On Lymphoedema

On Lymphoedema

What is Lymphoedema?

Lymphoedema is a long-term chronic condition. It ‘refers to tissue swelling, that is caused by a build-up of lymph fluid, that is usually drained through the body’s lymphatic system. Lymph nodes are a vital part of the lymphatic system. Any type of problem that blocks the drainage of lymph fluid can cause Lymphoedema.[1]

This is an image of an Asian man with a swollen cheek. He is suffering with inflammation of the parotid gland, called Parotitis. This has been caused by lymphedema, which is when lymph nodes do not drain lymph fluid away.

 Symptoms

The symptoms for lymphoedema include; swelling, a feeling of heaviness or tightness, repeated skin infections and tight or thickened skin. Fluid leaking through skin or wart like growths, are also symptomatic of lymphedema. Many of my symptoms are congruent with those of lymphoedema. I have persistent swelling on the left side of my face. The tissue feels tight and heavy, and I have had recurrent infections in my parotid gland for many years. Hardened, calcified tissue was found in my parotid tissue, as were reactive lymph nodes. I do not have fluid leaking through the skin.

This is an image of an Asian man, holding his cheek, suffering with facial pain. The purpose of the image is to demonstrate somebody suffering with symptoms of lymphedema.

‘Lymph nodes play a vital role in protecting the body against infection and disease. They contain immune cells that detect and destroy bacteria.’

Medical news today.

Function of Lymph nodes

The lymphatic system is a network of lymph glands and vessels that help fight infection and remove excess fluid. The function of the lymph nodes is to drain fluid, filter out harmful substances, and fight infection.

This image shows the human lymph node anatomy in the head and neck. The purpose of this image is to demonstrate where the lymph nodes are, that are possibly damaged, and causing lymphedema

Human Lymph Nodes Anatomy Illustration

Tissues in the body excrete lymphatic fluid or lymph, in order to eliminate waste products. The vessels take excess fluid from the body’s tissues and direct it towards the lymph nodes.  The lymph nodes then filter lymph fluid and destroy the bacteria, as it arrives from the scalp, neck and face. They then release the clean fluid back to the blood. A lymph node swells when it has to work hard to remove harmful substances from the lymph fluid. Lymphadenopathy is when lymph nodes swell, and this swelling is normally caused by either cancer or infection.

The Lymphatic system, acts to drain fluid from the tissues and return it to the circulation.

Teach Me Anatomy.

The Facial Lymphatic System

‘There are around 800 lymph nodes in the human body, and approximately 300 of these, are in the head and neck region. Henri Rouvière was the first to classify cervical lymph nodes in 1932 into; Submental, facial, submandibular, parotid, mastoid, occipital and retropharyngeal node groups.’[2]

This image shows the facial lymphatic system

Head and Neck Nodes

  • Occipital: These lymph nodes are located in the back of the head. They collect lymph from the occipital area of the scalp.
  • Mastoid: There are 2 mastoid lymph nodes, called the post-auricular lymph nodes. They are located posterior to the ear and lie on the insertion of the sternocleidomastoid muscle into the mastoid process. They collect lymph from the posterior neck, upper ear and the back of the ear canal.
  • Pre-auricular: Pre-auricular lymph nodes are located anterior to the auricle of the ear, and collect lymph from the superficial areas of the face and temporal region.
  • Parotid: The parotid lymph nodes are a small group of nodes located superficially to the parotid gland. They collect lymph from the nose, the nasal cavity, the external acoustic meatus, the tympanic cavity and the lateral borders of the orbit. There are also parotid lymph nodes deep to the parotid gland that drain the nasal cavities and the nasopharynx.
  • Submental: These lymph nodes are located superficially to the mylohoid muscle. They collect lymph from the central lower lip, the floor of the mouth and the apex of the tongue.
  • Submandibular: Three to six nodes are located below the mandible in the submandibular triangle and collect lymph from the cheeks, the lateral aspects of the nose, upper lip, lateral parts of the lower lip, gums and the anterior tongue. They also receive lymph from the submental and facial lymph nodes.
  • Facial: This group comprises the maxillary/infraorbital, buccinator and supramandibular lymph nodes. They collect lymph from the mucous membranes of the nose and cheek, eyelids and conjunctiva.
  • Superficial Cervical:  The anterior nodes collect lymph from the superficial surfaces of the anterior neck. The posterior lateral nodes collect lymph from superficial surfaces of the neck.[3]

A Clever Rheumatologist

This is an image of a rheumatologist examining a person's body. The purpose of this image is to demonstrate the work of a rheumatologist, who is being referred to in this paragraph, because he thought that I am suffering with lymphedema

I consulted with a clever rheumatologist about my facial pain, at a private hospital in London from May, 2014- February, 2016. He was the consultant, who I have seen the most consistently during this ten-year episode, and who I trusted. The rheumatologist was unable to give me a definitive diagnosis, so he treated my condition with empirical therapy. He examined the consistent raises in my neutrophil count, White Blood Count and ESR, and saw first-hand how oral antibiotics stabilised my bloods, and how much better I was when I took them. He prescribed long-term antibiotics, which significantly stabilised my condition.

Empirical Treatment

This image shows a packet of antibiotics called, Azithromycin, which were used as empirical treatment.

The antibiotics that the rheumatologist prescribed cyclically were; Rifampicin,600mg, Doxycycline, 100mg, and Cephalexin, 500mg. We tried Levofloxacin and Ciprofloxacin, which we had to stop, because I developed Achilles Tendonitis as a side effect from taking them. We also tried Clindamycin, 500mg, Metronidazole, 400mg and Azithromycin, 500mg. These antibiotics (apart from Rifampicin,) are all known to treat complicated soft-tissue infections. They controlled my symptoms, but when I stopped taking them, my infection markers shot up, and my symptoms returned.

Lymphatic Drainage Damage

The rheumatologist thought that my facial pain and swelling was possibly caused by lymphatic drainage damage, and that I could be suffering with Lymphoedema. He thought that the infection had damaged the lymphatic drainage on the left side of my face. This meant that lymph fluid was not draining away, and infection was not being killed off. He thought that lymphoedema could explain the stubborn nature of my facial pain and swelling, and why my symptoms returned when I stopped taking the antibiotics.

The Parotid Gland

This is an image of the parotid gland. The purpose of this image is to demonstrate the area that facial lymph nodes reside re possible lymphedema diagnosis.

Human’s head with three main paired salivary glands: Parotid, Submandibular, and Sublingual. Exocrine glands that produce saliva through a system of ducts.

The parotid gland has been the main source of my facial pain. In 2015, the pain in my masseter and parotid region was so bad, that I was unable to eat or drink. The rheumatologist identified that the problem was my left parotid gland. He referred me to Oral Maxillofacial surgery. It was detected, via ultrasound scanning and sialography that there was obstruction and a thickening of saliva in my left parotid gland, which was treated with ongoing sialendoscopies.

Parotid Gland Histology

This image shows a patient having an operation to remove sialolithiasis from parotid gland. The purpose of this image is to demonstrate that a possible cause for lymphedema is a damaged parotid gland.

In 2018, I had some of the superficial lobe of my parotid gland removed. The histology showed; dense secretions in the ducts, hardened tissue, and reactive lymph nodes. The parenchyma was sialolithiasis. A scan done, one year after surgery showed that there is still some superficial lobe remaining, the deep lobe is all there, and there is some accessory parotid tissue over the masseter muscle. The residual tissue is rock hard. It swells when I eat and drink, causing the left side of my face to inflate.

My Facial Pain

This image shows the parotid and masseter area of a man's face. The purpose of this image is to show clearly, where in my face I have the most pain. This also relates to the part of my face which could be causing possibly lymphedema.

In My Facial Pain, I explain that whilst the main source of pain is in the masseter and parotid region, I also have pain in the middle of the cheek, which extends all the way up to my zygomatic arch. Alongside the pathology found in my parotid gland, left masseter enlargement has been identified, and benign abnormality has recently been detected in the buccinator, maxillary region.

This is a radiology image from an MRI Neck scan. It shows abnormality in the buccinator, maxillary region. The purpose of the image is to accompany the text, which refers to this.

An MRI Neck radiology image, showing unexplained abnormality in the left buccinator, maxillary region.

A second radiology image from MRI Neck scan, showing abnormality in buccinator, maxillary region.

A radiology image from an MRI Neck scan, showing unexplained abnormality in the left buccinator, maxillary region.

A radiology image from an MRI Neck scan, showing abnormality in the left buccinator, maxillary region.

A radiology image from an MRI Neck scan, showing unexplained abnormality in the left buccinator, maxillary region.

The facial lymph nodes, which reside in the maxillary, buccinator region, collect lymph from the nose and cheek. The submandibular nodes also collect lymph from the cheek. The pre-Auricular nodes, which sit within the parotid gland, just in front of the ear, collect lymph fluid from the superficial areas of the face and temporal region.

Question

If I do have lymphedema, and if my lymph nodes are not draining fluid away, could this explain the persistent pain and swelling in the superficial and temporal area of my face?

My Periocular Pain

This is image of an eye. The purpose of this image is to demonstrate the concept of periocular pain.

In My Periocular Pain, I describe the pain and swelling around my left temporal artery and upper eyelid. The lymph nodes within the parotid gland, which, in my case, have been found to be reactive, collect lymph from the lateral border of the orbit. The facial nodes, which reside in the maxillary, buccinator region also collect lymph from the eyelids. As abnormality has recently been detected in the buccinator and maxillary region, I am wondering whether these lymph nodes could be damaged.

Question

Is it possible that my persistent periocular pain and swelling is being caused by the facial and parotid gland lymph nodes not draining away fluid from my eyelid?

A radiology image from an MRI Neck scan, showing inflammation around the left eye. The purpose of the image is to demonstrate visually, what I have been speaking about in the text about my periocular swelling.

MRI Neck scan image, showing unexplained left periocular swelling.

My Ear Pain

This is an image of an ear. The purpose of this image is to accompany the paragraph about ear pain.

In My Ear Pain, I explain that my symptoms include a feeling of pressure and fullness in my left ear. This is not dissimilar to Airplane ear (ear barotrauma), which people experience when on an airplane that’s climbing after take-off, or descending for landing. I asked was whether my left ear pain was being caused by Eustachian Tube Dysfunction, or the enlarged mastoid on the affected side.

This a radiology image from one of my CT Neck scans, done with contrast. The purpose of this image is to show an enlarged mastoid on the affected, left side.

A radiology image from my CT Neck scan, from 2021. It shows an enlarged mastoid on the affected, (left) side.

Question

Further research that I have done into the facial lymphatic system has raised new questions. The lymph nodes, within the parotid gland, collect lymph from the acoustic meatus (the ear canal). The Post Auricular/mastoid nodes, behind the ear, where I experience pain, collect lymph from the upper ear and the back of the ear canal. If I am suffering with lymphedema, could my left-sided ear pain be an accumulation of lymph fluid that the parotid and mastoid lymph nodes, are not draining away?

Reflections

This is an image of a person, sitting, looking out at sea, thinking. The purpose of this image is to demonstrate the concept of reflection.

One of the things that has baffled so many physicians, is that ten years is an unusual amount of time for a soft tissue infection to go on for. It is unclear why the oral antibiotics that I take do not clear it away. If the lymphatic drainage on the left side of my face is not functioning properly, the lymph nodes will not be able to fight off infection. They will neither be able to drain away excess fluid. This may explain a) the stubborn nature of this infection, b) my persistent facial swelling and c) why the oral antibiotics only partially work.

I am unsure if lymphoedema explains all of my symptoms. However, I do wonder if it could be a contributing factor behind my facial pain. The question is; with a delayed diagnosis and treatment plan of ten years, is it too late for this to now be treated?

MRI Neck Radiology image, showing difference on affected (left) side.

MRI Neck radiology image, showing abnormality in left cheek and eye.

A radiology image from an MRI Neck scan, showing abnormality in the parotid, masseter region.

Radiology image, showing abnormality in left parotid region.

This is an image of a question mark. The purpose of the image is to accompany the final question of the text, about whether my condition is treatable after a 10 year delayed diagnosis with a visual question mark.

Footnotes

[1]Lymphedema – Symptoms and causes – Mayo Clinic

[2] Dr Moideen, SP; Lymph Node Levels of Head and Neck, DrSamu.com

[3] Fitzgerald, G; Lymphatic Drainage of The Head and Neck, Teach Me Anatomy.com, August, 2023

Recommended Articles

Lymphoedema – NHS (www.nhs.uk)

Lymphatic drainage | The Royal Marsden

Lymph nodes: Purpose, location, and disease warning signs (medicalnewstoday.com)

Lymphatic Dysfunction (Lymphedema): Symptoms and Treatments (healthline.com)

Blog Authored By Felicia Kate Solomon

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