LYMPHATICS OF HEAD & NECK

PRESETED BY: Dr.Apala Baduni

WILLIAM HARVEY

 ALEXANDER OF WINIWARTER

HIPPOCRATES

RUFUS OF EPHESUS

THOMAS BARTHOLIN

HISTORY

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

EMBRYOLOGY Lymphatic vessels  hemangioblastic stem cells

First signs  5th week

Begins to develop by end of fifth week IU

Develop from lymph sacs that arise from developing veins, derived from mesoderm.

Six primary lymph sacs are formed.

The first lymph sacs to appear are paired jugular lymph sacs .

Development of lymphatic system:

Capillary plexuses enlarge.

Form lymphatic vessels .

Each jugular lymph sac retains at least one connection with its jugular vein.

Left one develops into the superior portion of the thoracic duct.

8th wk of IU-Retroperitoneal lymph sacs forms.

9th wk of IU cisterna chili develops-lower part of the thoracic duct develops from left jugular sac.

Later stages-lymph sacs are invaded by lymphocytes.

Transformed into group of lymph nodes

Development of Spleen & Thymus

The spleen develops from mesenchymal cells between layers of the dorsal mesentery of the stomach.

The thymus arises as an outgrowth of the third pharyngeal pouch.

The lymph nodes develop in the early fetal period through a septation of the lymph sacs by mesenchymal cells.

The spaces thus delimited become the sinus of the adult lymph nodes.

PHYSIOLOGY AND ANATOMY

. Key Components of Lymphatic System

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)

MAIN FUNCTIONS

Restoration of excess interstitial fluid and proteins to the blood

Absorption of fats and fat-soluble vitamins from the digestive system and transport of these elements to the venous circulation

Defense against invading organisms

Components Of Lymphatic System

Organ Function

Lymph Contains nutrients, oxygen, hormones, and fatty acids, as well as toxins and cellular waste products, that are transported to and from cellular tissues

Lymphatic vessels Transport lymph from peripheral tissues to the veins of the cardiovascular system

Lymph nodes •Monitors the composition of lymph, •the location of pathogen engulfment •eradication, the immunologic response, and the regulation site

Spleen Monitors the composition of blood components, the location of pathogen engulfment and eradication, the immunologic response, and the regulation site

Thymus Serves as the site of T-lymphocyte maturation, development, and control

LYMPH Lymph blood plasma.

It is pushed out through the capillary wall by pressure exerted by the heart or by osmotic pressure at the cellular level.

Lymph contains

As the lymph passes through the lymph nodes, lymphocytes and monocytes enter it.

NutrientsOxygenHormonesToxins Cellular Waste

Water (96%)

Solids (4 %) Organic substances

Proteins (2 – 6 % of solids)

Lipids (5– 15% of solids)

Carbohydrates

Amino acids

AlbuminGlobulinFibrinogenProthrombinOther clotting factorsAntibodiesEnzymesChylomicrons Lipoproteins

Glucose(120 mg%)

All amino acids presents in plasma

Composition of lymph

In Other nitrogenous substances

organic substances In low conc.

than in plasma

UreaCreatinine

SodiumPotassiumCalcium

In higher conc. than in plasma

ChloridesBicarbonates

Cellular contents Lymphocytes 1000 -2000 cells per cu mm

Other cells MonocytesMacrophagesPlasma cells

Components of lymphatic system Lymph Lymphatic Vessels Lymphatic Capillaries Lymphatic Vessels Lymphatic Trunks Lymphatic Ducts

All tissues of body have special lymph channels to drain excess fluid directly from interstitial spaces except :

superficial portion of skin, CNS endomysium of muscles, bones

They have minute interstitial channels called prelymphatics .

Fluid eventually empties into lymphatic vessels , or in case of brain into CSF & then directly back into blood.

Lymphatics 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 ductDrains the rest of the body

Empties into the left subclavian vein

Only 2 areas in head and neck have no direct lymphatics: a) orbit- is virtually devoid of lymphatics. b) muscles- do not have lymphatics

Their lymph drains in fascial planes between muscles and around the blood vessels that supply them.

LYMPH VESSELS ARE NOT PRESENT IN : CNS Bones Alveoli of lungs

LYMPHATIC VESSELS

.Lymphatic capillaries –

Blind-ended tubes

Thin endothelial walls.

Overlapping pattern

The lymphatic capillaries coalesce to form larger meshlike networks of tubes that are located deeper in the body

Lymphatic vessels

The lymphatic vessels

2 lymphatic ducts

 

Lymphatic vessels have 1-way valves to prevent any

backflow 

The right lymphatic duct Drains the upper right quadrant

The thoracic ductWhich drains the remaining lymphatic tributaries

RATE OF FLOW

About 120 ml lymph flows into blood per hour 100 ml/hr – Thoracic duct 20 ml/hr - Rt. Lymphatic duct

 

Lymphatic Organs

PRIMARY ORGANS Red bone marrow Thymus gland

SECONDARY ORGANS Lymph nodes Lymph nodules Spleen

central

central

peripheral

peripheral

Thymus

In the thymus, t lymphocytes dont respond to pathogens and foreign organisms.

After maturation

They enter the blood and go to other lymphatic organs where they help provide defense.

Bilobed lymphoid organ

Superior mediastinum of the thorax, posterior to the sternum

Function Processing and maturation of t lymphocytes. Produces thymosin, a hormone that helps stimulate maturation of t lymphocytes in other lymphatic organs

SPLEEN

It is surrounded by a connective tissue capsule that extends inward to divide the organ into lobules

Red pulp venous sinuses filled with blood and cords of lymphocytes and macrophages

White pulp lymphatic tissue consisting of lymphocytes around the arteries.

Lymphocytes are densely packed within the cortex of the spleen.

•Largest lymphatic organ

•Convex lymphoid structure located Below the diaphragm and behind The stomach.

•Cells•small blood vessels•tissue known as red and white pulp.

FUNCTIONS Reservoir of lymphocytes

It filters blood

It plays an important role in red blood cell and iron metabolism through macrophage phagocytosis of old and damaged red blood cells

It recycles iron by sending it to the liver

It serves as a storage reservoir for blood

It contains T lymphocytes and B lymphocytes for immunologic response

Mucosa Associated Lymphoid TissueMALT

Non encapsulated lymphoid tissue

2 major components of MALT:

BALT (Bronchial Associated Lymphoid Tissue) GALT (Gut Associated Lymphoid Tissue) GALT

Peyer’s patches Appendix – also known as belly tonsil / intestinal tonsil

Minor components of MALT Nose-associated lymphoid tissue (NALT) Vulvovaginal-associated lymphoid tissue (VALT) Skin associated lymphoid tissue (SALT) is not mucosal but has the

same characteristics of the MALT

Tonsils

Aggregates of lymph node tissue located under the epithelial lining of the oral and pharyngeal areas.

The predominance of lymphocytes and macrophages in these tonsillar tissues offers protection against harmful pathogens and substances that may enter through the oral cavity or airway

• The palatine tonsils (on the sides of the oropharynx)• The pharyngeal tonsils (on the roof of the nasopharynx; also known as adenoids)•Lingual tonsils (on the base of the posterior surface of the tongue).

Type Epithelium Capsule Crypts Location

Adenoids (also termed "pharyngeal tonsils")

Ciliated pseudostratified columnar (respiratory epithelium)

Incompletely encapsulated

No Roof of pharynx

Tubal tonsils

Ciliated pseudostratified columnar (respiratory epithelium)

Partially encapsulated

Roof of pharynx

Palatine tonsils Non-keratinized stratified squamous

Incompletely encapsulated

Long, branched

Sides of oropharynx between palatoglossaland palatopharyngeal arches

Lingual tonsilsNon-keratinized stratified squamous

Incompletely encapsulated

Long, unbranchedBehind terminal sulcus (tongue)

Lymphatic Organs – Lymph Nodes

Oval, bean shaped structures scattered throughout body along lymph vessels

May be deep or superficial

Concentrated along the respiratory tree and GI tract, in the mammary glands, axillae, and groin

Filter lymph fluid to trap foreign organisms, cell debris, and tumor cells

Lymphatic Organs – Lymph Nodes

Covered by a fibrous connective tissue capsule

Trabeculae extend from cortex to medulla

Stroma – the internal supportive connective tissue network of reticular fibers

Structure of a Lymph Node outer cortex - filled with lymph follicles

outer edge of follicle contains more T cells inner germinal center is the site of B-cell

proliferation

inner medulla - medullary cords of lymphocytes, macrophages, plasma cells (activated B cells)

Cortex

Medulla

Structure of a Lymph Node

Medullary cords extend from the cortex and contain B cells, T cells, and plasma cells

Throughout the node are lymph sinuses crisscrossed by reticular fibers

Macrophages reside on these fibers where they phagocytize foreign matter

follicles withgerminal centers

Histology of Lymph Nodes

Circulation in the Lymph Nodes Lymph enters via a number of afferent

lymphatic vessels

It then enters a large subcapsular sinus and travels into a number of smaller sinuses

It meanders through these sinuses and exits the node at the hilus via efferent vessels

The node acts as a “settling tank,” because there are fewer efferent vessels, lymph stagnates somewhat in the node

This allows lymphocytes and macrophages time to carry out their protective functions

Only lymph nodes filter lymph!

Fluid enters cortex through afferent vessels Filter and trap damaged cells,

microorganisms, foreign substances, tumor cells by reticular fibers

Macrophages phagocytize some, lymphocytes destroy some by immune defenses

Exits medulla by efferent vessels at hilus

Lymph Flow Through Lymph Nodes

Blood Flow Through Lymph Nodes

Blood vessels enter and exit at the hilus

This blood provides nutrition for the node’s tissues

route for leukocytes to enter into or exit from the lymphatic tissue of the node

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

Deep lymph nodes

1. Prelaryngeal and pretracheal

2. Paratracheal

3. Retropharyngeal

OCCIPITAL NODES Situated at the apex of

posterior triangle of neck

Recieves lymph from back of scalp

Drains into deep cervical lymph nodes

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

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

Regional to: Anterior temporal

region Lateral part of

forehead Eyelids posterior part of

cheek part of external ear parotid gland

PREAURICULAR/ POSTAURICULAR

INFRA AURICULAR / SUPERFICIAL & DEEP CERVICAL NODES

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.

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

Regional to: Skin on the anterior

surface of face

Secondary to: Deeper part of face Mucous memberane

of lips & cheek. Occasionally even

from upper/lower teeth & adjacent gingiva.

Submandibular lymph nodes

Situated on

a) superficial surface of submandibular salivary gland.

b) Beneath investing layer of deep cervical facia.

They are divided into:

Anterior group :submental vein close to chin.

Middle group : around facial vein& facial artery above submandibular salivary gland.

Posterior group : behind facial vein.

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.

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 chinDrains into submandibular & deep cervical nodes

Regional to Middle part of lower lip Skin of chin tip of tongue lower incisors & gingiva

Secondary lymph nodes of this region are in part submandibular & in part superior deep cervical lymph nodes

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.

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

Primary to :

Base of tongue

Sublingual region

Posterior part of palate

They are secondary and tertiary nodes into which the lymph of auricular, submental, submandibular & accessory nodes of face empty.

They are also secondary to nuchal nodes, deep lymph nodes of neck, retropharyngeal, infrahyoid, pretracheal, paratracheal lymph nodes.

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

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

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.

Laryngeal lymph nodes

Situated in front of larynx on cricothyroid ligament.

Recieves lymph from larynx, trachea, isthmus of thyroid.

Drains into deep cervical lymph nodes.

Tracheal lymph nodes Situated

Pretracheal in front of trachea.

Paratracheal lateral to trachea.

Recieves lymph :

Oesophagus, trachea, larynx.

Drains into deep cervical lymph nodes

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.

Tonsils

Dr. owais pg Ist yr ENT SMHS

Grading the Size of Tonsils

Grading system:A. 0 – tonsils in fossaB. +1 – tonsils less than 25%C. +2 – tonsils less than 50%D.+3 – tonsils less than 75%E. +4 – tonsils greater than 75%

Anatomy

Blood supply - Tonsils

Facial a.

Lingual a. Dorsal lingual

Ascending pharyngeal ECA

Greater palatine branch of maxillary artery

Tonsillar branch Tonsil (main branch)

Ascending palatine Tonsil

Anatomy

Blood supply – Adenoids

Ascending palatine branch of facial a. Ascending pharyngeal a. Pharyngeal branch of IMAX. Ascending cervical branch of thyrocervical trunk.

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

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.

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.

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).

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

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

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

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

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

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

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

Face and Scalp Anterior Facial, Ib

  Lateral Parotid

  Posterior Occipital, V

Eyelids Medial Ib

  Lateral Parotid, II

Chin   Ia, Ib, II

External Ear Anterior Parotid, II

  Posterior Post auricular, II, V

Middle Ear   Parotid, II

Floor of mouth Anterior Ia, Ib, IIa > IIb

  Lower incisors Ia, Ib, IIa > IIb

  Lateral Ib, IIa > IIb, III

  Teeth except incisors Ib, IIa > IIb, III

Nasal Cavity Anterior Ib

  Posterior Retropharyngeal, II, V

Common Nodal Drainage Patterns

Nasal Cavity Posterior Retropharyngeal, II, V

Nasopharynx   Retropharyngeal, II, III, V

Oropharynx   IIb > IIa, III, IV, V

Larynx Supraglottic IIa > IIb, III, IV

  Subglottic VI, IV

Cervical esophagus   IV, VI

Thyroid   VI, IV, V, Mediastinal

Tongue Tip Ia, Ib, IIa > IIb, III, IV

  Lateral Ib, IIa > IIb, III, IV

Common Nodal Drainage Patterns

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)

carcinomas metastatise by lymphatic route sarcomas by haematogenous route.

The wall of lymphatics is readily invaded by cancer cells & forms a continuous growth in lymphatic channels c/a lymphatic permeation, or may detach to form tumor emboli to be carried along to the next lymph node.

Tumor emboli enter the lymph node at it’s convex surface & are lodged in subcapsular sinus.

SPREAD OF ORAL CANCER VIA LYMPH NODES

Mucosal lip cancers represent approximately 2 to 42% of oral cavity

cancers.

10% of lower lip cancers and 20% of cancers in the upper lip and commissure are found to metastasize to the nodes.

Metastasis from the lower lip is to the submental, submandibular, and perifacial nodes (level I more commonlythan level II).

Preauricular, periparotid,and submandibular nodes drain cancers of the upper lip and commissure (level II more commonly than level I).

Bilateral neck metastasis may develop if the lower lip lesion is near or has crossed the midline;

however, the upper lip rarely exhibits crossover between right- and left-side lymphatics.

Carcinoma of the buccal mucosa represents 2 to 10% of all SCC of the oral cavity

lymphatic drainage from the buccal mucosa is level I followed by level II.

Cervical metastases are observed in 10 to 27% of presenting patients.

Alveolar ridge or gingival carcinoma represents 2 to 18% of oral cancers and occurs predominantly on the mandibular alveolus.

Lymph node metastasis tends to occur more frequently in mandibular ridge tumors than in maxillary tumors.

Nodal drainage is principally to levels I and II for both the maxillary and mandibular lesions and is found in 24 to 28% of patients at diagnosis.

Tumors of the retromolar trigone represent 2 to 6% of all oral cavity carcinomas.

Lymphatic drainage from this area is predominantly to the submandibular nodes (level IB)

and the upper jugulo-digastricnodes (level II).

Lesions of this region tend to be more aggressive in nature with regard to developing cervical metastasis, because 27 to 56% of individuals present with metastatic disease.

There is a paucity of lymphatics to the hard palate.

Approximately 10 to 25% of individuals present with evidence of metastasis, generally to levels I and II.

Hard palate lesions may also metastasize to retropharyngeal nodes

or nodes that are not palpable on a clinical examination or

readily removable with a traditional neck dissection.

Lymphatic drainage of the oral tongue is principally to level II, followed by levels III

Carcinoma of the lateral border generally metastasizes

ipsilaterally

but SCC of the tip or body of the tongue may exhibit bilateral metastases.

Approximately 40% of patients have evidence of clinical node metastasis at the time of diagnosis.

Sentinel Lymph Node History

1955 First echelon node 1960 “Sentinel node” 1977 Demonstrated in penile cancer 1992 Morton reintroduced concept in N0

melanoma Currently widely used in melanoma and breast cancer

therapy.

Sentinel lymph node concept

Tumor spreads via lymphatics to a primary node.

Examination of primary echelon nodes for tumor direct the need for surgical management of the nodal basins.

Sentinel lymph node concept

Difficulties of lymphatic mapping in head and neck (O’Brien).

1. It is difficult to visualize lymphatic channels using lymphoscintigraphy because of proximity to the injection site.

2. The radiotracer travels fast in the lymphatic vessels.

3. If more than one node is visible, it can be difficult to distinguish first echelon nodes from second-echelon nodes.

4. The SLN may be small and not easily accessible (eg, in the parotid gland).

see if cancer has spread from the primary tumour to the lymph nodes This information is used to determine the stage (the extent

of cancer in the body). help plan treatment reduce the chance of lymphedema (buildup of lymph fluid)

developing SLNB reduces, but does not completely eliminate, the risk

of lymphedema.

Senital node biopsy The surgeon injects a radioactive substance (radiotracer), a blue dye or both into the

tissue around the tumour or into the area from where the tumour was removed.

The radiotracer is injected anywhere from 1–16 hours before the surgical procedure.

It takes about 5 minutes for the blue dye to reach the sentinel nodes, so the dye is often injected in the operating room just before the surgery.

The dye or radioactive substance is taken up by the lymph vessels. It travels along the lymph vessels draining the area around the cancer to the sentinel lymph node(s).

A special scanning device detects the radioactivity in the sentinel lymph node(s), or the surgeon looks for the lymph node(s) stained blue. Sometimes, the sentinel lymph node cannot be identified. If the sentinel lymph node is positive or if it cannot be identified, then more

lymph nodes will need to be removed.

The surgeon makes a small cut (incision) over the node(s).

The radioactive or blue lymph node(s) is removed and sent to the laboratory to be examined under a microscope by a pathologist (a doctor who specializes in the causes and nature of disease).

EXAMINATION OF LYMPHATI C SYSTEM

LOCAL EXAMINATION Inspection Swelling

1. Number

2. Position

3. Size

4. Shape

5. Surface Skin over the swelling

Palpation

1. Rise in local temperature

2. Tenderness

3. Situation and extent

4. Size and shape

5. Surface

6. Margin

7. Consistency (Soft, elastic and rubbery, firm, hard and stony hard)

8. Nodes separate or matted together- periadenitis

9. Fixity to surrounding structures(skin, muscle,nerve,vessel,bone or any viscus)

Look for the primary focus in the drainage area

Examine the lymph vessels

Acute lymphangitis- lymph vessels show reddened, tender, indurated streaks ascending to the regional lymph nodes from the point of infection

Carcinoma- multiple hard subcutaneous nodules in path b/w primary focus and lymph nodes

Lymphedema-stasis of lymph(lymphatic obstruction)

swelling of affected limb

Early- pitting is seen

Late – fibrosis, prolonged pressure to pit

Finally extreme fibrosis- no pitting

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.

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.

SUBMANDIBULAR NODES

Palpated from behind the patient, with patient,s chin tipped slightly towards the chest.

SUBMENTAL NODES

Roll the fingers below the chin(in the midline) with patient’s head tilted forwards

PAROTID NODES/PREAURICULAR NODES

Roll the finger in front of ear , against the maxilla

POSTAURICULAR/ MASTOID NODES

Roll the finger behind the ear

Occipital nodes

Palpated behind the ear at the base of skull

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.

PALPATION

Soft and fluctuating

Firm ,discreet ,shotty

Stony hard

matted

CONDITIONS

Hodgkins lymphoma

Syphilis

Secondary carcinoma

TB , Acute lymphadenitis, metasttic carcimoma

Laboratory Studies Directed by the history and physical examination, overall clinical assessment

CBC count, peripheral blood smear.

Evaluation of hepatic and renal function, urine underlying systemic disorders

Skin testing for tuberculosis is usually indicated.

Specific regional adenopathy, lymph node aspirate for culture may be important if lymphadenitis is clinically suspected.

Titers for specific microorganisms-generalized adenopathy is present.

These may include epstein-barr virus, cytomegalovirus (cmv), b henselae, toxoplasma species, and human immunodeficiency virus (hiv).

Imaging Studies Chest radiography -primary screening tool

Elucidating mediastinal adenopathy and underlying diseases affecting the lungs

.

Supraclavicular adenopathy,-CT scanning of the chest, abdomen, or both.

Positron-emission tomography (PET) scanning is not helpful as a screening tool as benign and malignant conditions may cause intense uptake

•Tuberculosis,• Coccidioidomycosis, •Lymphomas, •Neuroblastoma, •Histiocytoses,•Gaucher disease

PET scanning is helpful in the evaluation of lymphomas once a clinical or tissue-based diagnosis is made.

scanning is helpful in the evaluation of lymphomas.

Ultrasonography -evaluating the changes in the lymph nodes and in evaluating the extent of lymph node involvement in patients with lymphadenopathy

Patients with matted nodes were more likely to develop distant metastases, whereas patients with normal nodes were more likely to develop a local recurrence

Sensitivity % (range)

Specificity % (range)

Palpation 35 (30-40) 35 (27-42)

CT 45 (17-86) 11 (3-21)

US 46 (42-50) 21 (11-33)

MRI 42 (20-70) 14 (5-26)

Accuracy of diagnostic methods in detecting occult cervical metastases.

A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography

BIOPSY

If the size, location, or character of the lymphadenopathy suggests malignancy and laboratory testing is inconclusive, a lymph node biopsy is immediately indicated.

Best performed on regional lymph nodes suggestive of metastasis using a fine-bore needle to aspirate cells for cytologic examination.

Ultrasound-guided fine-needle aspiration cytology is now favored. 

Fine needle aspiration -small samples with limited ability to perform flow cytometry and chromosomal analysis

So some prefer excisional biopsy.

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

2. Secondary Malignant melanoma

Autoimmune Disorders (i) Juvenile rheumatoid arthritis (ii) Other collagen diseases such as Systemic lupus

erythomatosus, Polyarteritis nodosa and scleroderma.

CAUSES OF LYMPH NODE ENLARGEMENT

Sub mandibular Nodes Sinusitis Tonsillitis Conjunctivitis Pharyngitis

Sub mental Nodes • Periodontitis • Mononucleosis

(Epstein-Barr Virus)• Cytomegalovirus • Toxoplasmosis

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

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

1-lymph node draining a septic foicus* cervical : tonsilitis, scarlet fever, scalp infection.

* periauricular: otitis media.

Causes of localised lymphadenopathy

2-carcinomatous. * virchow’s: stomach * cervical: thyroid, tongue, parotid.

3- Systemic Infections Viruses: - Viral hepatitis Rt. supraclavecular L.N - German measles (cervical LN) Bacteria: T.B Generalized L.N. may start as localized L.N. as in Hodgkin’s disease

Causes of Generalised Lymphadenopathy

I- Infectious* Viruses:

a-Infectious mononucleosis b-Cytomegalo virus (C.M.V.)

* Bacteria: a- brucellosisb- T .B.

*Spirochetes:

* Protozoaa- kala azarb-toxoplasmosis.

Causes of Generalised Lymphadenopathy

2- leukemias: especially chronic lymphocytic leukamia (C.L.L.)

3- : a- Hodgkin’s disease (H.D.) b-Non- Hodgkin’s lymphoma (N.H.L)

4- Collagenosis: a-rheumatoid artheritis. b- Felty’s syndrome. .

5-Allergy6- Sarcoidosis7- Lipoidosis8-Miscellaneous

Characters of L.N. Enlargement in Some Diseases

1- Streptococcal infection of tonsils:

2- Scarlet Fever Sore throat.

3-Diphtheria

Uni or Bilateral * Tender & unmatted *Usually submandibular but may extend to lower cervical group.

marked enlargement of submandibular L.N. *Other cervical L.N. (bilateral, tender, discrete, suppuration is common

Enlarged submandibular L.N. usually bilateral,

tender, not matted.

4-German Measle:•OccipitaI L.N. enlargement are nearly always present, closely resembles that of infectious mononucleosis.

5-Infectious Mononucleosis: * Sore throat, Fever, sometimes headache, myalgia.* Palatal petechiae often, are present * Mild splenomegally in 50% of cases *Lymphocytosis in 75% of cases with some atypical lymphocytes.

Bilateral L.N. enlargement, firm, discrete, mobile.

* Appear first in posterior cervical area, adjacent to cervical spines, few days later , submandibular L.N. will be enlarged

6- T.B.: * The chiefly affected group is upper cervical group, generalized L.N. enlargement is exceptional. * Unilateral or Bilateral. * Often firm, matted, painful, may become adherent to skin or deep structures. * Cystic areas may occur due to caseation and later on cold abscess formation. * Overlying skin may break down giving T.B. ulcers or sinuses.

Syphilis:

PrimaryL.N draining a chancre-Rocky hard, uni Or bilateral, not tender.

Secondary-Generalized L.N. enlargement especially posterior triangle of the neck or epitrochlear gp (slightly enlarged, shotty, discrete, painless).

8- LYMPHOMATOUS L. N:

•May be associated with constitutional symptoms.(anorexia, fever, weight loss, sweating, ….. etc).

•Pel Ebstein fever: may be observed in H.D., it is a period of fever lasting for few days or weeks alternating with longer or shorter apyrexial periods .

• L.N. usually discrete at start & not tender (but may become tender during febrile periods).

•L.N. may increase in size during pyrexial periods and decrease in size during apyrexial periods

a-H.D.:* may be confined to one group at first esp. lower cervical group then later on generalized L.N. enlargement.•Glands are:

a- moderately enlarged, not tender.b- Firm, rubbery in consistency.c- Discrete, mobile however as a result of later extension

outside the capsule glands become matted or fixed

b-N.H .L:

*Also the cervical group is firstly affected*Rapid rate of growth results in large number of variable sized nodes which are hard in consistency, tend to become fused and fixed to deep structures & may give pressure manifestations.

9- LEUKAEMIC L. N:

*May be associated with general manifestations (fever, malaise, anorexia, headache, Hemorhagic tendency)a- Acute Leukaemia:*Late, slightly or moderately enlarged*Soft, discrete esp. cervical L.N. due to oral sepsis*May be tender bone.b-C.L.L: * May affect cervica1 L.N. but mostly all superficial L.N. are enlarged. *The glands usually are (firm, not tender, not matted, usually moderately enlarged, but in advanced stages may be markedly enlarged)c-C.M.L.: *Rare to be manifested by L.N. enlargement.

10- CARCINOMATOUS L.N.:

*Firm, but some times hard.*A stoney hard nodes fixed to underlying tissues are nearly always neoplastic in nature, however the reverse is not true.*Carcinomatous L.N. may be freely mobile

lymphangioma Lymphangioma is a benign hamartomatous tumor of lymphatic

channels, with a marked predilection for the head and neck region, at submandibular and parotid area .

CONCLUSION

Lymphatic system is a closed system of lymph channels through which lymph flows.

It is an one way system. The entire lymph from the head and neck drains

ultimately into deep cervical nodes either directly or through peripheral nodes.

In CNS- lymph is replaced by CSF It is essential to have appropriate knowledge of

tumor metastases for most appropriate treatment.