Lymph Nodes

Distribution

Regional lymph tissue

Humans have approximately 500-600 lymph nodes distributed throughout the body, with
clusters found in the underarms, groin, neck, chest, and abdomen.

Lymph nodes of the head and neck

Cervical lymph nodes

o Anterior cervical: These nodes, both superficial and deep, lie above and
beneath the sternocleidomastoid muscles. They drain the internal
structures of the throat as well as part of the posterior pharynx, tonsils, and
thyroid gland.
o Posterior cervical: These nodes extend in a line posterior to the
sternocleidomastoids but in front of the trapezius, from the level of the
Mastoid portion of the temporal bone to the clavicle. They are frequently
enlarged during upper respiratory infections.
Tonsillar (sub mandibular): These nodes are located just below the angle of the
mandible. They drain the tonsillar and posterior pharyngeal regions.
Sub-mandibular: These nodes run along the underside of the jaw on either side.
They drain the structures in the floor of the mouth and the maxillary anterior,
bicuspid and 1st and 2nd molars. They also drain all of the mandibular teeth
except the central incisors.

Retropharyngeal: Drains lymph from the soft palate and the 3rd molars.

Sub-mental: These nodes are just below the chin. They drain the central incisors
and midline of lower lip and tip of the tongue.
Supraclavicular lymph nodes: These nodes are in the hollow above the clavicle,
just lateral to where it joins the sternum. They drain a part of the thoracic cavity
and abdomen. Virchow's node is a left supraclavicular lymph node which receives
the lymph drainage from most of the body (especially the abdomen) via the
thoracic duct and is thus an early site of metastasis for various malignancies.

Lymph nodes of the thorax

Lymph nodes of the lungs: The lymph is drained from the lung tissue through
subsegmental, segmental, lobar and interlobar lymph nodes to the hilar lymph
nodes, which are located around the hilum (the pedicle, which attaches the lung to
the mediastinal structures, containing the pulmonary artery, the pulmonary veins,
the main bronchus for each side, some vegetative nerves and the lymphatics) of
each lung. The lymph flows subsequently to the mediastinal lymph nodes.
Mediastinal lymph nodes: They consist of several lymph node groups,
especially along the trachea (5 groups), along the esophagus and between the lung
and the diaphragm. In the mediastinal lymph nodes arises lymphatic ducts, which
draines the lymph to the left subclavian vein (to the venous angle in the
confluence of the subclavian and deep jugular veins).

The mediastinal lymph nodes along the esophagus are in tight connection with the
abdominal lymph nodes along the esophagus and the stomach. That fact facilitates
spreading of tumors cells through these lymphatics in cases of cancers of the stomach and
particularly of the esophagus. Through the mediastinum, the main lymphatic drainage
from the abdominal organs goes via the thoracic duct (ductus thoracicus), which drains
majority of the lymph from the abdomen to the above mentioned left venous angle.

Lymph nodes of the arm

These drain the whole of the arm, and are divided into two groups, superficial and deep.
The superficial nodes are supplied by lymphatics which are present throughout the arm,
but are particularly rich on the palm and flexor aspects of the digits.

Superficial lymph glands of the arm:

o Supratrochlear glands: Situated above the medial epicondyle of the
humerus, medial to the basilic vein, they drain the C7 and C8 dermatomes.
o Deltoideopectoral glands: Situated between the pectoralis major and
deltoid muscles inferior to the clavicle.

Deep lymph glands of the arm: These comprise the axillary glands, which are
20-30 individual glands and can be subdivided into:
o Lateral glands
o Anterior or pectoral glands
o Posterior or subscapular glands
o Central or intermediate glands
o Medial or subclavicular glands

Lower limbs

Superficial inguinal lymph nodes

The superficial inguinal lymph nodes form a chain immediately below the inguinal
ligament.
They lie deep to Camper's fascia which overlies the femoral vessels at medial aspect of
the thigh
They are found in the triangle bounded by the inguinal ligament superiorly, the border of
the sartorius muscle laterally, and the adductor longus muscle medially. (Femoral
Triangle of Scarpa)

Deep inguinal lymph nodes

The deep inguinal lymph nodes are located medial to the femoral vein and under the
cribriform fascia. There are approximately 3 to 5 deep nodes. The superior-most node is
located under the inguinal ligament and is called Cloquet's node.

Popliteal lymph nodes

The popliteal lymph nodes, small in size and some six or seven in number, are imbedded
in the fat contained in the popliteal fossa.
One lies immediately beneath the popliteal fascia, near the terminal part of the small
saphenous vein, and drains the region from which this vein derives its tributaries.
Another is placed between the popliteal artery and the posterior surface of the knee-joint;
it receives the lymphatic vessels from the knee-joint together with those which
accompany the genicular arteries.

The others lie at the sides of the popliteal vessels, and receive as efferents the trunks
which accompany the anterior and posterior tibial vessels.
The efferents of the popliteal glands pass almost entirely alongside the femoral vessels to
the deep inguinal glands, but a few may accompany the great saphenous vein, and end in
the glands of the superficial subinguinal group.

List of cranial nerves

Human cranial nerves are nerves evolutionarily homologous to those found in many other
vertebrates. Cranial nerves XI and XII evolved in the common ancestor to amniotes (nonamphibian tetrapods) thus totaling twelve pairs. These characters are synapomorphies for
their respective clades. In some primitive cartilaginous fishes, such as the spiny dogfish
or mud shark (Squalus acanthias), there is a terminal nerve numbered zero (as it exits the
brain before the traditionally designated first cranial nerve).

#
0

Sensory,
Motor Origin
or Both
Cranial nerve zero Sensory
(CN0 is not
traditionally
recognized.)
Name

Nuclei

Function

olfactory
trigone, medial New research
olfactory gyrus, indicates CN0 may
and lamina
play a role in the
terminalis
detection of

Anterior
olfactory
nucleus

Olfactory nerve

Purely
Sensory

II

Optic nerve

Purely
Sensory

Ganglion cells
of retina

Mainly
Motor

Midbrain

Oculomotor
nucleus,
EdingerWestphal
nucleus

Mainly
Motor

Midbrain

Trochlear
nucleus

III

Oculomotor nerve

IV Trochlear nerve

Trigeminal nerve Both

Pons
Sensory
and
Motor

Principal
sensory
trigeminal
nucleus, Spinal
trigeminal
nucleus,
Mesencephalic
trigeminal
nucleus,
Trigeminal
motor nucleus

pheromones Linked
to olfactory system in
human embryos
Transmits the sense
of smell; Located in
olfactory foramina in
the Cribriform plate
of ethmoid
Transmits visual
information to the
brain; Located in
optic canal
Innervates levator
palpebrae superioris,
superior rectus,
medial rectus, inferior
rectus, and inferior
oblique, which
collectively perform
most eye movements;
Also innervates m.
sphincter pupillae.
Located in superior
orbital fissure
Innervates the
superior oblique
muscle, which
depresses, rotates
laterally (around the
optic axis), and
intorts the eyeball;
Located in superior
orbital fissure
Receives sensation
from the face and
innervates the
muscles of
mastication; Located
in superior orbital
fissure (ophthalmic
nerve - V1), foramen
rotundum (maxillary
nerve - V2), and
foramen ovale
(mandibular nerve -

V3)
Innervates the lateral
rectus, which abducts
Mainly Posterior margin Abducens
VI Abducens nerve
the eye; Located in
Motor of Pons
nucleus
superior orbital
fissure
Provides motor
innervation to the
muscles of facial
expression, posterior
belly of the digastric
muscle, and stapedius
muscle, receives the
special sense of taste
Facial nucleus, from the anterior 2/3
Both
Pons
Solitary
of the tongue, and
Sensory (cerebellopontine nucleus,
provides
VII Facial nerve
and
angle) above
Superior
secretomotor
Motor olive
salivary
innervation to the
nucleus
salivary glands
(except parotid) and
the lacrimal gland;
Located and runs
through internal
acoustic canal to
facial canal and exits
at stylomastoid
foramen
Senses sound,
rotation and gravity
(essential for balance
& movement). More
Vestibulocochlear
specifically. the
nerve (or
Lateral to CN VII Vestibular
vestibular branch
auditoryMostly
VIII
(cerebellopontine nuclei,
carries impulses for
vestibular nerve sensory
angle)
Cochlear nuclei equilibrium and the
or statoacoustic
cochlear branch
nerve)
carries impulses for
hearing.; Located in
internal acoustic
canal
IX Glossopharyngeal Both
Medulla
Nucleus
Receives taste from
nerve
Sensory
ambiguus,
the posterior 1/3 of
and
Inferior
the tongue, provides
Motor
salivary
secretomotor
nucleus,
innervation to the

Vagus nerve

parotid gland, and

provides motor
innervation to the
stylopharyngeus.
Some sensation is
also relayed to the
Solitary
brain from the
nucleus
palatine tonsils.
Sensation is relayed
to opposite thalamus
and some
hypothalamic nuclei.
Located in jugular
foramen
Supplies
branchiomotor
innervation to most
laryngeal and all
pharyngeal muscles
(except the
stylopharyngeus,
which is innervated
by the
glossopharyngeal);
provides
parasympathetic
fibers to nearly all
Nucleus
thoracic and
Both
ambiguus,
abdominal viscera
Sensory Posterolateral
Dorsal motor down to the splenic
and
sulcus of Medulla vagal nucleus, flexure; and receives
Motor
Solitary
the special sense of
nucleus
taste from the
epiglottis. A major
function: controls
muscles for voice and
resonance and the
soft palate.
Symptoms of
damage: dysphagia
(swallowing
problems),
velopharyngeal
insufficiency.
Located in jugular
foramen

Accessory nerve
(or cranial
Mainly
XI accessory nerve or
Motor
spinal accessory
nerve)

XII Hypoglossal nerve

Tendon Reflex

Mainly
Motor

Cranial and
Spinal Roots

Nucleus
ambiguus,
Spinal
accessory
nucleus

Medulla

Hypoglossal
nucleus

Controls
sternocleidomastoid
and trapezius
muscles, overlaps
with functions of the
vagus. Examples of
symptoms of damage:
inability to shrug,
weak head
movement; Located
in jugular foramen
Provides motor
innervation to the
muscles of the tongue
(except for the
palatoglossus, which
is innervated by the
vagus) and other
glossal muscles.
Important for
swallowing (bolus
formation) and
speech articulation.
Located in
hypoglossal canal

When the tendon is tapped briskly, it quickly pushes in on the tendon and places a tiny, but quick
stretch on the muscle attached to that tendon. The Patellar tendon is the easiest to see and
describe. You always do a tendon test when the muscle is slightly stretched, so usually this is
done while sitting with knee bent at 90 degrees and the lower leg able to swing freely. When the
tap is done, just below the kneecap, the normal reaction of the quadriceps is to contract. When it
does it causes the knee to extend (the lower leg to swing out). The nerve loop that controls a
tendon reflex is a stretch receptor that travels up to the spinal cord and immediately loops over to
a motor nerve that travels down and activates the proper muscle.
The reflexes may be dulled by depressant medications, low metabolic states like low magnesium,
severe depression, or hypothyroidism. Also in low thyroid states, the reflexes not only will be
lessened, but they will be delayed. Reflexes may be accentuated by things like stimulants,
caffeine, anxiety, or hyperthyroidism. They also may be "reinforced" by either slight, active
contraction of the muscle/tendon being tested or by having the patient contract another set of
muscles forcefully. The usual maneuver for reinforcement is to have the patient grasp the fingers
of both hands together in front of the chest and to pull tightly. (Try doing this. First tap on the
tendon without grasping the hands. Then do it with the hand-pull. You will normally see a
significant increase in the force of the tendon reflex) Reinforcement is only used when there is a
problem seeing any reflex action at all.

Measuring the Reflexes

The evaluation of the reflexes is done on a numercial scale, but it is subject to the interpretation
of the examiner, so it is not quantified. The more experience, the more reproducible the test will
be between examiners, but it is still really a subjective measurement. If it were to be quantified
(measured in exact numbers) it would be by electromyography and would be a research test
The most common rating scale of tendon reflexes is as follows:
0 Unable to elicit any movement or contraction of the muscle
1+ - Little movement or only seen with reinforcement - lower end of normal
2+ - Normal (what "normal" looks like is learned through doing this 100's of times with hundreds
of "normal" people)
3+ - Brisk (more than is normally seen, but not causing injury to the examiner, lol) this is also
considered within the normal range.
4+ - Maximum movement and associated with some limited, extra repetitive movement(s) called
clonus. This is level and above is abnormal, or hyperactive.
5+ - Major kick with sustained, repetitive movements (sustained clonus). Also considered here
and in "4+" is if other muscle groups also react with contraction, called "spreading reflex." Clonus
is most often seen at the ankle. The doctor will press suddenly up on the toes, dorsiflexing the
ankle. With clonus the toes will repeatedly and rhythmically bounce downward if light pressure is
kept on the toes. Some doctors use a 0 to 4+ scale and use 4.5+ (sustained clonus) instead of
5+.

Clonus is normal in newborns who all have immature nervous systems. You can elicit clonus in
newborns by taking a finger and pushing up quickly under the ball of their foot. This will cause

the foot/toes to rhythmically move up and down. (taken from "Fun and Games to Play With Your
Newborn - Activities for Bored Parents, lol). In babies this is normal, but disappears within a
couple months as their nervous system matures.
0, 4+, and 5+ are abnormal and indicate neurological problems.
Hyperactive reflexes usually indicate a problem (lesion) in the spinal cord. You may hear this
being called an Upper Motor Neuron Sign. Or the doctor may find hyperactive reflexes and
diagnosis Myelopathy (disease of the spinal cord). This is one of the most freqently abnormal
tests on the neurological exam in a person with MS.