lymphatic drainage

1. LYMPHATIC DRAINAGE OF
HEAD AND NECK
PRESENTED BY
DR RUDRA DEO KUMAR

2. 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

3.  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

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

5. • 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

6. • 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

7. 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

8. 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

9. 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

10. 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

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

12. • 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

13. • 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

14. 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

15. 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.

16. 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.

17. LYMPH NODES OF HEAD AND NECK

18. LYMPH NODES OF HEAD AND NECK

19. SUPERFICIAL CERVICAL NODES OF FACE
a) Parotid
b) Submandibular
c) Submental

20. Parotid Lymph Nodes

21. 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

22. Submandibular Lymph Nodes

23. (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

24. Submental Lymph Nodes

25. (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

26. Occipital nodes

27. Retroauricular (mastoid) nodes

28. Buccal (facial) nodes

29. Superficial cervical nodes

30. Retropharyngeal Lymph Nodes
Drains :
• Nasopharynx
• Posterior nasal cavity
• Paranasal sinuses
• Posterior oropharynx
• Hypopharynx

31. Pretracheal Lymph Nodes
Drain
 Lower larynx
 Hypopharynx
 Cervical esophagus
 Upper trachea
 Thyroid

32. Spinal accessory Lymph Nodes
Drain :
 Scalp (parietal & occipital region
 Nape of neck
 Upper retropharyngeal
 Parapharyngeal nodes

33. 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

34. MIDDLE JUGULAR
Primary drainage sites
• Supraglottic larynx
• Lower pyriform sinus
• Post. Cricoid area
Secondary drainage sites
• Superior jugular
• Lower retropharyngeal

35. INFERIOR JUGULAR
Primary drainage sites
• Trachea
• Thyroid
• Cervical esophagus
Secondary drainge sites
• Superior jugular
• Middle jugular
• Paratracheal

36. 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.

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

38. 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.

39. LYMPHATIC DRAINAGE OF TONGUE
Tip
Submental nodes
Anterior 2/3 lateral border
Ipsilateral Submandibular node
ANTERIOR 2/3 CENTRALLY
Submandibular nodes on both sides
Posterior 1/3
Jugulo-omohyoid nodes
FINAL NODES TO BE INVOLVED ARE
Jugulo-omohyoid and deep cervical nodes

40. LEVELS OF CERVICAL LYMPH NODES

42. TNM CLASSIFICATION OF REGIONAL
NODE
Nx - nodes can not be assessed
N0 – No lymph node metastasis
N1 – metastasis in single ipsilateral
node 3cm or less.
N2a – single ipsilateral node >3cm but
<6cm
N2b – multiple ipsilateral nodes <6cm
N2c – bilateral / contralateral nodes
<6cm
N3 – metastasis in node >6cm

43. 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

44. 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

45. 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

46. 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

47. CLINICAL ASSESSMENT
• Careful medical history
• Physical examination
• Laboratory tests
• An excisional lymph node biopsy

48. 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

49. 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

50. Following characteristics should be noted and described:
Size
Pain / tenderness
Consistency
Matting
Location

51. 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 causes
Diameter > 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.

52. CONSISTENCY
Stony-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

53. 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)

54. 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

55. 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

56. 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
SLE
CHEST XRAY
Presence of a pulmonary infiltrate or mediastinal
lymphadenopathy suggest tuberculosis, histoplasmosis,
sarcoidosis, lung cancer or metastatic cancer

57. • 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

58. • Ultrasound
• CT scan
• MRI
• Positron emission tomography and single-photon
emission computed tomography
RADIOLOGICAL INVESTIGATIONS

59. 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

60. 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.

61. 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.

62. 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.

63. 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.

64. 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

65. 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

66. 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

67. • 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.

68. 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.

69. • 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 the
cheek and zygomatic regions of the face.

70. 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.

71. 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

72. 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

73. ANTERO LATERAL
Involves removal of lymph nodes
of level I ,II,III,IV

74. 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

75. 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

76. 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

77. 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

78. 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

80. 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

81. 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

82. 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

83. THANK YOU