Lymphatic Drainage of the Head & Neck

8/17/2019 Lymphatic Drainage of the Head & Neck

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LYMPHATIC DRAINAGE OF THEHEAD & NECK & APPLIED ASPECTS


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INTRODUCTION

Drainage system aess!ry t! t"e #en!$s system

tiss$e %$i ' (i)e $( *y

› t"e #en!$s en !+ t"e a(i,,aries

Lym("ati #esse,s -.'/. 0 !+ t"e tiss$e %$is1

Tiss$e %$i %!2ing t"r!$g" t"ese #esse,s is a,,eLYMPH

Lym(" rains int! Larger veins


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INTRODUCTION

LYMPH

Defnition3 Liquid o alkaline reaction ound inlymphatic vessels and derived rom tissue uid

Lymphatic system is absent in3

'C4N4S4

'C!rnea

'S$(er5ia, ,ayer !+ s)in

'6!nes

'A,#e!,i !+ ,$ng


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COMPONENTS OF LYMPHLymph

Water (96%) Others (4%)

Solids Cellular

Proteins

Lipids

Carbohydrates

Amino acids

on nitro!enous s"

#lectrolyte

Lymphocyte

$onocyte macropha!es

Plasma cell


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LYMPHATIC 7ESSELS


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LYMPHATIC 7ESSELS


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LYMPHATIC 7ESSELS

Lym("a(i,,aries

Lym("ati#esse,

Lym("N!e

Lym("atitr$n)

C!,,eting$t

S$*,a#ian#ein


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AFFERENT & EFFERENTLYMPHATICS


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LYMPH FLO8

-/.m,

&'OACC *+C&

,

-'& L.$P'A&C *+C&

H!2999


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C!niti!ns 2"i" inrease Tiss$e %$i Inrease Lym(" +!rmati!n''' H!2999

/iltration 00eabsorption

00 &issue1luid

ncreased'ydrostatic

Pressure

00 mo2ementinto

LYMPHATIC

CAPILLARIES


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FUNCTIONS OF LYMPH

N$triti#e

Drainage

Transmissi!n !+ (r!teins

A*s!r(ti!n !+ +ats

De+ense


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LYMPH NODES OF THEHEAD & NECK

II

III

I7

I7

a

7

*

7I

H Y O I D 6

4

C R I C O I D

C4

S T E R N U M


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T!ng$e

LYMPHATIC DRAINAGE OF7ARIOUS STRUCTURES

Mani*$,arinis!rs

F,!!r !+ t"em!$t"'Anteri!r

Li(s

C"ee)s

Li(s


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Teet" Har Pa,ateHar Pa,ate

Har Pa,ateS!+t Pa,ateOr!("aryn:

Latera, 2a,,

!+ n!se


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Paranasa, Sin$ses

E:terna, ear

Sa,(


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E;TRA'NODAL LYMPHOID TISSUE


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PALATINE TONSIL

A,m!n s"a(e

T!nsi,,ar sin$s !r +!ssa *et2een

› (a,at!g,!ssa,

› (a,at!("aryngea, ar"es

› Meia, s$r+ae3 intrat!nsi,,ar ,e+ts

› Latera, s$r+ae3 a(s$,e !+ t!nsi,3 )ee(s t!nsi, in(,ae $ring s2a,,!2ing

Lym("ati rainage3 Jugulodigastric node


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TU6AL TONSIL

Ar!$n E$sta"ian t$*e !(enings int"e nas!("aryn:4

E:tensi!ns !+ ("aryngea, t!nsi,s


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8ALDEYER=S RING


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8ALDEYER=S RING


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E;AMINATION OF LYMPHNODES

Ne) n!es are*etter (a,(ate

2"i,e staning at t"e*a) !+ t"e (atient

Ne) is s,ig"t,y

%e:e t! a"ie#ere,a:ati!n !+ m$s,es


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When a node or nodes are palpable, followingpoints are observed:

(i) Location of nodes

(ii) !mber of nodes

(iii) "i#e $- t! -4> m in greatest imensi!n

(iv) %onsistency: Metastati n!es'"ar?

,ym("!ma n!es'5rm an r$**ery?

"y(er(,asti n!es's!+t4


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(v) &iscrete'matted nodes

(vi) enderness: In%ammat!ry

n!es are tener4

(vii) *i+ity

(viii) "ystemic symptoms


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"!bmental odes

R!,, t"e 5ngers*e,!2 t"e "in 2it"(atient=s "ea ti,te+!r2ars


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"!bmandib!larodes

R!,, y!$r 5ngersagainst inner s$r+ae

!+ Mani*,e 2it"(atient@s "ea gent,yti,te t!2ars !ne

sie


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Post a!ric!lar(Mastoid odes)

R!,, t"e 5ngers*e"in t"e ear

•ccipital nodes


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-nternal .!g!larchain

› E:amine t"e

$((er1 mi,e an,!2er gr!$(s4

› ,ie ee( t!stern!mast!im$s,e 2"i" maynee t! *eis(,ae(!steri!r,y


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ransverse %ervical

odes "!praclavic!lar

("calene odes)

R!,, y!$r 5ngers gent,y*e"in t"e ,a#i,es4Instr$t t"e (atient t!!$g" !r t! *ear !2n

,i)e t"ey are "a#ing a*!2e, m!#ement4Oasi!na,,y anen,arge ,ym(" n!emay (!( $(


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-

%linical relevance

In "ea an ne)1 a,, ,ym(" $,timate,yrains int! ee( er#ia, gr!$( !+

n!es Se!nary arin!mat!$s e(!sits in

t"ese n!es are !mm!n


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ECHELON LYMPHNODES

-st n!a, stati!n rea"e *y ,ym("atirainage !+ an !rgan3 /st echelonnodal gro!p

-st e"e,!n L4N4 !nnet t! ea" !t"ert"r!$g" (!st',ym("n!a, !,,eting

$ts an 5na,,y rain t! m!re entra,eBerent L4N4 !r iret,y int! t"e #en!$ssystem t"r!$g" t"e main ,ym("atitr$n)


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NODAL METASTAIS

T$m!r s(rea regi!na, ,ym(" n!es an *ey!n !$rs #ia,ym("ati #esse,s 2"!se (r!,i+erati!n is (r!m!te *y gr!2t"+at!rs

!mor lymphangiogenesis0 !ntri*$tes t! isseminati!n 'stim$,ate *y +ami,y !+ VEGF-C,D

CD44 is m$,tistr$t$ra, e,, s$r+ae a"esi!n m!,e$,e'!#ere:(ressi!n !+ CD an its is!+!rms *y t$m!r e,,s may,ea t! inrease ,ym("ati an "emat!gen!$s s(rea

T$m!r (r!$ti!n !+ proteolytic enzymes- (r!(agati!n !+,ym(" n!e metastasis

Ot"er me"anisms' is!ntin$ity in *asement mem*rane !+(rimary t$m!r1 +at!rs t"at +ai,itate e,, migrati!n1 a"esi!n

an (r!,i+erati!n4


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H-"1Y

In -/1 Lin*erg" re(!rte metastasisin -->> (atients 2it" $((eraer!igesti#e trat s$am!$s e,,arin!ma

Primary t$m!rs 2it" in t"e !ra, a#ity

',e#e,s I1 II an III esening !rer1 Or!("aryngea,1 "y(!("aryngea, an

,aryngea, (rimary t$m!rs ',e#e,s II1 IIIan I7


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PATTERNS OF NECKMETASTASIS

F!r (rimary t$m!$rs in !ra, a#ity regi!na, L4N4 at "ig"estris) +!r ear,y isseminati!n *y metastati aner ,imite t!,e#e,s I1 II1 III4

"2ip metastasis t! Le#e,s I1 II1 III e:eeing,y rare

T"ere+!re1 i+ ne) is ,inia,,y negati#eN.1 ,e#e,s I7 an 7L4N4 genera,,y n!t at ris)

T$m!$rs !+ oropharyn+, hypopharyn+ and laryn+3 5rst

e"e,!n L4N4 are› ee( J$g$,ar L4N4 at ,e#e,s I1 III1 I7 !n i(si,atera, sie3 m!re at ris)

On,y /.'/>0 !+ (atients 2it" arin!mas !+ (ar!ti g,ane#e,!( regi!na, metastasis4


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7IRCHO8=S NODES

"ignal nodes' seat ofthe devil' s$(ra,a#i$,araen!(at"y

En,arge1 "ar L4N4 in t"e,e+t s$(ra,a#i$,ar +!ssa3roisier3s sign

Ass!iate 2it" metastasis

+r!m SCC !+ t"e "ea anne)1 (rimary ,$ng aner1es!("agea, aner1 anerin t"e a*!men an (e,#iregi!n


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TNM Staging gr!$(ing


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%ommon lymph node enlargements


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CAUSES OFLYMPHADENOPATHY

/-nfectio!s disease

A4 7ira, 'In+eti!$s m!n!n$,e!sis 'In+eti!$s "e(atitis

'Her(es sim(,e: 'R$*e,,a 'Meas,es 'H-4

64 6ateria, 'Cat srat" isease '6r$e,,!sis 'T$*er$,!sis 'Aty(ia, my!*ateria, in+eti!n 'Primary an se!nary sy("i,is 'Di(t"eria


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5 -mm!nologic disease (generali#edlymphadenopathy)

A4 R"e$mat!i art"ritis 64 Systemi ,$($s eryt"emat!$s C4 SJ!gren synr!me D4 Dr$g "y(ersensiti#ity

6 Malignant disease a4 Hemat!,!gia, 'H!g)in=s ,ym("!ma 'N!n H!g)in=s ,ym("!ma 'Hairy e,, ,e$)emia 'T'e,, ,ym("!ma 'M$,ti(,e mye,!ma 64 Metastasis

'Fr!m (rimary site


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7Lipid storage disease 'Ga$"er=s isease

'niemann'(i) isease

89ndocrine disease 'Hy(ert"yr!iism 'Arena, ins$ieny 'T"yr!iitis

ther disorder

'Sar!i!sis 'Lym("!mat!i gran$,!mat!sis 'Ka2asa)i isease 'Hist!yt!sis :


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CALCIFIED LYMPH NODES

Dystr!("i a,i5ati!n1 !mm!n ingran$,!mat!$s is!rers

Lym("!i tiss$e gets re(,ae *y

"yr!:ya(atite',i)e a,i$m sa,ts near,yeBaing a,, n!a, ar"itet$re

Sr!+$,a

M!st !mm!n3 s$*mani*$,ar1 er#ia,

an (rea$ri$,ar1 s$*menta, ,ym("n!es

May aBet sing,e ,ym(" n!e !r a ,inearseries3 ,ym(" n!e "aining


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IN7ESTIGATIONS

Histopathological 'C!n#enti!na, FNAC' *,in (r!e$re

'E:isi!na, *i!(sy !+ n!e

'Sentina, ,ym(" n!e *i!(sy

%ontrast lymphoangiography

*ine needle aspiration cytology0 *;%

U,tras!$n g$iane

CT G$iane

' It is m!re a$rate t"an *,ine FNAC

'Hig" sensiti#ity'01 "ig" s(ei5ity>'

0


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% < M1-0'CT & MRI eteting sie !+ n!e

'CT *etter t"an MRI ner!sis1e:traa(s$,ar s(rea

&istant metastasis imaging

'C"est rai!gra("y

'A*!mina, USG'Rai!n$,ie imaging

'6,!! st$ies t$m!$r mar)ers


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CT' LYMPH NODES


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ROUNDED SHAPE3

*enign n!e ,3*Q/3-

E:e(ti!ns's$*menta, n!es

r!$n rat"er t"an!#!i in s"a(e4

Lym("!mat!$sn!es are !+ten,arge an r!$ne

s"!rt n!rma,

#a,$e4


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ECHOGENICITY3H!m!gene!$se"! ar"itet$rein a ,arge n!emay re%et t"e5s" %es" gr!ssa((earane seen

in ,ym("!mat!$sn!es

Areas !+ anechoic

echogenicity2it"in a n!e mays$ggest necrosis an metastatic

malignancy


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PET SCAN

SENTINAL NODE


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SENTINAL NODE6IOPSY

SN63 g!, stanar in me,an!ma an *reast aner

SN6 in HNSCC "as *een s$ggeste as a met"! t! im(r!#e t"e

a$ray !+ staging an tai,!r treatments

Fr!m May - t! De /..1 /. !nse$ti#e (atients entere a(r!s(eti#e st$y3 -40 "a (rimary t$m!$r !+ t"e !ra, a#ity an/40 !+ t"e !r!("aryn:4 SN 2as n!t +!$n in / (atients

F$nti!na, !$t!mes a+ter SN6 are re!gnie as signi5ant,y *ettert"an a+ter SND

6$t r!,e !+ SN6 in HNSCC is sti,, $neie4 S$rge!ns s"!$, *ea2are t"at t"ese (atients "a#e a N. ne) an g!! (r!gn!sis1 ant"at e,eti#e SND "as (r!#en re,ia*i,ity an 2!r,2ie ae(tane

"entinel lymph node biopsy in s>!amo!s cell carcinoma of the head andnec2:/? years of e+perience

ACTA otorhinolaryngologica Italica 5?/5@65:/A058


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SENTINAL NODE MAPPING

Em(,!ys - !r a,, !+ t"e te"ni$es3

-4 Rai!is!t!(e sanimaging

/4 InJeti!n !+ *,$e ye4 Use !+ a "an"e,

is!t!(e traer (r!*e +!r,!a,iati!n

• Pre'!(erati#e te"neti$m san em(,!ye 5rst• Gamma amera images at min$tes1 ->min$tes1 an

e,aye image at -"!$r4• -st ,ym(" n!e ienti5e *y te"neti$m san3

sentina, L4N4


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Immeiate,y (ri!r t! s$rgia, (r!e$re1 isos!lfanbl!e dye inJete ar!$n (rimary t$m!$r

O(erati#e (r!e$re arrie !$t 2it"in .min$tes !+t"e inJeti!n

Gamma (r!*e $se4 Any n!e that has in0vivo /?0second co!nt more than 6 times that of

bac2gro!nd considered BhotC 6,$e ,ym(" n!e ,!a,ie *y *,$nt isseti!n4

Pr!*e $se t! !rre,ate *,$e n!e 2it" "ig"estrai!traer ati#ity3 e:ise an sent +!r (at"!,!gi

ana,ysis

I+ resi$a, rai!ati#ity in *asin-.0 !+ e:'#i#!!$nt !+ "!ttest n!e in *asin3 +$rt"er e:(,!rati!n +!rm!re sentina, n!es

SURGICAL TECHNIUES OF


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SURGICAL TECHNIUES OFREMO7AL OF LYMPH NODES

Raia, Ne) Disseti!n

M!i5e Raia, Ne) Disseti!n

›

Ty(eI› Ty(eII

› Ty(eIII


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CONCLUSION

Thus, a good understanding o the

lymphatic drainage o the head and the

neck help us to better understand the

pathological basis o various diseases.


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Than yo!"

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Lymphatic Drainage of the Head & Neck