7. neck dissection(87) dr. rahul tiwari

PRESENTED BY Dr RAHUL TIWARI

2nd Yr. MDSDept. of Oral and Maxillofacial Surgery

NECK DISSECTION

05/02/23 12:14 AM RT/7/NECK DISSECTION/87 1

Contents • Introduction• What is neck dissection ?• Cervical lymphatic – its drainage• The rationale of neck dissection• Studies on patterns of cervical lymphatic drainage• Levels of lymph nodes, sublevels - their

implications• Clinical assessment and staging • History of neck dissection• Classification• Surgical anatomy• Types of incisions and procedures• Complications• Future 05/02/23 12:14 AM RT/7/NECK DISSECTION/87 2

Introduction

• Surgery is the oldest and the most reliable form of treatment for oral malignancy.

• what is the need for the neck to be treated in oral malignancy ????


What is neck dissection?

• The term "neck dissection" refers to the removal of lymphnodes and lymphnode bearing tissues of neck from the inferior border of the mandible to the clavicle ,as a treatment of head and neck malignancy


How does tumor spread ?• Spread of disease of oral cavity to neck

-- palpable lymphadenopathy.

• Systemic homogenous spread rarely occurs in the lymphatics of the neck.

• early eradication of local and regional disease can prevent future systemic metastasis.


Division of neck levels by sublevels

•


The regional lymph node groups draining a specific primary site as

first echelon lymph nodes


Cervical lymphatics


Risk for nodal metastasis

• Various factors– Site– Size– T stage– Location of primary tumour– Histomorphologic characteristics of

primary tumor


Risk of nodal metastases increases in relation to location of the primary

tumor


Work-up and staging

TNM ( TUMOR –NODE – METASTASIS) SYSTEM


TNM STAGING • First reported by Pierre Denoix in the 1940s.

• The International Union against cancer (UICC) and AJCC eventually adapted the system

• It is important to realize that the TNM staging system is simply an anatomic staging system

• TNM Staging describes tumor burden in only two dimensions


A study of correlation of tumor thickness with risk of occult nodal

metastasis –Spiro et al*

*Spiro RH,Huvos AG, Wong GY ,Spiro JD, Strong EW .Predictive value of tumor thickness in SCC confined to the tongue and floor of the mouth Am J Surg 1986; 152: 345-35005/02/23 12:14 AM RT/7/NECK DISSECTION/87 13

T staging for tumors of the lip and oral cavity – AJCC 2002

• TX – Primary tumor cannot be assessed• T0 – No evidence of primary tumor• Tis – carcinoma in situ• T1 – Tumor 2 cm or less in greatest dimension• T2 – Tumor >2cm but not >4cm in greatest dimension• T3 – Tumor >4cm in greatest dimension• T4a

– Lip – Tumor invades through cortical bone, inferior alveolar nerve, floor of the mouth, or skin of face (i.e, chin or nose).

– Oral – Tumor invades through cortical bone, into deep (extrinsic)– Cavity – Muscle of tongue (genioglossus, hyoglossu,

palatoglossus, and styloglossus), maxillary sinus, or skin of face.• T4b – Tumor involves masticator space, pterygoid plates,

or skull base and/or encases internal carotid artery.


AJCC/UICC (2002) Staging system for cervical lymph nodes

NX – cannot be assessed, N3a – greater than 6cm , N3b-extn into supraclavicular fossa


Stage grouping for all head and neck sites except the nasopharynx and

thyroid AJCC (2002)

AJCC cancer staging manual, 6th Edition, 2002.05/02/23 12:14 AM RT/7/NECK DISSECTION/87 16

Patterns of cervical lymphatic metastasis

• lymphatic flow in the neck - consistent pattern - upper neck and then to the lower neck.

• This orderly lymphatic flow has been demonstrated by the work of Fisch and Sigel*

*Cervical lymphatic system as visualized by lymphography Annals of Otology,

Rhinology and Laryngology 73: 869-872.


History of neck dissections


Dr George Crile (1864-1943)

In 1906 paper

“Exicision of cancer of the head and neck ”

Gold standard procedure :

“Radical Neck dissection”05/02/23 12:14 AM RT/7/NECK DISSECTION/87 19

Dr. Hayes Martin (1892-1977)

In 1951 paper

“Neck Dissection”

“Routine prophylactic RND was impracticle”


Historical perspective on neck dissection

• RND should not be used for N0 neck, a philosophy that is largely observed in 2006.

• Nahum et al described a syndrome of pain following RND – “Shoulder Syndrome”*.*Nahum AM, Mullally W, Marmor L : A Syndrome resulting from

radical neck dissection. Arch otolaryngol 74 : 82,1961


Historical perspective on neck dissection

• 1880 – Kocher –proposed removal of nodal metastasis• 1906 – George crile –RND• 1933 & 1941 – Blair and Martin popularised RND• 1953 – Pietrantoni - recommended sparing SND• 1967-- Bocca and Pignataro described FND• 1975- Bocca established oncologic safety compared to

RND• 1980- Ballantyne –concept of selective neck dissection


Classifications of neck dissections


Concepts behind classification of neck dissection

• Based on 4 concepts– RND is the standard basic procedure - against

which all other modifications are compared

- preservation of any non - lymphatic structures are referred as MRND

- that preserves one or more groups or levels of LN`s is referred to as a SND

- removal of additional LN groups or non lymphatic structures relative to the RND – Extended neck dissection


1. Radical neck dissection (RND)2. Modified radical neck dissection

(MRND)3. Selective neck dissection (SND)

• Supraomohyoid type• Lateral type• Posterolateral type• Anterior compartment type

4. Extended radical neck dissection

Academy's classification


MEDINA CLASSIFICATION(1989)• Comprehensive neck dissection

1. Radical neck dissection (RND)2. Modified radical neck dissection (MRND)

• MRND I – Preserves spinal accessory nerve.• MRND II – Spinal accessory and sternocleidomastoid

muscle but sacrifices internal jugular vein.• MRND III – Requires preservation of SAN,

sternocleidomastoid muscle and internal jugular vein• Selective neck dissection (SND)

• Supraomohyoid neck dissection – I, II, III• Jugular neck dissection – II, III, IV• Anterior triangle neck dissection – I, II, III, IV• Central compartment neck dissection – VI• Posterolateral neck dissection – II, III, IV


Spiro’s classification

– Radical (4 or 5 nodes levels resected)• Conventional RND• MRND• Extended RND

– Selective (3 node levels resected)• SOHND• Jugular dissection (level II-IV)• Any other 3 levels

– Limited (no more than 2 node levels resected)• Para tracheal node dissection• Mediastinal node dissection• Any other 1 or 2 node levels resected


AAO-HNS CLASSIFICATION*1991 Classification 2001

Classification

* Neck dissection classification update-Revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery.


Rationale of RND• Understanding the anatomy of lymphatics of head

and neck and why we remove them • Understanging the concepts of lymphnode

metastasis• Understanding the concepts of neck incisions• Why we remove IJV ?• Why we Remove the submandibular gland ?• Why we remove the sternocleidomastoid muscle?• Why we remove the spinal accessory nerve and

when do we save it ? • The concept behind the ligation of carotid artery

and internal jugular vein05/02/23 12:14 AM RT/7/NECK DISSECTION/87 29

Surgical Anatomy


Radical neck dissection predominantly from behind forward makes use of the anatomical

fact that the IJV does not have posterior branches


The main arteries of the neck and face


Incisions


Anatomy of the vascularization of neck skin

• Kambic and Sirca 1967 stated that arterial supply is in a vertical direction.

• descending branches: facial and occipital artery

• ascending branches: transverse cervical and supraclavicular arterial branches .


Studies on the anatomy of the vascularization of neck skin

• Robertson et al 1985 “Arterial supply of the skin of the neck is

multifaceted ”

• four arterial branches pass from the platysma muscle through to the top of the skin’s surface.

• platysma cutaneous arteries supplying skin are in anastomosis with each other.


Studies on the anatomy of the vascularization of neck skin

• Ariyan 1986 - anastomosis remain intact during neck dissection while the platysma is dissected from the skin.

• Hetter 1972, Freeland and Rogers 1975 alternative development of arterial supply even if facial, occipital and transverse cervical are ligated.


The vasculature can be summarized into• upper neck region - anterior to the angle

of mandible - branches of facial and submental arteries.

• upper lateral neck - the area between ramus of mandible and the sternocleidomastoid muscle-Occipital and external auricular branches of external carotid .

• Lower half of neck - The transverse cervical artery and suprascapular artery

• Large platysma-cutaneous branches and branches of superior thyroid supplying the front middle portion of the neck.05/02/23 12:14 AM RT/7/NECK DISSECTION/87 42

Incisions• Incisions classified into

– Vertical– Horizontal

• The incisions used for neck dissections are– Tri-radiate incision and its modification– Hayes martin double ‘Y’ incision– McFee incision


Incisions for neck dissections


Basic needs of an incision are

• Good exposure of the neck and primary disease

• Ensure viability of the skin flaps. Avoid acute angles

• Protect carotid artery even in the cases of wound infection

• Facilitate reconstruction• Adapt to the condition of patient esp

after radiotherapy• It should be cosmetically acceptable05/02/23 12:14 AM RT/7/NECK DISSECTION/87 45

Differences between incisions

Transverse incision Vertical incisionHave cosmetic advantage as they follow natural skin folds of the skin

Disadvantages because they intersect to the natural skin folds of the skin and the vascular supply of the neck

Recovery of scar tissue in these folds are rapid and successful

They tend to contract along their long axis – leads to deformity and restricted action.

Easy to modify


Tri-radiate incision and its modifications

• Advantages– Incision provides good

exposure to surgical site.

• Disadvantages– Flap necrosis is high

due to disruption of vasculature of skin flaps

– Occurrence of flap separation at the trifurcation site.


Modification of Tri-radiate incision

• Schobinger (1957)

• Cramer & Culf

(1969)

• Conley (1970)


Schobinger (1957)

‘vertical limb instead of being straight should be curved posteriorly ’


Conley (1970)

• Suggested a posteriorly curving vertical incision rather than a horizontal incision


Hayes Martin Incision

• It is a paired ‘Y’ incision.• Here the submandibular

component is met by a vertical limb which below becomes continuous with an inverted ‘Y’ in the suprascapular region.

• This flap most often gets cyanosed.

• Flap necrosis and carotid exposure is more in this type of incision.


McFee Incision• It avoids a vertical

limb.• Two horizontal

incisions are used one in submandibular region and other in the suprascapular region.


Advantages DisadvantagesExcellent cosmetic result (McFee 1960, McNeil 1978)

Exposure is not good (Hetter 1972)

There is no lessening of vascularity in the centre of the flap (Ariyan 1986)

It is not suitable for bilateral simultaneous neck dissection (Chandler and Ponzoli 1969)

There is no angle intersection in incision (McFee 1960)

Operating period is long (McFee 1960)

Post operative wound recovery is rapid (McFee)

Posterior triangle dissection is difficult (Maran et al 1989, White et al 1993)

Suitable in necks receiving radiotherapy and in peripheral vascular disease (Maran et al 1989)

Difficulty may arise while working under the bridge flap

Recovery of flap excellent due to wide bipedicled flaps (Stella & Brown 1970, Daniel & McFee 1987)

In short neck it might be difficult to distinguish between the front tip of the incision from that of the tracheostomy.


Apron flaps• Described by Latyschevsky

and Freund 1960. • Only a horizontal incision

from mastoid to mentum gently curving inferiorly upto upper border of the thyroid cartilage is used.

• Advantages– Carotid artery is well protected– Protects the descending arterial

recovery• Disadvantages

– It will damage the ascending arterial and venous recovery

– Venous congestion and oedema might develop at the bottom corner


Hockey stick incision• Lahey et al (1940)

described.• Modified for RND by

Eckert & Byars 1952.• It has a longitudinal

and transverse incision• B/L hockey stick

incision allows the deglovement of the whole neck.


Radical neck dissection


Radical neck dissection• Current indications for classical radical neck

dissection. – N3 disease– Multiple gross metastases involving multiple

levels. – Recurrent metastatic disease in a previously

irradiated neck. – Grossly apparent extranodal spread with

invasion of the spinal accessory nerve and /or internal jugular vein at the base of the skull

– Involvement of accessory chain lymph nodes by metastatic disease.


Operative steps in the functional neck dissection


Incision


Dissection of the posterior triangle begins at the anterior border of

trapezius


Dissection of the posterior triangle medially leads to exposure of brachial plexus, phrenic

nerve and cutaneous roots of the cervical plexus


Specimen reflected posteriorly and anterior flap elevated to expose the sternal head of

SCMM


Sternocleidomastoid muscle is detached from the sternum and clavicle and retracted cephalad to expose the carotid sheath


Internal jugular vein is ligated and divided after common carotid and vagus nerve is

exposed and retracted medially


Dissection proceeds cephalad along the carotid sheath up the skull base


The upper skin flap is now elevated preseving the mandibular branch of the facial nerve


Surgical field following RND


Two suction drains inserted


Contra indications for RND

• Uncontrollable cancer of the primary site

• Evidence of distant metastasis• Fixed nodes unchanged by

radiotherapy or chemotherapy• Life expectancy of less than 3 months


Supraomohyoid neck dissection


Indications for supraomohyoid neck dissection

• Cancers of oral cavity that are N0 clinically

• Discreet N1 lesions can also be treated


Jugular neck dissection


Posterolateral neck dissection


Extended radical neck dissection


Complications of RND

• Intra operative problems• Post operative problems

• Late complications


Intra-operative problems• Injury to prenic nerve• Injury to vagus nerve• Brachial plexus injury• Common carotid injury• Internal carotid injury• Hypoglossal nerve injury• Lingual nerve injury


Post operative problems

• Haemorrhage• Lymph leak• Dysphagia• Carotid blow out• Facial edema


Complications of ligating bilateral internal jugular vein

simultaneously


Late complications • Shoulder droop• Shoulder pain• Brachial neuralgia• Neuroma• Strictures


Five-year survival rates in patients undergoing classical radical neck

dissection and modified radical neck dissection preserving the spinal

accessory nerve


Indications for postoperative radiation therapy to the neck

1. Gross residual disease following neck dissection

2. Multiple positive lymph nodes in the neck3. Extracapsular extension by metastatic diseae4. Perivascular or perineural invasion by tumor5. Other ominous findings such as tumor emboli

in lymphatics, cranial nerve invasion, or extension of disease to the base of the skull.


Future of neck dissections

• Sentinel lymph node biopsy

• Endoscopic neck dissections


Sentinal lymph node biopsy


conclusion


Knowing the surgical anatomy is

very important

before starting any surgical procedure.

References• Charles W. Cummings, John M. Fredrickson, Lee A.

Harker, Charles J. Krause, David E. Schurller. Neck Dissection. Otolaryngology- Head and neck surgery. Vol. II, 2nd edition. 1993: 1649-1672.

• Ian A. McGregor, Frances M. McGregor. Neck dissection. Cancer of the face and mouth – Pathology and management for surgeons. Churchill Livingstone.1986: 282- 320.

• Ian T. Jackson. Inrtra oral tumour and cervical lymphadenectomy. Grabb & Smith’s Plastic Surgery. Sherrel J. Aston, Robert W. Beasley, Charles H. M. Thorne. 5th edition. Lippincott- Raven . 1997 : 439 –452.

• L. H. Sobin & Ch Wittekind. TNM Classification of malignant tumours. 5th edition. UICC, A John Wiley & Sons Inc. Publication. 1997.. Surg. 1999: 28 : 197 – 202.


• P. Hermanek, R. V. P. Hutter, L. H. Sobin & Ch

Wittekind. TNM atlas. Illustrated guide to the TNM / pTNM classification of malignant tumours. 4th edition. Springer. 1997.

• Aydin Acar, Gürsel Dursun, Ömer Aydin,Yücel Akbaş. J incision in neck dissections. The journal of Laryngology and otology. 1998: 112: 55 - 60.

• Susumu Omura, Hiroki Bukawa, Ryoichi Kawabe, Shinjiro Aoki, Kiyohide Fujita. Comparision between hockey stick and reverse hockey stick incision: gently curved single linear neck incisions for oral cancer. Int. J. Oral Maxillofac


THANK YOU


7. neck dissection(87) dr. rahul tiwari

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