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the s u b d i gastric g r oup is the so c a lled principal node of Kuttner (1898) or 'ganglion superieur jugulaire of
Taillens' (1960). This node may exte n d behi n d the d i g a s t r i c m u scle and, when involved w i t h disease, can exte n d up to
the jugular foramen. These s u b d i gastric nodes v a r y in number fr o m two to ten and r each up to 1.5 cm in size.
Both Ducuing (1932) and R o u v i e r e (1932) n oted an accumulation of deep lateral cervical lymph nodes in the upper p a r t of
the neck at the j unction b e t w e e n the jugular and the spinal nodes. R ouviere c a lled this c o l l e c t i o n 'amas g a n g l i o n n a i r e de la junction' (junctional a g g l o m e r a t i o n of n o d e s ) .
S u b s e q u e n t c omparative r a d i o l o g i c a l and gross a n a t o m i c a l e x a m i n a t i o n of surgical s pecimens (Fisch and Sigel, 1964; Fisch, 1968) has c o n f i r m e d t h a t these nodes c o r r e s p o n d to the u p p e r d e e p lateral cervical nodal group w h i c h includes the s u b d i g a s t r i c node of Kuttner. T h e s e nodes h a v e b e e n c a l l e d junct i o n a l nodes (Fisch and Sigel, 1964). T h e y form a kind of c r o s s r o a d s for the c e r v i c a l lymph as they not o n l y r e c e i v e r e g i o n a l lymph from the oropharynx, tonsils, nasal sinuses, palate, b a s e of tongue, h y p o p h a r y n x and laryngeal v e s t i b u l e b u t also efferent lymph f rom the transitional nodes. U s i n g c e r v i c a l lymphography, F i sch d e m o n s t r a t e d the aver a g e n u m b e r of lymph nodes in the deep lateral cervical lymph g r o u p was
48 and of these, n i n e w e r e junctional and 11 w e r e jugular. He also stated it w o u l d be anatomically i n a c c u r a t e to refer to the junctional n o d e s as jugular, since v e r y f e w of them w ere a s s o c i a t e d in his experience with the i n t e r n a l jugular vein. O t her w o r k e r s h ave made similar o b s e r v a t i o n s and grouped the junctional n o d e s w i t h the lower p a r o t i d e a n and p o s t
auric u l a r lymph n o d e s (Spitalier and C o l o n n a D ' I s t r i a , 1961).
R o u v i e r e 's lateral internal jugular g r o u p e x t e n d e d from the d i g a s t r i c m u s c l e to the subclavian vein. T h e s e n odes are part of an e l o n g a t e d n e t w o r k of nodes and v e s s e l s w h i c h vary g r e a t l y in p a t t e r n and number. Some nodes m e a s u r e d 2-3 cm and v a r i e d in n u m b e r f r o m 10 to 20. In some c a s e s t h e r e is more than one l y m p h a t i c trunk, particularly in the c a u d a l p a r t of the chain. T h e jugular chain proper r e c e i v e s lymph from the t r a n s i t i o n a l a n d junctional nodes, t h e larynx, the t h y r o i d and p a r a t h y r o i d glands and c o m m u n i c a t e s w i t h the
spinal a c c e s s o r y a n d supraclavicular nodes. In m o d e r n textbooks the jugular lymph n o d e s p r o p e r are desc r i b e d as e i t h e r
s uperior and i n f e r i o r (Sessions et al, 1986) o r as u p p e r (subdigastric or jugulodigastric) , middle *(jugulo-omohyoid) and lower (Million and Cassisi, 1984).
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The lymph nodes of the spinal accessory nerve are s i t u a t e d in the r e g i o n of the lateral triangle of the neck and are d i s t r i b u t e d along the course of the eleventh cranial nerve. S u p e r i o r l y they are c l o s e l y connected with the
junctional nodes. R o u v i e r e (1932) d escribed six to 10 w hile F i s c h d e m o n s t r a t e d an average of 19 (Fisch, 1968). They drain the parietal r e g i o n of the scalp, the nuchal skin, and the s kin of the lateral cervical areas, as well as that of the shoulder. The spinal nodes const i t u t e regional stations for the lymph from the occipital posta u r i c u l a r and suprascapular lymph nodes. E f f e r e n t lymph passes to the supraclavicular lymph nodes.
The s u p r a c l a v i c u l a r nodes lie b e l o w the jugular nodes in the gap b e t w e e n the omohyoid and the clavicle. They s u r r o u n d the t r a n s v e r s e cervical artery and v e i n and are s omet i m e s c a l l e d the transverse cervical chain ('chaine
c e r v i c a l e transverse') of Taillens. Rouviere d e scribed six to 12 nodes w h i l e F i s c h d e m o n s t r a t e d nine. Others have called t h e s e nodes lower jugular nodes (Becker, 1963). They form the r egional s t a t i o n for the lymphatic vessels of the
s kin of the a n t e r o l a t e r a l part of the neck and thoracic wall and are c o n n e c t e d w i t h lymphatic c hannels from the spinal chain and axillary, i n f r a c l a v i c u l a r and mediastinal nodes. Efferent
lymphatics m e e t w i t h those from the a x i l l a r y nodes to end as a short s u b c l a v i a n trunk.
The existence of the nuchal lymph nodes is controversial. T h e y w e r e not mentioned by Rouviere, but have since been
d e s c r i b e d by others (Taillens, 1960; Fisch, 1968). They c o n sist of four to five lymph nodes lying u n d e r the origin of
t r a p e z i u s and which run down p a r a l l e l to its midline. The a f f e r e n t and efferent path w a y s of t hese nodes are poorly u n d e r s t o o d (Becker, 1963).
The Cervical Skin
In c o n t r a s t to the deep lateral cervical lymph nodes, t h e r e is less controversy c o n c e r n i n g the lymphatic drainage of the cerv i c a l skin (Rouviere, 1932? Fisch, 1968;
F eind, 1972) . The most i m p o r t a n t of the regional lymph n o d e s of the cervical skin are the d e e p lateral cervical l y m p h nodes (jugular, spinal a c c e s s o r y and s u p r a c l a v i c u l a r ) , a nd the lower lymph nodes of the p a r o t i d gland, the submental nodes, the lymph nodes along the e x t e r n a l jugular vein and the medial superficial c e r v i c a l nodes. The lymphatics of the c e r v i c a l s k i n are considered in five regions (Figure 11). T h e s e are the nape, lateral, s u p r a clavicular, suprahyoid and i n f r a h y o i d regions. The p o s t e r i o r n e c k vessels run
a n t e r i o r l y and obliquely d o w n w a r d to the lower end of the s p inal a c c e s s o r y chain. The lateral skin of the neck drains to the lower parotid nodes or the e x t e r n a l jugular chain.
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