Lymph node levels of the neck

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. Differing definitions exist across specialties 1-4. The following is a synthesis of accepted and radiologically useful definitions.

Level I: submental and submandibular
  • below mylohyoid muscle and above the lower margin of the hyoid bone (or the carotid bifurcation)
  • anterior to the posterior border of the submandibular glands
    • level Ia: submental nodes, i.e. between the anterior bellies of the digastric muscles
    • level Ib: submandibular nodes, i.e. posterolateral to the anterior belly of the digastric muscles and anterior to the posterior border of the submandibular glands
Level II: upper internal jugular (deep cervical) chain
  • base of the skull to the inferior border of hyoid bone (or the carotid bifurcation)
  • anterior to the posterior border of sternocleidomastoid (SCM) muscle
  • posterior to the posterior border of the submandibular glands
    • level IIa: inseparable from or anterior to the posterior edge of the internal jugular vein
      • most superior node is the jugulodigastric node
    • level IIb: posterior to the internal jugular vein and have a fat plane separating the nodes and the vein
Level III: middle internal jugular (deep cervical) chain
Level IV: lower internal jugular (deep cervical) chain
  • inferior margin of cricoid cartilage to level of the clavicle
  • anterior and medial to an oblique line drawn through the posterior edge of SCM and the posterolateral edge of the anterior scalene muscle 2
  • lateral to the medial margin of the CCA
Level V: posterior triangle (spinal accessory)
  • posterior to the posterior edge of the sternocleidomastoid muscle and anterior to the anterior border of the trapezius muscle 
    • level Va: superior half, posterior to levels II and III (between base of the skull and inferior border of cricoid cartilage)
    • level Vb: inferior half, posterior to level IV (between the inferior border of cricoid cartilage and the level of clavicles)
Level VI: anterior compartment (prelaryngeal, pre- and paratracheal)
Level VII: (anterior) superior mediastinal
  • from suprasternal notch to innominate artery
  • technically outside the neck but still considered regional lymph nodes
Variant anatomic boundaries

Minor variations to the above anatomic boundaries have been described. For example, two groups of head and neck surgeons proposed 1

  • level Ib is bounded posteriorly by the stylohyoid muscle
  • levels IIa and IIb are separated by the vertical plane defined by the spinal accessory nerve
  • the posterior border of levels II through IV and the anterior border of level V may also be defined by the plane of sensory branches of the cervical plexus, in addition to the posterior border of the sternocleidomastoid muscle
Additional neck levels

The above classification is not inclusive of several important groups, such as the supraclavicularparotid, retropharyngeal, and occipital nodes.

Other classification systems include these regions, but a consensus approach has not been reached. For example, the TNM atlas defines "region 7" as "supraclavicular nodes" 4, while radiation oncologists may consider "level VII" as "prevertebral nodes" 3. These multiple definitions can lead to confusion and thus it is best to be descriptive with lymph nodes outside of the established levels I-VII.

See also

Anatomy: Head and neck
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Article information

rID: 1615
System: Head & Neck
Synonyms or Alternate Spellings:
  • Cervical lymph node stations
  • Cervical lymph node levels
  • Neck nodal stations
  • Neck nodal levels

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Cases and figures

  • Lymph Node Levels...
    Figure 1: lymph node levels
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  • R Vb Necrotic Nod...
    Case 1: level Va node
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  • Figure 2: annotated CT
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  • Case 2: level VI (Delphian) node
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