Neck dissections

History Of CANCER Anatomy of HEAD & NECK LYMPH NODE levels Staging of CANCER NECK DISSECTIONS COMPLICATIONS

1880 Kocher advocates wide margin lymphadenectomy

1881 Kocher and Packard recommend dissection of submandibular triangle for lingual cancer

1885 Butlin questions RND for oral N0 disease

1888 Jawdynski describes en bloc resection with resection of

carotid, IJV, SCM.

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

1901 Solis-Cohen advocate lymphadenectomy for N0 laryngeal CA

1905 -1906 Crile describes en bloc resection in JAMA

1926 Bartlett and Callander advocate preservation of XI, IJV, SCM, platysma, stylohyoid, digastric

1933 Blair and Brown advocate removal of XI.

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

1951 Martin advocates Radical Neck Dissection after analysis of 1450 cases› Advocated RND for N+ cases.

1952 – Suarez describes a functional neck dissection› Preservation of SCM, omohyoid, submandibular gland, IJV, XI.› Enables protection of carotid.

1960’s – MD Anderson advocate selective ND of highest risk nodal basins

1967 - Bocca and Pignataro describe the “functional neck dissection”

1975 – Bocca establishes oncologic safety of the FND compared to the RND

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

The region of the The region of the body that lies body that lies between:between: The The LOWER LOWER

BORDER OF THE BORDER OF THE

MANDIBLEMANDIBLE&& The The SUPRASTERNAL SUPRASTERNAL

NOTCH NOTCH and the and the UPPER BORDER OF UPPER BORDER OF CLAVICLE.CLAVICLE.

• 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

Ext. jugularInt. jugular

Ant. jugular

Sup. thyroid

Middle thyroid

Inf. thyroid

• Origin – fascia overlying the pectoralis major and deltoid muscle• Insertion – 1) depression muscles of the corner of the mouth, 2) the mandible, and 3) the SMAS layer of the face• Function – 1) wrinkles the the neck2) depresses the corner of the mouth3) increases the diameter of the neck4) assists in venous return

platysma

Sternoclei-

domastoid

platysma

Surgical considerations – Increases blood supply to skin flaps – Absent in the midline of the neck – Fibers run in an opposite direction to the SCM

Prevertebral layerTrapezius

Investing layer

Pretracheal layer

Buccopharyngeal fascia

Carotid sheath

esophagus

s.c.m

scalenus

tracheathyroid

Infrahyoid m.

Internal jugular vein

Common carotid a.

Vagus n.

pretracheal fascia

• 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 ECA2) superior thyroid a.3) transverse cervical a.

Sternocleidomastoid

Function – turns head toward opposite side and tilts head toward the ipsilateral shoulder • Surgical considerations– Leave overlying fascia (superficial layer of deep

cervical fascia down)– Lateral retraction exposes the submuscular recess

• Origin – upper border of the scapula• Insertion – 1) via the intermediate tendon onto the clavicle

and first rib 2) hyoid bone lateral to the sternohyoid muscle • Blood supply – Inferior thyroid a. • Function – 1) depress the hyoid2) tense the deep cervical fascia

Surgical considerations – Absent in 10% of individuals – 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

• Origin – 1) medial 1/3 of the sup. Nuchal line2) external occipital protuberance3) ligamentum nuchae4) spinous process of C7 and T1-T12 • Insertion –1) lateral 1/3 of the clavicle2) acromion process3) spine of the scapula • Function – elevate and rotate the scapula andstabilize the shoulder

Surgical considerations – Posterior limit of Level V neck dissection – Denervation results in shoulder drop and

winged scapula

• Origin – digastric fossa of the mandible (at the symphyseal border

• Insertion – 1) hyoid bone via the intermediate tendon2) mastoid process• Function – 1) elevate the hyoid bone2) depress the mandible (assists lateral pterygoid)

– Posterior belly is superficial to:• ECA• Hypoglossal nerve• ICA• IJV – Anterior belly• Landmark for identification of mylohyoid for

dissection of the submandibular triangle

Division of the neckAnterior triangle

Suprahyoid region: submental triangle

submandibular triangle

Infrahyoid region: muscular triangle

carotid trianglePosterior triangle

Submental triangle Lies below the chin and is

bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone

Covered by skin, superficial fascia and investing fascia

Floor － mylohyoid muscles

Contents － submental lymph nodes

digastric (anterior and posterior belly)

stylohyoid

mylohyoid

Suprahyoid muscles

Submandibular triangle Bounded by anterior and posterior bellies of

digastric and lower border of the body of the mandible

Covered by skin, superficial fascia, platysma and investing fascia

Floor － mylohyoid, hyoglossus and middle constrictor of pharynx

Contents － submandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes

Carotid triangle sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles

Covered by skin, superficial fascia, platysma and investing fascia

Floor － prevertebral fascia and lateral wall of pharynx

Contents － common carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes

Muscular triangle Bounded by midline of the

neck, superior belly of the omohyoid and anterior border of the sternocleidomastoid.

Covered by skin, superficial fascia, platysma, anterior jugular v., coutaneous n. and investing fascia

Floor － prevertebral fascia Contents － sternohyoid,

sternothyroid, thyrohyoid, thyroid gland, parathyroid gland, cervical part of trachea and esophagus

Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and middle third of clavicle

Divided by inferior belly of omohyoid into occipital and supraclavicular triangles

Arteries: Arteries: SubclavianSubclavian (3 (3rdrd part) part) Superficial cervical Superficial cervical

& suprascapular & suprascapular (branches of (branches of thyrocervical trunkthyrocervical trunk, , a branch of a branch of 11stst part part of subclavian arteryof subclavian artery

OccipitalOccipital, a , a branch branch of external carotid of external carotid arteryartery

Nerves:Nerves: Branches of Branches of

cervical cervical plexusplexus

Spinal part of Spinal part of accessory accessory nervenerve

Brachial Brachial plexusplexus

Occipital triangle Bounded by posterior

border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid

Covered by skin, superficial fascia, and investing fascia

Floor － prevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae

Contents

› Accessory n. － emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius

› Cervical and brachial PLEXUS

Supraclavicular triangle Bounded by posterior

border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle

Covered by skin, superficial fascia, and investing fascia

Floor － prevertebral fascia and inferior parts of scalenus

Contents› Subclavian v. and

venous angle › Subclavian a.› Brachial plexus

Most commonly injury dissection level Ib

Landmarks:› 1cm anterior and inferior

to angle of mandible› Mandibular notch

Subplatysmal Deep to fascia of the

submandibular gland Superficial to facial vein

Motor nerve to the tongue

• Cell bodies are in the Hypoglossal nucleus of the

Medulla oblongata • Exits the skull via

the hypoglossal canal • Lies deep to the IJV,

ICA, CN IX, X, and XI

• Curves 90 degrees and passes between the IJV and ICA

– Surrounded by venous plexus • Extends upward along hyoglossus muscle and

into the genioglossus to the tip of the tongue. Iatrogenic injury – Most common site - floor of the submandibular

triangle, just deep to the duct

Penetrates deep surface of the SCM

Exits posterior surface of SCM deep to Erb’s point

Traverses the posterior triangle on the levator scapulae

Enters the trapezius about 5 cm above the clavicle

Ansa cervicalis

Hypoglossal n. (XII)

Accessory n. (XI)

Phrenic n.

Vagus n. (X)

CN XI – Relationship with the IJV

Crosses the IJV • Crosses lateral to the transverse process of the atlas • Occipital artery crosses the nerve • Descends obliquely in level II (forms Level IIa

and IIb

Developed by Memorial Sloan-Kettering Cancer Center

Ease and uniformity in describing regional nodal involvement in cancer of the head and neck

LYMPH NODES acts as a barrier to the spread of the disease .

Virchow in 1860

CAN BE DIVIDED INTO; a) SUPERFICIAL CHAIN OF LYMPH NODES….. b) VERTICAL DEEP CHAIN OF LYMPH NODES This consists of nodes lying in relation to

carotid sheath.These lie along the vessels,trachea,oesophagusand extend from base of skull to root of neck.

1. Submental

2. Submandibular

3. Parotid / tonsilar

4. Preauricular

5. Postauricular

6. Occipital

7. Anterior cervical superficial and deep

8. Supraclavicular

9. Posterior cervical

Ia Submental Ib Submandibular

IIa Upper jugular (Anterior to XI) IIb Upper jugular (Posterior to XI)

III Middle jugular

IVa Lower jugular (Clavicular) IVb Lower jugular (Sternal)

Va Posterior triangle (XI) Vb Posterior triangle (Transverse

cervical)

VI Central compartment

Submental triangle (Ia)› Anterior digastric› Hyoid› Mylohyoid

Submandibular triangle (Ib)› Anterior and

posterior digastric› Mandible.

Ia› Chin› Lower lip› Anterior floor of mouth› Mandibular incisors› Tip of tongue

Ib› Oral Cavity› Floor of mouth› Oral tongue› Nasal cavity (anterior)› Face

Upper Jugular Nodes Anterior Lateral border

of sternohyoid, posterior digastric and stylohyoid

Posterior Posterior border of SCM

Skull base Hyoid bone Carotid bifurcation

Level IIa anterior to XI Level IIb posterior to XI

Oral Cavity Nasal Cavity Nasopharynx Oropharynx Larynx Hypopharynx Parotid

Middle jugular nodes› Anterior Lateral border

of sternohyoid› Posterior Posterior

border of SCM › Inferior border of level II› Cricoid cartilage lower

border

Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx

Lower jugular nodes › Anterior Lateral

border of sternohyoid› Posterior Posterior

border of SCM› Cricoid cartilage lower

border › Omohyoid muscle › Clavicle

Hypopharynx Larynx Thyroid Cervical esophagus

Posterior triangle of neck › Posterior border of SCM› Clavicle› Anterior border of

trapezius› Va Spinal accessory

nodes› Vb Transverse cervical

artery nodes› Supraclavicular nodes

Nasopharynx Oropharynx Posterior neck and scalp

Anterior compartment› Hyoid› Suprasternal notch› Medial border of carotid

sheath› Perithyroidal lymph

nodes› Paratracheal lymph

nodes› Precricoid (Delphian)

lymph node

Thyroid Larynx (glottic and subglottic) Pyriform sinus apex Cervical esophagus

Face and Scalp Anterior Facial, Ib

  Lateral Parotid

  Posterior Occipital, V

Eyelids Medial Ib

  Lateral Parotid, II

Chin   Ia, Ib, II

External Ear Anterior Parotid, II

  Posterior Post auricular, II, V

Middle Ear   Parotid, II

Floor of mouth Anterior Ia, Ib, IIa > IIb

  Lower incisors Ia, Ib, IIa > IIb

  Lateral Ib, IIa > IIb, III

  Teeth except incisors Ib, IIa > IIb, III

Nasal Cavity Anterior Ib

  Posterior Retropharyngeal, II, V

Nasal Cavity Posterior Retropharyngeal, II, V

Nasopharynx   Retropharyngeal, II, III, V

Oropharynx   IIb > IIa, III, IV, V

Larynx Supraglottic IIa > IIb, III, IV

  Subglottic VI, IV

Cervical esophagus   IV, VI

Thyroid   VI, IV, V, Mediastinal

Tongue Tip Ia, Ib, IIa > IIb, III, IV

  Lateral Ib, IIa > IIb, III, IV

• “N” classification – AJCC (1997) • Consistent for all mucosal sites except the nasopharynx • Thyroid and nasopharynx have different

staging based on tumor behavior and prognosis • Based on extent of disease prior to first

treatment

Nx: Regional lymph nodes cannot be assessed.

N0: No regional lymph node metastases.

N1: Single ipsilateral lymph node, < 3 cm

N2a: Single ipsilateral lymph node 3 to 6 cm

N2b: Multiple ipsilateral lymph nodes > 6 cm

N2c: Bilateral or contralateral nodes > 6cm

N3: Metastases > 6 cm

• Standardized until 1991 • Academy’s Committee for Head and

Neck Surgery and Oncology publicized standard classification system

Academy’s classification – Based on 4 concepts• 1) RND is the standard basic procedure for

cervical lymphadenectomy against which all other modifications are compared

• 2) Modifications of the RND which include preservation of any non-lymphatic structures are referred to as modified radical neck dissection

(MRND)

Academy’s classification

• 3) Any neck dissection that preserves one or more groups or levels of lymph nodes is referred to as a selective neck dissection (SND)

• 4) An extended neck dissection refers to the removal of additional lymph node groups or non-lymphatic structures relative to the RND

Academy’s classification(1991)– 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

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

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

1. Presence of clinically positive N1, N2a, N2b & N3 nodes

Treatment of No neck is still a controversy.

2. Extra nodal spread (including skin involvement)

3. Recurrence after RT treatment

1. Uncontrolled primary lesion 2. Involvement of internal / common

carotid artery 3. Presence of distant metastasis. 4. Poor anaesthetic risk patient.

TYPES - Apron incision -Half apron incision -Conley incision -Double Y incision -H incision -Macfee incision - Y incision -Modified Schobinger incision -Schobinger

  1.Good exposure of the neck and

primary disease. 2. Ensure viability of the skin flaps.

Avoid acute angles 3. Protect carotid artery even in the

cases of wound infection.

4. Facilitate reconstruction Example, if pectoral muscle is used a lower limb should be near the clavicle to enable flap accommodation.

5. It should be cosmetically acceptable.

Removes › Nodal groups I-V› SCM, IJV, XI› Submandibular gland,

tail of parotid Preserves

› Posterior auricular› Suboccipital› Retropharyngeal› Periparotid› Perifacial› Paratracheal nodes

Removes› Nodal groups I-V

Preserves› SCM, IJV, XI (any

combination)

› TYPE A MRND

Three types (Medina 1989) commonly referred to not specifically named by committee.

• Type I: Preservation of SAN• Type II: Preservation of SAN and IJV• Type III: Preservation of SAN, IJV, and SCM

( “Functional neck dissection”)

• Indications – Clinically obvious lymph node metastases– SAN not involved by tumor–Intraoperative decision

• Indications

– Rarely planned– Intraoperative tumor found adherent to

the SCM, but not IJV and SAN

• Rationale– Suarez (1963) – necropsy and surgery specimens

of larynx and hypopharynx – lymph nodes do not share the same adventitia as adjacent BV’s

– Nodes not within muscular aponeurosis or glandular capsule (submandibular gland)

– Sharpe (1981) showed ) 0% involvement of the SCM in 98 RND specimens despite 73 have nodal metastases

– Survival approximates MRND Type I assuming IJV, and SCM not involved

Widely accepted in Europe• Neck dissection of choice for N0 neck

Rationale– Reduce postsurgical shoulder pain and

shoulder dysfunction– Improve cosmetic outcome– Reduce likelihood of bilateral IJV

resection - Contralateral neck involvement

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

Also known as an elective neck dissection• Rate of occult metastasis in clinically negative

neck 20-30%• Indication: primary lesion with 20% or greater risk

of occult metastasis• Studies by Fisch and Sigel (1964) demonstrated

predictable routes of lymphatic spread from mucosal surfaces of the H&N

• Need for post-op RT

• 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

Indications– Oral cavity carcinoma with N0 neck • Boundaries – Vermillion border of lips to

junction of hard and soft palate, circumvallate papillae

• Subsites - Lips, buccal mucosa, upper and lower

alveolar ridges, retromolar trigone, hard palate, and anterior 2/3s of the tongue and FOM

– Medina recommends SOHND with T2-T4 NO or TX N1 (palpable node is <3cm, mobile, and in levels I or II)

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 4mm) of the cheek• Byers does not advocate elective neck dissection

for buccal carcinoma – Adjuvant RT given to patients with > 2- 4

positive nodes +/- ECS.

• 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

• 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

• Definition – En bloc removal of lymph structures in

Level VI • Perithyroidal nodes • Pretracheal nodes • Precricoid nodes (Delphian) • Paratracheal nodes along recurrent

nerves – Limits of the dissection are the hyoid

bone, suprasternal notch and carotid sheaths

Indications – Selected cases of thyroid carcinoma – Parathyroid carcinoma – Subglottic carcinoma – Laryngeal carcinoma with subglottic

extension – CA of the cervical esophagus

• 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, and

• removal of retropharyngeal lymph nodes for tumors originating in the pharyngeal walls.

SUPERSELECTIVE NECK DISSECTION OF HEAD AND NECK cancer –

Yet to come

4 TYPES - INTRA OP - IMMEDIATE POST OP - LATE POST OP - DELAYED COMPLICATIONS

Inadequate planning Inadvertent injury to local blood

vessels and nerves . -marginal mandibular N. - Spinal accessory N. - Cervical plexus - Brachial plexus - Thoracic duct injury .

Haemorrhage: Needs evaluation of the extent of bleeding and occasionally may need re-exploration.

Lymph leak: When the drainage is of milky fluid and is persistently high >100ml /day after 2days.A possibility of lymph leak has to be considered.

Carotid blow out: A dreaded complication that occurs secondary to wound break down. If exposed the carotids have to be covered using vascularised flaps.

Facial oedema: A common occurrence usually settles down in 4-6 weeks.

Wound infection Fistulae Devitalisation of the reconstructed flap

Dysphagia ( CN V,IX, X, XI) Shoulder weakness Trismus

Pectoralis major myocutaneous flap Free fibula flap Deltoid muscle flap Forehead flap Cervical flap Radial forearm flap

• Cervical metastasis in SCCA of the upper aerodigestive tract continues to portend a poor prognosis

• Staging will help determine what type neck dissection should be performed

• Unified classification of neck nodal levels and classification of neck dissection has to understood well.

• Indications for neck dissection and type of neck dissection, especially in the N0 neck, is a still controversial

THANK YOU HAVE A NICE DAY