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CERVICAL LYMPH NODES
Dr. Diptiman Baliarsingh
1st Year PG, Dept. of ENT,
Hi-Tech Medical College & Hospital, Bhubaneswar
Introduction
 The cervical group of lymph nodes extend from
 Mandible & skull base superiorly
 Clavicle inferiorly
 Po...
Levels of Neck Nodes
 There are 7 levels of neck and most have
sublevels containing specific group of nodes
 Level I – S...
LEVEL I
 2 groups of LN’s
 Sublevel Ia – Submental
 Sublevel Ib – Submandibular
 Boundaries of Lvl I
 Body of Mandibl...
Submental (Sublevel Ia)
 LN’s in the triangular boundary formed by
 Ant belly of digastric muscles
 Hyoid Bone
 Involv...
Boundary Clinical Radiologic Surgical
LEVEL Ia
Superior
Inferior
Lateral
(Posterior)
Medial
Symphisis of
mandible
Body of ...
Submandibular (Sublevel Ib)
 LN’s in the triangular boundary formed by
 Ant belly of digastric muscle
 Stylohyoid & Pos...
Boundary Clinical Radiologic Surgical
LEVEL Ib
Superior
Inferior
Lateral
(Posterior)
Medial
Body of mandible
Plane through...
 Many of these lymph nodes lie in close proximity
to submandibular gland, and it is removed to
ensure thorough exenterati...
LEVEL II
 Contain Upper Jugular LN’s
 2 groups – Sublevel IIa & IIb
 LN’s are located around upper third of internal
ju...
 Sublevel IIa nodes are located anterior (medial)
to vertical plane defined by spinal accessory
nerve, whereas sublevel I...
Boundary Clinical Radiologic Surgical
LEVEL IIA
Superior
Inferior
Lateral
(Posterior)
Medial
Mastoid process
Horizontal pl...
Boundary Clinical Radiologic Surgical
LEVEL IIB
Superior
Inferior
Lateral
(Posterior)
Medial
Mastoid process
Horizontal pl...
 AHNS Committee recommends – perpendicular
plane formed by posterior aspect of
submandibular gland as radiologic marker o...
LEVEL III
 Contains Middle Jugular LN’s Group
 Located around middle third of IJV
 Extent
 Superiorly – Carotid bifurc...
 Involved in pathology of
 Oral cavity
 Nasopharynx, Oropharynx, Hypopharynx
 Larynx
 AHNS Committee recommends – Lat...
Boundary Clinical Radiologic Surgical
LEVEL III
Superior
Inferior
Lateral
(Posterior)
Medial
Horizontal plane
defined by t...
LEVEL IV
 Contains Lower Jugular LN’s Group
 Located around lower third of IJV
 Extent
 Superiorly – Junction of Omohy...
 Involved in pathology of
 Hypopharynx
 Thyroid
 Cervical Esophagus
 Larynx
 AHNS Committee recommends – Lateral bor...
Boundary Clinical Radiologic Surgical
LEVEL IV
Superior
Inferior
Lateral
(Posterior)
Medial
Horizontal plane
defined by th...
LEVEL V
 Contains Posterior Triangle LN’s Group
 Located along the lower half of spinal accessory
nerve & transverse cer...
 2 groups – Sublevel Va & Vb
 The Va is separated from Vb by a horizontal plane
marking the inferior border of the anter...
 Involved in pathology of
 Nasopharynx
 Oropharynx
 Cutaneous structures of posterior scalp
 Neck
Boundary Clinical Radiologic Surgical
LEVEL Va
Superior
Inferior
Lateral
(Posterior)
Medial
Apex of
convergence of
SCM & t...
Boundary Clinical Radiologic Surgical
LEVEL Vb
Superior
Inferior
Lateral
(Posterior)
Medial
Horizontal plane
defined by th...
LEVEL VI
 Contains LN’s of Anterior compartment of the
neck
 They surround the midline visceral structures of
the neck
...
 LN groups in the compartment are –
 Pretracheal N
 Paratracheal N
 Precricoid (Delphian) N
 Perithyroidal N
 LN’s a...
Boundary Clinical Radiologic Surgical
LEVEL VI
Superior
Inferior
Lateral
(Posterior)
Medial
Hyoid Bone
Superior edge of
ma...
LEVEL VII
 Contains Superior Mediastinal group of LN’s
 The LN are an extension of the paratracheal LN
chain extending i...
Boundary Clinical Radiologic Surgical
LEVEL VII
Superior
Inferior
Lateral
(Posterior)
Medial
Superior edge of
manubrium st...
Thank You...
 REFERENCES
 CUMMING’S Otolaryngolagy Head & Neck Surgery -
5th Ed
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
Cervical lymph nodes
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Cervical lymph nodes

Cervical lymph nodes - Levels

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Cervical lymph nodes

  1. 1. CERVICAL LYMPH NODES Dr. Diptiman Baliarsingh 1st Year PG, Dept. of ENT, Hi-Tech Medical College & Hospital, Bhubaneswar
  2. 2. Introduction  The cervical group of lymph nodes extend from  Mandible & skull base superiorly  Clavicle inferiorly  Posterior triangle of neck laterally & posteriroly  Midline viscera anteriorly  LN groups are categorized acc to original description by Memorial Sloan-Kettering Group
  3. 3. Levels of Neck Nodes  There are 7 levels of neck and most have sublevels containing specific group of nodes  Level I – Submental & Submandibular  Level II – Upper Jugular  Level III – Middle Jugular  Level VI – Lower Jugular  Level V – Posterior Triangle  Level VI – Anterior/Central Compartment  Level VII – Superior Mediastinal
  4. 4. LEVEL I  2 groups of LN’s  Sublevel Ia – Submental  Sublevel Ib – Submandibular  Boundaries of Lvl I  Body of Mandible  Ant. Belly of C/L digastric muscle  Post. Belly of I/L digastric muscle  Stylohyoid muscle
  5. 5. Submental (Sublevel Ia)  LN’s in the triangular boundary formed by  Ant belly of digastric muscles  Hyoid Bone  Involved in pathology of  Floor of mouth  Anterior oral tongue  Anterior mandibular alveolar ridge  Lower lip
  6. 6. Boundary Clinical Radiologic Surgical LEVEL Ia Superior Inferior Lateral (Posterior) Medial Symphisis of mandible Body of Hyoid N/A N/A Geniohyoid Muscle, Plane tangent to inf. Border of mandible Body of Hyoid Ant belly of I/L digastric mus. Ant belly of C/L digastric muscle Symphisis of mandible Body of Hyoid Ant belly of I/L digastric mus. Ant belly of C/L digastric muscle
  7. 7. Submandibular (Sublevel Ib)  LN’s in the triangular boundary formed by  Ant belly of digastric muscle  Stylohyoid & Post belly of digastric muscle  Body of Mandible  Involved in pathology of  Oral Cavity  Anterior Nasal Cavity  Soft tissue structures of midface  Submandibular gland
  8. 8. Boundary Clinical Radiologic Surgical LEVEL Ib Superior Inferior Lateral (Posterior) Medial Body of mandible Plane through Hyoid bone Ant border of SCM N/A Mylohyoid Mus, Body of mandible Inferior edge of hyoid bone Post edge of Submandibular Gl. Ant belly of digastric muscle Body of mandible Digastric tendon attachment to hyoid bone Post edge of Submandibular Gl Ant belly of digastric muscle
  9. 9.  Many of these lymph nodes lie in close proximity to submandibular gland, and it is removed to ensure thorough exenteration of all lymph nodes with in this traingle  Perifacial LN’s – drain Lip, buccal musoca, ant nasal caity & soft tissue of neck, sometimes get involved along with the Level I LN groups.  ND’s performed for nodal disease asso with primary lesions of these sites should be modified to encompass perifacial nodes
  10. 10. LEVEL II  Contain Upper Jugular LN’s  2 groups – Sublevel IIa & IIb  LN’s are located around upper third of internal jugular vein & adjacent spinal accessory nerve  Extent  Superiorly - Skull base  Inferirly - Inf border of Hyoid bone  Ant (medial) boundary – stylohyoid mus  Post (lateral) boundary – posterior border of SCM
  11. 11.  Sublevel IIa nodes are located anterior (medial) to vertical plane defined by spinal accessory nerve, whereas sublevel IIb nodes are located posterior (lateral) to the vertical plane defined by spinal accessory nerve  Involved in pathology of  Oral cavity, Nasal Cavity  Nasopharynx, Oropharynx, Hypopharynx  Larynx  Parotid gland
  12. 12. Boundary Clinical Radiologic Surgical LEVEL IIA Superior Inferior Lateral (Posterior) Medial Mastoid process Horizontal plane defined by the inferior border of hyoid bone N/A N/A Skull base, Caudal edge of C1 lateral process Horizontal plane defined by the inferior border of hyoid bone Post. border of IJV Post. edge of submandibular gland Skull base Carotid bifurcation Vertical plane defined by Spinal acc. nerve Post. edge of submandibular gland
  13. 13. Boundary Clinical Radiologic Surgical LEVEL IIB Superior Inferior Lateral (Posterior) Medial Mastoid process Horizontal plane defined by the inferior border of hyoid bone Lateral border of SCM N/A Skull base, Caudal edge of C1 lateral process Horizontal plane defined by the inferior border of hyoid bone Lateral border of SCM Medial edge of ICA, paraspinal (lev. scapulae) mus Skull base Carotid bifurcation Lateral border of SCM Vertical plane defined by Spinal acc. nerve
  14. 14.  AHNS Committee recommends – perpendicular plane formed by posterior aspect of submandibular gland as radiologic marker of this boundary
  15. 15. LEVEL III  Contains Middle Jugular LN’s Group  Located around middle third of IJV  Extent  Superiorly – Carotid bifurcation / Inferior aspect of body of hyoid bone  Inferiorly – Junction of Omohyoid mus with IJV / lower border of cricoid arch(cartilage)  Medially – Lateral border of sternohyiod muscle  Laterally – Post border of SCM muscle
  16. 16.  Involved in pathology of  Oral cavity  Nasopharynx, Oropharynx, Hypopharynx  Larynx  AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary
  17. 17. Boundary Clinical Radiologic Surgical LEVEL III Superior Inferior Lateral (Posterior) Medial Horizontal plane defined by the inferior border of hyoid bone Horizontal plane defined by the inferior border of cricod cartilage Lateral border of SCM Medial border of SCM Horizontal plane defined by the inferior border of hyoid bone Horizontal plane defined by the inferior border of cricod cartilage Lateral border of SCM Medial edge of ICA, paraspinal (lev. scapulae) mus Carotid bifurcation Omohyoid muscle Sensory branches of cervical plexus Sternohyoid muscle
  18. 18. LEVEL IV  Contains Lower Jugular LN’s Group  Located around lower third of IJV  Extent  Superiorly – Junction of Omohyoid mus with IJV / lower border of cricoid arch(cartilage)  Inferiorly – Clavicle  Medially – Lateral border of sternohyiod muscle  Laterally – Post border of SCM muscle
  19. 19.  Involved in pathology of  Hypopharynx  Thyroid  Cervical Esophagus  Larynx  AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary
  20. 20. Boundary Clinical Radiologic Surgical LEVEL IV Superior Inferior Lateral (Posterior) Medial Horizontal plane defined by the inferior border of cricod cartilage Clavicle Lateral border of SCM Medial border of SCM Horizontal plane defined by the inferior border of cricod cartilage 2cm cranial to sternoclavicular joint Lateral border of SCM Medial edge of CCA, paraspinal (scalenus) mus Omohyoid muscle Clavicle Sensory branches of cervical plexus Sternohyoid muscle
  21. 21. LEVEL V  Contains Posterior Triangle LN’s Group  Located along the lower half of spinal accessory nerve & transverse cervical artery  Extent  Superiorly (Apex) – convergence of SCM & trapezius muscle  Inferiorly – Clavicle  Medially – Post border of SCM muscle  Laterally – Anterior border of trapezius muscle
  22. 22.  2 groups – Sublevel Va & Vb  The Va is separated from Vb by a horizontal plane marking the inferior border of the anterior cricod arch  Sublvl Va includes – Spinal accessory nodes  Sublvl Vb includes – nodes following transverse cervical vessels & supraclavicular nodes (not Virchow’s Nodes – they are located in Level IV)
  23. 23.  Involved in pathology of  Nasopharynx  Oropharynx  Cutaneous structures of posterior scalp  Neck
  24. 24. Boundary Clinical Radiologic Surgical LEVEL Va Superior Inferior Lateral (Posterior) Medial Apex of convergence of SCM & trapezius muscle Horizontal plane defined by the inferior border of cricod cartilage Anterior border of Trapezius muscle Lateral border of SCM Apex of convergence of SCM & trapezius muscle Horizontal plane defined by the inferior border of cricod cartilage Anterior border of Trapezius muscle Lateral border of SCM Apex of convergence of SCM & trapezius muscle Horizontal plane defined by the inferior border of cricod cartilage Anterior border of Trapezius muscle Sensory branches of cervical plexus
  25. 25. Boundary Clinical Radiologic Surgical LEVEL Vb Superior Inferior Lateral (Posterior) Medial Horizontal plane defined by the inferior border of cricod cartilage Clavicle Anterior border of Trapezius muscle Lateral border of SCM Horizontal plane defined by the inferior border of cricod cartilage Clavicle Anterior border of Trapezius muscle Lateral border of SCM Horizontal plane defined by the inferior border of cricod cartilage Clavicle Anterior border of Trapezius muscle Sensory branches of cervical plexus
  26. 26. LEVEL VI  Contains LN’s of Anterior compartment of the neck  They surround the midline visceral structures of the neck  Extent  Superiorly – Hyoid Bone  Inferiorly – Suprasternal Notch  Laterally (on each side) – Medial border of Carotid sheath
  27. 27.  LN groups in the compartment are –  Pretracheal N  Paratracheal N  Precricoid (Delphian) N  Perithyroidal N  LN’s along Recurrent Laryngeal Nr  Involved in pathology of  Thyroid Gland  Glottic & Subglottic Larynx  Apex of pyriform sinus  Cervical esophagus
  28. 28. Boundary Clinical Radiologic Surgical LEVEL VI Superior Inferior Lateral (Posterior) Medial Hyoid Bone Superior edge of manubrium sterni CCA CCA Hyoid Bone Superior edge of manubrium sterni Medial Aspect of CCA Medial Aspect of CCA Hyoid Bone Superior edge of manubrium sterni CCA CCA
  29. 29. LEVEL VII  Contains Superior Mediastinal group of LN’s  The LN are an extension of the paratracheal LN chain extending inferiorly below the suprasternal notch along each side of cervical trachea to the level of the innominate artery  Extent  Superiorly – Superior edge of manubrium  Inferiorly – superior border of arch of aorta  Laterally (Left side) – CCA  Laterally (Right side) – Innominate Artery
  30. 30. Boundary Clinical Radiologic Surgical LEVEL VII Superior Inferior Lateral (Posterior) Medial Superior edge of manubrium sterni N/A N/A N/A Superior edge of manubrium sterni Innominate Artery Innominate Artery & Left CCA Innominate Artery & Left CCA Superior edge of manubrium sterni Innominate Artery Innominate Artery & Left CCA Innominate Artery & Left CCA
  31. 31. Thank You...  REFERENCES  CUMMING’S Otolaryngolagy Head & Neck Surgery - 5th Ed

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Cervical lymph nodes - Levels

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