The document provides a comprehensive overview of neck dissection, detailing its definition, indications, and classification. It outlines surgical techniques for removing lymph nodes in the context of malignancies and describes various complications, such as hemorrhage, chyle leakage, and neurological injuries. The presentation also emphasizes preoperative preparations and patient positioning for optimal surgical outcomes.

1. OVERVIEW OF NECK
DISSECTION

2.  PRESENTER—DR. MD. ABUBAKAR SHAH
 FCPS PART-II TRAINAE ,
 Dept. ORAL and Maxillofacial Surgery
 Dhaka Dental College Hospital

3.  The region of the bodyThe region of the body
that lies between:that lies between:
 TheThe LOWER BORDERLOWER BORDER
OF THEOF THE
MANDIBLEMANDIBLE&Mastoid&Mastoid
TIPTIP
 TheThe SUPRASTERNALSUPRASTERNAL
NOTCHNOTCH and theand the
UPPER BORDER OFUPPER BORDER OF
CLAVICLE.CLAVICLE.

4. DEFINITION OF NECK
DISSECTION
 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.
 It is a procedure to remove lymph nodes and surroundingIt is a procedure to remove lymph nodes and surrounding
fibro fatty tissues from neck to eradicate metastasis tofibro fatty tissues from neck to eradicate metastasis to
cervical lymph nodes in cancer of aerodigestive tractcervical lymph nodes in cancer of aerodigestive tract

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
rem
oving
nodal
m
etastases

6. 1967 - Bocca and
Pignataro
described the “functional neck

7. 1906 – George Crile
described the classic radical
neck dissection (RND)

8. INDICATION
 The metastases may originate from
tumours of the upper aerodigestive tract,
including the oral cavity tongue,
nasopharynx, oropharynx, hypopharynx,
and larynx, as well as the thyroid, parotid
and posterior scalp. Neck nodal
metastasis can sometimes also originate
from lung cancer or intra-abdominal
malignancy.

9. Oral cavity cancer

10. LARYNGEAL CARCINOMA

11. HYPOPHARYNGIAL
CARCINOMA

12. ORO-PHARYNGEAL CANCER

13. TYROID CARCINOMA

15.  CAN BE DIVIDED INTO;
a) SUPERFICIAL CHAIN OF LYMPH
NODES…..
b) VERTICAL DEEP CHAIN OF LYMPH
NODES
This consists of nodes lying in relation to
carotid sheath.These lie along the
vessels,trachea,oesophagusand extend from
base of skull to root of neck.

16. 1. Submental
2. Submandibular
3. Parotid / tonsilar
4. Preauricular
5. Postauricular
6. Occipital
7. Anterior cervical
superficial and deep
8. Supraclavicular
9. Posterior cervical

18.  Ia Submental
 Ib Submandibular
 IIa Upper jugular (Anterior to XI)
 IIb Upper jugular (Posterior to XI)
 III Middle jugular
 IVa Lower jugular (Clavicular)
 IVb Lower jugular (Sternal)
 Va Posterior triangle (XI)
 Vb Posterior triangle (Transverse
cervical)
 VI Central compartment

19. Level ILevel I
 SubmentalSubmental
triangle (Ia)triangle (Ia)
 Anterior digastricAnterior digastric
 HyoidHyoid
 MylohyoidMylohyoid
 SubmandibularSubmandibular
triangle (Ib)triangle (Ib)
 Anterior andAnterior and
posterior digastricposterior digastric
 MandibleMandible..

20. Level IILevel IIUpper Jugular NodesUpper Jugular Nodes
jugulodigastric, and upper
posterior cervical nodes
 AnteriorAnterior  Lateral borderLateral border
of sternohyoid, posteriorof sternohyoid, posterior
digastric and stylohyoiddigastric and stylohyoid
 PosteriorPosterior  PosteriorPosterior
border of SCMborder of SCM
 Skull baseSkull base
 Hyoid bone (clinicalHyoid bone (clinical
landmark)landmark)
 Carotid bifurcationCarotid bifurcation
(surgical(surgical
landmark)landmark)

21. Level IIILevel III
 Middle jugular nodesMiddle jugular nodes
 AnteriorAnterior  Lateral border ofLateral border of
sternohyoidsternohyoid
 PosteriorPosterior  Posterior border ofPosterior border of
SCMSCM
 Inferior border of level IIInferior border of level II
 Cricoid cartilage lower borderCricoid cartilage lower border
(clinical landmark)(clinical landmark)
 Omohyoid muscle (surgicalOmohyoid muscle (surgical
landmark)landmark)
 Junction with IJVJunction with IJV

22. Level IVLevel IV
 Lower jugular nodesLower jugular nodes
 AnteriorAnterior  Lateral border ofLateral border of
sternohyoidsternohyoid
 PosteriorPosterior  Posterior border ofPosterior border of
SCMSCM
 Cricoid cartilage lower borderCricoid cartilage lower border
(clinical landmark)(clinical landmark)
 Omohyoid muscle (surgicalOmohyoid muscle (surgical
landmark)landmark)
 Junction with IJVJunction with IJV
 ClavicleClavicle

23. Level VLevel V
 Posterior triangle of neckPosterior triangle of neck
 Posterior border of SCMPosterior border of SCM
 ClavicleClavicle
 Anterior border of trapeziusAnterior border of trapezius
 VaVa Spinal accessory nodesSpinal accessory nodes
 VbVb  Transverse cervical arteryTransverse cervical artery
nodesnodes
 Radiologic landmarkRadiologic landmark
 Inferior border of CricoidInferior border of Cricoid
 Supraclavicular nodesSupraclavicular nodes

24. Level VILevel VI
Anterior CompartmentAnterior Compartment
StructuresStructures
BoundariesBoundaries
• Above by Hyoid boneAbove by Hyoid bone
• Below by SuprasternalBelow by Suprasternal
notchnotch
• On either side byOn either side by
medial border ofmedial border of
Carotid sheathCarotid sheath
Lymph NodesLymph Nodes
 PerithyroidalPerithyroidal
 PretrachealPretracheal
 Precricoid NodesPrecricoid Nodes
(Delphian)(Delphian)
 Paratracheal nodesParatracheal nodes
along recurrentalong recurrent
laryngeal nerveslaryngeal nerves

25. Spinal Accessory NerveSpinal Accessory Nerve
 CN XI – Relationship with the IJVCN XI – Relationship with the IJV

26. StagingStaging
 Nx: Regional lymph nodes cannot be assessed.Nx: Regional lymph nodes cannot be assessed.
 N0: No regional lymph node metastases.N0: No regional lymph node metastases.
 N1: Single ipsilateral lymph node,N1: Single ipsilateral lymph node, << 3 cm3 cm

27. StagingStaging
 N2a: Single ipsilateral lymph node 3 to 6 cmN2a: Single ipsilateral lymph node 3 to 6 cm
 N2b: Multiple ipsilateral lymph nodesN2b: Multiple ipsilateral lymph nodes << 6 cm6 cm
 N2c: Bilateral or contralateral nodesN2c: Bilateral or contralateral nodes << 6cm6cm
 N3: Metastases > 6 cmN3: Metastases > 6 cm

28. • Academy’s Committee for Head and Neck
Surgery and Oncology publicized standard
classification syste(1991)
– 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

29.  Medina classification (1989)
– 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

30. Radical neck
Dissection:
Removing all
lymphatic
tissues(Lymphnode
,surrouding fascia
and fibo-fatty tisue)
in regions I - V and
include removal of
SAN, SCM and IJV
RADICAL NECK DISSECTION

31. Structures to be preservedStructures to be preserved
 Carotid arteryCarotid artery
 Brachial Plexus, Phrenic & vagusBrachial Plexus, Phrenic & vagus
nerve, cervical sympathetic chain,nerve, cervical sympathetic chain,
marginal mandibular, lingual andmarginal mandibular, lingual and
hypoglossal nerveshypoglossal nerves

32. INDICATION
 1. Significant operable neck
dissea (N2a,N2b, N3) with tumour
bulk near or directly involve spinal
accessory nerve and/or internal
jugular vein.
 2.Extensive recurrent disease after
previous surgery or radiotherapy.
 3.Clinical sign of gross extranodal
disease

33. Contra-indication
 1.Untreatable primary tumour or unresectable
neck disease(i.e-encasement of brachial
plexus, internal carotid artery, prevertebral
fascia.
 2.Patient unfit for major surgery
 3.Simaltaneous bilateral neck dissection
 4. Distant metatases

34. Modified radical neck dissection
 Modified radical neck
dissection:
 Excision of all lymph
nodes removed with
RND with preservation
of one or more non-
lymphatic structures,
SAN, SCM and/or IJV
 Subtype I: Preserve SAN
 Subtype II: Preserve
SAN & SJV
 Subtype III: preserve
SAN, SJV and SCM
 Known as Functional neck
dissection (Bocca

35. Modified radical neck
dissection

36.  Definition—is a procedure in
which one or more
lymphnode group are
preserved in addition to non
lymphatic structure.
– Four common subtypes:
 • Supraomohyoid neck
dissection
 • Posterolateral neck
dissection
 • Lateral neck dissection
 • Anterior neck dissection

37. INDICATION OF SELECTIVE
NECK DISSECTION
 1. Clinically No Neck
 2.Some author proposed –In case of N1
Neck can be done if single lymphnode
 3.When post operative plan for clinically N2
Neack , it can be done in very selected cases

38. SELECTIVE NECK DISSECTION
FOR ORAL CANCER
 1.SND (I-III) OR SUPRA-OMOHYOID IS indicated
for oral cancer.
 2. T1-T4 with clinical No neck
 3.indicted for contra-lateral neck in midline lession
of the floor of the mouth or ventral tongue.
 4. Other indication-extension of parotid surgery,
facial skin malignancy anterior to the tragus
 5. In case antero-lateral part of the tongue level I-IV
also be considered.

39. • Most commonly performed SND
• Definition
 – En bloc removal of cervical
lymph node groups I-III
– Posterior limit is the cervical
plexus and posterior border of
the SCM
– Inferior limit is the omohyoid
muscle overlying the IJV

40.  Indications
– Oral cavity carcinoma with N0 neck
 • Boundaries – Vermillion border of lips to
junction of hard and soft palate, circumvallate
papillae
• Subsites - Lips, buccal mucosa, upper and
lower
alveolar ridges, retromolar trigone, hard palate,
and anterior 2/3s of the tongue and FOM
– Medina recommends SOHND with T2-T4 NO or
TX N1 (palpable node is <3cm, mobile, and in
levels I or II)

41. BILATERAL SONDBILATERAL SOND
 1.Anterior tongue
 2. Oral tongue and FOM that
approach the midline
– SOHND + parotidectomy
3. Melanoma (Stage I – 1.5 to
4mm) of the cheek

42. • Definition
 – En bloc removal of the jugular lymph nodes
including Levels II-IV.
 Indications
 – N0 neck in carcinomas of the oropharynx,
hypopharynx, supraglottis, and larynx

43.  • Definition
– En bloc excision of lymph bearing tissues in
Levels II-IV and additional node groups –
suboccipital and postauricular.
 Indications
– Cutaneous malignancies
• Melanoma
• Squamous cell carcinoma
• Merkel cell carcinoma
– Soft tissue sarcomas of the scalp and neck

44.  • Definition
 – 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

45. CONTINUE--CONTINUE--
 Indications
 – Selected cases of thyroid carcinoma
 – Parathyroid carcinoma
 – Subglottic carcinoma
 – Laryngeal carcinoma with subglottic extension
– CA of the cervical esophagus

46.  • Definition
 – Removal of one or
more additional
lymphatic groups and/or
non-lymphatic structures
relatively to a radical
neck dissection.eg-level
VII, Retro-pharyngeal
lymphnode, hypoglosal
nerve, carotid artery.

47. INDICATIONINDICATION
 – Carotid artery invasion
 – Other examples:
 • Resection of the hypoglossal nerve resection or
digastric muscle,
 • dissection of mediastinal nodes and central
compartment for subglottic involvement, and
 • removal of retropharyngeal lymph nodes for tumors
originating in the pharyngeal walls.

48. PREOPERATIVE
PREPARATION
1. Ensure all documentation,
preoperative procedures, and orders
are complete.
2. Check the surgical consent form and
others for completeness.
3. Document allergies.
4. Document height and weight.
5. History and Physical.
6. Baseline vital signs.
7. Ensure results of all laboratory and
diagnostic tests are on the chart.
8. Document and report any abnormal
results.
9. Report special needs and concerns.

49. POSITION OF THE PATIENT
1. The patient is laid supine
2. The head turned opposite side and
hyperextended, resting on a head
ring
3. A Sand bag or a towel or pillow or
inflatable rubber bag is placed
below the shoulder
4. Upper end of the operating table
elevated approximately 30 degree.

50. Continue---
 When draping the surgical field
the following ipsilateral landmarks
should be visible
 Mastoid tip., Ear lobule, Body of
the mandible, midline of the chin,
supra-sternal notch, clavicle and
region of trapizius muscle
insertion

51.  1.Good exposure of the neck and primary
disease.
 2. Ensure viability of the skin flaps. Avoid
acute angles
 3. Protect carotid artery even in the cases of
wound infection
 4.Considered preoperative factor—previous
radio or chemotherapy.

52. Continue--
 5. Facilitate reconstruction Example, if
pectoral muscle is used a lower limb should
be near the clavicle to enable flap
accommodation.
 6. It should be cosmetically acceptable

53. VARIOUS INCISION IN NECK
DISSECTION

54. CONTINUE--

55. COMPLICATION OF NECK
DISSECTION AND THEIR
MANAGEMENT
Complications of neck
dissection can be broadly
divided into Early,
Intermediate and Late.

56. EARLY COMPLICATION
 1. Haemorrage
 2. Air embolism
 3.Respiratory distress
 4.Nurological injury
 5.chyle leakage

57. CONTINUE--
 If a hematoma is detected
early,“milking” the drains
occasionally may result in
evacuation of the accumulated blood
andt he problem will resolve.
 If this is not accomplished
immediately or if blood re-
accumulates quickly, it is best to
return the patient to the operating
room, explore the wound under
sterile conditions, evacuate the
hematoma, and control the bleeding

58. HAEMORRAGE
 Postoperative hemorrhage usually
occurs immediately after surgery.
External bleeding through the
incision often originates in a
subcutaneous blood vessel.
 In most patients, this may be readily
controlled by ligation, direct
cauterization or infiltration of the
surroundin tissues with an anesthetic
solution containing epinephrine.

59. CHYLOUS LEAKAGE
 This happens due injury to the
thoracic duct while performing a
radical surgery low in the neck
or mediastinum. If chylous
fistula is suspected every
attempt should be made to seal
itat the time of surgery by
identifying it by head down
positions and performing
modified valsalva manoeuvre.

60. Continue---
 It should be suspected when the drain
collection increases dramatically by volume.
Fat restricted diet, and daily pressure
dressings are the form of conservativ
treatment for chyle leak.
 When the drain collection reaches 600 ml per
day or more, it is an Indication for exploration
and repair of the injured thoracic duct under
microscope

61. Increased intracranial pressure
 This usually occurs when the internal
jugular vein is ligated. When one
internal jugular vein is ligated the
pressure rises by 3 fold and when
both are ligated it increases by 5 fold.
 This is usually is temporary and will
normalize in 24 hours. If it persists,
head end elevation,steroids and
mannitol can be used.

62. Carotid blowout
 Carotid blow-out
  This is associated with over 60%
morbidity and 50% mortality.
  Neurological sequaelae of emergency
ligation include hemiplegia, hemi-
anaesthesia, aphasia and dysarthria.
  If impending blow out is suspected,
endovascular techniques with stent-
grafts may be indicated rather than open
ligation although short-term
complications still occur.

63. Carotid sinus syndrome
 This is due to undue pressure
and manipulation on the
carotid sinus baroreceptor
which may result in
hypotension and bradycardia.
 Post operative scarring may
also make the receptor
sensitive to even palpation and
turning head.

64. AIR WAY OBSTRUCTION
 Airway obstruction In cases of
bilateral neck dissections there
may be associated soft tissue
edema.
 It is always prudent to carry out
a temporary elective
tracheotomy to protect the
airway.

65. PNEUMOTHORAX
 Too much lower neck dissection may
cause injury to the apical pleura
causing pneumothorax.
 Patient may become restless,
cyanosed and dyspnoeic after
operation.
 plain radiograph of chest most often
provides the diagnosis. Minimal
emphysema may resolve itself but
whereas severe cases may require
intercostal chest drains

66. AIR EMBOLOUS
  This is a rare event which
can occur following injury to
the IJV.
  Large emboli can produce
sudden falls in end-tidal
carbon dioxide and arterial
blood pressure.
  Local pressure should be
applied and the anaesthetist
informed so the patient can be
placed in the Trendelenburg
position and rotated to the left.
  In severe cases attempts can
be made to pass a catheter and
aspirate air from the right side
of the heart.

67. Spinal nerve injury
 Injury to the spinal
accessory nerve can
cause an
accessory nerve disorder
or spinal accessory
nerve palsy, which
results in diminished or
absent function of the
sternocleidomastoid
muscle and upper
portion of the trapezius
muscle.

68.  Immediate symptoms,
recognised by the
patient, include pain
over the affected
muscle, limitation of
movement
 loss of abduction), and
a feeling of heaviness
in the arm.

69.  Late sequelae o-:
 1 Drooping of the shoulder
secondary to trapezius paralysis
and Atrophy of the trapezius with
appreciable asymmetry
2, Weakness or loss of shoulder
abduction (usually lessthan 900);
3. Pain which is usually mild-a
persistent ache in the region of the
affected muscle-but may be severe
and involving not only the shoulder
but also the arm, forearm, hand,
scalp, and face of the affected side.
4.Contralateral pain has also been
recorded (6).e

70. ADVICE PHYSIOTHERAPY

71. LINGUAL NERVE INJURY
numbness and
tingling of the left
side of her tongue
and the floor of
her mouth

72.  The great auricular
nerve originates from the
cervical plexus, composed
of branches of spinal nerves
C2 and C3. It provides
sensory innervation for the
skin over parotid gland and
mastoid process, and both
surfaces of the outer ear.


73. HYPOGLOSAL NERVE
PARALYSIS
 Unilateral damage to
the nerve supply leads
to wasting, weakness
and fasciculation of that
side of the tongue
 immediately followed by
deviation of the tongue
to the same side as the
injury

74. Marginal mandibular nerve
 Injury to this nerve
causes an obvious
cosmetic deformity with
asymmetry of the
motion of the corner of
the mouth.

75. VAGUS NERVE
 Vagus nerve injury may
manifest as aspiration
and voice problems

76. INTERMEDIATE
COMPLICATIONS
1. WOUND DEHISCNCE—
--Exposed of the great vessel
--chylous fistula
2.Pulmonary complications
--Basal collapse and bronchopneumonia may occur in patients who
are smokers and have pre-existing chronic obstructive lung
disease.
3..Deep vein thrombosis
---This is seen in patients in old age, surgeries lasting for more
duration, long bedridden patients and patients with previous
history of deep vein thrombosis, pulmonary
embolism,myocardial infarction and thrombophilia

77. Carotid Artery rupture
 This usually occurs
when the skin wound
breaks down because
of previous
irradiation,secondary
infection, poor
metabolic condition of
the patient. It is a fatal
complication

79. LATE COMPLICATION
1.Recurrence
 ----IT can be at the primary site, in the neck
nodes or as a distant metastasis.
2.Lymph edema
lymphedema often follows owing to interruption
of the lymphatic drainage channels from the
head.
3.Hypertrophic scars

80. HYPERTROPIC SCAR

81. LYMPHOEDEMA