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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 N0 in recent studies may require
selective RND to reduce morbidity
NX: Regional lymph nodes can not be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph nodes, 3
cm or less in greatest dimension N2:
N2a:▪ Metastasis in a single epsilateral lymph nodes, more
than 3 cm but less than 6 cm
N2b:▪ Metastasis in multiple ipsilateral lymph
nodes, not more than 6 cm N2c:▪ Metastasis in bilateral or contralateral nodes
not more than 6 cm in diameterN3:
Metastasis in lymph nodes more than 6 cm in in greatest diameter
Meyers & Eugene: Operative Otolaryngology. 1997Meyers & Eugene: Operative Otolaryngology. 1997
Region I: Submental and submandibular triangle▪ Ia: Submental triangle:▪ Bounded by the anterior belly of digastric and the
mylohyoid muscle deep
▪ Ib: Submandibular triangle:▪ Formed by the anterior and posterior belly of the
digastric muscle and the body of the mandible
Memorial Sloan-kettering Cancer center
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
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
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
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
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
The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type:
1. Radical Neck Dissection (RND)2. Modified Radical Neck Dissection (MRND)3. Selective Neck Dissection (SND)
1. Supraomohyoid2. Posterolateral3. Lateral 4. Anterior
4. Extended Radical Neck Dissection (ERND)
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)
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
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 SCMMedina
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
Extended neck dissection: Any previous dissection and including
one or more additional lymph node groups and/or non-lymphatic tissues
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
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%
Radical Neck Dissection
1. Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN
2. Large metastatic tumor mass or multiple matted in upper part of the neck▪ Tumor should not be dissected to preserve
Structures
Modified radical neck dissection
MRND Type I:1. Clinically obvious neck lymph nodes
metastasis and SAN not involved by tumor2. Intraoperative decision just like
preservation of the facial nerve in parotid surgery
MRND Type II:1. Rarely planned2. Intra-operative decision for tumor found
adherent to SCM but away from SAN & IJV MRND Type III:
Depend on the autopsy reports1. Lymph nodes were in the fibrofatty and do not share
the same adventitia with blood vessels2. They are not found within the aponeurosis or
glandular capsule of the submandibular “Functional neck dissection”
MRND Type III: For treatment of N0 neck nodes
Indicated for N1 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
Selective/elective neck dissection: For treatment of N0 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 N0 and N1 with palpable mobile nodes less than 3 cm and located in level I and II
Upgrade intra-operatively following positive frozen section
ObserveRadiation therapyElective neck dissection
Low morbidity Staging neck for possible extended
surgery Need for post-operative radiotherapy
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
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
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 ▪ NO 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
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
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
A good option for N0 neckNot 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
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
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
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
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
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
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
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 11th cranial nerves and the IJV lie medial
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
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
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
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
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