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Presented by:
Dr.Ayesha Taha (JR I)
Department of Pedodontics
and Preventive Dentistry
Contents :-

Functions of Lymphatic System
Components of Lymphatic System
Lymph Nodes of Head & Neck
Lymphatic Drainage

Of all the body systems, the lymphatic system is

perhaps the least familiar to most people. Yet without
it, neither the circulatory system nor the immune
system could function—circulation would shut down
from fluid loss, and the body would be overrun by
infection for lack of immunity.

The lymphatic system is an endothelium-lined network

of blind-ended capillaries found in nearly all tissues,
draining via collecting vessels into large vascular trunks
that eventually empty via an evolutionarily conserved
drainage point into the blood circulatory system.
Functions of Lymphatic System
The lymphatic system has three functions:
1. Fluid recovery
Each day, we lose an excess of 2 to 4 L of water and
one-quarter to one-half of the plasma protein. The
lymphatic system absorbs this excess fluid and
returns it to the bloodstream by way of the lymphatic

2. Immunity
As the lymphatic system recovers excess tissue fluid,
also picks up foreign cells and chemicals from the
tissues. On its way back to the bloodstream, the fluid
passes through lymph nodes, where immune cells stand
guard against foreign matter. When they detect it,
3. Lipid absorption.

In the small intestine, special lymphatic vessels called

lacteals absorb dietary lipids that are not absorbed by
the blood capillaries.
Components of Lymphatic system
Lymph is usually a clear, colorless fluid, similar to blood
plasma but low in protein. Its composition varies
substantially from place to place.

Origin of Lymph :-
Lymph originates in microscopic vessels called
lymphatic capillaries. These vessels penetrate nearly
every tissue of the body but are absent from the central
nervous system, cartilage, bone, and bone marrow.

The gaps between lymphatic endothelial cells are so

large that bacteria and other cells can enter along with
the fluid.
Lymphatic Vessels:

They have a tunica interna with an endothelium

and valve, a tunica media with elastic fibers and
smooth muscle, and a thin outer tunica externa.

Their walls are thinner and their valves are more

numerous than those of the veins.
Flow of Lymph :-
Lymph takes the following route from the tissues back
to the bloodstream:

Thus, there is a continual recycling of fluid from blood to

tissue fluid to lymph and back to the blood.
Lymphatic Cells and Tissues:
T lymphocytes (T cells):

These are so-named because they develop for a time in

the thymus and later depend on thymic hormones.

B lymphocytes (B cells):

These are named after an organ in birds (the bursa of

Fabricius) in which they were first discovered. When
activated, B cells differentiate into plasma cells, which
produce circulating antibodies.

These cells, derived from monocytes of the blood,

phagocytize foreign matter (antigens) and “display”
fragments of it to certain T cells, thus alerting the
immune system to the presence of an enemy.
Macrophages and other cells that do this are
collectively called antigen-presenting cells (APCs).

Dendritic cells:

These are APCs found in the epidermis, mucous

membranes, and lymphatic organs. (In the skin, they
are often called Langerhans cells.)
Reticular cells:

These are branched cells that contribute to the stroma

(connective tissue framework) of the lymphatic organs
and act as APCs in the thymus.
Mucosa-associated Lymphatic
The simplest form of
lymphatic tissue is diffuse
lymphatic tissue—a sprinkling of
lymphocytes in the mucous
membranes and connective
tissues of many organs.

It is particularly
prevalent in body passages that
are open to the exterior—the
respiratory, digestive, urinary,
and reproductive tracts—where
it is called Mucosa-Associated
Lymphatic Tissue (MALT).
Peyers patches:

In some places, lymphocytes and

other cells congregate in dense
masses called lymphatic nodules

Lymphatic nodules are, however,

a relatively constant feature of
the lymph nodes and tonsils.

They also form clusters called

Peyers patches in the ileum, the
last segment of the small
Lymphatic Organs:


Lymphatic (lymphoid) organs contain large numbers of

lymphocytes, a type of white blood cell that plays a pivotal
role in immunity.

The primary lymphatic organs are

Red bone marrow and
Thymus gland

Lymphocytes originate and/or mature in these organs.

Red Bone Marrow
It is the site of stem cells that are ever capable of dividing
and producing blood cells.

Some of these cells become the various types of white

blood cells: neutrophils, eosinophils, basophils,
lymphocytes, and monocytes.

In a child, most of the bones have red bone marrow, but in

an adult it is limited to the sternum, vertebrae, ribs, part
of the pelvic girdle, and the proximal heads of the humerus
and femur.
The thymus is a member of both the lymphatic and
endocrine systems.

It houses developing lymphocytes and secretes hormones

that regulate their activity.

It is located between the sternum and aortic arch in the

superior mediastinum.

The thymus is very large in the fetus and grows slightly

during childhood, when it is most active.

After age 14, however, it begins to undergo involution

(shrinkage) so that it is quite small in adults.
the spleen,
the lymph nodes and
other organs, such as the tonsils.

All the secondary organs are the places where lymphocytes

encounter and bind with antigens, after which they
proliferate and become actively engaged cells.
The spleen is the body’s largest lymphatic organ. It is
located in the left hypochondriac region, just inferior
to the diaphragm and dorsolateral to the stomach.

Its parenchyma exhibits two types of tissue named

for their appearance in fresh specimens (not in
stained sections):
red pulp, which consists of sinuses gorged with
concentrated erythrocytes, and
white pulp, which consists of lymphocytes and
macrophages aggregated like sleeves along small
branches of the splenic artery.

It produces blood cells in the

fetus and may resume this role in
adults in the event of extreme

It monitors the blood for foreign


Lymphocytes and macrophages of

the white pulp are quick to detect
foreign antigens in the blood and Position of the spleen in the
upper left quadrant of the
activate immune reactions. abdominal cavity.
The spleen is an “erythrocyte graveyard”—old, fragile
RBCs rupture as they squeeze through the capillary walls
into the sinuses. Splenic macrophages phagocytize their
remains, just as they dispose of blood-borne bacteria and
other cellular debris.

The spleen also compensates for excessive blood volume by

transferring plasma from the bloodstream into the
lymphatic system.

A person can live without a spleen, but is somewhat more

vulnerable to infections.
It serve two functions:
to cleanse the lymph and
alert the immune system to pathogens.

There are hundreds of lymph nodes in the body.

They are especially concentrated in the cervical, axillary,

and inguinal regions close to the body surface, and in
thoracic, abdominal, and pelvic groups deep in the body

Most of them are embedded in fat.

A lymph node is an elongated or bean-shaped structure,

usually less than 3 cm long, often with an indentation
called the hilum on one side.
Anatomy of a Lymph Node.
(a) Bisected lymph node showing pathway of lymph flow.
(b) Detail in the boxed region.
The tonsils are patches of lymphatic tissue located at the
entrance to the pharynx, where they guard against
ingested and inhaled pathogens.

There are three main sets of tonsils:

 a single medial pharyngeal tonsil (adenoids) on the wall of the

pharynx just behind the nasal cavity,

a pair of palatine tonsils at the posterior margin of the oral

cavity, and

numerous lingual tonsils, concentrated in a patch on each side

of the root of the tongue.

The palatine tonsils are the largest and most often infected.

All lymph vessels of the head and neck drain into

the deep cervical nodes, either directly from the
tissues or indirectly via nodes in outlying groups.

Lymph is returned to the systemic venous

circulation via either the right lymphatic duct or
the thoracic duct.
Classification of nodes
in head and neck region

The lymph nodes in the head

and neck region can be
grouped into:
• Superficial nodes
• Deep nodes
The superficial Lymph nodes

 The superficial cervical lymph nodes lie above the

investing layer of the deep fascia.
 They consist of a few small nodes that lie
superficial to the external jugular and anterior
jugular veins.
The superficial lymph nodes
1. Occipital
2. Mastoid (retro auricular/ post-auricular)
3. Parotid (pre-auricular)
4. Buccal
5. Submandibular
6. Submental
7. Anterior cervical
8. Superficial cervical
cervical nodes
The Deep
Deep lymph
lymph nodes:

1. Upper deep cervical

2. Lower deep cervical

3. Waldyer’s ring

4. Nodes of midline
1. The upper deep cervical:
Jugulo-digastric group: lie along the upper part of
internal jugular vein deep to the sternomastoid muscle.
Structures drained: Tonsil and Tongue.
2. The lower deep cervical:
Jugulo-omohyoid group: arranged along the lower part
internal jugular vein deep also to the sternomastoid
Structures drained: Tongue.
Deep cervical nodes
3.The waldyer’s ring:The ring consists of the (from
superior to inferior):
 1 Pharyngeal Tonsils (or nasopharyngeal tonsil(s), due
to the location; also known as 'adenoid(s)' when

 2 Tubal Tonsil (bilaterally).

 2 Palatine Tonsils (commonly called "the tonsils" in

the vernacular, less commonly termed "faucial
tonsils"; located in the oropharynx.

 1 lingual Tonsils (on the posterior tongue)

4. Midline nodes are termed in
correspondence to the anatomical area
where they exist:
A. Infrahyoid
B. Prelaryngeal
C. Pretracheal
D. Paratracheal
The skin of the head and neck drains :

• The scalp drains into the occipital, mastoid and

parotid nodes.
• Lower eye lid and anterior cheek drains into buccal
• The cheeks drain into the parotid, buccal and
submandibular nodes.
• The upper lips and sides of the lower lips drain into
the submandibular nodes.
• While the middle third of the lower lip drains into the
submental nodes.
• The skin of the neck drains into the cervical nodes.
The drainage of the oral structures

• The Gingivae drain into the submandibular, submental

and upper deep cervical lymph nodes.

• The palate drains via lymph vessels that pass through

the pharyngeal wall to the upper deep cervical nodes.

• Anterior part of mouth floor drain into submental and

upper deep cervical

• while posterior part into submandibular and upper deep

Drainage of oral structures
Lymph drainage of external nose

Lymph drainage of external nose is primarily

to the submandibular group of nodes although
lymph from the root of the nose drains to
superficial parotid nodes.
Lymphatic drainage of nasal cavity

Lymph vessels from the anterior region of the nasal cavity pass
superficially to join those draining the external nasal skin, and
end in the submandibular nodes.

The rest of the nasal cavity, paranasal sinuses, nasopharynx

and pharyngeal end of the pharyngotympanic tube, all drain to
the upper deep cervical nodes either directly or through the
retropharyngeal nodes.

The posterior nasal floor drains to the parotid nodes.

Lymphatic drainage of tongue:

The lymphatic drainage of the tongue can be divided into 3

main regions: Marginal, Central and Dorsal.

The anterior region of the tongue drains into marginal and

central vessels, and the posterior part of the tongue behind
the circumvallate papillae drains into the dorsal lymph

The more central regions drain bilaterally into sub-mental

and sub-mandibular nodes.
Lymphatic drainage of teeth:

The lymph vessels from the teeth usually run directly into
the ipsi-lateral submandibular lymph nodes.

Lymph from the mandibular incisors, however, drains into

the submental lymph nodes.

Occasionally, lymph from the molars may pass directly into

the jugulo-digastric group of nodes.

When a lymph node is under challenge from a foreign

antigen, it may become swollen and painful to the touch— a
condition called lymphadenitis.

Commonly palpated and accessible lymph nodes are - the

cervical, axillary, and inguinal.

Lymph nodes are common sites of metastatic cancer

because cancer cells from almost any organ can break loose,
enter the lymphatic capillaries, and lodge in the nodes.

Lymphadenopathy is a collective term for all lymph node

Differential Diagnosis of cervical Lymphadenopathy based
on palpatory findings. TEXTURE OF LYMPH NODES
Conclusion :-

In conclusion, the lymphatic system and its organs are

widespread and scattered throughout the body.
Because the vessels of the lymphatic system span the
entire body it becomes an easy portal for the spread of
cancer and other diseases, which is why disorders and
diseases of this system can be very devastating.
A sound knowledge of the regional lymph nodes of the
head and neck is very important for dentists because it
is a reliable guide towards the origin of problem, and
because of the possible involvement of the lymphatic
system in the spread of infection or the spread of
malignant tumour cells (metastasis).
References :-

 Textbook of Head and Neck Anatomy (Hiatt – Gartner) 4 th Ed. 2010

 Grant's Atlas of Anatomy,13th Ed.
 Gray's Anatomy – 40th Ed.
 Anatomy of the Human Body - Henry Gray
 Saladin: Anatomy & Physiology: The Unity of Form and Function, 3 rd
 Embryology Atlas , John F Neas
 Life Map – Embryonic development & stem cell compendium
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Defects Res C Embryo Today. 2009 September ; 87(3): 222–231.
 Albrecht I, Christofori G, Molecular mechanisms of
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Ferrer R, Lymphadenopathy: Differential Diagnosis and Evaluation;
Am Fam Physician. 1998 Oct 15;58(6):1313-1320
Som P M, Hugh D C, Mancuso A A, An imaging-based classification
for the cervical nodes designed as an adjunct to recent clinically
based nodal classification;Arch Otolaryngol Head Neck Surg.
Oliver G, Detmar M, The rediscovery of the lymphatic system: old
and new insights intothe development and biological function of
the lymphatic vasculature; Genes Dev. 2002,16: 773-783
Sambandan T, Mabel C R, Cervical lymphadenopathy- a review;
Torabi M, Aquino S L, Harisinghani M G, Current concept in lymph
node imaging; J Nucl Med, 2004; 45:1509-1518.
Connor SEJ, Olliff JFC, Imaging of malignant cervical
lymphadenopathy – a review; Dentomaxillofacial Radiology,
“The earliest evidence of ancient dentistry -an amazingly detailed dental
work on a mummy from ancient Egypt that archaeologists have dated to
2000 BCE. The work shows intricate gold work around the teeth. This
mummy was found with two donor teeth that had holes drilled into
them. Wires were strung through the holes and then around the
neighboring teeth.” Source: metalonmetal blog.