Surgical Lymph Node Levels of the Neck

• Neck Lymph Nodes are divided into 7 levels

Level 1: Submental and Submandibular Nodes

• Boundaries:
  • Level IA (Submental): (in the midline)
    • Lateral (bilaterally): Anterior Digastric muscles
    • Inferior: Hyoid
    • Superior: Mandible
  • Level IB (Submandibular):
    • Anterior: Anterior Digastric muscle
    • Posterior: Posterior Digastric muscle
    • Lateral: Posterior edge of Submandibular Glands
    • Superior: Mandible
• Important Structures/Relationships:
  • Lingual Nerve
  • Hypoglossal Nerve
  • Submandibular Duct
  • Facial Artery
  • Facial Vein
    • Only structure found lateral to the Posterior Belly of Digastric
  • Marginal Mandibular Branch of Facial Nerve
    • Found in the fascia overlying the Submandibular Gland superficial to the Facial Artery and Vein
• Sites Draining:
  • Floor of mouth
  • Anterior Tongue
  • Lower Lip
  • Submandibular Gland
  • Nasopharynx

Level 2: Upper Jugular Nodes

• Boundaries:
  • Anterior:  Posterior edge of Submandibular Glands
  • Posterior: posterior border of the sternocleidomastoid muscle
  • Superior: skull base
  • Inferior: Level of the hyoid bone (clinical), carotid bifurcation (surgical)
  • Level II is divided by the accessory nerve into levels IIa (anteriorly) and IIB (posteriorly).
• Important Structures
  • Spinal Accessory Nerve (CN XI)
    • Runs deep to Posterior Digastric and Occipital Artery
    • Runs superficial to IJV for majority of the time
    • Often gives small branch to Trapezius before entering SCM
• Sites Draining:
  • Oropharynx
  • Nasopharynx
  • Nasal Cavity
  • Larynx
  • Parotid Gland

Level 3: Middle Jugular Nodes

• Boundaries:
  • Lateral: Posterior border of SCM
  • Medial: Lateral border of Sternohyoid
  • Superior: Hyoid Bone
  • Inferior: Inferior border of Cricoid Cartilage
• Important Structures:
  • Phrenic Nerve
    • Runs deep to the cervical rootlets and superficial to the Anterior Scalene muscle beneath the Deep layer of the Deep Cervical Fascia
• Sites Draining:
  • Oral Cavity
  • Nasopharynx
  • Hypopharynx
  • Larynx

Level 4: Lower Jugular Nodes

• Boundaries:
  • Lateral: Posterior border of SCM
  • Medial: Lateral border of Sternohyoid
  • Superior: Inferior border of Cricoid Cartilage
  • Inferior: Clavicle
• Important Structures:
  • From superficial to deep, the structures encountered:
    • Omohyoid
    • Carotid Sheath
    • Thoracic Duct (more commonly seen in the left neck)
    • Transverse Cervical Artery
    • Phrenic Nerve
    • Anterior Scalene muscle
  • Lung Apices may also be present at inferior aspect of Level 4
• Sites Draining:
  • Larynx
  • Hypopharynx
  • Thyroid
  • Cervical Oesophagus

Level 5: Posterior Triangle Nodes

• Boundaries:
  • Lateral: Trapezius
  • Medial: Lateral border of SCM
  • Inferior: Clavicle
  • Horizontal line extended from inferior border of Cricoid divides this level into 5A (superior to Cricoid) and 5B (inferior to Cricoid)
• Important Structures:
  • Phrenic Nerve
    • Embedded in fascia overlying Anterior Scalenes
    • Protected by staying superficial to this plane
  • Brachial Plexus
    • Courses on the floor of level 5B between Anterior and Middle Scalene
  • Suprascapular artery
  • Transverse cervical artery
• Sites Draining:
  • Nasopharynx
  • Oropharynx
  • Skin of Posterior Scalp and Neck
  • Virchow’s Node

Level 6: Central Compartment Nodes

• Boundaries:
  • Lateral: lateral border of the sternohyoid muscle
  • Superior: Hyoid Bone
  • Inferior: Sternum
  • Divided into left and right by the Trachea
• Important Structures:
  • Recurrent Laryngeal Nerve
  • Thyroid Gland
  • Parathyroid Glands
• Sites Draining:
  • Thyroid
  • Subglottic Larynx
  • Cervical Trachea
  • Hypopharynx
  • Cervical Oesophagus

Level 7: Superior Mediastinal Nodes

• Boundaries:
  • Superior: Inferior border of Suprasternal Notch
  • Inferior: Innominate Artery/Brachiocephalic Artery