Applied Anatomy of the
F. P. Millard, D.O.
LYMPHATIC DRAINAGE OF THE HEAD AND NECK
J. Deason, M.C., D. O.
Physiologic Properties of Lymph
To understand fully the function of an organ requires
not only that we understand its histologic and gross structure and the
relation of these to the work it has to do, but we must also understand
the structural and functional relations of this organ with other similar
Anatomically, lymph vessels are similar to veins
of the blood-vascular system in that they are thin-walled and serve as
drainage channels, but they are unlike veins in that they drain intracellular
spaces and serous sacs. They are also unlike veins in their abundant
interlacing anastomoses and the interruption of the continuity by lymph
glands or nodes. By virtue of this construction lymph vessels serve
as drainage channels from many parts not drained by the venous system.
Lymph vessels, therefore, serve a transitional function
between intracellular spaces and veins as they serve to collect the fluid
from the intracellular spaces and return it to the veins. Lymph vessels
may be thought of as the primary or first structures of circulation.
Lymph vessels bear a similar relation to the veins that the veins bear
to arteries, and all of these, in order, efferently, the arteries, veins,
and intracellular spaces, and afferently, the intracellular spaces, lymph
vessels and veins, constitute the essential circulatory mechanism and each
is important in carrying nutrition to and waste products from the cell,
which is fundamantally the unit of function.
Physiologically, lymph performs an important protective
function by virtue of its phagocytic cells and antibody content; a nutritional
function by virtue of its supply of nutrient material and drainage of cell
waste from tissue spaces; and a tissue fluid balance function because of
its osmotic properties. The lymphatic system, structurally and functionally,
bears a relation to the veins similar to that which the veins bear to the
Lymphatic vessels of the head and neck are distinguished
as superficial and deep. The former drain the subcutaneous tissues
and superficial muscles of the face and scalp and terminate in the superficial
glands of the neck. The deep vessels are those which drain the deep
muscles, the nasopharyngeal structures, sinuses and glands, the oropharynx
and contents, the orbit and contents, larynx, esophagus and trachea.
These empty into various groups of deep glands which form a belt about
Intracranial lymph vessels from the brain and meninges
follow the courses of the arteries and veins and empty into the deep cervical
Groups of Deep Cervical Glands
PAROTID LYMPH GLANDS. -- These glands are superficial
and deep, the superficial being located just beneath the fascia, and the
deep imbedded within the parotid gland. The superficial glands receive
afferent vessels from all anterior superficial parts of the scalp and face
including the external ear. Swelling of these glands may result from
infection of any of the parts drained. Efferents of these glands
drain into either superficial or deep cervical glands, which explains why
a deep cervical swelling may result from superficial infection.
The deep parotid lymph glands receive afferent vessels
from the external meatus, tympanum, soft palate, and posterior nares.
Efferent vessels drain into the super deep cervical glands.
APPLICATION. -- The swelling and tenderness of these
glands, together with ear pain, is quite diagnostic of infection of the
middle ear. Infections of the external ear are not so likely to cause
lymphatic swelling because there is usually free drainage.
Infections of the nasopharynx and posterior nares cause glandular
enlargement and these structures are nearly always involved in suppurative
“The deep part of the parotid gland is lodged in
a definite space behind the ramis of the lower jaw. This space is
increased in size when the head is extended, and when the inferior maxilla
is moved forward, as in protruding the chin.” (Treves). This
explains why pain is caused by all movements which tend to decrease the
space of this gland, such as chewing, swallowing, etc.
The superficial part of the gland lies over the masseter muscle
and the whole gland is invested in a fascial sac derived from cervical
fascia. The opening of the upper part of this sac is exposed to infections
from postpharyngeal abscess, which explains the common occurrence of pharyngitis
In otitis media, pharyngitis, postnasal, nasopharyngeal,
and tonsil infections, in addition to other treatment, it is essential
that lymphatic drainage of the parotid lymph glands be established and
maintained. Deep drainage treatment may be done by direct relaxation
behind and under the angles of the jaws with the head well extended.
By forcing the head and jaw backward thus compressing these glands and
again extending and repeating the direct deep drainage treatment, the glands
and vessels may be “pumped” and made to increase their function of drainage.
Except in acute inflammatory conditions, direct stretching of the soft
palate and dilatation of the posterior nares by means of the finger are
effective; also exercises for draining the cervical lymph glands and exercising
the muscles of the neck are effective.
PLATE XLVIII. Lymphatics
of the pharyngeal Region. -- (1) Nodes back of pharynx. (2
& 3) Deep cervical nodes. (4) Retro-pharyngeal node. (5)
Tracheal nodes. (6) Lymph vessels entering thoracic duct.
(7) Right lymphatic duct. (8) Thoracic duct. (9) Mastoid
nodes. (10) Carotid artery.
It is important to remember that the fascial sac
covering the parotid gland is closesd except at its upper part, and that
swelling of the gland and coverings retard drainage. Heat applied
intermittently, which may be accomplished best by means of an electric
pad or lamp with reflector, produces capillary dilatation and contraction
and materially assists in increasing drainage from the gland. Bier’s
hyperemic treatment may be done by placing a tight bandage immediately
beneath the glands until the face is flushed and the vessels are engorged.
The bandage is then removed, the head extended, and the deep manipulative
treatment behind and under the angles of the jaws causes an effective and
quick drainage. This flushing treatment may be repeated several times
daily with good effect.
POSTPHARYNGEAL LYMPH GLANDS. -- These glands are
located posterior to the walls of the pharynx, and anterior to the first
and second cervical vertebrae. They receive afferent vessels, from
the nasal cavities and the nasal accessory sinuses, from the nasopharynx,
pharyngeal tonsil, Eustachian tube, the middle ear, and other adjacent
deep structures. Since these structures are so commonly the source
of infection, the postpharyngeal glands are often involved and retro-pharyngeal
abscess, with its various complications, is not uncommon. Efferent
vessels of these glands drain into the deep cervical lymph glands, therefore
involvement of the cervical glands frequently results from infection of
the various structures named above.
APPLICATION. -- The abundant anastomoses of the lymphatic
vessels and the fact that lymph flows rather freely in any direction, explains
the common extension of infections from a glandular center. Extension
of infection from the postpharyngeal glands, involving the various structures
of the pharynx, larynx and oral cavity, is common. This explains
why tonsillitis, pharyngitis, and even infections of the gums, may result
from sinusitis or an infected nasopharynx, which is common, and this explains
why tonsillitis may often be relieved by removal of the adenoids and the
proper treatment of the nasopharynx, sinuses and nares. Inflammatory
(catarrhal) diseases of the Eustachian tube and middle ear frequently result
form infections of the nasopharynx, adenoid growths or adhesions resulting
from their incomplete atrophy, intranasal or sinus infections, and the
source of this inflammation must be successfully treated before the ear
affection can be controlled. Extension of inflammation along the
walls of the Eustachian tubes from pharyngeal infections is the most common
cause of catarrhal deafness. Tonsillar infection is the primary cause
of pharyngeal infection in some cases, but from the evidence given above
and from clinical observation, I believe that sinus, intranasal and nasophyaryngeal
infections are more often the cause of ear trouble that is tonsillitis.
Any treatment which does not actually remove the
cause of infection or physical irritation of the pharynx cannot be considered
an efficient treatment for catarrhal deafness. Sinus infections,
intranasal infections and definite obstructions to normal intranasal drainage
must be properly treated. The same is true of intrapharyngeal obstructions
and sources of infection. To crush adenoids or pharyngeal adhesions
without actually removing every part that may interfere with postnasal
drainage cannot produce the best results, because the source of the trouble
has not been removed, and here is wherein the so-called “finger surgery”
technic alone, fails to acomplish the best results. The direct treatment
of the Eustachian tube and surrounding structures will result in partial
and temporary results, only, unless the causes of inflammation are removed.
Persistent colds in the head, pharyngitis, laryngitis,
voice impairment, etc., likewise are often caused and maintained by extension
of infection from the postpharyngeal lymphatic glands, and the same principles
of treatment apply.
In acute infections of the postpharyngeal glands,
the same treatment as given above under “Parotid Lymph Glands,” applies.
However, in all acute infections it is a good rule to do no or very little
direct treatment of the parts involved. There are exceptions to this
rule, but, in general, it is a safe plan to follow because radical treatment
may often result in an extension of the infection rather than relieve it.
Anterior Pharyngeal Lymph Glands
According to Treves, “Accessory glands, belonging
to the thyroid body, are frequently found in the vicinity of the hyoid
bone. They are also found in the basal part of the tongue, near the
In many cases of acute disease the swelling of these
glands like the postpharyngeal glands cause much soreness and discomfort.
In tonsillitis, pharyngitis, etc., there is usually some affection of these
glands but, as stated above, direct treatment is not indicated during the
acute stage. Deep relaxation under the angles of the jaws externally
will facilitate drainage. After the acute stage has passed, direct
treatment may be done as follows: The two cornui of the hyoid are grasped
between the thumb and second fingers of the left hand, palm upward, while
the first and second fingers of the right hand are passed, palm downward,
over the base of the tongue thus holding the hyoid firmly between these
four fingers. The hyoid may now be lifted upward and thus by virtue
of its attachment to the thyroid cartilage, the entire larynx may be lifted
The hyoid is held in this position for a few seconds, then pulled firmly
forward and then downward and by these movements the pharyngeal constrictors
may be relaxed and lymphatic and venous drainage accomplished.
In chronic pharyngitis and laryngitis this treatment
will be found quite effective. To accomplish the desired results
the purpose and technic of the treatment must be considered and the treatment
must not be painful to the patient or the proper relaxation will not be
PLATE XLIX. Lymph Drainage
of Throat. -- (1) Parotid gland and nodes. (2) Three-fold drainage
by lingual lymphtics. (3) Nodes in relation to submaxillary bland.
(4) Lingual lymph vessels in relation to the sublingual gland.
(5) Carotid artery. (6) Internal jugular vein. (7) Nodes collecting
lymph from teeth, gums and tongue. (8) Lymphatic vessels collecting
lymph from the gums.
Tonsils and Lymph Drainage
The group of lymphoid tissue commonly known as Waldeyer’s
tonsillar ring, consisting of faucial, lingual and pharyngeal tonsils,
is frequently affected by infections carried through the lymph channels.
The pharyngeal tonsils or adenoids are often involved secondary to sinus
infections and the faucial tonsils are also frequently infected as a result
of either adenoid, posterior nasal or sinus infections. In all cases
of faucial tonsillitis it is essential to determine whether there is some
infection above. Many cases of faucial tonsillitis will be entirely
relieved by the proper treatment of the nasal accessory sinuses, posterior
nasal chambers and the nasopharynx.
There is no positive evidence that the faucial tonsils
have a function different from other lymphoid tissue, and since this tissue
is usually excessive there is no reason why the tonsils should not be removed
surgically so far as any loss of function is concerned when they are pathologically
involved beyond restoration to normal, but because of reasons given above
it is more logical to sacrifice the adenoid tissue first. Many cases
of faucial tonsil involvement will be promptly relieved by adenoidectomy
and the proper treatment of the entire nasopharynx sinuses.
From the study of my cases I am convinced that tubercular
infections of the tonsils is frequently secondary to tubercular sinusitis.
To diagnose tubercular tonsillitis it is necessary to first thoroughly
clean the entire pharynx by irrigation, swabbing and gargling and then
obtain pus from the crypts of the tonsils by cupping or by means of probing
deeply into the crypts and making stains of the pus thus obtained.
The tonsils may be the primary source of tubercular infection
but a tubercular infection of the tonsils is rarely confined to that locality
long. There is usually evidence of an extension to the sinuses, lungs
or cervical lymph glands and when there is an active involvement of any of these
other structures it is essential to arrest the active infection in the lungs,
sinuses or lymph glands before advising tonsillectomy.