neck dissection

1. PRESENTED BY:- Dr Pranav SatheDr Pranav Sathe
MDS IIIMDS III

2. 1. Surgical anatomy necessary for neck dissection
2. Various levels of lymph nodes and why are they
important
3. Incisions for neck dissection

3. 1. Introduction
2. Historical perspective
3. Anatomical considerations
4. Classification of neck dissection
5. Incisions
6. Conclusion
7. References

4.  World Oral health Report 2003 suggests that Oral
cancers are a major problem in the regions of the
world where tobacco habits in the form of chewing
and / or smoking with or without alcohol intake are
common.
 Usually 91% of the cases occur after the age of
forty years and highest incidence between ages
60 and 70 years.

5.  One-third of all cases of OSCC present as stage
I/II disease & two-thirds of patients present with
stage III or IV disease.
 Treatment of OSCC is primarily surgical followed
by chemoradiotherapy.
 Current trends are changing and the above
modalities might be used in an interchangeable
sequence. i.e. surgery followed by chemoradiation
or chemoradiotherapy followed by surgical
salvage or neck dissection.

6. 20-36.3 cases

7.  Patients with cervical nodal metastases show
increased likelihood for distant metastases and
local recurrence.
 Except distant metastases, the most adverse
independent prognostic factor in OSCC is
presence of positive cervical lymph nodes and
prognosis in such patients with extranodal spread
of tumor is poor.

8.  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

9.  By knowing the anatomy.
 By knowing the patterns of the cervical lymph
node drainage.
 The rationale behind neck dissections.
 Work up and staging of neck node metastases.
 The types of neck dissections.

10.  Chelius, 1847 - Importance of Cervical Lymph
node metastases in management of OSCC
 Kocher, 1880 – Positive lymph nodes must be
removed with more ample resection margins &
introduced a ‘Y’ incision – Kocher’s incision.

11.  Butlin, 1885 – Elective neck dissection for
management of cancer of tongue.
 Jawdynski, 1888 – performed a surgery similar
to that performed by Crile.
 Towpik, 1990, reported in his article ‘Centennial of
the first description of en bloc neck dissection’ that
Volkman & Langenback performed 4 RND
before Jawdynski first described it

12. In 1906 paper
“Exicision of cancer of the
head and neck ”
Gold standard procedure :
“Radical Neck dissection”

13. In 1951 paper
“Neck Dissection”
“Routine prophylactic RND was
impracticle”

14.  Martin et al, 1951 – RND should involve
removing the SCM, Omohyoid muscle, IJV,
Submandibular salivary gland en bloc.. Spinal
accessory nerve has to be sacrificed even if it
causes significant esthetic and functional
morbidity.
 Martin has stated “ Any technique that is
designed to preserve the spinal accessory
nerve should be condemned”

15.  Conley also supported the concept of radical neck
dissection.
 Suarez (Father of Functional neck
dissection), 1952 – developed Functional Neck
dissection to prevent significant long term morbidity
of RND:
1. shoulder dysfunction,
2. cosmetic deformity,
3. cutaneous paresthesia,
4. Chronic neck and shoulder pain syndrome..

16.  Pietrantoni, 1953 – A strong proponent of
bilateral elective neck dissection recommended
sparing the spinal accessory nerve and at least
one Internal jugular vein.
 Bocca & Pignataro, 1967 – Functional neck
dissection is a complete dissection of the lateral
cervical space, anatomically confined by a fascial
envelope and itself containing the major cervical
lymphatics.

17.  Bocca & Gavilan - popularized the Functional
neck dissection.
 Medina, 1989 – Lymphadenectomies should be
categorized as Comprehensive, Selective or
Extended.
 Robbins et al, 1991 – used the term ‘Selective’
to distinguish the patients who had one or more
group of lymph nodes preserved.

18.  PLATYSMA MUSCLE:
◦ Wide, quadrangular sheet like
muscle
◦ Extends obliquely from upper
chest to lower face, hence
does not cover a variable
inferiorly based triangle in the
anterior aspect of the neck &
posterolaterally.
◦ Located immediately deep to
the subcutaneous tissue.
◦ TIP: SPARK OF CAUTERY
SHOULD BE BELOW THE
PLATYSMA TO BE SURE
YOU’RE IN THE CORRECT
PLANE.

19.  MARGINAL MANDIBULAR NERVE:
◦ Supplies muscles of lower lip, hence needs preservation.
◦ In Dingman and Grabb's classic dissection of 100 facial
halves in 1962, the marginal mandibular branch was as
much as 1 cm below the inferior border in 19% of cases.
Anterior to the point where the nerve crossed the facial
artery, all dissections displayed the nerve above the
inferior border of the mandible.
◦ Identify nerve 1 cm in front and below the angle of
mandible - incise superficial layer of the deep cervical
fascia that envelops the Submandibular gland parallel to
nerve direction

20.  Another important
finding in the study by
Dingman and Grabb
was that only 21% of
cases had a single
marginal mandibular
branch; 67% had two
branches, 9% had
three branches, and
3% had four.

21.  Relevant neck
triangles during
Neck dissection:
1. Anterior triangle
2. Posterior triangle

22.  Bounded by:
 Anteriorly- Median plane
 Posteriorly-
Sternomastoid
 Superiorly- Inferior
border of mandible
 Inferiorly- Manubrium
sterni

23.  SUBMANDIBULAR
TRIANGLE:
◦ Bounded below by two
bellies of Digastric muscle &
above by lower border of
mandible..
◦ Floor is formed by
Mylohyoid muscle
◦ Roof of triangle formed by
skin & platysma.
◦ Contains submandibular
salivary gland which is
resected because of its
associated lymph nodes.

24.  Other contents of the triangle:
◦ Marginal mandibular nerve
◦ Facial vein & artery sectioned near the angle.
◦ Vein stays superficial to gland & runs downward &
backward deep to platysma.
◦ Facial artery arises from ECA & passes upwards towards
mandible. It approaches the triangle deep to the gland
and loops around it to emerge at the lower border
alongside the vein.

25. FACIAL ARTERY

26.  Anteriorly – Sternocleidomastoid
muscle
 Posteriorly – Trapezius muscle
 Base – Middle third of the clavicle
 Apex – Intersection of SCM & Trapezius
 Floor – Scalene, levator scapulae, splenius
capitis.
 Roof – Overlying skin, subcutaneous tissue,
platysma anteriorly
 Contents: Fibrofatty tissue & lymph nodes

27.  At apex, floor & roof are close to each other & at
base, floor passes to first rib & roof attaches to
clavicle..
 While clearing the fibrofatty tissue at the base,
care to be taken to avoid pulling the Subclavian
vein along with the loose mobile fat.
 Structures of surgical significance lie in the lower
part.
 At angle between SCM & Clavicle, EJV passes
into Subclavian vein.

28.  SPINAL ACCESSORY NERVE:
◦ Its extracranial course has three parts:
1. Below jugular foramen external branch of the spinal
accessory nerve is located medial to the digastric &
stylohyoid muscles & lateral to IJV in close proximity
to upper deep jugular nodes
2. Next it passes into the substance of the SCM &
emerges just above middle of the muscle
3. Thereafter it runs posterior and downwards through
posterior triangle to enter deep to trapezius approx. 2
cm above clavicle.

29.  Two peculiar characteristics of the third part of
surgical significance :-
1. Nerve does not enter Trapezius muscle but
courses along the deep surface of the muscle in
close relationship with transverse cervical
vessels.
2. Located rather superficial middle posterior
triangle of neck and can be easily injured while
raising posterior skin flaps

30.  CN XI – Relationship with the IJV

31.  LYMPH NODES & LYMPHATICS:
◦ Cervical lymphatic system is divided into superficial &
deep chains
◦ Superficial drains into deep after piercing superficial layer
of deep cervical fascia
◦ Superficial chain is less significant than deep from
surgical view point.
◦ Deep cervical lymphatics accompany the IJV or its
branches or lie within major salivary glands.

32.  Superior, middle & inferior groups of the anterior
group of Deep cervical lymphatics lie along the
wall of IJV up to its entry into subclavian vein.
 Thus anterior group lies between posterior belly of
digastric & clavicle.
 Subdigastric or superior Jugular nodes are most
frequently involved among the anterior group of
deep cervical lymphatics. Also called junctional
nodes of Fisch.

33.  Subdigastric nodes are most difficult to clear due
to their proximity to superoanterior part of
Accessory nerve.
 Lymph nodes of the Lateral neck are designated
as upper, middle and inferior cervical nodes – also
designated as spinal accessory group of nodes.
 They begin beneath upper part of SCM & extends
downward & backward following course of Spinal
Accessory nerve

34.  From surgical view point, spinal accessory group
receives drainage from nasopharynx but it
communicates with subdigastric nodes.
 Inferiorly, it turns forward into supraclavicular
group of lymph nodes to join the deep cervical
nodes or Internal jugular chain of lymph nodes.

35.  In submandibular area, there are three groups of
lymph nodes:
1. Preglandular
2. Interglandular
3. Prevascular & Retrovascular..
 They drain the mucosa of lower lip, cheeks,
alveolar region, floor of mouth, anterior tongue &
then empty into deep chain.

37.  IA (submental) Lymph
nodes within the triangular
boundary of the anterior
belly of the digastric
muscles and the hyoid bone
 IB (submandibular)
Lymph nodes within the
boundaries of the anterior
belly of the digastric muscle
and the stylohyoid muscle
and the inferior border of
the mandible

38.  IIA and IIB (upper jugular)
Lymph nodes located around
the upper third of the internal
jugular vein and the adjacent
spinal accessory nerve;
 Level IIA lymph nodes are
located anterior (medial) to the
spinal accessory nerve;
 Level IIB lymph nodes are
located posterior (lateral) to
the spinal accessory nerve

39. III (middle jugular) Lymph nodes
located around the middle third of
the internal jugular vein; nodes are
located between the inferior border
of the hyoid bone and the inferior
border of the cricoid cartilage
 IV (lower jugular) Lymph nodes
located around the lower third of
the internal jugular vein; nodes
extend from the inferior border of
the cricoid cartilage to the clavicle

40.  V (posterior triangle) Lymph
nodes located along the lower half
of the spinal accessory nerve and
the transverse cervical artery;
supraclavicular nodes are located
in this group of lymph nodes
 Level VA - along the lower half
of the spinal accessory
 Level VB - transverse cervical
artery

41.  VI (central
compartment) Lymph
nodes in the prelaryngeal,
pretracheal, and boundaries
are the hyoid bone to the
suprasternal notch and
between the medial borders
of the carotid sheaths;
lymph nodes are generally
not dissected in oral cancer
patients

42.  VII (superior mediastinal) Lymph nodes in the
anterior superior mediastinum and
tracheoesophageal grooves, extending from the
suprasternal notch to the innominate artery; lymph
nodes are generally not dissected in oral cancer
patients

44.  Clinical palpation
 Ultrasonography
 Fine needle aspiration cytology (FNAC)
 USG guided FNAC
 Computed tomogram scan (CT Scan)
 Magnetic resonance imaging (MRI)
 PET scan
 Intra operative sentinel node biopsy
 Intra operative frozen section

45.  Clinical palpation assesses criteria like site,
number, size, shape, consistency & fixity of the
neck nodes.
 Not uniformly reliable in the assessment of
regional metastatic disease as occult neck
disease can occur in up to 50% of patients, false
negative rate ranges between 0% and 77%.
 Prof. Robert Odd-Maryland University has
stated, “ When the lymph node is palpable, the
surgeon thinks it is positive; but he only ‘thinks’ it
is, for it may not always be so”

46.  Ultrasonography is superior to clinical palpation
for assessment of cervical nodes
 Ultrasound criteria for malignant and benign
nodes - size, shape, central necrosis,
extracapsular spread, roundness index &
status of hilum

47.  Size:
◦ Maximum transverse diameter
◦ Assesses true axial & transverse diameter
◦ 33% - 71% nodes < 1 cm found to have metastases
◦ optimal minimal axial diameter to distinguish between
positive and negative node proved to be 8mm for
subdigastric lymph node and 7mm for all other types of
lymph nodes

48.  Shape:
 Benign lymph nodes have
an elongated fusiform shape
 Malignant infiltration
commonly begins in cortex
of the lymph node.
 metastatic lymph nodes
tend to have an irregular
rounded shape that is
reflected by the decreased
ratio between the
longitudinal and transverse
(L/S) diameters of node

49. Round node
Oval node

50.  Extra Capsular Spread:
◦ Normal lymph node has smooth, well-delineated
margins.
◦ Metastatic node becomes ovoid; margins of the node
may remain smooth until the advanced stages of the
disease when extracapsular extension occurs.

51.  Hilum Of The Lymph Node:
 Normally the hilum of the lymph
node is centrally located and thick.
It is formed by the parallel
arrangement of the central
lymphatic sinuses and is a
reflection of the normal nodular
architecture.
 Malignant invasion of the cortical
parenchyma of the node makes the
hilum eccentric, thinned.

52.  Fine Needle Aspiration Cytology (FNAC)
 Technique is useful for diagnosis of deeply situated
masses
 Confirmation of tumor in suspiciously enlarged neck
nodes,
 Assessment of areas of possible recurrent diseases.
 Reliable and inexpensive
 Tolerated by patients.

53.  A needle is passed into the
target mass and cells are
aspirated. The success of this
method depends on the
accuracy of needle placement
and the reliability of the
diagnosis, on the skill and
experience of the pathologist.
When it is combined with
ultrasonography it is a highly
accurate technique for the
investigation of cervical lymph
node metastasis.

54.  CT Scan
◦ Helpful for evaluation of
the primary tumour as
well as for evaluation of
the neck nodes for
metastases,

55.  Tells about size, shape
(oval or spheroid) and also
whether they were
homogenous or cystic.
 The most accurate CT
criteria is the presence of
central necrosis which is
demonstrated as
peripheral/rim enhancement

57.  Sentinel Node Biopsy (SNB)
◦ Important role of sentinel node biopsy (SNB) clinically N0
neck in patients with oral squamous cell carcinoma.
◦ It is concluded overall sensitivity of the procedure using
the full pathologic protocol was 94% & sentinel node
biopsy could be used to stage the N0 neck in patients
with early sub clinical nodal disease.

58.  Rationale:
◦ Cervical metastasis is the single most important
prognostic factor in patients with oral cancer, with the
presence of nodal spread decreasing the 5-year disease-
free survival rate by approximately 50%.
◦ Improving the accuracy of staging while reducing the
morbidity caused by unnecessary lymphadenectomy in
carcinomas is useful

59.  Sentinel node mapping uses:
 (1) radioisotope scan imaging; (2) injection of blue
 dye; and (3) use of a handheld isotope tracer probe for
localization.
 It has been shown that the combination of all three techniques
increases the accuracy and the yield of sentinel lymph node
identification. A preoperative technetium scan is obtained first,
which requires injection of a radioactive technetium 99m–labeled
sulfur colloid. In general, 0.05 mCi of the isotope is injected in
four quadrants around the primary lesion, and a gamma camera
is used to obtain visual images at 3 minutes and 15 minutes and
a delayed image at 1 hour.

60.  Usually the first lymph node identified by the technetium
scan is considered the sentinel lymph node. In some
patients more than one sentinel lymph node is identified.
 Immediately prior to the surgical procedure, isosulfan
blue dye 1% (Lymphazurin) is injected similarly in four
quadrants around the primary tumor. No more than 0.5
mL of the dye is injected in the subdermal plane around
the tumor. The operative procedure then is carried out
within 30 minutes of the injection.

61.  Robbins who chaired The Committee for Head &
Neck Surgery and Oncology of the American
Academy of Otolaryngology – Head and Neck
Surgery, along with colleagues developed
standardized neck dissection terminology in 1991
and updated the classification in 2002.

62.  Original classification was based on the following
concepts:
(1) The RND is the fundamental procedure with which
all other neck dissections are compared,
(2) MRND denotes preservation of one or more
nonlymphatic structures,
(3) Selective neck dissections denote preservation of
one or more groups of lymph nodes,
(4) Extended RND denotes removal of one or more
additional lymphatic or nonlymphatic structures.

63. 1. Radical Neck Dissection
2. Modified Radical Neck Dissection
3. Selective Neck Dissection
a. SupraOmohyoid neck dissection (I, II, III)
b. Lateral neck dissection (II, III, IV)
c. PosteroLateral neck dissection ( II, III, IV, V)
d. Anterior
4. Extended neck dissection

64. 1. Radical Neck Dissection
2. Modified Radical Neck Dissection
3. Selective Neck Dissection
◦ Each variation is depicted by ‘‘SND’’ and the use of
parentheses to denote the levels or sublevels
removed
1. Extended neck dissection

65. Modified radical neck dissection (MRND)
was further classified
 MRND I – Preserves spinal
accessory nerve.
 MRND II – Spinal accessory and
sternocleidomastoid muscle but
sacrifices internal jugular vein.
 MRND III – Requires preservation of
SAN, sternocleidomastoid muscle and
internal jugular vein

66.  T – Tumor size
◦ Tx – tumor cant be assessed
◦ T0 - no evidence of primary tumor
◦ Tis – tumor in situ
◦ T1 – tumor size les than 2 cm
◦ T2 – tumor size between 2 – 4 cm
◦ T3 – tumor size more than 4 cm

67.  T4a (lip) – tumor invades adjoining bone, IAN, floor of
mouth, or skin of face, i.e., chin or nose
 T4a (Oral cavity) – tumor invades adjoining structures
like bone, deep [extrinsic] muscle of tongue
[genioglossus, hyoglossus, palatoglossus, and
styloglossus], maxillary sinus, and skin of face)
 T4b (Oral cavity) – tumor invades masticator space,
pterygoid plates, or skull base and/or encases internal
carotid artery

68.  Regional lymph nodes (N)
◦ Nx – Regional lymph nodes can not be assessed
◦ N0 - No regional lymph node metastasis
◦ N1 – Metastasis in single ipsilateral node, less than 3cm
in greatest dimension.

69.  N2A - Metastasis in single ipsilateral node, more than
3cm & less than 6cm in greatest dimension
 N2B - Metastasis in multiple ipsilateral nodes, none more
than 6cm in greatest dimension
 N2C - Metastasis in bilateral or contra lateral nodes, none
more than 6cm in greatest dimension
 N3 – Metastasis in lymph node more than 6cm in
greatest dimension.

71.  Distant metastasis (M)
◦ MX: Distant metastasis cannot be assessed
◦ M0: No distant metastasis
◦ M1: Distant metastasis

72.  Stage I
◦ T1, N0, M0
 Stage II
◦ T2, N0, M0
 Stage III
◦ T3, N0, M0
◦ T1, N1, M0
◦ T2, N1, M0
◦ T3, N1, M0

73.  Stage IVA
◦ T4a, N0, M0
◦ T4a, N1, M0
◦ T1, N2, M0
◦ T2, N2, M0
◦ T3, N2, M0
◦ T4a, N2, M0
 Stage IVB
◦ Any T, N3, M0
◦ T4b, any N, M0
 Stage IVC
◦ Any T, any N, M1

74.  Philosophy of management of metastatic disease
in the cervical lymph nodes has changed over last
few decades with a better understanding of nodal
metastasis, subclassification of L.N. & SND.
RND is largely replaced by
SND

75. ◦ Age & general condition of patient
◦ Site and size of primary
◦ Palpable neck nodes
◦ Extent of disease on imaging
◦ A simple guideline followed is to go 1 step below the
node.

76. ◦ T1N0 tongue – 30% cases will show occult metastases
◦ T1N0 floor of mouth – 20% cases will show occult
metastases
◦ Gingivo-buccal sulcus tumors show 46% nodal
metastasis most frequently in level I.
◦ Cervical metastasis most frequently in Level II
(Shah JP)
◦ Hence management of neck in N0 cases of tongue &
floor of mouth SCC is necessary

77.  Level I – 61%
 Level II – 57%
 Level III – 44%
 Level IV – 20%
 Level V – 4%

78.  JP Shah (1995):-
◦ Clinically N0 neck with little risk for cervical metastasis –
SND is performed with staging of tumor
◦ Grossly enlarged neck nodes – MRND with preservation
of Spinal accessory nerve.
 N0 and N1 neck – SND +/- radiotherapy
 N2, N3 neck – MRND + radiotherapy

80.  To avoid complications such as wound
breakdown, skin flap necrosis, exposure of carotid
artery following neck dissection, selection of
correct incision is necessary.
 Study on anatomy of blood supply of skin flaps of
neck conducted by Freeland & Rogers, 1975 –
gave rise to incisions like Apron incision, which
are most likely to safeguard blood supply of skin
flaps.

81. 1. Provide free access to the operative site
2. Should not lie on vital structures of the neck
3. Should be designed in such as way that blood
supply of the neck skin flaps is not compromised
– to avoid skin flap necrosis, wound dehiscence,
exposure of vital structures of neck eg. Carotid
artery.

82.  Incisions are of three main types: (McGregor)
1. Hayes – Martin incision
2. Tri-radiate incision or its modification
3. McFee incision

83. Transverse incision Vertical incision
Have cosmetic advantage as
they follow natural skin
folds of the skin
Not preferred because they
intersect the natural skin
folds and the vascular
supply of the neck
Recovery of scar tissue in
these folds are rapid and
successful
They tend to contract along
their long axis – leads to
deformity and restricted
action.
Easy to modify

84. 1. ‘Y’ incision of Crile (1906)
2. Double ‘Y’ incision of Martin et al (1951)
3. Schobinger incision (1957)
4. Superiorly based ‘Apronlike’ incision of Latyshevesky &
Freund (1960)
5. Mcfee incision (1960)
6. Conley incision (1970)
7. Modified Conley incision by Lasaridis et al (1994)

85.  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.

86.  Schobinger (1957)
 Cramer & Culf (1969)
 Conley (1970)

88.  It is a paired ‘Y’ incision.
 Here the submandibular
component is met by a
vertical limb which below
becomes continuous with
an inverted ‘Y’ in the
suprascapular region.
 This flap most often gets
cyanosed.
 Flap necrosis and carotid
exposure is more in this
type of incision.

90.  Suggested a posteriorly
curving vertical incision
rather than a horizontal
incision
 The incision starts from the
submental region and
ending by running
downwards along the
anterior border of the
trapezius to the level of
clavicle gently curving
posteriorly.

93.  It avoids a vertical
limb.
 Two horizontal
incisions are used
one in submandibular
region and other in
the suprascapular
region.

94. Advantages Disadvantages
Excellent cosmetic result (McFee 1960,
McNeil 1978)
Exposure is not good (Hetter 1972)
There is no lessening of vascularity in
the centre of the flap (Ariyan 1986)
It is not suitable for bilateral
simultaneous neck dissection (Chandler
and Ponzoli 1969)
There is no angle intersection in
incision (McFee 1960)
Operating period is long (McFee 1960)
Post operative wound recovery is rapid
(McFee)
Posterior triangle dissection is difficult
(Maran et al 1989, White et al 1993)
Suitable in necks receiving radiotherapy
and in peripheral vascular disease
(Maran et al 1989)
Difficulty may arise while working
under the bridge flap
Recovery of flap excellent due to wide
bipedicled flaps (Stella & Brown 1970,
Daniel & McFee 1987)
In short neck it might be difficult to
distinguish between the front tip of the
incision from that of the tracheostomy.

95.  Described by Latyschevsky and
Freund 1960.
 Only a horizontal incision from
mastoid to mastoid gently
curving inferiorly upto upper
border of the thyroid cartilage is
used.
 Advantages
◦ Carotid artery is well protected
 Disadvantages
◦ Venous congestion and oedema
might develop at the bottom corner

96.  Lower end of IJV
 Junction of Lateral border
of clavicle with the lower
edge of trapezius
 Submandibular traingle
 Upper end of IJV

97. PHILOSOPHY OF STELL AND MARAN:
AGGRESSIVE FIRST, CONSERVATIVE LATER

98.  END OF PART -1

99. 1. McGregor – Cancer of the head and neck
2. J.P. Shah
3. Oral & Maxillofacial Surgery clinics of North
America 2007
4. Otolaryngology Clinics of North America 2006
5. Laryngoscope
6. JOMS