Lymphatic System & Cervical Lymph Nodes by Dr. Ashish jaiswal

Dr. Ashish Jaiswal 1

Dr. Ashish Jaiswal

- Dr. Ashish K. Jaiswal1st Year MDS

Public health DentistrySibar Institute of Dental Sciences

Date – Monday 20th June 2011

Lymphatic System &The Cervical Lymph Nodes


Contents

• Introduction• Development• Lymphatic System• Immunology• Functions• Lymphatic Drainage• Examination• Lymphatic Diseases• Investigations• Management• Conclusion


LYMPHATIC SYSTEM

• Definition :– Lymphatic system can be defined as closed system

of channels through which the fluid is drained from interstitial spaces into the blood venous system via thoracic & right lymphatic duct.


Development

• Derived from mesoderm• Begins developing at the end of 6th week of

intrauterine life.• Originates from six lymph sacs:– Two Jugular– Two Ilial– One Retroperitonial– One Chyle Cistern


Lymphatic System

• Lymphoid Organs• Lymphoid Tissue• Lymphatic Cells• Lymph• Lymph Nodes• Lymph Capillaries• Lymphatic Trunks• Lymphatic Ducts

Dr. Ashish Jaiswal

Lymphatic System

• Lymphoid Organs :– Spleen– Thymus– Tonsils– Lymph nodes

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Spleen

• It lies behind the stomach, high up on the left side of the abdomen, on a level with the 9th to 11th ribs.

• Similar to a lymph node in shape and structure but is much larger.

• It is the largest lymphatic organ in the body.• Consists of two types of tissue called– White pulp & Red pulp


Function of Spleen

• Filters blood• Stores blood


Thymus • Location : It is located in the anterior superior

mediastinum, in front of the heart & behind the sternum.

• Function : Function of the thymus is the processing and maturation of the undifferentiated lymphocytes into T-lymphocytes or T-cells, which are associated with antibody production.



Tonsils

• Cluster of lymphatic tissue just under the mucous membranes that line the nose, mouth, and pharynx (throat) called tonsils.

• There are three groups of tonsils. 1. Pharyngeal tonsils 2. Palatine tonsils 3. Lingual tonsils

• Provide protection against harmful substances and pathogens that may enter the body through the nose or mouth.



•Pharyngeal Tonsil•Tubal Tonsil•Palatine Tonsil•Lingual Tonsil

Waldeyer’s Lymphatic Rings

Retropharyngeal Node

Jugulodigastric Node

Jugular Chain of Nodes

Submandibular Nodes

Submental Nodes

Inner Ring Outer Ring


Lymphatic Cells

Dr. Ashish Jaiswal

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)



Lymphatics

• Lymph capillaries• Lymph vessels• Lymphatic trunks• Lymphatic ducts


Lymphatic channels

• Lymph capillaries & vessels form the lymphatic channel.

• Almost all body tissues have special lymphatic channels.


Lymphatic Channels


• Lymph Capillaries :– Dead end– Thin walled with single layered endothelium– Numerous valves


LYMPH

• Lymph is nothing but interstitial fluid that flows into the lymphatics channels.

• It is a transparent, slightly yellow, often opalescent liquid.


LYMPH

• Lymph composition :– 96% water & 4% solids

• When lymph 1st enters the terminal lymphatics, it has almost the same composition as the interstitial fluid


LYMPH

• Soilds :– Protiens – The overall protein concentration

comes to 3-5g/dl

Liver Lymph - Protein Conc 6g/dlIntestinal Lymph - Protein Conc 3-5g/dlOther Body Tissues lymph - Protein Conc 2g/dl


LYMPH

• Soilds (cont.) :– Lipids– Carbohydrate– Nitrogenous substances– Electrolyte– Foreign bodies


LYMPH

• Cellular composition of lymph– Mostly contains lymphocytes– Normal lymphocyte count of lymph is 1000-

2000/cumm– Monocyte, macrophages & plasma cells are

occasionally present.


LYMPH

• Total quantity of lymph is 2-3 liters• 120ml of lymph flows into blood per hour

• Lymphatic flow determined by– Interstitial fluid pressure– Activity of lymphatic trunk


Functions of Lymph

• Return of proteins• Redistribution of body fluid• Removes foreign bodies• Maintenance of structural & functional

integrity of tissue


Lymph Nodes

• Lymph nodes are small glands that are interposed during the course of lymph vessels.


Structure of Lymph Node


Lymph Nodes

• Functions of lymph nodes– Filtration– Removal of foreign bodies


Lymph Nodes of the Head & Neck


Lymph Nodes of the Head & Neck

• The entire lymph from the head and neck drains ultimately into the deep cervical nodes either directly or through the peripheral nodes.

• Deep Cervical Lymph Nodes :– The deep cervical nodes form a vertical chain situated

along the entire length of the internal jugular vein.– For descriptive purpose they are grouped as

• Antero superior• Anteroinferior• Posterosuperior and• Posteroinferior


Jugulodigastric Node

• Location : The jugulodigastric node is a member of the antero-superior group.

• Drainage : It is the main node draining the tonsil.


Jugulo-Omohyoid Node

• Location : The jugulo-omohyoid node is a member of the postero-inferior group.

• Drainage : It is the main lymph node of the tongue


Path of Deep Cervical lymph Nodes

Efferents of the Deep Cervical Lymph Nodes

Right Jugular Trunk

Right Lymphati

c Duct

Angle of junction between the

Internal jugular and Subclavian vein

Left Jugular Trunk

Thoracic Duct


Peripheral Cervical lymph Nodes• The peripheral nodes are arranged in two circles,

– 1. Superficial and – 2. Deep

• The superficial circle of cervical lymph nodes is made up of the following groups:– (1) Submental – (2) Submandibular– (3) Buccal and mandibular (facial0– (4) Preauricular (parotid)– (5) Postaurtcular (masloicl)– (6) Occipital– (7) Anterior cervical– (8) Superficial cervical


Peripheral Cervical lymph Nodes

• The deep (inner) circle of cervical lymph nodes includes the followtng –– (1) Prelaryngeal and pretracheal– (2) Paratracheal and– (3) Retropharyngeal nodes.


Lymph Nodes

• Each lymph node is described under the following heads –– Location/Position– Drainage– Efferents


Submental Lymph Node

• Location :




• Drainage :– Superficial tissues below the chin– Central part of the lower lip– Lower incisors & gingiva– Anterior part of the floor of the mouth– Tip of the tongue– Mucous membrane of the lip & cheek

• Efferent : Their efferent pass to the submandibular nodes


Submandibular Lymph Node

• Location :

Submandibular Lymph node


Submandibular Lymph Node

• Drainage :– Upper & lower teeth & gingiva (except mandibular

incisor)– Anterior nasal cavity– Palate– Body of the tongue– Upper lip– Lateral angle of the eye– Submental nodes

• Efferents : Their efferent drains into the deep cervical nodes


Buccal & Mandibular Lymph Nodes

• Location :– Buccal lies on the buccinator– Mandibular lies on the lower border of the mandible

• Drainage :– Part of the cheek, lip & lower eyelid– Mucous membrane over the mandible

• Efferents :– Their efferents pass to antero-superior group of

deep cervical lymph node


Pre-auricular Lymph Node

• Location :

Pre-auricularLymph Nodes


Pre-auricular Lymph Node

• Drainage :– The temple– Side of the scalp– Lateral surface of the auricle– Middle ear– Parotid gland– Upper part of cheek– Parts of the eyelid & orbit

• Efferents :– They pass to upper group of deep cervical nodes


Posterior-auricular ( Mastoid ) Node

• Location :

Posterior-auricular Lymph Nodes


Posterior-auricular ( Mastoid ) nodes

• Drainage : – They drain a strip of scalp just above and behind

the auricle,– the upper half of the medial surface and margin of

the auricle and – posterior wall of the external acoustic meatus

• Efferents : Efferents pass to the postero superior group of deep cervical nodes.


Occipital Nodes

• Location :

Occipital Lymph Node


Occipital nodes

• Drainage : They drain the occipital region of the scalp.

• Efferents : Efferents pass to the supra-clavicular members of the postero-inferior group of deep cervical nodes.


Superficial Cervical Nodes

• Location :

Superficial Cervical Lymph Node


Superficial Cervical Nodes

• Drainage : They drain – the lobule of the auricle,– the floor of the external acoustic meatus,– and the skin over the lower parotid region and the

angle of the jaw.• Efferents : Efferents pass to the upper and

lower deep cervical nodes


Deep Cervical Lymph Nodes

(1) Prelaryngeal and pretracheal(2) Paratracheal and(3) Retropharyngeal nodes.


Prelaryngeal and Pretracheal Nodes

• Location :




• Drainage : – The larynx,– The trachea – Isthmus of the thyroid.

• Efferents : Their efferent to the nearby deep cervical nodes.


Paratracheal Nodes

• Location :

Paratracheal Lymph Node


Paratracheal Nodes

• Drainage : They receive lymph from the oesophagus, trachea & larynx

• Efferents : Efferents pass to the deep cervical nodes


Retropharyngeal Nodes

• Location :

Retropharyngeal nodes


Retropharyngeal Nodes

• Drainage : – The pharynx,– The auditory tube,– Soft palate, – The posterior part of the hard palate,– The nose.

• Efferents : Their efferents pass to the upper deep cervical nodes.


Main Lymphatic Trunks of the Neck


Thoracic Duct

• Thoracic duct is the largest lymph trunk of the body.

• It begins in the abdomen from the upper end of the cisterna chyli, traverses the thorax, and ends on the left side of the root of the neck by opening into angle of junction between the left internal jugular the left subclavian vein.

• Before its termination, it forms an arch at the level of the transverse process of vertebra C7 rising 3 to 4 cm above the clavicle.


• Receives lymph from :– (1) Its tributaries in abdomen & thorax– (2) The left jugular trunk– (3) the left subclavian trunk and– (4) the left bronchomediastinal trunk.

• Drainage : It drains most of the parts of the body except for the right upper limb, the right halves of the head & neck and the thorax and the superior surface of the liver.


Other Trunks

• Right Jugular Trunk : It drains half of the head and neck.

• Right Subclavian Trunk : It drains the upper limb.

• Bronchomediastinal Trunk : It drains the lung,

half of the mediastinum and parts of the anterior walls of the thorax and abdomen.


All lymph from the lower part of the body

Right side of the head & neckPart of the left thorax

Left arm &

Thoracic duct

Blood venous system


Lymph from right side of head & neck

Right arm &Parts of right thorax

Right Lymphatic Duct

Blood venous system


Main Lymphatic Trunks

• right bronchomediastinal trunk

• right jugular trunk

• left jugular trunk

• left subclavian trunk• right subclavian

trunk

• right lumbar trunk

• left bronchomediastinal trunk

• left lumbar trunk

• intestinal trunk


Main Lymphatic Trunks


Examination of Lymph Nodes

• Inspection– Position– Number– Pressure effect

• Palpation– Position– Number– Local temperature– Surface– Margin– Consistency


Examination• Principles of Palpation– Patient’s back erect– Stand behind the patient– Patient’s chin tipped slight

toward chest– Palmer aspect of finger tips– Maintain slight pressure



Examination

• Sequence to palpate cervical lymph nodes – Begin with the most superior nodes & work down

to clavicle– Anterior to tragus of the ear for pre-auricular node – Then mastoid & base of the skull for posterior

auricular & occipital nodes– Under the chin for submental nodes– Then proceed further to palpate submandibular &

sublingual lymph node


Examination

• Examination of deep cervical lymph nodes –– To examine ask the patient to sit erect & them

turn the head to one side to relax sternocliedomastoid muscle, use thumb & finger to palpate under the anterior 7 posterior border of relaxed muscle & repeat on other side.


Causes of Enlargement of Lymph Node

• Inflammatory – Acute or chronic

lymphaditis– Infection – Tuberculosis– Filariaris– Secondary syphilis– Infectious mononucleosis– Brucellosis

• Neoplastic– Carcinoma– Sarcoma

• Haematological– Hodgkins disease– Non-hodgkins lymphoma– Chronic lymphatic

leukemia

• Immunological– Aids– Drug reaction– Systemic lupus

erythromatosus– Rheumatoid arthritis


Diseases of Lymphatic System• Lymphadenopathy

– It is any disease of the lymph nodes• Lymphadenitis

– It is the inflammation of one or more lymph nodes• Lymphadenocele

– It the cyst of the lymph node• Lymphangiophlebitis

– Inflammation of the lymphatic channels• Lyphatitis

– Inflammation of some part of lymphatic system• Lymphadema

– Chronic swelling of a part due to accumulation secondary to the obstruction of the lymphatic vessels or lymph node

• Lymphogranuloma– Systemic infection leading to acute lymphadenopathy


Lymphatic Disease• Lymphoma

– Any neoplastic disorder of lymphoid tissue • Lymphoblastoma

– Poorly differentiated lymphocytic malignant lymphoma• Lymphoepithelioma

– A pleomorphic poorly differentiated carcinoma arising from epithelium overlying lymphoid tissue

• Lymphocytoma– Well differentiated lymphocytic malignant lymphoma

• Lymphadenoma– It is a type of lymphoma

• Lymphangioma– It is tumor of the newly formed lymph spaces & channels


Infections of Oral Cavity / Oral Sepsis


Lymph Node involvement

•Oral infections

•Antigenic Stimulation

•Proliferation of lymphocytes

•Enlargement of lymph nodes

•Antigen Catabolised

•Becomes Non-Antigenic

•Lymphocyte activation ceases

•Lymph nodes return to normal size


Infections of Oral Cavity / Oral Sepsis

• Following are the various infectectious diseases of the oral cavity -


Oral Sepsis

• Periapical Osteitis :– Bacteria from the necrotic pulp invade the marrow

spaces of bone in the periapical region & causes inflammation leading to periapical ostitis.

• Cellulitis :– It is defined as the as a non-suppurative

inflammation of the subcutenious tissue extending along the connective tissue & the intercellular spaces


Oral Sepsis

• Absecss :– It is a localised collection of pus, surrounded by an

area of inflamed tissue in which hypermia & infiltration of of leukocytes occurs.

• Acute Periapical Abscess :– It is the collection of pus in the alveolar bone, at

the root apex of the tooth, following death of the pulp.


Oral Sepsis

• Peridontal abscess :– It is the collection of pus in the periodontium

usually as a result of chronic peridontitis.• Acute Apical Perodontitis :– It is caused when inflammatory degradation

products from the infected pulp penetrate periodontal ligament


Oral Sepsis

• Pericoronal Abscess :– Also called as pericoronitis– Caused by infection of the surrounding soft tissues

of a partially erupted or impacted tooth • Folliculitis :– It is caused when follicle of developing

succedaneous teeth may become infected when their primary predecessord develop chronic perapical abscess


Oral Sepsis

• Ludwigs Angina :– It is defined as rapidly spreading septic cellulitis involving

the submandibular, submental & sublingual spaces.• Facial Spaces Infections :– They are the spaces situated between the planes of fascia

in which infection may spread.• Osteomylitis :– It can be defines as inflammatory condition of the bone

that begins as an infection of medullary cavity & the haversian system & extents to involve the periosteum of the affected area.


Investigations

• Complete Blood Count• Chest Radiography• Serological investigation• Nodal Biopsy• Fine Needle Biopsy• Bone Marrow Aspiration• C. T. Scan• M.R.I • Lymphography


Management

• Conventional– Diuretics– NSAID’s– Antibiotics– Lymphatic Drainage Therapy

• Surgical : Neck Dissection• Radiotherapy• Chemotherapy


Conclusion

• Knowledge of regional lymph nodes is important to prognosticate the probable involvement certain lymph nodes if the site of tumor or infection is known.

• Conversely the knowledge of regional lymph nodes permits the diagnosis of an obscure site of a pathological process if a lymph node or group of lymph node is found diseased.


Role of Pubic Health Dentist

• As public health dentists are the closest to the public – to the population, they should understand the lymphatic system & their diseases so as to identify them while general clinical examination in field studies & advice/perform necessary basic treatment & refer them for specific treatment.


References• B.D. Chaurasia : Human Anatomy, Regional And Applied Dissection

And Clinical 4th Edition• Bhatnagar Et Al : Essential Of Human Embryology 3 rd edition• Das S : A Manual On Clinical Surgery, • Davidson : Principles And Practice Of Medicine.• Gray’s Anatomy.• Inderbir Singh : Textbook Of Anatomy With Color Atlas.• Martini : Textbook of Anatomy• William G. Shafer Et Al : Textbook Of Oral Pathology.• Sembulingam : Text book medical physiology• Wikipedia – Lymphatic system & lymph nodes• Google Images


Thank You

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Lymphatic System & Cervical Lymph Nodes by Dr. Ashish jaiswal