Lymphatic & Venous System of Head and Neck / orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

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LYMPHATIC & LYMPHATIC & VENOUS SYSTEM VENOUS SYSTEM

OF HEAD AND OF HEAD AND NECKNECK

ModeratorModerator Dr David Dr David

TauroTauro

PresenterPresenter Dr Dr

Mahantesh.SMahantesh.Swww.indiandentalacademy.comwww.indiandentalacademy.com

Development of Development of lymphatic systemlymphatic system

Lymph fluidLymph fluid Lymph nodeLymph node Lymphatic Lymphatic

vesselsvessels Functions of Functions of

lymphatic systemlymphatic system

ClassificationClassificationDiagnosis of Diagnosis of LymphadenopathyLymphadenopathyConclusionConclusion ReferencesReferences

CONTENTS


WHY WHY LYMPHATICLYMPHATIC SYSTEMSYSTEM

??www.indiandentalacademy.comwww.indiandentalacademy.com

LYMPHATIC SYSTEMLYMPHATIC SYSTEM This system was This system was

described after the other described after the other parts of vascular system parts of vascular system are already known. are already known.

The reason for this The reason for this delay is their delicate delay is their delicate and transparent and transparent appearance. appearance.


EMBRY0LOGY OF EMBRY0LOGY OF LYMPHATIC SYSTEMLYMPHATIC SYSTEM

Lymph sacs -appear between 2Lymph sacs -appear between 2ndnd to 6to 6thth week of IUL. week of IUL.

77thth week - week -jugular channel spread to jugular channel spread to connect with subclavin lymph sacs.connect with subclavin lymph sacs.

99thth week - week - thoracic duct is continuous thoracic duct is continuous channel draining into IJ -subclavin vein channel draining into IJ -subclavin vein junction.junction.

1212thth week- week- all process are complete. all process are complete. 55thth month - month -valves begins to start.valves begins to start.


DEVELOPMENT OF LYMPH DEVELOPMENT OF LYMPH NODENODE

Jugular,Jugular, lymph lymph saccules and saccules and Peritoneal lymph Peritoneal lymph saccules saccules

Invasion of Invasion of neighboring neighboring Mesenchymal Mesenchymal cells so called cells so called lymph sinuses lymph sinuses evolve intra evolve intra nodally. nodally.


Primary / centralThymus and bone marrow

Secondary / peripheralSpleen, tonsil and lymph node

contents Cells, Organs Vessel Lymph fluid .

LYMPHATIC SYSTEMLYMPHATIC SYSTEM

lymphoid organ


LYMPH FLUIDLYMPH FLUID

CONTENTS•Proteins•Fats•Cells•Interstitial fluid

DefinitionTransparent,colorless,or slightly yellow watery fluid with specific gravity of 1.015.Same as blood plasma but more dilute


Lymph FluidLymph Fluid

PeripheralIntermediateCentral


FORMATION OF LYMPH FORMATION OF LYMPH FLUIDFLUID

FORMATIONFORMATION - Diffusion- Diffusion - Osmosis- Osmosis Terminal capillaries Terminal capillaries

in the Interstitium in the Interstitium 0.003ml/100kg/min 0.003ml/100kg/min

tissuestissues 2-3liters/day2-3liters/day

producedproduced


FACTORS AFFECTING FACTORS AFFECTING THE LYMPH THE LYMPH FORMATIONFORMATION

Environmental temperatureEnvironmental temperature Body movementBody movement


VELOCITY OF LYMPH VELOCITY OF LYMPH FLOWFLOW

Depends on Depends on – Intrinsic FactorsIntrinsic Factors– Extrinsic FactorsExtrinsic Factors

Velocity is generally Velocity is generally 3.1cm /min3.1cm /min


INTRINSIC EXTRINSIC

Intraluminal pressure

Lymphatic pump

Interstial pressure

MovementMuscularArterialrespiration


Conditions where lymph Conditions where lymph production increaseproduction increase

(pathologically)(pathologically) InflammationInflammation Venous stasisVenous stasis Mechanical insufficiency of vessels Mechanical insufficiency of vessels

and valvesand valves Drugs –Drugs –

Serotonin,Prostaglandins,TXA2, Serotonin,Prostaglandins,TXA2, Nor-adrenalineNor-adrenaline


These are the These are the raison d,etreraison d,etre of the of the lymphatic system lymphatic system

Local aggregation of lymphoid tissue. Local aggregation of lymphoid tissue. LymphaLympha colorlesscolorless – – yellow fluidyellow fluid

(lymphocytes)(lymphocytes) NodusNodus knot knot

LYMPH LYMPH NODE NODE


800800 L nodes in body L nodes in body 300300 are present in are present in

head and neckhead and neck 11stst defense station of defense station of

the body.the body. LocalizedLocalized mainly in mainly in

fattyfatty tissues tissues & & interposed between interposed between lymphatic flowlymphatic flow

LYMPH NODELYMPH NODE


SHAPE OF LYMPH SHAPE OF LYMPH NODE NODE

InguinalInguinal lymph nodes – large and round lymph nodes – large and round Outer iliacOuter iliac lymph nodes – longish mass lymph nodes – longish mass Inner iliacInner iliac lymph node – small and round lymph node – small and round Head and neckHead and neck lymph node- oval or lymph node- oval or

kidney or spindle shapedkidney or spindle shaped


SizeSize– 1- 30 um in diameter this 1- 30 um in diameter this

depends mainly on primary depends mainly on primary functionfunction

AbsorptionAbsorption -0.07ml/l node -0.07ml/l node

LYMPH NODELYMPH NODE


CELL ZONES

Zone 1

Extreme periphery

Loosely packed cells

lymphocytes, macrophages

Zone 2

More densely packed

small lymphocytes and

macrophages

Zone 3.

Germinal center

Large lymphoblasts


STRUCTURAL CHANGES:STRUCTURAL CHANGES:– Expansion of B and T lymphocytesExpansion of B and T lymphocytes– Cortical region enlargement Cortical region enlargement – Increase in no of macrophages in Increase in no of macrophages in

sinus , medullary sinussinus , medullary sinus

FUNCTIONAL CHANGESFUNCTIONAL CHANGES Reduced filtering capacityReduced filtering capacity Immune cells No. increaseImmune cells No. increasewww.indiandentalacademy.comwww.indiandentalacademy.com

FUNCTION OF LYMPH FUNCTION OF LYMPH NODE NODE

Biologic filtering Biologic filtering Production of lymphocytes in Production of lymphocytes in

context of immune reactions.context of immune reactions.


1. Biologic filtering1. Biologic filtering Capsule

Hilus

Afferent vessels

Marginal sinus

Marginal Zones

Medullary cords

Medullary sinus

Efferent vessels www.indiandentalacademy.comwww.indiandentalacademy.com

2.Immune reaction2.Immune reactionAntigen Margninal sinus

Bound to Macrophages & Reticular cells

Adjacent T-helper cells Present Ag to Immunocompetent

lymphocytes -- Mantle zone ( B-Lymphocytes)

Activated B cells

Immunoblastwww.indiandentalacademy.comwww.indiandentalacademy.com

IMMUNOBLAST

Move towards germinal centre

Immunocytes & Plasma cells

Differentiate


5-7 days, Plasma cells Medullary cords Ab into the medulla

Para cortical zone (T-lymphocytes)

Helper T cellsSuppressor T cells


LYMPHATIC VESSELSLYMPHATIC VESSELS

Anatomically Anatomically similar to veins similar to veins Are thin-walled , serve as drainage Are thin-walled , serve as drainage

channelschannels Initially lymph vessels are Finger-Initially lymph vessels are Finger-

shaped and blind.shaped and blind. they drain intercellular spaces and they drain intercellular spaces and

serous sacs. serous sacs. www.indiandentalacademy.comwww.indiandentalacademy.com

LYMPHATIC VESSELSLYMPHATIC VESSELS

Abundant interlacing anastomosesAbundant interlacing anastomoses Interruption of the continuity by lymph Interruption of the continuity by lymph

nodes. nodes. Drainage channels from many parts Drainage channels from many parts

not drained by the venous system not drained by the venous system www.indiandentalacademy.comwww.indiandentalacademy.com

LYMPHATIC VESSELS LYMPHATIC VESSELS

Wide vascular lumen. 30-50um .Wide vascular lumen. 30-50um . Lymph capillaries dose not contains Lymph capillaries dose not contains

valves. valves are there in valvular valves. valves are there in valvular precollectors .precollectors .

Diameter larger than 10um only can Diameter larger than 10um only can spread or metastasis can take place. spread or metastasis can take place.


STRUCTURE OF LYMPHATIC STRUCTURE OF LYMPHATIC VESSELVESSEL

Initial lymph vesselInitial lymph vessel Lymphatic collectorsLymphatic collectors

Endothelial cells that areSurrounded by an incomplete and interrupted basal membrane These cells overlap like roof tiles

Intima consists of endothelial cells

Collagen fibers and single muscle cells.

Media contains bundles of smooth

muscles surrounded By collagen fibers.

Adventitia –longitudinal bundles of

connective tissue,elastic fibers&

Single smooth muscle cells


FUNCTIONS OF FUNCTIONS OF ENDOTHELIAL CELLSENDOTHELIAL CELLS

Intense protein Intense protein synthesissynthesis

Increase cellular Increase cellular transportationtransportation


VALVESVALVES

Except initial lymphatic sinus or capillaries Except initial lymphatic sinus or capillaries every lymph vessels has valves.every lymph vessels has valves.

Valves may be Valves may be – BicuspidBicuspid– TricuspidTricuspid– QuadricuspidQuadricuspid



FUNCTIONS OF LYMPH FUNCTIONS OF LYMPH VESSELSVESSELS

Transitional function of fluid between Transitional function of fluid between

intercellular spaces and veins.intercellular spaces and veins. ImmunityImmunity Fats and proteins Fats and proteins


LYMPHATIC SYSTEM OF LYMPHATIC SYSTEM OF HEAD AND NECK HEAD AND NECK

REGIONREGION LS of aero digestive mucosa consists of LS of aero digestive mucosa consists of Narrow –meshed ,superficial vascular Narrow –meshed ,superficial vascular

system system Wide – meshed ,deeply situated Wide – meshed ,deeply situated

vascular systemvascular systemwww.indiandentalacademy.comwww.indiandentalacademy.com

LYMPHATIC DRAINAGE OF HEAD AND NECK

DEEP CERVICAL

Surrounds IJV

Spinal Accessory

Base of skull- Neck

SUPERFICIAL CERVICAL

Outer circle (Pericervical collar)

Inner circle (upper part of respiratory and alimentary passages)



SUPERFICIAL CERVICAL NODES (Inner circle)

Pre-laryngealPre-laryngeal Deep cervical Deep cervical fascia(beneath)fascia(beneath)

Anterior Anterior cervical nodescervical nodes

Deep cervical Deep cervical nodesnodes

Pre-trachealPre-tracheal

Para-trachealPara-tracheal

TracheaTrachea

Oesophagus Oesophagus and tracheaand trachea

Larynx,tracheaLarynx,trachea,oesophagus ,oesophagus and thyroid and thyroid

glandgland

Deep cervical Deep cervical nodesnodes

Retro-Retro-pharyngealpharyngeal

Retro-Retro-pharyngeal pharyngeal

spacespace

Pharynx,Pharynx,

palatine palatine tonsil,sphenoid tonsil,sphenoid

sinussinus

Upper deep Upper deep cervical nodescervical nodes


DEEP CERVICAL LYMPH NODES

Jugulo-Jugulo-digastric digastric nodesnodes

Triangular Triangular region(digastrregion(digastric, facial vein ic, facial vein and IJV)and IJV)

Palatine tonsil Palatine tonsil and and tongue(post.1/tongue(post.1/33rdrd))

Upper deep Upper deep cervicalcervicaljugjugular trunkular trunk

Jugulo-Jugulo-omohyoid omohyoid nodesnodes

On IJV above On IJV above intermediate intermediate tendon of tendon of omohyoidomohyoid

Tongue,sub-Tongue,sub-mental,sub-mental,sub-mandibular mandibular and upper deep and upper deep cervicalcervical

Jugular lymph Jugular lymph trunktrunk



SUB-MANDIBULAR

UPPER DEEP CERVICAL CHAIN OF NODES

SUB-MENTAL3rd Molars

Tongue (base)Tonsillar areaSoft palate

PAROTID NODES

LOWER DEEP CERVICAL CHAIN OF NODES


LOWER DEEP CERVICAL

Left lower body

(bilaterally)

THORACIC DUCT

Right Brachiocephalic vein

Right upper body

RIGHT LYMPHATIC DUCT

Left Brachiocephalic vein

Subclavian vein


Levels of Lymph nodes Levels of Lymph nodes (SLOAN –KETTERING CANCER CENTER, (SLOAN –KETTERING CANCER CENTER,

NYNY))

III

III

IV

VI v


CLINICAL CLINICAL CONSIDERATIONS CONSIDERATIONS

Normal lymph nodes not palpableNormal lymph nodes not palpable


LYMPHADENOPATHYLYMPHADENOPATHY


EXAMINATIONEXAMINATION How long swelling has been How long swelling has been

present?present?

Is it painful ?Is it painful ?

Does it vary with size?Does it vary with size?


GENERAL PRINCIPLESGENERAL PRINCIPLES

InspectionInspection

PalpationPalpation

Compare with contra lateral side.Compare with contra lateral side.

Site Site

SizeSize

ConsistencyConsistency

TendernessTenderness

Fixation Fixation


Stony hard Stony hard Metastatic cancer Metastatic cancer Firm, Rubbery Firm, Rubbery Lymphoma Lymphoma Soft Soft Infection Inflammatory Infection Inflammatory Shotty Shotty Viral infection Viral infection

Consistency/TextureConsistency/Texture


PALPABLE LYMPHNODES AND PALPABLE LYMPHNODES AND PROBABLE PROBABLE

ASSOCIATED CONDITIONS ASSOCIATED CONDITIONS TenderTender, , Mobile, enlargedMobile, enlarged Acute infection Acute infection Non-tenderNon-tender, , Mobile, EnlargedMobile, Enlarged Chronic Chronic

infection infection Matted, Non tenderMatted, Non tender Tuberculosis Tuberculosis Fixed, EnlargedFixed, Enlarged Carcinoma Carcinoma Rubbery, EnlargedRubbery, Enlarged Lymphomas Lymphomas


Benign

TB

Sarcoidosis

Lymphogranuloma venereum

Malignant

Metastatic carcinoma

Lymphomas

Matted:- Group of nodes – Connected – as a unit

Benign / Malignant


Key Points in Key Points in Diagnosing Diagnosing LymphadenopathyLymphadenopathy

In the absence of obvious infection In the absence of obvious infection consider it as metastatic tumor until consider it as metastatic tumor until otherwise proven.otherwise proven.

FNAC - useful investigation.FNAC - useful investigation. Open biopsy- recurrence, survival, Open biopsy- recurrence, survival,

further examination is difficult, further examination is difficult, fungation. nerve damage may occur.fungation. nerve damage may occur.


<16yrs<16yrsinfection,congenital, infection,congenital, neoplasia.neoplasia.

16-40yrs- inflammation, neoplasia16-40yrs- inflammation, neoplasia

>40yrs- neoplastic.>40yrs- neoplastic.

AGEAGE


ClassificatioClassificationn

Generalised

2 or more non contiguous area

Localised

Involve one area

CERVICAL CERVICAL LYMPHADENOPATHYLYMPHADENOPATHY


LocalLocal- InfectionInfection-dental infections, tonsillitis, skin -dental infections, tonsillitis, skin

sepsis, TB node.sepsis, TB node.- NeoplasiaNeoplasia-lymphoma or metastatic.-lymphoma or metastatic.- GeneralGeneral URTI, infectious mononucleosis, URTI, infectious mononucleosis,

toxoplasmosis, cat-scratch fever, HIVtoxoplasmosis, cat-scratch fever, HIV- Sarcodosis, Hodgkin's and non-Hodgkin's Sarcodosis, Hodgkin's and non-Hodgkin's

lymphoma.lymphoma.- Congenital-Congenital- cystic hygroma. cystic hygroma.

CAUSES FOR CERVICAL CAUSES FOR CERVICAL LYMPHADENOPATHYLYMPHADENOPATHY


CONCLUSIONCONCLUSION


REFERENCESREFERENCES Text book of surgical anatomy – Mag Craker Text book of general anatomy 39th ed –

Grants Clinical oriented anatomy –Moore Head &neck emergencys-Mike parry Text book of head &neck anatomy 2nd ed –

Holleinsheid Atlas of general histology – De Floire Text book of Human histology- Inderbir Singh Metastases of head and neck – R. Kim Davis Text book medicine-Davidsonwww.indiandentalacademy.comwww.indiandentalacademy.com

Thank Thank youyou


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