Radical neck dissection

2. Crile in 1906 introduced RND and is
followed by Martin as a the classical
procedure for the management of
cervical lymph node metastasis
Recently changes in classification and
indication led to inconsistency
N
0
in recent studies may require selective
RND to reduce morbidity

3. N
X
:
Regional lymph nodes can not be assessed
N
0
:
No regional lymph node metastasis
N
1
:
Metastasis in a single ipsilateral lymph nodes, 3 cm or less
in greatest dimension
N
2
:
N
2a:
▪Metastasis in a single epsilateral lymph nodes, more than 3 cm but
less than 6 cm

4. N
2b
:
▪Metastasis in multiple ipsilateral lymph nodes, not more
than 6 cm
N
2c
:
▪Metastasis in bilateral or contralateral nodes not more
than 6 cm in diameter
N
3
:
Metastasis in lymph nodes more than 6 cm in in
greatest diameter
Meyers & Eugene: Operative Otolaryngology. 1997Meyers & Eugene: Operative Otolaryngology. 1997

5. Region I:
Submental and submandibular triangle
▪I
a
: Submental triangle:
▪Bounded by the anterior belly of digastric and the mylohyoid
muscle deep
▪I
b
: Submandibular triangle:
▪Formed by the anterior and posterior belly of the digastric
muscle and the body of the mandible
Memorial Sloan-kettering Cancer center

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

7. Region II:
Upper third including upper jugular, jugulodigastric and
upper posterior cervical nodes
Bounded by the digastric muscle superiorly and the hyoid
bone or carotid bifurcation inferiorly
▪IIa:
▪nodes anterior to Spinal Accessory Nerve (SAN)
▪IIb:
▪nodes posterior to Spinal Accessory Nerve (SAN)
Memorial Sloan-kettering Cancer center

8. Region III:
Middle third jugular nodes from the carotid
bifurcation to cricothyroid notch or omohyoid
muscle
Region IV:
Lower third jugular nodes from omohyoid muscle
superiorly to the clavicle inferiorly
Memorial Sloan-kettering Cancer center

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

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

11. The RND is classified according to the
Academy’s Committee for Head & Neck
Surgery & Oncology into four major type:
gRadical Neck Dissection (RND)
:Modified Radical Neck Dissection (MRND)
MSelective Neck Dissection (SND)
▪Supraomohyoid
▪Posterolateral
▪Lateral
▪Anterior
CExtended Radical Neck Dissection (ERND)

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

13. Selective Neck dissection:
Any type of cervical lymphadenectomy with
preservation of one or more lymph node groups
Four subtype:
▪Supraomohyoid neck dissection
▪Posterolateral neck dissection
▪Lateral neck dissection
▪Anterior neck dissection

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

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

16. Extended neck dissection:
Any previous dissection and including one or more
additional lymph node groups and/or non-
lymphatic tissues

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

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

19. Radical Neck Dissection
2.Multiple clinically obvious cervical lymph node
metastasis particularly of posterior triangle and closely
related to SAN
4.Large metastatic tumor mass or multiple matted in
upper part of the neck
▪Tumor should not be dissected to preserve Structures

20. Modified radical neck dissection
MRND Type I:
1.Clinically obvious neck lymph nodes metastasis and
SAN not involved by tumor
2.Intraoperative decision just like preservation of the
facial nerve in parotid surgery

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

22. MRND Type III:
For treatment of N
0
neck nodes
Indicated for N
1
mobile nodes and not greater
than 2.5 – 3.0 cm
▪Contra-indicated in the presence of node fixation
▪Result is difficult to interpret because of the use of
radiation therapy

23. Selective/elective neck dissection:
For treatment of N
0
neck nodes
For N+ nodes when combined with radiotherapy
▪Adjuvant radiotherapy for patient with 2 – 4 positive
nodes or extra-capsular spread
Supraomohyoid is indicated for SCC of oral cavity
with N
0
and N
1
with palpable mobile nodes less
than 3 cm and located in level I and II
Upgrade intra-operatively following positive
frozen section

24. Observe
Radiation therapy
Elective neck dissection
Low morbidity
Staging neck for possible extended surgery
Need for post-operative radiotherapy

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

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

27. Shah, in his study produced a compelling
evidence of predictable nodal metastasis
from SCC from upper aerodigastive tract
He found a specific pattern for nodal spread by
location of primary
▪N
O
in patients with oral cavity SCC:
▪ 7/1119 (3.5%) had nodal involvement outside
supraomohyoid dissection
▪3 (1.5%) had isolated involvement outside level I - III
Friedman Laryngoscope 100; 54-59: 1990

28. N
+
nodes in patients with oral SCC:
▪50/246 had nodal metastasis outside level IV
▪10/246 had metastasis in level V
He examined nodal involvement in patients with
nasopharynx and other upper parts of the
aerodigastive tract
Conclusion:
SCC of the oral cavity:
▪Level I, II and III are at risk
SCC nasopharynx and larynx
▪Level II, III and IV are at risk
Shah Amer J Surg 160; 405-409: 1990
Shah Cancer July 1 ; 109-113: 1990

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

30. A good option for N0 neck
Not a suitable option for N+ neck
Is used N+ neck when combined with
radiotherapy
Intra-operative frozen section evaluation is
needed to confirm in cases of intraoperative
palpable nodes

31. Skin:
Blood supply:
▪Descending branches:
▪The facial
▪The submental
▪Occipital
▪Ascending branches
▪Transverse cervical
▪Suprascapular
The branches perforate the platysma muscle, anastomose to
form superficial vertically-directed network of vessels
Skin incision is superiorly based apron-like incision from
mastoid to mentum or to contralateral mastoid

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

33. Sternocleidomastoid muscle: SCM
Differentiated from the platysma by the
direction of its fibres
Crossed by the IJV and the great auricular
nerve from inferior to posterior deep to
platysma
The posterior border represent the
posterior boundary of nodes level II - IV

34. Marginal Mandibular nerve: MMN
Located 1 cm in front of and below the angle of
the mandible
Deep to the superficial layer of the deep cervical
fascia
Superficial to adventitia of the anterior facial vein

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

36. Trapezius muscle:
Its anterior border is the posterior boundary of
level V
Difficult to identify because of its superficial
position
Dissect superficial to the fascia in order to
preserve the cervical nerves

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

38. Omohyoid muscle:
Made of two bellies, and is the anatomic
separation of nodal levels III and IV
The posterior belly is superficial to the brachial
plexus, phrenic nerve and transverse cervical
artery and vein
The anterior belly is superficial to the IJV

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

40. Thoracic duct:
Located in the lower let neck posterior to the
jugular vein and anterior to phrenic nerve and
transverse cervical artery
Have a very thin wall and should be handled
gently to avoid avulsion or tear leading to chyle
leak

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

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