Description of lymphatic drainage of head and neck

1. LYMPHATIC DRAINAGE OF
HEAD & NECK
Dr Vasanthika S Thuduvage
Senior Lecturer/ Consultant ENT and
Head & Neck Surgeon

2.  The lymphatic system represents an accessory route
through which fluid flows from the interstitial spaces
into blood
 It is an essential part of body’s immune system.
Introduction

3. The lymphatic system consists of the following
 Fluid, known as lymph
 Vessels that transport lymph
 Organs that contain lymphoid tissue (eg,
lymph nodes, spleen, and thymus)

4. Lymphatic ultimately deliver lymph into 2
main channels
Right lymphatic
duct
Drains right side of
head & neck, right
arm, right thorax
Empties into the
right
subclavian vein
Thoracic duct
Drains the rest
of the body
Empties into
the
left subclavian
vein

5. Lymph Drainage of Head & Neck

6.  Afferent Lymph nodes in Head & Neck
 Deep cervical Lymph node
 Jugular trunks
 Right Lymphatic Duct Thoracic Duct

7. Superficial lymph nodes
 Sub-mental nodes
 Sub-mandibular nodes
 Buccal nodes
 Preauricular
 Postauriculal
 Occipital
 Anterior cervical
 Superficial cervical

8.  Deep lymph nodes
1. Infrahyoid/Prelaryngeal and pretracheal
2. Paratracheal
3. Retropharyngeal
4. Deep cervical nodes

9. OCCIPITAL NODES
 Situated at the apex of
posterior triangle of
neck
 Recieves lymph from
back of scalp
 Drains into deep
cervical lymph nodes

10. MASTOID /
RETROAURICULAR
LYMPH NODES
 Situated over lateral surface of
mastoid process of temporal
bone
 Recieves lymph from
a) Strip of scalp above auricle.
b) Posterior wall of external
auditory meatus
 Drains into
deep cervical lymph nodes

11. PAROTID LYMPH
NODES
 Situated on/ within
parotid gland.
 Receives lymph from
a) Strip of scalp above
parotid salivary gland.
B) lateral surface of auricle.
C) anterior wall of external
auditory meatus
D) lateral wall of external
auditory meatus.
E)lateral wall of eyelid
Drains into deep cervical nodes

12. CLINICAL SIGNIFICANCE
 The most common area that drains into
these nodes is skin, and thus the most
common tumors to metastasize to them are
melanoma and squamous cell carcinoma.

13. Buccal lymph nodes
 Situated over
buccinator muscle
close to facial vein.
 Recieves lymph from
Eyelids, cheek, mid
portion of face Rarely
gums & palate
Drains into submandibular
lymph nodes

14. Submandibular lymph
nodes
 Situated on
a) superficial surface of
submandibular salivary
gland.
b) Beneath investing layer
of deep cervical facia.

15. Recieves lymph from:
 Front of scalp.
 Anterior part of nasal cavity, palate & adjacent cheek.
 Upper & lower lip except central part.
 Frontal, maxillary, ethmoidal air sinuses.
 Upper& lower teeth except lower incisors.
 Anterior 2/3rd of tongue.
 Floor of mouth, vestibule.
Drains into deep cervical nodes.

16. Submental lymph nodes
 Lies b/w chin & hyoid
bone
 b/w anterior bellies of
digastric muscles in
submental triangles.
Recieves lymph from
A. Tip of tongue
B. floor beneath tongue
C. lower incisors
D. central part of lower lip
E. skin over chin Drains into submandibular &
deep cervical nodes

17. Cervical lymph nodes
 Distributed along the internal & external jugular veins.
 Acc. To their relation to deep fascia of neck, they are
divided into superficial & deep groups
 Superficial nodes restricted to upper region of neck&
found in angle b/w mandibular ramus & SCM muscle.
 Receive lymph from
 ear lobe
 adjacent part of skin.
 secondary to preauricular & postauricular lymph nodes.

19.  Deep cervical nodes divided into upper & lower group
 The superior & inferior deep cervical nodes that are situated in
front of SCM muscle: c/a anterior/ medial deep cervical
nodes.
 It follows the internal jugular vein so c/a JUGULAR CHAIN
 Those situated in posterior triangles of neck behind SCM
muscle are c/a posterior/ lateral deep cervical nodes.
 They are in close relation to accassory nerve, known as
ACCESSORY CHAIN

20. Jugulo digastric lymph nodes
 Situated at the level of greator horn of hyoid bone.
 Recieves lymph from tonsil and tongue.
Juglo-omohyoid nodes
 Situated related to the intermediate tendon of
omohyoid muscle.
 Recieves lymph from posterior 1/3rd of tongue.
 In general deep cervical nodes receive lymph from
regional lymph nodes and drain into jugular
lymph trunk

21. SUPERIOR DEEP CERVICAL NODES
INFERIOR DEEP CERVICAL/ SUPRACLAVICULAR
NODES.
THORASIC DUCT(left side)
LYMPHATIC DUCT (RIGHT SIDE)
VENOUS ANGLE (on either side), where internal jugular &
subclavian veins unite.
Thus the lymph enters the system of superior vena cava

22. Retropharyngeal lymph nodes
 Situated in retropharyngeal space b/w pharyngeal wall
& prevertebral fascia .
 Recieves lymph from: soft palate,nasal part of
pharynx, auditory tube, upper part of cervical vertebral
column.
 Drains into deep cervical lymph nodes.

23. Prelaryngeal lymph
nodes
 Situated in front of larynx
on cricothyroid ligament.
 Recieves lymph from
larynx, trachea, isthmus of
thyroid.
 Drains into deep cervical
lymph nodes.

24. Tracheal lymph nodes
 Situated
Pretracheal in front of trachea
Paratracheal lateral to
trachea.
 Recieves lymph :
Oesophagus, trachea, larynx.
 Drains into deep cervical
lymph nodes

25. WALDEYER RING
 Waldeyer's tonsillar ring (or pharyngeal lymphoid ring) is an
anatomical term describing the Lymphoid tissue ring located in
the pharynx and to the back of the oral cavity.
 Heinrich Wilhelm Gottfried von Waldeyer-Hartz.

26. Tonsils

27. LYMPHATIC DRAINAGE OF TONGUE
 Rich network of lymphtics
Enormous swelling
Carcinma of tongue:
Affected side is removed Surgically .With deep cervical node
Carcinoma of posterior one- third is more dangerous due to bilateral
lymphatic spread

28.  Tip of tongue drains bilaterally 
sub-mental nodes
 Right & left halves of remaining
halves of anterior 2/3rd drain
unilaterally  submandibular
nodes.
 Posterior 1/3rd drains bilaterally
juglo-digastric nodes.

29. APPLIED ANATOMY
The latest classification has been created by the
American Joint Committee on Cancer and
the American Academy of Otolaryngology -
Head and Neck Surgery.

30. Staging
 The TNM system devised by the AJCC is
designed to stratify cancer patients into
different stages based on the characteristics of
the primary tumor (T), regional lymph node
metastasis (N), and distant metastasis (M).

31. Regional Lymph Nodes (N)
Node Description
 NX Regional lymph nodes cannot be assessed
 N0 No regional lymph node metastasis
 N1 Metastasis in a single ipsilateral lymph node, 3 cm or less
in greatest dimension
 N2 Metastasis in a single ipsilateral lymph node, more than 3
cm but not more than 6 cm in greatest dimension; or in
multiple ipsilateral lymph nodes, none more than 6 cm in
greatest dimension; or in bilateral or contralateral lymph
nodes, none more than 6 cm in greatest dimension

32.  N2a Metastasis in a single ipsilateral lymph node more than 3
cm but not more than 6 cm in greatest dimension
 N2b Metastasis in multiple ipsilateral lymph nodes, none more
than 6 cm in greatest dimension
 N2c Metastasis in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
 N3 Metastasis in a lymph node more than 6 cm in greatest
dimension

33.  Level I - all nodes above hyoid
bone, below mylohyoid muscle,
and anterior to posterior edge of
submandibular gland
Level IA - all nodes between
medial margins of anterior
digastric muscles, above hyoid
bone, below mylohyoid muscle
Level IB - all nodes below
mylohyoid muscle, above hyoid
bone, posterior and lateral to
medial anterior digastric
muscle and anterior to
submandibular gland

34.  Level II - all nodes below skull
base at jugular fossa to hyoid
bone, anterior to posterior edge of
sternocleidomastoid muscle and
posterior to submandibular gland
 Level IIA - all nodes that lie
posterior to internal jugular
vein and are inseperable from
the vein or lie anterior, lateral or
medial to the vein
 Level IIB - all nodes that lie
posterior to internal jugular
vein and have a fat plane
separating the nodes and the
vein

35.  Level III - all nodes between
hyoid bone and cricoid
cartilage arch and anterior to
posterior
sternoclediomastoid muscle,
and lateral to the internal
carotid artery
Level IV - all nodes between
cricoid cartilage arch and
clavicle, anterior to posterior
sternocleidomastoid
muscleand posterolateral to
anterior scalene muscle and
lateral to common carotid
artery

36.  Level V - all nodes from skull
base posterior down to
posterior border of
sternocleidomastoid muscle to
level of clavicle, anterior to
trapezius muscle
 Level VA - all nodes between
skull base and cricoid cartilage
arch, behind posterior edge of
sternocleidomastoid muscle

Level VB - all nodes between
cricoid cartilage arch and
clavicle, behind
sternoclediomastoid muscle

37.  Level VI - all nodes
inferior to hyoid bone and
above top of manubrium,
between medial margins of
bilateral common carotid
and internal carotid
arteries
Level VII - all nodes
behind the manubrium
between medial margins of
common carotid arteries
bilaterally, extending
inferiorly to level of
innominate vein

38. METASTASIS
 Spread of tumor in such a way by invasion that
discontinuous secondary tumor masses are formed at the
site of lodgement.
 Routes of metasis:
1 Lymphatic spread
2 Haematogenous spread
3 Spread along body cavities and natural passages
( transcoelomic fluid, CSF)

39.  carcinomas metastatise by lymphatic route
 sarcomas by haematogenous route.

40. EXAMINATION OF LYMPH NODES
1. Lymph nodes should be examined from patient’s behind.
2. Examination is done by asking patient to flex his neck
slightly to reduce tension of muscles
3. To palpate, use the pads of all four fingertips.
4. Examine both sides of head simultaneously while applying
steady gentle pressure.

41. ANTERIOR/POSTERIOR CERVICAL LYMPH
NODES
 They lie anterior & posterior to sternomastoid muscle.
 Tip of fingers are used to palpate anterior nodes, medial to
sternomastoid muscle and posterior nodes behind the muscle
while patient,s head tipped slightly forwards.

42. SUBMANDIBULAR
NODES
 Palpated from behind
the patient, with
patient,s chin tipped
slightly towards the
chest.

43. SUBMENTAL NODES
 Roll the fingers below
the chin(in the midline)
with patient’s head
tilted forwards

44. PAROTID
NODES/PREAURICULAR
NODES
 Roll the finger in front of ear ,
against the maxilla

45. POSTAURICULAR/
MASTOID NODES
 Roll the finger behind the
ear

46. Occipital nodes
 Palpated behind the ear at
the base of skull

47. Supraclavicular lymph
nodes
 While patient’s head is tipped
forward, the index finger of
the examiner is placed in the
triangle and the area is
palpated with a rotary motion.

48. CAUSES OF ENLARGEMENT OF LYMPH
NODES
INFLAMMTORY
 (a) Acute Lymphadenitis
 (b) Chronic Lymphadenitis
 (c) Granulomatous Lymphadenitis
NEOPLASTIC
 (a) Benign – almost non-existent
 (b) Malignant
 1. Primary
 (i) Giant follicle lymphoma
 (ii) Lymphosarcoma
 (iii) Reticular cell sarcoma
 (iv) Hodgkin’s disease.
 ) Granulomatous Lymphadenitis

49.  2. Secondary
 Malignant melanoma
 Squamous cell carcinoma
Autoimmune Disorders
 (i) Juvenile rheumatoid arthritis
 (ii) Other collagen diseases such as Systemic lupus
erythomatosus, Polyarteritis nodosa and scleroderma.

50. CAUSES OF LYMPH NODE ENLARGEMENT
Sub mandibular Nodes
 Sinusitis
 Tonsillitis
 Pharyngitis
Sub mental Nodes
• Periodontitis
• Mononucleosis
(Epstein-Barr Virus)
• Cytomegalovirus
• Toxoplasmosis

51. Deep cervical nodes
 Pharyngitis
 Rubella
 Tuberculosis
 Lymphoma
 Head and neck cancer
Occipital nodes
• Local infection
• Secondary Syphillis
• Neoplasm
Postauricular nodes
• Otitis Externa
• Secondary Syphilis
• Rubella

52. Preauricular nodes
 Local infection
 Erysipelas
 Herpes Zoster
 Rubella
 Trachoma
 Viral Conjunctivitis
 Cat Scratch Disease
 Syphilis
 Tuberculosis

53. THANK YOU