LYMPHATICS

SURGIGAL ANATOMY
Primordial lymphatic system begins to develop during
6th
week of development adjacent to jugular vein as lymph
sacs.
Peripheral lymphatic systems develop from these
primordial
lymph sacs. Lymphatic system has three components.
Terminal
lymphatic capillaries, which have high porosity absorb
lymph,
macromolecules, cells and microbes from tissues into
the
system; lymphatic vessels which collect and transport
lymph;
lymph nodes which are interposed in the lymphatic
pathway
fi lter lymph and maintain immunity of the body.
Lymphatic
vessels run adjacent to main blood vessels reaching the
major
lymphatic channels. Cisterna chyli is formed in the
abdomen,
continues as thoracic duct (formed at 9th week of
gestation) in
the thorax which has got initial main course towards
right side of
the mediastinum; but later towards left side entering
the internal
jugular vein at its joining point of the subclavian vein. In
the
periphery there is hardly any lymphovenous
communications.
Lymphovenous communications occur at lymph node
level;
iliac, subclavian and jugular levels. Lymphatics are
absent in
epidermis, cornea, CNS, cartilage, tendon and muscle.
Great lymph ducts arethe thoracic ductsingle; right
lymph ductsingle; subclavian, bronchomediastinal
and
jugular trunks on both sides. These ducts contain
valves to
prevent backflow.
Cisterna chyli is formed by joining of right and left
lumbar
lymphatic trunks and intestinal lymphatic duct. Lumbar
trunks
are short lymph vessels arising from para-aortic lymph
glands.
It receives lymph from lower limb, pelvis and pelvic
viscera,
kidney, adrenal and deep lymphatics of abdominal wall.
Left
lumbar trunk is behind the aorta. Intestinal lymph duct
arises
from preaortic nodes. It joins the cisterna chyli from
front. I
convex surface which drains into right lymph duct),
spleen
and pancreas. Cisterna chyli is a lymph sac lying in
front of the
L1 and L2 vertebrae between aorta and crus of the
diaphragm.
From its upper end it continues as thoracic duct.
Tributaries of thoracic duct aretrunk
from lateral intercostal nodes from lower six spaces;
efferents
from posterior mediastinal nodes, lateral intercostal
nodes of
upper six spaces, left jugular lymph trunk from head
and neck
region, left subclavian lymph trunk from left upper limb,
left
bronchomediastinal trunk from left side of the thorax.
Single
termination of duct is common (77%); but
double/triple/quadruple
terminations are known to occur. Occasionally it may
end
in left subclavian vein, left vertebral vein, right internal
jugular
vein, right subclavian vein. Thoracic duct is 45 cm in
length
and 5 mm wide (wider at both ends; narrow in the
middle).
Right lymph duct is 2.5 cm in length, formed by right
jugular, right subclavian and right bronchomediastinal
trunks;
runs on the scalenus anterior joining the junction of
right
internal jugular vein and subclavian vein.

HISTORY

How long has the lump been there? If the lump has been present for
less than a few weeks, the likelihood is that it represents infective or
inflammatory lymphadenopathy, although some patients will present
with malignant neck lumps that have only been noticed within the last
few days. If, however, the lump has been present for longer than a few
weeks then malignancy must be excluded. Note that congenital neck
lumps have often been present for some time, but do not have to have
been present since birth. For example, branchial cysts may appear in
adults following an episode of infection.
 Has the lump got bigger, smaller, or stayed the same size? A
lump that is gradually increasing in size must be regarded as a
malignancy until proven otherwise. Remember that a progressive
increase in size of a malignant neck
lump may be reported as a sudden appearance by the patient.
Is the lump painful? Most neck lumps are not painful. The only
lumps that are
classically painful are acute infective lymphadenitis or an infected
branchial
cyst.
Are there any other lumps? If the patient has noticed other similar
lumps
elsewhere on their body (for example, groin or axilla) then it is likely
that the
lump represents either a systemic disease (e.g. HIV, tuberculosis) or
disseminated
malignancy (e.g. lymphoma).
Given that most neck lumps in adults are enlarged lymph glands, and
the most
common underlying causes are infection and malignancy, you should
ask:
Are there symptoms suggestive of infection? Ask about malaise,
fever, rigors,
etc. But note that fever, night sweats, and weight loss are also B
symptoms of
lymphoma. Th erefore the time course of symptoms can be useful
an acute history
favours infection whereas a more prolonged history favours
malignancy.
Th ere may also be more local symptoms of infection, such as pain
from a dental
abscess.
Are there any symptoms suggestive of head and neck cancer?
Head and
neck cancers are not usually associated with weight loss or malaise,
but there
are a number of other suggestive features. Th ose to enquire about
include:
dysphonia, stridor, stertor, breathing diffi culty, dysphagia,
odynophagia, globus, cough, haemoptysis , otalgia, unilateral
hearing loss, nasal discharge, epistaxis, and lumps or ulcers.

EXAMINATION
Is it in the anterior or the posterior triangle of the neck (i.e. in
front of or
behind the sternocleidomastoid)? If we only consider deep structures,
we
can usually allocate lesions to the anterior or posterior triangle as
follows:
Anterior triangle: branchial cyst/sinus/fi stula, carotid body
tumour
(chemodectoma), carotid artery aneurysm, salivary gland, laryngocele
Posterior triangle: cystic hygroma, cervical rib, pharyngeal pouch,
subclavian
aneurysm.
3) What is its relationship to muscle? Asking the patient to nod their
head
against resistance will tense the sternocleidomastoid muscle on both
sides
of the neck (this also demonstrates which triangle the lump is in).
Shrugging
the shoulder against resistance will contract trapezius. Any lump that
is
underneath the muscle will be concealed when the muscle contracts.
While we acknowledge that thyroid masses are strictly in the
anterior triangle, and that a single
nodule in the lateral aspect of a thyroid lobe may present as a lateral
lump, we have omitted discussing
them in this fi rst case for the sake of simplicity.
What other features of the lump should be characterized during
palpation?
Is there anything other than the lump that the GP should examine?
 Is it tender and/or warm? Th e only neck lumps that are classically
tender
and/or warm are infected or infl ammatory masses. An important
exception
in at-risk patient groups is a tuberculous adenitis. In the acute phase
this may
present with painless lymphadenopathy and overlying erythema,
whereas
progressive disease can present with a discharging sinus or a cold
abscess.
Is it solid or fl uctuant? Th ere are various textbook descriptions of
degrees
of lump fi rmness that correspond to diff erent causes of cervical
lymphadenopathy,
but in practice it can hard to distinguish a supposedly hard from a
rubbery lump. Classically, lumps can be divided into:
Hard lumps: malignant lymph nodes
Rubbery lumps: chronic infl ammatory lymph nodes (e.g.
tuberculosis) or
lymphomatous nodes
Soft lumps: acute infl ammatory lymph nodes
Fluctuant lumps: branchial cysts, cystic hygromas, pharyngeal
pouches,
laryngoceles, cold abscesses, epidermal cysts, dermoid cysts, lipomas.
Is it pulsatile? Subclavian or carotid aneurysms are pulsatile.
Chemodectomas
are often pulsatile but not necessarily so.
Is it mobile? Th is question relates principally to lymphadenopathy.
The majority of lymph nodes are relatively mobile. Malignant lymph
nodes may be tethered to adjacent structures, while tuberculous nodes
may appear matted
together. It is always important to examine the entire region
systematically.

PROVISIONAL DIAGNOSIS

Diff erential diagnosis for midline neck lump

Physiological goitre
Lipoma
Multinodular goitre
Dermoid cyst
Graves disease
Epidermal cyst
Hashimotos thyroiditis
Abscess
Thyroglossal cyst Lymphoma
Thyroid cyst
Solitary adenoma
Carcinoma

TREATMENT

Conservative

a. Elevation of the limb, exercise, weight reduction.

b. Static isometric activities like prolonged standing or carrying
weights should be avoided; rhythmic isotonic movements
like swimming/massaging should be encouraged.
c. Diuretics to reduce the oedema is controversial. It more often
causes eletrolyte imbalance than being benefi cial.
d. Benzopyrones are protienolytic agents/lympedim. They
are coumarin (I, 2 benzopyrones) derivatives with no anticoagulant
effect but increase the lymphatic peristalsis and
pumping mechanism along with proteolysis.
e. Daily wearing of below knee stockings.
f. Avoid trauma and infection.
g. Intermittent pneumatic compression devices (Pressure > 50
mmHg); multilayered lymphoedema bandaging (MLLB)
nonelastic type is preferred method; graded stockings.
h. Antibioticsfl ucloxacillin, erythromycin, long acting penicillins.
i. Topical antifungal 1% clotrimazole and systemic griseofulvin
250-1000 mg.
j. Regular washing and keeping the limb clean is very important.
k. Diethyl carbamazine citrate (DEC) 100 mg TID for 3 weeks.
l. Pain reliefby suitable means.
m. Skin care:
_ Keratolytics like salicylic acid 5%; bland emollient;
soft/liquid paraffi n.
_ Avoidance of skin sensitisers like some soaps.
_ Topical steroids.
_ Control of allergy.
_ Control of fungal infection by drugs like fl uconazole.
_ 3% benzoic acid ointment to prevent Athletes foot.
_ Control of lymphorrhoea.
_ Prevention/control of skin infections.
n. Complex decongestive therapy is a comprehensive two
phase program of elevation, exercise, massaging, and
compression wraps. First phase is intensive therapy and
second phase is maintenance therapy.
Compression wraps may be high stretch wraps or low
stretch wraps. Low stretch wraps are better accepted. It
should be worn initially for 24 hours. Compression wraps
are used in initial intensive phase of therapy. Graduated
elastic compression garments are used in maintenance
phase which provides maximum pressure of 50 mmHg
at the distal part with gradual reduction of pressure in
proximal portion.
Surgeries for lymphoedema has been classifi ed as:
a. Excisional
_ Charles operation.
_ Homans operation.
b. Physiological
_ Omentoplasty.
_ Nodovenous shunt (Neibulowitz).
_ Lymphovenous shunt (OBriens).
_ Ileal mucosal patch.
Here either communication between superfi cial and deep
lymphatics are created or new lymphatic channels are
mobilised to the site.
Omentoplasty (Omental pedicle): As omentum contains
plenty of lymphatics, omental transfer with pedicle will
facilitate lymph drainage.
c. Combined: Both excision + creation of communication
between superfi cial and deep lymphatics.
_ Sistrunk operation.
_ Thompsons operation.
_ Kondoleans operation.
_ Skin bridge across the thigh and abdomen (Gillies).
_ Nodovenous shunt.
_ Lymphovenous shunt using microscope.
_ Ileal mucosal patch (Kinmonth). Segment of ileum with
pedicle is isolated and opened to expose the mucosa;
mucosa is denuded and this mucosa is placed in the thigh
as burial to communicate with lymphatics to drain into
abdominal lymphatics across ileum.
_ Baumeister lymphatic grafting.
_ Autotransplantation of free lymphatic fl ap from opposite
sidedone in post-mastectomy lymphoedema (Trevidic
and Cormier).
e. Limb reduction surgeries:
_ Sistrunk operation: Along with excision of lymphoedematous
tissue, window cuts in deep fascia is done, so
as to allow communication into normal deep lymphatics.
_ Homans operation: Excision of lymphoedematous
tissue is done after raising skin fl aps. Later skin fl aps are
trimmed to required size and sutured primarily. Medial
and lateral sides of the limb are done at separate sittings
with 6 months interval.
_ Thompsons operation: Lymphoedematous tissue is
excised under the skin flaps.
_ Millers procedure: It is excision of subcutaneous
tissues under the skin fl ap with deep fascia in two stages.
First stage is done over the medial aspect of the limb;
second stage done after two months over lateral aspect
of the limb.
_ Charles (1912) operation: Done in severe lymphoedema
with elephantiasis. Along with excision of
lymphoedematous tissue, skin grafting is done. It
reduces the size and weight of the limb. Patient becomes
ambulatory. Wound sepsis, graft failure, dermatitis,
hyperkeratosis are the complications.
_ Reduction surgeries are done for lymphoedema of
scrotum, penis, labia and eyelid.