterior border of trapezius.• The flap is retracted upwards to expose the lower part of the neck until

dissection has proceeded far enough upwards to allow the resection specimen to be pulled through into the submandibular incision.

• This incision is said to give better cosmetic results by avoiding a vertical scar in the neck

REFERENCES• Anatomy of the Human Body, by Henry Gray (1918)• Clinical Anatomy By Regions Ninth Edition, by Richard Snell• Clinically Oriented Anatomy Seventh Edition, by Moore & Dailey• Sicher and Du BRUL`S oral anatomy. 8th edition• Last`s anatomy (regional and applied) –8th edition• Theime Atlas of Anatomy-general anatomy and musculoskeletal

system- Schuenke, Schulte & Schumacher.• Clinical Anatomy- Applied Anatomy for Students and Junior Doctors-

Harold ellis & vishy mahadevan, thirteenth edition.• Illustrated clinical anatomy-Abrahams,Cravans & Lumley.• Neck Dissection - Clinical Application and Recent Advances-Prof. Raja

Kummoona

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