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.

Swollen cervical lymph nodes: What does it mean?

Cervical lymph nodes are small nodes or glands in the neck. Swelling in the neck may indicate a nearby infection or other health condition.

The lymphatic system is a network of organs and tissues that helps support immunity. The lymph nodes are tiny, kidney-shaped structures that act as filters in this system. They trap and kill viruses, bacteria, and fungi before these pathogens can return to the bloodstream.

Swollen lymph nodes are usually a sign of infection but can stem from an inflammatory condition, an autoimmune disease, a reaction to a medication, or cancer. Sometimes they happen for no clear reason.

Swelling in the cervical lymph nodes may indicate a problem in the head, neck, throat, or lymphatic system.

This article outlines the potential causes of swollen cervical lymph nodes and information on treatment options and when to see a doctor.

Share on PinterestCoronation Dental Specialty Group, CC BY-SA 4.0, via Wikimedia Commons

Lymph nodes are part of the immune system. They can enlarge when the system is defending the body from a nearby infection.

Cervical lymph nodes are in the front, sides, and back of the neck. They are usually smaller than 1 centimeter in diameter. If they are bigger, this could be a sign of an infection or other health problem, such as:

• an ear infection
• a dental infection
• a skin infection
• acne
• a salivary gland infection
• inflammation due to hair dye use or tight hair braids
• COVID-19
• a cold or flu
• tonsillitis
• glandular fever (mononucleosis or mono)
• some types of cancer

Lymph nodes can also become noticeable under the chin, under the arms, and around the groin, depending on where an infection occurs.

A person may or may not be able to feel if their cervical lymph nodes are swollen. However, a doctor may be able to feel one or more bumps beneath the skin when examining the neck region.

The precise symptoms that may occur with swollen lymph nodes will depend on the cause, but common symptoms of an infection include:

• fever or chills
• a general feeling of being unwell, known as malaise
• fatigue
• body aches
• pain or tenderness around the swollen nodes

Many conditions can cause swollen cervical lymph nodes, each with its own symptoms.

Here are some possible causes:

• infections
• autoimmune diseases
• inflammatory conditions
• tumors or cancer
• genetic conditions present since birth
• medication use or exposure to toxins

Here we look at some examples.

Infection

Infection is a common cause of swollen lymph nodes anywhere in the body.

When an infection occurs somewhere in the body, the lymph nodes in that area fill with white blood cells. The white blood cells then start to destroy the pathogens responsible for the infection.

The accumulation of white blood cells in the lymph nodes causes them to swell.

Some common infections that may lead to swollen cervical lymph nodes include:

• the common cold
• strep throat or tonsillitis
• ear infections
• dental infections

Additional signs of infection depend on the specific illness but may include:

• sore throat
• coughing
• earache
• fever
• fatigue

Lymph nodes that swell due to infection may be painful when a person touches them. They usually return to their usual size once the infection clears.

HIV

Swollen lymph nodes are common in the early or acute stage of HIV infection. At this stage, the body starts fighting the infection.

Research suggests the virus reaches nearby lymph nodes 3–6 days after infection. Noticeable symptoms occur in around two-thirds of people within 2–4 weeks.

They include swelling in the lymph nodes. Swelling can affect any lymph nodes but commonly occurs in the cervical lymph nodes.

A 2016 study investigated lymph node abnormalities in 100 people with HIV and swollen lymph nodes. Of the participants, 60% had swelling in the cervical lymph nodes.

Other symptoms of the early or acute stage of HIV include:

• sore throat
• mouth ulcers
• night sweats
• muscle aches
• fever and chills
• fatigue
• a rash

Cancer

Swollen cervical lymph nodes can sometimes be a sign of cancer.

Cancers that can cause swelling in the lymph nodes are:

• Hodgkin lymphoma, which commonly appears first in the neck and usually affects young adults
• chronic lymphocytic leukemia (CLL), a type of blood cancer that may cause swollen lymph nodes in the neck, above the collarbone, and under the arms
• non-Hodgkin lymphoma, which can develop in lymph nodes anywhere in the body and is most common among people aged 64–74 years
• other cancers, especially head and neck cancers, which can spread to the cervical lymph nodes

Other symptoms that may occur with all these conditions include:

• fever
• night sweats
• fatigue
• unexplained weight loss

The outlook for most cancers is better if a person seeks early treatment.

Medication side effects

Rarely, swollen lymph nodes can occur as a side effect of a medication. When medication is the cause, swelling may develop in any of the nodes, including the cervical lymph nodes.

Medications and toxins that can cause swollen lymph nodes include:

• allopurinol (Zyloprim), used for gout
• atenolol (Tenormin), used for blood pressure and heart disease
• captopril (Capoten), an angiotensin-converting enzyme (ACE) inhibitor used for blood pressure
• carbamazepine (Tegretol), an anti-seizure and epilepsy medication
• cephalosporins, such as cephalexin (Keflex), an antibiotic
• hydralazine (Apresoline), a blood pressure medication
• penicillin
• phenytoin (Dilantin) and primidone (Mysoline), used to manage seizures
• quinidine (Quinidex), used for some irregular heartbeats
• sulfonamides, such as sulfasalazine (Azulfidine), a disease-modifying anti-rheumatic drug (DMARD) used to treat psoriatic arthritis and other chronic inflammatory conditions

In rare cases, a chemotherapy drug known as granulocyte colony stimulating factor may also cause swelling of the lymph nodes.

What autoimmune conditions are there?

A doctor can usually detect a swollen cervical lymph node by feeling a person’s neck. They may do additional tests to find out why the swelling has occurred.

A doctor will likely ask about:

• other symptoms
• personal and family medical history
• medications used and possible exposure to toxins
• lifestyle habits
• recent travel
• recent exposure to other people who may have an infectious disease

They may also order the following diagnostic tests to find out the reason for swelling:

• blood tests
• throat culture
• CT or MRI scan
• X-rays

If necessary, the doctor may also perform a biopsy of the cervical lymph nodes to check for the presence of cancer cells.

The treatment options for swollen lymph nodes depend on the underlying cause.

Infectious causes

A swollen lymph node usually occurs as a result of infection. In such cases, the lymph node should return to its usual size once the infection has cleared.

Swollen lymph nodes typically do not require treatment unless they are painful. However, the following home remedies may help relieve discomfort:

• applying a warm compress several times per day
• taking over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs)
• getting plenty of rest

A person should see their doctor if symptoms persist or worsen despite home treatment. The doctor may prescribe antibiotics if there are signs of a bacterial infection.

HIV

A person with HIV may receive antiretroviral medications to manage the virus. These drugs reduce the amount of the virus in a person’s blood and bodily fluids.

The drugs can reduce the viral load to where it is undetectable. Then, a person will no longer be able to pass on the disease. Many people can now live long and active lives with HIV, if they receive suitable treatment.

What does it mean when HIV is undetectable?

Cancer

Cancer treatments will depend on several factors, including:

• the type of cancer a person has
• the stage of the cancer
• the person’s overall health

Possible treatment options include:

• chemotherapy
• radiation therapy
• immunotherapy

In most cases, swollen cervical lymph nodes indicate the body is fighting an infection. Infections often go away without treatment, and the node should return to its usual size once the infection clears.

A person should seek medical advice if they experience:

• severe symptoms, such as pain, a high fever, or difficulty breathing
• swelling that lasts longer than 2 weeks
• additional symptoms, such as night sweats and a persistent fever
• swelling with no other symptoms, which may be a sign of cancer or an autoimmune disease
• a hard and painless swelling in the lymph node
• a rapid change in the size of the lymph node
• swelling in more than one area of lymph nodes, such as in the neck and the groin

Swollen cervical lymph nodes are common. In most cases, swelling is a temporary response to an infection, but it can also be a sign of a more severe underlying health condition.

A person should see their doctor if the swelling persists, worsens, or if it is causing concern. A doctor will investigate the cause and recommend a suitable course of treatment.

Lymphadenitis of the face and neck / Lipetsk city dental clinic №1

What are the lymph nodes on the face and where are they located

Lymph nodes on the face act as a kind of lymph filters from toxic substances. This defensive reaction is especially important on the face. Location of lymph nodes:

Behind both auricles on the head On the neck under the ears slightly shifted forward Under the jaw from below Under the beard Under the eyes

Causes of inflammation of the lymph nodes of the face

Facial lymph nodes play the role of “guards” of the body as a whole. And they are sensitive to the invasion of any infection or the beginning of an inflammatory process in the human body.

Inflammation of the lymph nodes on the face can be the result of such troubles as:

Infectious disease (cold, flu, rhinitis, sinusitis, tonsillitis) Tuberculosis Dental problems (periodontal disease, caries) Decreased immunity Skin diseases on the face Allergy Otitis Periodontitis

Inflammation of the lymphatic knots on the face often occur as a result of hypothermia of a person.

Lymphadenitis of the facial node

Inflammation of the lymph nodes on the face indicates that there is an infection in the human body and red blood cells “rushed into battle.” And it is worth not only treating the lymph nodes on the face, but conducting a complete diagnosis of the state of health to detect the underlying problem.

The main cause of lymphadenitis of the facial nodes are skin diseases: acne, acne.

Location of lymph nodes

Lymphadenitis of the parotid and behind the ear nodes

Thickening of the lymph nodes on the face near the ears is a companion of inflammatory processes that occur in the ear or salivary gland, or diseases of the throat.

In children, there is a thickening of the parotid and behind the ear nodes on the face with rubella, chickenpox. Such allergic reactions to vaccination are not uncommon. For a more accurate diagnosis, you should consult a surgeon.

Enlarged nodes in the lower part of the face

Lymph nodes in the lower part of the face can become inflamed for various reasons:

Dental problems (inflammation of the gums, caries) Sialoadenitis

With these diseases, there is an intensive removal of erythrocyte decay products from inflammation sites. Lymph nodes in the lower body do not have time to filter the lymph. This causes stagnation in the node and, as a result, its inflammation.

Lymphadenitis of the facial area symptoms

Inflammation of the lymph nodes on the face occurs with prolonged stagnation of lymph in the node itself. Main symptoms:

Skin thickening in this area Redness and itching Painful sensations when pressed Increased body temperature

Cases of purulent inflammation of the lymph nodes on the face are not uncommon. With such a complication, pus accumulates in the node itself. The final recovery of the patient occurs after the extraction of purulent accumulations. It can rupture on its own or be removed with minor surgery.

Remember! Inflammatory processes of the lymph nodes on the face are not an entirely innocent disease. It can lead to serious complications:

Meningitis Encephalitis

It is strictly forbidden to self-treat inflammation of the lymph nodes on the face.

Types of lymphadenitis

Lymphadenitis of the facial nodes is:

Acute Chronic Nonspecific lymphadenitis

The acute form of diseases of the lymph nodes on the face is characterized by the rapid onset of painful symptoms:

Thickening of the focus Redness of the skin Accumulation of pus Increased body temperature Painful sensations when pressed 04 Specific lymphadenitis on the face appears as concomitant manifestations of such diseases as:

AIDS Syphilis Tuberculosis

Nonspecific lymphadenitis manifests itself after various infectious bacteria enter the lymph:

Streptococcus Staphylococcus Various toxins

If pus accumulates in a lymph node on the face, it is purulent lymphadenitis.

Diagnosis

As noted above, lymphadenitis is one of the body’s signals that inflammatory processes are occurring in the human body. And it is worth making a full diagnosis to find the root cause. After all, eliminating the symptoms does not get rid of the main problem.

During the examination, the doctor pays special attention to the location of the inflamed lymph nodes. If they are near the ear, this may indicate otitis media. Purulent inflammation of the node on the face is most often the result of subcutaneous abscesses.

Purulent inflamed lymph nodes on the face in most cases are treated with surgery. But it is not uncommon that the abscess is torn. It is very good if the content comes out. It happens that pus gets inside. Then surgery is simply a must with a more thorough approach. Need general anesthesia and a long process of cleaning the affected area of ​​the face.

Prevention

Avoiding inflammation in the lymph node is quite easy:

Follow the strengthening of the immune system. This will help to avoid colds, viral diseases. Elementary hygiene of the oral cavity and ears will save you from stagnation of lymph in these areas of the face. Don’t skip the mandatory vaccination schedule. Try to avoid exposure to allergens on the body. Simple rules will relieve you of pain during lymphadenitis and strengthen the body.

MRI of the lymph nodes of the soft tissues of the neck

MRI Center – MRI of the lymph nodes

Neck soft tissue examination

A key part of the peripheral immune system consists of the lymph nodes. When metabolic / autoimmune pathologies occur, neoplasms occur, infection appears, lymph nodes increase in size. This process belongs to the general medical signs.

Such changes entail a variety of procedures and therapeutic examinations. The best way to examine this organ is tomography of the lymph nodes.

Price of MRI of lymph nodes in Moscow

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Why MRI of lymph nodes is necessary

MRI of the lymph nodes is the most advanced diagnostic method that reveals inconsistencies in the body. The display is based on a magnetic field combined with radio frequency pulses.

The positive aspect of this research method is its harmlessness and information content. During the examination, patients are spared from contact with highly radioactive substances, as well as from the perception of harmful radiation. The image quality factor makes it possible to recognize even the slightest modifications in the depicted organ.

Using only MRI of the lymph nodes, doctors can make a qualitative assessment of the state of the entire lymphatic system, as well as its individual elements

Indications for MRI of the lymph nodes

Lymph nodes in the human body perform the work of filtering of natural origin. Lymph flows through these filters, and they also trap all kinds of cells of the wrong composition.

MRI of the lymph nodes is usually done if:

• Immunity is impaired due to various diseases.
• There is an assumption of infectious diseases. This includes special diseases (tuberculosis or HIV).
• Symptoms are present that suggest the presence of metastases or tumors in the lymph nodes.

An appointment for MRI of the lymph nodes is issued if the patient has:

• As a result of infection, the lymph nodes have changed in size.
• If the size of the lymph nodes has changed for unknown reasons.
• Lymph nodes are enlarged on one side.
• The patient has already recovered, and the lymph nodes continue to grow.
• Lymph nodes have become larger. At the same time, the patient’s body temperature is elevated, the patient feels pain, there is a violation of swallowing functions.

For more effective diagnosis, the patient may be offered an MRI with contrast. This research method consists of introducing a contrast agent into the body by injection. This drug accumulates in the organ being examined.

Soft tissues of the neck

MRI of the soft tissues of the neck

From an anatomical point of view, the neck area is subject to the greatest load. It contains many organs that fit tightly to each other in a limited space. These organs belong to different systems such as nervous, circulatory, digestive, endocrine, lymphatic. Therefore, with the help of MRI of the soft tissues of the neck organs, it is possible to examine various changes in the structures (larynx, lymph nodes, thyroid gland, salivary glands).

Neck MRI is prescribed if there are suspicions of diseases of the vascular system, endocrine anomalies, when the salivary glands or the thyroid gland are inflamed. Also, tomography helps to identify tumors and metastases in the neck.

Where to get an MRI of lymph nodes in Moscow

If you need to diagnose lymph nodes, please contact our medical center, located near the metro station.