 Describe the landmarks for the

identification of different levels of neck

nodes.
 Describe the Individual levels of neck nodes.
 Understand the normal appearance of Neck
Nodes.
 Describe the appearance of abnormal Neck
Lymph nodes.

2
Cervical Lymph nodes may be involved in many
disease process:

Bacterial, mycobacterial and viral infections,

granulomatous conditions such as sarcoidosis,
Primary and secondary involvement in
lymphoma.

 Thyroid Mets.
Cervical Lymph nodes may be involved in many
disease process:

other metastatic neoplasms such as from breast

and lung,
More uncommon conditions such as sinus
histiocytosis, eosinophilic granuloma, Kimura's
disease, and Kikuchi's disease.
There are about 800 lymph nodes in the
human body and 300 are located in the neck.
 Size varies from 3 to 30 mm.
One or more cervical Lymph nodes can be
detected in about 70% of healthy Adults.

Bruneton JN et al J Ultrasound Med. 1994;13(2):

87−90.
 Normal lymph node morphology is characterized by
a connective tissue capsule
 It surrounds an outer cortex with the densely
packed lymphocytes forming lymphoid follicles.
 Inner medulla contains the blood vessels, lymphatic
sinuses, and connective tissue that provide
guidance for the blood vessels to the more
peripheral regions of the lymph node.
 The main artery to the lymph node enters at this
central hilus and subsequently branches into
smaller arterioles.
7
Normal cervical nodes are usually Oval in
shape, flattened hypoechoic structures with
varying amounts of hilar fat.
They may show hilar vascularity but are usually
hypovascular.
10
 Hilar vascularity is detected in about 90% of normal
lymph nodes with a transverse diameter larger than 5
mm
 Smaller normal lymph nodes usually appear
avascular.
 Reactive lymph nodes may have prominent hilar
vascularity because of both increased blood flow and
vessel diameter .
 In malignant lymph nodes, the vascular pattern is either
peripheral or diffuse (hilar and peripheral), oGen with
irregular distribution.
Level I
 Ia: Submental
 Ib: Submandibular
Level II: Anterior cervical lymph node chain.
Lymph nodes in the internal jugular
chain from the skull base to the level of
the hyoid bone.
 IIa: Nodes anterior, medial, or
lateral to the internal jugular vein
 IIb: Nodes posterior to the internal
jugular vein with a fat plane
between the node and the vessel
•
•
Level III: Nodes along the
internal jugular chain
between the hyoid bone
and the cricoid
cartilage

Level IV: Nodes along the

internal jugular chain
between the cricoid
cartilage and the clavicle

•
Level V: Nodes along the spinal
accessory chain, posterior to the
sternocleidomastoid muscle

VA: nodes from the skull base to

lower border of cricoid cartilage

VB: nodes from lower border of

cricoid cartilage to the clavicle
Level VI: Nodes in the visceral
compartment from the hyoid
bone superiorly to the
suprasternal notch inferiorly.
On each side, the lateral
border is formed by the
medial border of the carotid
sheath.

Level VII: Nodes in the superior

mediastinum
 Hyoid Bone  Normal documentation
 Cricoid Cartilage is transverse.
 Node documentation is
transverse and sagittal, 3
dimensions.
 ML Trans
 Start at submental
 Scan inferior until
echogenic arch is seen
 Thyroid and Cricoid Cartilages

Hyoid
Cricoid
 Cricoid
 ML Trans
 Inferior to Hyoid
 Inferior to Thyroid
cartilage
 Just superior or at
isthmus
 Superior to tracheal
rings
 Level IA
Midline under chin.
From mandible to Hyoid bone
Document transverse view
 Level IB
 Lateral to IA
 Medial to submandibular gland
 Superior to Hyoid.
Level IB
 Level IIA
 Medial to IJV
 Posterior to Submandibular gland
 Superior to Hyoid
Level IIA
 Level IIB
 PosteriorƒLateral to IJV
 Below ear
 Includes STM
 Superior to Hyoid
ST

M
Level IIB
 PosteriorƒLateral to IJV
 Below ear
 Includes STM
 Superior to Hyoid
 Level III and Level IV
III IV
 From level of hyoid to  From cricoid level to
cricoid. clavicle.
 Lateral to Carotid and  Lateral to Carotid and
includes Carotid. includes Carotid.
Scan along  Scan along
IJV IJ.
Level III

R T Trns I I I