indication of neck dissection

1. Neck
dissection
DR SAFIKA ZAMAN
DEPT OF ENT & HEAD NECK SURGERY
RKMSP, VIMS

2. Introduction
Neck dissection is removal of fibro-fatty tissue along with nodal tissue
with or without dissection of adjacent non node structure.
Sound knowledge of the 3-dimensional anatomy of the neck.
Anatomic relationships of the lymphatic nodal levels

3. History of neck dissection
Von Langenbeck, Billroth, von Volkmann and Kocher developed and
reported the early cases of different types of neck dissection.
1888, the Polish surgeon Jawdyńsky reported and described in detail
the first successful extended en bloc neck dissection.
Crile, in 1905 and 1906, reported the first significant series of radical
en bloc neck dissections
Crile's neck dissection
https://www.google.com/url?sa=i&url=https%3A%2F%2Fanzjsurg.onlinelibrary.wiley.com%2Fdoi%2Fpdf%2F10.1097%2FMLG.0b013e318135
44b7&psig=AOvVaw2F_tCLHYNczD1sqZAv3t_O&ust=1626704118397000&source=images&cd=vfe&ved=2ahUKEwjPtKma5-
zxAhWtwXMBHdgaCXQQr4kDegUIARChAQ

4. Martin and colleagues, who published a
monumental report in 1951 of 1,450 cases
that established the place and technique of
radical neck dissection in the modern
treatment of head and neck cancer
Late twentieth century, when the
principles of 'functional' neck dissection,
developed by Suárez and popularized by
Bocca, Gavilán, Ballantyne, Byers and
others, led to the acceptance of modified
radical neck dissection

5. Surgical anatomy of neck in
relation to neck dissection
Sternocleidomastoid muscle
Platysma
Trapezius muscle
Omo-hyoid muscle
Digastric muscle

6. Cont …

7. Cont..
Facial nerve
Brachial plexus & phrenic nerve
Greater auricular nerve
Spinal accessory nerve
Carotid artery
Internal jugular vein
Thoracic duct

8. Deep cervical fascia
Investing layer-
trapezius,sternocleidomastoid,submandibular and parotid
salivary gland.
Pre tracheal fascia (middle layer)- surrounds the pharynx,
larynx, trachea, esophagus, thyroid, parathyroids,
buccinators, and constrictor muscles of the pharynx, strap
muscle .
Prevertebral fascia -It surrounds the para-spinous muscles
and cervical vertebrae
carotid sheath- component of the deep cervical fascia.

9. Surgical Anatomy
Lymphatic network - 300 nodes
Strongly lateralized chains
Do not directly communicate between left and right
Midline structures -nasopharynx, pharyngeal wall, base of
the tongue, soft palate, and larynx.

10. Lymphatic vessels of head and
neck
Major groups; superficial vessels and deep
vessels.
Superficial lymph nodes – submental,
submandibular ,buccal, parotid
,supraclavicular .
Waldeyers ring

11. Deep lymph nodes
They are organised into a vertical chain
Proximity to internal jugular vein
Superior , middle and deep cervical lymph nodes
prelaryngeal, pretracheal, paratracheal,
retropharyngeal, infrahyoid, jugulodigastric
(tonsilar), jugulo-omohyoid.

12. Cont …
Left jugular lymphatic trunk – combines with the
thoracic duct at the root of the neck. This empties
into the venous system via the left subclavian vein.
Right jugular lymphatic trunk – forms the right
lymphatic duct at the root of the neck. This empties
into the venous system via the right subclavian vein.

13. lymphangiogenesis within sentinel lymph node (SLN), even before they
metastasize, possibly preparing the LN for their later arrival. Metastatic,
VEGF-A expressing SCC maintain their lymphangiogenic activity after
metastasis to SLN
Lymph node metastasis: A bearing on
prognosis in squamous cell carcinoma
C Kapoor1, S Vaidya2, V Wadhwan3, S
Malik4

14. Surface marking for neck nodes

15. Level Ia: Submental Group
Drainage -skin of the mental region, the mid-lower lip, anterior
portion of the oral tongue, and the floor of the mouth.
S: Symphysis of mandible
I: Hyoid bone
A (M): Left anterior belly of digastric
P (L): Right anterior belly of digastric

16. Level Ib: Submandibular Group
Drainage: efferent lymphatics from level Ia, the lower
nasal cavity,hard and soft palates,maxillary and
mandibular alveolar ridges. skin and mucosa of the
cheek, both upper and lower lips, the floor of the mouth,
and the anterior tongue.
S: Body of mandible
I: Posterior belly of digastric
A (M): Anterior belly of digastric
P (L): Stylohyoid muscle

17. Level II: Upper Jugular Group
Drainage : lymphatics of the face, parotid gland, level Ia, level Ib, and
retropharyngeal nodes, nasal cavity, pharyngeal axis, larynx, external auditory
canal, middle ear, sublingual and submandibular glands.
S: Lower level of bony margin of jugular fossa
I: Level of lower body of hyoid bone
A (M): Stylohyoid muscle
P (L): post border of sternocleidomastoid
Vertical plane defined by spinal accessory divides into - Ⅱ-A andⅡ-B

18. Level III: Middle Jugular Group
Drainage: lymphatics from level II and level V, and partially from
the retro-pharyngeal, pre-tracheal, and recurrent laryngeal
nodes. base of the tongue, tonsils, larynx, hypopharynx, and
thyroid gland
S: Level of lower body of hyoid bone
I: Horizontal plane along inferior border of anterior cricoid arch
A (M): Lateral border of sternohyoid muscle
P (L): Posterior border of sternocleidomastoid muscle or
sensory branches of the cervical plexus

19. Level IV: Lower Jugular Group
Drainage: lymphatics from levels III and V, retropharyngeal, pretracheal,
recurrent laryngeal nodes.larynx, hypopharynx,thyroid gland.
S: Horizontal plane along inferior border of anterior cricoid arch
I: Clavicle
A (M): Lateral border of sternohyoid muscle
P (L): Posterior border of sternocleidomastoid muscle or sensory
branches of the cervical plexus

20. Level Va and Vb: Posterior Triangle
Group
Drainage: lymphatics from the occipital, retro-auricular, occipital, and parietal
scalp nodes. skin of the lateral and posterior neck and shoulder, the
nasopharynx, oropharynx, and thyroid gland.
S: Convergence of SCM and trapezius muscles
A (M): Posterior border of sternocleidomastoid muscle or sensory branches
of the cervical plexus
P (L): Anterior border of trapezius muscle
I: Clavicle
Horizontal plane along inferior border of anterior cricoid arch divides into-
Ⅴa and Ⅴb

21. Level VI: Anterior Compartment
Group
Level VI - drains the integuments of the lower face and
the anterior neck.
These nodes most often contain metastatic deposits
from malignancies of the lower lip and soft tissues of
chin, such as advanced gingiva-mandibular carcinoma
S: Hyoid bone
I: Sternal notch
A (M): Common carotid artery
P (L): Common carotid artery

22. Assessment and staging
1. Palpation– inter-operator variability, shape of neck, absence or presence of significant subcutaneous fat
and varying size of involved cervical nodes.
2. CT & MRI
3.PET- scan
4. US & US Guided FNAC
5.Sentinel node biopsy
US, CT and MRI imaging modalities focus on morphologic (size and homogeneity) aspects of lymph nodes and
FDG PET focusses on glucose consumption.
None of these imaging techniques is able to detect small or microscopic subclinical metastases and to
subsequently change treatment strategies.

25. Sentinel node biopsy
Sentinel node biopsy is a surgical procedure used to determine whether cancer has spread beyond a primary
tumour into your lymphatic system.
Procedure – peri-tumoral injections of a technetium-99 m (99mTc)-labelled nano-colloid, or other radiotracer,
followed by lymphoscintigraphy using planar and single photon emission computed tomography/CT (SPECT-
CT) imaging. Based on the lymphoscintigraphy, the position of the SLN is marked on the skin.
Subsequently the marked SLN is surgically removed
while intraoperative detection is achieved using a portable gamma probe.
Finally, meticulous histopathological examination, including step serial sectioning and immunohistochemistry,
of the harvested SLN is performed

26. Sentinel node biopsy
The improvements in staging are particularly notable for the contralateral neck and the pretreated
neck

27. AJCC Nodal status

28. Neck dissection technique classification

29. Management of N0 neck
Management of neck metastases in
head and neck
cancer: United Kingdom National
Multidisciplinary
Guidelines
V PALERI1, T G URBANO2, H
MEHANNA3, C REPANOS4, J
LANCASTER5, T ROQUES6,
M PATEL7, M SEN8

31. Management of neck metastases in head and neck
cancer: United Kingdom National Multidisciplinary
Guidelines
V PALERI1, T G URBANO2, H MEHANNA3, C REPANOS4, J
LANCASTER5, T ROQUES6,
M PATEL7, M SEN8

32. N+ neck-surgery is primary modality
,M PATEL7, M SEN8Management of neck
metastases in head and neck
cancer: United Kingdom National
Multidisciplinary
Guidelines
V PALERI1, T G URBANO2, H MEHANNA3,
C REPANOS4, J LANCASTER5, T ROQUES6

33. N+ neck-chemoradiation is primary
modality

34. Incision

35. Steps
Initial exposure -

36. Cont..
Resection of submental triangle from mylohyoid
muscle
Incision of submandibular
salivary gland capsule

37. Cont..

38. Cont…

39. Cont…

40. Cont…

42. Complication of neck dissection
https://www.mjdrdypu.org/articles/2015/8/4/images/MedJDYPatilUniv_2015_8_4_458_160785_t1.jpg

43. Cont…
Haematoma - Prevention consists of preoperative
avoidance of anticoagulants and antiplatelet agents and
meticulous intraoperative hemostasis.
Hematomas are avoided by careful hemostasis,
application of pressure dressing and continuous suction
drainage.

44. Wound complication
Wound infection cellulitis with erythema, warmth, or
induration
Cervical skin flaps, abscess formation from an infected
seroma or hematoma
Proper pre-op preparation of surgical site
Asepsis
Antibiotics

45. Neural complications
Sensory branches of cervical root branches- sensory deficit that extends
from pinna to the chest wall below the clavicle.
Greater auricular nerve - sensory deficit of the auricle.
Lingual nerve - injury results in loss of taste from ipsilateral anterior two
third of the tongue and hypoesthesia or paresthesia of the hemitongue
with resultant difficulty with speech.
Spinal accessory nerve -Pain and weakness of the shoulder

46. Cont..
Marginal mandibular branch of the facial nerve - typically single
branch highly variable position . asymmetry of the motion of the
corner of the mouth.
Vagus nerve - High vagus nerve injuries result in significant
dysphonia from ipsilateral vocal cord paralysis and dysphagia with
pooling of secretions from pharyngeal paralysis and loss of
sensation in the larynx. A breathy voice , an inefficient cough, and
a subjective sense of dyspnea result.
The loss of more distal vagal innervations has little clinical effect

47. Cont…
Hypoglossal nerve - injury result in ipsilateral tongue
weakness, deviation of the tongue to the affected side
and difficulty with speech and swallowing
Phrenic nerve-rare complication of neck dissection and
leads to ipsilateral hemi-diaphragm elevation with or
without mediastinal shift on chest radiograph, and it may
contribute to postoperative pulmonary complications.

48. Cont…
Horner syndrome: Miosis, Ptosis, Anhydrosis , Transient blush and
nasal congestion.
No Horner syndrome will results from an injured below the stellate
gangion located behind the vertebral artery in the root of the neck

49. Internal jugular vein complication
Underdiagnosed condition
occur as a complication of head and neck infections,
surgery, central venous access, local malignancy,
polycythemia, hyper-homocysteinemia, neck massage,
and intravenous drug abuse.
Thrombosis itself can have serious potentially life-
threatening complications that include systemic sepsis,
chylothorax, papilledema, airway edema, and
pulmonary embolism.

50. Chyle fistula
Injury to thoracic duct

51. Carotid blow-out

52. Thank
you