LYMPHATIC SYSTEM

GRAYS ANATOMY

network or mesh composed of lymphatic

vessels and organs
collects and brings back to venous system
tissue fluid in interstitial spaces

I. Terminology
1. Lymphatic Vessels - e.g. Thoracic Duct (biggest)
2. Lymphoid Tissues - e.g. Spleen (biggest), Bone
Marrow, Thymus, and Lymph Nodes

Hydrostatic pressure
pushes blood (to interstitial spaces) out of
arteries towards the cells.
Toxins out (product of metabolism);
bacteria, absorbed nutrients)
Colloid Oncotic pressure brings back
interstitial fluid to circulation.
Virchows node left side of clavicle
located at the left supraclavicular area
(because thoracic duct passes on the left)
becomes enlarged because of the
phagocytes and macrophages engulfing
the cancer cells

Vasa vasorum & Nerve Fibers - drains

and sypply the lymphatic vessels

Pathology: Lymphangitis - acutely

infected lymphatic plexuses or vessels

III. Microscopic Structure

Single layer of endothelium

lacks basal laminae

few intercellular junctions
FILOPODIA

Extracellular filaments for anchoring to

sternum (surrounding stroma)

external connective tissue coat ->

envelopes larger vessels

3 layers seen in larger trunks

tunica inima, tunica media, & tunica

adventitia

more valves (semilunar) than veins

thoracic duct - similar to medium-sized

veins but thicker tunica media.

II. General Structure

LYMPHATIC VESSELS forms

capillaries plexuses in different regional
groups over the entire body
wider meshes (compared to veins) ;
begins as dilated tubes with close ends;
cross-sectional appearances are less
regular than blood capillaries; lacks BASAL
LAMINA (layer bet. t. media & t. intima)

Pathology: Once obstructed results to

OEDEMATOUS APPEARANCE of a particular area.
Almost present in all areas of the body
except: EPIDERMIS, HAIR, NAILS, CORNEA,
CARTILAGES, BONE MARROW, CNS

Lymph - mostly clear and colorless

dense and milky (chyle) in the terminal
vessels (lacteal) of small intestine due to
presence of lipid globules (chylomicrons)

lacteals milky, conveys chyme to the

intestines
chylomicrons makes lymph denser than
venous blood
absorbed in the interstitial villi
through the lacteals.
Pathology of lymph

in general lymph traverses a series of nodes

before reaching a major collecting duct

exception: thyroid gland, esophagus, coronary

and triangular ligaments of liver which passes
directly to the thoracic duct.

Superficial lymphatics of skin - accompanies

superficial veins; few connections with deep
lymphatics

Deep lymphatics trucks - accompanies

arteries or veins emptying into the thoracic duct or
right lymphatic duct then into left and right brachio
cephalic veins

Other Entry Points:

1. Inferior vena cava
2. Renal veins
3. Suprarenal veins
4. Azygos veins
5. Iliac veins

IV. Topography of Lymph nodes and

Vessels

Route of Drainage
1. Unimodal passes to only one node
2. Multimodal- most common
Primary Node -> Intermediary Node ->
Terminal Nodes (Regional Nodes)
* Primary node lymph nodes nearest to the
organ.
* Secondary node lymph nodes nearest to
the heart
-- farthest to the organ.
* Intermediary bet. primary and secondary
nodes
Topographical Naming:
1. Superficial or deep location - Deep Fascia
2. Related Vasculature
3. Related Organ
4. General Topographical location

EXAMPLES:
A. Vasculature
1. Buccal Node (Facial Vein)
2. Superficial Cervical Node (Ext. Jugular
Vein)
3. Anterior Cervical Node (Anterior Jugular
Vein)
4. Infraclavicular Node (cephalic vein)
5. Supratrochlear node (Basilic vein)
6. Superficial Inguinal Node (Great
Saphenous veins)
7. Aortic, common Iliac, internal iliac,
external iliac node
8. Left gastric, right gastro-epiploic,
hepatic, panoreaticosplenic node
9. Aortic node (aorta)
10. Hepatic node (hepatic vessels)
B. VISCERA
1. Superficial and deep parotid,
submandibular node
2. Pulmonary, bronchopulmonary, inferior
and superior tracheobronchial node
C. General Topography - Palpable
1. Leg - popliteal node, inguinal node

2. Arm - supratrochlear, axillary node

3. Head and Neck - submandibular, submental,
pre-auricular, post auricular nodes,
supraclavicular, infrahyoid, paratracheal

400-500 NODES = Ave. no. of lymph nodes in

normal young adult

limbs and superficial body = least nodes

head and neck = 70 nodes
G.I.T. and Respiratory Tract = most richly

served
-- due to GIT is where most infections occur
VI. Cervical Lymphovenous Portals
( Cervicolymphovenous portals)

RIGHT PORTAL

3 Trunks converge to form the RIGHT

LYMPHATIC TRUNK
1. Right Jugular Trunk - drains/conveys lymph
from the right half of the head and Neck
->Ventral lateral aspect of Int. Jugular vein
(,loc.)
2. Right subclavian Trunk - conveys lymph from
right upper limb, superficial tissues of right hlaf
of the thoraco-abdominal wall down to
umbilicus (Anterior) and Iliac crest (Posteriorly)
-> Along Axillary and SUBCLAVIAN VEINS (loc.)
3. Right Bronchomediastinal trunk
-conveys lymph from thoracic walls, right heart,
right diaphragm, right trachea, right lung, right
bronchi, small drainage from thoracic
esophagus
-> ascends over the trachea
-> the 3 trunks open into the ventral aspect of
the right jugular-subclavian veins junction. 80%
open independently.
-- 20 % converge to become R lymphatic duct

LEFT PORTAL

4 trunks converge to form the LEFT

LYMPHATIC TRUNK
1. Left Jugular trunk - mirrors its right fellow
2. Left subclavian trunk - also mirrors its
contralateral fellow
3. Left broncho mediastinal trunk - also similar to
the right trunk
4. Thoracic duct -drains all extensive remaining
parts of the body.

Posterior - vertebral colum, right aortic

intercostal arteries, accessory hemiazygos
and hemiazygos veins.
-- T5 ->inclines to the left and enters the
superior mediastinum and then ascends to
the thoraic inlet left of the esophagus
where it is crossed by the aortic arch and
then it runs posterior to the first segment
of the left subclavian artery in close
contact with the left mediastinal pleura
-- C7 (lateral of transverse process) -> arches
into the neck 3-4 cm above the clavicle
then curves anterior to: the vertebral artery
and vein, left sympathetic trunk,
thyrocervical artery, left phrenic nerve,
medial border of scalenus anterior muscle;
posterior to: left common carotid artery,
vagus nerve and Internal Jugular Vein.

Finally -> descends anterior to the

arched cervical First part of the left
subclavian artery and ends by opening into
the junction of the left subclavian and left
Internal Jugular veins

ORIGINS & TRIBUTONS:

Abdominal origin - T12 - lower border,
right of the midline

CISTERNA CHYLI - simple, saccular

dilatation at its origin

begins as Abdominal confluence - 5-7

cm anterolateral to the right of L1 and L2 and
right of abdominal aorta

Lumbar Trunks

formed by lateral aortic lymph node

drains lymph from lower limbs, pelvic,

perineal and infra-umbilical walla,
supraumbilical walls, pelvic viscera, tests,
ovaries, kidneys and suprarenals.

Intestinal Trunks
coeliac node (formed by)
drains stomach, intestine, pancreas,
spleen, antero-inferior liver

Tributaries of thoracic duct

Proper:
(as it ascends toward the heart)
1. Confluence of lymph Trunks
- Lumbar trunks and Intestinal Trunks
- formed by lateral aortic lymph nodes;
drains lower
limbs, pelvic and perineal area

Embryology

In the fetus, the thoracic ducts are a pair of

vessels which ascends through the posterior
mediastinum on each side of the descending Aorta.

Thoracic duct

30-45 cm
L2 up to the base of the neck

Course of Thoracic Duct:

T12 (Superior Pole) -> enters the diaphragms

aortic opening right of the nidline then ascends the
posterior mediastinum between the thoracic aorta
(left) and azygots vein (right)

Relations:
Anterior - diaphragm and esophagus

2. Bilateral Descending Throracic Lymph

Trunks
- Drains the intercostal lymph nodes of the
lower 6 or 7 I.C.S.
3. Bilateral Ascending Thoraric Lymph Trunks
-Drains the upper lateral aortic nodes
4. Upper Intercostal Trunks (bilateral)
-Draws the upper 5 or 8 left I.C.S.
5. Mediastinal Trunks
-Draws the diaphragmatic aspect of Liver,
diaphragm, pericardium, heart, and
esophagus
6. Left Subclavian Trunk

7. Left Jugular Trunk

8. Left Bronchomediastinal Trunk

VII. Lymphatic Drainage of HEAD & NECK

Primary, intermediary and Terminal

(collecting) group of Nodes

Terminal Group - related to carotid sheath

-- farthest to organ that they drain
where all lymph of Head & Neck drains
JUGULAR TRUNK (EFFERENT TRUNK)
-Right ->ends in Jugular subclavian junc. Or
right lymphatic trunk
-Left -> ends in thoracic duct or Int. Jugular,
subclavian veins junction.

Deep Cervical Lymphatic Nodes

1. Superior Deep Cervical Nodes
-adjoins the upper internal jugular vein
-mostly deep to the sternocmastoid muscle
-drains to lower group or jugular trunk
e.g. jugulo digastric group
2. Inferior deep cervical Nodes
-partly deep to the SCM; also related to Int. Jugular
vein
-extending into subclavian triangle
-drains also to jugular trunk
e.g. Jugular-omohyoid
** Mechanisms in propulsion of lymph:
1.) filtration pressure
2.) contractions of neighboring muscles
3.) pulsations of neighboring arteries
4.) respiratory movements
5.) sympathetic stimulation of smooth muscles in
lymphatic walls

LYMPHATIC DRAINAGE OF SUPERFICIAL

TISSUES OF HEAD AND NECK

most drains to local group of nodes which

then drains to deep cervical nodes.

Retropharyngeal Nodes - Median and

lateral groups

Lie between pharyngeal and

prevertebral fascia

Paratracheal Nodes - flank both

trachea and esophagus along the recurrent
laryngeal nerves

Lingual Nodes - ext. surface of

hyoglosus and between geniogloss.

Infrahyoid Nodes - ant. To thyrohyoid

membrane

pre-laryngeal nodes - ant to cricovecal

membrane

A.
Nasal cavity, nasopharynx
and Middle Ear

A.

SCALP & EAR

Superficial parotid nodes

retro-auricular nodes

submandibular node
Parotid Node
Retrepharyngeal Node

B.

Larynx, Trachea and Thyroid

Gland

superior and inferior deep cervical

node

pretrocheal and pretracheal node

prelaryngeal node
C.

Mouth, Teeth, Tonsil and Tongue

Mouth - submandibular, submental,

and
ratrepharyngeal node, deep cervical
node
-- Teeth - submandibular & Deep cervical
node
Tonsil - sup. Deep cervical node
jugulodigastric node

HEAD - occipital group, retroauricular group,

parotid group, buccal group
NECK - submandibular group, submental group,
anterior and superficial cervical group.

Pre-tracheal nodes - ant to trachea

Tongue

D.

node

Pharynx and cervical Esophagus

deep cervical node
retropharyngeal and paratrocheal
Infrahyoid node

superficial cervical nodes

occipital nodes

B.

FACE

Superficial and deep parotid nodes

Submandibular nodes
Buccal Nodes
Submental Nodes

Lymphatic Drainage of Deep Tissues of Head

and Neck

jhadee
O Lord, grant that I may see
The joke of things,
The little things that
Bother now and then.
Lord, grant my sense of humor
To be strong
To weep a bit and yet,
To smile again.
God, grant there be a
Chuckle in each tear,
To every trail, Lord, grant
A funny half.

Draws into deep cervical Nodes or

Retropharyngeal, paratrocheal, lingual, infrahyoid,
prelaryngeal, and pretracheal nodes