NECK
DISSECTION
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentala...
Contents
Introduction
Cervical lymphatics – its drainage
Levels & Sublevels of lymph nodes - their implications
What is ne...
Contents …
Incisions
Description of classical RND
Description of other types of neck dissection
Complications in RND
Clini...
Introduction

Surgery is the oldest and the most reliable form of
treatment for oral malignancy.
what is the need for the ...
Lymphatic system of head and neck

www.indiandentalacademy.com
Patterns of cervical lymphatic metastasis
Lymphatic flow in the neck - consistent pattern - upper neck and
then to the low...
Post floor of mouth

Mandibular incisors

Maxillary sinus

Tongue(tip)

Maxillary teeth except 3rd molar

Lower lip (middl...
RETROPHARYNGEAL

Scalp
Ear
Eyelids

PAROTID NODES

3rd Molars
Tongue (base)
Tonsillar area
Soft palate

UPPER DEEP CERVICA...
The regional lymph node groups draining a specific primary site as
first echelon lymph nodes

www.indiandentalacademy.com
The first echelon lymph nodes at highest risk from primary tumors in
the oral cavity

www.indiandentalacademy.com
Concept of Sentinel Node

Omgo E. Nieweg et al., Annals of Surgical Oncology, 8(6):538–541

“the first lymph node that
rec...
Risk for nodal metastasis
Various factors
Site
Size
T stage
Location of primary tumour
Histomorphologic characteristics of...
Risk of nodal metastases increases in relation to location of the
primary tumor

www.indiandentalacademy.com
Lymph drainage of tongue, as described by
Jamieson and Dobson

www.indiandentalacademy.com
The incidence of lymph node metastasis and survival in relation to the
thickness of the primary lesions for T1 and T2 SCC ...
The probability of
cervical metastases
(N)
related
to
primary staging (T) in
pts with head & neck
SCC

www.indiandentalaca...
Memorial Sloan – Kettering Cancer Center leveling system
of cervical lymph nodes

www.indiandentalacademy.com
Division of neck levels by sublevels
IA – submental nodes
IB – submandibular nodes
IIA & IIB – together
comprising
the
upp...
Rationale of sublevels
Suggested by Suen and Goepfert (1997)
Subzones have biological significance independent of
the larg...
Level II subzones
Oropharynx and nasopharynx – IIb
Oral cavity, larynx and hypopharynx – may not be
necessary to dissect I...
Neck Dissection

www.indiandentalacademy.com
What is neck dissection?
The term "neck dissection" refers to a surgical
procedure in which the fibro-fatty soft tissue
co...
Historical Perspective

www.indiandentalacademy.com
In 1906 paper
“Exicision of cancer of the

head and neck ”

Gold standard procedure :

“Radical Neck dissection”
Dr George...
In 1951 paper
“Neck Dissection”

“Routine prophylactic RND was
impracticle”

www.indiandentalacademy.com Martin
Dr. Hayes
...
1880 – Kocher –proposed removal of nodal metastasis
1906 – George Crile –RND
1933 & 1941 – Blair and Martin popularised RN...
Concepts behind classification of neck
dissection
Based on 4 concepts
RND: the standard basic procedure - against which al...
MEDINA CLASSIFICATION(1989)
Comprehensive neck dissection
1.
2.

Radical neck dissection (RND)
Modified radical neck disse...
Spiro’s classification
Radical (4 or 5 node levels resected)
Conventional radical neck dissection
Modified radical neck di...
AAO-HNS CLASSIFICATION *
1991

Classification

2001 Classification

* Neck dissection classification update-Revisions prop...
Surgical Anatomy
‘Anatomy is a language,
As dead as can be,
It killed the ancient medics,
And now it’s killing me’

www.in...
Fascial layers of the neck
Superficial cervical fascia
Deep cervical fascia
Superficial layer
• SCM, strap muscles, trapez...
www.indiandentalacademy.com
Triangles of neck

www.indiandentalacademy.com
Imp structures in posterior triangle

www.indiandentalacademy.com
Submandibular space

www.indiandentalacademy.com
Facial artery and submandibular gland

www.indiandentalacademy.com
Platysma
Origin – fascia overlying the pectoralis major and
deltoid muscle
Insertion – 1) depressor muscles of the corner ...
Surgical considerations
Absent in the
midline of the neck
& posteriorly in
part of post
triangle

Does platysma
supplies s...
Omohyoid muscle
Origin – upper border of the scapula
Insertion – 1) via the intermediate tendon onto the
clavicle and firs...
Surgical considerations
Absent in 10% of
individuals
Landmark demarcating
level III from IV
Inferior belly lies
superficia...
Trapezius muscle
Origin –
1) medial 1/3 of
sup. nuchal line
2) ext occipital
protub
3) ligamentum nuchae
4) spinous pr of ...
Function – elevate and rotate the scapula and stabilize
the shoulder
Surgical considerations
Posterior limit of Level V ne...
Digastric Muscle
Origin – digastric fossa of the mandible (at the
symphyseal border
Insertion – 1) hyoid bone via the inte...
Surgical considerations
Posterior belly is
superficial to:
•
•
•
•

ECA
Hypoglossal nerve
ICA
IJV

Anterior belly
• Landma...
Marginal Mandibular Nerve
Should be preserved
Most commonly injuredat level 1b
Can be found:
1 cm ant & inf to angle of
ma...
www.indiandentalacademy.com
Spinal accessory nerve
After emerging from jugular foramen, crosses the IJV
Occipital artery crosses the nerve
Descends ob...
CN XI – Relationship with the IJV

www.indiandentalacademy.com
Hypoglossal Nerve

www.indiandentalacademy.com
Venous system

www.indiandentalacademy.com
Thoracic Duct
Conveys lymph from the entire body back to the blood
Exceptions:
Right side of head and neck, RUE, right lun...
www.indiandentalacademy.com
www.indiandentalacademy.com
Anatomy of the vascularization of neck skin
Kambic and Sirca 1967 stated that arterial supply is
in a vertical direction.
...
The vasculature can be summarized into
upper neck region - anterior to the angle of mandible –
branches of facial and subm...
www.indiandentalacademy.com
Incisions
Incisions classified into
Vertical
Horizontal

The incisions used for neck dissections are
Tri-radiate incision ...
Basic needs of an incision are
Good exposure of the neck and primary disease
Ensure viability of the skin flaps. Avoid acu...
Differences between incisions
Transverse incision

Vertical incision

Have cosmetic advantage as they
follow natural skin ...
Tri-radiate incision and its modifications
Advantages
Incision
provides
good
exposure to surgical site.

Disadvantages
Fla...
Modification of Tri-radiate incision

Schobinger (1957)
Cramer & Culf (1969)
Conley (1970)

www.indiandentalacademy.com
Schobinger (1957)
Schobinger
suggested
that
vertical
limb
instead
of
being
straight
should
be
curved posteriorly in
order ...
Conley (1970)
Suggested a posteriorly
curving vertical incision
rather than a horizontal
incision
The incision starts from...
Hayes Martin Incision
Paired ‘Y’ incision.
the
submandibular
component is met by a
vertical limb which below
becomes conti...
McFee Incision
Avoids a vertical limb.
Two horizontal incisions
are
used
one
in
submandibular region
and other in the
supr...
Advantages

Disadvantages

Excellent cosmetic result (McFee
1960, McNeil 1978)

Exposure is not good (Hetter 1972)

No ↓ i...
Apron flaps
Described by Latyschevsky & Freund
1960.
Only a horizontal incision from mastoid
gently curving inferiorly upt...
Hockey stick incision
Lahey et al (1940)
Modified for RND by Eckert
& Byars 1952.
It has a longitudinal and
transverse inc...
Radical neck dissection

www.indiandentalacademy.com
RND… Indications
Current indications for classical RND
N3 disease
Multiple gross metastases involving multiple levels.
Rec...
Contraindications
Neck dissection is contraindicated in disease beyond
the superficial or deep cervical fascia. These incl...
The sequence of neck dissection
as described by Hayes Martin

www.indiandentalacademy.com
Incision

Dissection of post t’gle begins
at ant border of trapezius

www.indiandentalacademy.com
Radical neck dissection predominantly from behind forward
makes use of the anatomical fact that the IJV does not
have post...
Dissection of post t’gle medially →
exposure of brachial plexus, phrenic
n. & cut roots of cervical plexus

SCM dissected ...
IJV ligated & divided after
common carotid & vagus n
exposed & retracted medially

Dissection proceeds along the
carotid s...
www.indiandentalacademy.com
Surgical field
following RND

www.indiandentalacademy.com
Two suction drains inserted

www.indiandentalacademy.com

Final closure
Bilateral RND
Not often performed
Loss of both SCMs → difficulty in
lifting head, esthetics
Loss of both XI Ns → doubling ...
Complications of ligating bilat IJVs simultaneously

Always try to preserve one of the IJVs
An attempt at preservation of ...
Functional Neck Dissection
The versions which have been described are
RND — XI N
RND — XI N, IJV & SCM
RND — XI N, IJV, SC...
Rationale…
It is the length of the nerve bw its emergence from
the jugular foramen & its disappearance into SCM
which is i...
www.indiandentalacademy.com
Operative
steps in the
functional
neck
dissection

www.indiandentalacademy.com
Rationale of FND
The most controversial factor:
whether or not the post triangle with its nodes can be
left undisturbed wi...
Supraomohyoid neck dissection

•Cancers of oral cavity that are N0 clinically
•Discrete N1 lesions can also be treated
www...
Jugular neck dissection

www.indiandentalacademy.com
Posterolateral neck dissection

www.indiandentalacademy.com
Extended radical neck dissection

www.indiandentalacademy.com
CLINICAL CONTROVERSIES

www.indiandentalacademy.com
“Should we treat No neck or not ?”

www.indiandentalacademy.com
Studies of Patterns of cervical lymph node metastasis –
Jatin P Shah

Distribution of nodal
metastasis in
therapeutic
neck...
Treatment options for the No neck
Elective surgery
Elective radiotherapy
Elective neck investigation (CT or MRI)
‘Wait & w...
Selective neck dissection (N0 neck)
Organ

Nodal clearance

Oral cavity

I, II, III

Tongue

I, II, III, IV

Hypopharynx, ...
Pros and cons for elective neck dissection (END)
For END
Low morbidity & mortality

Against END
Results in a large no of u...
Vandenbrouk et al.,1980 (Cancer 46: 386-90) & Fakih
1989 (Am J Surg 158: 309-13)
NO benefit from elective surgery to the c...
Indications for elective neck treatment
Chance of subclinical neck ds > 20- 25 %
Vigilant follow – up not possible
Clinica...
When the primary tumor is being treated with radiotherapy (eg., T1 lat tongue border/floor of the mouth)
The elective Rx t...
Van den Berkel et al. (1999), Outcome of observing the
No neck using ultrasonic- guided cytology for follow- up
Arch Otola...
Single palpable mets in one side of the
neck < 3 cm in dia (N1)
Treatment of such nodes: Surgery
All 5 levels may be invol...
Bilateral & Contralateral Nodes (N2c)
Common primary sites involved: tongue base,
supraglottic larynx & hypopharynx
Progno...
Treatment of Contralat N0 Neck in early SCC of
Tongue: Elective Neck Dissection v/s Observation
Young Chang Lim, Laryngosc...
Complications
‘If anything can go wrong, it will.’
Murphy’s law

www.indiandentalacademy.com
Classification of complications
Major and minor
Early, intermediate & late
Local & systemic
General & specific

www.indian...
Immediate local complications
Bleeding
Airway obstruction
Incresed intracranial pressure
Carotid sinus syndrome
Nerve inju...
Increased intra – cranial pressure
Assoc with IJV ligation
Signs & symptoms:
Restlessness from headache
Slowing of the pul...
Intermediate local complications
Chylous fistula
Seroma
Skull – base syndrome
Wound infection
Failure of skin healing
Caro...
Clinical assessment of flap vitality

www.indiandentalacademy.com
Late complications
Recurrence
Primary
Nodal
Distant

Parotid tail hypertrophy
Lymphoedema
Hypertrophic scar
Contractures

...
Indications for postoperative radiation therapy to
the neck

1.

Gross residual disease following neck dissection

2.

Mul...
Conclusion
Thorough knowledge of surgical anatomy & lymphatic
system
Decision of how to manage the neck in cases of SCC of...
References
Stell and Maran’s Head and Surgery, 4/ed
Color atlas of operzative techniques in head and neck surgery- Jatin P...
Aydin Acar, Gürsel Dursun, Ömer Aydin,Yücel Akbaş. J incision in
neck dissections. The journal of Laryngology and otology....
Thank you…
www.indiandentalacademy.com
Upcoming SlideShare
Loading in …5
×

Rnd gaurav (nx power-lite) /certified fixed orthodontic courses by Indian dental academy

1,698 views
1,451 views

Published on



The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,698
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
17
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide
  • Cure rates drop in half when there is
    regional lymph node involvement
  • Motor nerve to the tongue
    • Cell bodies are in the Hypoglossal nucleus of the
    Medulla oblongata
    • Exits the skull via the hypoglossal canal
    • Lies deep to the IJV, ICA, CN IX, X, and XI
    • Curves 90 degrees and passes between the IJV and
    ICA
    – Surrounded by venous plexus (ranine veins)
    • Extends upward along hyoglossus muscle and into
    the genioglossus to the tip of the tongue
  • Elective treatment to the No node neck has been proposed b’se on retrospective evidence from elective RND specimens, there is a high incidence of subclinical ds in the neck.
  • Rnd gaurav (nx power-lite) /certified fixed orthodontic courses by Indian dental academy

    1. 1. NECK DISSECTION INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. Contents Introduction Cervical lymphatics – its drainage Levels & Sublevels of lymph nodes - their implications What is neck dissection ? History of neck dissection Classifications & Concepts behind classifications Surgical anatomy www.indiandentalacademy.com
    3. 3. Contents … Incisions Description of classical RND Description of other types of neck dissection Complications in RND Clinical controversies : management of N0 neck management of N+ neck Conclusion www.indiandentalacademy.com
    4. 4. Introduction Surgery is the oldest and the most reliable form of treatment for oral malignancy. what is the need for the neck to be treated in oral malignancy ???? www.indiandentalacademy.com
    5. 5. Lymphatic system of head and neck www.indiandentalacademy.com
    6. 6. Patterns of cervical lymphatic metastasis Lymphatic flow in the neck - consistent pattern - upper neck and then to the lower neck and superficial to deep. This orderly lymphatic flow has been demonstrated by the work of Fisch and Sigel* *Cervical lymphatic system as visualized by lymphography  Annals of Otology, Rhinology and Laryngology 73: 869-872. www.indiandentalacademy.com
    7. 7. Post floor of mouth Mandibular incisors Maxillary sinus Tongue(tip) Maxillary teeth except 3rd molar Lower lip (middle) Mandibular canines,1st & 2nd & Chin molars Ant. floor of mouth Tongue Nose, hard palate SUB-MENTAL Upper lip SUB-MANDIBULAR UPPER DEEP CERVICAL CHAIN OF NODES www.indiandentalacademy.com
    8. 8. RETROPHARYNGEAL Scalp Ear Eyelids PAROTID NODES 3rd Molars Tongue (base) Tonsillar area Soft palate UPPER DEEP CERVICAL CHAIN OF NODES LOWER DEEP CERVICAL CHAIN OF NODES www.indiandentalacademy.com
    9. 9. The regional lymph node groups draining a specific primary site as first echelon lymph nodes www.indiandentalacademy.com
    10. 10. The first echelon lymph nodes at highest risk from primary tumors in the oral cavity www.indiandentalacademy.com
    11. 11. Concept of Sentinel Node Omgo E. Nieweg et al., Annals of Surgical Oncology, 8(6):538–541 “the first lymph node that receives afferent lymphatic drainage from a primary tumor”. - Morton www.indiandentalacademy.com
    12. 12. Risk for nodal metastasis Various factors Site Size T stage Location of primary tumour Histomorphologic characteristics of primary tumor www.indiandentalacademy.com
    13. 13. Risk of nodal metastases increases in relation to location of the primary tumor www.indiandentalacademy.com
    14. 14. Lymph drainage of tongue, as described by Jamieson and Dobson www.indiandentalacademy.com
    15. 15. The incidence of lymph node metastasis and survival in relation to the thickness of the primary lesions for T1 and T2 SCC of the oral tongue and floor of mouth www.indiandentalacademy.com
    16. 16. The probability of cervical metastases (N) related to primary staging (T) in pts with head & neck SCC www.indiandentalacademy.com
    17. 17. Memorial Sloan – Kettering Cancer Center leveling system of cervical lymph nodes www.indiandentalacademy.com
    18. 18. Division of neck levels by sublevels IA – submental nodes IB – submandibular nodes IIA & IIB – together comprising the upper jugular node VA – nodes Spinal accessory VB – Transverse cervical and supraclavicular nodes www.indiandentalacademy.com
    19. 19. Rationale of sublevels Suggested by Suen and Goepfert (1997) Subzones have biological significance independent of the larger zones in which they lie Biologic significance for lymphatic drainage depending on site of tumor Level I subzones Lower lip, FOM, ventral tongue – Ia Other oral cavity subsites – Ib, II, and III www.indiandentalacademy.com
    20. 20. Level II subzones Oropharynx and nasopharynx – IIb Oral cavity, larynx and hypopharynx – may not be necessary to dissect IIb if level IIa is not involved Level V subzones Oropharynx, nasopharynx, and cutaneous – Va • spinal accessory nodes Thyroid – Vb • transverse cervical and supraclavicular nodes www.indiandentalacademy.com
    21. 21. Neck Dissection www.indiandentalacademy.com
    22. 22. What is neck dissection? The term "neck dissection" refers to a surgical procedure in which the fibro-fatty soft tissue content of the neck is excised to remove the lymph nodes that are contained therein*. * K Harish - Review Neck dissections: radical to conservative, World Journal of Surgical Oncology 2005, 3:21 www.indiandentalacademy.com
    23. 23. Historical Perspective www.indiandentalacademy.com
    24. 24. In 1906 paper “Exicision of cancer of the head and neck ” Gold standard procedure : “Radical Neck dissection” Dr George Crile (1864-1943 ) www.indiandentalacademy.com
    25. 25. In 1951 paper “Neck Dissection” “Routine prophylactic RND was impracticle” www.indiandentalacademy.com Martin Dr. Hayes (1892-1977 )
    26. 26. 1880 – Kocher –proposed removal of nodal metastasis 1906 – George Crile –RND 1933 & 1941 – Blair and Martin popularised RND 1953 – Pietrantoni - recommended sparing SAN 1967 - Bocca and Pignataro described FND 1975- Bocca established oncologic safety of FND compared to RND 1980- Ballantyne –concept of selective neck dissection 1989, 1991, and 1994 – Medina, Robbins and Byers respectively proposed classifications of neck dissections www.indiandentalacademy.com
    27. 27. Concepts behind classification of neck dissection Based on 4 concepts RND: the standard basic procedure - against which all other modifications are compared preservation of any non- lymphatic structures : MRND that preserves one or more gps or levels of LN`s : SND removal of additional LN groups or non lymphatic structures relative to the RND – Extended neck dissection www.indiandentalacademy.com
    28. 28. MEDINA CLASSIFICATION(1989) Comprehensive neck dissection 1. 2. Radical neck dissection (RND) Modified radical neck dissection (MRND) • • • MRND I – Preserves spinal accessory nerve. MRND II – preserves Spinal accessory and internal jugular vein but sacrifices sternocleidomastoid muscle. MRND III –preserves all- SAN, sternocleidomastoid muscle and internal jugular vein Selective neck dissection (SND) • • • • • Supraomohyoid neck dissection – I, II, III Jugular neck dissection – II, III, IV Anterior triangle neck dissection – I, II, III, IV Central compartment neck dissection – VI Posterolateral neck dissection – II, III, IV www.indiandentalacademy.com
    29. 29. Spiro’s classification Radical (4 or 5 node levels resected) Conventional radical neck dissection Modified radical neck dissection 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 www.indiandentalacademy.com
    30. 30. AAO-HNS CLASSIFICATION * 1991 Classification 2001 Classification * Neck dissection classification update-Revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and www.indiandentalacademy.com Neck Surgery.
    31. 31. Surgical Anatomy ‘Anatomy is a language, As dead as can be, It killed the ancient medics, And now it’s killing me’ www.indiandentalacademy.com
    32. 32. Fascial layers of the neck 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 www.indiandentalacademy.com
    33. 33. www.indiandentalacademy.com
    34. 34. Triangles of neck www.indiandentalacademy.com
    35. 35. Imp structures in posterior triangle www.indiandentalacademy.com
    36. 36. Submandibular space www.indiandentalacademy.com
    37. 37. Facial artery and submandibular gland www.indiandentalacademy.com
    38. 38. Platysma Origin – fascia overlying the pectoralis major and deltoid muscle Insertion – 1) depressor muscles of the corner of the mouth, 2) the mandible, and 3) the SMAS layer of the face Function – 1) wrinkles the the neck 2) depresses the corner of the mouth 3) increases the diameter of the neck 4) assists in venous return www.indiandentalacademy.com
    39. 39. Surgical considerations Absent in the midline of the neck & posteriorly in part of post triangle Does platysma supplies skin or skin supplies platysma ? www.indiandentalacademy.com
    40. 40. Omohyoid muscle Origin – upper border of the scapula Insertion – 1) via the intermediate tendon onto the clavicle and first rib 2) hyoid bone lateral to the sternohyoid m Blood supply – Inferior thyroid a. Function – 1) depress the hyoid 2) tense the deep cervical fascia www.indiandentalacademy.com
    41. 41. 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 www.indiandentalacademy.com
    42. 42. Trapezius muscle Origin – 1) medial 1/3 of sup. nuchal line 2) ext occipital protub 3) ligamentum nuchae 4) spinous pr of C7 & T1-T12 Insertion – 1) lat 1/3 of the clavicle 2) acromion pr 3) spine of the scapula www.indiandentalacademy.com
    43. 43. Function – elevate and rotate the scapula and stabilize the shoulder Surgical considerations Posterior limit of Level V neck dissection Denervation results in shoulder drop and winged scapula www.indiandentalacademy.com
    44. 44. Digastric Muscle Origin – digastric fossa of the mandible (at the symphyseal border Insertion – 1) hyoid bone via the intermediate tendon 2) mastoid process Function – 1) elevate the hyoid bone 2) depress the mandible (assists lateral pterygoid) www.indiandentalacademy.com
    45. 45. Surgical considerations Posterior belly is superficial to: • • • • ECA Hypoglossal nerve ICA IJV Anterior belly • Landmark for identification of mylohyoid for dissection of the submandibular triangle www.indiandentalacademy.com
    46. 46. Marginal Mandibular Nerve Should be preserved Most commonly injuredat level 1b Can be found: 1 cm ant & inf to angle of mandible At the mandibular notch Deep to fascia of the submand gland (superficial layer of deep cervical fascia) Superficial to adventitia of the facial vein More than one branch often present www.indiandentalacademy.com
    47. 47. www.indiandentalacademy.com
    48. 48. Spinal accessory nerve After emerging from jugular foramen, crosses the IJV Occipital artery crosses the nerve Descends obliquely in level II (forms Level IIa and IIb Penetrates the deep surface of the SCM Exits posterior surface of SCM deep to Erb’s point Traverses the posterior triangle ensheathed by the superficial cervical fascia and lies on the levator scapulae Enters the trapezius approx. 5 cm above the clavicle www.indiandentalacademy.com
    49. 49. CN XI – Relationship with the IJV www.indiandentalacademy.com
    50. 50. Hypoglossal Nerve www.indiandentalacademy.com
    51. 51. Venous system www.indiandentalacademy.com
    52. 52. Thoracic Duct Conveys lymph from the entire body back to the blood Exceptions: Right side of head and neck, RUE, right lung right heart and portion of the liver Begins at the cisterna chyli Enters posterior mediastinum between the azygous vein and thoracic aorta Courses to the left into the neck anterior to the vertebral artery and vein Enters the junction of the left subclavian and the IJV www.indiandentalacademy.com
    53. 53. www.indiandentalacademy.com
    54. 54. www.indiandentalacademy.com
    55. 55. Anatomy of the vascularization of neck skin Kambic and Sirca 1967 stated that arterial supply is in a vertical direction. descending branches: facial and occipital artery ascending branches: transverse supraclavicular arterial branches . www.indiandentalacademy.com cervical and
    56. 56. The vasculature can be summarized into upper neck region - anterior to the angle of mandible – branches of facial and submental arteries. upper lateral neck - the area between ramus of mandible and the sternocleidomastoid muscleOccipital and external auricular branches of external carotid . Lower half of neck – The transverse cervical artery and suprascapular artery Large platysma-cutaneous branches and branches of superior thyroid supply the front middle portion of the neck. www.indiandentalacademy.com
    57. 57. www.indiandentalacademy.com
    58. 58. Incisions Incisions classified into Vertical Horizontal The incisions used for neck dissections are Tri-radiate incision and its modification Hayes martin double ‘Y’ incision McFee incision Apron flap incision www.indiandentalacademy.com
    59. 59. Basic needs of an incision are Good exposure of the neck and primary disease Ensure viability of the skin flaps. Avoid acute angles Protect carotid artery even in the cases of wound infection Facilitate reconstruction Adapt to the condition of patient esp after radiotherapy It should be cosmetically acceptable www.indiandentalacademy.com
    60. 60. Differences between incisions Transverse incision Vertical incision Have cosmetic advantage as they follow natural skin folds of the skin Disadvantages because they intersect to the natural skin folds of the skin and the vascular supply of the neck Recovery of scar tissue in these folds are rapid and successful They tend to contract along their long axis – leads to deformity and restricted action. Easy to modify www.indiandentalacademy.com
    61. 61. Tri-radiate incision and its modifications Advantages Incision provides good exposure to surgical site. Disadvantages Flap necrosis is high due to disruption of vasculature of skin flaps Occurrence of flap separation at the trifurcation site. Carotid exposure/rupture www.indiandentalacademy.com
    62. 62. Modification of Tri-radiate incision Schobinger (1957) Cramer & Culf (1969) Conley (1970) www.indiandentalacademy.com
    63. 63. Schobinger (1957) Schobinger suggested that vertical limb instead of being straight should be curved posteriorly in order to avoid lying directly over the carotids. www.indiandentalacademy.com
    64. 64. Conley (1970) Suggested a posteriorly curving vertical incision rather than a horizontal incision The incision starts from the submental region and ends by running downwards along the anterior border of the trapezius to the level of clavicle gently curving posteriorly. www.indiandentalacademy.com
    65. 65. Hayes Martin Incision Paired ‘Y’ incision. the submandibular component is met by a vertical limb which below becomes continuous with an inverted ‘Y’ in the supraclavicular region. Disadv : Cyanosis of the skin flaps Flap necrosis and carotid exposure www.indiandentalacademy.com
    66. 66. McFee Incision Avoids a vertical limb. Two horizontal incisions are used one in submandibular region and other in the supraclavicular region. www.indiandentalacademy.com
    67. 67. Advantages Disadvantages Excellent cosmetic result (McFee 1960, McNeil 1978) Exposure is not good (Hetter 1972) No ↓ in vascularity in the centre of the flap (Ariyan 1986) Not suitable for bilat simultaneous neck dissection (Chandler and Ponzoli 1969) No angle intersection in incision (McFee 1960) Operating period is long (McFee 1960) Post - op wound recovery - rapid (McFee) Posterior triangle dissection is difficult (Maran et al 1989, White et al 1993) Suitable in necks receiving radiotherapy & in peripheral vascular ds (Maran et al 1989) Working under the bridge flap difficult Recovery of flap excellent due to wide bipedicled flaps (Stella & Brown 1970, Daniel & McFee 1987) In short neck it might be difficult to distinguish between the front tip of the incision from that of the tracheostomy. www.indiandentalacademy.com
    68. 68. Apron flaps Described by Latyschevsky & Freund 1960. Only a horizontal incision from mastoid gently curving inferiorly upto upper border of the thyroid. Advantages Carotid artery is well protected Protects the descending arterial supply Disadvantages Damage to the ascending arterial and venous supply Venous congestion and oedema might develop at the bottom corner www.indiandentalacademy.com
    69. 69. Hockey stick incision Lahey et al (1940) Modified for RND by Eckert & Byars 1952. It has a longitudinal and transverse incision B/L hockey stick incision allows the deglovement of the whole neck. www.indiandentalacademy.com
    70. 70. Radical neck dissection www.indiandentalacademy.com
    71. 71. RND… Indications Current indications for classical RND N3 disease Multiple gross metastases involving multiple levels. Recurrent metastatic disease in a previously irradiated neck. Grossly apparent extranodal spread with invasion of the spinal accessory nerve &/or IJV at the base of the skull Involvement of accessory chain lymph nodes by metastatic disease. www.indiandentalacademy.com
    72. 72. Contraindications Neck dissection is contraindicated in disease beyond the superficial or deep cervical fascia. These include: Poor surgical candidate. Rampant distant metastasis. Significant bilat neck disease. Base of skull disease. Mediastinal or infraclavicular disease. Unresectable or uncontrollable primary disease. Extension into deep vital structures of neck. www.indiandentalacademy.com
    73. 73. The sequence of neck dissection as described by Hayes Martin www.indiandentalacademy.com
    74. 74. Incision Dissection of post t’gle begins at ant border of trapezius www.indiandentalacademy.com
    75. 75. Radical neck dissection predominantly from behind forward makes use of the anatomical fact that the IJV does not have posterior branches www.indiandentalacademy.com
    76. 76. Dissection of post t’gle medially → exposure of brachial plexus, phrenic n. & cut roots of cervical plexus SCM dissected off & retracted to expose the carotid sheath & IJV www.indiandentalacademy.com
    77. 77. IJV ligated & divided after common carotid & vagus n exposed & retracted medially Dissection proceeds along the carotid sheath upto skull base www.indiandentalacademy.com
    78. 78. www.indiandentalacademy.com
    79. 79. Surgical field following RND www.indiandentalacademy.com
    80. 80. Two suction drains inserted www.indiandentalacademy.com Final closure
    81. 81. Bilateral RND Not often performed Loss of both SCMs → difficulty in lifting head, esthetics Loss of both XI Ns → doubling the disability Indications : Primary at base of the tongue/floor of the mouth at midline When metastatic nodes develop on contralat side of the neck after nodal clearance on ipsilat side Most often carried out as two separate operative procedures, separated in time (4 weeks) www.indiandentalacademy.com
    82. 82. Complications of ligating bilat IJVs simultaneously Always try to preserve one of the IJVs An attempt at preservation of the vein made on the 1st side dissected leaves the second available for www.indiandentalacademy.com another attempt, should the 1st be unsuccessful.
    83. 83. Functional Neck Dissection The versions which have been described are RND — XI N RND — XI N, IJV & SCM RND — XI N, IJV, SCM & nodes of the post triangle Resections corresponding to above two but in addition IJV is removed Common to all versions : removal of deep jugular chain of nodes + subm’lar gland & its assoc nodes www.indiandentalacademy.com
    84. 84. Rationale… It is the length of the nerve bw its emergence from the jugular foramen & its disappearance into SCM which is its most sensitive segmentin patological terms, b’se of its proximity to deep jugular nodes higher in the neck www.indiandentalacademy.com
    85. 85. www.indiandentalacademy.com
    86. 86. Operative steps in the functional neck dissection www.indiandentalacademy.com
    87. 87. Rationale of FND The most controversial factor: whether or not the post triangle with its nodes can be left undisturbed without compromising the pathological basis of resection??? Lindberg (1972) – overall incidence of nodes in post triangle… 2% Feind (1972) – a very low overall incidence of post triangle metastases • When positive nodes were present in post t’gle multiple positive nodes were also present elsewhere in the neck. www.indiandentalacademy.com
    88. 88. Supraomohyoid neck dissection •Cancers of oral cavity that are N0 clinically •Discrete N1 lesions can also be treated www.indiandentalacademy.com
    89. 89. Jugular neck dissection www.indiandentalacademy.com
    90. 90. Posterolateral neck dissection www.indiandentalacademy.com
    91. 91. Extended radical neck dissection www.indiandentalacademy.com
    92. 92. CLINICAL CONTROVERSIES www.indiandentalacademy.com
    93. 93. “Should we treat No neck or not ?” www.indiandentalacademy.com
    94. 94. Studies of Patterns of cervical lymph node metastasis – Jatin P Shah Distribution of nodal metastasis in therapeutic neck dissections www.indiandentalacademy.com % of patients with pathologically proven metastasis at that level
    95. 95. Treatment options for the No neck Elective surgery Elective radiotherapy Elective neck investigation (CT or MRI) ‘Wait & watch’ www.indiandentalacademy.com
    96. 96. Selective neck dissection (N0 neck) Organ Nodal clearance Oral cavity I, II, III Tongue I, II, III, IV Hypopharynx, larynx, oropharynx II, III, IV Some laryngeal and hypopharyngeal lesions where IIB is not removed IIA, III, IV Laryngeal, hypopharyngeal extending below glottis II, III, IV, VI Thyroid, hypopharynx, cervical trachea, cervical esophagus, sub-glottic larynx VI, Cutaneous carcinoma of posterior scalp and upper neck II – V, Post auricular, Suboccipital Cutaneous malignancy from pre-auricular, anterior scalp and temporal region II, III, VA, parotid, facial, external jugular nodes Cutaneous malignancy of anterior or lateral face I, II, III www.indiandentalacademy.com
    97. 97. Pros and cons for elective neck dissection (END) For END Low morbidity & mortality Against END Results in a large no of unnecessary surgical procedures & is assoc with inevitable morbidity Cure rate for neck dissection is ↓ed if gland Cure rates are no lower if the surgeon waits for enlargement occurs or multiple nodes the neck to convert from N0 to N1 appear Impossible to provide follow-up necessary to detect the earlier conversion of a neck from N0 to N1 Careful clinical follow-up will allow detection of the earliest conversion from N0 to N1 Allowing the neck metastases to develop increases the incidence of distant metastasis END removes the barrier to the spread of disease and also has a detrimental immunological effect If neck has been entered to remove the primary it is better to perform an incontinuity resection Radiation is as effective as neck dissection in N0 neck High incidence of occult metastatic disease www.indiandentalacademy.com
    98. 98. Vandenbrouk et al.,1980 (Cancer 46: 386-90) & Fakih 1989 (Am J Surg 158: 309-13) NO benefit from elective surgery to the clinically N0 neck Elective neck irradiation could eradicate > 90% subclinical ds in neck Pointon et al., 1990 & Dearnaley et al,. 1991 Elective neck irradiation may prolong survival by reducing subsequent local recurrent metastatic ds. www.indiandentalacademy.com
    99. 99. Indications for elective neck treatment Chance of subclinical neck ds > 20- 25 % Vigilant follow – up not possible Clinical evaluation of the neck- difficult Surgery is being performed for access or reconstruction Imaging suggests possible occult nodal spread www.indiandentalacademy.com
    100. 100. When the primary tumor is being treated with radiotherapy (eg., T1 lat tongue border/floor of the mouth) The elective Rx to the neck should be with radiotherapy to the 1st echelon nodes or whole neck Where midline extn occurs – Rx should be bilateral When the primary tumor is being treated with surgery (eg., larger T2/ T3 lat tongue border) Surgery should be carried out on the basis that: It provides further info for clinical staging Nodes in the area cleared to give access to vessels for reconstr purposes Local recurrence rates ↓ Survival enhanced www.indiandentalacademy.com
    101. 101. Van den Berkel et al. (1999), Outcome of observing the No neck using ultrasonic- guided cytology for follow- up Arch Otolaryngol Head Neck Surg 125:153-6 After transoral excision follow-up for bw 1-4 yrs using palpation & US – FNAC 14 pts (18%) had occult node metastases & subsequent neck failure. 9/14 were detected within 7 mos & of these, 6 were not palpable 10/14 were successfully salvaged but 4 died Conclusion: the high salvage rate (71%) indicated that a strict follow-up using US – FNAC enables early detection of recurrence in the high- risk No neck & justifies a policy of wait & watch. www.indiandentalacademy.com
    102. 102. Single palpable mets in one side of the neck < 3 cm in dia (N1) Treatment of such nodes: Surgery All 5 levels may be involved & should be dissected Therefore, minimum operation that should be performed: MRND Unless otherwise indicated, SCM muscle & IJV should be sacrificed. Role of radiotherapy- controvercial. Less efficient than surgery... represents a less preferred option unless the primary site is also being treated with radiotherapy. The classic eg. is Ca nasopharynx www.indiandentalacademy.com
    103. 103. Bilateral & Contralateral Nodes (N2c) Common primary sites involved: tongue base, supraglottic larynx & hypopharynx Prognosis depends on: size, no of nodes & +nce/-nce of extracapsular spread; rather than pure laterality Rx often worthwhile – if B/l nodes are either N1/N2a Post- op radiotherapy Pts with extensive tongue- base tumor & B/l cervical lymphadenopathy: inoperable Pts with B/l nodes where one side is fixed are usually incurable www.indiandentalacademy.com
    104. 104. Treatment of Contralat N0 Neck in early SCC of Tongue: Elective Neck Dissection v/s Observation Young Chang Lim, Laryngoscope, 116:461–465, 2006 ipsilat elective neck management is necessary during initial treatment of stages I and II for Ca tongue. study suggests… contralat occult lymph node metastasis was unlikely in early tongue SCC, and there was no survival benefit for pts who underwent elective neck dissection rather than “observation.” Thus, observation of contral N0 neck for the treatment of early oral tongue cancer may not be harmful. www.indiandentalacademy.com
    105. 105. Complications ‘If anything can go wrong, it will.’ Murphy’s law www.indiandentalacademy.com
    106. 106. Classification of complications Major and minor Early, intermediate & late Local & systemic General & specific www.indiandentalacademy.com
    107. 107. Immediate local complications Bleeding Airway obstruction Incresed intracranial pressure Carotid sinus syndrome Nerve injury www.indiandentalacademy.com
    108. 108. Increased intra – cranial pressure Assoc with IJV ligation Signs & symptoms: Restlessness from headache Slowing of the pulse A rise in BP Gross swelling & cyanosis of the face How to ↓ risk of raised ICP ?? No dressing around the neck DO NOT allow the pt to hyperextend the neck Sit the pt up as soon as possible after surgery www.indiandentalacademy.com
    109. 109. Intermediate local complications Chylous fistula Seroma Skull – base syndrome Wound infection Failure of skin healing Carotid artery rupture Flap failure Fistula formation www.indiandentalacademy.com
    110. 110. Clinical assessment of flap vitality www.indiandentalacademy.com
    111. 111. Late complications Recurrence Primary Nodal Distant Parotid tail hypertrophy Lymphoedema Hypertrophic scar Contractures www.indiandentalacademy.com
    112. 112. Indications for postoperative radiation therapy to the neck 1. Gross residual disease following neck dissection 2. Multiple positive lymph nodes in the neck 3. Extracapsular extension by metastatic diseae 4. Perivascular or perineural invasion by tumor 5. Other ominous findings such as tumor emboli in lymphatics, cranial nerve invasion, or extension of disease to the base of the skull. www.indiandentalacademy.com
    113. 113. Conclusion Thorough knowledge of surgical anatomy & lymphatic system Decision of how to manage the neck in cases of SCC of head & neck region, should be based on a sound & logical comprehensive treatment plan Bilat IJV dissection should be avoided Post – 0p care is also of utmost importace Radiotherapy, chemotheray or ‘wait & watch’ policy do have their roles in managing the neck www.indiandentalacademy.com
    114. 114. References Stell and Maran’s Head and Surgery, 4/ed Color atlas of operzative techniques in head and neck surgery- Jatin P. Shah (1990) Oral Cancer - Jatin P. Shah Charles W. Cummings, John M. Fredrickson, Lee A. Harker, Charles J. Krause, David E. Schurller. Neck Dissection. Otolaryngology- Head and neck surgery. Vol. II, 2nd edition. 1993: 1649-1672. Ian A. McGregor, Frances M. McGregor. Neck dissection. Cancer of the face and mouth – Pathology and management for surgeons. Churchill Livingstone.1986: 282- 320. Ian T. Jackson. Inrtra oral tumour and cervical lymphadenectomy. Grabb & Smith’s Plastic Surgery. Sherrel J. Aston, Robert W. Beasley, Charles H. M. Thorne. 5th edition. Lippincott- Raven . 1997 : 439 –452. www.indiandentalacademy.com
    115. 115. Aydin Acar, Gürsel Dursun, Ömer Aydin,Yücel Akbaş. J incision in neck dissections. The journal of Laryngology and otology. 1998: 112: 55 - 60. Susumu Omura, Hiroki Bukawa, Ryoichi Kawabe, Shinjiro Aoki, Kiyohide Fujita. Comparision between hockey stick and reverse hockey stick incision: gently curved single linear neck incisions for oral cancer. Int. J. Oral Maxillofac Vandenbrouk et al., (Cancer 46: 386-90) www.indiandentalacademy.com
    116. 116. Thank you… www.indiandentalacademy.com

    ×