lymphatics head and neck
TRANSCRIPT
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.