Diagram of the neck as seen from the left anterior view.
Left, The pertinent anatomy that relates to the nodal classification. Right, An outline of the levels of the classification.
Note that the line of separation between levels I and II is the posterior margin of the submandibular gland. The separation between levels II and III and level V is the posterior edge of the sternocleidomastoid muscle. However, the line of separation between levels IV and V is an oblique line extending from the posterior edge of the sternocleidomastoid muscle to the posterior edge of the anterior scalene muscle. The posterior edge of the internal jugular vein separates level IIA and IIB nodes. The top of the manubrium separates levels VI and VII.
Som PM, Curtin HD, Mancuso AA. An imaging-based classification for the cervical nodes designed as an adjunct to recent clinically based nodal classifications. Arch Otolaryngol-Head Neck Surg 1999; 125:388-396
Lymphatic nodes of the head and neck. Lateral view of the superficial and deep node groups of the cervicocephalic region.
B, buccal n.; DAJ, deep anterior jugular n.; DiP, deep intraparotid n.; F, facial n.; iH, infrahyoid n.; JD, jugulodigastric n. (Ku¨tner’s); JO, juguloomohyoid n. (Poirier’s); LDC, superior (s), middle (m) and inferior (i) lateral deep cervical n.; LsC, lateral supraclavicular n.; M, malar n.; MsC, medial supraclavicular n.; PDC, superior (s), middle (m) and inferior (i) posterior deep cervical n.; M, mastoid n.; pA, preauricular n.; pL, prelaryngeal n.; pT, pretracheal n.; R, recurrent n.; SAJ, superficial anterior jugular n.; sA, subauricular n.; SEJ, superficial external jugular n.; SiP, superficial intraparotid n.; sMd, submandibular n.; sMt, submental n.; sO, suboccipital n.; sP, subparotid n.; rPh, retropharyngeal n.
Lengelé B, Hamoir M, Scalliet P, Grégoire V. Anatomical bases for the radiological delineation of lymph node areas. Major collecting trunks, head and neck. Radiother Oncol. 2007;85(1):146-155. doi:10.1016/j.radonc.2007.02.009
Surgical and radiological delineation of head and neck lymph node areas. Node groups are currently classified into six levels (I–VI) to which should be added the parotid (P), retropharyngeal (rp) and buccal (B) areas. An additional external jugular level (VIII, in fact real VII) should also be considered.
The corresponding volumes are delineated on anatomical sections and corresponding CT images of the head and successive neck regions, respectively. The key structures for the delineation of the various target volumes are as follows: the sternocleidomastoid (SCM), infrahyoid (IH), digastric (D), pterygoid (Pt), longus capitis (LC), scaleni (S), splenius (Sp), levator scapulae (LS) and trapezius (T) muscles. Other landmarks are the internal (IJV), external (EJV), anterior (AJV) and posterior (PJV) jugular veins, the facial vein (FV), the submandibular (SMG) and thyroid glands (TG), cervical transverse artery (CTA) and the facial (FN), lingual (LN), vagus (VN) and spinal accessory (SAN) nerves.
Lengelé B, Hamoir M, Scalliet P, Grégoire V. Anatomical bases for the radiological delineation of lymph node areas. Major collecting trunks, head and neck. Radiother Oncol. 2007;85(1):146-155. doi:10.1016/j.radonc.2007.02.009
| Station | Named group | Primary drainage site | Efferent | Boundaries |
|---|---|---|---|---|
| Level IA | Submental | Chin, medial lower lip, tip of tongue, floor of mouth, anterior mandibular alveolus | Levels IB, II, & III | Hyoid, anterior bellies of the digastric muscles. |
| Level IB | Submandibular | Nose, cheek, anterior nasal cavity, upper lip, lateral lower lip, oral cavity, submandibular gland, and IA | Levels II & III | Body of mandible, posterior and anterior bellies of digastric muscle, posterior border of the submandibular gland/ stylohyoid muscle. |
| Level II | Upper jugular chain | Auricle, angle of mandible, oral/ nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, parotid gland, parotid LN, suboccipital LN, Retropharyngeal LN, and Level IB | Levels III–V | Skull base, stylohyoid muscle/carotid bifurcation, level of hyoid inferiorly, posterior border of sternocleidomastoid muscle. Spinal accessory nerve separates IIA from IIB. |
| Level III | Middle jugular chain | Oral cavity, Levels IA, IB, and II | Level IV | Level of the hyoid bone/ carotid bifurcation, level of the cricoid cartilage/ omohyoid, lateral border of the sternohyoid muscle, lateral border of the sternocleidomastoid muscle. |
| Level IV | Lower jugular chain | Level III, posterior scalp and | ||
| neck, and paratracheal LN | Thoracic duct and right lymphatic duct | Level of the cricoid cartilage/omohyoid, clavicle, lateral border of the sternohyoid muscle, lateral border of the sternocleidomastoid muscle. | ||
| Level VA | Spinal accessory chain | Posterior scalp and neck, nasopharynx, suboccipital LN, and retropharyngeal LN | Level IV | Level V is bounded by the lateral border of the sternocleidomastoid muscle, the anterior border of the trapezius, and the clavicle inferiorly. |
| Level VB | **Supraclavicular & transverse | |||
| Cervical** | Levels II and III, axillary LN | Level IV | VA and VB delineated at the level of the cricoid cartilage. | |
| Level VI | Anterior Jugular | Anterior neck, larynx, hypopharynx, thyroid, trachea, and cervical esophagus | Levels II–IV | Hyoid bone, sternal notch, common carotid arteries. |
| Level VII | Superior mediastinal nodes | Thyroid, subglottis, and cervical esophagus | ||
| Others | Suboccipital | Posterior scalp | Levels II and V | Deep to insertion of |
| trapezius muscle. | ||||
| Retroauricular (Mastoid) | Temporal scalp, Posterior auricle and external acoustic meatus | Level II | Superficially in the postauricular region. | |
| Parotid (Preauricular) | Forehead, anterior temporal scalp, eyelids, conjunctiva, Anterior ear and ear canal, nose, nasal cavity, and nasopharynx | Deeper or inferior parotid nodes, Level II | Superficial to parotid gland (subcutaneous), within the parotid gland (intraparotid), and in the inferior portion of the parotid gland (subparotid). | |
| Facial (Buccal) | Cheek and oral cavity | Levels IB and II | Both superficial and deep to facial artery & vein. | |
| Retropharyngeal | Nasopharynx, Eustachian tube, soft palate, paranasal sinuses, middle ears, and pharynx | Levels IB and II | Between prevertebral fascia and pharyngeal constrictor muscles. |
The functional pathways for lymphatic drain- age of the head and neck. The main lymphatic pathway initiating in the oral cavity, parotid nodes, or buccal nodes proceeds to levels IA, IB, or IIA and then to levels III and IV.
The anterior lymphatic pathway involves direct drainage from level IA to III or IV. The superficial lateral pathway also
| Pathway | Pathway | Description |
|---|---|---|
| Main pathway | IA/IB/IIA → III/IV | Initiates in the oral cavity, parotid nodes, or buccal nodes proceeds to levels IA, IB, or IIA and then to levels III and IV and finally drains into the major lymphatic ducts. |
| Posterior accessory pathway | IIB → VA/VB | Originates in the posterior scalp, postauricular, and suboccipital regions and proceeds through IIB, VA, and VB stations |
| Anterior pathway | IA → III/IV | Direct drainage from level IA to III or IV. |
| Level IA receives afferents from the anterior oral cavity, tip of the tongue, floor of the mouth, median part of lower lip, anterior buccal and gingival mucosa, and skin over the chin. | ||
| Superficial-lateral pathway | II → III | Begins with the suboccipital or retroauricular nodes, but instead proceeds along the superficial nodal group in level II and then merges with the nodal chain at level III. |
Cervical Lymph Node Metastases Patterns
| Distribution | Potential Primary Site |
|---|---|
| Levels II, III, VA | Oropharynx (palatine tonsil and the base of tongue), nasopharynx, and hypopharynx |
| Levels IV, VB, VI | Hypopharynx, supraglottic, cervical esophagus, thyroid gland, thorax, |
| abdomen (lung, breast, esophagus, gastric, gynecologic, etc) | |
| Parotid and superficial lateral LNs | Parotid gland, cutaneous face, scalp, sinonasal cavity |
| Levels IA, IB | Floor of mouth, submandibular gland, anterior oral cavity, sinonasal cavity, lips, periorbital tissues, cutaneous face |
| Facial LNs | Cutaneous face, oral cavity |
| Occipital LNs | Scalp, cutaneous face |
| Characteristics | Potential cancer |
|---|---|
| Cystic LN | p16-positive oropharyngeal cancer and thyroid papillary carcinoma |
| Homogeneous LN | Nasopharyngeal carcinoma, p16-positive oropharyngeal carcinomas |
| Calcified LN | Thyroid papillary & medullary carcinomas |
| Hypervascular LN | Papillary and medullary thyroid carcinoma, neuro- endocrine tumors, olfactory neuroblastoma, and renal cell carcinoma |
