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BackTable / ENT / Article
Level 4 Lymph Nodes: Lower Jugular
Reilly Fogarty • Updated May 8, 2025 • 145 hits
Level 4 lymph nodes, also known as lower jugular lymph nodes, are located in the lower part of the neck. These nodes are an integral part of the lymphatic drainage system, particularly in the context of head and neck cancers. Their role in draining lymph from the thyroid, larynx, and esophagus makes them clinically significant in cancer diagnosis, staging, and treatment. This article explores their anatomy, drainage pathways, and association with malignancies.
Table of Contents
(1) Anatomy of Level 4 Lymph Nodes
(2) Drainage of Level 4 Lymph Nodes
(3) Associated Malignancies
(4) Imaging & Clinical Management
Anatomy of Level 4 Lymph Nodes
Level 4 lymph nodes are located along the bottom third of the internal jugular vein, extending from the clavicle up to the cricoid cartilage. These nodes lie in close proximity to vital structures such as the common carotid artery, internal jugular vein, and subclavian vessels. This location makes them essential in the lymphatic drainage of delicate and important structures in the head, neck, and upper chest.
As part of the jugular chain these nodes serve as a pathway for lymphatic fluid from both the upper esophagus and respiratory tracts and lower neck regions. Their position in this lymphatic drainage path makes them valuable in assessing how malignancies spread from some areas of the head and neck.
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Drainage of Level 4 Lymph Nodes
Level 4 lymph nodes are responsible for draining lymphatic fluid from several key regions, including:
• Thyroid Gland: These nodes are a primary drainage site for the thyroid, making them particularly sensitive as a tool in the staging of differentiated thyroid cancers.
• Larynx: Structures such as the vocal cords and surrounding tissues drain into the lower jugular nodes, making them significant in laryngeal cancer assessment.
• Esophagus: The upper and middle portions of the esophagus contribute lymphatic drainage to these nodes, linking them to esophageal malignancies.
• Oropharynx: Lymphatic fluid from the tonsils and the posterior tongue also drain into the lower jugular lymph nodes.
This drainage pattern underscores the importance of level 4 lymph nodes in the progression and staging of cancers originating in these areas.
Associated Malignancies
Level 4 lymph nodes are often involved in the metastatic spread of several types of cancers, including:
• Thyroid Cancer: Differentiated thyroid carcinomas frequently metastasize to level 4 nodes. Their involvement can guide the extent of surgical interventions, such as central and lateral neck dissections.
• Laryngeal Cancer: Advanced laryngeal cancer often spreads to lower jugular lymph nodes, particularly when tumors are located in the glottic or subglottic regions.
• Esophageal Cancer: Lymphatic spread from esophageal carcinomas frequently include the level 4 lymph nodes, reflecting a more advanced stage of disease.
• Head and Neck Squamous Cell Carcinoma (HNSCC): These cancers, particularly when originating in the oropharynx, may metastasize to level 4 lymph nodes, indicating disease progression.
In many cases, the involvement of level 4 nodes is a marker of advanced disease, necessitating more aggressive treatments like radiation therapy, chemotherapy, or comprehensive surgical dissection.
Imaging & Clinical Management
Imaging techniques, including CT, MRI, and PET scans, play a central role in assessing level 4 lymph nodes for enlargement or metastasis. Identifying involvement in these nodes can help clinicians determine cancer staging and develop a tailored treatment plan.
When metastases are detected in level 4 lymph nodes, surgical removal is often recommended. Depending on the type and stage of cancer, this may be combined with adjuvant treatments such as radiation or chemotherapy to improve outcomes. The involvement of level 4 lymph nodes frequently guides the scope and extent of surgical and therapeutic interventions.
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] Huo L, Wu Q, Sun X, et al. Role of neck lymph node dissection in oropharyngeal cancer management. Head Neck. 2021;43(5):1501-1510. doi:10.1002/hed.26627.
[3] Ferris RL, Mlynarek AM, LaVigne S, et al. Level 3 lymph node involvement in laryngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2021;147(4):338-345. doi:10.1001/archotol.2020.1684.
[4] Kherani A, Rajan S, Mazzaferri EL. Thyroid cancer and its regional spread. J Endocrinol Invest. 2020;43(6):783-792. doi:10.1007/s40618-020-01216-3.
[5] Spector ME, Zaki HS, Kumar P. Clinical management of thyroid cancer and neck dissection. Laryngoscope. 2022;132(1):123-130. doi:10.1002/lary.28549.
Podcast Contributors
Dr. Mihir Patel
Dr. Mihir Patel is an otolaryngologist head and neck surgeon and assistant professor with Emory Healthcare in Atlanta, Georgia.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, May 21). Ep. 172 – HPV & Oropharyngeal Cancer: Evolving Insights & Implications [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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