Lymph node levels of Neck

Surgically, cervical lymph nodes are divided into 6-7 levels (only 6 according to many
authors who exclude the level VII nodes) for staging of carcinoma which would also
be the basis for selective neck dissection. There are 5 levels in the lateral
compartment and 2 in the central compartment. Nodes not included in these system of
levels are retropharyngeal group, periparotid group, buccinator group, post auricular
group and suboccipital group of nodes.

Visual mnemonic or schematic diagram showing boundaries of lymph node levels or

zones of neck
Level
A
I
B

II

III

A (Anterior to the
vertical line in
relation to spinal
accessory nerve)
B (Posterior to the
vertical line in
relation to spinal
accessory nerve)

Lymph nodes

Boundaries
Bilaterally: Anterior belly of digastrics
Submental nodes
Inferiorly: Hyoid bone
Superiorly: Mandible
Posteroinferiorly: Posterior belly of
Submandibular
digastrics
nodes
Anteroinferiorly: Anterior belly of
digastrics

Upper internal
jugular (deep
cervical) nodes

Superiorly: Skull base

Inferiorly: Inferior border of hyoid bone
and Carotid bifurcation
Posteriorly: Posterior border of
Sternocleidomastoid (SCM)
Anteriorly: Lateral border of Sternohyoid
and Stylohyoid

Mid internal
jugular (deep
cervical) nodes

Superiorly: Inferior border of hyoid bone

and Carotid bifurcation
Inferiorly: Inferior border of cricoid

IV

A (Above the
horizontal plane
marking the inferior
border of arch of
cricoids cartilage)
V
B (Below the
horizontal plane
marking the inferior
border of arch of
cricoids cartilage)
VI (Prelaryngeal or
Delphian, Pretracheal,
Paratracheal,
Prethyroidal)
VII

Lower internal
jugular (deep
cervical nodes)

cartilage and Junction of omohyoid

muscle and IJV
Posteriorly: Posterior border of SCM
Anteriorly: Lateral border of sternohyoid
Superiorly: Inferior border of cricoids
cartilage and Junction of omohyoid and
IJV
Inferiorly: Clavicle
Posteriorly: Posterior border of SCM
Anteriorly: Lateral border of sternohyoid

Superiorly: Convergence of SCM and

Posterior triangle trapezius
(spinal
Inferiorly: Clavicle
accessory) nodes Posteriorly: Anterior border of trapezius
Anteriorly: Posterior border of SCM

Anterior
Superiorly: Hyoid boneInferiorly:
compartment
Suprasternal notchBilaterally: Carotid
(midline) nodes arteries
Upper
mediastinal
nodes

Below suprasternal notch

Note:
The highest jugular digastric node near the angle of the mandible is called the
sentinel node.
The signal node is the lowest along the internal jugular chain called the virchow
nodes.

Probable source of Nodal metastasis:

Level 1: Oral cavity, submandibular gland

Level 2: Nasopharynx, oropharynx, parotid, supraglottic larynx
Level 3: Oropharynx, hypopharynx, supraglottic larynx
Level 4: Subglottic larynx, hypopharynx, esophagus, thyroid
Level 5: Nasopharynx, oropharynx
Level 6 & 7: Thyroid, larynx, lung

Note: Bilateral nodes are common with cancers of soft palate, tongue, epiglottis, and
nasopharynx.
Selective Neck dissection involves:

Supraomohyoid/Anterolateral: Level I to III

Extended Supraomohyoid: Level I to IV
Lateral: Level II to IV
Posterolateral: Level II to V
Anterior or Central: Level VI
Superior mediastinal: Level VII

Comprehensive Neck dissection inolves:

Radical and Modified Radical Neck Dissection: Level I to V