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Introduction
History of lymphatic system
Development of lymphatic system
Lymph
Lymph node
Lymph nodes of head and neck
Examination on neck nodes
Cervical lymphadenopathy
Refrences
2
Lymphatic system consist of fluid called LYMPH
DEFINITION:Transparent, slightly yellowish
liquid of alkaline reaction found in lymphatic
vessel and derived from tissue fluid
 Lymphatic system is absent in:
-C.N.S.
-Cornea
-Superficial layer of skin
-bones
-alveoli of lung
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3
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In 1650,John Paquet-cysterna chyli
In 1962,Gaspard Asseli -milky veins
Olauf Rudbeck-first person to describe the
lymphatic system
Alexander of winiwater-protocol for draining
lymphedenomas
F.D.Millard -diagnostic importance by
palpating lymphatic gland
Emil Vodder -technoque of lymphatic
dranaige
Brono Chilky-rhythm of lymphatic flow
4
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Starts at 5th week of intrauterine life.
First signs of lymphatic system are seen in
the form of a number of endothelium lined
lymph sacs
5
SIX PRIMARY LYMPH SACS ARE FORMED.
2 Jugular sacs (right and left)
 At the junction of subclavian and anterior cardinal veins.
2 iliac sac (right and left)
 At the junction of the iliac and posterior cardinal vein.
Retroperitonial sac (Unpaired)
 Near the root of the mesentery.
Cisterna chyli (unpaired)
 Dorsal to retroperitonial sac
All the sacs except the cisterna chyli are invaded by connective
tissue and lymphocytes and are converted into lymph nodes
6
LYMPH
WATER (96%)
OTHERS (4%)
SOLIDS
CELLULAR
PROTEINS
LYMPHOCYTE
LIPIDS
MONOCYTE,MACROPHAGES ,
CARBOHYDRATES
PLASMA CELL
AMINOACIDS
NON-NITROGENOUS SUSTANCES
ELETROLYTE
7
Rate of lymph flow:
About 120ml of lymph flows into blood
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120 ml OF LYMPH
100ml THROUGH
THORASIC DUCT
2O ml THROUGH
RIGHT
LYMPHATIC DUCT
8
Rate of flow of lymph along the human
thoracic duct is from 1-1.5ml/min.
 Regulation of the lymph flow mainly depends
upon :
 Interstitial pressure
 Atrial pulsation
 Intrathorasic pressure
 Muscular massage
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9
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Lymph is formed from tissue fluid,anything that
increases amount of tissue fluid, will increase the
rate of lymph formation
 Various mechanisms:
 Filteration from plasma normally exceeds
resorption leading to net formation of tissue
fluid
 Increase in interstitial fluid hydrostatic pressure
favouring the movement of tissue fluid into
lymphatic capillary forming lymph
10
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Nutritive
Drainage
Transmission of proteins
Absorption of fats
Defensive
11
It takes place with the help of:
 Contractile skeletal muscle
 Presence of valve
 Contraction of smooth muscle in large
lymphatic trunk
 Pressure change in muscle during breathing
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12
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FLOW CHART
LYMPHATIC CAPPILLARY
LYMPHATIC VESSEL
LYMPHATIC NODE
LYMPHATIC VESSEL
LYMPHATIC TRUNK
SUBCLAVIAN VEIN
13
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Before Lymph is returned to the blood
stream, it passes through at least one lymph
node and often through several
The Lymph vessels that carry lymph to a
lymph node are referred to as afferent &
those that transport it away from a node are
called efferent vessels
14
15
Lymph nodes are oval-shaped of bean-shaped
structures
 Some are as small as a pinhead and others as
large as a lima bean
 Each lymph node is enclosed by a fibrous
capsule
 Once lymph enters the node, it "percolates"
slowly through the spaces known as sinuses
before draining into a single efferent draining
vessel.
 One-way valves in both the afferent and efferent
vessels keep lymph flowing in one direction
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17
Fibrous septa or trabeculae extend from the
covering capsule toward the center of the node.
 Cortical nodules found within the sinuses along
the outer region of the node are separated from
each other by these trabeculae.
 Each cortical nodule is composed of packed
lymphocytes that surround a less dense area
called a germinal center.
 When an infection is present, germinal centers
form and the node begins to release
lymphocytes.
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18
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Lymphocytes begin their final stages of
maturation within the germinal center of the
nodule and then are pushed to the more densely
packed outer layers as they mature to become
antibody-producing plasma cells.
The center or medulla of a lymph node is
composed of sinuses and cords.
Both the cortical and medullary sinuses are lined
with specialized reticuloendothelial cells (fixed
macrophages) which are capable of
phagocytosis
19
20
LYMPH NODE OF
HEAD & NECK
HORIZONTAL
SUBMENTAL LN
VERTICAL
CENTRAL
LATERAL
SUBMANDIBULAR LN
PRELARYNGEAL LN
JUGULODIGASTRIC LN
PAROTID LN
PRETRACHEAL LN
JUGULO-OMOHYOID LN
PREAURICULAR LN
PARATRCHEAL LN
OCCIPITAL LN
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Upper horizontal chain of nodes:
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Submental
Submandibular
Parotid
Postauricular
Occipital
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23
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Lie on mylohyoid muscle in the submental
triangle
2 to 8 in number
Drainage –afferents come from the chin,
middle part of lower lip, anterior gums,
anterior floor of mouth and tip of tongue.
Efferents -they go to submandibular and
internal jugular chain
24
25
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They lie in submandibular triangle in relation
to submandibular gland.
Afferents come from lateral part of the lower
lip, upper lip, cheek,nasal vestibule and
anterior part of nasal cavity, gums,teeth
medial canthus, soft palate, anterior pillar,
anterior part of tongue, submandibular and
sublingual salivary glands and floor of mouth
Efferents go to internal jugular chain
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They lie in relation to the parotid salivary
gland.
Afferents come from the scalp,pinna,
external auditory canal,face,buccal mucosa.
Efferents go to internal jugular or external
jugular chain
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Also called as mastoid nodes
They lie behind the the pinna over the
mastoid.
Afferents come from the scalp, posterior
surface of pinna and skin of mastoid.
Efferents drain into internal jugular chain
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They lie at the apex of the posterior triangle
Afferents come from scalp, skin of upper
neck.
Efferents drain into upper accessory chain of
nodes
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Lateral cervical nodes
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They include nodes, superficial and deep to
sternocleidomastoid muscle and in the posterior
triangle.
Superficial external jugular group
Deep group
i. Internal jugular chain (upper,middle and lower
groups)
ii. Spinal accessory chain
iii. Transverse cervical chain
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a) Superficial group – it lies along external
jugular vein and drains into internal jugular
and transverse cervical nodes
b)Deep group
It consists of three chains, the internal jugular,
spinal accessory and transverse cervical
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36
Internal jugular chain
 Lymph nodes of internal jugular chain lie
anterior, lateral and posterior to internal jugular
vein.
 Upper group (jugulodigastric node) – drains oral
cavity, orpharynx, nasopharynx,hypopharynx,
larynx and parotid.
 Middle group drains hypopharynx, larynx,
throid, oral cavity, oropharynx.
 Lower jugular group drains larynx, thyroid and
cervical oesophagus
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Spinal accessory chain
 Lies along the spinal accessory nerve. Spinal
accessory chain drains the scalp, skin of the
neck, the nasopharynx, occipital and
postauricular nodes.
 Efferents from this chain drain into transverse
cervical chain
38
Transverse cervical chain (supraclavicular nodes)
 It lies horizontally, along the trasverse cervical
vessels, in thelower part of the posterior
triangle.
 The medial nodes of the group are called scalene
nodes.
 Afferents to those nodes come from the
accessory chain and also infraclavicular
structures,e.g. breast, lung, stomach, colon,
ovary and testis
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40
Anterior cervical nodes
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Anterior jugular chain
Juxtavisceral chain
i. Prelaryngeal
ii. Pretracheal
iii. Paratracheal
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They lie between the two carotids and below the level of hyoid
bone and consist of two chains:
(a) Anterior jugular chian
 It lies along anterior jugular vein and drains the skin of anterior
neck.
(b) Juxtavisceral chain
 It consists of prelaryngeal,pretracheal and paratracheal nodes
(i)
Prelaryngeal node (Delphian node)-lies on cricothyroid
membrane and drains subgottic region of larynx and pyriform
sinuses
(ii) Pretracheal nodes lie in front of the trachea, and drain thyroid
gland and the trachea.Efferents from these nodes go to
paratracheal, lower internal jugular and anterior mediastinal
nodes
(iii) Paratracheal Nodes – drain the thyroid lobes, subglottic larynx,
tracha and cervical oesophagus
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Level I
Submental (IA)
Submandibular (IB)
 Level II
Upper jugular
 Level III
middle jugular
 Level IV
Lower jugular
 Level V
Posterior triangle group(Spinal accessory and transverse cervical chains)
 Level VI
Prelaryngeal
Pretracheal
Paratracheal
 Level VII
Nodes of upper mediastinum
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Level I includes :
IA Submental nodes, which lie in the
submental triangle i.e. between right and
left anterior bellies of diagastric muscles and
the hyoid bone.
IB Submandibular ones, lying between
anterior and posterior bellies of diagastric
muscle and the body of mandible
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49
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Level II – Upper Jugular Nodes
They are located along the upper third of
jugular vein I.e. between the skull base
above, and the level of hyoid bone (or
bifurcation of carotid artery) below
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Level III – Middle Jugular Nodes
They are located along the middle third of
jugular vein, from the level of hyoid bone
above, to the level of upper border of cricoid
cartilage
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Level IV – Lower Jugular Nodes
They are located along the lower third of
jugular vein; from upper border of cricoid
cartilage to the clavicle
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Level V – Posterior Cervical Group
They are located in the posterior triangle i.e.
between posterior border of
sternocleidomastoid(anteriorly), anterior
border of trapezius (posteriorly), and the
clavicle below. They include lymph nodes of
spinal accessary chain,transverse cervical
nodes and supraclavicular nodes
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Level VI – Anterior Compartment Nodes
They are located between the medial borders
of sternocleidomastoid muscles (or carotid
sheaths) on each side, hyoid bone above and
superasternal notch below. They include
prelaryngeal,pretracheal, paratracheal nodes
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Level VII
They are located below the suprasternal
notch and include nodes of the upper
mediastinum
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Examination of neck nodes is important,
particularly in head and neck malignancies
and a systematic approach should be
followed.
Neck nodes are better palpated while
standing at the back of the patient.
Neck is slightly flexed to achieve relaxation of
muscles
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When a node or nodes are palpable, look for the following
points:
(i) Location of nodes
(ii) Number of nodes
(iii) Size – Abnormal Nodes
Greater than 1.5 c.m. in jugulo digastric area (level 1,2,3)
Greater than 1 c.m. elsewhere.
(iv) Consistency. Metastatic nodes are hard;lymphoma nodes are
firm and rubbery; hyperplastic nodes are soft. Nodes of
metastatic melanoma are also soft.
(v) Discrete or matted nodes.
(vi) Tenderness. Inflammatory nodes are tender.
(vii) Fixity to overlying skin or deeper structures. Mobility should be
checked both in the vertical and horizontal planes
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The nodes are examined in the following
manner so that none is missed.
a) Upper horizontal chain.
b) External jugular chain
c) Internal jugular chain
d) Spinal accessory chain
e) Transverse cervical chain
f) Anterior jugular chain
g) Juxtavisceral chain
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Submental Nodes
Roll the fingers below the chin with patient’s
head tilted forwards
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Submandibular Nodes
Roll your fingers against inner surface of
Mandible with patient's head gently tilted
towards one side
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Parotid (Preauricular) Nodes
Roll your finger in front of the ear, against the
maxilla
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Post auricular (Mastoid Nodes)
Roll the fingers behind the ear
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Occipital Nodes
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Internal jugular chain
Examine the upper, middle and lower groups.
Many of them lie deep to sternomastoid
muscle which may need to be displaced
posteriorly
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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
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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 a normal
response of the lymph nodes to an infection
elsewhere in the body.
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Cervical lymphadenopathy may be either an
important clue to an underlying disease
process or a specific clinical syndrome
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1.Infectious disease
A.Viral
-Infectious mononucleosis
-Infectious hepatitis
-Herpes simplex
-Rubella
-Measle
-Hiv
B.Bacterial
-Cat scratch disease
-Brucellosis
-Tuberculosis
-Atypical mycobacterial infection
-Primary and secondary syphilis
-Diptheria
C. Fungal
-Histoplasmosis
-Coccidioidomycosis
D.Parasitic
-Toxoplasmosis
-Filiriasis
E.Chlamydial
-Lymphogranuloma venerum
- Trachoma
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2.Immunologic disease
A.Rheumatoid arthritis
B.Systemic lupus erythematous
C.Sjogren syndrome
D.Drug hypersensitivity
E.Mixed connective tissue disease
3.Malignant disease
a.Hematological
-Hodgkin disease
-Non hodgkin disease
-Hairy cell leukamia
-T-cell lymphoma
-Multiple myeloma
B.Metastasis
-From primary site
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4.Lipid storage disease
-Gaucher’s disease
-niemann-pick disease
5.Endocrine disease
-Hyperthyroidism
-Adrenal insufficiency
-Thyroiditis
6.Other disorder
-Sarcoidosis
-Lymphomatoid granulomatosis
-Kawasaki disease
-Histocytosis x
-Kikuchi disease
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1.Location
A.Anatomical site
B.Presence of single or multiple nodes
C.Presence of localized or disseminated nodes
D.Palpable nodes are unilateral or bilateral
2.Consistency
A.Firm
B.Soft
C.Rubbery
D.Rock hard
E.Movable
F.Fixed
3.Size
A.<1 cm or >1cm
B.If nodes are bilateral,check for symmetry
4.Symptoms
A.Symptomatic
B.Tender
C.Painful
D.Associated with systemic symptoms or not
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Structures that can be mistaken for enlarged
lymph nodes include cystic hygromas,
branchial cleft cysts, thyroglossal duct cysts,
dental abscesses, dermoid cysts, and tumors
of thyroid or neural tissue
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Nx : Regional LN cannot be assessed
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No :no regional LN metastasis
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N1 :metastasis in a single ipsilateral LN
<3cm In greatest dimension
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N2a :metastsis in single ipsilateral LN
>3cm but <6cm in greatest dimension
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N2b :metastasis in the multiple ipsilateral LN
>6cm in greatest dimension
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N2c :metastasis in a bilateral or contralateral LN
none >6 cm in greatest dimension
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N3 :metastasis in lymphnode
>6cm In greatest dimensiom
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Tenderness, redness or warmth in the area of
the lymph node
Fever
Lymph node enlargement
Difficulty in swallowing or breathing
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Acetaminophen or ibuprofen may be given
for pain
Antibiotics if the cause is due to bacteria.
Viral infections do not need antibiotics.
Referral to a dentist if a tooth is abscessed
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Suspected Staphylococcus aureus or Group A Betahemolytic Streptococcus Infection
 For children who do not appear toxic and have no
apparent abscess or cellulitis, Oral empiric therapy
with cephalexin, oxacillin, or clindamycin
 For ill-appearing children who have abscess formation
or cellulitis,node aspiration and intravenous therapy
with cefazolin, nafcillin or oxacillin, or clindamycin
Suspected Infection With Anaerobic Bacteria
 For children who have cervical lymphadenitis
associated with periodontal disease, node aspiration
and therapy with penicillin or clindamycin
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Suspected Nontuberculous Mycobacteria Infection
 Surgical excision of the infected lymph node without
antibiotic therapy
 For patients in whom surgery is not feasible, a macrolidecontaining multidrug antimycobacterial regimen
Cat-scratch Disease
 Following needle aspiration and PCR diagnosis of
Bartonella infection, no antimicrobial therapy in patients
who have uncomplicated lymphadenopathy.
 Surgical removal of nodes infected with Bartonella
frequently results in persistent drainage and poor wound
healing. Repeated node aspiration for management of
suppurative lymphadenopathy caused by Bartonella
infection
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anatomy 15th edition
I.B.SinghText book of anatomy 3rd edition
Singh,Pal.Human embryology 7th edition
B D Chaurasia.Human Anatomy 4th edition vol3
Anand.Human Anatomy for Dental Students 1st
edition
Anil Ghom.Textbook of Oral Medicine 1st edition
Shafer.Textbook of Oral Pathology 5th edition
Infectitious diseases Cervical Lymphadenopathy
Pediatrics in Review Vol. 21 No. 12 December 2000
86