2.5 Lymphatics Flashcards
Who first described the lymphatics system and when?
Olaf Rudbeck (Sweden) in 1653
When did AT Still emphasize that diagnosis of the fascia and treatment of the lymphatic system was vital for maintaining health and treating disease?
1874
Who and when was Applied Anatomy of the Lymphatics published?
1922: Frederic Millard DO
When does lymphatic development begin? Significant?
5th week of gestation; 20 weeks
From which structures do lymphatic structures arise?
- Mesoderm - lymph vessels, lymph nodes, spleen, myeloid tissue
- Endoderm - thymus and parts of tonsils
When does lymphoid tissue increase until? what happens at this point?
puberty (roughly around 6-9 years)
- immune system matures, but lymphoid tissues slowly regress until 15-16 years
–Stable throughout adult lifespan
What happens to the immune system in geriatrics?
declines, may not mount a fever
What are the anatomic components of the lymph system? (3)
- tissues/organs: spleen, liver, thymus, tonsils, appendix, visceral lymphoid tissue, lymph nodes
- lymph fluid
- lymphatic vessels
What are the physiological functions of the lymphatic system? (4)
- immune
- digestive - nutrition
- fluid imbalance
- waste
Spleen: location, characteristics, function
-location: beneath ribs 9-11 on left, next to diaphragm
normally not palpable
- characteristics: largest single mass of lymphoid tissue, fluid movement driven by diaphragm movement
- functions: destroy damaged/deformed RBCs, synthesize Igs, clear bacteria
Liver: location, characteristics, function
- location: RUQ; palpable at R costal margin
- characteristics: movement of diaphragm important for movement of fluids
- function: half body’s lymph formed here, clears bacteria, “gate keeper” of shared hepato-billary pancreatic venous and lymphatic drainage
Thymus: location, characteristics, function
- location: anterior mediastinum
- characteristics: large in infancy and peaks at 2 yo, involutes after puberty and replaced by fatty tissue
- function: maturation of t cells, little or no function in adults
Tonsils: location, characteristics, function
- location: 3 types in posterior oropharynx: palantine (lateral pharynx), lingual (posterior 1/3 tongue), and pharyngeal (adenoids at nasopharyngeal border)
- characteristics: not visible until 6-9 mo, remain enlarged through childhood
- function: provide cells to influence and build immunity early in life, nonessential to adult immune function
Appendix: location, characteristics, function
- location: proximal end of the cecum (large intestine)
- characteristics: contains lymphoid pulp, atrophies with age
- function: part of GALT
What are examples of GALT (gastrointestinal association lymphoid tissue- visceral lymphoid tissue)?
- Peyer’s patches (ileum)
- lacteals (lymphatic capillaries of small bowel)
What is lymph fluid and what is is made of?
Substances that leak out of the arterial capillaries into the interstitium get taken up by lymphatic capillaries b/c of leakier junctions;
immune cells, foreign antigens, bacteria and viruses, clotting factors, chylomicrons post-prandial
How much fluid moves from capillaries to interstitial space each day? to where?
30 L
90% to capillaries, 10% to lymphatic system
½ of diffused plasma proteins re-enter system via lymph
What is the lymph role in purification and cleansing?
• bathes organs
• Cleanses extracellular spaces of particulate matter, toxins, bacteria, cellular waste products, and post-injury biochemical by-products
• Fluid then travels from vessel to node
–Node acts as purifying filter
How much drainage through the thoracic duct is associated with respiration?
35-60%
What tissues do not have lymphatic vessels?
- epidermis
- endomysium
- cartilage
- bone marrow
What do the lymph channels begin as? What are they composed of?
blind endothelial tubes/capillaries of single layer of leaky squamous epithelium supported by anchoring filaments.
What are the path of the lymphatic vessels? (8 structures)
- Terminal lymphatics: Interstitial space of tissues
- collecting vessels
- afferent lymph vessels
- lymph node(s)
- efferent lymph vessels
- lymphatic trunks
- thoracic duct or right lymphatic duct
- venous system
What are lymphagions?
chains of muscular units that possess two-leaflet bicuspid valves that contract regularly throughout the system and move lymph along in peristaltic waves
What is the afferent lymphatics?
channel that delivers lymph to the node from the peripheral tissues on the side opposite the hilum
What is the subcapsular space of a lymph node?
a meshwork of reticular fibers, macrophages, and dendritic cells where afferent vessels deliver lymph
What is the outer cortex of a lymph node?
rich in B cells that sit within germinal centers that resemble those of lymphoid nodules
What is the deep cortex of a lymph node?
contains lymph sinuses dominated by T cells
What is the medullary sinus of a lymph node?
located at core, region rich in B cells and plasma cells
What is the efferent lymphatics of a lymph node?
channel through which the lymph collected from the medullary sinus exits at the hilum
Where are superficial lymph nodes? examples?
Where are the deep lymph nodes?
within the subcutaneous tissue: cervical axillary, inguinal
deep: beneath fascia, muscle, organs
What are the functions of lymph nodes? (3)
- filtration of lymph fluid
- maturation of lymphocytes
- phagocytosis of bacteria and cellular debris
What do you look for when evaluating lymph nodes?
- size and shape
- consistency, tenderness, mobility
- color, warmth
Where is Virchow’s node?
left supra-clavicular (intra-thoracic/abd CA)
What do epitrochlear nodes indicate?
secondary syphilis
What does the thoracic duct drain?
Master lymph vessels and drains:
- Left head/neck
- LUE
- L thorax/abdomen
- below the umbilicus
- receives from lumbar lymphatics
Where is the origin and termination of the thoracic duct?
origin: cisterna chyli as a dilation at L1-2 level
termination: pierces Sibson’s fascia at superior inlet, U-turns to empty into left subclavicular/IJ veins
What is the origin and termination of the right lymphatic duct? What does it drain (5)?
- origin: junction of right jugular and subclavian trunks and occasionally the bronchomediastinal trunk
- termination: R subclavian/IJ venous junction
- drains:
1. R head/neck
2. RUE
3. R thorax
4. heart
5. lungs (except LUL)
Describe the lymphatic drainage of the pelvic organs
superficial inguinal –> deep inguinal –> lacunar –> external iliac –> common iliac
visceral pelvic –> internal iliac –> common iliac
common iliac –> right lumbar, intermediate lumbar, or left lumbar –> (right/left lumbar trunk) –> cisterna chyli –> thoracic duct
What is the normal interstitial fluid pressure (Pif)
-6.3 mmHg (negative pressure)
What are causes of positive pressure in lymph system? (pressure >/= 0 mmHg = lymph capillaries collapse, flow stops)
- increased hydrostatic pressure
- decreased colloid osmotic pressure
- increased capillary permeability
Does the SNS increase or decrease lymph flow?
decrease
•↑sympathetic tone -> tighter valves -> ↓lymph flow into the venous system
•↑sympathetic tone -> ↓peristalsis -> lymphatic congestion
What are the consequences of poorly functioning lymphatic system? Some causes?
-EDEMA: buildup of interstitial fluid from poor flow and imbalanced starling force
- ↑ arterial pressure: HTN, drugs, ↑ BV
- ↑ venous pressure: CHF, valvular dz, venous obstruction
- ↓ plasma osmotic pressure: cirrhosis, protein malnutrition (Kwarshiokor), DM
- ↑ capillary permeability: infection snake bite, trauma
What are the effects of edema? (4)
- compression of local structures:
- vascular: ↓ delivery of O2, nutrients, meds, hormones.
- neuronal: ↓ sensation, pain, or paresthesia
- pulmonary: SOB
- cerebral: ↓ LOC - ↓ tissue waste removal: pH changes
- ↓ pathogen clearance and immunity
- chronic states: fibrosis/contractures
What is lymphatic OMT?
diverse techniques designed to remove impediments to lymphatic circulation and promote and augment the flow of interstitial fluid and lymph
What are indications of lymphatic OMT? (5)
- edema, tissue congestion, lymphatic stasis (+/- pain)
- infection: URI
- inflammation: COPD, asthma, strain or sprain
- acute SD
- pregnancy
*approach chronic conditions with gentler techniques, shorter, but more frequent
What are contraindications to lymphatic treatments?
clinical judgement with attention to diagnosis, clinical condition, and medical therapy influencing choice, dose, duration, and frequency
what are ABSOLUTE contraindications to lymphatic OMT? (4)
- anuria- kidney failure
- necrotizing fasciitis (in the treatment area)
- pt unable to tolerate
- pt refuses
What are relative contraindications for lymphatic OMT?
examples:
- CHF pt’s: can’t handle pre-load
- COPD: specifically thoracic pump
- unstable cardiac
- untreated coagulation therapy
- cancer
- acute asthma exacerbation: risk of ↑ reflexive bronchospasm
- chronic infections: risk of re-activation
- diseased organs: spleen (MONO) or thyroid (hyperthyroid)
- pregnancy (for uterus/deep abd)
- circulation disorder
- bacterial infection
What are the principles of diagnosis from a lymphatics approach? (5)
Evaluate:
- risk-benefit ratio
- fascial patterns of Zink
- diaphragms/fascia: including thoracic inlet for restrictions that may limit lymphatic drainage
- SD
- tissue congestion
Compensatory patterns: common vs uncommon
common: 80% LRLR
uncommon: 20% RLRL
What are the transition zones of the spine for Zink patterns? (4)
- craniocervical: OA, C1, C2
- craniothoracic: C7, T1
- thoracolumbar: T12, L1
- lumbosacral: L5, sacrum
What are the transverse restrictors? (4)
- tentorium cerebelli
- thoracic inlet
- thoracolumbar diaphragm
- pelvic diaphragm
What are the OMT treatments to evaluate diaphragms/fascia?
- Thoracic inlet MFR (always 1st)
- Doming of the diaphragm (2nd for lymphatic problems inferior to the diaphragm)
- Suboccipital release by kneading or inhibition (2nd for HEENT lymphatic problems)
- Ischiorectal fossa release (3rd for lymphatic problems in the lower extremities)
Where do we feel to evaluate for lymphatic congestion?
- supraclavicular space (head and neck)
- epigastric region (abdomen and chest)
- posterior axillary fold (arm)
- inguinal region (lower extremity)
- popliteal region (leg)
- achilles region (ankle and foot)
What is the sequence of treatment for lymphatics?
- open pathways to remove restriction to flow
- maximize diaphragmatic functions (abdomen and pelvic diaphragms)
- increase pressure differentials or transmit motion (fluid pumps)
- mobilize targeted tissue fluids (localized to specific somatic dysfunctions)
what year did faculty at ATSU use skiagraphy (early form of x-ray) to research lymph and vascular distributions?
1898
Who stated, –“for every congested tissue there is a corresponding lymph disturbance”; and that “attempts to clear the lymph stream before clearing the edema in the clavicular regions is to over-tax the general lymph stream and cause profound reactions”
1922: Frederic Millard, D.O., published Applied Anatomy of the Lymphatics
What happens during fluid overload?
lymphatic system helps prevent tissue damage by clearing the excess
–“Second/third spacing”
What is the lymph role in defense?
Brings toxins, bacteria, and viruses into contact with the organized lymph tissue (i.e. lymph nodes)
–Contain high concentrations of immune cells
–Antigen processing and presentation
–Maturation of the immune cells –> immunity
•Free flow of lymph necessary for appropriate immune function
What is the lymph role in nutrition?
- Fat absorption via chylomicrons (packaged form of fats)
–Too big to cross capillary intercellular junctions
–Travel via lacteals -> larger lymph vessels -> thoracic duct -> venous system - Returns proteins to vasculature
–Proteins then bind nutrients (i.e. calcium-albumin)
Characteristics of terminal lymphatics
- lined with leaky endothelium, anchored to ECM by small filaments
–Endothelial cells overlap, creating one-way valves
–Lack smooth muscle walls
Characteristics of collecting vessels
- “lymphangions,”
- Contain smooth muscle
- Extensive autonomic innervation
- Afferent or prenodal vessels = collecting vessels prior to lymph node
- Efferent or postnodal vessels = collecting vessels draining the lymph node
function of lymph node (3)
–Filtration of lymph fluid
–Maturation of lymphocytes
–Phagocytosis of bacteria and cellular debris
characteristics and location of LNs?
• Most highly organized lymphoid tissue
• Dispersed along the course of lymph vessels
• Types:
–Superficial – within the subcutaneous tissue
•Ex. – cervical, axillary, and inguinal
–Deep – beneath fascia, muscle, organs
Path of lymph flow through a LN? (6)
- afferent lymphatics
- subcapsular space
- outer cortex
- deep cortex
- medullary sinus
- efferent lymphatics
What does the lumbar lymphatic trunk drain?
LE and pelvic organs
What does the intestinal lymphatic trunk drain?
abd viscera
What does the bronchomediastinal lymphatic trunk drain?
portions of thorax
What does the subclavian lymphatic trunk drain?
UE
What does the jugular lymphatic trunk drain?
neck and head
what is the Cisterna Chyli and its location?
- Located at the level of L1-2
- Drains lymphatic trunks of the lower body
- Gives rise to the thoracic duct
How do you locate and evaluate LN?
Size/Shape/Consistency/Tenderness/ Mobility/Color/Warmth
–Swollen, soft, painful? –> Infectious (look for source)
–Swollen, indurated (hard), non-painful, fixed? –> eval for malignancy
What is the Virchow’s Node and would could swelling here indicate?
Virchow’s Node: L supra-clavicular
–Intra-thoracic/abdominal cancer
What is the Epitrochlear Nodes and would could swelling here indicate?
Epitrochlear Nodes: cubital, UE LN
- secondary syphilis
LN of the neck: 6
- jugulodigastric
- Posterior triangle
- Supraclavicular
- Deep lateral cervical
- Submental
- Submandicular group
What does Posterior triangle LN drain? (5)
- nasopharynx
- posterior scalp
- ear
- temporal bone
- skull base
What does Supraclavicular LN drain? (3)
- thyroid
- piriform sinuses
- upper esophagus
What do submandibular LNs drain? (4)
- anterior 2/3 tongue
- floor of mouth
- gums
- cheek mucosa
What could swelling of the submental LNs indicate?
rarely involved early, except in lip cancer
What do deep lateral cervical LNs drain? (3)
- oral cavity
- pharynx/larynx
- tonsil
What are examples of visceral lymphoid tissue?
- GI: Peyer’s patch in ileum and lacteal in SI
2. Pulmonary lymphoid tissue scattered, filters toxins from lungs
How does direct diaphragmatic pressure move lymph?
- With each breath, contraction ↑ the negative intrathoracic pressure, pulls fluid centrally; Also exerts a direct force on the cisterna chyli, pushing fluid superiorly
- diaphragm muscles helps move fluids from the lower extremities and pelvis to the thoracic duct
In what conditions could diaphragm muscles be dysfunctional?
dysmenorrhea, endometriosis, post labor and delivery, BPH
What lymph technique is contraindicated for COPD pt’s and why?
thoracic pump with activation CI due to increased residual volume post treatment
Un-compensated patterns
LLLL or RLLR
usually symptomatic and involving trauma
What changes in lymph system are seen during pregnancy?
• Pregnancy ↑ plasma volume by 30-50% at term
–↑ Arterial volume = ↑ hydrostatic pressure, ↑ fluid pushed into the interstitial tissues
–Lymphatic system overwhelmed -> edema -> ↑ pressure on median nerve -> sx of carpal tunnel syndrome
Pregnant women comes in with:
- hypertonic paraspinal ms, ↑ lumbar lordosis, T5-9 N RrSl
- Smaller thenar eminence on right, decreased R grip strength, symptoms reproducible with tap on ventral R wrist, swollen right fingers, supraclavicular fullness on right
Carpal tunnel!
What can we do for tx?
- Open thoracic inlet
- Pectoral traction
- Rib raising
- Re-dome diaphragm
- Thoracic pump
- Effleurage and Petrissage of UE
What would a normal and abnormal LN feel like in terms of:
- size
- shape
- consistency
- Mobility
- Overlying skin
- size: N-pea sized/Abnorm- large
- shape: N-round/reg /Abnorm- irregular
- consistency: N-spongy /Abnorm- hard
- Mobility: N-mobile /Abnorm- nonmobile
- Overlying skin: N-baseline /Abnorm- red, warm, swollen
