Neck Dissection

Radical Neck Dissection
Overview
Metastatic neck disease is most important factor in spread

of H & N squamous cell ca. from primary site
Rate of ipsilateral metastatic disease in patients with T3-T4

sq. cell ca. of upper aerodigestive tract is ~ 50%
Lymph node metastasis reduces survival rate by half
Radical neck dissection is performed for surgical control of

metastatic neck disease in:
sq. cell ca. of upper aerodigestive tract (oral cavity /
nasopharynx / oropharynx / hypopharynx / supraglottis)
salivary gland tumors
skin cancer of H & N
thyroid cancer
Classification of Neck
Dissection
Radical
neck dissection
Modified
radical neck dissection
Selective
neck dissection
Extended
radical neck dissection
Lymph nodes of the Neck
Lymph nodes lie in the fibro-adipose tissue between

the investing (superficial) layer of deep fascia and
visceral and prevertebral layers underneath.
The nodes tend to aggregate around certain neural

and vascular structures, e.g. IJV, SAN.
Level I
Boundaries:
body of mandible
stylohyoid muscle
anterior belly of digastric muscle (contralateral)
Ia:
Submental triangle
Drainage: floor of mouth, anterior tongue, anterior
mandibular alveolar ridge, lower lip
Ib:
Submandibluar triangle
Drainage: oral cavity, anterior nasal cavity, soft tissue
structures of midface, submandibular gland
Also: perifacial and buccinator nodes
Level II
Boundaries:
upper third of IJV
skull base to inferior border of hyoid bone
posterior border of SCM
stylohyoid muscle
IIa
antero-inferior to SAN
IIb
postero-superior to SAN
Drainage: oral cavity, nasal cavity, nasopharynx,

oropharynx, hypopharynx, larynx, parotid gland
Level III
Boundaries:
middle third of IJV
hyoid
inferior border of cricoid
sternohyoid muscle
Drainage: Oral cavity, nasopharynx, oropharynx,

hypopharynx, larynx
Level IV
Boundaries:
lower third of IJV
inferior border of cricoid
clavicle
sternohyoid muscle
Drainage: larynx, hypopharynx, thyroid, cervical esophagus
Level V
Boundaries:
posterior triangle of neck
anterior border of trapezius
clavicle
Va:
above (superior to) inferior border of cricoid
nodes associated with SAN
Vb:
below (inferior to) inferior border of cricoid
transverse cervical and supraclavicular nodes
Drainage: nasopharynx, oropharynx, skin of posterior scalp

& neck
Level VI
Boundaries:
anterior (central) compartment of neck
carotid arteries
hyoid bone
suprasternal notch
Drainage: thyroid gland, subglottic larynx, cervical trachea,

hypopharynx, cervical esophagus
Includes:
paratracheal nodes (in tracheo-esophageal groove)
pretracheal nodes (in front of trachea)
parathyroid nodes (around thyroid gland)
precricoid node (on cricothyroid membrane)
Nodal Classification
< 3 cm
3 6 cm
> 6 cm
N1
N2a
N3
Multiple
ipsilateral nodes
N2b
N2b
N3
Bilateral /
Contralateral
node(s)
N2c
N2c
N3
Single node
Indications of RND
N2b, N2c, N3 disease
N1 / N2a with involvement of SAN or IJV
Clinical evidence and/or imaging studies showing evidence

of extranodal disease
Nodal disease with involvement of platysma and/or skin

(will require flap reconstruction)
Recurrent or persistent neck disease after previous

conservative neck dissection / irradiation / chemotherapy
Contra-indications of RND
Poorly prepared patient (e.g. cardiopulmonary disease)
Pre-operative imaging suggests deep infiltration of tumor

(prevertebral space, scalene muscles, levator scapula muscle, phrenic
nerve, and brachial plexus)
Primary tumor that cannot be controlled
N0 neck
Distant metastatic disease
Fixed neck mass in deep cervical fascia and/or skull base involvement
Circumferential or near-circumferential involvement and invasion of

carotid vessels if patient cannot tolerate a balloon occlusion test
Workup - 1
Palpation:
Sensitivity & specificity is 60 70 %
Difficult if:
short, obese neck
previous radiation to neck
previous surgery of neck
Workup - 2
Blood tests:
CBC
PT, APTT, INR
Electrolytes
Evaluation of SIADH
LFTs
BSR
BUN, creatinine
Blood type, screen, cross-match
Urinalysis
Workup - 3
Imaging:
CT reveals metastatic adenopathy by central necrosis and
extracapsular spread by enhancement of nodal capsule
MRI is less precise
CT/MRI cannot assess lymph nodes < 1 cm in size
USG-guided aspiration cytology has higher specificity
PET scan has highest sensitivity & specificity and
precision (5 mm)
If possibility of tumor involvement of carotid artery, then

complete pre-operative evaluation of carotid system:
balloon occlusion test
4-vessel cerebral angiography
CXR
Workup - 4
Mirror laryngoscopy, flexible nasopharyngolaryngoscopy
If primary lesion is known:

biopsy of primary lesion
Panendoscopy to exclude second primary tumor
If primary lesion not known:

panendoscopy to look for primary tumor
random biopsies of pyriform sinus, base of tongue, and
nasopharynx
ipsilateral tonsillectomy (controversial)
FNAC of neck mass
Sentinel lymph node biopsy: in research stage
Associated Surgeries
Laryngectomy
Composite resection
Glossectomy
Tracheotomy
Dermal graft
Intra-operative Details - 1
Supine position, shoulder roll, extended neck
Upper end of table elevated at 300
Several possible incisions, .e.g. hockey stick incision

Designed to avoid trifurcation over carotid artery and to
avoid narrow flaps
Make incision through platysma and elevate flap in subplatysmal plane. After raising superior lateral aspect of flap,
leave the greater auricular nerve and external jugular vein
on SCM. Elevate the posterior flap toward trapezius
Identify and preserve marginal mandibular nerve at superior

aspect of flap (it is deep to platysma, 2 cm below margin of
mandible, within fascia of submandibular gland)
Remove submental fatty tissue with Bovie electrocautery

and displace it inferiorly
Retract mylohyoid anteriorly, exposing submandibular

ganglion, lingual nerve, and submandibular duct
Ligate facial artery above digastric muscle
Cut and ligate submandibular duct
Remove submandibular nodes and submandibular duct and

displace them inferiorly
Continue dissection posteriorly, exposing posterior belly of

digastric and stylohyoid muscles and transect tail of parotid
gland
Expose SCM and incise it above clavicle with Bovie

electrocautery
Identify anterior and posterior belly of omohyoid with

transection of omohyoid posteriorly. Note that the omohyoid
crosses the IJV laterally.
Identify IJV and vagus nerve in lower aspect of neck before

ligation of IJV. Pass 2-0 silk suture around the vein and tie it
as depicted.
Intra-operative Details 7
Place a distal suture ligature with 2-0 silk while the vein is
still intact. Place 2 similar sutures cephalic and transect the
vein as seen.
Further identify carotid artery and vagus nerve. Open

supraclavicular fatty tissue using blunt dissection, either
with a finger or hemostat, with identification of phrenic
nerve and brachial plexus
SAN is sacrificed in RND, so no identification is required
Continue dissection along anterior border of trapezius.

Preserve phrenic nerve and brachial plexus
Follow cervical nerve branches and section them high on

specimen
Separate specimen from carotid & vagus, proceeding

superiorly, with identification of hypoglossal nerve
Preserve superior thyroid artery and superior laryngeal

nerve and carefully ligate the ranine veins
Cut SCM superiorly (just lateral to posterior belly of

digastric) in the same manner as described before
Intra-operative Details
10
Identify IJV superiorly (medial to posterior belly of digastric);

dissect and ligate as described before
11
Final aspect of surgical wound after removal of specimen:
12
Anatomical structures to be sacrificed:

Internal jugular vein
Spinal accessory nerve
Sternocleidomastoid muscle
Cutaneous branches of the cervical plexus

Submandibular gland and Wharton duct
Tail of the parotid gland
Greater auricular nerve
External jugular vein
Posterior facial vein
Facial artery
Omohyoid muscle
13
Anatomical structures to be preserved (if possible):

Marginal mandibular nerve
Digastric muscle with both bellies and tendon
Lingual nerve and submandibular ganglion
Superior laryngeal nerve
Superior thyroid artery
Hypoglossal nerve
Vagus nerve
Carotid vessels
Phrenic nerve
Brachial plexus
Thoracic duct
14
Irrigate with normal saline
Maintain hemostasis
Insert drains
Compression dressing
Immediate Post-op
Guidelines
NPO for 24 hours
Head elevation at 300
Monitor vital signs, intake, and output every 4 hours
Care of tracheostomy tube (humidification, suctioning, cleansing)
Pain medication as needed
Ensure that the drains:

are functioning properly
are maintained on continuous suction until they drain < 20-25 ml
per 24 hours
do not clot
Antibiotics for first 24 hours if upper aerodigestive tract was opened
Monitor for fever, bleeding, and hematoma formation
Avoid atelectasis
Monitor for possible fistula if upper aerodigestive tract was opened,

esp. on 3rd or 4th post-op day
Discharge Criteria
Once suction and drains have been removed, patient can be

discharged (usually 4th or 5th post-op day), if:
satisfactory healing of surgical wound
no evidence of bleeding or infection
adequate airway
adequate nutrition
hemodynamic stability
adequate family or home care support
initiation of shoulder therapy to shoulder joint before
discharge and continuation at home
Follow-up
Follow-up in 7 10 days
Check pathology report
Check status of neck
Remove sutures
Continue with shoulder physical therapy
Further follow-up monthly for first year, then every 2-4

months for five years to rule out recurrent tumor or
second primary tumor
Complications - 1
Intra-operative:
Hemorrhage
Carotid sinus reflex
Pneumothorax
Air embolus
Embolus
Nerve damage:
Sensation in neck
Marginal mandibular nerve
Cervical sympathetic chain
Spinal accessory nerve (SAN)
Hypoglossal nerve
Vagus nerve
Brachial plexus
Poor wound healing after radiation
Chylous fistula
Complications - 2
Post-operative:
Hematoma
Wound infection
Skin flap loss
Salivary fistula
Chylous fistula
Facial edema
Electrolyte disturbances (hyponatremia)
Carotid artery rupture

Neck Dissection

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What are the different types of neck dissections?

What are the different types of neck dissections?

What are the different levels of cervical lymph nodes?

What are the different levels of cervical lymph nodes?

Radical Neck Dissection

Metastatic neck disease is most important factor in spread

Rate of ipsilateral metastatic disease in patients with T3-T4

Lymph node metastasis reduces survival rate by half

Radical neck dissection is performed for surgical control of

radical neck dissection

radical neck dissection

Lymph nodes of the Neck

Lymph nodes lie in the fibro-adipose tissue between

The nodes tend to aggregate around certain neural

Also: perifacial and buccinator nodes

Drainage: oral cavity, nasal cavity, nasopharynx,

Drainage: Oral cavity, nasopharynx, oropharynx,

Drainage: larynx, hypopharynx, thyroid, cervical esophagus

Drainage: nasopharynx, oropharynx, skin of posterior scalp

Drainage: thyroid gland, subglottic larynx, cervical trachea,

N2b, N2c, N3 disease

N1 / N2a with involvement of SAN or IJV

Clinical evidence and/or imaging studies showing evidence

Nodal disease with involvement of platysma and/or skin

Recurrent or persistent neck disease after previous

Poorly prepared patient (e.g. cardiopulmonary disease)

Pre-operative imaging suggests deep infiltration of tumor

Primary tumor that cannot be controlled

Distant metastatic disease

Circumferential or near-circumferential involvement and invasion of

If possibility of tumor involvement of carotid artery, then

Mirror laryngoscopy, flexible nasopharyngolaryngoscopy

If primary lesion is known:

If primary lesion not known:

FNAC of neck mass

Sentinel lymph node biopsy: in research stage

Supine position, shoulder roll, extended neck

Upper end of table elevated at 300

Several possible incisions, .e.g. hockey stick incision

Identify and preserve marginal mandibular nerve at superior

Remove submental fatty tissue with Bovie electrocautery

Retract mylohyoid anteriorly, exposing submandibular

Ligate facial artery above digastric muscle

Cut and ligate submandibular duct

Remove submandibular nodes and submandibular duct and

Continue dissection posteriorly, exposing posterior belly of

Expose SCM and incise it above clavicle with Bovie

Identify anterior and posterior belly of omohyoid with

Identify IJV and vagus nerve in lower aspect of neck before

Further identify carotid artery and vagus nerve. Open

SAN is sacrificed in RND, so no identification is required

Continue dissection along anterior border of trapezius.

Follow cervical nerve branches and section them high on

Separate specimen from carotid & vagus, proceeding

Preserve superior thyroid artery and superior laryngeal

Cut SCM superiorly (just lateral to posterior belly of

Identify IJV superiorly (medial to posterior belly of digastric);

Final aspect of surgical wound after removal of specimen:

Anatomical structures to be sacrificed: