Cervical lymph nodes

Cervical lymph nodes - Levels

1. CERVICAL LYMPH NODES Dr. Diptiman Baliarsingh 1 st Year PG, Dept. of ENT, Hi-Tech Medical College & Hospital, Bhubaneswar

2. Introduction The cervical group of lymph nodes extend from Mandible & skull base superiorly Clavicle inferiorly Posterior triangle of neck laterally & posteriroly Midline viscera anteriorly LN groups are categorized acc to original description by Memorial Sloan-Kettering Group

3. Levels of Neck Nodes There are 7 levels of neck and most have sublevels containing specific group of nodes Level I – Submental & Submandibular Level II – Upper Jugular Level III – Middle Jugular Level VI – Lower Jugular Level V – Posterior Triangle Level VI – Anterior/Central Compartment Level VII – Superior Mediastinal

4. LEVEL I 2 groups of LN’s Sublevel Ia – Submental Sublevel Ib – Submandibular Boundaries of Lvl I Body of Mandible Ant. Belly of C/L digastric muscle Post. Belly of I/L digastric muscle Stylohyoid muscle

5. Submental (Sublevel Ia ) LN’s in the triangular boundary formed by Ant belly of digastric muscles Hyoid Bone Involved in pathology of Floor of mouth Anterior oral tongue Anterior mandibular alveolar ridge Lower lip

6. Boundary Clinical Radiologic Surgical LEVEL Ia Superior Inferior Lateral (Posterior) Medial Symphisis of mandible Body of Hyoid N/A N/A Geniohyoid Muscle, Plane tangent to inf. Border of mandible Body of Hyoid Ant belly of I/L digastric mus. Ant belly of C/L digastric muscle Symphisis of mandible Body of Hyoid Ant belly of I/L digastric mus. Ant belly of C/L digastric muscle

7. Submandibular (Sublevel Ib ) LN’s in the triangular boundary formed by Ant belly of digastric muscle Stylohyoid & Post belly of digastric muscle Body of Mandible Involved in pathology of Oral Cavity Anterior Nasal Cavity Soft tissue structures of midface Submandibular gland

8. Boundary Clinical Radiologic Surgical LEVEL Ib Superior Inferior Lateral (Posterior) Medial Body of mandible Plane through Hyoid bone Ant border of SCM N/A Mylohyoid Mus , Body of mandible Inferior edge of hyoid bone Post edge of Submandibular Gl. Ant belly of digastric muscle Body of mandible Digastric tendon attachment to hyoid bone Post edge of Submandibular Gl Ant belly of digastric muscle

9. Many of these lymph nodes lie in close proximity to submandibular gland, and it is removed to ensure thorough exenteration of all lymph nodes with in this traingle Perifacial LN’s – drain Lip, buccal musoca , ant nasal caity & soft tissue of neck, sometimes get involved along with the Level I LN groups. ND’s performed for nodal disease asso with primary lesions of these sites should be modified to encompass perifacial nodes

10. LEVEL II Contain Upper Jugular LN’s 2 groups – Sublevel IIa & IIb LN’s are located around upper third of internal jugular vein & adjacent spinal accessory nerve Extent Superiorly - Skull base Inferirly - Inf border of Hyoid bone Ant (medial) boundary – stylohyoid mus Post (lateral) boundary – posterior border of SCM

11. Sublevel IIa nodes are located anterior (medial) to vertical plane defined by spinal accessory nerve, whereas sublevel IIb nodes are located posterior (lateral) to the vertical plane defined by spinal accessory nerve Involved in pathology of Oral cavity, Nasal Cavity Nasopharynx , Oropharynx , Hypopharynx Larynx Parotid gland

12. Boundary Clinical Radiologic Surgical LEVEL IIA Superior Inferior Lateral (Posterior) Medial Mastoid process Horizontal plane defined by the inferior border of hyoid bone N/A N/A Skull base, Caudal edge of C1 lateral process Horizontal plane defined by the inferior border of hyoid bone Post. border of IJV Post. edge of submandibular gland Skull base Carotid bifurcation Vertical plane defined by Spinal acc. nerve Post. edge of submandibular gland

13. Boundary Clinical Radiologic Surgical LEVEL IIB Superior Inferior Lateral (Posterior) Medial Mastoid process Horizontal plane defined by the inferior border of hyoid bone Lateral border of SCM N/A Skull base, Caudal edge of C1 lateral process Horizontal plane defined by the inferior border of hyoid bone Lateral border of SCM Medial edge of ICA, paraspinal ( lev . scapulae) mus Skull base Carotid bifurcation Lateral border of SCM Vertical plane defined by Spinal acc. nerve

14. AHNS Committee recommends – perpendicular plane formed by posterior aspect of submandibular gland as radiologic marker of this boundary

15. LEVEL III Contains Middle Jugular LN’s Group Located around middle third of IJV Extent Superiorly – Carotid bifurcation / Inferior aspect of body of hyoid bone Inferiorly – Junction of Omohyoid mus with IJV / lower border of cricoid arch(cartilage ) Medially – Lateral border of sternohyiod muscle Laterally – Post border of SCM muscle

16. Involved in pathology of Oral cavity Nasopharynx , Oropharynx , Hypopharynx Larynx AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary

17. Boundary Clinical Radiologic Surgical LEVEL III Superior Inferior Lateral (Posterior) Medial Horizontal plane defined by the inferior border of hyoid bone Horizontal plane defined by the inferior border of cricod cartilage Lateral border of SCM Medial border of SCM Horizontal plane defined by the inferior border of hyoid bone Horizontal plane defined by the inferior border of cricod cartilage Lateral border of SCM Medial edge of ICA, paraspinal ( lev . scapulae) mus Carotid bifurcation Omohyoid muscle Sensory branches of cervical plexus Sternohyoid muscle

18. LEVEL IV Contains Lower Jugular LN’s Group Located around lower third of IJV Extent Superiorly – Junction of Omohyoid mus with IJV / lower border of cricoid arch(cartilage ) Inferiorly – Clavicle Medially – Lateral border of sternohyiod muscle Laterally – Post border of SCM muscle

19. Involved in pathology of Hypopharynx Thyroid Cervical Esophagus Larynx AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary

20. Boundary Clinical Radiologic Surgical LEVEL IV Superior Inferior Lateral (Posterior) Medial Horizontal plane defined by the inferior border of cricod cartilage Clavicle Lateral border of SCM Medial border of SCM Horizontal plane defined by the inferior border of cricod cartilage 2cm cranial to sternoclavicular joint Lateral border of SCM Medial edge of CCA, paraspinal ( scalenus ) mus Omohyoid muscle Clavicle Sensory branches of cervical plexus Sternohyoid muscle

21. LEVEL V Contains Posterior Triangle LN’s Group Located along the lower half of spinal accessory nerve & transverse cervical artery Extent Superiorly (Apex) – convergence of SCM & trapezius muscle Inferiorly – Clavicle Medially – Post border of SCM muscle Laterally – Anterior border of trapezius muscle

22. 2 groups – Sublevel Va & Vb The Va is separated from Vb by a horizontal plane marking the inferior border of the anterior cricod arch Sublvl Va includes – Spinal accessory nodes Sublvl Vb includes – nodes following transverse cervical vessels & supraclavicular nodes (not Virchow’s Nodes – they are located in Level IV)

23. Involved in pathology of Nasopharynx Oropharynx Cutaneous structures of posterior scalp Neck

24. Boundary Clinical Radiologic Surgical LEVEL Va Superior Inferior Lateral (Posterior) Medial Apex of convergence of SCM & trapezius muscle Horizontal plane defined by the inferior border of cricod cartilage Anterior border of Trapezius muscle Lateral border of SCM Apex of convergence of SCM & trapezius muscle Horizontal plane defined by the inferior border of cricod cartilage Anterior border of Trapezius muscle Lateral border of SCM Apex of convergence of SCM & trapezius muscle Horizontal plane defined by the inferior border of cricod cartilage Anterior border of Trapezius muscle Sensory branches of cervical plexus

25. Boundary Clinical Radiologic Surgical LEVEL Vb Superior Inferior Lateral (Posterior) Medial Horizontal plane defined by the inferior border of cricod cartilage Clavicle Anterior border of Trapezius muscle Lateral border of SCM Horizontal plane defined by the inferior border of cricod cartilage Clavicle Anterior border of Trapezius muscle Lateral border of SCM Horizontal plane defined by the inferior border of cricod cartilage Clavicle Anterior border of Trapezius muscle Sensory branches of cervical plexus

26. LEVEL VI Contains LN’s of Anterior compartment of the neck They surround the midline visceral structures of the neck Extent Superiorly – Hyoid Bone Inferiorly – Suprasternal Notch Laterally (on each side) – Medial border of Carotid sheath

27. LN groups in the compartment are – Pretracheal N Paratracheal N Precricoid ( Delphian ) N Perithyroidal N LN’s along Recurrent Laryngeal Nr Involved in pathology of Thyroid Gland Glottic & Subglottic Larynx Apex of pyriform sinus Cervical esophagus

28. Boundary Clinical Radiologic Surgical LEVEL VI Superior Inferior Lateral (Posterior) Medial Hyoid Bone Superior edge of manubrium sterni CCA CCA Hyoid Bone Superior edge of manubrium sterni Medial Aspect of CCA Medial Aspect of CCA Hyoid Bone Superior edge of manubrium sterni CCA CCA

29. LEVEL VII Contains Superior Mediastinal group of LN’s The LN are an extension of the paratracheal LN chain extending inferiorly below the suprasternal notch along each side of cervical trachea to the level of the innominate artery Extent Superiorly – Superior edge of manubrium Inferiorly – superior border of arch of aorta Laterally (Left side) – CCA Laterally (Right side) – Innominate Artery

30. Boundary Clinical Radiologic Surgical LEVEL VII Superior Inferior Lateral (Posterior) Medial Superior edge of manubrium sterni N/A N/A N/A Superior edge of manubrium sterni Innominate Artery Innominate Artery & Left CCA Innominate Artery & Left CCA Superior edge of manubrium sterni Innominate Artery Innominate Artery & Left CCA Innominate Artery & Left CCA

31. Thank You...  REFERENCES CUMMING’S Otolaryngolagy Head & Neck Surgery - 5th Ed