INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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LYMPHATIC & LYMPHATIC & VENOUS SYSTEM VENOUS SYSTEM
OF HEAD AND OF HEAD AND NECKNECK
ModeratorModerator Dr David Dr David
TauroTauro
PresenterPresenter Dr Dr
Mahantesh.SMahantesh.Swww.indiandentalacademy.comwww.indiandentalacademy.com
Development of Development of lymphatic systemlymphatic system
Lymph fluidLymph fluid Lymph nodeLymph node Lymphatic Lymphatic
vesselsvessels Functions of Functions of
lymphatic systemlymphatic system
ClassificationClassificationDiagnosis of Diagnosis of LymphadenopathyLymphadenopathyConclusionConclusion ReferencesReferences
CONTENTS
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LYMPHATIC SYSTEMLYMPHATIC SYSTEM This system was This system was
described after the other described after the other parts of vascular system parts of vascular system are already known. are already known.
The reason for this The reason for this delay is their delicate delay is their delicate and transparent and transparent appearance. appearance.
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EMBRY0LOGY OF EMBRY0LOGY OF LYMPHATIC SYSTEMLYMPHATIC SYSTEM
Lymph sacs -appear between 2Lymph sacs -appear between 2ndnd to 6to 6thth week of IUL. week of IUL.
77thth week - week -jugular channel spread to jugular channel spread to connect with subclavin lymph sacs.connect with subclavin lymph sacs.
99thth week - week - thoracic duct is continuous thoracic duct is continuous channel draining into IJ -subclavin vein channel draining into IJ -subclavin vein junction.junction.
1212thth week- week- all process are complete. all process are complete. 55thth month - month -valves begins to start.valves begins to start.
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DEVELOPMENT OF LYMPH DEVELOPMENT OF LYMPH NODENODE
Jugular,Jugular, lymph lymph saccules and saccules and Peritoneal lymph Peritoneal lymph saccules saccules
Invasion of Invasion of neighboring neighboring Mesenchymal Mesenchymal cells so called cells so called lymph sinuses lymph sinuses evolve intra evolve intra nodally. nodally.
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Primary / centralThymus and bone marrow
Secondary / peripheralSpleen, tonsil and lymph node
contents Cells, Organs Vessel Lymph fluid .
LYMPHATIC SYSTEMLYMPHATIC SYSTEM
lymphoid organ
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LYMPH FLUIDLYMPH FLUID
CONTENTS•Proteins•Fats•Cells•Interstitial fluid
DefinitionTransparent,colorless,or slightly yellow watery fluid with specific gravity of 1.015.Same as blood plasma but more dilute
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Lymph FluidLymph Fluid
PeripheralIntermediateCentral
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FORMATION OF LYMPH FORMATION OF LYMPH FLUIDFLUID
FORMATIONFORMATION - Diffusion- Diffusion - Osmosis- Osmosis Terminal capillaries Terminal capillaries
in the Interstitium in the Interstitium 0.003ml/100kg/min 0.003ml/100kg/min
tissuestissues 2-3liters/day2-3liters/day
producedproduced
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FACTORS AFFECTING FACTORS AFFECTING THE LYMPH THE LYMPH FORMATIONFORMATION
Environmental temperatureEnvironmental temperature Body movementBody movement
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VELOCITY OF LYMPH VELOCITY OF LYMPH FLOWFLOW
Depends on Depends on – Intrinsic FactorsIntrinsic Factors– Extrinsic FactorsExtrinsic Factors
Velocity is generally Velocity is generally 3.1cm /min3.1cm /min
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INTRINSIC EXTRINSIC
Intraluminal pressure
Lymphatic pump
Interstial pressure
MovementMuscularArterialrespiration
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Conditions where lymph Conditions where lymph production increaseproduction increase
(pathologically)(pathologically) InflammationInflammation Venous stasisVenous stasis Mechanical insufficiency of vessels Mechanical insufficiency of vessels
and valvesand valves Drugs –Drugs –
Serotonin,Prostaglandins,TXA2, Serotonin,Prostaglandins,TXA2, Nor-adrenalineNor-adrenaline
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These are the These are the raison d,etreraison d,etre of the of the lymphatic system lymphatic system
Local aggregation of lymphoid tissue. Local aggregation of lymphoid tissue. LymphaLympha colorlesscolorless – – yellow fluidyellow fluid
(lymphocytes)(lymphocytes) NodusNodus knot knot
LYMPH LYMPH NODE NODE
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800800 L nodes in body L nodes in body 300300 are present in are present in
head and neckhead and neck 11stst defense station of defense station of
the body.the body. LocalizedLocalized mainly in mainly in
fattyfatty tissues tissues & & interposed between interposed between lymphatic flowlymphatic flow
LYMPH NODELYMPH NODE
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SHAPE OF LYMPH SHAPE OF LYMPH NODE NODE
InguinalInguinal lymph nodes – large and round lymph nodes – large and round Outer iliacOuter iliac lymph nodes – longish mass lymph nodes – longish mass Inner iliacInner iliac lymph node – small and round lymph node – small and round Head and neckHead and neck lymph node- oval or lymph node- oval or
kidney or spindle shapedkidney or spindle shaped
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SizeSize– 1- 30 um in diameter this 1- 30 um in diameter this
depends mainly on primary depends mainly on primary functionfunction
AbsorptionAbsorption -0.07ml/l node -0.07ml/l node
LYMPH NODELYMPH NODE
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CELL ZONES
Zone 1
Extreme periphery
Loosely packed cells
lymphocytes, macrophages
Zone 2
More densely packed
small lymphocytes and
macrophages
Zone 3.
Germinal center
Large lymphoblasts
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STRUCTURAL CHANGES:STRUCTURAL CHANGES:– Expansion of B and T lymphocytesExpansion of B and T lymphocytes– Cortical region enlargement Cortical region enlargement – Increase in no of macrophages in Increase in no of macrophages in
sinus , medullary sinussinus , medullary sinus
FUNCTIONAL CHANGESFUNCTIONAL CHANGES Reduced filtering capacityReduced filtering capacity Immune cells No. increaseImmune cells No. increasewww.indiandentalacademy.comwww.indiandentalacademy.com
FUNCTION OF LYMPH FUNCTION OF LYMPH NODE NODE
Biologic filtering Biologic filtering Production of lymphocytes in Production of lymphocytes in
context of immune reactions.context of immune reactions.
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1. Biologic filtering1. Biologic filtering Capsule
Hilus
Afferent vessels
Marginal sinus
Marginal Zones
Medullary cords
Medullary sinus
Efferent vessels www.indiandentalacademy.comwww.indiandentalacademy.com
2.Immune reaction2.Immune reactionAntigen Margninal sinus
Bound to Macrophages & Reticular cells
Adjacent T-helper cells Present Ag to Immunocompetent
lymphocytes -- Mantle zone ( B-Lymphocytes)
Activated B cells
Immunoblastwww.indiandentalacademy.comwww.indiandentalacademy.com
IMMUNOBLAST
Move towards germinal centre
Immunocytes & Plasma cells
Differentiate
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5-7 days, Plasma cells Medullary cords Ab into the medulla
Para cortical zone (T-lymphocytes)
Helper T cellsSuppressor T cells
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LYMPHATIC VESSELSLYMPHATIC VESSELS
Anatomically Anatomically similar to veins similar to veins Are thin-walled , serve as drainage Are thin-walled , serve as drainage
channelschannels Initially lymph vessels are Finger-Initially lymph vessels are Finger-
shaped and blind.shaped and blind. they drain intercellular spaces and they drain intercellular spaces and
serous sacs. serous sacs. www.indiandentalacademy.comwww.indiandentalacademy.com
LYMPHATIC VESSELSLYMPHATIC VESSELS
Abundant interlacing anastomosesAbundant interlacing anastomoses Interruption of the continuity by lymph Interruption of the continuity by lymph
nodes. nodes. Drainage channels from many parts Drainage channels from many parts
not drained by the venous system not drained by the venous system www.indiandentalacademy.comwww.indiandentalacademy.com
LYMPHATIC VESSELS LYMPHATIC VESSELS
Wide vascular lumen. 30-50um .Wide vascular lumen. 30-50um . Lymph capillaries dose not contains Lymph capillaries dose not contains
valves. valves are there in valvular valves. valves are there in valvular precollectors .precollectors .
Diameter larger than 10um only can Diameter larger than 10um only can spread or metastasis can take place. spread or metastasis can take place.
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STRUCTURE OF LYMPHATIC STRUCTURE OF LYMPHATIC VESSELVESSEL
Initial lymph vesselInitial lymph vessel Lymphatic collectorsLymphatic collectors
Endothelial cells that areSurrounded by an incomplete and interrupted basal membrane These cells overlap like roof tiles
Intima consists of endothelial cells
Collagen fibers and single muscle cells.
Media contains bundles of smooth
muscles surrounded By collagen fibers.
Adventitia –longitudinal bundles of
connective tissue,elastic fibers&
Single smooth muscle cells
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FUNCTIONS OF FUNCTIONS OF ENDOTHELIAL CELLSENDOTHELIAL CELLS
Intense protein Intense protein synthesissynthesis
Increase cellular Increase cellular transportationtransportation
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VALVESVALVES
Except initial lymphatic sinus or capillaries Except initial lymphatic sinus or capillaries every lymph vessels has valves.every lymph vessels has valves.
Valves may be Valves may be – BicuspidBicuspid– TricuspidTricuspid– QuadricuspidQuadricuspid
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FUNCTIONS OF LYMPH FUNCTIONS OF LYMPH VESSELSVESSELS
Transitional function of fluid between Transitional function of fluid between
intercellular spaces and veins.intercellular spaces and veins. ImmunityImmunity Fats and proteins Fats and proteins
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LYMPHATIC SYSTEM OF LYMPHATIC SYSTEM OF HEAD AND NECK HEAD AND NECK
REGIONREGION LS of aero digestive mucosa consists of LS of aero digestive mucosa consists of Narrow –meshed ,superficial vascular Narrow –meshed ,superficial vascular
system system Wide – meshed ,deeply situated Wide – meshed ,deeply situated
vascular systemvascular systemwww.indiandentalacademy.comwww.indiandentalacademy.com
LYMPHATIC DRAINAGE OF HEAD AND NECK
DEEP CERVICAL
Surrounds IJV
Spinal Accessory
Base of skull- Neck
SUPERFICIAL CERVICAL
Outer circle (Pericervical collar)
Inner circle (upper part of respiratory and alimentary passages)
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SUPERFICIAL CERVICAL NODES (Inner circle)
Pre-laryngealPre-laryngeal Deep cervical Deep cervical fascia(beneath)fascia(beneath)
Anterior Anterior cervical nodescervical nodes
Deep cervical Deep cervical nodesnodes
Pre-trachealPre-tracheal
Para-trachealPara-tracheal
TracheaTrachea
Oesophagus Oesophagus and tracheaand trachea
Larynx,tracheaLarynx,trachea,oesophagus ,oesophagus and thyroid and thyroid
glandgland
Deep cervical Deep cervical nodesnodes
Retro-Retro-pharyngealpharyngeal
Retro-Retro-pharyngeal pharyngeal
spacespace
Pharynx,Pharynx,
palatine palatine tonsil,sphenoid tonsil,sphenoid
sinussinus
Upper deep Upper deep cervical nodescervical nodes
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DEEP CERVICAL LYMPH NODES
Jugulo-Jugulo-digastric digastric nodesnodes
Triangular Triangular region(digastrregion(digastric, facial vein ic, facial vein and IJV)and IJV)
Palatine tonsil Palatine tonsil and and tongue(post.1/tongue(post.1/33rdrd))
Upper deep Upper deep cervicalcervicaljugjugular trunkular trunk
Jugulo-Jugulo-omohyoid omohyoid nodesnodes
On IJV above On IJV above intermediate intermediate tendon of tendon of omohyoidomohyoid
Tongue,sub-Tongue,sub-mental,sub-mental,sub-mandibular mandibular and upper deep and upper deep cervicalcervical
Jugular lymph Jugular lymph trunktrunk
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SUB-MANDIBULAR
UPPER DEEP CERVICAL CHAIN OF NODES
SUB-MENTAL3rd Molars
Tongue (base)Tonsillar areaSoft palate
PAROTID NODES
LOWER DEEP CERVICAL CHAIN OF NODES
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LOWER DEEP CERVICAL
Left lower body
(bilaterally)
THORACIC DUCT
Right Brachiocephalic vein
Right upper body
RIGHT LYMPHATIC DUCT
Left Brachiocephalic vein
Subclavian vein
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Levels of Lymph nodes Levels of Lymph nodes (SLOAN –KETTERING CANCER CENTER, (SLOAN –KETTERING CANCER CENTER,
NYNY))
III
III
IV
VI v
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CLINICAL CLINICAL CONSIDERATIONS CONSIDERATIONS
Normal lymph nodes not palpableNormal lymph nodes not palpable
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EXAMINATIONEXAMINATION How long swelling has been How long swelling has been
present?present?
Is it painful ?Is it painful ?
Does it vary with size?Does it vary with size?
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GENERAL PRINCIPLESGENERAL PRINCIPLES
InspectionInspection
PalpationPalpation
Compare with contra lateral side.Compare with contra lateral side.
Site Site
SizeSize
ConsistencyConsistency
TendernessTenderness
Fixation Fixation
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Stony hard Stony hard Metastatic cancer Metastatic cancer Firm, Rubbery Firm, Rubbery Lymphoma Lymphoma Soft Soft Infection Inflammatory Infection Inflammatory Shotty Shotty Viral infection Viral infection
Consistency/TextureConsistency/Texture
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PALPABLE LYMPHNODES AND PALPABLE LYMPHNODES AND PROBABLE PROBABLE
ASSOCIATED CONDITIONS ASSOCIATED CONDITIONS TenderTender, , Mobile, enlargedMobile, enlarged Acute infection Acute infection Non-tenderNon-tender, , Mobile, EnlargedMobile, Enlarged Chronic Chronic
infection infection Matted, Non tenderMatted, Non tender Tuberculosis Tuberculosis Fixed, EnlargedFixed, Enlarged Carcinoma Carcinoma Rubbery, EnlargedRubbery, Enlarged Lymphomas Lymphomas
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Benign
TB
Sarcoidosis
Lymphogranuloma venereum
Malignant
Metastatic carcinoma
Lymphomas
Matted:- Group of nodes – Connected – as a unit
Benign / Malignant
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Key Points in Key Points in Diagnosing Diagnosing LymphadenopathyLymphadenopathy
In the absence of obvious infection In the absence of obvious infection consider it as metastatic tumor until consider it as metastatic tumor until otherwise proven.otherwise proven.
FNAC - useful investigation.FNAC - useful investigation. Open biopsy- recurrence, survival, Open biopsy- recurrence, survival,
further examination is difficult, further examination is difficult, fungation. nerve damage may occur.fungation. nerve damage may occur.
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<16yrs<16yrsinfection,congenital, infection,congenital, neoplasia.neoplasia.
16-40yrs- inflammation, neoplasia16-40yrs- inflammation, neoplasia
>40yrs- neoplastic.>40yrs- neoplastic.
AGEAGE
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ClassificatioClassificationn
Generalised
2 or more non contiguous area
Localised
Involve one area
CERVICAL CERVICAL LYMPHADENOPATHYLYMPHADENOPATHY
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LocalLocal- InfectionInfection-dental infections, tonsillitis, skin -dental infections, tonsillitis, skin
sepsis, TB node.sepsis, TB node.- NeoplasiaNeoplasia-lymphoma or metastatic.-lymphoma or metastatic.- GeneralGeneral URTI, infectious mononucleosis, URTI, infectious mononucleosis,
toxoplasmosis, cat-scratch fever, HIVtoxoplasmosis, cat-scratch fever, HIV- Sarcodosis, Hodgkin's and non-Hodgkin's Sarcodosis, Hodgkin's and non-Hodgkin's
lymphoma.lymphoma.- Congenital-Congenital- cystic hygroma. cystic hygroma.
CAUSES FOR CERVICAL CAUSES FOR CERVICAL LYMPHADENOPATHYLYMPHADENOPATHY
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REFERENCESREFERENCES Text book of surgical anatomy – Mag Craker Text book of general anatomy 39th ed –
Grants Clinical oriented anatomy –Moore Head &neck emergencys-Mike parry Text book of head &neck anatomy 2nd ed –
Holleinsheid Atlas of general histology – De Floire Text book of Human histology- Inderbir Singh Metastases of head and neck – R. Kim Davis Text book medicine-Davidsonwww.indiandentalacademy.comwww.indiandentalacademy.com
CLINICAL STAGINGCLINICAL STAGING
Scan and attachScan and attach
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