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

    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 arteries.

General Anatomy

    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 the neck.

    Intracranial lymph vessels from the brain and meninges follow the courses of the arteries and veins and empty into the deep cervical glands.

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 otitis media.

    “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 and parotiditis.

    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 foramen caecum.”

    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 accomplished.

    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.

Tubercular Tonsillitis

    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.