Dr. SAADVIK R YJR-II

DELINEATION OF THE NECK NODE

LEVELS FOR HEAD AND NECK

TUMOURS

• 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.

These include-

• Level Ia- submental group• Level Ib- submandibular group• Level II- upper jugular group• Level III- middle jugular group• Level IVa- lower jugular group• Level IVb- medial supraclavicular group• Level V- posterior triangle group• Level Va- upper posterior triangle nodes• Level Vb- lower posterior triangle nodes• Level Vc- lateral supraclavicular nodes

• Level VI- Anterior compartment group

• Level VIa- Anterior jugular nodes

• Level VIb- Prelaryngeal,pretracheal &paratracheal nodes.

• Level VII- Prevertebral group

• Level VIIa- Retropharyngeal nodes

• Level VIIb- Retro-styloid nodes

• Level VIII- Parotid group

• Level IX- Bucco-facial group

• Level X- Posterior skull group

• Level Xa- Retroauricular & subauricular nodes

• Level Xb- Occipital nodes

LEVEL Ia-SUBMENTAL GROUP

• Boundaries- Cranial- mylohyoid muscleCaudal- platysma (caudal edge of anterior belly of diagastric muscle)Anterior- symphysis mentiPosterior- body of hyoidLateral- medial edge of ant. belly of digastric muscle.

• It drains the skin of the chin, the mid-lower lip, the tip of the tongue and the anterior floor of the mouth.

• Risk of harboring metastases Are cancer arising from

the floor of the mouth, the anterior oral tongue, the anterior mandibular alveolar ridge, and the lower lip.

LEVEL Ia

LEVEL Ib-SUBMANDIBULAR GROUP• Boundaries-

Cranial- cranial edge of submandibular gland

caudal- plane through caudal edge of hyoid bone and caudal edge of submandibular gland.

Anterior- symphysis menti

Posterior- posterior edge of submandibular gland(caudally)/ posterior belly of digastric m.(cranially)

Lateral- medial aspect(innerside) of mandible down to caudal edge

Medial- lateral edge of anterior belly of digastric(caudally)/posterior belly of digastric(cranially)

• Receive efferent lymphatics from the submental lymph nodes (level Ia), the lower nasal cavity, the hard and soft palate, the maxillary and mandibular alveolar ridges, the cheek, the upper and lower lips, and most of the anterior tongue.

• Nodes in level Ib are at risk of harbouring metastases from

cancers of the oral cavity, anterior nasal cavity, soft tissue structures of the mid-face and the submandibular gland.

LEVEL Ib

LEVEL II-UPPER JUGULAR GROUP

• Boundaries-

Cranial- caudal edge of the lateral process of c1

Caudal- caudal edge of the body of the hyoid bone

Anterior- posterior edge of SM gland/ posterior edge of post. belly of digastric muscle.

Posterior- posterior edge of sternocleidomastoid muscle

Lateral- medial edge of SCM/platysma/parotid/post. belly of digastric m.

Medial- medial edge of internal carotid artery.

• Efferent lymphatics from the face, the parotid gland, and the submandibular, submental and retropharyngeal nodes.

• 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.

• Greatest risk of harboring metastases from cancers of

the nasal cavity, oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, and the major salivary glands.

LEVEL II

LEVEL III-MIDDLE JUGULAR GROUP

• Boundaries-

Cranial-Caudal edge of the body of the hyoid bone

Caudal-Caudal edge of cricoid cartilage

Anterior- anterior edge of SCM/post. third of thyro-hyoid m.

Posterior- posterior edge of SCM

Lateral- deep(medial) surface of SCM

Medial- medial edge of common carotid artery/scalenius mm

• Efferent lymphatics fromlevels II and V, and the retropharyngeal, pretracheal and recurrent laryngeal nodes.

• Direct lymphatics from the base of the tongue, tonsils, larynx, hypopharynx and thyroid gland.

• Greatest risk of harboring metastases from cancers of

the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx.

LEVEL III

LEVEL IVa-LOWER JUGULAR NODES

• Boundaries-

• Cranial- caudal edge of cricoid cartilage

• Caudal- 2 cm cranial to sternal manubrium

• Anterior- anterior edge of SCM m.(cranially)/body of SCM(caudally).

• Posterior- posterior edge of SCM m.(cranially)/scalenius m(caudally).

• Lateral- medial surface of SCM m.(cranially)/lateral edge of SCM m.(caudally).

• Medial- medial edge of common carotid artery/lateral edge of thyroid gland(cranially)./medial edge of SCM m.(caudally)

• Level IVa receives efferent lymphatics primarily from

levels III and V, retropharyngeal, pretracheal, and recurrent laryngeal nodes, hypopharynx, larynx, and thyroid gland

Level IVa nodes are at high risk for harboring metastases from cancers of

the hypo- pharynx, larynx, thyroid and cervical esophagus.

LEVEL IVa

LEVEL IVb-MEDIAL SUPRACLAVICULAR

GROUP• Boundaries-

• Cranial- caudal border of level IVa

• Caudal- cranial edge of sternal manubrium

• Anterior- deep surface of SCM m./ deep aspect of clavicle

• Posterior- anterior edge of scalenius mm.(cranially)/apex of lung, the brachiocephalic vein, the brachiocephalic trunk(right side) and the common carotid artery and subclavian artery on left side (caudally).

• Lateral- lateral edge of scalenius m.

• Medial- lateral border of level VI/ medial edge of common carotid artery.

• Level IVb receives efferent lymphatics primarily from levels IVa and Vc, pretracheal, and recurrent laryngeal nodes, and

• some lymphatics fromhypopharynx, esophagus, larynx, trachea and thyroid gland.

• High risk for harboring metastases from cancers of the

hypopharynx, sub-glottic larynx, trachea, thyroid and cervical esophagus.

LEVEL IVb

LEVEL V(a and b)-POSTERIOR TRIANGLE GROUP

• Boundaries-• Cranial- cranial edge of body of hyoid• Caudal- plane just below transverse cervical vessels• Anterior- posterior edge of SCM m.• Posterior- anterior border of trapezius m.• Lateral- platysma m./skin• Medial- levator scapulae mm/ scalenius m (caudally)

• Receives efferent lymphatics from the occipital and retroauricular nodes as well as those from the occipital and parietal scalp, the skin of the lateral and posterior neck and shoulder, the nasopharynx, the oropharynx and the thyroid gland.

• High risk for harboring metastases from cancers of the

nasopharynx, oropharynx and thyroid gland. the cutaneous structures of the posterior scalp.

LEVEL V

LEVEL Vc-LATERAL SUPRACLAVICULAR

GROUP• Boundaries-

• Cranial- plane just below transverse cervical vessels(caudal border of level V)

• Caudal- 2cm cranial to sternal manubrium

• Anterior- skin

• Posterior- anterior border of trapezius m.(cranially)/1 cm anterior to serratus anterior m. (caudally)

• Lateral- trapezius m (cranially)/clavicle (caudally)

• Medial- scalenius m./lateral edge of SCM m.

• Receives efferent lymphatics from the posterior triangle nodes (level Va and Vb)

• More commonly associated with nasopharyngeal tumors.

LEVEL Vc

LEVEL VIa-ANTERIOR JUGULAR NODES• Boundaries-

• cranial- caudal edge of hyoid bone or caudal edge of the submandibular gland, whichever is more caudal.

• Caudal- cranial edge of sternal manubrium

• Anterior- skin/platysma m.

• Posterior- anterior aspect of infrahyoid muscle

• Lateral- anterior edges of both sternoclediomastoid m.

Risk of metastasis-

lower lip tumors and advanced gingivo-mandibular carcinomas invading the soft tissues of the chin.

LEVEL VIa

LEVEL VIb-PRE-LARYNGEAL,PRE-TRACHEAL-RECURRENT LARYNGEAL

NERVE NODES• Boundaries-

• Cranial- caudal edge of thyroid cartilage

• Caudal- cranial edge of sternal manubrium

• Anterior- posterior aspect of infrahyoid m.

• Posterior- anterior aspect of larynx,thyroid gland and trachea/ pre-vertebral m.(right side)/esophagus(left side).

• Lateral- common carotid artery on both the sides

• Medial- lateral aspect of trachea and esophagus (caudally).

Receives efferent lymphatics from the

anterior floor of mouth, the tip of the tongue, the lower lip, the thyroid gland, the glottic and subglottic larynx, the hypopharynx, and the cervical esophagus

LEVEL VIb

LEVEL VIIa-RETROPHARYNEGAL NODES• Boundaries-

• Cranial- upper edge of body of c1/ hard palate

• Caudal- cranial edge of the body of hyoid

• Anterior- posterior edge of superior or middle pharyngeal constrictor m.

• Posterior- longus capitis m. and longus colli m.

• Lateral- medial edge of internal carotid artery

• Medial- a line parallel to the lateral edge of the longus capiti m.

• Retropharyngeal node receives efferent lymphatics from

the mucosa of the nasopharynx, the Eustachian tube and the soft palate.

• 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

LEVEL VIIb-RETRO-STYLOID NODES

• Boundaries-

• Cranial- base of skull (jugular foramen)

• Caudal- caudal edge of the lateral process of c1(upper limit of level II)

• Anterior- posterior edge of prestyoloid,para-pharyngeal space.

• Posterior- vertebral body of c1, base of skull

• Lateral- styloid process/ deep parotid lobe

• Medial- medial edge of the internal carotid artery.

• Risk of harboring metastases from cancers of

the nasopharynx, and from any other head and neck primary with massive infiltration of upper level II nodes through retrograde lymph flow.

LEVEL VIIb

LEVEL VIII-PAROTID NODE GROUP

• Boundaries-

• Cranial- zygomatic arch, external auditory canal

• Caudal- angle of the mandible

• Anterior- posterior edge of mandibular ramus & posterior edge of masseter m.(laterally), medial pterygoid m.(medially)

• Posterior- anterior edge of SCM.(laterally), posterior belly of digastric m.(medially)

• Lateral- subcutaneous tissue

• Medial- styloid process and styloid m.

• Efferent lymphatics 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.

LEVEL VIII

LEVEL IX-BUCCO-FACIAL GROUP

• Boundaries-• Cranial- caudal edge of the orbit• Caudal- caudal edge of the mandible• Anterior- subcutaneous tissue• Posterior- anterior edge of masseter m. & corpus adiposum

buccae (bichat’s fat pad)• Lateral- subcutaneous tissue• Medial- buccinator m.

• 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.

LEVEL IX

LEVEL Xa-RETROAURICULAR NODES• Boundaries-

• Cranial- cranial edge of external auditory canal

• Caudal- tip of the mastoid

• Anterior- anterior edge of the mastoid(caudally)/ posterior edge of the external auditory canal (cranially).

• Posterior- anterior border of occipital nodes-posterior edge of SCM m.

• Lateral- sucutaneous tissue

• Medial- splenius capitis m. (caudally)/ temporal bone (cranially).

• Retroauricular nodes receive efferent lymphatics from

the posterior surface of the auricle, the external auditory canal and the adjacent scalp.

• They are at risk of harboring metastases mainly from skin cancers of the retro-auricular area.

LEVEL Xa

LEVEL Xb-OCCIPITAL NODES

• Boundaries-• Cranial- external occipital protuberance• Caudal- cranial border of level V• Anterior- posterior edge of SCM m.• Posterior- anterior edge of trapezius m.• Lateral- subcutaneous tissue• Medial- splenius capitis m.

Level Xb nodes receive efferent lymphatics from the posterior part of the hair-bearing scalp and are at risk of metastases from skin cancers of the occipital area.

LEVEL Xb