Lymph node levels of the neck

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

Level I  

• below mylohyoid muscle and above the lower margin of the hyoid bone (or the carotid bifurcation)
• anterior to the posterior border of the submandibular glands
  • level Ia: submental nodes, i.e. between the anterior bellies of the digastric muscles
  • level Ib: submandibular nodes, i.e. posterolateral to the anterior belly of the digastric muscles and anterior to the posterior border of the submandibular glands

Level II

• internal jugular (deep cervical) chain
• base of the skull to the inferior border of hyoid bone (or the carotid bifurcation)
• anterior to the posterior border of sternocleidomastoid (SCM) muscle
• posterior to the posterior border of the submandibular glands
  • level IIa: anterior, lateral, medial, or posterior to the internal jugular vein. If the node is posterior to the internal jugular vein, it must be inseparable from it
    • most superior node is the jugulodigastric node
  • level IIb: posterior to the internal jugular vein and have a fat plane separating the nodes and the vein

Level III

• internal jugular (deep cervical) chain
• lower margin of hyoid to lower margin of cricoid cartilage (or the intermediate tendon of omohyoid)
• anterior to the posterior border of SCM
• lateral to the medial margin of the common carotid artery (CCA) / internal carotid artery (ICA)

Level IV

• internal jugular (deep cervical) chain
• lower margin of cricoid cartilage to level of the clavicle
• anterior and medial to an oblique line drawn through the posterior edge of SCM and the posterolateral edge of the anterior scalene muscle ⁴
• lateral to the medial margin of the CCA

Level V

• posterior triangle (spinal accessory) nodes
• posterior to the back of the sternocleidomastoid muscle and anterior to the trapezius muscle 
  • level Va: superior half, posterior to levels II and III (between base of the skull and inferior border of cricoid cartilage)
  • level Vb: inferior half, posterior to level IV (between the inferior border of cricoid cartilage and the level of clavicles)

Level VI

• prelaryngeal (Delphian node) / pretracheal
• anterior to visceral space
• from the inferior margin of hyoid bone to the manubrium
• anterior to levels III and IV

Level VII 

• superior mediastinal nodes
• between CCAs, below superior aspect of manubrium to level of the brachiocephalic vein

See also

• cervical lymph node staging