cervical lymph nodes
TRANSCRIPT
CERVICAL LYMPH NODESDr. Diptiman Baliarsingh1st Year PG, Dept. of ENT,Hi-Tech Medical College & Hospital, Bhubaneswar
IntroductionThe 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
Levels of Neck NodesThere 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
LEVEL I2 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
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
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
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
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
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
LEVEL IIContain 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
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
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
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
AHNS Committee recommends – perpendicular plane formed by posterior aspect of submandibular gland as radiologic marker of this boundary
LEVEL IIIContains 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
Involved in pathology of Oral cavity Nasopharynx, Oropharynx, Hypopharynx Larynx
AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary
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
LEVEL IVContains 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
Involved in pathology of Hypopharynx Thyroid Cervical Esophagus Larynx
AHNS Committee recommends – Lateral border of CCA serves as Radiologic marker for medial boundary
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
LEVEL VContains 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
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)
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 & 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
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
LEVEL VIContains 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
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
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
LEVEL VIIContains 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
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
Thank You...
REFERENCES CUMMING’S Otolaryngolagy Head & Neck Surgery
- 5th Ed