Lymphatic Drainage

Oral Biology

Alex Forrest
Associate Professor of Forensic Odontology Forensic Science Research & Innovation Centre, Griffith University Consultant Forensic Odontologist, Queensland Health Forensic and Scientific Services, 39 Kessels Rd, Coopers Plains, Queensland, Australia 4108

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Learning Goals

On completion of this topic you should be able to describe the general plan of the lymphatic drainage of the head and neck. You should be able to describe the positions of all the major groups of lymph nodes.

Learning Goals

You should be able to describe and demonstrate the ability to assess clinically the spread of infection in the head and neck using the major lymph node groups. You should demonstrate an understanding of the role played by the lymphatic system in controlling and directing the spread of infection and certain neoplasia in the head and neck.

Lymphatics

The lymphatic system is concerned with the removal and return to the blood system of tissue fluid not reabsorbed into the blood capillaries during circulation, with the absorption of fat from the small intestine, and most importantly, with immunity.

Lymphatics

It consists of lymphatic capillaries and vessels, lymph nodes, organs such as the thymus, spleen and bone marrow, and with masses of lymphatic tissue in the walls of the alimentary tract, together with circulating cells.

Lymphatics

In our discussion of the lymphatics in this session, we will restrict ourselves to a discussion of the structural components of the lymphatic system and the various groups of lymph nodes and lymphatic capillaries and vessels in the head and neck, and consider their importance in the spread of infection and in clinical diagnosis.

Vascular System

Recall that the blood vascular system is a body system that deals with two of the body's most important functions: transport and protection. It comprises the blood system, the lymphatic system, and the interstitial fluid. Each of these is related to the other, and their functions are closely allied as a result.

Vascular System

The blood system acts as the transport system for the body. The lymphatic system is the body's protective system. Interstitial fluid is the contact that each individual cell has with the fluid system of the body.

Fluid Movement

The heart acts as the fluid pump within the body. It pumps blood into arteries, and receives blood from veins.

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Fluid Movement

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On the right side, blood is sent into the pulmonary circuit. The pulmonary artery carries deoxygenated blood to the lungs, and the pulmonary vein returns oxygenated blood to the left side of the heart.

Fluid Movement

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The left ventricle of the heart pumps blood into the systemic circuit, though which it flows eventually back to the right atrium before revisiting the pulmonary circuit again.

Fluid Movement

Blood leaving the heart initially flows through large arteries. As these arteries become more distant from the heart, they subdivide, becoming smaller vessels known as arterioles. Arteries and arterioles have significant amounts of smooth muscle in their walls, and this helps maintain blood pressure, and absorbs some of the pumping force of the heart.
http://www.lab.anhb.uwa.edu.au/mb140/CorePage s/Vascular/Vascular.htm

Fluid Movement

Finally blood flows into smaller vessels still, known as capillaries. Capillaries are incredibly numerous, but are small in cross-section, and are quite permeable to a number of substances including fluid from the blood plasma.

http://www.lab.anhb.uwa.edu.au/mb140/CorePage s/Vascular/Vascular.htm

Fluid Movement

Due to the blood pressure in the initial part of the capillary, some of the plasma is filtered through the vessel wall and emerges from the capillary. This is the source of the interstitial fluid, the fluid that lies between the cells of the body.
http://www.chelationtherapyonline.com/articles/im ages/bloodvessels_4.gif

Fluid Movement

You may think of interstitial fluid as resulting in some respects from the natural leakiness of the capillaries. Within the interstitial fluid, nutrients and gases are carried to every cell of the body, and waste products are removed.

Fluid Movement

As the blood pressure falls along the length of the capillary, it becomes comparable with the osmotic force exerted by the concentration of large molecules remaining in the capillary lumen that did not escape into the surrounding tissues.

http://www.chelationtherapyonline.com/article s/images/bloodvessels_4.gif

Fluid Movement

As we move further along the capillary, and the blood pressure drops still further, the osmotic force begins to dominate, setting up an osmotic gradient that favours the return of the interstitial fluid back into the capillary.
Van de Graff, K. Human Anatomy, Wm. C. Brown Iowa, 2nd Ed. P 532

Fluid Movement

http://training.seer.cancer.gov/module_anatomy/unit8_2_lymph_compo.html

Approximately 80% to 90% of interstitial fluid is reabsorbed back into the capillaries in this way.

Fluid Movement

http://training.seer.cancer.gov/module_anatomy/unit8_2_lymph_compo.html

The remainder would waterlog the tissues, however, if it were allowed to remain, so instead it is gathered up into small vessels known as lymphatic capillaries, and channelled into the lymphatic system.

Fluid Movement

Here, it passes into lymphatic vessels, during its passage along which it will pass through lymph nodes. The lymph nodes play a role in controlling the spread of infection and in fighting it.
Van de Graff, K. Human Anatomy, Wm. C. Brown Iowa, 2nd Ed. P 532

Fluid Movement

Eventually, all this lymph fluid is returned to the blood system through two large lymphatic vessels, the right lymphatic duct and the thoracic duct, which drain into veins in the neck.

From Grays Anatomy, Longman, London, 35th Ed 1973p. 727.

Fluid Movement

The remainder of the blood returns to the heart through larger vessels, venules, which lead to veins, and these, in turn, return to the heart.

Van de Graff, K. Human Anatomy, Wm. C. Brown Iowa, 2nd Ed. P 532

Fluid Movement

Now that we can see the broad relationship between the three types of fluid, blood, lymph and interstitial fluid, and how the interstitial fluid and lymph are formed, let us examine the components of the system more closely.

Lymphatic Capillaries

Unlike the capillaries of the blood system, which bridge between the arterial part and the venous part of the circulation, there is no arterial part to the lymphatic system. It simply begins in the tissues, wherever excess tissue fluid collects from blood capillaries, as a system of blind lymphatic capillaries.

Lymphatic Capillaries

Lymphatic capillaries are tiny thin-walled vessels that begin as blind tubes in the spaces between cells in most tissues of the body except in cartilage and the central nervous system, the epidermis including the hair and nails, cornea of the eye, and also bone marrow.

www.anatomy.dal.ca/html/Human%20Histology/DHD/Lab2/ 4_lh.JPG

Lymphatic Capillaries

Basically, anywhere that there is circulation, there are also lymphatic capillaries. They are not therefore found in the avascular tissues such as those we listed above. Tissue fluid in the brain and spinal cord drains into the cerebrospinal fluid through spaces around the blood vessels.

Lymphatic Capillaries

In structure, lymph capillaries are most similar to blood capillaries, but differ in some respects.

www.anatomy.dal.ca/html/Human%20Histology/DHD/Lab2/ 4_lh.JPG

Lymphatic Capillaries

Lymph capillaries are lined by endothelial cells like blood capillaries, but in lymphatic capillaries, the endothelial cells overlap each other.

http://www.bmb.psu.edu/courses/bisci004a/immune/lympi ntak.jpg

Lymphatic Capillaries

This is important, because when pressure from the accumulating tissue fluid from outside the capillary pushes on its wall, the flap of endothelial cell beneath the overlap swings inwards to let the fluid into the vessel.

http://www.jdaross.mcmail.com/images/lympha tic.gif

Lymphatic Capillaries

Once the fluid is in the lumen, then it cannot escape again, because it simply pushes this flap closed again and is prevented from getting back out. Because of this structure, lymphatic capillaries are more permeable than blood http://www.jdaross.mcmail.com/images/lympha tic.gif capillaries, and substances of large molecular size, and even particles such as cell debris and micro-organisms can be accommodated.

Lymphatic Capillaries

They also have larger, more irregular lumens which are capable of holding larger particles in their contents. They are very hard to see in microscopic sections because they tend to collapse when they are empty.

http://www.bmb.psu.edu/courses/bisci004a/immune/lympi ntak.jpg

Lymphatic Capillaries

Lymphatic capillaries also possess valves which permit the lymphatic fluid to travel in one direction only. This is important, because it ensures that fluids and materials collected in a lymphatic capillary are directed through lymph nodes.

http://www.jdaross.mcmail.com/images/lympha tic.gif

Lymphatic Capillaries

These lymphatic capillaries form networks that eventually join together to form larger trunks, which have a structure similar to veins, but are thinner with less-well defined tunic layers. Along these larger vessels lie lymph nodes. Lymph from most parts of the body is forced to pass through one or more lymph nodes on its way back to the venous circulation, with the exception of the lymph from the thyroid gland and the oesophagus, which drains directly into the thoracic duct.

Lymph Vessels

Eventually, lymph vessels drain into either the thoracic duct or the right lymphatic duct. All of the lymphatic vessels of the body drain into the thoracic duct except for those of the right side of the head, the right upper limb, and the right neck and the right side of the thorax.

Lymph Vessels

The thoracic duct drains into the junction between the left internal jugular vein and the left subclavian vein. All the tissues of the right side of the head, the right upper limb, and the right neck and thorax drain into the right lymphatic duct which drains in turn into the junction between the right internal jugular vein and the right subclavian vein.
From Grays Anatomy, Longman, London, 35th Ed 1973p. 727

Lymph Vessels

Larger lymphatic vessels also possess valves, which once again forces the lymph to travel away from the tissues and towards the venous circulation in one direction only.

Lymphatic Nodules

Throughout the loose connective tissues of the body, small nodules of lymphatic tissue can be found. These are smallish masses, perhaps 1 mm or so in diameter, and they occur particularly in the connective tissue beneath mucous membranes.

Lymphatic Nodules

In the head and neck, they are particularly noticeable around the posterior part of the oral and nasal cavities. Elsewhere in the body, we find them in the walls of the intestines, around the anus, and in relation to the urinary tract.

Lymphatic Nodules

They are distributed strategically so as to protect underlying tissues that may be at risk of penetration by microorganisms from the digestive, respiratory and urinary tubes, all of which have surfaces that lie outside the body, and which may therefore harbour dangerous bacteria and viruses.

Lymphatic Nodules

An Atlas of Human Histology, Di Fiore M. Lea & Febiger, Philadelphia, 1st Edition 1961, p. 113.

If you examine such a lymph nodule with a microscope, you notice that it is packed with lymphocytes, but unlike the lymph nodes, the lymph nodules do not connect to lymph vessels.

Lymphatic Nodules

An Atlas of Human Histology, Di Fiore M. Lea & Febiger, Philadelphia, 1st Edition 1961, p. 113.

Sometimes, observation with the microscope will reveal centres where many immature lymphocytes are busily developing in response to some immune challenge that requires cells that can respond to a specific agent.

Lymphatic Nodules

An Atlas of Human Histology, Di Fiore M. Lea & Febiger, Philadelphia, 1st Edition 1961, p. 113.

Such areas are known as germinal centres.

Lymphatic Nodules

While most lymph nodules are smallish and occur as solitary structures, in some areas they are found as large clusters. Some of these we are already familiar with, such as the tonsils.
Copyright University of Queensland School of Dentistry

Lymphatic Nodules

Indeed, the tonsils form a kind of ring around the entry to the oropharynx and nasopharynx, made up of the single pharyngeal tonsil (adenoid), the two palatine tonsils, and the lingual tonsil. This ring is known as Waldeyer's Lymphatic Ring, after the worker who first described it.

Lymph Nodes

Lymph nodes are small, bean shaped masses of lymphatic tissue of varying size.

http://www.acm.uiuc.edu/sigbio/project/updatedlymphatic/lymph7.html

Lymph Nodes

The node is enclosed in a strong fibroelastic capsule, and extensions of this capsule run into the node, forming partitions that partially divide the node into several incomplete compartments.
Van de Graff, K. Human Anatomy, Wm. C. Brown, Iowa, 2nd Ed. P 534

Lymph Nodes

Lymph vessels that approach a lymph node, carrying their one-way load of lymph, divide up into a number of branches.

http://www.acm.uiuc.edu/sigbio/project/updatedlymphatic/lymph7.html

Lymph Nodes

Lymph flowing in along these branches is directed to the outside of the node, and must flow through channels called lymphatic sinuses within the node to get to the outgoing vessel in the region called the hilus of the node.
http://www.jdaross.mcmail.com/lymphnode.htm

Lymph Nodes

These channels are lined with lymphocytes and macrophages. As it passes through the lymph node, the lymph is filtered past these cells.
http://www.jdaross.mcmail.com/lymphnode.htm

Lymph Nodes

The lymph may contain debris including micro-organisms of varying types that have penetrated the body's defence barriers, phagocytic cells that may have been attracted to such a breach (some of which may either be alive or dead, and some of which may contain ingested microbes or other materials), damaged or worn-out tissue cells, cells from malignant tumours, or inhaled particles in nodes downstream from respiratory passages or the lungs.

Lymph Nodes

As these materials are exposed to the lymphocytes and macrophages, their organic components are either phagocytosed by the macrophages or destroyed by antibodies made by the B-lymphocytes.

Lymph Nodes

There are usually several lymph nodes between a region of tissue and the venous system. This means that material that was not filtered off and successfully dealt with in one lymph node passes on to the next and so on. By the time the lymph reaches the blood it has usually been cleaned of all impurities such as cell debris and foreign bodies.

Lymph Nodes

In some instances where phagocytation is incomplete the node may swell. You may well have experienced swollen cervical lymph nodes. These often accompany a sore throat due to streptococcal infection. Infections in almost any part of the body may result in swelling and tenderness of the lymph nodes associated with that part of the body.

Lymph Nodes

Activated T and B lymphocytes multiply in the lymph nodes, and T and B lymphocytes are added to the lymph as it flows through the sinuses. The lymph leaving the node therefore carries lymphocytes that will eventually pass into the blood. Antibodies produced by the B lymphocytes enter the lymph and the blood draining the node.

Lymph Nodes

Lymph nodes are therefore important to us clinically. If we know the route by which a body part is drained, and which groups of lymph nodes lie along the route taken by the vessels that drain it, then we can assess those nodes for swelling and hardness (induration) and tenderness to palpation.

Regional Lymph Nodes

We learn about the regional lymph nodes in the head and neck so that we can assess them to determine the spread of infection, and in some cases, so we can ensure that we remove all those nodes that may be affected by a spreading cancer.

Regional Lymph Nodes

We can divide the nodes of the head and neck into superficial groups and deep groups. The superficial groups tend to be more important to us clinically, because we can palpate them directly.

Regional Lymph Nodes

Superficial Groups:
Pericervical ring Nodes accompanying superficial neck veins

Deep Groups:
Perivisceral ring Deep cervical chain

Pericervical Ring

This group is clinically important and comprises:

Submental Group Submandibular Group Parotid or Pre-auricular Group Mastoid Group Occipital Group

Pericervical Ring

These groups of nodes drain the surface tissues of the head and the face.

From Grays Anatomy, Longman, London, 35th Ed 1973p. 729

Pericervical Ring

The drainage pattern is shown on this diagram.

Pericervical Ring

The scalp drains into all nodes, while the eyelids and cheeks drain into the parotid and submandibular groups.

Pericervical Ring

The external nose and the upper lip drain into the submandibular group, while the lower lip drains into the submental and submandibular groups.

Pericervical Ring

The floor of the mouth at the sides drains into the submandibular group and also to the deep cervical chain. The lateral parts of the lips drain into the submandibular group.

Pericervical Ring

The tip of the tongue, the central parts of the floor of the mouth and the lower lip drain bilaterally into the submental group. Anterior teeth as far back as the canines drain into the submandibular and submental groups, and premolar and molar teeth drain into the parotid group and the deep cervical chain.

Superficial Neck
The nodes accompanying superficial neck veins are also clinically important, since they are easily palpable in the clinic, and tell us about superficial infections and systemic infections. These lie in two chains which follow the anterior jugular vein and the external jugular vein respectively.

Superficial Neck
The nodes in the group following the external jugular vein are particularly easily palpated in the living individual because they lie superficially to the sternocleidomastoid muscle. You should take care to be sure you can recognize these as distinct from the nodes of the deep cervical chain.

Perivisceral Ring

The most anterior group of these nodes changes its name as it ascends in the neck, according to the structures alongside which it lies at any particular level:
pre-tracheal nodes pre-laryngeal nodes infrahyoid nodes

These lie anteriorly in the neck, in front of the larynx and trachea.

Perivisceral Ring

The posterior group also changes its name in the same way. Thus, we have:

retro-oesophageal nodes retro-pharyngeal nodes

Perivisceral Ring

The paratracheal group lies laterally alongside the trachea. The entire group surrounds the larynx, trachea and oesophagus, giving rise to its name, the perivisceral ring, since it surrounds the neck viscera.

Deep Cervical Chain

The deep cervical chain is difficult to palpate for most of its course since it lies deep to the sternocleidomastoid muscle, but at its upper and lower ends, it has two major nodes named for muscles close to which they lie. These are the jugulodigastric node (upper) and the jugulo-omohyoid node (lower). The other nodes in this chain are not named.

Deep Cervical Chain

All of the lymph from the head and neck eventually drains into the deep cervical chain on both sides. Premolar and molar teeth drain into its upper nodes, as do the sides of the tongue and the floor of the mouth at the sides. The palate drains into the upper nodes, and the pericervical groups also drain into this chain.

Deep Cervical Chain

The deep cervical chain drains into the right lymphatic duct on the right side, and into the thoracic duct on the left.

Learning Goals

On completion of this topic you should be able to describe the general plan of the lymphatic drainage of the head and neck. You should be able to describe the positions of all the major groups of lymph nodes.

Learning Goals

You should be able to describe and demonstrate the ability to assess clinically the spread of infection in the head and neck using the major lymph node groups. You should demonstrate an understanding of the role played by the lymphatic system in controlling and directing the spread of infection and certain neoplasia in the head and neck.

The End