1. 1 Dr. Ashish Jaiswal

2. - Dr. Ashish K. Jaiswal 1st Year MDS Public health Dentistry Sibar Institute of Dental Sciences Date – Monday 20th June 2011 Dr. Ashish Jaiswal Lymphatic System & The Cervical Lymph Nodes

3. Contents Introduction Development Lymphatic System Immunology Functions Lymphatic Drainage Examination Lymphatic Diseases Investigations Management Conclusion 3 Dr. Ashish Jaiswal

4. LYMPHATIC SYSTEM Definition : Lymphatic system can be defined as closed system of channels through which the fluid is drained from interstitial spaces into the blood venous system via thoracic & right lymphatic duct. 4 Dr. Ashish Jaiswal

5. Development Derived from mesoderm Begins developing at the end of 6th week of intrauterine life. Originates from six lymph sacs: Two Jugular Two Ilial One Retroperitonial One Chyle Cistern 5 Dr. Ashish Jaiswal

6. Lymphatic System Lymphoid Organs Lymphoid Tissue Lymphatic Cells Lymph Lymph Nodes Lymph Capillaries Lymphatic Trunks Lymphatic Ducts 6 Dr. Ashish Jaiswal

7. Lymphatic System Lymphoid Organs : Spleen Thymus Tonsils Lymph nodes 7 Dr. Ashish Jaiswal

9. Similar to a lymph node in shape and structure but is much larger.

10. It is the largest lymphatic organ in the body.Consists of two types of tissue called White pulp & Red pulp 8 Dr. Ashish Jaiswal

11. Function of Spleen Filters blood Stores blood 9 Dr. Ashish Jaiswal

12. Thymus Location : It is located in the anterior superior mediastinum, in front of the heart & behind the sternum. Function : Function of the thymus is the processing and maturation of the undifferentiated lymphocytes into T-lymphocytes or T-cells, which are associated with antibody production. 10 Dr. Ashish Jaiswal

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14. Tonsils Cluster of lymphatic tissue just under the mucous membranes that line the nose, mouth, and pharynx (throat) called tonsils. There are three groups of tonsils. 1. Pharyngeal tonsils 2. Palatine tonsils 3. Lingual tonsils Provide protection against harmful substances and pathogens that may enter the body through the nose or mouth. 12 Dr. Ashish Jaiswal

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17. Tubal Tonsil

18. Palatine Tonsil

19. Lingual TonsilInner Ring Outer Ring 14 Dr. Ashish Jaiswal

20. Lymphatic Cells 15 Dr. Ashish Jaiswal

21. Lymphatic Cells T-cells (Thymus dependent) Cytotoxic T-cells Regulatory T-cells Helper T-cells Suppressor T-cells Memory T-cells B-cells (Bone marrow derived) Plasma cells Memory B-cells NK cells (Natural Killer) Dr. Ashish Jaiswal

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23. Lymphatics Lymph capillaries Lymph vessels Lymphatic trunks Lymphatic ducts 18 Dr. Ashish Jaiswal

24. Lymphatic channels Lymph capillaries & vessels form the lymphatic channel. Almost all body tissues have special lymphatic channels. 19 Dr. Ashish Jaiswal

25. Lymphatic Channels 20 Dr. Ashish Jaiswal

26. Lymph Capillaries : Dead end Thin walled with single layered endothelium Numerous valves 21 Dr. Ashish Jaiswal

27. LYMPH Lymph is nothing but interstitial fluid that flows into the lymphatics channels. It is a transparent, slightly yellow, often opalescent liquid. 22 Dr. Ashish Jaiswal

28. LYMPH Lymph composition : 96% water & 4% solids When lymph 1st enters the terminal lymphatics, it has almost the same composition as the interstitial fluid 23 Dr. Ashish Jaiswal

29. LYMPH Soilds : Protiens – The overall protein concentration comes to 3-5g/dl 24 Dr. Ashish Jaiswal

30. LYMPH Soilds(cont.) : Lipids Carbohydrate Nitrogenous substances Electrolyte Foreign bodies 25 Dr. Ashish Jaiswal

31. LYMPH Cellular composition of lymph Mostly contains lymphocytes Normal lymphocyte count of lymph is 1000-2000/cumm Monocyte, macrophages & plasma cells are occasionally present. 26 Dr. Ashish Jaiswal

32. LYMPH Total quantity of lymph is 2-3 liters 120ml of lymph flows into blood per hour Lymphatic flow determined by Interstitial fluid pressure Activity of lymphatic trunk 27 Dr. Ashish Jaiswal

33. Functions of Lymph Return of proteins Redistribution of body fluid Removes foreign bodies Maintenance of structural & functional integrity of tissue 28 Dr. Ashish Jaiswal

34. Lymph Nodes Lymph nodes are small glands that are interposed during the course of lymph vessels. 29 Dr. Ashish Jaiswal

35. Structure of Lymph Node 30 Dr. Ashish Jaiswal

36. Lymph Nodes Functions of lymph nodes Filtration Removal of foreign bodies 31 Dr. Ashish Jaiswal

37. Lymph Nodes of the Head & Neck 32 Dr. Ashish Jaiswal

38. Lymph Nodes of the Head & Neck The entire lymph from the head and neck drains ultimately into the deep cervical nodes either directly or through the peripheral nodes. Deep Cervical Lymph Nodes : The deep cervical nodes form a vertical chain situated along the entire length of the internal jugular vein. For descriptive purpose they are grouped as Antero superior Anteroinferior Posterosuperior and Posteroinferior 33 Dr. Ashish Jaiswal

39. Jugulodigastric Node Location : The jugulodigastric node is a member of the antero-superior group. Drainage :It is the main node draining the tonsil. 34 Dr. Ashish Jaiswal

40. Jugulo-Omohyoid Node Location : The jugulo-omohyoidnode is a member of the postero-inferior group. Drainage : It is the main lymph node of the tongue 35 Dr. Ashish Jaiswal

41. Path of Deep Cervical lymph Nodes 36 Dr. Ashish Jaiswal

42. Peripheral Cervical lymph Nodes The peripheral nodes are arranged in two circles, 1. Superficial and 2. Deep The superficial circle of cervical lymph nodes is made up of the following groups: (1) Submental (2) Submandibular (3) Buccaland mandibular(facial0 (4) Preauricular(parotid) (5) Postaurtcular (masloicl) (6) Occipital (7) Anterior cervical (8) Superficial cervical 37 Dr. Ashish Jaiswal

43. Peripheral Cervical lymph Nodes The deep (inner) circle of cervical lymph nodes includes the followtng – (1) Prelaryngeal and pretracheal (2) Paratracheal and (3) Retropharyngeal nodes. 38 Dr. Ashish Jaiswal

44. Lymph Nodes Each lymph node is described under the following heads – Location/Position Drainage Efferents 39 Dr. Ashish Jaiswal

45. Submental Lymph Node Location : Submental Lymph Node 40 Dr. Ashish Jaiswal

46. Submental Lymph Node Drainage : Superficial tissues below the chin Central part of the lower lip Lower incisors & gingiva Anterior part of the floor of the mouth Tip of the tongue Mucous membrane of the lip & cheek Efferent : Their efferent pass to the submandibular nodes 41 Dr. Ashish Jaiswal

47. Submandibular Lymph Node Location : Submandibular Lymph node 42 Dr. Ashish Jaiswal

48. Submandibular Lymph Node Drainage : Upper & lower teeth & gingiva (except mandibular incisor) Anterior nasal cavity Palate Body of the tongue Upper lip Lateral angle of the eye Submental nodes Efferents : Their efferent drains into the deep cervical nodes 43 Dr. Ashish Jaiswal

49. Buccal & Mandibular Lymph Nodes Location : Buccal lies on the buccinator Mandibular lies on the lower border of the mandible Drainage : Part of the cheek, lip & lower eyelid Mucous membrane over the mandible Efferents : Their efferents pass to antero-superior group of deep cervical lymph node 44 Dr. Ashish Jaiswal

50. Pre-auricular Lymph Node Location : Pre-auricular Lymph Nodes 45 Dr. Ashish Jaiswal

51. Pre-auricular Lymph Node Drainage : The temple Side of the scalp Lateral surface of the auricle Middle ear Parotid gland Upper part of cheek Parts of the eyelid & orbit Efferents : They pass to upper group of deep cervical nodes 46 Dr. Ashish Jaiswal

52. Posterior-auricular ( Mastoid ) Node Location : Posterior-auricular Lymph Nodes 47 Dr. Ashish Jaiswal

53. Posterior-auricular ( Mastoid ) nodes Drainage : They drain a strip of scalp just above and behind the auricle, the upper half of the medial surface and margin of the auricle and posterior wall of the external acoustic meatus Efferents : Efferents pass to the postero superior group of deep cervical nodes. 48 Dr. Ashish Jaiswal

54. Occipital Nodes Location : Occipital Lymph Node 49 Dr. Ashish Jaiswal

55. Occipital nodes Drainage : They drain the occipital region of the scalp. Efferents : Efferentspass to the supra-clavicular members of the postero-inferior group of deep cervical nodes. 50 Dr. Ashish Jaiswal

56. Superficial Cervical Nodes Location : Superficial Cervical Lymph Node 51 Dr. Ashish Jaiswal

57. Superficial Cervical Nodes Drainage : They drain the lobule of the auricle, the floor of the external acoustic meatus, and the skin over the lower parotid region and the angle of the jaw. Efferents : Efferentspass to the upper and lower deep cervical nodes 52 Dr. Ashish Jaiswal

58. Deep Cervical Lymph Nodes Prelaryngeal and pretracheal Paratracheal and Retropharyngeal nodes. 53 Dr. Ashish Jaiswal

59. Prelaryngeal and Pretracheal Nodes Location : Prelaryngeal and Pretracheal Nodes 54 Dr. Ashish Jaiswal

60. Prelaryngeal and PretrachealNodes Drainage : The larynx, The trachea Isthmus of the thyroid. Efferents : Their efferent to the nearby deep cervical nodes. 55 Dr. Ashish Jaiswal

61. Paratracheal Nodes Location : Paratracheal Lymph Node 56 Dr. Ashish Jaiswal

62. Paratracheal Nodes Drainage : They receive lymph from the oesophagus, trachea & larynx Efferents : Efferents pass to the deep cervical nodes 57 Dr. Ashish Jaiswal

63. Retropharyngeal Nodes Location : Retropharyngeal nodes 58 Dr. Ashish Jaiswal

64. Retropharyngeal Nodes Drainage : The pharynx, The auditory tube, Soft palate, The posterior part of the hard palate, The nose. Efferents : Their efferents pass to the upper deep cervical nodes. 59 Dr. Ashish Jaiswal

65. Main Lymphatic Trunks of the Neck 60 Dr. Ashish Jaiswal

66. Thoracic Duct Thoracic duct is the largest lymph trunk of the body. It begins in the abdomen from the upper end of the cisternachyli, traverses the thorax, and ends on the left side of the root of the neck by opening into angle of junction between the left internal jugular the left subclavianvein. Before its termination, it forms an arch at the level of the transverse process of vertebra C7 rising 3 to 4 cm above the clavicle. 61 Dr. Ashish Jaiswal

68. Other Trunks Right Jugular Trunk : It drains half of the head and neck. Right SubclavianTrunk : It drains the upper limb. Bronchomediastinal Trunk : It drains the lung, half of the mediastinum and parts of the anterior walls of the thorax and abdomen. 63 Dr. Ashish Jaiswal

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71. Main Lymphatic Trunks left jugular trunk right jugular trunk left subclavian trunk right subclavian trunk left bronchomediastinal trunk right bronchomediastinal trunk right lumbar trunk left lumbar trunk intestinal trunk 66 Dr. Ashish Jaiswal

72. Main Lymphatic Trunks 67 Dr. Ashish Jaiswal

73. Examination of Lymph Nodes Inspection Position Number Pressure effect Palpation Position Number Local temperature Surface Margin Consistency 68 Dr. Ashish Jaiswal

74. Examination Principles of Palpation Patient’s back erect Stand behind the patient Patient’s chin tipped slight toward chest Palmer aspect of finger tips Maintain slight pressure 69 Dr. Ashish Jaiswal

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76. Examination Sequence to palpate cervical lymph nodes Begin with the most superior nodes & work down to clavicle Anterior to tragus of the ear for pre-auricular node Then mastoid & base of the skull for posterior auricular & occipital nodes Under the chin for submental nodes Then proceed further to palpate submandibular & sublingual lymph node 71 Dr. Ashish Jaiswal

77. Examination Examination of deep cervical lymph nodes – To examine ask the patient to sit erect & them turn the head to one side to relax sternocliedomastoid muscle, use thumb & finger to palpate under the anterior 7 posterior border of relaxed muscle & repeat on other side. 72 Dr. Ashish Jaiswal

78. Causes of Enlargement of Lymph Node Inflammatory Acute or chronic lymphaditis Infection Tuberculosis Filariaris Secondary syphilis Infectious mononucleosis Brucellosis Neoplastic Carcinoma Sarcoma Haematological Hodgkins disease Non-hodgkins lymphoma Chronic lymphatic leukemia Immunological Aids Drug reaction Systemic lupus erythromatosus Rheumatoid arthritis 73 Dr. Ashish Jaiswal

79. Diseases of Lymphatic System Lymphadenopathy It is any disease of the lymph nodes Lymphadenitis It is the inflammation of one or more lymph nodes Lymphadenocele It the cyst of the lymph node Lymphangiophlebitis Inflammation of the lymphatic channels Lyphatitis Inflammation of some part of lymphatic system Lymphadema Chronic swelling of a part due to accumulation secondary to the obstruction of the lymphatic vessels or lymph node Lymphogranuloma Systemic infection leading to acute lymphadenopathy 74 Dr. Ashish Jaiswal

80. Lymphatic Disease Lymphoma Any neoplastic disorder of lymphoid tissue Lymphoblastoma Poorly differentiated lymphocytic malignant lymphoma Lymphoepithelioma A pleomorphic poorly differentiated carcinoma arising from epithelium overlying lymphoid tissue Lymphocytoma Well differentiated lymphocytic malignant lymphoma Lymphadenoma It is a type of lymphoma Lymphangioma It is tumor of the newly formed lymph spaces & channels 75 Dr. Ashish Jaiswal

81. Infections of Oral Cavity / Oral Sepsis 76 Dr. Ashish Jaiswal

82. Lymph Node involvement 77 Dr. Ashish Jaiswal

83. Infections of Oral Cavity / Oral Sepsis Following are the various infectectious diseases of the oral cavity - 78 Dr. Ashish Jaiswal

84. Oral Sepsis PeriapicalOsteitis : Bacteria from the necrotic pulp invade the marrow spaces of bone in the periapical region & causes inflammation leading to periapicalostitis. Cellulitis : It is defined as the as a non-suppurative inflammation of the subcutenious tissue extending along the connective tissue & the intercellular spaces 79 Dr. Ashish Jaiswal

85. Oral Sepsis Absecss : It is a localised collection of pus, surrounded by an area of inflamed tissue in which hypermia & infiltration of of leukocytes occurs. Acute Periapical Abscess : It is the collection of pus in the alveolar bone, at the root apex of the tooth, following death of the pulp. 80 Dr. Ashish Jaiswal

86. Oral Sepsis Peridontal abscess : It is the collection of pus in the periodontium usually as a result of chronic peridontitis. Acute Apical Perodontitis : It is caused when inflammatory degradation products from the infected pulp penetrate periodontal ligament 81 Dr. Ashish Jaiswal

87. Oral Sepsis Pericoronal Abscess : Also called as pericoronitis Caused by infection of the surrounding soft tissues of a partially erupted or impacted tooth Folliculitis : It is caused when follicle of developing succedaneous teeth may become infected when their primary predecessord develop chronic perapical abscess 82 Dr. Ashish Jaiswal

88. Oral Sepsis Ludwigs Angina : It is defined as rapidly spreading septic cellulitis involving the submandibular, submental & sublingual spaces. Facial Spaces Infections : They are the spaces situated between the planes of fascia in which infection may spread. Osteomylitis : It can be defines as inflammatory condition of the bone that begins as an infection of medullary cavity & the haversian system & extents to involve the periosteum of the affected area. 83 Dr. Ashish Jaiswal

89. Investigations Complete Blood Count Chest Radiography Serological investigation Nodal Biopsy Fine Needle Biopsy Bone Marrow Aspiration C. T. Scan M.R.I Lymphography 84 Dr. Ashish Jaiswal

90. Management Conventional Diuretics NSAID’s Antibiotics Lymphatic Drainage Therapy Surgical : Neck Dissection Radiotherapy Chemotherapy 85 Dr. Ashish Jaiswal

91. Conclusion Knowledge of regional lymph nodes is important to prognosticate the probable involvement certain lymph nodes if the site of tumor or infection is known. Conversely the knowledge of regional lymph nodes permits the diagnosis of an obscure site of a pathological process if a lymph node or group of lymph node is found diseased. 86 Dr. Ashish Jaiswal

92. Role of Pubic Health Dentist As public health dentists are the closest to the public – to the population, they should understand the lymphatic system & their diseases so as to identify them while general clinical examination in field studies & advice/perform necessary basic treatment & refer them for specific treatment. 87 Dr. Ashish Jaiswal

93. References B.D. Chaurasia : Human Anatomy, Regional And Applied Dissection And Clinical 4th Edition Bhatnagar Et Al : Essential Of Human Embryology 3 rd edition Das S : A Manual On Clinical Surgery, Davidson : Principles And Practice Of Medicine. Gray’s Anatomy. InderbirSingh : Textbook Of Anatomy With Color Atlas. Martini : Textbook of Anatomy William G. Shafer Et Al : Textbook Of Oral Pathology. Sembulingam : Text book medical physiology Wikipedia – Lymphatic system & lymph nodes Google Images 88 Dr. Ashish Jaiswal

94. Thank You 89 Dr. Ashish Jaiswal