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Lymph node levels of Neck

Surgically, cervical lymph nodes are divided into 6-7 levels (only 6 according to many
authors who exclude the level VII nodes) for staging of carcinoma which would also be
the basis for selective neck dissection. There are 5 levels in the lateral compartment and
2 in the central compartment. Nodes not included in these system of levels
are retropharyngeal group, periparotid group, buccinator group, post auricular group and
suboccipital group of nodes.

Visual mnemonic or schematic


diagram showing boundaries of lymph node levels or zones of neck
Level Lymph nodes Boundaries

Bilaterally: Anterior belly of


digastrics
A Submental nodes Inferiorly: Hyoid bone

Superiorly: Mandible
Posteroinferiorly: Posterior belly of
digastrics
Anteroinferiorly: Anterior belly of
I B Submandibular nodes digastrics

A (Anterior to the vertical Superiorly: Skull base


line in relation to spinal Inferiorly: Inferior border of hyoid
accessory nerve) bone and Carotid bifurcation
Posteriorly: Posterior border of
B (Posterior to the vertical Sternocleidomastoid (SCM)
line in relation to spinal Upper internal jugular Anteriorly: Lateral border of
II accessory nerve) (deep cervical) nodes Sternohyoid and Stylohyoid

III Mid internal jugular Superiorly: Inferior border of hyoid


(deep cervical) nodes bone and Carotid bifurcation
Inferiorly: Inferior border of cricoid
cartilage and Junction of omohyoid
muscle and IJV
Posteriorly: Posterior border of SCM
Anteriorly: Lateral border of
sternohyoid

Superiorly: Inferior border of


cricoids cartilage and Junction of
omohyoid and IJV
Inferiorly: Clavicle
Posteriorly: Posterior border of SCM
Lower internal jugular Anteriorly: Lateral border of
IV (deep cervical nodes) sternohyoid

A (Above the horizontal


plane marking the inferior
border of arch of cricoids Superiorly: Convergence of SCM and
cartilage) trapezius
Inferiorly: Clavicle
B (Below the horizontal plane Posterior triangle Posteriorly: Anterior border of
marking the inferior border of (spinal accessory) trapezius
V arch of cricoids cartilage) nodes Anteriorly: Posterior border of SCM

VI (Prelaryngeal or Delphian, Superiorly: Hyoid boneInferiorly:


Pretracheal, Paratracheal, Anterior compartment Suprasternal notchBilaterally:
Prethyroidal) (midline) nodes Carotid arteries

Upper mediastinal
VII nodes Below suprasternal notch

Note:

The highest jugular digastric node near the angle of the mandible is called the sentinel
node.
The signal node is the lowest along the internal jugular chain called the virchow nodes.
Probable source of Nodal metastasis:
Level 1: Oral cavity, submandibular gland
Level 2: Nasopharynx, oropharynx, parotid, supraglottic larynx
Level 3: Oropharynx, hypopharynx, supraglottic larynx
Level 4: Subglottic larynx, hypopharynx, esophagus, thyroid
Level 5: Nasopharynx, oropharynx
Level 6 & 7: Thyroid, larynx, lung

Note: Bilateral nodes are common with cancers of soft palate, tongue, epiglottis, and
nasopharynx.

Selective Neck dissection involves:


Supraomohyoid/Anterolateral: Level I to III
Extended Supraomohyoid: Level I to IV
Lateral: Level II to IV
Posterolateral: Level II to V
Anterior or Central: Level VI
Superior mediastinal: Level VII
Comprehensive Neck dissection inolves:
Radical and Modified Radical Neck Dissection: Level I to V

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