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Letters to the Editor
June 2000

A Criterion for Distinguishing Level V Nodes From Clavicular Nodes

Arch Otolaryngol Head Neck Surg. 2000;126(6):806-807. doi:

In the April 1999 issue of the ARCHIVES, Som et al1 present radiologic criteria for classifying cervical lymph nodes on cross-sectional imaging studies to correspond to the clinically accepted level system. We believe that there is some ambiguity in distinguishing level V nodes from supraclavicular nodes.

Based on the American Academy of Otolaryngology–Head and Neck Surgery 1998 classification,2 Som and colleagues indicate that the inferior border of the level IV and V regions is the superior margin of the clavicle. Below the superior margin of the clavicle, nodes are defined as supraclavicular for concordance with the American Joint Committee on Cancer 1997 classification3 (Som et al,1 Table 2). This definition leads to a counterintuitive, but appropriate, definition in which "supraclavicular nodes" are actually inferior to the clavicle. Because the position of the clavicle may range widely on axial imaging, depending on the elevation of the shoulder, it is our experience that neck nodes proper are often called supraclavicular, simply because a portion of the clavicle is seen on the axial image. Typically, these nodes are well within the scope of a neck dissection, and are properly level IV or V. This ambiguity is made evident by Som and colleagues in Figure 6, in which nodes labeled as level V are, in the figure legend, stated to have been incorrectly labeled, and, rather, should be labeled supraclavicular nodes. In fact, the figure is correct as labeled, as elaborated below.

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