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BackTable / ENT / Article
The 7 Levels of Lymph Nodes in the Neck
Reilly Fogarty • Updated May 8, 2025 • 39 hits
The 7 levels of lymph nodes in the neck form a standardized classification system used in diagnosing, staging, and treating head and neck conditions. These levels are defined by anatomical landmarks and drainage patterns, helping clinicians identify the spread of malignancies and plan interventions like surgery or radiation therapy. Each level correlates with specific regions of the head and neck and their associated pathologies, which is vital for accurate disease management.
This article explores the anatomy, subdivisions, drainage patterns, and malignancy associations of the lymph node levels, starting with level 1 and progressing through to level 7. By understanding these details, clinicians can better evaluate lymphatic involvement in head and neck cancers and better tailor treatment strategies.
Table of Contents
(1) Level 1: Submental and Submandibular Nodes
(2) Level 2: Upper Jugular Nodes
(3) Level 3: Middle Jugular Nodes
(4) Level 4: Lower Jugular Nodes
(5) Level 5: Posterior Triangle Nodes
(6) Level 6: Anterior Compartment Nodes
(7) Level 7: Superior Mediastinal Nodes
Level 1: Submental and Submandibular Nodes
Level 1 lymph nodes are positioned in the anterior triangle of the neck and are divided into two sublevels: 1a (submental) and 1b (submandibular). These nodes play a central role in draining lymph from the lower face, oral cavity, and submandibular glands, making them commonly involved in oral cancers. The anatomical boundaries and subdivisions of level 1 nodes provide key insights into their drainage pathways and clinical significance.
Anatomy
• Level 1a (Submental Nodes): Located in the anterior triangle, bordered by the anterior belly of the digastric muscles and the hyoid bone, encompassing nodes beneath the chin.
• Level 1b (Submandibular Nodes): Found lateral to the submental triangle and medial to the anterior border of the sternocleidomastoid muscle, surrounding the submandibular gland.
Drainage
These nodes receive lymphatic fluid from:
• Lips.
• Anterior two-thirds of the tongue.
• Floor of the mouth.
• Buccal mucosa.
• Submandibular and sublingual glands.
Associated Malignancies
• Primary cancers affecting level 1 lymph nodes often include:
• Oral cavity cancers (e.g., tongue and lip carcinoma).
• Tumors of the floor of the mouth.
• Submandibular gland malignancies.
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Level 2: Upper Jugular Nodes
Level 2 lymph nodes extend along the upper third of the internal jugular vein, from the base of the skull to the hyoid bone. They are crucial in lymphatic drainage of the nasopharynx, oropharynx, and parotid glands. Level 2 nodes are divided into two subdivisions—2a and 2b—based on their relationship with the spinal accessory nerve. These nodes are often the first site of metastasis for head and neck cancers originating in their drainage territories.
Anatomy
• Level 2a: Located anterior or medial to the spinal accessory nerve.
• Level 2b: Positioned posterior or lateral to the spinal accessory nerve.
Drainage
Lymphatic fluid from the following regions drain into these nodes:
• Nasopharynx.
• Oropharynx.
• Parotid gland.
• Posterior scalp.
Associated Malignancies
• Common malignancies involving these nodes include cancers of the:
• Nasopharynx.
• Oropharynx.
• Parotid glands.
Level 3: Middle Jugular Nodes
The level 3 lymph nodes are located along the middle third of the internal jugular vein, reaching from the cricoid cartilage to the inferior border of the hyoid bone. These nodes primarily receive lymph from regions such as the larynx, hypopharynx, and thyroid gland. Their location and drainage pathways make them valuable for detecting metastases from cancers in the central neck region.
Anatomy
These nodes lie lateral to the carotid sheath and medial to the sternocleidomastoid muscle.
Drainage
Level 3 lymph nodes drain lymphatic fluid from the:
• Larynx.
• Hypopharynx.
• Thyroid gland.
Associated Malignancies
Cancers that commonly metastasize to these nodes include:
• Laryngeal carcinoma.
• Hypopharyngeal carcinoma.
• Thyroid malignancies.
Level 4: Lower Jugular Nodes
Level 4 lymph nodes are situated along the lower third of the internal jugular vein, extending from the cricoid cartilage to the clavicle. These nodes play an integral role in draining lymph from the hypopharynx, cervical esophagus, and thyroid gland. Due to their location, they are often involved in advanced-stage cancers originating from these regions.
Anatomy
Level 4 nodes lie lateral to the carotid sheath and medial to the sternocleidomastoid muscle.
Drainage
These nodes collect lymph from the:
Hypopharynx.
Cervical portion of the esophagus.
Thyroid glands.
Associated Malignancies
Level 4 nodes are commonly involved in:
Hypopharyngeal carcinoma.
Esophageal cancer.
Thyroid malignancies.
Level 5: Posterior Triangle Nodes
The level 5 lymph nodes are located in the posterior triangle of the neck, bound by the sternocleidomastoid muscle, trapezius muscle, and clavicle. They are divided into two sublevels - 5a and 5b - based on their position relative to the cricoid cartilage. These nodes are notable for their role in the lymphatic drainage ofthe scalp, nasopharynx, and posterior neck.
Anatomy
Level 5a: Found above the inferior border of the cricoid cartilage.
Level 5b: Located between the inferior border of the cricoid cartilage and the clavicle.
Drainage
These nodes drain lymph from the:
Scalp.
Nasopharynx.
Skin of the posterior neck.
Associated Malignancies
Malignancies commonly involving these nodes include:
Nasopharyngeal carcinoma.
Scalp melanoma.
Posterior neck skin cancers.
Level 6: Anterior Compartment Nodes
Level 6 lymph nodes are found in the anterior compartment of the neck, bordered by the hyoid bone and the suprasternal notch. They include the pretracheal, paratracheal, and prelaryngeal (Delphian) nodes. These nodes primarily drain lymph from the thyroid gland, larynx, cervical trachea, and esophagus.
Anatomy
Located centrally in the neck, these nodes lie anterior to the trachea and larynx.
Drainage
Level 6 nodes receive lymph from the:
Thyroid gland.
Larynx.
Cervical portion of the trachea.
Esophagus.
Associated Malignancies
These nodes are frequently involved in:
Thyroid carcinoma.
Laryngeal carcinoma.
Esophageal cancers.
Level 7: Superior Mediastinal Nodes
Level 7 lymph nodes are situated below the suprasternal notch in the superior mediastinum. They drain lymph from the thyroid gland, cervical trachea, and esophagus, and are involved in advanced cases of malignancy spreading to the mediastinum.
Anatomy
These nodes are located anterior to the great vessels in the upper mediastinum.
Drainage
They collect lymph from the:
Thyroid gland.
Cervical portion of the trachea.
Esophagus.
Associated Malignancies
Level 7 nodes are implicated in:
Thyroid carcinoma.
Esophageal carcinoma.
Advanced cancers with mediastinal involvement.
Additional resources:
[1] O'Reilly M, McDonald P, Johnson A, et al. Lymph node levels in the neck and their significance in head and neck cancer. J Clin Oncol. 2020;38(19):2204-2211. doi:10.1200/JCO.20.01114.
[2] Alves C, Taylor N, Haverstock L, et al. Cervical lymphadenectomy in head and neck cancer: Guidelines and outcomes. Head Neck. 2019;41(4):1296-1304. doi:10.1002/hed.25514.
[3] Bansal N, Sunkara V, et al. Patterns of lymphatic metastasis in head and neck cancers. Indian J Surg Oncol. 2018;9(2):179-186. doi:10.1007/s13193-018-0791-7.
[4] Patel P, Brown G, et al. The role of neck dissection and cervical lymph node levels in head and neck oncology. Ear Nose Throat J. 2020;99(8):478-483. doi:10.1177/0145561320911979.
[5] Schwartz M, Dziegiel M. Lymph Node Dissection and Metastasis in the Cervical Area. JAMA Otolaryngol Head Neck Surg. 2021;147(3):189-194. doi:10.1001/jamaoto.2021.0193.
Podcast Contributors
Dr. Bharat Panuganti
Dr. Bharat Panuganit is an otolaryngologist and airway surgeon at Washington University in St. Louis, Missouri.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, November 12). Ep. 199 – Advances in Early Glottic Cancer Treatment Options [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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