7. Lymphatic Drainage of H/N Flashcards
Lymphatic System: a passive, centripetal, vascular system
• Returns a portion of the extracellular (interstitial) fluid to the
systemic circulation through a thin-walled system of vessels.
• Arises from a network of highly permeable ____ arising blindly in tissues.
• With muscle contraction, fine filaments anchoring vessels to surrounding CT transfer tensional forces to endothelial cells, ____ spaces between cells allowing proteins and large particles present in the interstitial fluid to enter the lymphatic capillaries.
• Lymphatic capillaries collect this fluid from most parts of the body, after which it is passed through successively larger ____ and a network of nodes, trunks and ducts until it is returned to the ____ circulation at the base of the ____.
• The lymphatic system also absorbs and transports ____ and fats as dense and milky ____ from the ____ of the digestive system
lymphatic capillaries opening vasa lymphatica venous neck fatty acids chyle lacteals
Smaller vasa lymphatica act as tributaries which ultimately drain centrally to larger ____
Lymph nodes, ____ lymphoid organs of varying size,
lie at various points along this drainage system. The nodes present as round, oval or bean-shaped, usually featuring a depressed ____ on one side, through which ____ lymphatic vessels enter and ____ vessels emerge.
In the nodes:
• Pathologic cells, viruses, bacteria and cellular debris are filtered
from the clear, faintly yellow and slightly opalescent fluid; and
• B & T lymphocytes and APC’s initiate immune response to
foreign antigens
Though most trunks have ____ valves that prevent retrograde flow, these valves may become ____, thereby permitting
lymphatic flow and the spread of disease to occur ____.
Valvular incompetence is one potential cause of ____
lymphatic trunks secondary hilum afferent efferent
bicuspid
incompetent
centrifugally
lymphedema
Lymphatic vessels from superficial tissues of the head usually drain
first to the following local groups of nodes:
Parotid: drain the - EAM & auricle - \_\_\_\_ - Eyelids - \_\_\_\_ - Soft palate - \_\_\_\_
Superficial parotid nodes embedded in the gland are known nodes are aka ____ nodes
Mastoid (retro-auricular)
drain the ____ and auricle
Occipital
drain the ____
Buccal -drain the Buccal mucosa of the \_\_\_\_ vestibule - Nose - \_\_\_\_
middle ear
temple
posterior nasal cavity
preauricular
scalp
scalp
oral
upper lip
Lymphatic vessels from superficial tissues of the head usually drain
first to the following local groups of nodes:
- Superficial cervical
Lingual nodes:
lie on the superficial aspect of the ____
Submental nodes: drain - \_\_\_\_ - Chin - \_\_\_\_ - Anterior oral floor
Submandibular nodes: drain - \_\_\_\_ - Buccal & Submental nodes
Also: Anterior cervical
hyoglossus
lower lip
lingual apex
oral and perioral tissues
Anterior Cervical (inconsistent)
- ____
- ____
- ____
- ____
infrahyoid
prelaryngeal
paratracheal
pretracheal
These five groups of nodes are described collectively as comprising a ____ (____) at the junction of the head and neck
- Parotid
- Mastoid
- Occipital
- Submental
- Submandibular
superficial ring
pericervical collar
Ultimately, all lymphatics
of the head and neck drain to the ____ along the
carotid sheath, either ____ from tissues
or ____ through the aforementioned groups of outlying regional nodes
The “collecting” nodes along the internal jugular vein are referred to as ____ or ____ nodes
deep cervical lymph nodes
directly
indirectly
jugular
lateral deep cervical
Submandibular nodes
are associated with the ____ gland and the ____ vessels as they course over the inferior border of the mandible
submandibular salivary
facial
The submandibular salivary gland and lymph nodes are found in the ____ (____) triangle
submandibular
digastric
Submandibular nodes
receive lymphatics which accompany the ____ vessels and drain the lower ____ and the lateral part of the ____
Submandibular nodes also receive some of the drainage from the: • \_\_\_\_ • \_\_\_\_; and • \_\_\_\_ nodes
facial
face
anterior tongue
buccal
submental
lingual
Lymphatic drainage of most of the oral cavity is directed toward the \_\_\_\_ nodes, specifically: o \_\_\_\_ teeth, o Vestibular gingivae of maxilla and mandible o \_\_\_\_gingivae o Upper lip o Lateral parts of \_\_\_\_ o Posterior floor of mouth o Lateral body of \_\_\_\_
But there are some important exceptions…
submandibular maxillary mandibular lingual lower lip tongue
BUT the mandibular incisors may drain directly to the ____ nodes
Mandibular teeth drain directly to ____ nodes
Lymphatic drainage
of the mucosa and gingivae of the hard palate
may be directed thru the ____ to the
____ and ____ nodes
submental superior deep cervical superior constrictor retropharyngeal superior deep cervical
Embedded in the fascia between the posterior pharynx and vertebral column:
\_\_\_\_ nodes Also drain lymph from: - \_\_\_\_ - \_\_\_\_ - \_\_\_\_
Efferents drain to the ____ and ____ nodes
retropharyngeal
nasal cavity
soft palate
middle ear
jugulodigastric
superior deep cervical
Submental lymph nodes
Receive drainage from: • Anterior floor of the \_\_\_\_ • Median \_\_\_\_ • Apex of the \_\_\_\_ • \_\_\_\_
mouth
lower lip
tongue
chin
Submental nodes are found in the ____
submental triangle
Submental lymph nodes
Lying superficial to the ____ muscles, these nodes are the most significant structures in the submental triangle these nodes, in turn, drain to the ____ nodes
mylohyoid
submandibular
____ cell carcinoma of the lower lip, resulting from chronic sun exposure or a lifetime of pipe-smoking will metastasize to Submental nodes if ____
Submandibular nodes if ____
sqaumous
median (midline)
lateral (corners of mouth)
The lymphatic plexus of the lingual mucosa is continuous with an ____ plexus
Posterior to the vallate papillae, the tongue is drained by ____ vessels draining to ____ nodes
With the exception of the apex, the anterior tongue is drained by :
• Marginal vessels to ____ nodes
• Median vessels to ____ nodes
intramuscular
dorsal lymph
superior deep cervical
submandibular
deep cervical
Curiously,
vasa lymphatica draining each half of the tongue may cross the ____ and permit cancerous lesions arising on either lateral border of the tongue to metastasize to the ____ submental and submandibular nodes
midline
contralateral
Submandibular nodes
in turn drain into the
____ nodes
Recall that the
deep lateral cervical nodes lie along the ____
superior deep lateral cervical
internal jugular vein
Enlargement of the jugulo-omohyoid node, a deep cervical node related to the ____ tendon of the ____ muscle, may be a sign of ____ carcinoma
intermediate
omohyoid
lingual
Aggregated lymphoid nodules or TONSILS guard the boundaries
between the ____ and ____ cavities and the ____
____-Associated Lymphoid Tissue (MALT)
These tonsils form ____
oral nasal pharynx mucosa waldeyer's ring
Waldeyer’s ring a protective anulus of lymphoid tissue, arranged in \_\_\_\_ or follicles, is formed by four sets of tonsils: - \_\_\_\_ - \_\_\_\_ - \_\_\_\_ - \_\_\_\_
As well as ____ in between
nodules
pharyngeal
tubal
palatine
lingual
minor masses
Pharyngeal tonsil in the pharyngeal recess (fossa of ____)
Enlargement of these tonsils: ____
may interfere with normal ____ breathing and impact ____
Rosenmuller
adenoids
nasal
salivation
Palatine tonsil in ____ (note the ____…)
tonsilar fossa
tonsilar crypts
Tonsilar crypts
…invaginations of tonsilar epithelium that dramatically increase ____ between environmental influences and lymphoid tissue.
Chronic ____ or ____ drip may lead to formation of foul-smelling plugs of calcified mucus and bacteria known as…
____ - local inflammation
contact surface
sinusitis
postnasal
tonsiloliths
PALATOPHARYNGEAL FOLD
PALATOGLOSSAL FOLD
Note the ____ resting in the fossa between the two arches
Enlargement of the palatine tonsils with or without tonsiloliths may interfere with ____
deglutition
What about enlarged PALATINE TONSILS?
“____ TONSILS”
TONSILLECTOMY - risky procedure
TONSILLITIS - Can heal ____ or w ____
kissing
naturally
antibiotics
Note how the
SUPERIOR PHARYNGEAL CONSTRICTOR contributes to the floor of the ____ FOSSA
tonsilar
Palatine tonsils
Failure to resolve tonsilitis may lead to formation of a ____
parapharyngeal abscess
The parapharyngeal space connects to every other major fascial neck space. Infections in the parapharyngeal space usually originate in the ____ or ____, although local spread from ____ sources and lymph nodes may occur.
Symptoms include fever, sore throat, ____ and swelling in the ____ down to the ____ bone. Diagnosis is by ____. Treatment is ____ and surgical ____.
tonsils
pharynx
odynophagia neck hyoid CT antibiotics drainage
Anterior space abscesses cause ____ and ____ (thickening of tissues) along the angle of the mandible, with medial bulging of the ____ tonsil and ____ wall
Posterior space abscesses cause more ____ swelling, may erode the ____ until rupture, and produce septic thrombosis of the ____ as well as ____ deficits
trismus
induration
palatine
lateral pharyngeal
posterior pharyngeal
carotid artery
IJV
neurologic
A dense of plexus of lymphatic vessels surrounds each follicle; Efferent vessels arise from the plexus and pass to the superior deep cervical nodes, especially the ____ group
jugulodigastric
Jugulodigastric node
One of the
____ nodes
Drainage:
1. \_\_\_\_ tonsil 2. \_\_\_\_ tonsil
Q: sentinel node?
A: Since it receives afferent flow from regions which may be hard to assess on ____ exam, enlargement warns the DMD that further investigation is necessary
superior deep lateral cervical
pharyngeal
palatine
oral
Lymph nodes and vessels of the cervical region are divided into superficial and deep groups
• Superficial cervical nodes, previously introduced, receive afferent lymphatic vessels from the ____, ____, and ____.
These nodes lie superficial to the investing layer of ____ fascia
- External jugular and anterior jugular groups follow the superficial veins of the same name before draining into the ____ group of nodes
- An occasional member of the superficial lymph nodes of the neck, chronically enlarged by past infection, may be ____ in the normal neck
scalp
face
superficial neck
cervical
deep cervical
palpable
Some superficial cervical nodes accompany the ____ vertically across the superficial surface of ____, while others lie along the ____ in the root of the neck
external jugular vein
SCM
anterior jugular veins
Lymph nodes and vessels of the cervical region are divided into ____ and ____ groups
Deep lateral cervical nodes lie along the ____vein. They drain all ____ head and neck structures.
These head and neck areas drained by the deep lateral cervical nodes are prone to ____ and ____
– SUPERIOR deep lateral cervical nodes, which lie along the ____ vein, should be sought superiorly along the anterior border of the ____.
– INFERIOR deep lateral cervical nodes Are sometimes called the ____ or ____ NODES because of their position above the clavicle and upon the surface of the scalene muscles.
These nodes may also interrupt any of the major ____ draining into the large veins at the base of the neck… Thus they may serve as a final ____ for tumor cells spreading thru the lymphatic system arising from either ____ or ____ sites
superficial deep internal jugular vein ipsilateral infection carcinoma
internal jugular
sternocleidomastoid
supraclavicular
scalene
lymphatic trunks
filter
near
distant
SUPERIOR
Deep lateral cervical nodes
INFERIOR
Deep lateral cervical nodes
These nodes have therapeutic as well as diagnostic
importance - Therapeutically, the surgical procedure of ____ for head and neck carcinoma is designed
to remove all of these nodes in a “block”
which also includes
the ____, the ____ gland, and the major ____
to insure as complete
a lymph node extirpation as possible
radical neck dissection
sternocleidomastoid
submandibular
veins
One of the ____ nodes, the specifically named
Jugulodigastric node…
… drains the posterior ____ and ____ tonsils. It is commonly enlarged and can be located at the level of the greater horn of the ____ bone in a triangle formed by the posterior belly of the ____ muscle and the ____ and ____ veins
tongue
palatine
hyoid
digastric
facial
internal jugular
The Jugular Lymphatic Trunks
- Jugular lymphatic trunks are formed by efferents from the ____ cervical nodes on each side, transmitting the lymphatic drainage of the ipsilateral head and neck.
- On the right side, the jugular trunk may join with the ____ trunk draining the ____ upper limb and the ____ trunk draining the right side of the thorax, to commonly form a right ____ duct. These lymphatics empty into the junction of the right ____ and ____ veins as they form the right ____ vein.
On the left, ____, ____ and ____ trunks commonly join the thoracic duct
inferior deep lateral subclavian right bronchomediastinal lymphatic subclavian internal jugular brachiocephalic
jugular
subclavian
bronchomediastinal
The ____ transmits the lymphatic drainage of three-quarters of the body to the venous system at the root of the neck
thoracic duct
Thoracic duct arises from the ____, a lymphatic reservoir located just below the aortic ____ which receives the drainage of the ____ of the body and all ____ viscera
The duct ascends thru the posterior mediastinum, gradually crossing from right to left until it passes thru the ____ aperture
cisterna chyli
hiatus
lower half
abdomino-pelvic
superior thoracic
Before draining into the venous system, the thoracic duct receives drainage of the ____ wall and the ____ trunk
left thoracic
left broncho-mediastinal
Each broncho- mediastinal trunk receives the drainage of the ____ and ____ nodes among others
These nodes are implicated in the metastasis of ____
bronchopulmonary
tracheobronchial
primary lung carcinomas
THORACIC DUCT
The duct ascends out of the thorax and loops up behind the ____ before emptying into junction of the ____ and ____ veins
carotid sheath
left subclavian
internal jugular
Palpation of the supraclavicular fossa
____ Node aka “The Seat of the Devil”
virchow’s
The inferior deep lateral nodes are also called
____ nodes
since their enlargement on the right side should send the physician looking for a primary tumor site in the ____ quadrant of the body and their enlargement on the left indicates a primary site in the ____ or ____ quadrant of the body.
Therefore, lymph from the right upper quadrant of the body,
i.e., the right side of head and thorax and the right upper limb, drains into the great veins at the ____ of the base of the neck.
However, lymph from the lower half of the body and the left upper quadrant drains into the great veins on the ____ of the base of the neck.
____ are present in the the terminal parts of these lymphatic ducts
to prevent venous reflux.
sentinel
right upper
lower half
left upper
right side
left side
valves
The THYMUS
and the bone marrow are ____ organs and will
be discussed in BS VI
primary lymphoid
Sloan Kettering Nomenclature
Level I
____ and
____ nodes.
Level II
____ jugular nodes
Level III
____ jugular nodes
Level IV
____ Jugular nodes
between the ____
and the ____
Level V
Posterior ____ nodes
Level VI
Anterior ____ nodes
submental
submandibular
upper
middle
lower
omohyoid
clavicle
triangle
cervical
