Applied Anatomy of the Lymphatics
F. P. Millard, D.O.
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 nodes.

    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 liver.
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 nodes.

    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 trunk.

    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 the head.

    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.

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 Eye

    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 brain.

The Ear

    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.