LYMPHATIC DRAINAGE OF HEAD AND NECK

Dr. ZAKIRULLA. M

CONTENTS1. HISTORICAL PROSPECTIVES

2. DEVELOPMENT OF LYMPHATIC SYSTEM

3. LYMPHATIC SYSTEM

A) LYMPH

B) LYMPHATIC CHANNELS

C) LYMPHOID ORGANS

D) LYMPH NODES

4. TOPOGRAPHY OF LYMPH NODES

5. CLASSIFICATION OF LYMPH NODES

6. LYMPHATIC DRAINAGE OF INDIVIDUAL PART

7. CLINICAL CONSIDERATIONS

A) DISEASES OF LYMPHATICS AND LYMPH NODES

B) HODGKINS LYMPHOMA

C) CYSTIC HYGROMA

D) INFECTIOUS MONONUCLEOSIS

E) BLOCK DISSECTION OF NECK

Historical perspective

• Lymphatic system was known to ancient greeks like Hippocrates spoke of white blood, Aristotle described them as colorless fluid within tubules

• ERASISTRATUS in Alexandria was first to describe around 2000 years ago

• GASPARO ASELLI an Italian anatomist rediscovered lymphatic vessels in 1622

• VAN HOOK of leyden in 1652 demonstrated the presence of cisterna chyli and thoracic duct in humans

• STARLINGS work on hydrostatics and hydrodynamic forces

across the capillary membrane controlling the movement of

fluid described the dynamics of lymph formation

• OLOF RUDBECK of Swedish university described that

lymphatic system constitute a circulatory system separate

from blood circulation and was accepted by Royal Society of

London in 1751

• WILLIAM HUNTER in the late 18th century was the first

to describe

the functions of lymphatic system.

Historical perspective…..

Starts at 5th week of IUL First signs of lymphatic system are seen in the form of a number of

endothelium lined LYMPH SACS

Six primary lymph sacs are formedSix primary lymph sacs are formed1) 2 jugular sac (Right and Left) At the junction of subclavian and anterior cardinal veins

2) 2 Iliac sac (Right and Left) At the junction of the iliac and posterior cardinal vein

3) 1 Retroperitoneal (Unpaired) Near the root of the mesentry

4) 1 Cisterna chyli (Unpaired) Dorsal to retroperitoneal sac

DEVELOPMENT OF LYMPHATIC SYSTEM

JUGULAR LYMPH SAC

CISTERNA CHYLI

ILIAC SAC

RETROPERITONEAL LYMPH SAC

RELATIVE POSITIONS OF PRIMARY LYMPH SACS

LYMPHATIC VESSELS 1) From extension from the sac2) May form De novo and extend into various tissues

LYMPHNODESAll the sacs excepts the cisterna chyli are invaded by connective tissue and lymphocytes and are converted into groups of lymph nodes

LYMPH SINUSESRepresents portion of original cavity of the sac

THORACIC DUCTDerived from right and left channels that connect the cisterna chyli to the corresponding jugular sac.

DEVELOPMENT OF LYMPHATIC SYSTEM……

Accessory route by which the fluid can flow from the interstitial spaces into blood.

The removal of proteins from interstitial spaces is an essential function, without which we would die within about 24 hours.

Lymphatic system consist ofLymphatic system consist of

A) Lymph

B) Lymphatic channels

i) Lymphatic capillaries

ii) Lymphatic vessels

C) Lymphoid organs

D) Lymph nodes

LYMPHATIC SYSTEM LYMPHATIC SYSTEM

LYMPHLYMPH

Definition: Transparent, slightly yellowish liquid of alkaline reaction found in lymphatic vessels and derived from tissue fluid.

LYMPH is clear watery-appearing fluid found in lymphatic vessels.

Colloidal osmotic pressure < Plasma, but > Tissue fluid.

Formed by the passage of substances from blood capillaries into tissue spaces. This process is TRANSUDATION.

During fasting Transparent, yellowish color, alkaline in reactionAfter fatty food Milky due to presence of droplets of emulsified fat

COMPOSITION OF LYMPHCOMPOSITION OF LYMPH

1) WATER 94%2) SOLIDS 6%

A) PROTEINS (2-6%)AlbuminGlobulinFibrinogenProthrombinClotting factorsEnzymesAntibodies

B) LIPIDS (5-15%) Chylomicrons, Lipoproteins

C) CARBOHYDRATESGlucose 132.2 mg/100ml

D) OTHERSUrea, CreatininChlorides, PhosphorusCalcium

Proteins, calcium , phosphorus < plasma Chlorine, glucose > plasma

ARTERIES (BLOOD PLASMA)

BLOOD CAPILLARIES (BLOOD PLASMA)

LYMPHATIC VESSELS (LYMPH)

INTERSTITIAL SPACES (INTERSTITIAL FLUID)

LYMPHATIC CAPILLARIES (LYMPH)

LYMPHATIC DUCTS (LYMPH)

SUBCLAVIAN VEINS (BLOOD PLASMA).

FORMATION AND SEQUENCE OF FORMATION AND SEQUENCE OF FLUID FLOWFLUID FLOW

LYMPHATIC LYMPHATIC CIRCULATIONCIRCULATION

RATE OF LYMPH FLOWRATE OF LYMPH FLOW

Lymph flow through thoracic duct 100 ml/hr

Lymph flow through right lymphatic duct 20 ml/hr

Total lymph flow 120 ml/hr

• Lymph carries protein and large particulate matter away from the tissue space.

• 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.

FUNCTIONS OF LYMPHFUNCTIONS OF LYMPH

LYMPHATIC CAPILLARIES

• They form mesh like network of tiny tubes distributed throughout the tissue spaces.

• Begins as closed-ended vessels.• They lack well developed basal lamina• Lymphatic capillary vs blood capillary

LYMPHATIC CHANNELSLYMPHATIC CHANNELS

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

• These are attached by Anchoring filaments

• Partly composed of fine collagen fibrils

LYMPHATIC CAPILLARIES are not found in– CNS– Cartilage– Spleen– Epidermis– Internal ear– Eyeball ie, Cornea– Bone marrow– Alveoli of lungs

However,these tissues contain minor interstitial channels called Pre-lymphatics

LYMPHATIC LYMPHATIC VALVESVALVES

When pressure is greater in interstitial fluid than lymph, the cells separate slightly, fluid enters the lymphatic capillary and vice versa

• Lymphatic capillaries repeatedly join to form bigger lymphatic vessels.

• It consist of external CT with an endothelial lining

• It has all 3 layers as in veins

i) Tunica intima

ii) Tunica media

iii) Tunica adventitia

• Superficially- veins

Deep - arteries.

• It carries tissue fluid from tissues to veins.

LYMPHATIC LYMPHATIC VESSELSVESSELS

• Skin vessels lie in subcutaneous tissue and generally follow veins

• Viscera vessels generally follow arteries forming plexuses around them.

.Lymphoid organs are of two types; ENGESET (1959)

1 Primary lymphoid organs

Thymus

Bone marrow.( secondary)

2 Secondary lymphoid organs

Lymph node

Spleen

Palatine and pharyngeal tonsil

Payer’s patches

LYMPHOIDLYMPHOID

ORGANSORGANS

central

central

peripheral

peripheral

EPITHELIOEPITHELIO LYMPHOIDLYMPHOID TISSUETISSUE

SALT Skin associate lymphoid tissueGALT Gut associated lymphoid tissueBALT Bronchial associated lymphoid tissue

MALTI) D-MALT Located in lamina propria and submucosaII) O-MALT Scattered around the base of epithelium a) peripharyngeal lymphoid ring of tonsils b) Oesophageal nodules c) Nodules in GIT (absent in stomach)

THYMUS THYMUS GLANDGLAND

Thymus is a triangular, bilobed lymphatic organ Located in mediastinum, posterior to sternum and between

the lungs It is small in newborn infant, reaches its maximum size at 10-

12 yrs of age, follows gradual decrease in its size Most T cell arise before puberty, some continue to mature

through out the life

HISTOLOGY OF THYMUS

It consists of right and left lobes joined together by fibrous tissue

Each lobule consists of connective tissue capsule 1) CORTEX (outer) - composed of tightly packed lymphocytes epithelial cells, macrophages and T-cells 2) MEDULLA (Center) - Composed of epithelial cells Scattered lymphocytes

Medulla contains Thymic (Hassall's)corpuscles, which are remnants of dying cells

1) PROCESSING THE ‘T’’ LYMPHOCYTES

2) ENDOCRINE FUNCTIONS OF THYMUS They secretes hormones namely

a) Thymosin

b) Thymin

c) Thymic humoral factor

d) Thymulin

3) Medullary epithelial cells of thymus are thought to secrete

a) Lymphopoietin

b) Competence-inducing factor

FUNCTIONS OF THYMUS

Hyperactivity of thymus results in a condition known asMyasthenia Gravis

1) INVOLUTION OF THYMUS Enhanced a) Hypertropy of adrenal cortex b) Injection of cortisone or Androgenic hormone. Delayed Castration and adrenalectomy

2) MYASTHENIA GRAVIS CAUSE – Thymic hyperplasia or tumour C/F – Excessive fatiguability of voluntary muscles.

3) THYMIC TUMOURS may press on the trachea, oesophagus and large veins of neck causing - Hoarseness - Cough - Dysphagia - cyanosis

APPLIED ANATOMY

SPLEEN

Largest lymphoid tissue of the

body. It is a bean shape organ for

filtering blood.

Weighing about 150gm in adult

Situated in the left hypo- chondriac

region between stomach and

diaphragm lateral to the liver

There is no afferent lymphatic

vessels

MICROSCOPIC STRUCTURE

Capsule-with outer covering peritoneum

• Trabeculae

• Hilus (hilum)

• White pulp

• Red pulp

• Reticular network

• Blood vessels

White pulp is lymphatic tissue, mostly lymphocytes (B cells), arranged around central arteries.

Red pulp consists of venous sinuses filled with blood.

FUNCTIONS OF SPLEENFUNCTIONS OF SPLEEN

1) Formation of blood cells

2) Destruction of blood cells

3) Reservoir of blood

4) Role in defense of body

RUPTURED SPLEEN

SPLENOMEGALY - Malaria, CML, Cirrhosis, Typhoid.

SPLENECTOMY Results in 1) Moderate degree of hypochromic anaemia2) Cannot withstand severe anoxia3) Diminished resistance against infections4) Leucocyte count increases, may go upto 20,000-40,000 per cu.mm

Other structures, particularly red bone marrow and the liver, can take over functions normally carried out by the spleen

CLINICAL CONSIDERATIONCLINICAL CONSIDERATION

WALDEYER’S LYMPHATIC RING

• In relation to oropharyngeal isthmus, there are several aggregations of lymphoid tissue that constitute Waldeyer’s lymphatic ring.

• The most important aggregations are

1) Right and left palatine tonsils.

2) Pharyngeal tonsil.

3) Tubal tonsil

4) Lingual tonsil

Clinical anatomy

Tonsils are large in children, regress after puberty.

Tonsils are frequent sites of infection, specially in

children.

Tonsillectomy removal of tonsils due to

infections.

QUINSY -> Suppuration in the peritonsillar area

Tonsillitis may cause referred pain in ear GFN

LYMPH NODESLYMPH NODES

LYMPH NODES

• Lymph nodes are secondary lymphoid tissues, situated peripherally.

• Architecture of Lymph nodes

Capsule

Cortex lymphoid follicles

Germinal centers

Para cortex

Medulla

Sinuses

Blood vessels

LYMPH NODES STRUCTURE

CORTEX (OUTER REGION)

MEDULLA

MEDULLARY SINUSES

MEDULLARY CHORD

CELLS PRESENT

LYMPHOCYTES

PLASMA CELLS

MACROPHAGES

1.Capsule& Trabeculae (Type I collagen)

• Composed mainly of collagen fibers, a few fibroblasts and elastin fibers,

• From the capsule, trabeculae of dense connective tissue extend radially into the nodes interior,

trabeculae

capsule

Reticulum / Stroma (Type III collagen)

• Supports the cell masses within them.

• Filters lymph by slowing down the flow.

Artery

Vein

Lymphatic channels Afferent Efferent

LYMPHATIC CHANNELS

CELL ZONES IN LYMPH NODES

FUNCTIONS OF LYMPH NODES

1) They produce and supply lymphocytes to the blood T-cell CELL MEDIATED IMMUNITY B-cell HUMORAL IMMUNITY

2) Bacteria and other particulate matter are removed from lymph by phagocytosis3) They act as a mechanical filters4) They produces globulins5) They carry immunological responses and help in development of immunity6) They temporarily stop the spread of cancer cells

HOW ARE lymphocytes FORMED?HOW ARE lymphocytes FORMED?

TURNER ( 1969 )and HOGG et al ( 1982 ) They lie in between spleen and lymph node.

HAEMAL / HAEMO LYMPH HAEMAL / HAEMO LYMPH NODESNODES

These lymph nodes possess red colour, due to the presence of blood in them

FOUNDFOUND Retroperitoneal tissue Mediastinum

Spleen may be regarded as the modified haemal lymph node

TOPOGRAPHY OF LYMPH NODES

• SUPERFICIAL/ DEEP

• RELATED VASCULATURE Buccal nodes Cervical nodes Clavicular nodes Inguinal nodes External iliac Internal iliac

• RELATIONS TO VISCERA: SM, Parotid, Pulmonary,

• GENERAL LOCATIONS LEG, ARM, HEAD AND NECK

RELATED TO LYMPH NODE CHAINS Primary Intermediary Terminal

NUMBER AND REGIONAL DISTRIBUTION

Head and neck 60-70

Arms/superficial thorax 40

Legs/superficial buttocks 30

Thorax 100

Abdomen/pelvis 230

Total 450-500 LN

CLASSIFICATION OF CERVICAL LYMPH NODES

HORIZONTAL CHAIN - Outer circle

- Inner circle

- Waldeyers ring

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

LYMPHATIC DRAINAGE OF THE BODY

• 38-45 cm (15-18 in.) in length

• Begins as a dilation called the cisterna

chyli, anterior to the second lumbar

vertebra.

• Main collecting duct of lymphatic system.

• Receives lymph from left side of the head,

neck & chest, left upper limb, & entire body

inferior to the ribs

THORACIC DUCT (LEFT LYMPHATIC)

RIGHT LYMPHATIC DUCT• 1.25 cm (1/2 in.) long • Drains lymph from the upper right side of

the body • Collects lymph from right jugular trunk,

which drains right side of the head and neck.

• Right broncho mediastinal trunk, which drains the right side of the thorax, right lung, right side of the heart.

parotid

Sub mental Submandibular

occipitalmastoid

Lower deep cervical

Jugulo-omohyoid

Buccal

Superficial cervical

Upper deep cervical

prelaryngeal

pre tracheal

LYMPH NODES OF HEAD AND NECK REGION

LYMPH NODES OF HEAD AND NECK REGION

• Occipital nodes Superficial group 2-3 nodes lies b/w SCM and trapezius Deep group 1-3 nodes lies deep to splenius muscle • Post auricular nodes 2-4 nodes• Parotid nodes 20 nodes intra glandular extra glandular• Submandibular nodes pre glandular post glandular pre vascular post vascular intra capsular NODE OF STOHR

• Sub mental nodes 2-8 nodes• Sub lingual nodes• Retro pharyngeal nodes 2-3 nodes

• Anterior cervical group

1. Anterior jugular chain

2. Juxta visceral chain

a) Pre laryngeal group: cricothyroid membrane

b) Pre tracheal: isthmus of thyroid gland

c) Para tracheal: recurrent laryngeal nerve

• Lateral cervical nodes 1) Superficial group: E J V 2) Deep group: a) Spinal accessory chain b) Transverse cervical chain c) Internal jugular chain

• Spinal accessory chain: 20 nodes Drain : occipital, post auricle, supra scapular, posterior sclap • Transverse cervical group:12 nodes drain : spinal accessory, skin from upper thorax, lower neck

• Internal jugular chain Upper groupUpper group: above hyoid bone Middle groupMiddle group: b/w hyoid and cricoid cartilage Lower groupLower group: below cricoid cartilage

Drain: nasal fossa, pharynx, tongue, salivary glands thyroid & para thyroids. efferent: into thoracic duct and subclavian vein

• Sentinal nodes: Highest JD nodes near angle of mand.

• Signal nodes: Lowest along the IJV (Virchow’s Nodes)

OCCIPITAL LYMPH NODEOCCIPITAL LYMPH NODELOCATION: At the apex of the posterior triangle superficial

to the attachment of the trapezius.

AFFERENT: Occipital part of the scalp

Upper part of the back of the neck

EFFERENT: Deep cervical node

LYMPH NODES IN LYMPH NODES IN HEADHEAD

LOCATION: These nodes lie on the mastoid process superficial

to the sternomastoid

AFFERENT: Posterior parietal region of scalp

Skin of the mastoid region

Posterior auricle

EFFERENT: Infra parotid nodes

Internal jugular nodes

Spinal accessory nodes

RETRO AURICULAR NODESRETRO AURICULAR NODES

LOCATION: The parotid lymph nodes lie partly in the superficial

fascia and partly deep to the deep fascia

AFFERENT: Temple Side of the scalp Lateral surface of the auricle External acoustic meatus

EFFERENT: Deep cervical nodes

PAROTID LYMPH NODEPAROTID LYMPH NODE

LOCATION: The buccal node lies on the buccinator.

AFFERENT: Cheek Lower eyelid

EFFERENT: anterosuperior group

of deep cervical nodes.

BUCCAL LYMPH NODEBUCCAL LYMPH NODE

LOCATION: in the submental triangle and on surface of

mylohoid muscle

AFFERENT: lower lip (middle part),

Chin, tip of tongue, Anterior gingiva Anterior floor of mouth

EFFERENT: Submandibular nodes, Jugulo-omohyoid nodes

SUBMENTAL LYMPH NODESUBMENTAL LYMPH NODE

LOCATION: Submandibular region, between the SM gland and medial surface of mandible

AFFERENT: Upper & lower lip (lateral part), Cheek medial canthus of eye soft palate, submental nodes SM salivary gland, Anterior 2/3rd of tongue Posterior floor of mouth, teeth

EFFERENT: Jugular group of nodes

SUBMANDIBULAR LYMPH NODESUBMANDIBULAR LYMPH NODE

Lymphatic drainage of scalp and ear• Anterior part of scalp pre-auricular lymph nodes

• Posterior part of scalp post-auricular (mastoid)

occipital lymph nodes

• External acoustic meatus,

middle ear and auditory tube deep parotid lymph nodes

TO SUMMARISETO SUMMARISE

• Upper part Preauricular Lymph nodes

• Middle part. Submandibular lymph nodes

• Lower part Submental lymph nodes

LYMPHATIC DRAINAGE OF FACE

LYMPHATIC DRAINAGE OF THE SUPERFICIAL TISSUES OF LYMPHATIC DRAINAGE OF THE SUPERFICIAL TISSUES OF THE HEAD AND NECKTHE HEAD AND NECK

Groups concerned are:

2) In the head: Occipital Retro-auricular (Mastoid), Parotid, Buccal (Facial)

2) In the neckSubmandibularSubmentalAnterior cervicalSuperficial cervical.

Lymphatic drainage of deep tissue of head and neck

• Head and neck tissues deep to deep fascia

Deep cervical lymph nodes

• Nasopharynx, pharyngotympanic membrane.

Retropharyngeal

• Trachea, oesophagus, thyroid

Paratracheal

Lymphatic drainage of mouth, teeth, tonsil, tongue

• Gingiva Submandibular lymph nodes

• Hard palate Superficial deep cervical • etropharyngeal

• Soft palate Retropharyngeal

• Floor of the mouth Submental (deep cervical) Submandibular LN

• Teeth Submandibular and deep cervical Submental lymph nodes• Tonsil Jugulodigastric nodes

• Tip Submental (deep cervical)

• Anterior 2/3rds Submandibular and

Deep cervical

• Posterior 1/3rd Jugulo-omohyoid lymph

nodes.

TONGUETONGUE

• Mucous membrane of nasal cavity

anterior part

• Posterior part Deep cervical

• Frontal and maxillary sinus Submandibular

• Sphenoid and ethmoid Retropharyngeal

Submandibular deep cervical LN

Lymphatic drainage of nasal cavity and paranasal sinus

DISEASES OF LYMPHATICS

LYMPHANGITISLYMPHANGITIS 1.Acute lymphangitis

2.Chronic lymphangitis

3.Neoplasms of lymphatics:

a. Benign neoplasms

1. Cystic Hygroma [Hydrocoele]

2. Lymphangioma

b.Malignant neoplasms:

i. Lymphangiosarcoma

ii. lymphoedema

1)primary lymphoedema

2)secondary lymphoedema

• LYMPHADENITIS: 1.Inflammatory -Acute lymphadenitis -Chronic lymphadenitis -Granulomatous lymphadenitis

a.Bacterial origin b.Viral origin c.Fungal origin2. Neoplastic:- Benign:- almost non existing -Malignant a. primary b.secondary3. Lymphatic leukaemias4. Autoimmune disorders

DISEASES OF LYMPH NODES

CAUSES OF LYMPHADENOPATHY

1 INFECTIVE:• Bacterial: Streptococcal, TB, brucellosis• Viral: Epstein-Barr, HIV• Protozoal: Toxoplasmosis• Fungal: Histoplasmosis

2 NEOPLASTIC:• Primary: Leukaemias, lymphomas• Secondary: eg. Lung, breast, thyroid, stomach

3 CONNECTIVE TISSUE DISORDERS:• Rheumatoid arthritis • SLE

4 SARCOIDOSIS

5 AMYLOIDOSIS

6 DRUGS:• Phenytoin

INVESTIGATIONS

1. CLINICAL EXAMINATION2. BLOOD3. ASPIRATION4. MONTOUX TEST5. GORDONS BIOLOGICAL TEST6. BIOPSY7. RADIOLOGICAL EXAMINATION8. LYMPHANGIOGRAPHY9. LAPROSCOPY10. IMAGING

• “If a node is palpable, it must be abnormal”

• Most lymph nodes should be examined by

extraoral, bimanual palpation from behind the

patient.

CLINICAL EXAMINATION OF THE LYMPH NODES

• Do not extend the neck since sternomastoid must be

relaxed.

• Use the pulp of the finger tips and try to roll the

gland against adjacent harder structures.

GENERAL PRINCIPLES

• Inspection

• Palpation

• Compare with contra lateral side

• Assess

1) Number

2) Site

3) Size

4) Consistency

5) Tenderness

6) Fixation

EXAMINATION OF LYMPHNODES

Pre-auricular lymph nodes

Examination of submandibular lymph nodes:

•Submandibular-, patients head tipped to the side being examined.

•Operator stands behind the patient.

Examination of submental lymph nodes

Submental- Tip the head forward and try to roll the node against the inner aspect of the mandible

Palpation of Posterior Cervical Nodes:

• Dorsal pads of the fingertips are used to palpate along the anterior surface of the trapezius muscle

• Then moved slowly in a circular motion toward the posterior surface of the SCM muscle

Palpation for Supraclavicular Lymph Nodes

• The examiners free hand is used to flex the patient’s head forward to relax the soft tissues of the anterior neck

• The fingers are hooked over the clavicle lateral to the SCM muscle

:

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

rapid onset.

• Chronic infection large, firm, less tender, mobile

• Lymphoma rubbery hard, matted, painless,

multiple

• Metastatic cancer Stony hard, fixed to the

underlying tissues, painless

• Syphilis (primary) Firm discrete shotty

• Tuberculosis-

• Stage I: Lymph nodes enlarged without matting

• Stage II: Lymph nodes enlarged with matting

• Stage III: Cold abscess

PALPABLE NODE CHARACTERISTICS

HODGKINS LYMPHOMA

C/F:- Painless and progressive enlargement of lymph node. cervical lymphadenopathy followed by axillary and inguinal lymph nodes - Spread of LN in contiguity ie., from 1 set of LN to next

Symptoms: Fever, chills, night sweat, wt. loss., Typical fever (pel-Ebstein fever) Pain in bones and abdominal pain Hepatosplenomegaly.

Diagnosis: Reed sternberg cells

Treatment : Radiotherapy, chemotherapy.

The 4 stages of Hodgkin’s lymphoma

1- Involvement of single lymph node or extra lymphatic organ

2- Involvement of 2 or more lymph nodes on same side of

diaphragm or extra lymphatic organ and one or more lymph tissue involvement on the same side.

3- Involvement of lymph nodes on both the sides of the diaphragm and/ or extra lymphatic organ

4- Diffuse involvement of one or more lymphatic organ or tissue

CYSTIC HYGROMA

It is a cystic swelling which contains multiple locules of clear lymph

DEVELOPMENT

Site Posterior triangle of neck Cheek, axilla, groin AGE It manifest in early infancy Occasionally present at birth

SYMPTOMSLump or swellingSwelling gives impulse on coughing Surface smooth/ lobulatedTranslucency Brilliant translucent swelling

TREATMENT Surgical excision

INFECTIOUS MONONUCLEOSIS

CAUSE EB virus, predominantly affect young adults Transmitted in saliva and aerosol

C/FFever, headache, sore throatGeneralised lymph node enlargement Splenomegaly

DIAGNOSIS• Lymphocytosis in the blood• Paul-bunnel test

BLOCK DISSECTION OF NECKBLOCK DISSECTION OF NECK

INDICATIONINDICATION

When the primary growth is operable, the primary growth

is adequately excised along with excision of the involved nodes

STRUCTURES REMOVED EN BLOCSTRUCTURES REMOVED EN BLOC

Submental, SM, upper and lower deep cervical group

Posterior cervical group and supraclavicular group.

Sternomastoid muscle

IJV

Spinal accessary nerve

Branches of ECA

1. Human physiology; Chatterjee, 10th Edition,.

2. Text of Medical Physiology; Arthur C.Guyton, 10th Edition, W.B. Saunders Company.

3. Text of Physiology and biochemistry; George H.Bell, 9th Edition,.

4. Gray’s Anatomy; Henry Gray, 38th Edition, Churchill Livingstone.

5. Cunningham’s Textbook of Anatomy, G.J. Romanes, 12th Edition, Oxford University Press.

6. www.google.com

REFERENCES