2. INTRODUCTION
• The concept of neck dissection refers to the systematic
resection of lymph nodes, along with their fibrofatty
tissue, from the various compartments of neck.
• In the vast majority of times, performed in the context
of mucosal aerodigestive tract, salivary, cutaneous or
endocrine malignancies.
• The oncological rationale involves resecting LNs that
show clinical or radiological involvement (cN+) or
those are at risk of harbouring microscopic disease
(cNo).
3.
4. LEVELS OF NECK NODES
• 7 levels of neck nodes according to Memorial Sloan
Kettering Group.
Level I – Submental & Submandibular
Level II – Upper Jugular
Level III – Middle Jugular
Level IV – Lower Jugular
Level V – Posterior triangle
Level VI – Anterior/ Central compartment
Level VII – Superior Mediastinal
7. LEVEL II
• Located around the upper
third of IJV & adjacent spinal
accessory nerve.
• 2 groups – IIA & IIB
8.
9. LEVEL III
• Around middle third of IJV
LEVEL IV
• Around lower third of IJV
10.
11.
12. LEVEL V
• Located along the lower
half of spinal accessory
nerve & transverse
cervical artery.
• 2 groups – VA & VB
13.
14. LEVEL VI
• Prelaryngeal (Delphian)
• Pretracheal
• Paratracheal
• Perithyroidal
LEVEL VII
• Superior mediastinal
15. “N” Classification – AJCC 8th edition
• Thyroid and Nasopharynx have different staging.
Nx – Regional lymph nodes cannot be assessed
N0 – No regional lymph node metastasis
N1 – Metastasis in a single I/L LN, 3cm or less in greatest dimension without
extranodal extension
N2 – N2a : Metastasis in a single I/L LN, 3-6cm without extranodal extension
N2b : Metastasis in multiple I/L LNs, none more than 6cm without extranodal
extension
N2c : Metastasis in B/L or C/L LNs, none more than 6cm without extranodal
extension
N3 - N3a : Metastasis in a LN >6cm without extranodal extension
N3b : Metastasis in a single or multiple LNs with clinical extranodal extension
16. EXTRANODAL EXTENSION
• The presence of skin involvement or soft tissue invasion
with deep fixation/tethering to underlying muscle or
adjacent structures or clinical signs of nerve involvement.
17. HISTORICAL ASPECTS OF NECK DISSECTION
• Concepts of cervical LN metastasis – Joseph Von
Chelius in 1847.
• Theoder Kocher – proposed removing nodal
metastasis
• Classical RND : George Washington Crile in 1906 –
popularised by Hayes Martin.
• Functional neck dissection – popularised by Ettore
Bocca and Pignataro
• Selective neck dissection : Oswaldo Suarez – in 1963
20. CONTRAINDICATIONS FOR NECK DISSECTION
1) Unresectable disease – invasion into carotid
artery/ brachial plexus/ prevertebral fascia/ skull
base involvement.
2) Patient unfit for major surgery
3) Primary tumour that is uncontrollable
4) Distant metastasis
21. Preoperative Considerations
• Patient should be prepared as like any major operation
• Complete oncological work up.
• Planning of the neck incision, particularly if the primary tumor is
undergoing resection simultaneously.
Anaesthesia
• General endotracheal anaesthesia.
• Tracheostomy :-
* If the primary tumour is dissected in continuity with the
neck, especially if mandible is split for access.
*If there is a concern for significant airway obstruction due to
disease, anatomy or pre-existing treatment(previous radiation)
* Can be considered in bilateral neck dissection.
22. Position of the patient during surgery
• Supine position with head
end elevated to 300
• Neck is hyper-extended
with the use of a shoulder
roll, and rotated to the
opposite side.
23. INCISION
• Factors to be considered :-
* Skin flap viability
* adequate exposure of the surgical field with
protection of the major vessels.
* consider the localization of the primary tumour.
* consider to facilitate reconstructive surgery, if
needed.
* to include previous surgical fields (scars, incision
for biopsy etc).
* to produce an acceptable cosmetic results.
24. • The incisions used in the neck dissection are generally classified into –
vertical and horizontal.
• The combined incisions are also performed.
• Transverse incisions:-
* Cosmetically better as they follow the natural skin folds.
* Recovery of the scar are rapid and successful.
* Easy to modify.
* But destroys the neck’s venous drainage from top to bottom
and is a major cause for flap separation.
• Vertical incision :-
* They intersect the natural skin folds and the vascular supply
of the neck.
* Tend to contract along the long axis.
* Have more disadvantages and not recommended especially in
a post irradiated neck.
25.
26.
27.
28. RADICAL NECK DISSECTION
Enbloc removal of all I/L LN groups extending from the inferior
border of mandible to the clavicle, from the lateral border of
sternohyoid muscle, hyoid bone and C/L anterior belly of
digastric muscle medially to the anterior border of trapezius
along with SAN, IJV and SCM.
Structures removed
• LN Level I – V
• SCM
• Spinal Accessory N
• IJV
• Tail of parotid
• Submandibular gland
• Omohyoid
Structures preserved
• Carotid Artery
• Brachial plexus
• Phrenic & Vagus nerves
• Cervical sympathetic chain
• Marginal Mandibular, Lingual
and Hypoglossal nerves
29. INDICATIONS
1. Significant operable neck disease (N2a,N2b,N3) with
tumour bulk near to or directly involving SAN/SCM/IJV.
2. Extensive recurrent disease after a previous Selective
dissection or radiotherapy.
3. Clinical signs of gross extranodal disease (N3b).
• Simultaneous bilateral RND is contraindicated, to preserve
one IJV.
30. Boundaries of surgical field
• Superiorly – Inferior border of mandible
• Anteriorly – C/L anterior belly of
digastric, hyoid and
sternohyoid muscle
• Inferiorly – Clavicle
• Posteriorly – Anterior border of
trapezius
32. EXTENDED NECK DISSECTION
• RND + Removal of any adjacent structures due to
tumour involvement or LN metastasis into additional
lymph node groups.
• Eg : * Retropharyngeal LN, Nodes in the Parotid gland,
Level VI, VII.
* Hypoglossal N, Carotid A, Skin of neck etc
33. MODIFIED RADICAL NECK DISSECTION
• Excision of all LNs routinely removed by the RND with
preservation of 1 or more non-lymphatic structures –
SAN/IJV/SCM.
• The structure preserved should be specifically named.
Eg :- MRND with preservation of SAN.
34. INDICATIONS FOR MRND
• Type I – Bulky nodal disease with extracapsular
spread involving SCM and IJV, where SAN
is free of disease.
• Type II – Bulky nodal disease with SCM involvement
but sparing the IJV and SAN.
• Type III – Metastatic disease with limited
extracapsular spread and IJV, SAN and
SCM can all be dissected free.
35. SELECTIVE NECK DISSECTION
• Refers to a cervical lymphadenectomy in which there is
preservation of 1 or more of the LN groups that are routinely
removed in the RND in addition to the non-lymphatic
structures.
• Commonly used for a clinically N0 neck in which the LN levels
at the highest risk of containing micrometastasis are
dissected.
• For N1, N2 – if post-operative irradiation is planned.
• During surgery, if positive LNs are found, especially at
multiple levels, it may be necessary to convert the dissection
to a MRND.
• LN groups to be dissected are determined by the patterns of
metastatic spread for specific tumour locations.
36. * Nasal cavity, PNS – IB,II-III * Thyroid – IV, VI, VII
* Nasopharynx – II, III, V * Parotid – Pre-auricular,
* Oral cavity – I-III/IV Peri-parotid,
* Oropharynx – II-IV Intraparotid,
* Hypopharynx - II-IV, VI II, III, VA
* Larynx - II-IV, VI
37. 1. SUPRAOMOHYOID DISSECTION
• Levels I – III
• Indications :-
* For oral cavity cancers.
* For facial skin malignancies in a line
anterior to the tragus.
* B/L neck dissection in midline lesions of the
floor of mouth or ventral tongue.
• Extended Supraomohyoid dissection :-
* Levels I – IV
* For anterolateral part of tongue cancers.
38. 2. LATERAL DISSECTION
• Levels II – IV
• For oropharyngeal, hypopharyngeal and
laryngeal tumours.
• B/L dissection – Ca hypopharynx, supraglottic.
3. POSTEROLATERAL DISSECTION
• Levels II – V
• For tumours of scalp and neck
( posterior to tragus)
• Including suboccipital and postauricular nodes
39. 4. ANTERIOR OR CENTRAL DISSECTION
• Levels VI – VII
• For Differentiated thyroid cancers, Laryngeal
carcinoma with subglottic extension, Ca of cervical
esophagus.
40. Super selective ND
• Limited to 1 or 2 contiguous neck levels.
• Done in:–
* Elective treatment of No neck.
* Salvage treatment for persistent LNs after CTRT
Elective ND
• Performed to remove LN groups in patients who
have clinically No disease which have an increased
risk of harbouring occult disease.
Therapeutic ND
• Done if metastatic cervical lymphadenopathy is clinically
evident.
41.
42.
43. Salvage Neck Dissection
• Neck dissection in a neck that has been previously treated with
RT, CT, Surgery or a combination of these three modalities.
• Can be planned or unplanned
• Planned ND :- Performed 6 to 8 weeks after the completion of
CTRT when the probability of residual disease in the neck is
high.
• Selective neck dissections are more preferred.
• Technically more challenging due to the presence of scarring
and fibrosis.
• Increased rate of post surgical complications.
• The potential acute and long-term morbidity of a salvage ND is
higher than in primary procedures.
44. SENTINEL LYMPH NODE BIOPSY
• Sentinel lymph node – A LN to which a tumor first metastasize.
• Can be useful in patients with No neck where the problem is
whether to treat or wait and watch.
• Performed using radioactive probes and/or blue dye around the
tumour site, the LNs are identified with the help of gamma cameras
or hand-held probes and send for histopathological examinations.
• The assumption is that if SLNB is negative for
metastasis, LN dissection is not necessary.
• Found to be effective for malignant melanoma
• Drawbacks:-
* The head and neck lymphatic drainage
can be variable with skip metastasis, collateral channels.
* Injection of the dye or tracer around laryngeal and
hypopharyngeal tumours are troublesome.
* More learning curve
46. 1. Hemorrhage from major vessels
• Injury to Carotid artery : -
* Repair with vascular techniques and sutures.
• Carotid blowout : -
* Rupture of the Carotid A caused by tumour
involvement of the vessel.
* Increased risk in cases of previous RT, Salvage ND.
* Constant digital pressure over the area of
hemorrhage, ligatation/ endovascular stenting/
embolization of Carotid A.
• Injury to IJV :-
* Apply pressure and the tear should be ligated.
47. 2. Nerve injury
• Injury to Spinal accessory N :-
* In 33% cases of MRND.
* Shoulder Syndrome
- due to denervation of trapezius muscle.
- impaired abduction of the shoulder, pain,
stiffness and abnormal scapular rotation.
• Injury to Phrenic N : -
* Paralysis of I/L diaphragm, Atelectasis of lung.
* Prevention – Stay above the prevertebral fascia.
48. • Injury to Marginal mandibular N :-
* Altered function of lip depressors
• Injury to Vagus N :-
* Can be damaged during the ligation of IJV or
dissecting carotid sheath.
• Injury to Cervical sympathetic chain :-
* During the dissection of carotid sheath
* Horner’s Syndrome
• Others :-
* Injury to brachial plexus, hypoglossal N, lingual N
49. 3. Chyle leak/fistula
* Thoracic duct terminates at the
junction of Left IJV and Subclavian V
or drains directly into IJV.
* Incidence – 2-8%
* Chyle leak is apparent as clear fluid intraoperatively.
* The duct can be ligated along with surrounding tissue.
* Post-operatively if a fistula is suspected :-
- Patient’s head end is kept elevated, and a pressure
dressing should be applied.
- Use of TPN
- Surgical exploration and ligation of duct if, flap necrosis,
deteriorating general condition or a high output leak
( 500 mL/day ).
50. 4. Facial/Cerebral edema
* B/L RND may result in facial/cerebral edema.
* ICP rises 3 fold when one IJV is ligated and 5 fold
when both are tied.
* Usually resolves to a variable extent with time as collateral
circulation is established.
5. Wound dehiscence and Flap necrosis
* Prevention :-
- Skin flaps must be broad based
and should be in the subplatysmal
plane, to maximise blood supply
- Trifurcate incisions should be
avoided whenever possible
51. MINIMALLY INVASIVE NECK DISSECTION
• Using endoscopes and laparoscopic
instruments
• Advantages :-
* No scar in the neck
* Accelerated wound healing
* Enable to start post-op adjuvant
treatment within 10 days
• Disadvantages :-
* Only for NO neck
* Primary tumour not able to approach
* Limited manipulation with rigid endoscopes
52. ROBOTIC SURGERY & NECK DISSECTION
• Total thyroidectomy with central neck
dissection
• Modified lateral neck dissection
• Can be done by retroauricular approach
• Advantages:–
* Extremely precise surgical dissection
* 3D and 10 times magnified vision
* Absence of tremors
* Superior cosmetic outcome
• Disadvantages :-
* More difficult than a standard approach
* More expensive
53. REFERENCES
• Scott Brown’s Otorhinolaryngology Head & Neck
Surgery – 8th edition
• Cummings Otolaryngology Head & Neck Surgery – 6th
edition
• Stell and Maran’s Textbook of Head and Neck Surgery
and Oncology – 5th edition
• Textbook of Neck Dissection – BrendanC.Stack,
Mauricio A. Moreno
• Zakir Hussain’s Otorhinolaryngology - 4th edition
• Pubmed journals
