neck dissection ,types.surgical procedure of radical neck disection

1. GOOD MORNING

2. NECK DISSECTION
By
Dr.Rehana sultana
IIIrd yr post graduate(OMFS)

3. Contents
• Introduction
• History
• Surgical anatomy
• Levels of lymph nodes
• TNM staging
• Classifications
• Definitions of types of dissections
• Surgical procedure
• Complications
• Algorithm
• Conclusion
• References

4. Some simple
questions…..
• What is neck dissection??
• Why it is done??
• When it has to be done??
• Who developed it??
• Where it is done??
• How it is done??
• What are the structures involved??
• Any complications??

5. Introduction
• Cervical node metastasis is the single most important
prognostic factor in head and neck squamous carcinomas.
• Cure rates drop in half when there is regional lymph node
involvement

6. Definition
• The term neck dissection refers to a
surgical procedure in which the fibrofatty
contents of the neck are removed for the
treatment of cervical lymphatic metastases

7. EVOLUTION
• 1880 – Kocher proposed removing nodal metastases
• 1906 – George Crile described the classic radical neck
dissection (RND)
• 1933 and 1941 – Blair and Martin popularized the RND
• 1953 – Pietrantoni recommended sparing the spinal accessory
nerves
• 1967 - Bocca and Pignataro described the “functional neck
dissection” (FND)
• 1975 – Bocca established oncologic safety of the FND compared
to the RND
• 1989, 1991, and 1994 – Medina, Robbins, and Byers respectively
proposed classifications of neck dissections

8. ANATOMY
• Skin:
– Blood supply:
• Descending branches:
– The facial
– The submental
– Occipital
• Ascending branches
– Transverse cervical
– Suprascapular
– The branches perforate the platysma muscle,
anastomose to form superficial vertically-directed
network of vessels

9. • Platysma muscle:
– Wide, quadrangular sheet-
like muscle
– Run obliquely from the
upper part of the chest to
lower face
– Skin flap is raised
immediately deep to the
muscle
– The posterior border is
over or just anterior to
IJV and great auricular
nerve

10. • Sternocleidomastoid muscle:
– Differentiated from the
platysma by the direction of
its fibres
– Crossed by the EJV and the
great auricular nerve from
inferior to posterior deep to
platysma
– The posterior border
represent the posterior
boundary of nodes level II -
IV

11. OMOHYOID MUSCLE
• Inferior belly passes behind the
sternocleidomastoid
• Superior belly lies close to the
lateral border of the sternohyoid
and inserted into the lower border
of the body of the hyoid bone
• The central tendon of this muscle
is held in position by a fascial sling
derived from investing layer of deep
cervical fascia and is prolonged
down to be attached to the clavicle
and first rib

12. • MARGINAL MANDIBULAR
NERVE:
– Located 1 cm in front of
and below the angle of
the mandible
– Deep to the superficial
layer of the deep cervical
fascia
– Superficial to adventitia of
the anterior facial vein

13. • Spinal Accessory nerve:
– Emerge from the jugular
foramen medial to the digastric
and stylohyoid muscles and
lateral and posterior to IJV (30%
medial to the vein and in 3 -5%
split the vein)
– It passes obliquely downward
and backward to reach the
medial surface of the SCM near
the junction of its superior and
middle thirds, Erb’s point

14. • Trapezius muscle:
– Its anterior border is the
posterior boundary of
levelV
– Difficult to identify
because of its superficial
position
– Dissect superficial to the
fascia in order to preserve
the cervical nerves

15. • Digastric Muscle: Posterior
belly:
– Originate from a groove
in the mastoid process,
digastric ridge
– The marginal mandibular
nerve lie superficial
– The external and internal
carotid artery, hypoglossal
and 11th
cranial nerves and
the IJV lie medial

16. • Brachial Plexus & Phrenic nerve:
– The plexus exit between the
anterior and middle scalene
muscles, pass inferiorly deep
to the clavicle under the
posterior belly of the
omohyoid
– The phrenic nerve lie on top
of the anterior scalene
muscle and receive its
cervical supply from C3 – C5

17. • Thoracic duct:
– Located in the lower left
neck posterior to the
jugular vein and anterior to
phrenic nerve and
transverse cervical artery
– Have a very thin wall and
should be handled gently to
avoid avulsion or tear
leading to chyle leak

18. Hypoglossal nerve:
• Exit via the hypoglossal canal near
the jugular foramen
• Passes deep to the IJV and over the
ICA and ECA and then deep and
inferior to the digastric muscle and
enveloped by a venous plexus, the
ranine veins
• Pass deep to the fascia of the floor
of the submandibular triangle
before entering the tongue

19. Anatomy of the vascularization of neck skin
• Kambic and Sirca 1967 stated that arterial supply is in
a vertical direction.
• descending branches: facial and occipital artery
• ascending branches: transverse cervical and
supraclavicular arterial branches .

20. The vasculature can be summarized into
• upper neck region - anterior to the angle of mandible -
branches of facial and submental arteries.
• upper lateral neck - the area between ramus of mandible and
the sternocleidomastoid muscle-Occipital and external
auricular branches of external carotid .
• Lower half of neck - The transverse cervical artery and
suprascapular artery
• Large platysma-cutaneous branches and branches of superior
thyroid supplying the front middle portion of the neck.

21. LYMPH NODES OF HEAD &
NECK
Conventionally divided into three systems
• Waldeyers internal ring
• Superficial lymph node system (Waldeyers external ring)
• Deep lymph node system (cervical lymph nodes proper)

22. Waldeyer’s ring
• Circular collection of
lymphoid tissue within the
pharynx at the skull base.
• Ring includes the
adenoids, tubal and lingual
tonsils, palatine tonsils,
aggregates on the
posterior pharyngeal wall.

23. Superficial nodal system
• Drains the superficial tissues of
the head and neck.
• Two circles of nodes, one in the
head and the other in the neck.
• In the head – nodes are situated
around the skull base
• In the neck – submental,
submandibular and anterior
cervical nodes.

24. Deep lymph nodal system
Deeper fascial structures of
the head and neck drain
either directly into the deep
cervical nodes or through
the superficial system.
• A. junctional nodes
• B. internal jugular nodes
• C. spinal accessory nodes
• D. Supraclavicular nodes
• E. nuchal nodes
• F. Deep medial visceral
nodes

25. Classification of lymphnode levels by Memorial
Sloan-Kettering Cancer Center
The boundaries of each
being defined by
surgically visible bones,
muscles, blood
vessels or nerves.
Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW. Standardizing
neck dissection terminology. Official report of the academy’s committee for head and
neck surgery and oncology. Arch Otolaryngol Head Neck Surg 1991;117:601–5.

26. Levels of lymph nodes

27. Draining areas

28. Spread of cancer in
lymphatics
• Embolisation
• Permeation

29. T Classification
• T – Primary tumour :
• T x primary tumour that cannot be assessed.
• T 0 No evidence of primary tumour.
• T is Carcinoma in situ.
• T 1 Tumour 2 cms or less in the greatest diameter.
• T 2 Tumour 2cms but not more than 4cms in the
greatest diamension.
• T 3 Tumour more than 4 cms in the greatest

30. T 4 a – Lip :
Tumour invades through the cortical bone, inferior
alvoelar nerve, floor of the mouth or skin.
T 4 a – oral cavity :
Tumour invades through the cortical bone into the deep
extrensic muscles of the tongue ( genioglossus, hypoglossus,
palatoglossus, styloglossus ) , maxillary sinus or skin of the
face.
T 4 b – lip and oral cavity :
Tumour invades the massetric space, pterygoid plates, skull
base or encases the internal carotid artery.

31. T staging

32. N staging

33. • Distant metastases – M
• M x – distant metastases that cannot be assessed.
• M 0 – No distant metastases.
• M 1 – distant metastases.

34. Staging
N0 N1 N2 N3
T1 I
T2 II
T3 III
T4 IV

35. Impact of pattern of nodal metastasis on
neck dissection
Level of nodal involvement Site of primary tumour
Submental(IA) Floor of mouth, lips and anterior
part of tongue
Submandibular(IB) Retromolar trigone, glossopalatine
pillars,lateral floor of mouth&
anterior tongue
Jugulodigastric(II) Hypopharynx, base of tongue, tonsil,
nasopharynx & larynx
Mid jugular(III) Hypopharynx, base of tongue, tonsil,
nasopharynx & larynx
Lower jugular(IV) Thyroid, nasopharynx &
hypopharynx
Supraclavicular(V) Lung, thyroid, gastrointestinal &
genito urinary system
Posterior triangle(VI) Nasopharynx

36. Factors affecting nodal metastasis
• Anterior portions < posterior portions.
• Young patients > older patients.
• Risk of neck involvement by metastasis increases with an
increase in tumor size.
• Perineural and perivascular invasion are associated with a
high risk of nodal metastasis.
• Poorly differentiated tumors > well-differentiated tumors.

37. Assessment of cervical lymph nodes
• Computed tomography
• Magnetic resonance imaging
• Ultrasound
• Ultrasound guided fine
needle aspiration cytology
• Radionuclide scanning
• SPECT
• PET
• Sentinel node biopsy
• Lymphoscintigraphy

38. • PET scan showed the highest specificity (82%) while ultrasound
had highest sensitivity (84%)
• Due to high number of small lymph node metastases from oral
cavity carcinoma, the non-invasive neck staging methods are limited
to a maximum accuracy of 76%
• Elective neck treatment should be mandatory for all patients with
squamous cell carcinoma of the oral cavity

39. • Sentinel lymph node is defined as a lymph node
to which a tumor first metastasizes
• SLNB if negative for metastases, lymph node
dissection is not necessary.
• use in oral cancer – controversial
• One of the main problem of SLNB of oral cancer
is skip metastasis in which the disease by passes
level 1 and 2 nodes and goes directly to level 3-4
Sentinel node biopsy

40. When neck dissection has to be
done?
• The incidence of metastatic disease for the upper
aerodigestive tract varies widely, from 1-85%, depending on
the site, size, and differentiation of the tumor.
• The rate of ipsilateral metastatic disease in patients with
stage T3-T4 squamous cell carcinoma of the oral cavity,
oropharynx, hypopharynx, or supraglottis is approximately
50%.
• The rate of bilateral or contralateral metastatic disease in
these patients varies from 2-35%.
• 20 – 30 % of the malignancies of tongue metastasize to
clinically undetectabe cervical nodes

41. Patterns of cervical lymph node metastasis from squamous carcinomas of
the upper aerodigestive tract.
Am J Surg. 1990 Oct;160(4):405-9
• A consecutive series of 1,081 previously untreated patients
undergoing 1,119 RNDs for squamous carcinoma of the
head and neck was reviewed to study the patterns of
nodal metastases.
• Predominance of certain levels was seen for each primary
site. Levels I, II, and III were at highest risk for metastasis
from cancer of the oral cavity.
• SOHND (clearing levels I, II, and III) for NO patients with
primary squamous cell carcinomas is recommended

42. • For patients with clinical cervical lymph node metastases a
therapeutic neck dissection is necessary and a modified
radical dissection is regarded as the safest option.
Management of the neck in patients withT1 andT2 cancer in the
mouthBJOMSVol 40, issue 6 .December 2004, Pages 494-500

43. •Excluding the hard palate and lip, approximately 30% of
patients with oral cavity cancer will present with cervical
metastases
• Depth of invasion greater than 8 mm was associated with a
41% rate of occult metastasis.
•Tumour depth > 5mm --- Increased risk of neck metastasis

44. Does No neck require
treatment??
• The metastases rate to the neck from oral cancer is 34%.
• Observation if probability is less than 20%
• Elective neck dissection - >20 %
• The lymph nodes at the highest risk of metastases from oral cavity
cancers are those at level I, II, III.
• Contralateral neck dissection: The primary oral cancer is midline
,bilateral along the tip of tongue or approaches /crosses midline.

45. • The following surgical outline was suggested:
– SCC oral cavity anterior to circumvalate papilla
• Supraomohyoid
– SCC Oropharynx, larynx and hypopharynx
• level I- IV or level II-V
– SCC with N+ nodes
• RND
– SCC with 2-4 positive nodes or extracapsular spread
• RND and adjuvant therapy
Shah Cancer July 1;109-113: 1990

46. Goals
• Remove gross disease in patients with clinical evidence of
nodal involvement (therapeutic neck dissection)
• Remove occult metastases in patients whose tumor
characteristics make one suspicious of occult cervical
metastases (elective neck dissection or END)

47. The definition of the different types of neck dissections were
outlined in the 1991 classification :
1) The radical neck dissection is considered to be a standard
basic procedure for cervical lymphadenopathy.
2) When one or more of the non lymphatic structures are
preserved which otherwise are routinely removed during
radical neck dissection then it is termed as modified radical
neck dissection.

48. 3) When the alteration involves preserving the 1 or more
lymph node groups / levels routinely removed in radical
neck dissection the it is termed as selective neck dissection.
4) When the alteration involves the removal of additional
lymph node groups or non lymphatic structures relative to
the radical neck dissection the procedure is called as
extended radical neck dissection.

49. Classification
 1991 classification
1. Radical neck dissection
2. Modified radical neck
dissection
3. Selective neck dissection
a ) supra omohyoid
b ) lateral
c ) posterolateral
d ) anterior
4. Extended neck dissection
 2001 classification
1. Radical neck dissection
2. Modified radical neck
dissection
3. Selective neck dissection
Here each variation is
depicted by the term “ SND “
and the use of parentheses to
denote the levels or sublevels
removed
4. Extended neck dissection

50. Medina classification (1989)
– Comprehensive neck dissection
• Radical neck dissection
• Modified radical neck dissection
– Type I (XI preserved)
– Type II (XI, IJV preserved)
– Type III (XI, IJV, and SCM preserved)
– Selective neck dissection

51. Spiro’s three- tiered classification-1994
• Radical (4 or 5 levels resected)
• Conventional radical neck dissection
• Modified radical neck dissection
• Extended radical neck dissection
• Modified and extended radical neck dissection
• Selective (3 node levels resected)
• Supra-omohyiod neck dissection
• Jugular dissection (levels 11-1V)
• Any other 3-node levels resected
• Limited (no more than 2 nodes levels resected)
• Para tracheal node dissection
• mediastinal node dissection

52. Radical neck dissection
• Indications
– Extensive cervical involvement or matted lymph nodes
with gross extracapsular spread and invasion into the
SAN, IJV, or SCM
– Significant operable neck disease (N2a,2b,2c)
– Access prior to pedicled flap reconstruction
– Occult primary
– lymphangioma, haemlymphangioma, residual branchial
cyst, fistula

53. Contraindications
– Untreatable primary tumor
– Patients unfit for tumor surgery
– Distant metastasis
– Inoperable neck disease
– Significant bilateral neck disease

54. Extent:
Removes
Nodal groups I-V
SCM, IJV, XI
Submandibular gland, tail of
parotid
Preserves
Posterior auricular
Suboccipital
Retropharyngeal
Periparotid
Perifacial
Paratracheal nodes

55. Preoperative Considerations
1. Age and Sex of the patient
2. Consent /any allergies/ lab reports/vital signs
3. Location of the Primary
4. Unilateral vs. Bilateral Neck Dissection
5. Location of Adenopathy/ Type of Neck Dissection
6. Likelihood of Postoperative Radiation
7. Patterns of Skin Necrosis in different Skin flap designs
8. Potential for Wound healing problems
9. Need for reconstructive flaps
10. Tracheotomy may affect blood supply of some flap designs

56. POSITION OF THE PATIENT
1. The patient is laid supine
2. The head turned opposite side
and hyperextended, resting on
head ring
3.Upper end of the operating table
elevated approximately 30
degree.
4.Mastoid tip., Ear lobule, Body of the
mandible, midline of the chin,
supra-sternal notch, clavicle and
region of trapizius muscle
insertion should be visible

57. General Rules
General Rule of Placing the Incisions in Lines of
Relaxed SkinTension Lines (RSTL)
1. Horizontal Curving Incisions placed at a level in the neck depending on the
site of the tumor
2. Facial incisions for parotid tumors can be combined with various neck
incisions depending on preoperative considerations
3. High submandibular incisions should be placed at least 2cm below body of
mandible
4. General Rule of placing vertical incisions so that weakest blood supply
areas and trifurcations are away from (usually posterior to) carotid artery
and at right angles for at least 2cm then with a "lazy" S-shape to minimize
potential for scar contracture

58.
• 1.Good exposure of the neck and primary disease.
• 2. Ensure viability of the skin flaps.Avoid acute angles
• 3. Protect carotid artery even in the cases of wound infection
• 4.Considered preoperative factor—previous radio or
chemotherapy.
• 5. Facilitate reconstruction Example, if pectoral muscle is
used a lower limb should be near the clavicle to enable flap
accommodation.
• 6. It should be cosmetically acceptable

59. Incisions
Y incision Mc fee incision
59
Schobinger Incision
Modified schobinger Conley’s Double Y

60. Apron incision Half apron incision
60
H incision

61. Steps of Radical Neck Dissection

62. Incision

63. Dissection of the posterior triangle begins at
the anterior border of trapezius

64. Dissection of the posterior triangle medially leads
to exposure of brachial plexus, phrenic nerve and
cutaneous roots of the cervical plexus

65. Specimen reflected posteriorly and anterior flap
elevated to expose the sternal head of SCMM

66. Sternocleidomastoid muscle is detached from the
sternum and clavicle and retracted cephalad to
expose the carotid sheath

67. Internal jugular vein is ligated and divided after
common carotid and vagus nerve is exposed and
retracted medially

68. Dissection proceeds cephalad along the carotid
sheath up the skull base

69. The upper skin flap is now elevated preseving the
mandibular branch of the facial nerve

70. Supraclavicular dissection 70

71. Dissection of the posterior
triangle 71

72. Retraction of the posterior belly of digastric show the upper end of
the IJV in level II
72

73. Division of the veins related to
hypoglossal nerve 73

74. Levels II-V dissection
completed by
removing the
specimen and
dissecting the IJV from
carotid artery and
vagus nerve
74

75. Surgical field following RND

76. Shoulder syndrome
“Physical changes occuring in the shoulder joint due to
denervation of trapezius leading to destabilization of
scapula,pain and weakness and deformity of shoulder
girdle,restricting the patient’s ability to abduct shoulder
not above 90 ”
-NAHUM

77. Modified radical neck
dissection(MRND)
– Excision of same lymph
node bearing regions as
RND with preservation of
one or more non-
lymphatic structures (SAN,
SCM, IJV)
– MRND is analogous to the
“functional neck
dissection” described by
Bocca
77

78. Three types (Medina 1989) .
• Type I: Preservation of SAN
• Type II: Preservation of SAN and IJV
• Type III: Preservation of SAN, IJV, and
SCM ( “Functional neck
dissection”)
78

79. MRND TYPE I
MRND TYPE I MRND TYPE II

80. MRND TYPE III
Advantages :
– Reduce postsurgical
shoulder pain and shoulder
dysfunction
– Improve cosmetic outcome
– Reduce likelihood of
bilateral IJV resection in a pt
with bilateral lymph node
metastasis.

81. Selective Neck Dissection
– Cervical lymphadenectomy with preservation of one
or more lymph node groups
– Four common subtypes:
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection
Indication: primary lesion with 20% or greater
risk of occult metastasis

82. SND: Supraomohyoid type
• Most commonly performed
SND
• Definition
– En bloc removal of
cervical lymph node
groups I-III
– Posterior limit is the
cervical plexus and
posterior border of the
SCM
– Inferior limit is the
omohyoid muscle
overlying the IJV

83. Surgical procedure

84. SND: Lateral Type
• Definition
– En bloc removal of the
jugular lymph nodes
including Levels II-IV
• Indications
– N0 neck in carcinomas of
the oropharynx,
hypopharynx, supraglottis,
and larynx

85. SND: Posterolateral Type
• Definition
– En bloc excision of
lymph bearing tissues
in Levels II-IV and
additional node groups
– suboccipital and
postauricular
• Indications
– Cutaneous malignancies
• Melanoma
• Squamous cell
carcinoma
• Merkel cell
carcinoma
– Soft tissue sarcomas of
the scalp and neck

86. SND: Anterior Compartment
• Definition
– En bloc removal of lymph
structures in LevelVI
• Perithyroidal nodes
• Pretracheal nodes
• Precricoid nodes
(Delphian)
• Paratracheal nodes
along recurrent nerves
– Limits of the dissection
are the hyoid bone,
suprasternal notch and
carotid sheaths
• Indications
– Selected cases of
thyroid carcinoma
– Parathyroid carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma
with subglottic
extension
– CA of the cervical
esophagus

87. Types of neck dissections

88. Extended Neck Dissection
• Definition
– Any previous dissection
which includes removal of
one or more additional
lymph node groups and/or
non-lymphatic structures.
– Usually performed with N+
necks in MRND or RND
when metastases invade
structures usually
preserved.
• Indications
– Carotid artery invasion
– Other examples:
• Resection of the hypoglossal
nerve resection or digastric
muscle,
• dissection of mediastinal nodes
and central compartment for
subglottic involvement, and
• removal of retropharyngeal
lymph nodes for tumors
originating in the pharyngeal
walls.

89. Complications
INTRAOPERATIVE
• Hemorrhage
• Carotid sinus reflux
• Pneumothorax
• Air embolus
• Embolism
• Nerve damage
• Chylous fistula
POST OPERATIVE
• Hematoma
• Wound infection
• Skin flap loss
• Salivary fistula
• Chylous fistula
• Blindness
• Facial edema
• Electrolyte disturbances
• Carotid artery rupture

90. ALGORITHM FOR NECK DISSECTION

91. Important facts
• High incidence of occult mets in T1 & T2 leisons
involving floor of mouth ( 21% & 62%)
• Crossing the midline increases the incidence of contra/
bilateral nodal mets
leison 1cm away from midline …15%
leison within 1 cms of midline… 15-30%
leison crossing the midline……..>30 %
20 – 30 % of the malignancies of tongue metastasize to
clinically undetectabe cervical nodes
High incidence of skip metastasis- cancer of tongue

92. References
• Textbook on oral cancer – JATIN .P.SHAH
• Robbins KT. Classification of neck dissection: current
concepts and future considerations. Otolaryngol Clin North
Am.Aug 1998;31(4):639-55
• Shah JP: Patterns of lymph node metastasis from squamous
carcinomas of the upper aerodigestive tract. Am J Surg 1990,
160:405-409.
• Medina JE, Byers RM: Supraomohyoid neck dissection:
Rationale, indication and surgical technique.Head Neck
1989, 11:111-122