Neck dissection Dr. Mansoor Khan Resident Plastic Surgery

Introduction

Status of the cervical lymph nodes

important prognostic factor in the head and neck tumors

Introduction

Cure rates drop into half when there is regional

lymph node involvement

Emil Theodor KocherEarned Nobel Prize in 1909 for his work in thyroid and neck

surgery — the first ever awarded to a surgeon.

1880 – Kocher proposed

removing nodal

metastases

1906 – George Crile described the classic radical neck dissection (RND)

1967 - Bocca and Pignataro described the “functional neck dissection” (FND)

Level - I

Level - II

Level - III

Level - IV

Level - V

Level - VI

Subzones of Levels I-V

Level IAFloor of mouth, anterior oral tongue, anterior mandibular alveolar ridge, lower lip

Level IBOral cavity, anterior nasal cavity, softtissue of midface, submandibular gland

Level IIA & IIBOral cavity, nasal cavity, nasopharynx, oropharynx,, hypopharynx, larynx, parotid gland

Level IIIOral cavity, nasopharynx, oropharynx, hypopharynx, larynx

Level IVHypopharynx, thyroid, cervical esophagus, larynx

Level VA & VBNasopharynx, oropharynx, posterior scalp/neck skin

Level VIThyroid gland, glottic and subglottic larynx, apex of piriform sinus, cervical esophagus

Staging of the neck

“N” classification – AJCC (1997)Consistent for all mucosal sites except the nasopharynx

Thyroid and nasopharynx have different staging based on tumor behavior and

prognosis

Lymph node staging

No regional lymph node metastases

Single ipsilateral lymph node, < 3 cm

Single ipsilateral lymph node 3 to 6 cm

Multiple ipsilateral lymph nodes < 6 cm

Bilateral or contralateral nodes < 6cm

Metastases > 6 cm

ClassificationNeck Dissection

Comprehensive ND

Radiacal ND

Modified

radical ND

Selective ND

Supraomohyoid

ND

Latera

l ND

Anteriolateral

ND

Extended ND

Extent of Radical Neck Dissection

Radical Neck Dissection All lymph nodes in Levels I-V including spinal accessory nerve (SAN), SCM, and IJV

Modified Radical Neck Excision of same lymph node bearing regions as RND with preservation of one or more nonlymphatic structures (SAN, SCM, IJV)

MRND Type I

Preservation of SAN

MRND Type II

Preservation of SAN and IJV

MRND Type III

Preservation of SAN, IJV, and SCM ( “Functional neck dissection”)

Selective Neck Dissections

Sup

raom

ohyo

id n

eck

diss

ectio

n

Selective Neck Dissections

Lateral neck dissection

Extended Neck Dissection

Any dissection which includesremoval of one or more additional

lymph node groups and/or non-lymphatic structures.

Algorithm for treating an N0

T3 or T4 Oral cavity tumors and tumor thickness (>3 mm)

supraomohyoid neck dissection.

Increasing stage of the oropharynx, hypopharynx, and supraglottic larynx needs lateral

neck dissection.

Algorithm for treating an N0

N+ disease needs Comprehensive neck

dissection

“Surgical approach”

Incisions

A p r o n I n c i s i o n

H a l f A p r o n I n c i s i o n

C o n l e y I n c i s i o n

Y -

I n

c i s

i o

n

D o u b l e – Y I n c i s i o n

H - I n c i s i o n

M a c F e e I n c i s i o n

S c h o b i n g e r I n c i s i o n

M o d i f i e d S c h o b i n g e r

I n c i s i o n

Steps of Radical Neck Dissection