Radical Neck Dissection

1. Radical Neck Dissection: (RND) Radical Neck Dissection: (RND)
Classification, Indication and Classification, Indication and
TechniquesTechniques

2. IntroductionIntroduction
•Crile in 1906 introduced RND and is Crile in 1906 introduced RND and is
followed by Martin as a the classical followed by Martin as a the classical
procedure for the management of procedure for the management of
cervical lymph node metastasiscervical lymph node metastasis
•Recently changes in classification and Recently changes in classification and
indication led to inconsistencyindication led to inconsistency
–NN
00 in recent studies may require selective in recent studies may require selective
RND to reduce morbidityRND to reduce morbidity

3. Staging of Neck NodesStaging of Neck Nodes
•NN
XX: :
–Regional lymph nodes can not be assessedRegional lymph nodes can not be assessed
•NN
00::
–No regional lymph node metastasisNo regional lymph node metastasis
•NN
11::
–Metastasis in a single ipsilateral lymph nodes, Metastasis in a single ipsilateral lymph nodes,
3 cm or less in greatest dimension3 cm or less in greatest dimension
•NN
22::
–NN
2a2a::
•Metastasis in a single epsilateral lymph nodes, Metastasis in a single epsilateral lymph nodes,
more than 3 cm but less than 6 cm more than 3 cm but less than 6 cm

4. Staging of Neck NodesStaging of Neck Nodes
–NN
2b2b::
•Metastasis in multiple ipsilateral lymph Metastasis in multiple ipsilateral lymph
nodes, not more than 6 cm nodes, not more than 6 cm
–NN
2c2c::
•Metastasis in bilateral or contralateral Metastasis in bilateral or contralateral
nodes not more than 6 cm in diameternodes not more than 6 cm in diameter
•NN
33::
–Metastasis in lymph nodes more than 6 Metastasis in lymph nodes more than 6
cm in in greatest diametercm in in greatest diameter
Meyers & Eugene: Operative Otolaryngology. 1997Meyers & Eugene: Operative Otolaryngology. 1997

5. Lymph Node RegionsLymph Node Regions
•Region I:Region I:
–Submental and submandibular Submental and submandibular
triangletriangle
•II
aa: Submental triangle:: Submental triangle:
–Bounded by the anterior belly of digastric Bounded by the anterior belly of digastric
and the mylohyoid muscle deep and the mylohyoid muscle deep
•II
bb: Submandibular triangle:: Submandibular triangle:
–Formed by the anterior and posterior belly Formed by the anterior and posterior belly
of the digastric muscle and the body of the of the digastric muscle and the body of the
mandiblemandible
Memorial Sloan-kettering Cancer center

6. Lymph Node RegionsLymph Node Regions
•Region II – IV:Region II – IV:
–Lymph nodes are associated with the Lymph nodes are associated with the
Internal Jugular Vein (IJV) within the Internal Jugular Vein (IJV) within the
fibroadipose tissues that extend from fibroadipose tissues that extend from
the posterior border of sternocledo-the posterior border of sternocledo-
mastoid muscle (SCM) medial to mastoid muscle (SCM) medial to
lateral border of the sternohyoid lateral border of the sternohyoid
muscle muscle
Memorial Sloan-kettering Cancer center

7. Lymph Node RegionsLymph Node Regions
•Region II:Region II:
–Upper third including upper jugular, Upper third including upper jugular,
jugulodigastric and upper posterior cervical jugulodigastric and upper posterior cervical
nodesnodes
–Bounded by the digastric muscle superiorly Bounded by the digastric muscle superiorly
and the hyoid bone or carotid bifurcation and the hyoid bone or carotid bifurcation
inferiorlyinferiorly
•IIa:IIa:
–nodes anterior to Spinal Accessory Nerve (SAN)nodes anterior to Spinal Accessory Nerve (SAN)
•IIb:IIb:
–nodes posterior to Spinal Accessory Nerve (SAN)nodes posterior to Spinal Accessory Nerve (SAN)
Memorial Sloan-kettering Cancer center

8. Lymph Node RegionsLymph Node Regions
•Region III:Region III:
–Middle third jugular nodes from the Middle third jugular nodes from the
carotid bifurcation to cricothyroid carotid bifurcation to cricothyroid
notch or omohyoid musclenotch or omohyoid muscle
•Region IV:Region IV:
–Lower third jugular nodes from Lower third jugular nodes from
omohyoid muscle superiorly to the omohyoid muscle superiorly to the
clavicle inferiorlyclavicle inferiorly
Memorial Sloan-kettering Cancer center

9. Lymph Node RegionsLymph Node Regions
•Region V:Region V:
–Lymph nodes of the posterior triangle Lymph nodes of the posterior triangle
along the lower half of the SAN and the along the lower half of the SAN and the
transverse cervical arterytransverse cervical artery
–Bounded by the anterior border of the Bounded by the anterior border of the
trapezius posteriorly, the posterior trapezius posteriorly, the posterior
border of SCM anteriorly and the border of SCM anteriorly and the
clavicle inferiorlyclavicle inferiorly
Memorial Sloan-kettering Cancer center

10. Lymph Node RegionsLymph Node Regions
•Region VI:Region VI:
–Anterior compartment, lymph nodes Anterior compartment, lymph nodes
surrounding the midline visceral structures surrounding the midline visceral structures
that extend from the hyoid bone superiorly to that extend from the hyoid bone superiorly to
the suprasternal notch inferiorlythe suprasternal notch inferiorly
–The lateral boundary is the medial border of The lateral boundary is the medial border of
the carotid sheaththe carotid sheath
–Perithyroid, paratracheal, and lymph nodes Perithyroid, paratracheal, and lymph nodes
around the recurrent laryngeal nervearound the recurrent laryngeal nerve
Memorial Sloan-kettering Cancer center

11. Classification Classification
•The RND is classified according to the The RND is classified according to the
Academy’s Committee for Head & Neck Academy’s Committee for Head & Neck
Surgery & Oncology into four major typeSurgery & Oncology into four major type::
–Radical Neck DissectionRadical Neck Dissection (RND)(RND)
–Modified Radical Neck Dissection Modified Radical Neck Dissection (MRND)(MRND)
–Selective Neck Dissection Selective Neck Dissection (SND)(SND)
–SupraomohyoidSupraomohyoid
–PosterolateralPosterolateral
–Lateral Lateral
–AnteriorAnterior
–Extended Radical Neck Dissection Extended Radical Neck Dissection (ERND)(ERND)

12. ClassificationClassification
•Radical neck Dissection:Radical neck Dissection:
–Removing all lymphatic tissues in regions I - Removing all lymphatic tissues in regions I -
V and include removal of SAN, SCM and IJVV and include removal of SAN, SCM and IJV
•Modified radical neck dissection:Modified radical neck dissection:
–Excision of all lymph nodes removed with Excision of all lymph nodes removed with
RND with preservation of one or more non-RND with preservation of one or more non-
lymphatic structures, SAN, SCM and/or IJVlymphatic structures, SAN, SCM and/or IJV
•Subtype I: Preserve SANSubtype I: Preserve SAN
•Subtype II: Preserve SAN & SJVSubtype II: Preserve SAN & SJV
•Subtype III: preserve SAN, SJV and SCM Subtype III: preserve SAN, SJV and SCM
–Known as Functional neck dissection (Bocca)Known as Functional neck dissection (Bocca)

13. ClassificationClassification
•Selective Neck dissection:Selective Neck dissection:
–Any type of cervical lymphadenectomy Any type of cervical lymphadenectomy
with preservation of one or more with preservation of one or more
lymph node groupslymph node groups
–Four subtype:Four subtype:
•Supraomohyoid neck dissectionSupraomohyoid neck dissection
•Posterolateral neck dissectionPosterolateral neck dissection
•Lateral neck dissectionLateral neck dissection
•Anterior neck dissectionAnterior neck dissection

14. ClassificationClassification
–Supraomohyoid neck dissection:Supraomohyoid neck dissection:
•Removal of lymph nodes in regions I –III Removal of lymph nodes in regions I –III
•The posterior limit is the cutaneous branches of the The posterior limit is the cutaneous branches of the
cervical plexus and posterior border of SCMcervical plexus and posterior border of SCM
•The inferior limit is the superior belly of the The inferior limit is the superior belly of the
omohyoid where it cross IJN omohyoid where it cross IJN
–Posterolateral neck dissectionPosterolateral neck dissection
•Removal of suboccipital, retroauricular, levels II – Removal of suboccipital, retroauricular, levels II –
V and level VV and level V
•Subtyped I – III depending on the preservation of Subtyped I – III depending on the preservation of
SAN, IJV and /or SCMSAN, IJV and /or SCM Medina

15. ClassificationClassification
–Lateral neck dissection:Lateral neck dissection:
•Remove lymph nodes in levels II – IV Remove lymph nodes in levels II – IV
–Anterior neck dissection:Anterior neck dissection:
•Require the removal of the lymph nodes Require the removal of the lymph nodes
surrounding the visceral structure in the surrounding the visceral structure in the
anterior aspect of the neck, level VIanterior aspect of the neck, level VI
•Superior limit, hyoid boneSuperior limit, hyoid bone
•Inferior limit, suprasternal notchInferior limit, suprasternal notch
•Laterally, the carotid sheathLaterally, the carotid sheath

16. ClassificationClassification
•Extended neck dissection:Extended neck dissection:
–Any previous dissection and including Any previous dissection and including
one or more additional lymph node one or more additional lymph node
groups and/or non-lymphatic tissuesgroups and/or non-lymphatic tissues

17. FactsFacts
•General nodal metastasis produce General nodal metastasis produce
the following fact:the following fact:
–The most important factor in prognosis The most important factor in prognosis
of SCC of the upper aero-digestive of SCC of the upper aero-digestive
tract is the status of cervical lymph tract is the status of cervical lymph
nodesnodes
–Cure rate drops 50% with involvement Cure rate drops 50% with involvement
of the regional lymph nodesof the regional lymph nodes

18. Indications For NDIndications For ND
•Radical neck dissection was believed by Radical neck dissection was believed by
Martin to be the only method to control Martin to be the only method to control
cervical lymphadenectomycervical lymphadenectomy
•Anderson found that preservation of SAN Anderson found that preservation of SAN
did not change the survival or tumor did not change the survival or tumor
control in the neckcontrol in the neck
–Actual 5-year survival and neck failure rate Actual 5-year survival and neck failure rate
is:is:
•RND: 63% and 12 %RND: 63% and 12 %
•MRND: 71% and 12% MRND: 71% and 12%

19. IndicationsIndications
•Radical Neck DissectionRadical Neck Dissection
2.2.Multiple clinically obvious cervical lymph Multiple clinically obvious cervical lymph
node metastasis particularly of posterior node metastasis particularly of posterior
triangle and closely related to SANtriangle and closely related to SAN
4.4.Large metastatic tumor mass or multiple Large metastatic tumor mass or multiple
matted in upper part of the neckmatted in upper part of the neck
•Tumor should not be dissected to preserve Tumor should not be dissected to preserve
Structures Structures

20. IndicationsIndications
•Modified radical neck dissectionModified radical neck dissection
–MRND Type I:MRND Type I:
1.1.Clinically obvious neck lymph nodes Clinically obvious neck lymph nodes
metastasis and SAN not involved by metastasis and SAN not involved by
tumortumor
2.2.Intraoperative decision just like Intraoperative decision just like
preservation of the facial nerve in preservation of the facial nerve in
parotid surgeryparotid surgery

21. IndicationsIndications
•MRND Type II:MRND Type II:
1.1.Rarely plannedRarely planned
2.2.Intra-operative decision for tumor found Intra-operative decision for tumor found
adherent to SCM but away from SAN & adherent to SCM but away from SAN &
IJVIJV
•MRND Type III:MRND Type III:
–Depend on the autopsy reportsDepend on the autopsy reports
1.1.Lymph nodes were in the fibrofatty and do not Lymph nodes were in the fibrofatty and do not
share the same adventitia with blood vesselsshare the same adventitia with blood vessels
2.2.They are not found within the aponeurosis or They are not found within the aponeurosis or
glandular capsule of the submandibular glandular capsule of the submandibular
“Functional neck dissection” “Functional neck dissection”

22. IndicationsIndications
•MRND Type III:MRND Type III:
–For treatment of NFor treatment of N
00 neck nodes neck nodes
–Indicated for NIndicated for N
11 mobile nodes and not mobile nodes and not
greater than 2.5 – 3.0 cmgreater than 2.5 – 3.0 cm
•Contra-indicated in the presence of node Contra-indicated in the presence of node
fixationfixation
•Result is difficult to interpret because of Result is difficult to interpret because of
the use of radiation therapy the use of radiation therapy

23. IndicationsIndications
•Selective/elective neck dissection:Selective/elective neck dissection:
–For treatment of NFor treatment of N
00 neck nodes neck nodes
–For N+ nodes when combined with For N+ nodes when combined with
radiotherapyradiotherapy
•Adjuvant radiotherapy for patient with 2 – 4 positive Adjuvant radiotherapy for patient with 2 – 4 positive
nodes or extra-capsular spreadnodes or extra-capsular spread
–SupraomohyoidSupraomohyoid is indicated for SCC of oral is indicated for SCC of oral
cavity with Ncavity with N
00 and N and N
11 with palpable mobile with palpable mobile
nodes less than 3 cm and located in level I and nodes less than 3 cm and located in level I and
IIII
–Upgrade intra-operatively following positive Upgrade intra-operatively following positive
frozen sectionfrozen section

24. Treatment option for NTreatment option for N
00 nodes nodes
•ObserveObserve
•Radiation therapyRadiation therapy
•Elective neck dissectionElective neck dissection
–Low morbidityLow morbidity
–Staging neck for possible extended Staging neck for possible extended
surgerysurgery
–Need for post-operative radiotherapyNeed for post-operative radiotherapy

25. Rationale for S/ENDRationale for S/END
•Rate of occult metastasis in Rate of occult metastasis in
clinically negative nodes is 20 – 30% clinically negative nodes is 20 – 30%
using clinical and radiographic using clinical and radiographic
findingsfindings
–Ct scan combined with physical exam Ct scan combined with physical exam
decreased the rate of occult metastasis decreased the rate of occult metastasis
to 12%to 12%
–This suggested lowering of the criteria This suggested lowering of the criteria
for elective neck dissectionfor elective neck dissection
Friedman et al Laryngoscope 100; 54 – 59: 1990

26. Rationale for S/ENDRationale for S/END
•Anatomic studies showed that Anatomic studies showed that
lymphatic drainage from the lymphatic drainage from the
mucosal surfaces follow a constant mucosal surfaces follow a constant
and predictable routeand predictable route
•Lymph flow from SA chain to the Lymph flow from SA chain to the
jugular chain is unilateraljugular chain is unilateral
Shah. Ann Surg Oncol 1(6); 521-532: 1994

27. Rationale for S/ENDRationale for S/END
•Shah, in his study produced a compelling in his study produced a compelling
evidence of predictable nodal metastasis evidence of predictable nodal metastasis
from SCC from upper aerodigastive tractfrom SCC from upper aerodigastive tract
–He found a specific pattern for nodal spread He found a specific pattern for nodal spread
by location of primaryby location of primary
•NN
OO in patients with oral cavity SCC: in patients with oral cavity SCC:
– 7/1119 (3.5%) had nodal involvement outside 7/1119 (3.5%) had nodal involvement outside
supraomohyoid dissectionsupraomohyoid dissection
–3 (1.5%) had isolated involvement outside 3 (1.5%) had isolated involvement outside
level I - IIIlevel I - III
Friedman Laryngoscope 100; 54-59: 1990

28. Rationale for S/ENDRationale for S/END
–NN
++ nodes in patients with oral SCC: nodes in patients with oral SCC:
•50/246 had nodal metastasis outside level IV50/246 had nodal metastasis outside level IV
•10/246 had metastasis in level V10/246 had metastasis in level V
–He examined nodal involvement in patients He examined nodal involvement in patients
with nasopharynx and other upper parts of the with nasopharynx and other upper parts of the
aerodigastive tractaerodigastive tract
•Conclusion:Conclusion:
–SCC of the oral cavity:SCC of the oral cavity:
•Level I, II and III are at riskLevel I, II and III are at risk
–SCC nasopharynx and larynxSCC nasopharynx and larynx
•Level II, III and IV are at riskLevel II, III and IV are at risk
Shah Amer J Surg 160; 405-409: 1990
Shah Cancer July 1 ; 109-113: 1990

29. Rationale for S/ENDRationale for S/END
•Byers stated that SND combined with Byers stated that SND combined with
postoperative radiotherapy in selected postoperative radiotherapy in selected
patients with oral cavity SCC was adequate patients with oral cavity SCC was adequate
treatment with similar recurrence rate as treatment with similar recurrence rate as
those treated with MRND IIIthose treated with MRND III
•Spiro reported 12% with supraomohyoid Spiro reported 12% with supraomohyoid
dissection in N1 nodes but not all of them dissection in N1 nodes but not all of them
received radiotherapyreceived radiotherapy
Byers Head Neck Surg; Jan-Feb; 160-167: 1988

30. Selective/Elective Neck Selective/Elective Neck
DissectionDissection
•A good option for N0 neckA good option for N0 neck
•Not a suitable option for N+ neckNot a suitable option for N+ neck
•Is used N+ neck when combined Is used N+ neck when combined
with radiotherapywith radiotherapy
•Intra-operative frozen section Intra-operative frozen section
evaluation is needed to confirm in evaluation is needed to confirm in
cases of intraoperative palpable cases of intraoperative palpable
nodesnodes

31. The anatomyThe anatomy
•Skin:Skin:
–Blood supply:Blood supply:
•Descending branches: Descending branches:
–The facial The facial
–The submentalThe submental
–OccipitalOccipital
•Ascending branchesAscending branches
–Transverse cervicalTransverse cervical
–SuprascapularSuprascapular
–The branches perforate the platysma muscle, anastomose The branches perforate the platysma muscle, anastomose
to form superficial vertically-directed network of vesselsto form superficial vertically-directed network of vessels
•Skin incision is superiorly based apron-like incision
from mastoid to mentum or to contralateral mastoid

32. The anatomyThe anatomy
•Platysma muscle:Platysma muscle:
–Wide, quadrangular sheet-like muscleWide, quadrangular sheet-like muscle
–Run obliquely from the upper part of the Run obliquely from the upper part of the
chest to lower facechest to lower face
–Skin flap is raised immediately deep to the Skin flap is raised immediately deep to the
musclemuscle
–The posterior border is over or just anterior The posterior border is over or just anterior
to IJV and great auricular nerveto IJV and great auricular nerve
–Does not cover the inferior part of the Does not cover the inferior part of the
anterior triangle and the posterolateral neck anterior triangle and the posterolateral neck

33. The anatomyThe anatomy
•Sternocleidomastoid muscle:Sternocleidomastoid muscle: SCM SCM
–Differentiated from the platysma by the Differentiated from the platysma by the
direction of its fibresdirection of its fibres
–Crossed by the IJV and the great Crossed by the IJV and the great
auricular nerve from inferior to auricular nerve from inferior to
posterior deep to platysmaposterior deep to platysma
–The posterior border represent the The posterior border represent the
posterior boundary of nodes level II - IVposterior boundary of nodes level II - IV

34. The anatomyThe anatomy
•Marginal Mandibular nerve:Marginal Mandibular nerve: MMN MMN
–Located 1 cm in front of and below Located 1 cm in front of and below
the angle of the mandiblethe angle of the mandible
–Deep to the superficial layer of the Deep to the superficial layer of the
deep cervical fascia deep cervical fascia
–Superficial to adventitia of the anterior Superficial to adventitia of the anterior
facial vein facial vein

35. The anatomyThe anatomy
•Spinal Accessory nerve: SANSpinal Accessory nerve: SAN
–Emerge from the jugular foramen medial to Emerge from the jugular foramen medial to
the digastric and stylohyoid muscles and the digastric and stylohyoid muscles and
lateral and posterior to IJV (30% medial to lateral and posterior to IJV (30% medial to
the vein and in 3 -5% split the nerve)the vein and in 3 -5% split the nerve)
–It passes obliquely downward and backward It passes obliquely downward and backward
to reach the medial surface of the SCM near to reach the medial surface of the SCM near
the junction of its superior and middle thirds, the junction of its superior and middle thirds,
Erb’s pointErb’s point

36. The anatomyThe anatomy
•Trapezius muscle:
–Its anterior border is the posterior Its anterior border is the posterior
boundary of level Vboundary of level V
–Difficult to identify because of its Difficult to identify because of its
superficial positionsuperficial position
–Dissect superficial to the fascia in order Dissect superficial to the fascia in order
to preserve the cervical nerves to preserve the cervical nerves

37. The anatomyThe anatomy
•Digastric Muscle; Posterior belly:; Posterior belly:
–Originate from a groove in the mastoid Originate from a groove in the mastoid
process, digastric ridgeprocess, digastric ridge
–The marginal mandibular nerve lie The marginal mandibular nerve lie
superficial superficial
–The external and internal carotid The external and internal carotid
artery, hypoglossal and 11artery, hypoglossal and 11
thth
cranial cranial
nerves and the IJV lie medial nerves and the IJV lie medial

38. The anatomyThe anatomy
•Omohyoid muscle:
–Made of two bellies, and is the Made of two bellies, and is the
anatomic separation of nodal levels III anatomic separation of nodal levels III
and IVand IV
–The posterior belly is superficial to the The posterior belly is superficial to the
brachial plexus, phrenic nerve and brachial plexus, phrenic nerve and
transverse cervical artery and veintransverse cervical artery and vein
–The anterior belly is superficial to the The anterior belly is superficial to the
IJVIJV

39. The anatomyThe anatomy
•Brachial Plexus & Phrenic nerve:
–The plexus exit between the anterior The plexus exit between the anterior
and middle scalene muscles, pass and middle scalene muscles, pass
inferiorly deep to the clavicle under the inferiorly deep to the clavicle under the
posterior belly of the omohyoidposterior belly of the omohyoid
–The phrenic nerve lie on top of the The phrenic nerve lie on top of the
anterior scalene muscle and receive it anterior scalene muscle and receive it
is cervical supply from C3 – C5 is cervical supply from C3 – C5

40. The anatomyThe anatomy
•Thoracic duct:
–Located in the lower let neck posterior Located in the lower let neck posterior
to the jugular vein and anterior to to the jugular vein and anterior to
phrenic nerve and transverse cervical phrenic nerve and transverse cervical
arteryartery
–Have a very thin wall and should be Have a very thin wall and should be
handled gently to avoid avulsion or handled gently to avoid avulsion or
tear leading to chyle leaktear leading to chyle leak

41. The anatomyThe anatomy
•Exit via the hypoglossal canal near the Exit via the hypoglossal canal near the
jugular foramenjugular foramen
•Passes deep to the IJV and over the ICA Passes deep to the IJV and over the ICA
and ECA and then deep and inferior to and ECA and then deep and inferior to
the digastric muscle and enveloped by a the digastric muscle and enveloped by a
venous plexus, the ranine veinsvenous plexus, the ranine veins
•Pass deep to the fascia of the floor of the Pass deep to the fascia of the floor of the
submandibular triangle before entering submandibular triangle before entering
the tonguethe tongue

42. SummarySummary
•Unified classification is relatively newUnified classification is relatively new
•Indication and the type of ND, specially for N0, Indication and the type of ND, specially for N0,
is controversialis controversial
•The following surgical outline was suggested:The following surgical outline was suggested:
–SCC oral cavity anterior to circumvalate papillaSCC oral cavity anterior to circumvalate papilla
•SupraomohyoidSupraomohyoid
–SCC Oropharynx, larynx and hypopharynxSCC Oropharynx, larynx and hypopharynx
•level I- IV or level II-Vlevel I- IV or level II-V
–SCC with N+ nodes SCC with N+ nodes
•RND RND
–SCC with 2-4 positive nodes or extracapsular spreadSCC with 2-4 positive nodes or extracapsular spread
•RND and adjuvant therapyRND and adjuvant therapy
Shah Cancer July 1;109-113: 1990