Cervical Lymph Nodes of the Neck

Cervical Lymph Nodes of the Neck

Cervical Lymph Nodes of the neck can provide diagnostics clues to the origin of the pathology. There are a total of 7 levels, which this article discusses.

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Summary Card

1: Submental (1A), Submandibular (1B)
Superior: mandible
Inferior: anterior and posterior digastric muscle, hyoid.
Walls: N/A
Structures: submental nodes, submandibular nodes & gland.


2: Ant. upper jugular (2A), Post. upper jugular (2B)
Superior: jugular fossa
Inferior: hyoid bone
Walls: sternohyoid to sternocleidomastoid
Structures: spinal accessory nerve divides 2A & 2B


3: Midjugular region
Superior: hyoid bone
Inferior: lower border of the cricoid
Walls: sternohyoid to sternocleidomastoid
Structures: N/A


4: Lower jugular 4A (sternal SCM), 4B (clavicular SCM)
Superior: lower border of the cricoid
Inferior: clavicle
Walls: sternohyoid to sternocleidomastoid
Structures: Thoracic duct on the left


5: Posterior triangle above omohyoid (A), below omohyoid (B)
Superior: cranium at convergence of SCM & trapezius
Inferior: clavicle
Walls: posterior border of SCM and anterior border of trapezius.
Key Contents: spinal accessory nerve.


6: Anterior central compartment
Superior: Hyoid bone
Inferior: suprasternal notch
Walls: carotid sheaths
Structures: pre- and para-tracheal nodes.


Level 7: Upper mediastinum
Superior: suprasternal notch
Inferior: aortic arch
Walls: carotid sheaths
Sublevel: none


Cervical Lymphatic Drainage Pattern

Overview

In general, the lymphatic flow is from superficial to deeper, and from upper to the lower parts of the neck. The lymphatic system of the neck is divided into three systems:

  1. Waldeyer’s internal ring: nodes in adenoids, tonsils, and posterior pharyngeal wall which are at high risk for lymphatic spread.
  2. Waldeyer’s external ring: nodes in the occipital, post-auricular, parotid, superficial cervical, submandibular, submental and anterior cervical region. They drain superficial tissues from the scalp, eyelids, face, sinuses and oral cavity.
  3. Deep Lymph Node System: nodes in the upper, middle and lower cervical regions near the internal jugular vein, a spinal accessory group and neck midline.

Drainage Patterns

Each anatomical subgroup of lymph nodes acts as a reservoir for a specific site in the head and neck region. This creates the potential to identify the primary tumour based on the site of a specific group of lymph nodes.

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Tip: lymphatic involvement increases anterior to posterior in the aerodigestive tract. Tongue tumours have the highest incidence of metastasis, then floor of the mouth, buccal mucosa, hard palate and finally the lips5



Level 1 Cervical Lymph Nodes

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This contains the submental (1A) and submandibular (1B) triangles.

Level 1 cervical lymph nodes are two sublevels: submental (1A) & submandibular (1B). This can be visualized in the illustration below.

Level 1 Cervical Lymph Nodes, Level 1A, Level 1B, submental, submandibular, cervical nodes
Level 1 Cervical Lymph Nodes

Level 1A: Submental

  • Location: between anterior digastric bellies and hyoid bone.
  • Structures: submental nodes
  • Drainage: from lips, gum, tongue, anterior hard palate

Level 1B: Submandibular

  • Location: between digastric muscle and body of the mandible.
  • Structures: submandibular nodes and gland.
  • Drainage: from lips, gum, tongue, anterior hard palate


Level 2 Cervical Lymph Nodes

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Upper jugular neck nodes have anterior (2A) & posterior (2B) divisions.

Level 2 Cervical Lymph Nodes, Level 2A, Level 2B, spinal accessory nerve, upper jugular, cervical nodes
Level 2 Cervical Lymph Nodes

The location of level 2 cervical neck nodes are:

  • Superior: skull base at jugular fossa.
  • Inferior: hyoid bone or carotid bifurcation.
  • Posterior: posterior border sternocleidomastoid (SCM)
  • Anterior: continuation from level 1B (lateral border of the sternohyoid or posterior belly of digastric depending on resource).

Key points on level 2 neck nodes are:

  • Contents: spinal accessory nerve and upper jugular nodes
  • Divisions: Anterior (2A) & posterior (2B) divided by spinal accessory nerve.
  • Drainage: naso-/oro-/hypopharynx and parotid.


Level 3 Cervical Lymph Nodes

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The middle jugular group does not have sublevels. 

The location of level 3 cervical nodes are:

  • Superior: hyoid bone or carotid bifurcation
  • Inferior: lower cricoid or omohyoid muscle
  • Anterior: sternohyoid (don't get confused with stylohyoid)
  • Posterior: posterior border of sternocleidomastoid (SCM)

Level 3 tends to drain the naso-/oro-/hypopharynx and larynx.

Level 3 Cervical Lymph Nodes, Level 3, nodes ,middle jugular, cervical nodes
Level 3 Cervical Lymph Nodes


Level 4 Cervical Lymph Nodes

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Lower jugular group has 4A & 4B sublevels containing the thoracic duct and Virchow's node.

Level 4 Cervical Lymph Nodes, Level 4, nodes, lower jugular, cervical nodes
Level 4 Cervical Lymph Nodes

The location of level 4 cervical nodes are:

  • Superior: cricothyroid notch or omohyoid muscle
  • Inferior: clavicle
  • Anterior: Lateral border of sternohyoid muscle (same as level 3)
  • Posterior: posterior border of sternocleidomastoid (same as level 3)

The sublevels are described as follows:

  • Divisions: 4A is deep to sternal SCM, 4B is deep to clavicular SCM
  • Contents: lower jugular nodes, left thoracic duct, right lymphatic duct


Level 5 Cervical Lymph Nodes

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The posterior triangle group is divided into sublevels 5A & 5B by omohyoid.

Level 5 cervical neck lymph nodes drain the naso- and oro-pharynx.

The anatomical locations are:

  • Superior: skull base SCM and trapezius muscles
  • Inferior: clavicle
  • Anterior: posterior border of the SCM muscle
  • Posterior: anterior border of the trapezius muscle

The sublevels are described as follows:

  • 5A: superior to the omohyoid and contains the spinal accessory nodes.
  • 5B: inferior to the omohyoid and contains the transverse cervical and supraclavicular nodes

Level 5 Cervical Lymph Nodes, Level 5A, Level 5B, nodes, posterior triangle, cervical nodes
Level 5 Cervical Lymph Nodes


Level 6 Cervical Lymph Nodes

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Anterior compartment contains the paratracheal and Delphian node.

Level 6 is medial to levels III and IV. It drains the thyroid, parathyroid, cervical oesophagus, and larynx. The anatomical landmarks are:

  • Superior: hyoid bone
  • Inferior: manubrium/suprasternal notch
  • Walls: left and right common carotid arteries

Level 6 Cervical Lymph Nodes, Level 6, nodes, anterior compartment, cervical nodes
Level 6 Cervical Lymph Nodes


Level 7 Cervical Lymph Nodes

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Upper mediastinal nodes lie outside the borders of the neck.

The anatomical location of Level VII nodes are:

  • Superior: suprasternal notch
  • Inferior: aortic arch
  • Lateral: carotid arteries

These nodes are an extension of the paratracheal lymph node chain.


References

  1. Haynes J, Arnold K, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 2015;91(10):698-706. https://www.ncbi.nlm.nih.gov/pubmed/25978199.
  2. Robbins K, Shaha A, Medina J, et al. Consensus statement on the classification and terminology of neck dissection. Arch Otolaryngol Head Neck Surg. 2008;134(5):536-538. doi:10.1001/archotol.134.5.536
  3. Lymph nodes of the neck.P M SomRadiology1987165:3, 593-600
  4. Martin G. Mack, Jörg Rieger, Mehran Baghi, Sotirios Bisdas, Thomas J. Vogl,
    Cervical lymph nodes, European Journal of Radiology, Volume 66, Issue 3,
    2008, Pages 493-500, ISSN 0720-048X, https://doi.org/10.1016/j.ejrad.2008.01.019.
    (https://www.sciencedirect.com/science/article/pii/S0720048X08000399)
  5. Farr HW, Goldfarb PM, Farr CM. Epidermoid carcinoma of the mouth and pharynx at Memorial Sloan-Kettering Cancer Center, 1965 to 1969. Am J Surg. 1980 Oct;140(4):563-7. doi: 10.1016/0002-9610(80)90213-5. PMID: 7425241.
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