Neck Dissection-Dr Stanley John

1. NECK DISSECTION
Dr Stanley John Cheriyan
Oral & Maxillofacial Surgery

2. Introduction
• The term "neck dissection" refers to the removal of lymph nodes and
lymph node bearing tissues of neck from the inferior border of the
mandible to the clavicle ,as a treatment of head and neck malignancy.

3. How does tumor spread ?
• Spread of disease of oral cavity to neck -- palpable lymphadenopathy.
• Systemic homogenous spread rarely occurs in the lymphatics of the
neck.
• early eradication of local and regional disease can prevent future
systemic metastasis.

4. The regional lymph node groups draining a specific primary site
is first echelon lymph nodes

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

6. Risk for nodal metastasis
• Various factors
• Site
• Size
• T stage
• Location of primary tumour
• Histomorphologic characteristics of primary tumor

7. Risk of nodal metastases increases in relation to location of the
primary tumor

8. What is the rationale of treatment of
squamous cell carcinoma ?
• SCC has a distinct predilection for lymphatic spread
before distant systemic metastasis.
• early detection and eradication of local and regional
lymphatics prevents future metastasis

9. Memorial sloan kettering Cancer centre leveling
system

10. Division of neck levels by sublevels
• IA – submental nodes
• IB – submandibular nodes
• IIA & IIB – together
comprising the upper jugular
nodes
• III – middle jugular nodes
• IV – lower jugular nodes
• VA – Spinal accessory nodes
• VB – Transverse cervical and
supraclavicular nodes
• VI – anterior compartment
nodes

11. Clinical assessment and staging
• Important parameter for surgical management of the
neck is the staging of the neck itself.
• Results of the staging procedure have lower level of
certainty than biopsies

12. Assessment
• Clinical examination: 72% to 76% sensitivity
• CT and MRI : 84% to 92%

13. TNM Staging AJCC 8th Edition
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour 2 cm or less in greatest dimension
T2 Tumour more than 2 cm but not more than 4 cm in greatest
dimension
T3 Tumour more than 4 cm in greatest dimension
T4a (lip) Tumour invades through cortical bone, inferior alveolar nerve,
floor of mouth, or skin (chin or nose)
T4a (oral
cavity)
Tumour invades through cortical bone, into deep/extrinsic muscle
of tongue (genioglossus, hyoglossus, palatoglossus, and
styloglossus), maxillary sinus, or skin of face
T4b (lip
and oral
cavity)
Tumour invades masticator space, pterygoid plates, or skull base;
or encases internal carotid artery
T — Primary tumour 1,2

14. NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest dimension
N2 Metastasis as specified in N2a, 2b, 2c below
N2a Metastasis in a single ipsilateral lymph node, more than 3 cm
but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than
6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more
than 6 cm in greatest dimension
N3 Metastasis in a lymph node more than 6 cm in greatest
dimension
N - Regional Lymph Nodes##
M - Distant metastasis
M0 No distant metastasis
M1 Distant metastasis

15. Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 N1 M0
T3 N0, N1 M0
Stage IVA T1, T2, T3 N2 M0
T4a N0, N1, N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M1
Stage grouping

16. TNM STAGING
• First reported by Pierre Denoix in the 1940s.
• The International Union against cancer (UICC) and AJCC eventually
adapted the system
• It is important to realize that the TNM staging system is simply an
anatomic staging system
• TNM Staging describes tumor burden in only two dimensions

17. A study of correlation of tumor thickness with risk
of occult nodal metastasis –Spiro et al*
*Spiro RH,Huvos AG, Wong GY ,Spiro JD, Strong EW .Predictive value of tumor
thickness in SCC confined to the tongue and floor of the mouth Am J Surg 1986;
152: 345-350

18. Patterns of cervical lymphatic metastasis
• lymphatic flow in the neck - consistent pattern -
upper neck and then to the lower neck.
• 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.

19. Studies on Patterns of cervical lymph node
metastasis – Jatin P Shah
* The percentages represents percent of patients with
N0 neck

20. Distribution of nodal metastasis in patients with N+ neck
Studies on Patterns of cervical lymph node
metastasis – Jatin P Shah

21. Further studies to support
• low level of metastasis to level V was confirmed -study by Davidson
et al.
• an incidence of level V metastasis of 1% was found among 666 RND
performed
• Inference: Metastasis to level V never occurred in the absence of
clinically palpable nodes in other levels of neck.

22. History of neck dissections

23. Dr George Crile (1864-1943)
In 1906 paper
“Exicision of cancer of the
head and neck ”
Gold standard procedure :
“Radical Neck dissection”

24. Dr. Hayes Martin (1892-1977)
In 1951 paper
“Neck Dissection”
“Routine prophylactic RND was
impractical”

25. Historical perspective on neck dissection
• RND should not be used for N0 neck, a philosophy
that was largely observed in 2006.
• Nahum et al described a syndrome of pain following
RND – “Shoulder Syndrome”*.
*Nahum AM, Mullally W, Marmor L : A Syndrome resulting from radical neck
dissection. Arch otolaryngol 74 : 82,1961

26. Historical perspective on neck dissection
• 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 compared to
RND
• 1980- Ballantyne –concept of selective neck dissection

27. 1. Radical neck dissection (RND)
2. Modified radical neck dissection
(MRND)
3. Selective neck dissection (SND)
• Supraomohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type
4. Extended radical neck dissection
Classifications
Academy's classification

28. MEDINA CLASSIFICATION(1989)
• Comprehensive neck dissection
1. Radical neck dissection (RND)
2. Modified radical neck dissection (MRND)
• MRND I – Preserves spinal accessory nerve.
• MRND II – Spinal accessory and sternocleidomastoid
muscle but sacrifices internal jugular vein.
• MRND III – Requires preservation of 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

29. Spiro’s classification
• Radical (4 or 5 node levels resected)
• Conventional RND
• MRND
• Extended RND
• Selective (3 node levels resected)
• SOHND
• Jugular dissection (level II-IV)
• Any other 3 levels
• Limited (no more than 2 node levels resected)
• Para tracheal node dissection
• Mediastinal node dissection
• Any other 1 or 2 node levels resected

30. 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

31. 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 especially after radiotherapy
• It should be cosmetically acceptable

32. Differences between incisions
Transverse incision Vertical incision
Have cosmetic advantage as
they follow natural folds of
the skin
They intersect the natural
folds of the skin
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

33. 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.

34. Modification of Tri-radiate incision
• Schobinger (1957)
• Cramer & Culf (1969)
• Conley (1970)

35. Schobinger (1957)
‘Vertical limb instead of
being straight should be
curved posteriorly ’

36. Conley (1970)
Suggested a posteriorly
curving vertical incision
rather than a horizontal
incision

37. Hayes Martin Incision
• It is a paired ‘Y’ incision.
• Here the submandibular
component is met by a
vertical limb which below
becomes continuous with
an inverted ‘Y’ in the
suprascapular region.
• This flap most often gets
cyanosed.
• Flap necrosis and carotid
exposure is more in this
type of incision.

38. McFee Incision
• It avoids a vertical limb.
• Two horizontal incisions
are used one in
submandibular region
and other in the
suprascapular region.

39. Apron flaps
• Described by Latyschevsky and
Freund 1960.
• Only a horizontal incision from
mastoid to mentum gently curving
inferiorly upto upper border of the
thyroid cartilage is used.
• Advantages
• Carotid artery is well protected
• Disadvantages
• It will damage the ascending arterial
and venous recovery
• Venous congestion and oedema might
develop at the bottom corner

40. Hockey stick incision
• Lahey et al (1940) described.
• 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.

41. Radical Neck Dissection

42. Radical neck dissection
• Current indications for classical radical neck dissection.
• 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 and /or internal jugular vein at the base of the skull
• Involvement of accessory chain lymph nodes by metastatic disease.

43. Modified Radical Neck Dissection (MRND)
• Excision of same lymph node bearing regions as RND with
preservation of one or more nonlymphatic structures (SAN, SCM, IJV)
• Spared structure specifically named
• MRND is analogous to the “functional neck dissection” described by
Bocca

45. Modified Radical Neck Dissection
• Three types (Medina 1989) commonly referred to not 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”)

46. Incision

47. Dissection of the posterior triangle begins at the anterior border of
trapezius

48. Dissection of the posterior triangle medially leads to exposure of brachial plexus,
phrenic nerve and cutaneous roots of the cervical plexus

49. Specimen reflected posteriorly and anterior flap elevated to expose the sternal head
of SCMM

50. Sternocleidomastoid muscle is detached from the sternum and clavicle and retracted
cephalad to expose the carotid sheath

51. Internal jugular vein is ligated and divided after common carotid and vagus nerve is
exposed and retracted medially

52. Dissection proceeds cephalad along the carotid sheath up the skull base

53. The upper skin flap is now elevated preseving the mandibular branch of the facial
nerve

54. Surgical field following RND

55. Two suction drains inserted

56. Contraindications for RND
• Uncontrollable cancer of the primary site
• Evidence of distant metastasis
• Fixed nodes unchanged by radiotherapy or
chemotherapy
• Life expectancy of less than 3 months

57. Selective Neck Dissection
Definition
• Cervical lymphadenectomy with preservation of one or more lymph
node groups.
Four common subtypes
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection

58. SELECTIVE NECK
DISSECTION
• Also known as an elective neck dissection
• Rate of occult metastasis in clinically negative neck 20-30%
• Indication: primary lesion with 20% or greater risk of occult
metastasis
• Studies by Fisch and Sigel (1964) demonstrated predictable routes of
lymphatic spread from mucosal surfaces of the H&N

59. Supraomohyoid neck dissection
• Indications
• Oral cavity carcinoma with N0
neck
• Boundaries – Vermillion
border of lips to junction of
hard and soft palate,
circumvallate papillae
• Subsites - Lips, buccal mucosa,
upper and lower alveolar
ridges, retromolar trigone,
hard palate, and anterior 2/3s
of the tongue and FOM
• Medina recommends SOHND
with T2-T4NO ,TXN1 (palpable
node is <3cm, mobile, and in
levels I or II)

60. SND: Lateral Type
Indications
• N0 neck in carcinomas of the oropharynx, hypopharynx,
supraglottis, and larynx
• Rationale – Hypopharynx- Occult metastases in 30-35%
Johnson (1994)
• Medial pyriform (MP) vs. lateral pyriform carcinomas (LP)
• MP – 15% failed in the contralateral neck
• LP – 5% failed in the contralateral neck
• Johnson advocates bilateral SNDs for N0 MP carcinomas and
ipsilateral SND for N0 LP carcinomas
Bilateral SND is often indicated in the majority of
hypopharyngeal tumors because of extensive submucosal
spread and involvement of multiple subsites.

61. Posterolateral neck dissection

62. SND: Posterolateral Type
Definition
 En bloc excision of lymph bearing tissues in Levels II-IV and
additional node groups – suboccipital and postauricular.
 Indications :
 Cutaneous malignancies
 Melanoma
 Squamous cell carcinoma
 Merkel cell carcinoma
 Soft tissue sarcomas of the scalp and neck

63. Jugular neck dissection

64. Extended radical neck dissection
• Definition
• Any previous dissection which
includes removal of one or more
additional lymph node groups
and/or non-lymphatic structures.
• Usually performed with N+ necks in
MRND or RND when metastases
invade structures usually preserved

65. Complications of RND
• Intra operative complications
• Post operative complications
• Late complications

66. Intra-operative complications
• Injury to phrenic nerve
• Injury to vagus nerve
• Brachial plexus injury
• Carotid injury
• Hypoglossal nerve injury
• Lingual nerve injury

67. Post operative complications
• Haemorrhage
• Lymph leak
• Dysphagia
• Carotid blow out
• Facial edema

68. Complications of ligating bilateral internal jugular
vein simultaneously

69. Late complications
• Shoulder droop
• Shoulder pain
• Brachial neuralgia
• Neuroma
• Strictures

70. References
• Stell and Marans Head and Neck Surgery and Oncology - 5th Edition
• 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.
• L. H. Sobin & Ch Wittekind. TNM Classification of malignant tumours. 5th
edition. UICC, A John Wiley & Sons Inc. Publication. 1997.. Surg. 1999: 28 : 197
– 202.

71. • P. Hermanek, R. V. P. Hutter, L. H. Sobin & Ch Wittekind. TNM atlas.
Illustrated guide to the TNM / pTNM classification of malignant
tumours. 4th edition. Springer. 1997.
• 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

72. THANK YOU