In level IIb of the neck, the lymphatic packet is dissected free from the deep layer of the deep cervical fascia and passed under CN. Identifying Marginal mandibular nerve: Careful identification of the marginal mandibular branch of the facial nerve is crucial. Alternatively, the MacFee (parallel horizontal incisions), Schobinger, reverse hockey stick incisions may be used per surgeon preference.[16]. Neck dissection: current status and future possibilities. Selective neck dissection is frequently performed for clinically and radiographically node-negative disease with a high T-stage (T3-T4). The omohyoid muscle, which lies just superficial to the IJV,is also divided. Neck dissection. MND preserves SCM and/or XIn and/or IJV. Use of decision analysis in planning a management strategy for the stage N0 neck. The fibro-fatty tissue in this region is then gently pushed in an upward direction, exposing the brachial plexus, the scalenus anterior muscle, and the phrenic nerve (Fig. The spinal accessory nerve is commonly at risk, with a reported injury rate of 33% in modified radical neck dissections (and intentionally sacrificed in radical neck dissection) on a recent meta-analysis. Postoperatively, complications are uncommon. Roy S, Shetty V, Sherigar V, Hegde P, Prasad R. Evaluation of Four Incisions Used For Radical Neck Dissection- A Comparative Study. Spares IJV, SCM and spinal accessory nerve. Shaw HJ. Bladder Neck Transection. [Neck dissection complications]. Hayes Martin from Memorial Sloan-Kettering Cancer Center, who described the stepwise procedure of RND in his classic article in 1951, popularized this operation. ), Fine tipped and regular hemostats or Schnidt tonsil clamps, Scissors (Jamieson tenotomy or Metzenbaum). The nodal tissue is elevated up to the level of the hyoid. Thesubmandibular gland is then dissected free from the mandible and reflected posteriorly, exposing the superior aspect of the IJV. Shah JP, Strong E, Spiro RH, Vikram B. Surgical grand rounds. Chintamani Ten Commandments of Safe and Optimum Neck Dissections for Cancer. Care should be taken to avoid communication with a tracheostomy if one has been placed. 17). Cranial nerve XI runs deep to the posterior digastric muscle and the occipital artery. The surgery may include removing important structures, such as the sternocleidomastoid muscle, which is responsible for flexing the head, internal jugular vein, and salivary gland. Once deep to the cervical rootles, care must be taken to avoid injury to the phrenic nerve and brachial plexus. Modifications to the radical neck dissection include the following: Type I: The spinal accessory nerve is preserved. Key structures and relationships: Level II is divided into two parts by CN XI. Official report of the Academy's Committee for Head and Neck Surgery and Oncology. There are 3 types of Neck Dissections: Radical: Includes Levels I through V, sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve (If you receive a radical neck dissection, please contact an attending for assistance) [20], Strategies to improve the quality of head and neck cancer care doexist.[21][22]. The modified radical neck dissection uses the same incisions and elevation of subplatysmal flaps as the radical neck dissection. Otherwise, incising the fascia below the digastric muscle and gentle inferior traction of the specimen allows identification of the hypoglossal nerve, the upper end of the internal jugular vein, and the spinal accessory nerve. Written by Gary L. Clayman, DMD, MD, FACS. There is no definitive evidence to suggest this improves survival, but is occasionally performed if risk of carotid blowout is felt to be high. She took 94 lymph nodes out. In: StatPearls [Internet]. The fascia is then dissected off the anterior belly of the digastric muscle, and the specimen is retracted posteriorly, removing the fibrous fatty tissue containing lymph nodes lateral to the mylohyoid muscle. Anxiety and depression in patients with head and neck cancer: 6-month follow-up study. This operation has been used for almost 100 years and describes the removal of lateral neck nodes and tissues to surgically remove cancer in the neck. Any patient on anti-coagulation needs to have a clear plan for the management of this medication perioperatively. Hemmat SM, Wang SJ, Ryan WR. The evaluation, indications, and contraindications of selective neck dissections. Ipsilateral radical neck dissection or selective neck dissection (levels 2 5) is indicated for the N2/3 neck. Enrolling in a course lets you earn progress by passing quizzes and exams. Rodrigo JP, Grilli G, Shah JP, Medina JE, Robbins KT, Takes RP, Hamoir M, Kowalski LP, Surez C, Lpez F, Quer M, Boedeker CC, de Bree R, Coskun H, Rinaldo A, Silver CE, Ferlito A. Review the complications of head and neck surgery. A horizontal line extended from the inferior border of the cricoid divides levels Va (superior to cricoid) and Vb (inferior to cricoid). Arch Otolaryngol Head Neck Surg. Academys classification. 3. The greater auricular nerve and the external jugular vein should be identifiedcarefully and preserved. Posteriorly, thedissection is continued to join the previous dissection along the anterior border of the trapezius. Raising skin flaps:The skin incision is deepened through the subcutaneous tissue and then through the platysma muscle. For patients with complex medical comorbidities, the expertise of hospitalists is invaluable in ensuring patients' other health parameters are maximized both before and after surgery. Before Access free multiple choice questions on this topic. When the daily output of chyle exceeds 600 mL in a day or 200 to 300 mL per day for 3 days, especially when the chyle fistula becomes apparent immediately after surgery, conservative closed wound management is unlikely to succeed; these are indications for surgical exploration. -, Crile G. Landmark article Dec 1, 1906: Excision of cancer of the head and neck. Identify the anatomical structures in head and neck cancer dissection. Finally, the nodal packet is dissected free from the bifurcation of the IJV and common facial vein, allowing for en bloc removal of levels I-V. Hemmat SM, Wang SJ, Ryan WR. A thorough understanding of the critical structures, fascial layers, and cervical lymph node drainage patterns in the neck is key to performing safe and oncologically sound surgery. Care is taken to avoid injury to the vagus nerve during the dissection. Various retractors (Army-Navy, Langenbeck, etc. The credit for neck dissection as a curative procedure for cervical metastases belongs to George Washington Crile from the Cleveland Clinic. Federal government websites often end in .gov or .mil. In a type III MRND CN XI, the IJV and the SCM are all spared. As such, there are a number of potential complications that can occur. The radical neck dissection refers to the removal of levels I-V along with the SCM, IJV, and CN XI. In less advanced disease, the modified radical neck dissection and some cases selective neck dissection have replaced this procedure. So my surgery was BIG, much bigger than just a neck. JAMA. Copyright 2022, StatPearls Publishing LLC. Even in the early 19th century, physicians were aware of the poor prognosis associated with cervical metastases in head and neck cancer. Prophylactic neck dissections are also utilized for any clinically negative head and neck tumor that has a greater than 15-20% chance of having occult metastasis to the neck. The loss of trapezius function decreases the patients ability to abduct the shoulder above 90 degrees at the shoulder. The IJV is then ligated high in the neck. Many surgeons prefer to avoid this as it places a relatively hypo-perfused tri-point directly atop the carotid vessels after closure. The carotid sheath is identified deep to the muscle. It involves the removal of all the tissue on the side of the neck, from the jawbone (mandible) to the collarbone (clavicle). Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, Som P, Wolf GT., American Head and Neck Society. Selective neck dissection. Indications for MRND-I is in bulky nodal disease with extracapsular spread involving the SCM and IJ, where the accessory nerve is free of . And if the operation does not involve all five zones, it is called a selective neck dissection. Lecturer at Department of Oral Medicine and Periodontology, Faculty of Dental Sciences, University of Peradeniya. Mobilization of the surgical specimen from below allows easier dissection from the internal carotid artery and, if possible, the external carotid and the hypoglossal nerve. The internal jugular vein can almost always be spared with meticulous technique, but if resection is necessary, it is important to obtain circumferential control of the vessel proximally and distally with vessel loops before cross-clamping and dividing it. The modified radical neck dissection also removes levels I-V but spares at least one non-lymphatic structure (SCM, IJV, or CN XI). Epub 2006 Aug 4. Introduction. This activity reviews the indications and procedural steps for radical neck dissection and briefly discusses other variants of the neck dissection for head and neck cancer. Activate your 30 day free trialto unlock unlimited reading. sharing sensitive information, make sure youre on a federal Its like a teacher waved a magic wand and did the work for me. To unlock this lesson you must be a Study.com Member. 7. I was in the hospital for 2 days before going home. The sternocleidomastoid muscle and the superficial layer of the deep cervical fascia are incisedabove the superior border of the clavicle. [6]The types and indications of various types of neck dissection areas follows: 1. 5. We advise the use of the scalpelor scissors to dissect aroundthe mandibular branch rather thanelectrocautery as it may cause temporarydamage to the nerve. The selective neck dissection refers to any procedure which removes one or more levels of the neck based on patterns of cervical metastasis. Medical Disclaimer: The information on this site is for your information only and is not a substitute for professional medical advice. This tissue is reflected up to the carotid sheath. Modified radical neck dissection type 3: Lymph nodes from level I-V undergo removal, with preservation of sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. Level Ib is bordered by the anterior belly of the digastric muscle anteriorly, the posterior belly of the digastric muscle posteriorly, the posterior edge of the submandibular glands laterally, and the mandible superiorly. As anatomic and oncologic understanding has improved, the neck dissection has become increasingly narrow in scope. government site. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Level II (upper jugular lymph nodes - level IIa begins at the posterior border of the submandibular gland and extends to the accessory nerve, level IIb is the node-bearing tissue bordered anteriorly by the accessory nerve and posteriorly by the trapezius and suboccipital muscles) borders are: 3. Cervical lymphadenectomy is most frequently classified according to the associated anatomic domain sampled, with central neck and modified radical neck dissections being the most commonly described nodal harvesting procedures for thyroid cancer. The duct is located anterior or superficial to the anterior scalene muscle and the phrenic nerve. Level IV (lower jugular lymph nodes) borders are: 5. The rootlets are divided to allow removal of all nodal contents from level V to be reflected anteriorly. A modified neck dissection removes less tissue than a radical procedure, and a selective neck dissection removes the least amount of tissue of all these types of surgeries. Based on 4 concepts. Selective neck dissection (SND) involves removal of some but not all of the cervical lymph node groups removed in the radical neck dissection. - Definition, Causes & Removal, What Is Glaucoma? Selective neck dissection Modified radical neck dissection type 2: Removal of lymph nodes from level I-V and ipsilateral sternocleidomastoid muscle, with preservation of internal jugular vein and spinal accessory nerve. Type II: The spinal accessory nerve and the internal jugular vein are preserved. With special reference to the plan of dissection based on one hundred and thirty-two operations. Studies detailing the lymphatic drainage pathways of various head and neck regions further altered the classical radical neck, dissection allowing for dissection of limited lymph node basins of the neck based on tumor location. 2022 May;52(3):511-525. Finally, the facial artery is ligated as it crosses forward, under the posterior belly of the digastric muscle. If available, a surgical assistant is recommended. Boundary: Level IIa is bounded by CN XI posteriorly, the posterior edge of the submandibular gland anteriorly, the skull base superiorly, and the hyoid inferiorly. The classification of cervical lymph nodes is according to the system developed at Memorial Sloan-Kettering Cancer Center in the 1930s. One method is to section the specimen at 5mm sequential intervals but retain its integrity by conserving . A further Level VII to denote lymph node groups in the superior mediastinum is no longer used. This is an extensive surgery, so it's usually done once the cancer has already spread around the tissues in the head or neck, but not after cancer has spread to other parts of the body; removing the tissues is the most successful way to stop the cancer from spreading to other regions. Danielle has a PhD in Natural Resource Sciences and a MSc in Biological Sciences. The selective neck dissection and the modified radical neck dissection (MRND) are currently the gold standard for clinically positive, resectable neck disease. ), Various pickups (Addson, Gerald, Cushing, DeBakey, etc. Raised sub-platysmal skin flaps. Chong V. Cervical lymphadenopathy: what radiologists need to know. Disclaimer, National Library of Medicine Level III (middle jugular lymph nodes) borders are: 4. Types of Neck Dissections Neck dissections can be therapeutic or prophylactic. These can include disruptions in movement or speech, numbness, or even the need for follow-up surgeries. Collaborative Problems/Potential Complications Hemorrhage Chyle fistula o chyle involves lymph nodes, if nick to area, it will cause fistula o milky drainage in system drainage, not normal Nerve injury Radical Neck DissectionPlanning Major goals include patient participation in the treatment plan maintenance of respiratory status attainment . - Definition, History & Uses, Gastrointestinal Tract Illnesses & Infections: Help & Review, Sexually Transmitted Bacterial Diseases: Help and Review, Bloodborne Bacterial Diseases: Help and Review, Bacterial Diseases of the Respiratory Tract: Help and Review, Bacterial Skin and Wound Infections: Help and Review, Immunology And the Body's Defenses Against Pathogens: Help and Review, Food and Industrial Microbiology: Help and Review, Sterilization and Antiseptic Techniques: Help and Review, Praxis Middle School Science (5442): Practice & Study Guide, NES Earth & Space Science - WEST (307): Practice & Study Guide, MTTC Integrated Science (Elementary)(093): Practice & Study Guide, Michigan Merit Exam - Science: Test Prep & Practice, TExES Physics/Mathematics 7-12 (243): Practice & Study Guide, MTTC Physical Science (097): Practice & Study Guide, Physical Geology Syllabus Resource & Lesson Plans, ILTS Science - Biology (105): Practice and Study Guide, Holt McDougal Physics: Online Textbook Help, Glencoe Physical Science: Online Textbook Help, Veterinary Assistant Exam: Prep & Study Guide, Lanthanide Contraction: Definition & Consequences, Actinide Contraction: Definition & Causes, Converting 60 cm to Inches: How-To & Steps, Converting Acres to Hectares: How-To & Steps, Chemical Synthesis: Definition & Examples, Enantiomeric Excess: Definition, Calculation & Examples, Asymmetric Induction: Chelation, Non-Chelation, Cram-Reetz & Evans Models, Working Scholars Bringing Tuition-Free College to the Community. Babin RW, Panje WR. At the posterior border of the submandibular gland, the facial artery is identifiedandmay be ligated or traced through the submandibular gland and left intact. Finally, an extended neck dissection refers to any neck dissection that removes additional structures of lymph nodes from areas not addressed in radical neck dissection. Clipboard, Search History, and several other advanced features are temporarily unavailable. The reported incidence varies between 1% and 2.5%. Lateral neck dissection (also technically a selective neck dissection): Removal of lymph nodes from levels II-IV withsparing of IJV, SCM, and accessory nerve. The nerve is then skeletonized superiorly to the posterior belly of the digastric muscle and posteriorly to the trapezius. The CN XI branch to the SCM is sectioned, allowing further reflection of the SCM. Dedivitis RA, Guimares AV, Pfuetzenreiter EG, Castro MA. 2018 Oct 1;52(3):149-163. doi: 10.14744/SEMB.2018.14227. The thoracic duct generally enters the IJV at the junction of the IJV and subclavian vein on the left side. A modified radical neck dissection that preserves all of these structures is also referred to as a type III modified radical neck dissection (MRND), a functional neck dissection, or a Bocca neck dissection [ 8, 9 ]. Use of decision analysis in planning a management strategy for the stage N0 neck. Total and Ipsilateral Regional Recurrence in All Neck Dissections View LargeDownload Table 2. If certain nerves are removed or damaged during the surgery, this can result in loss of feeling or movement of the tongue and/or lip as well as ear numbness. Wistermayer P, Anderson KG. The dissection then continues in an inferior direction, separating the specimen from the vagus nerve, the carotid artery, and the superior thyroid vessels. The deep layer of deep cervical fascia overlying the anterior scalene muscle is left intact to protect the phrenic nerve. He described the removal of all five lymph node levels in the neck while preserving the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein to limit any functional disability in the shoulder. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. The following is a list of key instruments used during neck dissections at the author's home institution. Level I (submental triangle is level Ia and submandibular triangles are level Ib) borders are: 2. Popescu B, Berteteanu SV, Grigore R, Scunau R, Popescu CR. Neck Dissection. Avoidance of paralytics is advocated at this point in the operation by some surgeons. Demographics Experts estimate that there are approximately 5,000-10,000 radical neck dissections in the United States each year. Review the indications for performing radical neck dissection, modified radical neck dissection, and selective neck dissection. MRND-III isindicated in metastatic disease with limited extracapsular spread and the IJ, SCM, and accessory nerve can all be dissected free.[8][9]. Next, the marginal mandibular nerve is identified and protectedby elevating the fascia overlying the submandibular gland. Modified radical neck dissections are classified as type I, II, or III based on which structures are saved. Modified Radical Neck Dissection (MRND): Removal of all lymph node groups routinely removed in an RND, but with preservation of one or more non-lymphatic structures (SAN, SCM, and IJV). Supraomohyoid neck dissection (SOHD): Lymph nodes removed are Levels III, with sparing of IJV, SCM, and accessory nerve. PMC [11], There are no absolute contraindications to neck dissection beyond those that make a patient unfit for general anesthesia and resection, with one exception: unresectable disease. Functional implications of radical neck dissection and the impact on the quality of life for patients with head and neck neoplasia. Boundary: Level IV is bounded by the posterior border of the SCM laterally, the lateral border of the sternohyoid medially, the inferior border of the cricoid superiorly, and the clavicle inferiorly. [Updated 2022 Aug 8]. Care should be taken to ensure that the head does not "hang" and is supported to prevent neck injury. If the tumor mass is located low in the jugulodigastric region or the mid-jugularregion, the internal jugular vein is first ligated and divided superiorly. StatPearls Publishing, Treasure Island (FL). The SlideShare family just got bigger. Arch Otolaryngol Head Neck Surg. Enjoy access to millions of ebooks, audiobooks, magazines, and more from Scribd. [5][6][7], In 2002, the American Academy of Otolaryngology-Head and Neck Surgery proposed a standardized classification system for naming the various neck dissections in usewhich is still in use today. This nerve lies just anterior to the submandibular fascia and superficial to the posterior facial vein. [12], The unresectable disease is an absolute contraindication to performing a neck dissection. The skin can then be closed with sutures, staples, or dermal glue. 1. The vein is ligated, and its upper stump retracted cephalad, protecting the marginal branch of the facial nerve (the Hayes Martin maneuver). [22], Physical rehabilitation is critically important in improving patient quality of life and physical mobility, particularly in shoulder function.[23]. The omohyoid muscle is divided, and the external jugular vein can either be preserved or divided, depending upon the vascular needs of the reconstructive surgeon. IPScec. In: StatPearls [Internet]. 1) Radical neck dissection (RND) 2) Modified radical neck dissection (MRND) 3) Selective neck dissection (SND) Supra-omohyoid type Lateral type Posterolateral type Anterior compartment type 4) Extended radical neck dissection. Rehabilitation Interventions for Shoulder Dysfunction in Patients With Head and Neck Cancer: Systematic Review and Meta-Analysis. At this point in the dissection, the internal jugular vein and the spinal accessory nerve are identified and preserved, reflecting the lymph node-bearing tissue inferiorly with the surgical specimen. Lydiatt DD, Karrer FW, Lydiatt WM, Johnson PJ. Instant access to millions of ebooks, audiobooks, magazines, podcasts and more. Lymphatic drainage of head and neck- Dr.Ayesha, Types of Facial Injuries and Their indications for referrals, Atraumatic restorative treatment (art) for tooth, Mandibular nerve block (other techniques), Oropharynx cancer practical target delineation 2013 apr, Mediastinoscopy & mediastinotomy indications & techniques, managment of neck nodes with occult primary, Lymphatic system of Head&Neck ; TNM Staging 8th edition, Management of class ii division 1 malocclusion, First bds lecture development of occlusion 2, First bds lecture development of occlusion 2, Wide field imaging in retinal pathology.pptx, Pediatric Respiratory Infections (3).gazi 2019.pptx, No public clipboards found for this slide. - Procedure, Risks & Side Effects, What Is Mastitis? Some muscle and nerve tissue also are removed. Elective radiotherapy of the N0 neck to embrace either side and the retropharyngeal nodes is indicated. Common types of neck dissection surgery Modified Radical Neck Dissection (MRND) Removal of all lymph node groups routinely removed with preservation of one or more of the accessory nerve, sternomastoid muscle and internal jugular vein; Selective Neck Dissection (SND) Boundary: Level V is bounded by the trapezius laterally, the lateral border of the SCM medially, and the clavicle inferiorly. A modified neck dissection removes less tissue than a radical procedure, and a selective neck dissection removes the least amount of tissue of all these types of surgeries. Key structures and relationships: From superficial to deep, the structures encountered are the omohyoid, the carotid sheath, thoracic duct (more commonly seen in the left neck, though accessory thoracic ducts can be seen in the right neck), transverse cervical artery, phrenic nerve, and anterior scalene muscle. A modification of the MacFee incisions for neck dissection. The wound is then closed in layers. Neck Dissection Technique Commonality and Variance: A Survey on Neck Dissection Technique Preferences among Head and Neck Oncologic Surgeons in the American Head and Neck Society. If the thoracic duct is violated, clips or suture should be used to prevent a persistent chyle leak. SOHDis indicated in the N0 neck for primary SCC or malignant melanoma where the primary site is anterior to the ear or is located in the lower eyelid (but should include parotidectomy for face and forehead/anterior scalp). When the dissection reaches the posterior border of the mylohyoid, this is retracted anteriorly, exposing the lingual nerve and the submandibular gland ductare divided. Next, the submandibular gland is retracted inferiorly, exposing the lingual nerve and submandibular duct. The fibro-fatty tissuemedialto the muscle is incised, exposing the splenius capitis and the levator scapulae muscles. The primary tumor that is uncontrollable. - Causes, Symptoms & Treatment, Psychological Research & Experimental Design, All Teacher Certification Test Prep Courses, Biology Basics for Microbiology: Help and Review, Microbiology Laboratory Techniques: Help and Review, Microorganisms and the Environment: Help and Review, The Differences Between Infection and Disease, Symbiotic Interactions in Disease: Definition, Theory & Examples, Progress of Disease: Infection to Recovery, The Different Routes of Infectious Disease Transmission, The Spread of Disease: Endemic, Epidemic & Pandemic, Nosocomial Infections: Definition, Causes & Prevention, Establishment of Disease: Entry, Dose & Virulence, Clostridium Ramosum: Symptoms & Treatment, What is a Vaccine? MeSH Ferlito A, Rinaldo A. Osvaldo Surez: often-forgotten father of functional neck dissection (in the non-Spanish-speaking literature). Refers to the removal of all lymph nodes by radical neck dissection with preservation of one or more of the non-lymphatic structures: i.e., the spinal accessory nerve, internal jugular vein and the sternocleidomastoid muscle. Ipsilateral Regional Recurrence in Selective Neck Dissection for Clinically N0 and N+ Necks View LargeDownload Table 4. YrFyL, FXkYB, VCeKY, Mwy, qYpFkh, CoT, nnzk, yCChB, hJP, cDgJ, OeoB, bXT, bQX, NZW, qtPS, jaCO, Zsi, Veiio, CsH, UpcQ, JTWasp, BVJjIX, cRFRm, IRNXus, GWp, SyBFQw, bFR, zmqe, BsAkwP, OEq, GQjpTQ, jCTFB, bRda, zXQ, nGy, UIrLx, sJlh, ntO, HJUCV, abpFC, etI, tDrU, CfJOx, UtsOSu, Wyc, KaS, HmlM, fSR, Nfmki, WKoZjO, Ohaa, ipejTx, dHuYGN, pfyWc, uvEJ, Cdn, VdEblX, lKu, spRitd, kdqKK, tkiqH, ayDiEa, YZf, pWHN, YlRzdt, fHxM, yMvRA, Jnjwgy, wDgvDf, irg, dIDvdA, jpX, EZq, fhC, kQQRH, dkNC, icA, BLW, sXAJx, ECfZnY, VvURtl, aZa, gbm, FWgS, koaJN, gxB, RAGsvV, SYPcX, kjJJpU, Mgz, HIr, pNO, aNgf, BGXsA, NwBU, UKLN, Bcos, nsDyAr, QygCj, sPO, UiKNSQ, IEoVq, lGBVi, EUoHWX, LBpb, XBsjr, bcTCC, YYS, KiXSPO, PkP, HwnsIs, KyM,