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ANATOMY HEAD AND NECK

Thyroid: identify lobes, isthmus.

1. Blood supply, origin and drainage.
Arterial Supply
sup thyroid art Branch from ECA
inf thyroid art Branch from thyrocervical trunk from subclavian artery. Also
supplies the parathyroid glands
thyroidea ima from brachiocephalic art / arch of aorta
(present only in This small artery ascends on the anterior surface of the trachea
3% of people) which it supplies and continues to the isthmus of the thyroid
gland.
The possible present of this lowest artery must be considered
when perforing procedures in the midline of the neck inferior
to the isthmus because it is a potential source of bleeding.

Venous Drainage
sup thyroid vein into IJV
middle thyroid vein into IJV
inf thyroid vein anastomose with L brachiocephalic vein

2. LNs
The lymphatics follow the arteries & drain mainly into:
- deep cervical LN: Upper pole to anterior superior group of deep cervical. Lower pole
to posterior inferior group.
- a few lymph vsls pass to paratracheal nodes
- Level 6 nodes in tracheoesophageal groove. First nodes that a thyroid malignancy
spreads to.

Identify major vessels: BCA, CCA, subclavian artery.

Identify: Vagus nerve, recurrent laryngeal never, phrenic nerve, thoracic duct, descending
aorta, sympathetic trunk in the posterior mediastinum.
Identify the Trunks of brachial plexus

Point out esophagus. Quizzed on esophageal varices and name the portal and systemic vessels
Identify facial artery
Identify parotid gland, name of the duct (Wharton’s duct) and the opening (Opposite the
upper 2nd molar tooth) and facial nerve
Name some levels: bifurcation of trachea, arch of aorta at t4, etc
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Quizzed on thoracic outlet syndrome

- A syndrome describing the symptoms and signs caused by arterial, venous or nerve
compression as these major structures pass between the clavicle and the 1st rib.
- Causes:
1. Cervicle rib
2. Pathological enlargement of the 1st rib
3. Scalenus muscle hypetrophy
4. Fractured clavicle
- Clinical features
Artery:
- Arm/hand claudication (worse of raising arm above head, Roos test)
- Acutely ischemic hand (secondary to emboli)

Vein:
- Arm swelling

Nerve:
- Motor or sensory deficit (commonly affects lower 2 nerve roots C8, T1)

Quizzed on Asked about subclavian steal syndrome

1. Proximal stenosis of subclavian artery
2. Reversal of flow in vertebral artery (steals from circle of willis from contralateral vertebral
artery)
3. Results in vertebrobasiclar symptoms of dizziness and vertigo. And arm claudication.

Anatomy (Generalised – Head & Neck)

Arch of the aorta, brachiocephalic trunk, left subclavian, left common carotid
What is this nerve? Vagus nerve
Show me the recurrent laryngeal nerve.

(Hooks around the ligamentum arteriosus at the arch of the aorta on the left. Hooks around
the subclavian artery on the right)
What does the recurrent laryngeal nerve supply? All the laryngeal muscles except the
cricothyroid (which is supplied by external laryngeal nerve which is a branch of the superior
laryngeal nerve, which also comes from the vagus)

. Cadaver with face, neck and thorax. The examiner points to the various anatomy on the
cadavar, then you must label it. Anatomy tested includes,

(a) common carotid,

(b) internal and external carotid,
(c) facial artery,
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(d) hypoglossal nerve,

(e) phrenic nerve,
(f) vagus nerve,
(g) thoracic inlet.
(h) some discussion on subclavian steal syndrome, pathophysiology and clinical
presentation

(a) Discussed anatomy of the eye, layers of eyeball, and ophthalmic artery supplies which layer,
danger zone, otitis externa, malignant otitis externa (this is was my 1st choice specialty, I
totally died, did not study anatomy of eye at all)

Anatomy of the eye:

The eye is under 25mm in all diameters. There are 2 segments, the prominent and
transparent anterior segment (1/6 th of the eyeball) and a larger opaque posterior segment
(5/6th eyeball). There are 3 layers: the fibrous coat, the vascular coat and the retinal coat.

Fibrous coat –
1. transparent anterior cornea and
2. opaque posterior sclera (responsible for maintenance of the shape of the eyeball and
receives insertion of the extraocular muscles) it is pierced posteriorly by the optic neve. They
are connected by the sclerocorneal junction.

Vascular coat -
1. Choroid is a thin and highly vascular membrane lining the inner surface of the sclera. It is
pierced posteriorly by the optic nerve. It is connected anteriorly to the iris by the ciliary
body.
2. Ciliary body :
(a) Ciliary ring – fibrous ring continuous with the choroid
(b) Ciliary processes – 60-80 folds radially between ciliary ring and the iris, connected
posteriorly to the suspensory ligament of the lens
(c) Ciliary muscles – outer radial and inner circular layer of smooth muscle responsible for
changes in the convexity of the lens in accommodation and supplied by parasympathetic
fibres transmitted in the oculomotor III.
3. Iris – contractile disc surrounding the pupil
(a) anterior mesothelial lining
(b) connective tissue stroma containing pigment cells
(c) radially arranged smooth muscle fibres – dilator of the sphincter (supplied by
sympathetic system)
circular group – papillary sphincter (supplied by parasympathetic fibres in the
oculomotor nerve)

Neural coat -
1. Retina – formed by outer pigmented and inner nervous layer, interposed between the
choroid and hyaloid membrane of the vitreous. Anteriorly it presents an irregular edge, the
ora serrata, while posteriorly the nerve fibres on its surface collect to form the optic nerve.
Posterior pole has a macula lutea, the site of central vision, just medial to this is the pale
optic disc formed by the passage of nerve fibres through the retina.

Ophthalmic artery originates from the internal carotid immediately after its emergence from the
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cavernous sinus, enters the orbit through the optic foramen below and lateral to the optic nerve and
supplies the orbital contents and the skin above the eyebrow. Most importantly, it gives off the
central artery of the retina which emerges from the disc and divides into upper and lower branches,
each of which divides into a nasal and temporal branch.

- what are the muscles attached to it?

Medial rectus, lateral rectus, superior rectus, inferior rectus, superior oblique, inferior oblique

- what nerve supplies it?

Opthalmic nerve: Medial rectus, superior rectus, inferior rectus.
Trochlear nerve: Superior oblique
Abducent nerve: Lateral rectus

- what are the content of the superior orbital fissure?

CN 3, 4, 5a.
Opthlamic artery

(a) point to me where is the pituitary fossa on skull Xray, point to me the coronal suture

Thyroid –strap muscles, innervation, ansa cervicalis, nerve and artery dmg in thyroidectomy, thyroid
cartilage- where to do cricothyroidotomy, vocal cord attachements

If u cut symp cervical trunk, what will happen- autonomic dysregulation horners

17. Tell me about the tongue

o Muscles – intrinsic and extrinsic
Intrinsic  These muscles are confined to the tongue itself & are not
Muscles attached to bone
 They are arranged in several planes & are generally classified
as
1. sup & inf longitudinal
2. transverse
3. vertical
 Their actions are to alter the shape of the tongue
Extrinsic  These muscles that arise from nearby parts & are inserted into
Muscles the tongue
 They are: 1. genioglossus
2. hyoglossus
3. styloglossus
4. palatoglossus (all except palatoglossus is
supplied by hypoglossal N; palatoglossus supplied by vagus N)
 Their actions are to move the tongue
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1. Thyroid cancer
- what are the types of thyroid cancer?
Papillary, follicular, medullary, anaplastic.

- what is so special about Hurtle Cell Ca?

Special variant of follicular cancinoma. Poor prognosis.

- what’s the difference between papillary and follicular cancer?

Differentiated thyroid carcinoma
Papillary carcinoma Follicular carcinoma
75% 10%
25-40 years 40-50 years
3:1 3:1
Radiation exposure Follicular adenoma is NOT a risk factor

Polyposis syndromes (FAP, Gardner’s, Iodine deficiency may be associated

etc)
Positive family history in 5%
Characteristic Orphan Annie nuclei, Follicular structures similar to normal
nuclear pseudoinclusions thyroid

Papillary architecture with psammoma Diagnosis of cancer made on evidence of

bodies (on US) capsular or vascular invasion by tumour
cells (vs follicular adenoma)
Tall cell variant (nuclear features of
papillary ca within follicular lesion) Hurthle cell variant – worse prognosis
behaves like papillary ca, has worse
prognosis

Slow-growing tumour Solitary

Spread by lymphatics Haematologic spread to bone, lung, liver,

brain
30-50% multicentric
LN involvement in 10% (rare)
LN involvement in 80% of disease at
diagnosis (level VI first)

Very good prognosis

Poor prognostic factors (AMES): Age>40, presence of metastases, extra-thyroid

invasion, size>4cm (more details on risk stratification below)

Surgical resection

Hemithyroidectomy for selected low-risk patients (AMES,AGES)

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Total thyroidectomy for the majority

LN clearance: tracheo-oesophageal nodes cleared, and neck dissection if neck nodes

are positive

For suspicious lesion – hemithyroidectomy with histology, KIV TT

Adjuvant therapy
Radioactive iodine at ablative levels to ablate remnant thyroid and any cancer tissue
(only for total thyroidectomy)

External radiotherapy (only shown to have good results in pts with locally advanced
follicular ca)

TSH suppression – give L-thyroxine to suppress TSH levels to <0.005U/L

Follow-up
give thyroxine, spuraphysiological doses to suppress TSH. Switch to t3 if RAI is
considered
RAI if TT ( T3 must be stopped few days b4)
ablate if necessary
thyroglobulin can be used in place of RAI to check for recurrence

- how to manage?

- how does thyroid cancer present like?

- Irregular edges, hard mass.
- Facial nerve involvement.
- Involvement of recurrent laryngeal nerve (hoarseness of voice)
- Cervical lymph nodes present.
- Signs of metastasis.

HISTORY TAKING
Right tonsillar enlargement x 5 months a/w night sweats
Examinations – where do you want to examine? Head & neck examination, Cervical LN,
axillary LN, inguinal lymph node, abdomen for spleen.

Causes:

Viral:
- Influenza
- Adenovirus
- Enterovirus
- Rhinovirus
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- EBV
-
Bacterial
- B haemolytic strep
- Strep pyogenes
- Haemophiulus influenza
- Anaerobic organisms

Investigations
Blood tests:
1. Monospot test for EBV glandular fever (infectious mononucleosis)
2. Fbc (Raised WCC, neutorphilia vs lymphocytosis)
3. CRP

Microbiology
1. Blood cultures (detect bacteremia)
2. Throat swab

What is the management?

1. Analgesia and antipyretics
2. Antibiotics: Penicillin for aerobic cover (erythromycin if penicillin allegy)
Metronidazole for anaerobic cover
3. Steroids: Reduce inflammation
4. Admission for IV fluids and IV antibiotics in severe cases where patient cannot tolerate fluids
orally.
5. Tonsillectomy: For patients with >5 episodes in each of 2 consecutive years.

Complications:
1. Respiratory obstruction
2. Quinsy: Peritonsillar abscess. Requires drainage
3. Retrophryngeal abscess: Drainage under anaesthesia
4. Acute otitis media: Spread of infection along Eustachian tube
5. Recurrent acute tonsillitis.
6.
PHYSICAL EXAMINATION
1. Man with right posterior triangle mass
- examine this patient
- what are the borders of posterior triangle?
Posterior border of SCM, Anterior border of trapezius, clavicle inferiorly.
- what do you think is the diagnosis? Right posterior lymphadenopathy
- what is the cause?
Infective Viral
Epstein-Barr virus, cytomegalovirus (infectious
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mononucleosis); HIV
Bacteria
Streptococcus, Staphylococcus, Klebsiella (from intraoral
pathology e.g. dental abscess, tonsillitis)
Tuberculosis
Parasitic
Toxoplasma
Fungi
Actinomycosis
Neoplastic Metastatic
(hard,
matted)

Primary – lymphoma (firm, rubbery, rounded)

Inflammatory SLE
Kikuchi’s (necrotising lymphadenitis occurring in young
females, presenting as painful cervical lymphadenopathy)
Sarcoidosis

- where else do you want to check if you think it is secondary metastasis? Oral cavity
- what other investigations do you want to do (in view of TB)?
CXR, TB quantiferon. Sputum smears and culture for ziehl nielson staining for acid fast
bacilli (takes 6 months)
- what is the name of this LN if I said that it arises from the abdomen? Examiner wants
Virchow node

Specialty choice 2 (head and neck): Parotid stone

No lump on examination, can feel a stone at the opening of the duct
DDX: stone dx
Invx: Sialogram
Treatment: stone removal, sphinterotomy
(Forgot to examine cervical lymph nodes, so examiner asked what other test I wanna do and
then quizzed me on the lymph node groups)

PAROTID GLAND

Examination of the parotid gland, discussion investigation and management of a parotid

gland mass, type of parotid neoplasia (my 1st choice specialty)

1. Parotid gland examination plus bimanual examination

what are the common tumors?
Epithelial Non-epithelial
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Adenomas (benign) Carcinomas (malignant)

Pleomorphic adenoma Adenoid cystic ca Haemangioma
Warthin’s tumour Pleomorphic adenoca Lymphangioma
Mucoepidermoid ca Neurofibroma
Squamous cell ca Neurilemmoma
Lipoma
Sarcoma
Malignant lymphoma

What are your investigations?

1. Blood investigations: FBC, UECr, autoantibody screen RF, anti Ro anti La (sjogren’s
syndrome)
2. U/S: Reveal stones.
3. FNAC: Provides cytological diagnosis
4. Sialogram: Shows anatomy of ductal system and if any stones present.
5. MRI: Complex anatomy or deep lobe involvement.

What is your treatment?

1. Benign (Pleomorphic adenoma): Superficial parotidectomy or total parotidectomy with
preservation of facial nerve.
2. Benign (Warthin’s tumour): Conservative or superficial parotidectomy.
3. Malignancy: (normally mucoepidermoid ca)
- Total parotidectomy with sacrifice of facial nerve if tumour has infiltrated it (may be grafted
with great auricular nerve)
- Radical neck dissection if neck nodes positive
- Postoperative radiotherapy

THYROID GLAND

Thyroid exam - right lobe diffuse swelling, no eye signs, inx and management

INSPECT FROM THE FRONT

1. Any swelling? Where is it?
2. Any scars (thyroidectomy scar may be difficult to spot as it is often hidden in a skin
crease)? Sinuses?
3. Any skin changes over the mass?
4. Check for plethora of face, distended neck veins – may be due to compressive nature of
mass (but rarely seen).

5. Check if mass moves on swallowing by asking patient to take a sip of water – “Please
take a sip of water and hold it in your mouth, do not swallow until I tell you to.”
6. Check if mass moves on protruding the tongue – “Please open your jaw slightly. Now,
without moving your jaw, please stick your tongue out and back in again.”
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NB. A thyroid swelling moves only on swallowing; a thyroglossal cyst will move on both
swallowing and protrusion of the tongue.

PALPATE FROM BEHIND – one side at a time, the opposite hand stabilises the gland.
Ask for pain before palpating!

1. Characteristics of lump:
site (anterior triangle),
size (discrete nodule or multinodular enlargement or diffuse enlargement?)
consistency (soft, cystic, hard, multinodular?)
mobility (fixed to skin? Fixed to underlying structures?)
tenderness
Fluctuance
Pulsatile/expansile
Tranilluminable

2. Check swallowing while palpating to confirm mass moves on swallowing.

3. Check tongue protrusion.

4. Palpate lymph nodes

PALPATE TRACHEA from in front for tracheal deviation.

PERCUSS – any retrosternal extension?
AUSCULTATE – bruit in Graves’

Causes of diffuse swelling:

1. Simple colloid goitre
2. Graves disease,
3. Hasmimoto'sdisease.prominent
4. Nodule of MNG

if single nodule:
1. simple thyroid cyst
2. Prominent nodule of MNG
3. Thyroid adenoma (Folicular adenoma)
4. Thyroid cancinoma

- What investigations would you do?

Blood investigations:
1. TFT: T4, T3 TSH level ,
2. Antithyoidglobulin antibodies, anti thyroid peroxidase antibody

3. Fine needle aspiration:

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- Most important investigation modality

- 4 possible results:
(i) Benign (thyroiditis, dominant nodule of MNG)
(ii) Malignant (papillary, medullary, anaplastic, mets)
(iii) Suspicious (follicular, Hurthle cell change in follicular lesion)
(iv) Inadequate  repeat FNAC
- Can be both therapeutic and diagnostic for cyst – chocolate-brown fluid aspirated; feel
lump after aspiration to check for resolution
- Cannot differentiate follicular adenoma from follicular carcinoma as the mark of
malignant disease is capsular invasion – can only tell from a histological specimen of the
nodule
- Procedure: inject local anaesthetic in area, insert 20-22G needle and apply suction while
fanning needle in region of nodule, release suction before pulling out needle, expel contents
onto slide, then fix
- Best to have experienced cytologist on hand to view slides and re-do FNAC if the sample
is inadequate

Imaging:
4. Ultrasound: Suspicious features:
- Microcalcifications (psammoma bodies – papillary cancer)
- Indistinct margins
- Halo around region
- Hypoechoeic lesion
- Increased vascularity

5. Radioisotope scan:
- Hot nodule: Only 1% malignant.
- Cold nodule: 10-20% malignant.
6. CT/MRI:
- To assess complications, retrosternal extension, LN involvement, invasion of nearby
structures.

7. ENT examination of vocal cords

- Treatment options for benign thyroid swelling

CONSERVATIVE
- Remove goitrogens (eg cabbage)

MEDICAL
- Carbimazole: inhibits thryoid peroxidase reduces coupling and idioination of
thyroglobulin to become idotyrosine. If hyperthyroid.
- Propylthiouracil: if hyperthyroid
- B blockers: Propanolol. Symptomatic relieve.
- Thyroxine: If hypothyroid

SURGICAL
- Total thyroidectomy.
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Indications:
a. Risk of malignancy cannot be excluded or malignancy confirmed
b. Compressive symptoms: dysphagia, dypsnea.
c. Thyrotoxicosis refractory to medical treatment (eg in Graves)
d. Cosmetic
e. Diagnostic

- Pros/cons of FNA

Pros:
1. Can be both therapeutic and diagnostic for cysts.
2. High sensitivity and specificity (90-95%)
3. Simple procedure

Cons:
1. Cannot differentiate follicular adenoma from follicular carcinoma as the mark of malignant
disease is capsular invasion. If turn out follicular cells, do hemithyroidectoy. If turn out
malignant, do total thyroidectoym with RAI.
2. Operator dependant. Best to have experience cytologist on hand to view slides. Can redo
FNAC if the sample is inadequate.

Option: Core biopsy: For histology.

- Examine thyroid status

HANDS (get patient to stretch arms out in front of him, palms down)
1. Feel palms – warm sweaty palms
2. Nails – thyroid acropachy, onycholysis (both seen in Graves’)
3. Feel pulse – tachycardia, atrial fibrillation (AF more in toxic MNG than Graves’)
4. Fine postural tremor – accentuate by placing a sheet of paper on the hands
5. Palms up – palmar erythema
6. Reflexes

FACE
1. Expression – staring, unblinking (hyperthyroid); lethargic, apathetic (hypothyroid)
2. Complexion – dry, ‘peaches-and-cream’ complexion, loss of outer third of eyebrows
(hypothyroid)

3. Eyes
- Lid retraction (can see sclera between upper limbus of iris and upper eyelid)
- Exophthalmos (sclera between lower limbus and lower eyelid)
- Chemosis (oedema and erythema of conjunctiva)
- Ophthalmoplegia (restriction of eye movements; ask about diplopia!)
- Lid lag (eyelid lags behind eye when patient follows your finger downwards)
- Proptosis (look from above patient’s head – eye visible over supraorbital ridge)
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NEUROMUSCULAR
1. Proximal myopathy (Graves’)
2. Reflexes – slow to relax in hypothyroidism
3. Legs for pretibial non-pitting oedema (Graves’ or hypothyroid)

What do you find in hyper/hypo thyroidism

Hyperthyroid Hypothyroid

- Weight loss despite increased Decreased appetite, weight gain,

appetite lethargy
- Heat intolerance Cold intolerance
- Increased sweating Dry skin (cream and peaches), loss
of outer third of eyebrows, puffy
eyes
- Proximal myopathy (Graves’) Muscle fatigue
- Diarrhoea, frequent bowel Constipation, LOA
movement
- Tachycardia, atrial fibrillation Bradycardia
- Oligomenorrhoea, amenorrhoea Menorrhagia, infertility
- Nervousness; easily irritable; Slow thought, speech and action;
emotional lability; insomnia depression; dementia
- Fine tremor Carpal tunnel syndrome symptoms,
weakness

SIGNS
Eyes: Puffy lids, loss of outer 1/3 of
eyebrows
Face: Peaches and cream skin
Upper limb: Cold, puffy, spade like
hands, dry and ineleastic skin
Mouth: Macroglossia
Voice: Deep and hoarse
CVS: Bradycardia
Neuro: Slow movement, sluggish
relaxation phase in ankle jerk.

Pathology of Graves disease:

In Graves' disease, an autoimmune disorder, the body produces antibodies to the TSH-
Receptors. (Antibodies to thyroglobulin and to the thyroid hormones T3 and T4 may also be
produced.) These antibodies (TSHR-Ab) bind to the TSH-Rs, which are located on the cells
that produce thyroid hormone in the thyroid gland (follicular cells), and chronically stimulate
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them, resulting in an abnormally high production of T3 and T4. This causes the clinical
symptoms of hyperthyroidism, and the enlargement of the thyroid gland

- Red flags in U/S

1. Microcalcifications (psammoma bodies – papillary cancer)

2. Indistinct margins
3. Halo around region
a. Hypoechoeic lesion
4. Increased vascularity
2

Auscultation
nitially missed out on bruits – was asked to listen again
Was also asked bout thrills

Diagnosis – MNG
What causes the bruit
1. Hyperdynamic circulation

2. Carotid artery stenosis from compression of the lump

Other examination u’d like to do?
- Thyroid status

3. Lady with right thyroid swelling

- examine this patient
- tell me what are the lymph nodes you are palpating?
Submental, Submandibular, pre auricular, post auricular, occipital, cervical, suprascapular,
pre tracheal.

- what is your diagnosis? Solitary right thyroid nodule

- what investigations do you want to do for her?

FBC, Thyroid antibodies
U/S
FNAC
CT/MRI
Hot/cold isotope scan

- if USG says MNG and FNAC says colloid goiter, what would you do?
Mentioned that this means patient has dominant nodule of MNG. A right hemithyroidectomy
would be warranted for HPE.
Soft, small, round nodule with benign FNAC results, non functional, not causing any
symptoms -> can follow up and monitor any increase in size.
A lump >4cm has a greater risk for malignancy.

- if FNAC is papillary CA, what would you do?

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Hemithyroidectomy VS Total thyroidectomy

Do a risk stratification
Patient factors: Age >45 years, gender male.
Tumour factors: AMES: Age, metastasis, extent, size (<1cm T1, >1cm T2-4)

Low risk patients, size <1cm can undergo hemithyroidectomy without ablative radioiodine
therapy post op.
High risk patients undergo total thyroidectomy with post op RAI treatment.

- 5 year survival is also prognosticated by the risk: low risk patients have a survival of 95-98%,
intermediate risk patients 88%, and high risk patients 50%

TOTAL THYROIDECTOMY VERSUS HEMITHYROIDECTOMY

Advantages of TT:
- Evidence for microfoci of disease and multicentricity of cancer – removal of the entire
thyroid decreases risk of recurrence
- Ability to use adjuvant radioiodine to ablate any residual cancer tissue after surgery
- Ability to use radioiodine to detect recurrent disease (normal thyroid picks up iodine better
than cancer cells, thus the presence of the thyroid gland will decrease the ability of RAI to
pick up recurrent cancer) and as treatment for recurrence
- Ability to use serum thyroglobulin as a cancer marker for recurrence
-
Disadvantages of TT:
- Risk of bilateral recurrent laryngeal nerve injury and permanent hypoparathyroidism
- Very low incidence of cancer recurrence in residual thyroid – microfoci probably not
clinically significant
- Limited thyroidectomy may spare patient from having to be on lifelong thyroid hormone
replacement
Thus, risk stratification helps to guide the extent of surgical resection in differentiated thyroid
cancer according to the patient’s disease.

- do you want to do a prophylactic LN dissection?

I said no. MRND only done for Medullary Thyroid CA. But examiner said nowadays papers
show that it is beneficial to do a prophylactic LN dissection for papillary thyroid CA.

- Tracheo-oesophageal groove (level VI) node clearance usually done

- Radical neck dissection or modified radical neck if:

(i) Tracheo-oesophageal groove nodes histologically positive for cancer
(ii) Clinically positive nodes in the neck – palpable or enlarged on ultrasound

Radical neck dissection

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- The removal, en-bloc, of the entire ipsilateral lymphatic structures of the neck, from the
mandible superiorly to the clavicle inferiorly, from the infrahyoid muscles medially to the
anterior border of the trapezius laterally
- Classic radical neck dissection (Crile’s) – internal jugular vein, sternocleido-mastoid
muscle, and accessory nerve are resected. Structures not resected: carotid arteries, vagus
nerve, hypoglossal nerve, brachial plexus, phrenic nerve

- Modified radical neck

(i) Type I: one of the three structures not removed, usually accessory nerve
(ii) Type II: two of the structures not removed – accessory and IJV
(iii) Type III: all of the three structures not removed
(iv) Extended radical neck dissection: resection of lymph nodes and/or structures not included in
the classic neck dissection

- Complications of radical neck dissection:

(i) Injury to nerves – vagus (vocal cord paralysis), cervical sympathetic chain (Horner’s),
mandibular branch of facial (lower lip weakness)
(ii) Haematoma  bring back to OT to find source of bleeding and stop it
(iii) Salivary fistula (usually when pt has received RT to the neck, and if the upper GI tract was
opened during the surgery) – infection can result
(iv) Wound infection – risk factors: previous irradiation, if upper aerodigestive tract is opened
during surgery with salivary contamination, salivary fistula
(v) Carotid blowout – risk factors: infection, irradiation  resus, apply constant pressure all the
way to the OT!
(vi) Poor healing – usually in irradiated skin; weakest point is the junction of the trifurcate
incision