NECK

DISSECTION

SaiVeena
Pg III Year
 CONTENTS
• DEFINITION

• HISTORY

• RATIONALE FOR NECK DISSECTIONS

• SURGICAL ANATOMY OF THE NECK

• ANATOMY OF CERVICAL LYMPH NODES

• CERVICAL LYMPH NODES: LEVELS AND STAGES OF NODAL METASTSE

• CLASSIFICATION

• RADICAL NECK DISSECTION

• MODIFIED RADICAL NECK DISSECTION

• SELECTIVE NECK DISSECTION

• EXTENDED NECK DISSECTION

• COMPLICATIONS

• ADVANCES AND CURRENT TRENDS

• REFERENCES
 INTRODUCTION

• Neck dissection is a valuable procedure for treating metastatic

cancers of the head and neck.

• Head and neck cancer is an aggressive disease with substantial

morbidity associated with local invasion and regional lymphatic
spread.

• Performing an appropriate neck dissection results in minimal

morbidity for the patient, provides valuable data to accurately stage
the patient, and guides the need for further therapy.
 DEFINITION

The term "neck dissection" refers to a surgical procedure

in which the fibro-fatty soft tissue content of the neck is
excised to remove the lymph nodes.

K Harish - Review Neck dissections: radical to conservative, World Journal of

Surgical Oncology 2005, 3:21
 HISTORICAL
BACKGROUND OF NECK
DISSECTION
Dr John Collins
Warren performs the
first neck surgery at
Massachusetts
General hospital in
1846.

“The First operation

under Ether”
EVOLUTION OF NECK
DISSECTIONS
Kocher (1880)
Proposed removing nodal metastasis

George Crile(1906)
Description of classic RND

Blair(1933) & Martin(1941)

Popularized the RND

Saurez Began (1952)

Described functional or
conservative neck dissection

Pietrantoni (1953) Excision of cancer of the head and neck—with

special reference to the plan of dissection based
Recommended sparing SAN on 132 operations. J Am Med Assoc
1987;258:3286.
 Bocca and Pignatara (1967)
Described FND

Bocca (1975)
Oncologic safety of the FND compared
RND

Medina (1989), Robbins (1991) & Byers (1994)

Proposed classification of neck dissection

Medina JE. A rational classification of neck dissections. Otolaryngol Head Neck Surg 1989;100:169.
RATIONALE BEHIND NECK DISSECTION
 Cancer cells

Interstitial fluid

Lymphatic circulation
Circulation

Lymph nodes

lodges at various organs

Death
Post floor of mouth Mandibular incisors
Maxillary sinus Tongue(tip)
Maxillary teeth except 3rd molar Lower lip (middle)
Mandibular canines,1st & 2nd molars & Chin
Tongue Ant. floor of mouth
Nose, hard palate
SUB-MENTAL
Upper lip

SUB-MANDIBULAR

UPPER DEEP CERVICAL CHAIN OF NODES

 RETRO- 3rd Molars
Scalp
PHARYNGEAL Tongue (base)
Ear
Tonsillar area
Eyelids PAROTID NODES
Soft palate

UPPER DEEP CERVICAL CHAIN OF NODES

LOWER DEEP CERVICAL CHAIN OF NODES

• Nodal metastases : Survival rate by 50%.

• Lymphnode metastasis indicates more aggressive disease

with adverse biologic behavior and more advanced stage.

• Removal of at risk lymphatic basins serves 2 main

purposes:
Elective neck dissection
Therapeutic neck dissection

Shah J, Patel S, Singh B. Jatin Shah’s head and neck surgery and
oncology. 4th edition. Elsevier Health Sciences; 2012.
• Status of the cervical lymph nodes are the important prognostic

factor in Squamous cell carcinoma.

• Cure rates drop in half when there is regional lymph node

involvement.
SURGICAL
ANATOMY
 Skin :

It is freely movable over the deeper structures due to the looseness of the superficial fascia.

Superficial Fascia:
It contains
1) The upper decussating fibres of the platysma for 1 to 2 cm below
the chin.

2) The anterior jugular veins: beginning in the submental region

below the chin.

3) A few small submental lymph nodes lying on the deep fascia

below the chin

4) The terminal filaments of the transverse or anterior cutaneous

nerve of the neck may be present in it.
DEEP CERVICAL FASCIA (FASCIA COLLI) :

The deep fascia of the neck is condensed to form the following

layers:

(1) Investing layer

(2) Pre tracheal layer

(3) Prevertebral layer

(4) Carotid sheath

(5) Buccopharyngeal fascia

(6) Pharyngobasilar fascia

Investing layer

It lies deep to the platysma and surrounds the neck like a collar.
It forms the roof of the posterior triangle of the neck.

Features

The investing layer of deep cervical fascia splits to enclose:

(a) Muscles - trapezius and Sternocleidomastoid
(b) Salivary glands - Parotid and submandibular and
(c) Spaces - Suprasternal and supraclavicular.
Pre Tracheal Fascia
The importance of this fascia is
that it encloses and suspends the
thyroid gland and forms its false
capsule.

Pre Vertebral Fascia

It lies in front of the

prevertebral muscles
and forms the floor
of the posterior
triangle of the neck.
TRIANGLES OF THE NECK
SUBMENTAL TRIANGLE
CAROTID TRIANGLE
MUSCULAR
TRIANGLE
SUBMAXILLARY TRIANGLE
POSTERIOR TRIANGLE
Erb's point is an important landmark in the
posterior triangle
PLATYSMA
Surgical considerations
– Increases blood supply to
skin flaps
– Absent in the midline of
the neck
– Fibers run in an opposite
direction to the SCM
STERNOCLEIDOMASTOID MUSCLE
(SCM)
 Origin
 Medial third of the clavicle (clavicular
head)
 Manubrium (sternal head)
 Insertion
 Mastoid process
 Nerve supply - spinal
accessory N
 Blood supply
 Occipital A or direct from ECA
 Superior thyroid A
 Transverse cervical A
GREATER AURICULAR
NERVE
 THE ACCESSORY NERVE

Penetrates the deep surface of the SCM

• Exits posterior surface of SCM deep to Erb’s point
• Traverses the posterior triangle ensheathed by the superficial
cervical fascia and lies on the levator scapulae
• Enters the trapezius approx. 5 cm above the clavicle
TRAPEZIUS

Surgical considerations
– Posterior limit of Level V
neck dissection
– Denervation results in
shoulder drop and winged
scapula
 OMOHYOID MUSCLE
Surgical considerations
– Absent in 10% of individuals
– Landmark demarcating level III from
IV
– Inferior belly lies superficial to
• The brachial plexus
• Phrenic nerve
• Transverse cervical vessels
– Superior belly lies superficial to
• IJV
DIGASTRIC MUSCLE
FACIAL NERVE
HYPOGLOSSAL NERVE
 PHRENIC NERVE
•Sole nerve supply to the diaphragm
•Supplied by nerve roots C3-5
•Runs obliquely toward midline on the
anterior surface of anterior scalene
•Covered by prevertebral fascia
•Lies posterior and lateral to the carotid
sheath
INTERNAL JUGULAR VEIN
 Thoracic Duct
The duct lies anterior to the
phrenic nerve and the transverse
cervical artery and vein. The
preferred method to avoid a chyle
leak is by en bloc ligation of the
lymphatic pedicle in which the
lymphatic duct(s) lie. This can be
safe to perform only after the
Parotid artery, vagus nerve, UV,
and phrenic nerve are identified.
Suture ligation of the pedicle is
often warranted to prevent the tie
from slipping loose and resulting
in a leak. Fibrin glue has been
reported to be useful in these
situations.”
LYMPH NODE LEVELS

Developed by
Memorial SLOAN-KETTERING
CANCER CENTRE
Classified neck nodes into six levels.

The boundaries of each being defined by

surgically visible bones, muscles, blood
vessels or nerves.

Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW.
Standardizing neck dissection terminology. Official report of the academy’s
committee for head and neck surgery and oncology. Arch Otolaryngol Head
Neck Surg 1991;117:601–5.
CT and MRI offer
progressively more
refined anatomical
precision,
reproducibility, &
visualization of deep,
clinically inaccessible
structures.
 CLASSIFICATION UPDATED

The classification has been updated, with

refinements of some boundaries using
radiologic landmarks, and further definition
of sub-levels.

Robbins KT. Integrating radiological criteria into the classification of cervical lymph node disease. Arch Otolaryngol
Head Neck Surg 1999;125:385–7.
Robbins KT, Clayman G, Levine PA, et al. Neck Dissection classification update: revisions proposed by the
American Head and Neck Society and the American Academy of otolaryngologyHead and Neck Surgery. Arch
Otolaryngol Head Neck Surg. 2002;128(7): 751–8.
 LYMPH NODE LEVELS

Level I:
Submental &
submandibular
lymph nodes

Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by
the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck
Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751–8.
• Level II, III, IV:
nodes associated with IJV
within fibroadipose tissue
(posterior border of SCM &
lat. border of sternohyoid)

Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by
the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck
Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751–8.
Level II:

Upper third jugular chain,

juglodigastric & upper
posterior cervical nodes

 Boundaries - hyoid
bone (clinical landmark)
- carotid bifurcation
(surgical landmark)
Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by
the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck
Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751–8.
• Level III:
Middle jugular nodes
• Boundaries inferior
border of level II to
cricothyroid notch
(clinical) or omohyoid
M (surgical)

Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by
the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck
Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751–8.
• Level IV:
lower Jugular Nodes
• Boundaries inferior
border of level III to
clavicle

Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by
the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck
Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751–8.
• Level V:
Posterior triangle of neck
• Boundaries - post. Border
of SCM, clavicle, & ant.
Border of trapezius

Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by
the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck
Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751–8.
• Level VI: Anterior
compartment structures
(hyoid, suprasternal
notch, medial border of
carotid sheath)
• Level VII: Superior
mediastinal nodes
Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by
the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck
Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751–8.
 CLASSIFICATION UPDATE

• Concept of sublevels into the

classification, since certain zones have
been identified within the 6 levels, some
of which may have biological significance
independent of the larger zone in which
they lie.

• It did not recommend including additional

levels such as level VII for the superior
mediastinum.
 RATIONALE FOR SUBZONES
 Suggested by Suen & Goepfert (1997)
 Biologic significance for lymaphatic drainagedepending on site of tumor

 LEVEL I SUBZONES
▪ Lower lip, FOM, ventral tongue - Ia
▪ Other oral cavity subsites - Ib
 LEVEL II SUBZONES
▪ Oropharynx & nasopharynx - IIb
▪ Oral cavity, larynx & hypopharynx - not necessary to dissect IIb if
level IIa is not involved
 LEVEL IV SUBZONES
▪ Level IVa - increased risk in Level VI
▪ Level IVb - increased risk in Level V
 LEVEL V SUBZONES
▪ Oropharynx, nasopharynx - Va
▪ Thyroid - Vb
TNM CLASSIFICATION OF
CARCINOMAS OF ORAL
CAVITY
Lydiatt WM, Patel SG, O’Sullivan B, et al. Head and neck cancers - major changes in the American Joint
Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin 2017;67(2):122–37.
M- Distant Metastasis
• Mx – Distant metastasis cannot be assessed
• M0 – No distant metastasis
• M1 – Distant metastasis
 PREDICTABILITY OF
NODAL DRAINAGE
• Anterior oral cavity malignancies tend to drain first to nodes in
levels I, II, and III before involving nodes in levels IV and V.
• Inferior level III nodes under the omohyoid muscle can be the
only nodes involved with anterior oral tongue lesions.
• Cancers arising in the oropharynx, hypopharynx, and
supraglottic larynx initially metastasize to levels II, III, and IV.
• Level I nodes are infrequently involved in primary cancer of the
hypopharynx or supraglottic larynx without clinical evidence of
neck disease.
• Tumors of the thyroid gland may metastasize to levels II to IV,
including the paratracheal mph nodes, and to level V.
• A palpable level V node may be the only clinical evidence of a
thyroid malignancy. This predictability facilitates the selection
of specific modifications of neck dissection for specific patients.
 CLASSIFICATION OF NECK
DISSECTIONS

• Standardized until 1991

• Academy’s Committee for Head and Neck Surgery
and Oncology publicized standard classification
system
 NECK DISSECTION
CLASSIFICATION UPDATE

Robbins KT, Clayman G, Levine PA, et al. Neck Dissection classification update:
revisions proposed by the American Head and Neck Society and the American
Academy of otolaryngologyHead and Neck Surgery. Arch Otolaryngol Head Neck
Surg. 2002;128(7): 751–8.
CONCEPTS BEHIND CLASSIFICATION OF
NECK DISSECTION
Based on 4 concepts

› Radical Neck Dissection: the standard basic procedure -

against which all other modifications are compared

› preservation of any non- lymphatic structures : Modified

Radical Neck Dissection

› that preserves one or more levels of LN`s : Selective Neck

Dissection
 MEDINA CLASSIFICATION(1989)
• Comprehensive neck dissection
1. Radical neck dissection (RND)
2. Modified radical neck dissection (MRND)
• MRND I – Preserves spinal accessory nerve.
• MRND II – preserves Spinal accessory and internal jugular vein but sacrifices
sternocleidomastoid muscle.
• MRND III –preserves all- SAN, sternocleidomastoid muscle and internal
jugular vein

• Selective neck dissection (SND)

• Supraomohyoid neck dissection – I, II, III
• Jugular neck dissection – II, III, IV
• Anterior triangle neck dissection – I, II, III, IV
• Central compartment neck dissection – VI
• Posterolateral neck dissection – II, III, IV
 SPIRO’S CLASSIFICATION
 Radical (4 or 5 node levels resected)
 Conventional radical neck dissection
 Modified radical neck dissection
 Extended radical neck dissection

 Selective (3 node levels resected)

 SOHND
 Jugular dissection (Levels II-IV)
 Any other 3 node levels resected

 Limited (no more than 2 node levels resected)

 Paratracheal node dissection
 Mediastinal node dissection
 Any other 1 or 2 node levels resected
DIAGNOSTIC MODALITIES IN
PREOPERATIVE
EVALUATION
 ASSESSMENT OF CERVICAL LYMPH NODES
• Computed tomography
• Magnetic resonance imaging
• Ultrasound
• Ultrasound guided fine
needle aspiration cytology
• Radionuclide scanning
• SPECT
• PET
• Sentinel node biopsy
• Lymphoscintigraphy
 ANATOMY OF THE
VASCULARIZATION OF NECK SKIN
• Kambic and Sirca 1967 stated that arterial supply is in a
vertical direction.

• Descending branches: facial and occipital artery

• Ascending branches: transverse cervical and supraclavicular

arterial branches .
The vasculature can be summarized into

• Upper neck region - anterior to the angle of mandible

Branches of facial and submental arteries.
• Upper lateral neck - the area between ramus of mandible and
the sternocleidomastoid muscle –
Occipital and external auricular branches of external carotid.
• Lower half of neck –
The transverse cervical artery and suprascapular artery.
Large platysma cutaneous branches and branches of superior
thyroid supply the front middle portion of the neck.
 INCISIONS

• Incisions classified into

• Vertical
• Horizontal
• The incisions used for neck dissections are
• Tri-radiate incision and its modification
• Hayes martin double ‘Y’ incision
• McFee incision
• Apron flap incision
 BASIC NEEDS OF AN INCISION ARE

 Good exposure of the neck and primary disease

 Ensure viability of the skin flaps. Avoid acute angles

 Protect carotid artery even in the cases of wound infection

 Facilitate reconstruction

 Adapt to the condition of patient especially after radiotherapy

 It should be cosmetically acceptable

 DIFFERENCES BETWEEN INCISIONS
Transverse incision
Have cosmetic advantage as they
follow natural skin folds of the
skin
Recovery of scar tissue in these
folds are rapid and successful
Easy to modify
Vertical incision
Disadvantages because they
intersect to the natural skin folds
of the skin and the vascular
supply of the neck
They tend to contract along their
long axis – leads to deformity and
restricted action.
 TRI-RADIATE INCISION AND ITS
MODIFICATIONS
 ADVANTAGES
Incision provides good exposure
to surgical site.
 DISADVANTAGES
Flap necrosis is high due to
disruption of vasculature of skin
flaps
Occurrence of flap separation at
the trifurcation site.
Carotid exposure/rupture
MODIFICATION OF TRI-RADIATE
INCISION

• Schobinger (1957)

• Cramer & Culf (1969)

• Conley (1970)
 SCHOBINGER (1957)

 Schobinger suggested
that vertical limb instead
of being straight should
be curved posteriorly in
order to avoid lying
directly over the
carotids.
 CONLEY (1970)

 Suggested a posteriorly
curving vertical incision
rather than a horizontal
incision
 The incision starts from the
submental region and ends by
running downwards along the
anterior border of the trapezius
to the level of clavicle gently
curving posteriorly.
 HAYES MARTIN INCISION
 Paired ‘Y’ incision.

 The submandibular component is met

by a vertical limb which below

becomes continuous with an inverted

‘Y’ in the supraclavicular region.

 Disadv :
Cyanosis of the skin flaps
Flap necrosis and
Carotid exposure
 MCFEE INCISION
 Avoids a vertical limb.

 Two horizontal incisions are

used one in submandibular
region and other in the
supraclavicular region.
 Advantages Disadvantages

Excellent cosmetic result Exposure is not good

No ↓ in vascularity in the centre of Not suitable for bilat simultaneous

the flap neck dissection

No angle intersection in incision Operating period is long

Post - op wound recovery - rapid Posterior triangle dissection is

difficult

Suitable in necks receiving Working under the bridge flap -

radiotherapy difficult

Recovery of flap excellent due to In short neck it might be difficult to

wide bipedicled flaps distinguish between the front tip of
the incision from that of the
tracheostomy.
 APRON FLAPS
 Described by Freund 1960.
 Only a horizontal incision from mastoid
gently curving inferiorly upto upper
border of the thyroid.
 Advantages
Carotid artery is well protected
Protects the descending arterial
supply
 Disadvantages
Damage to the ascending arterial and
venous supply
Venous congestion and oedema might
develop at the bottom corner
 HOCKEY STICK INCISION
 Lahey et al (1940)
 Modified for RND by Eckert &
Byars 1952.
 It has a longitudinal and
transverse incision.
 B/L hockey stick incision
allows the deglovement of the
whole neck.
 RADICAL NECK DISSECTION

• Definition
All lymph nodes in Levels I-V

including
Spinal Accessory Nerve (SAN),
SCM
IJV.
 INDICATIONS
• Extensive cervical involvement or matted lymph nodes
with gross extracapsular spread and invasion into the
SAN, IJV, or SCM.
• N3 disease.
• Multiple gross metastases involving multiple levels.
• Recurrent metastatic disease in the previously irradiated
neck.
• Involvement of accessory chain lymph nodes by
metastatic disease.
 CONTRAINDICATIONS

› Poor surgical candidate.

› Rampant distant metastasis.
› Significant bilateral neck disease.
› Base of skull disease.
› Mediastinal or infraclavicular disease.
› Unresectable or uncontrollable primary disease.
› Extension into deep vital structures of neck.
SURGICAL TECHNIQUE

Skin incision

Elevation of the posterior flap

Dissection starts in the

postero inferior angle of the
posterior triangle

Transection of SCM at superior

border
 Forward traction of the specimen

Division of omohyoid

Ligation & division of EJV

Division of cervical plexus

Clearance of posterior triangle

Reflection of anterior skin flap

 Transection of SCM inferior attachments
Fascia b/w carotid sheath and strap muscles is incised

Blunt dissection is done around the carotid artery and

vagus
Lymphatics in vicinity of jugular vein

Thoracic duct requires special attention

 Elevation of the superior skin flap

Identification of MMN

Ligation of facial vessels

Clearance of submandibular &

submental triangle

Tail of the parotid gland is seperated

Ligation of IJV and spinal

accessory nerve
 BILATERAL RND

• Not often performed

• Loss of both SCMs → difficulty in lifting head,
esthetics
• Loss of both XI Ns → doubling the disability
• Indications :
• Primary at base of the tongue/floor of the mouth at midline
• When metastatic nodes develop on contralateral side of the
neck after nodal clearance on ipsilateral side
• Most often carried out as two separate operative
procedures, separated in time (4 weeks)
 Complications of ligating bilateral IJVs
simultaneously

 Always try to preserve one of the IJVs

 An attempt at preservation of the vein made on the 1st side
dissected leaves the second available for another attempt.
 MODIFIED RADICAL NECK
DISSECTION
• Definition
• Excision of same lymph node bearing regions as
RND with preservation of one or more non-
lymphatic structures (SAN, SCM, IJV).

• MRND is analogous to the “functional neck

dissection” described by Bocca.
Rationale

– Reduce postsurgical shoulder pain and shoulder

dysfunction

– Improve cosmetic outcome

– Reduce likelihood of bilateral IJV resection in contralateral

neck involvement
 Operable palpable neck
disease not involving
spinal accessory

 Can be performed for

N0 neck
Same indications as type I
Particularly for 2nd
surgery if microvascular
anastamosis is needed
 If IJV is not involved
Treatment of N0 neck
Treatment of differentiated
thyroid cancer
Skin tumors like melanoma,
SCC, merkel cell carcinoma in
the narrow band of scalp
between the ears
  SELECTIVE NECK
DISSECTION
• Definition
• Cervical lymphadenectomy with preservation of one or
more lymph node groups
• Five common subtypes:
Supraomohyoid neck dissection
Lateral neck dissection
Posterolateral neck dissection
Anterior neck dissection
Central compartment
 SUPRA OMOHYOID NECK
DISSECTION
• Most commonly performed SND
DEFINITION
• En bloc removal of cervical lymph node groups I-III.

• Posterior limit is the cervical plexus and posterior border

of the SCM.

• Inferior limit is the omohyoid muscle overlying the IJV.

 Indications

Oral cavity carcinoma

with N0 neck

Boundaries-
Vermillion border of
lips to junction of
hard and soft palate,
circumvallate
papillae
SURGICAL TECHNIQUE
 SND: LATERAL TYPE

• Definition
• En bloc removal of the
jugular lymph nodes
including Levels II-IV
• Indications
• N0 neck in carcinomas of
the oropharynx,
hypopharynx, supraglottis,
and larynx
 SND: ANTERIOR TYPE

• SOHND + Jugular SND

Indications

•Primary tumors of oral cavity and oropharynx

•Also address the risk of skip metastasis to level IV

 SND: POSTEROLATERAL TYPE
Definition
• En bloc excision of lymph bearing tissues in Levels II-IV
and additional node groups – suboccipital and postauricular

Indications
• Cutaneous malignancies
• Melanoma
• Squamous cell carcinoma
• Merkel cell carcinoma
• Soft tissue sarcomas of the scalp and neck
 SND : CENTRAL
COMPARTMENT
• Definition

• En bloc removal of lymph structures in Level VI

• Perithyroidal nodes
• Pretracheal nodes
• Precricoid nodes (Delphian)
• Paratracheal nodes along recurrent nerves

• Limits of the dissection are the hyoid bone,

suprasternal notch and carotid sheaths
• Indications
• Selected cases of thyroid carcinoma
• Parathyroid carcinoma
• Subglottic carcinoma
• Laryngeal carcinoma with subglottic extension
• CA of the cervical esophagus
 EXTENDED NECK DISSECTION

• Definition
• Any previous dissection which includes removal of
one or more additional lymph node groups and/or
non-lymphatic structures.

• Usually performed with N+ necks in MRND or

RND when metastases invade structures usually
preserved.
• Indications
• Carotid artery invasion
• Other examples:
• Resection of the hypoglossal nerve or digastric
muscle,
• Dissection of mediastinal nodes and central
compartment for subglottic involvement, and
• Removal of retropharyngeal lymph nodes for tumors
originating in the pharyngeal walls.
 COMPLICATIONS

• The complications can be divided into

I. Intraoperative and
II. Postoperative complications
 INTRA OPERATIVE COMPLICATIONS

Hemorrhage
Carotid sinus reflux
Pneumothorax
Air embolus
Embolism
Nerve damage
Chylous leak
 HEMORRHAGE

• Bleeding from the artery

• Bleeding from the vein

• 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.

• To minimize the chance of pneumothorax, carefully dissect

in the paratracheal area and base of the neck with good
hemostasis 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
 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.

• Adequate ligations and transfixion sutures are mandatory

 NERVE INJURY
• The spinal accessory, cervical cutaneous and great auricular nerves
are intentionally sacrificed during standard radical neck dissection.
• Brachial plexus, phrenic nerve
• Hypoglossal, vagus
• Marginal mandibular nerve
• Sacrifice of the cervical sympathetic chain produces horner
syndrome, which involves ptosis, anhydrosis, and miosis.
• On occasion, the formation of a neuroma at the end of a cut nerve
may cause paresthesias and pain.
• 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.
 CHYLOUS LEAK
• Usually prevented by isolating the lymphatic pedicle
between the carotid artery and the phrenic nerve and
clamping this pedicle prior to dividing and ligating it.

• Intraoperative chylous leak should be recognized as

opalescent fluid in posterior and inferior aspect of the
dissected neck.

• Once it has been isolated it should be clamped and secured

with a tie.
 POSTOPERATIVE COMPLICATIONS
 Hematoma
 Wound infection
 Skin flap loss
 Salivary fistula
 Chylous fistula
 Facial edema
 Electrolyte disturbances
 Carotid artery rupture
 HEMATOMA

• It is one of the more common complications that

predispose to wound infection, flap necroses,
carotid exposure and fistula formation.
• 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.
• 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.
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.
 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.
• 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.
 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.
 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.
• 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.
 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 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 internal jugular vein can lessen this complication.
ELECTROLYTE DISTURBANCES
• The most common electrolyte disturbance in the
postoperative period is hyponatremia.

• It is usually dilutional; due to 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

 PRIMARY RECURRENCE

• If tumor excision was initially complete subsequent

recurrence at the primary site should be uncommon.

• There are sometimes occasions when a recurrence at

the primary site may be treatable.
 DISTANT METASTASIS
• Distant metastasis in sites such as lung, liver and
bone should be assessed clinically at each post
operative visit.

• A chest x- ray may be performed once a year.

 HYPERTROPHIC SCAR

• Following neck dissection using the utility

or schobinger incision a band like formation
in the lower limb of the scar with
hypertrophy leads to contracture.
 INDICATIONS FOR POSTOPERATIVE RADIATION
THERAPY TO THE NECK

1. Gross residual disease following neck dissection

2. Multiple positive lymph nodes in the neck
3. Extracapsular extension by metastatic disease
4. Perivascular or perineural invasion by tumor
5. Other ominous findings such as tumor emboli in
lymphatics, cranial nerve invasion, or extension
of disease to the base of the skull
Studies of Patterns of cervical lymph node metastasis –
Jatin P Shah

Distribution of nodal % of patients with

metastasis in pathologically
therapeutic proven metastasis
neck dissections at that level
FUTURE /RECENT
TRENDS
 SENTINEL NODE BIOPSY:
• Identification and removal of the lymph node (‘‘sentinel
node’’) that would first receive metastases from a given
site.
• Technique- injecting the area surrounding the primary site
with a radioactive-labeled colloid: 99mtc-sulfur colloid.
(Various molecular weights can be chosen depending on the
transit time desired.)
• A radiograph can be taken to localize the sentinel node,
which is the first node that receives lymph flow from the
area of the tumor.
• The patient is then taken to the operating room where the
• This will also drain to the first node and stain it blue,
assisting the surgeon in its identification during surgery.
• Also, the surgeon will use a gamma detection probe
counter probe to identify the node with the highest
concentration of radioactive colloid.
• The node is then removed and if it is histologically
positive, further treatment such as completion of neck
dissection and/or radiation may be indicated.
• The technique of sentinel node biopsy has been investigated
in the head and neck with varying results.
• Problems with applying the sentinel node technique to the
oral cavity relate to the rich lymphatic drainage pattern with
possible bilateral drainage, and the complex anatomy in the
cervical region, which can lead to difficulty in dissecting a
single node from the neck.
 ENDOSCOPIC NECK DISSECTION
• Minimally invasive.
• Reduces the extent of surgical trauma and its associated
morbidity.
• Faster wound healing
• small incision – less scar

Disadvantages:
Prolonged operative time which however can be shortened as
surgeons became more experienced.
 CONCLUSION
• Cervical lymph nodes are frequently involved by metastases
from malignant head and neck tumors.
• The morbidity associated with RND has led to the further
development of more conservative techniques that might have less
morbidity, while preserving oncological effectiveness based on
staging of the disease at presentation.
• The various forms of neck dissection are important components of
the head and neck surgeon’s armamentarium as selection of
appropriate form of neck dissection will not only improve disease
control but also facilitate patient rehabilitation by reducing
postoperative functional and cosmetic deficiencies.
 REFERENCES
• Crile G. Landmark article Dec 1, 1906: Excision of cancer of the head
and neck—with special reference to the plan of dissection based on 132
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Head Neck Surg 1989;100:169.

• Preventing complications: principles of flap reconstruction. Operative .

techniques in otolaryngology--head and neck surgery, vol 11, no 2
(jun), 2000: pp 126-129.

• Neck dissection classification update. Arch Otolaryngol Head Neck

Surg 2002.
• Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update:
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• Marco Lucioni. Practical Guide to Neck Dissection. Springer-Verlag Berlin

Heidelberg 2007.

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Maxillofacial Surg Clin N Am 20 (2008) 459–475.

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edition. Elsevier Health Sciences; 2012

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