This document discusses neck dissections, including classifications, indications, and techniques. There are several types of neck dissections including radical neck dissection (RND), modified radical neck dissection (MRND), and selective neck dissection (SND). RND removes all lymph nodes from levels I-V while preserving important structures like the spinal accessory nerve (SAN) and internal jugular vein (IJV) distinguishes MRND from RND. SND only removes certain lymph node groups. The document outlines the surgical steps for performing neck dissections and discusses complications.
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Micro vascular free flaps used in head and neck reconstruction /certified fi...Indian dental academy
Welcome to Indian Dental Academy
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 has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
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Of all the body systems, the lymphatic system is perhaps the least familiar to most people. Yet without it, neither the circulatory system nor the immune system could function—circulation would shut down from fluid loss, and the body would be overrun by infection for lack of immunity.
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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.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
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Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
3. The neck dissection is a surgical procedure
for control of neck lymph node metastasis.
This can be done for clinically or radiologically
evident lymph nodes or as part of curative
surgery where risk of occult nodal metastasis
is deemed sufficiently high.
4. Status of the cervical lymph nodes
is important prognostic factor in SCCA of the
upper aerodigestive tract
Cure rates drop in half when there is
regional lymph node involvement
5. Emil Theodor Kocher
Earned Nobel Prize in 1909 for
his work in thyroid and neck
surgery — the first ever
awarded to a surgeon.
1880 – Kocher proposed
removing nodal
metastases
6. 1906 – George Crile
described the classic radical
neck dissection (RND)
7. 1967 - Bocca and Pignataro
described the “functional neck dissection”
(FND)
8.
9. 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
10.
11.
12.
13. Sternocleidomastoid Muscle
medial third of clavicle(clavicular
head), manubrium (sternal head)
Insertion – mastoid process
Nerve supply – spinal accessory
Blood supply –
1) occipital a. or direct from ECA
2) superior thyroid a.
3) transverse cervical a.
Function –
turns head toward opposite side
and tilts head toward the
ipsilateral shoulder
14. 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
muscle
Blood supply – Inferior thyroid a.
Function –
1) depress the hyoid
2) tense the deep cervical fascia
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
15. Origin –
1) medial 1/3 of the sup. Nuchal line
2) external occipital protuberance
3) ligamentum nuchae
4) spinous process of C7 and T1-T12
Insertion –
1) lateral 1/3 of the clavicle
2) acromion process
3) spine of the scapula
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
16. Origin – digastric fossa of the mandible
Insertion –
1) hyoid bone via the intermediate
tendon
2) mastoid process
Function – 1) elevate the hyoid bone
2) depress the mandible (assists
lateral pterygoid)
Surgical considerations
“Residents friend”
Posterior belly is superficial to:
ECA, Hypoglossal nerve, ICA, IJV
– Anterior belly
Landmark for identification of mylohyoid
for dissection of the submandibular
triangle
17. Should be preserved in
neck dissections
Most commonly injury
dissection level Ib
Can be found:
– 1cm anterior and inferior
to angle of mandible
Deep to fascia of the
submandibular gland
Superficial to adventitia of
the facial vein
18. Originates in the spinal nucleus
Passes through two foramen
– Foramen Magnum – enters the skull
posterior to the vertebral artery
– Jugular Foramen – exits the skull
with CN IX,X and 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
19. Sole nerve supply to the
diaphragm
Supplied by nerve roots
C3-5
Runs obliquely toward
midline on the anterior
surface of anterior
scalene
Covered by prevertebral
fascia
Lies posterior and lateral
to the carotid sheath
20.
21. 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
Extends upward along hyoglossus
muscle and into the genioglossus
to the tip of the tongue
Iatrogenic injury Most common site
- floor of the submandibular
triangle, just deep to the duct
22. “N” classification AJCC (1997)
Consistent for all mucosal sites except the
nasopharynx
Thyroid and nasopharynx have different
staging based on tumor behavior and
prognosis
23. NX: Regional lymph nodes cannot
be assessed
N0: No regional lymph node
metastasis
N1: Metastasis in a single ipsilateral
lymph node, < 3
N2a: Metastasis in a single
ipsilateral
lymph node 3 to 6 cm
N2b: Metastasis in multiple
ipsilateral
lymph nodes, none more than 6 cm
N2c: Metastasis in bilateral or
contralateral nodes < 6cm
N3: Metastasis in a lymph node
more than 6 cm in greatest
dimension
24.
25.
26.
27. Level IA
Floor of mouth, anterior oral tongue,
anterior mandibular alveolar ridge, lower lip
Level IA
Floor of mouth, anterior oral tongue,
anterior mandibular alveolar ridge, lower lip
Level IB
Oral cavity, anterior nasal cavity, soft
tissue of midface, submandibular gland
Level IB
Oral cavity, anterior nasal cavity, soft
tissue of midface, submandibular gland
29. With oral, tongue, retromolar trigone, and
tonsillar fossa subsites, the
jugulodigastric, submandibular, and
midjugular lymph node stations are
involved.
With the floor of the mouth as the subsite,
the submandibular and
jugulodigastric lymph node stations are
involved.
With the soft palate, base of the tongue,
oropharynx, supraglottis, and
hypopharynx subsites, the
jugulodigastric, midjugular, and
contralateral lymph node stations are
involved.
With the nasopharynx as the subsite,
lymph node stations of the widest nodal
distribution are involved.
30. Contralateral metastasis is found in the
supraglottis, the base of the tongue, and the
posterior pharyngeal wall palate.
Bilateral metastasis is found in the
nasopharynx, the base of the tongue, the soft
palate, the floor of mouth, and the supraglottis.
Multiple cervical metastases
(adenocarcinoma) occur with thyroid carcinoma,
breast carcinoma, and nasopharyngeal
carcinoma.
31.
32. Academy’s classification
1) Radical neck dissection (RND)
2) Modified radical neck dissection
(MRND)
3) Selective neck dissection (SND)
Supra-omohyoid type
Lateral type
Posterolateral type
Anterior compartment type
4) Extended radical neck dissection
33. Comprehensive neck dissection
Radical neck dissection
Modified radical neck dissection
Type I (XI preserved)
Type II (XI, IJV preserved)
Type III (XI, IJV, and SCM preserved)
Selective neck dissection
34. All lymph nodes in Levels
I-V including spinal
accessory nerve (SAN),
SCM, and IJV
Indications
– Extensive cervical
involvement or matted
lymph nodes with gross
extracapsular spread and
invasion into the SAN,
IJV, or SCM
35.
36. Excision of same lymph node bearing regions as
RND with preservation of one or more
nonlymphatic structures (SAN, SCM, IJV)
Type I: Preservation of SAN
Type II: Preservation of SAN and IJV
Type III: Preservation of SAN, IJV, and
SCM
38. Indications
– Clinically obvious lymph node metastases
– SAN not involved by tumor
Rationale
RND vs MRND Type I:
5-year survival and neck failure rates for RND
(63% and 12%) not statistically different from
MRND (71% and 12%).
No difference in pattern of neck failure
40. Rationale
Suarez (1963) – surgery specimens of
larynx and hypopharynx – lymph nodes do not share
the same adventitia as adjacent BV’s
Survival approximates MRND Type I assuming IJV,
and SCM not involved
Neck dissection of choice for N0 neck
41. 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
42. Also known as an elective neck dissection
Indication: primary lesion with 20% or greater risk
of occult metastasis
May elect to upgrade neck intraoperatively
Frozen section needed to confirm SCCA in
suspicious node
Need for post-op XRT
43. Indications
Oral cavity carcinoma with N0 neck
Subsites - Lips, buccal mucosa, upper and lower
alveolar ridges, retromolar trigone, hard palate, and
anterior 2/3s of the tongue and Floor Of Mouth.
– Medina recommends SOHND with T2-T4NO
or TXN1 (palpable node is <3cm, mobile, and
in levels I or II)
44. Indications
Anterior tongue
Oral tongue and
FOM that approach
the midline
Adjuvant XRT given
to patients with
> 2positive nodes +/-
45. En bloc removal of the
jugular lymph nodes
including Levels II-IV
Indications
N0 neck in
carcinomas of the
oropharynx,hypophar
ynx, supraglottis, and
larynx
46. En bloc excision of lymph bearing tissues in
Levels II-V
Indications
Cutaneous malignancies
Melanoma
Squamous cell carcinoma
Merkel cell carcinoma
Soft tissue sarcomas of the scalp and neck
47. En bloc removal of lymph structures in Level VI
Perithyroidal nodes
Pretracheal nodes
Precricoid nodes (Delphian)
Paratracheal nodes along recurrent nerves
– Limits of the dissection are the hyoid
bone,suprasternal notch and carotid sheaths
Indications
– Selected cases of thyroid carcinoma
– Parathyroid carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma with subglottic extension
– CA of the cervical esophagus
48. 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
Examples:
Resection of the hypoglossal nerve, resection of
digastric muscle, Carotid artery resection,
dissection of mediastinal nodes and central
compartment for subglottic involvement, and removal of
retropharyngeal lymph nodes for tumors originating in
the pharyngeal walls.
54. Flap raising
Make the skin incision through
the platysma and elevate the
flap in the subplatysmal plane.
Traction with the surgeon's
fingers and countertraction by
the assistant with skin hooks
Elevate the posterior flap toward
the trapezius muscle.
Identify and preserve the
marginal mandibular nerve at
the superior aspect of the flap.
55. The contents of the submental triangle
are then elevated from the inferior
border of the mandible and the
opposite digastric muscle off of the
mylohyoid muscle
Dissection in the proper plane allows
for an en bloc elevation of the
contents into the submandibular
triangle and to the posterior border
of the mylohyoid muscle.
Retraction of the mylohyoid muscle
anteriorly allows for identification of
the submandibular duct, which is
ligated and divided
The dissected contents of sublevels IA
and IB are then elevated over the
digastric muscle in continuity with
the nondissected portion of the neck
56. The contents dissected from level I are
elevated caudally to visualize the
superior internal jugular vein..
Identification of the SAN can be
performed anterior or posterior to the
SCM.
If the SAN can be preserved, dissection
is then continued from near to IJV
towards the trapezius muscle, dividing
the SCM. If the SCM is going to be
preserved, the SAN must be carefully
dissected by identifying the nerve both
anterior and posterior to the SCM.
A posterior to anterior dissection is then
performed beginning at the anterior
border of the trapezius muscle,
preserving the phrenic nerve and the
brachial plexus, located deep to this
fascia.
The SAN must then be freed from the
soft tissues of the posterior triangle and
can be carefully retracted away from the
region of dissection with a vessel loop or
nerve hook. Dissection is continued to
the posterior border of the SCM.
57. .
At this point, the posterior triangle contents,
with or without the SAN and SCM, have been
elevated to the lateral aspect of the IJV. If the
SCM is being resected, transection is
performed below the mastoid tip and above
the clavicle as in a RND.
The nodes along IJV can usually be removed
en bloc with the remainder of the dissection
in a posteroanterior fashion, sharply incising
the fascia of the jugular vein with a scalpel
blade using a feather-light touch. If the IJV
requires sacrifice due to metastatic nodal
involvement or tumor thrombosis, the vein is
ligated and divided superiorly and inferiorly
following identification and preservation of
the vagus nerve.
Dissection is continued anteriorly, elevating
the fascia and soft tissues up to the
infrahyoid strap muscles and the hyoid-
digastric junction.
Preservation of a fascial layer superficial to
the carotid artery is usually possible, and
exposure of the carotid artery should be
discouraged unless necessary.
Suction drains are strategically placed and a
layered closure is performed.