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Head and Neck Nodes

Level 1: Submandibular, submental.

Level 2: Internal jugular from skull base to carotid bifurcation.
Level 3: Internal jugular below carotid bifurcation to omohyoid.
Level 4: Internal jugular below omohyoid.
Level 5: Posterior triangle.
Level 6: Adjacent to thyroid.
Level 7: Tracheal esophageal groove and superior mediastinum.

Abnormal Node Size:
Level 1, 2, 3
All other levels

> 1.5 cm
> 1.0 cm
> 0.8 cm

Necrosis and extra capsular spread abnormal regardless of size.

Extracapsular Spread:
Spiculated margins.
Invasion of fatty hilum or surrounding fat.
Encasement of vessels.

CT versus MR:
CT = MR for detecting and sizing nodes.
CT better than MR for demonstrating necrosis.
CT better than MR for detecting extracapsular spread.

Nodes from Unknown Primary:

10% of patients with malignant cervical adenopathy have no obvious primary.
Most common sites for unknown primary:
Nasal Pharynx.
Pyriform Sinus.
Tongue Base.
Tonsillar Crypts.

Source of metatstatic nodes:

Level 1: Oral cavity, submandibular gland.
Level 2: Nasal pharynx, oral pharynx, parotid, superglottic larynx.
Level 3: Oral pharynx, hypopharynx, superglottic larynx.
Level 4: Subglottic larynx, hypopharynx, esophagus, thyroid.
Level 5: Nasal pharynx, oral pharynx.
Level 6 & 7: Thyroid, larynx, lung.
Note: Bilateral nodes are common with cancers of soft pallet, tongue, epiglottis, and nasal

1. Inflammatory disease leading to pseudo necrosis with TB or abnormal
enlargement with cat scratch, sarcoid. Suppuration can look like necrosis.
2. Post inflammatory fatty infiltration

1. Non-Hodgkin's lymphoma most common: Large nodes, enlargement of
Waldeyer's ring, extra lymphatic enlargement of particular glands such as the
2. Hodgkin's lymphoma may be present (25 percent of head & neck lymphoma)
particularly if there is also a mediastinal involvement.
3. Lymphomas can cross fascial planes easily.
4. Can undergo rapid enlargement.
5. Differential diagnosis: squamous cell cancer, viral and granulomatous dz.

1. Painless posterior neck mass.
2. Scrofula: Common in Southeast Asia, (California).
3. Necrotic nodes particularly in level 5.
4. Multi-loculated disturbed fat planes, thick rim enhancement.
5. May calcify following treatment.

1. Abnormal nodes in chest and head and neck.
2. Usually non-necrotic but brightly enhanced with contrast.

Infectious Mononucleosis:
1. Multiple large non-necrotic nodes.
2. Enlargement of Waldeyer's ring.
3. Appears similar to AIDS, sarcoid, leukemia, lymphoma.

Cat Scratch Fever:

1. Bilateral large nodes including intraparotid nodes.
2. Uncertain etiology ? viral or ricketsial.


Multiple small nodes.

Enlargement of Waldeyer's ring.
Associated lymphoepithelial cysts parotids.


Deep Lateral Cervical Group
1. Internal jugular chain (deep cervical).
2. Spinal accessory chain (posterior triangle).
3. Transverse cervical (supraclavicular).
Highest jugulodigastric node near the angle of the mandible is a sentinel node.
Lowest most internal jugular chain node called the virchow node and is a sentinel node.
If only a Virchow node is present, then should check the abdomen and/or chest for
primary source of metastasis.
The internal jugular chain is divided into:

High: Above the hyoid (level 2).

Mid: Between hyoid and cricoid (level 3).
Low: Below the cricoid (level 4).

The internal jugular chain is a common pathway for drainage from parotid, retropharynx,
and submandibular/submental groups. It drains to the subclavian vein and/or internal
jugular vein and/or into the right lymphatic duct and thoracic duct.
Spinal accessory (posterior triangle) nodal group receives occipital/mastoid, lateral neck,
scalp, nasal pharyngeal sources. Abnormal spinal accessory nodes may indicate the
presence of an early nasal pharyngeal cancer.
Transverse cervical chain receives drainage from deep cervical, supraclavicular,
subclavicular, upper chest, and anterior lateral neck. The drainage is the same as for the
internal jugular chain.

Submental/Submandibular Chain
Submental nodes receive drainage from adjacent skin, lips, floor of the mouth, and drain
to the submandibular nodal group.
Submandibular nodes are extra glandular and receive drainage from anterior face, flow of
the mouth, anterior oral cavity, and submental nodal group. Drainage is to the high
internal jugular chain.

Parotid Nodal Group

Intra or extra glandular nodes.
Receive drainage from external auditory canal, eustachian tube, adjacent skin, and bucal
mucosa (squamous cell skin cancer and melanoma frequently metastasize to this group).
Drainage is to high internal jugular chain.

Retropharyngeal Nodal Group

Two compartments: Medial and lateral retropharynxl.
Medial retropharyngeal receives drainage from nasopharynx and oral pharynx and drain
to high internal jugular chain.
Lateral retropharyngeal (node of Rouvire) are located just medial to the internal carotid
artery, lateral aspect of the pharynx.

Early sign of nasal pharyngeal cancer may be presence of abnormal lateral

retropharyngeal node in the patient over forty or posterior triangle adenopathy.

Anterior Cervical Nodal Group

Anterior jugular: superficial. Follows the course of the external jugular vein. Receives
drainage from skin and muscles of the anterior neck. Drains to the thoracic duct.
Paraesophageal group: Tracheoesophageal groove nodes and delphian node. Abnormal
delphian node is often an indicator subglottic laryngeal cancer extension.
This group receives drainages from hypopharynx, larynx, thyroid, and esophagus.
Drainage is then to the thoracic duct.