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Edit Comment Close Premium member Presentation Transcript LYMPHATICS OF HEAD AND NECK : Dr. owais pg Ist yr ENT SMHS LYMPHATICS OF HEAD AND NECK AN OVERVIEW OF LYMPHATIC SYSTEM Slide 2: Dr. owais pg Ist yr ENT SMHS IT IS THE SYSTEM TO RETURN THE EXTRA FLUID, MICROMOLECULES AND MACROMOLECULES TO THE VASCULAR SYSTEM. THE NET PRESSURE DIFFERENCE THAT DRIVES THIS EXTRA FLUID OUT IS 0.3mmHg WHICH PRODUCES LYMPH AT THE RATE OF 120ml per mt. Slide 3: Dr. owais pg Ist yr ENT SMHS Right lymphatic duct Formed by union of right jugular, subclavian, and bronchomediastinal trunks Ends by entering the right venous angle Receives lymph from right half of head, neck, thorax and right upper limb @20ml per mt Thoracic duct At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angle Just before termination, it receives the left jugular, subclavian and bronchomediastinal trunks @100ml per mt. Thoracic duct : Dr. owais pg Ist yr ENT SMHS Thoracic duct The Neck : Dr. owais pg Ist yr ENT SMHS The Neck The region of the body that lies between: The LOWER BORDER OF THE MANDIBLE& The SUPRASTERNAL NOTCH and the UPPER BORDER OF CLAVICLE. Slide 6: Dr. owais pg Ist yr ENT SMHS THE NECK IS DIVIDED INTO VARIOUS REGIONS. SUPRAHYOID INFRAHYOID LATERAL… LYMPHATICS OF NECK INCLUDE LYMPHATIC CHANNELS LYMPH NODES WALDEYER RING Triangles of the Neck : Dr. owais pg Ist yr ENT SMHS Triangles of the Neck Suprahyoid region : Dr. owais pg Ist yr ENT SMHS Suprahyoid region Submental triangle Lies below the chin and is bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone Covered by skin, superficial fascia and investing fascia Floor－mylohyoid muscles Contents－submental lymph nodes Slide 9: Dr. owais pg Ist yr ENT SMHS Submandibular triangle Bounded by anterior and posterior bellies of digastric and lower border of the body of the mandible Covered by skin, superficial fascia, platysma and investing fascia Floor－ mylohyoid, hyoglossus and middle constrictor of pharynx Contents－submandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes Infrahyoid region : Dr. owais pg Ist yr ENT SMHS Infrahyoid region Carotid triangle sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles Covered by skin, superficial fascia, platysma and investing fascia Floor－prevertebral fascia and lateral wall of pharynx Contents－common carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes Slide 11: Dr. owais pg Ist yr ENT SMHS Muscular triangle Bounded by midline of the neck, superior belly of the omohyoid and anterior border of the sternocleidomastoid. Covered by skin, superficial fascia, platysma, anterior jugular v., coutaneous n. and investing fascia Floor－prevertebral fascia Contents－sternohyoid, sternothyroid, thyrohyoid, thyroid gland, parathyroid gland, cervical part of trachea and esophagus Lateral region of neck : Dr. owais pg Ist yr ENT SMHS Lateral region of neck Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and middle third of clavicle Divided by inferior belly of omohyoid into occipital and supraclavicular triangles Contents : Dr. owais pg Ist yr ENT SMHS Contents Arteries: Subclavian (3rd part) Superficial cervical & suprascapular (branches of thyrocervical trunk, a branch of 1st part of subclavian artery Occipital, a branch of external carotid artery Slide 14: Dr. owais pg Ist yr ENT SMHS Nerves: Branches of cervical plexus Spinal part of accessory nerve Brachial plexus Slide 15: Dr. owais pg Ist yr ENT SMHS Veins: External jugular vein Formation Termination Tributaries Slide 16: Dr. owais pg Ist yr ENT SMHS Occipital triangle Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid Covered by skin, superficial fascia, and investing fascia Floor－prevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae Conents Accessory n.－emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius Cervical and brachial plexuses Slide 17: Dr. owais pg Ist yr ENT SMHS Supraclavicular triangle Bounded by posterior border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle Covered by skin, superficial fascia, and investing fascia Floor－prevertebral fascia and inferior parts of scalenus Conents Subclavian v. and venous angle Subclavian a. Brachial plexus LYMPH NODES OF NECK : Dr. owais pg Ist yr ENT SMHS LYMPH NODES OF NECK CAN BE DIVIDED INTO; a) SUPERFICIAL CHAIN OF LYMPH NODES….. b) VERTICAL DEEP CHAIN OF LYMPH NODES This consists of nodes lying in relation to carotid sheath.These lie along the vessels,trachea,oesophagusand extend from base of skull to root of neck. Superficial Lymph Nodes : Dr. owais pg Ist yr ENT SMHS Superficial Lymph Nodes Position of Nodes : Dr. owais pg Ist yr ENT SMHS Position of Nodes Submental Submandibular Parotid / tonsilar Preauricular Postauricular Occipital Anterior cervical superficial and deep Supraclavicular Posterior cervical Subgroups : Dr. owais pg Ist yr ENT SMHS Subgroups Ia Submental Ib Submandibular IIa Upper jugular (Anterior to XI) IIb Upper jugular (Posterior to XI) III Middle jugular IVa Lower jugular (Clavicular) IVb Lower jugular (Sternal) Va Posterior triangle (XI) Vb Posterior triangle (Transverse cervical) VI Central compartment/Juxtavisceral VII Anterior Mediastinal Basic Anatomy : Dr. owais pg Ist yr ENT SMHS Basic Anatomy Slide 23: Dr. owais pg Ist yr ENT SMHS Level I : Dr. owais pg Ist yr ENT SMHS Level I Ia Chin Lower lip Anterior floor of mouth Mandibular incisors Tip of tongue Ib Oral Cavity Floor of mouth Oral tongue Nasal cavity (anterior) Face Level II : Dr. owais pg Ist yr ENT SMHS Level II Upper Jugular Nodes Anterior Lateral border of sternohyoid, posterior digastric and stylohyoid Posterior Posterior border of SCM Skull base Hyoid bone (clinical landmark) Carotid bifurcation (surgical landmark) Level IIa anterior to XI Level IIb posterior to XI Submuscular recess Oropharynx > oral cavity and laryngeal mets Level II : Dr. owais pg Ist yr ENT SMHS Level II Oral Cavity Nasal Cavity Nasopharynx Oropharynx Larynx Hypopharynx Parotid Level III : Dr. owais pg Ist yr ENT SMHS Level III Middle jugular nodes Anterior Lateral border of sternohyoid Posterior Posterior border of SCM Inferior border of level II Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark) Junction with IJV Level III : Dr. owais pg Ist yr ENT SMHS Level III Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx Level IV : Dr. owais pg Ist yr ENT SMHS Level IV Lower jugular nodes Anterior Lateral border of sternohyoid Posterior Posterior border of SCM Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark) Junction with IJV Clavicle Level IV : Dr. owais pg Ist yr ENT SMHS Level IV Hypopharynx Larynx Thyroid Cervical esophagus Level V : Dr. owais pg Ist yr ENT SMHS Level V Posterior triangle of neck Posterior border of SCM Clavicle Anterior border of trapezius Va Spinal accessory nodes Vb Transverse cervical artery nodes Radiologic landmark Inferior border of Cricoid Supraclavicular nodes Level V : Dr. owais pg Ist yr ENT SMHS Level V Nasopharynx Oropharynx Posterior neck and scalp Level VI : Dr. owais pg Ist yr ENT SMHS Level VI Thyroid Larynx (glottic and subglottic) Pyriform sinus apex Cervical esophagus Level VI : Dr. owais pg Ist yr ENT SMHS Level VI Anterior compartment Hyoid Suprasternal notch Medial border of carotid sheath Perithyroidal lymph nodes Paratracheal lymph nodes Precricoid (Delphian) lymph node Common Nodal Drainage Patterns : Dr. owais pg Ist yr ENT SMHS Common Nodal Drainage Patterns Common Nodal Drainage Patterns : Dr. owais pg Ist yr ENT SMHS Common Nodal Drainage Patterns WALDEYER RING : Dr. owais pg Ist yr ENT SMHS WALDEYER RING Waldeyer's tonsillar ring (or pharyngeal lymphoid ring) is an anatomical term describing the Lymphoid tissue ring located in the pharynx and to the back of the oral cavity. It was named after the nineteenth century German anatomist Heinrich Wilhelm Gottfried von Waldeyer-Hartz. The ring consists of (from superior to inferior): Pharyngeal tonsil (also known as 'adenoids' when infected) Tubal tonsil (where Eustachian tube opens in the nasopharynx) Palatine tonsils (commonly called "the tonsils" in the vernacular, less commonly termed "faucial tonsils") Lingual tonsils Tonsils : Dr. owais pg Ist yr ENT SMHS Tonsils Anatomy : Dr. owais pg Ist yr ENT SMHS Anatomy Grading the Size of Tonsils : Dr. owais pg Ist yr ENT SMHS Grading the Size of Tonsils Grading system: 0 – tonsils in fossa +1 – tonsils less than 25% +2 – tonsils less than 50% +3 – tonsils less than 75% +4 – tonsils greater than 75% Slide 41: Dr. owais pg Ist yr ENT SMHS Anatomy : Dr. owais pg Ist yr ENT SMHS Anatomy Blood supply - Tonsils Facial a. Lingual a. Dorsal lingual Tonsil Ascending pharyngeal Tonsil Maxillary Lesser descending palatine Tonsil Tonsillar branch Tonsil (main branch) Ascending palatine Tonsil Anatomy : Dr. owais pg Ist yr ENT SMHS Anatomy Blood supply – Adenoids Ascending palatine branch of facial a. Ascending pharyngeal a. Pharyngeal branch of IMAX. Ascending cervical branch of thyrocervical trunk. Adenotonsillectomy-Indications : Dr. owais pg Ist yr ENT SMHS Adenotonsillectomy-Indications Primary snoring disorder: Loud snoring, mouth breathing, sleep pauses or breath holding, gasping, enuresis and restless sleeping. Daytime manifestations: hypersomnolence, AM headache, hyponasal speech, chronic nasal obstruction w/ or w/o rhinorrhea. Adenotonsillectomy-Indications : Dr. owais pg Ist yr ENT SMHS Adenotonsillectomy-Indications Obstructive apnea syndrome Obstructive hypopnea is defined as a decrease in airflow by 50% despite effort during the same time or breath cycles, associated with a desaturation or arousal. The apnea/hypopnea index (AHI) is the same as for adults: the total number of apneic events plus hypopneas per hour of sleep. An arousal index describes the number of arousals per hour of sleep. Defined in adults as cessation of airflow at nostrils and mouth for at least 10 seconds and a hypopnea (decrease in VT of at least 50% or drop in PO2 of 4%) with 5-10 episodes in one hour. Adenotonsillectomy-Indications : Dr. owais pg Ist yr ENT SMHS Adenotonsillectomy-Indications Dysphagia & speech impairment Large tonsils can interfere with pharyngeal phase of swallowing. Abnormal dentofacial growth Long face syndrome Halitosis No clinical trails support adenotonsillectomy for halitosis. Tonsillectomy-Indications : Dr. owais pg Ist yr ENT SMHS Tonsillectomy-Indications Recurrent tonsillitis Paradise et. Al. 1984, 2002. Temperatures above 38.5oC Cervical adenopathy > 2 cm Tonsillar exudate or (+) group A β-hemolytic strep. Cx. ≥7/yr, 5/yr x 2 yrs or 3/yr x 3 yrs. Failure of medical treatment Chronic tonsillitis > 3 months in duration with tonsillar inflammation, reasonable if patients have failed aggressive antibiotic therapy. Tonsillectomy-Indications : Dr. owais pg Ist yr ENT SMHS Tonsillectomy-Indications Peritonsillar abscess Streptococcal carriers Asymptomatic carriers that have family members with acute glomerulonephritis, carrier is food handler or hospital worker. Tonsillectomy should be reserved for those refractory to antibioics. Hemorrhagic tonsillitis Unilateral tonsil enlargement Adenoidectomy-Indications : Dr. owais pg Ist yr ENT SMHS Adenoidectomy-Indications Recurrent or chronic sinusitis or adenoiditis Poorly understood - possibly caused by obstructive adenoid tissue causing stasis of secretions predisposing the nasal cavity to infection. Otitis media Proximity of adenoid tissue to eustachian tube Adenoidectomy can be recommended on 1st set of tubes if nasal obstruction and recurrent rhinorrhea is present or on 2nd set of tubes if needed. Examination of the Neck : Dr. owais pg Ist yr ENT SMHS Examination of the Neck Lymph Nodes Perauricular: in front of the ear Posterior auricular: anterior to the mastoid Occipital: at the base of the skull posteriorly Tonsillar: at angle of mandible Submandibular and submental: beneath the jaw Adenotonsillectomy-Contraindications : Dr. owais pg Ist yr ENT SMHS Adenotonsillectomy-Contraindications Velopharyngeal insufficiency Overt cleft palate, submucous (covert) cleft Neurologic or neuromuscular abnormality leading to impaired palate function Hematologic Anemia Any disorder or hemostasis Surgery should not be undertaken if Hgb is less than 10 gm/dL, or Hct less than 30%. Adenotonsillectomy-Contraindications : Dr. owais pg Ist yr ENT SMHS Adenotonsillectomy-Contraindications Immunologic Respiratory allergy not treated for at least 6 months Infectious: Should not be done in the face of active infection unless urgent obstructive symptoms are present or: Appropriate antibiotics have been tried and unsuccessful Usually an interval of at least 3 weeks allow the patient to recuperate enough to reduce operative hemorrhage. Complications : Dr. owais pg Ist yr ENT SMHS Complications Noniatrogenic complications after adenoidectomy Regrowth of adenoid tissue, particularly in very young children, which may require revision (secondary) adenoidectomy. Hypernasality, because of temporary pain splinting. Persistent hypernasality is rare and probably caused by unrecognized pre-existing velopharyngeal weakness. Atlantoaxial subluxation (Grisel’s syndrome), which presents with persistent torticollis 1-2 weeks after surgery. Iatrogenic complications after adenoidectomy include Dental injury, from intubation or the mouth gag Nasopharyngeal stenosis, caused by excessive tissue removal. Eustachian tube injury, if the torus tubarius is cauterized or denuded. Surgical Atlas of Pediatric Otolaryngology Complications : Dr. owais pg Ist yr ENT SMHS Complications Non iatrogenic complications after tonsillectomy Bleeding in 1-2% of children, which is typically delayed (5-7 days); bleeding in the first 24 hours is less common. Most bleeding will stop spontaneously, but generally requires 24 hours of inpatient observation. Initial adjuvant techniques for hemostasis include clot removal, gargling with salt water or hydrogen peroxide, local cautery with silver nitrate sticks, and injection of epinephrine 1:200,000 Persistent bleeding, requiring control in the operating room 1. Rapid sequence anesthesia is used for induction. 2. Bleeding vessels are cauterized or suture ligated 3. Refractory hemorrhage requires external carotid artery embolization by an interventional neuroradiologist. 4. When embolization is unavailable, external carotid artery ligation Surgical Atlas of Pediatric Otolaryngology Complications : Dr. owais pg Ist yr ENT SMHS Complications Dehydration, requiring re-admission for hydration Airway obstruction, requiring observation in an intensive setting, parenteral steroids, racemic epinephrine, careful insertion of a nasopharyngeal airway of appropriate length, and consideration for re-intubation if necessary. Post obstructive pulmonary edema, which may result from increased intrathoracic venous and hydrostatic pressure relieved by intubation or surgery. Presenting signs include oxygen desaturation and pink frothy secretions. Diuretics and re-intubation may be needed. Atlantoaxial subluxation (Grisel’s syndrome), presenting with persistenttorticollis 1-2 weeks after surgery. Neurological or orthopedic consultation Surgical Atlas of Pediatric Otolaryngology Slide 56: Dr. owais pg Ist yr ENT SMHS 1-lymph node draining a septic foicus * cervical : tonsilitis, scarlet fever, scalp infection. * periauricular: otitis media. Causes of localised lymphadenopathy 2-carcinomatous. * virchow’s: stomach * cervical: thyroid, tongue, parotid. Slide 57: Dr. owais pg Ist yr ENT SMHS 3- Systemic Infections Viruses: - Viral hepatitis Rt. supraclavecular L.N - German measles (cervical LN) Bacteria: T.B Generalized L.N. may start as localized L.N. as in Hodgkin’s disease Slide 58: Dr. owais pg Ist yr ENT SMHS Causes of Generalised Lymphadenopathy I- Infectious * Viruses: a-Infectious mononucleosis b-Cytomegalo virus (C.M.V.) * Bacteria: a- brucellosis b- T .B. *Spirochetes: (2ry $) * Protozoa a- kala azar b-toxoplasmosis. Slide 59: Dr. owais pg Ist yr ENT SMHS Causes of Generalised Lymphadenopathy(2) 2- leukemias: especially chronic lymphocytic leukamia (C.L.L.) 3- : a- Hodgkin’s disease (H.D.) b-Non- Hodgkin’s lymphoma (N.H.L) 4- Collagenosis: a-rheumatoid artheritis. b- Felty’s syndrome. c-Still's disease. d- D.L.E. 5-Allergy: e.g., - Serum sickness. 6- Sarcoidosis 7- Lipoidosis 8-Miscellaneous Slide 60: Dr. owais pg Ist yr ENT SMHS Characters of L.N. Enlargement in Some Diseases 1- Streptococcal infection of tonsils: * Uni or Bilateral * Tender & unmatted *Usually submandibular but may extend to lower cervical group. 2- Scarlet Fever * Sore throat. * marked enlargement of submandibular L.N. *Other cervical L.N. (bilateral, tender, discrete, suppuration is common). 3-Diphtheria *Enlarged submandibular L.N. usually bilateral, tender, not matted. Slide 61: Dr. owais pg Ist yr ENT SMHS 4-German Measle: * OccipitaI L.N. enlargement are nearly always present, closely resembles that of infectious mononucleosis. 5-Infectious Mononucleosis: * Sore throat, Fever, sometimes headache, myalgia. * Bilateral L.N. enlargement, firm, discrete, mobile. * Appear first in posterior cervical area, adjacent to cervical spines, few days later , submandibular L.N. will be enlarged * Palatal petechiae often, are present * Mild splenomegally in 50% of cases *Lymphocytosis in 75% of cases with some atypical lymphocytes. Slide 62: Dr. owais pg Ist yr ENT SMHS 6- T.B.: * The chiefly affected group is upper cervical group, generalized L.N. enlargement is exceptional. * Unilateral or Bilateral. * Often firm, matted, painful, may become adherent to skin or deep structures. * Cystic areas may occur due to caseation and later on cold abscess formation. * Overlying skin may break down giving T.B. ulcers or sinuses. Slide 63: Dr. owais pg Ist yr ENT SMHS 7-Syphilis: * Iry $:- L.N draining a chancre -Rocky hard, uni Or bilateral, not tender. * 2ry $:- -Generalized L.N. enlargement especially posterior triangle of the neck or epitrochlear gp (slightly enlarged, shotty, discrete, painless). Slide 64: Dr. owais pg Ist yr ENT SMHS 8- LYMPHOMATOUS L. N: *May be associated with constitutional symptoms.(anorexia, fever, weight loss, sweating, ….. etc). * Pel Ebstein fever: may be observed in H.D., it is a period of fever lasting for few days or weeks alternating with longer or shorter apyrexial periods . * L.N. usually discrete at start & not tender (but may become tender during febrile periods). * L.N. may increase in size during pyrexial periods and decrease in size during apyrexial periods Slide 65: Dr. owais pg Ist yr ENT SMHS a-H.D.: * may be confined to one group at first esp. lower cervical group then later on generalized L.N. enlargement. Glands are: a- moderately enlarged, not tender. b- Firm, rubbery in consistency. c- Discrete, mobile however as a result of later extension outside the capsule glands become matted or fixed b-N.H .L: *Also the cervical group is firstly affected *Rapid rate of growth results in large number of variable sized nodes which are hard in consistency, tend to become fused and fixed to deep structures & may give pressure manifestations. Slide 66: Dr. owais pg Ist yr ENT SMHS 9- LEUKAEMIC L. N: *May be associated with general manifestations (fever, malaise, anorexia, headache, Hemorhagic tendency) a- Acute Leukaemia: *Late, slightly or moderately enlarged *Soft, discrete esp. cervical L.N. due to oral sepsis *May be tender bone. b-C.L.L: * May affect cervica1 L.N. but mostly all superficial L.N. are enlarged. *The glands usually are (firm, not tender, not matted, usually moderately enlarged, but in advanced stages may be markedly enlarged) c-C.M.L.: *Rare to be manifested by L.N. enlargement. Slide 67: Dr. owais pg Ist yr ENT SMHS 10- CARCINOMATOUS L.N.: *Firm, but some times hard. *A stoney hard nodes fixed to underlying tissues are nearly always neoplastic in nature, however the reverse is not true. *Carcinomatous L.N. may be freely mobile NECK DISSECTION : Dr. owais pg Ist yr ENT SMHS NECK DISSECTION Radical Gold standard operation Modified radical Preservation of non lymphatic structures Selective Preservation of lymph node groups Extended Removal of additional lymph node groups or non lymphatic structures Radical Neck Dissection : Dr. owais pg Ist yr ENT SMHS Radical Neck Dissection Removes Nodal groups I-V SCM, IJV, XI Submandibular gland, tail of parotid,omohyoid Preserves Posterior auricular Suboccipital Retropharyngeal Periparotid Perifacial Paratracheal nodes Modified Radical Neck Dissection : Dr. owais pg Ist yr ENT SMHS Removes Nodal groups I-V Preserves SCM, IJV, XI (any combination) TYPE I, II, III. Modified Radical Neck Dissection Selective Neck Dissection : Dr. owais pg Ist yr ENT SMHS Selective Neck Dissection Remove high risk lymph node groups based on tumor site. Supraomohyoid Levels I-III Lateral Levels II-IV Selective Neck Dissection : Dr. owais pg Ist yr ENT SMHS Selective Neck Dissection Posterolateral Levels II-V Postauricular nodes Suboccipital nodes ANTERIOR LEVEL VI LN Extended Neck Dissection : Dr. owais pg Ist yr ENT SMHS Extended Neck Dissection Removal of any structures that are routinely preserved in a neck dissection. Notated by naming the structure(s) removed. Accuracy of diagnostic methods in detecting occult cervical metastases. : Dr. owais pg Ist yr ENT SMHS Accuracy of diagnostic methods in detecting occult cervical metastases. A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography Sentinel Lymph Node History : Dr. owais pg Ist yr ENT SMHS Sentinel Lymph Node History 1955 First echelon node 1960 “Sentinel node” 1977 Demonstrated in penile cancer 1992 Morton reintroduced concept in N0 melanoma Currently widely used in melanoma and breast cancer therapy. Sentinel lymph node concept : Dr. owais pg Ist yr ENT SMHS Sentinel lymph node concept Tumor spreads via lymphatics to a primary node. Examination of primary echelon nodes for tumor direct the need for surgical management of the nodal basins. Sentinel lymph node concept : Dr. owais pg Ist yr ENT SMHS Sentinel lymph node concept Difficulties of lymphatic mapping in head and neck (O’Brien). It is difficult to visualize lymphatic channels using lymphoscintigraphy because of proximity to the injection site. The radiotracer travels fast in the lymphatic vessels. If more than one node is visible, it can be difficult to distinguish first echelon nodes from second-echelon nodes. The SLN may be small and not easily accessible (eg, in the parotid gland). N0 Neck : Dr. owais pg Ist yr ENT SMHS N0 Neck Occult neck disease Head and neck cancer 30% Oral cavity CA 20% to 45% Factors that indicate > 20% chance of subclinical metastases Tumor thickness > 4mm Size > 2 cm Anatomic location Pre op Technique : Dr. owais pg Ist yr ENT SMHS Pre op Technique Blue Dye Submucosal injection 2.5% Patent Blue dye No more than 20 min pre incision Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology Operative Technique : Dr. owais pg Ist yr ENT SMHS Operative Technique Limited incision guided by lymphoscintigraphy and gamma probe Frozen section analysis Operative Technique : Dr. owais pg Ist yr ENT SMHS Operative Technique Gamma probe Examine operative bed for increased signal Tumor extirpation Lead shield Removal of high signal nodes Examine removed node and compare to operative bed You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.