History Of CANCER

Anatomy of HEAD & NECK

LYMPH NODE levels
Staging of CANCER
NECK DISSECTIONS
COMPLICATIONS

1880 Kocher advocates wide margin

lymphadenectomy

1881 Kocher and Packard

recommend
dissection of
submandibular triangle for lingual
cancer

1885 Butlin questions RND for oral N0

disease

1888 Jawdynski describes en bloc

resection with resection of carotid,
IJV, SCM.

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

1901 Solis-Cohen advocate

lymphadenectomy for N0 laryngeal
CA

1905 -1906 Crile describes

en bloc resection in JAMA

1926 Bartlett and Callander

advocate preservation of XI, IJV,
SCM, platysma, stylohyoid,
digastric

1933 Blair and Brown advocate

removal of XI.
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

1951 Martin advocates Radical Neck Dissection after analysis

of 1450 cases

Advocated RND for N+ cases.

1952 Suarez describes a functional neck dissection

Preservation of SCM, omohyoid, submandibular gland, IJV, XI.

Enables protection of carotid.

1960s MD Anderson advocate selective ND of highest risk

nodal
basins

1967 - Bocca and Pignataro describe the functional neck

dissection

1975 Bocca establishes oncologic safety of the FND compared

to the RND

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

The region of the

body that lies
between:
The LOWER
BORDER OF THE
MANDIBLE&

The SUPRASTERNAL
NOTCH and the
UPPER BORDER OF
CLAVICLE.

 Superficial cervical fascia

Deep cervical fascia
Superficial layer
SCM, strap muscles, trapezius
Middle or Visceral Layer
Thyroid
Trachea
esophagus
Deep layer (also prevertebral fascia)
Vertebral muscles
Phrenic nerve

Sup. thyroid

Ext. jugular

Int. jugular
Middle
thyroid

Inf. thyroid
Ant. jugular

 Origin fascia overlying the pectoralis

major and deltoid muscle
Insertion 1) depression muscles of the
corner of the mouth, 2) the mandible, and
3) the SMAS layer of the face
Function
1) wrinkles the the neck
2) depresses the corner of the mouth
3) increases the diameter of the neck
4) assists in venous return

platysma

platysma

Sternocleidomastoid

Surgical considerations
Increases blood supply to skin flaps
Absent in the midline of the neck
Fibers run in an opposite direction to the SCM

pretracheal fascia
Infrahyoid m.

thyroid
Pretracheal layer

s.c.
m
Carotid sheat
h
Buccopharynge
al fascia

trachea esophagu
s
Internal jugular
vein
Common carotid
a.
Vagus n.

scalenus

Investing
layer

Trapezius

Prevertebral
layer

 Origin 1) medial third of the clavicle

(clavicular head)
2) manubrium (sternal head)
Insertion mastoid process
Nerve supply spinal accessory nerve (CN
XI)
Blood supply
1) occipital a. or direct from ECA
2) superior thyroid a.
3) transverse cervical a.

Sternocleidomastoid

Function turns head toward opposite side

and tilts head toward the ipsilateral shoulder
Surgical considerations
Leave overlying fascia (superficial layer of deep
cervical fascia down)
Lateral retraction exposes the submuscular recess

 Origin upper border of the scapula

Insertion
1) via the intermediate tendon onto the clavicle
and first rib
2) hyoid bone lateral to the sternohyoid muscle
Blood supply Inferior thyroid a.
Function
1) depress the hyoid
2) tense the deep cervical fascia

Surgical considerations
Absent in 10% of individuals
Landmark demarcating level III from IV
Inferior belly lies superficial to
The brachial plexus
Phrenic nerve
Transverse cervical vessels
Superior belly lies superficial to
IJV

 Origin
1) medial 1/3 of the sup. Nuchal line
2) external occipital protuberance
3) ligamentum nuchae
4) spinous process of C7 and T1-T12
Insertion
1) lateral 1/3 of the clavicle
2) acromion process
3) spine of the scapula
Function elevate and rotate the scapula and
stabilize the shoulder

Surgical considerations
Posterior limit of Level V neck dissection
Denervation results in shoulder drop and
winged scapula

 Origin digastric fossa of the mandible (at the

symphyseal border
Insertion
1) hyoid bone via the intermediate tendon
2) mastoid process
Function
1) elevate the hyoid bone
2) depress the mandible (assists lateral pterygoid)

Posterior belly is superficial to:

ECA
Hypoglossal nerve
ICA
IJV
Anterior belly
Landmark for identification of mylohyoid for
dissection of the submandibular triangle

Division of the neck

Anterior triangle

Suprahyoid region: submental triangle

submandibular triangle
Infrahyoid region: muscular triangle
carotid triangle
Posterior triangle

Submental triangle

Lies below the chin and is

bounded laterally by
anterior bellies of
digastric, and inferiorly
by the body of hyoid
bone
Covered by skin,
superficial fascia and
investing fascia
Floor mylohyoid
muscles
Contents submental
lymph nodes

Suprahyoid muscles

stylohyoid
digastric (anterior
and posterior belly)

mylohyoid

Submandibular triangle

Bounded by anterior and posterior bellies of

digastric and lower border of the body of the
mandible
Covered by skin, superficial fascia, platysma and
investing fascia
Floor mylohyoid, hyoglossus and middle
constrictor of pharynx
Contents submandibular gland, facial
a., v., hypoglossal n. and v., lingual n.,
submandibular ganglion and submandibular lymph
nodes

Carotid triangle

sternocleidomastoid,
superior belly of omohyoid
and posterior belly of
digastic muscles
Covered by skin, superficial
fascia, platysma and
investing fascia
Floor prevertebral fascia
and lateral wall of pharynx
Contents common carotid
a. and its branches, internal
jugular v. and its tributaries,
hypoglossal n. with its
descending branches, the
accessory and vagus
nerves, and part of the
chain of deep cervical
lymph nodes

Muscular triangle

Bounded by midline of the

neck, superior belly of the
omohyoid and anterior
border of the
sternocleidomastoid.
Covered by skin, superficial
fascia, platysma, anterior
jugular v., coutaneous n.
and investing fascia
Floor prevertebral fascia
Contents sternohyoid,
sternothyroid, thyrohyoid,
thyroid gland, parathyroid
gland, cervical part of
trachea and esophagus

Bounded by
posterior border of
sternocleidomastoid
, anterior border of
trapezius and
middle third of
clavicle
Divided by inferior
belly of omohyoid
into occipital and
supraclavicular
triangles

Arteries:
Subclavian (3rd part)
Superficial cervical
& suprascapular
(branches of
thyrocervical trunk,
a branch of 1st part
of subclavian artery
Occipital, a branch
of external carotid
artery

Nerves:
Branches of

cervical
plexus

Spinal part of

accessory
nerve

Brachial

plexus

Occipital triangle

Bounded by posterior
border of
sternocleidomastoid,
anterior border of
trapezius and superior
border of inferior belly of
omohyoid
Covered by skin,
superficial fascia, and
investing fascia
Floor prevertebral
fascia and scalenus
anterior, scalenus
medius, scalenus
posterior, splenius
capitis and levator
scapulae

Contents
Accessory n. emerges above the middle of

the posterior border of sternocleidomastoid

and crosses the occipital triangle to trapezius
Cervical and brachial PLEXUS

Supraclavicular triangle
Bounded by posterior
border of
sternocleidomastoid,
inferior belly of omohyoid
and middle third of
clavicle
Covered by skin,
superficial fascia, and
investing fascia
Floor prevertebral fascia
and inferior parts of
scalenus
Contents
Subclavian v. and

venous angle
Subclavian a.
Brachial plexus

Most commonly injury

dissection level Ib
Landmarks:
1cm anterior and inferior

to angle of mandible
Mandibular notch

Subplatysmal
Deep to fascia of the
submandibular gland
Superficial to facial vein

Motor nerve to the

tongue
Cell bodies are in
the Hypoglossal
nucleus of the
Medulla oblongata
Exits the skull via
the hypoglossal canal
Lies deep to the IJV,
ICA, CN IX, X, and XI

 Curves 90 degrees and passes between the IJV

and ICA
Surrounded by venous plexus
Extends upward along hyoglossus muscle and
into the genioglossus to the tip of the tongue.
Iatrogenic injury
Most common site - floor of the submandibular
triangle, just deep to the duct

Penetrates deep surface of

the SCM
Exits posterior surface of
SCM deep to Erbs point
Traverses the posterior
triangle on the levator
scapulae
Enters the trapezius about
5 cm above the clavicle

Accessory n. (XI)

Hypoglossal n. (XII)

Ansa cervicalis

Vagus n. (X)

Phrenic n.

CN XI Relationship with the IJV

Crosses the IJV

Crosses lateral to the transverse process of
the atlas
Occipital artery crosses the nerve
Descends obliquely in level II (forms Level IIa
and IIb

Developed by Memorial Sloan-Kettering

Cancer Center
Ease and uniformity in describing
regional nodal involvement in cancer of
the head and neck

LYMPH NODES acts as a barrier to the

spread of the disease .
Virchow in 1860

CAN BE DIVIDED INTO;

a) SUPERFICIAL CHAIN OF LYMPH NODES..
b) VERTICAL DEEP CHAIN OF LYMPH NODES
This consists of nodes lying in relation to
carotid sheath.These lie along the
vessels,trachea,oesophagusand extend from
base of skull to root of neck.

1.

Submental

2.

Submandibular

3.

Parotid / tonsilar

4.

Preauricular

5.

Postauricular

6.

Occipital

7.

Anterior cervical superficial

and deep

8.

Supraclavicular

9.

Posterior cervical

Ia
Ib

Submental
Submandibular

IIa Upper jugular (Anterior to XI)

IIb Upper jugular (Posterior to XI)

III

IVa Lower jugular (Clavicular)

IVb Lower jugular (Sternal)

Va Posterior triangle (XI)

Vb Posterior triangle (Transverse
cervical)

VI

Middle jugular

Central compartment

Submental triangle
(Ia)
Anterior digastric
Hyoid
Mylohyoid

Submandibular
triangle (Ib)
Anterior and

posterior digastric
Mandible.

Ia

Chin
Lower lip
Anterior floor of mouth
Mandibular incisors
Tip of tongue

Ib

Oral Cavity
Floor of mouth
Oral tongue
Nasal cavity (anterior)
Face

Upper Jugular Nodes

Anterior Lateral border
of sternohyoid, posterior
digastric and stylohyoid
Posterior Posterior
border of SCM
Skull base
Hyoid bone
Carotid bifurcation

Level IIa anterior to XI

Level IIb posterior to XI

Oral Cavity
Nasal Cavity
Nasopharynx
Oropharynx
Larynx
Hypopharynx
Parotid

Middle jugular nodes

Anterior Lateral border

of sternohyoid
Posterior Posterior
border of SCM
Inferior border of level II
Cricoid cartilage lower
border

Oral cavity
Nasopharynx
Oropharynx
Hypopharynx
Larynx

Lower jugular nodes

Anterior Lateral

border of sternohyoid
Posterior Posterior
border of SCM
Cricoid cartilage lower
border
Omohyoid muscle
Clavicle

Hypopharynx
Larynx
Thyroid
Cervical esophagus

Posterior triangle of
neck
Posterior border of SCM
Clavicle
Anterior border of

trapezius
Va Spinal accessory
nodes
Vb Transverse cervical
artery nodes
Supraclavicular nodes

Nasopharynx
Oropharynx
Posterior neck and scalp

Anterior compartment
Hyoid
Suprasternal notch
Medial border of carotid

sheath
Perithyroidal lymph
nodes
Paratracheal lymph
nodes
Precricoid (Delphian)
lymph node

Thyroid
Larynx (glottic and subglottic)
Pyriform sinus apex
Cervical esophagus

Face and Scalp Anterior

Eyelids

Lateral

Parotid

Posterior

Occipital, V

Medial

Ib

Lateral

Parotid, II

Chin
External Ear

Ia, Ib, II
Anterior

Parotid, II

Posterior

Post auricular, II, V

Middle Ear
Floor of mouth

Nasal Cavity

Facial, Ib

Parotid, II
Anterior

Ia, Ib, IIa > IIb

Lower incisors

Ia, Ib, IIa > IIb

Lateral

Ib, IIa > IIb, III

Teeth except incisors

Ib, IIa > IIb, III

Anterior

Ib

Posterior

Retropharyngeal, II, V

Nasal Cavity

Posterior

Retropharyngeal, II, V

Nasopharynx

Retropharyngeal, II, III, V

Oropharynx

IIb > IIa, III, IV, V

Larynx

Supraglottic IIa > IIb, III, IV

Subglottic

VI, IV

Cervical
esophagus

IV, VI

Thyroid

VI, IV, V, Mediastinal

Tongue

Tip

Ia, Ib, IIa > IIb, III, IV

Lateral

Ib, IIa > IIb, III, IV

 N classification AJCC (1997)

Consistent for all mucosal sites except the
nasopharynx
Thyroid and nasopharynx have different
staging based on tumor behavior and prognosis
Based on extent of disease prior to first
treatment

Nx: Regional lymph nodes cannot be

assessed.

N0: No regional lymph node metastases.

N1: Single ipsilateral lymph node, < 3 cm

N2a: Single ipsilateral lymph node 3 to

6 cm
N2b: Multiple ipsilateral lymph nodes
> 6 cm
N2c: Bilateral or contralateral nodes >
6cm

N3: Metastases > 6 cm

Standardized until 1991

Academys Committee for Head and
Neck Surgery and Oncology publicized
standard classification system

Academys classification
Based on 4 concepts
1) RND is the standard basic procedure for
cervical lymphadenectomy against which all
other modifications are compared

2) Modifications of the RND which include

preservation of any non-lymphatic structures are
referred to as modified radical neck dissection
(MRND)

Academys classification

3) Any neck dissection that preserves one or

more groups or levels of lymph nodes is referred
to as a selective neck dissection (SND)

4) An extended neck dissection refers to the

removal of additional lymph node groups or nonlymphatic structures relative to the RND

Academys classification(1991)
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
3) Selective neck dissection (SND)
Supra-omohyoid type
Lateral type
Posterolateral type
Anterior compartment type
4) Extended radical neck dissection

Medina classification (1989)

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)
Selective neck dissection

Spiros classification
Radical (4 or 5 node levels resected)
Conventional radical neck dissection
Modified radical neck dissection
Extended radical neck dissection
Modified and extended radical neck
dissection
Selective (3 node levels resected)
SOHND
Jugular dissection (Levels II-IV)
- Any other 3 node levels resected
Limited (no more than 2 node levels resected)
Paratracheal node dissection
Mediastinal node dissection
Any other 1 or 2 node levels resected

1. Presence of clinically positive N1,

N2a, N2b & N3 nodes
Treatment of No neck is still a
controversy.
2. Extra nodal spread (including skin
involvement)
3. Recurrence after RT treatment

1. Uncontrolled primary lesion

2. Involvement of internal / common
carotid artery
3. Presence of distant metastasis.
4. Poor anaesthetic risk patient.

TYPES

- Apron incision
-Half apron incision
-Conley incision
-Double Y incision
-H incision
-Macfee incision
- Y incision
-Modified Schobinger incision
-Schobinger

1.Good exposure of the neck and

primary disease.
2. Ensure viability of the skin flaps.
Avoid acute angles
3. Protect carotid artery even in the
cases of wound infection.

4. Facilitate reconstruction Example, if

pectoral muscle is used a lower limb
should be near the clavicle to enable
flap accommodation.
5. It should be cosmetically acceptable.

Removes
Nodal groups I-V
SCM, IJV, XI
Submandibular gland,

tail of parotid

Preserves

Posterior auricular
Suboccipital
Retropharyngeal
Periparotid
Perifacial
Paratracheal nodes

Removes
Nodal groups I-V

Preserves
SCM, IJV, XI (any

combination)

TYPE A MRND

Three types (Medina 1989) commonly referred to

not specifically named by committee.

Type I: Preservation of SAN

Type II: Preservation of SAN and IJV
Type III: Preservation of SAN, IJV, and SCM
( Functional neck dissection)

 Indications
Clinically obvious lymph node metastases
SAN not involved by tumor
Intraoperative decision

Indications

Rarely planned
Intraoperative tumor found adherent to
the SCM, but not IJV and SAN

 Rationale
Suarez (1963) necropsy and surgery specimens
of larynx and hypopharynx lymph nodes do not
share the same adventitia as adjacent BVs
Nodes not within muscular aponeurosis or
glandular capsule (submandibular gland)
Sharpe (1981) showed ) 0% involvement of the
SCM in 98 RND specimens despite 73 have nodal
metastases
Survival approximates MRND Type I assuming
IJV, and SCM not involved
Widely accepted in Europe
Neck dissection of choice for N0 neck

Rationale
Reduce postsurgical shoulder pain and
shoulder dysfunction
Improve cosmetic outcome
Reduce likelihood of bilateral IJV
resection - Contralateral neck
involvement

Definition
Cervical lymphadenectomy with
preservation of one or more lymph node
groups
Four common subtypes:
Supraomohyoid neck dissection
Posterolateral neck dissection
Lateral neck dissection
Anterior neck dissection

Also known as an elective neck dissection

Rate of occult metastasis in clinically negative
neck 20-30%
Indication: primary lesion with 20% or greater risk
of occult metastasis
Studies by Fisch and Sigel (1964) demonstrated
predictable routes of lymphatic spread from
mucosal surfaces of the H&N
Need for post-op RT

 Most commonly performed SND

Definition
En bloc removal of cervical lymph node groups
I-III
Posterior limit is the cervical plexus and
posterior border of the SCM
Inferior limit is the omohyoid muscle overlying
the IJV

Indications
Oral cavity carcinoma with N0 neck
Boundaries Vermillion border of lips to
junction of hard and soft palate,
circumvallate papillae
Subsites - Lips, buccal mucosa, upper and
lower
alveolar ridges, retromolar trigone, hard
palate, and anterior 2/3s of the tongue
and FOM
Medina recommends SOHND with T2-T4
NO or TX N1 (palpable node is <3cm,
mobile, and in levels I or II)

Bilateral SOHND
Anterior tongue
Oral tongue and FOM that approach the midline
SOHND + parotidectomy
Cutaneous SCCA of the cheek
Melanoma (Stage I 1.5 to 4mm) of the cheek
Byers does not advocate elective neck dissection
for buccal carcinoma
Adjuvant RT given to patients with > 2- 4
positive nodes +/- ECS.

Definition
En bloc removal of the jugular lymph
nodes including Levels II-IV.
Indications
N0 neck in carcinomas of the
oropharynx, hypopharynx, supraglottis,
and larynx

 Definition
En bloc excision of lymph bearing tissues
in Levels II-IV and additional node groups
suboccipital and postauricular.
Indications
Cutaneous malignancies
Melanoma
Squamous cell carcinoma
Merkel cell carcinoma
Soft tissue sarcomas of the scalp and neck

Definition
En bloc removal of lymph structures in
Level VI
Perithyroidal nodes
Pretracheal nodes
Precricoid nodes (Delphian)
Paratracheal nodes along recurrent
nerves
Limits of the dissection are the hyoid
bone, suprasternal notch and carotid
sheaths

Indications
Selected cases of thyroid carcinoma
Parathyroid carcinoma
Subglottic carcinoma
Laryngeal carcinoma with subglottic
extension
CA of the cervical esophagus

Definition
Any previous dissection which includes removal
of one or more additional lymph node groups
and/or non-lymphatic structures.
Usually performed with N+ necks in MRND or
RND when metastases invade structures usually
preserved

Indications
Carotid artery invasion
Other examples:
Resection of the hypoglossal nerve resection or
digastric muscle,

dissection of mediastinal nodes and central

compartment for subglottic involvement, and

removal of retropharyngeal lymph nodes for

tumors originating in the pharyngeal walls.

SUPERSELECTIVE NECK DISSECTION OF

HEAD AND NECK cancer
Yet to come

4 TYPES
INTRA OP
IMMEDIATE POST OP
LATE POST OP
DELAYED COMPLICATIONS

Inadequate planning
Inadvertent injury to local blood
vessels and nerves .
-marginal mandibular N.
- Spinal accessory N.
- Cervical plexus
- Brachial plexus
- Thoracic duct injury .

Haemorrhage: Needs evaluation of

the extent of bleeding and occasionally
may need re-exploration.
Lymph leak: When the drainage is of
milky fluid and is persistently high
>100ml /day after 2days.A possibility
of lymph leak has to be considered.

Carotid blow out: A dreaded

complication that occurs secondary to
wound break down. If exposed the
carotids have to be covered using
vascularised flaps.
Facial oedema: A common occurrence
usually settles down in 4-6 weeks.

Wound infection
Fistulae
Devitalisation of the reconstructed flap

Dysphagia ( CN V,IX, X, XI)

Shoulder weakness
Trismus

Pectoralis major myocutaneous flap

Free fibula flap
Deltoid muscle flap
Forehead flap
Cervical flap
Radial forearm flap

Cervical metastasis in SCCA of the upper

aerodigestive tract continues to portend a poor
prognosis
Staging will help determine what type neck
dissection should be performed
Unified classification of neck nodal levels and
classification of neck dissection has to
understood well.
Indications for neck dissection and type of neck
dissection, especially in the N0 neck, is a still
controversial

THANK YOU
HAVE A NICE DAY