CERVICAL LYMPH NODES

Dr. Diptiman Baliarsingh

1st Year PG, Dept. of ENT,
Hi-Tech Medical College & Hospital, Bhubaneswar
Introduction
 The cervical group of lymph nodes extend from
 Mandible & skull base superiorly
 Clavicle inferiorly
 Posterior triangle of neck laterally & posteriroly
 Midline viscera anteriorly

 LN groups are categorized acc to original

description by Memorial Sloan-Kettering Group
Levels of Neck Nodes
 There are 7 levels of neck and most have
sublevels containing specific group of nodes
 Level I – Submental & Submandibular
 Level II – Upper Jugular
 Level III – Middle Jugular
 Level VI – Lower Jugular
 Level V – Posterior Triangle
 Level VI – Anterior/Central Compartment
 Level VII – Superior Mediastinal
LEVEL I
 2 groups of LN’s
 Sublevel Ia – Submental
 Sublevel Ib – Submandibular

 Boundaries of Lvl I
 Body of Mandible
 Ant. Belly of C/L digastric muscle
 Post. Belly of I/L digastric muscle
 Stylohyoid muscle
Submental (Sublevel Ia)
 LN’s in the triangular boundary formed by
 Ant belly of digastric muscles
 Hyoid Bone

 Involved in pathology of
 Floor of mouth
 Anterior oral tongue
 Anterior mandibular alveolar ridge
 Lower lip
Boundary Clinical Radiologic Surgical

LEVEL Ia

Superior Symphisis of Geniohyoid Symphisis of

mandible Muscle, mandible
Plane tangent to
inf. Border of
mandible

Inferior Body of Hyoid Body of Hyoid Body of Hyoid

Lateral N/A Ant belly of I/L Ant belly of I/L

(Posterior) digastric mus. digastric mus.

N/A Ant belly of C/L Ant belly of C/L

Medial digastric muscle digastric muscle
Submandibular (Sublevel Ib)
 LN’s in the triangular boundary formed by
 Ant belly of digastric muscle
 Stylohyoid & Post belly of digastric muscle
 Body of Mandible

 Involved in pathology of
 Oral Cavity
 Anterior Nasal Cavity
 Soft tissue structures of midface
 Submandibular gland
Boundary Clinical Radiologic Surgical

LEVEL Ib

Superior Body of mandible Mylohyoid Mus, Body of mandible

Body of mandible

Inferior Plane through Inferior edge of Digastric tendon

Hyoid bone hyoid bone attachment to
hyoid bone

Lateral Ant border of SCM Post edge of Post edge of

(Posterior) Submandibular Gl. Submandibular Gl

Medial N/A Ant belly of Ant belly of

digastric muscle digastric muscle
 Many of these lymph nodes lie in close proximity
to submandibular gland, and it is removed to
ensure thorough exenteration of all lymph nodes
with in this traingle

 Perifacial LN’s – drain Lip, buccal musoca, ant

nasal caity & soft tissue of neck, sometimes get
involved along with the Level I LN groups.

 ND’s performed for nodal disease asso with

primary lesions of these sites should be modified
to encompass perifacial nodes
LEVEL II
 Contain Upper Jugular LN’s

 2 groups – Sublevel IIa & IIb

 LN’s are located around upper third of internal

jugular vein & adjacent spinal accessory nerve

 Extent
 Superiorly - Skull base
 Inferirly - Inf border of Hyoid bone
 Ant (medial) boundary – stylohyoid mus
 Post (lateral) boundary – posterior border of SCM
 Sublevel IIa nodes are located anterior (medial)
to vertical plane defined by spinal accessory
nerve, whereas sublevel IIb nodes are located
posterior (lateral) to the vertical plane defined by
spinal accessory nerve

 Involved in pathology of
 Oral cavity, Nasal Cavity
 Nasopharynx, Oropharynx, Hypopharynx
 Larynx
 Parotid gland
Boundary Clinical Radiologic Surgical

LEVEL IIA

Superior Mastoid process Skull base, Skull base

Caudal edge of
C1 lateral process

Inferior Horizontal plane Horizontal plane Carotid bifurcation

defined by the defined by the
inferior border of inferior border of
hyoid bone hyoid bone

Lateral N/A Post. border of IJV Vertical plane

(Posterior) defined by Spinal
acc. nerve

Medial N/A Post. edge of Post. edge of

submandibular submandibular
gland gland
Boundary Clinical Radiologic Surgical

LEVEL IIB

Superior Mastoid process Skull base, Skull base

Caudal edge of
C1 lateral process

Inferior Horizontal plane Horizontal plane Carotid bifurcation

defined by the defined by the
inferior border of inferior border of
hyoid bone hyoid bone

Lateral Lateral border of Lateral border of Lateral border of

(Posterior) SCM SCM SCM

Medial N/A Medial edge of Vertical plane

ICA, paraspinal defined by Spinal
(lev. scapulae) acc. nerve
mus
 AHNS Committee recommends – perpendicular
plane formed by posterior aspect of
submandibular gland as radiologic marker of this
boundary
LEVEL III
 Contains Middle Jugular LN’s Group

 Located around middle third of IJV

 Extent
 Superiorly – Carotid bifurcation / Inferior aspect of
body of hyoid bone
 Inferiorly – Junction of Omohyoid mus with IJV / lower
border of cricoid arch(cartilage)
 Medially – Lateral border of sternohyiod muscle
 Laterally – Post border of SCM muscle
 Involved in pathology of
 Oral cavity
 Nasopharynx, Oropharynx, Hypopharynx
 Larynx

 AHNS Committee recommends – Lateral border

of CCA serves as Radiologic marker for medial
boundary
Boundary Clinical Radiologic Surgical

LEVEL III

Superior Horizontal plane Horizontal plane Carotid bifurcation

defined by the defined by the
inferior border of inferior border of
hyoid bone hyoid bone

Inferior Horizontal plane Horizontal plane Omohyoid muscle

defined by the defined by the
inferior border of inferior border of
cricod cartilage cricod cartilage

Lateral Lateral border of Lateral border of Sensory branches

(Posterior) SCM SCM of cervical plexus

Medial Medial border of Medial edge of Sternohyoid

SCM ICA, paraspinal muscle
(lev. scapulae)
mus
LEVEL IV
 Contains Lower Jugular LN’s Group

 Located around lower third of IJV

 Extent
 Superiorly – Junction of Omohyoid mus with IJV /
lower border of cricoid arch(cartilage)
 Inferiorly – Clavicle
 Medially – Lateral border of sternohyiod muscle
 Laterally – Post border of SCM muscle
 Involved in pathology of
 Hypopharynx
 Thyroid
 Cervical Esophagus
 Larynx

 AHNS Committee recommends – Lateral border

of CCA serves as Radiologic marker for medial
boundary
Boundary Clinical Radiologic Surgical

LEVEL IV

Superior Horizontal plane Horizontal plane Omohyoid muscle

defined by the defined by the
inferior border of inferior border of
cricod cartilage cricod cartilage

Inferior Clavicle 2cm cranial to Clavicle

sternoclavicular
joint

Lateral Lateral border of Lateral border of Sensory branches

(Posterior) SCM SCM of cervical plexus

Medial Medial border of Medial edge of Sternohyoid

SCM CCA, paraspinal muscle
(scalenus) mus
LEVEL V
 Contains Posterior Triangle LN’s Group

 Located along the lower half of spinal accessory

nerve & transverse cervical artery

 Extent
 Superiorly (Apex) – convergence of SCM & trapezius
muscle
 Inferiorly – Clavicle
 Medially – Post border of SCM muscle
 Laterally – Anterior border of trapezius muscle
 2 groups – Sublevel Va & Vb
 The Va is separated from Vb by a horizontal plane
marking the inferior border of the anterior cricod
arch

 Sublvl Va includes – Spinal accessory nodes

 Sublvl Vb includes – nodes following transverse

cervical vessels & supraclavicular nodes (not
Virchow’s Nodes – they are located in Level IV)
 Involved in pathology of
 Nasopharynx
 Oropharynx
 Cutaneous structures of posterior scalp
 Neck
Boundary Clinical Radiologic Surgical

LEVEL Va

Superior Apex of Apex of Apex of

convergence of convergence of convergence of
SCM & trapezius SCM & trapezius SCM & trapezius
muscle muscle muscle

Inferior Horizontal plane Horizontal plane Horizontal plane

defined by the defined by the defined by the
inferior border of inferior border of inferior border of
cricod cartilage cricod cartilage cricod cartilage

Lateral Anterior border of Anterior border of Anterior border of

(Posterior) Trapezius muscle Trapezius muscle Trapezius muscle

Medial Lateral border of Lateral border of Sensory branches

SCM SCM of cervical plexus
Boundary Clinical Radiologic Surgical

LEVEL Vb

Superior Horizontal plane Horizontal plane Horizontal plane

defined by the defined by the defined by the
inferior border of inferior border of inferior border of
cricod cartilage cricod cartilage cricod cartilage

Inferior Clavicle Clavicle Clavicle

Lateral Anterior border of Anterior border of Anterior border of

(Posterior) Trapezius muscle Trapezius muscle Trapezius muscle

Medial Lateral border of Lateral border of Sensory branches

SCM SCM of cervical plexus
LEVEL VI
 Contains LN’s of Anterior compartment of the
neck

 They surround the midline visceral structures of

the neck

 Extent
 Superiorly – Hyoid Bone
 Inferiorly – Suprasternal Notch
 Laterally (on each side) – Medial border of Carotid
sheath
 LN groups in the compartment are –
 Pretracheal N
 Paratracheal N
 Precricoid (Delphian) N
 Perithyroidal N
 LN’s along Recurrent Laryngeal Nr

 Involved in pathology of
 Thyroid Gland
 Glottic & Subglottic Larynx
 Apex of pyriform sinus
 Cervical esophagus
Boundary Clinical Radiologic Surgical

LEVEL VI

Superior Hyoid Bone Hyoid Bone Hyoid Bone

Inferior Superior edge of Superior edge of Superior edge of

manubrium sterni manubrium sterni manubrium sterni

Lateral CCA Medial Aspect of CCA

(Posterior) CCA

Medial CCA Medial Aspect of CCA

CCA
LEVEL VII
 Contains Superior Mediastinal group of LN’s

 The LN are an extension of the paratracheal LN

chain extending inferiorly below the suprasternal
notch along each side of cervical trachea to the
level of the innominate artery

 Extent
 Superiorly – Superior edge of manubrium
 Inferiorly – superior border of arch of aorta
 Laterally (Left side) – CCA
 Laterally (Right side) – Innominate Artery
Boundary Clinical Radiologic Surgical

LEVEL VII

Superior Superior edge of Superior edge of Superior edge of

manubrium sterni manubrium sterni manubrium sterni

Inferior N/A Innominate Artery Innominate Artery

Lateral N/A Innominate Artery Innominate Artery

(Posterior) & Left CCA & Left CCA

Medial N/A Innominate Artery Innominate Artery

& Left CCA & Left CCA
 Thank You...

 REFERENCES
 CUMMING’S Otolaryngolagy Head & Neck Surgery -
5th Ed