neck dissection
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Neck DissectionNeck Dissection
DefinitionDefinition
It is a procedure to remove lymph nodes It is a procedure to remove lymph nodes and surrounding fibro fatty tissues from and surrounding fibro fatty tissues from neck to eradicate metastasis to cervical neck to eradicate metastasis to cervical lymph nodes in cancer of aerodigestive lymph nodes in cancer of aerodigestive
tract.tract.
Fascial layers of the neckFascial layers of the neck
Superficial cervical fasciaSuperficial cervical fascia
• • Deep cervical fasciaDeep cervical fascia
– – Superficial layerSuperficial layer • • SCM, strap muscles, trapeziusSCM, strap muscles, trapezius
– – Middle or Visceral LayerMiddle or Visceral Layer
• • ThyroidThyroid
• • TracheaTrachea
• • esophagusesophagus
– – Deep layer (also prevertebral fascia)Deep layer (also prevertebral fascia)
• • Vertebral musclesVertebral muscles
• • Phrenic nervePhrenic nerve
Level ILevel I
Submental triangle Submental triangle (Ia)(Ia)• Anterior digastricAnterior digastric• HyoidHyoid• MylohyoidMylohyoid
Submandibular Submandibular triangle (Ib)triangle (Ib)• Anterior and Anterior and
posterior digastricposterior digastric• Mandible.Mandible.
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
Level IILevel II
Upper Jugular NodesUpper Jugular Nodes Anterior Anterior Lateral Lateral
border of sternohyoid, border of sternohyoid, posterior digastric and posterior digastric and stylohyoidstylohyoid
Posterior Posterior Posterior Posterior border of SCMborder of SCM
Skull baseSkull base Hyoid bone (clinical Hyoid bone (clinical
landmark)landmark) Carotid bifurcation Carotid 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 cavity and laryngeal Oropharynx > oral cavity and laryngeal metsmets
Spinal Accessory NerveSpinal Accessory Nerve
CN XI – Relationship with the IJVCN XI – Relationship with the IJV
Level IILevel II
Oral CavityOral Cavity Nasal CavityNasal Cavity NasopharynxNasopharynx OropharynxOropharynx LarynxLarynx HypopharynxHypopharynx ParotidParotid
Level IIILevel III
Middle jugular nodesMiddle jugular nodes• Anterior Anterior Lateral border of Lateral border of
sternohyoidsternohyoid• Posterior Posterior Posterior border Posterior border
of SCM of SCM • Inferior border of level IIInferior border of level II• Cricoid cartilage lower Cricoid cartilage lower
border (clinical landmark) border (clinical landmark) • Omohyoid muscle (surgical Omohyoid muscle (surgical
landmark)landmark) Junction with IJVJunction with IJV
Level IIILevel III
Oral cavityOral cavity
NasopharynxNasopharynx
OropharynxOropharynx
HypopharynxHypopharynx
LarynxLarynx
Level IVLevel IV
Lower jugular nodes Lower jugular nodes • Anterior Anterior Lateral border Lateral border
of sternohyoidof sternohyoid• Posterior Posterior Posterior Posterior
border of SCMborder of SCM• Cricoid cartilage lower Cricoid cartilage lower
border (clinical landmark)border (clinical landmark)• Omohyoid muscle Omohyoid muscle
(surgical landmark)(surgical landmark) Junction with IJVJunction with IJV
• ClavicleClavicle
Level IVLevel IV
HypopharynxHypopharynx
LarynxLarynx
ThyroidThyroid
Cervical esophagusCervical esophagus
Level VLevel V
Posterior triangle of neck Posterior triangle of neck • Posterior border of SCMPosterior border of SCM• ClavicleClavicle• Anterior border of Anterior border of
trapeziustrapezius• VaVa Spinal accessory Spinal accessory
nodesnodes• Vb Vb Transverse cervical Transverse cervical
artery nodesartery nodes Radiologic landmarkRadiologic landmark
• Inferior border of CricoidInferior border of Cricoid
• Supraclavicular nodesSupraclavicular nodes
Level VLevel V
NasopharynxNasopharynx
OropharynxOropharynx
Posterior neck and scalpPosterior neck and scalp
Level VILevel VI
Anterior Compartment StructuresAnterior Compartment Structures
BoundariesBoundaries• Above by Hyoid boneAbove by Hyoid bone• Below by Suprasternal notchBelow by Suprasternal notch• On either side by medial border of On either side by medial border of
Carotid sheathCarotid sheath
Level VILevel VI
Lymph NodesLymph Nodes• PerithyroidalPerithyroidal• PretrachealPretracheal• Precricoid Nodes (Delphian)Precricoid Nodes (Delphian)• Paratracheal nodes along recurrent Paratracheal nodes along recurrent
laryngeal nerveslaryngeal nerves
Level VILevel VI
ThyroidThyroid
Larynx (glottic and subglottic)Larynx (glottic and subglottic)
Pyriform sinus apexPyriform sinus apex
Cervical esophagusCervical esophagus
SubgroupsSubgroups IaIa SubmentalSubmental IbIb SubmandibularSubmandibular
IIaIIa Upper jugular (Anterior to XI)Upper jugular (Anterior to XI) IIb IIb 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 (Transverse Posterior triangle (Transverse
cervical)cervical)
VIVI Central compartmentCentral compartment
Face and Face and ScalpScalp AnteriorAnterior Facial, IbFacial, Ib
LateralLateral ParotidParotid
PosteriorPosterior Occipital, VOccipital, V
EyelidsEyelids MedialMedial IbIb
LateralLateral Parotid, IIParotid, II
ChinChin Ia, Ib, IIIa, Ib, II
External EarExternal Ear AnteriorAnterior Parotid, IIParotid, II
PosteriorPosterior Post auricular, II, VPost auricular, II, V
Middle EarMiddle Ear Parotid, IIParotid, II
Floor of Floor of mouthmouth AnteriorAnterior Ia, Ib, IIa > IIbIa, Ib, IIa > IIb
Lower incisorsLower incisors Ia, Ib, IIaIa, Ib, IIa > IIb > IIb
LateralLateral Ib, IIaIb, IIa > IIb > IIb, III, III
Teeth except Teeth except
incisorsincisors Ib, IIa Ib, IIa > IIb> IIb, III, III
Nasal CavityNasal Cavity AnteriorAnterior IbIb
PosteriorPosteriorRetropharyngeal, Retropharyngeal,
II, VII, V
Common Nodal Drainage PatternsCommon Nodal Drainage Patterns
Nasal CavityNasal Cavity PosteriorPosterior Retropharyngeal, II, VRetropharyngeal, II, V
NasopharynxNasopharynx Retropharyngeal, II, Retropharyngeal, II,
III, VIII, V
OropharynxOropharynx IIb > IIa, III, IV, VIIb > IIa, III, IV, V
LarynxLarynxSupraglottSupraglott
icic IIa > IIb, III, IVIIa > IIb, III, IV
SubglotticSubglottic VI, IVVI, IV
Cervical Cervical esophagusesophagus IV, VIIV, VI
ThyroidThyroid VI, IV, V, MediastinalVI, IV, V, Mediastinal
TongueTongue TipTip Ia, Ib, IIa > IIb, III, IV Ia, Ib, IIa > IIb, III, IV
LateralLateral Ib, IIa > IIb, III, IVIb, IIa > IIb, III, IV
Common Nodal Drainage PatternsCommon Nodal Drainage Patterns
StagingStaging Nx: Regional lymph nodes cannot be assessed.Nx: Regional lymph nodes cannot be assessed.
N0: No regional lymph node metastases.N0: No regional lymph node metastases.
N1: Single ipsilateral lymph node, N1: Single ipsilateral lymph node, << 3 cm 3 cm
StagingStaging
N2a: Single ipsilateral lymph node 3 to N2a: Single ipsilateral lymph node 3 to 6 cm6 cm
N2b: Multiple ipsilateral lymph nodes N2b: Multiple ipsilateral lymph nodes << 6 cm 6 cm
N2c: Bilateral or contralateral nodes N2c: Bilateral or contralateral nodes << 6cm6cm
N3: Metastases > 6 cmN3: Metastases > 6 cm
StagingStaging
Nasopharyngeal CarcinomaNasopharyngeal Carcinoma• N1 – Unilateral < 6cmN1 – Unilateral < 6cm• N2 – Bilateral < 6 cmN2 – Bilateral < 6 cm• N3a > 6 cmN3a > 6 cm• N3b – Extension to N3b – Extension to
supraclavicular fossasupraclavicular fossa
ThyroidThyroid• N1 – Regional node metsN1 – Regional node mets
N1a - IpsilateralN1a - Ipsilateral N1b - Bilateral, midline, N1b - Bilateral, midline,
contralateral cervical or contralateral cervical or mediastinal LNmediastinal LN
Classification Classification
The RND is classified according to The RND is classified according to the Academy’s Committee for Head the Academy’s Committee for Head & Neck Surgery & Oncology into & Neck Surgery & Oncology into four major typefour major type::
1.1. Radical Neck Dissection Radical Neck Dissection (RND)(RND)
1.1. Modified Radical Neck Dissection Modified Radical Neck Dissection (MRND)(MRND)
3.3. Selective Neck Dissection Selective Neck Dissection (SND)(SND)
1.1. SupraomohyoidSupraomohyoid
1.1. PosterolateralPosterolateral
2.2. Lateral Lateral
3.3. AnteriorAnterior
4.4. Extended Radical Neck Dissection Extended Radical Neck Dissection (ERND)(ERND)
ClassificationClassification
Radical neck Dissection:Radical neck Dissection:• Removing all lymphatic tissues in regions I - V Removing all lymphatic tissues in regions I - V • Spinal Acessory NerveSpinal Acessory Nerve• Internal Jugular veinInternal Jugular vein• Sternocleidomastoid muscleSternocleidomastoid muscle• Submandibular Salivary glandSubmandibular Salivary gland• Tail of parotidTail of parotid• Omohyoid muscleOmohyoid muscle
ClassificationClassification
Modified radical neck dissection:Modified radical neck dissection:• Excision of all lymph nodes removed Excision of all lymph nodes removed
with RND with preservation of one or with RND with preservation of one or more non-lymphatic structures, SAN, more non-lymphatic structures, SAN, SCM and/or IJVSCM and/or IJV
Subtype I: Preserve SANSubtype I: Preserve SAN Subtype II: Preserve SAN & IJVSubtype II: Preserve SAN & IJV Subtype III: preserve SAN, IJV and SCM Subtype III: preserve SAN, IJV and SCM
• Known as Functional neck dissection (Bocca)Known as Functional neck dissection (Bocca)
ClassificationClassification
Selective Neck dissection:Selective Neck dissection:• Any type of cervical lymphadenectomy Any type of cervical lymphadenectomy
with preservation of one or more lymph with preservation of one or more lymph node groupsnode groups
• Four subtype:Four subtype: Supraomohyoid neck dissectionSupraomohyoid neck dissection Posterolateral neck dissectionPosterolateral neck dissection Lateral neck dissectionLateral neck dissection Anterior neck dissectionAnterior neck dissection
ClassificationClassification
• Supraomohyoid neck dissection:Supraomohyoid neck dissection: Removal of lymph nodes in regions I –III Removal of lymph nodes in regions I –III The posterior limit is the cutaneous branches of the The posterior limit is the cutaneous branches of the
cervical plexus and posterior border of SCMcervical plexus and posterior border of SCM The inferior limit is the superior belly of the omohyoid The inferior limit is the superior belly of the omohyoid
where it cross IJN where it cross IJN
• Posterolateral neck dissectionPosterolateral neck dissection Removal of suboccipital, retroauricular, levels II – V Removal of suboccipital, retroauricular, levels II – V
and level Vand level V Subtyped I – III depending on the preservation of Subtyped I – III depending on the preservation of
SAN, IJV and /or SCMSAN, IJV and /or SCM
ClassificationClassification
• Lateral neck dissection:Lateral neck dissection: Remove lymph nodes in levels II – IV Remove lymph nodes in levels II – IV
• Anterior neck dissection:Anterior neck dissection: Require the removal of the lymph nodes Require the removal of the lymph nodes
surrounding the visceral structure in the surrounding the visceral structure in the anterior aspect of the neck, level VIanterior aspect of the neck, level VI
Superior limit, hyoid boneSuperior limit, hyoid bone Inferior limit, suprasternal notchInferior limit, suprasternal notch Laterally, the carotid sheathLaterally, the carotid sheath
Structures to be preservedStructures to be preserved
Carotid arteryCarotid artery Brachial Plexus, Phrenic & vagus Brachial Plexus, Phrenic & vagus
nerve, cervical sympathetic chain,nerve, cervical sympathetic chain,
marginal mandibular, lingual andmarginal mandibular, lingual and
hypoglossal nerveshypoglossal nerves
IndicationsIndications
Radical Neck DissectionRadical Neck Dissection
1.1. Multiple clinically obvious cervical lymph Multiple clinically obvious cervical lymph node metastasis particularly of posterior node metastasis particularly of posterior triangle and closely related to SANtriangle and closely related to SAN
2.2. Large metastatic tumor mass or multiple Large metastatic tumor mass or multiple matted in upper part of the neckmatted in upper part of the neck
Tumor should not be dissected to preserve Tumor should not be dissected to preserve Structures Structures
ClassificationClassification
Extended neck dissection:Extended neck dissection:• Any previous dissection and including Any previous dissection and including
one or more additional lymph node one or more additional lymph node groups and/or non-lymphatic tissuesgroups and/or non-lymphatic tissues
FactsFacts
General nodal metastasis produce General nodal metastasis produce the following fact:the following fact:• The most important factor in prognosis The most important factor in prognosis
of SCC of the upper aero-digestive tract of SCC of the upper aero-digestive tract is the status of cervical lymph nodesis the status of cervical lymph nodes
• Cure rate drops 50% with involvement Cure rate drops 50% with involvement of the regional lymph nodesof the regional lymph nodes
IndicationsIndications
Modified radical neck dissectionModified radical neck dissection
• MRND Type I:MRND Type I:1.1. Clinically obvious neck lymph nodes Clinically obvious neck lymph nodes
metastasis and SAN not involved by tumormetastasis and SAN not involved by tumor
2.2. Intraoperative decision just like Intraoperative decision just like preservation of the facial nerve in parotid preservation of the facial nerve in parotid surgerysurgery
IndicationsIndications MRND Type II:MRND Type II:
1.1. Rarely plannedRarely planned2.2. Intra-operative decision for tumor found Intra-operative decision for tumor found
adherent to SCM but away from SAN & IJVadherent to SCM but away from SAN & IJV MRND Type III:MRND Type III:
• Depend on the autopsy reportsDepend on the autopsy reports1.1. Lymph nodes were in the fibrofatty and do not Lymph nodes were in the fibrofatty and do not
share the same adventitia with blood vesselsshare the same adventitia with blood vessels2.2. They are not found within the aponeurosis or They are not found within the aponeurosis or
glandular capsule of the submandibular “Functional glandular capsule of the submandibular “Functional neck dissection” neck dissection”
IndicationsIndications
MRND Type III:MRND Type III:• For treatment of NFor treatment of N00 neck nodes neck nodes
• Indicated for NIndicated for N11 mobile nodes and not mobile nodes and not greater than 2.5 – 3.0 cmgreater than 2.5 – 3.0 cm
Contra-indicated in the presence of node Contra-indicated in the presence of node fixationfixation
Result is difficult to interpret because of the Result is difficult to interpret because of the use of radiation therapy use of radiation therapy
IndicationsIndications Selective/elective neck Selective/elective neck
dissection:dissection:• For treatment of NFor treatment of N00 neck nodes neck nodes• For N+ nodes when combined with For N+ nodes when combined with
radiotherapyradiotherapy Adjuvant radiotherapy for Adjuvant radiotherapy for
patient with 2 – 4 positive nodes patient with 2 – 4 positive nodes or extra-capsular spreador extra-capsular spread
• Upgrade intra-operatively Upgrade intra-operatively following positive frozen sectionfollowing positive frozen section
SND : Supra Omohyoid TypeSND : Supra Omohyoid Type
Oral cavity carcinoma with NOral cavity carcinoma with N00 Neck NeckHoffman oral cavityHoffman oral cavity Level 1 – 30.1 %Level 1 – 30.1 % Level 2 – 35.7 %Level 2 – 35.7 % Level 3 – 22.8 %Level 3 – 22.8 % Level 4 – 9.1 %Level 4 – 9.1 % Level 5 – 2.2 %Level 5 – 2.2 %
SND : Lateral TypeSND : Lateral Type
NN00 Neck in carcinomas of Neck in carcinomas of• OropharynxOropharynx• HypopharynxHypopharynx• SupraglottisSupraglottis• Glottic Larynx Glottic Larynx
SND : Posterolateral TypeSND : Posterolateral Type
- Cutaneous malignancies- Cutaneous malignancies• MelanomaMelanoma• SCCSCC• Merkell cell CarcinomaMerkell cell Carcinoma
- Soft tissue sarcomas of scalp and - Soft tissue sarcomas of scalp and neckneck
SND : Anterior CompartmentSND : Anterior Compartment
Selected Cases of Thyroid CarcinomaSelected Cases of Thyroid Carcinoma
Parathyroid CarcinomaParathyroid Carcinoma
Subglottic CarcinomaSubglottic Carcinoma
CA of Cervical OesophagusCA of Cervical Oesophagus
Y Incision Y Incision
McFee IncisionMcFee Incision
H IncisionH Incision
J IncisionJ Incision
COMPLICATIONSCOMPLICATIONS
• Air embolusAir embolus• PneumothoraxPneumothorax• Chyle leak & Chylus fistulaChyle leak & Chylus fistula• Wry Neck (Torticollis Coli)Wry Neck (Torticollis Coli)• Shoulder dysfunctionShoulder dysfunction• Cerebral oedemaCerebral oedema
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