Lymph

01

Superficial Group

Lymph nodes in head and neck are divided into:

Superficial group
Deep group
Deepest group

A. Buccal and Mandibular Nodes

Buccal Node

Lies on the buccinator.

Mandibular Node

Lies at the lower border of the mandible, near the anteroinferior angle of the masseter.
It is in close relation to the marginal mandibular branch of the facial nerve.
They drain:

Part of the cheek
Lower eyelid

Their efferents pass to the anterosuperior group of deep cervical nodes.

B. Preauricular Nodes

Drain:

Parotid gland
Temporal region
Middle ear
etc.

C. Postauricular (Mastoid) Nodes

Lie on the mastoid process.
They are:

Superficial to the sternocleidomastoid
Deep to the auricularis posterior

They drain:

A strip of scalp region just above and behind the auricle
Upper half of the medial surface and margin of the auricle
Posterior wall of the external acoustic meatus

Their efferents pass to the posterosuperior group of deep cervical nodes.

D. Occipital Nodes

Lie at the apex of the posterior triangle.
They are superficial to the attachment of the trapezius.
They drain the occipital region of the scalp.
Their efferents pass to the supraclavicular members of the posteroinferior group of deep cervical nodes.

E. Anterior Superficial Cervical Nodes

Lie along the anterior jugular vein.
They are unimportant.
The suprasternal lymph node is a member of this group.
They drain the skin of the anterior part of the neck below the hyoid bone.
Their efferents pass to the deep cervical nodes of both sides.

F. Lateral Superficial Cervical Nodes

Lie along the external jugular vein, superficial to the sternocleidomastoid.
They drain:

Lobule of the auricle
Floor of the external acoustic meatus
Skin over the lower parotid region
Angle of the jaw

Their efferents pass around both borders of the sternocleidomastoid to reach the upper and lower deep cervical nodes.

02

Deep Group

The deep group comprises five levels of lymph nodes.
These nodes are very important because of their wide area of drainage.
They are very commonly enlarged.
The nodes lie beneath the deep cervical fascia on the surface of the internal jugular and subclavian veins.

A. Submental and Submandibular Nodes

Submental Nodes

Lie deep to the chin.
Drain lymph from:

Tip of tongue
Anterior part of floor of mouth

Submandibular Nodes

Drain:

Centre of the forehead
Nose with the frontal, maxillary and ethmoidal air sinuses
Inner canthus of the eye
Upper lip and anterior part of the cheek with the underlying gum and teeth
Outer part of the lower lip with the lower gums and teeth, excluding the incisors
Anterior two-thirds of the tongue, excluding the tip
Floor of the mouth

They also receive efferents from the submental lymph nodes.
The submandibular lymph nodes are clinically very important because of their wide area of drainage.
They are very commonly enlarged.

Efferents of Submandibular Nodes

Pass mostly to the jugulo-omohyoid node.
Partly pass to the jugulodigastric node.
These nodes are situated along the internal jugular vein.
They are members of the deep cervical chain.

B. Upper Lateral Nodes Around Internal Jugular Vein

Jugulodigastric Node

It is a member of this group.
It lies:

Below the posterior belly of digastric
Between the angle of the mandible and anterior border of sternocleidomastoid

It is situated in the triangle bounded by:

Posterior belly of digastric
Facial vein
Internal jugular vein

It is the main node draining the tonsil.

C. Middle Lateral Nodes Around Internal Jugular Vein

These drain the thyroid and parathyroid glands.
They receive efferents from:

Prelaryngeal lymph nodes
Pretracheal lymph nodes
Paratracheal lymph nodes

D. Lower Lateral Nodes Around Internal Jugular Vein

Jugulo-omohyoid Node

It is a group of nodes.
It lies just above the intermediate tendon of the omohyoid.
It is under cover of the posterior border of the sternocleidomastoid.
It is the main lymph node of the tongue.

03

Deepest Group

A. Prelaryngeal and Pretracheal Nodes

The prelaryngeal and pretracheal nodes lie deep to the investing fascia.
Prelaryngeal nodes lie on the cricothyroid membrane.
Pretracheal nodes lie in front of the trachea below the isthmus of the thyroid gland.
They drain:

Larynx
Trachea
Isthmus of the thyroid

They also receive afferents from the anterior cervical nodes.
Their efferents pass to the nearby deep cervical nodes.

B. Paratracheal Nodes

Lie on the sides of the trachea and oesophagus along the recurrent laryngeal nerves.
They receive lymph from:

Oesophagus
Trachea
Larynx

Their lymph passes onto the deep cervical nodes.

C. Retropharyngeal Nodes

Lie:

In front of the prevertebral fascia
Behind the buccopharyngeal fascia covering the posterior wall of the pharynx

They extend laterally:

In front of the lateral mass of the atlas
Along the lateral border of the longus capitis

They drain:

Pharynx
Auditory tube
Soft palate
Posterior part of hard palate
Nose

Their efferents pass to the upper lateral group of deep cervical nodes.

D. Waldeyer’s Ring

The ring comprises:

Lingual tonsils
Palatine tonsils
Tubal tonsils
Nasopharyngeal tonsils

04

Main Lymph Trunks at the Root of the Neck

A. Thoracic Duct

The thoracic duct is the largest lymph trunk of the body.
It begins in the abdomen from the upper end of the cisterna chyli.
It enters the thorax through the aortic opening.
It traverses the thorax.
It ends on the left side of the root of the neck by opening into the angle of junction between:

Left internal jugular vein
Left subclavian vein

Before its termination, it forms an arch at the level of the transverse process of vertebra C7.
The arch rises 3–4 cm above the clavicle.
Apart from its tributaries in the abdomen and thorax, the thoracic duct receives in the neck:

Left jugular trunk
Left subclavian trunk
Left bronchomediastinal trunk

It drains most of the body, except:

Right upper limb
Right half of the head
Right half of the neck
Right half of the thorax
Superior surface of the liver

B. Right Lymph Trunks

1. Right Jugular Trunk

Drains the right half of the head and neck.

2. Right Subclavian Trunk

Drains the right upper limb.

3. Right Bronchomediastinal Trunk

Drains:

Right lung
Right half of the mediastinum
Parts of the anterior walls of the thorax and abdomen

4. Right Lymph Trunk

On the right side, the subclavian, jugular and bronchomediastinal trunks unite to form the right lymph trunk.

It ends in a manner similar to the thoracic duct.

05

Clinical Anatomy

A. Deep Cervical Lymph Nodes and IJV

The deep cervical lymph nodes lie on the internal jugular vein.
These nodes often become adherent to the vein in:

Malignancy
Tuberculosis

Therefore, during operation on such patients, the vein is also resected.

These are examined from behind with the neck slightly flexed.

B. Palpation of Lymph Nodes

Superficial cervical, supraclavicular and lymph nodes of the anterior triangle can easily be palpated.

C. Palatine Tonsil and Jugulodigastric Nodes

Chronic infection of the palatine tonsil causes enlargement of the jugulodigastric lymph nodes.
These nodes adhere to the internal jugular vein.

D. Submandibular Lymph Nodes

Painful enlargement of the submandibular lymph nodes is common because infections in the:

Tongue
Mouth
Cheek

are quite common.

These nodes may be affected by tubercular bacteria.

E. Accessory Nerve and Posterior Triangle Nodes

The spinal root of the accessory nerve may get entangled in enlarged lymph nodes situated in the posterior triangle of the neck.
While taking a biopsy of the lymph node, care must be taken not to injure the accessory nerve, lest the trapezius gets damaged.

F. Left Supraclavicular Nodes

The left supraclavicular nodes are called Virchow’s lymph nodes.
Cancer from the stomach and testis may metastasize into these lymph nodes.
These nodes may become palpable.

06

Common Causes of Lymph Node Enlargement

A. Local Causes

Acute infection
Chronic infection
Malignancy of any part of the body

B. General Causes

Tuberculosis
Secondary syphilis
Hodgkin’s disease
Lymphatic leukaemia

LYMPHATIC DRAINAGE OF HEAD AND NECK