This document provides information about neck dissection procedures. It discusses the history and evolution of neck dissection, defines the different types of neck dissections including radical, modified radical and selective neck dissections, and describes the key steps in performing a modified radical neck dissection. Complications of neck dissection such as hemorrhage, wound infection, and carotid artery rupture are also summarized.

1. Dr. SANJAY MAHARJAN.
1ST YEAR RESIDENT.
ENT-HNS, MANIPAL.
NECK
DISSECTION

2. • Systematic removal of lymph nodes, along with their surrounding
fibrofatty tissue, from various compartments of neck
• Aim : to remove neck lymph nodes into which cancer cells may have
migrated
• Metastases may originate from tumours of oral cavity, tongue,
nasopharynx, oropharynx, hypopharynx, and larynx, as well as the thyroid,
parotid and posterior scalp.
INTRODUCTION:

3. • Therapeutic neck dissection is used when metastatic cervical
lymphadenopathy is clinically evident.
• Elective neck dissection is used to remove lymph node groups in pts
who have clinically node-negative disease and who have increased risk of
harboring occult disease in neck
• Salvage neck dissection is done when metastatic disease is clinically
evident in the neck after previous treatment

4. • 1888 - Jawdynski described en bloc resection with resection of carotid,
internal jugular vein and sternocleidomastoid muscle.
• 1906 - George W. Crile of the Cleveland Clinic describes radical neck
dissection.
• 1957 - Hayes Martin describes routine use of radical neck dissection for
control of neck metastases.
• 1967 - Oscar Suarez and E. Bocca describe a more conservative operation
which preserves SAN, IJV and SCM.
• Last 3 decades - Further operations have been described to selectively
remove the involved regional lymph groups.
HISTORY OF NECK DISSECTION:

5. DIVISION OF NECK LYMPH NODES BY LEVEL
AND SUB-LEVEL

6. • Suggested by Suen and Goepfert (1997)
• Biologic significance for lymphatic drainage depending on site of tumor
IMPORTANCE OF SUBDIVISIONS:

7. “N” classification – AJC (1997)
NX: Regional lymph nodes cannot be
assessed
N0: No regional lymph node
metastasis
N1: Metastasis in single ipsilateral
lymph node, 3 cm or less in greatest
dimension
N2a: single ipsilateral lymph node >3
cm but <6 cm in greatest dimension
N2b: multiple ipsilateral lymph nodes,
none >6 cm
N2c: bilateral or contralateral nodes,
<6 cm
N3: lymph node >6 cm
STAGING OF HEAD AND NECK
CANCER

8. • Thyroid and nasopharynx have different staging based on tumor behavior
and prognosis
• Staging in nasopharyngeal cancer
 N1: unilateral
 N2: bilateral (Both are above supraclavicular fossa & < 6 cm)
 N3: > 6 cm or in supraclavicular fossa
• Staging in thyroid cancer
 N1a: ipsilateral
 N1b: midline / bilateral / contralateral

10. Principles of Classification
• RND: standard basic procedure for
cervical lymphadenectomy, all other
represent one or more modifications
• MRND: When modification of RND
involves preservation of one or more
non-lymphatic strs.
• SND: When modification involves
one or more lymph node groups that
are routinely removed in RND.
• Extended RND: When modification
involves removal of additional lymph
node groups or non-lymphatic
structures relative to RND.
CLASSIFICATION OF NECK
DISSECTIONS

11. • Removal of all ipsilateral cervical
lymph node groups that extend from
 Body of mandible superiorly to
 Clavicle inferiorly and from
 Contralateral anterior belly of
digastric & lat border of strap
muscles anteriorly to
 Ant border of trapezius posteriorly
RADICAL NECK DISSECTION

12. • extensive lymph node metastases
with extension beyond capsule of
node or nodes that involves SAN
and IJV.
• Untreatable primary tumor
• Unfit form major surgery
• Distant metastasis
• Significant b/l neck diseases
INDICATIONS: CONTRA-INDICATIONS:

13. • En bloc removal of lymph node–
bearing tissue from one side of the
neck (I-V)
• Unlike RND, it preserves SAN, IJV,
and/or SCM
• TYPES:
I. Type I preserves SAN
II. Type II preserves SAN & IJV
III. Type III preserves SAN, IJV &
SCM
MODIFIED RADICAL NECK
DISSECTION:

14. • Type I :
 Operable palpable neck disease
(usually N1, N2a, N2b) not involving
accessory nerve
 Can occasionally be done for the N0
neck
• Type II :
 Where preservation of IJV is
important either when performing a
second side operation or
 microvascular anastomosis or
 when histology shows vein need not
be resected, i.e. differentiated thyroid
cancer.
INDICATIONS:

15. • Type III :
 comprehensive or functional neck
dissection
 Elective Rx for N0 neck in cell
carcinoma of the upper aerodigestive
tract

16. • Reduce postsurgical shoulder pain and shoulder dysfunction
• Improve cosmetic outcome
• Reduce likelihood of bilateral IJV resection
BENEFIT OF MRND:

17. • En bloc removal of one or more
lymph node groups at risk for
metastatic cancer
• Levels removed depend on location
of primary lesion and its known
pattern of spread.
• Types:
I. Supraomohyoid (m/c performed)
II. Extended supraomohyoid
III. Lateral
IV. Postero-lateral:
V. Anterior or central:
VI. Superior mediastinum:
SELECTIVE NECK DISSECTION

18. • Supraomohyoid:
 SND for Oral Cavity Cancer
 Dissection of I-III groups
 Cutaneous branches of cervical
plexus and post border of SCM
mark posterior limit of dissection.
 Inferior limit - junction betn sup
belly of omohyoid & IJV
 Indication:
o SCC oral cavity T1–T4: N0.
• Extended supraomohyoid:
 Skin cancer (SCC and melanoma) ant
to line of tragus in conjunction with
superficial parotidectomy
INDICATIONS:

19. • Lateral:
 SND for Oropharyngeal,
Hypopharyngeal, and Laryngeal
Cancer
 Dissection of II-IV groups
 Sup. limit of dissection - skull base
 Inf. limit – clavicle
 Ant. (medial) limit - lat border of
sternohyoid & stylohyoid m/s
 Post. (lateral) limit - cutaneous
branches of cervical plexus and post
border of SCM.
 Indication:
o SCC larynx, oropharynx and
hypopharynx, T2–T4: N0

20. • Posterolateral:
 SND for Cutaneous Malignancies
 Dissection of II-V & post-auricular
nodes
 Sup. limit - skull base ant and nuchal
ridge post
 Inf. limit - clavicle
 Med. (ant) limit - lat border of
sternohyoid and stylohyoid m/s
 Lat. (post) limit - ant border of the
trapezius muscle inferiorly and
midline of neck superiorly

21. • Anterior or central:
 SND for Cancer of Midline
Structures of Anterior Lower Neck
 Dissection of level VI groups
 superior limit - body of hyoid bone
 inferior limit - suprasternal notch
 lateral limits - medial border of the
carotid sheath (CCA).
 Indications:
• Differentiated thyroid carcinoma
• Subglottic and hypopharyngeal SCC

22. • Sup. Mediastinum:
 Differentiated and medullary thyroid
carcinoma
 Subglottic laryngeal and
hypopharyngeal SCC
 Cervical oesophageal carcinoma

23. • RND along with one or more
additional lymph node groups or
nonlymphatic strs or both
• lymph node grps include
retropharyngeal and parapharyngeal,
parotid nodes, or lymph nodes in
levels VI or VII.
• nonlymphatic strs include part of
mandible, parotid gland, part of
mastoid tip, prevertebral fascia and
musculature, digastric m/s, XIIn,
ECA as well as skin.
EXTENDED NECK DISSECTION

24. • compartmental removal of lymph
nodes limited to one or two
contiguous neck levels
• INDICATION:
 removal of lymph node disease as/w
supraglottic cancer
 residual disease following
chemoradiation that is confined to a
single level
SUPERSELECTIVE NECK
DISSECTION

25. • lymphoscintigraphy and sentinel
lymph node biopsy (SLNB)
• powerful adjunct to surgical
treatment
• minimally invasive, can accurately
stage clinically occult neck
LYMPHOSCINTIGRAPHY-DIRECTED
NECK DISSECTION

26. • Position:
 Supine
 Roll placed beneath shoulders to
optimally extend neck.
 Skin is prepped and draped to allow
full exposure of both sides of neck
with clear visualization of
surrounding landmarks
TECHNIQUE:

27. • Optimal exposure of all lymph node
levels to be dissected (I -V)
• Preserve as much blood supply as
possible
• Flaps raised should be broadly
based, sup or inf
• Should avoid any trifurcations,
particularly those that overlie carotid
sheath
• Incisions that fit these criteria
 Hockey stick
 Boomerang
 McFee incision
 Apron incision (b/l ND)
INCISION:

28.  Y type (or Crile)
 Schobinger incision
 Modified Schobinger incision
 horizontal-T (Hetter) incision
 Utility incision
DIFFERENT INCISIONS:

29. • Raised in subplatysmal plane
• Major corners of consternation:
 Lower end of internal jugular vein.
 Junction of lateral border of clavicle
with lower edge of trapezius.
 Upper end of internal jugular vein.
 Submandibular triangle.
• Minor corners of consternation:
 Retropharyngeal nodes.
 Parapharyngeal nodes.
 Chaissaignac’s triangle.
RAISING THE FLAP:

30. • Step 1:
 incision is made through skin, subcutaneous fat, and platysma muscle
 superior flap is elevated
 submandibular gland fascia is then incised
 Resection of fat and lymph nodes from submental triangle (Level Ia)
 submental triangle is resected inferiorly to hyoid bone with electro-cautery.
Deep plane of dissection is mylohyoid muscles
OPERATIVE STEPS FOR MRND:

33. • Step 2:
 addresses Level Ib
 submandibular gland capsule is
dissected from gland in a superior
direction in a subcapsular plane
 Resection of fat and lymph nodes
tucked anteriorly and deeply between
ant belly of digastric & mylohyoid
m/s

34.  Facial artery and vein are identified by blunt dissection with a fine haemostat
 Facial lymph nodes; if present, are dissected
 Divided and tied close to submandibular gland so as not to injure marginal
mandibular nerve
 This frees up gland superiorly, which can then be reflected away from
mandible
 addresses the lingual nerve, submandibular duct, and XIIn

37. • Step 3:
 fascia along lateral aspect of
digastric divided
 EJV divided
 post belly of digastric exposed along
its entire length
 Identification of XIIn deep to veins
that cross nerve
 Sternomastoid branch of occipital
artery that tethers XIIn identified
 Dividing this artery releases XIIn
 Then courses vertically and leads
directly to ant border of IJV

41. • Step 4:
 fatty tissue in Level II dissected
 XIn which may course lateral,
medial or very rarely through IJV
identified
 transverse process of C1 vertebra
can be palpated immediately post
to XIn and IJV

42. • Step 5:
 directed at anterior neck
 anteriorly based subplatysmal flap
raised
 exposing omohyoid and SCM
muscle inferiorly down the clavicle
 anterior jugular vein left in elevated
flap
 Omohyoid divided and levels II, III
cleared

43. • Step 6:
 Posteriorly-based flap elevated
 Platysma is often absent posteriorly
hence flap may be very thin
 Dissection continues until ant
border of trapezius is reached

44. • Step 7:
 dissecting out XIn and mobilizing Level IIb
 XIn is identified by dissecting at post border of SCM, approx 1-2cm post to
point where greater auricular nerve curves around m/s
 Once XIn exposed and freed from IJV, it is exposed distally to where it
disappears behind trapezius m/s
 Freed completely and branches sectioned to SCM

47. • Step 8:
 dissection of Level IIb and
transposition of the XIn
 SCM is divided below mastoid.
exposing fat at top of Level IIb
 dissection is carried deeper until
deep muscles of neck that run in a
posteroinferior direction appear
 dissection is then directed postero-
inferiorly, where greater occipital
nerve (C1) is divided
 Level IIb and IIa are then dissected
off
 XIn is now trans-located posteriorly

50. • Step 9:
 clavicular and sternal heads of
SCM divided
 not to dissect immediately lateral to
IJV, as right lymphatic duct (right
neck) or thoracic duct (left neck)
may be injured; chyle leak
 EJV is divided and ligated and
omohyoid divided
 Supraclavicular fat exposed.
 Brachial plexus, phrenic nerve &
transverse cervical vessels identified

54. • Step 10:
 freeing inferolateral part of Level V
 Identifying and dividing
supraclavicular nerves
 Incision of fatty vascular pedicle
containing transverse cervical artery
and vein
 isolation and division of transverse
cervical artery and its proximity to
XIn.

56. • Step 11:
 anterograde dissection of Levels II
-V with scalpel
 dissection proceeds over a broad
front until entire cervical plexus has
been exposed
 cervical plexus nerves are each
divided, taking care not to injure
phrenic nerve
 This brings carotid sheath into view
 carotid sheath is incised along full
course of vagus nerve, and neck
dissection specimen is stripped off
the IJV

60. • Step 12:
 final step is to:
 strip neck dissection specimen off
infrahyoid strap muscles
 to identify and preserve superior
thyroid vascular pedicle, and
 to deliver neck dissection specimen
• Closure:

61. • HAEMORRHAGE:
 perioperative or postoperative
 Damage to IJV at its upper or lower end before it has been ligated
 Secondary haemorrhage may occur as a result of carotid artery rupture
• WOUND INFECTION:
 four most important factors
1. Contamination of surgical field.
2. Contamination of surgical field as
operation involves in-continuity RND and primary excision
3. Postoperative haematoma which then becomes infected.
4. Flap necrosis and wound breakdown.
COMPLICATIONS

62. • CAROTID ARTERY RUPTURE:
 Following necrosis of arterial wall d/to infection
 preoperative radiotherapy is implicated in most series
• CHYLOUS FISTULA:
 More usually, a leak of fluid occurs when lower end of jugular vein is
being dissected
 Mild leak, i.e. < 100mL/day: conservative management
 Major leak: re-explore wound to identify source of leak and oversew
it

63. • PNEUMOTHORAX
 disease lower neck, apical pleura may be damaged during dissection
• NERVE INJURIES:
 standard radical neck dissection the nerves which are deliberately divided are:
 accessory nerve;
 branches of the cervical plexus.
 descendens hypoglossi
 Other nerves that may be damaged by accident include:
 facial nerve or its mandibular or cervical division;
 hypoglossal and lingual nerves;
 vagus, symphathetic trunk, phrenic nerve or brachial plexus.

64. • CEREBRAL OEDEMA;
 Usu. In b/l neck dissection
.

65. THE END…..