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Contents
Neck anatomy Levels of the neck Classification of neck dissection
Radical neck dissection Modified radical neck dissection Selective neck dissection Extended neck dissection
Boundaries
IA: submental
Superior
Symphysis
Inferior
Body of hyoid
Medial
Anterior belly of contralateral digastric
Lateral
Anterior belly of ipsilateral digastric
Boundaries
IA: submental Nodal spread from
Floor of mouth Anterior oral tongue Anterior lower alveolus Lower lip
Boundaries
IB: submandibular
Superior
Body of mandible
Inferior
Posterior belly of digastric
Anterior
Anterior belly of digastric
Posterior
Stylohyoid muscle
Boundaries
IB: submandibular Nodal spread from
Oral cavity Anterior nasal cavity Soft-tissue structures of midface and submandibular gland
Boundaries
II: upper jugular
Superior
Skull base
Inferior
Horizontal plane defined by the inferior body of the hyoid (clinical landmark) Carotid bifurcation (surgical landmark)
Anterior
Stylohoid muscle
Posterior
Posterior border of SCM
Boundaries
II: upper jugular Nodal spread from
Oral cavity Nasal cavity Nasopharynx Oropharynx Hypopharynx Larynx Parotid
Boundaries
III: middle jugular
Superior
Horizontal plane defined by inferior body of hyoid (clinical landmark) Carotid bifurcation (surgical landmark)
Inferior
Horizontal plane defined by inferior border of cricoid (clinical landmark) Junction of omohyoid and IJV (surgical landmark)
Anterior
Lateral border of sternohyoid
Posterior
Posterior border of SCM
Boundaries
III: middle jugular Nodal spread from
Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx
Boundaries
IV: lower jugular
Superior
Horizontal plane defined by inferior border of cricoid (clinical landmark) Junction of omohyoid and IJV (surgical landmark)
Inferior
Clavicle
Anterior
Lateral border of sternohyoid
Posterior
Posterior border of SCM
Boundaries
IV: lower jugular Nodal spread from
Hypopharynx Thyroid Cervical esophagus Larynx
Boundaries
V: posterior triangle
Superior
Apex of convergence of SCM and trapezius Clavicle Posterior border of SCM Anterior border of trapezius
Inferior
Anterior Posterior Horizontal plane defined by lower border of cricoid divides level into VA + VB Three lymphatic pathways
Nodes following XI as it traverses posterior triangle Nodes following transverse cervical artery Supraclavicular nodes (including Virchow s node)
Boundaries
V: posterior triangle Nodal spread from
Nasopharynx Oropharynx Cutaneous structures of posterior scalp and neck Thyroid Virchow
Any GI Breast
Boundaries
VI: central compartment
Superior
Hyoid bone
Inferior
Suprasternal notch
Medial
Contralateral carotid
Lateral
Ipsilateral carotid
Nodes involved
Pre and paratracheal Precricoid (Delphian) Perithyroidal
Boundaries
VI: central compartment Nodal spread from
Thyroid Glottic and subglottic larynx Apex of piriform sinus Cervical esophagus
Level II/IIA/IIB
Risk of nodal disease in sublevel IIB is less in primaries of the oral cavity and laryngeal than those in oropharynx If no clinical nodal disease in level IIA in oral cavity and larynx, unnecessary to dissect level IIB (which has high morbidity)
V/VA/VB
Superior component: spinal accessory lymph nodes Inferior component: Transverse cervical and supraclavicular nodes
Carry a more dire prognosis when positive for H+N cancers
Radiologic boundaries
Levels IB and IIA separated
Anatomic: by stylohyoid muscle Radiographic: by transverse line drawn at posterior surface of submandibular gland on each side of the neck
Comprehensive neck dissection: Any neck dissection addressing level I-V on one side Radical neck dissection Modified radical neck dissection
Purpose
Significantly decreased morbidity
Especially with preservation of XI
Currently
MRND with preservation of x
If N+ neck
Usually necessary to include IV and V (ie comprehensive neck dissection) Exception:
If nodal disease confined to levels I and II, SND (I-IV) is appropriate
If N+ bilaterally
Bilateral comprehensive neck dissections
Alveolar ridge:
For T3 and T4 primaries Poor differentiation
Oral tongue
If depth >2mm If anterior, or near midline, treat bilaterally
Floor of mouth
Some sources:
All T2-4 primaries, and T1 with poor differentiation
Other sources
SND if depth of primary >2mm
Treat bilaterally
Buccal mucosa
SND indicated in all cases
Hard palate
None vs. SND for T4 primaries
Glottis
Poor lymphatic drainage SND in bulky T4 disease
Subglottis
Bilateral SND in advanced disease
Transglottic
Bilateral SND
Selective neck dissection for oropharyngeal, hypopharyngeal, and laryngeal cancer Oropharynx
All T2-4 lesions require treatment of neck Bilateral SND if
Clinical disease on one side of the neck Lesion is central Lesion crosses midline
Selective neck dissection for oropharyngeal, hypopharyngeal, and laryngeal cancer Hypopharynx
Very rich lymphatic drainage All require bilateral treatment of neck
Only possible exception: very early lesions, where unilateral treatment of neck may be acceptable
Selective neck dissection for cancer of midline structures of anterior lower neck
SND (VI) +/- other neck levels indicated in
Thyroid cancer Advanced glottic and subglottic cancer Advanced piriform sinus cancer Cervical esophageal and tracheal cancer
Melanoma
Elective SND not indicated
General algorithm
Nodal staging
Features of positive nodes
Size:
Jugulodigastric: 1.5 cm or bigger All others: 1.0 cm or bigger
Nx: regional lymph nodes can not be assessed N0: no regional lymph node metastasis N1: metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2a: metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension N2b: metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c: metastasis in bilateral or contralateral nodes no more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension
Nodal staging
Staging in nasopharyngeal carcinoma
Different distribution of nodal spread Different prognostic impact of nodal disease
Nx and N0: same N1: unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa N2: Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa N3a: Greater than 6 cm in dimension N3b: extension to the supraclavicular fossa
Prognosis
5 year survival for H+N ca:
T1-2 NN+ 80 40 T3-4 40 20
Deformity
Scapula flares Droops Rotates anterolaterally
Some dysfunction often detectable after selective neck dissections Permanent dysfunction significantly compromises quality of life All patients undergoing neck dissection of any type should begin physiotherapy early in the post-operative course
Hematoma
Swelling or ballooning of skin flaps Milking drains may result in evacuation of blood If blood reaccumulates quickly, return to the OR Failure to drain hematoma may lead to wound infection
Conservative
Leak apparent after enteral feeds resumed Drainage < 600 cc/day Manage with closed wound drainage, pressure dressings, medium-chain fatty acid diet TPN may be necessary for high-output or intractable fistulas
Facial edema
May be preventable by preserving at least one EJV
Cerebral edema
May be the cause of impaired neurologic function and coma that occur after bilateral RND Bilateral ligation of IJV leads to increased ICP
May lead to SIADH (it does in dog studies) Vicious cycle:
The resulting expansion of extracellular fluids and dilutional hyponatremia aggravate the cerebral edema
Any patient undergoing bilateral IJ ligation requires careful peri- and post-operative monitoring of fluid status and electrolyte balance
In these cases, return to OR and cover carotid with wellvascularized tissue In event of rupture
Blowout usually near carotid bulb and pinpoint in size Manual pressure Fluids and blood Return to the OR
Expose and ligate carotid proximally and distally Attempts to repair area of rupture futile
Summary
Neck anatomy Levels of the neck Classification of neck dissection
Radical neck dissection Modified radical neck dissection Selective neck dissection Extended neck dissection