Download - Lymphatic Drainage of the Head & Neck
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LYMPHATIC DRAINAGE OF THEHEAD & NECK & APPLIED ASPECTS
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INTRODUCTION
Drainage system aess!ry t! t"e #en!$s system
tiss$e %$i ' (i)e $( *y
› t"e #en!$s en !+ t"e a(i,,aries
Lym("ati #esse,s -.'/. 0 !+ t"e tiss$e %$is1
Tiss$e %$i %!2ing t"r!$g" t"ese #esse,s is a,,eLYMPH
Lym(" rains int! Larger veins
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INTRODUCTION
LYMPH
Defnition3 Liquid o alkaline reaction ound inlymphatic vessels and derived rom tissue uid
Lymphatic system is absent in3
'C4N4S4
'C!rnea
'S$(er5ia, ,ayer !+ s)in
'6!nes
'A,#e!,i !+ ,$ng
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COMPONENTS OF LYMPHLymph
Water (96%) Others (4%)
Solids Cellular
Proteins
Lipids
Carbohydrates
Amino acids
on nitro!enous s"
#lectrolyte
Lymphocyte
$onocyte macropha!es
Plasma cell
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LYMPHATIC 7ESSELS
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LYMPHATIC 7ESSELS
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LYMPHATIC 7ESSELS
Lym("a(i,,aries
Lym("ati#esse,
Lym("N!e
Lym("atitr$n)
C!,,eting$t
S$*,a#ian#ein
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AFFERENT & EFFERENTLYMPHATICS
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LYMPH FLO8
-/.m,
&'OACC *+C&
,
-'& L.$P'A&C *+C&
H!2999
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C!niti!ns 2"i" inrease Tiss$e %$i Inrease Lym(" +!rmati!n''' H!2999
/iltration 00eabsorption
00 &issue1luid
ncreased'ydrostatic
Pressure
00 mo2ementinto
LYMPHATIC
CAPILLARIES
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FUNCTIONS OF LYMPH
N$triti#e
Drainage
Transmissi!n !+ (r!teins
A*s!r(ti!n !+ +ats
De+ense
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LYMPH NODES OF THEHEAD & NECK
II
III
I7
I7
a
7
*
7I
H Y O I D 6
4
C R I C O I D
C4
S T E R N U M
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T!ng$e
LYMPHATIC DRAINAGE OF7ARIOUS STRUCTURES
Mani*$,arinis!rs
F,!!r !+ t"em!$t"'Anteri!r
Li(s
C"ee)s
Li(s
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LYMPHATIC DRAINAGE OF7ARIOUS STRUCTURES
Teet" Har Pa,ateHar Pa,ate
Har Pa,ateS!+t Pa,ateOr!("aryn:
Latera, 2a,,
!+ n!se
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LYMPHATIC DRAINAGE OF7ARIOUS STRUCTURES
Paranasa, Sin$ses
E:terna, ear
Sa,(
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E;TRA'NODAL LYMPHOID TISSUE
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PALATINE TONSIL
A,m!n s"a(e
T!nsi,,ar sin$s !r +!ssa *et2een
› (a,at!g,!ssa,
› (a,at!("aryngea, ar"es
› Meia, s$r+ae3 intrat!nsi,,ar ,e+ts
› Latera, s$r+ae3 a(s$,e !+ t!nsi,3 )ee(s t!nsi, in(,ae $ring s2a,,!2ing
Lym("ati rainage3 Jugulodigastric node
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TU6AL TONSIL
Ar!$n E$sta"ian t$*e !(enings int"e nas!("aryn:4
E:tensi!ns !+ ("aryngea, t!nsi,s
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8ALDEYER=S RING
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8ALDEYER=S RING
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E;AMINATION OF LYMPHNODES
Ne) n!es are*etter (a,(ate
2"i,e staning at t"e*a) !+ t"e (atient
Ne) is s,ig"t,y
%e:e t! a"ie#ere,a:ati!n !+ m$s,es
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When a node or nodes are palpable, followingpoints are observed:
(i) Location of nodes
(ii) !mber of nodes
(iii) "i#e $- t! -4> m in greatest imensi!n
(iv) %onsistency: Metastati n!es'"ar?
,ym("!ma n!es'5rm an r$**ery?
"y(er(,asti n!es's!+t4
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(v) &iscrete'matted nodes
(vi) enderness: In%ammat!ry
n!es are tener4
(vii) *i+ity
(viii) "ystemic symptoms
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"!bmental odes
R!,, t"e 5ngers*e,!2 t"e "in 2it"(atient=s "ea ti,te+!r2ars
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"!bmandib!larodes
R!,, y!$r 5ngersagainst inner s$r+ae
!+ Mani*,e 2it"(atient@s "ea gent,yti,te t!2ars !ne
sie
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Post a!ric!lar(Mastoid odes)
R!,, t"e 5ngers*e"in t"e ear
•ccipital nodes
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-nternal .!g!larchain
› E:amine t"e
$((er1 mi,e an,!2er gr!$(s4
› ,ie ee( t!stern!mast!im$s,e 2"i" maynee t! *eis(,ae(!steri!r,y
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ransverse %ervical
odes "!praclavic!lar
("calene odes)
R!,, y!$r 5ngers gent,y*e"in t"e ,a#i,es4Instr$t t"e (atient t!!$g" !r t! *ear !2n
,i)e t"ey are "a#ing a*!2e, m!#ement4Oasi!na,,y anen,arge ,ym(" n!emay (!( $(
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%linical relevance
In "ea an ne)1 a,, ,ym(" $,timate,yrains int! ee( er#ia, gr!$( !+
n!es Se!nary arin!mat!$s e(!sits in
t"ese n!es are !mm!n
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ECHELON LYMPHNODES
-st n!a, stati!n rea"e *y ,ym("atirainage !+ an !rgan3 /st echelonnodal gro!p
-st e"e,!n L4N4 !nnet t! ea" !t"ert"r!$g" (!st',ym("n!a, !,,eting
$ts an 5na,,y rain t! m!re entra,eBerent L4N4 !r iret,y int! t"e #en!$ssystem t"r!$g" t"e main ,ym("atitr$n)
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NODAL METASTAIS
T$m!r s(rea regi!na, ,ym(" n!es an *ey!n !$rs #ia,ym("ati #esse,s 2"!se (r!,i+erati!n is (r!m!te *y gr!2t"+at!rs
!mor lymphangiogenesis0 !ntri*$tes t! isseminati!n 'stim$,ate *y +ami,y !+ VEGF-C,D
CD44 is m$,tistr$t$ra, e,, s$r+ae a"esi!n m!,e$,e'!#ere:(ressi!n !+ CD an its is!+!rms *y t$m!r e,,s may,ea t! inrease ,ym("ati an "emat!gen!$s s(rea
T$m!r (r!$ti!n !+ proteolytic enzymes- (r!(agati!n !+,ym(" n!e metastasis
Ot"er me"anisms' is!ntin$ity in *asement mem*rane !+(rimary t$m!r1 +at!rs t"at +ai,itate e,, migrati!n1 a"esi!n
an (r!,i+erati!n4
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H-"1Y
In -/1 Lin*erg" re(!rte metastasisin -->> (atients 2it" $((eraer!igesti#e trat s$am!$s e,,arin!ma
Primary t$m!rs 2it" in t"e !ra, a#ity
',e#e,s I1 II an III esening !rer1 Or!("aryngea,1 "y(!("aryngea, an
,aryngea, (rimary t$m!rs ',e#e,s II1 IIIan I7
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PATTERNS OF NECKMETASTASIS
F!r (rimary t$m!$rs in !ra, a#ity regi!na, L4N4 at "ig"estris) +!r ear,y isseminati!n *y metastati aner ,imite t!,e#e,s I1 II1 III4
"2ip metastasis t! Le#e,s I1 II1 III e:eeing,y rare
T"ere+!re1 i+ ne) is ,inia,,y negati#eN.1 ,e#e,s I7 an 7L4N4 genera,,y n!t at ris)
T$m!$rs !+ oropharyn+, hypopharyn+ and laryn+3 5rst
e"e,!n L4N4 are› ee( J$g$,ar L4N4 at ,e#e,s I1 III1 I7 !n i(si,atera, sie3 m!re at ris)
On,y /.'/>0 !+ (atients 2it" arin!mas !+ (ar!ti g,ane#e,!( regi!na, metastasis4
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7IRCHO8=S NODES
"ignal nodes' seat ofthe devil' s$(ra,a#i$,araen!(at"y
En,arge1 "ar L4N4 in t"e,e+t s$(ra,a#i$,ar +!ssa3roisier3s sign
Ass!iate 2it" metastasis
+r!m SCC !+ t"e "ea anne)1 (rimary ,$ng aner1es!("agea, aner1 anerin t"e a*!men an (e,#iregi!n
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TNM Staging gr!$(ing
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%ommon lymph node enlargements
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CAUSES OFLYMPHADENOPATHY
/-nfectio!s disease
A4 7ira, 'In+eti!$s m!n!n$,e!sis 'In+eti!$s "e(atitis
'Her(es sim(,e: 'R$*e,,a 'Meas,es 'H-4
64 6ateria, 'Cat srat" isease '6r$e,,!sis 'T$*er$,!sis 'Aty(ia, my!*ateria, in+eti!n 'Primary an se!nary sy("i,is 'Di(t"eria
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5 -mm!nologic disease (generali#edlymphadenopathy)
A4 R"e$mat!i art"ritis 64 Systemi ,$($s eryt"emat!$s C4 SJ!gren synr!me D4 Dr$g "y(ersensiti#ity
6 Malignant disease a4 Hemat!,!gia, 'H!g)in=s ,ym("!ma 'N!n H!g)in=s ,ym("!ma 'Hairy e,, ,e$)emia 'T'e,, ,ym("!ma 'M$,ti(,e mye,!ma 64 Metastasis
'Fr!m (rimary site
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7Lipid storage disease 'Ga$"er=s isease
'niemann'(i) isease
89ndocrine disease 'Hy(ert"yr!iism 'Arena, ins$ieny 'T"yr!iitis
ther disorder
'Sar!i!sis 'Lym("!mat!i gran$,!mat!sis 'Ka2asa)i isease 'Hist!yt!sis :
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CALCIFIED LYMPH NODES
Dystr!("i a,i5ati!n1 !mm!n ingran$,!mat!$s is!rers
Lym("!i tiss$e gets re(,ae *y
"yr!:ya(atite',i)e a,i$m sa,ts near,yeBaing a,, n!a, ar"itet$re
Sr!+$,a
M!st !mm!n3 s$*mani*$,ar1 er#ia,
an (rea$ri$,ar1 s$*menta, ,ym("n!es
May aBet sing,e ,ym(" n!e !r a ,inearseries3 ,ym(" n!e "aining
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IN7ESTIGATIONS
Histopathological 'C!n#enti!na, FNAC' *,in (r!e$re
'E:isi!na, *i!(sy !+ n!e
'Sentina, ,ym(" n!e *i!(sy
%ontrast lymphoangiography
*ine needle aspiration cytology0 *;%
U,tras!$n g$iane
CT G$iane
' It is m!re a$rate t"an *,ine FNAC
'Hig" sensiti#ity'01 "ig" s(ei5ity>'
0
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% < M1-0'CT & MRI eteting sie !+ n!e
'CT *etter t"an MRI ner!sis1e:traa(s$,ar s(rea
&istant metastasis imaging
'C"est rai!gra("y
'A*!mina, USG'Rai!n$,ie imaging
'6,!! st$ies t$m!$r mar)ers
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CT' LYMPH NODES
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ROUNDED SHAPE3
*enign n!e ,3*Q/3-
E:e(ti!ns's$*menta, n!es
r!$n rat"er t"an!#!i in s"a(e4
Lym("!mat!$sn!es are !+ten,arge an r!$ne
s"!rt n!rma,
#a,$e4
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ECHOGENICITY3H!m!gene!$se"! ar"itet$rein a ,arge n!emay re%et t"e5s" %es" gr!ssa((earane seen
in ,ym("!mat!$sn!es
Areas !+ anechoic
echogenicity2it"in a n!e mays$ggest necrosis an metastatic
malignancy
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PET SCAN
SENTINAL NODE
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SENTINAL NODE6IOPSY
SN63 g!, stanar in me,an!ma an *reast aner
SN6 in HNSCC "as *een s$ggeste as a met"! t! im(r!#e t"e
a$ray !+ staging an tai,!r treatments
Fr!m May - t! De /..1 /. !nse$ti#e (atients entere a(r!s(eti#e st$y3 -40 "a (rimary t$m!$r !+ t"e !ra, a#ity an/40 !+ t"e !r!("aryn:4 SN 2as n!t +!$n in / (atients
F$nti!na, !$t!mes a+ter SN6 are re!gnie as signi5ant,y *ettert"an a+ter SND
6$t r!,e !+ SN6 in HNSCC is sti,, $neie4 S$rge!ns s"!$, *ea2are t"at t"ese (atients "a#e a N. ne) an g!! (r!gn!sis1 ant"at e,eti#e SND "as (r!#en re,ia*i,ity an 2!r,2ie ae(tane
"entinel lymph node biopsy in s>!amo!s cell carcinoma of the head andnec2:/? years of e+perience
ACTA otorhinolaryngologica Italica 5?/5@65:/A058
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SENTINAL NODE MAPPING
Em(,!ys - !r a,, !+ t"e te"ni$es3
-4 Rai!is!t!(e sanimaging
/4 InJeti!n !+ *,$e ye4 Use !+ a "an"e,
is!t!(e traer (r!*e +!r,!a,iati!n
• Pre'!(erati#e te"neti$m san em(,!ye 5rst• Gamma amera images at min$tes1 ->min$tes1 an
e,aye image at -"!$r4• -st ,ym(" n!e ienti5e *y te"neti$m san3
sentina, L4N4
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Immeiate,y (ri!r t! s$rgia, (r!e$re1 isos!lfanbl!e dye inJete ar!$n (rimary t$m!$r
O(erati#e (r!e$re arrie !$t 2it"in .min$tes !+t"e inJeti!n
Gamma (r!*e $se4 Any n!e that has in0vivo /?0second co!nt more than 6 times that of
bac2gro!nd considered BhotC 6,$e ,ym(" n!e ,!a,ie *y *,$nt isseti!n4
Pr!*e $se t! !rre,ate *,$e n!e 2it" "ig"estrai!traer ati#ity3 e:ise an sent +!r (at"!,!gi
ana,ysis
I+ resi$a, rai!ati#ity in *asin-.0 !+ e:'#i#!!$nt !+ "!ttest n!e in *asin3 +$rt"er e:(,!rati!n +!rm!re sentina, n!es
SURGICAL TECHNIUES OF
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SURGICAL TECHNIUES OFREMO7AL OF LYMPH NODES
Raia, Ne) Disseti!n
M!i5e Raia, Ne) Disseti!n
›
Ty(eI› Ty(eII
› Ty(eIII
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CONCLUSION
Thus, a good understanding o the
lymphatic drainage o the head and the
neck help us to better understand the
pathological basis o various diseases.
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Than yo!"