S3) Lymphatic Drainage of the Head and Neck

Question 1

What does the lymphatic system consist of?

Answer 1

• Lymph nodes
• Lymphatics
• Lymph fluid

Question 2

What is the purpose of the lympathic system?

Answer 2

• Continuous removal of residual tissue fluid from the extracellular space to be returned back to blood circulation
• return small proteins and fluid that has leaked from capillaries
• immune defence and surveillance

Question 3

Lymph is just tissue fluid which has entered the lymphatic capillary.

Identify some of the contents of lymph

Answer 3

• Lipids (chylomicrons from gut lymphatics)
• Small proteins
• Damaged cells
• Tissue fluid
• Bacteria

Question 4

How much lymph does the body produce a day?

Answer 4

3 ‐ 4 L of lymphatic fluid produced per day

Question 5

What clinical manifestations are associated with the lymphatic vessels?

Answer 5

• lymphoedema = fluid accumulation (upper and lower limbs)
• lymphadenopathy = enlarged lymph nodes that are palpable due to infection or malignancy

Question 6

Illustrate how uni-directional flow occurs in the lymphatic system

Answer 6

Tissue fluid → lympathic capillary → lymphatic vessels → lymphatic nodes → lymphatic vessels → lymphatic trunks → lymphatic ducts → subclavian veins

Question 7

The lymphatic system is a low pressure system with no central pump.

How does the lymph flow?

Answer 7

• Valves: passive and intrinsic constriction
• Pulsation of an artery (close association)
• Muscle contraction

Question 8

Where in the venous circulation does the lymph drain?

Answer 8

Lymphatic system ends in two main lymphatic ducts which drain into subclavian veins

Question 9

What is lymphoedema?

Answer 9

Lymphoedema is the abnormal collection of protein‐rich fluid causing tissue swelling due to compromised lymphatic system

Question 10

Lymphoedema is a chronic condition.

Identify 5 of its causes

Answer 10

• Removal / enlargement of lymph nodes
• Infections e.g. certain parasites
• Damage to lymphatic system e.g. cancer treatments
• Lack of limb movement
• Congenital

Question 11

Provide 3 examples of lymphoid organs in the body

Answer 11

• Spleen
• Tonsils (Waldeyer’s ring)
• Thymus

Question 12

Describe the structure of lymph nodes

Answer 12

Connective tissue structures:

• Tough fibrous outer capsule
• Reticular connective tissue inside

Question 13

Describe, briefly, how lymph nodes provide defence against infection

Answer 13

• Physical filter
• Phagocytic filter
• Lymphocytes (T and B) : activate and proliferate in response to antigens

all can cause it to enlarge

Question 14

Enlarged lymph nodes is a very common patient presentation.

Which two underlying conditions cause this?

Answer 14

Lymphadenopathy:

• Reactive due to an Infection – most common, tender, mobile (can move around with finger)
• Cancer: - hard, irregular, stuck
• Metastasis - it has spread from somewhere to this lymph node. “hard and tethered, painless to palpate”
• lymphoma - rubbery, fast growing, painless to palpate

Question 15

What should one do when a patient presents with enlarged lymph nodes?

Answer 15

• Comprehensive history
• Examine the area of tissue it drains
• Examine other lymph nodes and body systems (if malignancy is suspected)

Question 16

Lymph nodes in the head and neck can be classified into two groups.

Identify them and describe their function

Answer 16

• Regional: receive drainage from scalp, face and neck (ring)
• Terminal: receive drainage from regional nodes (vertical)

Question 17

Describe the relative depth of terminal and regional lymph nodes

Answer 17

• Regional = superficial
• Terminal = deep

Question 18

Identify the 5 regions in body where collections of lymph nodes may be palpable

Answer 18

• neck
• auxilla
• groin

Question 19

How many lymph nodes are in the body?

Of those, how many can be found in the neck?

Answer 19

• 800 lymph nodes in the body
• 300 lymph nodes in the neck (equal amount on both sides)

Question 20

Where are regional lymph nodes located?

Answer 20

Superficial to the investing layer of deep cervical fascia

Question 21

Where are the terminal lymph nodes located?

Answer 21

• Deep to the investing layer of deep cervical fascia
• Most are associated with IJV (in carotid sheath)

Question 22

Identify the following superficial lymph nodes 1-5:

Answer 22

1) Submental (under chin)
2) Submandibular (under jaw)
3) Pre-auricular (behind the ear)
4) Post-auricular (in front of the ear)
5) Occipital

Question 23

Identify the following cervical lymph nodes 6-8:

Answer 23

6) Superficial: EJV
7) Posterior: EJV
8) Anterior: AJV

Question 24

Identify the following deep lymph nodes 9-11:

Answer 24

9) Jugulo‐digastric (tonsillar node)
10) Jugulo‐omohyoid
11) Supraclavicular lymph nodes

Question 25

What do supraclavicular lymph nodes do?

Answer 25

**Supraclavicular lymph nodes** oversee transport of lymph from thoracic cavity and abdomen * if it is palpable then it is a sign of gastric cancer * found in the posterior triangle

Question 26

Where are supraclavicular lymph nodes located?

Answer 26

Supraclavicular nodes are found in the **root of the neck** on either side

Question 27

What is Virchow's node?

Answer 27

**Virchow’s node** is a lymph node in the left supraclavicular fossa

Question 28

What is Trosier's sign?

Answer 28

**Trosier’s sign** is the enlargement of the left supraclavicular node (Virchow's node) secondary to metastatic abdominal malignancy

Question 29

Where is the jugulo-digastric node located and what does it do?

Answer 29

The **jugulo-digastric node** is located just below and behind the angle of the mandible and is concerned with lymph drainage of the palatine tonsil, oral cavity and the tongue

Question 30

What does the jugolo-omohyoid lymph node do?

Answer 30

The **jugulo-omohyoid node** is mainly associated with the lymph drainage of the tongue, oral cavity, trachea, oesophagus and the thyroid gland

Question 31

Where do deep lymph nodes drain?

Answer 31

Deep cervical lymph nodes eventually drain via the thoracic duct (or right lymphatic duct) into the **subclavian vein**

Question 32

The deep lymphatic vessels converge to form left and right jugular lymphatic trunks. Describe their location

Answer 32

- **Left jugular lymphatic trunk:** joins thoracic duct at root of neck - **Right jugular lymphatic trunk:** empties into right lymphatic duct at root of neck

Question 33

Why do some diseases involve both regional and terminal cervical lymph nodes?

Answer 33

Many structures of the head and neck drain via superficial lymph nodes into the deep cervical lymph nodes

Question 34

What is Waldeyer's ring?

Answer 34

**Waldeyer's ring** is an annular collection of lymphatic tissue (NOT nodes) surrounding the entrance to the aerodigestive tracts * tough outer capsule

Question 35

Identify the tonsils which form Waldeyer's ring

Answer 35

- Lingual tonsil (opening of mouth \*) - Palatine tonsils - Tubal tonsils - Pharyngeal tonsils (opening of nose \*) * \*in a good spot to fight immediate infection*\*

Question 36

Which tonsils are affected by tonsillitis?

Answer 36

Palatine tonsils

Question 37

Which of the lymphoid tissue in Waldeyer's ring can one most readily view when examining a patient?

Answer 37

Palatine tonsils - the ones that get swollen at the back of the mouth

Question 38

Which tonsils of Waldeyer's ring are also called the adenoids? Where are they located?

Answer 38

**Pharyngeal tonsils** – located in the roof of the nasopharynx (behind the uvula)

Question 39

Why might an enlargement of the adenoids cause middle ear problems?

Answer 39

- An enlarged adenoid (enlarged lymphoid tissue) can block the **Eustachian tube** - **Mucus** cannot drain properly and accumulates - **Infection** easily spreads into middle ear * also leads to obstruction of nasal breathing so they snore / breath through mouth

Question 40

what are some red flags when examining an enlarge lymph node?

Answer 40

* persisting \> 6 weeks * hard, fixed, irregular * rapidly growing in size * associated With generalised lymphadenopathy (other lymphs are enlarged too) * weight loss, night sweats * change in voice

Question 41

label this diagram that outlines the organisation of cervical lymph nodes and explain what is happening

Answer 41

1. superficial cervical lymph nodes drain into deep cervical lymph nodes

Question 42

what is the superficial cervical fascia continuous with?

Answer 42

* fascia of the face * just beneath the skin, draining lymphatic tissue * you can palpate these lymph nodes

Question 43

what is the cervical lymph nodes continuous with?

Answer 43

* drain into the deep tissues within neck

Question 44

what part of the head does the superficial occipital lymph nodes drain?

Answer 44

posterior scalp

Question 45

what part of the head does the superficial post - auricular lymph nodes drain?

Answer 45

posterolateral half of scalp

Question 46

what part of the head does the pre - auricular and parotid lymph nodes drain

Answer 46

anterolateral scalp upper half of face and eyelids cheeks

Question 47

what part of the head does the superficial submental nodes drain?

Answer 47

* inferior and posterior chin * floor of mouth * tip tongue * lower incisor teeth and gums

Question 48

what part of the head does the superficial submandibular lymph nodes drain?

Answer 48

* centre of face and cheek * teeth and gingivae (gums) * parts of the anterior lounge

Question 49

when approaching neck lumps what must you check

Answer 49

* location - midline or lateral (anterior or posterior triangle) * movement while swallowing (indicates a thyroid gland) * movement while stick out tongue

Question 50

if there is movement while sticking out tongue what malignancy does it suggest

Answer 50

* thyroglossal duct cyst (lump in midline)

Question 51

what does a lump in the neck always have as a potential cause

Answer 51

* lymphadenopathy

Question 52

what imaging technique should you use to investigate a neck lump

Answer 52

* ultrasound

Question 53

name neck lumps that can be found anteriorly

Answer 53

* salivary gland pathology * carotid body tumour * thyroglossal (more midline)

Question 54

thyroglossal duct malignancies

Answer 54

normally this duct should disappear when a fetus but if it remains then cysts can develop =\> thyroglossal duct cysts * these cysts are found midline below the hyoid * sign: if the cyst moves up when you stick tongue out and swallow

Question 55

how can you distinguish between goitre and throglossal duct cyst

Answer 55

* transilluminate as cyst is full of fluid * if there is no movement when the tongue sticks out then this is a sign of a goitre as there is no thyroglossal duct connecting tongue and the ‘cyst’ * aka thyroglossal cyst move with movement of the Tongue and goitre is to do with swallowing

Question 56

hyoid bone moving up when swallowing

Answer 56

due to the suprahyoid muscles to do with the pre tracheal fascia?

Question 57

what defines lymphadenopathy

Answer 57

lymph that are greater than 1cm, can be localised or generalised