Lymphadenitis in the OMF
Territory.
Sofia Lehtman, Doctor of Medicine,
Maxillofacial Department
Anatomical data
• Note that the tonsillar, submaxilary and submental
nodes drain portions of the mouth and throat as well as
the more superficial tissues of the face.
• Knowledge of the lymphatic system is important to a
sound clinical habit: whenever a malignant or
inflammatory lesion is observed, look for involvement
of the regional lymph nodes that drain it; whenever a
node is enlarged or tender, look for a source in the
area that it drains.
THE NECK
Survey. Inspect the neck, noting its symmetry and any
masses or scars. Look for enlargement of the parotid or
submaxillary glands, and note any visible nodes.
Lymph nodes. Palpate the lymph nodes. Using the pads
of your index and middle fingers, move the skin over the
underlying tissues in each area rather than moving your
fingers over the skin. The patient should be relaxed, with
neck flexed slightly forward and, if needed, slightly toward
the side of the examination. You can usually examine both
sides at once. For the submental node, however, it is helpful
to feel with one hand while bracing the top of the head with
the other
• Feel in sequence for the following nodes:
• Preauricular – in front of the ear
• Posterior auricular – superficial to the mastoid process
• Occipital – at the base of skull posteriorly
• Tonsillar – at the angle of the mandible
• Submaxillary – midway between the angle and the tip of the mandible.
These nodes are usually smaller and smoother than the lobulated
submaxillary glands against which they lie.
• Submental – in the midline a few cm behind the tip of the mandible
• Superficial cervical – superficial to the sternomastoid
• Posterior cervical chain – along the anterior edge of the trapezius
• Deep cervical chain – deep to the sternomastoid and often inaccessible to
examination. Hook your thumb and fingers around either side of the
sternomastoid muscle to find them.
• Supraclavicular – deep in the angle formed by the clavicle and the
sternomastoid
• Note their size, shape, delimitation (discrete or
matted together), mobility, consistency, and
tenderness. Small, mobile, discrete, no tender
nodes are frequently found in normal person.
• Enlarged or tender nodes, if unexplained, call for
reexamination of the regions they drain, and
careful assessment of lymph nodes elsewhere so
that you can distinguish between regional and
generalized lymphadenopathy.
1. Nodi lymphatici submentales
2. Nodi lymphatici submandibulares
3. Nodi lymphatici facealis/buccinatorii
4. Nodi lymphatici mandibularis
5. Nodi lymphatici cervicales superficiales
6. Nodi lymphatici cervicales profundi
7. Nodi lymphatici supraclaviculares
8. Nodi lymphatici occipitales
9. Nodi lymphatici mastoidei
10. Nodi lymphatici parotidei
Lymph glands in the maxilla-facial region of the frontal
and lateral neck part are divided into several groups,
depending on their position.
Lymph glands of the mental region are localized in the
pace follower of the triangle surface, situated between the
frontal bellies of digastric muscles and sublingual bone.
Their number usually fluctuates from 1 to 4. Frontal
mental gland is situated near the appex of mental region.
Dorsal are situated a little anterior from the sublingual
bone.
Submental lymph glands receive the lymph from tissues,
which surround frontal lower teeth, from the frontal part
of the alveolar bone and mandibular body, tongue root
and frontal part of sublingual region, lower lip and
adjacent check parts.
Submandibular lymph glands are situated in the
submandibular triangle and lie outside salivary
gland capsule in the form of chain along the
mandibular edge.
In submandibular glands fall tissue lymph vessels,
surrounding set of mandibular teeth – from the
canine level to third molar, from the corresponding
to these teeth parts of alveolar bone and mandibular
body.
Sublingual lymph glands are in the tight connection
with tongue lymph vessels.
• Facial or buccal lymph glands - are not big,
not always detected formations, situated along
the facial vein.
Ethiology and pathogenesis
The reason of maxillo-facial region lymphadenitis
can be an odontogenic infection: during acute
periodontitis and aggravation of this chronic process,
suppuration of the root cyst, odontogenic process in
periostenium, maxilla bone, perignathic soft tissues.
All lymphadenitis appeared in the result of an
odontogenic infection, are named odontogenic.
Maxillo-facial region lymphadenitis can develop as a
result of infection expansion during infectious
diseases and damage of mouth mucosa membrane
(stomatogenic), from tonsils (tonsillogenic), from the
tissue of external, drum and inner ear (otogenic).
More rarely the damage of lymph glands of the
maxillo-facial region can be connected with the
diseases and damage of skin integuments of the
face and head.
The reason of the lymphadenitis is pyogenic non
specific infection, specifically coccal flora, where
the mainstream significance has staphylococcus.
All lymphadenitis caused by this infection, are
defined as non specific process. In other cases,
rarely, lymphadenitis can be caused by the lambent
myco , tuberculosis mycobacteria (specific
lymphadenitis), or by virus (infectious
mononucleosis).
Classification of the lymphangitis
According to etiology: odontogenic and nonodontogenic,
rhinogenic, tonsillogenic, infectious and traumatic,
dermatogenic, tumoral, stomatogenic, specific and
nonspecific.
According to pathogenesis: lymphangitis, lymphadenitis,
adeno-abscesses, adeno-phlegmons.
According to the clinical picture: acute (serosal, purulent)
and chronic (purulent, proliferate)
Deep and superficial.
Pathomorphological chronic lymphadenitis is classified:
hiperplastica, descuamativa, hiperplastica-descuamativa,
productiva.
Lymphangitis – inflammation of the lymph
vessels.
• Lymphangitis develops as a result of penetration of microflora,
toxins in lymph tracts. Features of the lymph vessels – length
and caliber of the lymph vessels are more reduced in comparison
with other area of the body that explains the absence of the
clinical features of lymphangitis in inflammation processes of
the lymph system from this level.
Clinical picture.
Maxillo-facial lymphadenitis develops as reaction of
lymph nodes on any inflammatory process.
Lymphadenitis can be the one of the disease
symptom (acute or aggravation of the chronic
periodontitis, periostitis or osteomyelitis of the
maxilla and other), and also as independent disease.
Two types of lymphadenitis are distinguished: acute
and chronic lymphadenitis. Acute lymphadenitis can
proceed in serosal and purulent forms. Chronic
lymphadenitis proceeds in the hyperplastic form, it
can transform into the purulent form.
Acute serosal lymphadenitis.
Acute serosal lymphadenitis of the maxilla-facial and neck
region (lymphadenitis acuta) – is the primary stage of the
inflammatory changes of lymph nodes. The morbidity of
one or several lymph nodes appears.
The distinct can be palpated in the nature of roundish or
oval form, which has soft – elastic consistence. General
state during the acute serosal lymphadenitis suffers
insufficiently, but at the individual patients temperature
reaction, not exceeding 38 C, deterioration of general state
are observed.
• Acute serosal lymphadenitis can melt in
purulent lymphadenitis. A considerate
increase and indurations of one or some
lymph nodes appears. They are painless.
• Appearance of the morbidity shows the
aggravation of inflammation in the main
focus. During the chronic non specific
lymphadenitis lymph nodes, as a rule,
remain flexible do not solder with
surrounding tissues and skin.
Diagnostic, puncture
Antibiogram
Acute purulent lymphadenitis
Acute purulent inflammation of lymph nodes of the facial and
neck region appears rarer than chronic (blood changes,
leucocytosis, ESR increase).
Purulent fusion of the lymph nodes allows to establish future
growth of morbidity, increasing of swell in their circle, in mainly
cases slowly - in some days, and sometimes 1-2 weeks.
Consequently a progressive infiltration of the adjacent to lymph
node tissues can be observed, causing its movement limitation,
sealing of some teeth in one packet, and then mollities and
fluctuation.
During the acute lymphadenitis general incompatibles - is
indisposition, brokenness – can be absent or can be insignificant.
Body temperature is 37.6-37.8 C. in the blood similar changes, as
during the odontogenic abscesses of maxilla-facial region are
observed.
Acute purulent lymphadenitis submentales
Acute purulent lymphadenitis submandibulares
Acute purulent lymphadenitis
submandibulares
Acute purulent lymphadenitis submandibulares
Acute purulent lymphadenitis cervicales superficiales
Phlegmonous adenitis (adenophlegmone).
• Sometimes the capsule fusion of the lymph node and the
purulence penetrate in the surrounding it cellulose occurs.
In the result a phlegmonous inflammation - phlegmonous
adenitis, accompanied by the surrounding tissues edema
develops.
• Phlegmonous adenitis in the result of odontogenic
infection is localized predominantly in the submandibular
and submental region, rarer - on the lateral part of the
neck.
• In the majority of patients the body temperature does not
exceed 38-38.5 C, during the phlegmonous adenitis.
Rigor happens. In the blood moderate leucocytosis and
neutrophilia, ESR is increased.
Acute purulent lymphadenitis mandibularis
Acute purulent lymphadenitis mandibularis
Chronic lymphadenitis
Chronic lymphadenitis is the outcome of the acute
process in the lymph node. In some cases there is chronic
lymphadenitis with the unexpressed acute stage.
Clinic of the chronic lymphadenitis is characterized by
node increasing, by roundish or oval form, precise and
even contours, non solder with surrounding tissues.
During the palpation, the lymph node has solid elastic
consistence, painless. The general state of the patients
does not suffer, the body temperature is in norm.
Such picture of the chronic inflammatory process is
accepted to designate as chronic hyperplasic
lymphadenitis.
Chronic lymphadenitis submandibulares
• In separate cases, in the result of lymph node chronic
inflammation takes place the moderate granulation tissue
enlargement, which replace by itself lymphoid tissue, spreads
outward the node and grows to skin thereby make it thinner.
During the eruption of the thinned region the fistulous tract
appears. In the region of such process the suppuration can
develop, but proliferative reaction is more expressed. Speaking
about the purulent nature, it shows only discharge of pus from
the fistulous tract, often poor, or its accumulation under the scab
on the skin surface.
• The chronic hyperplastic lymphadenitis should be differentiated
with odontogenic subdermal and dermal granuloma, subdermal
form of the actinomycosis, scrofuloderma and mainly, with the
tumor metastasis.
Treatment
• During the acute lymphadenitis first of all the
corresponding intervention in the region of primary
inflammation focus is necessary (teeth extraction during
periostitis, manipulation and sanitation of the extracted
teeth cavity during the alveolitis and other), to prevent
the future entry of microorganisms in the lymph nodes.
• During the serosal lymphadenitis the treatment could be
conservative. Physiotherapeutic procedures are justified,
Bandage with Dimecsid solution (in dilution with
sol.Furacilini 1/3)
Vitamins, analgesics and antisensitizer are put on.
In the case of ineffectiveness of such therapy, the
stimulating arrangements are justified (autohemotherapy,
vitaminotherapy). It is necessary to scoop from the
purulent focus the remains of the halfbroken lymph node.
In the first days after opening of the purulent focus it is
efficiently to introduce Bandage with the Levomecol
ointment in the wound drainage (which promote the
supuration outflow).
During the phlegmonous adenitis the purulent cavity is
opened according to the general rules of phlegmons
opening.
Surgical therapy, The marking of the operative field by
the brilliant green
Anesthesia
Discission
Evacuation of suppuration from the
wound
Lavaj sol.H2O2 3%
Lavaj sol.Furacilini
Drain tube, Bandage with the Levomykoli
ointment (which promote the supuration outflow)
Acute purulent lymphadenitis submentales
Drain tube
