Neck Dissections

Introduction
• Head & Neck cancer - commonproblem
• Neck secondaries + in > 70% at presentation
• Metastases of Unknown origin(MUO)/ Cancerof
Unknown Primary(CUP) Neck- 5-7%
• Rate of mets in N0 Neck <20%->50%
• Proper treatment of Neck improves Survivalby
50%
 History

• 1880 - Kocher - Removal of Neck node mets

• 1906 – George Crile – RND
• 1933-41 – Blair and Martin - Popularized RND
• 1953 – Pietrantoni - Spared SAN
• 1967 – Bocca and Pignataro - FND for N0 Neck
• 1975 – Bocca – Established Oncological safety of FND
• 1980 -2016– Various Classifications of NDs
 Anatomy
• The side of the neck - quadrilateral outline

Posterior
Anterior triangle
triangle
Anterior Triangle
SUBMENTAL TRIANGLE
 SUBMANDIBULAR TRIANGLE
•Submandibular triangle is paired
• Arteries
–Facial
–Sublingual
–Submental

•Veins: same as arteries

•Nerves : Mylohyoid and

hypoglossal nerve
•Structures
–Submandibular gland
–Inferior portion of parotidgland
–Submandibular lymph node
 CAROTID TRIANGLE

•Contains arteries,veins,nerves and structures

Arteries: Veins:
–Common carotid (with carotid body) –Internal Jugalarvein
–Internal carotid (with carotidsinus) –Common facial vein
–Lingual Vein
- Superior thyroid
–Superior Thyroid vein
- Lingual –Middle thyroid vein
- Facial
-Ascending pharyngeal
- Occipital
 Carotid triangle
• Nerves
- Vagus • Structures
- External laryngeal -Larynx
-Thyroid
- Internal laryngeal
- Spinal Acessory
- Hypoglossal
- Ansacervicalis
- Sympathetic trunk
 MUSCULAR TRIANGLE

• Arteries
–Superior thyroid
• Veins
–Inferior thyroid
–Anterior jugular
• Nerves: Ansa cervicalis

• Structures
–Strap muscles
–Thyroid gland
–Parathyroid gland
–Larynx
–Trachea
–Esophagus
Posterior triangle
 Contents of Posterior triangle
Nerves: •Arteries
• Spinal acessory nerve. –Subclavian artery
• Great auricular –Transverse Cervical artery
• Lesser occipital –Suprascapular artery
• Branches of Cervical plexus
• Transverse cervical • Vein
• Supraclavicular –External jugular vein
• Roots and trunks of brachial (terminal part)
plexus.
• Dorsal scapular • Lymph Nodes
• Long thoracic –Occipital
• Phrenic –Supraclavicular
• Cervical lymph nodes are classified into groups
by Memorial Sloan Kettering Cancer centre in
the 1930’s
Level I: Lymph node groups – submental and
submandibular
• Level Ia*: Submentaltriangle
Boundaries – anterior bellies of the digastric
muscle and the hyoid bone
• Level Ib*: Submandibular triangle
Boundaries – body of the mandible,
anterior and posterior belly of the digastric
muscle
• Level II: Lymph node groups – upper jugular
Boundaries:
1) anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of thesternocleidomastoid
muscle
3) superior – skull base
4) inferior – level of the hyoid bone (clinical landmark) or
carotid bifurcation (surgicallandmark)
• Level III: Lymph node groups – middle jugular
Boundaries –
1)anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of the
sternocleidomastoid muscle
3) superior – hyoid bone (clinical landmark) or carotid
bifurcation (surgical landmark)
4) inferior – cricothyroid notch (clinical landmark)or
omohyoid muscle (surgical landmark)
• Level IV: Lymph node groups – lower jugular
Boundaries –
1) anterior – lateral border ofthe sternohyoid muscle
2) posterior – posterior border of thesternocleidomastoid
muscle
3) superior – cricothyroid notch (clinical landmark) oromohyoid
muscle (surgical landmark)
4) inferior – clavicle
• Level V: Lymph node groups – posterior triangle
Boundaries –
1)anterior – posterior border of the sternocleidomastoid
muscle
2) posterior – anterior border of the trapezius muscle
3) inferior - clavicle

Level Va – along the SAN

Level Vb – along the
Transverse cervical artery
• Level VI: Lymph node groups – prelaryngeal (Delphian),
pretracheal, paratracheal, and precricoid lymph nodes -
also known as the Anteriorcompartment.
• Boundaries – 1) lateral – carotid sheath
2) superior – hyoid bone
3) inferior – suprasternal notch
• Level VII: Lymph node groups
– Upper mediastinal
Boundaries –
1) lateral – carotid arteries
2) superior – suprasternal
notch
3) inferior – aortic arch
Platysma muscle:
• Situated within the superficial fascia ofneck
 Sternocleidomastoid Muscle (SCM)
• invested in the superficial layer of the deep cervical
fascia.
Omohyoid muscle Trapezius muscle
Digastric Muscle

• “residents friend”.
Marginal Mandibular Nerve (ramusmandibularis)

• Extension-The marginal mandibular nerve lies either

along the body of the mandible (80%) or it may briefly
enter the neck, where it lies within 1.2 cm of the lower
border of the body(20%).
 Spinal AccessoryNerve
• The spinal root of the accessory nerve is a union of
motor neurons whose cell bodies originate in the spinal
nucleus located in the anterior grey column of the spinal
cord.
• course:
 Brachial Plexus
• Formed by the union of the ventral rami of the lower
four cervical nerves and the greater part of the ventral
ramus ofthe first thoracic nerve (C5-8 and T1)
 Phrenic nerve

• The phrenic nerve

comprised of fibers
from cervical roots 3-5

• It runs obliquely
toward the midline
along the anterior
surface of the anterior
scalene muscle and is
covered by
prevertebral fascia
 Hypoglossal Nerve
• The hypoglossal nerve is
the motor nerve of the
tongue. Its cell bodies
originate in then
hypoglossal nucleus in the
medulla oblongata.
• The nerve exits the skullvia
the hypoglossal canal of
the occipital bone.
• As it exits the canal it lies
deep to the IJV, the
internal carotid artery,and
CNIX, X, and XI
Ansa cervicalis
 Thoracic Duct
• In the neck - lies anterior to the vertebral artery and vein,
the sympathetic trunk and the thyrocervical trunk.
• It is separated from the phrenic nerve by the prevertebral
fascia.
 Presentation of Head & Neckcancers
• Apparent Primary with enlargednodes
- The N+ Neck
• Apparent Primary with normal neck
nodes - The N0 Neck

• Enlarged neck nodes with no apparent

primary - MUO Neck
Metastasis of Unknown Origin(MUO):
• Neck Mass – Site and histology are the most
important indicators of thePrimary.
• Complete Head & Neck examination with special
attention to skin
• Palpation of Oropharynx
• Mirror and fibre optic examination of
Nasopharynx , Oropharynx ,Hypopharynx and
Larynx as clinically indicated
 Staging
Regional Lymph Nodes (N):
• Lip, oral cavity, oropharynx, hypopharynx, larynx, trachea,
paranasal sinuses,major salivary glands
 NX - Regional lymph nodes cannot be assessed
 N0 - No regional lymph node metastasis
 N1 - Single ipsilateral lymph node <3cm

 N2
N2a - Single ipsilateral lymph node 3-6cm
N2b- Multiple ipsilateral nodes < 6 cm
N2c - Bilateral lymph nodes < 6 cm

 N3 - Any node > 6 cm

Nasopharynx:
NX - nodes cannot be assessed
N0 - no regional lymph node metastasis
N1 - Unilateral metastasis in lymph nodes < 6 cm above
the supraclavicular fossa
N2 - Bilateral metastasis in lymph nodes < 6 cm above
the supraclavicular fossa
N3 - Metastasis in a lymph node(s)
• N3a > 6 cm
• N3b extension to the supraclavicular fossa
Thyroid:
NX - Regional lymph noses cannot be assessed
N0 - No regional lymph node metastasis
N1 Regional lymph node metastasis
• N1a - Metastasis in ipsilateral cervical lymph node(s)
• N1b - Metastasis in bilateral, midline, or
contralateral cervical or mediastinal lymph node(s)
 Treatment guidelines
• Practically every patient with Head and NeckCancer
needs treatment of Neck
• Primary found – Treat as per Primary

• Primary not found

Operable – Surgery+PORT
Inoperable – RT– Reassess forSurgery

• Prognosis depends on stage as if primary is under

control
• Surgery – The “Gold Standard” Management
 Classification of Neck dissections
• Committee for Head and Neck Surgery and Oncologyof
the American Academy of Otolaryngology/Head and
Neck Surgery(1991):
1) Radical neck dissection (RND)
2) Modified radical neck dissection(MRND)
3) Selective neck dissection (SND):
a. supra-omohyoid type
b. lateral type
c. posterolateral type
d. anterior compartment type
4) Extended radical neck dissection
Medina’s classification: 1989
1) 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)
2) Selective neck dissection
• When Neck Dissection is done in N0 Neck it is called
Elective Neck Dissection
• This is called ‘ Elective’ as we elected to do it even
though there is no evidence of disease
• Selective Neck Dissections should be done in the
setting of Elective Neck Dissection only i.e. in N0
Neck only .
• SNDsshould always be followed by postop
radiotherapy
 Radical neck dissection
• Gold Standard
• It involves removal of levels I-V, few nodes located in the
tail of the parotid gland, the perifacial and buccinator
nodes, the retropharyngeal nodes, and the paratracheal
nodes.
• In addition,removal of nonlymphatic structuresincluding
the SAN,IJV,SCM.
Indications:
• Extensive cervical lymph node metastasis and/or
extension beyond the capsule withinvasion into the
spinal accessory nerve, IJV, and SCM.
 Modified Radical Neck Dissection

• Modified radical neck dissection involves excision of

the level I-V lymph nodes bearing tissues from one
side of the neck with the preservation of one or
more nonlymphatic structure including the spinal
accessory nerve, the IJV, or the SCM.

• Medina subclassifies the MRND into Types I-III

• MRND is analogous to the “functionalneck
dissection”
 Indications
• Gross nodal metastasis tothe neck that does not directly
infiltrate or adhere to the non-lymphatic structures.

• Bilateral MRND - contralateral nodal involvement.

• Here,it is important to plan ahead if sacrifice of both IJVs

is anticipated because bilateral resection results in
massive edema and cases of blindness (ischemic optic
neuropathy), stroke, and death have beenreported.
 Rationale

• Modifications of the classic RNDaim to reduce

postsurgical neck pain and shoulder dysfunction
encountered when the spinal accessory is resected
without compromising adequate oncologictreatment.
• SCMpreservation - improves cosmetic appearance and
protects the carotid artery if adjuvant radiotherapy is
employed.
• Preserving the IJV becomes more significant in patients
requiring bilateral neckdissections.
Management of SecondariesNeck
Management of SecondariesNeck
 Selective neck dissection
• Definition:
- cervical lymphadenectomy with
preservation of one or more grps of lymphnodes
Four common subtypes:
1. Supraomohyoid neck dissection
2. Posterolateral neck dissection
3. Lateral neck dissection
4. anterior neck dissection
 SND: Supraomohyoid type
• Most commonly performed SND
• Definition: enbloc removal of cervical
lymohnodes levels I – III
• Posterior limits – cervical plexus and posterior
border of SCM
• Inferior limit is the omhyoid muscle overlyingthe
IJV

• INDICATION: oral cavity carcinoma with N0neck

 SND: Lateral type
• Defintion: Enbloc removal of the jugular
lymphnodea – levels II- IV
• Indications: carcinomas of oropharynx,hypopharynx,
supraglottis,larynx
 SND: Anterior compartment
• Definition: Enbloc removal of lymph structures inlevel
VI
• Limits of dissection – hyoid bone,suprasternalnotch,
carotid sheaths

Indications:
• Selected cases of ca. Thyroid
• Parathyroid carcinoma
• Suglottic carcinoma
• Laryngeal carcinoma with subglottic extension
• Carcinoma of the cervicaloesophagus
 SND: Posterolateral type
Definition: Enbloc excision of
lymph bearing tissues of level
II – V and additional node grps
– suboccipital , postauricular

Indications:
• Cutaneous malignancies –
Melanoma,SCC, Merkel cell
carcinoma
• Soft tissue sarcomas of scalp
and neck
Extended radical neck dissection
 Apron
Incision

120
 Half Apron
Incision

62
 Conley
Incision

63
 Double-Y
Incision

64
 H
Incision

65
 MacFee
Incision

66
 Y
Incision

67
 Modified Schobinger
Incision

68
 Schobinger
Incision

69
 Complications
• Hemorrhage,shock
• Carotid Blow out – occurs in 7-14days
-due to sepsis,woundbreakdown,arterial
adventitious stripping and necrosis
• Flap necrosis
• Infection
• Lymph ooze
• Seroma formation
• Frozen shoulder
 Conclusions
• Almost every Pt with Head and Neck Cancer needs
treatment of Neck

• Proper management of Neck results in almost 100%

control of neck with 50% ↑ Survival

• Sound understanding of anatomy and patterns of

spread has reduced the morbidity of Neck
Dissections with introduction of MRND and SND
 REFERENCES
• Fischer Mastery of Surgery,6th Edition
• ZOLLINGER’S atlas of surgical operations
• Jatin shah Head and Neck surgery and oncology
• Sabiston text book of Surgery 20th edition
• Netter atlas of anatomy