neck dissection

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


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)


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


• 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


• 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


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


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”


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

neck dissection

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