Neck Dissections

Neck Dissections:Neck Dissections:Classifications, Indications, Classifications, Indications,

andandTechniquesTechniques

Dr Kuljinder SodhiDr Kuljinder Sodhi

INTRODUCTIONINTRODUCTION

Status of the cervical lymph nodesStatus of the cervical lymph nodes

is important prognostic factor in SCCA of is important prognostic factor in SCCA of the upper aerodigestive tractthe upper aerodigestive tract

Cure rates drop in half when there isCure rates drop in half when there is

regional lymph node involvementregional lymph node involvement

SURGICAL ANATOMYSURGICAL ANATOMY Fascial layers of the Fascial layers of the

neckneck Superficial cervical fasciaSuperficial cervical fascia Deep cervical fasciaDeep cervical fascia – – Superficial layerSuperficial layer SCM, strap muscles, SCM, strap muscles,

trapezius trapezius – – Middle or Visceral LayerMiddle or Visceral Layer Thyroid,Trachea, Thyroid,Trachea,

esophagusesophagus – – Deep layer (also Deep layer (also

prevertebral fascia)prevertebral fascia) Vertebral musclesVertebral muscles Phrenic nervePhrenic nerve

Muscles of the neckMuscles of the neck Sternocleidomastoid MuscleSternocleidomastoid Muscle medial third of clavicle(clavicularmedial third of clavicle(clavicularhead), manubrium (sternal head)head), manubrium (sternal head) Insertion – mastoid processInsertion – mastoid process Nerve supply – spinal accessory Nerve supply – spinal accessory Blood supply –Blood supply – 1) occipital a. or direct from ECA 1) occipital a. or direct from ECA 2) superior thyroid a.2) superior thyroid a. 3) transverse cervical a.3) transverse cervical a.

Function – Function – turns head toward opposite side turns head toward opposite side

and tilts head toward the and tilts head toward the ipsilateral shoulderipsilateral shoulder

Omohyoid muscleOmohyoid muscle

Origin – upper border of the scapulaOrigin – upper border of the scapula Insertion – 1) via the intermediate tendonInsertion – 1) via the intermediate tendon onto the clavicle and first ribonto the clavicle and first rib 2) hyoid bone lateral to the sternohyoid 2) hyoid bone lateral to the sternohyoid

musclemuscle Blood supply – Inferior thyroid a.Blood supply – Inferior thyroid a. Function –Function – 1) depress the hyoid1) depress the hyoid2) tense the deep cervical fascia2) tense the deep cervical fasciaSurgical considerationsSurgical considerations– – Absent in 10% of individualsAbsent in 10% of individuals– – Landmark demarcating level III from IVLandmark demarcating level III from IV– – Inferior belly lies superficial to The Inferior belly lies superficial to The

brachial plexus, Phrenic nerve, brachial plexus, Phrenic nerve, transverse cervical vesselstransverse cervical vessels

Superior belly lies superficial to IJVSuperior belly lies superficial to IJV

TRAPEZIUSTRAPEZIUS

Origin –Origin – 1) medial 1/3 of the sup. Nuchal line1) medial 1/3 of the sup. Nuchal line 2) external occipital protuberance2) external occipital protuberance 3) ligamentum nuchae3) ligamentum nuchae 4) spinous process of C7 and T1-T124) spinous process of C7 and T1-T12 Insertion – Insertion – 1) lateral 1/3 of the clavicle1) lateral 1/3 of the clavicle 2) acromion process2) acromion process 3) spine of the scapula3) spine of the scapula Function – elevate and rotate the scapula andFunction – elevate and rotate the scapula and stabilize the shoulderstabilize the shoulder Surgical considerationsSurgical considerations – – Posterior limit of Level V neck dissectionPosterior limit of Level V neck dissection – – Denervation results in shoulder drop and winged scapulaDenervation results in shoulder drop and winged scapula

DIGASTRIC MUSCLEDIGASTRIC MUSCLE

Origin – digastric fossa of the mandible Origin – digastric fossa of the mandible Insertion –Insertion – 1) hyoid bone via the intermediate tendon1) hyoid bone via the intermediate tendon 2) mastoid process2) mastoid process Function – 1) elevate the hyoid boneFunction – 1) elevate the hyoid bone2) depress the mandible (assists2) depress the mandible (assistslateral pterygoid)lateral pterygoid)

Surgical considerationsSurgical considerations “ “Residents friend”Residents friend” Posterior belly is superficial to:Posterior belly is superficial to: ECA, Hypoglossal nerve, ICA, IJVECA, Hypoglossal nerve, ICA, IJV– – Anterior bellyAnterior belly Landmark for identification of mylohyoid Landmark for identification of mylohyoid

for dissection of the submandibular for dissection of the submandibular triangletriangle

MARGINAL MANDIBULAR NERVEMARGINAL MANDIBULAR NERVE

Should be preserved in Should be preserved in neck dissectionsneck dissections

Most commonly injury Most commonly injury dissection level Ibdissection level Ib

Can be found:Can be found:

– – 1cm anterior and inferior 1cm anterior and inferior to angle of mandibleto angle of mandible

Deep to fascia of the Deep to fascia of the submandibular glandsubmandibular gland

Superficial to adventitia of Superficial to adventitia of the facial veinthe facial vein

SPINAL ACCESSORY N.SPINAL ACCESSORY N.Originates in the Originates in the spinal nucleusspinal nucleus Passes through two foramenPasses through two foramen– – Foramen Magnum – enters the skull Foramen Magnum – enters the skull

posterior to the vertebral arteryposterior to the vertebral artery – – Jugular Foramen – exits the skull Jugular Foramen – exits the skull

with CN IX,X and the IJVwith CN IX,X and the IJV Occipital artery crosses the nerveOccipital artery crosses the nerve Descends obliquely in level IIDescends obliquely in level II (forms Level IIa and IIb)(forms Level IIa and IIb) Penetrates the deep surface of the Penetrates the deep surface of the

SCM Exits posterior surface of SCM SCM Exits posterior surface of SCM deep to Erb’s pointdeep to Erb’s point

Traverses the posterior triangle Traverses the posterior triangle ensheathed by the superficial cervical ensheathed by the superficial cervical fascia and lies on the levator scapulaefascia and lies on the levator scapulae

Enters the trapezius approx. 5 cm Enters the trapezius approx. 5 cm above the clavicleabove the clavicle

PHRENIC NERVEPHRENIC NERVE

Sole nerve supply to the Sole nerve supply to the diaphragmdiaphragm

Supplied by nerve roots Supplied by nerve roots C3-5C3-5

Runs obliquely toward Runs obliquely toward midline on the anterior midline on the anterior surface of anterior surface of anterior scalenescalene

Covered by prevertebral Covered by prevertebral fasciafascia

Lies posterior and lateral to Lies posterior and lateral to the carotid sheaththe carotid sheath

HYPOGLOSSAL N.HYPOGLOSSAL N.Motor nerve to the tongueMotor nerve to the tongueCell bodies are in the Cell bodies are in the Hypoglossal Hypoglossal

nucleus nucleus of the Medulla oblongataof the Medulla oblongata Exits the skull via the hypoglossal Exits the skull via the hypoglossal

canalcanal Lies deep to the IJV, ICA, CN IX, X, Lies deep to the IJV, ICA, CN IX, X,

and XIand XICurves 90 degrees and passes Curves 90 degrees and passes

between the IJV and ICAbetween the IJV and ICA Extends upward along hyoglossus Extends upward along hyoglossus

muscle and into the genioglossus muscle and into the genioglossus to the tip of the tongueto the tip of the tongue

Iatrogenic injury Most common site Iatrogenic injury Most common site - floor of the submandibular - floor of the submandibular triangle, just deep to the ducttriangle, just deep to the duct

STAGING OF THE NECKSTAGING OF THE NECK

“ “N” classification AJCC (1997)N” classification AJCC (1997)

Consistent for all mucosal sites except theConsistent for all mucosal sites except the

nasopharynxnasopharynx

Thyroid and nasopharynx have differentThyroid and nasopharynx have different

staging based on tumor behavior andstaging based on tumor behavior and

prognosisprognosis

NODAL STAGENODAL STAGENX: Regional lymph nodes cannot be NX: Regional lymph nodes cannot be

assessedassessed N0: No regional lymph node N0: No regional lymph node

metastasismetastasis N1: Metastasis in a single ipsilateral N1: Metastasis in a single ipsilateral

lymph node, < 3lymph node, < 3N2a: Metastasis in a single ipsilateralN2a: Metastasis in a single ipsilateral lymph node 3 to 6 cmlymph node 3 to 6 cmN2b: Metastasis in multiple ipsilateralN2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cmlymph nodes, none more than 6 cm N2c: Metastasis in bilateral or N2c: Metastasis in bilateral or

contralateral nodes < 6cmcontralateral nodes < 6cm N3: Metastasis in a lymph node more N3: Metastasis in a lymph node more

than 6 cm in greatest dimensionthan 6 cm in greatest dimension

LYMPH NODE LEVELSLYMPH NODE LEVELS

Patterns of lymphatic metastasis Patterns of lymphatic metastasis are as follows:are as follows:

With oral, tongue, retromolar trigone, and With oral, tongue, retromolar trigone, and tonsillar fossa subsites, the tonsillar fossa subsites, the jugulodigastric, submandibular, and jugulodigastric, submandibular, and midjugularmidjugular lymph node stations are lymph node stations are involved. involved.

With the floor of the mouth as the With the floor of the mouth as the subsite, the subsite, the submandibular and submandibular and jugulodigastricjugulodigastric lymph node stations are lymph node stations are involved. involved.

With the soft palate, base of the tongue, With the soft palate, base of the tongue, oropharynx, supraglottis, and oropharynx, supraglottis, and hypopharynx subsites, the hypopharynx subsites, the jugulodigastric, midjugular, and jugulodigastric, midjugular, and contralateralcontralateral lymph node stations are lymph node stations are involved. involved.

With the nasopharynx as the subsite, With the nasopharynx as the subsite, lymph node stations of the widest nodal lymph node stations of the widest nodal distribution are involveddistribution are involved. .

Contralateral metastasis is found in the Contralateral metastasis is found in the supraglottis, the base of the tongue, and the supraglottis, the base of the tongue, and the posterior pharyngeal wall palate. posterior pharyngeal wall palate.

Bilateral metastasis is found in the nasopharynx, Bilateral metastasis is found in the nasopharynx, the base of the tongue, the soft palate, the floor the base of the tongue, the soft palate, the floor of mouth, and the supraglottis. of mouth, and the supraglottis.

Multiple cervical metastases (adenocarcinoma) Multiple cervical metastases (adenocarcinoma) occur with thyroid carcinoma, breast carcinoma, occur with thyroid carcinoma, breast carcinoma, and nasopharyngeal carcinoma. and nasopharyngeal carcinoma.

Nodal metastasisNodal metastasis

Classification of NeckClassification of NeckDissectionsDissections

Academy’s classificationAcademy’s classification

1) Radical neck dissection (RND)1) Radical neck dissection (RND)

2) Modified radical neck dissection (MRND)2) Modified radical neck dissection (MRND)

3) Selective neck dissection (SND)3) Selective neck dissection (SND)

Supra-omohyoid typeSupra-omohyoid type

Lateral typeLateral type

Posterolateral typePosterolateral type

Anterior compartment typeAnterior compartment type

4) Extended radical neck dissection4) Extended radical neck dissection

Medina classification (1989)Medina classification (1989)

Comprehensive neck dissectionComprehensive neck dissection Radical neck dissectionRadical neck dissection Modified radical neck dissectionModified radical neck dissection Type I (XI preserved)Type I (XI preserved) Type II (XI, IJV preserved)Type II (XI, IJV preserved) Type III (XI, IJV, and SCM preserved)Type III (XI, IJV, and SCM preserved) Selective neck dissection (previouslySelective neck dissection (previously described)described)

RADICAL NECK DISSECTIONRADICAL NECK DISSECTION

All lymph nodes in Levels All lymph nodes in Levels I-V including spinal I-V including spinal accessory nerve (SAN), accessory nerve (SAN), SCM, and IJVSCM, and IJV

IndicationsIndications – – Extensive cervical Extensive cervical

involvement or matted involvement or matted lymph nodes with gross lymph nodes with gross extracapsular spread and extracapsular spread and invasion into the SAN, invasion into the SAN, IJV, or SCMIJV, or SCM

Modified Radical NeckModified Radical NeckDissection (MRND)Dissection (MRND)

Excision of same lymph node bearing Excision of same lymph node bearing regions as RND with preservation of one regions as RND with preservation of one or more nonlymphatic structures (SAN, or more nonlymphatic structures (SAN, SCM, IJV)SCM, IJV)

Type I: Preservation of SANType I: Preservation of SAN Type II: Preservation of SAN and IJVType II: Preservation of SAN and IJV Type III: Preservation of SAN, IJV, andType III: Preservation of SAN, IJV, and

SCM SCM

TYPE I TYPE IITYPE I TYPE II

TYPE IIITYPE III

MRND Type IMRND Type I

IndicationsIndications – – Clinically obvious lymph node metastasesClinically obvious lymph node metastases – – SAN not involved by tumorSAN not involved by tumor RationaleRationale

RND vs MRND Type I:RND vs MRND Type I: Actuarial 5-year survival and neck failure rates Actuarial 5-year survival and neck failure rates

for RND (63% and 12%) not statistically different for RND (63% and 12%) not statistically different compared to MRND I (71% and 12%)(Andersen)compared to MRND I (71% and 12%)(Andersen)

No difference in pattern of neck failureNo difference in pattern of neck failure

MRND Type IIMRND Type II

IndicationsIndicationsRarely plannedRarely planned Intraoperative tumor found adherent to theIntraoperative tumor found adherent to the

SCM, but not IJV and SANSCM, but not IJV and SAN

MRND IIIMRND III RationaleRationale Suarez (1963) – surgery specimens ofSuarez (1963) – surgery specimens of larynx and hypopharynx – lymph nodes do not sharelarynx and hypopharynx – lymph nodes do not share the same adventitia as adjacent BV’sthe same adventitia as adjacent BV’s Sharpe (1981) showed ) 0% involvement of the SCM inSharpe (1981) showed ) 0% involvement of the SCM in 98 RND specimens despite 73 have nodal metastases98 RND specimens despite 73 have nodal metastases Survival approximates MRND Type I assuming IJV,Survival approximates MRND Type I assuming IJV, and SCM not involvedand SCM not involved Neck dissection of choice for N0 neckNeck dissection of choice for N0 neck

•TYPE III

Selective Neck DissectionsSelective Neck Dissections

Cervical lymphadenectomy with Cervical lymphadenectomy with preservation of one or more lymph node preservation of one or more lymph node groupsgroups

Four common subtypes:Four common subtypes: Supraomohyoid neck dissectionSupraomohyoid neck dissection Posterolateral neck dissectionPosterolateral neck dissection Lateral neck dissectionLateral neck dissection Anterior neck dissectionAnterior neck dissection

SELECTIVE NECKSELECTIVE NECKDISSECTIONDISSECTION

Also known as an elective neck dissectionAlso known as an elective neck dissection Indication: primary lesion with 20% or Indication: primary lesion with 20% or

greater risk of occult metastasisgreater risk of occult metastasis May elect to upgrade neck May elect to upgrade neck

intraoperativelyintraoperatively Frozen section needed to confirm SCCA Frozen section needed to confirm SCCA

in suspicious node (Rassekh)in suspicious node (Rassekh) Need for post-op XRTNeed for post-op XRT

SND: Supraomohyoid typeSND: Supraomohyoid type

IndicationsIndications Oral cavity carcinoma with N0 neckOral cavity carcinoma with N0 neck Subsites - Lips, buccal mucosa, upper and lowerSubsites - Lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone, hard palate, andalveolar ridges, retromolar trigone, hard palate, and anterior 2/3s of the tongue and FOManterior 2/3s of the tongue and FOM– – Medina recommends SOHND with T2-T4NOMedina recommends SOHND with T2-T4NO or TXN1 (palpable node is <3cm, mobile, andor TXN1 (palpable node is <3cm, mobile, and in levels I or II)in levels I or II)

Bilateral SOHNDBilateral SOHND

Anterior tongueAnterior tongue Oral tongue and Oral tongue and

FOM that approach FOM that approach the midlinethe midline

Adjuvant XRT given Adjuvant XRT given to patients with to patients with

> 2positive nodes +/- > 2positive nodes +/- ECS.ECS.

SND: Lateral Type• Definition– En bloc removal of the jugular lymph nodesincluding Levels II-IV

SND: Lateral TypeSND: Lateral Type

En bloc removal of the En bloc removal of the jugular lymph nodesjugular lymph nodes

including Levels II-IVincluding Levels II-IV IndicationsIndications N0 neck in N0 neck in

carcinomas of the carcinomas of the oropharynx,hypopharoropharynx,hypopharynx, supraglottis, and ynx, supraglottis, and larynxlarynx

SND: Posterolateral TypeSND: Posterolateral Type

En bloc excision of lymph bearing tissues inEn bloc excision of lymph bearing tissues in

Levels II-V Levels II-V

IndicationsIndications

Cutaneous malignanciesCutaneous malignancies

MelanomaMelanoma

Squamous cell carcinomaSquamous cell carcinoma

Merkel cell carcinomaMerkel cell carcinoma

Soft tissue sarcomas of the scalp and neckSoft tissue sarcomas of the scalp and neck

SND: Anterior CompartmentSND: Anterior Compartment

En bloc removal of lymph structures in Level VIEn bloc removal of lymph structures in Level VI Perithyroidal nodesPerithyroidal nodes Pretracheal nodesPretracheal nodes Precricoid nodes (Delphian)Precricoid nodes (Delphian) Paratracheal nodes along recurrent nervesParatracheal nodes along recurrent nerves – – Limits of the dissection are the hyoid Limits of the dissection are the hyoid

bone,suprasternal notch and carotid sheathsbone,suprasternal notch and carotid sheaths IndicationsIndications – – Selected cases of thyroid carcinomaSelected cases of thyroid carcinoma – – Parathyroid carcinomaParathyroid carcinoma – – Subglottic carcinomaSubglottic carcinoma – – Laryngeal carcinoma with subglottic extensionLaryngeal carcinoma with subglottic extension – – CA of the cervical esophagusCA of the cervical esophagus

Extended Neck DissectionExtended Neck Dissection

Any previous dissection which includes removal of one or Any previous dissection which includes removal of one or more additional lymph node groups and/or non-lymphatic more additional lymph node groups and/or non-lymphatic structures.structures.

Usually performed with N+ necks in MRND or RND Usually performed with N+ necks in MRND or RND when metastases invade structures usually preservedwhen metastases invade structures usually preserved

Examples:Examples: Resection of the hypoglossal nerve, resection of digastric Resection of the hypoglossal nerve, resection of digastric

muscle, Carotid artery resection, muscle, Carotid artery resection, dissection of mediastinal nodes and central compartment dissection of mediastinal nodes and central compartment

for subglottic involvement, and removal of for subglottic involvement, and removal of retropharyngeal lymph nodes for tumors originating in retropharyngeal lymph nodes for tumors originating in the pharyngeal walls.the pharyngeal walls.

IncisionsIncisions

Apron incision Half apron Apron incision Half apron

Conley’s Double-YConley’s Double-Y

H incision MacfeeH incision Macfee

Y incision Modified schobingerY incision Modified schobinger

SchobingerSchobinger

StepsStepsFlap raisingFlap raising Make the skin incision through Make the skin incision through

the platysma and elevate the the platysma and elevate the flap in the subplatysmal plane. flap in the subplatysmal plane.

Traction with the surgeon's Traction with the surgeon's fingers and countertraction by fingers and countertraction by the assistant with skin hooksthe assistant with skin hooks

Elevate the posterior flap Elevate the posterior flap toward the trapezius muscle. toward the trapezius muscle.

Identify and preserve the Identify and preserve the marginal mandibular nerve at marginal mandibular nerve at

the superior aspect of the flapthe superior aspect of the flap. .

The contents of the submental The contents of the submental triangle are then elevated from triangle are then elevated from the inferior border of the mandible the inferior border of the mandible and the opposite digastric muscle and the opposite digastric muscle off of the mylohyoid muscleoff of the mylohyoid muscle

Dissection in the proper plane allows Dissection in the proper plane allows for an en bloc elevation of the for an en bloc elevation of the contents into the submandibular contents into the submandibular triangle and to the posterior border triangle and to the posterior border of the mylohyoid muscle.of the mylohyoid muscle.

Retraction of the mylohyoid muscle Retraction of the mylohyoid muscle anteriorly allows for identification anteriorly allows for identification of the submandibular duct, which of the submandibular duct, which is ligated and dividedis ligated and divided

The dissected contents of sublevels The dissected contents of sublevels IA and IB are then elevated over IA and IB are then elevated over the digastric muscle in continuity the digastric muscle in continuity with the nondissected portion of with the nondissected portion of the neckthe neck

The contents dissected from level I are The contents dissected from level I are elevated caudally to visualize the elevated caudally to visualize the superior internal jugular vein..superior internal jugular vein..

Identification of the SAN can be Identification of the SAN can be performed anterior or posterior to the performed anterior or posterior to the SCM. SCM.

If the SAN can be preserved, dissection If the SAN can be preserved, dissection is then continued from near to IJV is then continued from near to IJV towards the trapezius muscle, dividing towards the trapezius muscle, dividing the SCM. If the SCM is going to be the SCM. If the SCM is going to be preserved, the SAN must be carefully preserved, the SAN must be carefully dissected by identifying the nerve both dissected by identifying the nerve both anterior and posterior to the SCM. anterior and posterior to the SCM.

A posterior to anterior dissection is then A posterior to anterior dissection is then performed beginning at the anterior performed beginning at the anterior border of the trapezius muscle, border of the trapezius muscle, preserving the phrenic nerve and the preserving the phrenic nerve and the brachial plexus, located deep to this brachial plexus, located deep to this fascia.fascia.

The SAN must then be freed from the The SAN must then be freed from the soft tissues of the posterior triangle and soft tissues of the posterior triangle and can be carefully retracted away from can be carefully retracted away from the region of dissection with a vessel the region of dissection with a vessel loop or nerve hook. Dissection is loop or nerve hook. Dissection is continued to the posterior border of the continued to the posterior border of the SCM.SCM.

..

At this point, the posterior triangle contents, At this point, the posterior triangle contents, with or without the SAN and SCM, have been with or without the SAN and SCM, have been elevated to the lateral aspect of the IJV. If the elevated to the lateral aspect of the IJV. If the SCM is being resected, transection is SCM is being resected, transection is performed below the mastoid tip and above performed below the mastoid tip and above the clavicle as in a RND. the clavicle as in a RND.

The nodes along IJV can usually be removed The nodes along IJV can usually be removed en bloc with the remainder of the dissection in en bloc with the remainder of the dissection in a posteroanterior fashion, sharply incising the a posteroanterior fashion, sharply incising the fascia of the jugular vein with a scalpel blade fascia of the jugular vein with a scalpel blade using a feather-light touch. If the IJV requires using a feather-light touch. If the IJV requires sacrifice due to metastatic nodal involvement sacrifice due to metastatic nodal involvement or tumor thrombosis, the vein is ligated and or tumor thrombosis, the vein is ligated and divided superiorly and inferiorly following divided superiorly and inferiorly following identification and preservation of the vagus identification and preservation of the vagus nerve.nerve.

Dissection is continued anteriorly, elevating Dissection is continued anteriorly, elevating the fascia and soft tissues up to the infrahyoid the fascia and soft tissues up to the infrahyoid strap muscles and the hyoid-digastric strap muscles and the hyoid-digastric junction.junction.

Preservation of a fascial layer superficial to Preservation of a fascial layer superficial to the carotid artery is usually possible, and the carotid artery is usually possible, and exposure of the carotid artery should be exposure of the carotid artery should be discouraged unless necessary. discouraged unless necessary.

Suction drains are strategically placed and a Suction drains are strategically placed and a layered closure is performedlayered closure is performed. .

ComplicationsComplications Intraop.CxIntraop.CxHemorrhageHemorrhageNerve damageNerve damageThoracic duct injuryThoracic duct injuryPneumothoraxPneumothorax

Post op. CxPost op. Cx

HematomaHematomaWound infectionWound infectionSkin flap lossSkin flap lossSalivary fistulaSalivary fistulaChylous fistula 500 mlChylous fistula 500 mlFacial edemaFacial edemaCarotid artery ruptureCarotid artery rupture

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