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Neck dissection


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Neck dissection

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