CONTENTS
INTRODUCTION
CLASSIFICATION
1. CERVICAL NODAL LEVELS
2. NECK DISSECTION
INDICATIONS OF NECK DISSECTION
SURGICAL MANAGEMENT
REFERENCE
INTRODUCTION
Neck dissection removes potential or proven metastases to cervical lymph nodes. It Is a
comblex operation and requires a sound knowledge of the 3-dimensional anatomy of the neck.
Aim is to remove neck lymph nodes into which cancer cells may have migrated. Metastases may
originate from tumours of oral cavity, tongue, nasopharynx, oropharynx, hypopharynx, and
larynx, as well as the thyroid, parotid and posterior scalp.
CLASSIFICATION OF CERVICAL NODAL LEVELS
Level I:- is bound by the body of the mandible above, the stylohyoid muscle posteriorly, and
the anterior belly of the contralateral digastric muscle anteriorly revised classification uses the
posterior margin of the submandibular gland as the boundary between Levels I and II as it is
clearly identified on ultrasound, CT, or MRI.
Level I is subdivided into Level la, (sub-mental triangle) which is bound by the anterior bellies of
the digastric muscles and the hyoid bone, and Level Ib (submandibular triangle).
Level II :-extends between the skull base and hyoid bone.
The posterior border of the sternocleidomastoid defines its posterior border.
The stylohyoid muscle (alternately the posterior edge of the submandibular gland) defines its
anterior border.
The accessory nerve (XIn) traverses Level II obliquely and subdivides it into Level IIa (anterior to
XIn) and Level IIb (behind XIn)
Level III:- is located between the hyoid bone and the inferior border of the cricoid cartilage.
The sternohyoid muscle marks its anterior limit and the posterior border of the
sternocleidomastoid its posterior border.
Level IV:- is located between the inferior border of the cricoid cartilage and the clavicle.
The anterior boundary is the sternohyoid muscle, and the posterior border is the
posterior border of sternocleidomastoid
Level V:- is bound anteriorly by the posterior border of the sternocleidomastoid, and posteriorly
by the trapezius muscle.
It extends from the mastoid tip to the clavicle and is subdivided by a horizontal line drawn from
the inferior border of the cricoid cartilage into Level Va superiorly, and Level V6 inferiorly.
Level VI:- is the anterior, or central, compartment of the neck. It is bound laterally by the carotid
arteries, superiorly by the hyoid bone, and inferiorly by the suprasternal notch
NECK DISSECTION CLASSIFICATION
Neck dissection operations are classified according to the cervical lymphatic
regions that are resected
Selective neck dissection (SND)
is done for No necks (no clinical evidence of neck nodes) or for very limited cervical metastases.
Central neck dissection encompasses only Level VI
Comprehensive or therapeutic neck dissection
involves surgical clearance of Levels 1-V and may either be a radical or modified neck dissection.
RND includes resection of sternocleido-mastoid muscle and accessory nerve (XIn) and internal
jugular vein .MND preserves SCM and/or XIn and/or IJV.
MND type I entails preservation of 1/3 usually Xin
MND type II entails preservation of 2/3 usually XIn and IV with
MND type III all 3 structures are preserved.
MND type II is most commonly done and is oncologically acceptable in the absence of
adherence or cervical nodal metastases to XIn or IJV
Extended neck dissection
includes additional lymphatic groups (parotid, occipital, Level VI, mediastinal, retropharyngeal)
or non-lymphatic structures (skin, muscle, nerve, blood vessels etc.) not usually included in a
comprehensive neck dissection.
It has been proposed that neck dissections be more logically and precisely described and
classified by naming the structures and the nodal levels that have been resected.
INDICATIONS OF NECK DISSECTION
Radical neck dissection :-
extensive lymph node metastases with extension beyond capsule of node or
nodes that involves SAN and IJV.
Modified radical neck dissection :-
Type I:
Operable palpable neck disease (usually N1, N2a, N2b) not involving accessory nerve
Can occasionally be done for the NO neck
Type II:
Where preservation of IV is important either when performing a second side operation or
microvascular anastomosis
when histology shows vein need not be resected, i.e. differentiated thyroid cancer.
Type III:
comprehensive or functional neck dissection
Elective Rx for NO neck in cell carcinoma of the upper aerodigestive tract
Selective neck dissection
SCC oral cavity T1-T4: NO
SCC larynx, oropharynx and hypopharynx, T2-T4: NO
Differentiated thyroid carcinoma
Subglottic and hypopharyngeal SCC
Cervical oesophageal carcinoma
Extended Neck Dissection
When lymph node groups or non-lymphatic structures other than the ones removed in a RND
need to be removed e.g. external carotid artery, level VI lymph nodes.
Surgical management
Surgical management remains the primary modality of management of oral cancer.
The principle of treating oral cancer is eradication of the disease.
Cancer of the head and neck is the region, which is highly vascular with rich lymphatic drainage;
this facilitates early metastasis to regional lymph nodes.
Surgical management of metastatic neck nodes includes neck dissection
Sentinel lymph node biopsy
Sentinel lymph node (SLN) is the first lymph node to receive drainage directly from a tumor
SLNB is a minimally to moderately invasive technique which allows the surgeon to excise and
meticulously examine the primary draining lymph nodes in the clinically NO neck.
Clinical identifcation of these nodes is performed via iniection of numerous types of tracers,
dyes, and radioisotopes into the peritumoral site depending on the type and location of the
tumor
Labeled lymph nodes are surgically excised and histologically examined for the presence of
disease.
Identification and biopsy of the SLN can correctly indicate the status of the draining
lymph node basin.
The advantages of implementing SNB instead of ND include
decreased morbidity , operating room time, length of postoperative stay
Technique:-
The radioactive tracer travels within lymphatic channels and gets trapped in a lymph node. The first
node to receive drainage from a tumor is called the sentinel lymph node. Sentinel node will also trap
metastatic cancer cells before they spread to other lymph nodes. A special probe i.e gamma probe is
used to identify the greatest concentration of radioactive tracer. The display shows the amount of tracer
activity detected by the probe. High level of tracer activity indicates location of sentinel lymph node.The
sentinel node is identified again intraoperatively with the aid of a gamma probe. The area with elevated
radioactivity is explored to identify the sentinel lymph node. Tissue with sentinel lymph node is
identified
Frozen Section Biopsy
The frozen section procedure is a pathological laboratory procedure to perform rapid microscopic
analysis of a specimen.
Frozen section is done whenever biopsy report is needed at the earliest & usually done in a pathology
set up existing adjacent to the operation theatre An unfixed fresh tissue is frozen (using COz) in a metal
and sections are made and stained.
Method :- A thin slice of tissue that is cut from a frozen specimen and is often used for rapid
microscopic diagnosis section and a histologic section of tissue that has been frozen by
exposure to dry ice.
Advantage:-
it is quick and surgeon can decide the further steps of procedure in same sitting like nodal
clearance/type of resection to be done, etc.
Disadvantage:-
It is technically difficult; processing and staining is of inferior quality and often it is difficult to
give accurate results
Indication:-
Done in carcinoma breast or in follicular carcinoma of thyroid when FNAC fails.
During surgery after resection of the tumour to look for the clearance in the margin and depth
and also to study the lymph nodes for their positivity.
REFERENCE
Textbook of Oral& Maxillofacial surgery 3rd edition (SM BALAJI)
Textbook of Oral& Maxillofacial surgery 5th edition (NEELIMA ANIL MALIK)
SRB’S manual of surgery (Sriram Bhat M)
Ferlito A, Robbins KT, Shah JP, et al Proposal for a rational classification of neck
dissections. Head Neck. 2011 Mar;33(3):445-50
