634201080262067500

LYMPHATICS OF HEAD AND NECK
AN OVERVIEW OF LYMPHATIC SYSTEM
Dr. owais pg Ist yr ENT SMHS
IT IS THE SYSTEM TO RETURN THE EXTRA FLUID, MICROMOLECULES AND MACROMOLECULES TO THE VASCULAR SYSTEM. THE NET PRESSURE DIFFERENCE THAT DRIVES THIS EXTRA FLUID OUT IS 0.3mmHg WHICH PRODUCES LYMPH AT THE RATE OF 120ml per mt.
Right lymphatic duct
Formed by union of right jugular, subclavian, and bronchomediastinal trunks Ends by entering the right venous angle Receives lymph from right half of head, neck, thorax and right upper limb @20ml per mt At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angle Just before termination, it receives the left jugular, subclavian and bronchomediastinal trunks @100ml per mt.
Thoracic duct
Thoracic duct
The Neck
The region of the body that lies between: The LOWER BORDER OF THE MANDIBLE& The SUPRASTERNAL NOTCH and the
UPPER BORDER OF CLAVICLE.
THE NECK IS DIVIDED INTO VARIOUS REGIONS. SUPRAHYOID INFRAHYOID LATERAL LYMPHATICS OF NECK INCLUDE LYMPHATIC CHANNELS LYMPH NODES WALDEYER RING
Triangles of the Neck
Suprahyoid region
Submental triangle
Lies below the chin and is bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone Covered by skin, superficial fascia and investing fascia Floormylohyoid muscles Contentssubmental lymph nodes
Submandibular triangle

Bounded by anterior and posterior bellies of digastric and lower border of the body of the mandible Covered by skin, superficial fascia, platysma and investing fascia Floor mylohyoid, hyoglossus and middle constrictor of pharynx Contentssubmandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes
Infrahyoid region
Carotid triangle
sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles Covered by skin, superficial fascia, platysma and investing fascia Floorprevertebral fascia and lateral wall of pharynx Contentscommon carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes
Muscular triangle
Bounded by midline of the neck, superior belly of the omohyoid and anterior border of the sternocleidomastoid. Covered by skin, superficial fascia, platysma, anterior jugular v., coutaneous n. and investing fascia Floorprevertebral fascia Contentssternohyoid, sternothyroid, thyrohyoid, thyroid gland, parathyroid gland, cervical part of trachea and esophagus
Lateral region of neck
Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and middle third of clavicle Divided by inferior belly of omohyoid into occipital and supraclavicular triangles
Contents
Arteries:
Subclavian (3rd part) Superficial cervical & suprascapular (branches of thyrocervical trunk, a branch of 1st part of subclavian artery Occipital, a branch of external carotid artery
Nerves:
Branches of cervical plexus Spinal part of accessory nerve
Brachial plexus
Veins:
External jugular vein

Formation Termination Tributaries
Occipital triangle
Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid Covered by skin, superficial fascia, and investing fascia Floorprevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae Conents
Accessory n.emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius Cervical and brachial plexuses
Supraclavicular triangle Bounded by posterior border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle Covered by skin, superficial fascia, and investing fascia Floorprevertebral fascia and inferior parts of scalenus Conents

Subclavian v. and venous angle Subclavian a. Brachial plexus
LYMPH NODES OF NECK
CAN BE DIVIDED INTO; a) SUPERFICIAL CHAIN OF LYMPH NODES.. b) VERTICAL DEEP CHAIN OF LYMPH NODES This consists of nodes lying in relation to carotid sheath.These lie along the vessels,trachea,oesophagusand extend from base of skull to root of neck.
Superficial Lymph Nodes
Position of Nodes
1.
2. 3. 4. 5. 6. 7. 8.
Submental
Submandibular Parotid / tonsilar Preauricular Postauricular Occipital Anterior cervical superficial and deep Supraclavicular Posterior cervical
9.
Subgroups

Ia Ib IIa IIb III IVa IVb Va Vb VI VII
Submental Submandibular Upper jugular (Anterior to XI) Upper jugular (Posterior to XI) Middle jugular Lower jugular (Clavicular) Lower jugular (Sternal) Posterior triangle (XI) Posterior triangle (Transverse cervical) Central compartment/Juxtavisceral Anterior Mediastinal
Basic Anatomy
Level I
Ia

Chin Lower lip Anterior floor of mouth Mandibular incisors Tip of tongue
Ib

Oral Cavity Floor of mouth Oral tongue Nasal cavity (anterior) Face
Level II
Upper Jugular Nodes
Anterior Lateral border of sternohyoid, posterior digastric and stylohyoid Posterior Posterior border of SCM Skull base Hyoid bone (clinical landmark) Carotid bifurcation (surgical landmark)
Level IIa anterior to XI Level IIb posterior to XI

Submuscular recess Oropharynx > oral cavity and laryngeal mets

Level II

Oral Cavity Nasal Cavity Nasopharynx Oropharynx Larynx Hypopharynx Parotid

Level III
Middle jugular nodes
Anterior Lateral border of sternohyoid Posterior Posterior border of SCM Inferior border of level II Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark)
Junction with IJV
Level III

Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx
Level IV
Lower jugular nodes
Anterior Lateral border of sternohyoid Posterior Posterior border of SCM Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark) Junction with IJV Clavicle
Level IV

Hypopharynx Larynx Thyroid Cervical esophagus
Level V
Posterior triangle of neck
Posterior border of SCM Clavicle Anterior border of trapezius Va Spinal accessory nodes Vb Transverse cervical artery nodes Radiologic landmark
Inferior border of Cricoid
Supraclavicular nodes
Level V

Nasopharynx Oropharynx Posterior neck and scalp
Level VI

Thyroid Larynx (glottic and subglottic) Pyriform sinus apex Cervical esophagus
Level VI
Anterior compartment

Hyoid Suprasternal notch Medial border of carotid sheath Perithyroidal lymph nodes Paratracheal lymph nodes Precricoid (Delphian) lymph node
Common Nodal Drainage Patterns

Face and Scalp Anterior Lateral Facial, Ib Parotid
Posterior
Eyelids Chin External Ear Middle Ear Floor of mouth Anterior Lower incisors Anterior Posterior Medial
Occipital, V
Ib
Lateral
Parotid, II
Ia, Ib, II Parotid, II Post auricular, II, V Parotid, II Ia, Ib, IIa > IIb Ia, Ib, IIa > IIb
Lateral
Teeth except incisors Nasal Cavity Anterior Posterior
Ib, IIa > IIb, III

Ib, IIa > IIb, III Ib Retropharyngeal, II, V
Common Nodal Drainage Patterns

Nasal Cavity Nasopharynx Oropharynx Larynx Posterior Retropharyngeal, II, V Retropharyngeal, II, III, V IIb > IIa, III, IV, V Supraglottic IIa > IIb, III, IV Subglottic Cervical esophagus Thyroid Tongue Tip Lateral VI, IV
IV, VI
VI, IV, V, Mediastinal Ia, Ib, IIa > IIb, III, IV Ib, IIa owais pg Ist yr ENT SMHS Dr. > IIb, III, IV
WALDEYER RING
Waldeyer's tonsillar ring (or pharyngeal lymphoid ring) is an anatomical term describing the Lymphoid tissue ring located in the pharynx and to the back of the oral cavity. It was named after the nineteenth century German anatomist Heinrich Wilhelm Gottfried von Waldeyer-Hartz. The ring consists of (from superior to inferior): Pharyngeal tonsil (also known as 'adenoids' when infected) Tubal tonsil (where Eustachian tube opens in the nasopharynx) Palatine tonsils (commonly called "the tonsils" in the vernacular, less commonly termed "faucial tonsils") Lingual tonsils
Tonsils
Anatomy
Grading the Size of Tonsils
Grading system: A. 0 tonsils in fossa B. +1 tonsils less than 25% C. +2 tonsils less than 50% D. +3 tonsils less than 75% E. +4 tonsils greater than 75%
Anatomy
Blood supply - Tonsils
Facial a.
Tonsillar branch Tonsil (main branch)
Ascending palatine
Tonsil
Lingual a. Dorsal lingual Tonsil Ascending pharyngeal Tonsil Maxillary Lesser descending palatine Tonsil
Anatomy
Blood supply Adenoids

Ascending palatine branch of facial a. Ascending pharyngeal a. Pharyngeal branch of IMAX. Ascending cervical branch of thyrocervical trunk.
AdenotonsillectomyIndications
Primary snoring disorder:
Loud snoring, mouth breathing, sleep pauses or breath holding, gasping, enuresis and restless sleeping. Daytime manifestations: hypersomnolence, AM headache, hyponasal speech, chronic nasal obstruction w/ or w/o rhinorrhea.
Obstructive apnea syndrome

Obstructive hypopnea is defined as a decrease in airflow by 50% despite effort during the same time or breath cycles, associated with a desaturation or arousal. The apnea/hypopnea index (AHI) is the same as for adults: the total number of apneic events plus hypopneas per hour of sleep. An arousal index describes the number of arousals per hour of sleep. Defined in adults as cessation of airflow at nostrils and mouth for at least 10 seconds and a hypopnea (decrease in VT of at least 50% or drop in PO2 of 4%) with 5-10 episodes in one hour.
Dysphagia & speech impairment
Large tonsils can interfere with pharyngeal phase of swallowing. Long face syndrome
No clinical trails support adenotonsillectomy for halitosis.
Abnormal dentofacial growth
Halitosis
Tonsillectomy-Indications
Recurrent tonsillitis Paradise et. Al. 1984, 2002.
Temperatures above 38.5oC Cervical adenopathy > 2 cm Tonsillar exudate or (+) group A -hemolytic strep. Cx. 7/yr, 5/yr x 2 yrs or 3/yr x 3 yrs. Failure of medical treatment > 3 months in duration with tonsillar inflammation, reasonable if patients have failed aggressive antibiotic therapy.
Chronic tonsillitis
Tonsillectomy-Indications

Peritonsillar abscess Streptococcal carriers
Asymptomatic carriers that have family members with acute glomerulonephritis, carrier is food handler or hospital worker. Tonsillectomy should be reserved for those refractory to antibioics.
Hemorrhagic tonsillitis Unilateral tonsil enlargement
Adenoidectomy-Indications
Recurrent or chronic sinusitis or adenoiditis
Poorly understood - possibly caused by obstructive adenoid tissue causing stasis of secretions predisposing the nasal cavity to infection. Proximity of adenoid tissue to eustachian tube Adenoidectomy can be recommended on 1st set of tubes if nasal obstruction and recurrent rhinorrhea is present or on 2nd set of tubes if needed.
Otitis media
Examination of the Neck

Lymph Nodes Perauricular: in front of the ear Posterior auricular: anterior to the mastoid Occipital: at the base of the skull posteriorly Tonsillar: at angle of mandible Submandibular and submental: beneath the jaw
AdenotonsillectomyContraindications
Velopharyngeal insufficiency
Overt cleft palate, submucous (covert) cleft Neurologic or neuromuscular abnormality leading to impaired palate function
Hematologic

Anemia Any disorder or hemostasis Surgery should not be undertaken if Hgb is less than 10 gm/dL, or Hct less than 30%.
AdenotonsillectomyContraindications
Immunologic
Respiratory allergy not treated for at least 6 months
Infectious: Should not be done in the face of active infection unless urgent obstructive symptoms are present or:

Appropriate antibiotics have been tried and unsuccessful Usually an interval of at least 3 weeks allow the patient to recuperate enough to reduce operative hemorrhage.
Complications
Noniatrogenic complications after adenoidectomy Regrowth of adenoid tissue, particularly in very young children, which may require revision (secondary) adenoidectomy. Hypernasality, because of temporary pain splinting. Persistent hypernasality is rare and probably caused by unrecognized preexisting velopharyngeal weakness. Atlantoaxial subluxation (Grisels syndrome), which presents with persistent torticollis 1-2 weeks after surgery. Iatrogenic complications after adenoidectomy include Dental injury, from intubation or the mouth gag Nasopharyngeal stenosis, caused by excessive tissue removal. Eustachian tube injury, if the torus tubarius is cauterized or denuded.
Surgical Atlas of Pediatric Otolaryngology
Complications
Non iatrogenic complications after tonsillectomy Bleeding in 1-2% of children, which is typically delayed (5-7 days); bleeding in the first 24 hours is less common. Most bleeding will stop spontaneously, but generally requires 24 hours of inpatient observation. Initial adjuvant techniques for hemostasis include clot removal, gargling with salt water or hydrogen peroxide, local cautery with silver nitrate sticks, and injection of epinephrine 1:200,000 Persistent bleeding, requiring control in the operating room

1. Rapid sequence anesthesia is used for induction. 2. Bleeding vessels are cauterized or suture ligated 3. Refractory hemorrhage requires external carotid artery embolization by an interventional neuroradiologist. 4. When embolization is unavailable, external carotid artery ligation
Complications

Dehydration, requiring re-admission for hydration Airway obstruction, requiring observation in an intensive setting, parenteral steroids, racemic epinephrine, careful insertion of a nasopharyngeal airway of appropriate length, and consideration for re-intubation if necessary. Post obstructive pulmonary edema, which may result from increased intrathoracic venous and hydrostatic pressure relieved by intubation or surgery. Presenting signs include oxygen desaturation and pink frothy secretions. Diuretics and re-intubation may be needed. Atlantoaxial subluxation (Grisels syndrome), presenting with persistenttorticollis 1-2 weeks after surgery. Neurological or orthopedic consultation
Causes of localised lymphadenopathy

1-lymph node draining a septic foicus * cervical : tonsilitis, scarlet fever, scalp infection. * periauricular: otitis media.
2-carcinomatous. * virchows: stomach * cervical: thyroid, tongue, parotid.
3- Systemic Infections Viruses: - Viral hepatitis Rt. supraclavecular L.N - German measles (cervical LN) Bacteria: T.B
Generalized L.N. may start as localized L.N. as in Hodgkins disease
Causes of Generalised Lymphadenopathy

I- Infectious * Viruses: a-Infectious mononucleosis b-Cytomegalo virus (C.M.V.) * Bacteria: a- brucellosis b- T .B. *Spirochetes: (2ry $) * Protozoa a- kala azar b-toxoplasmosis.
Causes of Generalised Lymphadenopathy(2)

2- leukemias: especially chronic lymphocytic leukamia (C.L.L.) 3- : a- Hodgkins disease (H.D.) b-Non- Hodgkins lymphoma (N.H.L) 4- Collagenosis: a-rheumatoid artheritis. b- Feltys syndrome. c-Still's disease. d- D.L.E. 5-Allergy: e.g., - Serum sickness. 6- Sarcoidosis 7- Lipoidosis 8-Miscellaneous
Characters of L.N. Enlargement in Some Diseases

1- Streptococcal infection of tonsils: * Uni or Bilateral * Tender & unmatted *Usually submandibular but may extend to lower cervical group. 2- Scarlet Fever * Sore throat. * marked enlargement of submandibular L.N. *Other cervical L.N. (bilateral, tender, discrete, suppuration is common). 3-Diphtheria *Enlarged submandibular L.N. usually bilateral, tender, not matted.
4-German Measle: * OccipitaI L.N. enlargement are nearly always present, closely resembles that of infectious mononucleosis. 5-Infectious Mononucleosis: * Sore throat, Fever, sometimes headache, myalgia. * Bilateral L.N. enlargement, firm, discrete, mobile. * Appear first in posterior cervical area, adjacent to cervical spines, few days later , submandibular L.N. will be enlarged * Palatal petechiae often, are present * Mild splenomegally in 50% of cases *Lymphocytosis in 75% of cases with some atypical lymphocytes.
6- T.B.: * The chiefly affected group is upper cervical group, generalized L.N. enlargement is exceptional. * Unilateral or Bilateral. * Often firm, matted, painful, may become adherent to skin or deep structures. * Cystic areas may occur due to caseation and later on cold abscess formation. * Overlying skin may break down giving T.B. ulcers or sinuses.
7-Syphilis: * Iry $:L.N draining a chancre -Rocky hard, uni Or bilateral, not tender. * 2ry $:-Generalized L.N. enlargement especially posterior triangle of the neck or epitrochlear gp (slightly enlarged, shotty, discrete, painless).
8- LYMPHOMATOUS L. N: *May be associated with constitutional symptoms.(anorexia, fever, weight loss, sweating, .. etc). * Pel Ebstein fever: may be observed in H.D., it is a period of fever lasting for few days or weeks alternating with longer or shorter apyrexial periods . * L.N. usually discrete at start & not tender (but may become tender during febrile periods). * L.N. may increase in size during pyrexial periods and decrease in size during apyrexial periods
a-H.D.: * may be confined to one group at first esp. lower cervical group then later on generalized L.N. enlargement. Glands are: a- moderately enlarged, not tender. b- Firm, rubbery in consistency. c- Discrete, mobile however as a result of later extension outside the capsule glands become matted or fixed b-N.H .L: *Also the cervical group is firstly affected *Rapid rate of growth results in large number of variable sized nodes which are hard in consistency, tend to become fused and fixed to deep structures & may give pressure manifestations.
9- LEUKAEMIC L. N: *May be associated with general manifestations (fever, malaise, anorexia, headache, Hemorhagic tendency) a- Acute Leukaemia: *Late, slightly or moderately enlarged *Soft, discrete esp. cervical L.N. due to oral sepsis *May be tender bone. b-C.L.L: * May affect cervica1 L.N. but mostly all superficial L.N. are enlarged. *The glands usually are (firm, not tender, not matted, usually moderately enlarged, but in advanced stages may be markedly enlarged) c-C.M.L.: *Rare to be manifested by L.N. enlargement.
10- CARCINOMATOUS L.N.: *Firm, but some times hard. *A stoney hard nodes fixed to underlying tissues are nearly always neoplastic in nature, however the reverse is not true. *Carcinomatous L.N. may be freely mobile
NECK DISSECTION
Radical
Gold standard operation Preservation of non lymphatic structures
Modified radical
Selective
Preservation of lymph node groups

Removal of additional lymph node groups or non lymphatic structures
Extended
Radical Neck Dissection
Removes

Nodal groups I-V SCM, IJV, XI Submandibular gland, tail of parotid,omohyoid Posterior auricular Suboccipital Retropharyngeal Periparotid Perifacial Paratracheal nodes
Preserves

Modified Radical Neck Dissection
Removes
Nodal groups I-V SCM, IJV, XI (any combination) TYPE I, II, III.
Preserves
Selective Neck Dissection
Remove high risk lymph node groups based on tumor site. Supraomohyoid
Levels I-III Levels II-IV
Lateral
Selective Neck Dissection
Posterolateral

Levels II-V Postauricular nodes Suboccipital nodes
ANTERIOR LEVEL VI LN
Extended Neck Dissection
Removal of any structures that are routinely preserved in a neck dissection. Notated by naming the structure(s) removed.
Accuracy of diagnostic methods in detecting occult cervical metastases.

Sensitivity % (range) Palpation CT US MRI 35 (30-40) 45 (17-86) 46 (42-50) 42 (20-70) Specificity % (range) 35 (27-42) 11 (3-21) 21 (11-33) 14 (5-26)
A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography yr ENT SMHS Dr. owais pg Ist
Sentinel Lymph Node History

1955 First echelon node 1960 Sentinel node 1977 Demonstrated in penile cancer 1992 Morton reintroduced concept in N0 melanoma Currently widely used in melanoma and breast cancer therapy.
Sentinel lymph node concept
Tumor spreads via lymphatics to a primary node. Examination of primary echelon nodes for tumor direct the need for surgical management of the nodal basins.
Sentinel lymph node concept
Difficulties of lymphatic mapping in head and neck (OBrien).

1.
2. 3.
4.
It is difficult to visualize lymphatic channels using lymphoscintigraphy because of proximity to the injection site. The radiotracer travels fast in the lymphatic vessels. If more than one node is visible, it can be difficult to distinguish first echelon nodes from second-echelon nodes. The SLN may be small and not easily accessible (eg, in the parotid gland).
N0 Neck
Occult neck disease

Head and neck cancer 30% Oral cavity CA 20% to 45%
Factors that indicate > 20% chance of subclinical metastases

Tumor thickness > 4mm Size > 2 cm Anatomic location

Pre op Technique
Blue Dye
Submucosal injection 2.5% Patent Blue dye No more than 20 min pre incision
Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology
Operative Technique
Limited incision guided by lymphoscintigraphy and gamma probe Frozen section analysis
Operative Technique
Gamma probe

Examine operative bed for increased signal Tumor extirpation Lead shield Removal of high signal nodes Examine removed node and compare to operative bed

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LYMPHATICS OF HEAD AND NECK

AN OVERVIEW OF LYMPHATIC SYSTEM

Dr. owais pg Ist yr ENT SMHS

Right lymphatic duct

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Triangles of the Neck

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Lateral region of neck

Dr. owais pg Ist yr ENT SMHS

Branches of cervical plexus Spinal part of accessory nerve

Dr. owais pg Ist yr ENT SMHS

Formation Termination Tributaries

Dr. owais pg Ist yr ENT SMHS

Subclavian v. and venous angle Subclavian a. Brachial plexus

Dr. owais pg Ist yr ENT SMHS

LYMPH NODES OF NECK

Dr. owais pg Ist yr ENT SMHS

Superficial Lymph Nodes

Dr. owais pg Ist yr ENT SMHS

Ia Ib IIa IIb III IVa IVb Va Vb VI VII

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Upper Jugular Nodes

Level IIa anterior to XI Level IIb posterior to XI

Submuscular recess Oropharynx > oral cavity and laryngeal mets

Oral Cavity Nasal Cavity Nasopharynx Oropharynx Larynx Hypopharynx Parotid

Middle jugular nodes

Junction with IJV

Dr. owais pg Ist yr ENT SMHS

Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx

Dr. owais pg Ist yr ENT SMHS

Lower jugular nodes

Hypopharynx Larynx Thyroid Cervical esophagus

Dr. owais pg Ist yr ENT SMHS

Posterior triangle of neck

Inferior border of Cricoid

Dr. owais pg Ist yr ENT SMHS

Nasopharynx Oropharynx Posterior neck and scalp

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Common Nodal Drainage Patterns

Ib, IIa > IIb, III

Common Nodal Drainage Patterns

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Grading the Size of Tonsils

Dr. owais pg Ist yr ENT SMHS

Dr. owais pg Ist yr ENT SMHS

Primary snoring disorder:

Dr. owais pg Ist yr ENT SMHS

Obstructive apnea syndrome

Dr. owais pg Ist yr ENT SMHS

Dysphagia & speech impairment

Abnormal dentofacial growth