LYMPHATIC DRAINAGE OF THE

HEAD & NECK & APPLIED ASPECTS

INTRODUCTION

Drainage system accessory to the venous system

tissue fluid - picked up by
the venous end of the capillaries

Lymphatic vessels 10-20 % of the tissue fluids,

Tissue fluid flowing through these vessels is called

LYMPH

Lymph drains into Larger veins

INTRODUCTION

LYMPH
Definition: Liquid of alkaline reaction found in
lymphatic vessels and derived from tissue fluid
Lymphatic system is absent in:
-C.N.S.
-Cornea
-Superficial layer of skin
-Bones
-Alveoli of lung

COMPONENTS OF LYMPH
Lymph
Water (96%)

Others (4%)
Solids

Cellular
Proteins

Lymphocyte

Lipids

Monocyte, macrophages

Carbohydrates

Plasma cell

Amino acids
Non nitrogenous s.
Electrolyte

LYMPHATIC VESSELS

LYMPHATIC VESSELS

Lymph
capillaries

LYMPHATIC VESSELS
Lymphatic
vessel

Lymph
Node

Lymphatic
trunk

Collecting
duct

Subclavian
vein

AFFERENT & EFFERENT

LYMPHATICS

LYMPH NODE STRUCTURE

Oval or beanshaped
Small pinhead to
large as a lima
bean

LYMPH FLOW

How???

120ml

THORACIC DUCT
+
RIGHT LYMPHATIC DUCT

Conditions which increase Tissue fluid

Increase Lymph formation--- How???

Filtration >>
Reabsorption

>> Tissue
fluid

Increased
Hydrostatic
Pressure

>> movement
into
LYMPHATIC
CAPILLARIES

FUNCTIONS OF LYMPH

Nutritive
Drainage
Transmission of proteins
Absorption of fats
Defense

LYMPH NODES OF THE

HEAD & NECK
II

V
a

B.
D
I
O
HY

C.
D
I
O
CRIC

N UM
R
E
ST

III
VI

IV

V
b

LYMPHATIC DRAINAGE OF
VARIOUS STRUCTURES
Mandibular
incisors

Floor of the
mouthAnterior

Tongue

Lips
Lips

Cheeks

LYMPHATIC DRAINAGE OF
VARIOUS STRUCTURES
Teeth

Hard Palate

Oropharynx
Lateral wall
of nose

Hard
Soft Palate
Palate

LYMPHATIC DRAINAGE OF
VARIOUS STRUCTURES
Paranasal Sinuses

External ear
Scalp

EXTRA-NODAL LYMPHOID
TISSUE/ORGANS

MALT

PALATINE TONSIL

Almond shaped

Tonsillar sinus or fossa between

palatoglossal
palatopharyngeal arches
Medial surface: intratonsillar clefts
Lateral surface: capsule of tonsil: keeps tonsil in

place during swallowing

Lymphatic drainage: Jugulodigastric node

TUBAL TONSIL
Around Eustachian tube openings in
the nasopharynx.
Extensions of pharyngeal tonsils

WALDEYERS RING

WALDEYERS RING

EXAMINATION OF LYMPH
NODES

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, following

points are observed:
(i) Location of nodes
(ii) Number of nodes
(iii) Size 1

to 1.5 cm in greatest dimension

(iv) Consistency:
Metastatic nodes-hard;
lymphoma nodes-firm and rubbery;
hyperplastic nodes-soft.

(v) Discrete/matted nodes.

(vi) Tenderness: Inflammatory
nodes are tender.
(vii) Fixity
(viii) Systemic symptoms

Submental Nodes
Roll the fingers
below the chin with
patients 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

Occipital nodes

Post

auricular
(Mastoid Nodes)
Roll the fingers
behind the ear

Internal jugular
chain

Examine the
upper, middle and
lower groups.
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

Clinical relevance

In head and neck, all lymph ultimately

drains into deep cervical group of
nodes

Secondary carcinomatous deposits in

these nodes are common

31

ECHELON LYMPH
NODES

1st nodal station reached by lymphatic

drainage of an organ: 1st echelon
nodal group

1st echelon L.N. connect to each other

through post-lymphnodal collecting
ducts and finally drain to more central
efferent L.N. or directly into the venous
system through the main lymphatic
trunk

NODAL METASTAIS

Tumor spread regional lymph nodes and beyond occurs via

lymphatic vessels whose proliferation is promoted by growth
factors

Tumor lymphangiogenesis- contributes to dissemination stimulated by family of

VEGF-C,D

CD44 is multistructural cell surface adhesion moleculeoverexpression of CD44 and its isoforms by tumor cells may
lead to increased lymphatic and hematogenous spread

Tumor production of proteolytic enzymes- propagation of

lymph node metastasis

Other mechanisms- discontinuity in basement membrane of

primary tumor, factors that facilitate cell migration, adhesion
and proliferation.

HISTORY

In 1972, Lindbergh reported metastasis

in
1155
patients
with
upper
aerodigestive
tract
squamous
cell
carcinoma

Primary tumors with in the oral cavity

-levels I, II and III (descending order),
Oropharyngeal,
hypopharyngeal and
laryngeal primary tumors -levels II, III
and IV

PATTERNS OF NECK
METASTASIS

For primary tumours in oral cavity regional L.N. at highest

risk for early dissemination by metastatic cancer limited to
levels I, II, III.

Skip metastasis to Levels I, II, III exceedingly rare

Therefore, if neck is clinically negative(N0), levels IV and V
L.N. generally not at risk

Tumours of oropharynx, hypopharynx and larynx: first

echelon L.N. are
deep jugular L.N. at levels I, III, IV on ipsilateral side: more at risk

Only 20-25% of patients with carcinomas of parotid gland

develop regional metastasis.

VIRCHOWS NODES

Signal nodes/ seat of

the devil/ supraclavicular
adenopathy

Enlarged, hard L.N. in the

left supraclavicular fossa:
Troisiers sign

Associated with metastasis

from SCC of the head and
neck, primary lung cancer,
esophageal cancer, cancer
in the abdomen and pelvic
region

STAGING OF L.N.

TNM staging first reported by Pierre

Denoix in 1940s
Adapted by the International Union Against
Cancer (UICC) in 1968 for 23 body sites

Consistent for all mucosal sites except the

nasophaynx and hypopharynx

Thyroi, hypopharynx and nasophaynx have

different staging based on tumour behaviour
and prognosis

N OF TNM STAGING: REGIONAL

L.N.

TNM Staging grouping

Common lymph node enlargements

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 an immune

response of the lymph nodes to an infection
elsewhere in the body.
-Localized
-Generalized

CAUSES OF
LYMPHADENOPATHY
1.Infectious disease
A. Viral
-Infectious mononucleosis
-Infectious hepatitis
-Herpes simplex
-Rubella
-Measles
-HIV
B. Bacterial
-Cat scratch disease
-Brucellosis
-Tuberculosis
-Atypical mycobacterial infection
-Primary and secondary syphilis
-Diptheria

C. Fungal

-Histoplasmosis
-Coccidioidomycosis

D. Parasitic
-Toxoplasmosis
-Filariasis
E. Chlamydial
-Lymphogranuloma venerum
- Trachoma

2. Immunologic disease (generalized

lymphadenopathy)
A. Rheumatoid arthritis
B. Systemic lupus erythematous
C. Sjogren syndrome
D. Drug hypersensitivity
3. Malignant disease
a. Hematological
-Hodgkins lymphoma
-Non Hodgkins lymphoma
-Hairy cell leukemia
-T-cell lymphoma
-Multiple myeloma
B. Metastasis
-From primary site

4.Lipid storage disease

-Gauchers disease
-niemann-pick disease
5.Endocrine disease
-Hyperthyroidism
-Adrenal insufficiency
-Thyroiditis
6.Other disorder
-Sarcoidosis
-Lymphomatoid granulomatosis
-Kawasaki disease
-Histocytosis x

CALCIFIED LYMPH NODES

Dystrophic calcification, common in

granulomatous disorders
Lymphoid tissue gets replaced by
hydroxyapatite-like calcium salts nearly
effacing all nodal architecture
Scrofula
Most common: submandibular, cervical
and preauricular, submental lymph
nodes
May affect single lymph node or a linear
series: lymph node chaining

INVESTIGATIONS
Histopathological
-Conventional FNAC- blind procedure
-Excisional biopsy of node
-Sentinal lymph node biopsy
Contrast lymphoangiography
Fine needle aspiration cytology- F.N.A.C
Ultrasound guidance
CT Guidance
- It is more accurate than blinded FNAC
-High sensitivity(89-98%), high specificity(9598%)

C. T & M.R.I-CT & MRI detecting size of node

-CT better than MRI necrosis,
extracapsular spread

Distant metastasis imaging

-Chest radiography
-Abdominal USG
-Radionuclide imaging
-Blood studies (tumour markers)

CT- LYMPH NODES

ROUNDED SHAPE:
benign node l:b=
2:1
Exceptionssubmental nodes
round rather than
ovoid in shape.
Lymphomatous
nodes are often
large and rounded
short/long ratio of
< 0.5 normal
value.

IRREGULAR MARGIN:
Nodes irregular
-larger than average.
Capsule of the node
-ill defined
-incomplete when
malignant cells extend
into perinodal soft tissue
or adjacent muscle.
-This is one of the most
significant ultrasonographic
features of malignancy

MULTIPLE NODES:
Nodes that are matted
together or multiple
in >1 zone -pathologic.
Inflammatory conditions
such as tuberculosis
or cat scratch disease
may demonstrate these
features.
Lymphomatous nodes
are often multiple in
number

ECHOGENICITY:
Homogeneous
echo architecture
in a large node
may reflect the
fish flesh gross
appearance seen
in lymphomatous
nodes
Areas of anechoic
echogenicity
within a node may
suggest necrosis
and metastatic
malignancy

PET SCAN

SENTINAL NODE
BIOPSY

Sentinel lymph node biopsy in squamous cell carcinoma of the head and
neck:10 years of experience.
ACTA otorhinolaryngologica Italica 2012;32:18-25

SNB: gold standard in melanoma and breast cancer

SNB in HNSCC has been suggested as a method to improve the

accuracy of staging and tailor treatments

From May 1999 to Dec 2009, 209 consecutive patients entered a

prospective study: 61.7% had primary tumour of the oral cavity and
23.9% of the oropharynx. SN was not found in 26 patients

Functional outcomes after SNB are recognized as significantly better

than after SND

But role of SNB in HNSCC is still undecided. Surgeons should be

aware that these patients have a N0 neck and good prognosis, and
that elective SND has proven reliability and worldwide acceptance

SENTINAL NODE MAPPING

1.
2.
3.

Employs 1 or all of the 3

techniques:
Radioisotope scan
imaging
Injection of blue dye
Use of a handheld
isotope tracer probe for
localization

Pre-operative technetium scan employed first

Gamma camera images at 3minutes, 15minutes, and
delayed image at 1hour.
1st lymph node identified by technetium scan:
sentinal L.N.

Immediately prior to surgical procedure, isosulfan

blue dye injected around primary tumour
Operative procedure carried out within 30minutes of
the injection
Gamma probe used. Any node that has in-vivo 10second count more than 3 times that of
background considered hot
Blue lymph node localized by blunt dissection.
Probe used to correlate blue node with highest
radiotracer activity: excised and sent for pathologic
analysis
If residual radioactivity in basin>10% of ex-vivo
count of hottest node in basin: further exploration for
more sentinal nodes

SURGICAL TECHNIQUES OF
REMOVAL OF LYMPH NODES

Radical Neck Dissection

Modified Radical Neck Dissection
TypeI
TypeII
TypeIII

CONCLUSION

Thus, a good understanding of the

lymphatic drainage of the head and the
neck help us to better understand the
pathological basis of various diseases.

Thank you