The document describes the 7 levels of lymph nodes in the head and neck region according to their anatomical location. Level I nodes are located in the submental and submandibular areas. Level II nodes are located around the upper third of the internal jugular vein. Level III nodes are located around the middle third of the internal jugular vein. Level IV nodes are located around the lower third of the internal jugular vein. Level V nodes are located in the posterior triangle along the spinal accessory nerve and transverse cervical artery. Level VI nodes are located in the anterior/central compartment around the trachea and larynx. Level VII nodes are located in the superior mediastinum. Each level has the highest risk of metastases from primary cancers

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.