Elevate the skin flaps superiorly to the level of the ramus of mandible. Identify and protect the external jugular vein. Surgeon: Okay, elevating the skin flaps now. Carefully dissecting in the plane just deep to the platysma muscle. There's the external jugular vein, I'm protecting that as I elevate the flap. Almost to the level of the ramus now.

1. NECK
DISSECTION
By Prof. Muhammad Iqbal Butt
F.R.C.S. (Canada)
Chairman Department of E.N.T.
Lahore Medical & Dental College,
Dean Faculty of E.N.T.
College of Physicians and Surgeons, Pakistan

2. BENIGN AND MALIGNANT
LESIONS
 Benign lesions are discrete, movable, nontender (20%)
 Submandibular 25% are malignant
 Malignant lesions metastasizing to the regional lymph
nodes:
• Lip 31%
• Cheek 40%
• Alveolus 35%
• Tongue and floor of mouth 63%
• Nasopharynx 80%

3.  80% of lateral neck masses are malignant
 85% of these are from lesions of head and neck
 Most common sites:
1. Nasopharynx
2. Tonsils
3. Base of tongue
4. Supraglottis
5. Thyroid
6. Pharynx
7. Mouth
8. Palate

4. PRIMARY LESIONS
 Of the primary lesions of head and neck
 Laryngopharynx 40%
 Orophayrynx 40%
 Thyroid 10%
 Others 10%
 Squamous cell carcinoma is present in 50%
 45% of them are:
 Undifferentiated carcinoma
 Lymphoepithlioma
 Lymphosarcoma
 Adenocarcinoma
 5% occult primary

5. DIAGNOSIS
1. History
2. Examination of ear, nose, throat, oral cavity should
give you diagnosis in 95% cases
3. Examination of nasopharynx
4. Waldeyer’s ring especially tonsils if lymphoma is
suspected
5. Squamous cell carcinoma progresses slowly,
adenocarcinoma much more rapidly

6. DIAGNOSIS
 Mass superior jugular group and for tonsil, oropharynx,
supraglottis
 Mass in middle and inferior group usually arises from
larynx
 Mass in supraclavicular region arises below the clavicle:
 Stomach
 Intestine
 Lung
 Mass in posterior neck arises from nasopharynx and
paranasal sinuses or are primary lymphomas

7. IMPORTANT CONSIDERATIONS
 Before embarking on treating locally, distant
metastases may be considered
 FNAC
 Incisional biopsy is to be done only as a last
resort for making diagnosis
 MRI & CT scan

8. GROUPS OF LYMPH NODES
1. Occipital
2. Mastoid
3. Parotid
4. Submandibular
5. Submental
6. Facial
7. Sublingual
8. Retropharyngeal
9. Lateral cervical
10. Anterior cervical

9. PAROTID
a) Superficial part
b) Superficial subglandular lying beneath the parotid
sheath (Fascia parotidomasseter)
b1) Preauricular
b2) Intraauricular
c) Deep intraglandular
d) The lower pole of the parotid
These are removed in radical neck dissection

10. SUBMANDIBULAR
a) Preglandular
b) Prevascular: Usually one large prevascular
node is lying in front of the anterior facial vein
and on the external maxillary artery
c) Retrovascular: Usually two retrovascular
nodes are situated behind the anterior facial
vein

11. SUBMENTAL
a) Anterior
b) Middle
c) Posterior

12. RETROPHARYNGEAL
a) Medial: These are intercalated
b) Lateral: These are one to two lying between
prevertebral fascia and lateral pharyngeal wall
at the level of the atlas, near the carotid as it
enters the carotid canal

13. LATERAL CERVICAL
a) Superficial: There are one to four superficial nodes
over the upper half of sternocleidomastoid. These are
in close relation to the lower pole of the parotid.
b) Deep: The deep cervical nodes consist of three
chains:
i. Internal jugular
ii. Spinal accessory
iii. Transverse cervical

14. i. Internal jugular chain
 The internal jugular chain lies along the anterolateral aspect
of the internal jugular vein and spinal laterally to the
posterior aspect of the vein in the lower neck
 SUBDIGASTRIC: These are in relation to the posterior
belly of the digastric
 CAROTID NODES: These are in relation to the carotid
bifurcation
 OMHYOID: These are in relation to the superior belly of
the omhyoid
 SUPRACLAVICULAR: These are in relation to the
clavicle
 KUTTNER’S NODE: Also called the principle node of
Kuttner located anteriorly near the posterior belly of the
digastric

15. ii. Spinal accessory chain
 These are five to ten nodes that extend along the
accessory nerve

16. iii. Transverse cervical chain
 These are one to ten lymph nodes at the
jugulosubclavian junction. They accompany the
transverse cervical artery and vein. The most
medial of these is the Troissier’s node which may
be the site of metastasis of carcinoma of
stomach. These drain into the right lymphatic
duct.

17. ANTERIOR CERVICAL
NODES
 These lie between the two carotid sheaths
below the level of the hyoid bone
1. Superficial anterior jugular
2. Deep anterior cervical
Lymph nodes groups:
a) Prelaryngeal
b) Paratracheal
c) Recurrent nerve chain

18. LYMPHATIC DRAINAGE

20. GENERAL
CONSIDERATIONS
 If adenocarcinoma occult primary is high in the neck,
block dissection is performed with inspection of the
parotid gland
 If biopsy shows undifferentiated carcinoma, radiate
especially for 4cm lymph nodes and then clean residual
disease
 As a general rule, incurable lesions of the neck should
be first treated with radiation
 Block dissection is used to relieve intractible pain
 If adenocarcinoma is present in a supraclavicular LN,
look for primary in the thyroid

21.  Functional neck dissection is indicated:
i. When bilateral neck dissection is indicated
ii. Preserves muscle function and protects the
carotids
BLOCK DISSECTION

22. LEVELS OF LYMPH NODES
I. Submental and submandibular
II. Upper deep cervical group of
lymph nodes around internal
jugular vein. Skull base to
carotid bifurcation or hyoid
III. Middle third of internal
jugular vein to the carotid
bifurcation up to omhyoid
muscle or cricothyroid notch
IV. Lymph nodes from omhyoid
to the clavicle
V. Lymph nodes along the spinal
accesory and transverse
cervical artery
VI. Lymph nodes in anterior
compartment around midline
visual structures

23. SURGICAL MARGINS OF
RADICAL NECK DISSECTION

24. SURGICAL MARGINS OF
SUPRAOMOHYOID NECK
DISSECTION

25. LATERAL COMPARTMENT
NECK DISSECTION

26. POSTEROLATERAL NECK
DISSECTION

27. ELECTIVE THERAPEUTICS
 No palpable nodes
 Out of seventy operated cases only eight require
surgery
THERAPEUTICS (also called definitive)
 If nodes are palpable surgery is definite
treatment

28. TYPES OF NECK DISSECTIONS
1. Radical neck dissection
2. Modified radical neck dissection
3. Selective neck dissection
4. Extended radical neck dissection

29. 1- Radical Neck Dissection
Removal of:
a) Sternocleidomastoid muscle
b) All lymph node groups (level 1-5)
c) Spinal accessory nerve
d) Internal jugular vein

30. 2- Modified Radical Neck Dissection
Remove all lymph nodes (level 1-5), preservation
of one or more non-lymphatic structures
i. Type I Modified Radical Neck Dissection preserves
the spinal accessory nerve
ii. Type II Modified Radical Neck Dissection saves
spinal accessory nerve, internal jugular vein
iii. Type III Modified Radical Neck Dissection
preserves spinal accessory nerve, internal jugular
vein, sternocleidomastoid muscle. Known as
Functional Neck Dissection (Berry picking)

31. 3- Selective Neck Dissection
a) Preservation of one or more lymph node groups and
b) All non-lymphatic structures (accessory nerve,
internal jugular vein, sternocleidomastoid muscle)
i. Supra omhyoid LN removed (level 1-3)
ii. Posterolateral LN removed (level 2-5)
1. Post-auricular and
2. Suboccipital lymph node groups
iii. Lateral (level 2-4) removed
iv. Anterior (level 6) removed

32. 4- Extended Radical Neck
Dissection
 All structures in radical neck dissection and one
or more additional lymph node groups or non-
lymphatic structures or both

33. CONTRA-INDICATIONS OF
NECK DISSECTION
1. Mass in subclavian triangle
2. A large fixed mass
3. Mass extending to the mastoid
4. Undifferentiated carcinoma
5. Primary lesion that cannot be controlled
6. Distant metastases
7. Uncontrollable tumour will remain in neck after surgery
8. Papillary carcinoma of thyroid without extracapsular
invasion
9. Occult primary adenocarcinoma – sample nodal excision
with inspection of neck

34. INDICATIONS OF NECK
DISSECTION
 The tumour has extended to lymph nodes
 There is reasonable expectation of controlling
the PRIMARY TUMOUR
 Emphasis is on preservation of function
 Radiation failure
 Lymph nodes larger than 3cm

35. IMPORTANT LANDMARKS
 Transverse process of atlas
 Internal jugular, Internal carotid artery.
 IX, X, XI & XII cranial nerve.

36. SRUCTURES AT TIP OF
HYOID BONE
 Carotid bulb, External & Internal carotid artery
 Internal jugular vein
 Vagus nerve, Hypoglossal nerve passing lateral
to carotids
 Lingual vein, superior thyroid & facial vein
entering internal jugular vein
 Superior thyroid artery, Superior laryngeal nerve
& artery

37. TRANSVERSE PROCESS OF
VI CERVICAL VERTEBRA
 Also called carotid tubercle
 It lies at the level of cricoids cartilage
 Vertebral artery entering the foramen at this
level

47. PREOPERATIVE
1. Type cross match 2-3
units of whole blood
2. Patient anaesthetized using
various tubes
3. Pillow placed under the
shoulder, raise the head
30°
4. Scrub to prepare:
i. Lower face
ii. Ears
iii. Neck
iv. Shoulders
v. Upper chest

48. POSITION

49. POSITION

50. POSITION

51. POSITION

52. DRAPING
 Keep the ear outside
 First sheet from chin to ear
 Second sheet across upper chest
 Third sheet mastoid to shoulder
 Stitch the sheets

53. DRAPING

54. TYPES OF NECK INCISIONS

55. TYPES OF NECK INCISIONS

56. MARTIN INCISION
 Upper incision -
submental area to tip of
mastoid
 Lower incision -
suprasternal notch to
4cm above clavicle
 Vertical arm – posterior
to carotid vessels

57. CONLEY INCISION
 Incision is away from
carotid
 Difficult area of the
trapezius can be easily
approached

58. TYPES OF NECK INCISIONS

66. INCISION
 Protect the carotid with levator muscles, fascia
lata graft
 Incision should be carried out through
i. Skin
ii. Subcutaneus tissue
iii. Platysma muscle
 External jugular vein is not included with the
skin incision

67. INCISION
 Include the platysma muscle in skin flaps
 Use superior belly of omohyoid as medial guide
 Use scalenus fascia as guide for depth
 Critical areas and structures:
 Internal jugular vein superiorly and inferiorly
 Subclavian vein
 Posterior facial vein hidden in tail of parotid gland
 Superior laryngeal nerve deep to external and internal carotid arteries
 Thoracic duct on left side
 Apical pleura
 Place incision so that trifurcation does not overlie the carotid
vessels

68. SURGERY 1
 Skin flaps elevated:
i. Superiorly to ramus of
mandible
ii. Lift the deep cervical
fascia at level of hyoid
iii. Midline to strap
muscles
iv. Inferiorly to clavicle

69. SURGERY 2
 Find the notch made on the
inferior border of mandible
by the external maxillary
vessels, anterior facial vein
and superficial layer of deep
cervical fascia as reflected
 Sternocleidomastoid:
Upper and lower ends are cut
lose to the bone and up to
the deep fascia. The vein is
exposed and a 2cm strap is
left below
 Tied in continuity
 Two suture ligatures are put
in place

72. PROBLEM
 The lower end slips or tears
DO NOT PANIC
Remedy!
 JUGULAR VEINS: Always tie the lower end first
 OTHER VEINS:
1. Transverse cervical vein
2. Transverse scapular vein
3. Anterior jugular vein
Fascia of carotid sheath is stripped and vagus nerve and internal
carotid artery saved

73. LEFT SIDE
 THORACIC DUCT:
If you are 2cm above,
you should be alright. Still if
it is opened then white fluid
or blood will come out.
 Try to
 Repair it, or
 Tie it off

74. THYROID
 If involved with disease,
lobectomy on that side is
performed
 After cutting the
sternohyoid and
sternothyroid, return to
deep layer of deep
cervical fascia
1. Phrenic nerve
2. Brachial plexus
3. Nerve to serratus anterior
4. Subclavian artery and vein

75. PHRENIC NERVE
 Descends lateral to
medial crossing the
scalenus anticus – save it

76. SAVING THE ACCESSORY
NERVE
 Identify XIth CRANIAL
NERVE - save it if not
involved
If not possible, graft the
posterior auricular nerve
 It is identified ⅓rd from
clavicle, ⅔rd from
mastoid tip

77. ANTERIOR DISSECTION
 Separate the vein and thyroid from
carotid artery and vagus nerve
 CAROTID MASSAGE
 Vagus nerve may have to be
sacrificed
 Adherent lymph nodes to carotid
 Identify the phrenic nerve’s
cervical branches
 Insertions of anterior belly of
omhyoid, sternothyroid are
transected
 Identify the hypoglossal nerve
1.5cm above the carotid
bifurcation and lateral to it
 Superior laryngeal nerve passes
deep to the internal and external
carotid artery. Their section will
lead to problems in deglutition

78. SUBMAXILLARY TRIANGLE
 Digastric muscle is identified,
separated from hyoid bone
 Anterior border is transected just
below insertion
 The omhyoid muscle is transected
anteriorly
 Lower end transected ahead
 Upper end of external jugular vein
transected
 Dissection across lower pole of
parotid gland
 The stylomandibular ligament is
divided
 The superior aspect of
submandibular gland is dissected
 Facial vessels ligated
 Posterior belly of digastric is cut

79. SUBMANDIBULAR GLAND
 The submandibular gland is pulled
down exposing the lingual nerve
 Whartin’s duct: This is resected
 Facial artery is transected and ligated
just below the mandible
 The posterior belly of digastric and
thyrohyoid are transected exposing
the internal jugular vein
 Internal maxillary and occipital
arteries are identified and ligated
 If it cannot be tied, oxycyll / surgicell
pack is left in place
 Protect carotid artery with levator
scapulae
 Wash the wound floor
 Hemovac drain

80. CAUSES OF CAROTID
BLOWOUT
 Infection
 Incision line is on the carotid
 Flaps are lifted by blood or serum
 Injury during surgery
 Suction tip close to the carotid
 Radiated patient

81. WHEN TO TREAT CAROTID
BLOWOUT
 Do it as an elective procedure
Elective Ligation Emergency Ligation
Number of patients 64 (100 per cent) 87 (100 per cent)
Stroke 15 (23 per cent) 44 (50 per cent)
Deaths 11 (17 per cent) 33 (38 per cent)

82. PROTECTING THE CAROTID
 Muscle graft
 Fascia lata graft
 Dermal graft

83. LEVATOR SCAPULAE
MUSCLE GRAFT

84. DERMAL GRAFT
 1/12th of an inch
epidermis is elevated
 Graft should be 7cm
wide
 20 cm long
 1/20 to 1/24th of an inch
thick
 Use non-absorbable
sutures

85. PROTECTING THE CAROTID

86. PROTECTING THE CAROTID

91. VEIN GRAFT

93. LIGATING EXTERNAL
CAROTID

94. COMPLICATIONS
1. Delayed bleeding
2. Shock
3. Air embolism
i. Hissing sound
ii. Blood pressure falls
iii. Regurgitation in heart
iv. Fundoscopy
4. Airway obstruction
5. Carotid sinus syndrome
6. Pneumothorax

95. 7. Nerve damage
i. Superior laryngeal nerve
ii. Facial nerve
iii. Vagus nerve
iv. Recurrent laryngeal nerve
v. Phrenic nerve
vi. Hypoglossal nerve
vii. Cervical sympathetic chain (Horner’s syndrome)
viii. Spinal accesory nerve
ix. Lingual nerve
x. Brachial plexus

96. 8. Chylous fistula
9. Subcutaneous emphysema
10. Wound infection
11. Gangrene of flap tissue – prevent base to tip
ratio
12. Carotid artery rupture
13. Fluid electrolyte imbalance

97. 14. Increased central venous pressure – if CSF pressure rises
above 600 mmH2O, cerebral palsy
15. Injury to cervical vertebrae
16. Salivary fistula
17. Feeding tube syndrome:
1. Dehydration
2. Hypernatremia
3. Hyperchloridemia
4. Azotemia
5. Fever
6. Increased urinary output
7. Weight loss
8. Confusion

98. QUESTIONS?