Lymphatic drainage of

head, neck and face.

 The objective of this seminar is to cover the
embryology, anatomy and drainage pattern of the
lymphatic system of the head, neck and face.
Contents:

 Introduction
 Anatomy and embryology
 Drainage pattern
 Clinical aspects
 Detection of cervical metastasis
 Chyle leak
 conclusion
General outline of the lymphatic system
Superficial cervical L.N.
 Head
 Occipital
 Mastoid
 Parotid
 Facial

 Neck
 Submental
 Sub mandibular
 Suprf. Cervical
 Retropharyngeal
 Prelaryngeal
 Pretrachel
 Spinal accesory
 supraclavicular
Superficial cervical lymph nodes

(a) Parotid L.N.

(b) Submandibular L.N.

(c) Submental L.N.

 Superficial cervical lymph nodes

(a) Parotid L.N.

 Skin of temporal reg.
 Lateral part of forehead
 Lateral part of eyelids
 Post. Part of cheek
 Part of outer ear
 Parotid gland
 Superficial cervical lymph nodes
(b) Submandibular L.N.
 Central part of forehead
 Nose
 Sinuses (frontal, max.&eth)
 Inner canthus of eye
 Upper lip & anterior part of cheek
with underlying gums and teeth
 Outer part of lower lip with
underlying gums and teeth
 Anterior 2/3 of tongue excluding tip
 Floor of mouth
 Anterior part of hard palate
Superficial cervical lymph nodes

(c) Submental L.N.

 Middle part of lower
lip
 Skin of chin
 Tip of tongue
 Ant. Part of floor of
mouth
 Lower incisors and
adjacent gums
Superficial cervical lymph nodes

 Retropharyngeal L.N.
 Nasopharynx
 Posterior nasal cavity
 Paranasal sinuses
 Posterior oropharynx
 Hypopharynx
Superficial cervical lymph nodes

 Pretracheal L.N
 Lower larynx
 Hypopharynx
 Cervical esophagus
 Upper trachea
 Thyroid
Superficial cervical lymph nodes
 Spinal accessory L.N
 Scalp (parietal &
occipital region
 Nape of neck
 Upper retropharyngeal
 Parapharyngeal nodes
Deep cervical L.N.
(Superior jugular L.N.)
 Primary
 Soft palate
 Tongue(Post. & base)
 Tonsils
 Supraglottic larynx
 Pyriform sinus
 Secondary
 Parotid node
 Submandibular
 Retropharyngeal
 Spinal accessory
 Suprf. cervical
Deep cervical L.N.
(Middle jugular L.N.)
 Primary
 Supraglottic larynx
 Lower pyriform sinus
 Post. Cricoid area

 Secondary
 Superior jugular
 Lower retropharyngeal
Deep cervical L.N.
(Inferior jugular L.N.)
 Primary
 Trachea
 Thyroid
 Cervical esophagus

 Secondary
 Superior jugular
 Middle jugular
 Paratracheal
Lymphatic drainage of Tongue
 Tip
 Submental L.N.
 Anterior 2/3
 Submandibular
L.N.
 Post 1/3
 Jugulo-
omohyoid L.N.
LEVEL I GROUP OF
CERVICAL LYMPH
NODES
LEVEL III LEVEL
OF LYMPH NODES
LEVEL V GROUP OF
CERVICAL LYMPH
NODES
 Extended classification of lymph nodes of neck:
Level Ia: submental lymph nodes
Ib: submandibular lymph nodes
Level II: Upper Jugular Group
Level III: Middle Jugular Group
Level IVa: Lower Jugular Group
Level IVb: Medial Supraclavicular Group
Level Va and Vb : Posterior Triangle Group
Level Vc : Lateral Supraclavicular Group
Level VI: Anterior Compartment Group
Level VII: Prevertebral Compartment Group, including Levels VIIa and VIIb
Level VIIa: Retropharyngeal Nodes
Level VIIb : Retrostyloid Nodes
Level VIII: Parotid Group
Level IX: Buccofacial group
Level X: Posterior Skull Group, including Levels Xa and Xb
Level Xa : Retroauricular and Subauricular Nodes
Level Xb : Occipital Nodes
 Lymph nodes of the neck; Posterior view, Afferent vessel to deep cervical glands, Afferent
vessels of retropharyngeal glands, Retropharyngeal glands, Glandular nodule, Gland of deep
cervical chain, Efferent vessels of retropharyngeal glands. 
 Antigenic focus in the head and neck drains into surrounding
tissues.
 Phagocytosed material drained to nodes via afferent vessels.
 Lymphocyte reaction produces germinal centre with active
cell proliferation.
 Plasma cell activity increases size of node during antigenic
stimulus.
 Evaluation (contd.)
 During the clinical evaluation, carefully palpate the neck, with specific
attention to location, size, firmness, and mobility of each node. Direct
attention to nodes that appear fixed to underlying neurovascular structures
or visceral organs or that demonstrate skin infiltration
 Unfortunately, clinical palpation of the neck demonstrates a large variation
of findings among various examiners.
Evaluation (contd.)
If lymph nodes are detected, the following five characteristics should be
noted and described:
 Size
 Pain / tenderness
 Consistency
 Matting
 Location
 Nodes are generally considered to be normal if they are
up to 1 cm in diameter.
 However, authors suggest that cervical lymph nodes
should be considered abnormal if larger than 1 cm
except submandibular and jugulo-digastric lymph nodes
if larger than 1.5 cm.
 When a lymph node rapidly increases in size, its capsule
stretches and causes pain.
 Pain is usually the result of an inflammatory process or
suppuration, but pain may also result from hemorrhage
into the necrotic center of a malignant node.
 The presence or absence of tenderness does not reliably
differentiate benign from malignant nodes.
 Stony-hard nodes are typically a sign of cancer,
usually metastatic.
 Very firm, rubbery nodes suggest lymphoma.
 Softer nodes are the result of infections or
inflammatory conditions.
 Suppurative nodes may be fluctuant.
 The shotty are found in the cervical nodes of children
with viral illnesses.
 A group of nodes that feels connected and
seems to move as a unit is said to be "matted."
 Nodes that are matted can be either
 benign (e.g., tuberculosis, sarcoidosis or
lymphogranuloma venereum) or
 malignant (e.g., metastatic carcinoma or lymphomas).
 The anatomic location of localized adenopathy will
sometimes be helpful in narrowing the differential
diagnosis. For example,
 cat-scratch disease typically causes cervical or axillary
adenopathy,
 infectious mononucleosis causes cervical adenopathy and
 a number of sexually transmitted diseases are associated with
inguinal adenopathy
Detection of cervical metastasis

 Radiological investigations
 Ultrasound
 CT scan
 MRI
 Positron emission tomography and single-photon emission
computed tomography
 Fine needle aspiration cytology(FNAC)
LYMPHANGIOIGRAPHY

Also known as LYPMHNODE ANGIOGRAM.

It is a test which utilizes X ray technology along with injection of contrast agent,to view
lymphatic circulation and lymph nodes for diagnostic purposes.

It begins by injecting a Blue dye into hand or foot,lymph system picks up dye which in turn
will highlight the lymph vessels.
Ultrasonography.
Number and Distribution
•Normal cervical lymph nodes are detectable with ultrasound in healthy
people.
•Among the different regions of the neck, normal cervical lymph nodes
are commonly found in submandibular (19–23%), parotid (15–16%),
upper cervical (18–19%) regions and posterior triangle (35–37%)
•Therefore, patients with multiple lymph nodes in other regions should
raise the suspicion of pathology
Size
•Hajek et al. [22] and Solbiati et al. suggested that the normal upper limit
of the maximal short axis axial diameter of the cervical lymph node is 5
mm. Ho
•Bruneton et al. [29] and Ying et al.reported that normal cervical lymph
nodes have a maximal short axis axial diameter of 8 mm or less
 ULTRASONOGRAPHY.

•Shape:
• A lymph node with an S:L ratio less than 0.5 is oval in shape, whereas an S:L
ratio greater than or equal to 0.5 indicates round node
•. An oval node indicates normality whereas ,malignant nodes tend to be round
•The normal submandibular and parotid nodes are usually round, S:L 0.5 (95
and 59%, respectively) LI
•About 90% of normal cervical lymph nodes with maximum transverse diameter
greater than 5 mm showed an echogenic hilus
•Rubaltelli et al. suggested that the echogenic pattern of the nodal hilus mainly
corresponds to the presence of lymphatic sinuses,
•This was further proven by Vassallo et al. who reported that the echogenic
hilus corresponds to the abundance of collecting sinuses, which provide
acoustic interfaces to reflect a portion of the ultrasonic wave, making the hilus
echogenic.
• The age-related variation of the incidence of echogenic hilus is believed to be
due to the increased fatty deposition in lymph nodes in elderly, which makes
the nodal hilum more obvious
Elastography
Ultrasound (US) elastography refers to a noninvasive imaging technique that can
describe tissue displacement (i.e., strain) or stiffness in response to a given force

Stiff tissues tend to deform less and show less strain than compliant tissues in
response to the same imparted force. Therefore, the fundamentals of US
elastography are similar to manual palpation

At the time of writing, more than 10 pilot studies have been published on the use
of US elastography to evaluate the cervical lymph nodes.The 4-point
elastography scale is most frequently used for detecting malignant lymph nodes.

In general, metastatic lymph nodes demonstrate higher stiffness than benign

lymph nodes,

Elastographic scale scores of 1-2 indicate benign lymph nodes, and

elastographic scale scores of 3-4 indicate malignant lymph nodes
 MRI
With conventional MR imaging techniques, lymph nodes are visualized when they
have a size of at least 1.0–1.5 cm .

Optimized imaging techniques (body phased-array coil, 512 matrix, 3D acquisition)

or state-of-the-art spiral or multislice CT scanners D.

Depict lymph nodes as small at about 3–5 mm .

These techniques usually allow good evaluation of the lymph nodes adjacent to
the straight great vessels.

Nonactivated lymph nodes or lymph nodes not enlarged by metastasis have a

mean diameter of only a few millimeters.
 MRI
•Normal lymph nodes are markedly hypointense
relative to surrounding fat on T1-weighted images,
moderately hypointense on PD images, and
isointense to fat or slightly hyperintense on T2-
weighted images.
• At times, the fatty hilus can be differentiated from
the stroma in a normal lymph node
•Imaging of Abnormal Lymph Nodes – MRI/CT
•. In general, the lymph node stage determined from
MRI or CT fi ndings plays only a small role in
therapeutic decision making
•. If imaging demonstrates enlarged lymph nodes at
sites that do not correspond to the first site of
lymphatic spread of the patient’s primary tumor, this
is an important fi nding because these lymph nodes
should then be removed, not least for histologic
examination.
PET CT/MRI

•18F-FDG PET is superior to CT/MRI in the detection of cervical status of oral cavity

SCC.

• The sensitivity of 18F-FDG PET for the detection of cervical nodal metastasis on a

level-by-level basis was significantly higher than that of CT/MRI, whereas their

specificities appeared to be similar.

• Visual correlation of 18F-FDG PET and CT/MRI showed a trend of increased

diagnostic accuracy over 18F-FDG PET alone but without a statistically significant

difference, and its sensitivity was still not high enough to replace pathologic lymph

node staging based on neck dissection.

APPLIED
ASPECTS
 LYMPHANGIOMA
 Benign malformation of lymphatic spaces usually present on the
lateral cervical region along the jugular lymphatic chain.
 Etiology: Failure of local lymphatic channels to communicate with internal
jugular system.
 Characterized into three types:
 Capillary(lymphangioma simplex)
 Cavernous
 Cystic hygroma
 Usually congenital.
 Up to 90% are usually evident by 2 years of age.
 Sites: Head and neck, but may occur anywhere & present as soft, painless
mass.
 Larger angiomas may compress vital structures, cause dysphagia, dysnoea or
stridor.
• ORAL sites involved:Commonly – Tongue but others are Palate, Buccal mucosa,
Gingiva, and lips.

• Superficial lesions are papillary and tend to have same colour as surrounding
mucosa or be slightly more erythematous. Deeper lesions are present as diffuse
nodules or masses with no obvious colour changes.

• In adults , the anatomic location of the lesion is most important factor in

determining long term prognosis.

• Mc GILL & MUILIKEN subdivided lymphangiomas into two types based on

location:

TYPE 1
Below the Mylohyoid muscle -involving both anterior & posterior triangles. They
exhibit a sharp cystic demarcation on CT scan. 
TYPE 2
Above Mylohyoid muscle -involve the tongue, lip, or other locations in the oral
cavity. CT scan images exhibit a poorly demarcated mass that tends to be obscured
in various fat and muscle planes.
Infections
Below is a list of common causes of lymphadenopathy with associated histological findings:

Bacterial lymphadenitis: Predominately neutrophilic infiltrate can be found within the sinus and medullary
cords. Follicular hyperplasia can be seen as well.

Viral lymphadenopathy: Infiltration by macrophages and lymphoid hyperplasia. Necrosis can be seen in

those who are immunocompromised.

Sarcoidosis: Non-caseating granulomas that replace the normal architecture of the lymph node 

Non-Hodgkin lymphoma: There is partial or widespread loss of the lymph node by a single cell lineage.
Lymphoid cells can either proliferate in a disorderly manner or as those that mimic follicular center structures.

Hodgkin lymphoma: Can be classified by the histological appearance noted below. These histological types
are listed in order of most common to least.
Nodular-sclerosing

Mixed cellularity

Lymphocyte-rich

Lymphocyte-depleted
Neck dissection
 CYSTIC HYGROMAS
• Cystic hygromas is fluid filled sac that results from blockage in lymphatic
system.Most commonly located in neck or head region.

• Caused by-Genetic or Environmental factors that cause abnormal development of

abnormal lymphatic vascular system during embryonic growth.

• In Adults it may occur from Trauma or from earlier respiratory infections.

• Treatment-Complete removal not possible,other modalities

Chemotherapy,Radiation,Steroids.
 SENTINEL NODE

 The status of sentinel node predicts the presence of

metastasis in the rest of the nodes within nodal basin.
 Proliferating tumor replaces the architecture of node
 Tumor emboli exit through efferent vessel at hilum to
other node within the basin
 As hydrostatic pressure within nodes
increases ,tumor emboli will be directed to other
nodes in primary tumor nodal basin.
 Studies have demonstrated that when SLN is
negative for metastasis ,other node within nodal basin
is also negative.
 Chyle leak formation is an uncommon but serious sequela of head and neck
surgery when the thoracic duct is inadvertently injured, particularly with the
resection of malignancy low in the neck.
 The thoracic duct is the primary structure that returns lymph and chyle from
the entire left and right lower half of the body
 Chyle extravasation can result in delayed wound healing, dehydration,
malnutrition, electrolyte disturbances, and immunosuppression.
 Prompt identification and treatment of a chyle leak are essential for optimal
surgical outcome
Conclusion
 Patients who need an evaluation for a possible nodal
malignancy require a comprehensive multidisciplinary
evaluation of all potential sites of drainage to that node
to identify its primary source. This includes a thorough
evaluation of potential primary sites using endoscopic
techniques. When appropriate, include laryngoscopy,
esophagoscopy, bronchoscopy, and examination of the
nasopharynx.
 If no primary source is identified, taking blind mucosal
biopsy samples of the most likely head and neck
subsites is essential.