Applied Anatomy of the
F. P. Millard, D.O.
PART ONE -- LYMPHATICS OF THE EYE, EAR, NOSE AND
C. C. Reid, M.D., D. O., Denver, Colorado
A healthy lymphatic flow is essential to the life
and function of every important tissue. The large lymphatic vessels
empty into veins. The vessels start with capillaries. The lymphatic
system is composed of supervical and deep lymphatic vessels with many lymphatic
nodes scattered throughout the body. The lymphatic vessels are thinner-walled
than the veins. They do not have anastomoses except through lymphatic
All lymphatic vessels have valves. The lymphatic
nodes interposed in the lymphatic system have the function of counteracting
and destroying poison. Most of the lymph traverses some nodes before
entering the veins. The largest lymphatic nodes are only about three
centimeters in diameter.
Quite large lymphatic stems are found on each side
of the head and neck and in the abdominal viscera, into which the lymph
is gathered and emptied into the veins of the lower neck or upper thorax.
There are seven large lymphatic stems, three of which unite to form the
thoracic duct which also receives two other stems. The thoracic duct
begins at the level of the second lumbar vertebra and ascending upward
empties into the left subclavian vein. It receives the lymphatic
stem that drains the left side of the head and neck. The right lymphatic
duct empties into the right subclavian vein.
The right jugular lymphatic trunk drains the right
side of the neck and head. It originates from the deep cervical nodes.
The right subclavian trunk originates from the right axillary nodes and
carries the lymph from the right arm. The right bronchomediastinal
trunk originates from the bronchial and mediastinal nodes. It drains
the right thoracic wall, right lung, the heart, esophagus and part of the
Lymphatic Nodes of the Head and Neck
1. Under the skin upon the insertion of the
sternocleidomastoid muscle, which is back of the ear, are located two or
three small lymphatic nodes. The lymphatic capillaries gather into
these nodes from the posterior auricular region.
2. Just back of the posterior auricular nodes
upon the insertion of the trapezius muscle are usually one or two small
nodes which drain the occipital region and send efferent lymphatic vessels
through the superficial cervical nodes.
3. The parotid gland lies in front and below
the external auditory canal superficially. Upon this gland just under
the skin and in front of the ear are three or four small anterior auricular
nodes. Capillaries from the temporal region terminate in these nodes
by giving efferent vessels to the superficial cervical or submaxillary
4. Within the large parotid gland are found
a few lymphatic nodes. The lymphatic capillaries from the eyelids,
from the external ear and from the gland itself gather into these parotid
nodes. Efferent vessels from the parotid nodes pass to the superficial
cervical and superior deep cervical nodes.
5. Deep facial nodes are found upon the buccinator
muscle and in the lateral wall of the pharynx. These nodes receive
the deep lymphatic vessels of the face coming from the orbit, nose, palate,
cheeks and pharynx. They join with the deep cervical nodes.
6. Just beneath the mandible and between that
and the digastric muscle are eight or ten quite large lymphatic nodes.
These are known as the submaxillary lymphatic nodes. Just anterior
to these resting on the under surface of the mylohyoid muscle are the submental
nodes. These nodes drain the anterior part of the face and the chin.
7. The submental, submaxillary and deep cervical
nodes receive most of the lymph drainage from the tongue. Sometimes
there are found on the hypoglossal muscle one or more small lymphatic nodes
that receive part of the drainage from the tongue and send efferent vessels
to the submaxillary and submental nodes.
8. The superficial cervical nodes are found
just under the platysma myoides muscle and lie upon the sternocleidomastoid
mostly along its posterior body and at the inferior border of the parotid
gland in the anterior region of the neck. They receive the capillary
drainage from the region of the neck in which they are situated.
They also receive efferent vessels from the anterior and posterior auricular
nodes, the occipital and the parotid nodes. They terminate with vessels
in the deep cervical nodes.
9. Ten or fifteen nodes are found in the upper
cervical region along the internal jugular vein. These are known
as the superior deep cervical nodes. They collect the lymphatic capillary
drainage from the cranium and receive vessels of the facial, parotid and
submaxillary nodes. They also receive drainage from the pharynx,
tympanum, Eustachian tube, inner ear, part of the thyroid gland and larynx.
10. In the supraclavicular fossa and around
the lower part of the internal part of the jugular vein are the inferior
deep cervical nodes. They receive efferent branches from the superior
cervical nodes, also branches in the lower trachea and esophagus.
Most of the drinage from the head and neck passes through the inferior
deep cervical nodes. The superior and inferior deep cervical lymphatic
vessels join with the superficial lymphatic vessels and with their nodes
from the jugular lymphatic plexus and terminate below in the jugular lymphatic
A little study of the diseases of the eye, ear, nose
and throat in conjunction with lymphatic circulation and its nodes, will
aid materially in the understanding of right diagnosis and treatment.
In children having furunculosis of the external auditory
canal or some infection in that region, enlarged nodes may be noticed just
over the insertion of the sternocleidomastoid muscle. Infection in
the nasopharynx or pharynx and the sphenoidal sinus may cause enlargement
of the occipital nodes, the superior deep cervical nodes just back of the
sternocleidomastoid muscle. Also, the inferior deep cervical nodes
may be enlarged from disease, infection and poisoning from any region in
Infection in the parotid gland or its immediate vicinity,
the eyelids or the external ear will enlarge the parotid nodes, apparently
enlarging the parotid gland. Infection in the orbit, in the sinuses
in the region of the soft palate and pharynx may show an apparent thickening
in the region of the buccinator muscle on account of the nelargement of
the deep facial nodes.
The most common place to find enlarged lymphatic
nodes is in the submaxillary region. The reason for this is that
efferent vessels from practically all the nodes above enter the submaxillary
nodes. Any infections in the anterior nose or the teeth may cause
an enlargement of the submaxillary nodes. It is quite common to find
the supervicial cervical nodes enlarged which lie upon the sternocleidomastoid
and along its posterior border and at the inferior border of the parotid
gland. These nodes receive efferent vessels from the nodes above.
Infection in the pharynx, tonsils, nasopharynx, middle
ear, Eustachian tube or the internal ear may carry infection into the superior
deep cervical nodes in the carotid fossa along the internal jugular vein.
In tonsillar infection, one or two of the large superior deep cervical
nodes are almost constantly enlarged. It is one of the diagnostic
signs of infection or absorption of toxic material from the tonsillar area.
Our treatment should be directed to the opening up
not only of blood circulation but of freeing the lymph circulation in the
treatment of diseases of the eye, ear, nose and throat. The lymph
drainage, of course, is always in this region from above downward.
Any sources of focal infection should, of course, be cleared up in order
to relieve the lymph from the burden of counteracting, eliminating and
constantly absorbing toxins.
PART TWO -- LYMPHATICS OF THE EYE AND EAR
Glenn S. Moore, D. O., Chicago
Lymph drainage is an important feature in the balance
of the body mechanism, and the factors whereby this physiological equilibrium
is maintained are of utmost importance to the patient and to the profession.
In the following brief summary we shall endeavor
to give a concise and accurate statement of fact concerning the lymphatic
system, with suggestions as to the most effective points of approach for
the opening of the drainage from the eye and from the ear.
The lymphatics of the eye are numerous and extensive.
They consist largely of lymph spaces which communicate directly or indirectly
with one another. In addition to the lymph system of the lid, there
are virtually two lymph systems which are termed the anterior and posterior
group systems. In the anterior group are the lymph spaces of the
cornea, of the iris and of the aqueous humor. The aqueous humor passes
from the posterior chamber to the anterior chamber, escaping by way of
the spaces of Fontana and the canal of Schlemm, eventually draining through
the spheno-maxillary fissure to the internal maxillary and deep parotid
lymph glands. The posterior group of spaces contains the Hyaloid
canal which extends from the optic disc to the posterior pole of the lens,
draining the inter-vaginal space of the optic nerve. In addition
there is in this group the perichoroid lymph space whose lymph empties
into the Tenon space “by performation in the sclera around the venae verticose.”
Tenon’s space which empties into the supra-vaginal space, and the inter-vaginal
space complete the list, the last mentioned of which opens into the subdural
and subarachnoid spaces of the brain.
According to Deaver, any obstruction in the anterior
lymph channels will cause an increase in intra-ocular pressure. For
example, such conditions as annular posterior synechia, involving the entire
pupillary margin of the iris to the extent of causing it to adhere to the
anterior surface of the capsule of the lens will prevent the lymph of the
posterior chamber from entering the anterior chamber through the pupil.
This would result in causing the iris to project against the cornea, closing
off the drainage through the space of Fontana and the canal of Schlemm.
Such a serious condition gives rise to a symptom complex known as glaucoma.
In addition to this, glaucoma may result from a hypersecretion of lymph
in the eyeball. I am of the opinion that many cases of glaucoma which
we are treating today with good results are of this type.
In summarizing, therefore, we have a triple lymphatic
drainage from the eye by way of first, the eyelid, through the buccal and
submaxillary lymph glands of the head to the superficial lymph glands of
the neck. Secondly, this drainage is by way of the anterior lymph
channels of the eyeball (canal of Schlemm and spaces of Fontana and anterior
posterior chambers) all draining to the internal maxillary lymph glands.
The third avenue of drainage is by way of the posterior channels of the
eyeball (Hyaloid canal, supra- and infra-vaginal lymph spaces and perichoroid
lymph space) all draining to the subdural and subarachnoid spaces of the
The ear proper is divided into three parts, the External
ear, Middle ear, and Inner ear, each having a distinct lymphatic drainage.
The lymphatics of the external ear drain into the parotid and the superficial
cervical lymph glands. Infections of the external ear manifest themselves
by tenderness in the parotid lymph glands, maxillary lymph gland or superficial
lymph glands of the neck. The Middle Ear is drained by the lymphatics
which pass out through the external auditory canal to join the superficial
lymph glands of the neck. Lymph vessels also pass down the lymphatic
system of the neck. The lymph of the Inner Ear communicates with
the subdural and subarachnoid spaces of the brain.
In conclusion, it is to be noted that the eye and
the ear have a somwhat correlative system of lymph drainage. This
drainage includes the subdural and subarachnoid spaces of the brain which
are partia terminals of the drainage of the more intricate structures of
the organs. So far as the superficial and deep drainage of the neck
is concerned, the facilitation of this drainage is brought about by the
deep relaxing of the region of the clavical and first rib. By so
doing the drainage is “freed,” as we say, that is, there is brought about
an actual minute increase in the intervascular spaces allowing for the
greater flow of blood and lymphatic fluid because of the mechanical as
well as chemical changes which become possible.
The muscular relaxation which is involved in the
process helps to lift the mechanical pressure which by tightening of the
fibres has brought about contracture of the whole region. In addition
to this there is accomplished a metabolic process of repair of the cells
which, because of interference with drainage and nutrition, have become
over-laden with toxic products such as CO2 and other substancs.
By virtue of the “freeing up” process this intracellular drainage is accomplished
and the intercellular accumulation of edematous material is allowed to
flow more freely downward to the subclavian vein.
Therefore, the clavicular work is indicated in general
introductory work for all cases involving the lymphatics of Eye and Ear.
It should not be considered as purely introductory, for it will be well
in all cases of inflammation of either organ to continue the clavicular
treatment as long as indicated for drainage.
The special treatment as originated by Dr. Edwards for local
freeing of the lymph is of great value after the general freeing of the deep
and superficial lymph drainage of the neck. Treatment at the first, second
and third lumbar helps to open the cerebrospinal lymph drainage thus clearing
the way for the special local treatment of the inner ear.