head and neck exam 10-12

main function of lymphatic system

filters waste and toxins from the body and supports immune defense by producing lymphocytes (white blood cells)

key components of the lymphatic system

• lymph nodes

• lymph vessels

• tonsils

• lymph fluid

lymph nodes

• filter lymph and produce immune cells

lymph vessels

• Contain one-way valves to prevent backflow

tonsils

• lymphoid tissues located in the oral and pharyngeal region

• oral region: palatine tonsils, lingual tonsils

• pharyngeal tonsils: adenoids 

lymph fluid

• carries waste and immune cells

occipital lymph nodes

• located at the base of the skull

• posterior neck palpation

• paired

structures drained by occipital lymph nodes

• scalp

  • then drains into deep cervical lymph nodes

posterior auricular lymph nodes

• behind the ears near external acoustic meatus

• common site for scalp infections

• paired

posterior auricular lymph node drainage

• drains the scalp and ear

  • then drains into deep cervical lymph nodes

anterior auricular lymph nodes

• in front of ears

• palpated during facial exams

• paired

anterior auricular lymph node drainage

• drains the face, eyelids, scalp

  • then drains into deep cervical lymph nodes

submental lymph nodes

• located under the chin between the hyoid bone and mandibular symphysis 

• easily palpated with head tilted forward 

submental lymph node drainage

• mandibular incisors, apex of tongue, midline lower lip

• empties into submandibular nodes or directly into deep cervical lymph nodes

submandibular lymph node

• located under the jaw

• primary nodes for most dental infections

submandibular lymph node drainage

• all other teeth except mandibular incisors and maxillary 3rd molars

superficial cervical lymph nodes

• located over the sternocleidomastoid (SCM)

• palpate along the SCM by rolling the tissue over the muscles

• all lymph nodes of the neck are palpated and paired during an extraoral exam

superficial cervical lymph node drainage

• external ear, parotid region

deep cervical lymph node chain

• located beneath the SCM and extend to the base of your skull to the root of the neck

• deep palpation during head turn

deep cervical lymph node drainage

• drains oral cavity, pharynx, nasal cavity

supraclavicular lymph nodes

• located above the clavicle 

• should not be enlarged in healthy patients 

• acts as secondary lymph nodes for the occipital nodes 

supraclavicular lymph node drainage

• drains the thoracic cavity and abdomen

• located in the final endpoint of lymphatic drainage from the entire body

normal node characteristics

• mobile, soft, nontender

signs of infection or possible malignancy in lymph nodes

• enlarged, fixed, or hard

• non moveable or “knotted” into the tissue

palatine tonsils

• between anterior and posterior faucial fillers

• located in the back of the oral cavity 

lingual tonsils

• located at the base of the tongue

pharyngeal tonsils

• posterior wall of nasopharynx

• known as adenoids

• can be enlarged in children

tubal tonsils

• near opening of the auditory (eustachian) tube beneath the mucosa 

palpation of the thyroid gland

• ask patient to swallow and visualize the gland as it moves up and down

• bi manually palpate the gland by moving it from one side the the other

what is the key landmark to locate superficial and deep cervical nodes as well as the supraclavicular nodes

• the sternocleidomastoid 

superficial lymph nodes of the head

• old people are super funny

• occipital

• posterior auricular

• anterior auricular

• superficial parotid

• facial (4 divisions)

the four subdivisions of facial lymph nodes

• malar

• nasolabial

• buccal

• mandibular

• monday night business meeting

afferent vessels

• unfiltered lymph fluid flows into the lymph node through theses

• “A” for arriving at the lymph node

efferent vessels

• filtered lymph fluid flows out of the node through this vessel

• “E” for exiting 

deep lymph nodes of the head

• deep parotid

• retropharyngeal

primary lymph node

• lymph from a particular region first drains here then drains into a secondary node aka a central node in a more distant region

• everything comes from this first

lymphatic system

• part of the immune system that consists of vessels, nodes, ducts, and tonsils

• helps fight disease by filtering out waste from the body

• drain directly into vascular system

lymph nodes

• bean shaped lymphatic tissue filtering lymph by producing lymphocytes aka filter toxic products so they dont get into blood stream

lymphatic vessels

• heave one way valves

• drain into ducts that then drain into the vascular system

fascia

• layers of connective tissue under the skin that surrounds and separates muscles, vessels, and organs

• not actually empty spaces but contain structures that move through the space and loose connective tissue that help with movement and connect tissue together

vestibular space of the mandible

• sources of possible infection are near the posterior teeth and include the periosteum and gingiva

canine space

• located superior to the upper lip and lateral to the apex of the maxillary canine

• common source of infection is maxillary canine

• swelling above upper lip

buccal space

• between buccinator muscle and masseter muscle

• this space contains the buccal fat pad, facial artery, and parotid duct

• common source of infection is the buccal mucosa or molars

• cheek swelling

pterygomandibular space

• innervates inferior alveolar nerve which is relevant to the IA block

• inferior alveolar nerve block site

• infection risk with injection

submasseteric space

• located between the masseter muscle and the external surface of the vertical mandibular ramus

• infection here is rare but when it occurs the source is usually the 3rd molar resulting in swelling at the angle of the mandible

submental space

• midline between mandibular symphysis and hyoid bone

• common source of infection is mandibular anterior teeth

• midline chin swelling

sublingual space

• creates division between submandibular and sublingual spaces

• common source of infection is the mandibular premolars or 1st molar

• swelling in floor of the mouth

submandibular space

• common source of infection is the mandibular molars

• causes floor of mouth elevation

masticator space

• common source of infection is the mandibular molars

• can cause trismus (limited opening of mouth)

parapharyngeal space

• common source of infection is posterior to pharynx

• may cause infection pathway to thorax

retropharyngeal space

• common site of infection is behind throat, connects to danger space

• may cause airway obstruction risk!!

ludwigs angina

• severe cellulitis from submandibular space infection

• causes rapid swelling, risk of airway obstruction

• life threatening

danger space

• located between retropharyngeal and prevertebral fascia

• infection can spread from oral cavity —>thoracic cavity then —> heart and lungs

odontogenic infections

• originate from the teeth or supporting structures

common pathogens

• aerobic bacteria starts the process

• anaerobic bacteria sustain deep infections because they do not need oxygen

beta-lactamase enzyme

• destroys antibiotics like penicillin, making them less effective in treating infection

• virulence factor

• produced by gram-positive bacteria 

endotoxins/exotoxins

• damage host tissues and promote infection

• virulence factor

bacteremia

• bacteria in blood stream

• can spread via vascular routes

periapical abcess

• at tooth apex

  • pulpal origin

periodontal abscess

• located along periodontal pocket 

pericoronal

• associated with erupting 3rd molars

chronic abcess

• may lead to fistula formation (drainage tract)

palpation sequence

• begin at occipital, move anteriorly to posterior and anterior auricular, then down to SCM

• always compare bilaterally for asymmetry

normal findings during extraoral examination

• nodes are small, moveable, and non tender

abnormal findings

• hard, fixed, tender, or clustered nodes require follow up

lymphatic drainage pattern

• infections in teeth→ submandibular or submental→ superior deep cervical→ inferior deep cervical → thoracic duct → blood stream

maxillary 3rd molars are drained by

• superior deep cervical nodes

mandibular incisors are drained by 

• submental lymph nodes 

abcess

• infection with suppuration resulting from pathogens in a contained space

• can be acute or chronic

fistula

• can be caused by chronic abscess, a tract in the outer skin, mucosa, or alveolar process that allow drainage of infection

stoma

• opening of the fistula from tract 

pustule

• small, elevated lesion on outer skin or mucosa that contains suppuration

superficial cervical lymph nodes

• submental

• submandibular

• external jugular

• anterior jugular

types of fascia

• superficial

• deep

• investing

• visceral

• carotid

superficial fascia

• Contains blood vessels and nerves; minimal muscle (except face/neck).

• found just deep to the skin and attached to skin

• composed of fat and connective tissue

• encloses muscles of facial expression only

deep fascia

• consist of dense, inelastic fibrous tissue that forms sheaths around deep structures like bones, muscles, nerves

  • Divided into temporal,

  • masseteric-parotid,

  • and pterygoid fasciae.

investing layer

Outermost deep fascia; encloses SCM and trapezius muscles.

• most external layer

visceral fascia

• Surrounds thyroid, trachea, and esophagus.

• deep and parallel to carotid sheath, single midline tube

carotid sheath

• Contains vagus nerve, common carotid artery, internal jugular vein.

vertebral fascia

• deepest layer

• covers the spinal cord and vertebrae

buccopharyngeal fascia

• covers the pterygomandibular fold

phayngeal space

• shaped like an inverted pyramid

• adjacent to 9th, 11th, and 12th cranial nerve

• infection is serious due to its connection to retropharyngeal space

retropharyngeal space

• connected to pterygomandibular, buccal, and submasserteric spaces

• located posterior to pharynx

• communicates with pharyngeal space

• “danger space” — infections can spread rapidly

cellulitis

• diffuse inflammation of soft tissue spaces

abducens nerve paralysis

• includes double vision, exophthalmos, lacrimation, and signs of canvernous sinus thrombosis

deep fascia

• consists of pterygoid, masster-parotid, and temporal

parapharyngeal space

• posterior to pharynx, infection can pathway to thorax

deep parotid

• drains parotid and ear

• deep lymph node of the head

retropharyngeal lymph nodes

• drains behind throat

• deep lymph node of head

• drain palate, nasal cavity, and pharynx

anterior jugular nodes

• drains infrahyoid region and empty into deep cervical nodes

external jugular nodes

• usually act as secondary lymph nodes for superficial lymph nodes of the head and then empty into deep cervical nodes