Neck Dissection

Eric Meen Nov. 30 2009

Contents
Neck anatomy Levels of the neck Classification of neck dissection
Radical neck dissection Modified radical neck dissection Selective neck dissection Extended neck dissection

Staging Sequelae of neck dissection Complications of neck dissection

Levels of the neck

IA: Submental IB: Submandibular II: Upper jugular nodes III: Middle jugular nodes IV: Lower jugular nodes V: Posterior triangle VI: Central/anterior compartment

Boundaries
IA: submental
Superior
Symphysis

Inferior
Body of hyoid

Medial
Anterior belly of contralateral digastric

Lateral
Anterior belly of ipsilateral digastric

Boundaries
IA: submental Nodal spread from
Floor of mouth Anterior oral tongue Anterior lower alveolus Lower lip

Boundaries
IB: submandibular
Superior
Body of mandible

Inferior
Posterior belly of digastric

Anterior
Anterior belly of digastric

Posterior
Stylohyoid muscle

Boundaries
IB: submandibular Nodal spread from
Oral cavity Anterior nasal cavity Soft-tissue structures of midface and submandibular gland

Boundaries
II: upper jugular
Superior
Skull base

Inferior
Horizontal plane defined by the inferior body of the hyoid (clinical landmark) Carotid bifurcation (surgical landmark)

Anterior
Stylohoid muscle

Posterior
Posterior border of SCM

CN XI divides level into IIA and IIB

Boundaries
II: upper jugular Nodal spread from
Oral cavity Nasal cavity Nasopharynx Oropharynx Hypopharynx Larynx Parotid

Boundaries
III: middle jugular
Superior
Horizontal plane defined by inferior body of hyoid (clinical landmark) Carotid bifurcation (surgical landmark)

Inferior
Horizontal plane defined by inferior border of cricoid (clinical landmark) Junction of omohyoid and IJV (surgical landmark)

Anterior
Lateral border of sternohyoid

Posterior
Posterior border of SCM

Boundaries
III: middle jugular Nodal spread from
Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx

Boundaries
IV: lower jugular
Superior
Horizontal plane defined by inferior border of cricoid (clinical landmark) Junction of omohyoid and IJV (surgical landmark)

Inferior
Clavicle

Anterior
Lateral border of sternohyoid

Posterior
Posterior border of SCM

Boundaries
IV: lower jugular Nodal spread from
Hypopharynx Thyroid Cervical esophagus Larynx

Boundaries
V: posterior triangle
Superior
Apex of convergence of SCM and trapezius Clavicle Posterior border of SCM Anterior border of trapezius

Inferior

Anterior Posterior Horizontal plane defined by lower border of cricoid divides level into VA + VB Three lymphatic pathways
Nodes following XI as it traverses posterior triangle Nodes following transverse cervical artery Supraclavicular nodes (including Virchow s node)

Boundaries
V: posterior triangle Nodal spread from
Nasopharynx Oropharynx Cutaneous structures of posterior scalp and neck Thyroid Virchow
Any GI Breast

Boundaries
VI: central compartment
Superior
Hyoid bone

Inferior
Suprasternal notch

Medial
Contralateral carotid

Lateral
Ipsilateral carotid

Nodes involved
Pre and paratracheal Precricoid (Delphian) Perithyroidal

Boundaries
VI: central compartment Nodal spread from
Thyroid Glottic and subglottic larynx Apex of piriform sinus Cervical esophagus

Division into subzones

Recommended in 2001 by American Head and Neck Society Based on biological significance Level I/IA/IB
Unnecessary to dissect IA unless primary involves FOM, lip, structures of anterior midface, or if obvious lymphadenopathy present

Level II/IIA/IIB
Risk of nodal disease in sublevel IIB is less in primaries of the oral cavity and laryngeal than those in oropharynx If no clinical nodal disease in level IIA in oral cavity and larynx, unnecessary to dissect level IIB (which has high morbidity)

V/VA/VB
Superior component: spinal accessory lymph nodes Inferior component: Transverse cervical and supraclavicular nodes
Carry a more dire prognosis when positive for H+N cancers

Radiologic boundaries
Levels IB and IIA separated
Anatomic: by stylohyoid muscle Radiographic: by transverse line drawn at posterior surface of submandibular gland on each side of the neck

Levels VI and III/IV

Anatomic: lateral border of sternohyoid muscle Radiographic: common carotid or ICA

Neck dissection classification

Table 116-1 Classification of neck dissection 1991 classification Radical neck dissection Selective neck dissection 2001 classification Radical neck dissection Selective neck dissection: each variation depicted by SND and the use of parentheses to denote the levels or sublevels removed SND (I-III/IV) SND (II-IV) SND (II-V, postauricular, suboccipital) SND (VI) Extended neck dissection

Modified radical neck dissection Modified radical neck dissection

Supraomohyoid Lateral Posterolateral Anterior Extended neck dissection

Comprehensive neck dissection: Any neck dissection addressing level I-V on one side Radical neck dissection Modified radical neck dissection

Neck dissection classification

Radical neck dissection
En bloc removal of the lymph-node bearing tissue of one side of the neck (levels II-V) Borders:
Inferior border of mandible to clavicle; from lateral border of the strap muscles to the anterior border of trapezius Resection includes
Accessory nerve SCM IJV

Radical neck dissection

Indications
Extensive lymph node metastasis Extracapsular spread Nodes involving XI or IJV Many would say a modified RND is as suitable in these cases Surgical violation of involved LNs should not be risked for purpose of structure preservation

Neck dissection classification

Modified radical neck dissection En bloc removal of the lymph-node bearing tissue of one side of the neck (levels II-V) Borders:
Inferior border of mandible to clavicle; from lateral border of the strap muscles to the anterior border of trapezius

Preservation of one or more of

Spinal accessory nerve IJV SCM

Purpose
Significantly decreased morbidity
Especially with preservation of XI

Modified radical neck dissection

Modified radical neck dissection

Notation
Previously
MRND type 1: preservation of XI MRND type 2: preservation of XI and IJV MRND type 3: preservation of XI, IJV, SCM

Currently
MRND with preservation of x

Indications (same as RND)

Extensive lymph node metastasis Extracapsular spread Nodes involving XI or IJV

Neck dissection classification

SND (I-III) (supraomohyoid neck dissection) SND (I-IV) (extended supraomohyoid neck dissection SND (II-IV) (lateral neck dissection) SND (II-V, post-auricular, suboccipital nodes) (posterolateral neck dissection)

Neck dissection classification

Extended neck dissection
Any of the previously-mentioned neck dissections plus
Lymph node groups that are not routinely removed
Retropharyngeal, suboccipital, upper mediastinal

Other structure not routinely involved

Skin Carotid artery Levator scapulae Vagus Hypoglossal Etc.

Selective neck dissection

Performed for patients at risk for early lymph node metastasis Levels removed depends on the site of the primary tumor
Based on known pattern of nodal spread

Elective neck dissection

Remove at-risk areas, while avoiding risks associated with areas not likely to harbor occult mets Traditionally, indicated if chance of occult mets exceeds 20%

Staging neck dissection

Allows histolopathologic staging of clinically and radiographically negative necks May demonstrate when post-operative RT indicated
Multiple positive nodes Extracapsular spread neck dissection contents

Selective neck dissection for oral cavity cancer

Oral cavity subsites
Lip Alveolar ridge Oral tongue Retromolar trigone Floor of mouth Buccal mucosa Hard palate

Selective neck dissection for oral cavity cancer

SND (I-III) indicated for all sites
Except oral tongue (SND (I-IV)) due to skip metastases

If N+ neck
Usually necessary to include IV and V (ie comprehensive neck dissection) Exception:
If nodal disease confined to levels I and II, SND (I-IV) is appropriate

Elective SND of the contralateral neck indicated if primary of

Floor of mouth Anterior/midline oral tongue Tumor approaches midline

If N+ bilaterally
Bilateral comprehensive neck dissections

Treatment of N0 neck by subsite (finer details for seniors)

Lip:
If primary is bulky (>3cm) Tumor thickness >5mm Poor differentiation Perineural invasion present

Alveolar ridge:
For T3 and T4 primaries Poor differentiation

Oral tongue
If depth >2mm If anterior, or near midline, treat bilaterally

Treatment of N0 neck by subsite (finer details for seniors)

Retromolar trigone
SND indicated in all cases

Floor of mouth
Some sources:
All T2-4 primaries, and T1 with poor differentiation

Other sources
SND if depth of primary >2mm

Treat bilaterally

Buccal mucosa
SND indicated in all cases

Hard palate
None vs. SND for T4 primaries

Selective neck dissection for oropharyngeal, hypopharyngeal, and laryngeal cancer

SND (II-IV) Level IIB may be excluded for laryngeal and hypopharyngeal primaries Larynx Supraglottis
Very rich bilateral lymphatic drainage B/L SND

Glottis
Poor lymphatic drainage SND in bulky T4 disease

Subglottis
Bilateral SND in advanced disease

Transglottic
Bilateral SND

Selective neck dissection for oropharyngeal, hypopharyngeal, and laryngeal cancer Oropharynx
All T2-4 lesions require treatment of neck Bilateral SND if
Clinical disease on one side of the neck Lesion is central Lesion crosses midline

Retropharyngeal lymph nodes must be addressed either surgically or with RT

Selective neck dissection for oropharyngeal, hypopharyngeal, and laryngeal cancer Hypopharynx
Very rich lymphatic drainage All require bilateral treatment of neck
Only possible exception: very early lesions, where unilateral treatment of neck may be acceptable

SND (II-IV) vs. RT

Based on which modality used to treat primary

Selective neck dissection for cutaneous malignancies

Posterior scalp and upper neck
SND (II-V, postauricular, suboccipital) (ie extended neck dissection)

Anterior scalp, preauricular, temporal regions

SND (parotid and facial nodes, IIA, IIB, III, VA)

Anterior and lateral face

SND (parotid and facial nodes, I-III)

Selective neck dissection for cancer of midline structures of anterior lower neck
SND (VI) +/- other neck levels indicated in
Thyroid cancer Advanced glottic and subglottic cancer Advanced piriform sinus cancer Cervical esophageal and tracheal cancer

Selective neck dissection for other sites

Salivary gland neoplasms
SND (I-III) if
Primary >4cm SCC Adenocarcinoma Undifferentiated carcinoma High-grade mucoepidermoid carcinoma

Melanoma
Elective SND not indicated

Paranasal sinuses, nasal cavity

Elective SND not indicated

General algorithm

Nodal staging
Features of positive nodes
Size:
Jugulodigastric: 1.5 cm or bigger All others: 1.0 cm or bigger

Presence of central necrosis

Nx: regional lymph nodes can not be assessed N0: no regional lymph node metastasis N1: metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2a: metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension N2b: metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c: metastasis in bilateral or contralateral nodes no more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension

Nodal staging
Staging in nasopharyngeal carcinoma
Different distribution of nodal spread Different prognostic impact of nodal disease

Nx and N0: same N1: unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa N2: Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa N3a: Greater than 6 cm in dimension N3b: extension to the supraclavicular fossa

Prognosis
5 year survival for H+N ca:
T1-2 NN+ 80 40 T3-4 40 20

Positive neck decreases 5-year survival by 50%

Sequelae of neck dissection

Most notable sequela arises from removal of accessory nerve in RND Results in denervation of trapezius
Important shoulder abductor Destabilization of scapula Post neck dissection shoulder syndrome
Pain Weakness
Unable to abduct shoulder above 30 degrees at the shoulder

Deformity
Scapula flares Droops Rotates anterolaterally

Sequelae of neck dissection

Less shoulder dysfunction in nerve-sparing procedures Function usually improves over 1 yr in nerve-sparing procedures
Not so when nerve removed

Some dysfunction often detectable after selective neck dissections Permanent dysfunction significantly compromises quality of life All patients undergoing neck dissection of any type should begin physiotherapy early in the post-operative course

Complications of neck dissection

Air leaks Wound infection Bleeding Chylous fistula Facial/cerebral edema Blindness Neural complications Internal jugular rupture Carotid artery rupture

Complications of neck dissection

Air leaks
Circulation of air through a wound drain Usually occurs POD 1 May be due to either improperly placed drain, or incomplete closure Occlusive dressing may prevent further leak May represent communication with trach site or mucosal suture line
Identify early May require revision of wound closure in OR

Complications of neck dissection

Bleeding
Bleeding through incision: often due to subcutaneous blood vessel
Often controllable with ligation

Hematoma
Swelling or ballooning of skin flaps Milking drains may result in evacuation of blood If blood reaccumulates quickly, return to the OR Failure to drain hematoma may lead to wound infection

Complications of neck dissection

Chylous fistula
Usually identified and treated intraoperatively
Valsalva

Post-op chylous fistula occurs in 1-2 % of neck dissections Management

Intraoperative if
Noted immediately post-op Daily drainage > 600 cc

Conservative
Leak apparent after enteral feeds resumed Drainage < 600 cc/day Manage with closed wound drainage, pressure dressings, medium-chain fatty acid diet TPN may be necessary for high-output or intractable fistulas

Complications of neck dissection

Facial/cerebral edema
As a result of bilateral IJV ligation

Facial edema
May be preventable by preserving at least one EJV

Cerebral edema
May be the cause of impaired neurologic function and coma that occur after bilateral RND Bilateral ligation of IJV leads to increased ICP
May lead to SIADH (it does in dog studies) Vicious cycle:
The resulting expansion of extracellular fluids and dilutional hyponatremia aggravate the cerebral edema

Any patient undergoing bilateral IJ ligation requires careful peri- and post-operative monitoring of fluid status and electrolyte balance

Complications of neck dissection

Blindness
Rare
Only 5 cases ever reported But all texts list it as a complication Due to hypotension leading to optic nerve infarction?

Complications of neck dissection

Neural injury
Lingual nerve Marginal mandibular nerve Vagus nerve
Superior laryngeal RLN

XI Hypoglossal Phrenic Sensory nerves

Complications of neck dissection

Jugular vein rupture
Rare Present with multiple usually small bleeding episodes Life-threatening bleeding may occur Requires surgical exploration and ligation of vein

Complications of neck dissection

Carotid artery rupture
Rarely occurs in absence of pharyngocutaneous fistula Factors predisposing to rupture
Long exposed segment Large cutaneous defect Large, high-output fistulas

In these cases, return to OR and cover carotid with wellvascularized tissue In event of rupture
Blowout usually near carotid bulb and pinpoint in size Manual pressure Fluids and blood Return to the OR
Expose and ligate carotid proximally and distally Attempts to repair area of rupture futile

Summary
Neck anatomy Levels of the neck Classification of neck dissection
Radical neck dissection Modified radical neck dissection Selective neck dissection Extended neck dissection

Staging Sequelae of neck dissection Complications of neck dissection