Neck Disection

LYMPHATICS OF THE HEAD AND

NECK

Level I
IA (Submental) Between anterior belly of the digastric muscles and
cephalad
to the hyoid bone
IB (Submandibula) bounded by the anterior and posterior bellies of the
digastric muscle and the inferior border of the body of
the mandible
Level II Extending from base of the skull up to the bifurcation
(upper jugular of the carotid artery or the hyoid bone
group) Anterior border: lateral limit of the sternohyoid muscle
Posterior border: posterior border of the
sternocleidomastoid muscle
IIA Anterior to the spinal accessory nerve
IIB Posterior to the spinal accesory nerve
 Level III middle third of the internal jugular vein from the
(midjugular group) hyoid bone up to the inferior border of cricoid cartilage
Anterior border: lateral limit of the sternohyoid muscle
Posterior border: posterior border of the
sternocleidomastoid muscle

Level IV lymph nodes around the lower third of the internal

(lower jugular group) jugular vein from the inferior border of cricoid cartilage
up to the clavicle.
Anterior border: lateral limit of the sternohyoid muscle
Posterior border: posterior border of the
sternocleidomastoid muscle
 Level V Lymph nodes around the lower portion of
(posterior triangle the spinal accessory nerve and along the
group) transverse cervical vessels.
bounded by the triangle formed by the
clavicle, the posterior border of the
sternocleidomastoid muscle, and the
anterior border of the trapezius muscle.
VA Superior to the inferior border of the
cricoid cartilage
(along the SAN)
VB Inferior to the inferior border of the
cricoid cartilage
(along transcervical artery)

Level VI Includes lymph nodes in the prelaryngeal, pretracheal,

(central compartment (Delphian), paratracheal, and tracheoesophageal groove.
group) From the hyoid bone to the suprasternal notch and
between the medial borders of the carotid sheaths

Level VII Between the anterosuperior mediastinum and

(superior mediastinal tracheoesophageal grooves, extending from the
group) suprasternal notch to the innominate artery
PATTERNS OF NECK METASTASIS
 Tumor primer
melibatkan kedua
sisi  cenderung
metastase
oropharynx bilateral
 Tumor di dinding
medial sinus
piriformis 
metastase
bilateral
PATTERNS OF NECK METASTASIS

Risk for metastasis to regional lymphatics depend on:

 Site
 T stage
 Histomorphologic features of the primary tumor
 Risk of nodal metastasis increases
from the anterior to posterior
aspect
Larynx and pharynx, Risk of nodal metastasis
increases with progression
from the center to the
periphery
Hypopharynx
Oropharynx
oral cavity
Lips
Risk for nodal metastasis in H&N primary SCC:
T1  < 15%
T2  15% to 30%
T3  30% to 50%
T4  up to 75%

Endophytic >< exophytic tumors

Poorly differentiated carcinomas >< well-
differentiated

Tumor thickness  an independent predictor for cancers of

the tongue and floor of the mouth, > 4 mm in thickness >< thinner lesions
 Low risk nodal metastasis

Thyroid (papillary)  high risk (~50% occult metastases), elective dissection of regional lymph nodes is NOT
RECOMMENDED  no impact on prognosis
EVALUATION
• Clinically detectable metastasis
• clinical examination of the head and neck
• flexible fiberoptic nasolaryngoscopy
• fine-needle aspiration biopsy
• open biopsy is rarely indicated

• Occult metastasis
• Primary tumor not evident after a thorough clinical examination  FNAB 
(+) SCC  contrast-enhanced CT scan and PET  examination + endoscopy
under GA  biopsy
 Primary tumor  not
identified by routine
evaluation  consider
ipsilateral tonsillectomy 
primary tumors can be hidden
in the tonsillar crypts

If frozen-section
examination of directed
biopsy and tonsillectomy
specimens
does not yield a definitive
diagnosis  management of
the cervical lymph node
metastases is deferred until
the final pathology report
becomes available

Algorithm for workup and management of a patient with a

metastatic neck node from an unknown primary source
 The vast majority of metastatic lymph nodes from an occult
primary source 
Squamous cell or poorly/undifferentiated carcinomas
followed by adenocarcinoma, melanoma, and lymphoma

Check thyroglobulin and calcitonin  to rule out thyroid origin

FINALLY!  a core or open biopsy if cytologic examination raises suspicion

for a lymphoma
Management of the Postchemoradiation
Therapy Neck
RADIOGRAPHIC EVALUATION
• Ability to detect occult metastasis has improved with the availability
of anatomic imaging modalities such as US, helical CT, and MRI.

not easy to differentiate reactive from

metastatic nodes

role of 18F-fluorodeoxyglucose PET is debatable

• Patients with low-volume metastatic disease in the neck can be treated
equally well with neck dissection or radiation therapy
• When regional metastases are clinically palpable, comprehensive
clearance of all regional lymph nodes at risk is recommended  classic
radical neck dissection “GOLD STANDARD”
• Preservation of the spinal accessory nerve significantly reduces the
morbidity of neck dissection
• Preservation of the sternocleidomastoid muscle or internal jugular vein
in patients with gross cervical lymph node metastasis results in high
regional failure rates but may be considered for low-volume disease.
• Selective dissection of lymph nodes is usually considered a “staging
procedure”
• Primary tumors of the oral cavity with a clinically N0 neck requires
dissection of lymph nodes at levels I, II, and III and occasionally level
IV.
• For primary tumors of the pharynx and larynx, dissection of lymph
nodes at levels II, III, and IV is recommended.
• If the primary tumor crosses the midline, bilateral clearance of levels
II, III, and IV should be undertaken.
Classification of Neck Dissections
• Comprehensive Neck Dissection
• remove cervical lymph nodes from levels I to V
• classic radical neck dissection
• extended radical neck dissection (i.e., resection of additional regional lymph
nodes or sacrifice of other structures such as cranial nerves, muscles, or skin)
• Modified radical neck dissection type I (MRND-I)  selectively preserves the
spinal accessory nerve
• Modified radical neck dissection type II (MRND-II)  preserves the spinal
accessory nerve and the sternocleidomastoid muscle but sacrifices the internal
jugular vein
• Modified radical neck dissection type III (MRND-III)  preserves the spinal
accessory nerve, internal jugular vein and sternocleidomastoid muscle
Classification of Neck Dissections
• Selective Neck Dissection
• Remove select groups of lymph nodes at risk of micrometastasis in the clinically N0 neck
• Supraomohyoid neck dissection  levels I, II, and III for the primary tumors of the oral cavity
• levels I, II, III, and IV is recommended for primary cancers of the lateral border of the oral
tongue
• Jugular node dissection  levels II, III, and IV for primary tumors of the hypopharynx and larynx
• Anterolateral neck dissection  levels I, II, III, and IV for primary tumors of the oral cavity and
oropharynx
• Posterolateral neck dissection  suboccipital triangle, posterior triangle of the neck, level V, and
the deep jugular chain of lymph nodes at levels II, III, and IV for melanomas and squamous
carcinomas of the posterior scalp
• Central compartment neck dissection  level VI and in the tracheoesophageal groove for thyroid
cancer
Preoperative Preparation
• Incision
• Primary tumor to be resected?
• Reconstruction
Supraomohyoid Neck Dissection
Level I, II, III + Submandibular gland

• primary tumor + lymph nodes at levels I, II, and III removed in a

monobloc fashion (lower cheek flap) OR
• primary tumor through a peroral approach and SND through separate
transverse incision
Extended Supraomohyoid Neck Dissection
• Lateral border of the oral tongue  skip metastasis to level IV of the
ipsilateral neck
Jugular Node Dissection

primary tumor of the larynx or hypopharynx

Central Compartment Node Dissection

Primary differentiated thyroid gland carcinomas 

• extensive
• invasion of the capsule
• extension beyond the capsule
• satisfactory clearance of local and regional disease
Posterolateral Neck Dissection

primary skin carcinoma or melanoma of the posterior scalp

Modified Radical Neck Dissection Type I
Modified Radical Neck Dissection
• INSTRUMENTS AND MATERIALS
• basic head and neck surgical set
• POSITIONING
• supine position
• DRAPING
• lower lip should be visible  monitor possible signs of twitching due
to nerve irritation
 Superior subplatysmal flap
1. Neck lymph nodes exposure
 Infiltrate the skin flaps with lidocaine and epinephrine
 Incise the skin over the marked line.
PG SMG  Incise the subcutaneous tissue
SCM  Incise the platysma
 Dissect the cranial subplatysmal flap as high as the
GAN mandible, from the anterior border of the trapezius
Digastric muscle
muscle posteriorly  omohyoid muscle anteriorly.
Inferior part of subplatysmal flap
 Dissect the posterior flap, extending to the anterior
border of the trapezius muscle
 • Identify and preserve the greater auricular
nerve
Digastric muscle • Identify and preserve the external jugular
vein
GAN • Identify the accessory nerve (+ 1 cm
SMG posterior to the nerve point of neck/ Erb’s
Erb’s point
point)
• Dissect the anterior subplatysmal flap until
reaching the sternum and clavicles inferiorly,
and the omohyoid muscles anteriorly
SCM Omohyoid muscle
EJV

Lateral and medial supraclavicular nerve

 Level 1 Dissection
Ligated facial vein
Marginal mandibular nerve
SMG
Anterior digastric muscle
Posterior digastric muscle
• Incise the fascia of the submandibular gland inferiorly
or midway over the gland (incised just above the
hyoid)
• Dissect the submandibular gland first from its capsule
in a subcapsular plane in a superior direction (The
marginal mandibular nerve runs in an extracapsular
plane)
• Identify the facial vein and transect
• Retract the facial vein cranially, to protect the
marginal mandibular branch
• Dissect the lymphatic tissue between the anterior
and posterior bellies of the digastric muscles
Facial artery

Mylohyoid • Identify the facial artery by retracting

the submandibular gland toward
inferior & transect
• Retract the mylohyoid muscle
anteriorly
SMG
• Dissect the submandibular gland
posteriorly off the mylohyoid muscle
 Marginal mandibular nerve

Lingual nerve • Identify (by retracting the submandibular gland

Hyoglossal muscle
caudally) and preserve the lingual nerve
• Transect the submandibular duct
IA • Preserve the hypoglossal nerve
• Dissect the lymph nodes between the digastric
SMG and the mylohyoid muscle
Hypoglossal nerve
• Dissect the submandibular gland and the fascia
• Dissect the lymphatic tissue between the anterior
bellies of the digastric muscles on both sides and
the hyoid bone caudally
Level 2 dissection • Dissect the medial border of the
sternocleidomastoid muscle, including the
fascia
Digastric muscle • Dissect the digastric muscle
• Identify and preserve the accessory nerve
Accesory nerves • Preserve the internal jugular vein
II Vagal nerve • Dissect the lymphatic tissue behind the
Carotid arteryinternal jugular vein
IIB IJV • Preserve the hypoglossal nerve
SCM • Dissect the lymphatic tissue off the internal
jugular vein,
IIA
• Identify the carotid artery
Digastric muscle
SCM
 • Dissect the lymphatic tissue off the
Level 3 dissection anterior border of the
sternocleidomastoid muscle
Carotid artery • Dissect the lymphatic tissue off the
omohyoid muscle anteriorly
Ansa cervicalis • Retract the sternocleidomastoid
muscle posteriorly and the lymphatic
tissue anteriorly
III
• Identify and preserve the branches of
the cervical plexus (C3, C4 and phrenic
Omohyoid muscle Accesory nerve nerve)
SCM
IJV
Cervical plexus

SCM
 • Transect the external jugular vein
• Dissect the lymphatic tissue between the
cervical plexus and the
sternocleidomastoid muscle
• Preserve the branches of the cervical
plexus (C3, C4 and phrenic nerve) and
the brachial plexus if possible
Cervical nerve branches • Retract the omohyoid muscle in the
Accesory nerve caudal dissection plane
• Preserve the transverse cervical artery,
V located under the cervical plexus
• Identify the accessory nerve,
• Dissect the lymphatic tissue in cranio-
Phrenic nerve
caudal direction along the posterior
margin of the sternocleidomastoid
Levator scapulae muscle
muscle anteriorly,
• dissected from lateral to medial until the
Scalene muscle levator scapulae
• Transect level 3 & 5, after tunneling level
Transverse cervical artery 5 under the sternocleidomastoid muscle
Level 4 dissection
• Retract the omohyoid muscle caudally
IJV Middle thyroid vein • Dissect the lymphatic tissue in caudal
Level II,III,V direction until the level of the clavicle
• Dissect the lymphatic tissue between the
lateral margin of the sternocleidomastoid
IV
muscle posteriorly to the lateral border of
Omohyoid muscle
the sternohyoid muscle anteriorly
• Dissect the neck dissection specimen off
the infrahyoid
• Transect the middle thyroid vein
Sternocleidomastoid muscle resection
• Transect the greater
GAN
auricular nerve
• Dissect the
Accesory nerve sternocleidomastoid muscle
where the accessory nerve
Transected SCM exits the muscle
• Preserve the vagus nerve
Carotid artery
• Transect the
sternocleidomastoid muscle
caudally
Vagal nerve
Ligated IJV
Wound closure

• Insert one or two drains in the wound

• Close the platysma and subcutaneous tissue
COMPLICATIONS

• Injury to nerves
• ansa cervicalis  innervate the infrahyoid, sternothyroid, sternohyoid and omohyoid
muscles
• marginal mandibular branch of the facial nerve  damage cause inability to lower
the bottom lip, the corner of the lip and raise and protrude the lower lip
• vagus nerve  provides sensory innervation to the tongue  pain, altered sensation
lingual nerve
• hypoglossal nerve  extrinsic and intrinsic muscles of the tongue motor fallout
• brachial plexus  innervation of the upper limb
• spinal accessory nerve  innervates the sternocleidomastoid and trapezius muscles
• phrenic nerve  motor innervation to the diaphragm, and sensory innervation to
the pericardium, and mediastinal pleura
• Skin flap necrosis
• exposure of the carotid artery  rupture
• Airway obstruction
• Chyle leak
Terimakasih