ent

1. Dr. SANJAY MAHARJAN.
1ST YEAR RESIDENT.
ENT-HNS, MANIPAL.
NECK
DISSECTION

2. • Systematic removal of lymph nodes, along with their surrounding
fibrofatty tissue, from various compartments of neck
• Aim : to remove neck lymph nodes into which cancer cells may have
migrated
• Metastases may originate from tumours of oral cavity, tongue,
nasopharynx, oropharynx, hypopharynx, and larynx, as well as the thyroid,
parotid and posterior scalp.
INTRODUCTION:

3. • Therapeutic neck dissection is used when metastatic cervical
lymphadenopathy is clinically evident.
• Elective neck dissection is used to remove lymph node groups in pts
who have clinically node-negative disease and who have increased risk of
harboring occult disease in neck
• Salvage neck dissection is done when metastatic disease is clinically
evident in the neck after previous treatment

4. • 1888 - Jawdynski described en bloc resection with resection of carotid,
internal jugular vein and sternocleidomastoid muscle.
• 1906 - George W. Crile of the Cleveland Clinic describes radical neck
dissection.
• 1957 - Hayes Martin describes routine use of radical neck dissection for
control of neck metastases.
• 1967 - Oscar Suarez and E. Bocca describe a more conservative operation
which preserves SAN, IJV and SCM.
• Last 3 decades - Further operations have been described to selectively
remove the involved regional lymph groups.
HISTORY OF NECK DISSECTION:

5. DIVISION OF NECK LYMPH NODES BY LEVEL
AND SUB-LEVEL

6. • Suggested by Suen and Goepfert (1997)
• Biologic significance for lymphatic drainage depending on site of tumor
IMPORTANCE OF SUBDIVISIONS:

7. “N” classification – AJC (1997)
NX: Regional lymph nodes cannot be
assessed
N0: No regional lymph node
metastasis
N1: Metastasis in single ipsilateral
lymph node, 3 cm or less in greatest
dimension
N2a: single ipsilateral lymph node >3
cm but <6 cm in greatest dimension
N2b: multiple ipsilateral lymph nodes,
none >6 cm
N2c: bilateral or contralateral nodes,
<6 cm
N3: lymph node >6 cm
STAGING OF HEAD AND NECK
CANCER

8. • Thyroid and nasopharynx have different staging based on tumor behavior
and prognosis
• Staging in nasopharyngeal cancer
 N1: unilateral
 N2: bilateral (Both are above supraclavicular fossa & < 6 cm)
 N3: > 6 cm or in supraclavicular fossa
• Staging in thyroid cancer
 N1a: ipsilateral
 N1b: midline / bilateral / contralateral

10. Principles of Classification
• RND: standard basic procedure for
cervical lymphadenectomy, all other
represent one or more modifications
• MRND: When modification of RND
involves preservation of one or more
non-lymphatic strs.
• SND: When modification involves
one or more lymph node groups that
are routinely removed in RND.
• Extended RND: When modification
involves removal of additional lymph
node groups or non-lymphatic
structures relative to RND.
CLASSIFICATION OF NECK
DISSECTIONS

11. • Removal of all ipsilateral cervical
lymph node groups that extend from
 Body of mandible superiorly to
 Clavicle inferiorly and from
 Contralateral anterior belly of
digastric & lat border of strap
muscles anteriorly to
 Ant border of trapezius posteriorly
RADICAL NECK DISSECTION

12. • extensive lymph node metastases
with extension beyond capsule of
node or nodes that involves SAN
and IJV.
• Untreatable primary tumor
• Unfit form major surgery
• Distant metastasis
• Significant b/l neck diseases
INDICATIONS: CONTRA-INDICATIONS:

13. • En bloc removal of lymph node–
bearing tissue from one side of the
neck (I-V)
• Unlike RND, it preserves SAN, IJV,
and/or SCM
• TYPES:
I. Type I preserves SAN
II. Type II preserves SAN & IJV
III. Type III preserves SAN, IJV &
SCM
MODIFIED RADICAL NECK
DISSECTION:

14. • Type I :
 Operable palpable neck disease
(usually N1, N2a, N2b) not involving
accessory nerve
 Can occasionally be done for the N0
neck
• Type II :
 Where preservation of IJV is
important either when performing a
second side operation or
 microvascular anastomosis or
 when histology shows vein need not
be resected, i.e. differentiated thyroid
cancer.
INDICATIONS:

15. • Type III :
 comprehensive or functional neck
dissection
 Elective Rx for N0 neck in cell
carcinoma of the upper aerodigestive
tract

16. • Reduce postsurgical shoulder pain and shoulder dysfunction
• Improve cosmetic outcome
• Reduce likelihood of bilateral IJV resection
BENEFIT OF MRND:

17. • En bloc removal of one or more
lymph node groups at risk for
metastatic cancer
• Levels removed depend on location
of primary lesion and its known
pattern of spread.
• Types:
I. Supraomohyoid (m/c performed)
II. Extended supraomohyoid
III. Lateral
IV. Postero-lateral:
V. Anterior or central:
VI. Superior mediastinum:
SELECTIVE NECK DISSECTION

18. • Supraomohyoid:
 SND for Oral Cavity Cancer
 Dissection of I-III groups
 Cutaneous branches of cervical
plexus and post border of SCM
mark posterior limit of dissection.
 Inferior limit - junction betn sup
belly of omohyoid & IJV
 Indication:
o SCC oral cavity T1–T4: N0.
• Extended supraomohyoid:
 Skin cancer (SCC and melanoma) ant
to line of tragus in conjunction with
superficial parotidectomy
INDICATIONS:

19. • Lateral:
 SND for Oropharyngeal,
Hypopharyngeal, and Laryngeal
Cancer
 Dissection of II-IV groups
 Sup. limit of dissection - skull base
 Inf. limit – clavicle
 Ant. (medial) limit - lat border of
sternohyoid & stylohyoid m/s
 Post. (lateral) limit - cutaneous
branches of cervical plexus and post
border of SCM.
 Indication:
o SCC larynx, oropharynx and
hypopharynx, T2–T4: N0

20. • Posterolateral:
 SND for Cutaneous Malignancies
 Dissection of II-V & post-auricular
nodes
 Sup. limit - skull base ant and nuchal
ridge post
 Inf. limit - clavicle
 Med. (ant) limit - lat border of
sternohyoid and stylohyoid m/s
 Lat. (post) limit - ant border of the
trapezius muscle inferiorly and
midline of neck superiorly

21. • Anterior or central:
 SND for Cancer of Midline
Structures of Anterior Lower Neck
 Dissection of level VI groups
 superior limit - body of hyoid bone
 inferior limit - suprasternal notch
 lateral limits - medial border of the
carotid sheath (CCA).
 Indications:
• Differentiated thyroid carcinoma
• Subglottic and hypopharyngeal SCC

22. • Sup. Mediastinum:
 Differentiated and medullary thyroid
carcinoma
 Subglottic laryngeal and
hypopharyngeal SCC
 Cervical oesophageal carcinoma

23. • RND along with one or more
additional lymph node groups or
nonlymphatic strs or both
• lymph node grps include
retropharyngeal and parapharyngeal,
parotid nodes, or lymph nodes in
levels VI or VII.
• nonlymphatic strs include part of
mandible, parotid gland, part of
mastoid tip, prevertebral fascia and
musculature, digastric m/s, XIIn,
ECA as well as skin.
EXTENDED NECK DISSECTION

24. • compartmental removal of lymph
nodes limited to one or two
contiguous neck levels
• INDICATION:
 removal of lymph node disease as/w
supraglottic cancer
 residual disease following
chemoradiation that is confined to a
single level
SUPERSELECTIVE NECK
DISSECTION

25. • lymphoscintigraphy and sentinel
lymph node biopsy (SLNB)
• powerful adjunct to surgical
treatment
• minimally invasive, can accurately
stage clinically occult neck
LYMPHOSCINTIGRAPHY-DIRECTED
NECK DISSECTION

26. • Position:
 Supine
 Roll placed beneath shoulders to
optimally extend neck.
 Skin is prepped and draped to allow
full exposure of both sides of neck
with clear visualization of
surrounding landmarks
TECHNIQUE:

27. • Optimal exposure of all lymph node
levels to be dissected (I -V)
• Preserve as much blood supply as
possible
• Flaps raised should be broadly
based, sup or inf
• Should avoid any trifurcations,
particularly those that overlie carotid
sheath
• Incisions that fit these criteria
 Hockey stick
 Boomerang
 McFee incision
 Apron incision (b/l ND)
INCISION:

28.  Y type (or Crile)
 Schobinger incision
 Modified Schobinger incision
 horizontal-T (Hetter) incision
 Utility incision
DIFFERENT INCISIONS:

29. • Raised in subplatysmal plane
• Major corners of consternation:
 Lower end of internal jugular vein.
 Junction of lateral border of clavicle
with lower edge of trapezius.
 Upper end of internal jugular vein.
 Submandibular triangle.
• Minor corners of consternation:
 Retropharyngeal nodes.
 Parapharyngeal nodes.
 Chaissaignac’s triangle.
RAISING THE FLAP:

30. • Step 1:
 incision is made through skin, subcutaneous fat, and platysma muscle
 superior flap is elevated
 submandibular gland fascia is then incised
 Resection of fat and lymph nodes from submental triangle (Level Ia)
 submental triangle is resected inferiorly to hyoid bone with electro-cautery.
Deep plane of dissection is mylohyoid muscles
OPERATIVE STEPS FOR MRND:

33. • Step 2:
 addresses Level Ib
 submandibular gland capsule is
dissected from gland in a superior
direction in a subcapsular plane
 Resection of fat and lymph nodes
tucked anteriorly and deeply between
ant belly of digastric & mylohyoid
m/s

34.  Facial artery and vein are identified by blunt dissection with a fine haemostat
 Facial lymph nodes; if present, are dissected
 Divided and tied close to submandibular gland so as not to injure marginal
mandibular nerve
 This frees up gland superiorly, which can then be reflected away from
mandible
 addresses the lingual nerve, submandibular duct, and XIIn

37. • Step 3:
 fascia along lateral aspect of
digastric divided
 EJV divided
 post belly of digastric exposed along
its entire length
 Identification of XIIn deep to veins
that cross nerve
 Sternomastoid branch of occipital
artery that tethers XIIn identified
 Dividing this artery releases XIIn
 Then courses vertically and leads
directly to ant border of IJV

41. • Step 4:
 fatty tissue in Level II dissected
 XIn which may course lateral,
medial or very rarely through IJV
identified
 transverse process of C1 vertebra
can be palpated immediately post
to XIn and IJV

42. • Step 5:
 directed at anterior neck
 anteriorly based subplatysmal flap
raised
 exposing omohyoid and SCM
muscle inferiorly down the clavicle
 anterior jugular vein left in elevated
flap
 Omohyoid divided and levels II, III
cleared

43. • Step 6:
 Posteriorly-based flap elevated
 Platysma is often absent posteriorly
hence flap may be very thin
 Dissection continues until ant
border of trapezius is reached

44. • Step 7:
 dissecting out XIn and mobilizing Level IIb
 XIn is identified by dissecting at post border of SCM, approx 1-2cm post to
point where greater auricular nerve curves around m/s
 Once XIn exposed and freed from IJV, it is exposed distally to where it
disappears behind trapezius m/s
 Freed completely and branches sectioned to SCM

47. • Step 8:
 dissection of Level IIb and
transposition of the XIn
 SCM is divided below mastoid.
exposing fat at top of Level IIb
 dissection is carried deeper until
deep muscles of neck that run in a
posteroinferior direction appear
 dissection is then directed postero-
inferiorly, where greater occipital
nerve (C1) is divided
 Level IIb and IIa are then dissected
off
 XIn is now trans-located posteriorly

50. • Step 9:
 clavicular and sternal heads of
SCM divided
 not to dissect immediately lateral to
IJV, as right lymphatic duct (right
neck) or thoracic duct (left neck)
may be injured; chyle leak
 EJV is divided and ligated and
omohyoid divided
 Supraclavicular fat exposed.
 Brachial plexus, phrenic nerve &
transverse cervical vessels identified

54. • Step 10:
 freeing inferolateral part of Level V
 Identifying and dividing
supraclavicular nerves
 Incision of fatty vascular pedicle
containing transverse cervical artery
and vein
 isolation and division of transverse
cervical artery and its proximity to
XIn.

56. • Step 11:
 anterograde dissection of Levels II
-V with scalpel
 dissection proceeds over a broad
front until entire cervical plexus has
been exposed
 cervical plexus nerves are each
divided, taking care not to injure
phrenic nerve
 This brings carotid sheath into view
 carotid sheath is incised along full
course of vagus nerve, and neck
dissection specimen is stripped off
the IJV

60. • Step 12:
 final step is to:
 strip neck dissection specimen off
infrahyoid strap muscles
 to identify and preserve superior
thyroid vascular pedicle, and
 to deliver neck dissection specimen
• Closure:

61. • HAEMORRHAGE:
 perioperative or postoperative
 Damage to IJV at its upper or lower end before it has been ligated
 Secondary haemorrhage may occur as a result of carotid artery rupture
• WOUND INFECTION:
 four most important factors
1. Contamination of surgical field.
2. Contamination of surgical field as
operation involves in-continuity RND and primary excision
3. Postoperative haematoma which then becomes infected.
4. Flap necrosis and wound breakdown.
COMPLICATIONS

62. • CAROTID ARTERY RUPTURE:
 Following necrosis of arterial wall d/to infection
 preoperative radiotherapy is implicated in most series
• CHYLOUS FISTULA:
 More usually, a leak of fluid occurs when lower end of jugular vein is
being dissected
 Mild leak, i.e. < 100mL/day: conservative management
 Major leak: re-explore wound to identify source of leak and oversew
it

63. • PNEUMOTHORAX
 disease lower neck, apical pleura may be damaged during dissection
• NERVE INJURIES:
 standard radical neck dissection the nerves which are deliberately divided are:
 accessory nerve;
 branches of the cervical plexus.
 descendens hypoglossi
 Other nerves that may be damaged by accident include:
 facial nerve or its mandibular or cervical division;
 hypoglossal and lingual nerves;
 vagus, symphathetic trunk, phrenic nerve or brachial plexus.

64. • CEREBRAL OEDEMA;
 Usu. In b/l neck dissection
.

65. THE END…..