CERVICAL LYMPH

NODE GROUPS
ROBINA, Paulyn Crystal P.
LEVEL I
• Submental nodes
• Those contained within the boundaries of the
submental triangle (the anterior belly of the
digastric muscles and the hyoid bone)
• Submandibular nodes
• The nodes that lie within the boundaries of the
submandibular triangle (the anterior and posterior
bellies of the digastric muscle and the body of the
mandible)
LEVEL I
• Boundaries of level I lymph nodes
• Body of the mandible
• Anterior belly of the contralateral digastric muscle
• Posterior belly of the ipsilateral digastric muscle
• Stylohyoid muscle
• Perifacial lymph nodes, including the buccinators
nodes, are located outside of this triangle superior to
the mandibular body.
• These nodes may contain metastatic disease when
the primary site involved is the lip, buccal mucosa,
anterior nasal cavity, or soft tissue of the cheek.
LEVEL II
• is the region that contains the upper jugular lymph nodes.
• Location
• Around the upper third of the IJV and adjacent to the spinal
accessory nerve,
• Extending from the level of the carotid bifurcation (surgical
landmark) or
• Hyoid bone (clinical landmark) inferiorly to the skull base
superiorly.
• The lateral boundary is the posterior border of the SCM, and
the medial boundary is the stylohyoid muscle
• The perpendicular plane defined by the posterior aspect of
the submandibular gland could serve as the radiologic
landmark for this boundary
LEVEL III
• Contains the middle jugular lymph node group
• Location
• Around the middle third of the IJV and extend from the carotid
bifurcation superiorly (surgical landmark) or
• The level of the inferior aspect of the body of the hyoid bone (clinical and
radiologic landmark) to the junction of the omohyoid muscle with the IJV
(surgical landmark) or
• The lower border of the cricoid arch (clinical and radiologic landmark)
inferiorly.
• The lateral boundary is the posterior border of the SCM, and the
medial boundary is the lateral border of the sternohyoid muscle.
• The lateral border of the common carotid artery could serve as
the radiologic landmark for the medial boundary.
LEVEL IV
• Contains the lower jugular lymph node group
• These nodes
• surround the lower third of the IJV and
• extend from the omohyoid muscle (surgical landmark) or
cricoid arch (clinical landmark) superiorly to the clavicle
inferiorly
• The lateral boundary is the posterior border of the SCM,
and the medial or anterior boundary is the lateral
border of the sternohyoid muscle
• As with level II, the lateral border of the common carotid
artery could serve as the radiologic landmark for the
medial boundary.
LEVEL V
• Encompasses all lymph nodes contained within
the posterior triangle
• Collectively referred to as the posterior triangle
group
• Boundaries
• Anterior border of the trapezius muscle laterally
• posterior border of the SCM medially
• clavicle inferiorly
LEVEL V
• Using the horizontal plane that corresponds to the
inferior border of the cricoid cartilage, level V is divided
into two sublevels, VA and VB.
• Predominant lymphatic pathways:
• Nodes located along the spinal accessory nerve, as it traverses
the posterior triangle (sublevel VA)
• Nodes located along the transverse cervical artery, as it
courses along the lower third of the triangle (sublevel VB)
• Supraclavicular nodes located immediately above the clavicle
(sublevel VB).
• The supraclavicular nodes also extend below the level of the upper
horizontal border of the clavicle to include one particular node of
importance: the sentinel, or Virchow, node.
LEVEL VI
• Encompasses the lymph nodes of the anterior
compartment of the neck
• This group comprises nodes
• Surround the midline visceral structures of the neck
• Level of the hyoid bone superiorly
• Suprasternal notch inferiorly
• Lateral boundary is formed by the medial border of the carotid
sheath
• Located within this compartment
• Perithyroidal lymph nodes
• Paratracheal lymph nodes
• Precricoid (Delphian) lymph node
LEVEL VI
• These lymph nodes and their connecting
lymphatic channels
• represent pathways of spread from primary cancers
• originate in the thyroid gland, at the apex of the
piriform sinus, and in the subglottic larynx, cervical
esophagus, and cervical trachea
• With the exception of the lymph nodes that lie
along the superior thyroid artery, the superior
component of level VI does not routinely contain
any lymph node groups.
LEVEL VII
• AKA superior mediastinal lymph nodes
• Boundaries
• Superiorly by the superior edge of the manubrium
• Inferiorly by the superior border of the arch of the
aorta
• Laterally by the common carotid artery on the left
side and the innominate artery on the right.
DIVISION OF NECK LEVELS BY SUBLEVELS
KATHLYN V. SAGMAYAO
AHNS committee recommended the use of sublevels for defining selected
lymph node groups within levels I, II, and V on the basis of the biologic
significance independent of the larger zone in which they lie:

• Sublevels I the submental nodes;

• IB  the submandibular nodes;
• IIA and IIB  which together make up the upper jugular
nodes;
• VA  the spinal accessory nodes; and
• VB  the transverse cervical and supraclavicular nodes.
 Lymph Node Groups Found Within the
Six Neck Levels and the Six Sublevels
Description
Group
Submental (sublevel Lymph nodes within the triangular boundary of the anterior belly of
IA) the digastric muscles and the hyoid bone; these nodes are at the
greatest risk of harboring metastases from cancers that arise from
the floor of the mouth, anterior oral tongue, anterior mandibular
alveolar ridge, and lower lip
Submandibular Submandibular (sublevel IB) Lymph nodes within the boundaries of
(sublevel IB) the anterior belly of the digastric muscle, stylohyoid muscle, and
body of the mandible, including the preglandular and postglandular
and prevascular and postvascular nodes. The submandibular gland
is included in the specimen when the lymph nodes within this
triangle are removed. These nodes are at greatest risk for harboring
metastases from cancers that arise from the oral cavity, anterior
nasal cavity, and soft tissue structures of the midface and the
submandibular gland
Upper jugular (sublevels • Lymph nodes located around the upper third of the internal
IIA and IIB) jugular vein and the adjacent spinal accessory nerve, extending
from the level of the skull base above to the level of the inferior
border of the hyoid bone below.
• The anterior (medial) boundary is the stylohyoid muscle (the
radiologic correlate is the vertical plane defined by the posterior
surface of the submandibular gland); the posterior (lateral)
boundary is the posterior border of the sternocleidomastoid
muscle.
• Sublevel IIA nodes are located anterior (medial) to the vertical
plane defined by the spinal accessory nerve. Sublevel IIB nodes
are located posterior (lateral) to the vertical plane defined by
the spinal accessory nerve. The upper jugular nodes are at
greatest risk for harboring metastases from cancers that arise
from the oral cavity, nasal cavity, nasopharynx, oropharynx,
hypopharynx, larynx, and parotid gland

Middle jugular (level III) Lymph nodes located around the middle third of the internal jugular
vein, extending from the inferior border of the hyoid bone above to
the inferior border of the cricoid cartilage below.
The anterior (medial) boundary is the lateral border of the
sternohyoid muscle, and the posterior (lateral) boundary is the
posterior border of the sternocleidomastoid muscle. These nodes
are at greatest risk for harboring metastases from cancers that arise
from the oral cavity, nasopharynx, oropharynx, hypopharynx, and
larynx
Lower jugular (level IV) Lymph nodes located around the lower third of the internal jugular vein,
extending from the inferior border of the cricoid cartilage above to the clavicle
below. The anterior (medial) boundary is the lateral border of the sternohyoid
muscle, and the posterior (lateral) boundary is the posterior border of the
sternocleidomastoid muscle. These nodes are at greatest risk of harboring
metastases from cancers that arise from hypopharynx, thyroid, cervical
esophagus, and larynx
Posterior triangle This group is composed predominantly of the lymph nodes located along the
(sublevels VA and VB) lower half of the spinal accessory nerve and the transverse cervical artery. The
supraclavicular nodes are also included in the posterior triangle group. The
superior boundary is the apex formed by the convergence of the
sternocleidomastoid and trapezius muscles; the inferior boundary is the
clavicle, the anterior (medial) boundary is the posterior border of the
sternocleidomastoid muscle, and the posterior (lateral) boundary is the anterior
border of the trapezius muscle.
Sublevel VA is separated from sublevel VB by a horizontal plane that marks
the inferior border of the anterior cricoid arch. Thus sublevel VA includes the
spinal accessory nodes, whereas sublevel VB includes the nodes that follow
the transverse cervical vessels and supraclavicular nodes (with the exception
of the Virchow node, which is located in level IV). The posterior triangle nodes
are at greatest risk for harboring metastases from cancers that arise from the
nasopharynx, oropharynx, and cutaneous structures of the posterior scalp and
neck
Anterior compartment (level Anterior compartment (level VI) Lymph nodes in this
VI) compartment include the pretracheal and paratracheal
nodes, the precricoid (Delphian) node, and the
perithyroidal nodes, including the lymph nodes along the
recurrent laryngeal nerves. The superior boundary is the
hyoid bone, the inferior boundary is the suprasternal notch,
and the lateral boundaries are the common carotid
arteries. These nodes are at greatest risk for harboring
metastases from cancers that arise from the thyroid gland,
glottic and subglottic larynx, apex of the piriform sinus, and
cervical esophagus (

Superior mediastinum (level These nodes represent an extension of the paratracheal

VII [optional]) lymph node chain and extend inferiorly below the
suprasternal notch along each side of the cervical trachea
to the level of the innominate artery l