Neck dissections
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  • 1.  History Of CANCER Anatomy of HEAD & NECK LYMPH NODE levels Staging of CANCER NECK DISSECTIONS COMPLICATIONS
  • 2.  1880  Kocher advocates wide marginlymphadenectomy 1881  Kocher and Packard recommenddissection of submandibular trianglefor lingual cancer 1885  Butlin questions RND for oral N0disease 1888  Jawdynski describes en blocresection with resection of carotid,IJV, SCM.Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
  • 3.  1901  Solis-Cohen advocatelymphadenectomy for N0 laryngealCA 1905 -1906  Crile describes enbloc resection in JAMA 1926  Bartlett and Callanderadvocate preservation of XI, IJV,SCM, platysma, stylohyoid, digastric 1933  Blair and Brown advocateremoval of XI.Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
  • 4.  1951  Martin advocates Radical Neck Dissection after analysis of1450 cases› Advocated RND for N+ cases. 1952 – Suarez describes a functional neck dissection› Preservation of SCM, omohyoid, submandibular gland, IJV, XI.› Enables protection of carotid. 1960’s – MD Anderson advocate selective ND of highest risk nodalbasins 1967 - Bocca and Pignataro describe the “functional neckdissection” 1975 – Bocca establishes oncologic safety of the FND compared tothe RNDFerlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
  • 5.  The region of theThe region of thebody that liesbody that liesbetween:between: TheThe LOWER BORDERLOWER BORDEROF THE MANDIBLEOF THE MANDIBLE&& TheThe SUPRASTERNALSUPRASTERNALNOTCHNOTCH and theand theUPPER BORDER OFUPPER BORDER OFCLAVICLE.CLAVICLE.
  • 6. • Superficial cervical fascia• Deep cervical fascia – Superficial layer• SCM, strap muscles, trapezius – Middle or Visceral Layer• Thyroid• Trachea• esophagus – Deep layer (also prevertebral fascia)• Vertebral muscles• Phrenic nerve
  • 7. Ext. jugularInt. jugularAnt. jugularSup. thyroidMiddlethyroidInf. thyroid
  • 8. • Origin – fascia overlying the pectoralismajor and deltoid muscle• Insertion – 1) depression muscles of thecorner of the mouth, 2) the mandible, and3) the SMAS layer of the face• Function –1) wrinkles the the neck2) depresses the corner of the mouth3) increases the diameter of the neck4) assists in venous return
  • 9. platysma
  • 10. Sternoclei-domastoidplatysma
  • 11.  Surgical considerations – Increases blood supply to skin flaps – Absent in the midline of the neck – Fibers run in an opposite direction to the SCM
  • 12. PrevertebrallayerTrapeziusInvestinglayerPretracheal layerBuccopharyngeal fasciaCarotid sheathesophaguss.c.mscalenustracheathyroidInfrahyoid m.Internal jugularveinCommon carotida.Vagus n.pretracheal fascia
  • 13. • Origin – 1) medial third of the clavicle(clavicular head)2) manubrium (sternal head) • Insertion – mastoid process • Nerve supply – spinal accessory nerve (CNXI) • Blood supply –1) occipital a. or direct from ECA2) superior thyroid a.3) transverse cervical a.
  • 14. Sternocleidomastoid
  • 15.  Function – turns head toward opposite sideand tilts head toward the ipsilateral shoulder • Surgical considerations– Leave overlying fascia (superficial layer of deepcervical fascia down)– Lateral retraction exposes the submuscular recess
  • 16. • Origin – upper border of the scapula• Insertion –1) via the intermediate tendon onto the clavicle andfirst rib2) hyoid bone lateral to the sternohyoid muscle • Blood supply – Inferior thyroid a. • Function –1) depress the hyoid2) tense the deep cervical fascia
  • 17.  Surgical considerations – Absent in 10% of individuals – Landmark demarcating level III from IV – Inferior belly lies superficial to• The brachial plexus• Phrenic nerve• Transverse cervical vessels – Superior belly lies superficial to• IJV
  • 18.  • Origin –1) medial 1/3 of the sup. Nuchal line2) external occipital protuberance3) ligamentum nuchae4) spinous process of C7 and T1-T12 • Insertion –1) lateral 1/3 of the clavicle2) acromion process3) spine of the scapula • Function – elevate and rotate the scapula andstabilize the shoulder
  • 19.  Surgical considerations – Posterior limit of Level V neck dissection – Denervation results in shoulder drop and wingedscapula
  • 20. • Origin – digastric fossa of the mandible (at thesymphyseal border• Insertion –1) hyoid bone via the intermediate tendon2) mastoid process• Function –1) elevate the hyoid bone2) depress the mandible (assists lateral pterygoid)
  • 21.  – Posterior belly is superficial to:• ECA• Hypoglossal nerve• ICA• IJV – Anterior belly• Landmark for identification of mylohyoid fordissection of the submandibular triangle
  • 22. Division of the neckAnterior triangleSuprahyoid region: submental trianglesubmandibular triangleInfrahyoid region: muscular trianglecarotid trianglePosterior triangle
  • 23. Submental triangle Lies below the chin and isbounded laterally byanterior bellies of digastric,and inferiorly by the bodyof hyoid bone Covered by skin,superficial fascia andinvesting fascia Floor - mylohyoid muscles Contents - submentallymph nodes
  • 24. digastric (anteriorand posterior belly)stylohyoidmylohyoidSuprahyoid muscles
  • 25. Submandibular triangle Bounded by anterior and posterior bellies of digastricand lower border of the body of the mandible Covered by skin, superficial fascia, platysma andinvesting fascia Floor - mylohyoid, hyoglossus and middleconstrictor of pharynx Contents - submandibular gland, faciala., v., hypoglossal n. and v., lingual n.,submandibular ganglion and submandibular lymphnodes
  • 26. Carotid trianglesternocleidomastoid,superior belly of omohyoidand posterior belly ofdigastic muscles Covered by skin, superficialfascia, platysma andinvesting fascia Floor - prevertebral fasciaand lateral wall of pharynx Contents - commoncarotid a. and its branches,internal jugular v. and itstributaries, hypoglossal n.with its descendingbranches, the accessoryand vagus nerves, and partof the chain of deepcervical lymph nodes
  • 27. Muscular triangle Bounded by midline of theneck, superior belly of theomohyoid and anteriorborder of thesternocleidomastoid. Covered by skin, superficialfascia, platysma, anteriorjugular v., coutaneous n. andinvesting fascia Floor - prevertebral fascia Contents - sternohyoid,sternothyroid, thyrohyoid,thyroid gland, parathyroidgland, cervical part oftrachea and esophagus
  • 28.  Bounded byposterior border ofsternocleidomastoid,anterior border oftrapezius and middlethird of clavicle Divided by inferiorbelly of omohyoidinto occipital andsupraclaviculartriangles
  • 29.  Arteries:Arteries: SubclavianSubclavian (3(3rdrdpart)part) Superficial cervical &Superficial cervical &suprascapularsuprascapular(branches of(branches ofthyrocervical trunkthyrocervical trunk, a, abranch ofbranch of 11ststpart ofpart ofsubclavian arterysubclavian artery OccipitalOccipital, a, a branchbranchof external carotidof external carotidarteryartery
  • 30.  Nerves:Nerves: Branches ofBranches ofcervicalcervicalplexusplexus Spinal part ofSpinal part ofaccessoryaccessorynervenerve BrachialBrachialplexusplexus
  • 31. Occipital triangle Bounded by posteriorborder ofsternocleidomastoid,anterior border oftrapezius and superiorborder of inferior belly ofomohyoid Covered by skin,superficial fascia, andinvesting fascia Floor - prevertebralfascia and scalenusanterior, scalenus medius,scalenus posterior,splenius capitis andlevator scapulae
  • 32.  Contents› Accessory n. - emerges above the middle ofthe posterior border of sternocleidomastoid andcrosses the occipital triangle to trapezius› Cervical and brachial PLEXUS
  • 33. Supraclavicular triangle Bounded by posteriorborder ofsternocleidomastoid,inferior belly of omohyoidand middle third ofclavicle Covered by skin,superficial fascia, andinvesting fascia Floor - prevertebralfascia and inferior parts ofscalenus Contents› Subclavian v. andvenous angle› Subclavian a.› Brachial plexus
  • 34.  Most commonly injurydissection level Ib Landmarks:› 1cm anterior and inferior toangle of mandible› Mandibular notch Subplatysmal Deep to fascia of thesubmandibular gland Superficial to facial vein
  • 35.  Motor nerve to thetongue • Cell bodies are in theHypoglossal nucleus ofthe Medulla oblongata • Exits the skull via thehypoglossal canal • Lies deep to the IJV,ICA, CN IX, X, and XI
  • 36.  • Curves 90 degrees and passes between the IJVand ICA– Surrounded by venous plexus • Extends upward along hyoglossus muscle andinto the genioglossus to the tip of the tongue. Iatrogenic injury – Most common site - floor of the submandibulartriangle, just deep to the duct
  • 37.  Penetrates deep surface ofthe SCM Exits posterior surface ofSCM deep to Erb’s point Traverses the posteriortriangle on the levatorscapulae Enters the trapezius about 5cm above the clavicleAnsa cervicalisHypoglossal n. (XII)Accessory n. (XI)Phrenic n.Vagus n. (X)
  • 38.  CN XI – Relationship with the IJV
  • 39.  Crosses the IJV • Crosses lateral to the transverse process ofthe atlas • Occipital artery crosses the nerve • Descends obliquely in level II (forms Level IIa andIIb
  • 40.  Developed by Memorial Sloan-KetteringCancer Center Ease and uniformity in describingregional nodal involvement in cancer ofthe head and neck
  • 41. LYMPH NODES acts as a barrier to thespread of the disease .Virchow in 1860
  • 42.  CAN BE DIVIDED INTO;a) SUPERFICIAL CHAIN OF LYMPH NODES…..b) VERTICAL DEEP CHAIN OF LYMPH NODESThis consists of nodes lying in relation tocarotid sheath.These lie along thevessels,trachea,oesophagusand extend frombase of skull to root of neck.
  • 43. 1. Submental2. Submandibular3. Parotid / tonsilar4. Preauricular5. Postauricular6. Occipital7. Anterior cervical superficialand deep8. Supraclavicular9. Posterior cervical
  • 44.  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 (Transversecervical) VI Central compartment
  • 45.  Submental triangle(Ia)› Anterior digastric› Hyoid› Mylohyoid Submandibulartriangle (Ib)› Anterior and posteriordigastric› Mandible.
  • 46.  Ia› Chin› Lower lip› Anterior floor of mouth› Mandibular incisors› Tip of tongue Ib› Oral Cavity› Floor of mouth› Oral tongue› Nasal cavity (anterior)› Face
  • 47.  Upper Jugular Nodes Anterior  Lateral border ofsternohyoid, posteriordigastric and stylohyoid Posterior  Posterior borderof SCM Skull base Hyoid bone Carotid bifurcation Level IIa anterior to XI Level IIb posterior to XI
  • 48.  Oral Cavity Nasal Cavity Nasopharynx Oropharynx Larynx Hypopharynx Parotid
  • 49.  Middle jugular nodes› Anterior  Lateral border ofsternohyoid› Posterior  Posterior borderof SCM› Inferior border of level II› Cricoid cartilage lowerborder
  • 50.  Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx
  • 51.  Lower jugular nodes› Anterior  Lateral borderof sternohyoid› Posterior  Posteriorborder of SCM› Cricoid cartilage lowerborder› Omohyoid muscle› Clavicle
  • 52.  Hypopharynx Larynx Thyroid Cervical esophagus
  • 53.  Posterior triangle of neck› Posterior border of SCM› Clavicle› Anterior border of trapezius› Va Spinal accessorynodes› Vb  Transverse cervicalartery nodes› Supraclavicular nodes
  • 54.  Nasopharynx Oropharynx Posterior neck and scalp
  • 55.  Anterior compartment› Hyoid› Suprasternal notch› Medial border of carotidsheath› Perithyroidal lymph nodes› Paratracheal lymphnodes› Precricoid (Delphian)lymph node
  • 56.  Thyroid Larynx (glottic and subglottic) Pyriform sinus apex Cervical esophagus
  • 57. Face and Scalp Anterior Facial, IbLateral ParotidPosterior Occipital, VEyelids Medial IbLateral Parotid, IIChin Ia, Ib, IIExternal Ear Anterior Parotid, IIPosterior Post auricular, II, VMiddle Ear Parotid, IIFloor of mouth Anterior Ia, Ib, IIa > IIbLower incisors Ia, Ib, IIa > IIbLateral Ib, IIa > IIb, IIITeeth except incisors Ib, IIa > IIb, IIINasal Cavity Anterior IbPosterior Retropharyngeal, II, V
  • 58. Nasal Cavity Posterior Retropharyngeal, II, VNasopharynx Retropharyngeal, II, III, VOropharynx IIb > IIa, III, IV, VLarynx Supraglottic IIa > IIb, III, IVSubglottic VI, IVCervicalesophagus IV, VIThyroid VI, IV, V, MediastinalTongue Tip Ia, Ib, IIa > IIb, III, IVLateral Ib, IIa > IIb, III, IV
  • 59.  • “N” classification – AJCC (1997) • Consistent for all mucosal sites except thenasopharynx • Thyroid and nasopharynx have different stagingbased on tumor behavior and prognosis • Based on extent of disease prior to first treatment
  • 60.  Nx: Regional lymph nodes cannot beassessed. N0: No regional lymph node metastases. N1: Single ipsilateral lymph node, < 3 cm
  • 61.  N2a: Single ipsilateral lymph node 3 to 6cm N2b: Multiple ipsilateral lymph nodes > 6cm N2c: Bilateral or contralateral nodes >6cm N3: Metastases > 6 cm
  • 62.  • Standardized until 1991 • Academy’s Committee for Head andNeck Surgery and Oncology publicizedstandard classification system
  • 63.  Academy’s classification – Based on 4 concepts• 1) RND is the standard basic procedure for cervicallymphadenectomy against which all othermodifications are compared• 2) Modifications of the RND which includepreservation of any non-lymphatic structures arereferred to as modified radical neck dissection(MRND)
  • 64.  Academy’s classification• 3) Any neck dissection that preserves one or moregroups or levels of lymph nodes is referred to as aselective neck dissection (SND)• 4) An extended neck dissection refers to theremoval of additional lymph node groups or non-lymphatic structures relative to the RND
  • 65.  Academy’s classification(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
  • 66.  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
  • 67.  Spiro’s classification– Radical (4 or 5 node levels resected) • Conventional radical neck dissection • Modified radical neck dissection • Extended radical neck dissection • Modified and extended radical neck dissection– Selective (3 node levels resected) • SOHND • Jugular dissection (Levels II-IV)-• Any other 3 node levels resected– Limited (no more than 2 node levels resected) • Paratracheal node dissection • Mediastinal node dissection • Any other 1 or 2 node levels resected
  • 68.  1. Presence of clinically positive N1, N2a,N2b & N3 nodesTreatment of No neck is still acontroversy. 2. Extra nodal spread (including skininvolvement) 3. Recurrence after RT treatment
  • 69.  1. Uncontrolled primary lesion 2. Involvement of internal / commoncarotid artery 3. Presence of distant metastasis. 4. Poor anaesthetic risk patient.
  • 70.  TYPES - Apron incision -Half apron incision -Conley incision -Double Y incision -H incision -Macfee incision - Y incision -Modified Schobinger incision -Schobinger
  • 71.   1.Good exposure of the neck andprimary disease. 2. Ensure viability of the skin flaps. Avoidacute angles 3. Protect carotid artery even in thecases of wound infection.
  • 72.  4. Facilitate reconstruction Example, ifpectoral muscle is used a lower limbshould be near the clavicle to enableflap accommodation. 5. It should be cosmetically acceptable.
  • 73.  Removes› Nodal groups I-V› SCM, IJV, XI› Submandibular gland,tail of parotid Preserves› Posterior auricular› Suboccipital› Retropharyngeal› Periparotid› Perifacial› Paratracheal nodes
  • 74.  Removes› Nodal groups I-V Preserves› SCM, IJV, XI (anycombination)› TYPE A MRND
  • 75.  Three types (Medina 1989) commonly referred tonot specifically named by committee.• Type I: Preservation of SAN• Type II: Preservation of SAN and IJV• Type III: Preservation of SAN, IJV, and SCM( “Functional neck dissection”)
  • 76.  • Indications– Clinically obvious lymph node metastases– SAN not involved by tumor–Intraoperative decision
  • 77.  • Indications– Rarely planned– Intraoperative tumor found adherent to theSCM, but not IJV and SAN
  • 78.  • Rationale– Suarez (1963) – necropsy and surgery specimens oflarynx and hypopharynx – lymph nodes do notshare the same adventitia as adjacent BV’s– Nodes not within muscular aponeurosis or glandularcapsule (submandibular gland)– Sharpe (1981) showed ) 0% involvement of the SCMin 98 RND specimens despite 73 have nodalmetastases – Survival approximates MRND Type I assuming IJV,and SCM not involved Widely accepted in Europe• Neck dissection of choice for N0 neck
  • 79.  Rationale– Reduce postsurgical shoulder pain andshoulder dysfunction– Improve cosmetic outcome– Reduce likelihood of bilateral IJVresection - Contralateral neckinvolvement
  • 80.  Definition– Cervical lymphadenectomy withpreservation of one or more lymph nodegroups– Four common subtypes: • Supraomohyoid neck dissection • Posterolateral neck dissection • Lateral neck dissection • Anterior neck dissection
  • 81.  Also known as an elective neck dissection• Rate of occult metastasis in clinically negative neck20-30%• Indication: primary lesion with 20% or greater risk ofoccult metastasis• Studies by Fisch and Sigel (1964) demonstratedpredictable routes of lymphatic spread frommucosal surfaces of the H&N• Need for post-op RT
  • 82. • Most commonly performed SND• Definition – En bloc removal of cervical lymph node groups I-III– Posterior limit is the cervical plexus and posteriorborder of the SCM– Inferior limit is the omohyoid muscle overlying theIJV
  • 83.  Indications– Oral cavity carcinoma with N0 neck • Boundaries – Vermillion border of lips tojunction of hard and soft palate,circumvallate papillae• Subsites - Lips, buccal mucosa, upper andloweralveolar ridges, retromolar trigone, hardpalate, and anterior 2/3s of the tongue andFOM– Medina recommends SOHND with T2-T4 NOor TX N1 (palpable node is <3cm, mobile,and in levels I or II)
  • 84. Bilateral SOHND • Anterior tongue • Oral tongue and FOM that approach the midline– SOHND + parotidectomy • Cutaneous SCCA of the cheek • Melanoma (Stage I – 1.5 to 4mm) of the cheek• Byers does not advocate elective neck dissectionfor buccal carcinoma – Adjuvant RT given to patients with > 2- 4 positivenodes +/- ECS.
  • 85. • Definition – En bloc removal of the jugular lymphnodes including Levels II-IV. Indications – N0 neck in carcinomas of the oropharynx,hypopharynx, supraglottis, and larynx
  • 86.  • Definition– En bloc excision of lymph bearing tissues inLevels 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
  • 87.  • Definition – En bloc removal of lymph structures inLevel VI • Perithyroidal nodes • Pretracheal nodes • Precricoid nodes (Delphian) • Paratracheal nodes along recurrentnerves – Limits of the dissection are the hyoidbone, suprasternal notch and carotidsheaths
  • 88.  Indications – Selected cases of thyroid carcinoma – Parathyroid carcinoma – Subglottic carcinoma – Laryngeal carcinoma with subglotticextension– CA of the cervical esophagus
  • 89.  • Definition – Any previous dissection which includes removalof one or more additional lymph node groupsand/or non-lymphatic structures. – Usually performed with N+ necks in MRND or RNDwhen metastases invade structures usuallypreserved
  • 90.  Indications – Carotid artery invasion – Other examples: • Resection of the hypoglossal nerve resection ordigastric muscle, • dissection of mediastinal nodes and centralcompartment for subglottic involvement, and • removal of retropharyngeal lymph nodes fortumors originating in the pharyngeal walls.
  • 91.  SUPERSELECTIVE NECK DISSECTION OFHEAD AND NECK cancer –Yet to come
  • 92.  4 TYPES- INTRA OP- IMMEDIATE POST OP- LATE POST OP- DELAYED COMPLICATIONS
  • 93.  Inadequate planning Inadvertent injury to local blood vesselsand nerves .-marginal mandibular N.- Spinal accessory N.- Cervical plexus- Brachial plexus- Thoracic duct injury .
  • 94.  Haemorrhage: Needs evaluation of theextent of bleeding and occasionallymay need re-exploration. Lymph leak: When the drainage is ofmilky fluid and is persistently high>100ml /day after 2days.A possibility oflymph leak has to be considered.
  • 95.  Carotid blow out: A dreadedcomplication that occurs secondary towound break down. If exposed thecarotids have to be covered usingvascularised flaps. Facial oedema: A common occurrenceusually settles down in 4-6 weeks.
  • 96.  Wound infection Fistulae Devitalisation of the reconstructed flap
  • 97.  Dysphagia ( CN V,IX, X, XI) Shoulder weakness Trismus
  • 98.  Pectoralis major myocutaneous flap Free fibula flap Deltoid muscle flap Forehead flap Cervical flap Radial forearm flap
  • 99.  • Cervical metastasis in SCCA of the upperaerodigestive tract continues to portend a poorprognosis • Staging will help determine what type neckdissection should be performed • Unified classification of neck nodal levels andclassification of neck dissection has to understoodwell. • Indications for neck dissection and type of neckdissection, especially in the N0 neck, is a stillcontroversial
  • 100. THANK YOUHAVE A NICE DAY