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Transcript of Lymph Nodes of Head and Neck Region
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LYMPH NODES OF THE HEAD AND NECK
GUIDED BY: PRESENTED BY:
Dr. Girish Dr. Preyas Joshi
Dr. Mayank agrawal 2nd YEAR P.G
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INTRODUCTION
DEVELOPMENT
LYMPHATIC DRAINAGE APPLIED ASPECT
REFERENCE
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LYMPHA
The Lympha is an ancientRoman deity of fresh water.
She is one of twelve
agricultural deities listed as
leadersofRoman farmers,
because "without water all
agriculture is dry and poor."
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BODY FLUIDS
Body fluid, bodily fluids, or biofluids are liquids originating from insidethe bodies of living people. They include fluids that
are excreted or secreted from the body.
Approximately 60-65% of body water is contained within the cells
(in intracellular fluid) with the other 35-40% of body water contained
outside the cells (in extracellular fluid).
This fluid component outside of the cells includes the fluid between the cells
(interstitial fluid), lymph and blood.
There are approximately 6 to 10 liters of lymph in the body, compared to 3.5
to 5 liters of blood.
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WHAT IS LYMPH?
Lymph is a clear to yellowish watery fluid that is
found throughout the body.
It circulates through body tissues picking up fats,
bacteria, and other unwanted materials, and filtering
them out through the lymphatic system.
This fluid contains white blood cells, known
as lymphocytes, along with a small concentration of
red blood cells and proteins. 5
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Most of the items(water,proteins,gases,nutrients,hormones,wastes & leukocytes) are
dissolved in the blood plasma.
Therefore, if we could get fluid out of the capillary, we could get these dissolved
materials out, too.
capillaries can leak out material at the junctions between endothelial cells. These
spaces are rather small, keeping larger things (RBCs) inside, while letting the fluid
(plasma) out.
The capillaries are porous enough that the plasma within them is in contact with the
fluid outside of them (extracellular fluid/interstitial fluid).
whether they will do so or not depends on the pressures on the fluids.
EXCHANGE ACROSS CAPILLARIES
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LYMPHATIC SYSTEM
The lymphatic systemis part of the circulatory system,
comprising a network of lymphatic vessels that carry aclear fluid called lymph directionally towards the heart.
Unlike the cardiovascular system the lymphatic systemis not a closed system. The circulatory system
processes an average of 20 litres of blood per daythrough capillary filtration which removes plasma whileleaving the blood cells.
Roughly 17 litres of the filtered plasma get reabsorbed
directly into the blood vessels, while the remaining 3litres are left behind in the interstitial fluid. One of themain functions of the lymph system is to provide anaccessory route for these excess 3 litres per day to getreturned to the blood.
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IMPORTANCE OF LYMPH
Lymph is the fluid that circulates throughout the lymphatic
system. The lymph is formed when the interstitial fluid (the
fluid which lies in the interstices of all body tissues) iscollected through lymph capillaries. It is then transported
through lymph vessels to lymph nodes before emptying
ultimately into the right or the left subclavian vein, where it
mixes back with blood.
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Since the lymph is derived from the interstitial fluid,
its composition continually changes as the blood and
the surrounding cells continually exchange substances
with the interstitial fluid. Lymph returns protein andexcess interstitial fluid to the circulation. Lymph may
pick up bacteria and bring them to lymph nodes where
they are destroyed. Lymph also transports fats from
the digestive system.
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STRUCTURE OF LYMPH NODES
A lymph node is an oval-shaped organ of the lymphaticsystem.
It is distributed widely throughout the body and linked
by lymphatic vessels. Lymph nodes are major sites of B- and T- immunity cells.
Lymph nodes act as filters or traps for foreign particles and
are important in the proper functioning of the immune
system.
They are packed tightly with the white blood
cells called lymphocytes and macrophages.
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Each lymph node is surrounded by a fibrous capsule.
The substance of the lymph node is divided into the outer cortex and
the inner medulla.
The cortex is continuous around the medulla except at the hilum,
where the medulla comes in direct contact with the hilum(part of an
organ where structures such as blood vessels and nerves enters).
C O S O O S
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FUNCTIONS OF THE LYMPH NODES
They produce and supply lymphocytes to the blood
They make screening of lymph by means of phagocytic activity
They serve a great defense role against bacterial infection
They temporarily stop spread of cancer cells as these cells have to
penetrate through lymph vessels to the lymph nodes from where they
spread in the body.
They act as a mechanical filters to resist entrance of poisonous
substances into circulation
They carry out immunological responses and they help in elaboration
of antibodies and in the development of immunity
Lymph nodes produce gamma globulin 16
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EMBRYOLOGY OF LYMPH NODES
Lymphatic sacs form in the fifth week of embryo. The first signs of the
lymphatic system are seen in the form of two paired and two unpaired
endothelial sacs. Traditionally these sacs have been considered to be
outgrowth from veins. However, they are now regarded to be
predominantly independent formations from mesenchyme that
connect with the venous system secondarily.
L h l f h h d k d
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THE PRIMARY LYMPH SACS IN A 42-DAY-OLD HUMAN EMBRYO
The first primordial lymph sacs to appear are the paired jugular sacs in the neck.
The next sac to appear is unpaired and located at the mesenteric root in the retroperitoneal
space.
The final paired sacs are two posterior (iliac) sacs.
One so-called cisterna chyli dorsal to the retroperitoneal lymph sac. 18
Lymph vessels of the head, neck, and
arms grows out from the jugular sacs.
Lymph vessels of the gut grows out
from the retroperitoneal and cisternal
sacs.
Lymph vessels of the lower trunk and
legs grows out from the iliac sacs.
CLASSIFICATION OF LYMPH NODES IN THE HEAD AND NECK REGION
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CLASSIFICATION OF LYMPH NODES IN THE HEAD AND NECK REGION
The lymph nodes in the head and neck region can be grouped into:
Superficial nodes
Deep nodes
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THE SUPERFICIAL LYMPH NODES
The superficial cervical lymph
nodes lie above the investing layerof the deep fascia.
They consist of a few small nodes
that lie superficial to the external
jugular and anterior jugular veins.
1. Submental
2. Submandibular
3. Buccal
4. Parotid (pre-auricular)
5. Mastoid (retro auricular/ post auricular)
6. Occipital
7. Superficial lateral cervical
8. Superficial anterior cervical.
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THE DEEP LYMPH NODES
1. Upper deep cervical: Jugulo-digastric group: lie along the upper part of internal
jugular vein deep to the sternomastoid.
2. Lower deep cervical:jugulo-omohyoid group: arranged along the lower part of
IJV also deep to the sternomastoid.
3. Waldyersring: The waldyersring is formed by: lingual, palatine, tubal, andpharyngeal tonsils.
4. Nodes of midline: Midline nodes are termed in correspondence to the anatomicalarea where they exist:
a) Infrahyoid
b) Prelaryngeal
c) Pretracheal
d) Paratracheal
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Waldyersring
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LYMPHATIC DRAINAGE OF THE SUPERFICIAL NODES
SUBMENTAL LYMPH NODES: The submental nodes are situated
between the anterior bellies of the Digastric. Their afferents drain the central
portions of the lower lip and floor of the mouth and the apex of the tongue;
Their efferents pass partly to the submandibular lymph nodes and partly to a
gland of the deep cervical group situated on the internal jugular vein at the level
of the cricoid cartilage.
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SUBMANDIBULAR LYMPH NODES:
The afferents of the submandibular glands drain the cheek, the side of
the nose, the upper lip, the lateral part of the lower lip, the gums, and the
anterior part of the margin of the tongue.
The submandibular lymph nodes, three to six in number, are placed beneath
the body of the mandible in the submaxillary triangle, and rest on the
superficial surface of the submandibular gland.
Efferent vessels from the facial and submental glands also enter the
submaxillary glands. Their efferent vessels pass to the superior deep cervical
glands.
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PAROTID (PRE AURICULAR) :
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PAROTID (PRE -AURICULAR) :
DEEP PAROTID LYMPH NODES:
The afferents of the subparotid glands drain the nasal part of the pharynx and the
posterior parts of the nasal cavities.
Their efferents pass to the superior
deep cervical glands.
SUPERFICIAL PAROTID LYMPH NODES:Their afferent vessels drain the root of the nose, the eyelids, the frontotemporal region,
the external acoustic meatus and the tympanic cavity, possibly also the posterior parts of
the palate and the floor of the nasal cavity.
The efferents of these glands pass to the superior deep cervical glands.
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POSTERIOR AURICUALR LYMPH NODES/MASTOID
LYMPH NODES/RETROAURICULAR LYMPH NODES:
Usually two in number, located just beneath the ear, on the mastoid insertion of
the sternocleidomastoid muscle, beneath the posterior auricular muscle.
Mastoid lymph nodes receives lymph from the posterior part of the temporoparietal
region, the upper part of the cranial surface of the visible ear and the back of the ear
canal. The lymph then passes to the superior deep cervical glands.
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OCCIPITAL LYMPH NODES :
The occipital lymph nodes, one to three in number, are located on the back of the head
close to the margin of the Trapezius and resting on the insertion of the Semispinalis
capitis.
Their afferent vessels drain the occipital region of the scalp, while their efferents pass to
the superior deep cervical glands.
http://en.wikipedia.org/wiki/Semispinalis_capitishttp://en.wikipedia.org/wiki/Semispinalis_capitis -
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SUPERFI CIAL CERVICAL LYMPH NODES :
They can be broken down into:
Superficial anterior cervical lymph nodes: The superficial anterior cervical
lymph nodes are found in proximity to the anterior jugular vein.
Superficial lateral cervical lymph nodes: proximal to the external jugular vein.
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LYMPHATIC DRAINAGE OF THE DEEP LYMPH NODES
UPPER/SUPERIOR DEEP CERVICAL (JUGULO-DIGASTRIC):
The jugulodigastric lymph node is a large node found in the proximity of where the
posterior belly of the digastric muscle crosses the internal jugular vein. it receives
lymphatic drainage from the pharynx, palatine tonsil, and tongue.
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A A AC A A AC A O
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PRETRACHEAL: The pretracheal group consists of nodes between the isthmus of the
thyroid gland down to the level of the innominate vein.Varying from 2-12 in number, these
nodes drain the region of the thyroid gland and the trachea and receive afferent flow from the
prelaryngeal group. The pretracheal efferents empty in the internal jugular group and the
anterior superior mediastinal nodes.
PARATRACHEAL NODE: lie near the recurrent laryngeal nerve and drain the thyroid
lobes, parathyroid glands, subglottic larynx, trachea, and upper esophagus. The efferent
vessels travel to the lower jugular group or directly toward the junction of the internal jugular
vein and the subclavian vein.
PARATRACHEAL AND PRETRACHEAL LYMPH NODE:
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INFRAHYOID LYMPH NODE:
deep anterior cervical lymph nodes located between the levels of the hyoid bone
and thyroid cartilage.
PRE-LARYNGEAL LYMPH NODE:
Lie on conus elasticus and cricovocal membrane.They drain the anterior cervical
nodes, which in turn drain the skin of the anterior aspect of neck.
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WALDEYERS LYMPHATIC RING
In relation to the oropharyngeal isthmus, there are several aggregation of lymphoid
tissue that constitute waldeyers lymphatic ring. The most important aggregation
are the right and left palatine tonsils usually referred to simply as the tonsils.
Posteriorly and above there is the pharyngeal tonsil; laterally and above there are
the tubal tonsils, and inferiorly there is the lingual tonsil over the posterior part of
the dorsum of the tongue.
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METASTASIS
The development of secondary malignant growths at a distance from a primary
site of cancer.
Some cancer cells acquire the ability to penetrate the walls
of lymphatic and/or blood vessels, after which they are able to circulate
through the bloodstream (circulating tumor cells) to other sites and tissues in
the body.
After the tumor cells come to rest at another site, they re-penetrate the vessel
or walls and continue to multiply, eventually forming another clinically
detectable tumor. This new tumor is known as a metastatic (or secondary)
tumor.
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APPLI ED ANATOMY OF LYMPH NODES
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LYMPHATIC SPREAD OF METASTASIS
Lymphatic spread allows the transport of tumor cells to lymph
nodes and ultimately, to other parts of the body. This is the most
common route of metastasis for carcinomas. In contrast, it is
uncommon for a sarcoma to metastasize via this route. It is worth
noting that the lymphatic system does eventually drain into the
venous system, and therefore these metastatic cells can
eventually spread through the haematogenous route.
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TNM CLASSIFICATION
The latest classification has been created by the
American Joint Committee on Cancer(AJCC) and the American
Academy of Otolaryngology- Head and Neck Surgery.
The TNM(Tumor, Node, Metastasis) system devised by 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).
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R E G I O N A L L Y M P H N O D E S ( N )
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( )
Description:
NX = Regional lymph nodes cannot be assessed.
N0 = No regional lymph node metastasis.
N1 = Metastases in 13 regional lymph nodes.
N1a = Metastasis in 1 regional lymph node.
N1b = Metastases in 23 regional lymph nodes.
N2 = Metastases in 4 regional lymph nodes.
N2a = Metastases in 46 regional lymph nodes
N2b = Metastases in 7 regional lymph nodes.
EXAMI NATIO N OF THE LYMPHATIC SYSTE M
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EXAMI NATIO N OF THE LYMPHATIC SYSTE M(WHEN EXAMINING ONE AREA, ALWAYS COMPARE TO THE OTHER SIDE)
INSPECTION
Swelling
Number
Position
Size Shape
Surface
Skin over the swelling
PALPATION Rise in local temperature
Tenderness(Usually implies acuteinflammation or infection)
Situation andextent(localised/generalised)
Size and shape(Large nodes are usuallyabnormal,greater than 1 cm)
Surface
Margin
Consistency(Hard nodes suggestcarcinoma, soft may be normal
and rubbery nodes may be dueto lymphoma)
Nodes are separated/matted
Fixity to surrounding structures(Nodesthat are fixed to underlying structures aremore likely to be due to carcinoma)
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HOW TO PALPATE THE LYMPH NODES OF
HEAD AND NECK REGION
Lymph nodes should be examined frompatientsbehind.
Ask the patient to flex his neck slightly so as to reduce the tension of
muscles.
To palpate, use the pads of all four fingertips.
Using a gentle circular motion with your finger pads palpate
each lymph node.
It is a good idea to palpate both sides at the same time, comparing the
two sides symmetrically.
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CRITERIA FOR NORMAL LYMPH NODES
Normal cervical nodes should be less than one centimeter, movable, discrete, soft, and nontender.
ABNORMAL FINDINGS
If any nodes are palpable, enlarged, greater than 1 cm, and tender.
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PALPATION CONDITIONS
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Enlarged, tender and fixed lymph
nodes.
Discrete/matted.
Painless, firm, discrete and shotty
glands which do not suppurate.
elastic and rubbery, discrete and
movable with little tendency towards
matting, softening or suppuration.
nodes are enlarged, irregular, Hard
in consistency and fixed to all
structures including the skin.
Acute Lymphadenitis
Tuberculous Lymphadenitis
Syphilitic Lymphadenitis
Hodgkins Disease
Secondary Carcinoma
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LYMPHANGIOMA
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It is a benign tumour of lymphatic vessels.
Lymphangioma is a benign tumor of lymphatic vessels
Classiication (watson & McCarthy) Simple lymphangioma
Cavernous (most common)
Cellular
Diffuse systemic
Cystic hygroma
Clinical feature: age of onset is below 15 years.
Intra orally it commonly occurs on the tongue, but also seen on the palate, buccalmucosa, gingiva and lip.
Treatment: surgical excision
MALIGNANT LYMPHOMA
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It is derived from the basic cells of lymphoid tissue, the
lymphocytes, and histiocytes, in any of their developmental
stages.
Malignant lymphoma is following type:
I. Non Hodgkins lymphoma
II. Hodgkins lymphoma
III. Burkittslymphoma
NON HODGKINS LYMPHOMA
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NON-HODGKINS LYMPHOMA
The non-Hodgkins lymphoma involves lymph nodes and lymphoid
organs as well as extranodal organs and tissue.
Clinical features:
I. Affects persons of all age, from infants to the elderly and occurs in
both sexes.
II. Onset of symptoms may be acute or insidious and include
lymphadenopathy, abdominal and mediastinal enlargement.
III. Fever
IV. Night sweat
V. Weight loss
Treatment: Best treated by radiation or chemotherapy or both. 57
HODGKINS LYMPHOMA
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HODGKIN S LYMPHOMA
It is primarily one of lymph nodes and lymphoid organs. Lymph nodes
of the head and neck, particularly the cervical nodes, are often theinitial site of the involvement.
Clinical feature:
I. Bimodal age incidence peak, one in young adults and the second inthe fifth decade.
II. Painless enlargement of one or more cervical lymph nodes, and nodeusually firm and rubbery in consistency, and the overlying skin isnormal.
III. Pain may develop in the abdomen and back, owing to splendidenlargement and pressure of enlarged nodes or involvement of the
vertebrae.IV. Generalized weakness is sometimes as early feature.
V. Weight loss, cough, anorexia, itching of the skin.
Treatment: radiation therapy and combination of chemotherapy.
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BURKETTS LYMPHOMA
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In 1958-1959, Burkettsreported on a type of malignant
lymphoma seen with undue frequency, particularly
involving the jaws, in native children of Kampala,Uganda, in central East Africa. It also known as
AFRICAN JAW LYMPHOMA
Clinical feature:
It occurs between 2 and 14 years of age. In contrast to most non-Hodgkins lymphomas, it
particularly involves extra nodal tissue.
Begins as rapidly growing tumour mass of the jaws,
destroying the bone and causing loosening of the teethwith extension commonly to involve the maxillary,
ethmoid and sphenoid sinuses as well as orbit.
Treatment: fatal at one time but now being treated by
cytotoxic drug. 59
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T h e r e d s t r e a k e x t e n d s f r o m t h e a n k l e t o t h e g r o i n a n d f o l l o w s
l y m p h a t i c c h a n n e l s .
TREATMENT
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TREATMENT:
Patients in stable social situations who appear nontoxemic and who are
older than 3 years, afebrile, and well hydrated may be treated initially
with oral antibiotics in an outpatient setting.Ensure close follow-up.
Analgesics can be used to control pain, and anti-inflammatory
medications can help to reduce inflammation and swelling. Hot, moist
compresses also help to reduce inflammation and pain.
If possible, elevate and immobilize affected areas to reduce swelling,
pain, and the spread of infection. An abscess may require surgical
drainage.
CONCLUSION
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CONCLUSION
The lymphatic system, which is a subset of the circulatory system,also acts as a highway, transporting white blood cells to and from the
lymph nodes into the bones, and antigen-presenting cells to the lymph
nodes. It helps rid the body of toxins, waste and other unwanted
materials.
When bacteria are recognized in the lymph fluid, the lymph nodes
make more infection-fighting white blood cells, which can cause
swelling. The swollen nodes can sometimes be felt in the neck,
underarms and groin.
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REFERENCES
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REFERENCES
Grays anatomy by Henry Gray, Peter L. Williams
B D Chaurasia's Human Anatomy: Vol.3 Head and Neck, Brain (5 thedition)
Shafer's textbook of oral pathology (6thedition)
Human embryology by inderbir singh (6thedition)