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Neck dissection part 1

  1. 1. PRESENTED BY:- Dr Pranav SatheDr Pranav Sathe MDS IIIMDS III
  2. 2. 1. Surgical anatomy necessary for neck dissection 2. Various levels of lymph nodes and why are they important 3. Incisions for neck dissection
  3. 3. 1. Introduction 2. Historical perspective 3. Anatomical considerations 4. Classification of neck dissection 5. Incisions 6. Conclusion 7. References
  4. 4.  World Oral health Report 2003 suggests that Oral cancers are a major problem in the regions of the world where tobacco habits in the form of chewing and / or smoking with or without alcohol intake are common.  Usually 91% of the cases occur after the age of forty years and highest incidence between ages 60 and 70 years.
  5. 5.  One-third of all cases of OSCC present as stage I/II disease & two-thirds of patients present with stage III or IV disease.  Treatment of OSCC is primarily surgical followed by chemoradiotherapy.  Current trends are changing and the above modalities might be used in an interchangeable sequence. i.e. surgery followed by chemoradiation or chemoradiotherapy followed by surgical salvage or neck dissection.
  6. 6. 20-36.3 cases
  7. 7.  Patients with cervical nodal metastases show increased likelihood for distant metastases and local recurrence.  Except distant metastases, the most adverse independent prognostic factor in OSCC is presence of positive cervical lymph nodes and prognosis in such patients with extranodal spread of tumor is poor.
  8. 8.  The term "neck dissection" refers to a surgical procedure in which the fibro-fatty soft tissue content of the neck is excised to remove the lymph nodes
  9. 9.  By knowing the anatomy.  By knowing the patterns of the cervical lymph node drainage.  The rationale behind neck dissections.  Work up and staging of neck node metastases.  The types of neck dissections.
  10. 10.  Chelius, 1847 - Importance of Cervical Lymph node metastases in management of OSCC  Kocher, 1880 – Positive lymph nodes must be removed with more ample resection margins & introduced a ‘Y’ incision – Kocher’s incision.
  11. 11.  Butlin, 1885 – Elective neck dissection for management of cancer of tongue.  Jawdynski, 1888 – performed a surgery similar to that performed by Crile.  Towpik, 1990, reported in his article ‘Centennial of the first description of en bloc neck dissection’ that Volkman & Langenback performed 4 RND before Jawdynski first described it
  12. 12. In 1906 paper “Exicision of cancer of the head and neck ” Gold standard procedure : “Radical Neck dissection”
  13. 13. In 1951 paper “Neck Dissection” “Routine prophylactic RND was impracticle”
  14. 14.  Martin et al, 1951 – RND should involve removing the SCM, Omohyoid muscle, IJV, Submandibular salivary gland en bloc.. Spinal accessory nerve has to be sacrificed even if it causes significant esthetic and functional morbidity.  Martin has stated “ Any technique that is designed to preserve the spinal accessory nerve should be condemned”
  15. 15.  Conley also supported the concept of radical neck dissection.  Suarez (Father of Functional neck dissection), 1952 – developed Functional Neck dissection to prevent significant long term morbidity of RND: 1. shoulder dysfunction, 2. cosmetic deformity, 3. cutaneous paresthesia, 4. Chronic neck and shoulder pain syndrome..
  16. 16.  Pietrantoni, 1953 – A strong proponent of bilateral elective neck dissection recommended sparing the spinal accessory nerve and at least one Internal jugular vein.  Bocca & Pignataro, 1967 – Functional neck dissection is a complete dissection of the lateral cervical space, anatomically confined by a fascial envelope and itself containing the major cervical lymphatics.
  17. 17.  Bocca & Gavilan - popularized the Functional neck dissection.  Medina, 1989 – Lymphadenectomies should be categorized as Comprehensive, Selective or Extended.  Robbins et al, 1991 – used the term ‘Selective’ to distinguish the patients who had one or more group of lymph nodes preserved.
  18. 18.  PLATYSMA MUSCLE: ◦ Wide, quadrangular sheet like muscle ◦ Extends obliquely from upper chest to lower face, hence does not cover a variable inferiorly based triangle in the anterior aspect of the neck & posterolaterally. ◦ Located immediately deep to the subcutaneous tissue. ◦ TIP: SPARK OF CAUTERY SHOULD BE BELOW THE PLATYSMA TO BE SURE YOU’RE IN THE CORRECT PLANE.
  19. 19.  MARGINAL MANDIBULAR NERVE: ◦ Supplies muscles of lower lip, hence needs preservation. ◦ In Dingman and Grabb's classic dissection of 100 facial halves in 1962, the marginal mandibular branch was as much as 1 cm below the inferior border in 19% of cases. Anterior to the point where the nerve crossed the facial artery, all dissections displayed the nerve above the inferior border of the mandible. ◦ Identify nerve 1 cm in front and below the angle of mandible - incise superficial layer of the deep cervical fascia that envelops the Submandibular gland parallel to nerve direction
  20. 20.  Another important finding in the study by Dingman and Grabb was that only 21% of cases had a single marginal mandibular branch; 67% had two branches, 9% had three branches, and 3% had four.
  21. 21.  Relevant neck triangles during Neck dissection: 1. Anterior triangle 2. Posterior triangle
  22. 22.  Bounded by:  Anteriorly- Median plane  Posteriorly- Sternomastoid  Superiorly- Inferior border of mandible  Inferiorly- Manubrium sterni
  23. 23.  SUBMANDIBULAR TRIANGLE: ◦ Bounded below by two bellies of Digastric muscle & above by lower border of mandible.. ◦ Floor is formed by Mylohyoid muscle ◦ Roof of triangle formed by skin & platysma. ◦ Contains submandibular salivary gland which is resected because of its associated lymph nodes.
  24. 24.  Other contents of the triangle: ◦ Marginal mandibular nerve ◦ Facial vein & artery sectioned near the angle. ◦ Vein stays superficial to gland & runs downward & backward deep to platysma. ◦ Facial artery arises from ECA & passes upwards towards mandible. It approaches the triangle deep to the gland and loops around it to emerge at the lower border alongside the vein.
  26. 26.  Anteriorly – Sternocleidomastoid muscle  Posteriorly – Trapezius muscle  Base – Middle third of the clavicle  Apex – Intersection of SCM & Trapezius  Floor – Scalene, levator scapulae, splenius capitis.  Roof – Overlying skin, subcutaneous tissue, platysma anteriorly  Contents: Fibrofatty tissue & lymph nodes
  27. 27.  At apex, floor & roof are close to each other & at base, floor passes to first rib & roof attaches to clavicle..  While clearing the fibrofatty tissue at the base, care to be taken to avoid pulling the Subclavian vein along with the loose mobile fat.  Structures of surgical significance lie in the lower part.  At angle between SCM & Clavicle, EJV passes into Subclavian vein.
  28. 28.  SPINAL ACCESSORY NERVE: ◦ Its extracranial course has three parts: 1. Below jugular foramen external branch of the spinal accessory nerve is located medial to the digastric & stylohyoid muscles & lateral to IJV in close proximity to upper deep jugular nodes 2. Next it passes into the substance of the SCM & emerges just above middle of the muscle 3. Thereafter it runs posterior and downwards through posterior triangle to enter deep to trapezius approx. 2 cm above clavicle.
  29. 29.  Two peculiar characteristics of the third part of surgical significance :- 1. Nerve does not enter Trapezius muscle but courses along the deep surface of the muscle in close relationship with transverse cervical vessels. 2. Located rather superficial middle posterior triangle of neck and can be easily injured while raising posterior skin flaps
  30. 30.  CN XI – Relationship with the IJV
  31. 31.  LYMPH NODES & LYMPHATICS: ◦ Cervical lymphatic system is divided into superficial & deep chains ◦ Superficial drains into deep after piercing superficial layer of deep cervical fascia ◦ Superficial chain is less significant than deep from surgical view point. ◦ Deep cervical lymphatics accompany the IJV or its branches or lie within major salivary glands.
  32. 32.  Superior, middle & inferior groups of the anterior group of Deep cervical lymphatics lie along the wall of IJV up to its entry into subclavian vein.  Thus anterior group lies between posterior belly of digastric & clavicle.  Subdigastric or superior Jugular nodes are most frequently involved among the anterior group of deep cervical lymphatics. Also called junctional nodes of Fisch.
  33. 33.  Subdigastric nodes are most difficult to clear due to their proximity to superoanterior part of Accessory nerve.  Lymph nodes of the Lateral neck are designated as upper, middle and inferior cervical nodes – also designated as spinal accessory group of nodes.  They begin beneath upper part of SCM & extends downward & backward following course of Spinal Accessory nerve
  34. 34.  From surgical view point, spinal accessory group receives drainage from nasopharynx but it communicates with subdigastric nodes.  Inferiorly, it turns forward into supraclavicular group of lymph nodes to join the deep cervical nodes or Internal jugular chain of lymph nodes.
  35. 35.  In submandibular area, there are three groups of lymph nodes: 1. Preglandular 2. Interglandular 3. Prevascular & Retrovascular..  They drain the mucosa of lower lip, cheeks, alveolar region, floor of mouth, anterior tongue & then empty into deep chain.
  36. 36.  IA (submental) Lymph nodes within the triangular boundary of the anterior belly of the digastric muscles and the hyoid bone  IB (submandibular) Lymph nodes within the boundaries of the anterior belly of the digastric muscle and the stylohyoid muscle and the inferior border of the mandible
  37. 37.  IIA and IIB (upper jugular) Lymph nodes located around the upper third of the internal jugular vein and the adjacent spinal accessory nerve;  Level IIA lymph nodes are located anterior (medial) to the spinal accessory nerve;  Level IIB lymph nodes are located posterior (lateral) to the spinal accessory nerve
  38. 38. III (middle jugular) Lymph nodes located around the middle third of the internal jugular vein; nodes are located between the inferior border of the hyoid bone and the inferior border of the cricoid cartilage  IV (lower jugular) Lymph nodes located around the lower third of the internal jugular vein; nodes extend from the inferior border of the cricoid cartilage to the clavicle
  39. 39.  V (posterior triangle) Lymph nodes located along the lower half of the spinal accessory nerve and the transverse cervical artery; supraclavicular nodes are located in this group of lymph nodes  Level VA - along the lower half of the spinal accessory  Level VB - transverse cervical artery
  40. 40.  VI (central compartment) Lymph nodes in the prelaryngeal, pretracheal, and boundaries are the hyoid bone to the suprasternal notch and between the medial borders of the carotid sheaths; lymph nodes are generally not dissected in oral cancer patients
  41. 41.  VII (superior mediastinal) Lymph nodes in the anterior superior mediastinum and tracheoesophageal grooves, extending from the suprasternal notch to the innominate artery; lymph nodes are generally not dissected in oral cancer patients
  42. 42.  Clinical palpation  Ultrasonography  Fine needle aspiration cytology (FNAC)  USG guided FNAC  Computed tomogram scan (CT Scan)  Magnetic resonance imaging (MRI)  PET scan  Intra operative sentinel node biopsy  Intra operative frozen section
  43. 43.  Clinical palpation assesses criteria like site, number, size, shape, consistency & fixity of the neck nodes.  Not uniformly reliable in the assessment of regional metastatic disease as occult neck disease can occur in up to 50% of patients, false negative rate ranges between 0% and 77%.  Prof. Robert Odd-Maryland University has stated, “ When the lymph node is palpable, the surgeon thinks it is positive; but he only ‘thinks’ it is, for it may not always be so”
  44. 44.  Ultrasonography is superior to clinical palpation for assessment of cervical nodes  Ultrasound criteria for malignant and benign nodes - size, shape, central necrosis, extracapsular spread, roundness index & status of hilum
  45. 45.  Size: ◦ Maximum transverse diameter ◦ Assesses true axial & transverse diameter ◦ 33% - 71% nodes < 1 cm found to have metastases ◦ optimal minimal axial diameter to distinguish between positive and negative node proved to be 8mm for subdigastric lymph node and 7mm for all other types of lymph nodes
  46. 46.  Shape:  Benign lymph nodes have an elongated fusiform shape  Malignant infiltration commonly begins in cortex of the lymph node.  metastatic lymph nodes tend to have an irregular rounded shape that is reflected by the decreased ratio between the longitudinal and transverse (L/S) diameters of node
  47. 47. Round node Oval node
  48. 48.  Extra Capsular Spread: ◦ Normal lymph node has smooth, well-delineated margins. ◦ Metastatic node becomes ovoid; margins of the node may remain smooth until the advanced stages of the disease when extracapsular extension occurs.
  49. 49.  Hilum Of The Lymph Node:  Normally the hilum of the lymph node is centrally located and thick. It is formed by the parallel arrangement of the central lymphatic sinuses and is a reflection of the normal nodular architecture.  Malignant invasion of the cortical parenchyma of the node makes the hilum eccentric, thinned.
  50. 50.  Fine Needle Aspiration Cytology (FNAC)  Technique is useful for diagnosis of deeply situated masses  Confirmation of tumor in suspiciously enlarged neck nodes,  Assessment of areas of possible recurrent diseases.  Reliable and inexpensive  Tolerated by patients.
  51. 51.  A needle is passed into the target mass and cells are aspirated. The success of this method depends on the accuracy of needle placement and the reliability of the diagnosis, on the skill and experience of the pathologist. When it is combined with ultrasonography it is a highly accurate technique for the investigation of cervical lymph node metastasis.
  52. 52.  CT Scan ◦ Helpful for evaluation of the primary tumour as well as for evaluation of the neck nodes for metastases,
  53. 53.  Tells about size, shape (oval or spheroid) and also whether they were homogenous or cystic.  The most accurate CT criteria is the presence of central necrosis which is demonstrated as peripheral/rim enhancement
  54. 54.  Sentinel Node Biopsy (SNB) ◦ Important role of sentinel node biopsy (SNB) clinically N0 neck in patients with oral squamous cell carcinoma. ◦ It is concluded overall sensitivity of the procedure using the full pathologic protocol was 94% & sentinel node biopsy could be used to stage the N0 neck in patients with early sub clinical nodal disease.
  55. 55.  Rationale: ◦ Cervical metastasis is the single most important prognostic factor in patients with oral cancer, with the presence of nodal spread decreasing the 5-year disease- free survival rate by approximately 50%. ◦ Improving the accuracy of staging while reducing the morbidity caused by unnecessary lymphadenectomy in carcinomas is useful
  56. 56.  Sentinel node mapping uses:  (1) radioisotope scan imaging; (2) injection of blue  dye; and (3) use of a handheld isotope tracer probe for localization.  It has been shown that the combination of all three techniques increases the accuracy and the yield of sentinel lymph node identification. A preoperative technetium scan is obtained first, which requires injection of a radioactive technetium 99m–labeled sulfur colloid. In general, 0.05 mCi of the isotope is injected in four quadrants around the primary lesion, and a gamma camera is used to obtain visual images at 3 minutes and 15 minutes and a delayed image at 1 hour.
  57. 57.  Usually the first lymph node identified by the technetium scan is considered the sentinel lymph node. In some patients more than one sentinel lymph node is identified.  Immediately prior to the surgical procedure, isosulfan blue dye 1% (Lymphazurin) is injected similarly in four quadrants around the primary tumor. No more than 0.5 mL of the dye is injected in the subdermal plane around the tumor. The operative procedure then is carried out within 30 minutes of the injection.
  58. 58.  Robbins who chaired The Committee for Head & Neck Surgery and Oncology of the American Academy of Otolaryngology – Head and Neck Surgery, along with colleagues developed standardized neck dissection terminology in 1991 and updated the classification in 2002.
  59. 59.  Original classification was based on the following concepts: (1) The RND is the fundamental procedure with which all other neck dissections are compared, (2) MRND denotes preservation of one or more nonlymphatic structures, (3) Selective neck dissections denote preservation of one or more groups of lymph nodes, (4) Extended RND denotes removal of one or more additional lymphatic or nonlymphatic structures.
  60. 60. 1. Radical Neck Dissection 2. Modified Radical Neck Dissection 3. Selective Neck Dissection a. SupraOmohyoid neck dissection (I, II, III) b. Lateral neck dissection (II, III, IV) c. PosteroLateral neck dissection ( II, III, IV, V) d. Anterior 4. Extended neck dissection
  61. 61. 1. Radical Neck Dissection 2. Modified Radical Neck Dissection 3. Selective Neck Dissection ◦ Each variation is depicted by ‘‘SND’’ and the use of parentheses to denote the levels or sublevels removed 1. Extended neck dissection
  62. 62. Modified radical neck dissection (MRND) was further classified  MRND I – Preserves spinal accessory nerve.  MRND II – Spinal accessory and sternocleidomastoid muscle but sacrifices internal jugular vein.  MRND III – Requires preservation of SAN, sternocleidomastoid muscle and internal jugular vein
  63. 63.  T – Tumor size ◦ Tx – tumor cant be assessed ◦ T0 - no evidence of primary tumor ◦ Tis – tumor in situ ◦ T1 – tumor size les than 2 cm ◦ T2 – tumor size between 2 – 4 cm ◦ T3 – tumor size more than 4 cm
  64. 64.  T4a (lip) – tumor invades adjoining bone, IAN, floor of mouth, or skin of face, i.e., chin or nose  T4a (Oral cavity) – tumor invades adjoining structures like bone, deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, and skin of face)  T4b (Oral cavity) – tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery
  65. 65.  Regional lymph nodes (N) ◦ Nx – Regional lymph nodes can not be assessed ◦ N0 - No regional lymph node metastasis ◦ N1 – Metastasis in single ipsilateral node, less than 3cm in greatest dimension.
  66. 66.  N2A - Metastasis in single ipsilateral node, more than 3cm & less than 6cm in greatest dimension  N2B - Metastasis in multiple ipsilateral nodes, none more than 6cm in greatest dimension  N2C - Metastasis in bilateral or contra lateral nodes, none more than 6cm in greatest dimension  N3 – Metastasis in lymph node more than 6cm in greatest dimension.
  67. 67.  Distant metastasis (M) ◦ MX: Distant metastasis cannot be assessed ◦ M0: No distant metastasis ◦ M1: Distant metastasis
  68. 68.  Stage I ◦ T1, N0, M0  Stage II ◦ T2, N0, M0  Stage III ◦ T3, N0, M0 ◦ T1, N1, M0 ◦ T2, N1, M0 ◦ T3, N1, M0
  69. 69.  Stage IVA ◦ T4a, N0, M0 ◦ T4a, N1, M0 ◦ T1, N2, M0 ◦ T2, N2, M0 ◦ T3, N2, M0 ◦ T4a, N2, M0  Stage IVB ◦ Any T, N3, M0 ◦ T4b, any N, M0  Stage IVC ◦ Any T, any N, M1
  70. 70.  Philosophy of management of metastatic disease in the cervical lymph nodes has changed over last few decades with a better understanding of nodal metastasis, subclassification of L.N. & SND. RND is largely replaced by SND
  71. 71. ◦ Age & general condition of patient ◦ Site and size of primary ◦ Palpable neck nodes ◦ Extent of disease on imaging ◦ A simple guideline followed is to go 1 step below the node.
  72. 72. ◦ T1N0 tongue – 30% cases will show occult metastases ◦ T1N0 floor of mouth – 20% cases will show occult metastases ◦ Gingivo-buccal sulcus tumors show 46% nodal metastasis most frequently in level I. ◦ Cervical metastasis most frequently in Level II (Shah JP) ◦ Hence management of neck in N0 cases of tongue & floor of mouth SCC is necessary
  73. 73.  Level I – 61%  Level II – 57%  Level III – 44%  Level IV – 20%  Level V – 4%
  74. 74.  JP Shah (1995):- ◦ Clinically N0 neck with little risk for cervical metastasis – SND is performed with staging of tumor ◦ Grossly enlarged neck nodes – MRND with preservation of Spinal accessory nerve.  N0 and N1 neck – SND +/- radiotherapy  N2, N3 neck – MRND + radiotherapy
  75. 75.  To avoid complications such as wound breakdown, skin flap necrosis, exposure of carotid artery following neck dissection, selection of correct incision is necessary.  Study on anatomy of blood supply of skin flaps of neck conducted by Freeland & Rogers, 1975 – gave rise to incisions like Apron incision, which are most likely to safeguard blood supply of skin flaps.
  76. 76. 1. Provide free access to the operative site 2. Should not lie on vital structures of the neck 3. Should be designed in such as way that blood supply of the neck skin flaps is not compromised – to avoid skin flap necrosis, wound dehiscence, exposure of vital structures of neck eg. Carotid artery.
  77. 77.  Incisions are of three main types: (McGregor) 1. Hayes – Martin incision 2. Tri-radiate incision or its modification 3. McFee incision
  78. 78. Transverse incision Vertical incision Have cosmetic advantage as they follow natural skin folds of the skin Not preferred because they intersect the natural skin folds and the vascular supply of the neck Recovery of scar tissue in these folds are rapid and successful They tend to contract along their long axis – leads to deformity and restricted action. Easy to modify
  79. 79. 1. ‘Y’ incision of Crile (1906) 2. Double ‘Y’ incision of Martin et al (1951) 3. Schobinger incision (1957) 4. Superiorly based ‘Apronlike’ incision of Latyshevesky & Freund (1960) 5. Mcfee incision (1960) 6. Conley incision (1970) 7. Modified Conley incision by Lasaridis et al (1994)
  80. 80.  Advantages ◦ Incision provides good exposure to surgical site.  Disadvantages ◦ Flap necrosis is high due to disruption of vasculature of skin flaps ◦ Occurrence of flap separation at the trifurcation site.
  81. 81.  Schobinger (1957)  Cramer & Culf (1969)  Conley (1970)
  82. 82.  It is a paired ‘Y’ incision.  Here the submandibular component is met by a vertical limb which below becomes continuous with an inverted ‘Y’ in the suprascapular region.  This flap most often gets cyanosed.  Flap necrosis and carotid exposure is more in this type of incision.
  83. 83.  Suggested a posteriorly curving vertical incision rather than a horizontal incision  The incision starts from the submental region and ending by running downwards along the anterior border of the trapezius to the level of clavicle gently curving posteriorly.
  84. 84.  It avoids a vertical limb.  Two horizontal incisions are used one in submandibular region and other in the suprascapular region.
  85. 85. Advantages Disadvantages Excellent cosmetic result (McFee 1960, McNeil 1978) Exposure is not good (Hetter 1972) There is no lessening of vascularity in the centre of the flap (Ariyan 1986) It is not suitable for bilateral simultaneous neck dissection (Chandler and Ponzoli 1969) There is no angle intersection in incision (McFee 1960) Operating period is long (McFee 1960) Post operative wound recovery is rapid (McFee) Posterior triangle dissection is difficult (Maran et al 1989, White et al 1993) Suitable in necks receiving radiotherapy and in peripheral vascular disease (Maran et al 1989) Difficulty may arise while working under the bridge flap Recovery of flap excellent due to wide bipedicled flaps (Stella & Brown 1970, Daniel & McFee 1987) In short neck it might be difficult to distinguish between the front tip of the incision from that of the tracheostomy.
  86. 86.  Described by Latyschevsky and Freund 1960.  Only a horizontal incision from mastoid to mastoid gently curving inferiorly upto upper border of the thyroid cartilage is used.  Advantages ◦ Carotid artery is well protected  Disadvantages ◦ Venous congestion and oedema might develop at the bottom corner
  87. 87.  Lower end of IJV  Junction of Lateral border of clavicle with the lower edge of trapezius  Submandibular traingle  Upper end of IJV
  89. 89.  END OF PART -1
  90. 90. 1. McGregor – Cancer of the head and neck 2. J.P. Shah 3. Oral & Maxillofacial Surgery clinics of North America 2007 4. Otolaryngology Clinics of North America 2006 5. Laryngoscope 6. JOMS

Notas do Editor

  • Polish surgeon, was first to describe it but work went un noticed &amp; he did not know the importance of it.
  • Martin refined Crile’s surgery &amp; popularised it in America &amp; stated that spinal accessory n. had to be sacrificed even if it caused significant esthetic and functional morbidity.
  • Functional neck dissection preserves SCM, IJV, Spinal accessory nerve.
  • It was first limited to elective neck dissections and later on applied to therapeutic neck dissections.
  • Forms an easily identifiable plane to raise skin flaps
  • True upper border is not lower border of mandible but up its medial surface at attachment of Mylohyoid m.
    Submandibular gland loops around the mylohyoid muscle between mylohyoid &amp; hyoglossus.
  • They are sectioned here.
    Facial vein joins the anterior div. of retromandibular vein to form Common Facial vein which drains in the IJV.
  • Hence there is more space and contents increase in volume as compared to apex. They become more fatty &amp; softer as well as looser. Sweeping with Gauze piece is sufficient to free it from its attachments &amp; expose the prevertebral fascia.
  • Approx 4 cm or more below the mastoid process at Erb’s point i.e. where greater auricular nerve turns at the SCM.
  • 1. Isolation of the nerve to level of ant. Border of trapezius does not ensure preservation of the nerve during dissection below this point in a bloody field
  • Superficial lymphatics get involved in late stages &amp; require resection of large areas of skin. Deep lymphatics receive drainage from mucous memb. Lining mouth, pharynx, larynx, major sal. Glands, thyroid, skin of Head and neck
  • Preglandular nodes lie on anterior part of submandibular glands
    Interglandular nodes lie within the gland and drain the floor of the mouth and mid portion of the anterior tongue.
    Prevascular &amp; retrovascular nodes lie anterior and posterior to facial artery &amp; vein at the lower edge of mandible. They are most often first to be involved by metastatic cancer from oral cavity.
  • In order to establish a consistent and easily reproducible and user friendly method for description of regional cervical lymph nodes which would establish a common language between the clinician and the pathologist, the head and neck service at the Memorial Sloan-Kettering Cancer Centre in NY described a levelling system of the cervical lymph nodes which we now follow. This system divides the lymph nodes in the lateral aspect of the neck in 5 groups.
  • preoperative assessment of neck nodes has a bearing on the prognosis in oral cancer. Hence assessment plays a vital role in planning of therapy
  • A needle is passed into the target mass and cells are aspirated. The success of this method depends on the accuracy of needle placement and the reliability of the diagnosis, on the skill and experience of the pathologist. When it is combined with ultrasonography it is a highly accurate technique for the investigation of cervical lymph node metastasis.
  • 2002 classification does not differ significantly from 1991. it was a consensus between Surgeons of American Head neck society and American academy of Otolaryngology Head neck Surgery.