Lymph Nodes in the neck are grouped into levels 1 to 7 .

1. LEVELS OF LYMPH NODES
IN HEAD AND NECK

2. IN HEAD AND NECK
• CLASSIFICATION OF LYMPH NODE OF HEAD AND NECK REGION ACCORDING TO ITS LEVELS :
• 1. LEVEL I : a. Sub mental ( I A ) AND
• b. Submandibular ( I B )
• 2. LEVEL II : Upper Jugular Group
• 3. LEVEL III : Middle Jugular Group
• 4. LEVEL IV : Lower Jugular Group
• 5. LEVEL V : Posterior Triangle Group ( Spinal Accessory and Transverse Cervical Chains)
• 6. LEVEL VI : Anterior Compartment
• a. Prelaryngeal
• b. Pretracheal
• c. Paratracheal
• 7. LEVEL VII : Nodes Of Upper Mediastinum ( upper )
• LYMPH NODES IN THE NECK HAVE BEEN HISTORICALLY DIVIDED INTO SEVEN ANATOMIC LEVELS FOR
THE PURPOSE OF HEAD AND NECK CANCER STAGING AND THERAPY PLANNING.

4. LEVEL I LYMPH NODES
• Nodes within the triangular boundary of
• ANTERIOR AND POSTERIOR BELLY OF THE DIGASTRIC MUSCLES AND THE HYOID BONE.
• I A SUBMENTAL NODES:
• Lies in the SUBMENTAL TRIANGLE
• i.e. Between right and left anterior bellies of digastric muscles and the hyoid bone.
• These nodes are at greatest risk for harbouring metastases from cancers arising from the :
• Floor Of The Mouth
• Anterior Oral Tongue
• Anterior Mandibular Alveolar Ridge
• Lower Lip
• I B SUBMANDIBULAR NODES:
• Lies within the boundaries of the
• Anterior and Posterior Bellies of the digastric muscles
The Stylohyoid Muscle
And The body of the Mandible
Radiographically , the vertical plane at the posterior aspect of the submandibular gland forms a use means of demarcating the posterior aspect of Level I B from II
A.

5. • The Group includes the :
• PRE AND POSTGLANDULAR NODES
• PRE 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 harbouring metastases from the cancers arising from :
• Oral Cavity
• Anterior Nasal Cavity
• Soft Tissue Of Midface
• Submandibular Gland

6. LEVEL II LYMPH NODES : ( UPPER JUGULAR GROUP )
• All nodes below skull base at jugular fossa to hyoid bone ,
• Anterior to Posterior edge of Sternocleidomastoid Muscle
• And Posterior to Submandibular Gland
• Nodes located around the
• Upper third of the INTERNAL JUGULAR VEIN and 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 – lateral border of the STERNOHYOID MUSCLE and the STYLOHYOID MUSCLE.
• The posterior ( lateral ) boundary is the posterior border of the STERNOCLEIDOMASTOID MUSCLE.
• SUBLEVEL II A NODES :
• Located anterior ( medial ) to the vertical plane defined by the SPINAL ACCESSORY NERVE.
• SUBLEVEL II B NODES :
• Located posterior ( lateral ) to the vertical plane defined by the SPINAL ACCESSORY NERVE.
The upper jugular nodes are at greatest risk for harbouring metastases from cancers arising from :
• Oral Cavity
• Nasal Cavity
• Naso pharynx , Oropharynx , Hypo pharynx , Larynx
• Parotid Gland

7. LEVEL III LYMPH NODES : (MIDDLE JUGULAR
GROUP)
• 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 )
• JUGULO OMOHYOID NODE ( which lies immediately above the superior belly of the omohyoid
muscle as it crosses the Internal jugular vein ) also included in this level.
• These nodes are at the greatest risk for harbouring metastases from cancers arising from:
• Oral Cavity
• Nasopharynx , Oropharynx , Hypopharynx and Larynx.
•

8. LEVEL IV LYMPH NODES : ( LOWER JUGULAR
GROUP )
• 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.
• The posterior (lateral) boundary is the posterior border of the STERNOCLEIDOMASTOID
MUSCLE.
• These nodes are at greatest risk for harboring metastases from cancers arising from the
• Hypo pharynx
• Cervical Esophagus
• Larynx

9. LEVEL V LYMPH NODES : ( POSTERIOR TRIANGLE
GROUP )
• This group is comprised predominantly of the lymph nodes located along the
• lower half of the spinal accessory nerve
• tranverse cervival artery
• The SUPRACLAVICULAR NODES are also included in the Posterior Triangle Group.
• The superior boundary is the apex formed by a 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.
• The posterior (lateral) boundary is the boundary is the anterior border of the TRAPEZIUS Muscle.
• SUBLEVEL V A is separated from SUBLEVEL V B by a horizontal plane marking the inferior border of the arch of the CRICOID
CARTILAGE.
• SUBLEVEL V A includes the SPINAL ACCESSORY NODES.
• SUBLEVEL V B includes the nodes following the TRANSVERSE CERVICAL NODES and the SUPRACLAVICULAR NODES.
• The posterior triangle nodes are at greatest risk for harbouring metastases from cancers arising from the
• Nasopharynx and Oropharynx – SUBLEVEL V A
• Thyroid Gland – SUBLEVEL V B

10. LEVEL VI LYMPH NODES : ( ANTERIOR / CENTRAL
COMPARTMENT GROUP )
• Lymph nodes in the compartment include the
• Pre and paratracheal nodes
• Precricoid (Delphain) node
• 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.
• The lateral boundaries are the COMMON CAROTID ARTERIES.
• The nodes are at greatest risk for harboring metastases from cancers arising from the
• Thyroid Gland
• Glottic and Subglottic Larynx
• Apex of the Piriform Sinus
• Cervical Esophagus

11. LEVEL VII LYMPH NODES : ( NODES OF
MEDIASTINUM )
• Infraclavivular Anterior Mediastinal ( THYMIC )
• SUPERIOR MEDIASTINAL ( ANTERIOR )
• From Suprasternal Notch to the INNOMINATE Artery
• Technically outside the neck but still considered regional lymph nodes.