radiological nodal delineation

1. Dr. SAADVIK R Y
JR-II
DELINEATION OF
THE NECK NODE
LEVELS FOR
HEAD AND NECK
TUMOURS

2. • 10 node groups are defined with a concise description of their main anatomic boundaries, the normal
structures juxtaposed to these nodes, and the main tumor sites at risk for harboring metastases in those
levels.
These include-
• Level Ia- submental group
• Level Ib- submandibular group
• Level II- upper jugular group
• Level III- middle jugular group
• Level IVa- lower jugular group
• Level IVb- medial supraclavicular group
• Level V- posterior triangle group
• Level Va- upper posterior triangle nodes
• Level Vb- lower posterior triangle nodes
• Level Vc- lateral supraclavicular nodes

3. • Level VI- Anterior compartment group
• Level VIa- Anterior jugular nodes
• Level VIb- Prelaryngeal,pretracheal &paratracheal nodes.
• Level VII- Prevertebral group
• Level VIIa- Retropharyngeal nodes
• Level VIIb- Retro-styloid nodes
• Level VIII- Parotid group
• Level IX- Bucco-facial group
• Level X- Posterior skull group
• Level Xa- Retroauricular & subauricular nodes
• Level Xb- Occipital nodes

4. LEVEL Ia-SUBMENTAL
GROUP
• Boundaries-
Cranial- mylohyoid muscle
Caudal- platysma (caudal edge of
anterior belly of diagastric muscle)
Anterior- symphysis menti
Posterior- body of hyoid
Lateral- medial edge of ant. belly of
digastric muscle.

5. • It drains
the skin of the chin,
the mid-lower lip,
the tip of the tongue and
the anterior floor of the mouth.

6. • Risk of harboring metastases
Are cancer arising from
the floor of the mouth,
the anterior oral tongue,
the anterior mandibular
alveolar ridge, and
the lower lip.
LEVEL Ia

7. LEVEL Ib-
SUBMANDIBULAR GROUP
• Boundaries-
Cranial- cranial edge of submandibular gland
caudal- plane through caudal edge of hyoid bone and caudal edge of
submandibular gland.
Anterior- symphysis menti
Posterior- posterior edge of submandibular gland(caudally)/ posterior
belly of digastric m.(cranially)
Lateral- medial aspect(innerside) of mandible down to caudal edge
Medial- lateral edge of anterior belly of digastric(caudally)/posterior belly
of digastric(cranially)

8. • Receive efferent lymphatics from
the submental lymph nodes (level
Ia),
the lower nasal cavity,
the hard and soft palate,
the maxillary and mandibular
alveolar ridges,
the cheek,
the upper and lower lips, and
most of the anterior tongue.

9. • Nodes in level Ib are at risk of
harbouring metastases from
cancers of the oral cavity,
anterior nasal cavity,
soft tissue structures of
the mid-face and
the submandibular gland.
LEVEL Ib

10. LEVEL II-UPPER
JUGULAR GROUP
• Boundaries-
Cranial- caudal edge of the lateral process of c1
Caudal- caudal edge of the body of the hyoid bone
Anterior- posterior edge of SM gland/ posterior edge of post.
belly of digastric muscle.
Posterior- posterior edge of sternocleidomastoid muscle
Lateral- medial edge of SCM/platysma/parotid/post. belly of
digastric m.
Medial- medial edge of internal carotid artery.

11. • Efferent lymphatics from
the face,
the parotid gland, and
the submandibular, submental and retropharyngeal nodes.
• Directly receives the collecting lymphatics from
the nasal cavity,
the pharynx,
the larynx,
the external auditory canal,
the middle ear, and
the sublingual and submandibular glands.

12. • Greatest risk of harboring
metastases from cancers of
the nasal cavity,
oral cavity,
nasopharynx,
oropharynx,
hypopharynx,
larynx, and
the major salivary glands.
LEVEL II

13. LEVEL III-MIDDLE
JUGULAR GROUP
• Boundaries-
Cranial-Caudal edge of the body of the hyoid bone
Caudal-Caudal edge of cricoid cartilage
Anterior- anterior edge of SCM/post. third of thyro-hyoid m.
Posterior- posterior edge of SCM
Lateral- deep(medial) surface of SCM
Medial- medial edge of common carotid artery/scalenius mm

14. • Efferent lymphatics from
levels II and V, and
the retropharyngeal,
pretracheal and
recurrent laryngeal nodes.
• Direct lymphatics from the
base of the tongue,
tonsils,
larynx,
hypopharynx and
thyroid gland.

15. • Greatest risk of harboring
metastases from cancers of
the oral cavity,
nasopharynx,
oropharynx,
hypopharynx and
larynx.
LEVEL III

16. LEVEL IVa-LOWER
JUGULAR NODES
• Boundaries-
• Cranial- caudal edge of cricoid cartilage
• Caudal- 2 cm cranial to sternal manubrium
• Anterior- anterior edge of SCM m.(cranially)/body of SCM(caudally).
• Posterior- posterior edge of SCM m.(cranially)/scalenius m(caudally).
• Lateral- medial surface of SCM m.(cranially)/lateral edge of SCM
m.(caudally).
• Medial- medial edge of common carotid artery/lateral edge of thyroid
gland(cranially)./medial edge of SCM m.(caudally)

17. • Level IVa receives efferent lymphatics primarily from
levels III and V,
retropharyngeal,
pretracheal, and
recurrent laryngeal nodes,
hypopharynx,
larynx, and
thyroid gland

18. Level IVa nodes are at high risk
for harboring metastases from
cancers of
the hypo- pharynx,
larynx,
thyroid and
cervical esophagus.
LEVEL IVa

19. LEVEL IVb-MEDIAL
SUPRACLAVICULAR
GROUP• Boundaries-
• Cranial- caudal border of level IVa
• Caudal- cranial edge of sternal manubrium
• Anterior- deep surface of SCM m./ deep aspect of clavicle
• Posterior- anterior edge of scalenius mm.(cranially)/apex of lung, the
brachiocephalic vein, the brachiocephalic trunk(right side) and the
common carotid artery and subclavian artery on left side (caudally).
• Lateral- lateral edge of scalenius m.
• Medial- lateral border of level VI/ medial edge of common carotid artery.

20. • Level IVb receives efferent lymphatics primarily from
levels IVa and Vc,
pretracheal, and
recurrent laryngeal nodes, and
• some lymphatics from
hypopharynx,
esophagus,
larynx, trachea and
thyroid gland.

21. • High risk for harboring
metastases from cancers of
the
hypopharynx,
sub-glottic larynx,
trachea,
thyroid and
cervical esophagus.
LEVEL IVb

22. LEVEL V(a and b)-POSTERIOR
TRIANGLE GROUP
• Boundaries-
• Cranial- cranial edge of body of hyoid
• Caudal- plane just below transverse cervical vessels
• Anterior- posterior edge of SCM m.
• Posterior- anterior border of trapezius m.
• Lateral- platysma m./skin
• Medial- levator scapulae mm/ scalenius m (caudally)

23. • Receives efferent lymphatics from the
occipital and retroauricular nodes as well as those from
the
occipital and parietal scalp,
the skin of the lateral and posterior neck and shoulder,
the nasopharynx,
the oropharynx and
the thyroid gland.

24. • High risk for harboring
metastases from cancers of the
nasopharynx,
oropharynx and
thyroid gland.
the cutaneous structures
of the posterior scalp.
LEVEL V

25. LEVEL Vc-LATERAL
SUPRACLAVICULAR
GROUP• Boundaries-
• Cranial- plane just below transverse cervical vessels(caudal border
of level V)
• Caudal- 2cm cranial to sternal manubrium
• Anterior- skin
• Posterior- anterior border of trapezius m.(cranially)/1 cm anterior to
serratus anterior m. (caudally)
• Lateral- trapezius m (cranially)/clavicle (caudally)
• Medial- scalenius m./lateral edge of SCM m.

26. • Receives efferent lymphatics
from the posterior triangle nodes
(level Va and Vb)
• More commonly associated
with nasopharyngeal tumors.
LEVEL Vc

27. LEVEL VIa-ANTERIOR
JUGULAR NODES
• Boundaries-
• cranial- caudal edge of hyoid bone or caudal edge of
the submandibular gland, whichever is more caudal.
• Caudal- cranial edge of sternal manubrium
• Anterior- skin/platysma m.
• Posterior- anterior aspect of infrahyoid muscle
• Lateral- anterior edges of both sternoclediomastoid m.

28. Risk of metastasis-
lower lip tumors and
advanced gingivo-
mandibular carcinomas
invading the soft tissues
of the chin.
LEVEL VIa

29. LEVEL VIb-PRE-LARYNGEAL,PRE-
TRACHEAL-RECURRENT LARYNGEAL
NERVE NODES
• Boundaries-
• Cranial- caudal edge of thyroid cartilage
• Caudal- cranial edge of sternal manubrium
• Anterior- posterior aspect of infrahyoid m.
• Posterior- anterior aspect of larynx,thyroid gland and trachea/
pre-vertebral m.(right side)/esophagus(left side).
• Lateral- common carotid artery on both the sides
• Medial- lateral aspect of trachea and esophagus (caudally).

30. Receives efferent lymphatics
from the
anterior floor of mouth,
the tip of the tongue,
the lower lip,
the thyroid gland,
the glottic and subglottic
larynx,
the hypopharynx, and
the cervical esophagus
LEVEL VIb

31. LEVEL VIIa-
RETROPHARYNEGAL NODES
• Boundaries-
• Cranial- upper edge of body of c1/ hard palate
• Caudal- cranial edge of the body of hyoid
• Anterior- posterior edge of superior or middle pharyngeal
constrictor m.
• Posterior- longus capitis m. and longus colli m.
• Lateral- medial edge of internal carotid artery
• Medial- a line parallel to the lateral edge of the longus capiti m.

32. • Retropharyngeal node receives
efferent lymphatics from
the mucosa of the nasopharynx,
the Eustachian tube and
the soft palate.
• Risk of harboring metastases from
cancers of
the nasopharynx,
the posterior pharyngeal wall
and
the oropharynx (mainly the
tonsillar fossa and the soft
palate).
LEVEL VIIa

33. LEVEL VIIb-RETRO-
STYLOID NODES
• Boundaries-
• Cranial- base of skull (jugular foramen)
• Caudal- caudal edge of the lateral process of c1(upper limit of
level II)
• Anterior- posterior edge of prestyoloid,para-pharyngeal space.
• Posterior- vertebral body of c1, base of skull
• Lateral- styloid process/ deep parotid lobe
• Medial- medial edge of the internal carotid artery.

34. • Risk of harboring metastases from
cancers of
the nasopharynx, and
from any other head and neck
primary with massive
infiltration of upper level II
nodes through retrograde
lymph flow.
LEVEL VIIb

35. LEVEL VIII-PAROTID
NODE GROUP
• Boundaries-
• Cranial- zygomatic arch, external auditory canal
• Caudal- angle of the mandible
• Anterior- posterior edge of mandibular ramus & posterior edge of
masseter m.(laterally), medial pterygoid m.(medially)
• Posterior- anterior edge of SCM.(laterally), posterior belly of
digastric m.(medially)
• Lateral- subcutaneous tissue
• Medial- styloid process and styloid m.

36. • Efferent lymphatics from
the frontal and temporal skin,
the eyelids,
the conjunctiva,
the auricle,
the external acoustic meatus,
the tympanum,
the nasal cavities,
the root of the nose,
the nasopharynx, and
the Eustachian tube.
LEVEL VIII

37. LEVEL IX-BUCCO-FACIAL
GROUP
• Boundaries-
• Cranial- caudal edge of the orbit
• Caudal- caudal edge of the mandible
• Anterior- subcutaneous tissue
• Posterior- anterior edge of masseter m. & corpus adiposum
buccae (bichat’s fat pad)
• Lateral- subcutaneous tissue
• Medial- buccinator m.

38. • Risk of harboring
metastases from cancers
of
the skin of the face,
the nose,
the maxillary sinus
(infiltrating the soft
tissue of the cheek)
and
the buccal mucosa.
LEVEL IX

39. LEVEL Xa-
RETROAURICULAR NODES
• Boundaries-
• Cranial- cranial edge of external auditory canal
• Caudal- tip of the mastoid
• Anterior- anterior edge of the mastoid(caudally)/ posterior edge of
the external auditory canal (cranially).
• Posterior- anterior border of occipital nodes-posterior edge of SCM
m.
• Lateral- sucutaneous tissue
• Medial- splenius capitis m. (caudally)/ temporal bone (cranially).

40. • Retroauricular nodes receive
efferent lymphatics from
the posterior surface of the
auricle,
the external auditory canal
and
the adjacent scalp.
• They are at risk of harboring
metastases mainly from skin
cancers of the retro-auricular
area.
LEVEL Xa

41. LEVEL Xb-OCCIPITAL
NODES
• Boundaries-
• Cranial- external occipital protuberance
• Caudal- cranial border of level V
• Anterior- posterior edge of SCM m.
• Posterior- anterior edge of trapezius m.
• Lateral- subcutaneous tissue
• Medial- splenius capitis m.

42. Level Xb nodes receive efferent
lymphatics from the posterior
part of the hair-bearing scalp and
are at risk of metastases from
skin cancers of the occipital area.
LEVEL Xb