Synonyms and related keywords: complete neck dissection, block neck

dissection, classic neck dissection, neck tumor, metastatic neck disease, neck
lymph node metastasis, cervical lymphatic metastasis, head and neck squamous
cell carcinoma, neck metastasis, classic neck dissection, neck cancer, oral cavity
cancer, pharyngeal cancer, laryngeal cancer, thyroid cancer, thyroid carcinoma,
skin cancer of the head and neck, nasopharyngeal carcinoma, neck mass,
metastatic neck mass, cervical lymphadenopathy, modified radical neck
dissection, cervical adenopathy, selective neck dissection, neck node cancer,
metastatic cervical lymphatic spread, squamous cell carcinoma of the upper
aerodigestive tract, radical neck dissection

INTRODUCTION
Section 2 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
 References

Metastatic neck disease is the most important factor in the spread of head and
neck squamous cell carcinoma from primary sites. The primary sites most
commonly involved in the spread of this carcinoma are the mucosal areas of the
upper aerodigestive tract, particularly the larynx, oropharynx, hypopharynx, and
oral cavity.

Lymph node metastasis reduces the survival rate of patients with squamous cell
carcinoma by half. The survival rate is less than 5% in patients who previously
underwent surgery and have a recurrent metastasis in the neck. Therefore, the
control of the neck is one of the most important aspects in the successful
management of these particular tumors.
Radical neck dissection is an operation that was created in 1906 to solve the
problem of metastatic neck disease. It is a well-designed operation that is
relatively easy for the trained head and neck surgeon to learn and to perform.
Classic radical neck dissection is still the criterion standard for surgical control of
a neck metastasis.

In the last 3 decades, progressive advances have occurred in the understanding

of cervical fascial planes, lymphatic drainage patterns, preoperative staging, and
extracapsular spread. A concern to maximize control and to minimize morbidity
has prompted modifications to the classic neck dissection. One such modification
is the preservation of 1 or more non lymphatic structures (eg, spinal accessory
nerve, internal jugular vein, sternocleidomastoid muscle). Further observations
have indicated that the pattern of nodal disease depends on the primary site.
Therefore, these findings led to another neck dissection modification, which is the
selective preservation of 1 or several lymph node groups.

History of the Procedure

In 1906, George W. Crile was the first person to describe radical neck dissection,
which encompasses the surgical removal of neck metastasis contained between
the superficial and deep fascial layers of the neck. Hayes Martin routinely used
radical neck dissection for the management of neck metastasis in the 1950s. The
main goal of this procedure was to remove, en bloc, the entire ipsilateral
lymphatic structures from the mandible superiorly to the clavicle inferiorly and
from the infrahyoid muscles to the anterior border of the trapezius.

The resection included the spinal accessory nerve, the internal jugular vein, the
sternocleidomastoid muscle, and the submandibular gland. The anatomic
structures that remained were the carotid arteries, vagus nerve, hypoglossal
nerve, brachial plexus, and phrenic nerve. This operation and its oncologic
concept are still valid; however, the procedure has been modified to decrease its
morbidity but to maintain its oncologic efficacy. In the 1960s, O. Suarez and E.
Bocca independently described a more conservative operation that involved
removing all the lymph nodes but sparing the spinal accessory nerve,
sternocleidomastoid muscle, and internal jugular vein. Finally, further procedures
were designed to remove only selected regional lymph groups involved,
depending on the primary site of origin.

The multiple modifications to the radical neck operation brought about new terms
to describe such changes, and the terms for the same modification varied from
author to author. Many cases of unclear terminology created confusion among
clinicians from different geographical areas and institutions. Therefore,
standardization was necessary. In 1991, the American Academy of
Otolaryngology-Head and Neck Surgery published an official report that
standardized the terminology for the different types of neck dissection.
In 2001, the report was updated with only a few changes, which dealt with the
application of various types of selective neck dissection procedures for oral cavity
cancer, pharyngeal and laryngeal cancer, thyroid cancer, and cutaneous
malignancies. In addition, 2 new neck sublevels, Va and Vb, were added, for a
total of 6 neck levels and 6 neck sublevels. (The 1991 version of the report listed
only 4 neck sublevels.) With the exception of the 2 added neck sublevels, the
terminology in the updated report is the same as that of the 1991 version. This
nomenclature is widely used today.

Modifications to the radical neck dissection include the following:

 Type I: The spinal accessory nerve is preserved.

 Type II: The spinal accessory nerve and the internal jugular vein are
preserved.
 Type III: The spinal accessory nerve, the internal jugular vein, and the
sternocleidomastoid muscle are preserved.
 Extended radical neck dissection: The lymph node groups and/or
additional structures not included in the classic neck dissection are
resected.

Problem

Lymphatic metastasis is the most important mechanism of spread in head and

neck squamous cell carcinoma. The risk of lymph node involvement by
metastasis varies depending on the site of origin, size of primary tumor,
histologic grade of the primary tumor, perineural invasion, perivascular invasion,
and extracapsular spread. Management of the neck lymph nodes is an integral
part of treatment of head and neck cancer. Conversely, no single standardized
treatment for cervical metastasis exists.

The indications and type of neck dissection to be performed in the N+ neck and
management of the N0 neck remain controversial. Management is based on
personal experience and retrospective studies. Radical neck dissection was the
first attempt at adequately treating metastatic cervical lymphatic spread. The
classic operation was subsequently modified several times to decrease morbidity
without decreasing oncologic control. The 2 procedures in common use today
are the modified radical and the selective neck dissections.

Frequency

The incidence of metastatic disease for the upper aerodigestive tract varies
widely, from 1-85%, depending on the site, size, and differentiation of the tumor.
The rate of ipsilateral metastatic disease in patients with stage T3-T4 squamous
cell carcinoma of the oral cavity, oropharynx, hypopharynx, or supraglottis is
approximately 50%. The rate of bilateral or contralateral metastatic disease in
these patients varies from 2-35%.
Nasopharyngeal carcinoma appears as a neck mass in approximately 50% of
patients. Metastatic neck disease in thyroid gland tumors occurs as follows:
papillary, 55%; medullary, 50%; and follicular, 25%.

Tumors localized in the oral cavity, oral mucosa, oropharynx, hypopharynx, and
supraglottis have a higher incidence of metastasis than tumors of the superior
gingiva, hard palate, and glottis. Many other factors contribute to the risk of neck
metastasis, including the following:

 Anterior portions of the oral cavity are associated with smaller risk of neck
metastasis than posterior portions.
 Young patients with oral carcinoma have a higher risk of developing nodal
metastasis than older patients.
 Risk of neck involvement by metastasis increases with an increase in
tumor size.
 Perineural and perivascular invasion are associated with a high risk of
nodal metastasis. The extracapsular spread of the nodes also carries a
high probability for lymphatic spread.
 Poorly differentiated tumors are associated with a higher risk of neck
metastasis than well-differentiated tumors.

Etiology

Radical neck dissection is performed for the surgical control of metastatic neck
disease in patients with squamous cell carcinomas of the upper aerodigestive
tract, salivary gland tumors, and skin cancer of the head and neck (including
melanomas). Radical neck dissection is also indicated for the surgical control of
metastatic carcinoma to the neck when the nasopharynx and thyroid are the
primary sites.

Pathophysiology

Metastasis occurs frequently in malignancies. The tumor grows at the primary

site by dysfunction in cellular proliferation, differentiation, and death. Mutations
due to chemical carcinogens, radiation, or viruses may cause activation of
oncogenes by normal cells, multiple genetic mutations, activation of proto-
oncogenes, and/or inactivation of tumor suppressor genes, which may cause
alterations in growth control.

Tumor cells move through the basement lamina of the epithelium and the stroma
into the lymphatic and vascular channels (ie, the tumor progresses from
carcinoma in situ to microinvasive tumor). This process is related to the
production of cytokines, enzymes, and growth factors that destroy the basement
membrane and create abnormal angiogenesis, which, in turn, triggers
neovascularization and growth. The tumor spreads into the regional lymph nodes
by lymphatic and vascular channel invasion and may seed other parenchymal
sites if tumor invasion is not controlled at the lymphatic level. The usual sites of
secondary spread include the lungs, liver, bone, brain, and adjacent skin, as well
as other sites, depending on the tumor histology.

Clinical

Most patients present with a unilateral or bilateral neck mass. Usually, the patient
is already aware of the primary lesion, or it is found during physical examination
of the upper aerodigestive tract.

In 15% of patients, a metastatic neck mass is present without an obvious primary

lesion. In this situation, making every effort to identify the primary lesion is
difficult. These patients require a careful evaluation of all mucous membranes of
the upper aerodigestive tract with blind biopsies and an ipsilateral tonsillectomy.

Nodal classification

The most important prognostic factor in patients with squamous cell carcinoma of
the head and neck is the status of the neck nodes. The extent of cervical
lymphadenopathy constitutes the N portion of the tumor, node, metastases
(TNM) classification by the American Joint Committee on Cancer. This
committee assigns N1-N3 ratings to different degrees of cervical adenopathy,
with subgroupings of a, b, and c for certain stages. The nodal classification is as
follows:

 NX - Cervical neck nodes not assessable

 N0 - No cervical node metastasis
 N1 - Single ipsilateral node metastasis, 3 cm or less in diameter
 N2a - Single ipsilateral node, more than 3 cm but not more than 6 cm in
diameter
 N2b - Multiple positive ipsilateral nodes no more than 6 cm in diameter
 N2c - Bilateral or contralateral positive nodes no more than 6 cm in
diameter
 N3 - Massive adenopathy more than 6 cm in diameter

Palpation

The accuracy of nodal status relates to the physician's ability to detect cervical
adenopathy. Palpation is the technique used most in the detection of neck
metastasis. Although palpation is inexpensive and easy to perform, it is not totally
reliable.

Sensitivity and specificity of the neck examination by palpation range from 60-
70%. A short obese neck and/or previous radiation or surgery makes the physical
examination more difficult. Therefore, negative palpation findings of the neck still
indicate a risk for occult metastatic disease. This risk increases according to the
site, size, and particular characteristics of the primary lesion.

Imaging

Imaging is an integral part of clinical diagnosis and staging, and the results are
helpful in deciding treatment. Among these techniques are computed
tomography (CT) scanning, magnetic resonance imaging (MRI), ultrasonography,
and ultrasound-guided aspiration cytology.

CT reveals metastatic adenopathy by central necrosis and extracapsular spread

by enhancement of the nodal capsule. MRI is less precise than CT scan in
identifying tumor necrosis and extracapsular spread, but MRI is better in
assessing enlarged lymph nodes that do not necessarily represent metastasis.
Both techniques can not detect lymph nodes smaller than 1 cm. which, on
occasion, independently of the size, are involved in metastasis. Ultrasound-
guided aspiration cytology has a higher specificity than CT and MRI in analyzing
lymph nodes, particularly in smaller nodes of less than 10 mm. However, the
yield of this technique is directly related to the experience of the ultrasonographer
and the pathologist.

Positron emission tomography (PET) has recently been used to assist in the
diagnosis of lymph node metastasis. PET provides information about the
metabolic activity of the tissues. Tissues with squamous cell carcinoma cells
capture [18F] fluoro-2-deoxy-D-glucose (FDG) at increased rates compared with
normal tissues. Therefore, a minimal amount of tumor tissue must be present for
the finding to be positive. Thus, precision is limited in tumors smaller than 1 cm.

Recent literature has demonstrated the higher sensitivity and specificity of

the FDG-PET compared with ultrasonography, CT scan, and MRI in the
assessment of metastatic staging of neck carcinomas. This finding could signify a
positive role for PET in the identification of metastatic disease in patients with a
clinically N0 neck. PET findings could provide early diagnosis of recurrent head
and neck cancer, as well as indicate the status of the neck after
chemoradiotherapy. PET is discussed further in Workup.

Histologic examination

Finally, the criterion standard for the detection of lymph node metastasis in the
neck is the careful histologic examination of all nodes by the pathologist after the
neck dissection is completed. Detection and accurate staging of neck metastasis
are extremely important because staging has major implications for prognosis
and treatment.

The most widely accepted terminology to define the regions of involvement of the
cervical lymph node groups is the one developed originally by head and neck
surgeons at the Memorial Sloan-Kettering Hospital. The terminology is as
follows:

 Region/level I - Submental and submandibular nodes


o Ia - Nodes in the submental triangle bound by the anterior belly of
the digastric and the hyoid bone
o Ib - Nodes in the triangle bound by the anterior and posterior bellies
of the digastric and body of the mandible
 Region/level II - Upper jugular lymph nodes, including the jugulodigastric
nodes

o IIa - Nodes in the region anterior to the spinal accessory nerve
o IIb - Nodes in the region posterior to the spinal accessory nerve
 Region/level III - Nodes from the carotid bifurcation to the omohyoid
muscle
 Region/level IV - Nodes of the lower jugular area that extend from the
omohyoid to the clavicle
 Region/level V - All lymph nodes within the posterior triangle of the neck
 Region/level VI - Nodes in the anterior compartment group, including the
lymph nodes that surround the midline structures of the neck (These
nodes extend from the hyoid bone superiorly to the suprasternal notch
inferiorly.)

The 2001 report of the American Head and Neck Society's Neck Dissection
Committee recommended the use of 6 neck levels and 6 sublevels, which added
2 extra sublevels at level V. The 6 sublevels are Ia (submental nodes), Ib
(submandibular nodes), IIa and IIb (upper jugular nodes), Va (spinal accessory
nodes), and Vb (transverse cervical and supraclavicular nodes).

INDICATIONS
Section 3 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
  Future And Controversies
 Acknowledgments
 Multimedia
 References

Indications for radical neck dissection have evolved over the last 2 decades.
Today, when oncologic principles are not compromised (ie, no gross evidence of
extension to the spinal accessory nerve or the internal jugular vein), modified
radical neck dissection is preferred.

Indications for radical neck dissection include the following:

 Multiple positive neck nodes that are clinically present in an untreated

patient or in a patient treated with surgery, irradiation, chemotherapy, or a
combination thereof
 One or more positive neck nodes that are clinically present and
extracapsular extension with involvement of the spinal accessory nerve
and internal jugular vein

Radical neck dissection is effective in controlling a post irradiation cervical

metastasis from a nasopharyngeal carcinoma if the primary site is under control.

Indications (usually an intraoperative assessment) for a modified radical neck

dissection include the following:

 Modified radical neck dissection type I - A clinically positive lymph node

metastasis that does not include the spinal accessory nerve
 Modified radical neck dissection type II - Metastatic tumor mass that
involves the sternocleidomastoid muscle but not the internal jugular vein
or spinal accessory nerve
 Modified radical neck dissection type III - Indicated to remove clinically
positive lymph node metastasis that does not infiltrate the nonlymphatic
structures
o Modified radical neck dissection type III is also indicated for
patients with a palpable metastasis caused by a differentiated
carcinoma of the thyroid.
o According to some authors, modified radical neck dissection type III
is indicated in patients with squamous cell carcinoma and an N0
neck when the original tumor is in the larynx, hypopharynx, or both.
Other authors prefer further modification by sparing the
submandibular triangle nodes because of low risk of metastasis to
those nodes.
RELEVANT ANATOMY
Section 4 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
 References

A comprehension of the relevant neck anatomy is mandatory to understand how

to perform an adequate radical neck dissection. From the surgical point of view,
each side of the neck is divided into 2 cervical triangles.

Cervical Neck Triangles

The neck is divided into an anterior and a posterior cervical triangle.

The borders of the anterior cervical triangle are the inferior border of the
mandible, the sternocleidomastoid muscle, and the midline of the neck.

The anterior cervical triangle is further subdivided into 4 smaller triangles: the
submandibular triangle, submental triangle, muscular triangle, and carotid
triangle. Understanding and identifying each of these areas guide the surgeon in
performing a complete removal of the entire contents of the anterior cervical
triangle.

The inferior border of the mandible and the 2 bellies of the digastric muscle
delineate the submandibular triangle. The mylohyoid and hyoglossus muscles
form the floor. Contents are the submandibular gland, lymphatic structures,
anterior facial vein, and facial artery. The lingual nerve is above the muscular
floor and below the deep layer of the deep cervical fascia.
The anterior belly of the digastric muscle, the hyoid bone, and the midline of the
neck delineate the submental triangle. The mylohyoid muscle forms the floor of
the submental triangle. It contains a few lymph nodes and small tributaries of the
anterior jugular vein.

The omohyoid muscle in the anterior cervical triangle delineates the muscular
triangle below and the carotid triangle above.

The posterior cervical triangle is also referred to as the lateral cervical triangle
and is limited by the anterior margin of the trapezius muscle, the posterior border
of the sternocleidomastoid muscle, and the middle third of the clavicle.

The posterior aspect of the omohyoid muscle further subdivides the posterior
cervical triangle into 2 smaller triangles, the occipital triangle, which is located
above the omohyoid muscle, and the supraclavicular triangle, which is located
inferiorly to the muscle.

Cervical Lymph Nodes

The cervical lymph nodes are divided into superficial and deep chains.

Superficial lymph nodes are involved in a late stage of cancer; therefore, they
have less oncologic importance.

Deep cervical lymph nodes receive drainage from areas of the oral cavity,
pharynx, larynx, salivary glands, thyroid, and the skin of the head and neck.
These deep cervical (superior, middle, inferior) lymph nodes accompany the
internal jugular vein and its branches. Oncologically, the superior jugular nodes
(ie, the group that is near the anterosuperior aspect of the accessory nerve) are
crucial. They represent the most difficult area in the resection of the deep jugular
nodes.

Cervical lymph nodes localized in the posterior triangle of the neck are classified
into the upper, middle, and inferior cervical nodes. Posterior triangle nodes are
located beneath the upper portion of the sternocleidomastoid muscle and extend
posteriorly along the course of the spinal accessory nerve. This group of
lymphatics receives drainage from the nasopharynx and communicates directly
with the upper deep nodes from the internal jugular vein. The posterior triangle
nodes in the inferior aspect progress anteriorly to the supraclavicular area to join
the internal jugular vein at the base of the neck.

The above groups are easier to understand if they are divided into levels or
zones.

 Level I - Nodal group that involves the submental and the submandibular
regions, also referred to also as IA and IB
  Level II - Upper jugular group
 Level III - Middle jugular group
 Level IV - Lower jugular group
 Level V - Posterior triangle group
 Level VI - Central anterior neck group

Nonlymphatic Structures

Platysma muscle

The rectangular and sheetlike platysma muscle extends obliquely from the upper
chest to the lower face, from posteroinferior to anterosuperior. Its undersurface
creates an ideal plane in which to elevate the skin flaps in a neck dissection. The
platysma muscle is absent in the lower anterior midline of the neck and in the
area posterior to the external jugular vein and greater auricular nerve.

Sternocleidomastoid muscle

The sternocleidomastoid muscle runs from its anteroinferior attachment to the

sternum and medial clavicle, posterosuperiorly to the mastoid tip and surrounding
skin. The greater auricular nerve and the external jugular vein cross the upper
aspect of this muscle. These structures guide the surgeon to the right plane of
dissection and should be left on the surface of the sternocleidomastoid during
flap elevation.

The fascial envelope of the muscle is a key structure for selective neck
dissections.

Spinal accessory nerve

The spinal accessory nerve crosses over the internal jugular vein in
approximately 70% of individuals. The nerve then passes medially to the
posterior belly of the digastric and stylohyoid muscles. Anatomic variations
include the spinal accessory nerve that runs medially to the internal jugular vein
(approximately 30% of individuals) and that runs through the vein (approximately
3% of individuals).

The nerve then enters obliquely into the sternocleidomastoid muscle from
superior to inferior with the exit at Erb point. The Erb point is near the greater
auricular nerve at the posteroinferior edge of the sternocleidomastoid muscle.

Digastric muscle

The posterior belly of the digastric is an important landmark. This belly extends
from the hyoid bone to the undersurface of the mastoid tip. Important and
delicate structures are recognized medial to the muscle. Therefore, it is
superficial to the external and internal carotid artery, the hypoglossal nerve, and
the internal jugular vein. Lateral to the posterior belly of the digastric, the only
structure to be preserved is the marginal mandibular nerve.

Marginal mandibular nerve

The marginal mandibular nerve is localized deep to the superficial layer of the
deep cervical fascia, which covers the submandibular gland and is superficial to
the anterior facial vein.

The best way to preserve the nerve is to identify it carefully at the above
locations. Once the nerve is identified, the tissue lateral and inferior to the nerve
can be divided for exposure of the posterior belly of the digastric.

Trapezius muscle

The trapezius muscle extends from the posterior occiput to the lateral third of the
clavicle. The anterior border of the trapezius is the posterior edge of level V, or
the posterior triangle, of the neck.

Omohyoid muscle

Like the digastric muscle, the omohyoid muscle has 2 bellies. The anterior belly
is superficial to the internal jugular vein. The posterior belly is superficial to the
brachial plexus, phrenic nerve, and transverse cervical artery and vein.

Like the digastric muscle, the omohyoid is a key anatomic landmark in radical
neck dissection.

Hypoglossal nerve and vagus nerve

The vagus nerve in the neck is intimately associated with the carotid sheath and
is immediately deep to the internal jugular vein. The vagus nerve may be injured
during the dissection and division of the lower portion of the internal jugular vein.
Identification of the vagus nerve before division of the internal jugular is
mandatory.

The hypoglossal nerve in the neck travels under the internal jugular vein, passes
over the internal and external carotid arteries, and continues inferior to the
posterior belly of the digastric muscle to enter the tongue musculature. Identifying
this nerve is important to avoid injury.

Brachial plexus and phrenic nerve

The phrenic nerve lies above the anterior scalene muscle and deep to the
transverse cervical artery. The brachial plexus exits lower in the neck and then
passes between the anterior and middle scalene muscles.

Identify the anterior and middle scalene muscles before clamping the lymphatic
structures. Avoid dissection in the supraclavicular area before phrenic and
brachial plexus visualization.

Thoracic duct

The thoracic duct, located in the lower left neck, arises posterior to the internal
jugular vein and anterior to the phrenic and transverse cervical artery. The
anatomy is variable, and the duct has multiple interdigitated channels.

CONTRAINDICATIONS
Section 5 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
 References

Since the development of newer surgical procedures minimizing surgical

morbidity, the contraindications to a neck dissection have been controversial.
However, patients who have too great a surgical risk because of
cardiopulmonary disease and whose condition cannot be optimized
preoperatively should not be considered for this operation.

Patients in whom preoperative imaging suggests deep infiltration of the tumor in

the prevertebral space, scalene muscles, levator scapula muscle, phrenic nerve,
and brachial plexus should not be considered suitable candidates. Despite a poor
prognosis due to the advanced disease, the resulting morbidity, if not possible
mortality, poses no advantage to the patient.

The treatment of patients undergoing carotid vessel management remains

controversial. From a radiologic standpoint, carotid artery encasement is defined
as disease having surrounded the common carotid or internal carotid artery over
more than 270° of encirclement. Many have advocated the preoperative
evaluation of these patients with a balloon occlusion test.

Patients who can tolerate the occlusion of the ipsilateral carotid artery without
any evidence of neurologic dysfunction may be candidates in whom the carotid
segment may be safely resected. The help of a vascular surgeon or a
neurosurgeon in these cases may be advisable for reconstruction of the resected
segment.

Because patients with significant carotid artery involvement often have

preexisting atherosclerotic vascular disease, resection of the carotid artery
results in significant morbidity, if not mortality, for most of these individuals.

Contraindications for radical neck dissection also include the following:

 Primary tumor that cannot be controlled

 N0 neck
 Distant metastatic disease
 Fixed neck mass in the deep cervical fascia
 Circumferential or near circumferential involvement and invasion of the
carotid vessels if the patient cannot tolerate a balloon occlusion test

WORKUP
Section 6 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
  References

Lab Studies

 CBC count and differential: The CBC count is important because it gives
the clinician a baseline regarding the patient's preoperative hematologic
status. Patients with advanced cancers of the head and neck may present
with preexisting anemia, which may require further characterization.
 Prothrombin time (PT), activated partial thromboplastin time (aPTT), and
international normalized ratio (INR) measurements: These studies are
especially important in patients with preexisting bleeding diathesis, with
hepatitis, or who are taking anticoagulants. Prolonged study results may
need to be reversed preoperatively.
 Electrolyte tests

o Preoperative evaluation is important in patients with head and neck
cancers. Many present with other medical problems or take
medications that affect their electrolyte status.
o A subgroup of squamous cell cancers may result in paraneoplastic
syndromes; the most common is the syndrome of inappropriate
secretion of antidiuretic hormone (SIADH). Management may
necessitate consultation with an internist or an endocrinologist.
 Liver enzyme profile is useful.
 Glucose test: This study is useful preoperatively in patients with a history
of diabetes.
 BUN and creatinine testing is useful.
 Blood type and screen: Because of refinements in the surgical techniques,
blood loss has been significantly reduced in these procedures. In
situations in which blood loss is expected to be significant, either typing
and screening or typing and cross-matching are necessary.
 Urinalysis is useful.

Imaging Studies

 An esophagogram may be helpful in evaluating an occult esophageal

primary tumor.
 CT scan and MRI may be used if they would help to define node status
and treatment planning further. They may be crucial in delineating the
extent of bony structures, deep cervical musculature, and carotid artery
circumferential involvement.

o CT scanning with contrast can depict excellent anatomic details.
 o In general, CT is the radiologic technique most commonly used to
evaluate the staging of the primary lesion; therefore, also include
the neck in the examination.
o Criteria for assessing nodal metastases with CT include increased
size, a rounder shape, presence of central necrosis, and nodal
grouping. The most accurate CT criterion for the presence of
metastatic adenopathy is central necrosis. The node periphery is
usually thick and enhances with contrast. CT scanning also reveals
extracapsular spread by enhancement of the nodal capsule.
o Some radiologists feel that CT demonstrates paratracheal node
involvement better than MRI.
o MRI reveals tumor necrosis and extracapsular spread with less
precision than CT scan, but MRI is better for assessing enlarged
lymph nodes that are not necessarily metastatic.
o MRI may also be used in patients who are allergic to iodinated
contrast.
o According to some radiologists, MRI also appears to reveal
retropharyngeal node involvement better than CT.
 Some institutions use ultrasonography and ultrasound-guided aspiration
cytology to determine cervical neck metastasis. Ultrasound-guided
aspiration cytology has a specificity of nearly 100%.
 PET has recently emerged as an adjunct in the diagnosis of lymph node
metastasis.

o In recent studies, PET has shown positive findings for lymph node
metastasis when CT scan and MRI findings were negative. An
FDG-PET scan provides physiologic and biochemical data.
Glucose metabolism in neoplastic cells produces increased uptake
on FDG-PET scanning, which correlates strongly with viable tumor
cells. Therefore, FDG-PET may be helpful in the assessment of
neck metastasis and even distant metastasis.
o Additionally, PET scanning has shown the ability to differentiate
active tumors from chronic fibrotic changes. Therefore, PET may
become more useful than CT and MRI in the detection of recurrent
head and neck cancer. Furthermore, the dual use of the PET and
CT scanners produces fused PET and CT images, which can
further enhance the results of the PET scan. The definitive role of
PET and PET/CT scans is evolving and showing great potential in
the assessment of metastatic neck disease, the early diagnosis of
recurrent head and neck cancer, and the status of the neck after
chemoradiotherapy.
 If tumor involvement of the carotid artery is possible, a complete
preoperative evaluation of the carotid system is indicated. This includes a
balloon occlusion test and a 4-vessel cerebral angiography to evaluate the
status of the contralateral carotid, intracerebral circulation, and carotid
back pressure.
  Perform chest radiography to exclude metastatic disease.

Other Tests

 A complete physical examination is mandatory and includes evaluation of

neurologic, cardiovascular, and respiratory status.

o Palpate the patient's neck to define size, location, mobility, and
degree of softness or hardness of any mass.
o Evaluate the patient's weight and nutritional status.
 Perform an ECG as indicated.
 Evaluation by medical service personnel and further medical consultations
may be indicated.

Diagnostic Procedures

 Use mirror laryngoscopy, flexible nasopharyngolaryngoscopy, or both to

supplement the examination.
 When the primary tumor is known, perform a panendoscopy to exclude a
second primary tumor. Performing biopsy of the primary lesion is
necessary. When the primary tumor is not known, perform a
panendoscopy to look for the primary tumor and to perform random
biopsies of the pyriform sinus, base of tongue, and nasopharynx to
exclude occult tumors. An ipsilateral tonsillectomy is also advocated;
however, this has been the subject of controversy for many surgeons.
 When the patient has a neck mass, a fine-needle aspiration biopsy for
cytology evaluation may be useful in helping the clinician determine
management.
 An open biopsy of a neck node is indicated only when the previous
measures of physical examination, needle aspiration biopsy, random
biopsies, and endoscopy are inconclusive. To circumvent this situation,
patients are asked to sign a consent form for a possible neck dissection
when a frozen section diagnosis confirms the presence of malignancy in
the open node biopsy specimen.

Histologic Findings

Biopsies of the primary site reveal the etiology of the initial mass and the
characteristics of the tumor involved, such as squamous cell carcinoma of the
upper aerodigestive tract, nasopharyngeal carcinoma, thyroid carcinomas, and
skin cancer of the head and neck.

Fine-needle aspiration cytology of the neck confirms the pathology findings of the
primary tumor. It also helps to determine the etiology of the cervical adenopathy
when the patient has a neck metastasis from an occult primary tumor.
TREATMENT
Section 7 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
 References

Surgical therapy

Surgical alternatives include the following:

 Radical neck dissection (classic)

 Modified radical neck dissection type I
 Modified radical neck dissection type II
 Modified radical neck dissection type III

Other associated surgeries include the following:

 Laryngectomy
 Composite resection
 Glossectomy
 Tracheotomy (The patient may need a tracheotomy for control of the
airway, particularly when radical neck dissection is associated with a
composite resection. Also, consider a tracheotomy in any patient
undergoing surgery that may lead to airway compromise.)
Dermal graft (Although optional, a dermal graft has been used over the
bifurcation of the carotid artery when a pharyngotomy surgery is combined with a
radical neck dissection or radiation therapy. The levator scapulae muscle can be
transposed forward over the carotid system for the same reason.)
Preoperative details

The following items should be noted on the patient's record before performing
surgery:

 Physical examination findings, including those of a head and neck

examination
 Medical history (eg, allergies to medications; hypertension, diabetes,
cardiopulmonary disease, and other chronic illnesses; previous surgeries,
radiation therapy)
 Medical clearance and recommendations
 All test results, including biopsy and fine-needle aspiration results
 Informed consent with risks and complications having been fully discussed
with the patient
 Summarized problem and treatment plan, including alternative plans

Other preoperative details include the following:

 Evaluate the airway and dentition of the patient.

 Evaluate the ability of the patient to open his or her mouth adequately for
intubation.
 If the patient has a tracheotomy, evaluate the airway and status of the
tracheotomy.
 The patient should remain on nothing by mouth (NPO) status after
midnight.
 Instruct the patient to take the usual medications up to midnight the night
before the surgical procedure.
 Note premedication order on record.
 Void on call to the operating room.
 Preoperative antibiotics are required if the procedure involves going
through the neck into the upper aerodigestive tract.

Intraoperative details

If the airway is obstructed (see Preoperative details), performing a tracheotomy

with the patient under local anesthesia is preferred. An obstructing neoplasm of
the upper aerodigestive tract can bleed easily at intubation, producing a sudden,
total airway obstruction in an already compromised airway. Prevention and
planning are mandatory. The anesthetist may also perform an orotracheal
intubation. In the difficult airway, good communication and understanding
between the surgeon and the anesthetist is a first priority.
A urologic catheter is not needed during radical neck dissection. If the surgery is
performed with other procedures that are more complex and prolonged, insert a
catheter for better control of urine output.

Place the patient in the supine position with a shoulder roll extending the neck.
Elevate the upper half of the operating table to a 30° angle. The patient's neck
and upper chest are prepared and draped in a sterile fashion for the proposed
surgery. Use staples or sutures to delineate the field.

Several incisions are designed and used by various surgeons. If a radical neck
dissection is to be performed alone, the hockey stick incision is generally
preferred. The neck incision changes depending on the location of the primary
tumor and whether one or both sides of the neck are operated on. In general, the
incisions are designed to avoid trifurcation over the carotid artery and to avoid
narrow flaps.

Mark the skin incision with methylene blue or a surgical marking pen. Some
authors infiltrate the skin incision with 10 mL of lidocaine with 1:100,000
epinephrine to minimize bleeding. The author's institution does not infiltrate the
skin incision.

Make scratch marks to assist in the alignment of the flaps at the end of the
operation.

Make the skin incision through the platysma and elevate the flap in the
subplatysmal plane (see Image 1). Traction with the surgeon's fingers and
countertraction by the assistant with 2 double skin hooks are helpful in this
maneuver. After raising the superior lateral aspect of the flap, leave the greater
auricular nerve and external jugular vein on the sternocleidomastoid muscle.
Elevate the posterior flap toward the trapezius muscle.

Identify and preserve the marginal mandibular nerve at the superior aspect of the
flap. This nerve passes deep to the platysma muscle, often dropping inferiorly to
2 cm below the body of the mandible. This nerve passes within the fascia of the
submandibular gland. A simple way to protect this nerve is to divide the common
facial vein at the anterior border of the sternocleidomastoid muscle and to dissect
the superior flap deep to this vein.

Some surgeons proceed from below to above, and others do the opposite. The
author's institution usually proceeds first with the zone I dissection and then from
inferior to superior.

Remove submental fatty tissue with Bovie electrocautery and displace it

inferiorly. Retract the mylohyoid muscle anteriorly, exposing the submandibular
ganglion, lingual nerve, and submandibular duct. Ligate the facial artery above
the digastric muscle. Cut and ligate the submandibular duct. Remove the
submandibular nodes and the submandibular gland and displace them inferiorly.
The dissection continues posteriorly, exposing the posterior belly of the digastric
and stylohyoid muscles and transecting the tail of the parotid gland.

Expose the sternocleidomastoid muscle and incise it above the clavicle with
Bovie electrocautery (see Image 2).

Identify the anterior and posterior belly of the omohyoid with transection of the
omohyoid posteriorly. Note that the omohyoid crosses the internal jugular vein
laterally (see Image 3).

Identify the internal jugular vein and vagus nerve in the lower aspect of the neck
before ligation of the internal jugular vein. Pass a 2-0 silk suture around the vein
and tie it (see Image 4). Using 2-0 silk, place a distal suture ligature while the
vein is still intact. Place 2 similar sutures cephalic and transect the vein (see
Image 5).

Further identify the carotid artery and the vagus nerve. Open the supraclavicular
fatty tissue using blunt dissection, either with a finger or hemostat, with
identification of the phrenic nerve and brachial plexus (see Image 6). Once the
brachial plexus is visualized, blunt dissection with the surgeon's finger permits
clamping of the fibrofatty tissue with a large clamp. The spinal accessory nerve is
sacrificed in the radical neck dissection; therefore, no identification of the nerve is
required.

Dissect from inferior to superior (see Image 7). Continue the dissection along the
anterior border of the trapezius. Preserve the phrenic nerve and brachial plexus.
Follow the cervical nerve branches and section them high on the specimen.
Separate the surgical specimen from the carotid and vagus, proceeding
superiorly, with identification of the hypoglossal nerve. Preserve the superior
thyroid artery and superior laryngeal nerve and carefully ligate the ranine veins.
Cut the sternocleidomastoid muscle superiorly in the same manner as described
above. The division is made high, and the surgeon is just lateral to the posterior
belly of the digastric muscle. Identify the internal jugular vein superiorly, medial to
the posterior belly of the digastric muscle. Dissect and ligate in the fashion
described above (see Images 8-9).

Irrigate with isotonic sodium chloride solution. Maintain hemostasis. Insert drains
(0.125-in Hemovac or Jackson-Pratt); usually, use 2 for each side of the neck.
Close the wounds in layers with 3-0 Vicryl through the platysmal flaps and
staples or 4-0 nylon for the skin.

No compressive dressing is used for bilateral neck dissections. Some surgeons

use a compression dressing for unilateral neck dissection.
When preparing the pathology specimen, plastic plates with life-size drawings of
the different areas of the neck are recommended for orientation. The unfixed
specimen is placed as it appears in the patient and brought to the pathology
department from the operating room. The type of dissection performed is written
clearly on the requisition slip.

Special considerations

Advanced deeply attached neck metastasis, recurrence after radiation or

chemoradiation, and metastatic neck abscess pose several technical challenges
for the head and neck surgeon in the salvage operation. Frequently, the neck has
acquired a hard boardlike consistency or a frozen-neck appearance, which
makes the dissection and identification of anatomical structures difficult. In these
cases, the authors proceed with radical neck dissection in a nonstandardized
fashion—from the known to the unknown, from superficial to deep, and from the
easy areas to the more difficult areas. Along the way, the authors identify major
vascular and nervous structures and take small dissection steps.

Most of the time, the Bovie electrocautery unit is used with the assistance of the
gentle spreading action of an intermediate hemostat. With this technique, the
metastatic mass is dissected en bloc in a circular fashion (superiorly, inferiorly,
laterally, medially [in no particular order]). The authors Identify key anatomical
structures such as the anterior and posterior belly of the digastric muscle; the
omohyoid muscle; the facial artery; the vagus, hypoglossal, and phrenic nerves;
the internal jugular vein; and the carotid artery until the entire specimen is
dissected, except in its deepest plane.

In cases of advanced metastasis, recurrence after chemoradiation, or metastatic

neck abscess, the internal jugular vein is not usually problematic because, in
most cases, this vein is already nonfunctional, either because of invasion or
compression-blockage by the mass, which occurs superiorly, inferiorly, or both.
The vein is usually smaller, and ligation or transfixation-ligation is feasible.
However, careful dissection is required over the carotid artery, particularly if
infiltration by the tumor is present. Therefore, the deep plane of the mass over
the carotid artery is addressed last, as further assessment is needed to
determine involvement or invasion prior to consideration of different surgical
options.

Modifications to the radical neck dissection

If the spinal accessory nerve is preserved, identify the nerve in the posterior
triangle and dissect it from the anterior border of the trapezius to the
sternocleidomastoid muscle until it is free. If the internal jugular vein is preserved,
identify it posteriorly after the cervical nerve branches are divided. Then, peel the
vein from the surrounding tissue until it is free. Perform this in the same fashion
in selective neck dissection. If the sternocleidomastoid is to be preserved, the
procedure is performed by peeling the fascia from the muscle. This is done in the
same fashion in selective neck dissection.

Postoperative details

 Maintain nothing by mouth status for at least the first 24 hours. If the
radical neck dissection has been combined with more extensive surgical
procedures, a longer period may be needed.
 Maintain head elevation at a 30° angle.
 Monitor vital signs, intake, and output every 4 hours.
 Maintain constant humidification, suctioning, and cleansing of the
tracheotomy tube.
 Administer pain medications as needed.
 Ensure that the Hemovacs or drains are functioning properly.
 Ensure that drains are maintained on continuous suction until they drain
less than 20-25 mL in 24 hours.
 Ensure that the drains do not clot.
 Administer antibiotics for the first 24 hours if the surgery involved opening
the neck and the upper aerodigestive tract.
 Monitor for fever, bleeding, or hematoma formation in the postoperative
period.
 Avoid atelectasis. Move the patient out of bed the day after surgery with
assistance. Encourage deep breathing and early ambulation with
assistance.
 Monitor for possible fistula if the oral or upper digestive tract was opened,
particularly during the third or fourth postoperative day.

Discharge criteria

Once the suction and drains have been removed, the patient can be discharged
from the hospital, usually on the fourth or fifth postoperative day, if the following
conditions are met:

 Satisfactory healing of the surgical wound

 No evidence of bleeding or infection
 Adequate airway and nutrition
 Hemodynamic stability
 Adequate family or home care support
 Initiation of physical therapy to the shoulder before discharge and
continuation at home

If another surgical procedure was performed in addition to radical neck

dissection, the discharge day varies.

Follow-up
  Call the patient at home after discharge to check on progress.
 Arrange for the patient to return to clinic (RTC) in 7-10 days.
 Check the pathology report for complete or incomplete resection and free
margins.
 Check the pathology status of the neck.
 Evaluate for further consultations and adjunctive treatment as needed.
 Remove sutures or clips at 7-14 days; however, when radiation therapy
has been administered, they should remain in place for at least 10 days
after the operation.
 Continue with shoulder physical therapy if necessary.

Follow-up care is mandatory to check for recurrent tumor or development of a

second primary tumor. Therefore, the patient should be seen every month for the
first year, particularly if no primary lesion was initially found. Continue follow-up
care every 2-4 months for up to 5 years. After this interval, the patient may be
seen yearly. Advise the patient to call for an immediate appointment if the
patient's condition suddenly changes.

For excellent patient education resources, visit eMedicine's Cancer and Tumors
Center. Also, see eMedicine's patient education article Cancer of the Mouth and
Throat.

COMPLICATIONS
Section 8 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
 References
Radical neck dissection has been a well-established procedure for surgical
removal of neck node cancer for almost a century. A radical neck dissection
alone has low morbidity and mortality rates; however, the association of
composite resection and ablation of a large surface of mucosal area adjacent to
the neck markedly increases the rate of complications.

Previous radiation therapy is another factor associated with a high complication

rate. Other factors, such as poor general health, chronic malnutrition, alcoholism,
diabetes mellitus, advanced age, and systemic illness, also increase the
percentage of complications.

Intraoperative Complications

Hemorrhage

Severe blood loss is an uncommon complication for an experienced head and

neck surgeon. The average blood loss in the realization of a radical neck
dissection is 200 mL or less; it varies slightly according to the surgical technique
and among surgeons. With careful attention to anatomy, hemostasis with the
electrocautery unit or bipolar forceps and use of clamps and suture ligation have
allowed an almost bloodless neck operation. Major vessel trauma, laceration,
tear, or transection (internal jugular vein, junction of internal jugular vein and
subclavian and/or carotid arteries) is presently a rare occurrence. Immediately
repair injury to the carotid artery during surgery.

Consultation with a vascular surgeon may be useful depending on the

intraoperative findings. A small tear or laceration requires primary closure with a
6-0 continuous vascular suture. Other types of injuries may require ligation or
reconstruction. Injury to the internal jugular vein at the upper or lower ends may
be a serious problem.

If the lower end of the jugular vein bleeds excessively, pressure is the first aid,
followed by adequate visualization and suctioning until the stump is identified,
dissected, and ligated properly. Occasional uncontrollable bleeding requires the
assistance of a thoracic surgeon to enter the superior mediastinum.

If the upper end of the vein bleeds and the stump has retracted into the temporal
bone, packing the jugular foramen with large pieces of Surgicel, plicating with the
posterior belly of the digastric muscle, or both are sufficient to solve the problem.

Carotid sinus reflux

Hypotension caused by carotid sinus reflux may occur upon dissection around
the carotid bifurcation. This may be avoided by careful dissection at the carotid
bifurcation without manipulation, injection of 2 mL of local anesthetic into the
adventitia at the carotid bifurcation between the internal and external carotid
arteries, or both.

Pneumothorax

Pneumothorax involves a sudden compromise of the respiratory and circulatory

system and causes difficult breathing, bronchospasm, and decrease in oxygen
saturation. The pressure of the anesthetic bag does not cause normal expansion
of the thorax.

This complication is rare today. To minimize the chance of pneumothorax,

carefully dissect in the paratracheal area and base of the neck with good
hemostasis, adequate visualization, and careful dissection of the tissues close to
the apex of lung.

If the pneumothorax is small, close the wound with an airtight seal. Follow-up
care with conservative management controls the situation without sequelae.
Conversely, a large pleural leak with a tension pneumothorax requires immediate
aspiration with a No-14 or No-16 needle in the upper anterior thorax, placement
of a chest tube with an underwater drain, or both.

Air embolus

This complication is also rare today. Air embolism can occur when a large vein is
inadvertently opened. A large volume of air enters rapidly into the open vein by
negative pressure and passes directly into the right atrium, causing a sudden
alteration of the central circulation, leading to tamponade of the heart and even
death. Clinically, cyanosis, hypotension, and a loud churning noise over the
precordial area appear suddenly, and the peripheral pulse disappears.

The treatment of air embolism requires packing or clamping the offending vein
immediately and turning the patient onto the left side with the head down.
Cardiac arrest may occur, requiring aspiration of the air from the heart, massage,
and standard resuscitation procedures. Prevention is best, with careful
identification and clamping of the major veins of the neck. Adequate ligations and
transfixion sutures are mandatory.

Embolism

Embolism may occur and lead to stroke. Most patients with cancer are of the age
at which arterial cerebrovascular disease is common. Careful handling of the
carotid arterial system in the neck with gentle retraction, ligation, and
manipulation prevents the dislodgment of arteriosclerotic plaques from the
internal carotid system.

Nerve damage
The neck area has multiple sensory nerves that are sacrificed during radical neck
dissection. Therefore, a loss of sensation occurs in multiple areas, including the
neck, posterior occiput, external ear, mandibular region, lateral shoulder, deltoid
area, and upper pectoral area. On occasion, the formation of a neuroma at the
end of a cut nerve may cause paresthesias and pain.

The ramus mandibularis is preserved in most neck dissections unless it is

involved by metastatic disease. The transection of the marginal mandibular
branch of the facial nerve produces lower lip weakness. If the tail of the parotid is
resected, follow the nerve into the parotid tissue before the removal of this tissue.

The sacrifice of the cervical sympathetic chain produces Horner syndrome, which
involves ptosis, anhidrosis, and miosis.

The sacrifice of the spinal accessory nerve, mandatory in the classic radical neck
dissection, produces shoulder drop with local pain in the affected area and
limitation in the range of motion of the arm and shoulder. Most patients tolerate
this disability and improve markedly with physical therapy. In type I modified neck
dissection, the spinal accessory nerve is preserved, therefore sparing the
consequences of the nerve's sacrifice.

Unilateral resection of the hypoglossal nerve is usually well tolerated without

serious sequelae; however, bilateral hypoglossal nerve resection causes a
severe disability with serious difficulties in feeding, swallowing, and speaking. On
occasion, a feeding gastrostomy tube is recommended for adequate nutrition.

Resection of the lower or middle neck of the vagus nerve, which carries motor
and sensory branches to the larynx and pharynx, causes vocal cord paralysis.

Avoid injuring the brachial plexus by properly identifying the anatomic planes.
Reapproximate the sectioned brachial plexus with an 8-0 or 9-0 nylon
monofilament or silk.

Wound healing after radiation therapy

Patients who have received radiation therapy before radical neck dissection tend
to have increased postoperative complications (eg, wound infection, fistula, flap
necrosis, osteoradionecrosis, carotid artery rupture). Few institutions reserve
surgery for salvage after radiotherapy failure in the treatment of cancer of the
head and neck.

Chylous fistula

Chylous fistula is a complication occasionally produced during dissection of the

thoracic duct region. Most chylous fistulas occur on the left side. If it occurs,
ligate the thoracic duct.
Reinspect the area before completing the surgery. Ask the anesthesiologist to
apply positive pressure to reevaluate if further leaking occurs. A small leak can
be identified with the assistance of the microscope. Ligation is mandatory. A
suture ligation with a figure 8 using 4-0 silk is usually satisfactory. Hemoclips also
have been used when the leakage is clearly visualized.

Postoperative Complications

Hematoma

Meticulous hemostasis during the surgical procedure is mandatory. Use suction

drains to avoid accumulation of blood under the skin flap and to prevent the
formation of a hematoma. Some surgeons also use a floppy, moderately
compressive dressing in addition to the suctioning system mentioned above. The
disadvantage is that the compressive dressing leaves the flaps unavailable for
inspection, which is the best way to watch for the formation of a hematoma.

A hematoma is usually evident in the first few hours after the operation. Sudden
bleeding in the postoperative period indicates that an untied vessel has opened
or that a ligature has slipped from the vessel. Blood under the flap accumulates
rapidly.

The treatment of a hematoma comprises taking the patient to the operating room,
opening and elevating the neck flaps, and evacuating the hematoma. Irrigate the
surgical field with isotonic sodium chloride solution, and, if any source of bleeding
is found, ligate, suture, or electrocauterize to achieve hemostasis.

If the hematoma is recognized and treated early, no adverse consequences

occur. However, if the hematoma is found late, airway compromise, infection, or
flap necrosis may occur.

Wound infection

Wound infection is unlikely when radical neck dissection is performed alone;

however, when radical neck dissection is performed in combination with the
opening of the upper aerodigestive tract as part of a composite resection or a
laryngectomy, the potential for wound infection increases markedly. A salivary
contamination from the oral cavity is possible, with the consequences of bacterial
invasion and wound infection.

All irradiated tissues are more susceptible to infection because of ischemia and
hypoxemia. Other factors that increase the possibilities of wound infection
include malnutrition, chemotherapy, anemia, diabetes mellitus, and advanced
tumor mass.
If a wound infection develops, open the flap, culture and evacuate pus, and
irrigate the wound. Administer antibiotics that cover anaerobic, gram-positive,
and gram-negative organisms. Carefully debride necrotic tissue. Local care with
frequent dressing changes, control of salivary fistula, and irrigation of the wound
is important. Once the infection is under control and the necrotic tissue is
removed, healthy granulation tissue appears.

Skin flap loss

Necrosis of the skin flap can be caused by several occurrences (eg, poor
vascularity, errors in design, elevation, poor handling, improper postoperative
care). Preexisting scars, hematoma, infection, and poor nutrition may contribute
to the skin flap loss. If skin flap necrosis occurs and the carotid is not exposed, a
conservative approach is mandatory. Carefully and progressively trim necrotic
tissue and dress the wound regularly.

However, if the carotid artery is exposed because of the loss of skin, coverage is
needed to avoid carotid artery rupture. The flaps used in the management of
carotid exposure include the deltopectoral, pectoralis major, and trapezius.

When skin necrosis, infection, and accumulation of pus adjacent to the carotid
wall are present, the carotid artery may rupture. Management is on a patient-by-
patient basis. Initially, control of infection, wound cleansing, and local care are
priorities. The decision between flap coverage and secondary healing is then
made.

Salivary fistula

Salivary fistula occurs more frequently when a patient has received previous
radiation therapy and the oral cavity, pharynx, or cervical esophagus has been
opened in association with the neck dissection. Good surgical technique with
double-layer closures and watertight closures without tension minimize this
complication. Use Vicryl or Dexon sutures in high-risk patients. Low-suction
drainage is recommended. Do not place Hemovac drains over the carotid
arteries. Usually, the fistula appears within 4-5 days of surgery; however, fistulas
may be seen after an interval of up to 2-3 weeks in patients with a history of
preoperative irradiation.

The fistula may range from a small leak that is well managed by conservative
measures (eg, frequent change of dressing, local care) to a large leak that
involves infection of the whole neck with flap necrosis. These patients require
enteral or parenteral feeding, controlled exteriorization of the fistula, and local
care before closure of local skin or myocutaneous flaps.

Chylous fistula
Chylous fistula is evident in the postoperative period in approximately 1-2% of
patients who undergo neck dissection procedures. Chyle can be identified by the
appearance of a milky clouded fluid in the Hemovac drains. Chyle accumulation
under the flap can cause redness and swelling of the flap with induration of the
surrounding tissues. The leak, if minimal, is usually controlled by aspiration,
pressure dressings, and a low-fat diet. Ligation of the offending thoracic duct is
required when the leak is extensive with more than 500 mL of drainage and when
conservative management has not led to demonstrated improvement.

Facial edema

Unilateral radical neck dissection may result in swelling of the lower face and
neck on the ipsilateral side. The edema reaches a maximum at 1 week and
progressively decreases in a few weeks.

Bilateral radical neck dissection performed simultaneously with ligation or

resection of both internal jugular veins results in facial edema, cerebral edema,
or both. Mechanical obstruction of venous drainage and the increase of
intracranial pressure can cause neurologic deficit and coma.

Facial edema commonly appears in patients with previous irradiation and can
lead to chemosis. Edema of the lids may be sufficient to prevent opening of the
eyes. Airway management with a tracheotomy is required. If bilateral radical neck
dissection is needed, preserving one external jugular vein can lessen this
complication. Staging the neck dissections 4-6 weeks apart also helps.

Electrolyte disturbances

The most common electrolyte disturbance in the postoperative period is

hyponatremia. It is usually dilutional; however, it may be related to the secretion
of antidiuretic hormone. Clinically, it can be manifested by mental changes,
including depression and hallucinations. Occasionally, hypernatremia,
hypokalemia, hypercalcemia, and hypophosphatemia are also associated with
radical neck operations.

Carotid artery rupture

The incidence of this complication ranges from 3-7%. The precipitating factors of
carotid artery rupture include the following:

 Radiation therapy
 Infection and salivary fistula
 Suction catheters that cause erosion of the vessel wall
 Exposure by dehiscence of the suture line or necrosis of the dermis
Rupture occurs in patients who underwent neck surgery with exposure of the
carotid artery and one or more of the precipitating factors named above. Most
patients have prodromal bleeding (ie, sentinel bleed) within 48 hours of the
carotid rupture. Therefore, the initial bleeding should indicate that a serious
complication could be avoided with the elective ligation of the offending artery.
Immediate treatment for carotid rupture includes the following:

 Apply direct and firm pressure to the affected area. The operating room
should be prepared for neck surgery. Suctioning, good illumination, and
adequate instrumentation are imperative.
 Cannulize a peripheral vein in each of the patient's arms with a large-bore
catheter for immediate administration of fluids (Ringer lactate or isotonic
sodium chloride solution). Controlling blood pressure and blood volume
before the ligation is important.
 The airway should be adequate and stable. If the patient does not undergo
a tracheotomy, orotracheal intubation may be necessary.
 Type blood and cross-match it for 4-6 units.
 Move the patient to the operating room.
 If the bleeding cannot be controlled by pressure, clamp the common
carotid artery as an emergency procedure after the blood pressure and
pulse are within the reference range.

Definitive treatment for carotid artery rupture includes the following:

 Ligate the carotid artery.

 Avoid repair or diversion in an area of infection.
 Use general endotracheal anesthesia.
 Have adequate instrumentation ready.

Adequate exposure, both proximally and distally, to the source of bleeding and
contaminated or infected areas helps avoid a second rupture.

Ligation is accomplished with a 1-0 silk suture that is reinforced, distally and
proximally, with a 2-0 silk suture. The ligated stumps are then buried in the
surrounding healthy tissue. Occasionally, ligating the carotid artery beneath the
clavicle is necessary. Resection of the medial half of the clavicle is necessary for
exposure if the ligation has to be performed inferior to the supraclavicular
triangle.

Prophylaxis for carotid artery rupture includes the following:

 Do not traumatize the carotid vessel. Adequate handling of the carotid

artery and preservation of the adventitia are most important.
 Avoid suction catheters that lie adjacent to the carotid artery.
 If a fistula is present, it is diverted away from the carotid area.
 Use adequate dressings that retain moisture.
  Cover the carotid artery with a dermal graft using the levator scapulae or
posterior scalene muscle.
 Treat infection aggressively with drainage, culture, and appropriate
antibiotics.

OUTCOME AND PROGNOSIS

Section 9 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
 Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
 References

Outcome

Radical neck dissection results include the following:

 In a neck with negative histologic findings, the recurrence rate is 3-7%.

 In a neck with positive histologic findings, the recurrence rate is 20-70%.
 Extracapsular spread commonly is found in small nodes (25%) and large
nodes (75%). The extracapsular spread can decrease survival by half and
can decrease the disease-free interval.
 Macroscopic extracapsular spread is associated with a recurrence rate of
45%, and microscopic extracapsular spread is associated with a
recurrence rate of 25%.
 Perineural and perivascular invasion are associated with more aggressive
tumor behavior.
 Involvement of the tumor margins carries a poor prognosis and a high risk
of recurrent neck disease.
 Patients with several involved nodes (>4) have a worse prognosis than
those with only one involved node.
  Multiple levels of involvement are associated with a recurrence rate of
70%; only one level of involvement is associated with a recurrence rate of
35%.

Prognosis

In general, the characteristics of nodal metastasis that affect the prognosis in

radical neck dissection include the following:

 Extracapsular spread: This adversely affects the prognosis. The

pathologist looks systematically for extracapsular spread, which is
commonly encountered. Tumor spread beyond the capsule of a lymph
node is the most important prognostic factor related to recurrence in the
neck.
 Perivascular and perineural invasion: Perineural and perivascular
infiltration of the tumor is correlated with the risk of lymph node metastasis
in the neck.
 Sites of nodal involvement: The prognosis and survival rates are poor
when multiple levels of neck nodes are involved. Posterior triangle and
contralateral involvement is also an indication of poor prognosis.
 Number of nodes: A greater number of involved lymph nodes portends a
poorer prognosis. This leads to a higher risk of recurrence and a poorer
survival rate.
 Node fixation: Fixation is adherence to the surrounding structures.
Adherence to the carotid artery or a muscle is an ominous sign. In
general, fixation occurs with large masses and portends a poor prognosis.
 Involvement of surgical margin: Positive surgical margins are common in
advanced tumors and carry a poor prognosis.
 Recurrent disease: Recurrent disease after surgical neck dissection is an
ominous sign.
 Degree of differentiation: The risk of cervical metastasis correlates with
the grade of tumor differentiation at the primary site. Poorly differentiated
tumors are more aggressive and carry a poor prognosis.

FUTURE AND CONTROVERSIES

Section 10 of 13

 Authors and Editors

 Introduction
 Indications
 RELEVANT ANATOMY
 Contraindications
 Workup
  Treatment
 Complications
 Outcome And Prognosis
 Future And Controversies
 Acknowledgments
 Multimedia
 References

Controversies

Once the neck has metastatic disease, adequate treatment is essential.

Preoperatively, no ideal method exists to identify metastatic disease clearly.
Therefore, false-positive and false-negative results are common. Adequate
treatment for metastatic neck disease is radiation therapy, surgery, or both.
Recently, the concurrent administration of postoperative chemotherapy and
radiotherapy has been added to the armamentarium for treatment of patients with
high-risk criteria after resection of head and neck cancer. The management is not
standardized and varies between institutions, geographical areas, and surgeons.
Initially, radical neck dissection was the operation used to control metastatic neck
disease and an N0 neck. Now, most head and neck surgeons would agree that a
radical neck dissection is not indicated in the absence of palpable neck
metastasis or an N0 neck.

Modified radical neck dissections are adequate operations for palpable neck
metastasis. The selection of a modified radical neck dissection is controversial
because the decision to preserve nonlymphatic structures remains an
intraoperative decision.

The N0 neck is a controversial subject. Many treatment choices exist, including

whether to treat electively or to wait and observe, whether to perform surgery or
radiation therapy, whether to operate on one side or both, and whether to use
modified radical neck dissection or selective neck dissection. Indications need to
be standardized.

Future

Future considerations in the management of neck metastasis include the

following:

 Develop better techniques for evaluation of neck metastasis.

 Define and standardize the clinical criteria worldwide for a particular neck
dissection.
  Define and standardize indications for preoperative or postoperative
radiation therapy of the neck.
 Define and standardize indications for chemoradiation, before and after
surgery.
 Define and standardize indications for an N0 neck.
 Define and standardize indications for an N+ neck.

Investigate and analyze the prognostic factors