Lymphatic Drainage of the Head and Neck

The lymphatic system functions to drain tissue fluid, plasma proteins and other cellular debris back into the blood stream, and is also involved in immune defence. Once this collection of substances enters the lymphatic vessels, it is known as lymph. Lymph is subsequently filtered by lymph nodes and directed into the venous system.

This article will explore the anatomy of lymphatic drainage throughout the head and neck, and how this is relevant clinically. We will also look at Waldeyer’s ring, the collection of lymphatic tissue surrounding the superior pharynx.

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Lymphatic Vessels

The lymphatic vessels of the head and neck can be divided into two major groups; superficial vessels and deep vessels.

Superficial Vessels

The superficial vessels drain lymph from the scalp, face and neck into the superficial ring of lymph nodes at the junction of the neck and head.

Deep Vessels

The deep lymphatic vessels of the head and neck arise from the deep cervical lymph nodes. They converge to form the left and right jugular lymphatic trunks:

• Left jugular lymphatic trunk – combines with the thoracic duct at the root of the neck. This empties into the venous system via the left subclavian vein.

• Right jugular lymphatic trunk – forms the right lymphatic duct at the root of the neck. This empties into the venous system via the right subclavian vein.

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Lymph Nodes

The lymph nodes of the head and neck can be divided into two groups; a superficial ring of lymph nodes, and a vertical group of deep lymph nodes.

Superficial Lymph Nodes

The superficial lymph nodes of the head and neck receive lymph from the scalp, face and neck. They are arranged in a ring shape; extending from underneath the chin, to the posterior aspect of the head. They ultimately drain into the deep lymph nodes.

• Occipital: There are usually between 1-3 occipital lymph nodes. They are located in the back of the head at the lateral border of the trapezius muscle and collect lymph from the occipital area of the scalp.

• Mastoid: There are usually 2 mastoid lymph nodes, which are also called the post-auricular lymph nodes. They are located posterior to the ear and lie on the insertion of the sternocleidomastoid muscle into the mastoid process. They collect lymph from the posterior neck, upper ear and the back of the external auditory meatus (the ear canal).

• Pre-auricular: There are usually between 1-3 pre-auricular lymph nodes. They are located anterior to the auricle of the ear, and collect lymph from the superficial areas of the face and temporal region.

• Parotid: The parotid lymph nodes are a small group of nodes located superficially to the parotid gland. They collect lymph from the nose, the nasal cavity, the external acoustic meatus, the tympanic cavity and the lateral borders of the orbit. There are also parotid lymph nodes deep to the parotid gland that drain the nasal cavities and the nasopharynx.

• Submental: These lymph nodes are located superficially to the mylohoid muscle. They collect lymph from the central lower lip, the floor of the mouth and the apex of the tongue.

• Submandibular: There are usually between 3-6 submandibular nodes. They are located below the mandible in the submandibular triangle and collect lymph from the cheeks, the lateral aspects of the nose, upper lip, lateral parts of the lower lip, gums and the anterior tongue. They also receive lymph from the submental and facial lymph nodes.

• Facial: This group comprises the maxillary/infraorbital, buccinator and supramandibular lymph nodes. They collect lymph from the mucous membranes of the nose and cheek, eyelids and conjunctiva.

• Superficial Cervical: The superficial cervical lymph nodes can be divided into the superficial anterior cervical nodes and the posterior lateral superficial cervical lymph nodes. The anterior nodes lie close to the anterior jugular vein and collect lymph from the superficial surfaces of the anterior neck. The posterior lateral nodes lie close to the external jugular vein and collect lymph from superficial surfaces of the neck.

Fig 1 – The superficial and deep lymph nodes of the head and neck.

Deep Lymph Nodes

The deep (cervical) lymph nodes receive all of the lymph from the head and neck –  either directly or indirectly via the superficial lymph nodes. They are organised into a vertical chain, located within close proximity to the internal jugular vein within the carotid sheath. The efferent vessels from the deep cervical lymph nodes converge to form the jugular lymphatic trunks.

The nodes can be divided into superior and inferior deep cervical lymph nodes. They are numerous in number, but include the prelaryngeal, pretracheal, paratracheal, retropharyngeal, infrahyoid, jugulodigastric (tonsilar), jugulo-omohyoid and supraclavicular nodes.

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Clinical Relevance: Virchow’s Node

Virchow’s node is a supraclavicular node, located in the left supraclavicular fossa (located immediately superior to the clavicle). It receives lymph drainage from the abdominal cavity.

The finding of an enlarged Virchow’s node is referred to as Troisier’s sign – and indicates of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels.

[end-clinical]

Waldeyer’s Ring

Waldeyer’s tonsillar ring refers to the collection of lymphatic tissue surrounding the superior pharynx. This lymphatic tissue responds to pathogens that may be ingested or inhaled. The tonsils that make up the ring are as follows:

• Lingual tonsil – located on the posterior base of the tongue to form the antero-inferior part of the ring.

• Palatine tonsils – located on each side between the palatoglossal and palatopharyngeal arches. These are the common ‘tonsils’ that can be seen within the oral cavity. They form the lateral part of the ring.

• Tubal tonsils – these are located where each Eustachian tube opens into the nasopharynx and form the lateral part of the ring.

• Pharyngeal tonsil –  also called the nasopharyngeal/adenoid tonsil, located in the roof of the nasopharynx, behind the uvulva and forms the postero-superior part of the ring.

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Clinical Relevance: Inflamed Palatine Tonsils (Tonsillitis)

The palatine tonsils can become inflamed due to a viral or bacterial infection. In such a case, they appear red and enlarged, and are accompanied by enlarged jugulo-digastric lymph nodes.

Chronic infection of the palatine tonsils can be treated with their removal, a tonsillectomy. When performing a tonsillectomy, there may be bleeding primarily from the external palatine vein and secondarily from the tonsilar branch of the facial artery.

If an infection spreads to the peritonsillar tissue, it can cause abscess formation. This can cause deviation of the uvula, known as quinsy. A quinsy is a medical emergency, as it can potentially cause obstruction of the pharynx. It is treated with draining of the abscess and antibiotics.

Fig 2 – Quinsy – inflammation of the peritonsillar tissue. Note also how the uvula has deviated to the right as a result of the inflammation.

[end-clinical]

Lymphatics of the Brain

It was thought that lymphatics were absent from the brain until in 2015, scientists located lymphatic vessels in the brains of mice and subsequently humans. Work is underway to determine and describe the lymphatic vessels involved.

Anatomy, Head and Neck, Lymph Nodes – StatPearls

Introduction

The head and neck, as a general anatomic region, is characterized by a large number of critical structures situated in a relatively small geographic area. It is inclusive of osseous, nervous, arterial, venous, muscular, and lymphatic structures. Lymphadenopathy is a significant clinical finding associated with acute infection, granulomatous disease, autoimmune disease, and malignancy. The involvement of specific nodal groups is an indicator of pathologically-affected organs and tissues, especially in the context of malignancy. As such, intimate knowledge of the anatomic relationships of the lymphatic nodal levels and the structures they drain is critical in the delivery of appropriate therapy in many patients with cancers of the head and neck. This knowledge is especially crucial in guiding the approach to proper locoregional therapy, whether by surgery or irradiation. A detailed understanding of the principle lymphatic nodal levels of the neck is required, including their anatomical configuration and boundaries, patterns of drainage, and risk of metastatic involvement in the context of malignancy.

Blood Supply and Lymphatics

The head and neck contains a rich and elaborate lymphatic network of more than 300 nodes and their intermediate channels. Aponeuroses bind them together with the muscles, nerves, and vessels of the head and neck. These lymphatic chains are strongly lateralized and typically do not directly communicate between left and right in the absence of a pathologic process. This lymphatic drainage originates at the base of the skull, then proceeds to the jugular chain adjacent to the internal jugular vein. From there it moves into the spinal accessory chain adjacent to the spinal accessory nerve, or cranial nerve XI, and then meets the supraclavicular chain. The lymphatics then drain on both sides. On the left side, they drain either directly into the vasculature via the jugulo-subclavian venous confluence or directly into the thoracic duct. On the right side, they flow directly into the lymphatic duct. Conversely, most structures drain ipsilaterally, except in the case of structures situated at the anatomic midlines. These include the nasopharynx, pharyngeal wall, base of the tongue, soft palate, and larynx. The lymph nodes of the neck are further classified by level. These levels are Ia, Ib, II, III, IV, V, VI, VII, VIII, IX, X. [1][2][3][4][5]

Level Ia: Submental Group

• Anatomy

  • Level I nodes are those bounded by the mandible superiorly and laterally and by the hyoid bone inferiorly. Level Ia contains the submental nodal group, bounded superiorly by the symphysis menti and inferiorly by the hyoid bone. It is bounded anteriorly by the platysma muscle, posteriorly by the mylohyoid muscles, laterally by the anterior belly of the digastric muscle, and medially by the virtual anatomic midline. These boundaries form a triangular region also termed the submental triangle.

• Drainage

  • This group drains the skin of the mental region, or chin, the mid-lower lip, the anterior portion of the oral tongue, and the floor of the mouth.

• Associated primary malignancies

  • These nodes most often contain metastatic deposits from malignancies of the floor of the mouth, anterior oral tongue, mandibular alveolar ridge, and lower lip.

Level Ib: Submandibular Group

• Anatomy

  • Level Ib contains the submandibular nodal group, bounded superiorly by the mylohyoid muscle and inferiorly by the hyoid bone. It is bounded anteriorly by the symphysis menti, posteriorly by the posterior edge of the submandibular gland, laterally by the inner surface of the mandible, and medially by the digastric muscle. These boundaries form a triangular region also termed the submandibular triangle.

• Drainage

  • They drain the efferent lymphatics from level Ia, the lower nasal cavity, both the hard and soft palates, and both maxillary and mandibular alveolar ridges. They also drain them from the skin and mucosa of the cheek, both upper and lower lips, the floor of the mouth, and the anterior oral tongue.

• Associated primary malignancies

  • These nodes most often contain metastatic deposits from malignancies of the oral cavity, anterior nasal cavity, soft-tissues of the mid-face, and submandibular gland.

Level II: Upper Jugular Group

• Anatomy

  • Level II represents the beginning of the jugular chain. It contains the upper jugular nodal group, adjacent to the top third of the internal jugular vein (IJV) and upper spinal accessory nerve. It is bounded superiorly by the insertion of the posterior belly of the digastric muscle into the mastoid process, and inferiorly by the caudal border of the hyoid bone or alternatively, as a surgical landmark, the carotid bifurcation. It is bounded anteriorly by the posterior edge of the submandibular gland, posteriorly by the posterior edge of the sternocleidomastoid muscle (SCM), laterally by the medial surface of the SCM, and medially by the internal carotid artery and scalenus muscle.

• Drainage

  • This group drains the efferent lymphatics of the face, parotid gland, level Ia, level Ib, and retropharyngeal nodes. It receives direct drainage from the nasal cavity, the entire pharyngeal axis, larynx, external auditory canal, middle ear, and the sublingual and submandibular glands.

• Associated primary malignancies
  • These nodes most often contain metastatic deposits from malignancies of the nasal and oral cavities, nasopharynx, oropharynx, hypopharynx, larynx, and major salivary glands. It is the most commonly involved nodal level. [6][7][8][9][10]

Level III: Middle Jugular Group

• Anatomy

  • Level III contains the middle jugular nodal group, adjacent to the middle third of the IJV. It is bounded superiorly by the caudal border of the hyoid bone, and inferiorly by the caudal edge of the cricoid cartilage or alternatively, as a surgical landmark, the plan where the omohyoid muscle crosses the IJV. It is also bounded anteriorly by the anterior edge of the SCM, or the posterior third of the thyrohyoid muscle, and posteriorly by the posterior border of the SCM. Finally, it is bordered laterally by the medial surface of the SCM, and medially by the internal carotid artery and scalenus muscle.

• Drainage

  • This group drains the efferent lymphatics from level II and level V, and partially from the retropharyngeal, pretracheal, and recurrent laryngeal nodes. It receives direct drainage from the base of the tongue, tonsils, larynx, hypopharynx, and thyroid gland.

• Associated primary malignancies
  • These nodes most often contain metastatic deposits from malignancies of the oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx. [11][12][13][14][15]

Level IVa: Lower Jugular Group

• Anatomy

  • Level IVa contains the lower jugular nodal group adjacent to the inferior third of the IJV. It is bounded superiorly by the caudal border of the cricoid cartilage, and inferiorly by a virtual level two centimeters superior to the sternoclavicular joint, based off surgical conventions of level IVa dissection. It is bounded anteriorly by the anterior edge of the SCM (more superiorly) and the body of the SCM (more inferiorly), and posteriorly by the posterior edge of the SCM (more superiorly) and the SM(more inferiorly. This group is also laterally bound by the medial edge of the SCM (more superiorly) and the lateral edge of the SCM (more inferiorly). Finally, it is medially bordered by the medial edge of the common carotid artery, the medial edge of the thyroid gland and scalenus muscle (more superiorly), and the medial edge of the SCM (more inferiorly).

• Drainage

  • This group drains the efferent lymphatics from levels III and V, and partially from the retropharyngeal, pretracheal, and recurrent laryngeal nodes. It receives direct drainage from the larynx, hypopharynx, and thyroid gland.

• Associated primary malignancies

  • These nodes most often contain metastatic deposits from malignancies of the hypopharynx, larynx, thyroid, cervical esophagus, and rarely, the anterior oral cavity. Deposits from the anterior oral cavity can manifest without proximal nodal involvement.

Level IVb: Medial Supraclavicular Group

• Anatomy

  • This nodal group is a continuation of level IVa to the superior edge of the sternal manubrium. It is bounded anteriorly by the deep surface of the SCM. Posteriorly, it is bound by the anterior edge of the scalenus muscle (more superiorly) and the lung apex, brachiocephalic vein, and artery on the right, as well as the common carotid and subclavian arteries on the left (more inferiorly). It is bounded laterally by the lateral edge of the scalenus muscle, and medially by the medial border of the common carotid artery which is also adjacent to level VI.

• Drainage

  • This group drains the efferent lymphatics from levels IVa and Vc, and partially from the pretracheal and recurrent laryngeal nodes. It receives direct drainage from the larynx, trachea, hypopharynx, esophagus, and thyroid gland.

• Associated primary malignancies

  • These nodes most often contain metastatic deposits from malignancies of the hypopharynx, subglottic larynx, trachea, thyroid, and cervical esophagus.

Level Va and Vb: Posterior Triangle Group

• Anatomy

  • These nodal groups are contained with the posterior triangle. They are situated posteriorly to the SCM, and adjacent to the inferior portion of the spinal accessory nerve and transverse cervical vessels. It is bounded superiorly by the superior edge of the hyoid bone and inferiorly by a virtual plane crossing the transverse vessels. It is bound anteriorly by the posterior margin of the SCM, and posteriorly by the anterior border of the trapezius muscle. It is also bound by the platysma muscle and skin laterally, and by the levator scapulae (more superiorly) and scalenus muscle (more inferiorly) medially. A virtual plane at the inferior edge of the cricoid cartilage divides this group into upper, or Va, and lower, or Vb, posterior triangles.

• Drainage

  • These nodal groups drain the efferent lymphatics from the occipital, retro-auricular, occipital, and parietal scalp nodes. It receives direct drainage from the skin of the lateral and posterior neck and shoulder, the nasopharynx, oropharynx, and thyroid gland.

• Associated primary malignancies

  • These nodes most often contain metastatic deposits from malignancies of the nasopharynx, oropharynx, and thyroid.

Level Vc: Lateral Supraclavicular Group

• Anatomy

  • This nodal group is a continuation of levels Va and Vb; it contains the lateral supraclavicular group. It is bounded superiorly by a virtual plan crossing the transverse vessels, and inferiorly by a virtual plan 2 cm superior to the sternoclavicular join. It is also bounded anteriorly by the skin and posteriorly by the anterior border of the trapezius muscles (more superiorly) and the serratus anterior (more inferiorly). Laterally, it is bounded by the trapezius muscle (more superiorly) and the clavicle (more inferiorly). Medially, it is bordered by the scalenus muscle and lateral edge of the SCM, and is directly adjacent to the lateral edge of level IVa.

• Associated primary malignancies

Level VI: Anterior Compartment Group

The anterior compartment contains this nodal group, which is symmetric about the anatomic midline. It is also further subdivided into the superficially-located anterior jugular nodes, or level VIa, and the deeper pre-laryngeal, pre-tracheal, and para-tracheal (recurrent laryngeal) nodes, or level VIb. Level VIa

• Anatomy

  • Level VIa is bounded superiorly by the inferior edge of level Ib and inferiorly by the superior edge of the sternal manubrium. It is bounded anteriorly by the skin and platysma, posteriorly by the anterior surface of the infrahyoid muscles, and bilaterally by the anterior edges of the SCMs.

• Associated primary malignancies

Level VIb

• Anatomy

  • Level VIb is bounded superiorly by the superior edge of the thyroid cartilage and inferiorly by the superior border of the sternal manubrium. It is also bounded anteriorly by the posterior margin of the infrahyoid muscles, and posteriorly by the anterior larynx, thyroid gland, and trachea at the midline, the pre-vertebral muscles on the right, and the esophagus on the left. This group is bordered laterally by the common carotid artery and medially by the lateral aspects of the trachea and esophagus.

• Drainage

  • Level VIb drains the efferent lymphatics from the anterior floor of the mouth, tip of the oral tongue, lower lip, thyroid gland, glottic and supraglottic larynx, hypopharynx, and cervical esophagus.

• Associated primary malignancies
  • These nodes most often contain metastatic deposits from malignancies of the lower lip, oral cavity (floor of the mouth and anterior oral tongue), thyroid, glottic and subglottic larynx, the apex of the piriform sinus, and the cervical esophagus. [16][17]

Level VII: Prevertebral Compartment Group, including Levels VIIa and VIIbLevel VIIa: Retropharyngeal Nodes

• Anatomy

  • These nodes are contained in the retropharyngeal space. They are divided into medial and lateral subgroups. The lateral groups are bounded superiorly by the superior edge of the C1 vertebral body, or the hard palate, and inferiorly by the superior edge of the body of the hyoid bone. Anteriorly, they are bounded by the posterior edge of the superior/middle pharyngeal constrictor muscles. They are bordered posteriorly by the longus capitis and longus colli muscles, laterally by the medial edge of the internal carotid artery, and medially by a virtual line parallel to the lateral edge of the longus capitis muscle. The medial groups are approximated at the midline and not well-defined.

• Associated primary malignancies

  • These nodes most often contain metastatic deposits from malignancies of the nasopharynx, pharyngeal wall, and oropharynx including tonsillar fossa and soft palate.

Level VIIb: Retrostyloid Nodes

• Anatomy

  • These nodes are contained in the fatty space surrounding the large vessels of the neck leading to the jugular foramen. They are the superior continuation of level II. Level VIIb is bounded superiorly by the jugular foramen at the base of skull, and inferiorly by the inferior edge of the lateral process of the C1 vertebral body, the superior boundary of level II. These nodes are bounded anteriorly by the posterior edge of the prestyloid parapharyngeal space, and posteriorly by the C1 vertebral body and base of skull. Finally, they are bordered laterally by the styloid process and deep parotid lobe, and medially by the medial edge of the internal carotid artery.

• Associated primary malignancies

Level VIII: Parotid Group

• Anatomy

  • This group includes the subcutaneous pre-auricular, superficial and deep intraparotid, and subparotid nodes. It is bounded superiorly by the zygomatic arch and external auditory canal, and inferiorly by the mandibular angle. This group is bounded anteriorly by the posterior edge of the mandibular ramus, the posterior edge of the masseter muscle (more laterally), and medial pterygoid muscle (medially). It is also bordered posteriorly by the anterior edge of the SCM (more laterally) and posterior belly of the digastric muscle (more medially). These nodes are bordered laterally by superficial muscular aponeurotic system (SMAS) layer within the subcutaneous tissues, and medially by the styloid process and muscle.

• Drainage

  • These nodes drain the efferent lymphatics from the frontal and temporal skin, eyelids, conjunctivae, auricles, external acoustic meatus, tympanum, nasal cavities, the root of the nose, nasopharynx, and the eustachian tube.

• Associated primary malignancies
  • These nodes most often contain metastatic deposits from malignancies of the previously named draining structures, as well as the orbit, external auditory canal, and parotid gland.[18]

Level IX: Buccofacial group

• Anatomy

  • This group contains the malar and the buccofacial nodes. These are superficial nodes surrounding the facial vessels on the external surface of the buccinator muscle. It is bounded superiorly by the inferior edge of the orbit and inferiorly by the inferior border of the mandible. It is also bounded anteriorly by the SMAS layer within the subcutaneous tissue, and posteriorly by the anterior edge of the masseter muscle and the corpus adiposum buccae. The lateral border is the SMAS layer, and the medial border is the buccinator muscle.

• Associated primary malignancies

  • These nodes most often contain metastatic deposits from malignancies of the facial skin, nose, and buccal mucosa, as well as the maxillary sinus if invading soft tissues of the cheek.

Level X: Posterior Skull Group, including Levels Xa and Xb

Level Xa: Retroauricular and Subauricular Nodes

• Anatomy

  • This group includes superficial nodes on the mastoid process. It is bounded superiorly by the superior edge of the external auditory canal, and inferiorly by the mastoid tip. It is also bounded anteriorly by the anterior edge of the mastoid (inferiorly) and posterior edge of the external auditory canal (superiorly), and posteriorly by the posterior edge of the SCM. This group is bordered laterally by subcutaneous tissue, and medially by the splenius capitis muscles (inferiorly) and the temporal bone (superiorly).

• Drainage

  • These nodes drain the efferent vessels from the posterior auricular surface, external auditory canal, and adjacent scalp.

• Associated primary malignancies

Level Xb: Occipital Nodes

• Anatomy

  • This group is the superior and superficial continuation of level Va. It is bounded superiorly by the external occipital protuberance, and inferiorly by the superior border of level V. It is also bounded anteriorly by the posterior edge of the SCM, which is the posterior border of level Xa, and posteriorly by the anterior/lateral side of the trapezius muscle. Finally, this group is bordered laterally by subcutaneous tissues, and medially by the splenius capitis muscle.

• Associated primary malignancies
  • These nodes most often contain metastatic deposits from malignancies of the occipital skin.  [5]

Clinical Significance

The lymphatic drainage of the head and neck is unique. Its remarkably well-delineated and characterized anatomic subgroups are closely associated with draining anatomic structure. These, in turn, are related to malignant neoplasms arising from specific anatomic structures. Intimate knowledge of this network allows the surgeon to complete an oncologically-appropriate dissection. It also helps the radiation oncologist appropriately treat elective nodal levels to reduce recurrence, and the primary care physician to guide the path to the necessary work up.

Structure, Function, Types, and Diseases

Lymph nodes or lymph glands are an important part of the immune system, acting as “nodes” between the lymphatic vessels that span the body. Immune cells that cluster in these nodes stand ready to attack any bacteria, viruses, or other foreign substances that enter the body.

The lymph nodes are susceptible to diseases such as infections, cancer, and trauma.  Let’s look at the role these nodes play in the day to day function of your body, as well as their role in disease.

Structure

Lymph nodes are small, bean-shaped glands that are located along the lymphatic system (a system of vessels similar to arteries and veins through which lymph fluid travels). Lymph nodes are classified as “secondary” lymphoid organs, with the primary lymph organs being the thymus gland, tonsils, spleen, and bone marrow.

If you visualize the primary lymph organs as the courthouse, the lymphatic vessels are the highways the immune police cells travel to survey the body, and the lymph nodes are like police stations along the way. There are hundreds of lymph nodes throughout the body, but they are clustered in certain regions.

Composition

The structure of a lymph node is actually quite complex. Lymph nodes are divided into lobules, each of which contains an outer cortex, followed by a paracortex, with the medulla (core) on the inside.

Simplistically, B lymphocytes (B cells) are found in the cortex, with T lymphocytes (T cells) and dendritic cells in the paracortex. Plasma cells and macrophages are present in the medulla. The entire lymph node is enclosed by a tough fibrous capsule.

Size

Lymph nodes can vary in size from only a few millimeters to up to 2 centimeters in diameter.

Function

Lymph nodes work like filters, or in our analogy security guards to filter bacteria, viruses, parasites, other foreign material (even cancer cells) that are brought to the nodes via lymphatic vessels.

This is the reason that lymph nodes are evaluated in people with cancer, as this is the first place where cancer cells may be “caught” on their journey to explore and set up home elsewhere in the body.

Lymph nodes play important roles in fighting infections. Not only do they “trap” viruses and bacteria so that T cells can attack, but one type of T cells presents the invader (or an antigen from the invader) to B cells so the B cells can make antibodies against the invader. In this way, lymph nodes are a place where immune cells can communicate and work together.

Types and Locations

Lymph nodes are well-known as the “swollen glands” people may note in their neck when they are fighting a cold or sore throat, but these nodes are actually located in many regions of the body.

Lymph nodes that lie near the surface of the skin, such as in the neck, armpit, groin, and sometimes those in the arm (elbow) and back of the knee may be felt when enlarged, but others may only be seen on imaging studies such as a computed tomography (CT) scan.

Lymph nodes are more easily felt in people who are thin, and sometimes finding nodes that are seldom felt in general can be alarming. Some important lymph nodes include:

Cervical (Neck) Lymph Nodes

Cervical lymph nodes are the nodes you have likely felt in your neck when fighting an upper respiratory tract infection, and filter lymphatic fluid coming from the head, scalp, and neck.

Cervical lymph nodes (lymph nodes in the neck) in turn, can be broken down into three primary regions, and which region is involved can give doctors important information when diagnosing an illness:

• Anterior cervical lymph nodes: Lymph nodes nearest the front of your neck are referred to as anterior cervical lymph nodes. It is these nodes that most people have felt at some time when battling the common cold or strep throat.
• Posterior cervical lymph nodes: Lying behind the band of muscle that runs on the lateral side of the neck (sternocleidomastoid) lie the posterior nodes. These nodes are frequently enlarged when people contract mono (infectious mononucleosis).
• Occipital lymph nodes: These nodes lie on the back of the neck at the base of the skull, and are also frequently enlarged in people who have mono.

Lymph nodes may also be felt in front of and behind the ear and along the jawline. 

Axillary (Armpit) Lymph Nodes

Axillary lymph nodes are the lymph nodes located in your armpit. In the movie “Terms of Endearment,” these nodes heralded breast cancer, but there are more common causes for enlargement. There are usually between 10 and 40 lymph nodes in the axilla, many of which are removed when a person has an axillary lymph node dissection for breast cancer.

The axillary lymph nodes can be used to describe an important finding with cancer. When cancer cells are picked up in the lymphatic fluid, they first travel to lymph nodes. It’s been found that these lymph nodes are affected in order.

A sentinel lymph node biopsy may be done with breast cancer or melanoma and can often spare a person from having all nodes removed. A tracer is injected into the cancer, and only the first few nodes to which the cancer would travel may be to be biopsied.

Supraclavicular Lymph Nodes (Above the Collarbone)

Supraclavicular lymph nodes are, when enlarged, can be felt just above the collarbone (clavicle). Most of the time, enlargement of these nodes signifies a serious underlying problem (such as lung cancer or a lymphoma).

Mediastinal Lymph Nodes

Mediastinal lymph nodes reside in the mediastinum, the area in the center of the chest between the lungs. People cannot feel these nodes, but they can be visualized on imaging studies such as a CT scan or positron emission tomography (PET) scan. Determining whether cancer is present in these nodes is important in staging lung cancer and some lymphomas.

Inguinal (Groin) Lymph Nodes

Inguinal lymph nodes are present in the groin region. Since they drain tissues from the feet to the groin, there are many reasons why these nodes can become inflamed. Most often they become swollen after an injury or infection in the legs, but may also be a sign of anything from a sexually transmitted disease to cancer.

Keep in mind that most people experience swollen inguinal nodes at some time, and the vast majority of the time they are not a problem; they are only doing their job of catching viruses or bacteria that enter your body from a sore on your feet or legs.

Retroperitoneal Lymph Nodes

Retroperitoneal lymph nodes lie deep in the abdomen and can only be seen on imaging studies. They are the nodes to which testicular cancer first spreads.

Mesenteric Lymph Nodes

Mesenteric lymph nodes are similar to retroperitoneal nodes, lying deep in the abdomen in the membranes that surround the intestine. In adolescents, these nodes may become inflamed (mesenteric lymphadenitis) with symptoms that can sometimes mimic appendicitis. They may be enlarged with some cancers, but this is much less common.

Pelvic Lymph Nodes

Pelvic lymph nodes lie deep in the pelvis and can only be seen on imaging studies. They may be involved with cancers such as those of the bladder, prostate, and more.

Other Lymph Nodes

There are clusters of lymph nodes near the elbow, behind the knee, along the large airways (tracheobronchial), along the aorta (paraaortic), and many other regions of the body.

Associated Conditions

There are many conditions in which lymph nodes become involved. Doctors use the term lymphadenopathy to describe inflammation or swelling in these glands. When doctors evaluate lymph nodes there are a number of terms they may use:

• Mobile vs. fixed: Mobile lymph nodes are those that can easily be moved around when touched, whereas fixed appear to be attached to a structure deeper in the body. In general, mobile lymph nodes are benign whereas fixed nodes suggest the possibility of cancer.
• Painful vs. non-painful: In general, infections can cause tender lymph nodes and cancerous nodes are often not tender. But there are many exceptions.
• Localized vs. generalized: The term localized refers to enlarged lymph nodes in only one location. When generalized lymphadenopathy (enlarged nodes) is present, it is more likely to be infections such as mononucleosis (but can also be due to other conditions).
• Matted: Sometimes lymph nodes appear to be attached together in a clump and the term matted is used.

Illustration by Brianna Gilmartin, Verywell

Infections

Since lymph nodes store the white blood cells that are our first line of defense against infection, they are often enlarged due to infections. Enlargement of lymph nodes with an infection can be good or bad.

It is good in the sense that they are the powerhouses storing immune cells. In other words, enlargement of the lymph nodes may mean your body is doing its job to resolve ​an infection.

This concept was not always well understood, however, and for a long time it was thought that removing the tonsils would help prevent infections. When tonsils are severely damaged, removing them can be a good idea.

But if they are healthy and only doing their job, removing them gets rid of the functional “first place” where bacteria traveling in the lymphatic vessels could be “arrested. ”

Lymphadenitis/Lymphangitis

Lymph nodes can catch viruses and bacteria but are also susceptible to infections themselves. For those who have been told to watch for a “red streak” after an injury have learned that infections (usually staph or strep) may begin in an infected wound and spread rapidly along lymph channels.

Infections involving the lymph nodes often cause a significant fever and chills. Cat scratch fever is an infection caused by the bacterium Bartonella henselae and is transmitted by exposure (usually via a break in the skin) from an infected cat. Enlarged lymph nodes related to catch scratch fever are usually non-tender but can be very large.

Cancer

Lymph nodes are commonly involved with cancer, but their role often differs between solid tumors and lymphomas. With solid tumors such as breast cancer, the cancer cells usually travel to lymph nodes before traveling (metastasizing) to other regions of the body. 

Cancers that have spread to lymph nodes are usually a higher stage than those that have not, meaning they have a greater risk of recurring or spreading. In a sense, the spread of cancer cells to lymph nodes has declared its intent to travel elsewhere.

With lymphomas, in contrast, the cancer begins in the lymph nodes. When lymphomas spread to regions other than lymph nodes, it is not referred to as metastasis as with solid tumors, but rather as “extranodal involvement.”

Other Conditions

There are many other conditions that can cause enlarged lymph nodes, ranging from autoimmune diseases (such as rheumatoid arthritis) to genetic syndromes, sarcoidosis, and more.

Injuries and Trauma

Since the lymph nodes are the rest stops for the “workers” or the white blood cells which clean up a site of trauma, they are often enlarged with any injury. You can think of the lymph nodes as being a truck stop near a natural disaster where the firemen and paramedics are hanging out ready to do their job.

A Word From Verywell

We often think of lymph nodes as heralding disease, but most of the time they are performing their job in fighting off foreign invaders. Even with solid tumors, the lymph nodes are catching the first cancer cells to travel before they can move farther in the body.

Lymph node | anatomy | Britannica

Lymph node, any of the small, bean-shaped masses of lymphoid tissue enclosed by a capsule of connective tissue that occur in association with the lymphatic vessels. As part of the lymphatic system, lymph nodes serve as filters for the blood, providing specialized tissues where foreign antigens can be trapped and exposed to cells of the immune system for destruction. They are typically found concentrated near junctions of the major lymphatic vessels, most prominently in the neck, groin, and armpits.

Read More on This Topic

lymphatic system: Lymph nodes

The lymph nodes, or lymph glands, are small, encapsulated bean-shaped structures composed of lymphatic tissue. Thousands of lymph nodes…

Each lymph node is divided into two general regions, the capsule and the cortex. The capsule is an outer layer of connective tissue. Underlying the capsule is the cortex, a region containing mostly inactivated B and T lymphocytes plus numerous accessory cells such as dendritic cells and macrophages. The cortex is further divided into two functional areas: the outer cortex and inner cortex, or paracortex. These regions surround an inner medulla, which consists primarily of activated antibody-secreting plasma cells.

lymph node

Internal and external structures of a lymph node.

Encyclopædia Britannica, Inc.

Cells enter the lymph node through two primary routes. Lymph and its associated cells enter through the afferent lymphatic vessels, which drain into each node through its convex surface. These vessels may drain directly from the lymphatic capillaries, or they may be connected to a previous node. Lymphocytes generally enter through specialized blood vessels called high endothelial venules (HEVs). HEVs contain a single layer of large endothelial cells that possess surface receptors specific for B and T lymphocytes. As these cells pass through the HEVs, they bind to the receptors and are carried into the paracortex of the lymph node.

The structural divisions within a lymph node serve different purposes. Most of the lymphocytes within a node are “naive”—i.e., they have yet to encounter antigen—and therefore must migrate to regions where they will be most effective in recognizing foreign agents. B cells enter the paracortex through the HEVs and then migrate into the outer cortex and join specialized dendritic cells and macrophages to form follicles. Primary follicles consist of a resting B cell surrounded by a loose network of dendritic cells. After encountering a foreign antigen, the B cell becomes activated and is surrounded by a more tightly packed association of dendritic cells and macrophages, forming a germinal centre. The germinal centre in turn is enclosed by a mantle zone—a ring of resting B cells and dendritic cells. The germinal centre and mantle together compose a secondary follicle, which is the site of antigen-dependent B-cell maturation. The activated B cells then migrate through the paracortex to the medulla, where they proliferate as antibody-secreting plasma cells. T cells enter the lymph node through the HEVs and remain in the paracortex, where the cortical macrophages and dendritic cells present antigenic peptides to the naive T cells, stimulating them to become activated helper T cells or cytotoxic T lymphocytes. All activated lymphocytes migrate through the medulla and enter the lymphatic circulation through the efferent lymphatic vessel, which drains either into adjacent lymph nodes or ultimately into the thoracic duct, a major vessel of the lymphatic system.

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The central role played by lymph nodes in filtering microorganisms and other undesired substances from the blood is critical to the functioning of the immune system but also makes lymph nodes vulnerable to cancer. As cancerous cells spread by metastasis, they can become trapped and concentrated in lymph nodes, where they proliferate. Virtually all cancers have the potential of spreading to lymph nodes, a condition that greatly complicates treatment. In most cases surgery alone will not remove the cancer from the nodes, and therefore postoperative radiation or chemotherapy is required.

How to check your lymph nodes

You have been diagnosed with a skin cancer that on occasions can spread into the lymphatic system. That is why as part of your examination your lymph nodes are examined by your doctor or Skin Cancer Clinical Nurse Specialist at follow-up appointments. The lymph nodes examined depend on the location of your skin cancer e.g. if your skin cancer was on your leg then the lymph nodes in your inguinal area (groin) will be felt or if on your face then the nodes in the head and neck would be examined. The aim is to detect any enlargement of the lymph nodes and undertake investigation at an early stage. Some people express a interest in knowing which lymph nodes to examine and how to undertake this procedure between clinic appointments.

The Lymphatic System

This system consists of lymphatic vessels and tissue which drains lymph fluid from the tissues of the body,  helping to protect you from infection and disease. Lymph nodes are small oval lumps of lymphatic tissue found at certain parts of the body.

These lymph nodes filter out bacteria and disease cells from the lymphatic fluid before it is returned to the blood stream. Lymph nodes can only be felt in the areas shown in the diagram.

Usually lymph nodes are not enlarged and thus not able to  be felt, but if you have previously had an infection (such as tonsillitis) you may have noticed and felt lymph node  becoming enlarged, painful and tender. Lymph nodes can also become enlarged due to cancer cells lodging in them.

There is also a YouTube video which illustrates this, which you may find beneficial:

How often should I check my lymph nodes?

Checking the lymph nodes once a month is sufficient and this can be done at the same time as you check your skin for any changing moles. Checking them more often may result in difficulty noticing any change.

Do not panic if you feel a lymph node, as it may be due to an infection but if it has not gone in a week contact your doctor or clinical nurse specialist.

How to check lymph nodes in the head and neck

 

 

Examine in the order shown starting at number 1.

 

 

 

 

With your fingertips and a gentle circular motion feel the lymph nodes illustrated

Start with the nodes in front of the ear (1) then follow in order finishing just above the collar bone (10)

Always check your nodes in this order

 

Check both sides for comparison. If you have an enlarged lymph node it may feel like a swelling the size of a pea, sometimes they can be larger.

When feeling for the nodes in the neck (marked 8), tilt your head towards the side you are examining, this helps to relax the muscle

Now press your fingers under the muscle

 

When checking the lymph nodes above the collar bone, hunch your shoulders and bring your elbows forward to relax the skin

Now feel the area illustrated in diagram 4.

How to check lymph nodes in the armpit

• Remove top clothing down to the waist to get easy access to the armpits.
• Sit in a comfortable position.
• Check each armpit in turn.
• To check the left side lift your arm slightly then place the fingers of your right hand high into the armpit and then lower your arm.

1. Feel in the central area of the armpit.  Now move your fingers firmly against the chest wall as follows
2. Along the front border of the armpit
3. Along the back border of the armpit
4. Feel along the inner border of the arm

Now check the other armpit.

How to check for lymph nodes in the groin

There are two areas to look for inguinal (groin) nodes:

1. Feel the horizontal chain of nodes in the right groin just below the ligament.
2. Feel the vertical chain along the upper  thigh.
3. Check the lymph nodes in the other groin.

If you have any concerns or feel you have  detected enlarged lymph nodes. Contact your Skin Cancer Nurse Specialist.

Leaflet developed by Skin Cancer CNS’s NHSCT with permission from the British Association of Dermatologists

 

 

 

 

 

 

An Imaging-Based Classification for the Cervical Nodes Designed as an Adjunct to Recent Clinically Based Nodal Classifications | Head and Neck Cancer | JAMA Otolaryngology–Head & Neck Surgery

 
Over the past 18 years, numerous classifications have been proposed to distinguish among the diverse nodal levels. Some classifications have used surgical landmarks, others physical assessment criteria. These classifications do not agree precisely and exhibit sufficient variation that competent physicians could arrive at slightly different staging of the patient’s nodal disease. In the past 2 decades, computed tomography and magnetic resonance imaging have offered progressively more refined anatomical precision, reproducibility, and visualization of deep, clinically inaccessible structures. Because the majority of patients with head and neck malignancies presently undergo sectional imaging prior to treatment planning, we felt a need to integrate anatomical imaging criteria with the 2 most commonly used nodal classifications: those of the American Joint Committee on Cancer and those of the American Academy of Otolaryngology–Head and Neck Surgery. The imaging-based nodal classification proposed herein has been developed in consultation with surgeons interested in such classifications in the hope that the resultant classification would find ready acceptance by both clinicians and imagers. It is our desire that the best attributes of imaging, combined with those of the physical assessment, can result in a better and more consistently reproducible nodal staging than is possible by either approach alone.

The definition of a classification is “a systematic arrangement in groups or categories according to established criteria.”¹ This definition implies that there are, in fact, established criteria. However, when it comes to nodal classifications, such well-accepted criteria are often difficult to identify.

For nearly 4 decades, the most commonly used classification for the cervical lymph nodes was that developed by Rouviere² in 1938. His work followed an earlier classification by Trotter³ in 1930, which was based on an even earlier work by Poirer and Charpy⁴ in 1909. Many of the landmarks used in these classifications had their origin in the superficial triangles of the neck, areas that were easily accessible to palpation and referred to by familiar names. In 1981, Shah et al⁵ suggested that the anatomically based terminology should be replaced with a simpler “level”-based system. Since then, a number of clinically and radiologically based classifications have been proposed that use such nonanatomical terminology.^5-15

However, when these varied classifications are reviewed and compared, there remain several areas that either are not precisely defined or are defined so variously that the present systems preclude precise classification of nodal disease in these areas and potentially could lead to confusion. We believe that the anatomical precision offered by current-day computed tomography (CT) and magnetic resonance imaging (MRI) can resolve some of these issues and can contribute significantly to an improved classification of nodal disease. The contribution of imaging may be especially germane to those lymph nodes that are situated deeply and that, by their very location, are difficult, if not impossible, to palpate.

To this end, our classification was initially designed to be used adjunctively with the American Joint Committee on Cancer (AJCC) classification. However, history shows that nodal classifications are continuously evolving, with modifications constantly being proposed to better allow surgeons to plan the most appropriate surgery for nodal disease. Most recently, Robbins¹⁶ modified and updated the 1991 American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) guidelines, and we hope that our proposed imaging-based nodal classification will be used as an adjunct to both the AJCC and the AAO-HNS classifications. It is also our desire that the best attributes of both the physical and the imaging assessments of the patient can be used conjointly to arrive at a more consistently reproducible and accurate classification than is possible by either method alone.

Based on the classifications cited above, there were 10 specific points that we believed needed to be addressed to add consistency and accuracy to a nodal classification, while maintaining consistency with the prior staging literature.

• What terminology should be used to refer to the various nodal areas? The tendency in the literature over the past 2 decades has been to use a descriptive term such as level,^5,7,11,13,17region,^10,14 or zone¹⁵ rather than the anatomical terminology used by Rouviere.² Of these terms, level is the one that is most frequently used and the one that is used by the AJCC; therefore, we will use it in the following section.

• How can one consistently differentiate between a posterior level I node and a level II node?

• Is it preferable to group the submental and submandibular nodes together as level I nodes, or should there be an option to distinguish between these 2 nodal groups. If so, what should the imaging landmarks be?

• For clarity and reproducibility, there should be well-defined, consistent divisions between level II, III, and IV nodes. However, in the present classifications, level II has been defined variably as extending from the skull base to either the “hyoid bone,”^{8,13,14,17-19} the “bottom of the hyoid body,”¹⁵ the “top of the greater cornu of the hyoid bone,”²⁰ the “common facial vein,^2,13 or “the carotid bifurcation.”^{2,11-13,19,20}

• From which portion of the skull base do level II nodes begin, and how can one differentiate a high level II node from a retropharyngeal node, a nodal group not discussed in most of these classifications?

• The demarcation between level III and level IV nodes has been given variably as the “cricoid cartilage,”^8,17 the “top of the cricoid cartilage,”⁶ the “bottom of the cricoid arch,”¹⁵ the “cricothyroid membrane,”^13,14 the “cricothyroid notch,”¹² or the level at which the “omohyoid muscle crosses the internal jugular vein. “^10-12,19,20 Of these landmarks, is there one that is easily seen on axial images and that anatomically is consistent with the division used to separate level II and III nodes?

• What are the lower limits of level IV and V nodes, and is it necessary to distinguish these nodes from supraclavicular nodes on imaging studies?^2,13 This point becomes relevant when the recent AJCC classification for staging nasopharyngeal carcinomas is being used.

• How does one define level V nodes on imaging studies, while maintaining consistency with the prior classifications?

• If one is to include in the classification the ability to differentiate level V nodes into subgroups, should there be 3 subgroups (upper, middle, and lower)¹³ or just upper and lower subdivisions (VA and VB)?¹⁶ Furthermore, what landmark(s) should be used to define these groups?

• On clinical examination, the suprasternal notch is a well-defined region. However, on axial imaging studies, it is vaguely defined and may extend over several centimeters in craniocaudal extent.^2,13 Is there a better imaging landmark that one can use to differentiate level VI from level VII nodes?

Patients who have very small or superficial tumors may be assessed well by physical examination alone. However, in our experience, most of the patients have more deeply situated head and neck cancers, and, at present, these cases require either a CT or an MRI study before treatment planning can be finalized. Thus, we believed that it was practical to incorporate the precise anatomical information provided by these imaging studies into a nodal classification.

Regarding terminology, one can only state a preference concerning the use of the terms level, region, or zone. Review of the literature of the past 2 decades clearly indicates preferential usage of the term level. Although this in itself does not make level the “best” term, its use by the AJCC helped us to select it as the one term that would be the most consistent with the majority of the prior classifications and with most of the otolaryngological literature.

In his detailed nodal description, Rouviere² noted that the inferior jugular nodal group extended to the base of the internal jugular vein and that the transverse cervical nodes were situated at the level of the clavicle and connected the caudal spinal accessory nodes with the internal jugular nodes at the level of the jugulosubclavian junction. Although there are some potential problems with patient positioning, we chose the level of the clavicle, as seen on each axial image, to represent the caudal end of level IV and V nodes. Nodes at or below the clavicle will be considered supraclavicular nodes. The top of the manubrium can serve to differentiate between level VI and VII nodes as defined in the 1997 AJCC system, because it is a more precisely defined landmark than the suprasternal notch.

An area that has been addressed by only 2 prior classifications is the precise distinction between level I and level II nodes.^14,15 We agree with van den Brekel¹⁴ and Curtin et al¹⁵ that the posterior edge of the submandibular gland is a consistent landmark that can be easily used to differentiate between level I and level II nodes. The posterior edge of the submandibular gland is also a more consistent landmark than the anterior border of the sternocleidomastoid muscle, which can change position relative to the submandibular gland with mild head turning, muscle atrophy, or muscle hypertrophy. Since we believe that the separation of the submental nodes from the submandibular nodes may be useful in further studies, we chose to offer subclassifications of level I nodes into levels IA and IB.

Regarding the problem of distinguishing level II from level III nodes and level III from level IV nodes, for consistency we chose to use the bottom of the hyoid body as the landmark to separate level II from level III nodes and the bottom of the cricoid arch as the landmark to separate level III and level IV nodes, both of these landmarks being seen in the axial plane. By using the bottoms of both the hyoid body and the cricoid arch, we provide concise, consistent, and easily detectable landmarks for delineating these nodal levels. The lower margin of the cricoid arch can also be used to differentiate level V nodes into 2 subgroups: upper (VA) and lower (VB) nodes, as we also believe that the subclassification of the level V nodes may provide useful information in future studies (see “Level V” section).

REGARDING THE PROBLEM of how to consistently differentiate internal jugular nodes from spinal accessory nodes, we noted that Rouviere² and others have stated that any distinction between the upper internal jugular nodes and the upper spinal accessory nodes may be impossible, because these groups of nodes merge at this level. We decided that any new classification should recognize that distinction between these 2 nodal groups may be impossible, especially in the upper neck area, and that artificial criteria would be necessary to give reproducibility to the classification. Using the definition of level V nodes given in most clinically based classifications, we chose to define a posterior triangle nodal group using the classic definition of the posterior triangle. Thus, especially in the upper and middle areas of the neck, our level II, III, and IV nodes include the internal jugular nodes and those spinal accessory nodes deep to the sternocleidomastoid muscle. The posterior triangle nodes are those nodes posterior to the posterior border of the sternocleidomastoid muscle and anterior to the trapezius muscle.

Initially, we defined the posterior border of the level II, III, and IV nodes as a transverse line drawn through the posterior border of the sternocleidomastoid muscle on each axial scan. Any node lying posterior to this line would be considered to be a level V node. However, this led to a problem regarding the classification of the lowest jugular nodes, which, as Rouviere noted, were located on the anterior scalene muscle and which therefore were often referred to as the prescalene nodes.^2,21 In many people, the posterior border of the sternocleidomastoid muscle lies anterior to the anterior scalene muscle on axial scans of the lower neck area. In such cases, if the posterior border of the sternocleidomastoid muscle were to be used as the division between the lowest level IV and V nodes, it would result in these scalene nodes being classified as level V nodes. Such classification would be contrary to the classic classification of the scalene nodes as being part of the internal jugular chain. Therefore, to separate level IV and level V nodes caudal to the bottom of the cricoid arch, we decided to use an oblique line extending from the posterior border of the sternocleidomastoid muscle to the lateral posterior edge of the anterior scalene muscle. Such a line would always place the scalene nodes in the internal jugular chain. The nodal classification that results from using these new landmarks is completely consistent with the recent AJCC classification and virtually all previous clinically based classifications.

Trying to address the point raised by Robbins¹⁶ concerning the separation of the lower level IV nodes into those that lie deep to the sternal head (IVA) and those that lie deep to the clavicular head (IVB) of the sternocleidomastoid muscle proved a difficult challenge. Although the 2 heads of the sternocleidomastoid muscle can be seen on the most caudal scans through the muscle, the medial margin of the clavicle so closely approximates the sagittal plane of the carotid artery that distinction between level IVA and level VI nodes is impossible. If this subclassification eventually proves useful, it may be a distinction best left to clinical differentiation.

Again in response to Robbins, it was also deemed appropriate to subdivide the level II nodes into internal jugular (IIA) and spinal accessory (IIB) nodes. To best approximate these 2 subgroups, we classified as level IIB those nodes that lie posterior to the internal jugular vein and that are separated from the vein by a fat plane. By definition, therefore, level IIA nodes are those nodes that lie posterior to the internal jugular vein and are inseparable from the vein, or they are nodes that lie anterior, medial, or lateral to the vein.

There was also a slight difference between the subclassification of level V nodes as described by the AJCC and the AAO-HNS. In the AJCC classification, there were 3 subgroups to level V: upper, middle, and lower. The planes used to separate these groups were the same as those used to separate levels II and III and levels III and IV. The AAO-HNS classification suggests that it is more practical to simply divide the level V nodes into upper (VA) and lower (VB) groups. This simpler approach was suggested because there are actually few, if any, nodes in the AJCC upper level V region. We elected to follow the guidelines of the AAO-HNS classification, and in our system the plane dividing VA and VB nodes is the bottom of the cricoid arch.

For the purposes of this categorization, we define the portion of the skull base at which level II nodes start as the inferior bony margin of the jugular fossa. Immediately inferior to the skull base, we define a node that lies anterior or lateral to the carotid sheath as a high level II node. A node that lies medial to the internal carotid artery is defined as a lateral retropharyngeal node. We thought that this distinction was clinically relevant, because the identification of retropharyngeal nodes affects treatment planning. Furthermore, the retropharyngeal nodes represent a nodal group whose identification is almost solely in the purview of imaging.

Distinction between supraclavicular and low level IV and V nodes has become important, since the 1997 AJCC staging for nasopharyngeal cancer has shown that supraclavicular nodes specifically affect staging of these tumors. The AJCC defined the supraclavicular fossa as the Ho triangle, a triangular plane defined by 3 points: (1) the upper sternal end of the clavicle, (2) the upper lateral end of the clavicle, and (3) the point at which the posterior portion of the neck meets the shoulder.¹³ It is interesting to observe that the AJCC also noted that the caudal portions of levels IV and V were included within this triangle, and recognized the difficulty in differentiating between these nodal groups.

However, because of the slope of the shoulder and neck junction, it is difficult on axial imaging to identify a consistent anatomical level by which to separate a supraclavicular node from a low level IV or V node. That is, the Ho triangle cannot reliably be identified on axial images. Also, the plane of the clavicle is tilted with respect to the axial plane: the clavicle’s anterior end lies more caudal than its posterior margin. As a result, the entire clavicle is not seen on a single axial image. Lastly, any elevation of the patient’s shoulder, as commonly occurs on imaging, will cause the clavicle to be seen on more cranial images than normal, and this may lead to an erroneous localization of the level of the supraclavicular fossa.

Despite all these problems, we still decided that the visualized portion of the clavicle, as seen on each of the axial images through the region, remains the most reliable imaging marker of the supraclavicular fossa. Thus, if a node is located at or below the level of the portion of the clavicle seen on a specific image, that node can be placed in the supraclavicular fossa. Using the clavicle as the inferior border of levels IV and V also maintained consistency with both the AJCC and the AAO-HNS classifications.

Based on the decisions discussed above, we suggest the following imaging-based nodal classification system (Table 1). A comparison of the new classification with the 1997 AJCC classification and the 1998 modification of the 1991 AAO-HNS classification is shown in Table 2. The axial plane referred to in this imaging-based classification should be with the patient’s head in a “neutral” position, with the axial images aligned in the inferior orbitomeatal plane. If possible, the examination should be performed as a postcontrast study to allow the best possible differentiation of nodes from vessels. With CT, the examination is performed as contiguous 3-mm scans from the skull base to the manubrium or as a spiral study reconstructed as contiguous 2- or 3-mm slices. With MRI, the scans should be no thicker than 5 mm, with a 1-mm interslice gap. For consistency, and because the axial image is the basis of this classification, the terms anterior and posterior will be used rather than ventral and dorsal. Figure 1 diagrams the pertinent anatomy and the landmarks used for the classification. For consistency, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6 through Figure 7 are all CT scans that demonstrate the use of the new classification; MRIs could as easily be used.

Level I includes all the nodes above the hyoid bone, below (superficial to) the mylohyoid muscles, and anterior to a transverse line drawn on each axial image through the posterior edge of the submandibular gland (Figure 3). Thus, level I nodes include the submental and submandibular nodes. If the line drawn along the posterior edge of the submandibular gland transects a node, this node will be classified as a level I node if the majority of its cross-sectional area lies anterior to this line. If the majority of the nodal cross-sectional area is posterior to this line, the node will be regarded as a level II node. Level I nodes can be subclassified into levels IA and IB.

Level IA. Level IA represents the nodes that lie between the medial margins of the anterior bellies of the digastric muscles, above the hyoid bone and below the mylohyoid muscle.

Level IB. Level IB represents the nodes that lie below (superficial to) the mylohyoid muscle, above the hyoid bone, posterior and lateral to the medial edge of the anterior belly of the digastric muscle, and anterior to a transverse line drawn on each axial image tangent to the posterior surface of the submandibular gland on each side of the neck.

Level II extends from the skull base, at the lower level of the bony margin of the jugular fossa, to the level of the lower body of the hyoid bone. Level II nodes lie anterior to a transverse line drawn on each axial image through the posterior edge of the sternocleidomastoid muscle and posterior to a transverse line drawn on each axial scan through the posterior edge of the submandibular gland. If a node situated within 2 cm of the skull base lies anterior, lateral, or posterior to the carotid sheath, it is classified as a level II node. If the node lies medial to the internal carotid artery (ie, a coronal plane tangent to the medial margin of the internal carotid artery), it is classified as a retropharyngeal node (Figure 2). Caudal to 2 cm below the skull base, level II nodes can lie anterior, lateral, medial, and posterior to the internal jugular vein. When either of these transverse lines transects a node, the node is a level II node if the majority of its cross-sectional area is posterior to the submandibular gland line and anterior to the sternocleidomastoid muscle line. Level II nodes can be subclassified into levels IIA and IIB.

Level IIA. Level IIA nodes lie posterior to the internal jugular vein and are inseparable from the vein, or they are nodes that lie anterior, medial, or lateral to the vein.

Level IIB. Level IIB nodes lie posterior to the internal jugular vein and have a fat plane separating the nodes and the vein.

Level III nodes lie between the level of the lower body of the hyoid bone and the level of the lower margin of the cricoid cartilage arch. These nodes lie anterior to a transverse line drawn on each axial image through the posterior edge of the sternocleidomastoid muscle. If the transverse line transects a node, the node is considered a level III node, provided that most of its cross-sectional area is situated anterior to this line; otherwise, it is considered a level V node (Figure 4 and Figure 5). Level III nodes also lie lateral to either the common carotid arteries or the internal carotid arteries, which separate level III and level VI nodes.

Level IV nodes lie between the level of the lower margin of the cricoid cartilage arch and the level of the clavicle as seen on each axial scan. These nodes lie anterior and medial to an oblique line drawn through the posterior edge of the sternocleidomastoid muscle and the lateral posterior edge of the anterior scalene muscle on each axial image (Figure 6). The common carotid artery is the landmark that separates level IV nodes, which lie lateral to this artery, from level VI nodes, which lie medial to the common carotid artery. When the oblique line transects a node, the node is considered a level IV node if the majority of its cross-sectional area is anterior to this line; otherwise, it is considered a level V node.

Level V nodes extend from the skull base, at the posterior border of the attachment of the sternocleidomastoid muscle, to the level of the clavicle as seen on each axial scan. Level V nodes all lie anterior to a transverse line drawn on each axial scan through the anterior edge of the trapezius muscle. Between the levels of the skull base and the bottom of the cricoid arch, these nodes are situated posterior to a transverse line drawn on each axial scan through the posterior edge of the sternocleidomastoid muscle. Between the axial level of the bottom of the cricoid arch and the level of the clavicle, level V nodes lie posterior and lateral to an oblique line through the posterior edge of the sternocleidomastoid muscle and the lateral posterior edge of the anterior scalene muscle (Figure 4, Figure 5, Figure 6). If either of these anterior lines transects a node, then that node is considered a level V node, provided that the majority of the nodal cross-sectional area lies posterior to the lines. If the majority of the nodal cross-sectional area lies anterior to these lines, the node is classified as a level II, III, or IV node, depending on its craniocaudal location. The level V nodes can be subdivided into VA (upper) and VB (lower) level V nodes.

Level VA (Upper Level V). Level VA nodes lie between the skull base and the level of the lower margin of the cricoid cartilage arch.

Level VB (Lower Level V). Level VB nodes lie between the level of the lower margin of the cricoid cartilage arch and the level of the clavicle as seen on each axial scan.

Level VI nodes lie inferior to the lower body of the hyoid bone, superior to the top of the manubrium, and between the left and right common carotid arteries or the internal carotid arteries. They are the visceral nodes.

Level VII nodes lie caudal to the top of the manubrium in the superior mediastinum, between the left and right common carotid arteries (Figure 7). These are the superior mediastinal nodes, and they extend caudally to the level of the innominate vein.

For consistency with the prior classifications, the following nodal groups, as well as the other superficial nodes, will still be referred to by their anatomical names, eg, supraclavicular, retropharyngeal, parotid, facial, occipital, and postauricular.

Today, CT and MRI form an integral part of the assessment of most cases of head and neck cancer. The imaging findings clearly complement the physical examination. We hope that the new definitions that we propose will establish clearly defined, easily reproducible, and easily documented nodal levels and enable more accurate and reproducible classification of nodal disease. Also, we hope that this proposed classification will provide the radiologist with clinically acceptable guidelines with which to classify the cervical nodes and then to communicate the imaging findings to the clinicians in a mutually acceptable way. This new classification will provide added precision and reproducibility to nodal localization and will enhance the value of the data to be accumulated in pending multi-institutional studies involving squamous cell carcinoma.²²

Accepted for publication October 13, 1998.

Reprints: Peter M. Som, MD, Department of Radiology, Mount Sinai Hospital, One Gustave Levy Place, New York, NY 10029.

1.

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 M Computed tomography of cervical and retropharyngeal lymph nodes: normal anatomy, variants of normal, and application in staging head and neck cancer, II: pathology.  Radiology. 1983;148715- 723Google Scholar7.Spiro
 R The management of neck nodes in head and neck cancer: a surgeon’s view.  Bull N Y Acad Med. 1985;61629- 637Google Scholar8.

Som
 P An Approach to Tumors of the Head and Neck: The Role of Computed Tomography in the Staging and Follow-up of Patients.  San Francisco University of California1985;

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 M Metastatic hypernephroma to the head and neck.  AJNR Am J Neuroradiol. 1987;81103- 1106Google Scholar10.Medina
 J A rational classification of neck dissections.  Otolaryngol Head Neck Surg. 1989;100169- 176Google Scholar11.

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 K Pocket Guide to Neck Dissection and TNM Staging of Head and Neck Cancer.  Alexandria, Va American Academy of Otolaryngology–Head and Neck Surgery Foundation Inc1991;

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American Joint Committee on Cancer Staging, American Joint Committee on Cancer Staging Manual. 5th ed. Philadelphia, Pa Lippincott Raven1997;

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van den Brekel
 M Assessment of Lymph Node Metastases in the Neck: A Radiological and Histopathological Study.  Utrecht, the Netherlands University of Amsterdam1992;

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 et al.  Comparison of CT and MR imaging in staging of neck metastases.  Radiology. 1998;207123- 130Google Scholar16.Robbins
 KT Classification of neck dissection: current concepts and future considerations.  Otolaryngol Clin North Am. 1998;31639- 655Google ScholarCrossref 18.Mancuso
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 R Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts.  Cancer. 1972;291446- 1449Google ScholarCrossref 21.

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 R Surgical Anatomy.  St Louis, Mo Mosby–Year Book Inc1993;

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Lymph nodes of the head, neck and arm

Lymph nodes of the head, neck and arm: want to learn more about it?

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Author:
Benjamin Aghoghovwia
•

Reviewer:
Ryan Sixtus MPhEd

Last reviewed: August 31, 2020

Reading time: 7 minutes

The lymphatic system consists of:

• lymphatic vessels or lymphatics (a network of thin-walled vessels with abundant lymphatic valves)
• lymphatic ducts
• lymphatic trunks
• lymphoid tissue (sites that produce lymphocytes, such as those aggregated in the walls of the digestive tract, the spleen and thymus)
• lymph organs, such as spleen
• lymph nodes

Lymph nodes are small, oval or kidney-shaped bodies, 0.1-2.5 cm long, that lie along the course of lymphatic vessels. They are encapsulated centres of antigen presentation and lymphocyte activation, differentiation and proliferation. They generate mature, antigen-primed, B and T cells, and filter particles, such as microbes, from the lymph by the action of numerous phagocytic macrophages. The lymph is usually a clear, watery, and slightly yellow tissue fluid that enters lymph capillaries, and is similar in composition to blood plasma. A normal young adult body contains up to 450 lymph nodes, of which 60-70 are found in the head and neck, 100 in the thorax and as many as 250 in the abdomen and pelvis.

Lymph nodes are particularly numerous in the following locations:

• neck
• mediastinum
• posterior abdominal wall
• abdominal mesenteries
• pelvis
• proximal regions of the limbs (axillary and inguinal lymph nodes)
• close to the viscera, especially in the mesenteries, where the greatest number of lymph nodes lie

Lymph nodes of the arm

Lymph nodes of the arm include the cubital and deltopectoral lymph nodes. Superficial lymphatic vessels arising from the lymphatic plexuses in the skin of the fingers, palm, and dorsum of the hand drain lymph from these parts, as well as from the forearm, into the cubital lymph nodes. These are located proximal to the medial epicondyle of the humerus.

Efferent vessels from these lymph nodes ascend in the arm to terminate in the humeral or lateral axillary lymph nodes. Other superficial lymphatic vessels accompanying the cephalic vein also drain the arm, to terminate in the apical axillary lymph nodes, while some drain into the deltopectoral lymph nodes. The humeral axillary lymph nodes also receive deep lymphatic vessels, which are less numerous than the superficial lymphatic vessels. The superficial and deep lymphatics of the upper limb drain initially into the lateral and apical axillary lymph nodes. Axillary or central axillary lymph nodes are drained in turn by the subclavian lymphatic trunk.

Lymph nodes of the head and neck

Distribution and drainage

In the head and neck, lymph nodes are arranged in two horizontal rings and two vertical chains on either side of the neck. The outer, superficial ring consists of the occipital, preauricular (parotid), submandibular and submental nodes. The inner, deep ring is formed by clumps of mucosa associated lymphoid tissue (MALT) located primarily in the naso- and oropharynx (Waldeyer’s ring).

Lymph nodes in the head and neck are also distributed in terminal and outlying groups. The terminal group is related to the carotid sheath and contains the deep cervical lymph nodes. All lymph vessels of the head and neck drain into this group, either directly from the tissues or indirectly through nodes in the outlying groups. Efferents of the deep cervical nodes form the jugular lymphatic trunk. The right jugular lymphatic trunk collects lymph from the right arm, the right half of the thorax and the right parts of the head and neck. This trunk may end in the jugulosubclavian junction or the right lymphatic duct. Lymph from the left aspect of those regions drain into left jugular trunk ,which usually enters the thoracic duct. It may also join the internal jugular or subclavian vein.

Deep cervical lymph nodes (anterior view)

Lymph nodes of the head

Each group of lymph nodes in the head receives lymph from a specific organ or part of the head, and some of these groups of lymph nodes are named according to such parts. The groups include:

• Fascial group of lymph nodes: inferior maxillary, buccinators, infraorbital and the malar lymph nodes
• Submandibular group: preglandular, prevascular, retrovascular, retroglandular and intracapsular lymph nodes
• Parotid group: subfacial orextraglandular, deep intraglandular and suprafasciallymph nodes
• Submental group: anterior, middle and posterior submental lymph nodes
• Sublingual group: anterior/superior and posterior/inferior sublingual lymph nodes
• Mastoid group
• Occipital groups

Submental lymph nodes (anterior view)

Lymph nodes of the neck

In the neck, lymph nodes also form groups, as outlined below:

• Anterior cervical group: superficial anterior jugular chain, prelaryngeal and pretracheal lymph nodes
• Retropharyngeal group: lateral and medial retropharyngeal lymph nodes
• Lateral cervical group: supraclavicular or transverse cervical group, superior jugular group, midjugular group, inferior jugular group, and the spinal accessory or posterior triangle group of lymph nodes).

​Superior deep cervical lymph nodes are found attached to the upper part of the internal jugular vein. Most are deep to the sternocleidomastoid, but a few extend beyond it. A subgroup of nodes known as the jugulodigastric group, which is located in a triangular region bounded by the posterior belly of digastric, facial and internal jugular veins, is concerned with drainage of the tongue.

Inferior deep cervical lymph nodes lie in relation to the lower part of the internal jugular vein, the brachial plexus and the subclavian vessels.

Jugulo-omohyoid node lies in relation to the intermediate tendon of omohyoid, and is part of the lymphatic drainage of the tongue.

Paratracheal lymph nodes are situated along the recurrent laryngeal nerves. Efferents pass to the corresponding deep cervical nodes.

Paratracheal lymph nodes (lateral left view)

Infrahyoid, prelaryngeal and pretracheal lymph nodes lie beneath the deep cervical fascia and drain afferently from the anterior cervical nodes.

Lingual lymph nodes lie on the external surface of hypoglossal and also between the genioglossi, and drain to the upper deep cervical nodes.

Spread of malignant disease in the neck

A good knowledge of lymph nodes of the neck is required to make appropriate nodal clearance and/or avoidance during surgery to treat cancer. It is necessary to know which levels of lymph nodes are likely to be involved in the metastatic spread of a particular cancer arising in the head and neck. Usually, cancers arising in the head and neck have predictable patterns of spread through the chains of lymph nodes in the neck.

Lymph nodes of the head, neck and arm: want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

What do you prefer to learn with?

“I would honestly say that Kenhub cut my study time in half.”
–
Read more.
Kim Bengochea, Regis University, Denver

Show references

References:

• K. L. Moore and A. F. Dalley: Clinically oriented anatomy, 5th edition, (2006), p.749-750.
• S. Standring: Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 40th edition, (2008), p.72 – 74, 401, 454.

Illustrators:

• Deep cervical lymph nodes (anterior view) – Begoña Rodriguez
• Submental lymph nodes (anterior view) – Yousun Koh
• Paratracheal lymph nodes (lateral left view) – Irina Münstermann

© Unless stated otherwise, all content, including illustrations are exclusive property of Kenhub GmbH, and are protected by German and international copyright laws. All rights reserved.

90,000 Inflammation of the lymph nodes in the neck, treatment of lymph nodes in pain

Inflammation of the lymph nodes is an extremely unpleasant phenomenon. Acute painful sensations associated with this condition can upset the usual course of affairs for a fairly long time. The pain with normal movements can feel endless. It is physically exhausting and therefore the course of the disease is aggravated and seems unbearable.In order to figure out what to do in this case, it is first of all important to understand the causes of inflammation of the lymph nodes and learn to distinguish the symptoms of this condition – otherwise the correct treatment will simply be impossible to find.

Why does inflammation of the lymph nodes in the neck occur?

So why does inflammation of the lymph nodes in the neck occur? Lymph nodes are an integral part of the human immune system, part of its protection, a kind of biofilter that prevents the development of many diseases.If the filter is “clogged”, it simply cannot cope with pathogenic microorganisms, inflammation occurs. Thus, if your lymph nodes hurt, it means that there is an infection in the body that threatens health. In total, nine pairs can be attributed to the cervical lymph nodes, one way or another associated with the face or neck area. They are located next to the ears, jaw, above the collarbones and even under the tongue, so the occurrence of painful sensations in these areas may indicate inflammation of the lymph nodes.

Most often, the cervical lymph nodes become inflamed with angina or an ear infection.Also, the cause of the onset of a painful condition can be ARVI, which takes its peak in the autumn and spring periods, influenza, any diseases of the oral cavity, ranging from stomatitis and ending with caries. The lymph nodes near the ears become inflamed with otitis media. The location of the lymph nodes plays an important role in determining the focus of infection, since they usually signal the disease of nearby organs.

Much less often, pain in the lymph nodes occurs due to metabolic disorders, alcoholism, thyroid disease, or a simple allergy, however, it would be completely wrong to exclude these options.

In addition, inflammation of the lymph nodes, unfortunately, can be associated with serious problems, for example, mechanical damage (injury) to the lymph node itself or nearby tissues, as well as cancerous degeneration of lymph tissue cells.

Be that as it may, inflamed lymph nodes are a sign of a dysfunction of the immune system. In this regard, there is a widespread misconception that painful sensations in individual nodes, their increase, may indicate the presence of AIDS in a person.This is not entirely correct, since HIV-infected people suffer from enlargement of entire groups of lymph nodes.

What to do if lymph nodes hurt?

Treatment of the lymph nodes depends entirely on the causes of the inflammation. In order not to “overlook” the disease, it is enough to be attentive during a visual examination. With inflammation, the lymph nodes increase – the familiar, for example, the submandibular relief becomes smoother. There are about a hundred diseases associated with this condition, so self-diagnosis is a bad idea.A much more correct solution would be to contact a therapist: he will be able to conduct a comprehensive examination, after which he will refer you to a narrow specialist, depending on the nature of the inflammation.

Characteristic symptoms of the course of inflammation are also a change in the consistency of the lymph node (it can become soft from suppuration, or hard with the development of cancer cells of the lymphatic tissue), the occurrence of painful sensations on palpation or swallowing, reddening of the skin at the site of the lesion, as well as apathy, fatigue characteristic of many diseases , headaches and temperature inevitable with inflammation.

If the lymph nodes in the neck hurt from a sore throat or any other disease in which such sensations are only a symptom, then the pain will pass along with the end of the underlying disease. Mild symptoms (mild pain or tingling when swallowing or pressing, general weakness and frequent colds) indicates a general deterioration of the immune system.

In the second case, the most common treatment method is ultra-high-frequency therapy – a painless and non-discomforting procedure performed using special equipment.Antibiotics and anti-inflammatory drugs can be prescribed by a doctor in case of urgent need, however, in general, it is sufficient to observe bed rest, take vitamins and abundant warm drinks. Echinacea tincture will help alleviate the course of the disease – a truly magical plant, a natural antiseptic that eliminates inflammation and strengthens the immune system. Decoctions of mint, chamomile, or calendula will help you feel better, and gargling with salt and baking soda will help fight inflammation.

Remember that inflamed lymph nodes should in no case be warmed up, rubbed, and also apply an iodine mesh in this area.Such procedures aggravate the course of the disease and accelerate the spread of the infection.

Prevention of inflammation of the lymph nodes

As we mentioned above, the lymph nodes are part of the immune system, and the occurrence of inflammation is a signal that it is not working correctly. To prevent painful conditions from arising, it is enough to maintain immunity by all known methods: to temper, observe personal hygiene, take vitamins, avoid hypothermia and drafts, do not start the course of infections and pay sufficient attention to microtraumas and wounds.

Ultrasound of the lymph nodes of the neck – indications for, features, price, services of the Medical Center in Kolomenskoye

duplex

Doppler blood flow mapping veins (upper or lower extremities)

1530.00

knots, soft tissues

Ultrasound of lymph nodes and soft tissues began to be used not so long ago, i.e.because the latest generations of ultrasound devices have sufficient power of safe ultrasound with which you can visualize these formations. The lymph nodes in our body act as a biological filter for the immune system. They look like round, oval, bean-shaped or small ribbon formations located near the blood vessels. A specialist in a healthy person can probe only three groups of lymph nodes – inguinal, axillary and submandibular (cervical). They are, as a rule, single, painless, mobile, soft-elastic consistency.The average size of healthy lymph nodes is from 5 mm to 1 cm. An increase in size and a thickening of the consistency can become a symptom of various kinds of inflammatory and oncological diseases.

Indications for ultrasound of lymph nodes: the size of the lymph nodes increased after infection, but did not change within two weeks after recovery, if an external examination revealed an increase in all lymph nodes, if a change in the size of the nodes of the lymphatic system occurred regardless of infectious and colds, occurring in the past, when the enlargement of the lymph nodes is accompanied by a high fever, dysfunction of swallowing or breathing, sore throat, if there is an increase in only one lymph node in the neck region or its size significantly exceeds the size of the other, if the chin and thoracic nodes are palpated on palpation, supraclavicular and subclavian, thoracic, ulnar and / or popliteal.

As a rule, two areas of the lymph nodes are examined on ultrasound machines: the neck region and the abdomen region . The lymph nodes of the abdomen are examined while holding the breath during a deep breath. Usually, changes in size indicate pathologies in the intestines and stomach, pancreas and liver, uterus and ovaries. As for the cervical lymph nodes, their examination is carried out in a calm state of the patient. A change in the size of the cervical lymph nodes clearly indicates pathology in the tonsils and hard palate, ear, in the salivary glands, and also in the thyroid gland. Ultrasound of soft tissues is performed for bruises, injuries – to exclude internal hemorrhages.

.

Ultrasound diagnostics
Ultrasound of the hepatobiliary zone	2800.00
Integrated ultrasound of internal organs	3300.00
Ultrasound of the liver	1400.00
Ultrasound of the gallbladder	1250.00
Ultrasound of the gallbladder with determination of its contractility	1400.00
Ultrasound of the pancreas	1250.00
Preoperative marking of veins and perforators of the lower limb	1210.00
Ultrasound of the spleen	1250.00
Ultrasound determination of fluid in the abdominal cavity	Ultrasound of the kidneys and adrenal glands	2300.00
Ultrasound of the kidneys and adrenal glands (1st kidney)	1300.00
Ultrasound of the urinary bladder	1400.00
Ultrasound of the prostate	1800.00
Ultrasound of the prostate and bladder with determination of residual urine	2900.00
Ultrasound of the prostate transrectal	24
Ultrasound of the scrotum	2300.00
Determination of residual urine volume	900.00
Ultrasound of the bladder (determination of urine output from the orifice of the ureter in case of suspected upper urinary tract obstruction)	1250.00
Ultrasound of the bladder and determination of the volume of residual urine	1900.00
Ultrasound of the thyroid and parathyroid glands	2400.00
Ultrasound examination during puncture	2310.00
(one ultrasound of the lymph nodes anatomical zone)	2100.00
Ultrasound of the salivary glands	1400.00
Ultrasound of soft tissues (one anatomical zone)	1400.00
Ultrasound of the mammary glands + ultrasound of regional lymph nodes	2800.00
Ultrasound of the mammary glands (control ultrasound of one breast at a second visit)	1900.00
Ultrasound of the joint	1800.00
Ultrasound pleural cavity	1280.00
Ultrasound of the uterus and appendages transvaginal	2500.00
Ultrasound of the uterus and appendages transabdominal	2500.00
Ultrasound of folliculogenesis	2500.00
Ultrasound of the fetus (up to 10 weeks)	2400.00
Ultrasound of the fetus at 11-14 weeks	4100.00
Ultrasound of the fetus (in 2-3 trimesters pregnancy)	4500.00
3D ultrasound (ultrasound after 15 weeks of pregnancy)	5700.00
3D ultrasound (Doppler ultrasound after 15 weeks of pregnancy)	6800.00
Fetal ultrasound (in 2-3 trimesters) of pregnancy multiple	5500.00
3D ultrasound (ultrasound after 15 weeks of pregnancy) multiple	7000.00
3D ultrasound (Doppler ultrasound after 15 weeks of pregnancy) multiple	8000.00
Fetal ultrasound (up to 10 weeks) multiple	3000.00
Fetal ultrasound (at 11-14 weeks) multiple	4900.00
Doppler ultrasound of the arteries by monitoring (in obstetrics and gynecology)	1900.00
Fetal cardiotocography	1910.00
Echocardiography (ECHO KG)	3500.00
3500.00
Triplex scanning of brachiocephalic arteries with color Doppler blood flow mapping	3500.00
Duplex scanning of the vessels (arteries and veins) of the upper limbs	4710.00
Triplex scanning of the vessels (arteries and veins) of the upper limbs	4710.00
Duplex scanning of the arteries (1st upper or lower limb )	2000.00
Duplex scanning of vessels (arteries and veins of the 1st upper or lower limb)	3100.00
Duplex scanning of vessels (arteries and veins) of the lower extremities	5800.00
Triplex scanning of vessels (arteries and veins) of the lower extremities	5800.00
Duplex scanning of transcranial arteries and veins	3500.00
Triplex scanning of transcranial arteries and veins	3500.00
4100.00
Triplex scan (1st upper or lower extremity)	2000.00
Duplex scanning of arteries (upper or lower extremities)	3600.00
Triplex scanning of arteries (upper or lower limbs)	3600.00
Duplex scanning of renal arteries	3500.00
renal arteries	3500.00
Duplex scan of the aorta	3300.00
Triplex scan of the aorta	3300.00
Ultrasound examination of the eyeball with Doppler sonography of the vessels of the eyes and orbit (1 eye)	2400.00
Ultrasound examination of the eyeball with triplex scanning of the vessels of the eyes and orbits (1 eye)	2400.00
Ultrasound examination eyeball with Doppler sonography of the vessels of the eyes and orbit (2 eyes)	4100.00
Ultrasound examination of the eyeball with triplex scanning of the vessels of the eyes and orbits (2 eyes)	4100.00
Functional diagnostics
Electrocardiography (ECG)	1530.00
Electrocardiography with exercise (20 squats)	2740.00
Examination of unprovoked tidal volumes and flows
Study of tidal volumes using drugs	2000.00
Holter blood pressure monitoring (ABPM)	4000.00
Holter heart rate monitoring (HM-ECG) + ECG	4800.00
Holter heart rate monitoring (HM-ECG)	4000.00
Holter heart rate monitoring (HM-ECG) + ECG 48 hours	6000.00
Holter heart rate monitoring (HM-ECG) + ECG 72 hours	7500.00
Electroencephalography (EEG)	3500.00
Rheoencephalography (REG)	1900.00
Rheovasography (RVG)	1900.00
Echoencephalography (ECHO EG)	1660.00
Treadmill 9060 test