Chronic lymphocytic leukaemia | NHS inform

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1. 
   1.
   
   About chronic lymphocytic leukaemia
   
2. 
   2.
   
   Diagnosing chronic lymphocytic leukaemia
   
3. 
   3.
   
   Treating chronic lymphocytic leukaemia
   
4. 
   4.
   
   Complications of chronic lymphocytic leukaemia
   
5. 
   5.
   
   Causes of chronic lymphocytic leukaemia
   

About chronic lymphocytic leukaemia

Chronic lymphocytic leukaemia is a type of cancer that affects the white blood cells and tends to progress slowly over many years.

It mostly affects people over the age of 60 and is rare in people under 40. Children are almost never affected.

In chronic lymphocytic leukaemia (CLL), the spongy material found inside some bones (bone marrow) produces too many white blood cells called lymphocytes that aren’t fully developed and don’t work properly.

Over time this can cause a range of problems, such as an increased risk of picking up infections, persistent tiredness, swollen glands in the neck, armpits or groin, and unusual bleeding or bruising.

CLL is different from other types of leukaemia, including chronic myeloid leukaemia, acute lymphoblastic leukaemia and acute myeloid leukaemia.

Symptoms of CLL

CLL doesn’t usually cause any symptoms early on and may only be picked up during a blood test carried out for another reason.

When symptoms develop, they may include:

• getting infections often
• anaemia – persistent tiredness, shortness of breath and pale skin
• bleeding and bruising more easily than normal
• a high temperature (fever)
• night sweats
• swollen glands in your neck, armpits or groin
• swelling and discomfort in your tummy
• unintentional weight loss

You should speak to your GP if you have any persistent or worrying symptoms. These symptoms can have other causes other than cancer, but it’s a good idea to get them checked out.

Read more about diagnosing CLL and complications of CLL.

Treatments for CLL

As CLL progresses slowly and often has no symptoms at first, you may not need to be treated immediately.

If it’s caught early on, you’ll have regular check-ups over the following months or years to see if it’s getting any worse.

If CLL starts to cause symptoms, or isn’t diagnosed until later on, the main treatments are:

• chemotherapy – where medication is taken as a tablet or given directly into a vein is used to destroy the cancerous cells
• a stem cell or bone marrow transplant – where donated cells called stem cells are transplanted into your body so you start to produce healthy white blood cells

Treatment can’t usually cure CLL completely, but can slow its progression and lead to periods where there are no symptoms. Treatment may be repeated if the condition comes back.

Read more about treating CLL.

Outlook for CLL

The outlook for CLL depends on how advanced it is when it’s diagnosed, how old you are when diagnosed, and your general health.

Younger, healthier people who are diagnosed when CLL is still in the early stages generally have the best outlook.

Although it can’t normally be cured, treatment can help control the condition for many years.

Causes of CLL

It’s not clear what causes CLL. There’s no proven link with radiation or chemical exposure, diet or infections. You can’t catch it from anyone else or pass it on.

However, having certain genes can increase your chances of developing CLL. You may be at a slightly higher risk of it if you have a close family member with it, although this risk is still small.

Diagnosing chronic lymphocytic leukaemia

Most cases of chronic lymphocytic leukaemia (CLL) are detected during blood tests carried out for another reason.

However, you should speak to your GP if you have worrying symptoms of CLL, such as persistent tiredness, unusual bleeding or bruising, unexplained weight loss or night sweats.

Your GP may:

• ask about your symptoms and your medical and family history
• carry out a physical examination to check for problems such as swollen glands and a swollen spleen
• send off a blood sample for testing

If your GP thinks you could have CLL, you’ll be referred to a hospital doctor called a haematologist, a specialist in blood disorders, for further tests.

Blood tests

The main test used to help diagnose CLL is a type of blood test called a full blood count.

This is where the number and appearance of the different blood cells in a sample of your blood are checked in a laboratory.

An abnormally high number of unusual white blood cells (lymphocytes) can be a sign of CLL. A detailed examination of these cells can usually confirm the diagnosis.

X-rays and scans

You may also have:

• a chest X-ray
• an ultrasound of your tummy
• a computerised tomography (CT) scan

These tests can check for problems caused by CLL, such as swollen glands or a swollen spleen, and help rule out other possible causes of your symptoms.

Bone marrow biopsy

Sometimes the haematologist may recommend removing a sample of your bone marrow (bone marrow biopsy) so they can examine it under a microscope to check it for cancerous cells.

The sample is removed using a needle inserted into your hip bone. Local anaesthetic is normally used to numb the area where the needle is inserted, although you may experience some discomfort during the biopsy.

The procedure will last around 15 minutes and you shouldn’t need to stay in hospital overnight. You may have some bruising and discomfort for a few days afterwards.

Lymph node biopsy

In some cases, removing and examining a swollen lymph gland can help confirm a diagnosis of CLL. This is known as a lymph node biopsy.

The gland is removed during a minor operation carried out under either local or general anaesthetic, where you’re asleep. You won’t usually need to stay in hospital overnight.

After the operation, you’ll be left with a small wound that will be closed with stitches.

Genetic tests

Tests may also be carried out on your blood and bone marrow samples to check for any unusual genes in the cancerous cells.

Identifying unusual genes in these cells can help your doctors decide how soon you should start treatment and which treatment is best for you.

Some treatments for CLL don’t work as well in people with certain abnormal genes in the affected cells.

Treating chronic lymphocytic leukaemia

Treatment for chronic lymphocytic leukaemia (CLL) largely depends on what stage the condition is at when it’s diagnosed.

You may just need to be monitored at first if it’s caught early on. Chemotherapy is the main treatment if it’s more advanced.

Treatment can often help keep CLL under control for many years.

It may go away after treatment initially (known as remission), but will usually come back (relapse) a few months or years later and may need to be treated again.

Stages of CLL

Doctors use stages to describe how far CLL has developed and help them determine when it needs to be treated.

There are 3 main stages of CLL:

• stage A – you have enlarged lymph glands in fewer than 3 areas (such as your neck, armpit or groin) and a high white blood cell count
• stage B – you have enlarged lymph glands in 3 or more areas and a high white blood cell count
• stage C – you have enlarged lymph glands or an enlarged spleen, a high white blood cell count, and a low red blood cell or platelet count

Stage B and C CLL are usually treated straight away. Stage A generally only needs to be treated if it’s getting worse quickly or starting to cause symptoms.

Monitoring early-stage CLL

Treatment may not be needed if you don’t have any symptoms when you’re diagnosed with CLL.

This is because:

• CLL often develops very slowly and may not cause symptoms for many years
• there’s no benefit in starting treatment early
• treatment can cause significant side effects

In these cases, you will normally just need regular visits to your doctor and blood tests to monitor the condition.

Treatment with chemotherapy will usually only be recommended if you develop symptoms, or tests show that the condition is getting worse.

Chemotherapy for more advanced CLL

Many people with CLL will eventually need to have chemotherapy. This involves taking medication to keep the cancer under control.

There are a number of different medicines for CLL, but most people will take 3 main medications in treatment cycles lasting 28 days.

These medicines are:

• fludarabine – usually taken as a tablet for 3 to 5 days at the start of each treatment cycle
• cyclophosphamide – also usually taken as a tablet for 3 to 5 days at the start of each treatment cycle
• rituximab – given into a vein over the course of a few hours (intravenous infusion) at the start of each treatment cycle

Fludarabine and cyclophosphamide can usually be taken at home. Rituximab is given in hospital, and sometimes you may need to stay in hospital overnight.

A number of different medicines can also be tried if you can’t have these medicines, you’ve tried them but they didn’t work, or your CLL has come back after treatment.

These include bendamustine, chlorambucil, ibrutinib, idelalisib, obinutuzumab, ofatumumab and prednisolone (a steroid medication).

Side effects of treatment

The medicines used to treat CLL can cause some significant side effects, including:

• persistent tiredness
• feeling sick
• an increased risk of infections
• easy bruising or bleeding
• anaemia – shortness of breath, weakness and pale skin
• hair loss or thinning
• an irregular heartbeat
• an allergic reaction

Most side effects will pass once treatment stops. Let your care team know if you experience any side effects, as there are some treatments that can help.

Read more about the side effects of chemotherapy

Stem cell or bone marrow transplants

Stem cell or bone marrow transplants are sometimes used to try to get rid of CLL completely, or control it for longer periods.

Stem cells are cells produced by the spongy material found in the centre of some bones (bone marrow) that can turn into different types of blood cells, including white blood cells.

A stem cell transplant involves:

• having high-dose chemotherapy and radiotherapy to destroy the cancerous cells in your body
• removing stem cells from the blood or bone marrow of a donor – this will ideally be someone closely related to you, such as a sibling
• transplanting the donor stem cells directly into one of your veins

This is the only potential cure for CLL, but it’s not done very often as it’s an intensive treatment and many people with CLL are older and not well enough for the benefits to outweigh the risks.

The initial treatment with chemotherapy and radiotherapy can place a significant strain on your body and cause troublesome side effects.

There’s also a risk of serious problems after the transplant, such as graft versus host disease. This is where the transplanted cells attack the other cells in your body.

Other treatments for CLL

There are also a number of other treatments that are sometimes used to help treat some of the problems caused by CLL, particularly if you can’t have chemotherapy or it doesn’t work.

These include:

• radiotherapy to shrink enlarged lymph glands or a swollen spleen
• surgery to remove a swollen spleen
• antibiotics, antifungals and antiviral medications to help reduce your risk of picking up an infection during treatment
• blood transfusions to provide more red blood cells and platelets (clotting cells) if you experience severe anaemia or problems with bleeding and bruising
• immunoglobulin replacement therapy – a transfusion of antibodies taken from donated blood that can help prevent infections
• injections of medication called granulocyte-colony stimulating factor (G-CSF) to help boost the number of white blood cells

You may also need additional treatment for any complications of CLL that develop.

Deciding against treatment

As many of the treatments for CLL can have unpleasant side effects that may affect your quality of life, you may decide against having a particular type of treatment.

This is entirely your decision and your treatment team will respect any decision you make.

You won’t be rushed into deciding about your treatment, and before making a decision you can talk to your doctor, partner, family and friends.

Pain relief and nursing care will still be available as and when you need it.

Complications of chronic lymphocytic leukaemia

Chronic lymphocytic leukaemia (CLL) can sometimes cause a number of further complications.

Infections

People with CLL usually have a weakened immune system and are more vulnerable to infections because they have a lack of healthy, infection-fighting white blood cells.

Treatment with chemotherapy can also further weaken the immune system.

If you have CLL, it’s a good idea to:

• report any possible symptoms of an infection to your GP or care team immediately – things to look out for include a high temperature (fever), aching muscles, diarrhoea or headaches
• ensure your vaccinations are up-to-date – speak to your GP or care team for advice about any additional vaccines you might need, as some aren’t safe if you have a weak immune system
• avoid close contact with anyone who has an infection – even if it’s an infection to which you were previously immune, such as chickenpox

You may also be prescribed regular doses of medications such as antibiotics to help reduce the risk of infection.

Richter’s syndrome

In up to 1 in every 20 people with CLL, the condition will change to become very similar to an aggressive form of non-Hodgkin lymphoma. This is called Richter’s transformation or Richter’s syndrome.

Symptoms of Richter’s syndrome include:

• sudden swelling of your lymph glands
• a high temperature (fever)
• night sweats
• unintentional weight loss
• tummy (abdominal) pain

Richter syndrome is usually treated with a combination of chemotherapy and other powerful medicines.

The Cancer Research UK website has more information on Richter’s syndrome.

Autoimmune haemolytic anaemia

Around 1 in every 10 people with CLL will develop a condition called autoimmune haemolytic anaemia.

This is where the immune system starts to attack and destroy red blood cells. It can cause severe anaemia, making you feel breathless and easily tired.

It’s usually treated with steroid medication

Psychological effects

Being diagnosed with CLL can be very distressing and difficult to take in at first, particularly as it can’t necessarily be cured and you may be advised to wait for it to get worse before starting treatment.

Having to wait years to see how the condition develops can also be very stressful and make you feel anxious or depressed. Speak to your GP or care team if you’re finding it difficult to cope.

You may also find it useful to talk to other people who are living with leukaemia. Your GP or care team will be able to provide you with the details of support groups in your area.

Macmillan Cancer Support provides an excellent level of help and support. Their helpline number is 0808 808 00 00, Monday to Friday, 9am to 8pm.

Causes of chronic lymphocytic leukaemia

It’s not known what causes most cases of leukaemia. However, there are many risk factors that are known to increase your chances of getting chronic lymphocytic leukaemia.

Risk factors for chronic lymphocytic leukaemia include:

• having a family history of the condition
• being of European, American or Australian origin
• having certain medical conditions
• being male 

Family history

In some cases, chronic lymphocytic leukaemia appears to run in families. It’s thought that an inherited gene mutation (change to a gene) could increase your susceptibility to developing the condition. This means there may be certain genes in your family that make it more likely that you’ll develop chronic lymphocytic leukaemia.

More research is needed, but having a parent or sibling (brother or sister) with chronic lymphocytic leukaemia slightly increases your chances of also developing the condition.

Ethnicity

Chronic lymphocytic leukaemia most commonly affects people of European, American and Australian origin.

It’s rare in people from China, Japan and South East Asia, and it affects more white people than black people. It’s not known why the condition affects people of some ethnic backgrounds and not others.

Other medical conditions

Research has shown that having certain medical conditions slightly increases your chances of developing chronic lymphocytic leukaemia. These conditions include:

• pneumonia (chest infection) 
• sinusitis 
• shingles 
• autoimmune haemolytic anaemia
• long-term (chronic) osteoarthritis
• prostatitis (an inflamed prostate)

However, rather than causing chronic lymphocytic leukaemia, some of these conditions may occur as a result of having lowered immunity during the early stages of the condition.

Having a lowered immunity due to having a condition such as HIV or AIDS, or taking immunity lowering medication following an organ transplant can also increase your risk of developing chronic lymphocytic leukaemia.

Radiation exposure

Exposure to radiation is known to increase the risk of getting other types of leukaemia, but it’s not been linked specifically to chronic lymphocytic leukaemia.

The Cancer Research UK website has more information about the risk factors for chronic lymphocytic leukaemia.

Sex and age

For reasons that are unclear, men are around twice as likely to develop chronic lymphocytic leukaemia than women. The risk of developing leukaemia also increases as you get older.

Ultrasound scan – Tests and treatments

An ultrasound scan, sometimes called a sonogram, is a procedure that uses high-frequency sound waves to create an image of part of the inside of the body.

An ultrasound scan can be used to monitor an unborn baby, diagnose a condition, or guide a surgeon during certain procedures.

How ultrasound scans work

A small device called an ultrasound probe is used, which gives off high-frequency sound waves.

You can’t hear these sound waves, but when they bounce off different parts of the body, they create “echoes” that are picked up by the probe and turned into a moving image.

This image is displayed on a monitor while the scan is carried out.

Preparing for an ultrasound scan

Before having some types of ultrasound scan, you may be asked to follow certain instructions to help improve the quality of the images produced. For example, you may be advised to:

• drink water and not go to the toilet until after the scan – this may be needed before a scan of your unborn baby or your pelvic area
• avoid eating for several hours before the scan – this may be needed before a scan of your digestive system, including the liver and gallbladder

Depending on the area of your body being examined, the hospital may ask you to remove some clothing and wear a hospital gown.

If you need a sedative to help you relax, this will be given through a small tube into the back of your hand or into your arm. In some cases, you may also be given an injection of a harmless substance called a contrast agent before the scan, as this can make the images clearer.

What happens during an ultrasound scan

Most ultrasound scans last between 15 and 45 minutes. They usually take place in a hospital radiology department and are performed either by a radiologist or a sonographer.

They can also be carried out in community locations such as GP practices and may be performed by other healthcare professionals, such as midwives or physiotherapists who have been specially trained in ultrasound.

There are different kinds of ultrasound scans, depending on which part of the body is being scanned and why. The 3 main types are:

• external ultrasound scan – the probe is moved over the skin
• internal ultrasound scan – the probe is inserted into the body
• endoscopic ultrasound scan – the probe is attached to a long, thin, flexible tube (an endoscope) and passed further into the body

These techniques are described below.

External ultrasound scan

An external ultrasound scan is most often used to examine your heart or an unborn baby in your womb. It can also be used to examine the liver, kidneys and other organs in the tummy and pelvis, as well as other organs or tissues that can be assessed through the skin, such as muscles and joints.

A small handheld probe is placed onto your skin, and moved over the part of the body being examined.

A lubricating gel is put onto your skin to allow the probe to move smoothly. This also ensures there is continuous contact between the probe and the skin.

You should not feel anything other than the sensor and gel on your skin (which is often cold). If you are having a scan of your womb or pelvic area, you may have a full bladder that causes you a little discomfort. There will be a toilet nearby to empty your bladder once the scan is complete.

Internal or transvaginal ultrasound scan

An internal examination allows a doctor to look more closely inside the body at organs such as the prostate gland, ovaries or womb.

A ‘transvaginal’ ultrasound means ‘through the vagina’.

During the procedure, you’ll be asked to either lie on your back, or on your side with your knees drawn up towards your chest.

A small ultrasound probe with a sterile cover, not much wider than a finger, is then gently passed into the vagina or rectum, and images are transmitted to a monitor.

Internal examinations may cause some discomfort, but don’t usually cause any pain and shouldn’t take very long.

Endoscopic ultrasound scan

During an endoscopic ultrasound scan, an endoscope is inserted into your body, usually through your mouth, to examine areas such as your stomach or gullet (oesophagus).

You’ll usually be asked to lie on your side as the endoscope is carefully pushed down towards your stomach.

The endoscope has a light and an ultrasound device on the end. Once it has been inserted into the body, sound waves are used to create images in the same way as an external ultrasound.

You’ll usually be given a sedative to keep you calm and local anaesthetic spray to numb your throat, as an endoscopic ultrasound scan can be uncomfortable and may make you feel sick. You may also be given a mouth guard to keep your mouth open and protect your teeth, in case you bite the endoscope.

What happens after an ultrasound scan

In most cases, there are no after-effects and you can go home soon after the scan is finished. If a sedative wasn’t used, you can drive, eat, drink and return to your other normal activities straight away.

If you had an endoscopic ultrasound and were given a sedative to help you relax, you’ll usually be advised to stay in hospital for a few hours, until the medication starts to wear off. You’ll need to arrange for someone to pick you up from the hospital and stay with you for the next 24 hours. You shouldn’t drive, drink alcohol or operate machinery during this time.

You may be told the results of your scan soon after it’s been carried out, but in most cases the images will need to be analysed and a report will be sent to the doctor who referred you for the scan. They will discuss the results with you a few days later or at your next appointment, if one has been arranged.

Are there any risks or side effects of an ultrasound scan?

There are no known risks from the sound waves used in an ultrasound scan. Unlike some other scans, such as computerised tomography (CT) scans, ultrasound scans don’t involve exposure to radiation.

External and internal ultrasound scans don’t have any side effects and are generally painless, although you may experience some discomfort as the probe is pressed over your skin or inserted into your body.

If you’re having an internal scan and you’re allergic to latex, it’s important to let the sonographer or doctor carrying out the scan know this, so they can use a latex-free probe cover.

Endoscopic ultrasounds can be a bit more uncomfortable and they can cause temporary side effects, such as a sore throat or bloating. There’s also a small risk of more serious complications, such as internal bleeding.

128. Anatomy and topography of the lymphatic vessels and regional lymph nodes of the head and neck.

From the organs of the head
lymphatic vessels carry lymph
to the lymph nodes lying in the form
small groups on the border of the head and neck
[occipital, mastoid (behind the ear),
parotid, pharyngeal, facial,
submandibular, submental]
(Fig. 93). From these nodes, lymph through the vessels
heading for the surface and
deep lymph nodes of the neck
(front, side, rear), in which
lymphatic vessels also drain from
neck organs. Efferent lymphatic
vessels of the nodes of the largest cervical
chains – lateral deep
cervical (internal jugular) lymphatic
nodes – form the jugular (lymphatic)
trunk.

Occipital
lymph nodes, nodi
lymphatici
occipitdles
(1-6),
lie on the surface of the cervical
fascia, behind the insertion
sternocleidomastoid muscle, and
also under this sheet on the belt muscle
head and under this muscle near the occipital
blood vessels. To the occipital
lymph nodes fit lymph
vessels from the skin of the occipital region and from
deep tissues of the neck. Take-out
lymphatic vessels of the occipital nodes
heading towards the lateral deep
cervical lymph nodes (nodes of the chain
accessory nerve).

Mastoid
(behind the ear)
lymphatic
nodes, nodi
lymphatici
mastoidei
(1-4),
located behind the auricle
mastoid process at the site
attachments of the sternocleidomastoid
causoid muscle. They take lymph
vessels from the auricle and parietal skin
areas. Efferent lymphatic
the vessels of these nodes are sent to
parotid, superficial cervical
(near the external jugular vein) and to
lateral deep cervical (internal
jugular) lymph nodes.

Parotid
lymph nodes, nodi
lymphatici
parotidei ,
located
in the region of the salivary gland of the same name.
Outside (lateral) of this gland
lie superficial
parotid lymph nodes, nodi
lymphatici
parotidei
superficiales
(1-4),
and under the capsule of the gland and in the thickness of the parotid
glands between its lobules are
small sizes deep
parotid (intraglandular) lymphatic
nodes, nodi
lym phatici
parotidei
profundi
intraglanduldres
(4-10).
To parotid lymph nodes
lymphatic vessels are sent from
skin and other organs of the frontal and parietal
areas of the head, from the auricle,
external auditory canal, auditory
tubes, upper lip, parotid
glands. Efferent lymphatic vessels
of these nodes are sent to the surface
(near the external jugular vein) and lateral
deep (along the internal jugular
veins) cervical lymph nodes.

Retropharyngeal
lymph nodes, nodi
lymphatici
retropha – ryngeales
(1-3),
lie on the prevertebral plate
cervical fascia behind the pharynx and on the lateral
its walls. These nodes are directed
lymphatic vessels from the walls of the pharynx,
nasal mucosa and
paranasal (adnexal) sinuses, from
tonsils and palate, auditory tube and *
tympanic cavity of the middle ear.
Efferent lymphatic vessels
pharyngeal nodes flow into the lateral
deep cervical (internal jugular)
The lymph nodes.

Mandibular
lymph nodes, nodi
lymphatici
tap- dibuldres
(I-3),
inconsistent, lie in the subcutaneous basis
on the outer surface of the lower body
jaw, near the facial arteries and
veins. Subcutaneous (fiber)
cheeks near the facial vessels are located
also non-permanent facial
(buccal) lymph nodes, nodi
lymphatici
facidtes
( buccina – torii ).
K
lymph nodes of these groups
vessels are directed from the skin of the face, soft
tissues of the eyelid, nose, lips, cheeks. Them enduring
vessels drain into submandibular
lymph nodes, nodi
lymphatici
submandibulares
(6-8),
which are located in the submandibular
triangle, anterior and posterior to
salivary gland of the same name.
Lymphatic vessels of the submandibular
knots are directed down along the front
veins and flow into the lateral deep
cervical (internal jugular) lymphatic
nodes. Subchin
lymph nodes, nodi
lym phatici
submentdles
(1-8),
located on the bottom surface
geniohyoid muscle, between
anterior bellies of right and left
digastric muscles from
chin to the body of the hyoid bone.

At the heart of the division
lymph nodes of the neck put them
relation to the surface plate
cervical fascia, as well as to large
neck vessels. In this regard, allocate
superficial cervical lymphatics
nodes lying on the surface
plate, and deep, located under
her. Separate regional groups
lymph nodes lie near large
vessels – veins of the neck (Fig. 94).

Surface
cervical lymph nodes, nodi
lymphatici
cervicles
superficidles
(1-5),
found in ³ / ₄
cases, located near the outer
jugular vein (1-3 nodes), on the trapezius
muscle (1-2 nodes), in the back of the neck and
rarely – near the anterior jugular vein (1
node). Their efferent lymphatics
heading towards the lateral deep
cervical lymph nodes lying
near the internal jugular vein and
external branch of the accessory nerve.

Deep
cervical lymph nodes, nodi
lymphatici
cer vicdles
profundi ,
concentrated
in the anterior and lateral regions
neck. To the anterior deep cervical
lymph nodes

relate
preglottal
lymph nodes, nodi
lymphatici
prelaryngedles
(1-2),
thyroid,
nodi
lymphatici
thyroidei
(1-2),
pre-tracheal,
nodi
lymphatici
pretracheales
(1
– 8), paratracheal,
nodi
lymphatici
paratracheales
(1-7),
lying next to the trachea. In the lateral
neck areas are numerous
lymph nodes (11-68), which
form several regional
groups. It’s lateral
neck deep (internal
jugular) lymphatic
nodes, nodi
tici
cervicles
laterales
profundi
(7-60).
They are located near the inner
jugular vein; 1-8 lymph nodes
in the form of a chain adjacent to the outer branch
accessory nerve. Near the surface
branch of the transverse artery of the neck is
1 to 8 lymph nodes. In the lateral
neck areas are present
Also
non-permanent lymph nodes (1-2),
lying on the belt muscle of the head. By
efferent lymphatic vessels of these
lymph nodes flow to the lateral cervical
deep lymph nodes, which
adjacent to the internal jugular vein
all sides from the base of the skull to
confluence with the subclavian vein. IN
group of lateral cervical deep
lymph nodes secrete
jugular-bigastric
node, nodus
jugulodigdstricus ,
and
jugular-scapular-hyoid
node, nodus
juguloomohyoideus ,
k
which are directed mainly
lymphatic vessels of the tongue. First of
these nodes is at the level of intersection
posterior belly of the digastric muscle with
internal jugular vein, and the second – in
the place where the abdomen of the scapular-hyoid
muscles adjacent to the anterior surface
internal jugular vein.

Take-out
lymphatic vessels of the lateral cervical
deep lymph nodes form
on each side of the neck jugular
barrel, tr ( incus
juguldris
( dexter
and
sinister ).
This
the trunk flows into the venous angle or into one
from the corresponding veins that form it
side or in the right lymphatic
duct and terminal thoracic duct
(left).

28S

Kalmin O.V.	Lectures on normal human anatomy

LYMPH NODES AND VESSELS OF THE HEAD AND NECK

Lymph nodes and vessels of the head Lymph nodes and vessels of the neck endocrine, as well as large blood vessels and nerves.

Numerous lymph nodes are located at the border of the head and neck and directly on the neck, which, as a rule, are affected in inflammatory or tumor diseases of the organs. As the nodes grow in size, they can compress nearby vessels and nerves.

Lymph nodes of the head lie on the border of the head and neck and are divided according to their position into groups that are located on the path of lymph flow from the organs and soft tissues of the head to the lymphatic collectors of the neck.

The modern classification of groups of lymph nodes located on the border of the head and neck is as follows.

1. Posterior lymph nodes

∙ occipital

∙ mastoid

2. Lateral lymph nodes

∙ superficial parotid

∙ deep parotid

∙ anterior

∙ inferior auricular

∙ intraglandular

∙ buccal (facial) )

∙mandibular

∙submandibular

∙lingual

3. Anterior lymph nodes

∙ mental

4. Prevertebral lymph nodes

∙ pharyngeal

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Kalmin O.V.

Lectures on normal human anatomy
	Lymph nodes and vessels of the head and neck

Posterior lymph nodes

Occipital lymph nodes

Occipital lymph nodes are absent only in isolated cases and can be divided into three secondary groups: superficial (suprafascial), subfascial, and axillary (sublingual) (Fig. 1).

Superficial (suprafascial) occipital lymph nodes lie above the superficial cervical fascia, in the region of the beginning of the sternocleidomastoid muscle and on the fibrous-tendinous fibers covering the superior nuchal line. These nodes also lie behind and above the beginning of the sternocleidomastoid muscle on the occipital muscle or on the fascia covering the belt muscle in the gap between the sternocleidomastoid and trapezius muscles. The number of superficial nodes ranges from 1 to 6. The superficial occipital nodes are closely related to the external branch of the occipital artery and to the greater occipital nerve.

Subfascial occipital lymph nodes are very rare and lie under the superficial cervical fascia near the superior nuchal line, on the splenius capitis. In some cases, the entire occipital group of lymph nodes is represented by one subfascial node. Subfascial occipital nodes

can be considered as the uppermost deep lateral lymph nodes of the neck.

Deep occipital lymph nodes are permanent. In an amount from 1 to 3, they are located under the initial part of the splenius muscle of the head, near the occipital vessels.

Lymphatic vessels come to the occipital lymph nodes from the skin of the scalp, the skin of the occipital region, and partly the deep tissues of the occiput. The

efferent lymphatic vessels of the occipital nodes go down to the deep lateral lymph nodes of the neck, most often to the nodes of the accessory nerve chain.

Mastoid lymph nodes

Mastoid lymph nodes are located behind the auricle at the attachment of the sternocleidomastoid muscle to the mastoid process and were formerly called posterior auricular lymph nodes (Fig. 1). The number of mastoid lymph nodes is small, often 1-2.

Lymphatic vessels flow into the mastoid lymph nodes from the parietal region and the auricle. The efferent vessels of these nodes are sent to the parotid lymph nodes located at the lower edge of the gland of the same name, or to the internal jugular lymph nodes. To the parotid nodes, the lymphatic vessels go along the anterior edge of the sternocleidomastoid muscle, and the vessels following to the internal jugular nodes can either go around the anterior valve of this muscle, or pierce its tendon and end in the upper group of the posterior internal jugular lymph nodes. nodes at the junction with the lymph nodes of the accessory nerve.

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	Lymph nodes and vessels of the head and neck

Lateral lymph nodes

Parotid lymph nodes

Lymph nodes located in the region of the parotid salivary gland are called parotid (Fig. 2). Previously, these nodes were called superficial facial, or zygomatic lymph nodes, anterior ear. Later, taking into account the position of these lymph nodes, they were identified as parotid and assigned to them all the nodes lying in the region of the parotid salivary gland.

They are divided into three independent groups: superficial suprafascial, subfascial extraorganic (extraglandular) and deep intraorganic (intra-glandular) lymph nodes.

Superficial parotid lymph nodes lie anterior to the tragus, but may be found above or below it, and behind the parotid salivary gland. The number of superficial parotid (suprafascial) nodes ranges from 1 to 4.

Deep parotid lymph nodes are located between the tissue of the parotid salivary gland and the fascia covering it. Some nodes lie between the fascia and the outer surface of the gland, anterior to the tragus or closer to the anterior edge of the gland (anterior nodes). Some of these nodes are partially embedded in the tissue of the parotid gland. Other subfascial nodes are located at the lower edge of the gland, next to the external jugular vein. These lymph nodes lie between the lower edge of the gland and the anterior edge of the sternocleidomastoid muscle. These are the lower parotid (lower ear) nodes, occurring in the amount of 1-3.

Deep intraorgan parotid lymph nodes (intraglandular) in an amount of 4 to 6 lie in the thickness of the parotid salivary gland, usually along the external carotid and superficial temporal arteries or near the external jugular vein. These nodes are always located in a thin layer of connective tissue between the lobules of the gland.

Lymphatic vessels go to the parotid lymph nodes from the skin of the scalp, soft tissues of the face, and the auricle. So, to the parotid superficial

and lymphatic vessels from the skin and other organs of the temporal region, the root of the nose, the upper and lower eyelids, the auricle and the external auditory meatus come to the deep anterior lymph nodes. Often these nodes receive lymph from the walls of the auditory tube. The lower ear lymph nodes are regional nodes for the nose, parotid salivary gland, buccal mucosa. Less commonly, lymphatic vessels from the gums and chin come here. In these nodes, the efferent vessels of the mastoid lymph nodes are also pumped. Intraorganic (deep parotid, intraglandular) lymph nodes flow into the afferent lymphatic vessels of the salivary and lacrimal glands, some part of the temporal and frontal regions, the auditory tube and other parotid lymph nodes.

Three main pathways for the efferent vessels of the parotid lymph nodes were identified: posterior, venous (toward the external jugular vein) and arterial (down along the superficial temporal artery). The posterior path is represented by the efferent lymphatic vessels of the nodes located behind the parotid salivary gland. These vessels run along the posterior edge of the gland or between the lobules of its posterior

	Lectures on normal human anatomy
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la down and end in one of the upper internal jugular nodes. Some of the lymphatic vessels of this path terminate in the inferior ear nodes.

The venous pathway is formed by the efferent lymphatic vessels of the superficial and deep parotid lymph nodes, which approach one of the nodes located next to the external jugular vein. Further, the lymphatic vessels of this path follow the jugular vein downwards and end in the lower internal jugular nodes.

The arterial pathway begins in the deep parotid lymph nodes. The

efferent lymphatic vessels of these nodes go down along the superficial temporal artery and, upon reaching the external carotid artery, descend along it, medially from the

posterior abdomen of the digastric and stylohyoid muscles to the anterior superior internal jugular nodes.

The venous lymph flow from the parotid salivary gland is sometimes absent. In these 90,003 90,002 cases, the lymphatic vessels of this gland and its regional lymph nodes flow into the submandibular lymph nodes.

Submandibular, mandibular and buccal (facial) lymph nodes

Submandibular lymph nodes are divided into three groups: anterior, middle and posterior. The anterior submandibular nodes lie in a triangular gap bounded by the lower margin of the mandible, the anterior belly of the digastric muscle, and the anterior margin of the submandibular salivary gland.

The median submandibular nodes are located between the lower edge of the jaw and the upper edge of the submandibular salivary gland, anterior to the facial artery.

The posterior submandibular lymph nodes are located behind the facial artery. Usually they lie at the lateral edge of the body of the jaw.

Lymphatic vessels go to the submandibular nodes from the soft tissues of the face, from the anterior part of the nasal mucosa, gums, palate, body of the tongue, sublingual and submandibular salivary glands, bottom of the mouth, submental lymph nodes (Fig. 3). The afferent lymphatic vessels of the submandibular lymph nodes, coming from the face area, are interrupted on their way by small nodes that lie mainly along the facial artery and vein. For the name of these lymph nodes, various terms were used: “buccal”, “facial”, “mouth”. But the most appropriate term for these nodes is “facial lymph nodes”. They are considered as intercalary on the route of the bringing vessels to the submandibular nodes.

Mandibular lymph nodes (1-3) lie on the outer surface of the body of the lower jaw near the facial artery or vein, occur in 10% of cases. Buccal lymph nodes were found in 20% of cases in the fatty tissue of the cheek along the facial artery and vein at the level of the oral fissure. The so-called infraorbital and zygomatic lymph nodes are very rare. The infraorbital nodes lie along the facial vessels, and the zygomatic nodes lie in the region of the zygomatic bone on the path of the lymphatic vessels of the upper eyelid.

The efferent lymphatic vessels of the submandibular lymph nodes are directed down along the facial vein or facial artery, bypassing the anterior belly of the digastric muscle from the medial side, and end in one of the anterior upper

Kalmin O. V.	Lectures on normal human anatomy
	Lymph nodes and vessels of the head and neck

internal jugular nodes. Very often, the efferent lymphatic vessels of the submandibular nodes end in the nodes located at the upper edge of the scapular-hyoid muscle. The efferent lymphatic vessels of the submandibular nodes also flow into the submental lymph nodes. Lymph outflow from the submandibular to the internal jugular nodes of the opposite side is possible along this path.

Lingual lymph nodes

Lingual lymph nodes are intercalary in the path of the main lymphatic vessels of the tongue (Fig. 4). They occur in 8.6% of cases. Among them, lateral and median nodes are distinguished. The lateral lingual nodes are located along the lingual artery and vein on the path of the lateral lymphatic vessels of the tongue, and the medial

– along the central lymphatic vessels of the back of the tongue, running between the right and left genio-lingual muscles.

Lateral lingual nodes are located on the outer surface of the maxillary-lingual or hyoid-lingual muscles, and medial – on the medial surface of the maxillary-lingual muscle.

Anterior lymph nodes

Mental lymph nodes

Mental lymph nodes are located between the anterior bellies of the right and left digastric muscles, from the chin to the body of the hyoid bone on the geniohyoid muscle, both on and under the fascia (Fig. 5). Their number ranges from 1 to 8. The greater the number of nodes, the smaller their size. Depending on

Bridges from the level of their location among the submental lymph nodes can be divided into anterior, middle and posterior. The anterior nodes are non-permanent (found in half of the cases) and lie somewhat posterior to the digastric fossa on the mandible. The posterior nodes are often absent, and if present, they lie next to the body of the hyoid bone. The middle nodes are located between the bellies of the digastric muscles, usually along the geniohyoid suture between the anterior and posterior nodes.

Lymphatic vessels from the soft tissues of the chin area, the middle part of the lower lip, cheeks, gums, the tip of the tongue and the floor of the mouth, as well as the efferent vessels of the submandibular lymph nodes flow into the mental lymph nodes.

The efferent lymphatic vessels of the mental lymph nodes go to the submandibular and internal jugular lymph nodes.

Prevertebral lymph nodes

Retropharyngeal lymph nodes

According to topography, retropharyngeal lymph nodes are divided into lateral and medial. The lateral retropharyngeal lymph nodes are located in the retropharyngeal space at the lateral edge of the posterior pharyngeal wall (Fig. 6). Behind, they are adjacent to the prevertebral fascia, in front – to the back wall of the pharynx, and laterally – to the internal

neutral carotid artery at the place of its entry into the canal of the carotid artery and to the superior cervical sympathetic ganglion. The level of localization of these nodes corresponds to the lateral masses of the first cervical vertebra.

Kalmin O.V.	Lectures on normal human anatomy
	Lymph nodes and vessels of the head and neck

The medial pharyngeal lymph nodes lie directly on the posterior pharyngeal wall, with which they are often soldered. The level of location of these nodes corresponds to the connection of the body of the second cervical vertebra with its tooth at the level of the midline or near it (Fig. 7).

The afferent lymphatic vessels of the lateral pharyngeal lymph nodes come from the nasal mucosa (air sinuses), from the palate, middle ear and pharynx. The efferent lymphatic vessels of these nodes go downward and outward, bypassing the neurovascular bundle (internal carotid artery, internal jugular vein, vagus nerve) behind, and end in the external lymph nodes of the internal jugular chain. As for the medial (middle) pharyngeal nodes, they are considered as intercalary lymph nodes located on the path of the lateral pharyngeal nodes that bring lymphatic vessels, coming from the pharyngeal wall.

The most rational classification of neck lymph nodes is as follows.

1. Superficial cervical lymph nodes

∙ anterior

∙ lateral

∙ posterior

2. Deep cervical lymph nodes

∙Anterior deep cervical lymph nodes

∙Preglottic

∙Prethyroid

∙Pretracheal

∙Paratracheal

∙Lateral deep cervical lymph nodes 9L lymph nodes of the transverse artery of the neck

∙Superficial lymph nodes

Superficial cervical lymph nodes

Anterior superficial cervical lymph nodes

These nodes are located along the anterior jugular vein on the superficial cervical fascia at the intersection of this vein with the vast saphenous

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peeling between the legs of the left sternocleidomastoid muscle (supraclavicular fossa minor) (Fig. 8).

These nodes were found only in 8% of cases. They are approached by lymphatic vessels from the skin and subcutaneous tissue of the anterior region of the neck. The efferent lymphatic vessels go around the lateral edge of the sternocleidomastoid muscle and flow into the lymph node lying near the medial surface of the external jugular vein.

Lateral superficial cervical lymph nodes

Lateral superficial cervical lymph nodes in number from 1 to 3 were found in 54% of cases. The nodes of this group are located along the external jugular vein on the superficial cervical fascia covering the anterior surface of the sternocleidomastoid muscle (Fig. 8).

The afferent lymphatic vessels of the lateral superficial lymph nodes of the neck come from the skin of the lateral and posterior regions of the neck, the soft tissues of the face, accompanying the external jugular vein and its tributaries. In 52% of cases, such vessels originate from the lymph nodes of the head located at the border of the head and neck (mastoid, occipital, parotid) (Fig. 9).

The efferent lymphatic vessels of the lateral superficial lymph nodes go first along the external jugular vein, then go around the posterior or anterior edge of the sternocleidomastoid muscle, or both the anterior and posterior edges of this muscle, pierce the superficial cervical fascia and flow into the deep lymph nodes neck. In 93% of cases, these efferent lymphatic vessels end in nodes along the internal jugular vein, and in 7% of cases, in nodes located near the external branch of the accessory nerve.

Posterior superficial cervical lymph nodes

These nodes are located throughout the outer (posterior) surface of the cervical part of the trapezius muscle. They occur in 46% of cases.

In all cases, the afferent vessels from the soft tissues of the posterior neck region are directed to the superficial cervical lymph nodes of the posterior region of the neck, and in 35% of cases, the efferent lymphatic vessels of the occipital lymph nodes also end in these nodes. The efferent lymphatic vessels of these nodes pierce the superficial plate of the cervical fascia and in 69% of cases end in the nodes of the chain of the accessory nerve, in 13% – in the nodes of the transverse chain of the neck, in 9% in the nodes lying on the belt muscle of the head. In 9% of cases, these vessels simultaneously fell into the nodes of the accessory nerve chain and the transverse cervical chain.

Thus, three superficial lymphatic pathways are formed on each side of the neck, carrying lymph from the soft tissues of the head and neck to deep lymph nodes located in the lower parts of the neck.

1. The anterior superficial cervical lymphatic pathway is formed by lymphatic vessels and nodes located along the anterior jugular vein, which conducts lymph from the face and the anterior surface of the neck.

2. The lateral superficial cervical lymphatic pathway is formed by lymphatic vessels and nodes adjacent to the external jugular vein.

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lymph from the soft tissues of the face, lateral and back areas of the neck, mastoid, occipital and parotid nodes.

3. The posterior superficial cervical lymphatic pathway is represented by lymphatic vessels and nodes lying on the trapezius muscle, it conducts lymph from the soft tissues of the back of the neck and occipital lymph nodes.

Deep cervical lymph nodes

Deep neck lymph nodes are subdivided into anterior and lateral on the basis of the topographic-anatomical principle, taking into account the direction of lymph flow from the organs of the head and neck.

Anterior deep cervical lymph nodes

Deep cervical lymph nodes of the anterior region of the neck are located under the proper fascia of the neck (pretracheal plate) in fatty tissue in front of the larynx (preglottic), near the thyroid gland (prethyroid), in front of the trachea (pretracheal) and at its lateral surfaces (peritracheal ) (Fig. 10).

The total number of anterior deep cervical lymph nodes in adults ranges from 4 to 17.

Prethyroid lymph nodes in the amount of 1-2 are found in 14% of cases. go to the preglottal nodes, or flow into their efferent vessels, or go to the pretracheal lymph nodes (very rarely).

Preglottic lymph nodes occur in 38% of cases. The afferent lymphatic vessels of the preglottic lymph nodes come from the larynx, thyroid gland, and prethyroid lymph nodes. Lymphatic vessels from the laryngeal mucosa below the vocal fold travel to the preglottic ganglions, passing through foramina in the cricothyroid ligament, along with the right and left cricothyroid arteries. The efferent lymphatic vessels of the preglottic lymph nodes in 79% of cases go from nodes to the right and to the left to the superior thyroid veins. Then, following next to these veins, they reach the deep cervical lymph nodes located near the right and left internal jugular veins. In 14% of cases, the efferent lymphatic vessels of the unpaired preglottic group of nodes reached the nodes lying only near the right internal jugular vein, in 7% – near the left internal jugular vein.

Lymph nodes lying on the anterior wall of the cervical part of the trachea and on the sides of it and called pretracheal and paratracheal lymph nodes are distinguished under the name of tracheal lymph nodes (Fig. 11).

Pretracheal lymph nodes lie in fatty tissue between the posterior surface of the own fascia of the neck (pretracheal plate) and the anterior surface of the trachea. They were found in 74% of cases in an amount of 1 to 8.

Lymph nodes lying on the anterior surface of the trachea receive from 2 to 4 afferent lymphatic vessels coming from the trachea, the lower edge of the isthmus, the lower poles of the right and left lobes of the thyroid gland, in isolated cases – from the prethyroid lymph nodes. The afferent lymphatic vessels from the anterior mediastinal, right and left tops also approach the pretracheal nodes.0003

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	Lymph nodes and vessels of the head and neck

of them tracheobronchial nodes, lymphatic vessels from the superficial muscles of the neck, thymus.

The efferent lymphatic vessels of the pretracheal nodes drain into the peritracheal lymph nodes located at the lateral surfaces of the trachea (Fig. 12).

The peritracheal lymph nodes, both on the right and on the left, are permanent. Located at the lateral surface of the trachea, these nodes are bounded from above by the lower edge of the corresponding lobe of the thyroid gland, and their lower border is at the level of the branch of the right subclavian artery from the brachiocephalic trunk

esophagus.

The efferent lymphatic vessels of the right paratracheal nodes most often (84%) end in the lower deep jugular lymph nodes. In 12% of cases

The efferent vessels of these nodes are involved in the formation of the right jugular trunk and in 4% – independently flow into the internal jugular vein in the region of the right venous angle. The efferent lymphatic vessels of the left paratracheal nodes most often (66% of cases) flow into the deep jugular lymph nodes, in 14% – into the cervical part of the thoracic duct, in 12% – participate in the formation of the left jugular trunk, and in 8% they flow independently into the internal jugular and subclavian veins in the region of the left venous angle.

Lateral deep cervical lymph nodes

Lymph nodes located in the lateral region of the neck under the superficial cervical fascia are referred to as lateral deep cervical lymph nodes. They are grouped along the internal jugular vein, along the external branch of the accessory nerve, near the transverse artery of the neck and on the surface of the splenius head muscle, in the gap between the sternocleidomastoid and trapezius muscles. These lymph nodes are permanent (Figure 13).

The total number of lateral deep lymph nodes of the neck in adults ranges from 11 to 68.

Internal jugular lymph nodes – us with the posterior belly of the digastric muscle until it merges with the subclavian vein. The number of internal jugular lymph nodes in adults ranges from 7

to 60.

Internal jugular lymph nodes, located near the internal jugular vein on its medial, lateral, anterior and posterior surfaces, are unevenly distributed along the entire length of this vein. From a topographic point of view, three groups are distinguished among these nodes: upper, middle and lower (Fig. 14).

The upper group of nodes contains a larger node than the others, located under the lower edge of the posterior belly of the digastric muscle, lateral and anterior to the internal jugular vein. In the medical literature, it is known under various terms: “the main gland of the carotid angle”, “angular node”,

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	Lymph nodes and vessels of the head and neck

“subgastric node”, “major gland of the venous angle”, “precarotid node”, currently it is commonly called the jugular-bigastric node (Fig. 1).

On the border of the middle and lower third of the internal jugular vein, i.e. at the intersection of its intermediate tendon of the scapular-hyoid muscle, there are often 1-3 large lymph nodes, called the jugular-scapular-hyoid node.

The afferent lymphatic vessels of the internal jugular lymph nodes come from the lymph nodes of the head, lying on the border of the head and neck, from the organs of the head, neck, from the deep lymph nodes of the anterior region of the neck (periorgan), superficial and deep nodes of the lateral region of the neck (Fig. . 15).

Most of the groups of lymph nodes located on the border of the head and neck,

are connected by efferent lymphatic vessels to the upper deep cervical lymph nodes. So, lymphatic vessels from the occipital, mastoid, parotid and submandibular nodes flow into the nodes of the upper group.

The afferent lymphatic vessels for the lymph nodes lying near the middle section of the internal jugular vein are the afferent lymphatic vessels of the nodes of the upper group. In addition, lymphatic vessels from the occipital lymph nodes, from the larynx, go to the nodes of the middle group.

There is information about the flow into the lymph nodes of the middle group of lymphatic vessels from the lateral surface of the tongue, from the mucous membrane of the lower part of the pharynx.

The lymphatic vessels that bring to this group of nodes also come from the tip of the tongue, the upper and lower lips, the corner of the mouth, the pharynx and esophagus, and the larynx (Fig. 16). According to clinical data, damage to the internal jugular lymph nodes (lower group) occurs in cancer of various parts of the larynx, parotid salivary gland, and thyroid gland.

Lymph nodes of the lower group drain lymphatic vessels of peristernal, submandibular, submental, lower tracheobronchial (bifurcation), anterior upper mediastinal and tracheobronchial lymph nodes.

Located at the surfaces of the internal jugular vein, the internal jugular lymph nodes are connected by lymphatic vessels, forming anterior, posterior, lateral and medial chains.

Accessory nerve lymph nodes

Accessory nerve lymph nodes are lymph nodes located near the external branch of the accessory nerve, lie under the superficial cervical fascia, from the level of the appearance of the external branch of the accessory nerve from under the lateral surface of the internal jugular vein to its entry under the anterior edge of the trapezius muscle, which corresponds to the position of the scapular-trapezoid triangle (Fig.