Principles of Neck Dissection

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Principles of Neck Dissection

Head and Neck Surgery
Author Credentials 

Laureano A. Giráldez Rodríguez, MD
Adjunct Faculty
University of Puerto Rico Department of Surgery
Otolaryngology – Head and Neck Surgery Section

Module Summary

Cervical lymphanedectomy was described by Kocher in 1880. Neck dissection has become standard surgical treatment for the staging and treatment of head and neck metastasis of the upper aerodigestive tract. Current management of head and cancer demands thorough understanding of the anatomy and indication, as well as, the surgical technique that involves neck dissection.

Module Learning Objectives 
  1. Review the anatomy of the neck from a radiologic perspective (Ultrasound, CT Scan, MRI).
  2. Explain the staging of neck malignancy based on their etiology.
  3. Recognize the principal surgical landmarks of neck levels I-IV.
  4. Review the role of Fine Needle Aspiration Biopsy, Excisional and Incisional Biopsy in the diagnosis of neck masses.
  5. Describe the role of MRI, CT and PET/CT scan in evaluation and treatment of metastatic neck disease.
  6. Describe the approach and incisions to all different types of neck dissection.
  7. Recognize the patterns of nodal drainage of primary sites and their implications for neck dissection (i.e. salivary gland, sinus/paransal sinus, lip/oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, non-melanoma skin malignancy, and thyroid).
  8. Review the role of imaging in short and long-term follow up of neck metastatic disease.

Anatomy

Learning Objectives 

Understand the different clinical and radiologic anatomic lymph node levels, boundaries and implications for surgery.

  • Level Ia and Ib (Subemntal and Submandibular)
  • Level IIa and IIb (Upper jugular nodes)
  • Level III (Middle Jugular Nodes)
  • Level IV (Lower jugular nodes)
  • Level Va and Vb (Posterior triangle)
  • Level VI (Anterior compartment)
References 
  1. Rouviere H. Anatomie des Lymphatiaues de l’Homme (Anatomy of the Human Lymphatic System). Paris: Masson et Cie, 1932.
  2. Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer. 1972;29:1446-1449.
  3. Byers RM. Modified neck dissection. A study of 967 cases from 1970 to 1980. Am J Surg. 1985;150:414-421.
  4. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg. 1990;160:405-409.
  5. Fisch UP, and Sigel ME. Cervical lymphatic system as visualized by lymphography. Ann Otol Rhinol Laryngol. 1964;73:870-882.

Surgical Therapies

Learning Objectives 
  1. Discuss and dominate the different types of neck dissection for head and neck metastatic disease.
  2. Discuss the different types of incisions for head and neck dissections
    1. Open Neck Biopsy 
    2. Selective Neck Dissection (Supraomohyoid I-III; with and without level IIb) 
    3. Selective Neck Dissection (Lateral II-IV; with and without level IIb) 
    4. Selective Neck Dissection (Posterolateral II-V) with dissection of CN XI in the posterior triangle 
    5. Posterior lateral neck dissection (to include suboccipital and retroauricular nodes) 
    6. Modified Radical Neck Dissection (Types I, II, III) 
    7. Radical Neck Dissection (familiarity with sacrifice of CN XI, SCM, IJV)
    8. Central Neck Dissection
    9. Extended Neck Dissection
    10. Sentinel Lymph Node Biopsy
References 
  1. Jesse RH, Ballantyne AJ, and Larson D. Radical or modified neck dissection: a therapeutic dilemma. Am J Surg. 1978;136:516-519.
  2. Byers RM. Modified neck dissection. A study of 967 cases from 1970 to 1980. Am J Surg. 1985;150:414-421.
  3. Byers RM, Weber RS, Andrews T, et al. Frequency and therapeutic implications of “skip metastases” in the neck from squamous carcinoma of the oral tongue. Head Neck. 1997;19:14-19.

Staging

Learning Objectives 
  1. Describe neck nodal staging for upper aerodigestive tract malignancies.
    1. salivary gland
    2. sinus/paransal sinus
    3. lip/oral cavity
    4. nasopharynx
    5. oropharynx
    6. hypopharynx
    7. larynx
    8. non-melanoma skin malignancy
  2. Describe staging for thyroid malignancies.
References 
  1. Xu JJ, Yu E, McMullen C, Pasternak J, Brierley J, Tsang R, Zhang H, Eskander A, Rotstein L, Sawka AM, Gilbert R, Irish J, Gullane P, Brown D, de Almeida JR, Goldstein DP. Patterns of regional recurrence in papillary thyroid cancer patients with lateral neck metastases undergoing neck dissection. J Otolaryngol Head Neck Surg. 2017 May 31;46(1):43. 
  2. Eskander A, Merdad M, Freeman JL, Witterick IJ. Pattern of spread to the lateral neck in metastatic well-differentiated thyroid cancer: a systematic review and meta-analysis. Thyroid. 2013 May;23(5):583-92. 

Complications

Learning Objectives 

Understand the major complications of neck dissection before and after radiotherapy.

  1. Carotid artery blowout
  2. Blindness
  3. Facial cerebral edema
  4. Air leaks
  5. Bleeding
References 
  1. Crumley RL, and Smith JD. Postoperative chylous fistula prevention and management. Laryngoscope. 1976;86:804-813.
  2. Spiro JD, Spiro RH, and Strong EW. The management of chyle fistula. Laryngoscope. 1990;100:771-774.
  3. Royster HP. The relation between internal jugular vein pressure and cerebrospinal fluid pressure in the operation of radical neck dissection. Ann Surg. 1953;137:826-832.
  4. Sugarbaker ED, and Wiley HM. Intracranial-pressure studies incident to resection of the internal jugular veins. Cancer. 1951;4:242-250.
Resources 

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  1. Annual Meeting Webcast (AMW):