The Radiology Assistant : Cervical Lymph Node Map

modified from Robbins

Aurelia Fairise and Robin Smithuis

Institut de Cancérologie de Lorraine in Nancy, France and the Alrijne hospital in Leiderdorp, the Netherlands

Publicationdate 2022-07-11

This article is based on the nomenclature proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery.

10 node groups are defined with a concise description of their main anatomic boundaries, the normal structures juxtaposed to these nodes, and the main tumor sites at risk for harboring metastases in those levels [1]. 

Overview

In this cervical lymph node map the levels were extended to 10.

Some of these are being divided into sub-levels to correspond more completely with the TNM atlas.

Borders

Important landmarks are:

• Hyoid bone
• Cricoid
• Carotids
• Sternocleidomastoid muscle
• Manubrium of sternum

Axial CT

Axial CT slices in correlation to overview illustration.

Axial CT slices in more detail.
Enlarge images by clicking on them.

Levels

I – Submental and submandibular

Nodes in level I are at risk of developing metastases from cancers of the oral cavity, anterior nasal cavity and the soft tissues of the mid-face and the submandibular gland.

Level Ia 
is a median region located between the anterior belly of the digastric muscles, which contains the submental nodes.

Level Ib 
contains the submandibular nodes located in the space between the inner side of the mandible laterally and the digastric muscle medially, from the symphysis menti anteriorly to the submandibular gland posteriorly.

II – Upper jugular

Level II receives lymphatics from the face, the parotid gland, and the submandibular, submental and retropharyngeal nodes.
Level II also directly receives the collecting lymphatics from the nasal cavity, the pharynx, the larynx, the external auditory canal, the middle ear, and the sublingual and submandibular glands [1]. 

Level II can be divided into level IIa and level IIb by drawing a line at the posterior edge of the internal jugular vein.

The nodes in level IIa and IIb are at risk of harboring metastases from cancers of the nasal and oral cavity, nasopharynx, oropharynx, hypopharynx, larynx and major salivary glands.

Level IIb is more likely associated with primary tumors of the oropharynx or nasopharynx, and less frequently with tumors of the oral cavity, larynx or hypopharynx [1].

III – Mid jugular

Level III receives efferent lymphatics from levels II and V, and some efferent lymphatics from the retropharyngeal, pretracheal and recurrent laryngeal nodes.
It collects the lymphatics from the base of the tongue, tonsils, larynx, hypopharynx and thyroid gland.

The inferior border of the cricoid is the border between level III and IVA.

Nodes in level III are at risk of harboring metastases from cancers of the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx.

IV – Lower jugular and medial supraclavicular

The border between level IVa and IVb is set arbitrarily 2 cm cranial to the sterno-clavicular joint.

Level IVa
These nodes are at risk for harboring metastases from cancers of the hypopharynx, larynx, thyroid and cervical esophagus.
Rarely metastases from the anterior oral cavity may manifest in this location with minimal or no proximal nodal disease.

Level IVb
These nodes are at risk for harboring metastases from cancers of the hypopharynx, subglottic larynx, trachea, thyroid and cervical esophagus.

V – Posterior triangle and Supraclavicular

Level V contains the nodes of the posterior triangle group located posteriorly to the sternocleidomastoid muscle around the lower part of the spinal accessory nerve and the transverse cervical vessels.

Nodes in level V are most often associated with primary cancers of the nasopharynx, the oropharynx, the cutaneous structures of the posterior scalp, and the thyroid gland.

Level Vc – Supraclavicular

This level contains the lateral supraclavicular nodes located in the continuation of the posterior triangle nodes (level Va and Vb) from the cervical transverse vessels down to a limit set arbitrarily 2 cm cranial to the sternal manubrium.
It corresponds partly to the area known as the supraclavicular fossa.

Level Vc receives efferent lymphatics from the posterior triangle nodes (level Va and Vb) and is more commonly associated with nasopharyngeal tumors [1]. 

Transverse cervical artery
Scroll through the images for the anatomy of the transverse cervical artery.

VI – Anterior cervical

This level contains the superficial anterior jugular nodes (level VIa) and the deeper prelaryngeal, pretracheal, paratracheal and recurrent laryngeal nerve nodes (level VIb).

Level VIa
This level contains the superficially located anterior jugular nodes.

Level VIb
This level is contained between the medial borders of the common carotid arteries.
The nodes in this area are:

• pre-laryngeal nodes in front of the larynx and cricoid
• pre-tracheal nodes in front of the trachea 
• paratracheal nodes also called recurrent laryngeal nerve nodes

Delphian lymph node

The Delphian lymph node derived its name from the oracle of Delphi, whose prophecy would be a death secondary to laryngeal cancer.

It is a pretracheal node in level VIa located anterior to the cricoid and in between the cricothyroid muscles.

The recurrent laryngeal nerves branch off the vagus, the left at the aortic arch, and the right at the right subclavian artery.

The left laryngeal nerve can be compressed by subaortic lymph node metastases in the aorto-pulmonary window as seen in patients with lung cancer.

VII – Retropharyngeal and retrostyloid

Retropharyngeal nodes receive lymphatics from the mucosa of the nasopharynx, the Eustachian tube and the soft palate. 

These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate).

Level VIIa – retropharyngeal

These nodes lie within the retropharyngeal space, extending cranially from the upper edge of the first cervical vertebrae (massa lateralis) to the cranial edge of the body of the hyoid bone caudally (figure).

This space is bounded anteriorly by the pharyngeal constrictor muscles and posteriorly by the longus capitis and longus colli muscles.
Laterally, the retropharyngeal nodes are limited by the medial edge of the internal carotid artery.

Retropharyngeal nodes receive efferent lymphatics from the mucosa of the nasopharynx, the Eustachian tube and the soft palate.
These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate).

Level VIIb – retrostyloid

The retro-styloid nodes are the cranial continuation of the level II nodes.
They are located in the fatty space around the jugulo-carotid vessels up to the base of skull at the jugular foramen. 

Click to enlarge

The retro-styloid space is delineated by the internal carotid artery medially, by the styloid process and the deep parotid lobe laterally, by the vertebral body of C1 and the base of skull posteriorly and by the pre-styloid para-pharyngeal space anteriorly.

VIII – Parotid

This level contains the parotid node group, which includes the subcutaneous pre-auricular nodes, the superficial and deep intraparotid nodes and the subparotid nodes. 

These nodes extend from the zygomatic arch and the external auditory canal down to the mandible.

They extend from the subcutaneous tissue laterally to the styloid process medially, and from the posterior edge of the masseter and the pterygoid muscles anteriorly to the anterior edge of the sternocleidomastoid muscle and the posterior belly of the digastric muscle posteriorly [1].

Click to enlarge

The parotid group receive lymphatic from the frontal and temporal skin, the eyelids, the conjunctiva, the auricle, the external acoustic meatus, the tympanum, the nasal cavities, the root of the nose, the nasopharynx, and the Eustachian tube.  

They are at risk of harboring metastases from cancers of the frontal and temporal skin, orbit, external auditory canal, nasal cavities and parotid gland.

IX – Buccofacial

Level IX contains the malar and bucco-facial node group, which includes inconsistent superficial lymph nodes around the facial vessels on the external surface of the buccinator muscle.
These nodes extend from the caudal edge of the orbit (cranially) down to the caudal edge of the mandible (caudally) where they reached level Ib. 

They lay on the buccinators muscle (medially) in the sub-cutaneous tissue, from the anterior edge of the masseter muscle and the Bichat’s fat pad (posteriorly) to the anterior sub-cutaneous tissue of the face.

The bucco-facial nodes receive efferent vessels from the nose, the eyelids, and the cheek. 

They are at risk of harboring metastases from cancers of the skin of the face, the nose, the maxillary sinus (infiltrating the soft tissue of the cheek) and the buccal mucosa.

X – Retroauricular and occipital

Level Xa contains the retroauricular (also called mastoid) and subauricular nodes, which includes superficial nodes lying on the mastoid process from the cranial edge of the external auditory canal cranially to the tip of the mastoid caudally. 

Level Xb contains the occipital lymph nodes, which are the cranial and superficial continuation of the level Va nodes up to the cranial protuberance. They lie from the posterior edge of the sternocleidomastoid muscle to the anterior (lateral) edge of the trapezius muscle.

Lymph node metastases in level X are from skin cancers of the retro-auricular area (Xa) and skin cancers of the occipital area (Xb).

Click on the image below to get more information about Medical Action Myanmar, a medical organization run by Nini Tun and Frank Smithuis, who happens to be the brother of Robin Smithuis.

1. Delineation of the neck node levels for head and neck tumors: A 2013 update. DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI, RTOG, TROG consensus guidelines

   DAHANCA, EORTC, HKNPCSG,NCIC CTG, NCRI, RTOG, TROG consensus guidelines.
   by V Grégoire et al.
   Radiother Oncol 2014 ;110:172–81.

2. Integrating radiological criteria into the classification of cervical lymph node disease.
   by Robbins KT.
   Arch Otolaryngol Head Neck Surg 1999 ;125:385–7.

3. International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration.

   by El-Sherief AH, Lau CT, Wu CC, Drake RL, Abbott GF, Rice TW.
   Radiographics. 2014 Oct;34(6):1680-91.

Primary Neck Cancers ‣ Anatomy

In order to fully understand primary neck cancers, it helps to understand the anatomy and function of the structures in the neck. The neck is a complex anatomic region between the head and the body.

In the front, the neck extends from the bottom part of the mandible (lower jaw bone) to the bones of the upper chest and shoulders (including the sternum and collar bones). The back of the neck is mostly comprised of muscles, as well as the spine. 

The neck is essentially a passageway for air, food, liquids, blood, and more to travel between the head and the rest of the body, through structures such as blood vessels, nerves, and lymph nodes, as well as the larynx, trachea, and esophagus.  

Important Structures in the Neck

Sternocleidomastoid Muscle
This is the large muscle on either side of the neck. This muscle covers and protects many important deeper structures such as the carotid artery and the jugular vein. This muscle starts at the skull just behind the ear (mastoid bone) and travels down to the sternum (breastbone) and clavicles (collarbones).

Thyroid Gland
The thyroid is located at the midline of the neck, under the skin and a few layers of thin muscles. It sits just in front of and to the side of the upper trachea. It secretes thyroid hormone which is important in regulating many functions of the body. The thyroid gland has a right and left lobe which are connected by an isthmus. Learn more about the thyroid.

Parathyroid Glands
These four glands are located just behind the thyroid gland, two on each side. They are critical in helping to regulate levels of calcium in the blood.

Carotid Sheath
This is an envelope of fascia that envelopes three major structures: the carotid artery, internal jugular vein, and vagus nerve.

Additional Major Arteries & Nerves
Just behind the carotid sheath sits the sympathetic nerve plexus, which helps with blood pressure control and other important functions. There are also other major nerves such as the hypoglossal nerve (which controls tongue movement), the spinal accessory nerve (which controls neck and shoulder movement), and the phrenic nerve that innervates the diaphragm (which facilitates breathing).

Larynx
The larynx is often called the voice box because it houses the vocal cords and is responsible for producing sound during speech. It is part of the throat and is located in the middle of the neck.  The framework of the larynx is formed by the cricoid and thyroid cartilage, as well as, other smaller cartilages. Learn more about the larynx.

Esophagus
The esophagus is the passageway for eating. It is located behind the trachea in the lower neck. Food and liquids travel through this muscular tube which travels from the neck through the chest until it connects to the stomach in the abdomen. 

Trachea
The trachea is the passageway for breathing. It begins just below the cricoid cartilage of the larynx and extends into the chest to eventually split into left and right bronchi which continue to divide in the lungs. The trachea is made up of multiple c-shaped cartilage rings and a posterior muscular wall.

Salivary Glands
The submandibular salivary glands and the tail of the parotid salivary gland are located in the upper part of the neck. Learn more about salivary glands.

Lymph Nodes
There are lymph nodes located throughout the body, and several in the neck. Lymph nodes filter fluid in the body and help to fight infections and cancers. Cancers from a site in the head and neck can drain into lymph nodes and lead to the growth of cancer within the lymph node (called a metastatic lymph node). Learn more about lymph nodes.

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Lymph nodes : normal anatomy

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Literature

• Terminologia Anatomica: International Anatomical Terminology – FCAT Federative Committee On Anatomical Terminology, Federative Committee on Anatomical Terminology – Thieme, 1998 – ISBN 3131152516, 9783131152510
• Selection and delineation of lymph node target volumes in head and neck conformal radiotherapy. Proposal for standardizing terminology and procedure based on the surgical experience. Grégoire V, Coche E, Cosnard G, Hamoir M, Reychler H. Radiother Oncol. 2000 Aug;56(2):135-50. Review.PMID: 10927132
• CT-based definition of thoracic lymph node stations: an atlas from the University of Michigan.Chapet O, Kong FM, Quint LE, Chang AC, Ten Haken RK, Eisbruch A, Hayman JA.Int J Radiat Oncol Biol Phys. 2005 Sep 1;63(1):170-8.
• Definition of the supraclavicular and infraclavicular nodes: implications for three-dimensional CT-based conformal radiation therapy. Madu CN, Quint DJ, Normolle DP, Marsh RB, Wang EY, Pierce LJ. Radiology. 2001 Nov;221(2):333-9.
• Standardizing Neck Dissection Terminology: Official Report of the Academy’s Committee for Head and Neck Surgery and Oncology
  K. Thomas Robbins; Jesus E. Medina; Gregory T. Wolfe; Paul A. Levine; Roy B. Sessions; Charles W. Pruet
  Arch Otolaryngol Head Neck Surg. 1991;117(6):601-605.

anatomical structures

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What to do if the lymph nodes in the neck are inflamed

The enlargement of the lymph nodes in the neck, as a rule, occurs as a result of contact with bacteria and viruses. If the enlargement is caused by an infection, it is called lymphadenitis. Rarely, cancer can be the cause.

The lymphatic system plays a vital role in keeping our body alive and is a major component of our immunity. Lymph nodes can be felt in the neck, chin, armpits and groin. In some cases, no action is required for treatment and a warm compress is enough. Treatment depends on the cause.

Symptoms

The lymphatic system includes a network of organs and lymph nodes located throughout the body. Most of them are in the head and neck area. Swollen lymph nodes indicate that something is wrong in the body. The first signs are sensitivity, soreness and an increase in lymph nodes to the size of a bean and even more.

Depending on the cause of the appearance, the symptoms of the disease may be as follows:

Runny nose, sore throat, fever and other signs of an upper respiratory tract infection.
Swollen lymph nodes throughout the body may indicate HIV, mononucleosis, or immune disorders such as lupus or rheumatoid arthritis.
Swollen limbs may indicate a blockage in the lymphatic system caused by tumors in the lymph nodes that are deep under the skin and cannot be felt.

When treatment of lymph nodes in the neck requires a visit to a doctor

Lymph nodes return to normal over time if the cause of the increase was an infection that could be treated. But there are a number of factors in which you should consult a doctor:

• Swelling without apparent cause
• Duration 2-4 weeks
• Knots are difficult to feel and do not move when pressed
• Associated with persistent fevers, night sweats and weight loss
• Accompanied by sore throat and difficulty swallowing.

Why lymph nodes in the neck become inflamed – causes

A lymph node is a small, round or bean-shaped cluster of cells covered with a capsule of connective tissue. The cells are a combination of lymphocytes that produce protein particles that fight viruses and macrophages that break down harmful substances. Lymphocytes and macrophages filter the lymphatic fluid that flows throughout the body and protects us.

Lymph nodes are located in groups, each of which serves a specific area of ​​the body. An increase in a specific area may suggest a cause. The most common is an infection, especially a viral one, such as a cold. But there are other types0019 lymphadenitis of the cervical lymph nodes , such as parasitic or bacterial, which can cause enlargement of the lymph nodes.

Common infections:

• Measles
• Ear infections
• Infection of the tooth – abscess
• Mononucleosis
• Skin infections
• HIV

Atypical infections:

• Tuberculosis
• Sexually transmitted (syphilis and others)
• Toxoplasmosis
• Cat scratch bacterial infection

Autoimmune diseases:

• Lupus
• Rheumatoid arthritis

Cancer:

• Lymphoma
• Leukemia
• Other cancers that have spread to lymph nodes

Complications

If the cause is an infection and not properly treated, complications may occur.

Abscess formation. Localization of the accumulation of pus caused by infection. Pus contains fluid, white blood cells, dead tissue, bacteria, and other harmful elements. If an abscess occurs, drainage or antibiotic treatment may be required. Significant damage can be done if vital organs are affected.

Bloodstream infection. Bacterial, can start anywhere in your body and progress to sepsis caused by significant blood poisoning. Sepsis can lead to multiple organ failure and death. Treatment includes hospitalization and intravenous antibiotics.

Diagnosis

To diagnose an illness, your doctor may need to:

• Medical history
• Medical examination
• Blood test
• Chest x-ray and computed tomography
• Lymph node biopsy (as a last resort).

Treatment of lymph nodes in the neck

If the cause is a virus, the lymph nodes in the neck will recover on their own after the infection itself is treated. But if this does not happen or there is another reason, the following treatment may be required:

• Infection.