1. Neck DissectionNeck Dissection
Jeffrey Buyten, MDJeffrey Buyten, MD
Susan McCammon, MDSusan McCammon, MD
Francis B. Quinn, MDFrancis B. Quinn, MD
University of Texas Medical BranchUniversity of Texas Medical Branch
Department of OtolaryngologyDepartment of Otolaryngology
Grand Rounds PresentationGrand Rounds Presentation
September 2006September 2006

2. OutlineOutline
 HistoryHistory
 AnatomyAnatomy
– Nodal levelsNodal levels
– Common nodal drainage patternsCommon nodal drainage patterns
 StagingStaging
 ClassificationClassification
 Sentinel Lymph NodeSentinel Lymph Node

3. HistoryHistory
 Metastatic cervical lymph nodesMetastatic cervical lymph nodes
– Early 19Early 19thth
CenturyCentury  incurable diseaseincurable disease
– 2020thth
CenturyCentury  improved treatment ofimproved treatment of
neck diseaseneck disease
– 2121stst
CenturyCentury  second worst prognosticsecond worst prognostic
indicator for head and neck SCCAindicator for head and neck SCCA

4. 1919thth
CenturyCentury
 18801880  Kocher advocates wide marginKocher advocates wide margin
lymphadenectomylymphadenectomy
 18811881  Kocher and Packard recommendKocher and Packard recommend
dissection of submandibular triangledissection of submandibular triangle
for lingual cancerfor lingual cancer
 18851885  Butlin questions RND for oral NButlin questions RND for oral N00
diseasedisease
 18881888  Jawdynski describes en blocJawdynski describes en bloc
resection with resection of carotid,resection with resection of carotid,
IJV, SCM.IJV, SCM.
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

5. 2020thth
CenturyCentury
 19011901  Solis-Cohen advocateSolis-Cohen advocate
lymphadenectomy for Nlymphadenectomy for N00 laryngeallaryngeal
CACA
 1905 -19061905 -1906  Crile describes enCrile describes en
bloc resection in JAMAbloc resection in JAMA
 19261926  Bartlett and CallanderBartlett and Callander
advocate preservation of XI, IJV,advocate preservation of XI, IJV,
SCM, platysma, stylohyoid,SCM, platysma, stylohyoid,
digastricdigastric
 19331933  Blair and Brown advocateBlair and Brown advocate
removal ofremoval of XI.XI.
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

6. 2020thth
CenturyCentury
 19511951  Martin advocates Radical Neck Dissection after anaysis ofMartin advocates Radical Neck Dissection after anaysis of
1450 cases1450 cases
– Advocated RND for all cases.Advocated RND for all cases.
– Standardized the Radical Neck DissectionStandardized the Radical Neck Dissection
 1952 – Suarez describes a functional neck dissection1952 – Suarez describes a functional neck dissection
– Preservation of SCM, omohyoid, submandibular gland, IJV, XI.Preservation of SCM, omohyoid, submandibular gland, IJV, XI.
– Enables protection of carotid.Enables protection of carotid.
 19601960’’s – MD Anderson advocate selective ND of highest risk nodals – MD Anderson advocate selective ND of highest risk nodal
basinsbasins
 1967 - Bocca and Pignataro describe the1967 - Bocca and Pignataro describe the ““functional neckfunctional neck
dissectiondissection””
 1975 – Bocca establishes oncologic safety of the FND compared to1975 – Bocca establishes oncologic safety of the FND compared to
the RNDthe RND
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

7. AnatomyAnatomy
 Lymph Node LevelsLymph Node Levels
– Sloan Kettering nomenclatureSloan Kettering nomenclature
– SubgroupsSubgroups
 Common Nodal Drainage PatternsCommon Nodal Drainage Patterns

9. Level ILevel I
 Submental triangleSubmental triangle
(Ia)(Ia)
– Anterior digastricAnterior digastric
– HyoidHyoid
– MylohyoidMylohyoid
 SubmandibularSubmandibular
triangle (Ib)triangle (Ib)
– Anterior andAnterior and
posterior digastricposterior digastric
– Mandible.Mandible.

10. Marginal Mandibular NerveMarginal Mandibular Nerve
 Most commonly injuryMost commonly injury
dissection level Ibdissection level Ib
 Landmarks:Landmarks:
– 1cm anterior and inferior1cm anterior and inferior
to angle of mandibleto angle of mandible
– Mandibular notchMandibular notch
 SubplatysmalSubplatysmal
 Deep to fascia of theDeep to fascia of the
submandibular glandsubmandibular gland
 Superficial to facial veinSuperficial to facial vein

11. Marginal Mandibular NerveMarginal Mandibular Nerve

12. Hypoglossal nerveHypoglossal nerve
 Lies deep to the IJV,Lies deep to the IJV,
ICA, CN IX, X, and XIICA, CN IX, X, and XI
 Curves 90 degreesCurves 90 degrees
and passes betweenand passes between
the IJV and ICAthe IJV and ICA
 Ranine veinsRanine veins
 Lateral to hyoglossusLateral to hyoglossus
 Deep to mylohyoidDeep to mylohyoid

13. Level ILevel I
 IaIa
– ChinChin
– Lower lipLower lip
– Anterior floor of mouthAnterior floor of mouth
– Mandibular incisorsMandibular incisors
– Tip of tongueTip of tongue
 IbIb
– Oral CavityOral Cavity
– Floor of mouthFloor of mouth
– Oral tongueOral tongue
– Nasal cavity (anterior)Nasal cavity (anterior)
– FaceFace

14. Level IILevel II
 Upper Jugular NodesUpper Jugular Nodes
 AnteriorAnterior  Lateral borderLateral border
of sternohyoid, posteriorof sternohyoid, posterior
digastric and stylohyoiddigastric and stylohyoid
 PosteriorPosterior  PosteriorPosterior
border of SCMborder of SCM
 Skull baseSkull base
 Hyoid bone (clinicalHyoid bone (clinical
landmark)landmark)
 Carotid bifurcationCarotid bifurcation
(surgical landmark)(surgical landmark)
 Level IIa anterior to XILevel IIa anterior to XI
 Level IIb posterior to XILevel IIb posterior to XI
– Submuscular recessSubmuscular recess
– Oropharynx > oral cavityOropharynx > oral cavity
and laryngeal metsand laryngeal mets

15. Spinal Accessory NerveSpinal Accessory Nerve
 CN XI – Relationship with the IJVCN XI – Relationship with the IJV

16. Level IILevel II
 Oral CavityOral Cavity
 Nasal CavityNasal Cavity
 NasopharynxNasopharynx
 OropharynxOropharynx
 LarynxLarynx
 HypopharynxHypopharynx
 ParotidParotid

17. Level IIILevel III
 Middle jugular nodesMiddle jugular nodes
– AnteriorAnterior  Lateral border ofLateral border of
sternohyoidsternohyoid
– PosteriorPosterior  Posterior borderPosterior border
of SCMof SCM
– Inferior border of level IIInferior border of level II
– Cricoid cartilage lowerCricoid cartilage lower
border (clinical landmark)border (clinical landmark)
– Omohyoid muscle (surgicalOmohyoid muscle (surgical
landmark)landmark)
 Junction with IJVJunction with IJV

18. Level IIILevel III
 Oral cavityOral cavity
 NasopharynxNasopharynx
 OropharynxOropharynx
 HypopharynxHypopharynx
 LarynxLarynx

19. Level IVLevel IV
 Lower jugular nodesLower jugular nodes
– AnteriorAnterior  Lateral borderLateral border
of sternohyoidof sternohyoid
– PosteriorPosterior  PosteriorPosterior
border of SCMborder of SCM
– Cricoid cartilage lowerCricoid cartilage lower
border (clinicalborder (clinical
landmark)landmark)
– Omohyoid muscleOmohyoid muscle
(surgical landmark)(surgical landmark)
 Junction with IJVJunction with IJV
– ClavicleClavicle

20. Phrenic NervePhrenic Nerve
 Sole nerve supplySole nerve supply
to the diaphragmto the diaphragm
 C3-5C3-5
 Anterior surface ofAnterior surface of
anterior scaleneanterior scalene
 Under prevertebralUnder prevertebral
fasciafascia
 Posterolateral toPosterolateral to
carotid sheathcarotid sheath

21. Thoracic ductThoracic duct
 Conveys lymph from theConveys lymph from the
entire body back to the bloodentire body back to the blood
– Exceptions:Exceptions:
 Right side of head and neck,Right side of head and neck,
RUE, right lung right heartRUE, right lung right heart
and portion of the liverand portion of the liver
– Begins at the cisterna chyliBegins at the cisterna chyli
– Enters posterior mediastinumEnters posterior mediastinum
between the azygous veinbetween the azygous vein
and thoracic aortaand thoracic aorta
– Courses to the left into theCourses to the left into the
neck anterior to the vertebralneck anterior to the vertebral
artery and veinartery and vein
– Enters the junction of the leftEnters the junction of the left
subclavian and the IJVsubclavian and the IJV

22. Thoracic DuctThoracic Duct

23. Level IVLevel IV
 HypopharynxHypopharynx
 LarynxLarynx
 ThyroidThyroid
 Cervical esophagusCervical esophagus

24. Level VLevel V
 Posterior triangle of neckPosterior triangle of neck
– Posterior border of SCMPosterior border of SCM
– ClavicleClavicle
– Anterior border ofAnterior border of
trapeziustrapezius
– VaVa Spinal accessorySpinal accessory
nodesnodes
– VbVb  Transverse cervicalTransverse cervical
artery nodesartery nodes
 Radiologic landmarkRadiologic landmark
– Inferior border of CricoidInferior border of Cricoid
– Supraclavicular nodesSupraclavicular nodes

25. Spinal Accessory NerveSpinal Accessory Nerve
 Penetrates deep surface ofPenetrates deep surface of
the SCMthe SCM
 Exits posterior surface ofExits posterior surface of
SCM deep to ErbSCM deep to Erb’’s points point
 Traverses the posteriorTraverses the posterior
triangle on the levatortriangle on the levator
scapulaescapulae
 Enters the trapezius aboutEnters the trapezius about
5 cm above the clavicle5 cm above the clavicle

26. Level VLevel V
 NasopharynxNasopharynx
 OropharynxOropharynx
 Posterior neck and scalpPosterior neck and scalp

27. Level VILevel VI
 Anterior compartmentAnterior compartment
– HyoidHyoid
– Suprasternal notchSuprasternal notch
– Medial border of carotidMedial border of carotid
sheathsheath
– Perithyroidal lymph nodesPerithyroidal lymph nodes
– Paratracheal lymph nodesParatracheal lymph nodes
– Precricoid (Delphian)Precricoid (Delphian)
lymph nodelymph node

28. Level VILevel VI
 ThyroidThyroid
 Larynx (glottic and subglottic)Larynx (glottic and subglottic)
 Pyriform sinus apexPyriform sinus apex
 Cervical esophagusCervical esophagus

29. Level VLevel V
 NasopharynxNasopharynx
 OropharynxOropharynx
 Posterior neck and scalpPosterior neck and scalp

30. SubgroupsSubgroups
 IaIa SubmentalSubmental
 IbIb SubmandibularSubmandibular
 IIaIIa Upper jugular (Anterior to XI)Upper jugular (Anterior to XI)
 IIbIIb Upper jugular (Posterior to XI)Upper jugular (Posterior to XI)
 IIIIII Middle jugularMiddle jugular
 IVaIVa Lower jugular (Clavicular)Lower jugular (Clavicular)
 IVbIVb Lower jugular (Sternal)Lower jugular (Sternal)
 VaVa Posterior triangle (XI)Posterior triangle (XI)
 VbVb Posterior triangle (TransversePosterior triangle (Transverse
cervical)cervical)
 VIVI Central compartmentCentral compartment

31. Face and Scalp Anterior Facial, Ib
Lateral Parotid
Posterior Occipital, V
Eyelids Medial Ib
Lateral Parotid, II
Chin Ia, Ib, II
External Ear Anterior Parotid, II
Posterior Post auricular, II, V
Middle Ear Parotid, II
Floor of mouth Anterior Ia, Ib, IIa > IIb
Lower incisors Ia, Ib, IIa > IIb
Lateral Ib, IIa > IIb, III
Teeth except incisors Ib, IIa > IIb, III
Nasal Cavity Anterior Ib
Posterior Retropharyngeal, II, V
Common Nodal Drainage PatternsCommon Nodal Drainage Patterns

32. Nasal Cavity Posterior Retropharyngeal, II, V
Nasopharynx Retropharyngeal, II, III, V
Oropharynx IIb > IIa, III, IV, V
Larynx Supraglottic IIa > IIb, III, IV
Subglottic VI, IV
Cervical
esophagus IV, VI
Thyroid VI, IV, V, Mediastinal
Tongue Tip Ia, Ib, IIa > IIb, III, IV
Lateral Ib, IIa > IIb, III, IV
Common Nodal Drainage PatternsCommon Nodal Drainage Patterns

33. StagingStaging
 Nx: Regional lymph nodes cannot beNx: Regional lymph nodes cannot be
assessed.assessed.
 N0: No regional lymph node metastases.N0: No regional lymph node metastases.
 N1: Single ipsilateral lymph node,N1: Single ipsilateral lymph node, << 3 cm3 cm

34. StagingStaging
 N2a: Single ipsilateral lymph node 3 toN2a: Single ipsilateral lymph node 3 to
6 cm6 cm
 N2b: Multiple ipsilateral lymph nodesN2b: Multiple ipsilateral lymph nodes
<< 6 cm6 cm
 N2c: Bilateral or contralateral nodesN2c: Bilateral or contralateral nodes <<
6cm6cm
 N3: Metastases > 6 cmN3: Metastases > 6 cm

35. StagingStaging
 Nasopharyngeal CarcinomaNasopharyngeal Carcinoma
– N1 – Unilateral < 6cmN1 – Unilateral < 6cm
– N2 – Bilateral < 6 cmN2 – Bilateral < 6 cm
– N3a > 6 cmN3a > 6 cm
– N3b – Extension toN3b – Extension to
supraclavicular fossasupraclavicular fossa
 ThyroidThyroid
– N1 – Regional node metsN1 – Regional node mets
 N1a - IpsilateralN1a - Ipsilateral
 N1b - Bilateral, midline,N1b - Bilateral, midline,
contralateral cervical orcontralateral cervical or
mediastinal LNmediastinal LN

36. ClassificationClassification
 RadicalRadical
– Gold standard operationGold standard operation
 Modified radicalModified radical
– Preservation of non lymphatic structuresPreservation of non lymphatic structures
 SelectiveSelective
– Preservation of lymph node groupsPreservation of lymph node groups
 ExtendedExtended
– Removal of additional lymph nodeRemoval of additional lymph node
groups or non lymphatic structuresgroups or non lymphatic structures

37. Radical Neck DissectionRadical Neck Dissection
 RemovesRemoves
– Nodal groups I-VNodal groups I-V
– SCM, IJV, XISCM, IJV, XI
– Submandibular gland,Submandibular gland,
tail of parotidtail of parotid
 PreservesPreserves
– Posterior auricularPosterior auricular
– SuboccipitalSuboccipital
– RetropharyngealRetropharyngeal
– PeriparotidPeriparotid
– PerifacialPerifacial
– Paratracheal nodesParatracheal nodes

38.  RemovesRemoves
– Nodal groups I-VNodal groups I-V
 PreservesPreserves
– SCM, IJV, XI (anySCM, IJV, XI (any
combination)combination)
 Notate according toNotate according to
which structures arewhich structures are
preservedpreserved
Modified Radical Neck DissectionModified Radical Neck Dissection

39. Selective Neck DissectionSelective Neck Dissection
 Remove high risk lymph node groupsRemove high risk lymph node groups
based on tumor site.based on tumor site.
 SupraomohyoidSupraomohyoid
– Levels I-IIILevels I-III
 LateralLateral
– Levels II-IVLevels II-IV

40. Selective Neck DissectionSelective Neck Dissection
 PosterolateralPosterolateral
– Levels II-VLevels II-V
– Postauricular nodesPostauricular nodes
– Suboccipital nodesSuboccipital nodes

41. Selective Neck DissectionSelective Neck Dissection
 AnteriorAnterior
– Level VILevel VI
– RLN injuryRLN injury
– HyperparathyroidismHyperparathyroidism

42. Extended Neck DissectionExtended Neck Dissection
 Removal of any structures that areRemoval of any structures that are
routinely preserved in a neckroutinely preserved in a neck
dissection.dissection.
 Notated by naming the structure(s)Notated by naming the structure(s)
removed.removed.

43. Sentinel Lymph NodeSentinel Lymph Node
 OverviewOverview
 NN00 NeckNeck
 TechniquesTechniques
 ResultsResults

44. Sentinel Lymph Node HistorySentinel Lymph Node History
 1955  First echelon node
 1960  “Sentinel node”
 1977  Demonstrated in penile
cancer
 1992  Morton reintroduced concept
in N0 melanoma
 Currently widely used in melanoma
and breast cancer therapy.

45. Sentinel lymph node conceptSentinel lymph node concept
 Tumor spreads via lymphatics to aTumor spreads via lymphatics to a
primary node.primary node.
 Examination of primary echelonExamination of primary echelon
nodes for tumor direct the need fornodes for tumor direct the need for
surgical management of the nodalsurgical management of the nodal
basins.basins.

46. Sentinel lymph node conceptSentinel lymph node concept
 Difficulties of lymphatic mapping in headDifficulties of lymphatic mapping in head
and neck (Oand neck (O’’Brien).Brien).
1.1. It is difficult to visualize lymphatic channelsIt is difficult to visualize lymphatic channels
using lymphoscintigraphy because ofusing lymphoscintigraphy because of
proximity to the injection site.proximity to the injection site.
2.2. The radiotracer travels fast in the lymphaticThe radiotracer travels fast in the lymphatic
vessels.vessels.
3.3. If more than one node is visible, it can beIf more than one node is visible, it can be
difficult to distinguish first echelon nodes fromdifficult to distinguish first echelon nodes from
second-echelon nodes.second-echelon nodes.
4.4. The SLN may be small and not easilyThe SLN may be small and not easily
accessible (eg, in the parotid gland).accessible (eg, in the parotid gland).

47. NN00 NeckNeck
 Occult neck diseaseOccult neck disease
– Head and neck cancerHead and neck cancer  30%30%
– Oral cavity CAOral cavity CA  20% to 45%20% to 45%
 Factors that indicate > 20% chanceFactors that indicate > 20% chance
of subclinical metastasesof subclinical metastases
– Tumor thickness > 4mmTumor thickness > 4mm
– Size > 2 cmSize > 2 cm
– Anatomic locationAnatomic location

48. SensitivitySensitivity
% (range)% (range)
SpecificitySpecificity
% (range)% (range)
PalpationPalpation 35 (30-40)35 (30-40) 35 (27-42)35 (27-42)
CTCT 45 (17-86)45 (17-86) 11 (3-21)11 (3-21)
USUS 46 (42-50)46 (42-50) 21 (11-33)21 (11-33)
MRIMRI 42 (20-70)42 (20-70) 14 (5-26)14 (5-26)
US FNACUS FNAC 42 (27-50)42 (27-50) 00
Accuracy of diagnostic methods in detecting occultAccuracy of diagnostic methods in detecting occult
cervical metastases.cervical metastases.
A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role ofA new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of
sentinel node biopsy and positron emission tomographysentinel node biopsy and positron emission tomography

49. NN00 Neck TreatmentNeck Treatment
 T1/T2 N0 oral SCCAT1/T2 N0 oral SCCA
– Better 10-year survival in pts who hadBetter 10-year survival in pts who had
elective neck dissection.elective neck dissection.
 T1/T2 N0 tongue SCCAT1/T2 N0 tongue SCCA
– 5-year actuarial benefit for elective neck5-year actuarial benefit for elective neck
managementmanagement

50. Sentinel Lymph Node Biopsy andSentinel Lymph Node Biopsy and
NN00 Oral Cavity SCCAOral Cavity SCCA
 Multiple small case series display theMultiple small case series display the
feasibility of SLNB in oral SCCAfeasibility of SLNB in oral SCCA
 Majority of lesions T1/T2Majority of lesions T1/T2
 No standardized techniquesNo standardized techniques
 All series compareAll series compare
– Pre op lymphoscintigraphyPre op lymphoscintigraphy
– Intra-op localizationIntra-op localization
– Post op pathologyPost op pathology

51. Pre op TechniquePre op Technique
 TechnetiumTechnetium
– Day before surgeryDay before surgery
– Submucosal injectionsSubmucosal injections
– 10-30 MBq Tc 99m per10-30 MBq Tc 99m per
quadrantquadrant
– +/- local anesthesia+/- local anesthesia
– Avoid spillageAvoid spillage
– Rinse mouthRinse mouth
 Dosage does not correlateDosage does not correlate
with ability to identifywith ability to identify
nodesnodes

52. Pre op TechniquePre op Technique
 LymphoscintigraphyLymphoscintigraphy
– DynamicDynamic
 45 -60 minutes45 -60 minutes
 Necessary to clearly identifyNecessary to clearly identify
sentinel nodessentinel nodes
 SLNs seen within 15 minutesSLNs seen within 15 minutes
– StaticStatic
 Confirms dynamic imagesConfirms dynamic images
 AP / Lateral / ObliqueAP / Lateral / Oblique
 Delayed images for nonDelayed images for non
revealing dynamic studiesrevealing dynamic studies
– Cobalt pencilCobalt pencil
 Labels anatomical pointsLabels anatomical points
– Left / right mandibleLeft / right mandible
– ChinChin
– Cricoid cartilageCricoid cartilage
– Sternal notchSternal notch

53. Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection HistopathologyOral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology

54. Oral Cancer: Correlation of Sentinel LympOral Cancer: Correlation of Sentinel Lymp

55. Pre op TechniquePre op Technique
 Blue DyeBlue Dye
– Submucosal injectionSubmucosal injection
– 2.5% Patent Blue dye2.5% Patent Blue dye
– No more than 20 minNo more than 20 min
pre incisionpre incision
Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection HistopathologyOral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology

56. Operative TechniqueOperative Technique
 Limited incision guided byLimited incision guided by
lymphoscintigraphy and gammalymphoscintigraphy and gamma
probeprobe
 Frozen section analysisFrozen section analysis

57. Operative TechniqueOperative Technique
 Gamma probeGamma probe
– Examine operativeExamine operative
bed for increasedbed for increased
signalsignal
– Tumor extirpationTumor extirpation
– Lead shieldLead shield
– Removal of highRemoval of high
signal nodessignal nodes
– Examine removedExamine removed
node and comparenode and compare
to operative bedto operative bed

58. ComplicationsComplications
 Reported complication rates < 1%Reported complication rates < 1%
– Cutaneous malignancy casesCutaneous malignancy cases
 Injury of VII, XI due to limitedInjury of VII, XI due to limited
exposureexposure

59. ResultsResults
 Sentinel nodes found in > 90% ofSentinel nodes found in > 90% of
cases.cases.
– Experience mattersExperience matters
– Surgeons with less than 10 casesSurgeons with less than 10 cases 
56% success in SLNB56% success in SLNB
 Lymphoscintigraphy revealedLymphoscintigraphy revealed
unexpected bilateral or contralateralunexpected bilateral or contralateral
disease in about 14% of ptsdisease in about 14% of pts
 About 2-3 SLN per patientAbout 2-3 SLN per patient

60. ResultsResults
 Up to 46% of SLN harbor metastasesUp to 46% of SLN harbor metastases
– Fine section frozen analysisFine section frozen analysis
 Increases sensitivity to about 95%Increases sensitivity to about 95%
– Immunohistochemical stainingImmunohistochemical staining
 False negative ratesFalse negative rates
– 10%10%
– Grossly involved nodes less likely to take upGrossly involved nodes less likely to take up
tracertracer
 Better sensitivity for T1/T2 lesionsBetter sensitivity for T1/T2 lesions
– Most false negative results associated withMost false negative results associated with
larger T3 lesionslarger T3 lesions

61. BibliographyBibliography
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cavity and oropharynx LAURENT TSCHOPP, MD, MICHELcavity and oropharynx LAURENT TSCHOPP, MD, MICHEL
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4.4. A new approach to pre-treatment assessment of the N0 neck inA new approach to pre-treatment assessment of the N0 neck in
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June 1, 2001 / Volume 91 / Number 11June 1, 2001 / Volume 91 / Number 11