Lymph node levels of the neck

Lymph nodes in the neck have been historically divided into at least six anatomic levels for the purpose of head and neck cancer staging and therapy planning. Differing definitions exist across specialties 1-4. The following is a synthesis of radiologically useful boundaries for each level.

Level I: submental and submandibular

There are two sublevels:

  • level Ia (submental nodes): anteromedial between the anterior bellies of both digastric muscles
  • level Ib (submandibular nodes): posterolateral to the anterior belly of the digastric muscles
Level II: upper internal jugular (deep cervical) chain

​There are two sublevels:

Level III: middle internal jugular (deep cervical) chain
  • superiorly: inferior border of the hyoid bone
  • inferiorly: inferior border of the cricoid cartilage
  • anteriorly: anterior border of the sternocleidomastoid muscle
  • posterolaterally: posterior border of the sternocleidomastoid muscle
  • medially: medial border of the common carotid artery
Level IV: lower internal jugular (deep cervical) chain
  • superiorly: inferior border of the cricoid cartilage
  • inferiorly: level of the clavicle
  • anteriorly: anterior border of the sternocleidomastoid muscle
  • posterolaterally: oblique line drawn through the posterolateral edge of the sternocleidomastoid muscle and the lateral edge of the anterior scalene muscle 2
  • medially: medial border of the common carotid artery
  • includes medial supraclavicular nodes including Virchow node 1
Level V: posterior triangle
  • superiorly: skull base at the apex of the convergence of sternocleidomastoid and trapezius muscles
  • inferiorly: level of the clavicle
  • anteromedially: posterior border of the sternocleidomastoid muscle
  • posterolaterally: anterior border of the trapezius muscle

​There are two sublevels:

  • level Va: superior half, superior to inferior border of the cricoid cartilage (posterior to levels II and III); includes spinal accessory nodes
  • level Vb: inferior half, inferior to inferior border of the cricoid cartilage (posterior to level IV); includes lateral supraclavicular nodes 1
Level VI: anterior compartment
  • superiorly: inferior border of hyoid bone
  • inferiorly: superior border of manubrium (suprasternal notch)
  • anteriorly: platysma muscle 8
  • posteriorly: trachea (medially) and prevertebral space (laterally) 8
  • laterally: medial borders of both common carotid arteries (medial to levels III and IV)
  • includes anterior jugular, pretracheal, paratracheal, prelaryngeal/precricoid (Delphian), and perithyroidal nodes
Variant anatomic boundaries

Minor variations to the above anatomic boundaries have been described. For example, head and neck surgeons may use different intraoperative landmarks 1,4

  • levels IIa and IIb are separated by the vertical plane defined by the spinal accessory nerve
  • the medial border of levels III and IV and lateral border of level VI is defined by the lateral border of the sternohyoid muscle
  • the posterior border of levels II through IV and anterior border of level V may also be defined by the plane of sensory branches of the cervical plexus
Additional neck levels

The above classification is not inclusive of several important groups:

Other classification systems include some these regions, but a consensus approach has not been reached. For example, with respect to "level VII," radiologists may apply this label to superior mediastinal nodes 2, radiation oncologists may apply this label to "prevertebral nodes" 3, and head and neck surgeons omit this level from their nomenclature altogether 1. Thus, it is best to name lymph node groups outside of the established levels I-VI. If "level VII" is used for superior mediastinal lymph nodes, it should refer to the extension of the paratracheal chain below the suprasternal notch but above the level of the brachiocephalic artery 4.

See also

Anatomy: Head and neck
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Article information

rID: 1615
System: Head & Neck
Synonyms or Alternate Spellings:
  • Cervical lymph node stations
  • Cervical lymph node levels
  • Neck nodal stations
  • Neck nodal levels

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Cases and figures

  • Figure 1: lymph node levels
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  • Case 1: level Va node
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  • Figure 2: annotated CT
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  • Case 2: level VI (Delphian) node
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