Neck Dissection.Overview


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Neck Dissection.Overview

  2. 2.  PRESENTER—DR. MD. ABUBAKAR SHAH  FCPS PART-II TRAINAE ,  Dept. ORAL and Maxillofacial Surgery  Dhaka Dental College Hospital
  3. 3.  The region of the bodyThe region of the body that lies between:that lies between:  TheThe LOWER BORDERLOWER BORDER OF THEOF THE MANDIBLEMANDIBLE&Mastoid&Mastoid TIPTIP  TheThe SUPRASTERNALSUPRASTERNAL NOTCHNOTCH and theand the UPPER BORDER OFUPPER BORDER OF CLAVICLE.CLAVICLE.
  4. 4. DEFINITION OF NECK DISSECTION  The neck dissection is a surgical procedure for control of neck lymph node metastasis. This can be done for clinically or radiologically evident lymph nodes or as part of curative surgery where risk of occult nodal metastasis is deemed sufficiently high.  It is a procedure to remove lymph nodes and surroundingIt is a procedure to remove lymph nodes and surrounding fibro fatty tissues from neck to eradicate metastasis tofibro fatty tissues from neck to eradicate metastasis to cervical lymph nodes in cancer of aerodigestive tractcervical lymph nodes in cancer of aerodigestive tract
  5. 5. Emil Theodor Kocher Earned Nobel Prize in 1909 for his work in thyroid and neck surgery — the first ever awarded to a surgeon. 1880 – Kocher proposed rem oving nodal m etastases
  6. 6. 1967 - Bocca and Pignataro described the “functional neck
  7. 7. 1906 – George Crile described the classic radical neck dissection (RND)
  8. 8. INDICATION  The metastases may originate from tumours of the upper aerodigestive tract, including the oral cavity tongue, nasopharynx, oropharynx, hypopharynx, and larynx, as well as the thyroid, parotid and posterior scalp. Neck nodal metastasis can sometimes also originate from lung cancer or intra-abdominal malignancy.
  9. 9. Oral cavity cancer
  14. 14.  CAN BE DIVIDED INTO; a) SUPERFICIAL CHAIN OF LYMPH NODES….. b) VERTICAL DEEP CHAIN OF LYMPH NODES This consists of nodes lying in relation to carotid sheath.These lie along the vessels,trachea,oesophagusand extend from base of skull to root of neck.
  15. 15. 1. Submental 2. Submandibular 3. Parotid / tonsilar 4. Preauricular 5. Postauricular 6. Occipital 7. Anterior cervical superficial and deep 8. Supraclavicular 9. Posterior cervical
  16. 16.  Ia Submental  Ib Submandibular  IIa Upper jugular (Anterior to XI)  IIb Upper jugular (Posterior to XI)  III Middle jugular  IVa Lower jugular (Clavicular)  IVb Lower jugular (Sternal)  Va Posterior triangle (XI)  Vb Posterior triangle (Transverse cervical)  VI Central compartment
  17. 17. Level ILevel I  SubmentalSubmental triangle (Ia)triangle (Ia)  Anterior digastricAnterior digastric  HyoidHyoid  MylohyoidMylohyoid  SubmandibularSubmandibular triangle (Ib)triangle (Ib)  Anterior andAnterior and posterior digastricposterior digastric  MandibleMandible..
  18. 18. Level IILevel IIUpper Jugular NodesUpper Jugular Nodes jugulodigastric, and upper posterior cervical nodes  AnteriorAnterior  Lateral borderLateral border of sternohyoid, posteriorof sternohyoid, posterior digastric and stylohyoiddigastric and stylohyoid  PosteriorPosterior  PosteriorPosterior border of SCMborder of SCM  Skull baseSkull base  Hyoid bone (clinicalHyoid bone (clinical landmark)landmark)  Carotid bifurcationCarotid bifurcation (surgical(surgical landmark)landmark)
  19. 19. Level IIILevel III  Middle jugular nodesMiddle jugular nodes  AnteriorAnterior  Lateral border ofLateral border of sternohyoidsternohyoid  PosteriorPosterior  Posterior border ofPosterior border of SCMSCM  Inferior border of level IIInferior border of level II  Cricoid cartilage lower borderCricoid cartilage lower border (clinical landmark)(clinical landmark)  Omohyoid muscle (surgicalOmohyoid muscle (surgical landmark)landmark)  Junction with IJVJunction with IJV
  20. 20. Level IVLevel IV  Lower jugular nodesLower jugular nodes  AnteriorAnterior  Lateral border ofLateral border of sternohyoidsternohyoid  PosteriorPosterior  Posterior border ofPosterior border of SCMSCM  Cricoid cartilage lower borderCricoid cartilage lower border (clinical landmark)(clinical landmark)  Omohyoid muscle (surgicalOmohyoid muscle (surgical landmark)landmark)  Junction with IJVJunction with IJV  ClavicleClavicle
  21. 21. Level VLevel V  Posterior triangle of neckPosterior triangle of neck  Posterior border of SCMPosterior border of SCM  ClavicleClavicle  Anterior border of trapeziusAnterior border of trapezius  VaVa Spinal accessory nodesSpinal accessory nodes  VbVb  Transverse cervical arteryTransverse cervical artery nodesnodes  Radiologic landmarkRadiologic landmark  Inferior border of CricoidInferior border of Cricoid  Supraclavicular nodesSupraclavicular nodes
  22. 22. Level VILevel VI Anterior CompartmentAnterior Compartment StructuresStructures BoundariesBoundaries • Above by Hyoid boneAbove by Hyoid bone • Below by SuprasternalBelow by Suprasternal notchnotch • On either side byOn either side by medial border ofmedial border of Carotid sheathCarotid sheath Lymph NodesLymph Nodes  PerithyroidalPerithyroidal  PretrachealPretracheal  Precricoid NodesPrecricoid Nodes (Delphian)(Delphian)  Paratracheal nodesParatracheal nodes along recurrentalong recurrent laryngeal nerveslaryngeal nerves
  23. 23. Spinal Accessory NerveSpinal Accessory Nerve  CN XI – Relationship with the IJVCN XI – Relationship with the IJV
  24. 24. StagingStaging  Nx: Regional lymph nodes cannot be assessed.Nx: Regional lymph nodes cannot be assessed.  N0: No regional lymph node metastases.N0: No regional lymph node metastases.  N1: Single ipsilateral lymph node,N1: Single ipsilateral lymph node, << 3 cm3 cm
  25. 25. StagingStaging  N2a: Single ipsilateral lymph node 3 to 6 cmN2a: Single ipsilateral lymph node 3 to 6 cm  N2b: Multiple ipsilateral lymph nodesN2b: Multiple ipsilateral lymph nodes << 6 cm6 cm  N2c: Bilateral or contralateral nodesN2c: Bilateral or contralateral nodes << 6cm6cm  N3: Metastases > 6 cmN3: Metastases > 6 cm
  26. 26. • Academy’s Committee for Head and Neck Surgery and Oncology publicized standard classification syste(1991) – 1) Radical neck dissection (RND) – 2) Modified radical neck dissection (MRND) – 3) Selective neck dissection (SND)  • Supra-omohyoid type  • Lateral type  • Posterolateral type  • Anterior compartment type – 4) Extended radical neck dissection
  27. 27.  Medina classification (1989) – Comprehensive neck dissection  • Radical neck dissection  • Modified radical neck dissection – Type I (XI preserved) – Type II (XI, IJV preserved) – Type III (XI, IJV, and SCM preserved) – Selective neck dissection
  28. 28. Radical neck Dissection: Removing all lymphatic tissues(Lymphnode ,surrouding fascia and fibo-fatty tisue) in regions I - V and include removal of SAN, SCM and IJV RADICAL NECK DISSECTION
  29. 29. Structures to be preservedStructures to be preserved  Carotid arteryCarotid artery  Brachial Plexus, Phrenic & vagusBrachial Plexus, Phrenic & vagus nerve, cervical sympathetic chain,nerve, cervical sympathetic chain, marginal mandibular, lingual andmarginal mandibular, lingual and hypoglossal nerveshypoglossal nerves
  30. 30. INDICATION  1. Significant operable neck dissea (N2a,N2b, N3) with tumour bulk near or directly involve spinal accessory nerve and/or internal jugular vein.  2.Extensive recurrent disease after previous surgery or radiotherapy.  3.Clinical sign of gross extranodal disease
  31. 31. Contra-indication  1.Untreatable primary tumour or unresectable neck disease(i.e-encasement of brachial plexus, internal carotid artery, prevertebral fascia.  2.Patient unfit for major surgery  3.Simaltaneous bilateral neck dissection  4. Distant metatases
  32. 32. Modified radical neck dissection  Modified radical neck dissection:  Excision of all lymph nodes removed with RND with preservation of one or more non- lymphatic structures, SAN, SCM and/or IJV  Subtype I: Preserve SAN  Subtype II: Preserve SAN & SJV  Subtype III: preserve SAN, SJV and SCM  Known as Functional neck dissection (Bocca
  33. 33. Modified radical neck dissection
  34. 34.  Definition—is a procedure in which one or more lymphnode group are preserved in addition to non lymphatic structure. – Four common subtypes:  • Supraomohyoid neck dissection  • Posterolateral neck dissection  • Lateral neck dissection  • Anterior neck dissection
  35. 35. INDICATION OF SELECTIVE NECK DISSECTION  1. Clinically No Neck  2.Some author proposed –In case of N1 Neck can be done if single lymphnode  3.When post operative plan for clinically N2 Neack , it can be done in very selected cases
  36. 36. SELECTIVE NECK DISSECTION FOR ORAL CANCER  1.SND (I-III) OR SUPRA-OMOHYOID IS indicated for oral cancer.  2. T1-T4 with clinical No neck  3.indicted for contra-lateral neck in midline lession of the floor of the mouth or ventral tongue.  4. Other indication-extension of parotid surgery, facial skin malignancy anterior to the tragus  5. In case antero-lateral part of the tongue level I-IV also be considered.
  37. 37. • Most commonly performed SND • Definition  – En bloc removal of cervical lymph node groups I-III – Posterior limit is the cervical plexus and posterior border of the SCM – Inferior limit is the omohyoid muscle overlying the IJV
  38. 38.  Indications – Oral cavity carcinoma with N0 neck  • Boundaries – Vermillion border of lips to junction of hard and soft palate, circumvallate papillae • Subsites - Lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone, hard palate, and anterior 2/3s of the tongue and FOM – Medina recommends SOHND with T2-T4 NO or TX N1 (palpable node is <3cm, mobile, and in levels I or II)
  39. 39. BILATERAL SONDBILATERAL SOND  1.Anterior tongue  2. Oral tongue and FOM that approach the midline – SOHND + parotidectomy 3. Melanoma (Stage I – 1.5 to 4mm) of the cheek
  40. 40. • Definition  – En bloc removal of the jugular lymph nodes including Levels II-IV.  Indications  – N0 neck in carcinomas of the oropharynx, hypopharynx, supraglottis, and larynx
  41. 41.  • Definition – En bloc excision of lymph bearing tissues in Levels II-IV and additional node groups – suboccipital and postauricular.  Indications – Cutaneous malignancies • Melanoma • Squamous cell carcinoma • Merkel cell carcinoma – Soft tissue sarcomas of the scalp and neck
  42. 42.  • Definition  – En bloc removal of lymph structures in Level VI  • Perithyroidal nodes  • Pretracheal nodes  • Precricoid nodes (Delphian)  • Paratracheal nodes along recurrent nerves  – Limits of the dissection are the hyoid bone, suprasternal notch and carotid sheaths
  43. 43. CONTINUE--CONTINUE--  Indications  – Selected cases of thyroid carcinoma  – Parathyroid carcinoma  – Subglottic carcinoma  – Laryngeal carcinoma with subglottic extension – CA of the cervical esophagus
  44. 44.  • Definition  – Removal of one or more additional lymphatic groups and/or non-lymphatic structures relatively to a radical neck VII, Retro-pharyngeal lymphnode, hypoglosal nerve, carotid artery.
  45. 45. INDICATIONINDICATION  – Carotid artery invasion  – Other examples:  • Resection of the hypoglossal nerve resection or digastric muscle,  • dissection of mediastinal nodes and central compartment for subglottic involvement, and  • removal of retropharyngeal lymph nodes for tumors originating in the pharyngeal walls.
  46. 46. PREOPERATIVE PREPARATION 1. Ensure all documentation, preoperative procedures, and orders are complete. 2. Check the surgical consent form and others for completeness. 3. Document allergies. 4. Document height and weight. 5. History and Physical. 6. Baseline vital signs. 7. Ensure results of all laboratory and diagnostic tests are on the chart. 8. Document and report any abnormal results. 9. Report special needs and concerns.
  47. 47. POSITION OF THE PATIENT 1. The patient is laid supine 2. The head turned opposite side and hyperextended, resting on a head ring 3. A Sand bag or a towel or pillow or inflatable rubber bag is placed below the shoulder 4. Upper end of the operating table elevated approximately 30 degree.
  48. 48. Continue---  When draping the surgical field the following ipsilateral landmarks should be visible  Mastoid tip., Ear lobule, Body of the mandible, midline of the chin, supra-sternal notch, clavicle and region of trapizius muscle insertion
  49. 49.  1.Good exposure of the neck and primary disease.  2. Ensure viability of the skin flaps. Avoid acute angles  3. Protect carotid artery even in the cases of wound infection  4.Considered preoperative factor—previous radio or chemotherapy.
  50. 50. Continue--  5. Facilitate reconstruction Example, if pectoral muscle is used a lower limb should be near the clavicle to enable flap accommodation.  6. It should be cosmetically acceptable
  52. 52. CONTINUE--
  53. 53. COMPLICATION OF NECK DISSECTION AND THEIR MANAGEMENT Complications of neck dissection can be broadly divided into Early, Intermediate and Late.
  54. 54. EARLY COMPLICATION  1. Haemorrage  2. Air embolism  3.Respiratory distress  4.Nurological injury  5.chyle leakage
  55. 55. CONTINUE--  If a hematoma is detected early,“milking” the drains occasionally may result in evacuation of the accumulated blood andt he problem will resolve.  If this is not accomplished immediately or if blood re- accumulates quickly, it is best to return the patient to the operating room, explore the wound under sterile conditions, evacuate the hematoma, and control the bleeding
  56. 56. HAEMORRAGE  Postoperative hemorrhage usually occurs immediately after surgery. External bleeding through the incision often originates in a subcutaneous blood vessel.  In most patients, this may be readily controlled by ligation, direct cauterization or infiltration of the surroundin tissues with an anesthetic solution containing epinephrine.
  57. 57. CHYLOUS LEAKAGE  This happens due injury to the thoracic duct while performing a radical surgery low in the neck or mediastinum. If chylous fistula is suspected every attempt should be made to seal itat the time of surgery by identifying it by head down positions and performing modified valsalva manoeuvre.
  58. 58. Continue---  It should be suspected when the drain collection increases dramatically by volume. Fat restricted diet, and daily pressure dressings are the form of conservativ treatment for chyle leak.  When the drain collection reaches 600 ml per day or more, it is an Indication for exploration and repair of the injured thoracic duct under microscope
  59. 59. Increased intracranial pressure  This usually occurs when the internal jugular vein is ligated. When one internal jugular vein is ligated the pressure rises by 3 fold and when both are ligated it increases by 5 fold.  This is usually is temporary and will normalize in 24 hours. If it persists, head end elevation,steroids and mannitol can be used.
  60. 60. Carotid blowout  Carotid blow-out   This is associated with over 60% morbidity and 50% mortality.   Neurological sequaelae of emergency ligation include hemiplegia, hemi- anaesthesia, aphasia and dysarthria.   If impending blow out is suspected, endovascular techniques with stent- grafts may be indicated rather than open ligation although short-term complications still occur.
  61. 61. Carotid sinus syndrome  This is due to undue pressure and manipulation on the carotid sinus baroreceptor which may result in hypotension and bradycardia.  Post operative scarring may also make the receptor sensitive to even palpation and turning head.
  62. 62. AIR WAY OBSTRUCTION  Airway obstruction In cases of bilateral neck dissections there may be associated soft tissue edema.  It is always prudent to carry out a temporary elective tracheotomy to protect the airway.
  63. 63. PNEUMOTHORAX  Too much lower neck dissection may cause injury to the apical pleura causing pneumothorax.  Patient may become restless, cyanosed and dyspnoeic after operation.  plain radiograph of chest most often provides the diagnosis. Minimal emphysema may resolve itself but whereas severe cases may require intercostal chest drains
  64. 64. AIR EMBOLOUS   This is a rare event which can occur following injury to the IJV.   Large emboli can produce sudden falls in end-tidal carbon dioxide and arterial blood pressure.   Local pressure should be applied and the anaesthetist informed so the patient can be placed in the Trendelenburg position and rotated to the left.   In severe cases attempts can be made to pass a catheter and aspirate air from the right side of the heart.
  65. 65. Spinal nerve injury  Injury to the spinal accessory nerve can cause an accessory nerve disorder or spinal accessory nerve palsy, which results in diminished or absent function of the sternocleidomastoid muscle and upper portion of the trapezius muscle.
  66. 66.  Immediate symptoms, recognised by the patient, include pain over the affected muscle, limitation of movement  loss of abduction), and a feeling of heaviness in the arm.
  67. 67.  Late sequelae o-:  1 Drooping of the shoulder secondary to trapezius paralysis and Atrophy of the trapezius with appreciable asymmetry 2, Weakness or loss of shoulder abduction (usually lessthan 900); 3. Pain which is usually mild-a persistent ache in the region of the affected muscle-but may be severe and involving not only the shoulder but also the arm, forearm, hand, scalp, and face of the affected side. 4.Contralateral pain has also been recorded (6).e
  69. 69. LINGUAL NERVE INJURY numbness and tingling of the left side of her tongue and the floor of her mouth
  70. 70.  The great auricular nerve originates from the cervical plexus, composed of branches of spinal nerves C2 and C3. It provides sensory innervation for the skin over parotid gland and mastoid process, and both surfaces of the outer ear. 
  71. 71. HYPOGLOSAL NERVE PARALYSIS  Unilateral damage to the nerve supply leads to wasting, weakness and fasciculation of that side of the tongue  immediately followed by deviation of the tongue to the same side as the injury
  72. 72. Marginal mandibular nerve  Injury to this nerve causes an obvious cosmetic deformity with asymmetry of the motion of the corner of the mouth.
  73. 73. VAGUS NERVE  Vagus nerve injury may manifest as aspiration and voice problems
  74. 74. INTERMEDIATE COMPLICATIONS 1. WOUND DEHISCNCE— --Exposed of the great vessel --chylous fistula 2.Pulmonary complications --Basal collapse and bronchopneumonia may occur in patients who are smokers and have pre-existing chronic obstructive lung disease. 3..Deep vein thrombosis ---This is seen in patients in old age, surgeries lasting for more duration, long bedridden patients and patients with previous history of deep vein thrombosis, pulmonary embolism,myocardial infarction and thrombophilia
  75. 75. Carotid Artery rupture  This usually occurs when the skin wound breaks down because of previous irradiation,secondary infection, poor metabolic condition of the patient. It is a fatal complication
  76. 76. LATE COMPLICATION 1.Recurrence  ----IT can be at the primary site, in the neck nodes or as a distant metastasis. 2.Lymph edema lymphedema often follows owing to interruption of the lymphatic drainage channels from the head. 3.Hypertrophic scars