Neck Dissection

Definition
It is a procedure to remove lymph nodes and surrounding fibro fatty tissues from neck to eradicate metastasis to cervical lymph nodes in cancer of aerodigestive tract.

Fascial layers of the neck

Superficial cervical fascia

Deep cervical fascia Superficial layer SCM, strap muscles, trapezius

 Middle or Visceral Layer Thyroid Trachea esophagus Deep layer (also prevertebral fascia) Vertebral muscles Phrenic nerve

Level I

Submental triangle (Ia)

Anterior digastric Hyoid Mylohyoid

Submandibular triangle (Ib)

Anterior and posterior digastric Mandible.

Level I

Ia
Chin Lower lip Anterior floor of mouth Mandibular incisors Tip of tongue

Ib
Oral Cavity

Floor of mouth
Oral tongue Nasal cavity (anterior)

Face

Level II

Upper Jugular Nodes

Anterior Lateral border of sternohyoid, posterior digastric and stylohyoid Posterior Posterior border of SCM Skull base Hyoid bone (clinical landmark) Carotid bifurcation (surgical landmark)

Level IIa anterior to XI

Level IIb posterior to XI

Submuscular recess Oropharynx > oral cavity and laryngeal mets

Spinal Accessory Nerve

CN XI Relationship with the IJV

Level II

Oral Cavity Nasal Cavity Nasopharynx Oropharynx Larynx Hypopharynx Parotid

Level III

Middle jugular nodes

Anterior Lateral border of sternohyoid Posterior Posterior border of SCM Inferior border of level II Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark)

Junction with IJV

Level III

Oral cavity Nasopharynx

Oropharynx
Hypopharynx Larynx

Level IV

Lower jugular nodes

Anterior Lateral border of sternohyoid Posterior Posterior border of SCM Cricoid cartilage lower border (clinical landmark) Omohyoid muscle (surgical landmark)

Junction with IJV

Clavicle

Level IV

Hypopharynx Larynx Thyroid Cervical esophagus

Level V

Posterior triangle of neck

Posterior border of SCM Clavicle Anterior border of trapezius Va Spinal accessory nodes Vb Transverse cervical artery nodes

Radiologic landmark
Inferior border of Cricoid

Supraclavicular nodes

Level V

Nasopharynx Oropharynx Posterior neck and scalp

Level VI
Anterior Compartment Structures Boundaries Above by Hyoid bone Below by Suprasternal notch On either side by medial border of Carotid sheath

Level VI
Lymph Nodes
Perithyroidal Pretracheal Precricoid Nodes (Delphian) Paratracheal nodes along recurrent laryngeal nerves

Level VI

Thyroid Larynx (glottic and subglottic) Pyriform sinus apex Cervical esophagus

Subgroups

Ia Ib IIa IIb III

Submental Submandibular Upper jugular (Anterior to XI) Upper jugular (Posterior to XI) Middle jugular

IVa Lower jugular (Clavicular) IVb Lower jugular (Sternal) Va Vb VI Posterior triangle (XI) Posterior triangle (Transverse cervical) Central compartment

Common Nodal Drainage Patterns

Face and Scalp Anterior Lateral Posterior Facial, Ib Parotid Occipital, V

Eyelids
Chin External Ear

Medial
Lateral Anterior Posterior

Ib
Parotid, II Ia, Ib, II Parotid, II Post auricular, II, V Parotid, II

Middle Ear Floor of mouth Anterior

Ia, Ib, IIa > IIb

Lower incisors
Lateral Teeth except incisors Nasal Cavity Anterior

Ia, Ib, IIa > IIb

Ib, IIa > IIb, III Ib, IIa > IIb, III Ib

Common Nodal Drainage Patterns

Nasal Cavity Nasopharynx Oropharynx Larynx Posterior Retropharyngeal, II, V Retropharyngeal, II, III, V IIb > IIa, III, IV, V Supraglott ic IIa > IIb, III, IV Subglottic VI, IV IV, VI

Cervical esophagus Thyroid

Tongue Tip Lateral

VI, IV, V, Mediastinal

Ia, Ib, IIa > IIb, III, IV Ib, IIa > IIb, III, IV

Staging

Nx: Regional lymph nodes cannot be assessed. N0: No regional lymph node metastases.

N1: Single ipsilateral lymph node, < 3 cm

Staging

N2a: Single ipsilateral lymph node 3 to 6 cm N2b: Multiple ipsilateral lymph nodes < 6 cm N2c: Bilateral or contralateral nodes < 6cm

N3: Metastases > 6 cm

Staging

Nasopharyngeal Carcinoma N1 Unilateral < 6cm N2 Bilateral < 6 cm N3a > 6 cm N3b Extension to supraclavicular fossa Thyroid N1 Regional node mets N1a - Ipsilateral N1b - Bilateral, midline, contralateral cervical or mediastinal LN

Classification

The RND is classified according to the Academys Committee for Head & Neck Surgery & Oncology into four major type: 1. Radical Neck Dissection (RND) 1. Modified Radical Neck Dissection (MRND)

3. Selective Neck Dissection (SND)

1.

Supraomohyoid Posterolateral Lateral Anterior

1.

2.

3.

4. Extended Radical Neck Dissection (ERND)

Classification

Radical neck Dissection:

Removing all lymphatic tissues in regions I - V Spinal Acessory Nerve Internal Jugular vein Sternocleidomastoid muscle Submandibular Salivary gland Tail of parotid Omohyoid muscle

Classification

Modified radical neck dissection:

Excision of all lymph nodes removed with RND with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJV

Subtype I: Preserve SAN Subtype II: Preserve SAN & IJV Subtype III: preserve SAN, IJV and SCM
Known as Functional neck dissection (Bocca)

Classification

Selective Neck dissection:

Any type of cervical lymphadenectomy with preservation of one or more lymph node groups Four subtype:

Supraomohyoid neck dissection Posterolateral neck dissection Lateral neck dissection Anterior neck dissection

Classification
Supraomohyoid neck dissection:

Removal of lymph nodes in regions I III The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCM The inferior limit is the superior belly of the omohyoid where it cross IJN
Removal of suboccipital, retroauricular, levels II V and level V Subtyped I III depending on the preservation of SAN, IJV and /or SCM

Posterolateral neck dissection

Classification
Lateral neck dissection:

Remove lymph nodes in levels II IV

Require the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VI Superior limit, hyoid bone Inferior limit, suprasternal notch Laterally, the carotid sheath

Anterior neck dissection:

Structures to be preserved
Carotid artery Brachial Plexus, Phrenic & vagus nerve, cervical sympathetic chain, marginal mandibular, lingual and hypoglossal nerves

Indications

Radical Neck Dissection

1. Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN 2. Large metastatic tumor mass or multiple matted in upper part of the neck

Tumor should not be dissected to preserve Structures

Classification

Extended neck dissection:

Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues

Facts

General nodal metastasis produce the following fact:

The most important factor in prognosis of SCC of the upper aero-digestive tract is the status of cervical lymph nodes Cure rate drops 50% with involvement of the regional lymph nodes

Indications

Modified radical neck dissection

MRND Type I:
1.

2.

Clinically obvious neck lymph nodes metastasis and SAN not involved by tumor Intraoperative decision just like preservation of the facial nerve in parotid surgery

Indications

1. Rarely planned 2. Intra-operative decision for tumor found adherent to SCM but away from SAN & IJV

MRND Type II:

MRND Type III:

1. 2.

Depend on the autopsy reports

Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels They are not found within the aponeurosis or glandular capsule of the submandibular Functional neck dissection

Indications

MRND Type III:

For treatment of N0 neck nodes Indicated for N1 mobile nodes and not greater than 2.5 3.0 cm

Contra-indicated in the presence of node fixation Result is difficult to interpret because of the use of radiation therapy

Indications

Selective/elective neck dissection:

For treatment of N0 neck nodes For N+ nodes when combined with radiotherapy Adjuvant radiotherapy for patient with 2 4 positive nodes or extra-capsular spread Upgrade intra-operatively following positive frozen section

SND : Supra Omohyoid Type

Oral cavity carcinoma with N0 Neck Hoffman oral cavity Level 1 30.1 % Level 2 35.7 % Level 3 22.8 % Level 4 9.1 % Level 5 2.2 %

SND : Lateral Type

N0 Neck in carcinomas of Oropharynx Hypopharynx Supraglottis Glottic Larynx

SND : Posterolateral Type

- Cutaneous malignancies

Melanoma SCC Merkell cell Carcinoma

- Soft tissue sarcomas of scalp and neck

SND : Anterior Compartment

Selected Cases of Thyroid Carcinoma Parathyroid Carcinoma Subglottic Carcinoma CA of Cervical Oesophagus

Y Incision

McFee Incision

H Incision

J Incision

COMPLICATIONS

Air embolus Pneumothorax Chyle leak & Chylus fistula Wry Neck (Torticollis Coli) Shoulder dysfunction Cerebral oedema