Neck Dissection

By Tegegne ( RIII )
Moderator , Dr Fanaye(OMFS Consultant)

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 Objective
• The objectives of this seminar is to :
• Understand the concept of neck dissection
• Know the patterns of lymph node metastasis
• Classify neck dissection
• Identify and managing the complication of
neck dissection

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 Outlines
• Objectives of the seminar
• Introduction to neck dissection
• Lymphatic and vascular drainage
• Patterns of lymph node metastasis
• Classification of ND
• Indication & contraindication
• Surgical approaches
• Complication and its management

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 Introduction
• Neck dissection is defined as surgical removal of
cervical lymph nodes as prophylactic or therapeutic
for HAN cancers. It can be 3 types based on
Indication.
• Elective neck dissection or prophylactic
• Therapeutic neck dissection
• Functional neck dissection
– Comprehensive neck dissection for N+
– Selective neck dissection for No

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• Goals of the neck dissection :
– To improve survival rate of the patient
– To control regional metastasis of the tumor
• Neck dissection for No(elective) Vs N+(therapeutic)
– Over all survival and diseases free survival is better
for elective than therapeutic ND
• If primary tumor is managed surgically, then ND is also
recommended
• If primary tumor is managed by radiotherapy, then neck
irradiation is also recommended

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 Cervical Lymphatic drainage
• Out of 500 lymph nodes in our body, 70 of them are
found on HAN region
• All lymph nodes from the head and neck drains into
deep cervical lymph node
• Efferent nodes form jugular trunk
• Rt side drains into right lymphatic duct
• Left side drains into thoracic duct

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• They can be
– Superficial : superficial to EJV ,AJV & investing
fascia
– Deep :Deep to SCM ,strap and vertebral muscles
& are along IJV and superior &inferior thyroid
vein
– Waldeyer ring chain
– Deep cervical jugular chain
– Anterior neck deep cervical nodes

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 Superficial cervical lymph nodes
• Sub mental
• Sub mandibular
• Buccal
• Preauricular
• Retroauricular
• Occipital
• Superficial cervical

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 Deep cervical lymph nodes
• Deep jugular chains
• Waldeyer ring chains
• Midline neck nodes
– Infra hyoid
– Pre laryngeal
– Pre and para tracheal

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Level of cervical lymph nodes

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 Patterns of lymph node metastasis
• Oral cavity cancer lymph node metastasis involves
• levels I, II, and Ill.
• Carcinomas of the oropharynx,hypopharynx, and
larynx involves
• levels II, III,and IV
• The lymph nodes in level V were not involved in the
absence of metastases at other levels.

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• Metastases to the
retropharyngeal lymph
nodes can occur with
SCC of the :
• Hypopharynx,
• Tonsil, soft palate
• Posterior and lateral
oropharynx
• Nasopharynx,and
supraglottis
apparatus
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• Cervical lymph node metastasis can be determined by
• Clinical palpation=30%
• SLND=82%_100%
• MRI =80%
• PET_FDG=90%_94%
• US guided FNAC=80%_95%
• CT=82%_85%
• Contrated CT=90%

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• Cervical lymph node metastasis reduce survival rate
of the patient by 50%
• 30% to 40% of HAN cancer has cervical lymph node
metastasis
• 20 % of HAN cancer has occult metastasis
• Size,shape,laterality,necrosis,ECS,perinodal
permeation determines the prognosis of the patient

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 Classification of ND
• Neck dissections are used for surgical Rx of cancer
of the head and neck region
• Universal nomenclature of HAN lymph nodes are
outlined from I to VI
• Cervical lymph nodes are denoted by Roman number

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• Three descriptions are used to label a neck
dissection:
• L" or "R" for Unilateral & bilateral if both sides
are involved
• The levels and sublevels of lymph nodes
removed designated by Roman numerals I
through VII
• The non lymphatic structures removed
designated by SCM for sternocleidomastoid
muscle, IJV for internal jugular vein,SAN
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• The current classification of neck dissections are
based on
• The cervical lymph node groups removed
• Secondary structures preserved
– SCM
– SAN
– IJV

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• There are 2 major types of ND
A. Comprehensive ND
– Radical neck dissection
– Modified radical neck dissection
– Extended neck dissection
B. Selective neck dissection

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 Radical Neck Dissection
• This operation is defined as the en bloc removal of
the lymph node-bearing tissues of one side of the
neck.
• Level I-V lymph nodes
• SCM,IJV, SAN
• it was impossible to remove the lymphatic of the neck
completely without resecting the SCM and IJV
because of the close association lymphatic structures

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• RND is indicated in case of :
• Multiple clinically obvious cervical lymph node
metastases(posterior triangle , SAN)
• Large metastatic tumor or when multiple matted
nodes are present in the upper part of the neck
• Inflammation, hematoma or ecchymosis that
follows ill-advised excisional biopsies of neck
metases.

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 Modified Radical Neck Dissection
• Is modifications of the RNDs developed with the
intention of reducing the morbidity of the operation
by preserving one or more of these structures:
• SAN
• IJV
• SCM.
• Three Sub division that differ by the number of
neural, vascular and muscular structures preserved

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A. MRND Type I : removal of I to V ,SCM, IJV with
preservation of the spinal accessory nerve
B. MRND Type II :removal of I to V with preservation
of SAN and the IJV
C. MRND Type III : removal of I to V with
preservation of the SAN, IJV and SCM.
• It is called functional neck dissection

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 Type I MRND
• Surgical morbidity and cosmetic deformity is
minimized because SAN is preserved
• Indicated for clinically apparent cervical lymph
node metastasis
• The tumor is not in close proximity to SAN
• Recurrence rate with post op radiotherapy is 8.3%

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 MRND Type II
• Preserves IJV & SAN
• Rarely performed neck dissection
• Tumor is adherent to SCM so that violated
• Is commonly done for laryngeal and hypo pharyngeal
tumor

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 MRND Type III
• Preserves SAN, IJV, SCM ,+/- Submandibular gland
• Removes lymph nodes from I to V
• Is indicated for
• No to N+1 ( specially for level lII &III lymph nodes)
• Cervical LN are not located within the muscular
&Vascular Apo neurosis
– So CN 11,12 are preserved
– Vagus , phrenic and brachial plexus are within the
Apo neurosis, so violated

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 Selective Neck Dissection
• Removal of only the lymph node groups at highest risk of
containing metastases in proximity to primary tumor that
preserve SAN, the IJV and the SCM
• 4 Sub types
– Supra omohyoid SND(I to III, I to IV extended SND)
– Lateral neck SND(II to IV, Larnyx ,Oro/ hypopharnyx)
– Anterior neck SND (Level VI)
– Postero lateral SND (II to V, cutaneous malignancies)

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 Extended Neck Dissection
• Neck dissections can be extended to include either
lymph node groups that :
– Are not routinely removed (i.e., retropharyngeal,
para tracheal,upper mediastinal)
– Or other structures that are not routinely removed
(skin of the neck, carotid artery. Levator scapulae,
vagus or hypoglossal nerve).
– Skin , Muscles and nevres can be violated

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• Muscle group removed
• Digastric muscles , strap muscles, vertebral
musle,
• Nerves violated
• CN 12 =41% ,lingual =7%,vagus=4%, phrenic=
3%
• Carotid artery
• Skin
• Retro pharyngeal,para and pre tracheal lymph node

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 Indication of ND
• Significant operable neck disease (N2a, N2b, N3)
• Tumor bulk near to or directly involving SAN or IJV
• Extensive recurrent disease after previous selective
surgery or radiotherapy
• Clinical signs of gross extra nodal disease

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 Contraindication of ND
• Untreatable primary tumor or un resectable neck
disease
– Encasement of internal carotid artery,
– Brachial plexus
– Prevertebral fascia
– Patient unfit for major surgery
– Distant metastases
– Simultaneous bilateral RND

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 Surgical approaches
• There numerous skin incision for ND
• The goal of the incision is
• Adequate vascularization of the skin flaps;
• Adequate exposure of the surgical field;
• Localization of the primary tumor
• Adequate protection of the major NVS

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Anatomic landmark in ND

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 Preoperative patient preparation for ND

• Adequate anesthesiologist evaluation

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• Four area seek special
attention in neck
dissection
• Lower end of IJV
• Junction of lateral
border of clavicle
with lower edge of
trapezius
• Upper end IJV
• Submandibular
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 Upper end of IJV
• Hypoglossal nerve
• Lingual nerve
• Marginal mandibular
nerve
• Carotid vessels

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 Lateral neck
• Subclavian artery
• Supra scapular
• Occipital
• Brachial plexus
• Cervical plexus
• SAN

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 Supraclavicular region(lower end of IJV

• Sub clavian vessels

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 Posterior neck
• Posterior Cervical nerves
• SAN,Rt lymphatic duct
• No platsyma muscle, vascular supply reduced

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 SAN
• Deep to SCM and goes into trapezius muscle

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Anterior neck
• AJV
• Thyroid,parathyroid
• Trachea,esophagus
• RLN
• Thyroid vessels

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 COMPLICATION
• Destabilization of the scapula
– Progressive flaring at the vertebral border
– Drooping ,lateral and anterior rotation of scapula
• Shoulder syndrome of
– Pain , weakness
– Deformity of the shoulder girdle
• Secondary gleno humeral stiffness caused by
– Weakness of the scapulo humeral girdle muscles
– Postoperative immobility
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• Infection
• (Amox +sulbactam) 1.7% vs 13.7%
• Air leak
• Can be because of drain , skin graft,
tracheostomy, mucosal, Secretion )
• Bleeding
• Arterial or venous bleeding

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 Chylous fistula
• Is abnormal communication between vein and
lymphatic vessels that leads to chyle leak.
• High flow or low flow
– Rt lymphatico venous fistula
– Chylothorax fistula
• This can lead to life theatening
• Hypo volemia
• Hypo albuminema
• Electrolyte derangement
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• Management
• Intra op
– Fibrin glue application with muscular flap
reconstruction
• Post op step wise management
– Low of fat free diet
– TPN
– Suction
– S/C octreotide (somatostatin)
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 Surgical management
• Exploration and ligation of thoracic duct
– Haemoclip and silk “o” stitch to ligate
– Pressure packing
– Lymphgiography& thoracic duct
embolization
– Additional muscular flap reconstruction

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 Facial or cerebral edema
• If both IJV are ligated, it can result in the
development of
• Facial edema
• Cerebral edema.
• Both
• More severe in Hx of radiation, resection of lateral
and posterior pharyngeal walls

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 Blindness
• Catastrophic complication in case of bilateral RND
• Can be caused by :
• Intra orbital optic nerve infarction,suggesting
intraoperative hypotension and severe venous
distention .
• Bilateral occipital lobe infarcts
• Management:
• unilateral ligation or embolization of carotid
vessels

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 Apnea
• Result of loss of their hypoxic ventilatory responses
due to carotid body denervation after bilateral neck
dissection.
• Management
• Release manipulation of carotid body

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 IJV blow out Syndrome
• Rupture of IJV
• Common in MRND complicated by a pharyngo
cutaneous fistula
• IJV thrombosis , is common after preoperative high
dose radiotherapy
• Management
• Ligation from inferior and superior

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 Carotid artery rupture
• Most commonly lethal complication after neck
surgery is exposure and rupture of the carotid artery.
• Is called the carotid blowout syndrome
• Risk factor :
• In proper designed skin flap
• Radiation , DM
• Mal nutirion, infection
• less bulk flap design reconstruction

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• Type I
• Exposed carotid artery identified by imaging or
clinical examination
• Type III
• Impending &episodic self limiting bleeding
managed by pressure or dressing
• Type III
• Fatal carotid artery bleeding

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• Carotid artery rupture risk proportion
• Radiotherapy ( 89% )
• Nodal metastasis (69%)
• Radical neck dissection (63%).
• Soft tissue necrosis in the neck (55%)
• Muco cutaneous fistulas ( 40%).
• Unilateral ECA ligation has no complication

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 Flap loss& delayed wound healing
• Delayed wound healing and flap reconstruction loss can be
caused by
• Previously irradiated patients with advanced fibrosis
• Inadequate sub platysma flap
• Surgical site wound infection
• Fascio cutaneous fistula formation
• Uncontrolled Comorbidities
• Risk :erosion of large vessels in the neck that leads to life
threatening bleeding

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 Sudden Death
• In ND, sudden death accounts about
• 0.5%in first 3 post op day
• 1.3% in first 30 post op day
• Cause: thromboembolic event
• Stroke : rare complication
• Death within first 30 post op day accounts < 1%
• Risk factors: Elder,Comorbidities&Bilateral ND

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 Management
• Focused finger pressure and resuscitation
• Endovascular embolization (56%)
• Endo vascular stenting (36%).
• Ligation was used in only 7% as primary
management
• Anti thrombolytic prophylaxis
• Cause 63 % death or stroke

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 Summary
• Thorough knowledge of anatomy and physiology is
necessary to understand neck dissection.
• PET/CT identify N0 metastasis from 50%to 80%
• SLNB is feasible to identify early tongue Ca.
• Classification of neck dissections depends on extent
of lymphatic and non lymphatic structures removed

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• The rate of tumor recurrence in the neck is decreased
by the addition of postoperative radiation when
multiple nodes are involved and ECS spread
• The presence of ECS of the tumor is indication for
postoperative chemo radiation.
• The most common sequelae following any type of
neck dissection is paralysis of the trapezius muscle.

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References

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