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Lymph node levels of the neck

Dr Alexandra Stanislavsky and Dr Frank Gaillard et al.

Lymph nodes in the neck have been divided into 7 levels, generally for the purpose of squamous cell carcinoma staging. This is however not all inclusive as several groups such as the supraclavicular, parotid and retropharyngeal space nodes are not accounted for in this system.

Level I

below myohyoid muscle and above the lower margin of the hyoid bone
anterior to the posterior border of the submandibular glands
- level Ia : sub mental - between the anterior bellies of the digastric muscle
- level Ib : sub mandibular - posterolateral to the anterior belly of digastric

Level II

jugulodigastric
base of skull to lower margin of hyoid bone
anterior to the posterior border of sternocleidomastoid (SCM)
posterior to the posterior border of the submandibular glands
- level IIa : anterior, lateral, or medial to the vein or posterior to the internal jugular vein and inseparable from it.
- level IIb : posterior to the internal jugular vein and have a fat plane separating the nodes and the vein

Level III

middle jugular nodes
lower margin of hyoid to lower margin of cricoid cartilage
anterior to the posterior border of SCM
lateral to the medial margin of the CCA / ICA

Level IV

low jugular nodes
lower margin of cricoid cartilage to level of the clavicle
anterior and medial to an oblique line drawn through the posterior edge of the sternocleidomastoid muscle and the posterolateral edge of the anterior scalene muscle⁴
lateral to the medial margin of the CCA