2.  History Of CANCER
 Anatomy of HEAD & NECK
 LYMPH NODE levels
 Staging of CANCER
 NECK DISSECTIONS
 COMPLICATIONS

4.  1880  Kocher advocates wide margin
lymphadenectomy
 1881  Kocher and Packard recommend
dissection of submandibular triangle
for lingual cancer
 1885  Butlin questions RND for oral N 0
disease
 1888  Jawdynski describes en bloc
resection with resection of carotid,
IJV, SCM.
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

5.  1901  Solis-Cohen advocate
lymphadenectomy for N0 laryngeal
CA
 1905 -1906  Crile describes en
bloc resection in JAMA
 1926  Bartlett and Callander
advocate preservation of XI, IJV,
SCM, platysma, stylohyoid, digastric
 1933  Blair and Brown advocate
removal of XI.
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

6.  1951  Martin advocates Radical Neck Dissection after analysis of
1450 cases
› Advocated RND for N+ cases.
 1952 – Suarez describes a functional neck dissection
› Preservation of SCM, omohyoid, submandibular gland, IJV, XI.
› Enables protection of carotid.
 1960’s – MD Anderson advocate selective ND of highest risk nodal
basins
 1967 - Bocca and Pignataro describe the “functional neck
dissection”
 1975 – Bocca establishes oncologic safety of the FND compared to
the RND
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

8.  The region of the
body that lies
between:
 The LOWER BORDER
OF THE MANDIBLE&
 The SUPRASTERNAL
NOTCH and the
UPPER BORDER OF
CLAVICLE.

9. • 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

11. Sup. thyroid
Ext. jugular
Int. jugular
Middle
thyroid
Inf. thyroid
Ant. jugular

12. • Origin – fascia overlying the pectoralis
major and deltoid muscle
• Insertion – 1) depression muscles of the
corner of the mouth, 2) the mandible, and
3) the SMAS layer of the face
• Function –
1) wrinkles the the neck
2) depresses the corner of the mouth
3) increases the diameter of the neck
4) assists in venous return

13. platysma

14. platysma
Sternoclei-
domastoid

15.  Surgical considerations
 – Increases blood supply to skin flaps
 – Absent in the midline of the neck
 – Fibers run in an opposite direction to the SCM

18. pretracheal fascia
Infrahyoid m.
trachea esophagu
thyroid s
Internal jugular
Pretracheal layer
vein
s.c. Common carotid
m
Carotid sheath a.
Vagus n.
Buccopharynge scalenus
al fascia
Investing
layer
Prevertebral
Trapezius layer

19. • Origin – 1) medial third of the clavicle
(clavicular head)
2) manubrium (sternal head)
 • Insertion – mastoid process
 • Nerve supply – spinal accessory nerve (CN
XI)
 • Blood supply –
1) occipital a. or direct from ECA
2) superior thyroid a.
3) transverse cervical a.

20. Sternocleidomastoid

21.  Function – turns head toward opposite side
and tilts head toward the ipsilateral shoulder
 • Surgical considerations
– Leave overlying fascia (superficial layer of deep
cervical fascia down)
– Lateral retraction exposes the submuscular recess

22. • 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

24.  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

25.  • 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

27.  Surgical considerations
 – Posterior limit of Level V neck dissection
 – Denervation results in shoulder drop and winged
scapula

28. • Origin – digastric fossa of the mandible (at the
symphyseal border
• Insertion –
1) hyoid bone via the intermediate tendon
2) mastoid process
• Function –
1) elevate the hyoid bone
2) depress the mandible (assists lateral pterygoid)

30.  – Posterior belly is superficial to:
• ECA
• Hypoglossal nerve
• ICA
• IJV
 – Anterior belly
• Landmark for identification of mylohyoid for
dissection of the submandibular triangle

31. Division of the neck
Anterior triangle
Suprahyoid region: submental triangle
submandibular triangle
Infrahyoid region: muscular triangle
carotid triangle
Posterior triangle

33. Submental triangle
 Lies below the chin and is
bounded laterally by
anterior bellies of digastric,
and inferiorly by the body
of hyoid bone
 Covered by skin,
superficial fascia and
investing fascia
 Floor － mylohyoid muscles
 Contents － submental
lymph nodes

34. Suprahyoid muscles
stylohyoid
digastric (anterior
and posterior belly)
mylohyoid

35. Submandibular triangle
 Bounded by anterior and posterior bellies of digastric
and lower border of the body of the mandible
 Covered by skin, superficial fascia, platysma and
investing fascia
 Floor － mylohyoid, hyoglossus and middle
constrictor of pharynx
 Contents － submandibular gland, facial
a., v., hypoglossal n. and v., lingual n.,
submandibular ganglion and submandibular lymph
nodes

37. Carotid triangle
sternocleidomastoid,
superior belly of omohyoid
and posterior belly of
digastic muscles
 Covered by skin, superficial
fascia, platysma and
investing fascia
 Floor － prevertebral fascia
and lateral wall of pharynx
 Contents － common
carotid a. and its branches,
internal jugular v. and its
tributaries, hypoglossal n.
with its descending
branches, the accessory
and vagus nerves, and part
of the chain of deep
cervical lymph nodes

38. Muscular triangle
 Bounded by midline of the
neck, superior belly of the
omohyoid and anterior
border of the
sternocleidomastoid.
 Covered by skin, superficial
fascia, platysma, anterior
jugular v., coutaneous n. and
investing fascia
 Floor － prevertebral fascia
 Contents － sternohyoid,
sternothyroid, thyrohyoid,
thyroid gland, parathyroid
gland, cervical part of
trachea and esophagus

39.  Bounded by
posterior border of
sternocleidomastoid,
anterior border of
trapezius and middle
third of clavicle
 Divided by inferior
belly of omohyoid
into occipital and
supraclavicular
triangles

40.  Arteries:
 Subclavian (3rd part)
 Superficial cervical &
suprascapular
(branches of
thyrocervical trunk, a
branch of 1st part of
subclavian artery
 Occipital, a branch
of external carotid
artery

41.  Nerves:
 Branches of
cervical
plexus
 Spinal part of
accessory
nerve
 Brachial
plexus

42. Occipital triangle
 Bounded by posterior
border of
sternocleidomastoid,
anterior border of
trapezius and superior
border of inferior belly of
omohyoid
 Covered by skin,
superficial fascia, and
investing fascia
 Floor － prevertebral
fascia and scalenus
anterior, scalenus medius,
scalenus posterior,
splenius capitis and
levator scapulae

43.  Contents
› Accessory n. － emerges above the middle of
the posterior border of sternocleidomastoid and
crosses the occipital triangle to trapezius
› Cervical and brachial PLEXUS

44. Supraclavicular triangle
 Bounded by posterior
border of
sternocleidomastoid,
inferior belly of omohyoid
and middle third of
clavicle
 Covered by skin,
superficial fascia, and
investing fascia
 Floor － prevertebral
fascia and inferior parts of
scalenus
 Contents
› Subclavian v. and
venous angle
› Subclavian a.
› Brachial plexus

45.  Most commonly injury
dissection level Ib
 Landmarks:
› 1cm anterior and inferior to
angle of mandible
› Mandibular notch
 Subplatysmal
 Deep to fascia of the
submandibular gland
 Superficial to facial vein

47.  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

48.  • Curves 90 degrees and passes between the IJV
and ICA
– Surrounded by venous plexus
 • 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

49.  Penetrates deep surface of
the SCM
 Exits posterior surface of
SCM deep to Erb’s point
 Traverses the posterior Accessory n. (XI)
triangle on the levator Hypoglossal n. (XII)
scapulae
Ansa cervicalis
 Enters the trapezius about 5
cm above the clavicle
Vagus n. (X)
Phrenic n.

50.  CN XI – Relationship with the IJV

51.  Crosses the IJV
 • Crosses lateral to the transverse process of
the atlas
 • Occipital artery crosses the nerve
 • Descends obliquely in level II (forms Level IIa and
IIb

54.  Developed by Memorial Sloan-Kettering
Cancer Center
 Ease and uniformity in describing
regional nodal involvement in cancer of
the head and neck

55. LYMPH NODES acts as a barrier to the
spread of the disease .
Virchow in 1860

56.  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.

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

58.  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

60.  Submental triangle
(Ia)
› Anterior digastric
› Hyoid
› Mylohyoid
 Submandibular
triangle (Ib)
› Anterior and posterior
digastric
› Mandible.

61.  Ia
› Chin
› Lower lip
› Anterior floor of mouth
› Mandibular incisors
› Tip of tongue
 Ib
› Oral Cavity
› Floor of mouth
› Oral tongue
› Nasal cavity (anterior)
› Face

62.  Upper Jugular Nodes
 Anterior  Lateral border of
sternohyoid, posterior
digastric and stylohyoid
 Posterior  Posterior border
of SCM
 Skull base
 Hyoid bone
 Carotid bifurcation
 Level IIa anterior to XI
 Level IIb posterior to XI

63.  Oral Cavity
 Nasal Cavity
 Nasopharynx
 Oropharynx
 Larynx
 Hypopharynx
 Parotid

64.  Middle jugular nodes
› Anterior  Lateral border of
sternohyoid
› Posterior  Posterior border
of SCM
› Inferior border of level II
› Cricoid cartilage lower
border

65.  Oral cavity
 Nasopharynx
 Oropharynx
 Hypopharynx
 Larynx

66.  Lower jugular nodes
› Anterior  Lateral border
of sternohyoid
› Posterior  Posterior
border of SCM
› Cricoid cartilage lower
border
› Omohyoid muscle
› Clavicle

67.  Hypopharynx
 Larynx
 Thyroid
 Cervical esophagus

68.  Posterior triangle of neck
› Posterior border of SCM
› Clavicle
› Anterior border of trapezius
› Va Spinal accessory
nodes
› Vb  Transverse cervical
artery nodes
› Supraclavicular nodes

69.  Nasopharynx
 Oropharynx
 Posterior neck and scalp

70.  Anterior compartment
› Hyoid
› Suprasternal notch
› Medial border of carotid
sheath
› Perithyroidal lymph nodes
› Paratracheal lymph
nodes
› Precricoid (Delphian)
lymph node

71.  Thyroid
 Larynx (glottic and subglottic)
 Pyriform sinus apex
 Cervical esophagus

72. Face and Scalp Anterior Facial, Ib
Lateral Parotid
Posterior Occipital, V
Eyelids Medial Ib
Lateral Parotid, II
Chin Ia, Ib, II
External Ear Anterior Parotid, II
Posterior Post auricular, II, V
Middle Ear Parotid, II
Floor of mouth Anterior Ia, Ib, IIa > IIb
Lower incisors Ia, Ib, IIa > IIb
Lateral Ib, IIa > IIb, III
Teeth except incisors Ib, IIa > IIb, III
Nasal Cavity Anterior Ib
Posterior Retropharyngeal, II, V

73. Nasal Cavity Posterior Retropharyngeal, II, V
Nasopharynx Retropharyngeal, II, III, V
Oropharynx IIb > IIa, III, IV, V
Larynx Supraglottic IIa > IIb, III, IV
Subglottic VI, IV
Cervical
esophagus IV, VI
Thyroid VI, IV, V, Mediastinal
Tongue Tip Ia, Ib, IIa > IIb, III, IV
Lateral Ib, IIa > IIb, III, IV

75.  • “N” classification – AJCC (1997)
 • Consistent for all mucosal sites except the
nasopharynx
 • Thyroid and nasopharynx have different staging
based on tumor behavior and prognosis
 • Based on extent of disease prior to first treatment

76.  Nx: Regional lymph nodes cannot be
assessed.
 N0: No regional lymph node metastases.
 N1: Single ipsilateral lymph node, < 3 cm

77.  N2a: Single ipsilateral lymph node 3 to 6
cm
 N2b: Multiple ipsilateral lymph nodes > 6
cm
 N2c: Bilateral or contralateral nodes >
6cm
 N3: Metastases > 6 cm

79.  • Standardized until 1991
 • Academy’s Committee for Head and
Neck Surgery and Oncology publicized
standard classification system

80.  Academy’s classification
 – Based on 4 concepts
• 1) RND is the standard basic procedure for cervical
lymphadenectomy against which all other
modifications are compared
• 2) Modifications of the RND which include
preservation of any non-lymphatic structures are
referred to as modified radical neck dissection
(MRND)

81.  Academy’s classification
• 3) Any neck dissection that preserves one or more
groups or levels of lymph nodes is referred to as a
selective neck dissection (SND)
• 4) An extended neck dissection refers to the
removal of additional lymph node groups or non-
lymphatic structures relative to the RND

82.  Academy’s classification(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

83.  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

84.  Spiro’s classification
– Radical (4 or 5 node levels resected)
 • Conventional radical neck dissection
 • Modified radical neck dissection
 • Extended radical neck dissection
 • Modified and extended radical neck dissection
– Selective (3 node levels resected)
 • SOHND
 • Jugular dissection (Levels II-IV)
-• Any other 3 node levels resected
– Limited (no more than 2 node levels resected)
 • Paratracheal node dissection
 • Mediastinal node dissection
 • Any other 1 or 2 node levels resected

85.  1. Presence of clinically positive N1, N2a,
N2b & N3 nodes
Treatment of No neck is still a
controversy.
 2. Extra nodal spread (including skin
involvement)
 3. Recurrence after RT treatment

86.  1. Uncontrolled primary lesion
 2. Involvement of internal / common
carotid artery
 3. Presence of distant metastasis.
 4. Poor anaesthetic risk patient.

87.  TYPES
 - Apron incision
 -Half apron incision
 -Conley incision
 -Double Y incision
 -H incision
 -Macfee incision
 - Y incision
 -Modified Schobinger incision
 -Schobinger

92.
 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.

93.  4. Facilitate reconstruction Example, if
pectoral muscle is used a lower limb
should be near the clavicle to enable
flap accommodation.
 5. It should be cosmetically acceptable.

94.  Removes
› Nodal groups I-V
› SCM, IJV, XI
› Submandibular gland,
tail of parotid
 Preserves
› Posterior auricular
› Suboccipital
› Retropharyngeal
› Periparotid
› Perifacial
› Paratracheal nodes

101.  Removes
› Nodal groups I-V
 Preserves
› SCM, IJV, XI (any
combination)
› TYPE A MRND

104.  Three types (Medina 1989) commonly referred to
not specifically named by committee.
• Type I: Preservation of SAN
• Type II: Preservation of SAN and IJV
• Type III: Preservation of SAN, IJV, and SCM
( “Functional neck dissection”)

105.  • Indications
– Clinically obvious lymph node metastases
– SAN not involved by tumor
–Intraoperative decision

106.  • Indications
– Rarely planned
– Intraoperative tumor found adherent to the
SCM, but not IJV and SAN

107.  • Rationale
– Suarez (1963) – necropsy and surgery specimens of
larynx and hypopharynx – lymph nodes do not
share the same adventitia as adjacent BV’s
– Nodes not within muscular aponeurosis or glandular
capsule (submandibular gland)
– Sharpe (1981) showed ) 0% involvement of the SCM
in 98 RND specimens despite 73 have nodal
metastases
 – Survival approximates MRND Type I assuming IJV,
and SCM not involved
 Widely accepted in Europe
• Neck dissection of choice for N0 neck

108.  Rationale
– Reduce postsurgical shoulder pain and
shoulder dysfunction
– Improve cosmetic outcome
– Reduce likelihood of bilateral IJV
resection - Contralateral neck
involvement

109.  Definition
– 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

110.  Also known as an elective neck dissection
• Rate of occult metastasis in clinically negative neck
20-30%
• Indication: primary lesion with 20% or greater risk of
occult metastasis
• Studies by Fisch and Sigel (1964) demonstrated
predictable routes of lymphatic spread from
mucosal surfaces of the H&N
• Need for post-op RT

111. • 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

112.  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)

113. Bilateral SOHND
 • Anterior tongue
 • Oral tongue and FOM that approach the midline
– SOHND + parotidectomy
 • Cutaneous SCCA of the cheek
 • Melanoma (Stage I – 1.5 to 4mm) of the cheek
• Byers does not advocate elective neck dissection
for buccal carcinoma
 – Adjuvant RT given to patients with > 2- 4 positive
nodes +/- ECS.

114. • 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

115.  • 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

116.  • 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

117.  Indications
 – Selected cases of thyroid carcinoma
 – Parathyroid carcinoma
 – Subglottic carcinoma
 – Laryngeal carcinoma with subglottic
extension
– CA of the cervical esophagus

118.  • Definition
 – 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

119.  Indications
 – 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.

120.  SUPERSELECTIVE NECK DISSECTION OF
HEAD AND NECK cancer –
Yet to come

121.  4 TYPES
- INTRA OP
- IMMEDIATE POST OP
- LATE POST OP
- DELAYED COMPLICATIONS

122.  Inadequate planning
 Inadvertent injury to local blood vessels
and nerves .
-marginal mandibular N.
- Spinal accessory N.
- Cervical plexus
- Brachial plexus
- Thoracic duct injury .

123.  Haemorrhage: Needs evaluation of the
extent of bleeding and occasionally
may need re-exploration.
 Lymph leak: When the drainage is of
milky fluid and is persistently high
>100ml /day after 2days.A possibility of
lymph leak has to be considered.

124.  Carotid blow out: A dreaded
complication that occurs secondary to
wound break down. If exposed the
carotids have to be covered using
vascularised flaps.
 Facial oedema: A common occurrence
usually settles down in 4-6 weeks.

125.  Wound infection
 Fistulae
 Devitalisation of the reconstructed flap

126.  Dysphagia ( CN V,IX, X, XI)
 Shoulder weakness
 Trismus

127.  Pectoralis major myocutaneous flap
 Free fibula flap
 Deltoid muscle flap
 Forehead flap
 Cervical flap
 Radial forearm flap

128.  • Cervical metastasis in SCCA of the upper
aerodigestive tract continues to portend a poor
prognosis
 • Staging will help determine what type neck
dissection should be performed
 • Unified classification of neck nodal levels and
classification of neck dissection has to understood
well.
 • Indications for neck dissection and type of neck
dissection, especially in the N0 neck, is a still
controversial

130. THANK YOU
HAVE A NICE DAY