This document discusses the arterial system, specifically the development of the aortic arches and the arterial supply to the head and neck region. It begins with an overview of the development of the six pairs of aortic arches and how they give rise to various arteries. It then describes the major arteries of the head and neck including the external and internal carotid arteries, their branches, course and distribution. It compares the differences between arteries and veins.

2. Presented by,
K. Manoj Kumar,1st year PG
Under the guidance of
Dr . Mehaboob shaik MDS MOMS,RCPS(U.K)

3. ARTERIAL SYSTEM
• Development.
• Description between arteries and veins.
• Classification of arteries in head and neck.
• Vital structures associated.
• Applied anatomy.

4. AORTIC ARCHES
As the pharyngeal arches form during the 4th and 5th
weeks, they are supplied by arteries called aortic
arches from the aortic sac

5. The aortic arches arise from the aortic sac and
terminate in the dorsal aorta of the ipsilateral side
Though six pairs of aortic arches usually develop
All are not present at the same time
By the time the sixth pair of aortic arches has
formed, the first two pairs disappear
During the eighth week, the aortic arch pattern is
transformed to final fetal arterial arrangement

6. DEVELOPMENT OF ARTERIAL SYSTEM

8. 1st pair of aortic arch.
2nd pair of aortic arch.
3rd pair of aortic arch.
4th pair of aortic arch.
5th pair
6th pair of aortic arch
Maxillary arteries and
external carotid.
Stapedial arteries.
Common carotid and
internal carotid.
Subclavian artery.
No vasculature.
Proximal part-pulmonary
artery and distal part-
ductus arteriosus.
DerivativesAortic arches

9. Arteries Veins
Oxygen Concentration: Arteries carry oxygenated
blood (with the
exception of
the pulmonary artery and
umbilical artery).
Veins carry deoxygenated
blood (with the
exception of pulmonary
veins and umbilical vein).
Types: Pulmonary and systemic
arteries.
Superficial veins, deep
veins, pulmonary veins
and systemic veins
Direction of Blood Flow: From the heart to various
parts of the body.
From various parts of the
body to the heart.
Anatomy: Thick, elastic muscle
layer that can handle
high pressure of the
blood flowing through
the arteries.
Thin, elastic muscle layer
with semilunar valves
that prevent the blood
from flowing in the
opposite direction.
Overview: Arteries are red blood
vessels that carry blood
away from the heart.
resistance vessels
Veins are blue
blood vessels that carry
blood towards the heart.
capacitance vessels
Rigid walls: more rigid collapsible
Thickest layer: Tunica media Tunica adventitia

10. DIFFERENCES BETWEEN ARTERIES AND
VEINS

11. CLASSIFICATION
Arch of aorta
Left sub clavian artery
Brachiocephalic
artery
Right
subclavian
Right common
carotid
Left common
carotid
External C
A Internal
CA
Ext C A
Int C A

13. EXTERNAL CAROTID ARTERY
COURSE & DISTRIBUTION:
The external carotid artery, arises opposite the upper border of the thyroid
cartilage, and taking a slightly curved course, ascends upwards and
forwards, and then inclines backwards, to the space b/w the neck of the
condyle of the lower jaw, and the external meatus, where it divides into
the temporal $ internal maxillary arteries.
BRANCHES
RINEE KHANNA
ANTERIOR
Superior thyroid
Lingual
facial POSTERIO
R
Occipital
Posterior
auricular
Medial
Ascending
pharyngeal
TERMINAL
Superficial
Temporal
Internal
maxillary

15. In the neck, both arteries runs
upward within the carotid
sheath.
Contents of carotid sheath-
- Common carotid artery
(medially)
- Internal jugular vein (laterally)
- Vagus nerve between the artery
& vein (posterially)
At the level of the upper border
of thyroid cartilage the artery
dividing into the external and
internal carotid arteries.

16. CAROTID SINUS
The termination of CCA or
beginning of the internal
carotid artery shows a
slight dilatation known as
carotid sinus.
Acts as a baroreceptor
(pressure receptor)
& regulates blood pressure.

17. CAROTID BODY
Small, oval reddish
brown structure situated
behind the bifurcation of
CCA.
Receive nerve supply
from glossopharyngeal &
vagus nerve.
Act as a chemoreceptor
& responds to change in
the O2 & CO2 content of
blood.

18. EXTERNAL CAROTID ARTERY & ITS BRANCHES

20. SUPERIOR THYROID ARTERY
COURSE:
It arises from the anterior
aspect of ECA close to its
origin. It runs downwards
and forwards deep to the
infrahyoid muscles to the
upper pole of thyroid
gland.
BRANCHES :
Infra hyoid branch
Superior laryngeal
Cricothyoid
Anterior thyroid
Sternomastoid

21. COURSE:
It arises from anterior aspect of
ECA forms a typical loop which
is crossed by XII nerve. Its 2nd
part lies deep to the hyoglossus.
The 3rd part runs along the ant.
Border of hyoglossus $ 4th part
runs forwards under the surface
of tongue.
DISTRIBUTION:
It is chief artery of muscular
tongue. It supplies various
muscles, papillae n taste buds.
also gives branches to tonsils.
LINGUAL ARTERY

22. FACIAL ARTERY
It is chief artery of face
It arises from the ECA just above the tip of the greater
cornu of the hyoid bone
Two parts of facial artery-
1. Cervical part- runs upwards in the neck
2. Facial part- on the face
CERVICAL PART-
It runs upwards on the pharynx deep to the posterior belly
of the digastric & to the ramus of mandible
It grooves the posterior border of submandibular gland

23. BRANCHES OF CERVICAL PART
1. Ascending palatine-
- supplies the tonsil & root of the tongue
2. Tonsillar-
- supplies the tonsils
3. Submental-
- supplies the submental triangle & sublingual
salivary gland.
4.Glandular branches-
- supplies submandibular salivary gland & lymph
nodes

24. FACIAL PART
Course-
It enters the face by winding around the base of the mandible, by
piercing the deep cervical fascia at the antero-inferior angle of the
masseter muscle.
First it runs upwards & forwards to a point half an inch lateral to
the angle of the mouth.
Then it ascensds by the side of the nose up to the medial angle of
the eye, where it terminates by supplying the lacrimal sac & by
anastomosing with the dorsal nasal branch of the ophthalmic
artery.
The facial artery is very tortuous.( Tortuosity of the artery prevents
its walls from being unduly stretched during movement of
mandible,lips & the cheeks)

25. Facial artery
Ophthalmic
Artery

26. BRANCHES OF FACIAL PART
1. Inferior labial –
- supplies lower lip
2. Superior labial-
- supplies the upper lip & the anteroinferior part
of the nasal septum.
3. Lateral nasal-
- supplies to the ala & dorsum of the nose.

27. At the medial angle of the eye terminal branches of the
facial artery anastomosis with branches of the ophthalmic
artery (it is the site for anastomosis between the branches
of ECA & ICA)

28. LITTLE’S AREA
The anteroinferior part of septum contains anastomoses
between the superior labial branch of the facial artery and
sphenopalatine artery.

29. Occipital artery-
Arises from the posterior aspect of the ECA.
Opposite the origin of facial artery
Supplies the occipital belly of occipitofrontalis & skin
& pericranium associated with the scalp.

30. 5. Posterior auricular artery-
Arises from the posterior aspect of ECA just above the
posterior belly of digastric.
Supplies back of the auricle, the skin over the mastoid
process & over the back of the scalp.
6. Ascending pharyngeal artery-
Arises from the medial side of ECA.
Supplies the side wall of the pharynx, tonsil, medial
wall of the middle ear & the auditory tube.

31. 7. MAXILLARY ARTERY
The maxillary artery, larger of the two terminal
branches of the external carotid artery.
3 parts
1. Mandibular- runs horizontally between neck of
mandible & sphenomandibular ligament.
2. Pterygoid- superficial or deep to the lower head of
the lateral pterygoid.
3. Pterygopalatine- between the two heads of the lateral
pterygoid through pterygomaxillary fissure

32. First portion
The first or mandibular portion passes horizontally
forward, between the neck of the mandible and the
sphenomandibular ligament, where it lies parallel to and a
little below the auriculotemporal nerve; it crosses
the inferior alveolar nerve, and runs along the lower border
of the lateral pterygoid muscle.
Branches include:
Deep auricular artery
Anterior tympanic artery
Middle meningeal artery
Inferior alveolar artery which gives off its mylohyoid
branch just prior to entering the mandibular foramen
Accessory meningeal artery

33. Second portion
The second or pterygoid portion runs obliquely
forward and upward under cover of the ramus of the
mandible and insertion of thetemporalis, on the
superficial (very frequently on the deep) surface of
the lateral pterygoid muscle; it then passes between the
two heads of origin of this muscle and enters the fossa.
Branches include:
Masseteric artery
Pterygoid branches
Deep temporal arteries (anterior and posterior)
Buccal artery

34. Third portion
The third or pterygopalatine portion lies in
the pterygopalatine fossa in relation with the pterygopalatine
ganglion. This is considered the terminal branch of the maxillary
artery.
Branches include:
Sphenopalatine artery (Nasopalatine artery is the terminal
branch of the Maxillary artery)
Descending palatine artery
Infraorbital artery
Posterior superior alveolar artery
Artery of pterygoid canal
Pharyngeal artery
Middle superior alveolar (a branch of the infraorbital artery)
Anterior superior alveolar arteries (a branch of the infraorbital
artery)

36. TRANSVERSE FACIAL ARTERY
Branch of superficial temporal artery.
After emerging from the parotid gland, it runs
forward over the masseter between the parotid
duct & zygomatic arch.
Accompanied by the upper buccal branch of facial
nerve.
It supplies the parotid gland & its duct ,the
masseter & overlying skin.

37. 3. INTERNAL CAROTID ARTERY
The ICA begins in the neck as one of the terminal branches of
CCA (at the level of upper border of the thyroid cartilage).
It divided into 4 parts-
1. Cervical part- in the neck it gives no branches.
2. Petrous part- in the petrous part of temporal bone gives 2
branches-
a) Corticotympanic branch
b) Pterygoid branch
3. Cavernous part- within the cavernous sinus.
a) Cavernous branches to the trigeminal ganglion
b) Superior & inferior hypophyseal branches

38. 4. Cerebral part- lies at the base of the brain after emerging from
the cavernous sinus.
Ophthalmic
Anterior cerebral
Middle cerebral
Posterior communicating
Anterior choroidal
‘S’ shaped figure called as carotid siphon of angiograms

39. APPLIED ANATOMY..LIGATION OF ECA
Indications-
Bleeding from Oral Malignancies.
Slipping of Superior pedicle of Thyroid Gland.
Arterio Venous Malformation of Scalp.
Anaesthesia- General Anaesthesia
Position- Supine with neck extended to opposite side
Incision-Oblique incision along the anterior border of Sterno Mastoid over the middle
third.
Procedure-
1. Skin and Platysma are cut along the line of incision
2. Anterior border of Sternomastoid is retracted posteriorly
3. Internal Jugular Vein (IJV) is identified
4. Common carotid Artery is found medial to IJV
5. Bifurcation of the Common carotid artery defined
6. External Carotid Artery (ECA) is identified by its branches
7. Internal Carotid Artery (ICA) has no branch in the neck
8. Safeguard the Hypoglossal Nerve which crosses ICA and ECA just above hyoid
bone.

41. To expose the carotid bifurcation, periarterial dissection of
the surrounding tissues is continued superiorly. During the
exposure of the carotid bifurcation and the carotid sinus,
bradycardia may occur. Recognizing any significant
alterations in heart rate and rhythm at this point in the
procedure is critical because many patients with carotid
artery stenosis have coexisting coronary artery disease.
If sinus bradycardia occurs, 1-2 mL of 1% lidocaine may be
administered topically between the ICA and the ECA to
block nerve conduction to the carotid sinus. Some
surgeons routinely administer lidocaine at the time of
bifurcation exposure to prevent sinus bradycardia.

42. Under normal circumstances, all
internal carotid artery blood flow is directed intracranially,
and flow through the collateral pathways is from intracranial
vessels to the external carotid artery branches,
normally
the external carotid arteries do not contribute significantly to
intracranial or ocular blood flow. In the case of internal
carotid artery occlusion, the direction of flow in the collateral
pathways reverses, and flow courses from the external ca
rotid branches to the intracranial branches of the internal
carotid artery,
Thus, with occlusion of the internal carotid
artery, the external carotid artery may become an important
source of blood flow to the brain..

44. Veins
Systemic veins Pulmonary Veins
-Right Pulmonary vein
-Left Pulmonary vein
Head & Neck Abdomen & Thorax Upper limb Lower limb

45. External group
a) Internal jugular
b) External jugular
c) Anterior jugular
d) Oblique jugular
e) Posterior external jugular
Internal group
a) Venous sinuses
b) Emissary veins
c) Diploic veins

46. Superficial
External jugular Facial
Superficial temporal
Deep
Pterygoid plexus
Internal jugular

47. Supra orbital vein
Supra trochlear vein
Facial vein
Common facial vein
Retromandibular vein
Superficial temporal vein
Maxillary vein
Posterior auricular vein

48. Applied anatomy:
A. Facial vein is common source of bleeding following
surgery involving posterior vestibule lateral to
mandible
B. Infection from face can spread in a retrograde direction
and cause thrombosis of the cavernous sinus. This is
specially occur in presence of infection in upper lip and
lower part of nose. Called dangerous area of the face.
Dangerous area of the face.

49. Lingual vein
 The lingual veins begin on the
dorsum, sides, and under
surface of the tongue, and,
passing backward along the
course of the lingual artery, end
in the internal jugular vein.
 Drains tongue and
sublingual region
 Three branches
a) Dorsal lingual veins
b) Deep lingual veins
c) Sublingual vein

50. Superficial temporal vein
•It begins on the side and vertex of
the skull in a plexus which
communicates with the frontal vein
and supraorbital vein, with the
corresponding vein of the opposite
side, and with the posterior auricular
vein and occipital vein.
•From this network frontal and
parietal branches arise, and unite
above the zygomatic arch to form
the trunk of the vein, which is joined
by the middle temporal
vein emerging from the temporalis
muscle.

51. Maxillary vein
• It begins in the infratemporal fossa
•It collects blood from the pterygoid
Plexus
•Through the pterygoid plexus It
receives the middle meningeal,
posterior superior alveolar, inferior
alveolar and other veins from the
nose and palate (areas served by
The maxillary artery)
•After that it merges with the
superficial temporal vein to form
the retromandibular vein

52. Posterior auricular vein
•The posterior auricular
vein begins upon the side of the
head, in a plexus which
communicates with the
tributaries of the occipital
vein and superficial temporal
veins.
•It descends behind
the auricula, and joins the
posterior division of
the posterior facial vein to form
the external jugular.

53. •start below the chin, pass
beneath the platysma to the
suprasternal notch.
•Pierce the deep fascia and is
connected to the other side
by an anastomosing vein the
jugular arch
•angle laterally to pass deep
to sternocleidomastoid and
open in the external

54. Tributaries:
1. Skin
2. Superficial tissues of neck
Applied anatomy:
1. Special care required to
preserve the vein during
surgical treatment
of wry neck

55. Veins of the Head and neck
• Internal jugular vein:
• It receive blood from the brain, face
and the neck.
• It emerges through the jugular
foramen,as a continuation of the
sigmoid sinus descend down in the
neck, first behind then lateral to
the internal carotid artery inside
the carotid sheath
• Terminate beneath the triangular
interval between the sternal and
the clavicular head of the
sternocleidomastoid muscle joining
the subclavian vein to form the
brachiocephalic vein

56. Relations:
a) Superficially
• Sternocleidomastoid
• Posterior belly of digastric
• Superior belly of omohyoid
• Parotid gland
• Styloid process
• Accessory vein
• Posterior auricular artery
• Occipital artery
• Sternocleidomastoid artery
• Lower root of ansa cervicalis
• Infrahyoid muscle
• Anterior jugular vein
• Deep cervical lymph nodes
• Internal carotid artery
• 9th, 10th,11th & 12th nerve

57. b) Posteriorlly
• Rectus capitis lateralis
• Transverse process of atlas
• Levator scapulae
• Scaleneus medius
• Cervical plaxus
• Scalenus anterior
• Phrenic nerve
• Thyrocervical trunk
• Inferior thyroid artery

58. c) Medially
• Internal carotid
artery
• Common carotid
artery
• Vagus nerve

59. Tributaries
1. Inferior petrosal sinus
2. Pharyngeal veins
3. Common facial vein
4. Lingual vein
5. Superior thyroid vein
6. Kocher vein
7. Occipital vein
8. Thoracic duct (left)
9. lymphatic duct (right)

60. Communications
1. With external jugular by oblique jugular
2. With cavernous sinus by inferior petrosal sinus

61. Superficial
cerebral
veins
Superior
sagittal
sinus
Right
transverse
sinus
Right
sigmoid
sinus
Right IJV
Special characteristics of the blood flow
Deep
cerebral
vein
Great
cerebral
vein
Straight
sinus
Left
transverse
sinus
Left
sigmoid
sinus
Left IJV
1
2

62. APPLIED ANATOMY:
1. Infection from middle ear spreads to IJV
2. Surgical removal of deep cervical nodes can puncture
IJV
3. Easy accessibility between two heads of
sternocleidomastoid muscle for introduction of
cannula
4. Thrombophlebitis can occur by spread of infection in
caverous sinus
5. Systolic thrill felt over the vein in mitral stenosis
6. During CCF dilatation of vein occur
7. Queckenstedt’s test – to find out block in CSF
cerculation the test is perform during lumbar puncture

63. Jugular venous pulse (JVP)
• Determine activity of
atrium
• Seen better then felt
• Preferable over EJV
• Elevation of JVP indicative
of cardiac failure
Hepato Jugular reflex
• Elicited by deep compression
of right lobe of liver

64. Anastomosis of facial vein

65. INTRACRANIAL VENOUS CONNECTION
The facial vein has numerous connections with venous
channels passing into deeper regions of the head.
1. Near the medial corner of the orbit it comminicates with
ophthalmic veins.
2. In the area of the cheek it communicates with veins
passing into the infra orbital foramen.
3. It communicates with veins passing into deeper regions of
the face (i.e. the deep facial vein connecting with the
pterygoid plexus of veins).

66. Pterygoid
plexus
Inferior
ophthalmic vein
Facial vein
Cavernous sinus

67. Formation:
• Venous spaces between the osteal and meningeal layers of
duramater
• Formed by reduplication of meningeal layer
Features:
• Lined by endothelium
• Receive blood from
a) Brain
b) Orbit
c) Internal ear
d) CSF
• Valveless
• Bidirectional flow

68. Classification
Posterosuperior group Anteroinferior group
Unpaired
a) Superior sagittal
b) Inferior sagittal
c) Straight
d) Occipital
Paired
a) Transverse
b) Sigmoid
c) Petrosquamous
Unpaired
a) Anterior intercavernous
b) Posterior intercavernous
c) Basilar
Paired
a) Cavernous
b) Superior petrosal
c) Inferior petrosal
d) Sphenoparietal
e) Middle meningeal

69. Confluence of sinus:
•The point where the superior
sagittal sinus, straight sinus
and occipital sinus unite
called Confluence of sinus
•Located on the right side of
the internal occipital
protuberance

70. 1. Paired sinus, large venous space situated in MCF
2. Extent: petrous part of temporal bone to SOF

71. Relation:
Medially Pituitary gland
Sphenoidal sinus
Laterally Temporal lobe with uncus
Superiorly Optic tract, optic chiasma,
Olfactory tract,ICA
Inferiorly Foramen lacerum , junction of body & greater
wing of sphenoid bone
Anteriorly Superior orbital fissure & apex of orbit
Posteriorly Petrous part of temporal bone

72. Structure passing
through sinus
Structures in
lateral wall of
sinus
ICA
VI cranial nerve
III cranial nerve
IV cranial nerve
V 1 and V2 division
of V cranial nerve

73. Applied anatomy:
1. Arterio – venous aneurysm occurs due to rupture of
internal carotid artery
Symptoms:
a) Loud systolic thrill
b) Exophthalmos
c) Conjunctivitis
2. Thrombosis of the sinus resulting in meningitis due to
infections in dangerous area of face , nasal cavity and
PNS
Symptoms:
a) pain in eye
b) Oedema of eye lids , cornea and root of nose
c) Exophthalmos

79. Lymphatic drainage

80. Definition:
The lymphatic system is the part of the immune
system comprising a network of conduits called
lymphatic vessels that carry a clear fluid called lymph
(from Latin lympha "water") in a unidirectional
pathway.
The widely and extensively dispersed vessel system
collects tissue fluids from all regions of the body to
eventually convey them towards the heart.

81. EMBRY0LOGY OF LYMPHATIC
SYSTEM
Lymph sacs -appear between 2nd to 6th
week of IUL.
7th week -jugular channel spread to connect
with subclavin lymph sacs.
9th week - thoracic duct is continuous
channel draining into IJ -subclavin vein
junction.
12th week- all process are complete.
5th month -valves begins to start.

82. CELL ZONES
Zone 1
Extreme periphery
Loosely packed cells
lymphocytes,
macrophages
Zone 2
More densely packed
small lymphocytes and
macrophages
Zone 3.
Germinal center
Large lymphoblastswww.indiandentalacademy.com

83. VALVES
Except initial lymphatic sinus or capillaries every lymph
vessels has valves.
Valves may be
Bicuspid
Tricuspid
Quadricuspid

84. Functions:
• It is responsible for the removal of interstitial fluid
from tissues i.e. act as "drains“
to collect the excess fluid and return it to the venous
blood just before it reaches the heart preventing
massive edema (which can cause tissue destruction:
“pressure necrosis”).
•Returns back to circulation, the protiens that may
have escaped into interstitial spaces.

85. Lymphatic tissue is a specilized connective tissue -
reticular connective, that contains large quantities of
lymphocytes(filter fluids prior to adding it to
circulation).
It transports immune cells to and from the lymph
nodes in to the bones
The lymph transports antigen-presenting cells (APCs),
such as dendritic cells, to the lymph nodes where an
immune response is stimulated.
works with the circulatory system to deliver nutrients,
oxygen, and hormones from the blood to the cells that
make up the tissues of the body.
It absorbs and transports fatty acids and fats as chyle to
the circulatory system

86. SHAPE OF LYMPH NODE
Inguinal lymph nodes – large and round
Outer iliac lymph nodes – longish mass
Inner iliac lymph node – small and round
Head and neck lymph node- oval or kidney or spindle
shaped
www.indiandentalacademy.com

87. A sound knowledge of the regional lymph nodes of the
head and neck is very important for dentists because
it is a reliable guide towards the origin of
problem, and because of the possible involvement of
the lymphatic system in the
spread of infection or the spread
of malignant tumour cells
(metastasis).
Role in dental practice

88. Role in dental practice
Clinical significance:
1. Diagnostic value
2. Aid in prediction of treatment outcome
(modification of treatment plan/course)
3. Prediction of disease history and therefore
prognosis.
4. Lymph vessels can also transmit other substances
such as injected material or neoplastic cells.

89. Classification of nodes
in head and neck region

90. The lymph nodes in the head and neck region can be
grouped into:
• Superficial nodes
• Deep nodes.
Classification of nodes
in head and neck region

91. The superficial cervical lymph nodes lie above the
investing layer of the deep fascia.
They consist of a few small nodes that lie superficial
to the external jugular and anterior jugular veins.
The superficial lymph nodes

92. The superficial lymph nodes
1. Submental
2. Submandibular
3. Buccal
4. Parotid (pre-auricular)
5. Mastoid (retro auricular/ post-auricular)
6. Occipital
7. Superficial cervical
8. Anterior cervical.

93. Superficial cervical nodes

94. The Deep lymph nodes:
1. Upper deep cervical
2. Lower deep cervical
3. Waldyer’s ring
4. Nodes of midline

95. The upper deep cervical (Jugulo-digastric group: lie
along the upper part of internal jugular vein deep to
the sternomastoid.
The lower deep cervical (jugulo-omohyoid gp):
arranged along the lower part of IJV also deep to the
SMm.
Deep cervical nodes

96. Deep cervical nodes

97. The waldyer’s ring is formed by: lingual,
palatine, tubal, and pharyngeal tonsils.
Midline nodes are termed in correspondence to
the anatomical area where they exist:
A. Infrahyoid
B. Prelaryngeal
C. Pretracheal
D. Paratracheal

98. Efferents of lower deep cervicals then collect into
larger lymph vessel called the “jugular lymph trunk”.
This trunk joins another two lymph trunks lymph
(subclavian and brachiocephalic trunks) to form the
so called the “lymph ducts” (right or left).
This “duct” finally opens into the angle between
internal jugular and subclavian veins to drain its
contents back to venous circulation.

99. The right and left lymph ducts are NOT of
equal size.
The left lymph duct (also called the “Thoracic
duct” )
which is considered the largest lymphatic vessel in the
body.
It collects most of the lymph in the body (except that
from the right arm and the right side of the chest,
neck and head, which is collected by the right
lymphatic duct).
Thoracic duct

102.  Composition of lymph- clear colour less fluid
formed by 96% water and 4% solids
 Solids- may be inorganic , organic and cellular
content.
 Inorganic –
- Na
-Ca
- K
- Cl
- HCo3

103. Organic-
- proteins (albumin, globulin, fibrinogen,
prothrombin, other clotting factors antibodies,
enzymes)
-lipids in the form of chylomicrons and lipo
protiens
-carbohydrates- glucose
-non protein nitrogenous substances like urea
and creatinine

104. Cellular contents-
lymphocytes
monocytes
Macrophages
Plasma cells

106. • It begins down as low as level of L2
(at the cisterna chyli) and extends upward to drain
into the region near the junction of the left
subclavian and internal jugular veins, with tributaries
from the cervical, subclavian and mediastinal trunks.
Thoracic duct

107. Lymphatic drainage

108. Regional Lymph Nodes

109. Regional Lymph Nodes

110. The skin of the head and neck drains :
• The scalp drains into the occipital, mastoid and parotid
nodes.
• Lower eye lid and anterior cheek drains into buccal
LNs.
• The cheeks drain into the parotid, buccal and
submandibular nodes.
• The upper lips and sides of the lower lips drain into the
submandibular nodes.
While the middle third of the lower lip drains into the
submental nodes
• The skin of the neck drains into the cervical nodes.

111. The drainage of the oral structures
• The gingivae drain into the submandibular,
submental and upper deep cervical lymph nodes.
• The palate drains via lymph vessels that pass
through the pharyngeal wall to the upper deep
cervical nodes.
• Teeth drain into the submandibular and deep
cervical lymph nodes.
• Anterior part of mouth floor drain into submental
and upper deep cervical while posterior part into
submandibular and upper deep cervical.

113. Levels of Lymph nodes (SLOAN –KETTERING CANCER
CENTER, NY)
I
II
III
IV
VI v
www.indiandentalacademy.com

114. PALPABLE LYMPHNODES AND PROBABLE
ASSOCIATED CONDITIONS
Tender, Mobile, enlarged  Acute infection
Non-tender, Mobile, Enlarged  Chronic infection
Matted, Non tender  Tuberculosis
Fixed, Enlarged  Carcinoma
Rubbery, Enlarged  Lymphomas

116. Level I
Submental triangle
(Ia)
–Anterior digastric
–Hyoid
–Mylohyoid
Submandibular
triangle (Ib)
–Anterior and
posterior digastric
–Mandible.

117. Level I
Ia
– Chin
– Lower lip
– Anterior floor of mouth
– Mandibular incisors
– Tip of tongue
Ib
– Oral Cavity
– Floor of mouth
– Oral tongue
– Nasal cavity (anterior)
– Face

118. Level II
Upper Jugular Nodes
Anterior limit -Lateral
border of sternohyoid
Posterior limit-Posterior
border of SCM
Skull base
Hyoid bone (clinical landmark)
Carotid bifurcation (surgical
landmark)
Level IIa anterior to XI
Level IIb posterior to XI
– Oropharynx > oral cavity
and laryngeal mets

119. Level II
Oral Cavity
Nasal Cavity
Nasopharynx
Oropharynx
Larynx
Hypopharynx
Parotid

120. Level III
Middle jugular nodes
– Anterior limit -Lateral border
of
sternohyoid
– Posterior limit-Posterior border
of SCM
– Inferior border of level II
– Cricoid cartilage lower
border (clinical landmark)
– Omohyoid muscle (surgical
landmark)

121. Level IV
Lower jugular nodes
–Anterior limit- Lateral border
of sternohyoid
–Posterior limit-Posterior
border of SCM
–Cricoid cartilage lower
border (clinical landmark)
–Omohyoid muscle
(surgical landmark)
Junction with IJV
–Clavicle

122. Level V
Posterior triangle of neck
–Posterior border of SCM
–Clavicle
–Anterior border of
trapezius
–Va Spinal accessory
nodes
–Vb Transverse cervical
artery nodes
Radiologic landmark
Inferior border of Cricoid
–Supraclavicular nodes

123. Level V
Nasopharynx
Oropharynx
Posterior neck and scalp

124. Level VI
Anterior compartment
– Hyoid
– Suprasternal notch
Medial border of carotid
sheath
– Perithyroidal lymph nodes
– Paratracheal lymph nodes
– Precricoid (Delphian)
lymph node

125. Level VI
Thyroid
Larynx (glottic and subglottic)
Pyriform sinus apex
Cervical esophagus

126. Staging
Nx: Regional lymph nodes cannot be
assessed.
N0: No regional lymph node metastases.
N1: Single ipsilateral lymph node, <3 cm

128. Sentinel Lymph Node History
1955 First echelon node
1960 “Sentinel node”
1977 Demonstrated in penile
cancer
1992 Morton reintroduced
concept in N0 melanoma
Currently widely used in melanoma
and breast cancer therapy.

129. Sentinel lymph node concept
Tumor spreads via lymphatics to a
primary node.
Examination of primary echelon
nodes for tumor direct the need for
surgical management of the nodal
basins.

132. Classification of Neck
Dissections
• Standardized until 1991
• Academy’s Committee for Head and Neck
Surgery and Oncology published standard
classification system

133. Classification of Neck
Dissections
• Academy’s classification
• 3) Any neck dissection that preserves one or more
groups or levels of lymph nodes is referred to as a
selective neck dissection (SND)
• 4) An extended neck dissection refers to the removal
of additional lymph node groups or non-lymphatic
structures relative to the RND

134. Classification of Neck Dissections
• Academy’s classification
– 1) Radical neck dissection (RND)
– 2) Modified radical neck dissection
(MRND)
– 3) Selective neck dissection (SND)
• Supra-omohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type
– 4) Extended radical neck dissection

135. Radical Neck Dissection
• Indications
– Extensive cervical involvement or matted
lymph nodes with gross extracapsular spread and invasion
into the SAN, IJV, or SCM

136. Modified Radical Neck
Dissection (MRND)
• Definition
– Excision of same lymph node bearing regions
as RND with preservation of one or more non-lymphatic
structures (SAN, SCM, IJV)
– Spared structure specifically named
– MRND is analogous to the “functional neck
dissection” described by Bocca

137. Modified Radical Neck
Dissection
• Three types (Medina 1989) commonly
referred to not specifically named by committee.
• Type I: Preservation of SAN
• Type II: Preservation of SAN and IJV
• Type III: Preservation of SAN, IJV, and
SCM ( “Functional neck dissection)”)

138. Double-Y IncisionConley Incision
Half Apron Incision
Apron Incision
H-Incision

139. Modified Schobinger Incision
Y Incision
MacFee Incision
Schobinger Incision