Seminar: Lymphatic Drainage Of Head & Neck

SEMINAR LYMPHATIC DRAINAGE OF HEAD & NECK SHANIMA SHERIN KC FIRST YEAR MDS ORAL MEDICINE & RADIOLOGY

CONTENTS Lymphatic system Development & functions of lymphatic system Anatomy of lymph nodes Lymphatic drainage

Lympadenopathies References

Lymphatic system

Lymphatics can carry proteins & large particulate matter away from the tissue spaces, neither of which can be removed by absorption directly into the blood capillaries

This return of proteins to the blood from the interstitial spaces is an essential function without which we would die within about 24 hours

Hall JE. Guyton and Hall textbook of medical physiology. Elsevier Health Sciences; 2006 May 31. Sembulingam K, Sembulingam P. Essentials of medical physiology. JP Medical Ltd; 2012 Sep 30

Development 5th week of intrauterine life -

formation of 6 endothelial lined

lymph sacs ◦ 2 jugular (at the junction of the subclavian & anterior cardinal veins) ◦ 2 iliac (at the junction of the iliac & posterior cardinal veins) ◦ Retroperitoneal (near the root of the mesentery) ◦ Cisterna chyli (dorsal to the retroperitoneal sac)

1st trimester - lymphatic plexuses forms either by extension of the

sacs or may form de novo - extend into various tissues ◦ Plexuses are studded by small collection of lymphoblasts ◦ Invasion of the sacs by lymphocytes and the connective tissues

◦ Formation of groups of lymph nodes

2nd trimester - differentiation into cortex and medulla

Blood vessels branch into the lymph nodes and later develop into high end venules Day 18 after birth - secondary follicles appear indicating B cell migration

Thoracic duct - develops from the distal portion of the right thoracic duct, & anastomosis b/w right & left channels, & the cranial portion of the left thoracic duct

Right lymphatic duct -- derived from the cranial portion of the right thoracic duct

ORGANIZATION:

• Almost all tissues of the body have special lymph channels • The exceptions include the superficial portions of the skin, the central nervous system, the endomysium of muscles, and the bones ----- Prelymphatics • Prelymphatics ------- lymphatic vessels or, in the case of the brain, into the cerebrospinal fluid ------ blood

Terminal Lymphatic Capillaries and Their Permeability:

•

Most of the fluid filtering from the arterial ends of blood capillaries ----- cells -------- venous ends of the blood capillaries

• Average, about 1/10 of the fluid enters the lymphatic capillaries and returns to the blood through the lymphatic system • The total quantity of all this lymph is normally only 2 to 3 liters each day • High molecular weight, such as proteins,cannot be absorbed from the tissues in any other way, although they can enter the lymphatic capillaries almost unimpeded

Hall JE. Guyton and Hall textbook of medical physiology. Elsevier Health Sciences; 2006 May 31

• The reason for this is a special structure of the lymphatic capillaries

Lymphatics valves : • At the very tips of the terminal lymphatic capillaries • Along larger vessels up to the point where they empty into the blood circulation

Hall JE. Guyton and Hall textbook of medical physiology. Elsevier Health Sciences; 2006 May 31

SITUATION

LYMPH VESSELS ARE SITUATED

LYMPH VESSELS NOT SITUATED

1. Deeper layers of skin

1. Superficial layers of skin

2. Subcutaneous tissues

2. Central nervous system

3. Diaphragm

3. Cornea

4. Wall of abdominal cavity

4. Bones

5. Omentum

5. Alveoli of lungs

6. Linings of respiratory tract except alveoli 7. Linings of digestive tract 8. Linings of urinary tract 9. Linings of genital tract 10. Liver 11. Heart Sembulingam K, SembulingamEssentials of medical physiology. JP Medical Ltd; 2012 Sep 30

Lymphoid organs Primary lymphoid organs Red bone marrow Thymus gland Secondary lymphoid organs Spleen Lymph nodes Tonsils, Peyer patches, Appendix

Lymph nodes Peripheral lymphoid organs that are connected to circulation by afferent and efferent lymphatic vessels & by post capillary high endothelial venules Most common pathologic mass in the neck 800 lymph nodes in the body,300 lie in the head and neck

Lymphatic cells T-cells (Thymus dependent) ◦ Cytotoxic T-cells ◦ Regulatory T-cells ◦ Helper T-cells ◦ Suppressor T-cells ◦ Memory T-cells B-cells (Bone marrow derived) ◦ Plasma cells ◦ Memory B-cells NK cells (Natural Killer)

Lymph Lymph is usually a clear, colourless fluid, similar to blood plasma but low in protein Lymph is derived from interstitial fluid that flows into the lymphatics • Lymph --- liver ----protein Protein concentration: 2g/dl concentration

Rate of

6 g/dl • Lymph--- intestines ----protein concentration 3 to 4 g/dl • Because about120 two ml/h thirds of lymph normally is derived lymph flow: orall2–3 liters per day from the liver and intestines, the thoracic duct lymph---protein concentration of 3 to 5 g/dl.

Sembulingam K, SembulingamEssentials of medical physiology. JP Medical Ltd; 2012 Sep 30 Hall JE. Guyton and Hall textbook of medical physiology. Elsevier Health Sciences; 2006 May 31

Tissue fluid diffuses through permeable lymphatic capillaries Becomes lymph

Carried by lymph vessels of varying sizes

Lymph nodes intervene

Emptied into venous circulation

Entire lymph from head and neck R-half of head and neck

Upper limb

Lung, Rhalf of mediasti num, thorax and abdomen

Deep cervical nodes

R-Jugular lymphatic trunks

L-Jugular lymphatic trunks

R-Subclavian trunk

L-Subclavian trunk

Bronchomediastin al lymphatic trunk

Bronchomediastina l lymphatic trunk

R- lymphatic duct IJV SUBCLAVIAN VEIN

L-half of head and neck

Thoracic duct IJV SUBCLAVIAN VEIN

Venous system

Lower limb

Lung, Lhalf of mediasti num, thorax and abdomen

Flow of lymph

Functions Tissue drainage ◦ Return of tissue fluid & serum proteins to circulation ◦ Maintains blood volume Immunity ◦ Production & maturation of lymphocytes (T and B cells) ◦ Bacteria, toxins & other foreign bodies are removed from tissues via lymph ◦ Lymph flow is responsible for the maintenance of structural and functional integrity of tissue Fat absorption ◦ Lymph vessels of the villi in the intestine ◦ Take up fat & fat soluble materials

Lymphnodes

Lymph nodes are small glandular structures located in the course of lymph vessels The lymph nodes are also called lymph glands or lymphatic nodes Each lymph node constitutes masses of lymphatic tissue, covered by a dense connective tissue capsule The structures are arranged in three layers Cortex Paracortex Medulla

Sembulingam K, SembulingamEssentials of medical physiology. JP Medical Ltd; 2012 Sep 30

Sembulingam K, SembulingamEssentials of medical physiology. JP Medical Ltd; 2012 Sep 30

Lymph Nodes of head & neck Arranged into: ◦ Outer Circle (Superficial) ◦ Inner Circle (Deep) Lymph from superficial nodes drains into deep cervical nodes

Lie along the internal jugular vein

Deep to the sternocleidomastoid

Superficial lymph nodes 1. Submental 2. Submandibular 3. Parotid/Preauricular 4. Mastoid/Retroauricular/Postauricular 5. Occipital

6. Buccal (Facial) 7. Anterior cervical 8. Superficial cervical

Deep nodes 1. Prelaryngeal 2. Retropharyngeal 3. Pretracheal & paratracheal

4. Deep cervical lymphnodes Divided into 2 groups ◦ Superior/upper (jugulodigastric) ◦ Inferior/lower (juguloomohyoid)

Waldeyers ring Lymphoid tissue surrounds the opening into respiratory & digestive systems forms a ring

Lymphatic drainage

Scalp

Face

• Median part of lower lip • Chin • Floor of mouth

• Forehead • Lateral part of eyelid • Conjunctiva • Lateral part of cheek

• Medial part of eyelids • Nose, medial part of cheeks • Upper lips & lateral part of lower • Lips

Nasal cavity

Orbit No lymph vessels or nodes are present in the orbital cavity

Palate

Floor of mouth Floor of mouth Gums

Submandibular Nodes  Deep cervical nodes

Teeth

Anterior part of FOM --- Submental Nodes

Tonsil Palatine tonsil -

Jugulodigastric & Upper deep cervical nodes

Tongue

Pharynx Directly - deep cervical lymph nodes

Indirectly - retropharyngeal / paratracheal nodes into the deep cervical nodes

Larynx Above the vocal fold - thyrohyoid membrane to upper deep cervical group of nodes

Below the vocal folds - cricovocal membrane to reach prelaryngeal & pretracheal nodes to deep cervical nodes

Some vessels pass below the cricoid cartilage - lower deep cervical nodes

Thyroid gland Drains mainly laterally into the deep cervical lymph nodes, few descend to the paratracheal nodes

Parathyroid Deep cervical & paratracheal lymph nodes

Oral cavity 1 2 3 4

5 6 7

Maxillary gingiva Buccal – submandibular Palatal – superior Maxillary teeth deep cervical Submandibular Hard palate Superior deep cervical Soft palate Retropharyngeal Superior deep cervical Retropharyngeal Tongue Tip of the tongue – submental Anterior 2/3rd – Mandibular teeth submandibular - lower deep Mandibular gingiva Incisors - submental cervical Buccal Canines- submandibular and posterior Posterior 1/3rd - upper teeth deep – Lingual: submandibular cervical • Anterior - submandibular • Posterior - deep cervical nodes

EAR

Examination of lymphnode Anterior to the tragus of the ear-pre auricular lymphnodes Mastoid and base of the skull for- post auricular & occipital lymph nodes Under the chin in the mid line on the either side-submental lymph nodes

Further posteriorly along the mandible-submandibular lymph nodes Superficial cervical lymph nodes –superficial to sternocleido mastoid Deep cervical lymph nodes-deep to sternocleido mastoid muscle

Lymphadenopathy - Nodes that are abnormal in either size, consistency or number It is a clinical manifestation of regional & systemic disease & serves as an excellent clue to the underlying disease

Upadhyay N. Cervical lymphadenopathy. J Dental Sci. 2012 Jan:30-3

History Pain -

infection/inflammation

Age of the patient - in children-urt infection, TB - In older age-secondary ca Duration

- acute- infection

- Sub acute-tb,syphilis - Chronic-tb,neoplastic

Number of lymph nodes Numerous nodes (generalized) AIDS,lymphoma,leukemia,Infectious mononucleosis SolitaryInfections, lymphosarcoma, secondary Ca

Consistency Normal – firm Infection – soft Hodgkin’s disease – rubbery TB – matted Malignancy – stony hard

Mobility Malignant cells penetrate the capsule & invade the adjacent tissue-fixed Fixation also due to –inflammatory process that penetrated the nodes capsule and caused fibrosis of surrounding tissue

Classification of lymphadenopathy 3 types ◦ Localized lymphadenopathy ◦ Generalized lymphadenopathy ◦ Dermatopathic lymphadenopathy Based on the duration ◦ Acute (2 weeks duration)

◦ Subacute (2-6 weeks duration) ◦ Chronic (doesnot 2 resolve by 6 weeks) Upadhyay N. Cervical lymphadenopathy. J Dental Sci. 2012 Jan:30-3

Based on the number of LN affected ◦ Solitary ◦ Multiple

Based on the specificity of infection ◦ Specific ◦ Non specific

PATHOPHYSIOLOGY Dendritic cells & macrophages trap & phagocytose, - present the organisms as antigen on MHC molecule Antigens are presented to T cells - proliferation of clonal cells & release of cytokines B cell with help of T cells are activated, proliferate & release Igs - aids in immune response Cellular hyperplasia, leukocyte infiltration, tissue oedema, vasodilatation, capillary leak & capsule distension - tenderness in lymph node Parisi E, Glick M. Cervical lymphadenopathy in the dental patient: a review of clinical approach. Quintessence Int. 2005 Jun 1;36(6):423-36.

Causes of cervical lymphadenopathy INFECTIONS A) VIRAL Infectious mononucleosis Infectious hepatitis Rubella Measles

B) BACTERIAL Streptococcus Staphylococcus Tuberculosis

C) FUNGAL Histoplasmosis Coccidiodmycosis D) CHLAMYDIAL Lymphogranuloma Venerum E) PARASITIC Toxoplasmosis Leismaniasis

IMMUNOLOGICAL DISEASE ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦

Rheumatoid arthritis SLE Sjogren’s syndrome Mixed connective tissue disease Dermatomyositis Serum sickness Drug hypersensitivity Primary biliary cirrhosis Graft-vs-host disease Silicone-associated

MALIGNANT DISEASES

oHematologic ---- (Hodgkin’s, nonHodgkin’s, ALL, CLL, hairy cell leukemia, malignant histocytosis, T-cell lymphoma, multiple myeloma with amyloidosis) o Metastatic—from primary sites

LIPID STORAGE DISORDERS

◦ Gaucher’s disease ◦ Niemann pick’s disease ◦ Tangier disease

ENDOCRINE DISEASE

◦ Hyperthyroid ◦ Adrenal insufficiency ◦ Thyroiditis

OTHER DISORDERS a.

Castleman’s disease (giant lymph node hyperplasia)

b.

Sarcoidosis

c.

Dermatopathic lymphadenitis

d.

Lymphomatoid granulomatosis

e.

Kikuchi’s disease (histiocytic nectrotizing lymphadenitis)

f.

Kawasaki’s disease (mucocutaneous lymph node syndrome)

g.

Histocytosis X

h.

Severe hypertriglyceridemia

Parisi E, Glick M. Cervical lymphadenopathy in the dental patient: a review of clinical approach. Quintessence Int. 2005 Jun 1;36(6):423-36.

MEDICATIONS Allopurinol

Hydralazine

Atenolol

Penicillin

Captopril

Phenytoin

Primidone Carbamazepine

Cephalosporin Gold

Pyrimethamine Quinidine

Autoimmune Juvenile rheumatoid arthritis Systemic lupus erythematosis Scleroderma Wegener’s granulomatosis

Causes of generalized lymphadenopathy Tuberculosis Infectious mononucleosis Syphilis Sarcoidosis Brucellosis Toxoplasmosis HIV infection Hodgkin’s disease Lymphosarcoma Lymphatic leukemia

Tuberculous lymphadenopathy

Matted lymphnodes

Collar stud abscess

Caseation

Sinus formation

D/D Anatomical

Developmental Infections Tumors

Calcified masses

Anatomical structures ◦ Cervical rib ◦ Transverse process of atlas ◦ Greater cornu of hyoid bone ◦ Prominent styloid process ◦ Thyroid cartilage

•Bilateral •Hard •Non mobile •USG •Radiograph - specific anatomical

Developmental conditions

◦ Cystic hygroma ◦ Thyroglossal cysts ◦ Branchial cysts ◦ Dermoid cysts

•Position •Since birth •Dermoid – doughy consistency

• Soft •Moves during deglutition

Infections ◦ TB abscess ◦ Actinomycosis ◦ Mumps ◦ Sebaceous cysts

•Diffuse swelling •Abscess - soft to rubbery •Tender - viral parotitis •Nonmobile mass •Punctum - sebaceous

Tumors ◦ Lipoma ◦ Hemangioma ◦ Salivary gland tumors

•Asymptomatic, elevation of ear lobe

•Soft, slip sign

•Since birth, Diascopy +, portwine stains

Calcified masses ◦ Salivary calculi ◦ Calcified lymphnode

Sialolith •Painful swelling •Symptoms aggravated during meal time •Smooth outline •Duct - cylindrical in nature •Sialography Calcified •Asymptomatic •Well defined, irregularcauliflower shaped •History of tuberculosis •Radiograph

Diagnosis A. History

B. Examination a) Location b) Physical characteristics C. a) b) c)

Routine investigations Full blood count Erythrocyte sedimentation rate Examination of blood film

D. Additional investigations: a) Chest radiograph b) Antibody screening c) Microbial cultures

E. Specialized Investigations a) b) c) d)

Ultrasonography Contrast Enhanced CT (CECT) M.R. Evaluation Fine Needle Aspiration Cytology/Biopsy (FNAC/B) e) Lymph Node Biopsy f) Lymphangiography

FNAC

Biopsy

USG

CT

MRI

Parisi E, Glick M. Cervical lymphadenopathy in the dental patient: a review of clinical approach. Quintessence Int. 2005 Jun 1;36(6):423-36.

References Hall JE. Guyton and Hall textbook of medical physiology. Elsevier Health Sciences; 2006 May 31. Sembulingam K, Sembulingam P. Essentials of medical physiology. JP Medical Ltd; 2012 Sep 30. Singh I. Human embryology. JP Medical Ltd; 2014 Sep 30. Sadler TW. Langman's medical embryology. Lippincott Williams & Wilkins; 2011 Dec 15. Blum ks, pabst r. Keystones in lymph node development. Journal of anatomy. 2006 nov 1;209(5):585-95.

References Scully C. Oral and maxillofacial medicine: the basis of diagnosis and treatment. Elsevier Health Sciences; 2012 Nov 26. Upadhyay N. Cervical lymphadenopathy. J Dental Sci. 2012 Jan:30-3. Wood NK, Goaz PW. Differential diagnosis of oral lesions. Mosby Elsevier Health Science; 1985. Parisi E, Glick M. Cervical lymphadenopathy in the dental patient: a review of clinical approach. Quintessence Int. 2005 Jun 1;36(6):423-36.

References Willard-mack CL. Normal structure, function, and histology of lymph nodes. Toxicologic pathology. 2006 aug 1;34(5):409-24. Moore KL, Dalley AF, Agur AM. Clinically oriented anatomy. Lippincott Williams & Wilkins; 2013 Feb 13.