3 anatomy & physiology of esophagus


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3 anatomy & physiology of esophagus

  1. 1. Zou Hua ENT Depart. The Second Affiliated Hospital Sun Yat Sen University Email: zouhua28@163.com
  2. 2. overview <ul><li>Anatomy & physiology of esophagus ( gullet) </li></ul><ul><li>Anatomy & physiology of trachea, Tracheotomy </li></ul><ul><li>Anatomy of cervical part </li></ul><ul><li>Neck masses </li></ul><ul><li>Neck Dissection </li></ul>
  3. 3. Anatomy & physiology of esophagus
  4. 4. Esophageal Anatomy <ul><li>Muscular tube </li></ul><ul><li>connecting the </li></ul><ul><li>pharynx to the </li></ul><ul><li>Stomach, channel </li></ul><ul><li>for the transport of </li></ul><ul><li>food </li></ul><ul><li>18 to 26 cm in length </li></ul><ul><li>Back: vertebra (C6---T11) </li></ul><ul><li>Front: larynx & lower airway </li></ul>
  5. 5. Esophageal Anatomy <ul><li>Upper End : C6 (the inferior pharyngeal constrictor merges with the cricopharyngeus ) __ Upper esophageal sphincter (UES) </li></ul><ul><li>Lower End : T11 (thickened circular smooth muscle) __ Lower esophageal sphincter (LES) </li></ul>
  6. 6. Esophageal Anatomy <ul><ul><li>38-40cm from incisors </li></ul></ul>
  7. 7. Esophageal Anatomy <ul><li>It is divided into three parts </li></ul><ul><li>Cervical parts </li></ul><ul><li>Thoracic parts </li></ul><ul><li>Abdominal parts </li></ul>
  8. 8. Esophageal Constrictions <ul><li>The esophagus has 3 areas of narrowing: </li></ul><ul><li>Superiorly: level of cricoid cartilage, juncture with pharynx </li></ul><ul><li>Middle: crossed by aorta and left main bronchus </li></ul><ul><li>Inferiorly: diaphragmatic sphincter </li></ul>
  9. 9. Esophageal Constrictions <ul><li>These narrowing areas have important clinical significance </li></ul><ul><li>where most esophageal foreign bodies become entrapped. </li></ul>
  10. 10. Esophageal Anatomy <ul><li>Innervation mainly by celiac ganglia ( Vagus n.) </li></ul>
  11. 11. Esophageal physiology <ul><li>1. swallow (Esophageal Transport by Gravity) </li></ul><ul><li>The oropharyngeal phase : Swallowing begins when a food bolus is propelled into the pharynx from the mouth. It is voluntary . </li></ul><ul><li>The esophageal phase. It is involuntary. </li></ul><ul><li>It takes approximately 8 to 10 seconds from initiation of the swallow to entry into the stomach . </li></ul><ul><li>In rapid sequence and with precise coordination, the larynx is elevated and the epiglottis seals the airway. </li></ul>
  12. 12. Esophageal physiology <ul><li>2.Secretion (submucosal mucous glands) </li></ul><ul><li>3.Protection : Gastroesophageal reflux (machenic , secretion ) </li></ul>
  13. 13. Gastroesophageal reflux (GER) <ul><li>The gastric content ( acid, pepsin, bile salts, and pancreatic enzymes ) refluxed into the esophagus. </li></ul><ul><li>It can damage the mucosa through the presence of hydrochloric. </li></ul>
  14. 14. Tests <ul><li>X-ray </li></ul><ul><li>Plain X-ray : mental or some foreign bodies </li></ul><ul><li>Barium X-ray : As the oesophagus, stomach and duodenum are soft tissue structures, they are not usually seen on a plain X-ray. By using barium to coat the inner lining of these areas, the Radiologist can see them clearly on the X-ray screen; and can watch the way the organs function during this study. </li></ul><ul><li>Barium is a chalky substance that can be suspended in water and is visible on X-rays </li></ul>
  15. 15. Tests a plain X-ray Barium X-ray
  16. 16. Barium X-ray
  17. 17. Tests <ul><li>X-ray barium test indications </li></ul><ul><li>Difficulty or pain in swallowing; </li></ul><ul><li>Be troubled by indigestion or acid reflux; </li></ul><ul><li>An ulcer or blockage in the stomach is suspected. </li></ul>
  18. 18. Tests <ul><li>Endoscopy (Rigid & flexible telescope-under sedation) </li></ul>Rigid Endoscopy
  19. 19. Tests flexible telescope
  20. 20. Anatomy & physiology of the Respiratory tract
  21. 21. The Respiratory tract <ul><li>The airway begins at the mouth or nose, and accesses the trachea via the pharynx through which air flows, to get from the external environment to the alveoli. </li></ul><ul><ul><li>Upper respiratory passages filter and humidify incoming air </li></ul></ul><ul><ul><li>Lower passageways include delicate conduction passages and alveolar exchange surfaces </li></ul></ul>
  22. 22. The Components of the Respiratory System <ul><li>the mouth or nose, the </li></ul><ul><li>pharynx. the larynx </li></ul><ul><li>(cricoid cartilage), the </li></ul><ul><li>trachea, the left and </li></ul><ul><li>right main bronchi , </li></ul><ul><li>large bronchioles, </li></ul><ul><li>clusters of alveoli. </li></ul>
  23. 23. The Components of the Respiratory System <ul><li>The cricoid cartilage, or simply cricoid (&quot;ring-shaped&quot;), is the only complete ring of cartilage around the trachea. It is very important to support the airway. </li></ul>
  24. 24. The Anatomy of the Trachea The trachea is a tubular structure which is located at the front of the neck Begins : the level of the C6 ( the thyroid cartilage). Bifurcating: into right and left main bronchi (the level of the T5 ) Length: 10 to 15cm Diameter :16-18 mm
  25. 25. The Anatomy of the Trachea Structure of the Trachea wall Anterior wall: cartilaginous rings (16 to 20 C-shaped ) Posterior wall: fibromuscular sheet (ligaments) Posterior : esophagus
  26. 26. Physiology of the Trachea <ul><li>Respiration: air moving in and out of the lungs </li></ul><ul><li>Filter particulate matter, humidify inspired air, and aid in expectoration of secretions. </li></ul><ul><li>Physiology of Airway Protection: coughing reflex </li></ul>
  27. 27. Physiology of the Trachea <ul><li>The hyaline cartilage in the tracheal wall provides support and keeps the trachea from collapsing. </li></ul><ul><li>The posterior soft tissue allows for expansion of the esophagus, which is immediately posterior to the trachea. </li></ul>
  28. 28. Tracheotomy
  29. 29. Definition <ul><li>An opening surgically created </li></ul><ul><li>through the neck into the trachea </li></ul><ul><li>(windpipe). A tube is usually </li></ul><ul><li>placed through this opening </li></ul><ul><li>(tracheostomy tube also trach tube) </li></ul><ul><li>to provide an airway and to allow </li></ul><ul><li>removal of secretions from the </li></ul><ul><li>lungs. </li></ul><ul><li>It provides an alternative </li></ul><ul><li>airway, by passing the upper </li></ul><ul><li>passages . </li></ul>
  30. 30. Tracheostomy tubes <ul><li>Inserted through </li></ul><ul><li>the tracheostomy </li></ul><ul><li>to maomtaom a </li></ul><ul><li>patent airway </li></ul><ul><li>Secured in place </li></ul><ul><li>by tapes tied </li></ul><ul><li>around the neck </li></ul>
  31. 31. Purpose <ul><li>A tracheotomy is performed if enough air is not getting to the lungs, if the person cannot breathe . </li></ul><ul><li>The conditions in which a tracheotomy may be used </li></ul><ul><li>1. Acute setting </li></ul><ul><li>Maxillofacial injuries </li></ul><ul><li>Large tumors of the head and neck, congenital tumors, e.g. branchial cyst </li></ul><ul><li>Acute inflammation of head and neck </li></ul><ul><li>2. Chronic / elective setting - when there is need for long term mechanical ventilation to pump air into the lungs for a long period of time and tracheal toilet </li></ul><ul><li>comatose patients, </li></ul><ul><li>surgery to the head and neck. </li></ul>
  32. 32. Operative procedures <ul><li>Emergency tracheotomy (cricothyroidotomy) </li></ul><ul><li>Surgical tracheotomy </li></ul><ul><li>(nonemergency tracheotomy ) </li></ul>
  33. 33. <ul><li>(A). An incision is made in the skin just above the sternal notch Just below the thyroid, </li></ul><ul><li>(B). The membrane covering the trachea is divided </li></ul><ul><li>(C). The trachea itself is cut </li></ul><ul><li>(D). A cross incision is made to enlarge the opening </li></ul><ul><li>(E). A tracheostomy tube may be put in place </li></ul>Completed tracheotomy
  34. 34. Operative procedures Completed tracheotomy 1 - Vocal cords 2 - Thyroid cartilage 3 - Cricoid cartilage 4 - Tracheal cartilages 5 - Balloon cuff
  35. 35. Complications <ul><li>Bleeding . In very rare situations, the need for blood products or a blood transfusion. </li></ul><ul><li>Need for further and more aggressive surgery . </li></ul><ul><li>Infection . </li></ul><ul><li>Impaired swallowing and vocal function. </li></ul><ul><li>Scarring of the neck. </li></ul><ul><li>Air trapping in the surrounding tissues ( subcutaneous emphysema) or chest (Pneumothorax). In rare situations, a chest tube may be required. </li></ul><ul><li>Need for a permanent tracheostomy. This is most likely the result of the disease process which made the a tracheostomy necessary, and not from the actual procedure itself. </li></ul>
  36. 36. Complications (rare) <ul><li>Damage to the larynx (voice box) or airway with resultant permanent change in voice </li></ul><ul><li>Airway obstruction ( tube obstruction) and aspiration of secretions/ accidental decannulation –the most common cause of death. </li></ul><ul><li>Scarring of the airway or erosion of the tube into the surrounding structures </li></ul>
  37. 37. Postoperative care <ul><li>Objective : ensure patent airway. Prevent the complications </li></ul><ul><li>Chest x- ray </li></ul><ul><li>Antibiotics </li></ul><ul><li>Suctioning and clearing the tracheotomy tube </li></ul><ul><li>Humidifying the air </li></ul>
  38. 38. Postoperative care <ul><li>Normally nasal breathing </li></ul><ul><li>Humidifies, filters and warms air before it enters the lungs </li></ul><ul><li>The tracheostomy bypasses these mechanisms so that the air is cooler, dryer, and not as clean. In response to these changes the body produces more mucous, which may require humidification to aid expulsion. </li></ul>
  39. 39. Postoperative care <ul><li>Tracheostomy tube changs </li></ul><ul><li>Tracheostomy tubes are changed weekly or any time a blockage is suspected. </li></ul><ul><li>To prevent build up of secretios on the wall of the tube </li></ul>
  40. 40. Postoperative care <ul><li>Some precautions with a Tracheostomy </li></ul><ul><li>Water is a serious threat </li></ul><ul><li>No swimming </li></ul><ul><li>No showering </li></ul><ul><li>Avoid clothing that blocks the Tracheostomy </li></ul><ul><li>Accidental decannulation -most common cause of death. </li></ul>
  41. 41. Postoperative care <ul><li>The tube will be removed if the tracheotomy is temporary. Then the wound will heal quickly and only a small scar may remain. </li></ul><ul><li>Weaning is a gradual decrease in the tube size and ultimate removal of the tube. </li></ul><ul><li>If the tracheotomy is permanent, the hole stays open. </li></ul>
  42. 42. Anatomy of neck
  43. 43. Introduction <ul><li>The neck contains important communications between the head and the body, including air and food passages, major blood vessels and nerves, and the spinal cord. Many vital structures are compressed into a narrow area which is engineered for maximal mobility to permit variation in head position relative to body. </li></ul>
  44. 44. Anatomy of neck <ul><li>Skeleton: vertebral column,hyoid bone, and laryngeal and tracheal cartilages </li></ul><ul><li>Muscles </li></ul><ul><li>Nerves </li></ul><ul><li>Major Vascular Structures </li></ul><ul><li>Visceral Column - pharynx, larynx, trachea, and esophagus. </li></ul><ul><li>Thyroid Gland </li></ul>Between Mandibular notch and Clavicle
  45. 45. Anatomic triangles <ul><li>The neck can be divided into two major triangles (anterior and posterior triangles) by the sternocleidomastoid (SCM), with multiple smaller triangles </li></ul>Anatomic triangles
  46. 46. Anatomic triangles <ul><li>Two major triangles </li></ul><ul><li>Anterior triangle - bordered by the anterior border of the SCM, midline of the neck, and the mandible </li></ul><ul><li>Posterior triangle - bordered by the posterior border of the SCM, trapezius, and clavicle </li></ul><ul><li>A : muscular triangle, carotid triangl, esubmental triangle, submandibular triangle </li></ul>P : supraclavicular triangle, occipital triangle
  47. 47. Muscles of neck
  48. 48. Major Vascular
  49. 49. Major Vascular <ul><li>Major Vascular Structures bifurcates into: </li></ul><ul><li>Internal (intracranial) - no branches in the neck </li></ul><ul><li>External (extracranial) </li></ul><ul><li>Thyrocervical trunk </li></ul><ul><li>Vertebral artery </li></ul><ul><li>Internal jugular vein (within carotid sheath) </li></ul><ul><li>External jugular vein </li></ul>
  50. 50. Lymphatic drainage <ul><li>Lymphatic drainage: major head and neck lymph node groups. The lymph nodes of the neck can be divided into six levels within the defined anatomic triangles. </li></ul><ul><li>I --Submental and </li></ul><ul><li>submandibular nodes </li></ul><ul><li>II --Upper jugulodigastric </li></ul><ul><li>group </li></ul><ul><li>III --Middle jugular nodes </li></ul><ul><li>IV --Inferior jugular nodes </li></ul><ul><li>V -- Posterior triangle group </li></ul><ul><li>VI --Anterior compartment </li></ul><ul><li>group </li></ul>
  51. 51. Lymphatic drainage <ul><li>These groups and the areas that they drain are particularly important when locating and working up a &quot;neck mass&quot; or possible malignancy. The groups and drainage areas are as follows. </li></ul>
  52. 52. Lymphatic drainage Individual Lymph Nodes in the Head and Neck
  53. 53. Lymphatic drainage ( Level I) <ul><li>Submental triangle (Ia) </li></ul><ul><ul><li>Anterior digastric </li></ul></ul><ul><ul><li>Hyoid </li></ul></ul><ul><ul><li>Mylohyoid </li></ul></ul><ul><li>Submandibular triangle (Ib) </li></ul><ul><ul><li>Anterior and posterior digastric </li></ul></ul><ul><ul><li>Mandible. </li></ul></ul>
  54. 54. Lymphatic drainage <ul><li>Ia </li></ul><ul><ul><li>Chin </li></ul></ul><ul><ul><li>Lower lip </li></ul></ul><ul><ul><li>Anterior floor of mouth </li></ul></ul><ul><ul><li>Mandibular incisors </li></ul></ul><ul><ul><li>Tip of tongue </li></ul></ul><ul><li>Ib </li></ul><ul><ul><li>Oral Cavity </li></ul></ul><ul><ul><li>Floor of mouth </li></ul></ul><ul><ul><li>Oral tongue </li></ul></ul><ul><ul><li>Nasal cavity (anterior) </li></ul></ul><ul><ul><li>Face </li></ul></ul>
  55. 55. Lymphatic drainage ( Level II ) <ul><li>Upper Jugular Nodes </li></ul><ul><li>Anterior  Lateral border of sternohyoid, posterior digastric and stylohyoid </li></ul><ul><li>Posterior  Posterior border of SCM </li></ul><ul><li>Skull base </li></ul><ul><li>Hyoid bone (clinical landmark) </li></ul><ul><li>Carotid bifurcation (surgical landmark) </li></ul>
  56. 56. Lymphatic drainage ( Level II ) <ul><li>Oral Cavity </li></ul><ul><li>Nasal Cavity </li></ul><ul><li>Nasopharynx </li></ul><ul><li>Oropharynx </li></ul><ul><li>Larynx </li></ul><ul><li>Hypopharynx </li></ul><ul><li>Parotid </li></ul>
  57. 57. Lymphatic drainage (Level III) <ul><li>Middle jugular nodes </li></ul><ul><li>Anterior  Lateral border of sternohyoid </li></ul><ul><li>Posterior  Posterior border of SCM </li></ul><ul><li>Inferior border of level II </li></ul><ul><li>Cricoid cartilage lower border (clinical landmark) </li></ul><ul><li>Omohyoid muscle (surgical landmark) </li></ul><ul><ul><ul><li>Junction with IJV </li></ul></ul></ul>
  58. 58. Lymphatic drainage (Level III) <ul><li>Oral cavity </li></ul><ul><li>Nasopharynx </li></ul><ul><li>Oropharynx </li></ul><ul><li>Hypopharynx </li></ul><ul><li>Larynx </li></ul>
  59. 59. Lymphatic drainage (Level IV) <ul><li>Lower jugular nodes </li></ul><ul><li>Anterior  Lateral border of sternohyoid </li></ul><ul><li>Posterior  Posterior border of SCM </li></ul><ul><li>Cricoid cartilage lower border (clinical landmark) </li></ul><ul><li>Omohyoid muscle (surgical landmark) </li></ul><ul><li>Junction with IJV </li></ul><ul><li>Clavicle </li></ul>
  60. 60. Lymphatic drainage (Level IV) <ul><li>The thoracic duct: </li></ul><ul><li>Conveys lymph from the entire body back to the blood </li></ul><ul><li>Exceptions:Right side of head and neck, RUE, right lung right heart and portion of the liver </li></ul><ul><li>Begins at the cisterna chyli </li></ul><ul><li>Enters posterior mediastinum between the azygous vein and thoracic aorta </li></ul><ul><li>Courses to the left into the neck anterior to the vertebral artery and vein </li></ul><ul><li>Enters the junction of the left subclavian and the IJV </li></ul>
  61. 61. Lymphatic drainage (Level IV) <ul><li>Hypopharynx </li></ul><ul><li>Larynx </li></ul><ul><li>Thyroid </li></ul><ul><li>Cervical esophagus </li></ul>
  62. 62. Lymphatic drainage (Level V ) <ul><li>Posterior triangle of neck </li></ul><ul><li>Posterior border of SCM </li></ul><ul><li>Clavicle </li></ul><ul><li>Anterior border of trapezius </li></ul><ul><li>Va  Spinal accessory nodes </li></ul><ul><li>Vb  Transverse cervical artery nodes </li></ul><ul><li>Radiologic landmark: Inferior border of Cricoid </li></ul><ul><li>Supraclavicular nodes </li></ul>
  63. 63. Lymphatic drainage (Level V ) <ul><li>Nasopharynx, </li></ul><ul><li>Oropharynx, Posterior neck and </li></ul><ul><li>scalp </li></ul>
  64. 64. Lymphatic drainage (Level VI ) <ul><li>Thyroid </li></ul><ul><li>Larynx(glottic and subglottic) </li></ul><ul><li>Pyriform </li></ul><ul><li>sinus apex </li></ul><ul><li>Cervical esophagus </li></ul>
  65. 65. A Neck Mass
  66. 66. Introduction <ul><li>Neck masses are very common </li></ul><ul><li>Inflammatory and infectious causes : cervical adenitis </li></ul><ul><li>Congenital masses : branchial anomalies and thyroglossal duct cysts </li></ul><ul><li>Neck masses resulting from trauma: hematomas firm masses because of fibrosis . </li></ul><ul><li>Neoplasms (benign and malignant) Malignancy is the greatest concern in a patient with a neck mass. </li></ul>
  67. 67. Normal Anatomy <ul><li>The central portion : the hyoid bone, thyroid cartilage, and cricoid cartilages, the thyroid gland . </li></ul><ul><li>Carotid arteries are pulsatile and can be quite prominent if atherosclerotic disease is present. </li></ul><ul><li>The sternocleidomastoid muscles should be palpated along their entirety </li></ul>
  68. 68. Diagnosis <ul><li>Normal variations in anatomy can be distinguished from true pathology without the need for additional diagnostic testing </li></ul><ul><li>The only easy way to diagnose a neck mass is to know exactly what the patient has before you begin. </li></ul><ul><li>your only challenge is to prove it </li></ul><ul><li>The next most challenging is to have some idea of what the patient has, perform a few tests, narrow the differential, and then prove the final diagnosis. </li></ul>
  69. 69. Diagnosis <ul><li>The patient's age and the size and duration of the mass are the most significant predictors of neoplasia </li></ul><ul><li>Malignancy is the greatest concern in a patient with a neck mass. </li></ul>
  70. 70. Diagnosis <ul><li>The occurrence of symptoms and their duration must also be determined. </li></ul><ul><li>Acute symptoms, such as fever, sore throat, and cough, suggest adenopathy resulting from an upper respiratory tract infection. </li></ul><ul><li>Chronic symptoms of sore throat, dysphagia, change in voice quality, or hoarseness are often associated with anatomic or functional alterations in the pharynx or larynx. </li></ul>
  71. 71. Diagnostic Steps <ul><li>History: A careful medical history can provide important clues to the diagnosis of a neck mass. </li></ul><ul><ul><li>Developmental time course </li></ul></ul><ul><ul><li>Associated symptoms (dysphagia, otalgia, voice) </li></ul></ul><ul><ul><li>Personal habits (tobacco, alcohol) </li></ul></ul><ul><ul><li>Previous irradiation or surgery </li></ul></ul><ul><li>Physical Examination </li></ul><ul><ul><li>Complete head and neck exam (visualize & palpate) </li></ul></ul><ul><ul><li>Emphasis on location, mobility and consistency </li></ul></ul><ul><ul><li>endoscopic evaluation, with possible excisional biopsy or neck dissection. </li></ul></ul>
  72. 73. Fine needle aspiration biopsy (FNAB) <ul><li>Diagnostic yields reach as high as 90% for both infection and neoplasm. </li></ul>
  73. 74. Imaging techniques <ul><li>Computed tomography (CT) or with contrast </li></ul><ul><li>Magnetic resonance imaging (MRI) or with contrast </li></ul><ul><li>Ultrasonography </li></ul><ul><li>Nuclear scanning </li></ul><ul><li>Positron emission tomography (PET) the metabolic activity of the tissues </li></ul>
  74. 76. Biopsy <ul><li>Biopsy should be considered for neck masses with progressive growth, location within the supraclavicular fossa, or size greater than 3 cm. </li></ul><ul><li>Biopsy also should be considered if a patient with a neck mass develops symptoms associated with lymphoma. Frozen-section examination of the mass followed by neck dissection should be performed if the mass proves to be metastatic carcinoma. </li></ul><ul><li>The risk of having a malignant neck mass becomes greater with increasing age. </li></ul>
  75. 77. Lymph node groups with the most likely sites of the primary lesion. Diagnosis (metastatic lymph node)
  76. 78. algorithm
  77. 80. Evaluation and management of a neck mass in the adult patient. (PPD = purified protein derivative) Algorithm
  78. 81. Management <ul><li>Many inflammatory lymph nodes resolve with no treatment, although close observation is required. </li></ul><ul><li>A single course of therapy with a broad-spectrum antibiotic and reassessment in one to two weeks is a reasonable treatment choice when a patient with a neck mass has signs and symptoms of an inflammatory process (i.e., fever, painful mass, erythema) or a history of recent infection </li></ul>
  79. 82. Management <ul><li>Benign neoplasm: surgical treatment </li></ul>
  80. 83. Neck Dissection
  81. 84. overview <ul><li>Anatomy </li></ul><ul><ul><li>Nodal levels </li></ul></ul><ul><ul><li>Common nodal drainage patterns </li></ul></ul><ul><li>Staging </li></ul><ul><li>Classification </li></ul><ul><li>Sentinel Lymph Node </li></ul>
  82. 85. Introduction <ul><li>The neck dissection is a surgical procedure for control of neck lymph node metastasis from squamous cell carcinoma ( SCC ) of the head and neck. </li></ul><ul><li>The aim of the procedure is to remove lymph nodes from one side of the neck into which cancer cells may have migrated. </li></ul><ul><li>The metastases may originate from SCC of the upper aerodigestive tract, including the oral cavity, tongue, nasopharynx, oropharynx, hypopharynx, and larynx, as well as the thyroid, parotid and posterior scalp. </li></ul>
  83. 86. Introduction <ul><li>Lymph node metastasis reduces the survival rate of patients with squamous cell carcinoma by half. </li></ul><ul><li>The survival rate is less than 5% in patients who previously underwent surgery and have a recurrent metastasis in the neck. </li></ul><ul><li>Therefore, the control of the neck is one of the most important aspects in the successful management of these particular tumors. </li></ul>
  84. 87. Anatomy <ul><li>Lymph Node Levels: To describe the lymph nodes of the neck for neck dissection, the neck is divided into 6 areas called Levels </li></ul>
  85. 88. Common Nodal Drainage <ul><li>Level I : Chin, Lower lip, Anterior floor of mouth, Mandibular incisors, Tip of tongue, Oral Cavity, Floor of mouth, Oral tongue, Nasal cavity (anterior), Face </li></ul><ul><li>Level II : Oral Cavity, Nasal Cavity, Nasopharynx, Oropharynx, Larynx, Hypopharynx, Parotid </li></ul><ul><li>Level III : Oral cavity, Nasopharynx, Oropharynx, Hypopharynx,Larynx </li></ul>
  86. 89. Common Nodal Drainage Level IV : Hypopharynx, Larynx, Thyroid, Cervical esophagus Level V : Nasopharynx, Oropharynx, Posterior neck and scalp Level VI : Thyroid, Larynx (glottic and subglottic), Pyriform sinus apex, Cervical esophagus
  87. 90. Classification <ul><li>Radical Neck Dissection (RND) </li></ul><ul><ul><li>Gold standard operation </li></ul></ul><ul><li>Modified Radical Neck Dissection (MRND) </li></ul><ul><ul><li>Preservation of non lymphatic structures </li></ul></ul><ul><li>Selective Neck Dissection (SND) </li></ul><ul><ul><li>Preservation of lymph node groups </li></ul></ul><ul><li>Extended Neck Dissection </li></ul><ul><ul><li>Removal of additional lymph node groups or non lymphatic structures </li></ul></ul>
  88. 91. Radical Neck Dissection <ul><li>Removes </li></ul><ul><ul><li>all ipsilateral cervical lymph node groups I-V </li></ul></ul><ul><ul><li>SCM, IJV, XI </li></ul></ul><ul><ul><li>Submandibular gland, tail of parotid </li></ul></ul><ul><li>Preserves </li></ul><ul><ul><li>Posterior auricular </li></ul></ul><ul><ul><li>Suboccipital </li></ul></ul><ul><ul><li>Retropharyngeal </li></ul></ul><ul><ul><li>Periparotid </li></ul></ul><ul><ul><li>Perifacial </li></ul></ul><ul><ul><li>Paratracheal nodes </li></ul></ul>
  89. 92. Modified Radical Neck Dissection <ul><li>Removes </li></ul><ul><ul><li>Nodal groups I-V </li></ul></ul><ul><li>Preserves </li></ul><ul><ul><li>SCM, IJV, XI (any combination) </li></ul></ul><ul><li>Notate according to which structures are preserved </li></ul>
  90. 93. Selective Neck Dissection <ul><li>Remove high risk lymph node groups based on tumor site. </li></ul><ul><li>For oropharyngeal, hypopharyngeal and laryngeal cancers, SND (II-IV) is the procedure of choice . </li></ul>
  91. 94. Extended Neck Dissection <ul><li>To removal of one or more additional lymph node groups or nonlymphatic structures, or both, not encompassed by the RND </li></ul><ul><li>Notated by naming the structure(s) removed. </li></ul>
  92. 95. Operative Technique <ul><li>Limited incision guided by lymphoscintigraphy and gamma probe </li></ul><ul><li>Frozen section analysis (incised margin ) </li></ul>
  93. 96. Complications <ul><li>Nerve injury : Shoulder dysfunction (the accessory nerve ) </li></ul><ul><li>Vessel injury : Bleeding </li></ul><ul><li>Infections: Wound infections may also occur and can usually be managed in the clinic with antibiotics and minor wound care. </li></ul>
  94. 97. Complications <ul><li>Lymphatic Leak </li></ul><ul><li>Major lymph channels are encountered at the lower aspect of the neck, especially on the left side. </li></ul><ul><li>Occasionally a lymphatic leak occurs despite these efforts. </li></ul><ul><li>Food in the stomach can increase the amount of lymphatic flow. A diet change and a pressure dressing can usually control this problem, </li></ul><ul><li>Return to the operating room for repair if necessary . </li></ul>
  95. 98. Emphasis <ul><li>Anatomy features of the trachea and physiology . </li></ul><ul><li>What is tracheotomy? What is the indications? </li></ul><ul><li>What important structures in the neck? </li></ul><ul><li>Esophageal three Constrictions. What are the clinic significance? </li></ul>
  96. 99. Emphasis <ul><li>Two major triangles of the neck </li></ul><ul><li>How many levels of Lymphatic drainage of the neck </li></ul><ul><li>Neck masses classification and algorithm of diagnosis </li></ul><ul><li>Classification of the neck dissection </li></ul>
  97. 100. 无论遇到什么事, 我一定会支持你,绝对不让你掉下去。 Thank you 如果你感到郁闷,如果你也不开心, 那一定要告诉我。 我要把所有的快乐和你一起分享, 那你就把你的烦恼给我一半好了。 Thank you