3. The Lymphatics of the Head, Face, and Neck

The lymph glands of the head are arranged in the following groups: 1

Occipital.		Facial.
Posterior Auricular.		Deep Facial.
Anterior Auricular.		Lingual.
Parotid.		Retropharyngeal.

The occipital glands (lymphoglandulæ occipitales), one to three in nu ber, are placed on the back of the head close to the margin of the Trapezius and resting on the insertion of the Semispinalis capitis. Their afferent vessels drain the occipital region of the scalp, while their efferents pass to the superior deep cervical glands. 2 The posterior auricular glands (lymphoglandulæ auriculares; mastoid glands), usually two in number, are situated on the mastoid insertion of the Sternocleidomastoideus, beneath the Auricularis posterior. Their afferent vessels drain the posterior part of the temporoparietal region, the upper part of the cranial surface of the auricula or pinna, and the back of the external acoustic meatus; their efferents pass to the superior deep cervical glands. 3

FIG. 602– Superficial lymph glands and lymphatic vessels of head and neck. (See enlarged image) The anterior auricular glands (lymphoglandulæ auriculares anteriores; superficial parotid or preauricular glands), from one to three in number, lie immediately in front of the tragus. Their afferents drain the lateral surface of the auricula and the skin of the adjacent part of the temporal region; their efferents pass to the superior deep cervical glands. 4 The parotid glands (lymphoglandulæ parotideæ), form two groups in relation with the parotid salivary gland, viz., a group imbedded in the substance of the gland, and a group of subparotid glands lying on the lateral wall of the pharynx. Occasionally small glands are found in the subcutaneous tissue over the parotid gland. Their afferent vessels drain the root of the nose, the eyelids, the frontotemporal region, the external acoustic meatus and the tympanic cavity, possibly also the posterior parts of the palate and the floor of the nasal cavity. The efferents of these glands pass to the superior deep cervical glands. The afferents of the subparotid glands drain the nasal part of the pharynx and the posterior parts of the nasal cavities; their efferents pass to the superior deep cervical glands. 5 The facial glands comprise three groups: (a) infraorbital or maxillary, scattered over the infraorbital region from the groove between the nose and cheek to the zygomatic arch; (b) buccinator, one or more placed on the Buccinator opposite the angle of the mouth; (c) supramandibular, on the outer surface of the mandible, in front of the Masseter and in contact with the external maxillary artery and anterior facial vein. Their efferent vessels drain the eyelids, the conjunctiva, and the skin and mucous membrane of the nose and cheek; their efferents pass to the submaxillary glands. 6 The deep facial glands (lymphoglandulæ faciales profunda; internal maxillary glands) are placed beneath the ramus of the mandible, on the outer surface of the Pterygoideus externus, in relation to the internal maxillary artery. Their afferent vessels drain the temporal and infratemporal fossæ and the nasal part of the pharynx their efferents pass to the superior deep cervical glands. 7 The lingual glands (lymphoglandulæ linguales) are two or three small nodules lying on the Hyoglossus and under the Genioglossus. They form merely glandular substations in the course of the lymphatic vessels of the tongue. 8

FIG. 603– Lymphatics of pharynx. (Poirier and Charpy. (See enlarged image) The retropharyngeal glands (Fig. 603), from one to three in number, lie in the buccopharyngeal fascia, behind the upper part of the pharynx and in front of the arch of the atlas, being separated, however, from the latter by the Longus capitis. Their afferents drain the nasal cavities, the nasal part of the pharynx, and the auditory tubes; their efferents pass to the superior deep cervical glands. 9 The lymphatic vessels of the scalp are divisible into (a) those of the frontal region, which terminate in the anterior auricular and parotid glands; (b) those of the temporoparietal region, which end in the parotid and posterior auricular glands; and (c) those of the occipital region, which terminate partly in the occipital glands and partly in a trunk which runs down along the posterior border of the Sternocleidomastoideus to end in the inferior deep cervical glands. 10

The lymphatic vessels of the auricula and external acoustic meatus are also divisible into three groups: (a) an anterior, from the lateral surface of the auricula and anterior wall of the meatus to the anterior auricular glands; (b) a posterior, from the margin of the auricula, the upper part of its cranial surface, the internal surface and posterior wall of the meatus to the posterior auricular and superior deep cervical glands; (c) an inferior, from the floor of the meatus and from the lobule of the auricula to the superficial and superior deep cervical glands. 11 The lymphatic vessels of the face (Fig. 604) are more numerous than those of the scalp. Those from the eyelids and conjunctiva terminate partly in the submaxillary but mainly in the parotid glands. The vessels from the posterior part of the cheek also pass to the parotid glands, while those from the anterior portion of the cheek, the side of the nose, the upper lip, and the lateral portions of the lower lip end in the submaxillary glands. The deeper vessels from the temporal and infratemporal fossæ pass to the deep facial and superior deep cervical glands. The deeper vessels of the cheek and lips end, like the superficial, in the submaxillary glands. Both superficial and deep vessels of the central part of the lower lip run to the submental glands. 12

FIG. 604– The lymphatics of the face. (After Küttner.) (See enlarged image) Lymphatic Vessels of the Nasal Cavities.—Those from the anterior parts of the nasal cavities communicate with the vessels of the integument of the nose and end in the submaxillary glands; those from the posterior two-thirds of the nasal cavities and from the accessory air sinuses pass partly to the retropharyngeal and partly to the superior deep cervical glands. 13 Lymphatic Vessels of the Mouth.—The vessels of the gums pass to the submaxillary glands; those of the hard palate are continuous in front with those of the upper gum, but pass backward to pierce the Constrictor pharyngis superior and end in the superior deep cervical and subparotid glands; those of the soft palate pass backward and lateralward and end partly in the retropharyngeal and subparotid, and partly in the superior deep cervical glands. The vessels of the anterior part of the floor of the mouth pass either directly to the inferior glands of the superior deep cervical group, or indirectly through the submental glands; from the rest of the floor of the mouth the vessels pass to the submaxillary and superior deep cervical glands. 14 The lymphatic vessels of the palatine tonsil, usually three to five in number, pierce the buccopharyngeal fascia and constrictor pharyngis superior and pass between the Stylohyoideus and internal jugular vein to the uppermost of the superior deep cervical glands. They end in a gland which lies at the side of the posterior belly of the Digastricus, on the internal jugular vein; occasionally one or two additional vessels run to small glands on the lateral side of the vein under cover of the Sternocleidomastoideus. 15

FIG. 605– Lymphatics of the tongue. (Poirier and Charpy.) (See enlarged image) The lymphatic vessels of the tongue (Fig. 605) are drained chiefly into the deep cervical glands lying between the posterior belly of the Digastricus and the superior belly of the Omohyoideus; one gland situated at the bifurcation of the common carotid artery is so intimately associated with these vessels that it is known as the principal gland of the tongue. The lymphatic vessels of the tongue may be divided into four groups: (1) apical, from the tip of the tongue to the suprahyoid glands and principal gland of the tongue; (2) lateral, from the margin of the tongue—some of these pierce the Mylohyoideus to end in the submaxillary glands, others pass down on the Hyoglossus to the superior deep cervical glands; (3) basal, from the region of the vallate papillæ to the superior deep cervical glands; and (4) median, a few of which perforate the Mylohyoideus to reach the submaxillary glands, while the majority turn around the posterior border of the muscle to enter the superior deep cervical glands. 16 The Lymph Glands of the Neck—The lymph glands of the neck include the following groups: 17

Submaxillary.		Superficial Cervical.
Submental.		Anterior Cervical.
Deep Cervical.

The submaxillary glands (lymphoglandulæ submaxillares) (Fig. 604), three to six in number, are placed beneath the body of the mandible in the submaxillary triangle, and rest on the superficial surface of the submaxillary salivary gland. One gland, the middle gland of Stahr, which lies on the external maxillary artery as it turns over the mandible, is the most constant of the series; small lymph glands are sometimes found on the deep surface of the submaxillary salivary glands. The afferents of the submaxillary glands drain the medial palpebral commissure, the cheek, the side of the nose, the upper lip, the lateral part of the lower lip, the gums, and the anterior part of the margin of the tongue; efferent vessels from the facial and submental glands also enter the submaxillary glands. Their efferent vessels pass to the superior deep cervical glands. 18 The submental or suprahyoid glands are situated between the anterior bellies of the Digastrici. Their afferents drain the central portions of the lower lip and floor of the mouth and the apex of the tongue; their efferents pass partly to the submaxillary glands and partly to a gland of the deep cervical group situated on the internal jugular vein at the level of the cricoid cartilage. 19 The superficial cervical glands (lymphoglandulæ cervicales superficiales) lie in close relationship with the external jugular vein as it emerges from the parotid gland, and, therefore, superficial to the Sternocleidomastoideus. Their afferents drain the lower parts of the auricula and parotid region, while their efferents pass around the anterior margin of the Sternocleidomastoideus to join the superior deep cervical glands. 20 The anterior cervical glands form an irregular and inconstant group on the front of the larynx and trachea. They may be divided into (a) a superficial set, placed on the anterior jugular vein; (b) a deeper set, which is further subdivided into prelaryngeal, on the middle cricothyroid ligament, and pretracheal, on the front of the trachea. This deeper set drains the lower part of the larynx, the thyroid gland, and the upper part of the trachea; its efferents pass to the lowest of the superior deep cervical glands. 21 The deep cervical glands (lymphoglandulæ cervicales profundæ) (Figs. 602, 605) are numerous and of large size: they form a chain along the carotid sheath, lying by the side of the pharynx, esophagus, and trachea, and extending from the base of the skull to the root of the neck. They are usually described in two groups: (1) the superior deep cervical glands lying under the Sternocleidomastoideus in close relation with the accessory nerve and the internal jugular vein, some of the glands lying in front of and others behind the vessel; (2) the inferior deep cervical glands extending beyond the posterior margin of the Sternocleidomastoideus into the supraclavicular triangle, where they are closely related to the brachial plexus and subclavian vein. A few minute paratracheal glands are situated alongside the recurrent nerves on the lateral aspects of the trachea and esophagus. The superior deep cervical glands drain the occipital portion of the scalp, the auricula, the back of the neck, a considerable part of the tongue, the larynx, thyroid gland, trachea, nasal part of the pharynx, nasal cavities, palate, and esophagus. They receive also the efferent vessels from all the other glands of the head and neck, except those from the inferior deep cervical glands. The inferior deep cervical glands drain the back of the scalp and neck, the superficial pectoral region, part of the arm (see page 701), and, occasionally, part of the superior surface of the liver, In addition, they receive vessels from the superior deep cervical glands. The efferents of the superior deep cervical glands pass partly to the inferior deep cervical glands and partly to a trunk which unites with the efferent vessel of the inferior deep cervical glands and forms the jugular trunk. On the right side, this trunk ends in the junction of the internal jugular and subclavian veins; on the left side it joins the thoracic duct. 22

FIG. 606– The superficial lymph glands and lymphatic vessels of the upper extremity. (See enlarged image) The lymphatic vessels of the skin and muscles of the neck pass to the deep cervical glands. From the upper part of the pharynx the lymphatic vessels pass to the retropharyngeal, from the lower part to the deep cervical glands. From the larynx two sets of vessels arise, an upper and a lower. The vessels of the upper set pierce the hyothyroid membrane and join the superior deep cervical glands. Of the lower set, some pierce the conus elasticus and join the pretracheal and prelaryngeal glands; others run between the cricoid and first tracheal ring and enter the inferior deep cervical glands. The lymphatic vessels of the thyroid gland consist of two sets, an upper, which accompanies the superior thyroid artery and enters the superior deep cervical glands, and a lower, which runs partly to the pretracheal glands and partly to the small paratracheal glands which accompany the recurrent nerves. These latter glands receive also the lymphatic vessels from the cervical portion of the trachea. 23

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