anatomy of neck triangles . topography of neck lymph nodes . diagnosis of metastatic neck node . management of occult primary disease .

1. Metastatic neck disease
Dr , Ibrahim Habib
E N T consultant
( M. D.)

13. Subdivision of anterior triangle of neck
1- digastric triangle .
2- carotid triangle .
3- muscular triangle .
4- 1/2 submental triangle .

24. Contents of carotid triangle
- 3 carotid arteries ( C.C.A. , I.C.A. , E.C.A. )
-I.J.V. & 3 of its tributries ( common facial , lingual & sup. thyroid veins )
- last 3 cranial nerves ( 10th , 11th, 12th )
-3 small nerves ( descending hypoglossi , descending cervicalis , n. to thyrohyoid )
- cervical sympathetic chain .
- deep cervical lymph nodes .

34. Floor of carotid triangle
Anteriorly : Thyrohyoid & hyoglossus mm
Posteriorly : Middle & inf. constrictor mm of pharynx

51. Posterior triangle of neck
Boundaries :
Infront : post. border of SCM.
Behind : ant. border of trapezius m.
Below : middle of clavicle .
Above : meeting SCM & trapezius m.
Floor : 1- scalenus medius
2- levator scapulae
3- splenus capetis .

52. Posterior triangle of neck
Roof :
1- skin 2- superfacial fascia 3- deep fascia
Deep fascia contains :
1- platysma
2- cut. Branches of cervical plexus .
3- ext. jugular v.

53. Posterior triangle of neck
Contents :
1- inf belly of omhyoid m
2- third part of subclavian a.
3- suprascapular a.
4- tranverse cervical a.
5- 3rd part of occipital a.
6- subclavian v.
7- ext. jugular v.
8- spinal accessory n.
9- brachial plexus .
10- cervical plexus .
11- occipital L. N.
12- supraclavicular L. N.

57. Topography of cervical lymph nodes
- level 1 : submental & submandibular groups: lymph nodes within submental & submandibular triangles .
- level II : upper jugular group .
Lymph nodes around upper 1/3 of I.J.V.
-level III : middle jugular group .
Lymph nodes around middle 1/3 of I.J.V.

58. Topography of cervical lymph nodes
- level IV : lower jugular group .
Lymph nodes around lower 1/3 of I.J.V.
- level V : . Posterior triangle group .
Lymph nodes along lower ½ of spinal accessory n. & trnsverse cervical a.
. Supraclavicular group

62. The 6 levels of the neck .

63. The 6 sublevels of the neck .

67. Groups of L Ns & certain areas drained
Submental N
Submandibular N.
Jugulodigastric N.
Midjugular N.
Ant. Part of mouth & lip .
Face , nose , max. sinus , buccal mucosa , floor of mouth , submandibular g.
Nasoph. , supragllotic larynx , tonsillar fossa , hypoph. , tongue
base , parotid g.
Hypoph. , larynx , thyroid .

68. Groups of L Ns & certain areas drained
Lower jugular N
Post. Triangle N
Supraclavicular N
Preauricular N
Post auricular N
Esophagus , subglottic larynx , thyroid g.
Nasoph. , post. Scalp .
Pyriform sinus , breast , lung , G. I. T. .
Anterior part of scalp , lat. Orbit , forehead , ear canal , parotid gland .
Scalp & external ear .

70. Factors increases incidence of
palpable lymph node at presentation .
1- site of Iry tumour
2- size of Iry tumour
3- differentiation of Iry tumour .
Nasoph. , hypoph. , oroph. , oral cavity .
+++ size ------> +++ metast.
Lymph node .
Poor diff. ------> ++ metast.
Lymph node .

71. Clinical staging of cervical nodes
Nx
No
N1
N2a
N2b
N2c
N3
Regional L. N. can’t be assessed .
No regional L. N. metastases .
Single ipsilateral L. N. ( < or = 3 cm. )
Single ipsilateral L. N. ( 3 – 6 cm. )
multiple ipsilateral L. N. ( 3 – 6 cm. )
Bilateral or contralateral L.N. 3 – 6 cm.
Any L. N. > 6 cm .

72. Assessment of cervical L. N.
1- History & clinical L. N.
2- radiology .
3- Fine needle aspiration cytology in occult primary .

73. Radiology
C.T. scan
M. R. I.
L. N. neck size > 1.5 cm ( submand. & jugulodigastric L. N. )
> 1 cm ( other L. N. )
with contrast :
-peripheral enhancement ,
-central necrosis .
Size > 13 mm
- clear differentiation between L. N. & surrounding .

74. Radiology
Ultrasound
Radioisotopes
P. E. T.
Can be used wit FNAC .
With Gallium e` camera > 2 cm
With Technicium .
Not yet fully evaluated .

76. Management of metastatic neck disease
1- radiotherapy .
2- Surgery .
3-pre or post operative radiotherapy .

77. Indications of radiotherapy for
metastatic neck disease
1- Iry tumour treated with radiotherapy e.g ( N.ph.)
2- post operative radiotherapy .
3- prophylactic N0 ( oral cavity , ph. , supraglottic larynx )
4- palliative .

78. Surgery for metastatic neck disease
1- radical neck dissection .
2- modified radical neck dissection .
3- selective neck dissection .

79. Radical neck dissection
1- lymph nodes removed
2- non lymphatic structures removed
3- Lymphatic tissue not included in speciemen
From level I up to level V.
1- spinal accessory n.
2- internal jugular v.
3- sternocleidomastoid m.
4- submandibular g.
5- tail of parotid g.
6- omohyoid muscle .
7- cervical plexus nerves .
Level VI L.N.

81. The radical neck dissection .

82. Modified radical neck dissection
Removal of all lymph node groups removed in radical neck dissection with preservation of one or more of non lymphatic structures routinely removed in radical neck dissection .
M.R.D. three types .

83. Modified radical neck dissection
1- Type I
2- type II
3- type III
( spinal accessory n. preserved )
( spinal accessory n. & I. J. V.
Preserved )
( spinal accessory n. , I.J.V. & SCM preserved )

84. Modified radical neck dissection with preservation of the sternocleidomastoid muscle, spinal accessory nerve, and internal jugular vein.

85. Modified radical neck dissection with preservation of the internal jugular vein and spinal accessory nerve.

86. Modified radical neck dissection with preservation of spinal accessory nerve.

87. Selective neck dissection
Any type preserving one or more of lymph node removed in R.N.D.
4 types:
1- supraomohyoid neck dissection.
2- lateral neck dissection .
3- anterior compartment neck dissection .
4- extended R.N.D.

88. Selective neck dissection
1-supraomohyoid neck dissection.
2- lateral neck
Dissection
3- anterior compartment
neck dissection .
4- extended RND
Removal of level I, II, III, as in ( cancer oral cavity )
Removal of level II, III, IV, as in ( melanoma of posterior scalp & neck )
Removal of level VI nodes including pretracheal , paratracheal , perithyroid & precricoid( delphian ) n. as in subglottic
larynx & hypopharynx .
Removal of one or more additional L. N. & or nonlymphatic structure not routinely removed in R.N.D. as paratracheal L.N. , carotid a. , hypoglossal n. , vagus n. .

89. Selective neck dissection (SND) for oral cavity cancer: SND (I-III) or supraomohyoid neck dissection.

90. Selective neck dissection (SND) for oropharyngeal, hypopharyngeal, and laryngeal cancer: SND (II-IV) or lateral neck dissection.

91. Selective neck dissection (SND) for thyroid cancer: SND (VI) or anterior neck dissection.

92. Selective neck dissection (SND) for posterior scalp and upper posterolateral neck cutaneous malignancies: SND (II-V), postauricular, suboccipital) or posterolateral neck dissection.

93. Extended neck dissection (common carotid artery).

94. Contraindication for neck dissection
1- patient unfit for surgery .
2- Iry not treatable ( irresectable ):
-adherent to common or internal carotid a.
- invasion of skull base .
3- extensive bilateral neck disease .
4- distant metastases .

95. Other terminology of neck dissection
Radical neck dissection
Modified neck dissection III
Complete neck dissection
= comprehensive , standard , classical .
= functional neck dissection , conservative N.D.
Removal of L.N. from level I to V either radical or modified radical .

96. Complications of R. N. D.
1- hge .
2- wound infection .
3- carotid a. rupture .
4- chylus fistula .
5- pneumothorax .
6- nerve injury .
7- cerebral oedema .

97. Occult primary
- posterior triangle metastatic L.N. indicate post nasal space tumour as 1st possibility .
- metastatic neck node may be secondary to lung , stomach , breast , ovary or testis primary .
- metastatic supraclavicular node :
. 1/3-1/2 SCC
. ¼ undifferentiated or anaplastic .
. ¼ adenocarcinoma .

98. Occult primary
- 1/3 occult 1ry can’t be found inspite of careful investigation .
- 1ry sites in order of frequency :
. Nasopharynx ,tonsil , retromolar trigone , tongue base , pyriform sinus , miscellaneous ( malignant thyroid , melanoma ) , bronchus , breast , stomach .

99. Investigation: history
- painless mass in neck for several weeks quickly increases in size .
- ask about :
.dysphagia , hoarseness, sore throat , nasal obstruction , cough , haemoptysis , indigestion , loss of weight .
- primary arise from vagus n. cause hoarseness due to paralysis of vagus nerve .

100. Investigation : examination
- lump : size , mobility , fixation to deep tissue
- carotid body tumour mobile from side to side , not up & down .
- carotid body tumour can be compressed with gentle pressure & refill again slowly with release of pressure .
- lump arise from pyriform sinus or tonsil may be due to direct extention through thyrohyoid membrane or pharynx . This lump moves up and down with swallowing .

101. Investigation : examination
- full head & neck examination including neck nodes .
- if lymphoma suspected , examine axilla , grions , liver & spleen .
- abdomen exam. For stomach , liver & spleen – testicular examination is mandatory .

102. Investigation : FNAC
- done on 1st visit .
- confirm diagnosis if result SCC .
- if result adenocarcinoma , further imaging needed e.g thyroid gland .
- if lymphoma suspected , an open neck node biopsy indicated .

103. Investigation : radiology .
- C T scan neck , chest , abdomen & pelvis for
detection of 1ry or secondary .
- if thyroid tumour suspected , MRI is more useful than CT with iodine contrast as this may negate use of post operative radioiodine for up to 6 month following the scan .

104. Investigation : endoscopy
- under G. A. for : examination of nasopharynx .
- palpation : tongue base & tonsil ( detection of small tumour )
- biopsy if 1ry tumour found .
If tumour not found : blind biopsy taken from :
both sides of nasopharynx , tongue base , tonsillectomy on side of neck .

105. Treatment
- 1ry site known :
. Tumour small and submucosal e.g. tongue base or nasopharynx .
ttt e` RND or MRND e` post op. R.T. to neck & 1ry site .
. If disease in midline as in nasopharyngeal ca. , both sides of neck should be irradiated .
. If T1 or T2 tonsil , widely resection done e` post op. R.T. to neck & 1ry .

106. Treatment of unknown 1ry
-undedected 1ry
-, FNAC ,
1- shows SCC ttt e` RND or MRND e` post op. R.T. to neck & suspected 1ry .
2- not clear , incisional biopsy and frozen section analysis :
. SCC & operable disease , ttt e` RND e` post op. R.T. to presumed 1ry site . Follow up 5 yrs , if 1ry site revealed in up to 33% , further ttt. e` cure rate 30 to 50% 0f patients .
. Adenocarcinoma from thyroid gland , ttt on its merits
. Anaplastic ca or SCC supraclvicular , shoudn’t ttt radically as 1ry site below clavicle , refer to clinical oncologist .

107. Meeting you next lecture
DR, IBRAHIM HABIB(M.D)
THANK YOU ALL