Lymphatic Drainage of the Head & Neck

LYMPHATIC DRAINAGE OF THEHEAD & NECK & APPLIED ASPECTS INTRODUCTION   Drainage system accessory to the venous system tissue fluid - picked up by › the venous end of the capillaries  Lymphatic vessels 10-20 % of the tissue fluids,  Tissue fluid flowing through these vessels is called LYMPH  Lymph drains into  Larger veins INTRODUCTION   LYMPH Definition: Liquid of alkaline reaction found in lymphatic vessels and derived from tissue fluid Lymphatic system is absent in: -C.N.S. -Cornea -Superficial layer of skin -Bones -Alveoli of lung COMPONENTS OF LYMPH Lymph Water (96%) Others (4%) Solids Cellular Proteins Lymphocyte Lipids Monocyte. macrophages Carbohydrates Plasma cell Amino acids Non nitrogenous s. Electrolyte . LYMPHATIC VESSELS . LYMPHATIC VESSELS . Lymph capillaries LYMPHATIC VESSELS Lymphatic vessel Lymph Node Lymphatic trunk Collecting duct Subclavian vein . AFFERENT & EFFERENT LYMPHATICS . LYMPH NODE STRUCTURE Oval or beanshaped Small pinhead to large as a lima bean . LYMPH FLOW How??? 120ml THORACIC DUCT + RIGHT LYMPHATIC DUCT . How??? Filtration >> Reabsorption >> Tissue fluid Increased Hydrostatic Pressure >> movement into LYMPHATIC CAPILLARIES .Conditions which increase Tissue fluid Increase Lymph formation--. FUNCTIONS OF LYMPH      Nutritive Drainage Transmission of proteins Absorption of fats Defense . LYMPH NODES OF THE HEAD & NECK II I V a B. D I O CRIC N UM R E ST III VI IV V b . D I O HY C. LYMPHATIC DRAINAGE OF VARIOUS STRUCTURES Mandibular incisors Floor of the mouthAnterior Tongue Lips Lips Cheeks . LYMPHATIC DRAINAGE OF VARIOUS STRUCTURES Teeth Hard Palate Oropharynx Lateral wall of nose Hard Soft Palate Palate . LYMPHATIC DRAINAGE OF VARIOUS STRUCTURES Paranasal Sinuses External ear Scalp . EXTRA-NODAL LYMPHOID TISSUE/ORGANS MALT . PALATINE TONSIL  Almond shaped  Tonsillar sinus or fossa between › palatoglossal › palatopharyngeal arches › Medial surface: intratonsillar clefts › Lateral surface: capsule of tonsil: keeps tonsil in place during swallowing  Lymphatic drainage: Jugulodigastric node .  Extensions of pharyngeal tonsils  .TUBAL TONSIL Around Eustachian tube openings in the nasopharynx. WALDEYER’S RING . WALDEYER’S RING . EXAMINATION OF LYMPH NODES  Neck nodes are better palpated while standing at the back of the patient  Neck is slightly flexed to achieve relaxation of muscles . . lymphoma nodes-firm and rubbery.When a node or nodes are palpable. following points are observed: (i) Location of nodes (ii) Number of nodes (iii) Size –1 to 1.5 cm in greatest dimension (iv) Consistency: Metastatic nodes-hard. hyperplastic nodes-soft. (vi) Tenderness: Inflammatory nodes are tender. (vii) Fixity (viii) Systemic symptoms .(v) Discrete/matted nodes.  Submental Nodes Roll the fingers below the chin with patient’s head tilted forwards .  Submandibular Nodes Roll your fingers against inner surface of Mandible with patient's head gently tilted towards one side . against the maxilla . Parotid (Preauricular) Nodes Roll your finger in front of the ear. •Occipital nodes Post auricular (Mastoid Nodes) Roll the fingers behind the ear . › lie deep to sternomastoid muscle which may need to be displaced posteriorly . middle and lower groups. Internal jugular chain › Examine the upper. Instruct the patient to cough or to bear down like they are having a bowel movement. Transverse Cervical Nodes Supraclavicular (Scalene Nodes) Roll your fingers gently behind the clavicles. Occasionally an enlarged lymph node may pop up . Clinical relevance  In head and neck. all lymph ultimately drains into deep cervical group of nodes  Secondary carcinomatous deposits in these nodes are common 31 . N.ECHELON LYMPH NODES  1st nodal station reached by lymphatic drainage of an organ: 1st echelon nodal group  1st echelon L. or directly into the venous system through the main lymphatic trunk . connect to each other through post-lymphnodal collecting ducts and finally drain to more central efferent L.N. . propagation of lymph node metastasis  Other mechanisms.contributes to dissemination stimulated by family of VEGF-C.D  CD44 is multistructural cell surface adhesion moleculeoverexpression of CD44 and its isoforms by tumor cells may lead to increased lymphatic and hematogenous spread  Tumor production of proteolytic enzymes.discontinuity in basement membrane of primary tumor. . adhesion and proliferation. factors that facilitate cell migration.NODAL METASTAIS  Tumor spread – regional lymph nodes and beyond occurs via lymphatic vessels whose proliferation is promoted by growth factors  Tumor lymphangiogenesis. III and IV  . hypopharyngeal and laryngeal primary tumors -levels II. II and III (descending order).HISTORY  In 1972. Oropharyngeal. Lindbergh reported metastasis in 1155 patients with upper aerodigestive tract squamous cell carcinoma  Primary tumors with in the oral cavity -levels I. are › deep jugular L. hypopharynx and larynx: first echelon L. generally not at risk   Tumours of oropharynx. levels IV and V L. III.N.N. II. IV on ipsilateral side: more at risk  Only 20-25% of patients with carcinomas of parotid gland develop regional metastasis. if neck is clinically negative(N0). . III.N.PATTERNS OF NECK METASTASIS  For primary tumours in oral cavity regional L. at levels I.N.  Skip metastasis to Levels I. III exceedingly rare Therefore. II. at highest risk for early dissemination by metastatic cancer limited to levels I. VIRCHOW’S NODES  Signal nodes/ seat of the devil/ supraclavicular adenopathy  Enlarged. esophageal cancer. in the left supraclavicular fossa: Troisier’s sign  Associated with metastasis from SCC of the head and neck. hard L. cancer in the abdomen and pelvic region . primary lung cancer.N. hypopharynx and nasophaynx have different staging based on tumour behaviour and prognosis .   TNM staging first reported by Pierre Denoix in 1940s Adapted by the International Union Against Cancer (UICC) in 1968 for 23 body sites  Consistent for all mucosal sites except the nasophaynx and hypopharynx  Thyroi.N.STAGING OF L. “N” OF TNM STAGING: REGIONAL L.N. TNM Staging grouping Common lymph node enlargements LYMPHADENITIS AND LYMPHADENOPATHY  Lymphadenitis is an infection in the lymph nodes. They help the body fight infection by filtering germs. Lymph nodes are glands that are part of the immune system. They become enlarged when infection is present  Lymphadenopathy is usually an immune response of the lymph nodes to an infection elsewhere in the body. -Localized -Generalized . Bacterial -Cat scratch disease -Brucellosis -Tuberculosis -Atypical mycobacterial infection -Primary and secondary syphilis -Diptheria .CAUSES OF LYMPHADENOPATHY 1.Infectious disease A. Viral -Infectious mononucleosis -Infectious hepatitis -Herpes simplex -Rubella -Measles -HIV B. Fungal -Histoplasmosis -Coccidioidomycosis D. Chlamydial -Lymphogranuloma venerum .Trachoma . Parasitic -Toxoplasmosis -Filariasis E.C. Hematological -Hodgkin’s lymphoma -Non Hodgkin’s lymphoma -Hairy cell leukemia -T-cell lymphoma -Multiple myeloma B.2. Metastasis -From primary site . Drug hypersensitivity 3. Malignant disease a. Immunologic disease (generalized lymphadenopathy) A. Sjogren syndrome D. Systemic lupus erythematous C. Rheumatoid arthritis B. 4.Endocrine disease -Hyperthyroidism -Adrenal insufficiency -Thyroiditis 6.Other disorder -Sarcoidosis -Lymphomatoid granulomatosis -Kawasaki disease -Histocytosis x .Lipid storage disease -Gaucher’s disease -niemann-pick disease 5. CALCIFIED LYMPH NODES      Dystrophic calcification. cervical and preauricular. submental lymph nodes May affect single lymph node or a linear series: lymph node chaining . common in granulomatous disorders Lymphoid tissue gets replaced by hydroxyapatite-like calcium salts nearly effacing all nodal architecture Scrofula Most common: submandibular. F.blind procedure -Excisional biopsy of node -Sentinal lymph node biopsy Contrast lymphoangiography Fine needle aspiration cytology.It is more accurate than blinded FNAC -High sensitivity(89-98%).C Ultrasound guidance CT Guidance .INVESTIGATIONS Histopathological -Conventional FNAC.N. high specificity(9598%) .A. R.C. T & M.I-CT & MRI detecting size of node -CT better than MRI – necrosis. extracapsular spread Distant metastasis imaging -Chest radiography -Abdominal USG -Radionuclide imaging -Blood studies (tumour markers) . CT.LYMPH NODES . ROUNDED SHAPE:  benign node l:b= 2:1  Exceptionssubmental nodes round rather than ovoid in shape.5 normal value. .  Lymphomatous nodes are often large and rounded  short/long ratio of < 0. -This is one of the most significant ultrasonographic features of malignancy . Capsule of the node – -ill defined -incomplete when malignant cells extend into perinodal soft tissue or adjacent muscle.IRREGULAR MARGIN: Nodes –irregular -larger than average. Inflammatory conditions such as tuberculosis or cat scratch disease may demonstrate these features. Lymphomatous nodes are often multiple in number .MULTIPLE NODES: Nodes that are matted together or multiple in >1 zone -pathologic.  ECHOGENICITY: Homogeneous echo architecture in a large node may reflect the “fish flesh” gross appearance seen in lymphomatous nodes Areas of anechoic echogenicity within a node may suggest necrosis and metastatic malignancy . PET SCAN . 32:18-25  SNB: gold standard in melanoma and breast cancer  SNB in HNSCC has been suggested as a method to improve the accuracy of staging and tailor treatments  From May 1999 to Dec 2009.9% of the oropharynx. ACTA otorhinolaryngologica Italica 2012.SENTINAL NODE BIOPSY Sentinel lymph node biopsy in squamous cell carcinoma of the head and neck:10 years of experience. Surgeons should be aware that these patients have a N0 neck and good prognosis. and that elective SND has proven reliability and worldwide acceptance . SN was not found in 26 patients  Functional outcomes after SNB are recognized as significantly better than after SND  But role of SNB in HNSCC is still undecided. 209 consecutive patients entered a prospective study: 61.7% had primary tumour of the oral cavity and 23. SENTINAL NODE MAPPING  1. 15minutes. 1st lymph node identified by technetium scan: sentinal L. 3. 2.N. and delayed image at 1hour. . • • • Employs 1 or all of the 3 techniques: Radioisotope scan imaging Injection of blue dye Use of a handheld isotope tracer probe for localization Pre-operative technetium scan employed first Gamma camera images at 3minutes. Any node that has in-vivo 10second count more than 3 times that of background considered “hot” Blue lymph node localized by blunt dissection. isosulfan blue dye injected around primary tumour Operative procedure carried out within 30minutes of the injection Gamma probe used. Probe used to correlate blue node with highest radiotracer activity: excised and sent for pathologic analysis If residual radioactivity in basin>10% of ex-vivo count of hottest node in basin: further exploration for more sentinal nodes .      Immediately prior to surgical procedure. SURGICAL TECHNIQUES OF REMOVAL OF LYMPH NODES   Radical Neck Dissection Modified Radical Neck Dissection › TypeI › TypeII › TypeIII . CONCLUSION  Thus. a good understanding of the lymphatic drainage of the head and the neck help us to better understand the pathological basis of various diseases. . Thank you… .