Cervical lymph nodes

CERVICAL LYMPH NODESDr. Diptiman Baliarsingh1st Year PG, Dept. of ENT,Hi-Tech Medical College & Hospital, Bhubaneswar

IntroductionThe 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

Levels of Neck NodesThere 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

LEVEL I2 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

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

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

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


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

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

LEVEL IIContain 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

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


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



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


LEVEL IIB

Superior

Inferior

Lateral(Posterior)

Medial

Mastoid process



Lateral border of SCM

N/A

Skull base,Caudal edge of

C1 lateral process




Medial edge of ICA, paraspinal (lev. scapulae)

mus

Skull base

Carotid bifurcation


Vertical plane defined by Spinal

acc. nerve

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

LEVEL IIIContains 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

Involved in pathology of Oral cavity Nasopharynx, Oropharynx, Hypopharynx Larynx

AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary


LEVEL III

Superior

Inferior

Lateral(Posterior)

Medial




inferior border of cricod cartilage


Medial border of SCM






Medial edge of ICA, paraspinal (lev. scapulae)

mus

Carotid bifurcation

Omohyoid muscle

Sensory branches of cervical plexus

Sternohyoid muscle

LEVEL IVContains 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

Involved in pathology of Hypopharynx Thyroid Cervical Esophagus Larynx

AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary


LEVEL IV

Superior

Inferior

Lateral(Posterior)

Medial



Clavicle


Medial border of SCM



2cm cranial to sternoclavicular

joint


Medial edge of CCA, paraspinal (scalenus) mus

Omohyoid muscle

Clavicle


Sternohyoid muscle

LEVEL VContains 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

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)

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


LEVEL Va

Superior

Inferior

Lateral(Posterior)

Medial

Apex of convergence of SCM & trapezius

muscle



Anterior border of Trapezius muscle



muscle






muscle






LEVEL Vb

Superior

Inferior

Lateral(Posterior)

Medial



Clavicle





Clavicle





Clavicle



LEVEL VIContains 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

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


LEVEL VI

Superior

Inferior

Lateral(Posterior)

Medial

Hyoid Bone

Superior edge of manubrium sterni

CCA

CCA

Hyoid Bone


Medial Aspect of CCA

Medial Aspect of CCA

Hyoid Bone


CCA

CCA

LEVEL VIIContains 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


LEVEL VII

Superior

Inferior

Lateral(Posterior)

Medial


N/A

N/A

N/A


Innominate Artery

Innominate Artery& Left CCA



Innominate Artery



Thank You...

REFERENCES CUMMING’S Otolaryngolagy Head & Neck Surgery

- 5th Ed

Health & Medicine

Cervical lymph nodes