Session 2 - Lecture 1 - Lymph Nodes & Neck Lumps Flashcards
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Cervical Lymph Nodes and Neck Lumps
2 - Intended Learning Outcomes
Intended Learning Outcomes
By the end of this lecture, supported by your further reading, you should be able to:
• Outline common and important pathology affecting the lymphatic system, which may give rise to lymphadenopathy in the neck (e.g. infection, malignancy).
• Describe and be able to identify the general location of the superficial and deep cervical lymph
nodes and the general areas of the head and neck that these drain.
• Describe the anatomy and function of Waldeyer’s ring of lymphoid tissue.
• Outline common/important causes of neck lumps (including but not limited to
lymphadenopathy) and the key symptoms and clinical examination findings associated with
them
• Recall the red flags for neck lumps (lymphadenopathy), which indicate concerning underlying
pathology e.g. head and neck cancer.
“And this is kind of what we’re going to do in terms of ILO – today’s lecture, feel comfortable in being able to answer qs that relate to LOs – go v briefly to what the lymphatic system.”
3 - Overview (Lecture)
Overview
• Broad review of function of lymphatic system
- What are lymph nodes and what causes them to enlarge (lymphadenopathy)?
• Organisation of the lymph nodes in the head and neck region
- Superficial and deep
• General areas of head and neck drained by specific lymph node groups
• Collections of lymphoid tissue surrounding the upper aerodigestive tract
- Waldeyer’s ring
• Neck lumps
- Common and/or important causes
- Red flags (for lymph nodes)
“Erm, then we’re going to go into a little bit of detail and think about LNs importance in lymphatic system, think about their impotance in the neck – what is it that causes them to enlarge – going to think about what might cause them to get bigger and more palpable as we examine someone’s neck? Then we might think about learning names for LNs in the neck – more palpable, and also some deeper LNs in the neck, don’t need to know individual names for, but appreciate relationship between 2 broad groups of LNs in neck – so superficial and deep. So obviously we need to nkwo what roughly areas of head and neck are drained by LNs – enlarged LN know which part of the H&N, infection, more concerning, might be a wide LN bc starting to swell. Another collection of lymphoid tissue – not LNs that we find q deep inside the H&N that is called Waldeyer’s ring – they have an important role as part of lymphatic system, but they are not LNs – will look at what they are – only c a portion of some of the lymphoid tissue – and then we’ll finish up on looking at some neck lumps – large LNs, common cause of neck lumps, but actually lots of other common and/or important causes of neck lumps, how you might determine some of the clinical features, what the neck lump might be whether it’s a LN or something else.”
4 - Overview of Lymphatic System
Overview of Lymphatic System
- Remove excess fluid from interstitial space
- Returns small proteins (including pathogens) and fluid that leaked from capillaries
- Key role in immune defence and immune surveillance
- – Physical and phagocytic barrier
- – Source of lymphocytes
Clinical manifestations of disease involving the lymphatic system
– Lymphoedema
– Lymphadenopathy: swollen lymph node(s) due to infection or malignancy
(primary and secondary)
“So this is on your slides, so if you remember from BL in Yr 1 – when your body creates tissue fluid, the diff in clutches around capillary bed, not only is tissue fluid is reabsorbed, so we’re actually left with residual amount of fluid in the interstita that if we didn’t have lymphatic system it would stay there – clears away excess fluid, ultimately returns it to circulation, lymphatic vessels. We also have few proteins things that make their way out into the cells – within capillary bed, can’t get back into blood vessels and therefore also taken up by lymphatics and regulate – now those proteins could be pathogens, that layer of skin in infection, those bugs could enter into lymphatic system, could make their way into LN draining the area – same could be said for malignant cells – cancer – malignant cells invading area of tissue – take to LN – cause LN to swell up. When you get to a LN, it has a rly important role in immune defence and surveillance – scopign out any pathogens for the body to deal with before pathogen can travel any further along the system before it gets into blood – rly important physical barriers – by way of arrangement and also for phagocytes and lymphocytes qwhich can mount an immune response – pathogens it doesn’t recognise. Q a few clin manifestations of diseases – did a lot about lymphaoedema – another arm sort of diseases, lymphadenopathy – when LNs swell up – can think about it v broadly either due to an infection or malignancy – focus going to be around LNs in H&n.”
5 - Lymph Nodes
Lymph Nodes
• All substances transported in lymph pass through ≥ 1 lymph node
- Physical filter
- Phagocytic filter
- Full of lymphocytes (T & B) cells): Activate and proliferate in response to antigens
–>
Swell/enlarge
Microscopic –> 2.5 cm
“So this just reiteras what I already said – if you remember the LN has a number of lymphatic afferent vessels and a single efferent – so what do you think having numerous inputs into a LN with a single output is going to do to the flow of fluid through the LN? Lots of input but only 1 output – fluid is going to slow down across LN to give it time to filter to particular CT, actually filter – all bugs and things, phagocytes can come in, also you can activatre lymphocytes, so if you have something that causes the activation and proliferation of lymphocytes, the LNs can swell – that’s what causes the swollen/enlarged LNs – lymphocytic response to something in the lymph fluid that shouldn’t be there – whether virus, cancer, malignancy etc. So that’s why LNs enlarged. Now they’re v v small – microscopic, when we’re in DR next, won’t actually see any LNs – can’t actually see on cadaver, but rest assured they do exist, we just don’t really c it in DR.”
6 - Where are lymph nodes found?
Specific regions in body where collections of lymph nodes may be palpable
Nearly ½ of all the body’s lymph nodes are found in the neck
- NECK (CERVICAL)
- ARMPIT (AXILLARY)
- Diaphragm
- Spleen
- Abdominal
- Pelvic
- GROIN (FEMORAL)
“So we know that there are collections of LNs that are superficial when first able to palpate – armpit, axillar and groin area – but loads in the neck – nearly half of all bodies lymph nodes are actually in the neck – so a lot of LNs in that region of your body – do neck exam v freq clinically – need to know where and what you’re feeling – need to know what a LN is should you feel enlarged or normal.”
7 - What are the causes for enlarged lymph nodes?
Enlarged Lymph Node…
• Lymphadenopathy is a very common cause for a neck lump
Enlarged lymph node(s) (Lymphadenopathy)
- Infection (most common)
- – Tender, mobile
- Malignancy
- – Hard, matted, Non- tender
- – Rubbery, mobile, fast-growing
If a lymph node is found to be enlarged:
• Comprehensive history
• Examine the area of tissue it drains
• If systemic disease/malignancy suspected examine other lymph nodes and body systems
“So when we talk about neck lumps, there are many many causes for neck lymps – most common cause is going to be an enlarged LN – v much so in children and young adults – as we start to get into older adult population, whilst it could be infected, start to worry a lot more about malignant cause of lymphadenopathy – so is it infective (reactive inflammation? More often than not it is, particularly in children) or is it something q concerning, a sign of cancer? So when you feel LNs you can determine characteristics of LN – determine whether to be worried or not. So any LN that is tender, touch ist is q mobile, cough and cold, then lymphadenopathy probs from infecrtion, reassure pt or parents or child, settle down as infection resolves. However, if when you feel enlarged LN it feels q hard – it feels q tethered, as if infiltrated subcutaneous tissue – matted i.e. stuck to things, then you’re a lil bit worried might be a lymphadenopathy from a cancer that has spread to a LN. The other feature to a LN which you might read about in textbooks – something described as rubbery, mobile feel to LN – most know to when it feels rubbery, something like that is fast-growing, sign of malignancy – type of lymphoma – lymphoma can v commonly presently with enlarged LNs in neck, front of neck, side of neck, often described as feeling rubbery and grow q fast – short hx of LN enlargement in size. Now obvs with any pt always going to take a hx first – want to know what’s going on with patient – examine – and then if you think it is a LN ,t thinking it’s infected, or even omething malignant – want to examine the tissues that the LN drains – need to know so you can inspect them adequately – so hx and exam – think about what sorts of things need to ask by being in keeping with infective cause or more in keeping of underlying cancer. What might be some of the symptoms that a pt presents with? What might they report in hx? Weight loss – excellent – a red flag – something that rings an alarm bell – someone with infected LN should not be associated with weight loss unless it’s a chronic infection such as HIV, and ofc weight loss associated – anything else – what if it were lymphoma, wht are the symptoms might the pt complain of? Night sweats, yep. Weight loss, night sweats – that sort of hx with a neck lump makes you q concerned there might be more sinister underlying LN enlargement cause.”
8 - Organisation of Lymph Nodes
Organisation of Lymph Nodes
Superficial or Deep
Skin | Superficial node Superficial node /Within superficial fascia/ |* Deep node /Many associated with route of IJV in carotid sheath, in the neck/
*In neck=investing layer of fascia
“Okay, so last week we looked at the organisation of the neck in terms of fascial planes, so hopefully we started to get that in your minds a lil bit, appreciate where you’re going to find the LNs in the head and neck, so on this img here, here’s the skin, obvs this is more superficial, just going to put this onto both projectors now, doesn’t want to go onto the projector … okay, so here’s the skin, more superficial, as we go through the skin we get into what we call the SC tissue or superficial cervical fascia, within that we find collection of nodes that we will group and call superficial cervical LNs. Okay, if we were to then go deeper, this here denotes the investing layer of fascia , thicker tougher CT – circles or invests the neck like a collar – go deep to that to find another collection of LNs called the deep LNs – many of these are going to be associated with the IJV – and that is found in the carotid sheath, so underlying the IJV we have a number of deep LNs situated within there. Superficial nodes, sometimes called regional – deep nodes sometimes called terminal, I think using the words superficial and deep more helpful. All the supercicial LNs will drain into deep LNs, these eventually drain out lymphatic fluid into venous circulation. “
9 - Superficial and deep lymph nodes
Superficial and deep lymph nodes Anterior Infrahyoids Thyroid gland Larynx/trachea Pharynx/oesophagus SCM Vertebrae Muscles Posterior
- Superficial cervical fascia..continuous with fascia of face
Superficial lymph nodes
–>
More readily palpable
–>
Drain into
–>
Deep to this layer will lie deep lymph nodes most associated with IJV, along its length, within carotid sheath - Investing layer of deep cervical fascia
“Okay, this is kind of presenting the same thing – should be reasonably familiar to you – schematic arrangement of cross-section of neck – anterior and posterior, vertebrae and muscles collectively at back of neck. SCM muscle and 2 carotid sheaths -and neurovascular bundle running through. So in this point here, pale green, superficial cervical fascia, this is where superficial LNs – say what they’re called as well – superficial cervical fascia is continuous of the face – some of the LNs you’re going to look at are actually located in response to the face, superficial fascia is continuous with the face. So once lymphatic fluid reaches these lymph vessels in a superficial layer, eventually they will make their way into the deeper LNs that we’ll find inside, the uperficial ones, bc literally beneath the skin, more palpable when a lil bit enlarged, in children in particular, sometimes normal LN might be palpable – so that might be normal for that person – so a hx and how it’s changed over time will be important to decipher.”
10 - Superficial Lymph Nodes Draining The Face, Scalp and Neck
Superficial Lymph Nodes Draining The Face, Scalp and Neck
- Mental protuberance
- Mandible
- Auricle (ear)
- Occiput (occipital bone)
- Sternocleidomastoid (SCM)
“When we start thinking about naming, going to start ith superficial LNs first- these are the ones ready to palpate, q a few names associated with them – if we just look at a few bony featurss – help us understand why we give the LNs certain names – so the v front prominence of the chin – that bit there is called the mental protuberance. Okay,so this bit here is mandible, another name for oyur ear is auricle and then there’s a firm ridge, hard bone at back of head which is occipital bone – sometimes called the occiput. Okay, so just remember the names of these parts of the head bc they’ll help you understand why we have the LNs and the names of them.”
11 - Superficial Lymph Nodes
Superficial Lymph Nodes Draining The Face, Scalp and Neck
1. submental
2. submandibular
3. pre auricular
4. post auricular
5. occipital
Readily palpable, sometimes even in health (!) but especially if become even slightly enlarged
(6. Superficial cervical: EJV)
7. Posterior cervical: EJV
8. Anterior cervical: AJV
Superficial nodes in the neck, are associated with route of EJV or AJV
EJV= external jugular vein
AJV = anterior jugular veins
http://markingpaper.blogspot.com/2011/01/head-anatomy-side-view.html
“And you might be able to guess some of them on the basis of where we find them. So then looking on your slides then, same picture here, what name do you think is going to be given to number 1? Submental – sub underneath mental – mental protuberance of your chin. What about number 2? Submandibular – underneath the resto f the mandible. Sub means under, underneath bones or featureso f bones that have particular names. What about number 3? Pre=auricular (in front of), ear. What other ones just behind, by the mastoid process? Post-auricular, or mastoid as well, because of the mastoid process. SO we’ll call them post-auricular on the slide. In front of and behind the ear. What about number 5? Occipital, right around the back of your head. Ridge at the back of your head. So can you see how we have a ring of LNs actually around the base of your head essentially (same on both sides) – so forms a ring around the base of your head, and we also have remaining in this superficial layer, still in superficial layer, have some LNs in the neck, base of the head, these actually coming into the neck. These are all going to be immediately underneath your skin, you’ll have a group here, all called the cervical LNs actually in the neck – superifical cervical on top of SCM, and a group just in front and behind, which are anterior and posterior. Now a lot of these LNs actually in your neck associated with the EJV and AJV, so your EJV is likely to be running down your neck in this direction, have LNs associated with it. Okay, so that’s what I’ve put at the bottom here. Associated with these superficial jugular veins that we find there. So that’s what they’re called, that’s where they are, in due course, you’ll know where to actually put your hands on someone’s head and neck to feel them. But next thing is to find out where do they drain?”
12 - Lymph Node Drainage
The Superficial Lymph Nodes Draining The Face and Scalp Drain into Lymph Nodes in the Neck
Lymph node groups:
- Occipital
- Post auricular
- Pre auricular
- Submental
- Superficial cervical
- Submandibular
Posterior cervical
Anterior cervical
- External jugular vein
- Subclavian vein
Superficial lymph nodes
–Drain into–>
Deep cervical lymph nodes
Image from Clinically Orientated Anatomy: 7th Edition
“Best picture I could find for regions of head and scalp that these LNs are draining.And there’s a general rule, if you were to look at their position, on the vertebral lying down, you can kind of infer the parts of the head they’re going to drain i.e. occipital going to drain back of scalp. Ones behind here, are going to be draining more lateral, more lateral part of salp. THe ones in front of your ear, pre-auricular ones, they also include the eye and tissues of the neck, so pts who do present with conjunctivitis may have palpable with pre-auricular LN, actually part of the head that this LN drains. What else might you want to examine if someone presented with LN on pre-auricualr region? Parotid cancer, yes maybe. But also inside the ear, if palpable LN if nothing around scalp or eye unusual. Most of the rest of face will drain to submandibular gland. The ones at the v v tip of chin, tjey drain the lip and tip of your tongue and bones, more posterior bit of tongue will drain with submandibular branch. So swelling under chin make sure you look inside their mouth – make sure there isn’t something I ntheir or under the tongue can be under their chin. In terms of these cervical LNs in the neck, that’s your anterior route and posterior route, and then you’ve got superficial cervical, generally speaking, cervical superficial LNs in neck v much in asspociation with EJV and AJV. “
13 - Deep lymph nodes
Deep lymph nodes
Note: some structures within the neck e.g. thyroid, posterior tongue drain directly to the deep cervical lymph nodes
Deep cervical lymph nodes
• Deep to SCM
• Closely related to IJV and carotid sheath
9. Jugulo-digastric (9)
10. Jugulo-omohyoid (10)
11. Supraclavicular lymph nodes (within supraclavicular fossa)
- deep lymph nodes also known as terminal
http: //markingpaper.blogspot.com/2011/01/head-anatomy-side-view.html
“So ultimately they’ll all drain into deeper LNs, so what this image is hsowing and why we’re looking at them in such hollow circles is many things are deep to SCM, so not going to be palpable unless q enlarged. Now all of these, all of them are deep cervical LNs, all of them. There’s only 3 of those that are important for you to know the names of and where they are and what they drain. So number 9, is something called jugulo-digastric (one of the deep cervical LNs – drain your tonsils. So if you have tonisilitis that’s the one that tends to swell up under neck. Jugulo to do with jugular vein, digastric, close to diagastric muscle we find someonewhere in neck. Jugular or omohyoid, bit further down, relates to IJV, in close proximity of omohyoid muscle (strap muscle), that one drains posterior tongue, structures of the pharynx, larynx and thyroid – lump in neck, deep cervical LNs, noty going to see anything in skin, but structures deep inside neck, potetnailly cancer, need to stop and refer on appropriately. Other group of deep cervical LNs are supraclvaiular LNs (in posterior triangle) behind SCM, the stuff in the neck can also drain things in your chest or abdomen. So if someone rpesents with a neck lump in supraclavicular LN, their problem might be somewhere in lugns or GI tract, could have lung cancer or bowel cancer or stomach cancer – even though if presented with lump in neck. So why are superficial LNs all drain into ultimately deep LNs back to venous circulation, many structure just drain direct to these LNs like thyroid gland etc., so all deep cervical LN swelling may present.”
14 - What are deep cervical lymph nodes associated with?
In this image SCM is removed, and we are looking deeper into neck, at the internal jugular vein to see the deep cervical lymph nodes
( ) = Deep cervical lymph node group
- (*Jugulo-digastric)
- (*Jugulo-omohyoid)
- Internal jugular vein (IJV)
Image from Clinically Orientated Anatomy: 7th Edition
“And that’s just to reiterate their arrangement with their IJV and SCM muscle. So if you’re thinking deep cervical, think IJV.”
15 - Examining Lymph Nodes of the Head and Neck
Examining Lymph Nodes of the Head and Neck
https://www.youtube.com/watch?v=NpH3I2MQbwQ
”- posterior triangle so posterior cervical LNs.
When palpating neck, feel deeper cervical LNs, he’ll kind of push his fingers firmly in, along anterior border of SCM to actually palpate them out.
When you’re examining the neck you come from behind the pt, see how he’s rolling his fingers, and what we’ll do as we’re going down SCM, also feel a lil bit more firmly to see if feel deeper cervical LN enlarged underneath muscle there.”
