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Neck dissection
Neck dissection
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Neck dissection

  1. 1. NECK DISSECTION By Prof. Muhammad Iqbal Butt F.R.C.S. (Canada) Chairman Department of E.N.T. Lahore Medical & Dental College, Dean Faculty of E.N.T. College of Physicians and Surgeons, Pakistan
  2. 2. BENIGN AND MALIGNANT LESIONS  Benign lesions are discrete, movable, nontender (20%)  Submandibular 25% are malignant  Malignant lesions metastasizing to the regional lymph nodes: • Lip 31% • Cheek 40% • Alveolus 35% • Tongue and floor of mouth 63% • Nasopharynx 80%
  3. 3.  80% of lateral neck masses are malignant  85% of these are from lesions of head and neck  Most common sites: 1. Nasopharynx 2. Tonsils 3. Base of tongue 4. Supraglottis 5. Thyroid 6. Pharynx 7. Mouth 8. Palate
  4. 4. PRIMARY LESIONS  Of the primary lesions of head and neck  Laryngopharynx 40%  Orophayrynx 40%  Thyroid 10%  Others 10%  Squamous cell carcinoma is present in 50%  45% of them are:  Undifferentiated carcinoma  Lymphoepithlioma  Lymphosarcoma  Adenocarcinoma  5% occult primary
  5. 5. DIAGNOSIS 1. History 2. Examination of ear, nose, throat, oral cavity should give you diagnosis in 95% cases 3. Examination of nasopharynx 4. Waldeyer’s ring especially tonsils if lymphoma is suspected 5. Squamous cell carcinoma progresses slowly, adenocarcinoma much more rapidly
  6. 6. DIAGNOSIS  Mass superior jugular group and for tonsil, oropharynx, supraglottis  Mass in middle and inferior group usually arises from larynx  Mass in supraclavicular region arises below the clavicle:  Stomach  Intestine  Lung  Mass in posterior neck arises from nasopharynx and paranasal sinuses or are primary lymphomas
  7. 7. IMPORTANT CONSIDERATIONS  Before embarking on treating locally, distant metastases may be considered  FNAC  Incisional biopsy is to be done only as a last resort for making diagnosis  MRI & CT scan
  8. 8. GROUPS OF LYMPH NODES 1. Occipital 2. Mastoid 3. Parotid 4. Submandibular 5. Submental 6. Facial 7. Sublingual 8. Retropharyngeal 9. Lateral cervical 10. Anterior cervical
  9. 9. PAROTID a) Superficial part b) Superficial subglandular lying beneath the parotid sheath (Fascia parotidomasseter) b1) Preauricular b2) Intraauricular c) Deep intraglandular d) The lower pole of the parotid These are removed in radical neck dissection
  10. 10. SUBMANDIBULAR a) Preglandular b) Prevascular: Usually one large prevascular node is lying in front of the anterior facial vein and on the external maxillary artery c) Retrovascular: Usually two retrovascular nodes are situated behind the anterior facial vein
  11. 11. SUBMENTAL a) Anterior b) Middle c) Posterior
  12. 12. RETROPHARYNGEAL a) Medial: These are intercalated b) Lateral: These are one to two lying between prevertebral fascia and lateral pharyngeal wall at the level of the atlas, near the carotid as it enters the carotid canal
  13. 13. LATERAL CERVICAL a) Superficial: There are one to four superficial nodes over the upper half of sternocleidomastoid. These are in close relation to the lower pole of the parotid. b) Deep: The deep cervical nodes consist of three chains: i. Internal jugular ii. Spinal accessory iii. Transverse cervical
  14. 14. i. Internal jugular chain  The internal jugular chain lies along the anterolateral aspect of the internal jugular vein and spinal laterally to the posterior aspect of the vein in the lower neck  SUBDIGASTRIC: These are in relation to the posterior belly of the digastric  CAROTID NODES: These are in relation to the carotid bifurcation  OMHYOID: These are in relation to the superior belly of the omhyoid  SUPRACLAVICULAR: These are in relation to the clavicle  KUTTNER’S NODE: Also called the principle node of Kuttner located anteriorly near the posterior belly of the digastric
  15. 15. ii. Spinal accessory chain  These are five to ten nodes that extend along the accessory nerve
  16. 16. iii. Transverse cervical chain  These are one to ten lymph nodes at the jugulosubclavian junction. They accompany the transverse cervical artery and vein. The most medial of these is the Troissier’s node which may be the site of metastasis of carcinoma of stomach. These drain into the right lymphatic duct.
  17. 17. ANTERIOR CERVICAL NODES  These lie between the two carotid sheaths below the level of the hyoid bone 1. Superficial anterior jugular 2. Deep anterior cervical Lymph nodes groups: a) Prelaryngeal b) Paratracheal c) Recurrent nerve chain
  19. 19. GENERAL CONSIDERATIONS  If adenocarcinoma occult primary is high in the neck, block dissection is performed with inspection of the parotid gland  If biopsy shows undifferentiated carcinoma, radiate especially for 4cm lymph nodes and then clean residual disease  As a general rule, incurable lesions of the neck should be first treated with radiation  Block dissection is used to relieve intractible pain  If adenocarcinoma is present in a supraclavicular LN, look for primary in the thyroid
  20. 20.  Functional neck dissection is indicated: i. When bilateral neck dissection is indicated ii. Preserves muscle function and protects the carotids BLOCK DISSECTION
  21. 21. LEVELS OF LYMPH NODES I. Submental and submandibular II. Upper deep cervical group of lymph nodes around internal jugular vein. Skull base to carotid bifurcation or hyoid III. Middle third of internal jugular vein to the carotid bifurcation up to omhyoid muscle or cricothyroid notch IV. Lymph nodes from omhyoid to the clavicle V. Lymph nodes along the spinal accesory and transverse cervical artery VI. Lymph nodes in anterior compartment around midline visual structures
  26. 26. ELECTIVE THERAPEUTICS  No palpable nodes  Out of seventy operated cases only eight require surgery THERAPEUTICS (also called definitive)  If nodes are palpable surgery is definite treatment
  27. 27. TYPES OF NECK DISSECTIONS 1. Radical neck dissection 2. Modified radical neck dissection 3. Selective neck dissection 4. Extended radical neck dissection
  28. 28. 1- Radical Neck Dissection Removal of: a) Sternocleidomastoid muscle b) All lymph node groups (level 1-5) c) Spinal accessory nerve d) Internal jugular vein
  29. 29. 2- Modified Radical Neck Dissection Remove all lymph nodes (level 1-5), preservation of one or more non-lymphatic structures i. Type I Modified Radical Neck Dissection preserves the spinal accessory nerve ii. Type II Modified Radical Neck Dissection saves spinal accessory nerve, internal jugular vein iii. Type III Modified Radical Neck Dissection preserves spinal accessory nerve, internal jugular vein, sternocleidomastoid muscle. Known as Functional Neck Dissection (Berry picking)
  30. 30. 3- Selective Neck Dissection a) Preservation of one or more lymph node groups and b) All non-lymphatic structures (accessory nerve, internal jugular vein, sternocleidomastoid muscle) i. Supra omhyoid LN removed (level 1-3) ii. Posterolateral LN removed (level 2-5) 1. Post-auricular and 2. Suboccipital lymph node groups iii. Lateral (level 2-4) removed iv. Anterior (level 6) removed
  31. 31. 4- Extended Radical Neck Dissection  All structures in radical neck dissection and one or more additional lymph node groups or non- lymphatic structures or both
  32. 32. CONTRA-INDICATIONS OF NECK DISSECTION 1. Mass in subclavian triangle 2. A large fixed mass 3. Mass extending to the mastoid 4. Undifferentiated carcinoma 5. Primary lesion that cannot be controlled 6. Distant metastases 7. Uncontrollable tumour will remain in neck after surgery 8. Papillary carcinoma of thyroid without extracapsular invasion 9. Occult primary adenocarcinoma – sample nodal excision with inspection of neck
  33. 33. INDICATIONS OF NECK DISSECTION  The tumour has extended to lymph nodes  There is reasonable expectation of controlling the PRIMARY TUMOUR  Emphasis is on preservation of function  Radiation failure  Lymph nodes larger than 3cm
  34. 34. IMPORTANT LANDMARKS  Transverse process of atlas  Internal jugular, Internal carotid artery.  IX, X, XI & XII cranial nerve.
  35. 35. SRUCTURES AT TIP OF HYOID BONE  Carotid bulb, External & Internal carotid artery  Internal jugular vein  Vagus nerve, Hypoglossal nerve passing lateral to carotids  Lingual vein, superior thyroid & facial vein entering internal jugular vein  Superior thyroid artery, Superior laryngeal nerve & artery
  36. 36. TRANSVERSE PROCESS OF VI CERVICAL VERTEBRA  Also called carotid tubercle  It lies at the level of cricoids cartilage  Vertebral artery entering the foramen at this level
  37. 37. PREOPERATIVE 1. Type cross match 2-3 units of whole blood 2. Patient anaesthetized using various tubes 3. Pillow placed under the shoulder, raise the head 30° 4. Scrub to prepare: i. Lower face ii. Ears iii. Neck iv. Shoulders v. Upper chest
  38. 38. POSITION
  39. 39. POSITION
  40. 40. POSITION
  41. 41. POSITION
  42. 42. DRAPING  Keep the ear outside  First sheet from chin to ear  Second sheet across upper chest  Third sheet mastoid to shoulder  Stitch the sheets
  43. 43. DRAPING
  46. 46. MARTIN INCISION  Upper incision - submental area to tip of mastoid  Lower incision - suprasternal notch to 4cm above clavicle  Vertical arm – posterior to carotid vessels
  47. 47. CONLEY INCISION  Incision is away from carotid  Difficult area of the trapezius can be easily approached
  49. 49. INCISION  Protect the carotid with levator muscles, fascia lata graft  Incision should be carried out through i. Skin ii. Subcutaneus tissue iii. Platysma muscle  External jugular vein is not included with the skin incision
  50. 50. INCISION  Include the platysma muscle in skin flaps  Use superior belly of omohyoid as medial guide  Use scalenus fascia as guide for depth  Critical areas and structures:  Internal jugular vein superiorly and inferiorly  Subclavian vein  Posterior facial vein hidden in tail of parotid gland  Superior laryngeal nerve deep to external and internal carotid arteries  Thoracic duct on left side  Apical pleura  Place incision so that trifurcation does not overlie the carotid vessels
  51. 51. SURGERY 1  Skin flaps elevated: i. Superiorly to ramus of mandible ii. Lift the deep cervical fascia at level of hyoid iii. Midline to strap muscles iv. Inferiorly to clavicle
  52. 52. SURGERY 2  Find the notch made on the inferior border of mandible by the external maxillary vessels, anterior facial vein and superficial layer of deep cervical fascia as reflected  Sternocleidomastoid: Upper and lower ends are cut lose to the bone and up to the deep fascia. The vein is exposed and a 2cm strap is left below  Tied in continuity  Two suture ligatures are put in place
  53. 53. PROBLEM  The lower end slips or tears DO NOT PANIC Remedy!  JUGULAR VEINS: Always tie the lower end first  OTHER VEINS: 1. Transverse cervical vein 2. Transverse scapular vein 3. Anterior jugular vein Fascia of carotid sheath is stripped and vagus nerve and internal carotid artery saved
  54. 54. LEFT SIDE  THORACIC DUCT: If you are 2cm above, you should be alright. Still if it is opened then white fluid or blood will come out.  Try to  Repair it, or  Tie it off
  55. 55. THYROID  If involved with disease, lobectomy on that side is performed  After cutting the sternohyoid and sternothyroid, return to deep layer of deep cervical fascia 1. Phrenic nerve 2. Brachial plexus 3. Nerve to serratus anterior 4. Subclavian artery and vein
  56. 56. PHRENIC NERVE  Descends lateral to medial crossing the scalenus anticus – save it
  57. 57. SAVING THE ACCESSORY NERVE  Identify XIth CRANIAL NERVE - save it if not involved If not possible, graft the posterior auricular nerve  It is identified ⅓rd from clavicle, ⅔rd from mastoid tip
  58. 58. ANTERIOR DISSECTION  Separate the vein and thyroid from carotid artery and vagus nerve  CAROTID MASSAGE  Vagus nerve may have to be sacrificed  Adherent lymph nodes to carotid  Identify the phrenic nerve’s cervical branches  Insertions of anterior belly of omhyoid, sternothyroid are transected  Identify the hypoglossal nerve 1.5cm above the carotid bifurcation and lateral to it  Superior laryngeal nerve passes deep to the internal and external carotid artery. Their section will lead to problems in deglutition
  59. 59. SUBMAXILLARY TRIANGLE  Digastric muscle is identified, separated from hyoid bone  Anterior border is transected just below insertion  The omhyoid muscle is transected anteriorly  Lower end transected ahead  Upper end of external jugular vein transected  Dissection across lower pole of parotid gland  The stylomandibular ligament is divided  The superior aspect of submandibular gland is dissected  Facial vessels ligated  Posterior belly of digastric is cut
  60. 60. SUBMANDIBULAR GLAND  The submandibular gland is pulled down exposing the lingual nerve  Whartin’s duct: This is resected  Facial artery is transected and ligated just below the mandible  The posterior belly of digastric and thyrohyoid are transected exposing the internal jugular vein  Internal maxillary and occipital arteries are identified and ligated  If it cannot be tied, oxycyll / surgicell pack is left in place  Protect carotid artery with levator scapulae  Wash the wound floor  Hemovac drain
  61. 61. CAUSES OF CAROTID BLOWOUT  Infection  Incision line is on the carotid  Flaps are lifted by blood or serum  Injury during surgery  Suction tip close to the carotid  Radiated patient
  62. 62. WHEN TO TREAT CAROTID BLOWOUT  Do it as an elective procedure Elective Ligation Emergency Ligation Number of patients 64 (100 per cent) 87 (100 per cent) Stroke 15 (23 per cent) 44 (50 per cent) Deaths 11 (17 per cent) 33 (38 per cent)
  63. 63. PROTECTING THE CAROTID  Muscle graft  Fascia lata graft  Dermal graft
  65. 65. DERMAL GRAFT  1/12th of an inch epidermis is elevated  Graft should be 7cm wide  20 cm long  1/20 to 1/24th of an inch thick  Use non-absorbable sutures
  68. 68. VEIN GRAFT
  70. 70. COMPLICATIONS 1. Delayed bleeding 2. Shock 3. Air embolism i. Hissing sound ii. Blood pressure falls iii. Regurgitation in heart iv. Fundoscopy 4. Airway obstruction 5. Carotid sinus syndrome 6. Pneumothorax
  71. 71. 7. Nerve damage i. Superior laryngeal nerve ii. Facial nerve iii. Vagus nerve iv. Recurrent laryngeal nerve v. Phrenic nerve vi. Hypoglossal nerve vii. Cervical sympathetic chain (Horner’s syndrome) viii. Spinal accesory nerve ix. Lingual nerve x. Brachial plexus
  72. 72. 8. Chylous fistula 9. Subcutaneous emphysema 10. Wound infection 11. Gangrene of flap tissue – prevent base to tip ratio 12. Carotid artery rupture 13. Fluid electrolyte imbalance
  73. 73. 14. Increased central venous pressure – if CSF pressure rises above 600 mmH2O, cerebral palsy 15. Injury to cervical vertebrae 16. Salivary fistula 17. Feeding tube syndrome: 1. Dehydration 2. Hypernatremia 3. Hyperchloridemia 4. Azotemia 5. Fever 6. Increased urinary output 7. Weight loss 8. Confusion
  74. 74. QUESTIONS?