This document outlines a journal club presentation on neck dissection, covering its nomenclature, classification, and technique as presented by Dr. Kamini Dasena and guided by multiple specialists. It details the anatomical levels of lymph nodes, the evolution of neck dissection techniques, and complications associated with the procedures. The presentation emphasizes the importance of identifying and managing metastatic lymph nodes in head and neck cancer patients.

1. GOOD MORNING

2. Journal club presentation
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY
PRESENTED BY:
DR. KAMINI DASENA

3. Journal club presentation
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY
GUIDED BY:
DR. RAMNIK SINGH MADAN DR. VINAY KHARSAN
DR. AKSHAY DAGA DR. ABHISHEK BALANI
DR. SUMIT TIWARI DR. GAZAL PARVEEN

4. Neck
Dissection: Nomenclature,
Classification, and Technique
JON D. HOLMES, DMD, MD, FACS
ORAL AND FACIAL SURGERY OF ALABAMA, 1500 19TH STREET SOUTH, BIRMINGHAM, AL 35205, USA
UNIVERSITY OF ALABAMA AT BIRMINGHAM, BIRMINGHAM, AL, USA
Oral Maxillofacial Surg Clin N Am 20 (2008) 459–475
George Crile (1864–1943).

5. Outline:
1. Introduction
2. Lymph node levels: anatomy and nomenclature
3. Evolution of neck dissection in the management of
head and neck cancer
4. Classification of neck dissections
5. Technique
6. Sentinel node biopsy
7. Complications
8. Conclusion
9. References
Oral Maxillofacial Surg Clin N Am 20 (2008) 459–475

6. Introduction
 Unfortunately, approximately 40% of patients with oral
cancer will harbor cervical lymph node metastasis at
presentation
W.M. Mendenhall, R.R. Million, N.J. Cassisi Elective neck irradiation in squamous cell
carcinoma of the head and neck Head Neck Surg, 3 (1980), pp. 15–19

7. Introduction
 Removal of the at-risk lymphatic basins serves two
important purposes.
 First, it allows the removal and identification of occult
metastasis in patients in whom cervical metastasis are a
risk, - Elective neck dissection.
 Secondly, it allows the removal of disease in patients in
whom metastasis are highly suspected based on imaging,
clinical examination or fine needle aspiration, -
Therapeutic neck dissection.

8. Lymph node levels:
Memorial Sloan-kettering Cancer Center.
The American Head And Neck Society And The American Academy Of Otolaryngology

9. Lymph node levels:
Level I
1. Level I a: submental nodes
2. Level I b: submandibular
nodes
• H. Rouviere, 1938 and R.
Lindberg, 1972 - highest
risk in oral cancers
involving the skin of the
chin, lower lip, tip of the
tongue, and floor of the
mouth.
H. Rouviere Anatomy of the human lymphatic system. (Translation by Tobies MJ) Edwards Brother, Ann Arbor (MI) (1938)
R. Lindberg Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts Cancer, 29 (1972), pp. 1446–1449

10. Lymph node levels:
Level II: upper jugular LN
1. Level II a:
2. Level II b:
H. Rouviere, 1938 and R.
Lindberg, 1972 Nodal tissue
within level II receives efferent
lymphatics the parotid,
submandibular, submental,
and retropharyngeal nodal
groups
H. Rouviere Anatomy of the human lymphatic system. (Translation by Tobies MJ) Edwards Brother, Ann Arbor (MI) (1938)
R. Lindberg Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts Cancer, 29 (1972), pp. 1446–1449

11. Lymph node levels:
Level III: middle third of the internal
jugular
Level III can receive efferent lymphatics
from the retropharyngeal, pretracheal,
tongue base, and tonsils.

12. Lymph node levels:
Level IV:
inferior third of the internal jugular vein.
It receive efferent flow primarily from
levels III and IV.
The retropharyngeal, pretracheal,
hypopharyngeal, laryngeal and thyroid
lymphatics also make a contribution.

13. Lymph node levels:
Level V
Level V a: Begins at the apex formed by
the intersection of the
sternocleidomastoid and the trapezius.
Level V b: Begins at a line defined by the
inferior edge of the cricoid cartilage and
extends to the clavicle

14. Lymph node levels:
Memorial Sloan-kettering Cancer Center.
The American Head And Neck Society And The American Academy Of Otolaryngology
Level VI
The anterior compartment lymph node
group is of minimal importance in
primaries originating in the oral cavity. It
is made up of the lymph node bearing
tissue occupying the visceral space. It
begins at the hyoid bone, extends
inferior to the suprasternal notch, and
laterally is bound by the common carotid
arteries.

15. EVOLUTION OF NECK
DISSECTION

16. Evolution of neck dissection
 Chelius and Kocher - seperately recommended
removal of regional lymph nodes in the treatment of H
& N cancer in the mid-nineteenth century
 George Crile – Receives credit for his systematic
description of management of cervical lymphatics in H
& N cancer
 1905 - The Transactions of the Southern Surgical and
Gynecological Association and
 1906 - JAMA.
J.P. Shah Foreward J. Gavilan, J. Herranz, L.W. DeSanto (Eds.), Functional and neck dissection, Thieme, New York (2002), p. vii

17. Evolution of neck dissection
 Crile was strongly influenced by Halsted's work in
breast cancer.
 Although Crile suggested in his early publications that
the spinal accessory nerve could be preserved if not
directly involved with cancer,
 Later surgeons recommended its removal in all cases.
[G.W. Crile Excision of cancer of the head and neck with special reference to the plan of dissection based upon one hundred thirty-
two operations JAMA, 47 (1906), pp. 1780–1786
G.W. Crile On the surgical treatment of cancer of the head and neck Transactions Southern Surgical Gynecological Association, 18
(1905), pp. 109–127
G.W. Crile Carcinoma of the jaws, tongue, cheek and lips Surg Gynecol Obstet, 36 (1923), pp. 159–162

18. Evolution of neck dissection
 Martin and colleagues stated that any attempt to
preserve the spinal accessory nerve should be
“condemned unequivocally.” Other structures, such as
the submandibular gland were also preserved in some
cases presented by Crile
 Martin in 1951 summarized his indications, technique,
and outcomes with the radical neck dissection
H. Martin, B. Delvalle, H. Ehrlich, et al. Neck dissection Cancer, 4 (1951), pp. 441–499

19. Evolution of neck dissection
 In 1967, Bocca and Gavilian, Following technique of
“functional neck dissection” which preserved non-
lymphatic cervical structures, and in cases without
direct involvement, the submandibular gland, thereby
sparing morbidity without sacrificing loco-regional
control.
C.V. Calearo, G. Teatini Functional neck dissection: anatomical grounds, surgical technique clinical observations Ann Otol Rhinol
Laryngol, 92 (1983), pp. 215–222
E. Bocca Supraglottic laryngectomy and functional neck dissection J Laryngol Otol, 80 (1966), pp. 831–838
J. Gavilan, A. Monux, J. Herranz, et al.Functional neck dissection: surgical technique Operative Techniques in Otolaryngology-Head
and Neck Surgery, 4 (1993), pp. 258–265

20. Evolution of neck dissection
 Terminology of neck dissection was standardized by
the American Academy of Otolaryngology's
Committee for Head and Neck Surgery and Oncology
in 1991
 An update, published in 2002
K.T. Robbins, J.E. Medina, G.T. Wolfe, et al. Standardizing neck dissection terminology. Official report of the Academy's Committee
for Head and Neck Surgery and Oncology Arch Otolaryngol Head Neck Surg, 117 (1991), pp. 601–605
K.T. Robbins, G. Clayman, P.A. Levine, et al. Neck dissection classification update Arch Otolaryngol Head Neck Surg, 128 (2002), pp.
751–758

21. Classification of neck
dissections
Radical neck dissection (RND):
 Included are levels I– V. This entails
the removal of three important, non-
lymphatic structures: the internal
jugular vein, the sternocleidomastoid
muscle, and the spinal accessory nerve

22. Classification of neck
dissections
Modified radical neck dissection (MRND):
 three types:
 type I preserves the spinal accessory nerve;
 type II preserves the spinal accessory nerve and the
sternocleidomastoid muscle; and
 type III preserves the spinal accessory nerve, the
sternocleidomastoid muscle, and the internal jugular
vein;

23. Classification of neck
dissections
Selective neck dissection (SND)
Refers to the preservation of one or
more lymph node groups normally
removed in a radical neck dissection

24. Classification of neck
dissections
Extended neck dissection
 The term extended neck
dissection refers to the removal
of one or more additional lymph
node groups, non-lymphatic
structures or both, not
encompassed by a radical neck
dissection, for example,
mediastinal nodes or non-
lymphatic structures, such as the
carotid artery and hypoglossal
nerve

26. Technique
There are two approaches for the
MRND:
• The original anterior-posterior
approach of suerez, which was
popularized by bocca, and
• The suen approach, which is an
anterior approach popular in the
united states.
• The later requires good
retraction of the scm laterally to
access the posterior neck, and
yet access may still be limited.
E. Bocca, O. Pignataro A conservation technique in radical neck dissection Ann Oto Rhino Laryngol, 76 (1967), pp. 975–978
J.Y. Suen Functional neck dissection J.C. Ballantyne, D.F.N. Harrison (Eds.), Rob and Smith's operative surgery, Butterworth, London (1986), pp. 382–390
L.L. Gleich Modified neck dissection J.L. Gluckman, J.T. Johnson (Eds.), Surgical management of neck metastases, Martin Dunitz, London (2003), pp. 59–69

27. Technique
Preserving four nerves:
1. The marginal mandibularis;
2. The spinal accessory;
3. The hypoglossal; and
4. The lingual nerve,
All of which serve as landmarks along the
pathway to completion of the neck dissection.

28. Technique
Division of facial vein with suture left long for
retraction of the marginal branch of the facial nerve.
Note the fascia has been elevated off the submandibular
gland.

29. Technique
(A) Incising node bearing tissue over spinal accessory nerve. (From Lore JM, Medina J. An atlas of head and neck surgery. 4th
edition. Philadelphia: Saunders; 2004. p. 809; with permission.)
(B) passing node bearing tissue from level IIb under nerve. (From Lore JM, Medina J. An atlas of head and neck surgery. 4th edition.
Philadelphia: Saunders; 2004. p. 809; with permission.)
(C) Intraoperative photo demonstrating passing tissue under nerve following dissection on submuscular recess (level IIb). Note right
angle retraction of posterior belly of digastric and sternocleidomastoid muscle).

30. Technique
Nodal contents of posterior triangle brought underneath the spinal accessory nerve in the posterior triangle. (From
Lore JM, Medina J. An atlas of head and neck surgery. 4th edition. Philadelphia: Saunders; 2004. p. 810; with
permission

31. Technique
Demonstrating dissection of posterior triangle passing underneath the SCM in the
anterior-posterior approach. (From Lore JM, Medina J. An atlas of head and neck
surgery. 4th edition. Philadelphia: Saunders; 2004. p. 810;

32. Technique
Blade dissection along the internal jugular vein. (From Lore JM, Medina J. An
atlas of head and neck surgery. 4th edition. Philadelphia: Saunders; 2004. p.
813; with permission.)

33. Technique
Retraction of the posterior edge of the
mylohyoid muscle anteriorly and of the
submandibular triangle contents inferiorly
brings the lingual nerve into view.

34. Technique

35. Sentinel node biopsy
 The sentinel node technique, first popularized for
melanoma.
 It allows the identification and removal of the lymph
node (“sentinel node”) that would first receive
metastases from a given site.
 D.N. Krag et al in 1995 and L.F. Glass et al in 1996, In
melanoma, sentinel node biopsy has a reported
sensitivity of 82%–100%, and very few false negatives
D.L. Morton, D.R. Wen, J.H. Wong, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma Arch Surg, 127 (1992), pp. 392–399
D.L. Morton, D.R. Wen, L.J. Foshag, et al. Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early stage melanomas of the head
and neck J Clin Oncol, 11 (1993), pp. 1751–1756
D.N. Krag, S.J. Meijer, D.L. Weaver, et al. Minimal access surgery for staging of malignant melanoma Arch Surg, 130 (1995), p. 654–658
L.F. Glass, J.L. Messina, W. Cruse, et al. The use of intraoperative radiolymphoscintigraphy for sentinel node biopsy in patients with malignant
melanoma Dermatol Surg, 22 (1996), pp. 715–720

36. Sentinel node biopsy
 Problems with applying the sentinel node
technique to the oral cavity relate to
1. The rich lymphatic drainage pattern with possible
bilateral drainage, and
2. The complex anatomy in the cervical region.

37. Sentinel node biopsy
 In the future, the SNB as the ultimate evolution of
selective neck dissection may become the operative
procedure of choice for dealing with the N0 neck.
 Pitman and her colleagues concluded, that SNB
remains an experimental technique in head and neck
cancers and has not become a standard of care
K.T. Pitman, A. Ferlito, K.O. Devaney, et al. Sentinal lymph node biopsy in head and neck cancer Oral Oncol, 39 (2003), pp.
343–349

38. Complications
 Neurologic injury
 Vascular injury
 Thoracic duct injury (chyle leak)
 Wound infection.

39. Neurologic injury
1. Spinal accessory nerve
2. Facial nerve
3. Hypoglossal nerve
4. Phrenic nerve
5. Brachial plexus injury
6. Cervical sympathetic trunk
7. Vagus nerve
8. Lingual nerve

40. Spinal Accessory Nerve Injury
 D.H. Kraus et al in 1996 suggested that dissection of
level IIB (above the nerve) is unnecessary in the
clinically node-negative neck because of the low
incidence of metastases in this area (1.6%), and is
recommended only if bulky disease is present in level
IIa.
 It is this author's practice to exclude extensive
dissection of this area in most oral cavity cancers, and
the clinically N0 neck.
D.H. Kraus, D.B. Rosenberg, B.J. Davidson, et al. Supraspinal accessory lymph node metastases in supraomohyoid neck dissection Am J Surg, 172 (1996), pp.
646–649

41. facial nerve injury
1. Marginal mandibular branch – more common
2. cervicofacial division
3. main trunk
 Injury recognized intraoperatively or in the early
postoperative period should be repaired

42. Hypoglossal nerve injury
 In addition, bulky nodal disease in the area can lead to
nerve transection while trying to obtain adequate
margins.
 Immediate repair can be considered, but results are
unsatisfying in most cases.
 Fortunately, unilateral injury to the hypoglossal nerve
is fairly well tolerated by most patients

43. Phrenic nerve injury
 A.A. de Jong et al in 1991, incidence is as high as 8%
 Incidence in modified and selective neck dissections is
much lower .
 Injury is usually manifested by elevation of the hemi-
diaphragm noted on postoperative chest radiographs;
bilateral injury can lead to respiratory failure.
A.A. de Jong, J.J. Manni Phrenic nerve paralysis following neck dissection Eur Arch Otorhinolaryngol, 248 (1991), pp. 132–134

44. Brachial plexus injury
 Injury to the brachial plexus can similarly occur when
dissection is inadvertently performed deep to the
prevertebral fascia low in the neck.
 It is a devastating injury, and early recognition should
lead to appropriate consultation and consideration of
repair

45. Cervical Sympathetic Trunk Injury
 Horner's syndrome (ie, ptosis, miosis, and anhydrosis)
results from injury to the cervical sympathetic trunk,
which lies posterior to the carotid sheath.

46. Vagus nerve injury
 Damage results in unilateral vocal cord paralysis, which
is manifested by a “breathy,” weak voice.
 If the injury is high in the neck before the branch of
the superior laryngeal nerve, then laryngeal sensation
is impaired and aspiration becomes a risk.
 Vocal cord augmentation or medialization procedures
may be helpful

47. Lingual Nerve Injury
 This is especially true when the lingual nerve has been
mobilized aggressively during the extirpation of the
primary.
 In addition, blind clamping of lingual vessels can lead
to its injury.
 The attachments between the nerve and
submandibular gland should be carefully transected
while keeping the nerve in view.

48. Vascular injury
 Intraoperative
1. Carotid sinus sensitivity
2. Vessels laceratins
3. Thorasic duct injury
 Late
1. Post operative hemorrhage

49. Carotid sinus sensitivity
 Results from manipulation of the carotid body,
 typically manifests as acute bradycardia and decreased
cardiac output.
 Atropine
 small amount (<1 cc) of plain 1% lidocaine

50. Intraoperative hemorrhage
 This can make the dissection much more tedious,
leading to injury and ligation of unintended vessels,
such as the internal carotid artery.
 Laceration of the common or internal carotid arteries
should be promptly repaired if a preoperative
assessment to establish the presence of collateral
cerebral circulation (carotid occlusion test) has not
been done

51. Thoracic duct injury

52. Thoracic duct injury

53. Late vascular complications
Carotid Blowout
 Loss of free tissue transfers with avulsion of the arterial
pedicle can also result in late hemorrhage.
 Leaving failed flaps in place for a period of time,
caution should be exercised as the vascular pedicle can
break down resulting in significant haemorrhage.
M.J. Wheatley, T.R. Meltzer The management of unsalvageable free flaps J Reconstr Microsurg, 12 (1996), pp. 227–229

54. Late vascular complications
Prevention strategies include:
1. appropriate use of prophylactic antibiotics;
2. importation of vascularized tissue in compromised
situations; and
3. optimization of the patient's ability to heal
through careful handling of tissues, maximizing
nutrition, and confirming adequate thyroid
function in the previously irradiated patient.
M.J. Wheatley, T.R. Meltzer The management of unsalvageable free flaps J Reconstr Microsurg, 12 (1996), pp. 227–229

55. Wound infection
 Several well-controlled studies have demonstrated that
antibiotics started before the incision and continued for
no more that 24 hours serve to minimize perioperative
infections and the emergence of resistant strains.
 Continuation beyond 24 hours should be considered in
patients at increased risk or those with ongoing
contamination.
 First generation cephalosporins and clindamycin
represent the most commonly used prophylactic
antibiotics in oral cancer surgery.
 Topical antimicrobials, such as chlorhexidine and
clindamycin rinses, have also been shown to successfully
reduce the incidence of infections.
G.D. Becker, G.J. Parell Cefazolin prophylaxis in head and neck cancer surgery Ann Otol Rhinol Laryngol, 88 (1979), pp. 183–186
G. Mombelli, L. Coppens, P. Dor, et al. Antibiotic prophylaxis in surgery for head and neck cancer: comparative study of short and prolonged administration of
carbencillin J Antimicrob Chemother, 7 (1981), pp. 665–671

56. Summary
 Surgical management of cervical lymph node
metastasis, both occult and evident, continues to
evolve. It is clear that metastases are an indication of
aggressiveness, and that they portend a poorer
prognosis.
 Blake Cady MD, FACS referred to “lymph node
metastases as the speedometers of the oncologic
vehicle, not the engine. Indicators, not governors of
survival”
 the role for the radical neck dissection has diminished
greatly as less invasive surgical techniques for dealing
with the cervical lymphatics have gained popularity.

57. References
[1] W.M. Mendenhall, R.R. Million, N.J. Cassisi Elective neck irradiation in squamous cell carcinoma of the head and neck Head Neck Surg, 3
(1980), pp. 15–19
[2] E.R. Carlson, I. Miller Surgical management of the neck in oral cancer Oral Maxillofac Surg Clin North Am, 18 (2006), pp. 533–546
[3] H. Rouviere Anatomy of the human lymphatic system. (Translation by Tobies MJ) Edwards Brother, Ann Arbor (MI) (1938)
[4] R. Lindberg Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts
Cancer, 29 (1972), pp. 1446–1449
[5] P. Strauli The lymphatic system and cancer localization R.W. Wiser, Tl Ado, S. Wood (Eds.), Endogenous factors influencing host-tumor
balance, University of Chicago Press, Chicago (1967), pp. 249–254
[6] K.T. Robbins, J.L. Atkinson, R.M. Byers, et al. The use and misuse of neck dissection for head and neck cancer J Am Coll Surg, 193 (2001), pp.
91–102
[7] H.C. Pillsbury, M. Clark A rationale for therapy of the N0 neck. Joseph H. Ogura Lecture Laryngoscope, 107 (1997), pp. 1294–1315
[8] K.T. Robbins, G. Clayman, P.A. Levine, et al. Neck dissection classification update Arch Otolaryngol Head Neck Surg, 128 (2002), pp. 751–758
[9] J.P. Shah Foreward J. Gavilan, J. Herranz, L.W. DeSanto (Eds.), Functional and neck dissection, Thieme, New York (2002), p. vii
[10] G.W. Crile Excision of cancer of the head and neck with special reference to the plan of dissection based upon one hundred thirty-two
operations JAMA, 47 (1906), pp. 1780–1786
[11] G.W. Crile On the surgical treatment of cancer of the head and neck Transactions Southern Surgical Gynecological Association, 18 (1905), pp.
109–127
[12] G.W. Crile Carcinoma of the jaws, tongue, cheek and lips Surg Gynecol Obstet, 36 (1923), pp. 159–162
[13] H. Martin, B. Delvalle, H. Ehrlich, et al. Neck dissection Cancer, 4 (1951), pp. 441–499
[14] G.E. Ward, J.O. Robben A composite operation for radical neck dissection and removal of cancer of the mouth Cancer, 4 (1951), pp. 98–109
[15] C.V. Calearo, G. Teatini Functional neck dissection: anatomical grounds, surgical technique clinical observations Ann Otol Rhinol Laryngol, 92
(1983), pp. 215–222

58. References
[16] E. Bocca Supraglottic laryngectomy and functional neck dissection J Laryngol Otol, 80 (1966), pp. 831–838
[17] J. Gavilan, A. Monux, J. Herranz, et al.Functional neck dissection: surgical technique Operative Techniques in Otolaryngology-Head and Neck
Surgery, 4 (1993), pp. 258–265
[18] O. Suarez El problema de las metastasis linfaticas y alejades del cancer de laringe e hipofaringe Rev Otorrinolaringol Santiago, 23 (1963), pp.
83–99
[19] K.T. Robbins, J.E. Medina, G.T. Wolfe, et al. Standardizing neck dissection terminology. Official report of the Academy's Committee for Head
and Neck Surgery and Oncology Arch Otolaryngol Head Neck Surg, 117 (1991), pp. 601–605
[20] J.E. Medina A rational classification of neck dissections Otolaryngol Head Neck Surg, 100 (1989), pp. 169–176
[21] J.P. Shah, F.C. Candela, A.K. Poddar The patterns of cervical lymph node metastases from squamous cell carcinoma of the oral cavity Cancer,
66 (1990), pp. 109–113
[22] R.H. Spiro, E.W. Strong Discontinuous partial glossectomy and radical neck dissection in selected patients with epidermoid carcinoma of the
mobile tongue Am J Surg, 126 (1973), pp. 544–546
[23] C.R. Leemans, R. Tiwari, J.J. Nauta, et al. Discontinuous versus in-continuity neck dissection in carcinoma of the oral cavity Arch Otolaryngol
Head Neck Surg, 117 (1991), pp. 1003–1006
[24] J.P. Shah Head and neck surgery and oncology (3rd edition)Elsivier, New York (2003)
[25] D. Kademani, E.J. Dierks A straight-line incision for neck dissection: technical note J Oral Maxillofac Surg, 63 (2005), pp. 563–565
[26] E. Bocca, O. Pignataro A conservation technique in radical neck dissection Ann Oto Rhino Laryngol, 76 (1967), pp. 975–978
[27] J.Y. Suen Functional neck dissection J.C. Ballantyne, D.F.N. Harrison (Eds.), Rob and Smith's operative surgery, Butterworth, London (1986), pp.
382–390
[28] L.L. Gleich Modified neck dissection J.L. Gluckman, J.T. Johnson (Eds.), Surgical management of neck metastases, Martin Dunitz, London
(2003), pp. 59–69
[29] J. Yoel, C.A. Linares The Schobinger incision: Its advantages in radical neck dissections Am J Surg, 108 (1964), pp. 526–528
[30] J.E. Medina, J.M. Loré The neck J.M. Loré, J.E. Medina (Eds.), An atlas of head and neck surgery (4th edition. Chapter 24), Elsevier, Philadelphia
(2005), p. 804

59. References
[31] R.M. Byers, R.S. Weber, T. Andrews, et al. Frequency and therapeutic implications of “skip metastasis” in the neck from squamous carcinoma
of the tongue Head Neck, 19 (1997), pp. 14–19
[32] J.P. Shah, F.C. Candela, A.K. Poddar The pattern of cervical lymph node metastases from squamous carcinoma of the oral cavity Cancer, 66
(1990), pp. 109–113
[33] D.L. Morton, D.R. Wen, J.H. Wong, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma Arch Surg, 127
(1992), pp. 392–399
[34] D.L. Morton, D.R. Wen, L.J. Foshag, et al. Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early stage
melanomas of the head and neck J Clin Oncol, 11 (1993), pp. 1751–1756
[35] T.D. Schellenberger Sentinal lymph node biopsy in the staging of oral cancer Oral Maxillofac Surg Clin North Am, 18 (2006), pp. 547–563
[36] D.N. Krag, S.J. Meijer, D.L. Weaver, et al. Minimal access surgery for staging of malignant melanoma Arch Surg, 130 (1995), pp. 654–658
[37] L.F. Glass, J.L. Messina, W. Cruse, et al. The use of intraoperative radiolymphoscintigraphy for sentinel node biopsy in patients with malignant
melanoma Dermatol Surg, 22 (1996), pp. 715–720
[38] F.J. Civantos, C. Gomez, C. Duque, et al. Sentinal node biopsy in oral cavity cancer: correlation with PET scan and immunohistochemistry Head
Neck, 25 (2003), pp. 1–9
[39] K.T. Pitman, J.T. Johnson, M.L. Brown, et al. Sentinal lymph node biopsy in head and neck squamous cell carcinoma Laryngoscope, 112 (2002),
pp. 2101–2113 Am, 18 (2006), pp. 547–563
[36] D.N. Krag, S.J. Meijer, D.L. Weaver, et al. Minimal access surgery for staging of malignant melanoma Arch Surg, 130 (1995), pp. 654–658
[37] L.F. Glass, J.L. Messina, W. Cruse, et al. The use of intraoperative radiolymphoscintigraphy for sentinel node biopsy in patients with malignant
melanoma Dermatol Surg, 22 (1996), pp. 715–720
[38] F.J. Civantos, C. Gomez, C. Duque, et al. Sentinal node biopsy in oral cavity cancer: correlation with PET scan and immunohistochemistry Head
Neck, 25 (2003), pp. 1–9
[39] K.T. Pitman, J.T. Johnson, M.L. Brown, et al. Sentinal lymph node biopsy in head and neck squamous cell carcinoma Laryngoscope, 112 (2002),
pp. 2101–2113

60. References
[[40] N.C. Hyde, E. Prvulovich, L. Newman, et al. A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the
role of sentinel node biopsy and positron emission tomography Oral Oncol, 39 (2003), pp. 350–360
[41] K.T. Pitman, A. Ferlito, K.O. Devaney, et al. Sentinal lymph node biopsy in head and neck cancer Oral Oncol, 39 (2003), pp. 343–349
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61. Thank you