Radical Neck Dissection

Overview Metastatic neck disease is most important factor in spread

of H & N squamous cell ca. from primary site Rate of ipsilateral metastatic disease in patients with T3-T4

sq. cell ca. of upper aerodigestive tract is ~ 50% Lymph node metastasis reduces survival rate by half Radical neck dissection is performed for surgical control of

metastatic neck disease in:◦ sq. cell ca. of upper aerodigestive tract (oral cavity /

nasopharynx / oropharynx / hypopharynx / supraglottis)◦ salivary gland tumors◦ skin cancer of H & N◦ thyroid cancer

Classification of Neck DissectionRadical neck dissection

Modified radical neck dissection

Selective neck dissection

Extended radical neck dissection

Lymph nodes of the Neck Lymph nodes lie in the fibro-adipose tissue between

the investing (superficial) layer of deep fascia and visceral and prevertebral layers underneath.

The nodes tend to aggregate around certain neural and vascular structures, e.g. IJV, SAN.

Level I Boundaries:

body of mandible stylohyoid muscle anterior belly of digastric muscle (contralateral)

Ia: Submental triangle

Drainage: floor of mouth, anterior tongue, anterior mandibular alveolar ridge, lower lip

Ib: Submandibluar triangle

Drainage: oral cavity, anterior nasal cavity, soft tissue structures of midface, submandibular gland

Also: perifacial and buccinator nodes

Level II Boundaries:

◦ upper third of IJV◦ skull base to inferior border of hyoid bone◦ posterior border of SCM◦ stylohyoid muscle

IIa◦ antero-inferior to SAN

IIb◦ postero-superior to SAN

Drainage: oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, parotid gland

Level III Boundaries:

◦ middle third of IJV◦ hyoid◦ inferior border of cricoid◦ sternohyoid muscle◦ posterior border of SCM

Drainage: Oral cavity, nasopharynx, oropharynx, hypopharynx, larynx

Level IV Boundaries:

◦ lower third of IJV◦ inferior border of cricoid◦ clavicle◦ sternohyoid muscle◦ posterior border of SCM

Drainage: larynx, hypopharynx, thyroid, cervical esophagus

Level V Boundaries:

posterior triangle of neck posterior border of SCM anterior border of trapezius clavicle

Va: above (superior to) inferior border of cricoid nodes associated with SAN

Vb: below (inferior to) inferior border of cricoid transverse cervical and supraclavicular nodes

Drainage: nasopharynx, oropharynx, skin of posterior scalp & neck

Level VI Boundaries:

◦ anterior (central) compartment of neck◦ carotid arteries◦ hyoid bone◦ suprasternal notch

Drainage: thyroid gland, subglottic larynx, cervical trachea, hypopharynx, cervical esophagus

Includes:◦ paratracheal nodes (in tracheo-esophageal groove)◦ pretracheal nodes (in front of trachea)◦ parathyroid nodes (around thyroid gland)◦ precricoid node (on cricothyroid membrane)

Nodal Classification< 3 cm 3 – 6 cm > 6 cm

Single node N1 N2a N3

Multiple ipsilateral nodes

N2b N2b N3

Bilateral / Contralateral node(s)

N2c N2c N3

Indications of RND N2b, N2c, N3 disease

N1 / N2a with involvement of SAN or IJV

Clinical evidence and/or imaging studies showing evidence of extranodal disease

Nodal disease with involvement of platysma and/or skin (will require flap reconstruction)

Recurrent or persistent neck disease after previous conservative neck dissection / irradiation / chemotherapy

Contra-indications of RND Poorly prepared patient (e.g. cardiopulmonary disease)

Pre-operative imaging suggests deep infiltration of tumor (prevertebral space, scalene muscles, levator scapula muscle, phrenic nerve, and brachial plexus)

Primary tumor that cannot be controlled

N0 neck

Distant metastatic disease

Fixed neck mass in deep cervical fascia and/or skull base involvement

Circumferential or near-circumferential involvement and invasion of carotid vessels if patient cannot tolerate a balloon occlusion test

Workup - 1 Palpation:

◦ Sensitivity & specificity is 60 – 70 %◦ Difficult if:

short, obese neck previous radiation to neck previous surgery of neck

Workup - 2 Blood tests:

◦ CBC◦ PT, APTT, INR◦ Electrolytes◦ Evaluation of SIADH◦ LFTs◦ BSR◦ BUN, creatinine◦ Blood type, screen, cross-match◦ Urinalysis

Workup - 3 Imaging:

◦ CT reveals metastatic adenopathy by central necrosis and extracapsular spread by enhancement of nodal capsule

◦ MRI is less precise◦ CT/MRI cannot assess lymph nodes < 1 cm in size◦ USG-guided aspiration cytology has higher specificity◦ PET scan has highest sensitivity & specificity and

precision (5 mm)

If possibility of tumor involvement of carotid artery, then complete pre-operative evaluation of carotid system:◦ balloon occlusion test◦ 4-vessel cerebral angiography

CXR

ECG as indicated

Workup - 4 Mirror laryngoscopy, flexible nasopharyngolaryngoscopy

If primary lesion is known:◦ biopsy of primary lesion◦ Panendoscopy to exclude second primary tumor

If primary lesion not known:◦ panendoscopy to look for primary tumor◦ random biopsies of pyriform sinus, base of tongue, and

nasopharynx◦ ipsilateral tonsillectomy (controversial)

FNAC of neck mass

Sentinel lymph node biopsy: in research stage

Associated Surgeries Laryngectomy

Composite resection

Glossectomy

Tracheotomy

Dermal graft

Intra-operative Details - 1 Supine position, shoulder roll, extended neck Upper end of table elevated at 300

Several possible incisions, .e.g. hockey stick incision◦ Designed to avoid trifurcation over carotid artery and to

avoid narrow flaps

Intra-operative Details - 2 Make incision through platysma and elevate flap in sub-

platysmal plane. After raising superior lateral aspect of flap, leave the greater auricular nerve and external jugular vein on SCM. Elevate the posterior flap toward trapezius

Intra-operative Details - 3 Identify and preserve marginal mandibular nerve at superior

aspect of flap (it is deep to platysma, 2 cm below margin of mandible, within fascia of submandibular gland)

Remove submental fatty tissue with Bovie electrocautery and displace it inferiorly

Retract mylohyoid anteriorly, exposing submandibular ganglion, lingual nerve, and submandibular duct

Ligate facial artery above digastric muscle Cut and ligate submandibular duct Remove submandibular nodes and submandibular duct and

displace them inferiorly

Continue dissection posteriorly, exposing posterior belly of digastric and stylohyoid muscles and transect tail of parotid gland

Intra-operative Details - 4 Expose SCM and incise it above clavicle with Bovie

electrocautery

Intra-operative Details - 5 Identify anterior and posterior belly of omohyoid with

transection of omohyoid posteriorly. Note that the omohyoid crosses the IJV laterally.

Intra-operative Details - 6 Identify IJV and vagus nerve in lower aspect of neck before

ligation of IJV. Pass 2-0 silk suture around the vein and tie it as depicted.

Intra-operative Details – 7 Place a distal suture ligature with 2-0 silk while the vein is

still intact. Place 2 similar sutures cephalic and transect the vein as seen.

Intra-operative Details – 8 Further identify carotid artery and vagus nerve. Open

supraclavicular fatty tissue using blunt dissection, either with a finger or hemostat, with identification of phrenic nerve and brachial plexus

Intra-operative Details – 9 SAN is sacrificed in RND, so no identification is required Continue dissection along anterior border of trapezius.

Preserve phrenic nerve and brachial plexus Follow cervical nerve branches and section them high on

specimen Separate specimen from carotid & vagus, proceeding

superiorly, with identification of hypoglossal nerve Preserve superior thyroid artery and superior laryngeal

nerve and carefully ligate the ranine veins Cut SCM superiorly (just lateral to posterior belly of

digastric) in the same manner as described before

Intra-operative Details – 10 Identify IJV superiorly (medial to posterior belly of digastric);

dissect and ligate as described before

Intra-operative Details – 11 Final aspect of surgical wound after removal of specimen:

Intra-operative Details – 12 Anatomical structures to be sacrificed:

◦ Internal jugular vein◦ Spinal accessory nerve◦ Sternocleidomastoid muscle◦ Cutaneous branches of the cervical plexus◦ Submandibular gland and Wharton duct◦ Tail of the parotid gland◦ Greater auricular nerve◦ External jugular vein◦ Posterior facial vein◦ Facial artery◦ Omohyoid muscle

Intra-operative Details – 13 Anatomical structures to be preserved (if possible):

◦ Marginal mandibular nerve◦ Digastric muscle with both bellies and tendon◦ Lingual nerve and submandibular ganglion◦ Superior laryngeal nerve◦ Superior thyroid artery◦ Hypoglossal nerve◦ Vagus nerve◦ Carotid vessels◦ Phrenic nerve◦ Brachial plexus◦ Thoracic duct

Intra-operative Details – 14 Irrigate with normal saline Maintain hemostasis Insert drains Compression dressing

Immediate Post-op Guidelines NPO for 24 hours Head elevation at 300

Monitor vital signs, intake, and output every 4 hours Care of tracheostomy tube (humidification, suctioning, cleansing) Pain medication as needed Ensure that the drains:

◦ are functioning properly◦ are maintained on continuous suction until they drain < 20-25

ml per 24 hours◦ do not clot

Antibiotics for first 24 hours if upper aerodigestive tract was opened

Monitor for fever, bleeding, and hematoma formation Avoid atelectasis Monitor for possible fistula if upper aerodigestive tract was

opened, esp. on 3rd or 4th post-op day

Discharge Criteria Once suction and drains have been removed, patient can be

discharged (usually 4th or 5th post-op day), if:◦ satisfactory healing of surgical wound◦ no evidence of bleeding or infection◦ adequate airway◦ adequate nutrition◦ hemodynamic stability◦ adequate family or home care support◦ initiation of shoulder therapy to shoulder joint before

discharge and continuation at home

Follow-up Follow-up in 7 – 10 days Check pathology report Check status of neck Remove sutures Continue with shoulder physical therapy

Further follow-up monthly for first year, then every 2-4 months for five years – to rule out recurrent tumor or second primary tumor

Complications - 1 Intra-operative:

Hemorrhage Carotid sinus reflex Pneumothorax Air embolus Embolus Nerve damage:

Sensation in neck Marginal mandibular nerve Cervical sympathetic chain Spinal accessory nerve (SAN) Hypoglossal nerve Vagus nerve Brachial plexus

Poor wound healing after radiation Chylous fistula

Complications - 2 Post-operative:

◦ Hematoma◦ Wound infection◦ Skin flap loss◦ Salivary fistula◦ Chylous fistula◦ Facial edema◦ Electrolyte disturbances (hyponatremia)◦ Carotid artery rupture