lymphatics condensed grayscale slides

7/27/2019 Lymphatics Condensed Grayscale Slides

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Lymphatic DrainageLymphatic Drainage

Alex ForrestAssoci ate Profess or of For ensic Od ontol ogyForensic Science Research & Innovation Centre, Griffith UniversityConsultant Forensic Odontologist,Queensland Health Forensic and Scientific Services,

39 Kessels Rd, Coopers Plains, Queensland, Australia 4108

Oral Biology

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The material in this communication may be subject to copyright under the

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Do not remove this notice

Learning GoalsLearning Goals

On completion of this topic you should be able to describe

the general plan of the lymphatic drainage of the headand neck.

You should be able to describe the positions of all the

major groups of lymph nodes.


You should be able to describe and demonstrate the

ability to assess clinically the spread of infection in thehead and neck using the major lymph node groups.

You should demonstrate an understanding of the role

played by the lymphatic system in controlling and

directing the spread of infection and certain neoplasia

in the head and neck.


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LymphaticsLymphatics

The lymphatic system is concerned with the removal and

return to the blood system of tissue fluid not reabsorbed

into the blood capillaries during circulation, with the

absorption of fat from the small intestine, and mostimportantly, with immunity.


It consists of lymphatic capillaries and vessels, lymph

nodes, organs such as the thymus, spleen and bone

marrow, and with masses of lymphatic tissue in the

walls of the alimentary tract, together with circulatingcells.


In our discussion of the lymphatics in this session, we

will restrict ourselves to a discussion of the structuralcomponents of the lymphatic system and the various

groups of lymph nodes and lymphatic capillaries and

vessels in the head and neck, and consider their

importance in the spread of infection and in clinical

diagnosis.

Vascular SystemVascular System

Recall that the blood vascular system is a body system

that deals with two of the body's most importantfunctions: transport and protection.

It comprises the blood system, the lymphatic system,

and the interstitial fluid. Each of these is related to the

other, and their functions are closely allied as a result.


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Vascular SystemVascular System

The blood system acts as the transport system for the

body.

The lymphatic system is the body's protective system.

Interstitial fluid is the contact that each individual cell has

with the fluid system of the body.

Fluid MovementFluid Movement

The heart acts as

the fluid pump

within the body.

It pumps blood into

arteries, andreceives blood from

veins.

http://www.mhhe.com/biosci/ap/dynamichuman2/content/gifs/0136B.gif


On the right side, blood is sent into the pulmonary circuit. The

pulmonary artery carries deoxygenated blood to the lungs, and

the pulmonary vein returns oxygenated blood to the left side of

the heart.

http://www.mhhe.com/biosci/ap/dynamichuman2/content/gifs

/0140.gif


The left ventricle of the heart pumps blood into the systemic

circuit, though which it flows eventually back to the right atrium

before revisiting the pulmonary circuit again.

http://www.mhhe.com/biosci/ap/dynamichuman2/content/gifs

/0140.gif


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Blood leaving the heart initially

flows through large arteries. As

these arteries become more distant

from the heart, they subdivide,

becoming smaller vessels known

as arterioles.

Arteries and arterioles have

significant amounts of smoothmuscle in their walls, and this helps

maintain blood pressure, and

absorbs some of the pumping force

of the heart.http://www.lab.anhb.uwa.edu.au/mb140/CorePage

s/Vascular/Vascular.htm


Finally blood flows into smaller

vessels still, known as

capillaries.

Capillaries are incredibly

numerous, but are small in

cross-section, and are quitepermeable to a number of

substances including fluid from

the blood plasma.http://www.lab.anhb.uwa.edu.au/mb140/CorePage

s/Vascular/Vascular.htm


Due to the blood pressure in the

initial part of the capillary, some

of the plasma is filtered throughthe vessel wall and emerges

from the capillary.

This is the source of the

interstitial fluid, the fluid that lies

between the cells of the body.

http://www.chelationtherapyonline.com/articles/im

ages/bloodvessels_4.gif


You may think of interstitial fluid as resulting in somerespects from the natural leakiness of the capillaries.

Within the interstitial fluid, nutrients and gases are carried

to every cell of the body, and waste products are

removed.


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As the blood pressure falls

along the length of the

capillary, it becomes

comparable with the

osmotic force exerted by the

concentration of large

molecules remaining in thecapillary lumen that did not

escape into the surrounding

tissues. http://www.chelationtherapyonline.com/articles/images/bloodvessels_4.gif


As we move further

along the capillary, and

the blood pressure

drops still further, the

osmotic force begins to

dominate, setting up an

osmotic gradient thatfavours the return of the

interstitial fluid back into

the capillary.

Van de Graff, K. Human Anatomy, Wm. C. Brown Iowa, 2 nd Ed. P

532


Approximately 80% to 90% of interstitial fluid is reabsorbed

back into the capillaries in this way.

http://training.seer.cancer.gov/module_anatomy/unit8_2_lymph_compo.html


http://training.seer.cancer.gov/module_anatomy/unit8_2_lymph_compo.html

The remainder would waterlog the tissues, however, if it were

allowed to remain, so instead it is gathered up into small

vessels known as lymphatic capillaries, and channelled into

the lymphatic system.


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Here, it passes into

lymphatic vessels, during

its passage along which it

will pass through lymph

nodes.

The lymph nodes play arole in controlling the

spread of infection and in

fighting it.

Van de Graff, K. Human Anatomy, Wm. C. Brown Iowa, 2 nd

Ed. P 532


Eventually, all this lymph

fluid is returned to the

blood system through two

large lymphatic vessels,

the right lymphatic duct

and the thoracic duct,which drain into veins in

the neck.

From Grays Anatomy, Longman, London, 35 th Ed 1973p.

727.


The remainder of the blood

returns to the heart through

larger vessels, venules,

which lead to veins, and

these, in turn, return to the

heart.

Van de Graff, K. Human Anatomy, Wm. C. Brown Iowa, 2 nd

Ed. P 532


Now that we can see the broad relationship between the

three types of fluid, blood, lymph and interstitial fluid, and

how the interstitial fluid and lymph are formed, let us

examine the components of the system more closely.


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Lymphatic CapillariesLymphatic Capillaries

Unlike the capillaries of the blood system, which bridge

between the arterial part and the venous part of the

circulation, there is no arterial part to the lymphatic

system.

It simply begins in the tissues, wherever excess tissue

fluid collects from blood capillaries, as a system of blind

lymphatic capillaries.


Lymphatic capillaries are

tiny thin-walled vessels

that begin as blind tubes

in the spaces between

cells in most tissues of

the body except in

cartilage and the central

nervous system, the

epidermis including the

hair and nails, cornea of

the eye, and also bone

marrow.www.anatomy.dal.ca/html/Human%20Histology/DHD/Lab2/

4_lh.JPG


Basically, anywhere that there is circulation, there are also

lymphatic capillaries.

They are not therefore found in the avascular tissues such as

those we listed above.

Tissue fluid in the brain and spinal cord drains into the

cerebrospinal fluid through spaces around the blood vessels.


In structure, lymph

capillaries are most

similar to blood

capillaries, but differ in

some respects.

www.anatomy.dal.ca/html/Human%20Histology/DHD/Lab2/

4_lh.JPG


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Lymph capillaries are lined by

endothelial cells like blood

capillaries, but in lymphatic

capillaries, the endothelial

cells overlap each other.

http://www.bmb.psu.edu/courses/bisci004a/immune/lympi

ntak.jpg


This is important, because

when pressure from the

accumulating tissue fluid from

outside the capillary pushes

on its wall, the flap of

endothelial cell beneath the

overlap swings inwards to let

the fluid into the vessel. http://www.jdaross.mcmail.com/images/lymphatic.gif


Once the fluid is in the lumen,

then it cannot escape again,

because it simply pushes this

flap closed again and is

prevented from getting backout.

Because of this structure,

lymphatic capillaries are more

permeable than blood

capillaries, and substances ofhttp://www.jdaross.mcmail.com/images/lympha

tic.gif

large molecular size, and even particles such as cell debris

and micro-organisms can be accommodated.


They also have larger, more

irregular lumens which are

capable of holding larger

particles in their contents.

They are very hard to see in

microscopic sections because

they tend to collapse when

they are empty.

http://www.bmb.psu.edu/courses/bisci004a/immune/lympi

ntak.jpg


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Lymphatic capillaries also

possess valves which permit

the lymphatic fluid to travel in

one direction only.

This is important, because it

ensures that fluids andmaterials collected in a

lymphatic capillary are

directed through lymph nodes.http://www.jdaross.mcmail.com/images/lympha

tic.gif


These lymphatic capillaries form networks that eventually join

together to form larger trunks, which have a structure similar

to veins, but are thinner with less-well defined tunic layers.

Along these larger vessels lie lymph nodes.

Lymph from most parts of the body is forced to pass through

one or more lymph nodes on its way back to the venouscirculation, with the exception of the lymph from the thyroid

gland and the oesophagus, which drains directly into the

thoracic duct.

Lymph VesselsLymph Vessels

Eventually, lymph vessels drain into either the thoracic duct or

the right lymphatic duct.

All of the lymphatic vessels of the body drain into the thoracic

duct except for those of the right side of the head, the right

upper limb, and the right neck and the right side of the thorax.


The thoracic duct drains into the

junction between the left internal

jugular vein and the left subclavian

vein.

All the tissues of the right side ofthe head, the right upper limb, and

the right neck and thorax drain into

the right lymphatic duct which

drains in turn into the junction

between the right internal jugular

vein and the right subclavian vein.

From Grays Anatomy, Longman, London, 35 th Ed 1973p. 727


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Larger lymphatic vessels also possess valves, which once

again forces the lymph to travel away from the tissues and

towards the venous circulation in one direction only.

Lymphatic NodulesLymphatic Nodules

Throughout the loose connective tissues of the body, small

nodules of lymphatic tissue can be found. These are smallish

masses, perhaps 1 mm or so in diameter, and they occur

particularly in the connective tissue beneath mucous

membranes.


In the head and neck, they are particularly noticeable aroundthe posterior part of the oral and nasal cavities.

Elsewhere in the body, we find them in the walls of the

intestines, around the anus, and in relation to the urinary tract.


They are distributed strategically so as to protect underlyingtissues that may be at risk of penetration by microorganisms

from the digestive, respiratory and urinary tubes, all of which

have surfaces that lie outside the body, and which may

therefore harbour dangerous bacteria and viruses.


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If you examine such a lymph nodule with a microscope, you

notice that it is packed with lymphocytes, but unlike the lymph

nodes, the lymph nodules do not connect to lymph vessels.

An Atlas of Human Histology, Di Fiore M. Lea & Febiger, Philadelphia, 1st Edition 1961, p. 113.


Sometimes, observation with the microscope will reveal centres

where many immature lymphocytes are busily developing in

response to some immune challenge that requires cells that

can respond to a specific agent.



Such areas are known as germinal centres.



While most lymph

nodules are smallish

and occur as solitary

structures, in some

areas they are found

as large clusters.

Some of these we are

already familiar with,

such as the tonsils.

Copyright University of Queensland School of Dentistry


12/20


Indeed, the tonsils form a kind of ring around the entry to the

oropharynx and nasopharynx, made up of the single

pharyngeal tonsil (adenoid), the two palatine tonsils, and the

lingual tonsil.

This ring is known as Waldeyer's Lymphatic Ring, after theworker who first described it.

Lymph NodesLymph Nodes

Lymph nodes are small,

bean shaped masses of

lymphatic tissue of

varying size.

http://www.acm.uiuc.edu/sigbio/project/updated-

lymphatic/lymph7.html


The node is enclosed in a

strong fibroelastic

capsule, and extensionsof this capsule run into

the node, forming

partitions that partially

divide the node into

several incomplete

compartments.

Van de Graff, K. Human Anatomy, Wm. C. Brown, Iowa, 2 nd

Ed. P 534


Lymph vessels that

approach a lymphnode, carrying their

one-way load of

lymph, divide up into a

number of branches.

http://www.acm.uiuc.edu/sigbio/project/updated-

lymphatic/lymph7.html


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Lymph flowing in along

these branches is

directed to the outside

of the node, and must

flow through channels

called lymphatic

sinuses within the

node to get to theoutgoing vessel in the

region called the hilus

of the node.

http://www.jdaross.mcmail.com/lymphnode.htm


These channels are

lined with

lymphocytes and

macrophages.

As it passes throughthe lymph node, the

lymph is filtered past

these cells.

http://www.jdaross.mcmail.com/lymphnode.htm


The lymph may contain debris including micro-organisms of

varying types that have penetrated the body's defence

barriers, phagocytic cells that may have been attracted tosuch a breach (some of which may either be alive or dead,

and some of which may contain ingested microbes or other

materials), damaged or worn-out tissue cells, cells from

malignant tumours, or inhaled particles in nodes downstream

from respiratory passages or the lungs.


As these materials are exposed to the lymphocytes andmacrophages, their organic components are either

phagocytosed by the macrophages or destroyed by antibodies

made by the B-lymphocytes.


14/20


There are usually several lymph nodes between a region of

tissue and the venous system. This means that material that

was not filtered off and successfully dealt with in one lymph

node passes on to the next and so on.

By the time the lymph reaches the blood it has usually beencleaned of all impurities such as cell debris and foreign

bodies.


In some instances where phagocytation is incomplete the

node may swell.

You may well have experienced swollen cervical lymph nodes.

These often accompany a sore throat due to streptococcal

infection.

Infections in almost any part of the body may result in swellingand tenderness of the lymph nodes associated with that part

of the body.


Activated T and B lymphocytes multiply in the lymph nodes,

and T and B lymphocytes are added to the lymph as it flows

through the sinuses.

The lymph leaving the node therefore carries lymphocytes that

will eventually pass into the blood.

Antibodies produced by the B lymphocytes enter the lymph

and the blood draining the node.


Lymph nodes are therefore important to us clinically.

If we know the route by which a body part is drained, and

which groups of lymph nodes lie along the route taken by the

vessels that drain it, then we can assess those nodes for

swelling and hardness (induration) and tenderness to

palpation.


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Regional Lymph NodesRegional Lymph Nodes

We learn about the regional lymph nodes in the head and

neck so that we can assess them to determine the spread of

infection, and in some cases, so we can ensure that we

remove all those nodes that may be affected by a spreadingcancer.


We can divide the nodes of the head and neck into superficial

groups and deep groups.

The superficial groups tend to be more important to us

clinically, because we can palpate them directly.


Superficial Groups:

Deep Groups:

Pericervical ri ng

Nodes accompanying superficial neck veins

Perivisceral ring

Deep cervical chain

Pericervical RingPericervical Ring

This group is clinically important and comprises:

Submental Group

Submandibular Group

Parotid or Pre-auricular Group

Mastoid Group

Occipital Group


16/20


These groups of

nodes drain the

surface tissues

of the head and

the face.

From Grays Anatomy, Longman,

London, 35th Ed 1973p. 729


The drainage

pattern is

shown on this

diagram.


The scalp drains

into all nodes, whilethe eyelids and

cheeks drain into

the parotid and

submandibular

groups.


The external nose and

the upper lip drain intothe submandibular

group, while the lower

lip drains into the

submental and

submandibular

groups.


17/20


The floor of the mouth

at the sides drains into

the submandibular

group and also to the

deep cervical chain.

The lateral parts of thelips drain into the

submandibular group.


The tip of the tongue, the

central parts of the floor of

the mouth and the lower lip

drain bilaterally into the

submental group.

Anterior teeth as far back as

the canines drain into the

submandibular andsubmental groups, and

premolar and molar teeth

drain into the parotid group

and the deep cervical chain.

Superficial NeckSuperficial Neck

The nodes accompanying

superficial neck veins are

also clinically important,

since they are easily

palpable in the clinic, and

tell us about superficial

infections and systemic

infections.

These lie in two chains

which follow the anterior

jugular vein and the

external jugular vein

respectively.

Superficial NeckSuperficial Neck

The nodes in the group

following the external

jugular vein are particularly

easily palpated in the living

individual because they lie

superficially to thesternocleidomastoid

muscle.

You should take care to be

sure you can recognize

these as distinct from the

nodes of the deep cervical

chain.


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Perivisceral RingPerivisceral Ring

The most anterior group of these nodes changes its name as it

ascends in the neck, according to the structures alongside

which it lies at any particular level:

pre-tracheal nodes

pre-laryngeal nodes

infrahyoid nodes

These lie anteriorly in the neck, in front of the larynx and

trachea.


The posterior group also changes its name in the same way.

Thus, we have:

retro-oesophageal nodes

retro-pharyngeal nodes


The paratracheal group lies laterally alongside the trachea.

The entire group surrounds the larynx, trachea and

oesophagus, giving rise to its name, the perivisceral ring,

since it surrounds the neck viscera.

Deep Cervical ChainDeep Cervical Chain

The deep cervical chain is difficult to

palpate for most of its course since it

lies deep to the sternocleidomastoid

muscle, but at its upper and lower

ends, it has two major nodes namedfor muscles close to which they lie.

These are the jugulodigastric node

(upper) and the jugulo-omohyoid

node (lower).

The other nodes in this chain are not

named.


19/20


All of the lymph from the head and

neck eventually drains into the deep

cervical chain on both sides.

Premolar and molar teeth drain into

its upper nodes, as do the sides of

the tongue and the floor of the mouth

at the sides.

The palate drains into the upper

nodes, and the pericervical groups

also drain into this chain.


The deep cervical chain drains into

the right lymphatic duct on the right

side, and into the thoracic duct on the

left.


On completion of this topic you should be able to describe

the general plan of the lymphatic drainage of the headand neck.

You should be able to describe the positions of all the

major groups of lymph nodes.


You should be able to describe and demonstrate the

ability to assess clinically the spread of infection in thehead and neck using the major lymph node groups.

You should demonstrate an understanding of the role

played by the lymphatic system in controlling and

directing the spread of infection and certain neoplasia

in the head and neck.


20/20

The End

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