Lymph Node Levels of the Neck

Head and neck imaging approach: Assign every suspicious node a side and level, then describe size, morphology, necrosis or cystic change, extranodal extension, and relationship to vessels and the primary tumor. Use levels I–VI for the standard cervical compartments and name retropharyngeal, parotid, facial, occipital, or mediastinal nodes specifically.

Visual Reference

Illustrated cervical lymph node levels — Cervical Nodal MapClick to enlarge

Cervical lymph node stations and imaging criteria — Levels I–VI OverviewClick to enlarge

Supraclavicular lymph node drainage and significance — Supraclavicular NodesClick to enlarge

Imaging features of malignant cervical lymph nodes — Malignant Nodal FeaturesClick to enlarge

Differential diagnosis for low density cervical nodes — Low-Density NodesClick to enlarge

Levels I and II

Suprahyoid nodal groupsLevel I surrounds the submandibular and submental spaces. Level II follows the upper internal jugular chain from the skull base to the hyoid.

Level I

IA: between the anterior digastric bellies, above the hyoid and below the mylohyoid.
IB: posterolateral to the anterior digastric belly in the submandibular triangle.

Level II

IIA: anterior to, lateral to, or inseparable from the internal jugular vein.
IIB: posterior to the vein with an intervening fat plane.

Common drainage includes the oral cavity, oropharynx, nasopharynx, parotid region, and upper aerodigestive tract.

Levels III and IV

Middle and lower jugular chainThe hyoid separates levels II and III; the cricoid arch separates levels III and IV.

Level III

Extends from the hyoid to the cricoid, between the anterior and posterior margins of the sternocleidomastoid, lateral to the carotid space.

Level IV

Extends from the cricoid to the clavicle along the lower internal jugular chain. Medial supraclavicular nodes are included.

Drainage pattern

Levels III and IV receive drainage from the pharynx, larynx, cervical esophagus, thyroid, and other upper aerodigestive sites. Lower left-sided nodes may also reflect thoracic or abdominal malignancy.

Levels V and VI

Posterior triangle and central compartmentLevel V is posterior to the sternocleidomastoid. Level VI lies between the carotid arteries in the anterior visceral compartment.

Level V

VA: above the cricoid, including the spinal accessory chain.
VB: below the cricoid, including lateral supraclavicular nodes.

Level VI

From hyoid to manubrium, medial to the common carotid arteries; includes prelaryngeal (Delphian), pretracheal, paratracheal, and perithyroidal nodes.

Typical associations

Level V: nasopharyngeal, cutaneous, and thyroid primaries. Level VI: thyroid, subglottic larynx, cervical esophagus, and trachea.

Boundary Quick Reference

Level	Superior → inferior	Key landmark
I	Mandible/mylohyoid → hyoid	Anterior digastric separates IA and IB
II	Skull base → hyoid	IJV relationship separates IIA and IIB
III	Hyoid → cricoid	Middle jugular chain
IV	Cricoid → clavicle	Lower jugular chain
V	Skull base → clavicle	Posterior to SCM; cricoid separates VA/VB
VI	Hyoid → manubrium	Between common carotids

Nodes Outside Levels I–VI

Name these groups directly rather than forcing them into the six-level scheme:

Retropharyngeal
Parotid and preauricular
Facial, buccal, and mandibular
Occipital and posterior auricular
Superior mediastinal

Nomenclature: Some surgical systems call superior mediastinal nodes “level VII,” but usage is inconsistent. A precise anatomic name is clearer in an imaging report.

Assessing a Suspicious Node

Morphology: round shape, loss of fatty hilum, irregular margin, heterogeneous enhancement.
Necrosis or cystic change: highly suspicious in the appropriate clinical setting; in an adult, consider HPV-associated oropharyngeal carcinoma and papillary thyroid carcinoma.
Extranodal extension: indistinct capsule, infiltration of adjacent fat or muscle, matted nodes, or invasion of nearby structures.
Vascular relationship: describe narrowing, occlusion, or circumferential contact with the carotid artery and internal jugular vein.

Size thresholds vary by nodal group and clinical context; morphology and interval change can outweigh short-axis diameter.

Reporting Checklist

Location: side, level, and nodal group; report the largest or most suspicious node in each relevant station.

Morphology: short-axis size, cystic/necrotic component, calcification, enhancement, and extranodal extension.

Extent: adjacent vessel, muscle, skin, prevertebral, skull-base, and mediastinal involvement; note bilateral or contralateral disease.

Primary search: correlate the drainage pattern with mucosal, thyroid, salivary, cutaneous, thoracic, and abdominal primary sites.

Supraclavicular pearl

Right-sided nodes predominantly receive right thoracic drainage. Left supraclavicular (Virchow) nodes receive thoracic-duct drainage and may reflect thoracic or abdominopelvic malignancy.