• Gross anatomy: – Components of the lymphatic system: lymphatic plexuses, lymphatics, lymphoid tissue – Plan of the lymphatic system: Superficial lymphatic vessels, deep lymphatic vessels, lymph nodes, lymph trunks, cysterna chyli, lymph ducts: right lymph duct and thoracic duct. – Lymphatic drainage of the lower limb • Superficial inguinal lymph nodes: arrangement and drainage area. • Deep inguinal lymph nodes: arrangement and drainage area. The popliteal lymph nodes – Lymphatic drainage of the upper limb • Superficial and deep lymphatics. Supratrochlear and infraclavicular lymph nodes. • Axillary lymph nodes: arrangement and drainage area. – Plan of the lymphatic drainage of the head and neck: deep cervical lymph nodes, inner and outer circle of lymph nodes. • Deep cervical lymph nodes: location of the upper and lower groups, jugulodigastric node, jugulo-omohyoid, supraclavicular lymph nodes. Drainage area and efferent vessels. • The outer circle of lymph nodes: submental, submandibular, buccal, mandibular, parotid, mastoid, occipital: location, drainage area and efferent vessels. • The inner circle of lymph nodes: pretracheal, paratracheal and retropharyndeal. • The tonsils and Waldeyer’s ring. – Lymphatic drainage of the thorax: • Lymph nodes of the chest wall: Parasternal, intercostal, and phrenic • Lymph nodes of the mediastinum: Nodes around the division of the trachea and the main bronchi, anterior and posterior mediastinal nodes. – Plan of lymphatic drainage of the abdomen: lumbar and intestinal lymph trunks. • Pre-aortic lymph nodes: mesenteric, celiac, superior and inferior mesenteric lymph nodes. • Para-aortic lymph nodes. • MALT & Peyer’s patches. – Lymphatic drainage in the pelvis: External and internal iliac lymph nodes, lymph nodes in fascial sheaths, sacral and common iliac lymph nodes. • Applied anatomy • Functional and clinical importance of the lymphatic system; Virchow’s lymph nodes; Retropharyngeal abscess; Clinical applications of enlarged thoracic lymph nodes: involvement of left recurrent laryngeal nerve and phrenic nerve. Pressure on the esophagus. Carinal lymph nodes and bronchoscopy; Communications of lymphatics between thorax and abdomen. • Radiographic anatomy: – Lymphangiogrms. • Surface anatomy of palpable lymph node groups: superficial inguinal, axillary, infraclavicular, outer circle of crevical lymph nodes, deep cervical lymph nodes.

1. Anatomy of the Lymphatic
System
Dr.Akram Jaffar, Ph.D.
Dr. Akram Jaffar
Dr. Akram Jaffar

2. References and suggested reading
• Moore KL et al. (2010): Clinically Orientated Anatomy. 6th Ed. Lippincott, Williams &
Wilkins. Philadelphia.
• Snell RS (2006): Clinical anatomy by systems. Lippincott Williams & Wilkins.
Baltimore.
• Young B, Lowe JS, Stevens A & Heath JW (2006): Wheater’s functional histology. 5th
ed. Churchill Livingstone Elsevier. Philadelphia. pp: 263-273.
• Lymphangiograhpy: http://www.answers.com/topic/lymphangiography?cat=health
Dr. Akram Jaffar
Dr. Akram Jaffar

3. Objectives
• Gross anatomy:
– Components of the lymphatic system: lymphatic plexuses, lymphatics, lymphoid tissue
– Plan of the lymphatic system: Superficial lymphatic vessels, deep lymphatic vessels, lymph nodes, lymph trunks,
cysterna chyli, lymph ducts: right lymph duct and thoracic duct.
– Lymphatic drainage of the lower limb
• Superficial inguinal lymph nodes: arrangement and drainage area.
• Deep inguinal lymph nodes: arrangement and drainage area. The popliteal lymph nodes
– Lymphatic drainage of the upper limb
• Superficial and deep lymphatics. Supratrochlear and infraclavicular lymph nodes.
• Axillary lymph nodes: arrangement and drainage area.
– Plan of the lymphatic drainage of the head and neck: deep cervical lymph nodes, inner and outer circle of lymph nodes.
• Deep cervical lymph nodes: location of the upper and lower groups, jugulodigastric node, jugulo-omohyoid,
supraclavicular lymph nodes. Drainage area and efferent vessels.
• The outer circle of lymph nodes: submental, submandibular, buccal, mandibular, parotid, mastoid, occipital:
location, drainage area and efferent vessels.
• The inner circle of lymph nodes: pretracheal, paratracheal and retropharyndeal.
• The tonsils and Waldeyer’s ring.
– Lymphatic drainage of the thorax:
• Lymph nodes of the chest wall: Parasternal, intercostal, and phrenic
• Lymph nodes of the mediastinum: Nodes around the division of the trachea and the main bronchi, anterior and
posterior mediastinal nodes.
– Plan of lymphatic drainage of the abdomen: lumbar and intestinal lymph trunks.
• Pre-aortic lymph nodes: mesenteric, celiac, superior and inferior mesenteric lymph nodes.
• Para-aortic lymph nodes.
• MALT & Peyer’s patches.
– Lymphatic drainage in the pelvis: External and internal iliac lymph nodes, lymph nodes in fascial sheaths, sacral and
common iliac lymph nodes.
• Applied anatomy
• Functional and clinical importance of the lymphatic system; Virchow’s lymph nodes; Retropharyngeal abscess; Clinical
applications of enlarged thoracic lymph nodes: involvement of left recurrent laryngeal nerve and phrenic nerve. Pressure on
the esophagus. Carinal lymph nodes and bronchoscopy; Communications of lymphatics between thorax and abdomen.
• Radiographic anatomy:
Dr. Akram Jaffar
– Lymphangiogrms.
• Surface anatomy of palpable lymph node groups: superficial inguinal, axillary, infraclavicular, outer circle of cervical lymph
nodes, deep cervical lymph nodes.
Dr. Akram Jaffar

4. Components of the lymphatic system
Widely distributed throughout most of the body but absent from CNS, eyeball, internal
ear, cartilage and bone
• Lymphatic plexuses: network of lymphatic
capillaries.
• Lymphatic vessels (lymphatics): thin walled
vessels with abundant valves. Beaded
appearance.
– What are the factors influencing the
lymph flow?.
• Lymph nodes.
• Lymphoid tissue: Sites that produce
lymphocytes, such as that aggregated in the
walls of the digestive tract; in the Lymphatic vessel valve
spleen, thymus, and lymph nodes..
Dr. Akram Jaffar
Dr. Akram Jaffar

5. Functional and clinical importance
• Function
– Assist the capillaries:
• Returns some plasma proteins that leak into the extracellular spaces
as well as cellular debris that cannot return through the wall of blood
capillaries.
– Essential for immonological defenses.
• Clinical importance:
– Obstruction  Lymphoedema.
– Conduit for the spread of malignant disease and infection
• Cells loosened from the primary tumor enter and travel via lymphatics.
• The cells are filtered through and trapped by the lymph nodes. Which
thus become secondary (metastatic) cancer sites.
– May be the site of primary tumor.
Dr. Akram Jaffar
Dr. Akram Jaffar

6. Plan of the lymphatic system
• Superficial lymphatic vessels drain the skin and follow the venous drainage.
• Superficial lymphatic vessels drain into deep lymphatic vessels that accompany the
arteries and also receive the drainage of internal organs.
• Both superficial and deep lymphatic vessels traverse lymph nodes as they course
proximally.
• The larger lymphatic vessels enter large collecting vessels called lymph trunks
which unite to form either the right lymph duct or the thoracic duct.
• The lymph ducts drain into the venous system.
• Lymphatic vessels communicate freely with each other and with veins in many parts
of the body. Consequently, ligation of a lymphatic trunk may have only a transient
effect.
Dr. Akram Jaffar
Dr. Akram Jaffar

7. Lymph ducts
• Right lymph duct
– Drains lymph from the body’s
right upper quadrant (right side
of the head, neck, right side of
the thorax, and the right upper
limb.
– Enters the right venous angle
(junction of the right internal
jugular and right subclavian
veins).
• Thoracic duct
– Drains lymph from the
Internal
remainder of the body. jugular v. Thoracic duct
– Enters the left venous angle.
Subclavian v.
Dr. Akram Jaffar
Dr. Akram Jaffar

8. Cisterna chyli
Venous angle
• A dilated collecting sac.
• Located in the abdomen in front
of the bodies of the 1st and 2nd
lumbar vertebrae. Thoracic duct
• Drain lymphatic trunks of the
lower part of the body.
• Give rise to the thoracic duct
which ascends through the aortic Cysterna chyli
opening of the diaphragm into
the thorax.
Dr. Akram Jaffar
Dr. Akram Jaffar

9. Lymphatic drainage of the lower limb
• Superficial inguinal lymph nodes: Inguinal lig.
• Arrangement: Superficial
Inguinal LN
– T-shape: one row runs parallel to and (horizontal gp)
below the inguinal ligament, while the Superficial
other row is arranged vertically along Inguinal LN
(vertical gp)
the great saphenous vein.
• Drainage area:
– Superficial tissues (everything popliteal LN
superficial to the deep fascia)
– Lower limb (including the buttocks)
except posterolateral part of the calf
Great saphenous v
(drains to popliteal lymph nodes)
– Lower abdominal wall below the
umbilicus.
– External genitalia (excluding the testes).
– Perineum, the lower part of anal canal
and vagina
– Cornu of the uterus by means of
lymphatics that follow the round
Dr. Akram Jaffar
ligament.
Dr. Akram Jaffar

10. Lymphatic drainage of the lower limb
External iliac LN
• Deep inguinal lymph nodes:
Three of four nodes. Lie medial to
the femoral vein, one being in the Femoral a & v
femoral canal.
• Drainage area: Deep inguinal LN Femoral ring
– Deep lymphatics that
accompany the femoral vessels
from the popliteal fossa
– Glans penis (or clitoris).
– Efferent lymphatics from the
superficial inguinal nodes that
pass through the cribriform
Cribriform fascia
fascia.
• Efferent vessels from the deep
inguinal lymph nodes pass through External iliac LN
the femoral canal to enter the
external iliac group of lymph nodes. Femoral ring
Deep inguinal LN
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Superficial
Inguinal LN
Dr. Akram Jaffar

11. Inguinal lymphangiogram
External iliac LN
Deep inguinal LN
Dr. Akram Jaffar
http://www.answers.com/topic/lymphangiography?cat=health
Dr. Akram Jaffar

12. Lymphatic drainage of the upper limb
Infraclavicular LN
• Superficial lymphatics
Cephalic v.
– From the thumb, index finger, and
lateral part of the hand follow the
cephalic vein  infraclavicular
lymph nodes.
– From the medial part of the hand Axillary LN
follow the basilic vein 
supratrochlear lymph node which
lies just above the medial
epicondyle of the humerus  lateral Supratrochlear LN
group of axillary lymph nodes.
• Deep lymphatics: follow the arteries  Basilic v.
lateral group of axillary lymph nodes.
Dr. Akram Jaffar
Dr. Akram Jaffar

13. Axillary lymph nodes
apical gp
• Arrangement:
Central gp
• Anterior or pectoral group lying deep Pectoralis
to pectoralis major along the inferior Minor m.
border of pectoralis minor muscle: Axillary v.
drain most of the lymph of the breast.
• Posterior or subscapular group, lie in
front of subscapularis on the posterior
wall of the axilla.
• Lateral group lying along the axillary
vein.
• Central group lying in the axillary fat.
• Apical group lying behind the clavicle
at the apex of the axilla.
• Drainage area
– Breast.
– Pectoral region.
Anterior gp.
– Upper part of the abdominal wall.
– Upper part of the back. posterior gp.
– Upper limb.
lateral gp.
Dr. Akram Jaffar
Dr. Akram Jaffar

14. Axillary lymphangiogram
• Four days after the injection
of lipoidol into a lymph
vessel into the dorsum of
the hand.
Dr. Akram Jaffar
Dr. Akram Jaffar

15. Lymph drainage of the head & neck: General plan
• Deep cervical lymph nodes:
– Surround the whole length of the
internal jugular vein.
– Ultimately drain all the lymph from the
head and neck.
– Most of this lymph has already filtered
through outlying nodes that are
arranged in two ‘circles’.
• The outer circle is made up of superficial
nodes from chin to occiput.
• The inner circle lies within it, surrounding
the upper air and alimentary passages.
Dr. Akram Jaffar
Dr. Akram Jaffar

16. Deep cervical nodes
• The upper group
• Situated in the angle between the lower border
of the mandible and anterior border of Jugulo-digastric LN
sternomastoid.
• One is related to the posterior belly of digastric
and is therefore called the jugulo-digastric node.
– Often tender and enlarged in infections of
the tonsil and is therefore called the tonsillar
gland.
Internal jugular v.
Dr. Akram Jaffar
Examination of upper deep cervical lymph nodes
Dr. Akram Jaffar

17. Deep cervical nodes
• The lower group
• Situated in the angle between the
sternomastoid and the clavicle.
• One lying deep to sternomastoid above the
inferior belly of omohyoid and is called
jugulo-omohyoid.
– Associated with lymphatic drainage of
the tongue, it is also called the lingual
node.
Internal jugular v.
Jugulo-omohyoid LN
Dr. Akram Jaffar
Dr. Akram Jaffar

18. Deep cervical nodes
• The lower group
• Supraclavicular nodes: lie in the posterior
triangle behind the posterior border of
sternomastoid.
• Efferents from the lower deep cervical group
form the jugular lymph trunk, which joins the
thoracic duct on the left side.
Thoracic duct
Examination of surpraclavicular
lymph nodes
supraclavicular LN
Dr. Akram Jaffar
Dr. Akram Jaffar

19. Supraclavicular lymph nodes
• In tumors of the bronchus and some
abdominal organs e.g. stomach,
supraclavicular lymph nodes particularly on
the left side may enlarge indicating spread.
• Backflow of lymph from the thoracic duct can
pass into the supraclavicular nodes. This is
probably the reason why nodes on the left
side are most commonly involved.
Right lymph duct Jugular lymph trunk
Subclavian lymph trunk
Bronchomediastinal lymph trunk
Virchow’s lymph node
Dr. Akram Jaffar
Dr. Akram Jaffar

20. The outer circle
• Submental nodes
• Lie beneath the chin.
• Drain a wedge of tissue including the
tip of the tongue, floor of the mouth,
gum opposite the incisor teeth and the
same extent of the lower lip.
• Bilateral drainage. Submental LN
• Drain into the submandibular group but
few into the jugulo-omohyoid node.
Submandibular LN
Jugulo-omohyoid LN
Dr. Akram Jaffar
Submental lymphadenopathy
Dr. Akram Jaffar

21. The outer circle
• Submandibular nodes
Jugulo-digastric LN
• Lie on the surface of the submandibular salivary gland.
• Drain from the submental nodes, face,
anterior 2/3rd of the tongue (excluding tip),
Submandibular
floor of the mouth, anterior half of the nose, salivary gland
frontal, maxillary and middle and anterior
ethmoidal sinuses.
• Drain into the jugulo-digastric node; a few
drain into the jugulo-omohyoid node.
Submental LN
Submandibular LN
Jugulo-omohyoid LN
Internal jugular v.
To submandibular
nodes
To submental
Dr. Akram Jaffar
nodes
Dr. Akram Jaffar

22. The outer circle
Upper deep cervical group
• Buccal node
– Small node, which lies on the parotid LN
buccinator muscle.
• Mandibular node
Buccal LN
– Lie on the lower border of the mandible
at the anterior border of masseter.
• They drain part of the cheek and lower Mandiblar LN
eyelids. To which nerve is it closely related?
• Their efferents pass to the superior deep
cervical nodes.
• Pre-auricular (parotid) nodes
• Lie on or within the parotid gland.
• Dain the temple, vertex, eyelids, and orbits
and the external acoustic meatus.
• Efferents drain into the upper deep cervical
lymph nodes.
Dr. Akram Jaffar
Dr. Akram Jaffar

23. The outer circle Occipital LN
• Retroauricular (mastoid) nodes Mastoid LN
– Drain the scalp, auricle, and external
auditory meatus.
• Occipital nodes
– Lie at the apex of the posterior triangle.
– Drain the posterior part of the scalp.
• Efferents drain into the lower deep cervical
nodes.
Lower deep cervical group
Dr. Akram Jaffar
Dr. Akram Jaffar

24. The inner circle
Retropharyngeal LN
• Surround the larynx, trachea, and pharynx.
• Pre-tracheal and paratracheal nodes drain the
lower larynx and trachea and thyroid isthmus. Deep cervical LN
• Retropharyngeal nodes drain the soft palate,
posterior part of the hard palate and nose, and
the pharynx.
– Are involved in a retropharyngeal abscess.
• Drain to the nearest group of deep cervical
nodes.
Pretracheal LN
Dr. Akram Jaffar
Dr. Akram Jaffar

25. Retropharyngeal abscess
Retropharyngeal LN
• Accumulates in the space between the
prevertebral fascia and the buccopharyngeal
membrane.
• May compress the pharynx resulting into
dysphagia and dysartheria.
?
?
Dr. Akram Jaffar
Retro-pharyngeal abscess
Dr. Akram Jaffar

26. The tonsils
• Discontinuous ring (Waldeyer's ring) of
lymphatic tissue around the entrance of
the mouth and nose into the pharynx.
• Paired:
– Palatine tonsil
– Tubal tonsil
• Unpaired
– Pharyngeal tonsil
– Lingual tonsil
Dr. Akram Jaffar
Tonsillitis
Dr. Akram Jaffar

27. Lymphatic drainage of the thorax
Thoracic
duct
Bronchomediastiinal
trunk intercostal
• Lymph nodes of the chest wall:
– Parasternal
– Intercostal
– diaphragmatic (phrenic) parasternal
• Lymph nodes of the mediastinum:
– nodes around the division of the
trachea and the main bronchi
– posterior mediastinal nodes
– anterior mediastinal nodes
Anterior
mediastiinal
Nodes around
Trachea & bronchi
Posterior phrenic
mediastiinal
Dr. Akram Jaffar
Dr. Akram Jaffar

28. Lymph nodes of the chest wall
• Parasternal nodes parasternal
– along the internal thoracic vessels
at the anterior end of the
intercostal spaces.
– Most important afferents are from
the medial half of the breast.
Internal thoracic vessels
Dr. Akram Jaffar
Dr. Akram Jaffar

29. Lymph nodes of the chest wall
• Intercostal nodes
– At the posterior ends of the
intercostal spaces. intercostal
• Diaphragmatic nodes
– Around the periphery of the upper
surface of the diaphragm.
phrenic
Dr. Akram Jaffar
Dr. Akram Jaffar

30. Nodes around the division of the trachea and main
bronchi
tracheobronchial
• Divided into pulmonary (in the lung itself),
bronchopulmonary (along the large bronchi in
the hilum) (hilar) and tracheobronchial (around
the division of the trachea) nodes.
• Efferents form the right and left
bronchomediastinal lymph trunks.
Bronchomediastiinal
trunk
Nodes around
Trachea & bronchi
bronchopulmonary
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pulmonary
Dr. Akram Jaffar

31. Nodes around the division of the trachea and main
bronchi
• On left side these nodes lie near the
L. recurrent laryngeal n.
recurrent laryngeal nerve, which may
be pressed on by enlarged nodes 
voice being affected.
• Involvement of the phrenic nerve  Lymph nodes
paralysis of the diaphragm.
Phrenic n.
Dr. Akram Jaffar
Dr. Akram Jaffar

32. Posterior mediastinal nodes
• Lie posterior to the pericardium. Their
afferents come from the esophagus and
posterior part of the pericardium, and their
efferents go to the thoracic duct.
Enlargement of the posterior mediastinal
nodes may indent the esophagus as seen
radiologically in barium swallow. Esophagus
Pericardium
Posterior
mediastiinal
Dr. Akram Jaffar
Dr. Akram Jaffar

33. Anterior mediastinal nodes
• Lie in front of the brachiocephalic veins
(brachiocephalic nodes). Their afferents come
from the thymus, thyroid gland, and anterior part of
the pericardium. Their efferents go to the
bronchomediastinal trunk.
Anterior
Bronchomediastiinal mediastiinal
trunk
Dr. Akram Jaffar
Anterior
mediastiinal
Dr. Akram Jaffar

34. Connections with the abdomen
• The lower part of the anterior thoracic wall has
lymphatic connections with the upper part of
the anterior abdominal wall.
• Cancer of the breast can spread along these
connections to the abdominal cavity.
• The upper surface of the diaphragm has
lymphatic connections with its lower surface.
These vessels provide another channel for the
spread of cancer from the thorax to the
abdomen.
Dr. Akram Jaffar
Dr. Akram Jaffar

35. Thoracic duct lymphangiogram
Dr. Akram Jaffar
Dr. Akram Jaffar

36. Lymph node groups in the abdomen
• Closely related to the main arteries
– Pre-aortic: related to the three
ventral branches of the aorta
– Para-aortic: related to the lateral
branches
Dr. Akram Jaffar
Dr. Akram Jaffar

37. Coeliac nodes
L.gastric LN
splenic LN
celiac LN
• Around the stem of the coeliac trunk
drain from groups related to the main
arteries of the region
– Left gastric, splenic, hepatic
groups; in addition to the pyloric
and right gastroepiploic groups
related to the gastroduodenal
branch of the hepatic artery
pyloric LN
gastroepiploic LN
Dr. Akram Jaffar
Dr. Akram Jaffar

38. Superior and inferior mesenteric lymph nodes
• Drain the small and large intestines
• Drain the intestines via lymph nodes close to intestinal wall and intermediate
nodes in the mesentery
Epicolic LN
Paracolic LN
Sup. mesenteric LN
Inf. mesenteric LN
Mesocolic LN
mesenteric LN
Dr. Akram Jaffar
Dr. Akram Jaffar

39. Mucosa Associated Lymphoid Tissue
• Non-encapsulated lymphoid tissue which is located in the mucosa and submucosa of
the gastrointestinal, respiratory and urogenital tracts.
• The mucosa-associated lymphoid tissue (MALT) takes the form of diffuse infiltrates or
more discrete nodules: it provides immunologic protection against invasion by
pathogens via vulnerable exposed absorptive surfaces.
Dr. Akram Jaffar
Dr. Akram Jaffar

40. Peyer’s patches
• Lymphoid nodules clusters located in
the lamina propria of the ileum.
• Most exhibit germinal centers,
• May be large enough to produce
visible bulge on the luminal surface
and extend into the submucosa.
• Contain B lymphocyes, T
lymphocytes, macrophages, and
plasma cells.
Dr. Akram Jaffar
Peyer’s patch
Dr. Akram Jaffar

41. Para-aortic nodes
• Drain iliac nodes which receive from
the pelvis and lower limb
• Drain kidneys, suprarenals, and
gonads
Dr. Akram Jaffar
Dr. Akram Jaffar

42. Plan of the lymphatic drainage in the abdomen
Thoracic duct
coeliac
Cisterna chyli
Stomach
Liver
Spleen
suprarenal Pancreas
Para-aortic
kidney Intestinal lymph trunk
gonads
intestines
Common iliac Aorta Superior and
inferior
mesenteric
External iliac
Internal iliac
Dr. Akram Jaffar
Lower limb Pelvis Dr. Akram Jaffar

43. Lymphangiogrm
Immediately after completion of injection of contrast Taken 24hrs after. Lymph nodes are completely opacified
medium. Lymphatic vessels are filled
Para-aortic LN
Common
iliac LN
External
iliac LN
Dr. Akram Jaffar
Dr. Akram Jaffar

44. Lymphatic drainage in the pelvis
• Lymph nodes along the
external, internal, and common iliac Internal
vessels in addition to the sacral iliac LN
vessels
External
• Lymph nodes between the layers of iliac LN
the broad ligament and in the fascial
sheath of the rectum and the urinary
bladder.
LN in fascial sheath
Sacral LN
Dr. Akram Jaffar
Dr. Akram Jaffar

45. Lymphatic drainage in the pelvis
• The external iliac lymph nodes:
– Receive from the deep inguinal nodes, the deeper layer of the anterior abdominal
wall below the umbilicus, urinary bladder and prostate or the uterus and upper
vagina.
– Efferents go to the common iliac lymph nodes.
• The internal iliac lymph nodes
– Receive from all pelvic viscera, deep part of the perineum, and the gluteal region.
– Efferent vessels go to the common iliac lymph nodes.
• The sacral nodes
– Receive lymph from the rectum, bladder, prostate or cervix, and the posterior
pelvic wall.
– Efferents go to the internal and common iliac lymph nodes.
• The common iliac lymph nodes
– Receive from the external and internal iliac nodes, may receive lymph directly
from pelvic viscera.
– Efferent lymphatics go to para-aortic lymph nodes.
Dr. Akram Jaffar
Dr. Akram Jaffar