Can you give me an outline of the lymph and lymphatic drainage pathway from head to the neck?

Question

This is with Indian Head massage in mind; so please; no information on tumours...

Answer 1

There are two "circles" of lymph nodes that drain the head and upper neck. The inner circle includes the retro-pharyngeal, para-tracheal , and pre-tracheal nodes (these drain the inner areas, such as the pharyngeal regions, tracheal areas, and laryngeal regions--think deep mouth and neck). The outer circle includes the occipital , pre-auricular , buccal , sub-mandibular , and sub-mental nodes (these drain the posterior and anterior scalp regions, ear and parotid regions, cheek regions, and mouth). There are also ones that run along with the internal jugular vein, which are called the deep cervical nodes (this is where all of the inner and outer circle nodes drain). The deep cervical nodes eventually insert into the venous system.

Answer 2

III. Drainage Pathways

The lymphatic drainage of squamous cell carcinoma varies with the anatomic subsite. Within specific subsites, however, the lymphatic drainage occurs in a relatively predictable manner. The following section will review the drainage of each anatomic subsite that was described by Rouvière. As a result, some subsites will not be described. The intent is to help the radiologist focus on the lymph node groups that are at greatest risk for cervical nodal metastases in patients with squamous cell carcinoma of different regions. The percentages of nodal involvement for the lymph node levels presented below are derived from the classic articles by Lindberg and Byers, which reported the distribution of cervical lymph nodes metastases from various sites in the head and neck(21, 24). The specifics of the analysis are described in the appendix(25).

A. Nasopharynx
The lymphatic vessels drain in two general directions, lateral and medial. The lymphatic channels of the lateral drainage pathway pierce the superior constrictor muscle and drain into the lateral retropharyngeal, high Level II and high Level V lymph nodes. Tumors that invade the eustachian tube, external auditory canal, or tympanic membrane may occasionally drain to the intraparotid lymph nodes(1, 25)

The lymphatic channels of the roof and posterior wall of the nasopharynx drain medially. These channels penetrate the visceral fascia at the skull base and drain into the median retropharyngeal lymph nodes(1, 25).

Often the lymphatic drainage is bilateral. So it should be remembered that both sides of the neck are at risk for cervical nodal metastases from nasopharyngeal cancer.

B. Oral Cavity


The lymphatic drainage is divided into an anterior and posterior complex. The anterior complex drains the anterior half of the FOM and anterior portion of the sublingual gland. These terminate in the Level I nodes.

The posterior complex drains the posterior two-thirds of the FOM. These lymphatics primarily drain to the ipsilateral Level II lymph nodes. Occasionally, there is a direct lymphatic drainage to Level III nodes that bypass Level II nodes.

Anatomic studies have shown significant crossover of the lymphatic drainage in superficial lymphatic capillaries. As a result, both sides of the neck are at often at risk for metastases arising from FOM malignancies(1, 25).

A superficial and deep lymphatic network drains the oral tongue. The superficial network extends from the tip of the tongue to the circumvalate papillae and drains into the deep muscular network(1, 25).

There are three main components of the deep lymphatic network for the oral tongue: anterior, lateral, and central. The anterior (apical) pathway drains the tip of the oral tongue and primarily drains to Level III or less likely Level I. The lateral (marginal) group drains the lateral one-third of the dorsum of the tongue from the tip to the circumvallate papillae. These lymphatic channels drain to Levels I, II, or III. The central pathway drains the central two-thirds of the tongue. These vessels drain to the Group I nodes or course through a sublingual node and terminate in Group III nodes(1, 25).

Cross-drainage in the oral tongue is common. As a result, both sides of the neck at risk for nodal metastases(1, 25)

C. Oropharynx

Similar to the oral tongue, the lymphatic drainage of the tongue base also consists of superficial and deep muscular lymphatic networks. The superficial network is continuous with the superficial lymphatic network that drains the oral tongue.

The deep lymphatic drainage may drain ipsilaterally or have direct branches that drain to the contralateral neck. Thus both sides of the neck are at risk for nodal metastases(1, 25).

The lymphatic drainage of the tonsil is to the ipsilateral Level II and retropharyngeal lymph nodes. A less common route of drainage is to the Level III nodes. Rouvière did not describe cross-lymphatic drainage for this area(1, 25).

* Soft Palate
Rouvière defined three separate drainage pathways for the soft palate: anterior, middle, and posterior. Of these three, the middle is the most constant pathway(1, 25).

The lymphatic vessels of the middle pathway extend from the soft palate to the inner margin of the posterior belly of the digastric muscle and drain primarily to Level II. The middle pathway normally has crossed lymphatic drainage thereby placing both necks at risk for nodal metastases(1, 25).


The lymphatics that comprise the posterior pathways are present in 60% of cases. These vessels penetrate the superior constrictor muscle into the retropharyngeal space and normally drain into the lateral retropharyngeal lymph nodes. Crossed drainage of the posterior pathways has been shown to be present in 50% of individuals(1, 25).

The anterior pathway is present in half of individuals, and drains into the Group I lymph nodes. This region has crossed lymphatics in 50% of cases placing both sides of the neck at risk for nodal metastases. Although both the anterior and posterior pathways are potential drainage pathways for the soft palate, the posterior pathway is the more common pathway for the soft palate lesions while the anterior pathway is more common for hard palate tumors(1, 25).

The above information necessitates treatment of the retropharyngeal lymph nodes and both necks in patients with soft palate carcinomas(1, 25).

D. Larynx


The lymphatic drainage is separated into two components, a superficial mucosal component that drains into a deep system of collecting ducts. The deep system unites with the lymphatic drainage of the inferior pharynx(1, 25).

The draining vessels of the unified deep system exit the larynx through the natural defect in the thyrohyoid membrane that permits passage of the superior laryngeal neurovascular bundle. At this point, one component of the lymphatic drainage extends superiorly and terminates in the ipsilateral Level II nodes while a second component extends lateral and drains into nodes located at the junction of Levels II and III. There is occasionally a third component that drains into the nodes located in Level III nodes(1, 25).

Tumors involving the supraglottic larynx are at risk for crossed lymphatic drainage. However, the drainage mechanism is unclear. There appears to be cross-drainage of the superficial mucosal lymphatics, however, no consistent direct cross-drainage of the deep collecting duct has been described(1, 25).


There is a paucity of lymphatics draining the true vocal cords (TVC). The superficial mucosal lymphatics form a continuous layer along the posterior shtmlect of the larynx. However, the lymphatics draining the TVC are sparse are form a natural barrier between the supraglottic and infraglottic larynx. The predominant lymphatic drainage of the advanced TVC carcinoma occurs by acquiring the lymphatic drainage that occurs by extension into the supraglottic or subglottic larynx(24, 25).

E. Pyriform Sinus
The lymphatic drainage is divided into anterior and posterior groups. The anterior collecting system exits along with the lymphatics of the supraglottic larynx through the natural defect in the thyrohyoid membrane described above. These vessels course through pre-laryngeal lymph nodes and primarily drain into the Levels II, III and the Level VII nodes. Advanced disease may involve Levels IV and V(1, 25).


The posterior group penetrates the superior constrictor muscle and drains into the lateral retropharyngeal lymph nodes and the internal jugular chain. Cross-lymphatic drainage occurs from the superficial lymphatics along the midline of the posterior pharyngeal wall(1, 25).

As a result, pyriform sinus carcinomas have a rich drainage system. Both ipsilateral and contralateral lymph nodes from the skull base to the base of the neck are at risk for metastases in patients with moderately advanced tumors(1, 25).