LYMPH NODES OF HEAD AND NECK

CONTENTS

Introduction
Lymph
Formation and transport of tissue fluid
Lymphatic system

Anatomic variations
Functions
Components
Lymph vessels
Lymphatic capillaries
Lymphatic vessels
Lymph trunk
Lymphatic ducts
Lymph cells
Lymph organs
Lymph Nodes

 Cervical Lymph nodes

Regional lymph drainage
Examination of lymph nodes in head and neck

Preauricular
Postauricular
Occipital
Tonsillar
Submandibular
Submental
Superficial cervical
Deep cervical
Supraclavicular
Infraclavicular

 Applied anatomy
LYMPHADENOPATHY :

Causes of regional node enlargement

Physical Examination
Lymph node groups
Location
Drainage
Causes
Causes of generalized lymphadenopathy
Imaging of lymph nodes
Medications causing lyphadenopathy
Causes of regional lymphadenopathy
Treatment
Tonsilitis
Lymphoma

Conclusion
References

INTRODUCTION
LYMPH :
Lymph is an alkaline fluid that originates as interstitial fluid in your body. In
this context, an interstitial spaceis basically an empty space between tissue
structures. Interstitial fluid flows in the space between and around tissues
and cells.
Lymph is collected within lymphatic vessels, which carry it away from your
tissues and eventually return it to your bloodstream. Lymph helps clear
your body of cellular wastes and infectious organisms. Chyle, a specialized
version of lymph, transports fats from your intestine to your bloodstream.
Lymph Composition
Lymph contains a variety of substances, including proteins, salts, glucose,
fats, water, and white blood cells. Unlike your blood, lymph does not
normally contain any red blood cells.

FORMATION AND TRANSPORT OF LYMPH

LYMPHATIC SYSTEM
Essentially a drainage system accessory to venous system.
Larger particles that escape into tissue fluid can only be removed via
lymphatic system .
FUNCTIONS :

Reabsorbs excess interstitial fluid:

returns it to the venous circulation

maintain blood volume levels
prevent interstitial fluid levels from rising out of control.

Transport dietary lipids:

Transported through lacteals

Drain into larger lymphatic vessels
Eventually into the bloodstream.

COMPONENTS OF LYMPHATIC SYSTEM

Lymph
Lymphatic Vessels
Lymphatic Capillaries
Lymphatic Trunks
Lymphatic Ducts

Lymph
Lymphatic Vessels
Lymphatic Capillaries
Lymphatic Trunks
Lymphatic Ducts

Lymphatic Organs

Lymphatic Organs

Primary :

Primary :

Thymus
Bone marrow

Secondary :

Lymph Nodes
Spleen

MALT :

Tonsils ,
Appendix ,
Solitary Lymphoid nodules ,
Peyer patches on skin

Lymphatic cells

Thymus
Bone marrow

Secondary :

Lymph Nodes
Spleen

MALT :

Tonsils ,
Appendix ,
Solitary Lymphoid nodules ,
Peyer patches on skin

Lymphatic cells

LYMPHATIC VESSELS
LYMPH CAPILLARIES or lymphatic capillaries
are tiny thinwalled vessels, closed at one end and are loca
ted in the spaces
between cells throughout
the body, except in the CNS, and in non
vascular tissues.
The main purpose of these vessels is to drain
excess tissue fluids from aroundthe cell ready
to be filtered and returned to the venous circ
ulation.
LYMPH TRUNKS : Lymph trunk is
a lymph vessel that carries lymph, and is
formed by confluence of many
efferent lymph vessels. It in turn drains into
one of the two lymph ducts (right lymph duct
and the thoraxic duct).

LYMPHATIC DUCTS
Right lymphatic duct

Formed by union of right jugular,

subclavian, and bronchomediastinal
trunks
Ends by entering the right venous
angle

Thoracic duct

Begins in front of L1 as a dilated sac,

the cisterna chyli,
formed by left and right lumbar
trunks and intestinal trunk
Enter thoracic cavity & ascends
Travels upward, veering to the left at
the level of T5

DRAINAGE PATTERN
RIGHT LYMPHATIC DUCT
Receives lymph from right half of
head, neck, thorax and right upper
limb, right lung, right side of heart,
right surface of liver .

THORACIC DUCT
Drains lymph from lower limbs,
pelvic cavity, abdominal cavity, left
side of thorax, and left side of the
head, neck and left upper limb .

LYMPHATIC CELLS
Also called lymphoid cells.
Located in both the lymphatic
system and the cardiovascular
system.
Work together to elicit an
immune response.
Types of lymphatic cells are:

macrophages
epithelial cells
dendritic cells
lymphocytes

LYMPHATIC ORGANS
Primary organs
Bone marrow
Thymus gland

Secondary organs
Lymph nodes
Lymph nodules
Spleen

LYMPH NODES
Small, bean
shaped masses of tissue scattered along
the lymphatic system
that act as filters and immune monitors,
removing fluids, bacteria, or cancer
cells that travel through the lymph syste
m.

Features :

Bean-shaped bodies
With afferent vessels (entering at the
periphery) and efferent lymph
vessels(emerging at the hilus)
Arranged in groups, along the blood
vessels or the flexural side of the joint
Divided into superficial and deep
groups .

REGIONAL LYMPH NODE

It is the lymph node where the
lymph of the organ or part of the
body drainage to firstly and they
are of two types :
Regional Lymph drainage
Sentinel Lymph Node(in clinic)

LYMPHATIC NODULES
Oval clusters of lymphatic cells with
some extracellular matrix that are
not surrounded by a connective
tissue capsule.
Filter and attack antigens.
In some areas of the body, many
lymphatic nodules group together
to form larger structures.
mucosa-associated lymphatic tissue
(MALT) or tonsils
very prominent in the mucosa of the
small intestine, primarily in the ileum

Peyer patches are also present in

the appendix ..

LYMPH NODE LEVELS IN HEAD AND NECK

Level system is used for describing the
location of lymph nodes in the neck:
Level I - submental and
submandibular group;
Level II - upper jugular group;
Level III - middle jugular group;
Level IV - lower jugular group;
Level V - posterior triangle group;
Level VI
pretracheal
Paratracheal
prelaryngeal

Level vii: superior mediastinal.

REGIONAL LYMPH DRAINAGE

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Occipital
Retroauricular (mastoid)
Preauricular (parotid)
Buccal (facial)
Submandibular
Submental
Anterior cervical
Superficial cervical
Retropharyngeal
Laryngeal
Tracheal (pre & paratracheal)

EXAMINATION OF LYMPH NODES IN HEAD

AND NECK
Occipital nodes Palpate the occipital nodes about
one inch above and below the hairline.
Auricular Palpate the pre and post auricular
nodes bilaterally using the pads of the index,
middle and ring fingers , roll your finger in front of
the ear, against the maxilla.
Cervical Chain Palpate the nodes medial to the
sternocleidomastoid muscle using a bidigital
technique and the nodes posterior to the muscle
with a bimanual technique.
Supraclavicular These nodes are examined using
digital compressions just superior to the clavicle.
Submandibular Palpate the submandibular nodes
by pulling or rolling the tissues under the chin up
and over the inferior border of the mandible. Ask
the patient to firmly press the roof of the mouth
with the tongue. This will allow you to assess the
muscles and any pathology associated with the
submandibular lymph node areas.

Sub occipital lymph nodes - are palpable

immediately behind the ear.
Sub maxillary and Sub mental nodes: Roll your
fingers against inner surface of Mandible with
patient's head gently tilted towards one side.
Tonsillar nodes: At the angle of Mandible.
Deep cervical lymph nodes should be palpated,
one side at a time. Gently bend the patient's head
forward and roll your fingers over the deeper
muscles along the carotid arteries.
To feel Scalene nodes roll your fingers gently
behind the clavicles. Instruct the patient to cough
or to bear down like they are having a bowel
movement. Occasionally an enlarged lymph node
may pop up.

APPLIED ANATOMY

LYMPHADENOPATHY
An abnormality in size and consistency of lymph nodes
Lymph nodes become swollen/ enlarged and may be painful
to touch.
It could be due to infection, auto-immune disease, or
malignancy.
TYPES :
LOCALIZED LYMPHADENOPATHY :

due to localized spot of infection e.g.,an infected spot on the sc

alp will cause lymph nodes in the neck on
that same side to swell up

GENERALIZED LYMPHADENOPATHY :

due to generalized infection all over the body e.g., influenza

PERSISTENT GENERALIZED LYMPHADENOPATHY (PGL) :

persisting for a long time, possibly without an apparent cause

DERMATOPATHIC LYMPHADENOPATHY :

lymphadenopathy associated with skin disease.

PHYSICAL EXAMINATION
Five characteristics should be noted and
described:

Size : normal if < 1 cm in diameter;

Pain/Tenderness : inflammatory process or
suppuration, hemorrhage into the necrotic
center of a malignant node.
Consistency :

Stony-hard nodes: cancer, usually metastatic.

Very firm, rubbery nodes: lymphoma.
Softer nodes: infections or inflammatory conditions.
Suppurant nodes may be fluctuant.
"shotty" (small nodes that feel like buckshot under
the skin) cervical nodes of children with viral
illnesses.

Matting :

Benign (e.g., tuberculosis, sarcoidosis or

lymphogranuloma venereum)
Malignant (e.g., metastatic carcinoma or
lymphomas).

Location.

CAUSES FOR LYMPHADENOPATHY

Infections: Typhoid fever, TB, AIDS,
mononucleosis, CMV, rubella, varicella,
rubeola, histoplasmosis, toxoplasmosis
Autoimmune diseases: RA, SLE,
dermatomyositis
Malignancies:
primary: HD, NHL, histiocytic disorders,
metastatic: leukemia, NB, RMS
Lipid storage diseases: Gaucher,
Niemann-Pick
Drug reactions

Medications That May Cause

Lymphadenopathy

Allopurinol
Atenolol
Captopril
Carbamazepine
Cephalosporins
Gold
Hydralazin
Penicillin
Phenytoin
Primidone
Pyrimethamine
Quinidine
Sulfonamides
Sulindac

MANAGEMENT
Preliminary considerations

Patients age
Localised/ Generalised lymphadenopathy
Clinical characters of the node
Duration of the swelling
Associated signs and symptoms

Clinical approach

Complete medical history

Social and family history
Clinical features
Location
Hematologic testing
Other diagnostic tools

HISTORY

H/O systemic illness

Contact with infectious diseases.
Animal scratch
Recurrent fever, sweats, anemia
Any Nasopharyngeal cause suggesting
symptoms
H/O drugs

EXAMINATION

Temperature
Identify node, drainage area.
Check for dental, oropharynageal, skin
causes
Primary Cause identified biopsy
Bilateral suggests systemic cause.

INVESTIGATIONS

Complete hemogram with peripheral blood smear examination

hypodensity/necrosis

ESR or C-reactive protein

Lactate dehydrogenase

Patients with cervical adenopathy - to rule out head and neck cancersCECT (head and neck)

Uric acid

Bone marrow aspiration and/or biopsy - Haematological malignancy

Liver function tests

ELISA for HIV

Purified Protein Derivative skin test (PPD)

Viral titers

Fine needle aspiration cytology (FNAC) and/or lymph node biopsy. This
is the most important diagnostic tool in patients with
lymphadenopathy. In most patients with lymphadenopathy, an initial
FNAC will provide the diagnosis, e.g.

Other titers - Toxoplasmosis, Bartonella henselae

Chest X-ray (PA) view will help define

Demonstration of caseous necrosis and granulomas in TB

lymphadenitis. Ziehl Neelsen staining may reveal acid-fast bacilli.

Metastatic cancers

Pretracheal, mediastinal lymph node enlargement

Lung parenchymal lesion, e.g. tuberculosis
Lung malignancyprimary and metastasis

Ultrasonography and contrast enhanced CT of the abdomen to

delineate

Hepatomegaly
Splenomegaly
Any hepatic/splenic deposits
Intra-abdominal lymph nodesidentification of any specific character, e.g.
central

LYMPHOMAS
Lymphoma is a form of cancer that affects the
immune system - specifically, it is a cancer of
immune cells called lymphocytes, a type of white
blood cell. There are two broad types of
lymphoma and many subtypes.
The two types of lymphoma are described as:
Hodgkin's lymphoma
Non-Hodgkin's lymphoma

Hodgkin's lymphoma
Hodgkin's lymphoma, the cancer cells are usually
an abnormal type of B lymphocyte, named ReedSternberg cells.
Non-Hodgkin's lymphoma
In non-Hodgkin's lymphoma, B-cells and T-cells are
affected - both being types of lymphocyte white
blood cell with special roles in immunity.

SYMPTOMS
Painless swelling of the lymph nodes
(glands), often in the neck or armpits where
these nodes are concentrated.
Swelling in the legs or ankles
Cramping and bloating of the abdomen
Chills
Unusual itching
Pain or altered sensation
Loss of appetite , weight loss
Unusual tiredness/lack of energy
Persistent coughing
Breathlessness
Night sweats

Spread of lymphoma
In Hodgkin's lymphoma, this spread usually
occurs in a sequential fashion, affecting one
lymph node after another in order
In non-Hodgkin's lymphoma, tumors may
arise in disparate lymph nodes, skipping some
nodes.

INVESTIGATION

A physical examination will follow for all cases of suspected

lymphoma - palpating areas of the body where any swollen lymph
nodes may be felt.

Biopsy testing can also confirm the particular type of lymphoma, and
so provide a guide to prognosis and treatment.

The most common forms of biopsy procedure are

Excisional biopsy - the surgeon cuts through the skin to remove an

entire lymph node for analysis

Blood tests - including complete blood count (CBC), white blood

count, protein levels, liver function tests, kidney function tests, uric
acid level, inflammatory markers and lactate dehydrogenase (LDH)
level.

Biopsy - a sample of cells is taken from the blood and looked at under
a microscope. The results of a biopsy are key to the diagnosis and
classification of lymphoma. A biopsy can reveal whether a tumor
originated from B-cells or T-cells, with the former being much more
common. The biopsy will also help a pathologist determine the
classification, or type, of non-Hodgkin's lymphoma that is present

Incisional biopsy - the surgeon removes only part of a large suspected

lymph tumor.

CT (computed tomography X-ray imaging) scans of the chest,

abdomen, and pelvis, sometimes using a contrast, to check for tumors

If a lymphoma diagnosis has already been confirmed by biopsy, further

testing is carried out to determine the stage of the cancer, to see
whether it has spread (metastasized) to other parts of the body.

MRI for detailed images of tissues

Ultrasound scanning for tumors

Staging tests include a choice from the following, depending on the

case:

PET (positron emission tomography) scan, in which radioactive tracers

pick out cancer

Bone marrow biopsy in some cases, to check for lymphoma cells in

the sample

Spinal tap - a long, thin needle is used under local anesthetic to

remove some spinal fluid, which is tested for lymphoma.

TREATMENT

Biologic Therapy
This treatment increases your body's natural ability to fight
cancer. It does this by giving a boost to your immune
system.There are several kinds of biologic therapy:
Monoclonal Antibodies: These are drugs like Rituxan, which
directly target lymphoma cells and do not harm normal
cells.These drugs are sometimes called "smart drugs" or
"guided missiles" because they know exactly where to go in
your body.
Radioimmunotherapy: These are therapies like Rituxan, which
have a radioisotope attached to them.These "guided missiles"
are able to destroy cancer cells because they attach to the
lymphoma and deliver small doses of medicine to the cells.
Interleukin 2: This is a medicine that activates the immune
system so that it can kill cancer cells.
Vaccines: These are treatments that help the body protect itself
against the lymphoma.

Chemotherapy (Chemo)

This treatment uses drugs to kill cancer cells and reduce the size
of cancer tumors. Chemotherapy drugs may also affect healthy
cells and cause side effects like hair loss or mouth sores. There
are many types of chemotherapy drugs.

Radiation Therapy :

This treatment uses radiation (high energy x-rays) to kill cancer

cells. The treatment often only takes place in the part of your
body where the lymphoma is located.

Transplants

Sometimes high doses of chemotherapy destroy the lymphoma

cells and your bone marrow, which is the "factory" for blood
cells. To help your bone marrow make new healthy blood cells,
some stem cells (immature cells that will grow up into red
blood cells, white blood cells, and platelets) may be taken with
a special machine before chemotherapy is given.
These cells are then transplanted (put back) into the body.
These transplanted cells will then find their way to the bone
marrow and restore it, so that it can build healthy new blood
cells.
There are two types of transplants:
1) Autologous transplants- this uses your own bone marrow or
stem cells.
2) Allogeneic transplants- this uses bone marrow or stem cells
from a donor (someone else, often a brother or sister).

TONSOLITIS
Tonsillitis is inflammation due to infection
of the tonsils.
It is a very common condition, most
frequent in children aged 5-10 years and
young adults between 15 and 25 years.
Symptoms
Pain in the throat is sometimes severe
and may last more than 48 hours, along
with pain on swallowing.
Pain may be referred to the ears.
Small children may complain of
abdominal pain.
Headache.
Loss of voice or changes in the voice.

Signs
The throat is reddened, the tonsils are
swollen and may be coated or have white
flecks of pus on them.
Possibly a high temperature.
Swollen regional lymph glands.
Classical streptococcal tonsillitis has an
acute onset, headache, abdominal pain
and dysphagia.
Examination shows intense erythema of
tonsils and pharynx, yellow exudate and
tender, enlarged anterior cervical glands.

TREATMENT
Gargles are anecdotally helpful but
there is no evidence base to support
their use.
'Watchful waiting' is appropriate for
children with mild recurrent sore
throats.
Antipyretic analgesics such as
paracetamol and ibuprofen are of
value.
A rapid strep test or throat swab
culture. Both tests involve gently
swabbing the back of the throat close
to the tonsils with a cotton swab.

CONCLUSION

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