hand out- neck dissection -vinod narayanan

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Neck Dissections

• Vinod Narayanan

• MDS, FDSRCS(Eng), MOMSRCPS(Glasg)

• Saveetha University



Cervical node metastasis is the single

most important prognostic factor in

head and neck squamous carcinomas.



Preoperative staging by palpation androutine magnetic resonance imaging

cannot be relied upon to detect early

cervical metastatic disease

FDG!PET /CT is a useful tool for preoperative evaluation of theneck because it accurately detected metastatic lymph nodes equal

and more than 5mm and less false positive cases than CT



Micrometastasis less than 2mm



30" risk of occult lymph node metatsasis # Level 1 to 3 $in clinically negative necks # N0 $



Gingivo buccal 80"No Neck ! 11" were positive

Tongue /FOM 70"No Neck ! 34" were positive

# Shah etal $



Distribution of nodal

metastasis in therapeuticneck dissections

Distribution of nodal

metastasis in elective neckdissections



Risk of nodal metastasis from oral cancer is related to

several factors:

• Location of the primary tumor,

• T-stage

• Degree of Differentiation

• Depth of invasion.



• Excluding the hard palate and lip,

approximately 30% of patients with oralcavity cancer will present with cervical

metastases

• Depth of invasion greater than 8 mmwas associated with a 41% rate of occult

metastasis.



• Tumour depth > 5mm --- Increased risk

on neck metastasis



Comprehensive Neck Dissection



Goals of neck dissection

• 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)



Radical Neck Dissection

Removal of all ipsilateral cervical lymph nodegroups extending from the inferior border of themandible to the clavicle, from the lateral borderof the sternohyoid muscle, hyoid bone, andcontralateral anterior belly of the digastricmuscle medially,to the anterior border of thetrapezius. Included are levels I through V.

Removal of three important

nonlymphatic structures

Internal jugular vein,

Sternocleidomastoid muscle,

Spinal accessory nerve.



Extended Neck Dissection

Removal of one or more additional lymph

node groups - mediastinal nodes

or

Nonlymphatic structures such as the carotidartery or hypoglossal nerve.



Schobinger



McFee



Utility / U Shaped



• No difference

• Worse outcomes in stage II cancer of thetongue with discontinuous neck dissection,-

local recurrence rates of 19.1% versus

5.3% and a 5-year survival of 63% versus80%.

In-continuity versus discontinuous neck

dissections

C li i



Complications• Excessive bleeding,• Chylous leak• Slipping of the

stump of theinternal jugular vein , middlethyroid vein, in thesupraclavicularfossa near the

internal jugular vein, slipping ofthe transversecervical vessels

• Air Embolism



• Frozen shoulder syndrome,• Winging of the scapula

• Massive facial edema with bilateral neck

dissections.



Shoulder complaints

• Reduced range of motion (decreased

shoulder abduction), reduced strength inthe trapezius muscle

• Shoulder pain

• Disfigurement, and disability in dailyactivities

Even with preservation of the nerve, shoulder complaintsdeveloped in 18 % 77" after modi&ed radical neck dissection, and

in 29 to 39" after selective dissection.



Slipping of the jugular vein in the inferior

portion may lead to air embolism

Nitrous oxide anesthesia should be stopped and

the patient ventilated with 100% oxygen.The patient should be positioned in the left

lateral decubitus position so that the air can be

trapped in the right atrium.

Aspiration of the air embolus can be performed

through cardiac puncture or aspirating through

the central venous catheter.



Chyle leak

• External chylous fistula (in 1% to 2% of cases)

• Chylothorax is extremely rare

• The chyle leak should be suture ligated or

controlled with hemo clips.• Conservative management of postoperative

chyle fistula includes a medium-chain

triglyceride diet, low-fat diet, pressure

dressings, and suction of the drains.



Wound infections

Primary wound

infections - Rare

Secondary to oralcommunication

Gram -ve

(Klebsiella sp)



Selective Neck Dissection

Encompass those node groups most at risk # levels I to III $ and bereferred to as a selective neck dissection # levels I to III $



Suarez O: El problema de las meta ' stasis linfa ' ticas y

B E Pi O A i h i i di l k



Suarez O: El problema de las meta stasis linfa ticas yalejadas del ca ' ncer de laringe e hipofaringe. Revista deOtorinolaryngologia # Santiago de Chile $ 23:83!99, 1963

Bocca E, Pignataro O: A conservation technique in radical neckdissection. Ann Otol Rhinol Laryngol 76:975!987, 1967

hand out- neck dissection -vinod narayanan

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