This document discusses types of neck dissection procedures performed to treat neck metastases from head and neck cancers. It describes radical neck dissection, modified radical neck dissection, and selective neck dissection. Radical neck dissection removes all lymph nodes from levels I-V, while modified versions preserve one or more non-lymphatic structures like the spinal accessory nerve or internal jugular vein. Selective neck dissection removes only the lymph nodes at levels that drain the primary tumor site. The indications, techniques, and complications of these neck dissection procedures are examined in detail.

1. TYPES OF NECK DISSECTION
BY: DR.SAHAR J. HADI
ENT CENTER- SULAIMANYIA TEACHING HOSPITAL-
SULAIMANYIA- IRAQ

2. CONTENTS
• 1- Introduction
• 2- Historical Review.
• 3-Neck anatomy.
• 3-Cervical Lymph Nodes Levels And Staging.
• 4-Classification of neck dissection.
• 5- Indication Of Neck Dissection.
• 6- Complication.
• 7- Summary.

3. INTRODUCTION
Neck dissection(cervical lymphadenectomy)
mean systemic removal of lymph nodes along
with their surrounding fibrofatty tissue in
different compartments of the neck to eradicate
metastatic disease to the regional lymph nodes
of the neck. these metastases originate from
primary lesions that involve mucosal sites of
the upper aerodigestive tract.

4. TYPES OF NECK DIESSECTION
• 1-therapeutic neck dissection.
• 2- planned neck dissection.
• 3-salvage neck dissection .

5. ELECTIVELY NECK DISSECTION IN N0
• Depended on:-
• 1-Histology.
• 2-Tumor (T stage) classification
• 3- Location of the primary tumor.
• 4-Overall treatment plan.

6. HISTORICAL REVIEW
• Kocher 1880
• Advocate wide marginal lymphadenectomy
• In 1888, Jawdynski
• described en bloc resection of cervical lymph nodes with
• resection of IJV ,SCM and SAN with very high rate of mortality.
• In 1906, George W. Crile of the Cleveland Clinic
• described the radical neck dissection.
• In 1967 - Oscar Suarez and E. Bocca
• described a more conservative operation with MRND

7. ANATOMY:-VASCULAR SUPPLY OF THE NECK SKIN

8. NECK TRIANGLES

9. ANATOMY:- LAYERS OF CERVICAL FASCIA

10. ANATOMY:-NECK MUSCLES

11. MARGINAL MANDIBULAR NERVE

12. SPINAL ACCESSORY NERVE

14. THORACIC DUCT

15. CERVICAL LYMPH NODES

17. CERVICAL LYMPH NODES STAGING
• NX:
• Regional lymph nodes can not be assessed
• N0:
• No regional lymph node metastasis
• N1:
• Metastasis in a single ipsilateral lymph nodes, 3 cm or
less in greatest dimension
• N2:
• N2a:
• Metastasis in a single ipsilateral lymph nodes, more
than 3 cm but less than 6 cm

18. • N2b:
• Metastasis in multiple ipsilateral lymph nodes, not
more than 6 cm
• N2c:
• Metastasis in bilateral or contralateral nodes not
more than 6 cm in diameter
• N3:
• Metastasis in lymph nodes more than 6 cm in in greatest
diameter

20. CLASSIFICATION OF ND
• According to the Academy’s Committee for Head &
Neck Surgery & Oncology in 1997 we have 4 major
types:-
1. Radical Neck Dissection (RND)
2. Modified Radical Neck Dissection (MRND)
• Subtype I: Preserve SAN
• Subtype II: Preserve SAN & IJV
• Subtype III: preserve SAN, IJV and SCM
• Known as Functional neck dissection (Bocca)

21. 3-Selective Neck Dissection (SND)
1. Supraomohyoid
2. Posterolateral
3. Lateral
4. Anterior
4-Extended Radical Neck Dissection (ERND)

23. RADICAL NECK DISSECTION
• This operation is defined as the en bloc removal
of the lymph node-bearing tissues of one side of
the neck from the inferior border of the
mandible to the clavicle and from the
contralateral anterior belly of digastric and
lateral border of the strap muscles to the anterior
border of the trapezius that include level l----V.
with spinal accessory nerve, SCM and IJV.

26. INDICATION OF RND
.
• 1- RND is indicated for patients with extensive lymph node metastases
with operable neck dis(N2a,N2b,N3)
• 2- extension beyond the capsule of the node or nodes that involves the
spinal accessory nerve , IJV and SCM.
• 3- access prior to pedicled flab reconstruction.
• 4- large tumor with risk or presence of occult metastasis.
• 5- Recurrence after RT.

27. CONTRAINDICATION OF RND
• 1- those patients whose primary tumors are untreatable.
• 2-any patient who is unfit for major surgery because of a serious
medical condition which would render anesthesia and major
surgery unsafe.
• 3- patients with distant metastases.
• In those patients who are deemed inoperable, radical
radiotherapy with or without adjuvant chemotherapy is seldom
curative but may provide excellent palliation.

28. TECHNIQUE OF RND
• 1-preoperative preparation of the patient.
• 2-position.
• 3-incision planning:-
• a- factors.
• b- criteria
• c- types(advantage and disadvantage).
• d- biopsy

30. RADICAL NECK DISSECTION AS PART OF A COMBINED
PROCEDURE
• When a primary tumour is removed in continuity with a neck dissection, a
band of continuity may be kept between the neck dissection and the
primary growth.
• Laryngeal cancer
• In a total laryngectomy, the neck dissection should b e left attached along
the whole length of the larynx to include the superior and inferior lymphatic
pedicles. A neck dissection is never carried out with a hemilaryngectomy
but for a supraglottic laryngectomy, it is pedicled on the thyrohyoid
membrane.
• Pharyngeal cancer
• When a pharyngectomy i s performed, the pedicle should be as broad as
possible and is best left along the whole length o f the pharynx.

31. • Oral cancer
• Oral cancers drain to the submandibular, submental and upper deep
cervical lymph nodes in levels I, II and III. The specimen should be left
attached along the lower border of the mandible and include the inner
layer of periosteum to preserve continuity if possible when neck
dissection is combined with radical resections.
• Oropharyngeal cancer
• Tumors of the oropharynx drain by a pedicle to the upper deep cervical
nodes in levels II, III and IV. Therefore, leave a specimen attached near
the tail of the parotid gland if possible.

32. COMPLICATION
• 1-major and minor.
2-early, intermediate and late.
• 3-local and systemic.
• 4- general and specific.
• Up to 20 %of patients will have a major
complication.
• the mortality rate 1 %

33. • The complication rate may be increase :-
• 1- patient receive radiotherapy
• 2-chemotherapy.
• 3-associted with upper aerodigestive tract
procedure

34. A- general complication:-
• Atelectasis
• Basal collapse
• Pneumonia
• Urinary retention
• Deep venous thrombosis.

35. • B- specific complication
• Air lake
• Hemorrhage
• Wound infection
• Chylous leak and fistula.
• Pneumothorax
• Nerve injury
• Facial and cerebral edema
• Blindness
• Carotid artery rupture

36. MODIFIED NECK DISSECTION
• This operation consists of removal of all lymph nodes
groups (levels I-V) with preservation of one or more non
lymphatic structures
• major purpose of these modifications relates to the
morbidity encountered when the spinal accessory nerve is
removed. Although the degree of morbidity is less for
removal of the SCM and the IJV, this issue becomes far
more important if bilateral neck dissections are required.
Simultaneous sacrifice of both IJVs may result in severe
swelling of the face with increased intracranial pressure.

38. • We have three types MRND:-
• Modified radical neck dissection (type 1 ) . This operation is
indicated for patients with cervical metastases where the spinal
accessory nerve is not involved.
• It may be used for elective treatment of the NO neck but, as
previously described, there are more conservative procedures
currently available to treat this condition

40. • Modified radical neck dissection (type 2) :-
• Preservation of the internal jugular vein in squamous cell
carcinoma is often not carried out when operating for palpable
disease .
• In addition to the indications described above for a type 1
dissection.
• A type 2 dissection may be carried out where preservation of the
internal jugular vein is important either when performing a
second side operation, for microvascular anastomosis or when
histology dictates that the vein need not be resected, i.e.
differentiated thyroid cancer.

42. • Modified radical neck dissection (type 3):-
• This operation, otherwise known as a comprehensive or
functional neck dissection.
• Has been used for elective treatment for the NO neck in patients
with squamous cell carcinoma of the upper aerodigestive tract.
• This is appropriate treatment if the patient has had previous
radiotherapy.
• It is also indicated for patients with skin tumors such as
melanoma, squamous cell carcinoma and Merkel cell carcinoma
that originate in the narrow band of the scalp within the confines
of the anterior and posterior aspects of the auricle.

44. Type dissection Indications
1-type 1
2-type 2
3-type3
-Operable palpable neck disea se ( N1, N 2a,
N2b) not i nvolving the SAN
-Can occasionally be done for N0 neck.
-the same indications as for a type 1 –
procedure particularly for a second side
opera tion when there is need for
microvascular anastomosis or when histology
dictate IJV not need be resected , i.e.
differentiated thyroid cancer.
-Treatment of the NO neck.
-Treatment of differentiated thyroid cancer.
-Skin tumors such as melanoma , squamou s
cell carcinoma and M erkel cell carcinom a.

45. SELECTIVE NECK DISSECTION
• SND is performed for patients who are at risk for early lymph
node metastases.
• The procedure consists of the en bloc removal of one or more
lymph node groups at risk for harboring metastatic cancer, an
assessment that is based on the location of the primary tumor.
Thus the levels removed depend on the location of the primary
lesion and its known pattern of spread.
• More functionally and cosmetically type.
• Used for staging the neck in disease tumor amenable to remove
by surgery alone.

46. TYPES OF SELECTIVE NECK
DISSECTION

47. • 1-supraomohyoid and extended supraomohyoid type:-
• used for oral cavity cancer, the procedure of choice is SND
(levels I through III)
• The procedure involves removal of the lymph nodes in the
levels I, II, III .
• The cutaneous branches of the cervical plexus and the
posterior border of the SCM mark the posterior limit of the
dissection. The inferior limit is the junction between the
superior belly of the omohyoid muscle and the IJV.

49. • Indication:-
• 1-oral cavity cancer with high risk of occult metastasis.
• 2-low volume LN disease N1 with indication of post/op radiotherapy.
• When the there is tongue C.A so the dissection involve level I, II, III,IV.
• The first echlon of the oral cavity is I.II.III.
• If the oral C.A with N0 so the treatment either:-
• 1-surgery of the primary tumor with SND
• 2-RT so the SND not recommented.
• If oral C.A with N+ so the treatment either:-
• 1-MRND
• 2-SND I,II.III.IV If the disease limited to the level I AND II.

50. • Indication of the contralateral SND:-
• 1-primary tumors of floor of mouth.
• 2-primary tumors on the lateral or vental surface of the
tongue.
• 3-patient planned for ipsilateral SND without post op
RT.
• 4-With all patient with N2c.

51. • 2-lateral neck dissection.
• for Oropharyngeal, Hypopharyngeal, and Laryngeal Cancer .
• The procedure refers to the removal of level II, III ,IV.
• The superior limit of dissection is the skull base, and the inferior limit
is the clavicle; the anterior (medial) limit is the lateral border of the
sternohyoid muscle and the stylohyoid muscle, and the posterior
(lateral) limit of the dissection is marked by the cutaneous branches of
the cervical plexus and the posterior border of SCM.

53. • 3-posteriolateral Neck dissection
• it is primarily used to eradicate nodal metastasis associated with cutaneous
malignancies and soft tissue sarcomas.
• Posterolateral neck dissection involves the removal of the suboccipital,
retroauricular, LEVELS II ,III, IV,V.
• The superior limit of dissection is the skull base anteriorly and the nuchal
ridge posteriorly; the inferior limit is the clavicle; the medial (anterior) limit is
the lateral border of the sternohyoid muscle and the stylohyoid muscle; and
the lateral (posterior) limit is the anterior border of the trapezius muscle
inferiorly and the midline of the neck superior .
• it is important to remove the intervening subdermal fat and underlying fascia
between the lymph node groups and the primary disease, which ensures the
removal of smaller nests of metastasizing tumor cells characteristic of
malignancies that originate in cutaneous soft tissue.

54. INDICATION
• A- when the primary lesion in the posterior scalp and upper neck:
• the procedure of choice is an SND of levels II through V (postauricular and
suboccipital LN).
• B-cutaneous malignancies that arise on the preauricular, anterior
scalp, and temporal regions.
• the elective neck dissection of choice is SND that includes the parotid
and facial nodes; levels IIA, IIB, III, and VA; and the external jugular
nodes.
• C-cutaneous malignancies that arise on the anterior and lateral
face.
• the elective neck dissection of choice is SND of the parotid and facial
nodes in levels IA, IB, II, and III.

55. 4-ANTERIOR NECK DISSECTION
• Selective Neck Dissection for Cancer of the Midline Structures of the
Anterior Lower Neck
• The procedure is most often indicated, with or without dissection of
other neck levels, for cancer of the thyroid, advanced glottic and
subglottic larynx cancer, advanced piriform sinus cancer, and cervical
esophageal/tracheal cancer.
• Including the paratracheal, precricoid (Delphian), and perithyroid
nodes and the nodes located along the recurrent laryngeal nerves.
• The superior limit of dissection is the body of the hyoid bone, and the
inferior limit is the suprasternal notch; the lateral limits are defined by
the medial border of the carotid sheath (the common carotid artery).

56. INDICATION OF SND
type Level involve in
dissection
indication
supraomohyiod I-III T, -T4 N0 SCC oral cavity
Extended supraomohyiod I-IV Skin cancer (SCC and melanoma)
anterior to the line of the tragus.
Performed in conjunction with a
superficial parotidectomy.
lateral II,III,IV T2-T4: N0 SCC larynx, oropharynx and
hypopharynx.
posteriolateral II-V Skin cancer (SCC and melanoma)
posterior to the line of the tragus
central VI Differantiated thyroid carcinoma
Subglottic and hypopharyngea l SCC

57. EXTENDED NECK DISSECTION
• Any of the neck dissections described previously may be extended to
remove other lymph node groups or vascular, neural, or muscular
structures that are not routinely removed in other neck dissection
• It is indicated when the primary tumour arises in the parotid gland or
pharynx when a retropharyngeal node dissection is required. Finally, it
is indicated for transglottic and subglottic carcinomas along with
carcinomas of the cervical oesophagus and thyroid when it is
necessary to remove the paratracheal, pretracheal and anterior
compartment nodes with an associated neck dissection

58. SUMMARY
• Neck dissection is an operative procedure designed to remove
metastases that involve the regional cervical lymph nodes.
• The gold standard procedure is RND, which for most patients is too
extensive and results in excessive morbidity. Modifications of the RND
procedure have evolved, and these were designed to reduce morbidity
by sparing non lymphatic structures (modified RND) and to treat early
nodal disease by removing only the lymph node groups at greatest risk
for harboring metastases (selective neck dissection).
• To help the reader determine which type of neck dissection is most
appropriate for the management of nodal disease associated with the
three major sites of the upper aerodigestive tract .

61. Thank you