Neck dissection

Neck dissection

1. Dr. SANJAY MAHARJAN. 1 ST YEAR RESIDENT. ENT-HNS, MANIPAL. Neck dissection

2. S ystematic removal of lymph nodes , along with their surrounding fibrofatty tissue, from various compartments of neck Aim : to remove neck lymph nodes into which cancer cells may have migrated Metastases may originate from tumours of oral cavity, tongue, nasopharynx , oropharynx, hypopharynx , and larynx, as well as the thyroid, parotid and posterior scalp . INTRODUCTION:

3. Therapeutic neck dissection is used when metastatic cervical lymphadenopathy is clinically evident . Elective neck dissection is used to remove lymph node groups in pts who have clinically node-negative disease and who have increased risk of harboring occult disease in neck Salvage neck dissection is done when metastatic disease is clinically evident in the neck after previous treatment

4. 1888 - Jawdynski described en bloc resection with resection of carotid, internal jugular vein and sternocleidomastoid muscle. 1906 - George W. Crile of the Cleveland Clinic describes radical neck dissection. 1957 - Hayes Martin describes routine use of radical neck dissection for control of neck metastases. 1967 - Oscar Suarez and E. Bocca describe a more conservative operation which preserves SAN, IJV and SCM. Last 3 decades - Further operations have been described to selectively remove the involved regional lymph groups. History of neck dissection:

5. Division of neck Lymph nodes by level and sub-level

6. Suggested by Suen and Goepfert (1997) Biologic significance for lymphatic drainage depending on site of tumor Importance of subdivisions:

7. “N” classification – AJC (1997 ) NX : Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in single ipsilateral lymph node, 3 cm or less in greatest dimension N2a: single ipsilateral lymph node >3 cm but <6 cm in greatest dimension N2b: multiple ipsilateral lymph nodes, none >6 cm N2c: bilateral or contralateral nodes, < 6 cm N3: lymph node > 6 cm Staging of head and neck cancer

8. Thyroid and nasopharynx have different staging based on tumor behavior and prognosis Staging in nasopharyngeal cancer N1: unilateral N2 : bilateral ( Both are above supraclavicular fossa & < 6 cm) N3 : > 6 cm or in supraclavicular fossa Staging in thyroid cancer N1a: ipsilateral N1b: midline / bilateral / contralateral

9. Principles of Classification RND: standard basic procedure for cervical lymphadenectomy, all other represent one or more modifications MRND: When modification of RND involves preservation of one or more non-lymphatic strs . SND: When modification involves one or more lymph node groups that are routinely removed in RND. Extended RND: When modification involves removal of additional lymph node groups or non-lymphatic structures relative to RND. Classification of Neck Dissections

10. R emoval of all ipsilateral cervical lymph node groups that extend from B ody of mandible superiorly to C lavicle inferiorly and from C ontralateral anterior belly of digastric & lat border of strap muscles anteriorly to A nt border of trapezius posteriorly Radical neck dissection

11. extensive lymph node metastases with extension beyond capsule of node or nodes that involves SAN and IJV. Untreatable primary tumor Unfit form major surgery Distant metastasis Significant b/l neck diseases Indications: Contra-Indications:

12. En bloc removal of lymph node–bearing tissue from one side of the neck (I-V) Unlike RND, it preserves SAN, IJV, and/or SCM TYPES: Type I preserves SAN Type II preserves SAN & IJV Type III preserves SAN, IJV & SCM Modified radical neck dissection:

13. Type I : Operable palpable neck disease (usually N1, N2a, N2b) not involving accessory nerve Can occasionally be done for the N0 neck Type II : Where preservation of IJV is important either when performing a second side operation or microvascular anastomosis or when histology shows vein need not be resected, i.e. differentiated thyroid cancer. Indications:

14. Type III : comprehensive or functional neck dissection Elective Rx for N0 neck in cell carcinoma of the upper aerodigestive tract

15. Reduce postsurgical shoulder pain and shoulder dysfunction Improve cosmetic outcome Reduce likelihood of bilateral IJV resection Benefit of MRND:

16. E n bloc removal of one or more lymph node groups at risk for metastatic cancer L evels removed depend on location of primary lesion and its known pattern of spread . Types: Supraomohyoid (m/c performed) Extended supraomohyoid Lateral Postero -lateral: Anterior or central: Superior mediastinum: Selective neck dissection

17. Supraomohyoid : SND for Oral Cavity Cancer Dissection of I-III groups Cutaneous branches of cervical plexus and post border of SCM mark posterior limit of dissection. Inferior limit - junction betn sup belly of omohyoid & IJV Indication: SCC oral cavity T1–T4: N0. E xtended supraomohyoid : Skin cancer (SCC and melanoma) ant to line of tragus in conjunction with superficial parotidectomy Indications:

18. Lateral : SND for Oropharyngeal , Hypopharyngeal , and Laryngeal Cancer Dissection of II-IV groups Sup. limit of dissection - skull base Inf. limit – clavicle Ant. (medial ) limit - lat border of sternohyoid & stylohyoid m/s Post. (lateral) limit - cutaneous branches of cervical plexus and post border of SCM . Indication: SCC larynx, oropharynx and hypopharynx , T2–T4: N0

19. Posterolateral : SND for Cutaneous Malignancies Dissection of II-V & post- auricular nodes Sup. limit - skull base ant and nuchal ridge post Inf. limit - clavicle Med. ( ant) limit - lat border of sternohyoid and stylohyoid m/s Lat. (post) limit - ant border of the trapezius muscle inferiorly and midline of neck superiorly

20. Anterior or central : SND for Cancer of Midline Structures of Anterior Lower Neck Dissection of level VI groups superior limit - body of hyoid bone inferior limit - suprasternal notch lateral limits - medial border of the carotid sheath (CCA). Indications: Differentiated thyroid carcinoma Subglottic and hypopharyngeal SCC

21. Sup. Mediastinum: Differentiated and medullary thyroid carcinoma Subglottic laryngeal and hypopharyngeal SCC Cervical oesophageal carcinoma

22. RND along with one or more additional lymph node groups or nonlymphatic strs or both lymph node grps include retropharyngeal and parapharyngeal , parotid nodes, or lymph nodes in levels VI or VII . nonlymphatic strs include part of mandible, parotid gland, part of mastoid tip, prevertebral fascia and musculature, digastric m/s, XIIn , ECA as well as skin. Extended Neck Dissection

23. compartmental removal of lymph nodes limited to one or two contiguous neck levels INDICATION: removal of lymph node disease as/w supraglottic cancer residual disease following chemoradiation that is confined to a single level SUPERSELECTIVE NECK DISSECTION

24. lymphoscintigraphy and sentinel lymph node biopsy (SLNB ) powerful adjunct to surgical treatment minimally invasive , can accurately stage clinically occult neck LYMPHOSCINTIGRAPHY-DIRECTED NECK DISSECTION

25. Position: S upine Roll placed beneath shoulders to optimally extend neck . S kin is prepped and draped to allow full exposure of both sides of neck with clear visualization of surrounding landmarks Technique:

26. O ptimal exposure of all lymph node levels to be dissected (I - V) P reserve as much blood supply as possible F laps raised should be broadly based, sup or inf S hould avoid any trifurcations, particularly those that overlie carotid sheath Incisions that fit these criteria H ockey stick B oomerang McFee incision A pron incision ( b/l ND) Incision:

27. Y type (or Crile ) Schobinger incision Modified Schobinger incision horizontal-T ( Hetter ) incision Utility incision Different incisions:

28. Raised in subplatysmal plane Major corners of consternation : Lower end of internal jugular vein. Junction of lateral border of clavicle with lower edge of trapezius. Upper end of internal jugular vein. Submandibular triangle . Minor corners of consternation : Retropharyngeal nodes. Parapharyngeal nodes. Chaissaignac’s triangle. Raising the flap:

29. Step 1: incision is made through skin, subcutaneous fat, and platysma muscle superior flap is elevated submandibular gland fascia is then incised Resection of fat and lymph nodes from submental triangle (Level Ia ) submental triangle is resected inferiorly to hyoid bone with electro-cautery. Deep plane of dissection is mylohyoid muscles Operative steps for MRND:

30. Step 2: addresses Level Ib submandibular gland capsule is dissected from gland in a superior direction in a subcapsular plane Resection of fat and lymph nodes tucked anteriorly and deeply between ant belly of digastric & mylohyoid m/s

31. Facial artery and vein are identified by blunt dissection with a fine haemostat F acial lymph nodes; if present, are dissected Divided and tied close to submandibular gland so as not to injure marginal mandibular nerve This frees up gland superiorly, which can then be reflected away from mandible addresses the lingual nerve, submandibular duct, and XIIn

32. Step 3: fascia along lateral aspect of digastric divided EJV divided post belly of digastric exposed along its entire length Identification of XIIn deep to veins that cross nerve Sternomastoid branch of occipital artery that tethers XIIn identified Dividing this artery releases XIIn Then courses vertically and leads directly to ant border of IJV

33. Step 4: fatty tissue in Level II dissected XIn which may course lateral, medial or very rarely through IJV identified transverse process of C1 vertebra can be palpated immediately post to XIn and IJV

34. Step 5: directed at anterior neck anteriorly based subplatysmal flap raised exposing omohyoid and SCM muscle inferiorly down the clavicle anterior jugular vein left in elevated flap Omohyoid divided and levels II, III cleared

35. Step 6: P osteriorly-based flap elevated P latysma is often absent posteriorly hence flap may be very thin D issection continues until ant border of trapezius is reached

36. Step 7: dissecting out XIn and mobilizing Level IIb XIn is identified by dissecting at post border of SCM, approx 1-2cm post to point where greater auricular nerve curves around m/s Once XIn exposed and freed from IJV , it is exposed distally to where it disappears behind trapezius m/s Freed completely and branches sectioned to SCM

37. Step 8 : dissection of Level IIb and transposition of the XIn SCM is divided below mastoid. exposing fat at top of Level IIb dissection is carried deeper until deep muscles of neck that run in a posteroinferior direction appear dissection is then directed postero -inferiorly, where greater occipital nerve (C1) is divided Level IIb and IIa are then dissected off XIn is now trans-located posteriorly

38. Step 9 : clavicular and sternal heads of SCM divided not to dissect immediately lateral to IJV, as right lymphatic duct (right neck) or thoracic duct (left neck) may be injured; chyle leak EJV is divided and ligated and omohyoid divided Supraclavicular fat exposed. Brachial plexus, phrenic nerve & transverse cervical vessels identified

39. Step 10 : freeing inferolateral part of Level V Identifying and dividing supraclavicular nerves Incision of fatty vascular pedicle containing transverse cervical artery and vein isolation and division of transverse cervical artery and its proximity to XIn .

40. Step 11 : anterograde dissection of Levels II - V with scalpel dissection proceeds over a broad front until entire cervical plexus has been exposed cervical plexus nerves are each divided, taking care not to injure phrenic nerve This brings carotid sheath into view carotid sheath is incised along full course of vagus nerve, and neck dissection specimen is stripped off the IJV

41. Step 12 : final step is to: strip neck dissection specimen off infrahyoid strap muscles to identify and preserve superior thyroid vascular pedicle, and to deliver neck dissection specimen Closure:

42. HAEMORRHAGE: perioperative or postoperative Damage to IJV at its upper or lower end before it has been ligated Secondary haemorrhage may occur as a result of carotid artery rupture WOUND INFECTION: four most important factors 1. Contamination of surgical field. 2. Contamination of surgical field as operation involves in-continuity RND and primary excision 3 . Postoperative haematoma which then becomes infected . 4. Flap necrosis and wound breakdown. Complications

43. CAROTID ARTERY RUPTURE : Following necrosis of arterial wall d/to infection preoperative radiotherapy is implicated in most series CHYLOUS FISTULA: More usually, a leak of fluid occurs when lower end of jugular vein is being dissected Mild leak, i.e. < 100mL/day: conservative management Major leak: re-explore wound to identify source of leak and oversew it

44. PNEUMOTHORAX disease lower neck, apical pleura may be damaged during dissection NERVE INJURIES: standard radical neck dissection the nerves which are deliberately divided are : accessory nerve; branches of the cervical plexus. descendens hypoglossi Other nerves that may be damaged by accident include : facial nerve or its mandibular or cervical division; hypoglossal and lingual nerves; vagus , symphathetic trunk, phrenic nerve or brachial plexus.

45. CEREBRAL OEDEMA; Usu. In b/l neck dissection .

46. The end…..