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Surgical anatomy of neck and types of neck dissection

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Surgical anatomy of neck and types of neck dissection

  2. 2. FASCIAL LAYERS OF THE NECK  Superficial cervical fascia  Deep cervical fascia  Superficial layer  SCM,  Strap muscles,  Trapezius  Middle or Visceral Layer  Thyroid  Trachea  Esophagus  Deep layer (also prevertebral fascia)  Vertebral muscles  Phrenic nerve
  3. 3. FASCIA OF NECK Superficial fascia: - Connective tissue below dermis - Completely surrounds neck - thin and hard to demonstrate - Contains Platysma
  4. 4. DEEP CERVICAL FASCIA  Form the boundaries of compartments  Used as a guide to surgical dissection  Allow the neck structures to glide past one another  Supports the thyroid, lymph nodes and blood vessels  Fascial spaces can communicate infection or fluid to other regions of the body
  5. 5. Deep Cervical Fascia
  6. 6. Deep Cervical Fascia
  7. 7. SUPERFICIAL STRUCTURES  Platysma  External jugular vein  Marginal mandibular nerve
  8. 8. Platysma •Muscle of Facial Expression •Innervated by the cervical branch of the facial nerve •Blood supply to skin through this muscle •Strength to flap
  9. 9. EXTERNAL JUGULAR VEIN • The vein is formed by the union of the posterior division of the retromandibular vein with the posterior auricular vein and begins near the mandibular angle just below or in the parotid gland. • It descends from the angle, running obliquely, superficial to the sternocleidomastoid, to the root of the neck. • Here it crosses the deep fascia and ends in the subclavian vein, behind the clavicle.
  10. 10. MARGINAL MANDIBULAR NERVE Present-  Superficial layer of deep cervical fascia and advantasia of facial vein  More than one branch often present  Should be preserved in neck dissections  Can be preserved by- Identifying then dissecting along its course and reflecting superiorly it flap
  11. 11. MUSCLES
  12. 12. STERNOCLEIDOMASTOID MUSCLE (SCM) • Origin – 1) medial third of the clavicle (clavicular head) 2) manubrium (sternal head) • Insertion – mastoid process • Nerve supply – spinal accessory nerve (CN XI) • Blood supply – 1. occipital a. or direct from ECA 2. superior thyroid a. 3. transverse cervical a.
  13. 13. OMOHYOID MUSCLE • Origin – upper border of the scapula • Insertion – Intermediate tendon 1. hyoid bone lateral to the sternohyoid muscle • Blood supply – Inferior thyroid a. Innervation – Upper belly-Superior root of ansa Inferior belly- Ansa Cervicalis • Function – 1. depress the hyoid 2. tense the deep cervical fascia
  14. 14. OMOHYOID MUSCLE Surgical considerations – Landmark demarcating level III from IV – Inferior belly lies superficial to • The brachial plexus • Phrenic nerve • Transverse cervical vessels – Superior belly lies superficial to IJV
  15. 15. DIGASTRIC MUSCLE • Origin – digastric fossa of the mandible (at the symphyseal border • Insertion – 1) hyoid bone via the intermediate tendon 2) mastoid process • Function – 1) elevate the hyoid bone 2) depress the mandible (assists lateral pterygoid)
  16. 16. DIGASTRIC MUSCLE posterior belly •Origin – Deep to SCM superficial to: • ECA • ICA • IJV • Assessory nerve • Hypoglossal nerve
  17. 17. DIGASTRIC MUSCLE  Intermediate tendon- Associated superficially with- • Submandibular gland • Facial artery o Anterior belly • Landmark for identification of mylohyoid for dissection of the submandibular triangle
  18. 18. TRAPEZIUS MUSCLE • Origin – 1) medial 1/3 of the sup. Nuchal line 2) external occipital protuberance 3) ligamentum nuchae 4) spinous process of C7 to T12 • Insertion – 1) lateral 1/3 of the clavicle 2) acromion process 3) spine of the scapula • Function – elevate and rotate the scapula and stabilize the shoulder
  19. 19. TRAPEZIUS • Surgical considerations – Posterior limit of Level V neck dissection – Denervation results in shoulder drop and winged scapula
  21. 21. Anterior Triangle
  22. 22. 1. Submandibular triangle 2. Carotid triangle 3. Muscular triangle 4. Submental triangle
  23. 23. Submental Triangle formed by • the anterior bellies of the digastric, • hyoid, Content- • Submental lymph nodes;3 or 4 in no. situated in the superficial fascia below the chin • Submental branch of facial artery • Commencement of ant. Jugular vein Floor- mylohyoid
  24. 24. SUBMANDIBULAR TRIANGLE formed by mandible, posterior belly of the digastric, and anterior belly of the digastric Floor anteriorly – mylohyoid Posteriorly- hyogloassus
  25. 25. CAROTID TRIANGLE formed by superior belly of the omohyoid, SCM, posterior belly of the Digastric
  26. 26. Muscular Triangle formed by the midline, superior belly of the omohyoid, and SCM CONTENT • No significant structures • Beneath its floor lie thyroid glands,larynx,trachea,esophagus • Infrahyoid muscle are present in this triangle
  27. 27. Posterior Triangle of the Neck 1. Occipital Triangle 2. Subclavian Triangle
  28. 28. OCCIPITAL TRIANGLE BOUNDARIES • Front-post. Border of SCM • Behind-anterior border of trapezius muscle • Below- inf. Belly of omohyoid • Floor- 1. spinalis capitis muscle 2. levator scapulae 3. scalenus medius and posterior
  29. 29. SUPRACLAVICULAR TRIANGLE Formed by – Inferior belly of omohyoid SCM Clavilce
  31. 31. CONTENTS OF SUBMANDIBULAR TRIANGLE • Submandibular gland and its lymph nodes • Subamdibular duct • Facial vein • Facial artery • Hypoglossal nerve and accompanying vein • Lingual artery
  32. 32. CONTENTS OF CAROTID TRIANGLE  CCA and its two terminal branches  In the carotid triangle the ICA is posterolateral while ECA is anteromedial  Branches of ECA 1. Superior thyroid artery 2. Lingual artery 3. Facial artery 4. occipital artery 5. Ascending pharyngeal artery  INT CAROTID artery does not give any branches in this triangle Arteries
  33. 33. NERVES IN CAROTID TRIANGLE  Portion of spinal part of accessory nerve  Loop of hypoglossal  Ansa Cervicalis  Vagus nerve; passes downward within carotid sheath between IJV laterally and carotid system of arteries medially
  34. 34. SPINAL ACCESSORY NERVE • Originates from jugular foramen • Crosses the IJV • Downward backward to upper part of SCM • Descends obliquely in level II (forms Level IIa and Iib • Penetrates the deep surface of the SCM • Exits posterior surface of SCM deep to Erb’s point •
  35. 35. SPINAL ACCESSORY NERVE • In posterior triangle and lies between superficial cervical fascia and prevetebral fascia ;above the levator scapulae • Before it enters SCM joined by C2 • Before it enters Trapizus joined by C3 and C4 • Enters the trapezius approx. 5 cm above the clavicle
  36. 36. CLINICAL SIGNIFICANCES  While operating in the posterior triangle one should keep in mind that this nerve runs in the roof and not floor and hence can be damaged during elevation of flap itself.  Damage to spinal accessary leads to- Paralysis of SCM and Trapizius • leading to asymmetric neckline • a drooping shoulder • Winged Scapula • weakness of forward elevation of the shoulder
  37. 37. ERB’S POINT • At posterior border of the SCM where the four superficial branches of the cervical plexus emerge from behind the SCM.  greater auricular  lesser occipital  transverse cervical  supraclvicular nerve • approximately at the junction of the upper and middle thirds of this muscle. • the accessary nerve courses through the to enter the anterior border of the trapizius muscle • The spinal accessory nerve can often be found 1 cm above Erb's point
  39. 39. ANSA CERVICALIS • Part of the cervical plexus • • It lies superficial to the IJV in carotid triangle. • Superior root • Inferior root • Branches from the ansa cervicalis innervate • sternothyroid • sternohyoid • omohyoid muscles .
  40. 40. VEINS PRESENT IN THE CAROTID TRIANGLE  Internal jugular vein; extends from the base of skull to the root of neck and collects blood from the brain ,superficial part of the face and neck  Also present are the tributaries of IJV such as sup. Thyroid, lingual ,common facial, pharyngeal,and sometimes occipital veins
  41. 41. LIGATION OF INTERNAL JUGULAR VEIN  Lower end of internal jugular vein is approached first by dividing the SCM because it reduces chances of air emboli and vessel doesn't get collapsed.  Care should be taken not to harm a thoracic duct  Upper end can be identify by dividing SCM  The position can be located by palpation of transverse portion of atlas over which it lies .
  42. 42. CONTENTS OF OCCIPITAL TRIANGLE  Cutaneous branches of cervical plexus 1. lesser occipital nerve(c2) 2. great auricular nerve(c2,c3) 3. transverse cervical nerve(c2,c3) 4. Supraclavicular nerve(c3,c4) • Lies on levator scapulae and Saclenus medius muscle • Lies deep to Prevertibral fascia, IJV , SCM
  43. 43. BRANCHES
  44. 44. PHRENIC NERVE  Formed by nerve roots C3-5  Runs obliquely toward midline on the anterior surface of anterior scalene  Covered by prevertebral fascia  Lies directly on anterior surface of anterior scalene muscle  Lies posterior and lateral to the carotid sheath  Sole nerve supply to the diaphragm
  46. 46. CONTENTS OF SUPRACLAVICULAR TRIANGLE [1]nerves- (a)trunks of brachial plexus [2]vessels- (a)Third part of subclavian artery and subclavian vein (b)Suprascapular artery and vein (c) transverse cervical artery (d)Lower part of external jugular vein [3]lymph nodes- [4] Thorasic duct
  48. 48. THORACIC DUCT • Conveys lymph from the entire body back to the blood • Enters the base of neck lies between right subclavian and CCA • Arches upwards, forwards laterally runs infront of vertibral artery • Arches above subclavian artery passes between IJV and ant.scalene • Enters the junction of the left subclavian and the IJV
  49. 49. CLINICAL CONSIDERATION THORACIC DUCT  Injury to thoracic duct may lead to Chyle leak  Chyle extravasation can result in • delayed wound healing • dehydration • malnutrition • electrolyte disturbances • immunosuppression o Prompt identification and treatment of a chyle leak are essential for optimal surgical outcome
  50. 50. CLINICAL CONSIDERATION THORACIC DUCT  Intraoperative Diagnosis of Chyle leak- • Maneuvers that increase intrathoracic or intra-abdominal pressure may facilitate the identification of a CL as well. • Trendelenburg positioning and Valsalva maneuver while the anesthesiologist applies positive pressure to raise intrathoracic pressure • manual abdominal compression • Can propagate hydrostatic forces through the course of the thoracic duct to increase chyle flow • Distend the distal thoracic duct to improve visibility.
  51. 51. CLINICAL CONSIDERATION THORACIC DUCT  Management- intraoperative Chyle leak • Thoracic duct may be ligated with surgical clips or nonabsorbable suture. • Locoregional flaps may be incorporated for additional coverage of the surgical bed. • The clavicular head of the sternocleidomastoid can be dissected free and sutured to the wound bed
  52. 52. CLINICAL CONSIDERATION THORACIC DUCT  Postoperative Diagnosis of Chyle leak- • Increases in drain output, especially following resumption of feedings that contain fat . • Neck may exhibit erythema, lymphedema, or a palpable fluid collection in the supraclavicular region. • Creamy or milky drain contents. • Drain fluid with triglyceride level >100 mg/dL
  53. 53. CLINICAL CONSIDERATION THORACIC DUCT  Management- Postoperative Diagnosis of Chyle leak- • Activity • Diet • Wound care • Surgical reexploration
  57. 57. CLASSIFICATION OF NECK DISSECTIONS 61 • Academy’s Committee for Head and Neck Surgery and Oncology publicized standard classification system
  58. 58. CLASSIFICATION OF NECK DISSECTIONS 62 • Academy’s classification – 1) Radical neck dissection (RND) – 2) Modified radical neck dissection (MRND) – 3) Selective neck dissection (SND) • Supra-omohyoid type • Lateral type • Posterolateral type • Anterior compartment type – 4) Extended radical neck dissection
  59. 59. CLASSIFICATION OF NECK DISSECTIONS 63 • Medina classification (1989) – Comprehensive neck dissection • Radical neck dissection • Modified radical neck dissection – Type I (XI preserved) – Type II (XI, IJV preserved) – Type III (XI, IJV, and SCM preserved) – Selective neck dissection
  60. 60. CLASSIFICATION OF NECK DISSECTIONS • Spiro’s classification – Radical (4 or 5 node levels resected) • Conventional radical neck dissection • Modified radical neck dissection • Extended radical neck dissection • Modified and extended radical neck dissection – Selective (3 node levels resected) • SOHND • Jugular dissection (Levels II-IV) • Any other 3 node levels resected – Limited (no more than 2 node levels resected) • Paratracheal node dissection • Mediastinal node dissection • Any other 1 or 2 node levels resected
  61. 61. RADICAL NECK DISSECTION 65 Definition- All lymph nodes in Levels I-V including spinal accessory nerve (SAN), SCM, and IJV Indications- Extensive cervical involvement or matted lymph nodes with gross extracapsular spread and invasion into the SAN, IJV, or SCM –
  62. 62. MODIFIED RADICAL NECK DISSECTION 66 • Type I:Preservation of SAN • Type II: Preservation of SAN and IJV • Type III: Preservation of SAN, IJV, and SCM ( “Functional neck dissection”)
  63. 63. SELECTIVE NECK DISSECTIONS 68 • Definition – Cervical lymphadenectomy with preservation of one or more lymph node groups – Four common subtypes: • Supraomohyoid neck dissection • Posterolateral neck dissection • Lateral neck dissection • Anterior neck dissection
  64. 64. SND: SUPRAOMOHYOID TYPE • Most commonly performed SND • Definition – En bloc removal of cervical lymph node groups I-III – Posterior limit is the cervical plexus and posterior border of the SCM – Inferior limit is the omohyoid muscle overlying the IJV
  65. 65. SND: SUPRAOMOHYOID TYPE 70 • Indications – Oral cavity carcinoma • Subsites - Lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone, hard palate, and anterior 2/3s of the tongue and FOM – Bilateral SOHND • Anterior tongue • Oral tongue and FOM that approach the midline – SOHND + parotidectomy • Cutaneous SCCA of the cheek • Melanoma (Stage I – 1.5 to 3.99mm) of the cheek
  66. 66. SND: LATERAL TYPE 71 • Definition – En bloc removal of the jugular lymph nodes including Levels II-IV • Indications – N0 neck in carcinomas of the oropharynx, hypopharynx, supraglottis, and larynx
  67. 67. SND: POSTEROLATERAL TYPE • Definition – En bloc excision of lymph bearing tissues in Levels II-IV and additional node groups – suboccipital and postauricular • Indications – Cutaneous malignancies • Melanoma • Squamous cell carcinoma • Merkel cell carcinoma – Soft tissue sarcomas of the scalp and neck
  68. 68. SND: ANTERIOR COMPARTMENT • Definition – En bloc removal of lymph structures in Level VI • Perithyroidal nodes • Pretracheal nodes • Precricoid nodes (Delphian) • Paratracheal nodes along recurrent nerves • Indications – Selected cases of thyroid carcinoma – Parathyroid carcinoma – Subglottic carcinoma – Laryngeal carcinoma with subglottic extension – CA of the cervical esophagus
  69. 69. EXTENDED NECK DISSECTION • Definition – Any previous dissection which includes removal of one or more additional lymph node groups and/or non-lymphatic structures. – Usually performed with N+ necks in MRND or RND when metastases invade structures usually preserved • Indications – Carotid artery invasion – Other examples: • Resection of the hypoglossal nerve resection or digastric muscle, • dissection of mediastinal nodes and central compartment for subglottic involvement • removal of retropharyngeal lymph nodes for tumors originating in the pharyngeal walls.
  70. 70. REFERENCES • Gray H. Anatomy Descriptive and Surgical:(" Gray's Anatomy"). Classics of Medicine Library; 1981 • Netter FH. Atlas of Human Anatomy, Saunders Elsevier, 2014: Atlas of Human Anatomy. Bukupedia; 2014 Nov 14 • Textbook of Surgical Anatomy- Hollingshead • Shah JP, Johnson NW, Batsakis JG. Oral cancer. CRC Press; 2002 Dec 19 • Press CR. Stell & Maran's textbook of head and neck surgery and oncology. CRC Press; 2011 Dec 30
  71. 71. THANK YOU

Notas do Editor

  • The various structures of neck are surrounded by different facias which is actully a thickening of connective tissue
  • Contains variable amount of fat
    Platysma is embeded in this region
  • Supeerficial layer of dCp thoughy to arise from vertebral spinous process enclosing trapizius muscle two layers unite runs forwards devides at post border of scm and joins again
    Facia around strap muscles superiorly attaches to hyoid bone and inf. Goes downward splits into 2 layers just abouve the sternum ant and post to sternum forms presternal space of burns
    Carotid sheath- surrpunds IJV, CCD, X between superfial and pretracheal fasica
  • Pretracheal fasica- behind strap muscles facial anterior to trachea blends with cervical facial laterally trached doen it fuses fibrus pericardium
    Prevertibral fascia – arise from vertbral spinal process lies on outer surface of muslces of back deep to trapizius muscle
  • Passes upward laterally
    Enclosed by sperfical layer of deep fasica
    Transverse colli, GAN EJV lie above this muscle
    Lower part it covers lateral part of strap muscles

    Occipital – at hyoid level
    Sup.thy.-at lower part of carotid triangle
    Trans cerval- lower end
  • Formed by lower border of mandible, scm and midline
  • and drains the lymph from the central part of lower lip,adjoining gums,floor of the mouth and tip of tongue
  • Duct passes over post border of mylohyoid muscle
    Facial vein crosses over the gland while artery loops around gland to go between gland and muscle
    Pass just above the hyoglossus muscle
    l.a.- close to angle formed by 2 bellies
  • Infrahyoid muscles are arranged in two layers;
    Superficial –sternohyoid and omohyoid
    Deep-sternothyroid and thyrohyoid
  • Duct passes over post border of mylohyoid muscle
    Facial vein crosses over the gland while artery loops around gland to go between gland and muscle
    Pass just above the hyoglossus muscle
    l.a.- close to angle formed by 2 bellies
  • Ligation-
  • In fact vagus is not a content of this triangle as it overlapped by SCM
  • Originates from jugular foramen -Crosses the IJV- Crosses lateral to the transverse process of the atlas- Descends obliquely in level II (forms Level IIa and Iib- Penetrates the deep surface of the SCM
    - Exits posterior surface of SCM deep to Erb’s point
    - Traverses the posterior triangle and lies in superficial cervical fascia and above the levator scapulae
    - Enters the trapezius approx. 5 cm above the clavicle

  • Originates from jugular foramen -Crosses the IJV- Crosses lateral to the transverse process of the atlas- Descends obliquely in level II (forms Level IIa and Iib- Penetrates the deep surface of the SCM
    - Exits posterior surface of SCM deep to Erb’s point
    - Traverses the posterior triangle and lies in superficial cervical fascia and above the levator scapulae
    - Enters the trapezius approx. 5 cm above the clavicle

  • C1 gives fibers to join hypo to form superior root of ansa
    Fibers from c2 and c3 inferior root of ansa
  • Formed by union od anterior rami of 2,3,4 cevrical nerves .
    C1 gives fibers to join hypo to form superior root of ansa
    Fibers from c2 and c3 inferior root of ansa
    Cutaneous branches derived from simple loop of 2,3,4
    Lesser occipital- skin over side of neck behind ear
    GAN- skin over parotid,almost all auricle, skin over mastoid
    TC-turns around scm moves forvrds divdes in ascending descing branches supply skin of ant.portion of neck
    SCN- divides in 3 sets- anterior,middle,lateral
  • Occipital artery emrges under cover of splinus capitus muscle and pentrate trapizius muscles
  • Emerges thr anterior and middle scalene muscle