AN OVERVIEW OF

LYMPHATIC SYSTEM

Dr.N.R.K.Anil Kumar,Dept.Of Oral and Maxillofacial Surgery,Vishnu Dental College,Bhimavaram

LYMPHATICS OF HEAD AND NECK

CONTENTS • History• Development of lymphatic system• Lymphatic system

• Lymph• Lymphatic Channels • Lymph node• Lymphoid organs

• Lymph nodes of head and neck• Diseases of lymphatic system

HISTORY • Ancient greeks Hippocrates and Aristotle described lymph

as white fluid.

• Gasparo aselli an italian anatomist

discovered lymphatic vessels in 1622.

• Van hook in 1652 demonstrated the presence of cisterna

chyli and thoracic duct in humans.

• William hunter in the late 18th century

was the first to describe the functions

of lymphatic system.

• Olof Rudbeck of swedish university

described that lymphatic system

constitute a circulatory system separate

from blood circulation and this fact was

accepted by Royal society of London.

DEVELOPMENT

• Develop at the end of 5th wk of

embryonic life

• Lymphatic vessels develop

from lymph sacs which arise

from developing veins and are

derived from mesoderm

• 1st lymph sac to appear paired

jugular lymph sacs at junction

of internal jugular & subclavian

veins

DE

VE

LO

PM

EN

T

• JUGULAR LYMPH SACS • Retains one connection with its

Jugular vein• Spreads lymphatic capillary plexuses

to Thorax , upper limbs , head &neck.• Left one develops into superior

portion of thoracic duct.

• RETROPERITONEAL LYMPH SAC • It is unpaired and develops from primitive vena cava & mesonephric

veins.• Spreads capillary plexuses & lymphatic vessels to abdominal viscera &

diaphragm.• Develops connections with cisterna chyli & loses connections with

neighboring veins

CISTERNA CHYLI • develops inferior to diaphragm on

post abdominal wall.

• gives rise to inferior portion of

thoracic duct.

POSTERIOR LYMPH SACS

• Develops from iliac veins.

• Gives capillary plexuses & lymphatic

vessels to abdominal wall , pelvic

region & lower limbs.

• Join cisterna chyli & loose

connections with adjacent veins

Development

• Lymph vessels grow out from the lymph sacs, along the major veins.

• Except for the upper portion of the cisterna chyli, which persists, the lymph sacs are transformed into groups of lymph nodes during early fetal life, at about 3 months.

Development • PALATINE TONSILS – second pair of pharyngeal

pouches• TUBAL (PHARYNGOTYMPANIC) TONSILS -

aggregations of lymph nodules around the openings of the auditory tubes

• PHARYNGEAL TONSILS (adenoids) - aggregation of lymph nodules in the nasopharyngeal wall

• LINGUAL TONSILS - aggregations of lymph nodules in the root of the tongue

• LYMPH NODULES also are seen in the mucosa of the digestive tract and respiratory tract

• SPLEEN - aggregation of mesenchymal cells in the dorsal mesentery of the stomach

LYMPAHATIC SYSTEM

• Lymphatic comes from the Latin word lymphaticus, meaning "connected to water," as lymph is clear.

• Network of vessels & lymph nodes which are located in all major tissues of body.

• Lymphatic system is absent in CNS, Cornea, Superficial layer of skin, Bones, Alveoli of lung.

• CONSIST OF

– Lymph – Lymphatic Channels – Lymph Nodes – Lymph Organs

CapillariesVesselsDucts

LYMPH Lymph is • Transudative fluid.• Transparent & slightly yellowish

liquid.• Alkaline in nature.• Derived from tissue fluid.• When blood passes through

tissues

9/10 of fluid - venous end

1/10 of fluid - lymph capillaries• “CHYLE” - Lymph from small

intestine.

FORMATION OF LYMPH Starling’s hypothesis

COMPOSITION OF LYMPH

COMPOSITION OF LYMPH

PROTEINS : 2 to 6 % of solids.

Depending upon the part of body from which it is collected

Albumin, globulin, clotting factors (fibrinogen, prothrombin) , all antibodies

and enzymes.

LIPIDS : 5-15 % - mainly chylomicrons and lipoproteins.

CARBOHYDRATES : Sugar - 132 mg per 100 ml (Mainly glucose).

Non protein nitrogenous substances : Urea, A.A & Creatinine.

ELECTROLYTES : sodium, calcium, potassium, Chloride & bicarbonate.

CELLULAR CONTENT : mainly lymphocytes 1000-2000 per cu mm

96% water 4% solids

RATE OF LYMPH FLOW

• Total estimated lymph flow is 120 ml / hr

• About 100 ml flows through Thoracic duct in resting man per hour

• Approx 20 ml flow into circulation through other channels

• 3 – 4 liters / day

• Lymph carries protein and large particulate matter away from the

tissue space.

• End products of digestion are absorbed mainly by lymph channels.

• Important role in redistribution of fluid in the body.

• Bacteria, toxins and other foreign bodies are removed from the

tissues.

• Maintenance of structural and functional integrity of tissue.

• In immune response of the body.

• Production and maturation of lymphocytes.

FUNCTIONS OF LYMPHATIC SYSTEM

LYMPAHATIC SYSTEM

LYMPHATIC CAPILLARIES

• Smallest lymphatic vessels

• They begin in the tissue spaces as blind-ended sacs.

• These capillaries form plexuses which collect lymph from

the interstitial space mark the beginning of lymphatic

system

• They are lined by a single layer of endothelial cells.

• These are attached to C.T by anchoring filaments.

• The edge of one endothelial cell

overlaps the adjacent cell.

• Overlapping edge is free to flap inward minute valve.

• Permits passage of high molecular weight substance.

LYMPHATIC CAPILLARIES

LYMPHATIC VESSELS

• Lymph capillaries merge to form lymphatic

vessels.

• Resemble veins but

– Thin walls (Diameter - 0.2 – 0.3 mm)

– More valves (formed from folds of

tunica intima)

– Lymph Nodes are located at

interval along its

course

Have 3 coats (Tunica intima, Tunica media,

Tunica adventitia)

BEADED in appearance (semilunar valves).

Collagenous fibers attaches the endothelium

to the outer tissues ( fibrous sheath of

muscle)

LYMPHATIC DUCTS

RIGHT LYMPHATIC DUCT

THORACIC DUCT

THORACIC / LEFT LYMPHATIC DUCT

• 38 – 45 cm long

• Begins as a dilation called cisterna chyli

anterior to 2nd lumber vertebra.

• Main duct for return of lymph to blood

• Receives lymph from left side of head, neck,

Left upper limb, chest & entire body inferior

to ribs

• Joins the venous system at the junction of Left

Sub clavian & Left internal jugular veins &

drains lymph via Lt subclavian vein.

Origin, course, relations, and termination

• Arises in the abdomen from cisterna chyli under cover of diaphragm.

• Enters the thorax through the aortic opening.• It continues upward through the posterior mediastinum, on

the left, first with the aortic arch and then with the left pleura.

• It enters the root of the neck, where it arches laterally behind the left carotid sheath, to terminate in the upper end of the left innominate vein, in the angle of junction of the internal jugular and subclavian veins. 

• Chyle leak.• Virchows or scalene nodes or signal nodes – supra

clavicular nodes.

RIGHT LYMPHATIC DUCT

• 1.2 cm long • 3 lymphatic trunks drain into Rt lymphatic duct

– Rt Jugular trunk-drains Rt side of head & neck– Rt subclavian trunk-Rt upper limb – Rt bronchomediastinal trunk-Rt side of thorax, Rt lung,

Rt side of heart , & part of liver • Rt lymphatic duct joins the venous system at the junction of Rt Sub clavian

& Rt internal jugular veins

LYMPHOID ORGANS

Primary or Central lymphocytes are produced and undergo development and

are supplied to secondary organs. • Thymus • Bone marrow

Secondary or peripheral organs :lymphocytes are activated to participate in specific immune

response. • Lymph nodes • Spleen • Tonsils

LYMPHOID ORGANS

BONE MARROW

• Bone marrow contains two types of cells multipotent stem cells

• NON – LYMPHOID STEM CELLS differentiate in bone marrow.

• Erythrocytes , granulocytes , monocytes & platelets.

• LYMPHOID STEM CELLS differentiate in bone marrow & then

migrate to lymphoid tissue.

• B & T lymphocytes.

• T- lymphocytes ( 75-80 %)

- based on coreceptor divided into

T - helper cells (with CD 4 coreceptors)

T - cytotoxic cells(with CD 8 coreceptors)

• B- lymphocytes

plasma cells

memory cells

LYMPHOCYTES

THYMUS

• Primary organ of Lymphatic System.

• Unpaired organ.

• Consists of 2 pyramidal lobes.

• Delicate & finely lobulated surface.

• Located in mediastinum.

• Extending

• Upwards - into neck as far as lower edge of thyroid gland

• Downwards - as far as fourth costal cartilage

• Largest at puberty and weighs 35 to 40 gms - Pinkish grey.

• Gradually atrophies in old age- yellowish in colour ( fat).

FUNCTIONS OF THYMUS

- Thymus contains lobes divided into lobules.- Each lobule – cortex ( immature T lymphocytes, Macrophages) – medulla ( T lymphocytes, thymic corpuscels)

1) Processing the “T’’ Lymphocytes2) Endocrine functions Of Thymus They Secretes Hormones namely A) Thymosin B) Thymin C) Thymic Humoral Factor D) Thymulin

SPLEEN• Located in left hypochondrium,

directly below diaphragm, above

left kidney & descending colon

& behind fundus of stomach.

STRUCTURE Roughly ovoid shape

Varies in size in diff individuals

Same individuals differs in size from time to time

Hypertrophy in infections

Atrophies in old age

Surrounded by fibrous capsule

Its extensions run inwardly roughly dividing the organ into compartments

WHITE PULP and RED PULP ( Splenic cords & sinusoids).

FUNCTIONS OF SPLEEN

• DEFENSE : as the blood passes through sinusoids of spleen,

microorganism from the blood are destroyed

• HEMOTOPOIESIS : monocytes & lymphocytes complete

development in spleen

• Worn – out RBC & platelets are destroyed

• Acts as a RESERVOIR of blood (200-350 ml )

• Main source of circulating antibody in the body.

LYMPHATIC NODULES

• Egg shaped masses of lymphatic tissue

not surrounded by capsule.

• They are scattered through out the GIT,

urinary & reproductive tracts and

respiratory airways and are referred to as

Mucosa – Associated Lymphatic tissue ( MALT )

• Many lymphatic nodules are small & solitary

• Peyers patches

• Some occur in multiple aggregation in specific parts of body

TONSIL

In relation to oropharyngeal

isthmus , they are several

aggregates of lymphoid

tissue

• Rt & Lf palatine tonsil

• Pharyngeal tonsil

• Tubal tonsil

• Lingual tonsil

WALDEYER’S RING

• Tonsil are located under mucous

membrane and back of throat

• There are depression of surface epithelium

around which aggregate of lymph nodule

are grouped called CRYPTS.

• Intratonsillar crypt

• Peritonsillar abscess begins in this cleft

• It is a collection of pus between fibrous

capsule of the tonsil usually at its upper

pole and the superior constrictor muscle

of pharynx.

TONSILS

LINGUAL TONSILS

• Hyperplasia is the most common abnormality

of the lingual tonsil. • Lingual tonsils sit on the base of the tongue and extend to

the vallecula and do not have a capsule. • Can be visualized by indirect mirror or flexible

laryngoscopy• Clinically, infection is marked by erythema and

enlargement of tonsillar tissue.• Although the lymphoid tissue in Waldeyer's ring tends to

decrease with advancing age, the lingual tonsil may increase in size. Important cause of lingual tonsil hypertrophy is the occurrence of compensatory hyperplasia following adenotonsillectomy.

ADENOIDS

• Pathological hypertrophy of nasopharyngeal tonsils.• Mostly between 3 to 5 years of age.

CLINICAL PRESENTATION• Nasal obstruction ( mouth breathing, snoring, nasal tone,

difficulty while suckling and eating)• Adenoid facies

( elongated, flat, expressionless,

without nasolabial folds,

open mouth, dry lips, high palate,

receded chin

• Mucopurulent anterior and posterior nasal discharge.

• Sleep disturbances (snoring, night enuresis due to hypercapnia )

• Feeding problems ( indigestion, loss of appetite )• Decreased mental performance• Recurrent ear problems• Respiratory problems

LYMPH NODES

• A normal young adult body contains some 400-450 lymph nodes.

• Head and neck -- 60-70 • Arms/superficial thorax – 40• Legs/superficial buttocks – 30 • Thorax – 100

• Abdomen/pelvis – 230

LYMPH NODES

• Small oval or bean shaped body

• Range from 10 to 20 mm in diameter.

• Positioned along the course of lymph vessel.

• Slight depression called

HILUS

(blood vessels enter & leave

through it)

MICROSCOPIC STRUCTURE OF LYMPH NODES

Each lymph node is enclosed by a fibrous capsule

It consist of Capsule, Cortex, Medulla.

Fibrous septa or trabeculae extend from covering capsule toward centre of node.

Cortical nodule packed lymphocytes surrounded by less dense area Germinal Center

Cortical nodules within cortex separated from each other by trabeculae

MEDULLA is composed of Sinuses & Medullary Cords

CELL ZONES IN LYMPH NODES

ZONE 1 - is a region of loosely packed cells, predominantly small lymphocytes, macrophages and occasional plasma cells.

ZONE 2 - is a denser region internal to zone 1,composed mainly of small lymphocytes and macrophages

ZONE 3 - comprises the germinal centers of follicles, its cells include large lymphoblast, dendritic cells and macrophages.

FUNCTIONS OF LYMPH NODES

DEFENSE

As lymph passes through lymph Node reticuloendothelial cells

remove microorganisms & other injurious particles

HEMATOPOIESIS

Site for final stage of maturation of lymphocytes & monocytes that

have migrated from bone marrow

CLASSIFICATION OF LYMPH NODES

HORIZONTAL CHAIN - Outer circle

- Inner circle

VERTICAL CHAIN

level 1 consist of sub mental,

submandibular nodes

level 2 consist of upper jugular nodes

level 3 consist of middle jugular group

level 4 lower jugular group

level 5 posterior triangle group

level 6 anterior compartment group

level 7 superior mediastinal group

level 8 supraclavicular nodes

level 9 retropharyngeal nodes

Base of skull

Bifurcation of carotid or hyoid bone

Inferior border of cricoid cartilage or omohyoid muscle

clavicle

The

Lymphatic

Drainage of the Tissue

of the Head

and

Neck

1. The superficial tissues2. The deeper structures

and viscera

The two layers are separated by deep cervical fascia.

1.

Lymphatic Drainage of the

Superficial Tissues of the Head

and

Neck

Regional lymph nodes

Superficial tissues

Deep cervical nodes

Neck Regionaldrainage

Lymph nodes of Headof superficial tissues

and

- Occipital

- Retroauricular

- Parotid

- Buccal (facial)

- Submandibular

- Submental- Anterior cervical

Occipital lymph nodes

Afferent – Back of scalp

Efferent – Deep cervical lymph nodes

At the apex of posterior triangle, superficial to trapezius

Retroauricular (mastoid) Lymph Nodes

Afferent

- Strip of scalp above auricle

- Posterior external auditory meatus

Efferent - Deep cervical nodes

superficial to sternocleidomastoid and mastoid process and deep to auricularis posterior muscle

Parotid Lymph Nodes

- Superficial parotid nodes

- Deep parotid nodes

Afferent of superficial parotid

nodes

- Strip of scalp above the parotid salivary gland

- Lateral surface of auricle

- Anterior wall of external auditory meatus

- Lateral part of the eyelid

Afferent of deep parotid nodes- Middle ear

Efferent

- Deep cervical nodes

5 to 6 in number

Buccal Lymph Nodes

Afferent – lower eye lid, part of cheek buccinator

muscle, facial vein

Efferent - Submandibular lymph node

On the surface of buccinator muscle in Relation to facial vein

Submandibular Lymph Nodes

Afferent

- Front of scalp

- Nose and adjacent cheek

- Upper lip

- Lower lip ( except center part )

- Frontal, maxillary, ethmoidal air sinus

- Upper and lower teeth

( except lower incisor )

- Anterior 2/3 of tongue ( except tip)

- Floor of mouth, vestibule, gums- Deep cervical lymph nodes

Efferent

Submental Lymph Nodes

Afferent - Tip of tongue

- Floor of mouth beneath the tip of tongue

- Incisor teeth and associated gum

- Center part of lower lip

- Skin over chiin

Efferent – Submandibular node

- Deep cervical lymph nodes

(Jugulo-omohyoid nodes)

Superficial Cervical Lymph Nodes

Afferent - Skin over the angle of jaw

- Skin over apex of parotid salivary gland and lobule of ear

Efferent - Deep cervical lymph nodes

2.

Lymphatic

Drainage of the Deeper Tissues

of

Head

and

Neck

Deeper tissues of head and neck

Regional lymph nodes

Deep cervical lymph nodes

Regional Lymph Node

- Retropharyngeal

- Paratracheal

- Infrahyoid

- Prelaryngeal

- Pretracheal- Lingual

Infrahyoid node

Prelaryngeal node

Pretracheal node

Retropharyngeal lymph nodes

– Located between pharynx &

atlas.

– Afferents

Pharynx ,

Auditory tube ,

Soft palate ,

post part of hard palate,

Nose.

Paratracheal Lymph Nodes

Afferent - Neighboring structures- Thyroid

glandEfferent - Deep cervical lymph nodes

Paratracheal node

Infrahyoid, Prelaryngeal, PretrachealLymph

Afferent – Anterior cervical nodes

Efferent – Deep cervical lymph nodes

Infrahyoid node

Prelaryngeal node

Pretracheal node

Nodes

Superior Deep Cervical Lymph Nodes

-Jugulodigastric lymph nodes

-Located - below posterior belly of digastric , between angle of the mandible & ant border of sternocleidomastoid

-One larger node and few small nodes

Afferent – Tongue, tonsil

Efferent - Lower deep cervical lymph

nodes and Jugular trunk

Inferior deep cervical lymph nodes

Jugular Omohyoid

Located - angle between the Int J V

and superior belly of omohyoid

Afferent – Tongue & Superficial and

superior deep cervical nodes.

Efferent - Jugular trunk

lymph nodes

LYMPHATIC DRAINAGE OF FACE

– Upper part Parotid Lymph nodes

– Middle part Submandibular lymph nodes

– Lower part Submental lymph nodes

Gingiva Submandibular lymph nodes

Hard palate Superficial deep cervical

and retropharyngeal

Soft palate Retropharyngeal

Floor of the mouth Submandibular and Submental

Teeth Submandibular and deep cervical

submental

Tonsil Jugulodigastric nodes

LYMPHATIC DRAINAGE OF MOUTH, TEETH, TONSIL

Tip Submental

Anterior 2/3rds Submandibular & deep cervical

Posterior 1/3rd Jugulodigastric lymph nodes

LYMPHATIC DRAINAGE OF TONGUE

LYMPHATIC DRAINAGE OF PARANASAL AIR SINUSES

• FRONTAL SINUS SUBMANDIBULAR NODES

• MAXILLARY SINUS SUBMANDIBULAR NODES

• ETHMOIDAL SINUSES SUBMANDIBULAR NODES

• SPHENOIDAL NODES RETROPHARYNGEAL NODES

DISEASES OF LYMPHATIC SYSTEM

• Diseases of Lymphatics

• Diseases of Lymph Nodes

DISORDERS OF LYMPHATICS

• Caused --- Haemolytic sreptococci,

Staphylococcal infections

• Infection occurs - distal limb - spreads

to regional lymph. N

• Lymph N - enlarged , tender & later

abscess may occur– Treatment --- conservative

Penicillin --- drug of choice

• Caused -repeated attack of Acute Lymphangitis

LYMPHANGITIS inflammation of peripheral lymphatics

• Appear as red streaks progressing towards regional lymph N

Acute Chronic

LYMPHOEDEMA

• Condition in which swelling of tissue in the extremities occurs

due to obstruction of the lymphatics & accumulation of lymph

• Etiology

– Primary lymphoedema

– Secondary lymphoedema

CLASSIFICATION

• According to the distribution of edematous fluid: (a) Local edema:(brain edema, pulmonary edema, etc).(b) Generalized edema:(cardiac edema, renal edema).

• According to the causes of edema:a) cardiac edemab) renal edemac) hepatic edemad) idiopathic edema• According to the gravity of edema: a) recessive (non-pitting) edema;b) frank (pitting) edema.

• Frank (pitting) edema: • 99% of interstitial fluid is fixed to collagen,

mucopolysaccharide and hyaluronic acid (gel), (connective tissue), which called fixed water.

• 1% of interstitial fluid is free water (moving freely). 

Mechanism of edema caused by increased CHP

capillary hydrostatic pressure(CHP)↑   effect hydrostatic pressure(EHP)↑  effective filtration pressure(EFP)↑   interstitial fluid ↑. 

Mechanism of decreased COP leading to edema

plasma colloidal OP↓

 

effective COP↓

 

Effective filtration pressure ↑

Interstitial fluid ↑

Mechanism of leading to edema in increased permeability of capillary wall

 permeability of capillary wall ↑ protein and fluid leak to interstitial space  tissue COP↑ plasma COP ↓  effective COP↓  effective filtration pressure↑  interstitial fluid ↑

mechanism of lymph edema

obstructed lymphatic vessels   backflow of protein in interstitial fluid is blocked,  the interstitial COP will increase effective COP decrease  effective FP increase  more fluid accumulates in interstitial space.

3. Characteristics of edema

(1) Properties of edematous fluid------------------------------------------------------------------------------------------Edematous causes protein appearance specific fluid concentration gravity------------------------------------------------------------------------------------------transudate ↑effective filtration 1～ 2g % clear low pressure

exudates ↑permeability of 4g % muddy high vascular wall

lymph obstruction of 4～ 5 % chyliform higher lymphatic vessel-----------------------------------------------------------------------------------------

• Lymphoedema Congenita– Oedma present at birth– Occurs ---- 10 % of cases

• Lymphoedema Parecox– Starts at adolescents ( 15 – 25 age )– Occurs ---- 75 % of cases

• Lymphoedema Tarda– Occurs after 35 yrs– Seen in 15 % of pts

PRIMARY LYMPHOEDEMADevelopmental error of lymphatic system

3 types

SECONDARY LYMPHOEDEMA

• Caused - Neoplastic / inflammatory process

• Surgical excision / Radiotherapy

• Parasitic infection with Filariasis

DISORDERS OF LYMPH NODES

• Lymphadenities ---- due to primary inflammatory reactions

• Lymphadenopathy ---- due to primary immune reactions

• LYMPHADENITIES

– Acute

– Chronic

ACUTE LYMPHADENITIES

– All kinds of acute inflammation

– Common causes

• Microbiological infections

• Foreign body in wound

– Nodes ---- enlarged , tender , may be fluctuant , over lying skin is

red hot.

CHRONIC LYMPHADENITIES– Commonly called --- Reactive lymphoid hyperplasia

– Cause --- repeated attacks of acute lymphadenities

lymph from malignant tumours

EXAMINATION OF LYMPHNODES

• Normal lymph node --- Non palpable

• Inspection :

– Swelling --- Number, position ,size

– Skin over swelling ---

• Acute lymphadenites --- inflamed , red , edema

• Chronic lymphadenites --- no change

• T B & Cold abscess --- skin is cold

• Lymphosarcoma --- tense , shining with dilated

subcutaneous veins

PALPATION :

– Number, size , tenderness , local temp , surface margins ,

consistency , fixation to underlying tissues

• Acute infection --- large, soft, painful, mobile,

• Chronic infection --- large, firm, less tender, mobile

• Lymphoma --- rubbery hard, matted, painless and multiple

• Metastatic cancer --- stony hard, fixed to the underlying tissues,

painless.

• Syphilis --- Firm discrete shotty

• Tuberculosis- Stage I: Lymph nodes enlarged without matting

Stage II: Lymph nodes enlarged with matting

Stage III: Cold abscess

LYMPH NODE EXAMINATION

• Pt relaxed & unstrained position with out head support

• Depending on site – Bilateral ---- behind pt– Unilateral ---- front of pt

• Palpation is done by placing flat surface of finger tips at same position on both sides

• Commencing with most superior nodes & working down to the clavicle

• Lymphography• valuable tool for detection of lymphatic fistulas

and lymphatic leakage• Ethidiol

• Lymphangioscintigraphy • Tc-99m albumin –intradermally, and after 1 minute

and again after 10–30 minutes,• High-resolution scintiscan camera

• Ultrasonography• Computed Tomography• PET• MRI (MR lymphography)• Fluorescein Microlymphangiography (isothiocynate)

• BIOPSY

INVESTIGATIONS

Thank you

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