Neck dissection

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  • 1. Neck Dissection RAKSHITH AVB
  • 2. Definition It is a procedure to remove lymph nodes and surrounding fibro fatty tissues from neck to eradicate metastasis to cervical lymph nodes in cancer of aerodigestive tract.
  • 3. Fascial layers of the neck
    • Superficial cervical fascia
    • • Deep cervical fascia
    • – Superficial layer
    • • SCM, strap muscles, trapezius
  • 4.
    • – Middle or Visceral Layer
    • • Thyroid
    • • Trachea
    • • esophagus
    • – Deep layer (also prevertebral fascia)
    • • Vertebral muscles
    • • Phrenic nerve
  • 5.  
  • 6. Level I
    • Submental triangle (Ia)
      • Anterior digastric
      • Hyoid
      • Mylohyoid
    • Submandibular triangle (Ib)
      • Anterior and posterior digastric
      • Mandible.
  • 7. Level I
    • Ia
      • Chin
      • Lower lip
      • Anterior floor of mouth
      • Mandibular incisors
      • Tip of tongue
  • 8.
    • Ib
      • Oral Cavity
      • Floor of mouth
      • Oral tongue
      • Nasal cavity (anterior)
      • Face
  • 9. Level II
    • Upper Jugular Nodes
        • Anterior  Lateral border of sternohyoid, posterior digastric and stylohyoid
        • Posterior  Posterior border of SCM
        • Skull base
        • Hyoid bone (clinical landmark)
        • Carotid bifurcation (surgical landmark)
  • 10.
    • Level IIa anterior to XI
    • Level IIb posterior to XI
      • Submuscular recess
      • Oropharynx > oral cavity and laryngeal mets
  • 11. Spinal Accessory Nerve
    • CN XI – Relationship with the IJV
  • 12. Level II
    • Oral Cavity
    • Nasal Cavity
    • Nasopharynx
    • Oropharynx
    • Larynx
    • Hypopharynx
    • Parotid
  • 13. Level III
    • Middle jugular nodes
      • Anterior  Lateral border of sternohyoid
      • Posterior  Posterior border of SCM
      • Inferior border of level II
      • Cricoid cartilage lower border (clinical landmark)
      • Omohyoid muscle (surgical landmark)
        • Junction with IJV
  • 14. Level III
    • Oral cavity
    • Nasopharynx
    • Oropharynx
    • Hypopharynx
    • Larynx
  • 15. Level IV
    • Lower jugular nodes
      • Anterior  Lateral border of sternohyoid
      • Posterior  Posterior border of SCM
      • Cricoid cartilage lower border (clinical landmark)
      • Omohyoid muscle (surgical landmark)
        • Junction with IJV
      • Clavicle
  • 16. Level IV
    • Hypopharynx
    • Larynx
    • Thyroid
    • Cervical esophagus
  • 17. Level V
    • Posterior triangle of neck
      • Posterior border of SCM
      • Clavicle
      • Anterior border of trapezius
      • Va  Spinal accessory nodes
      • Vb  Transverse cervical artery nodes
        • Radiologic landmark
          • Inferior border of Cricoid
      • Supraclavicular nodes
  • 18. Level V
    • Nasopharynx
    • Oropharynx
    • Posterior neck and scalp
  • 19. Level VI
    • Anterior Compartment Structures
    • Boundaries
    • Above by Hyoid bone
    • Below by Suprasternal notch
    • On either side by medial border of Carotid sheath
  • 20. Level VI
    • Lymph Nodes
      • Perithyroidal
      • Pretracheal
      • Precricoid Nodes (Delphian)
      • Paratracheal nodes along recurrent laryngeal nerves
  • 21. Level VI
    • Thyroid
    • Larynx (glottic and subglottic)
    • Pyriform sinus apex
    • Cervical esophagus
  • 22. Subgroups
    • 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
  • 23. Common Nodal Drainage Patterns Face and Scalp Anterior Facial, Ib   Lateral Parotid   Posterior Occipital, V Eyelids Medial Ib   Lateral Parotid, II Chin   Ia, Ib, II External Ear Anterior Parotid, II   Posterior Post auricular, II, V Middle Ear   Parotid, II Floor of mouth Anterior Ia, Ib, IIa > IIb   Lower incisors Ia, Ib, IIa > IIb   Lateral Ib, IIa > IIb , III   Teeth except incisors Ib, IIa > IIb , III Nasal Cavity Anterior Ib   Posterior Retropharyngeal, II, V
  • 24. Common Nodal Drainage Patterns Nasal Cavity Posterior Retropharyngeal, II, V Nasopharynx   Retropharyngeal, II, III, V Oropharynx   IIb > IIa, III, IV, V Larynx Supraglottic IIa > IIb, III, IV   Subglottic VI, IV Cervical esophagus   IV, VI Thyroid   VI, IV, V, Mediastinal Tongue Tip Ia, Ib, IIa > IIb, III, IV   Lateral Ib, IIa > IIb, III, IV
  • 25. Staging
    • Nx: Regional lymph nodes cannot be assessed.
    • N0: No regional lymph node metastases.
    • N1: Single ipsilateral lymph node, < 3 cm
  • 26. Staging
    • N2a: Single ipsilateral lymph node 3 to 6 cm
    • N2b: Multiple ipsilateral lymph nodes < 6 cm
    • N2c: Bilateral or contralateral nodes < 6cm
    • N3: Metastases > 6 cm
  • 27. Staging
    • Nasopharyngeal Carcinoma
      • N1 – Unilateral < 6cm
      • N2 – Bilateral < 6 cm
      • N3a > 6 cm
      • N3b – Extension to supraclavicular fossa
    • Thyroid
      • N1 – Regional node mets
        • N1a - Ipsilateral
        • N1b - Bilateral, midline, contralateral cervical or mediastinal LN
  • 28. Classification
    • The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type :
      • Radical Neck Dissection (RND)
      • Modified Radical Neck Dissection (MRND)
  • 29.
      • Selective Neck Dissection (SND)
        • Supraomohyoid
        • Posterolateral
        • Lateral
        • Anterior
      • Extended Radical Neck Dissection (ERND)
  • 30. Classification
    • Radical neck Dissection:
      • Removing all lymphatic tissues in regions I - V
      • Spinal Acessory Nerve
      • Internal Jugular vein
      • Sternocleidomastoid muscle
      • Submandibular Salivary gland
      • Tail of parotid
      • Omohyoid muscle
  • 31. Classification
    • 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 & IJV
        • Subtype III: preserve SAN, IJV and SCM
          • Known as Functional neck dissection (Bocca)
  • 32. Classification
    • Selective Neck dissection:
      • Any type of cervical lymphadenectomy with preservation of one or more lymph node groups
      • Four subtype:
        • Supraomohyoid neck dissection
        • Posterolateral neck dissection
        • Lateral neck dissection
        • Anterior neck dissection
  • 33. Classification
      • Supraomohyoid neck dissection:
        • Removal of lymph nodes in regions I –III
        • The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCM
        • The inferior limit is the superior belly of the omohyoid where it cross IJN
      • Posterolateral neck dissection
        • Removal of suboccipital, retroauricular, levels II – V and level V
        • Subtyped I – III depending on the preservation of SAN, IJV and /or SCM
  • 34. Classification
      • Lateral neck dissection:
        • Remove lymph nodes in levels II – IV
      • Anterior neck dissection:
        • Require the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VI
        • Superior limit, hyoid bone
        • Inferior limit, suprasternal notch
        • Laterally, the carotid sheath
  • 35. Structures to be preserved
    • Carotid artery
    • Brachial Plexus, Phrenic & vagus
    • nerve, cervical sympathetic chain,
    • marginal mandibular, lingual and
    • hypoglossal nerves
  • 36. Indications
    • Radical Neck Dissection
      • Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN
      • Large metastatic tumor mass or multiple matted in upper part of the neck
        • Tumor should not be dissected to preserve Structures
  • 37. Classification
    • Extended neck dissection:
      • Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues
  • 38. Facts
    • General nodal metastasis produce the following fact:
      • The most important factor in prognosis of SCC of the upper aero-digestive tract is the status of cervical lymph nodes
      • Cure rate drops 50% with involvement of the regional lymph nodes
  • 39. Indications
    • Modified radical neck dissection
      • MRND Type I:
        • Clinically obvious neck lymph nodes metastasis and SAN not involved by tumor
        • Intraoperative decision just like preservation of the facial nerve in parotid surgery
  • 40. Indications
    • MRND Type II:
      • Rarely planned
      • Intra-operative decision for tumor found adherent to SCM but away from SAN & IJV
    • MRND Type III:
      • Depend on the autopsy reports
        • Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels
        • They are not found within the aponeurosis or glandular capsule of the submandibular “Functional neck dissection”
  • 41. Indications
    • MRND Type III:
      • For treatment of N 0 neck nodes
      • Indicated for N 1 mobile nodes and not greater than 2.5 – 3.0 cm
        • Contra-indicated in the presence of node fixation
        • Result is difficult to interpret because of the use of radiation therapy
  • 42. Indications
    • Selective/elective neck dissection:
      • For treatment of N 0 neck nodes
      • For N+ nodes when combined with radiotherapy
        • Adjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spread
      • Upgrade intra-operatively following positive frozen section
  • 43. SND : Supra Omohyoid Type
    • Oral cavity carcinoma with N 0 Neck
    • Hoffman oral cavity
    • Level 1 – 30.1 %
    • Level 2 – 35.7 %
    • Level 3 – 22.8 %
    • Level 4 – 9.1 %
    • Level 5 – 2.2 %
  • 44. SND : Lateral Type
    • N 0 Neck in carcinomas of
    • Oropharynx
    • Hypopharynx
    • Supraglottis
    • Glottic Larynx
  • 45. SND : Posterolateral Type
    • - Cutaneous malignancies
        • Melanoma
        • SCC
        • Merkell cell Carcinoma
    • - Soft tissue sarcomas of scalp and neck
  • 46. SND : Anterior Compartment
    • Selected Cases of Thyroid Carcinoma
    • Parathyroid Carcinoma
    • Subglottic Carcinoma
    • CA of Cervical Oesophagus
  • 47. Y Incision
  • 48. McFee Incision
  • 49. H Incision
  • 50. J Incision
  • 51. COMPLICATIONS
    • Air embolus
    • Pneumothorax
    • Chyle leak & Chylus fistula
    • Wry Neck (Torticollis Coli)
    • Shoulder dysfunction
    • Cerebral oedema