Since then, many retrospective studies have repeatedly demonstrated the oncologic safety in preserving these structures. Fig. Prompt identification and treatment of a chyle leak are essential for optimal surgical outcome. Radical neck dissection is performed for the surgical control of You may be able to take showers (unless you have a drain near your incision). Lymph nodes are small, round or bean-shaped glands that act like filters and remove germs from your body, help fight infection, and trap cancer cells. RND imparts considerable comorbidity to the patients and should be avoided when oncologically possible. As a general rule, selective neck dissection is performed in patients with cancer arising in the head and neck region who are considered at risk for metastatic disease in the regional cervical lymph nodes. 10.2a). If disease may not be cleared even with extended RND, the morbidity of the surgery may not be justified. This nerve lies just anterior to the submandibular fascia and superficial to the posterior facial vein. The procedure is indicated for patients with bilateral cervical lymph node metastases so situated that a two-stage radical neck dissection could not be done without cutting through cancer tissue. How long you stay depends on why you need surgery and how much tissue was taken out. This procedure has an indication of therapeutic neck dissection for thyroid cancer with lateral neck nodes 13). If you take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, be sure to talk to your doctor. 1981;11(1):25-33, Yagi S, Suyama Y, Fukuoka K, Takeuchi H, Kitano H. Recipient Vessel Selection in Head and Neck Reconstruction Based on the Type of Neck Dissection. The sutures or staples will be removed at this time. It is possible that not all three structures (SAN, IJV, and SCM) implicit in RND need to be resected in every patient who has had a previous neck dissection or radiation. Your doctor or physiotherapist will help you with this. For most people, these problems go away in 6 to 12 months. This procedure causes considerable morbidity, predominantly from shoulder dysfunction, and numerous studies have since demonstrated that the surgical preservation of non-invaded structures was oncologically sound. Most people are able to go back to work in 2 to 3 weeks. Rachel Giese and Richard Wong 2007 Apr;27(2):309-16, Gogna S, Gupta N. Cancer, Neck Resection and Dissection. We have in the past evaluated the morbidity and survivals in stomal cases and present here our revised indications and techniques. You may always feel a little numb, stiff, or weak in some areas. That is, preferably, the disease will be surrounded by nondiseased (normal) tissue. Neck Dissection Jatin P. Shah Ian Ganly Introduction The single most important factor affecting prognosis of squamous cell carcinoma of the head and neck, the sixth most common cancer worldwide, is the status of the cervical lymph nodes. If a neck muscle was removed, your neck may look flatter or thinner. You may also needSupraomohyoid Neck DissectionModified Radical Neck DissectionNeck Dissection for Thyroid CarcinomaClinical Assessment of Neck LymphadenopathiesSalvage Neck Dissection: Indications, Workup, and Technical ConsiderationsHistory/Classification of Nodal Levels and Neck DissectionsNeck Dissection for Salivary Gland MalignanciesComplications of Neck Dissection For example, if the carotid artery is involved and cannot be safely sacrificed or when sacrifice of the carotid is not guaranteed to remove all disease in the neck, it may be wiser to consider nonsurgical options including systemic therapy, radiation therapy, or entry into a clinical trial. You have cancer of the mouth, tongue, thyroid gland, or other areas of the throat or neck. The specimen encompassed lymph nodes and fibrofatty tissue spanning levels I to V and includes the spinal accessory nerve (SAN), sternocleidomastoid muscle (SCM), and internal jugular vein (IJV). Finally, the facial artery is ligated as it crosses forward, under the posterior belly of the digastric muscle. When neck dissection is indicated and a surgeon lacks the expertise, refer to another centre for neck dissection. Indications for this procedure are in N0 neck for squamous cell carcinoma (SCC) of larynx and hypopharynx. If cancer has not spread far, fewer lymph nodes have to be removed. One example may be a metastasis that is immobile in preoperative clinical evaluation because it is adherent to the SCM. Simultaneous bilateral radical neck dissection is an operation entailing acceptable risk if used in propertly selected cases. The loss of trapezius function decreases the patient’s ability to abduct the shoulder above 90 degrees at the shoulder. }, author={A. Ohshima and H. … google_ad_client: "ca-pub-9759235379140764", Indications for bilateral modified radical neck dissection in patients with papillary carcinoma of the thyroid. 6 Radical Neck Dissection Head Neck. The standardization of terminology is important to communicate to other practitioners which levels were dissected and which structures were resected for postoperative management. The fibro-fatty tissue medial to the muscle is incised, exposing the splenius capitis and the levator scapulae muscles. Careful identification of the marginal branch of the facial nerve is crucial. Neck dissection is indicated for metastatic disease in the superficial or deep cervical fasciae of the neck. This depends on your job and the extent of your surgery. You may be given stretching exercises to do at home. Radical neck dissection is indicated when the neck is lymph node positive for squamous cell carcinoma (SCC) where spinal accessory nerve involved and/or extensive soft tissue disease with the invasion of sternocleidomastoid muscle and internal jugular vein 9). Acta Otorhinolaryngol Ital. The first reports of removal of neck metastases came from independent efforts of four European surgeons: von Langenbeck, Billroth, von Volkmann, and Kocher.1 Later, Sir Henry Butlin demonstrated that surgically removing metastases from the neck for oral cavity cancer improved survival. The cancer could spread to other parts of the body. The vein is ligated, and its upper stump retracted cephalad, protecting the marginal branch of the facial nerve. Neck dissection does not increases the risk of stroke in thyroid cancer: A national cohort study. One or two suction drains should remain in place. The drain(s) should not rest immediately over the carotid artery or in the area of the thoracic duct. Your health care provider will give you a prescription for pain medicines. The lymph nodes are removed to prevent cancer from spreading to other parts of your body. It is important to note not all cervical nodal disease may be surgically resectable. Level III (middle jugular lymph nodes) borders are: 4. In 1888, a Polish surgeon, Franciszek Jawdynski, reported on a procedure similar to a radical neck dissection (RND). An RND is now performed only when necessary due to the extent and growth pattern of the disease. You are choking or coughing when you eat or swallow. If one side of your face or mouth is weaker, chew food on the stronger side of your mouth. 6.3, Fig. As a general guideline, if a structure is not clearly involved by disease, and a clean resection can be achieved, then it should be structurally preserved. Posteriorly the greater auricular nerve and the external jugular vein overlying the sternocleidomastoid muscle come into view as the elevation of the flap continues. Indications for radical neck dissection following radiation therapy. Regarding indications for RND, some patients may have such extensive disease that more extended resection is needed than a traditional RND. Conversely, some neck dissections may require removal of parapharyngeal and paraspinal lymphatics that are not included in the levels I to V of the RND. To help get ready for going home, you may have received help with: You may leave the hospital with stitches in your cut (incision). In 1900, he performed different types of neck dissections and subsequently described the classic operation of radical neck dissection in his seminal article of 1905 published in the Transactions of the Southern Surgical and Gynecological Association. PLoS One. 2004 Jul;114(7):1177-8. If you have not had a bowel movement after a couple of days, ask your doctor about taking a mild laxative. The thoracic duct is the primary structure that returns lymph and chyle from the entire left and right lower half of the body 16). Try to walk every day. Radical neck dissection is the standard; Exceptions Preserve spinal accessory nerve when adequate tumor removal is not compromised. Some have suggested that RND is appropriate routinely for N3 disease of the upper neck, invasion of the SAN, and/or recurrent or persistent disease following definitive radiotherapy, chemoradiotherapy, or previous selective neck dissection.9 Presumably, the recommendation of RND for all N3 diseases implies that a 6-cm metastasis would encompass the SAN and involve the SCM and IJV due to the confined anatomy of the neck and restricted space for spread. The standardization of terminology is important to communicate to other practitioners which levels were dissected and which structures were resected for postoperative management. Stating that a patient had an RND accurately transmits the idea of extensive or invasive metastatic nodal disease in the neck. Because there were so many variations between lymphatic levels and structures sacrificed, the American Head and Neck Society (AHNS) standardized the terminology for classification of neck dissection in 1991 and there have been multiple revisions thereafter.6 Most recently, the AHNS defined the RND as a cervical lymphadenectomy including en bloc removal levels I to V, the IJV, SCM, SAN, and the submandibular gland.7 According to the AHNS classification, any neck dissection that preserves the three structures should be termed a “modified RND” and preserved structures should be stated when naming the procedure, an adaptation of Medina’s terminology for structures preserved published in 1989. This classical surgical procedure involves not only resection of level I to V lymph nodes of the neck but also the tail of the parotid, submandibular gland, sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. J Laryngol Otol. Your doctor will tell you how to take care of it. If your doctor told you how to care for your incision, follow your doctor’s instructions. In this manner equal emphasis can be given to the primary cancer, You can shower after you return home. The recent trend has been away from elective neck dissection in the management of patients with cancer of the head and neck. The flap is elevated up to the anterior border of the trapezius muscle. A modification of the MacFee incisions for neck dissection. patient. CT or MRI images with intravenous contrast should be carefully evaluated to assess relationships between nodal disease and normal structures ( Fig. The lymph system carries white blood cells around the body to fight infection. MARTIN H, DEL VALLE B, EHRLICH H, CAHAN WG. FIGS. Early surgeries resulted in serious complications and morbidity. It is possible that not all three structures (SAN, IJV, and SCM) implicit in RND need to be resected in every patient who has had a previous neck dissection or radiation. The classification of cervical lymph nodes is according to the system developed at Memorial Sloan-Kettering Cancer Center in the 1930s 4). 6.3, Fig. At this point in the dissection, the internal jugular vein and the spinal accessory nerve are divided if the location and extent of the tumor permit it. Some have suggested that RND is appropriate routinely for N3 disease of the upper neck, invasion of the SAN, and/or recurrent or persistent disease following definitive radiotherapy, chemoradiotherapy, or previous selective neck dissection.9 Presumably, the recommendation of RND for all N3 diseases implies that a 6-cm metastasis would encompass the SAN and involve the SCM and IJV due to the confined anatomy of the neck and restricted space for spread. The posterior flap is then raised in the subplatysmal plane by applying traction to the flap with skin hooks and counter-traction of the deeper soft tissues. Clin Bull. In most dissections, this means the disease is within the capsule of the lymph node, but this is not typical of nodal disease in most cases requiring RND. Your doctor will tell you if you need to return to have these removed. Do not stop taking them just because you feel better. The following chapter addresses the history, techniques, morbidity, post-operative considerations, and potential complications of a radical neck dissection. In: StatPearls [Internet]. Getting enough sleep will help you recover. Radical Neck Dissection: (RND) Classification, Indication and Techniques May consider selective Levels I, II, III, IV neck dissection if a solitary small Level I lymph node is involved (N 1). DO NOT scrub or let the shower spray directly on your wound. You may have a drain near your incision. You may still have a tube called a drain in your neck. The sternocleidomastoid muscle and the superficial layer of the deep cervical fascia are incised above the superior border of the clavicle. 6.1). The radical neck dissection was originally described by George Crile Sr in 1906. End results of a prospective trial on elective lateral neck dissection vs type III modified radical neck dissection in the management of supraglottic and transglottic carcinomas. When you lie down, put 2 or 3 pillows under your upper back and shoulders so that your neck and head are supported. Don’t use hydrogen peroxide or alcohol, which can slow healing. However, it is now these operations are carried out effectively with a single skin crease incision in the mid-neck of sufficient length. INDICATIONS. Stating that a patient had an RND accurately transmits the idea of extensive or invasive metastatic nodal disease in the neck. The most notable complications observed in patients who have undergone a radical neck dissection are related to removal of the spinal accessory nerve. Neck dissection is surgery to examine and remove the lymph nodes in the neck. The initial concept of surgically removing cervical lymphatics en bloc represented a major conceptual advance in oncology. Superselective neck dissection is described as dissection of only one or two contiguous nodal stations primarily to reduce the morbidity of neck dissection. However, the specific relationships between disease and each anatomic structure in the neck should be better evaluated on a case-by-case basis, and adaptations and consideration of risks of involvement of each structure must be applied to each individual patient. You can eat your regular foods unless your doctor has given you a special diet. Early surgeries resulted in serious complications and morbidity. Continue to do this 2 or 3 times a day after you go home. : Radical Head and Neck Surgery in Irradiated Patients , Surg Clin N Amer 45:567-572 ( (June) ) 1965. 2018;13(3):e0195074. If disease may not be cleared even with extended RND, the morbidity of the surgery may not be justified. Removal of levels II–V, suboccipital, retro-auricular nodes with sparing of squamous cell carcinoma (SCC). However, in cases with extracapsular spread, the resection of adjacent structures such as SCM, IJV, and SAN may be required to get a “margin” around the disease, justifying the RND. Take your pain medicine 30 minutes before meals. Indications for neck dissection or irradiation in parotid cancers. Documentation of arm and shoulder range of motion and strength should be made prior to surgery to assess SAN and brachial plexus function. Corgill, D.: Complications of Neck Dissections, International Workshop on Cancer of Head and Neck, New York, May 1965. The duct is located anterior or superficial to the anterior scalene muscle and the phrenic nerve. On account of this widely demonstrated fact, management of neck disease in head and neck cancer has been considered one of the most important aspects of treatment. Abstract Ultimately, the surgeon needs to discuss the options with the patients and tailor individualized treatment to each patient’s particular clinical situation. 2011 Jan-Feb;77(1):65-9. The term “modified RND” refers to preservation of nonlymphatic structures, whereas the term “selective neck dissection” refers to preservation of levels of lymphatics. Make sure your home is safe while you are recovering. However, the specific relationships between disease and each anatomic structure in the neck should be better evaluated on a case-by-case basis, and adaptations and consideration of risks of involvement of each structure must be applied to each individual patient. Goodwin WJ Jr, Chandler JR. That is, preferably, the disease will be surrounded by nondiseased (normal) tissue. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536998. Laryngoscope. 6.1 Depressed right shoulder following radical neck dissection with resection of the spinal accessory nerve. The goal of curative oncologic surgery should be the complete removal of all neoplastic tissue. Removal of levels II to V lymph nodes with relative sparing of sternocleidomastoid muscle, internal jugular vein, spinal accessory nerve and submaxillary gland. }); Park B, Min C, Choi HG. More recent modifications of neck dissection are now performed that selectively remove the lymph nodes in the anatomic levels that are at highest risk for harboring metastatic nodal disease while preserving key structures, and carry much less morbidity. The lymph nodes are removed to prevent cancer from spreading to other parts of the body and to decide if any more treatment is needed. Try to avoid constipation and straining with bowel movements. 1977 May;87 (5 Pt 1 ... Over 60 transsternal radical neck dissections have been performed in the past 20 years. The high incidence rate of occult cervical metastases (> 20%) in tumors of the lower part of the oral cavity is the main argument in favor of elective treatment of the neck. Your doctor may recommend neck dissection procedure if: More than 50% of patients with squamous cell carcinoma (SCC) of the oral cavity have lymph node metastases and histological confirmation of metastatic disease is the most important prognostic factor 2). Supraomohyoid neck dissection is indicated in N0 neck for squamous cell carcinoma (SCC) of oral cavity and oropharynx (include level 4) and N0 neck malignant melanoma where primary site is anterior to ear (include parotidectomy for face and scalp). 6.4 Preoperative Counseling and Evaluation Although neck dissections are not pathologically assessed for margins unless it is an en bloc resection of direct tumor spread, surgeons have applied the same reasoning that is used in tumor resection when resecting the lymphatics of the neck. Tumor fixation to the SCM may make it seem immobile, but there may be tissue planes between the IJV and SAN that facilitate its removal, and allow preservation of these structures. 6.2 Axial MRI showing metastatic carcinoma invading the internal jugular vein, sternocleidomastoid muscle, and deep neck musculature. Oral Oncol 2002;38:747-51, Shah JP, Strong E, Spiro RH, Vikram B. Surgical grand rounds. Such a global suggestion also likely stems from concerns that the posttreatment scarring may obscure tissue planes, making the clean removal of disease from the SAN, IJV, and SCM challenging. 6. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). During this step of the operation, it is important to preserve the branches of the cervical plexus that innervate the levator scapulae muscle, unless the extent of the disease in the neck precludes it. King, E.D. You will be asleep during the surgery. Documentation of arm and shoulder range of motion and strength should be made prior to surgery to assess SAN and brachial plexus function. One example may be a metastasis that is immobile in preoperative clinical evaluation because it is adherent to the SCM. The surgeon must remain very vigilant on the left side to be able to identify thoracic duct, which arches downward and forward from behind the common carotid to open into the internal jugular vein, the subclavian vein, or the angle formed by the junction of these two vessels. Fixed neck mass in the deep cervical fascia and/or skull base involvement, Numbness in the skin and ear on the side of the surgery, which may be permanent, Damage to the nerves of the cheek, lip, and tongue, Drooping shoulder on the side of the surgery, Caring for your surgical wound in any drains, Breathing and handling secretions in your throat. Neck dissection: current status and future possibilities. DO NOT take a tub bath for the first few weeks after your surgery. 1994 May;79(5):140-4, Shaw HJ. The first is for the removal of palpable metastatic cervical lymph nodes, and the second is for the removal of presumed occult metastatic disease in the neck. For most people, the swelling starts to go away 4 to 5 days after surgery. Photos may aid in the preoperative counseling of the patient to set expectations for postoperative neck, shoulder, and arm function ( Fig. Get it filled when you go home so you have the medicine when you need it. The provider will tell you how to care for it. The muscle, nerve, and blood vessel in the neck may also be saved. Patients should be counseled preoperatively about the possible morbidity of RND, but the decision to resect structures is sometimes made intraoperatively when assessment of resectability of the disease can be better assessed. Metastases to the regional lymph nodes reduces the 5-year survival rate by 50% compared with that of… Indications for this procedure is in N0 neck malignant melanoma where the primary site is posterior to ear. 6.3 Indications for Radical Neck Dissection Surgeons at Memorial Hospital first classified the cervical lymph nodes into levels and later Byers et al described the levels most at risk for spread based on the primary tumor site in the head and neck.5 When it became clear not all cervical lymphatics needed to be resected that an RND encompassed, surgeons modified the neck dissection to involve the lymphatics at highest risk for disease spread. Risks for anesthesia and surgery in general are: Other risks for neck dissection surgery are: Chyle leak formation is an uncommon but serious complication of head and neck surgery when the thoracic duct is inadvertently injured, particularly with the resection of malignancy low in the neck. You may want to take a fiber supplement every day. The following chapter addresses the history, techniques, morbidity, post-operative considerations, and potential complications of a radical neck dissection. Only gold members can continue reading. Neck metastasis is the most important prognostic factor in head and neck squamous cell carcinomas (SCC) 3). Recognizing that loss of these structures caused patients significant functional and cosmetic morbidity, Suarez modified the procedure in 1963 to preserve nonlymphatic structures when oncologically feasible. They are closed with stitches, staples, or skin clips. Carotid artery rupture. Radical neck dissection is a surgical operation used to remove cancerous tissue in the head and neck. Next, try soft foods like pudding, yogurt, canned or cooked fruit, scrambled eggs, and mashed potatoes. However, this operative procedure is not without morbidity, as it results in a cosmetic deformity and dysfunction of shoulder movement. A conservation technique in radical neck dissection. Ferlito et al proposed a further modification to this terminology suggesting that each level and structure resected should be clarified, with an RND termed ND (I–V, SCM, IJV, and cranial nerve [CN] XI).8. Such a global suggestion also likely stems from concerns that the posttreatment scarring may obscure tissue planes, making the clean removal of disease from the SAN, IJV, and SCM challenging. The dissection is continued posteriorly and inferiorly along the anterior border of the trapezius muscle. As a general guideline, if a structure is not clearly involved by disease, and a clean resection can be achieved, then it should be structurally preserved. Intraoperatively, after the skin and platysmal flaps are raised and superior and inferior SCM attachments are released, the tumor may become more mobile. Superior – the lower border of the body of the mandible; Posterior – posterior border of the sternocleidomastoid, Posterior – the anterior border of the trapezius, Anterior – the posterior border of the sternocleidomastoid, Lateral – medial border of the carotid sheath on either side, Severe cardiopulmonary disease, COPD with poor functional status, Preoperative imaging showing deep infiltration of the tumor in the prevertebral space, scalene muscles, levator scapula muscle, phrenic nerve, and brachial plexus are not suitable candidates. This procedure causes considerable morbidity, predominantly from shoulder dysfunction, and numerous studies have since demonstrated that the surgical preservation of non-invaded structures was oncologically sound. Your surgical wounds are bleeding, are red or warm to the touch, or have a thick, yellow, green, or milky drainage. If the tumor mass is located low in the jugulodigastric region or the mid-jugular region, the internal jugular vein is first ligated and divided superiorly. Take them as directed. Ask your provider when is it is OK for you to return to work. 7. There are two major indications for radical neck dissection. In the rare case of bilateral IJV sacrifice, the patient must be counseled of the risk of potential facial and neck edema and decreased cerebral venous outflow. Synchronous bilateral radical neck dissections, in which both internal jugular veins undergo ligation, can result in the development of facial edema, cerebral edema, or both; blindness; and hypoxia 20). 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 Indications. Your doctor may have prescribed antibiotics. Fig. Brazilian Head and Neck Cancer Study Group. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) Level VII: (superior mediastinal lymph nodes) borders are: Footnote: A diagram showing levels of cervical lymph nodes. 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 8). Related 6.2 Axial MRI showing metastatic carcinoma invading the internal jugular vein, sternocleidomastoid muscle, and deep neck musculature. 6.4). They will leave scars that fade with time. 1951 May;4(3):441-99, Pugazhendi SK, Thangaswamy V, Venkatasetty A, Thambiah L. The functional neck dissection for lymph node neck metastasis in oral carcinoma. This term is appropriate because it is a radical removal of sites of metastatic spread to the neck, sacrificing the SAN, SCM, and IJV. Tags: Neck Dissection 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 19). Lymph nodes from level I-V, ipsilateral sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve undergo removal. Chyle extravasation can result in delayed wound healing, dehydration, malnutrition, electrolyte disturbances, and immunosuppression. DO NOT take aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve, Naprosyn). Ann Otol Rhinol Laryngol 1967; 76: ... Supraomohyoid neck dissection: Rationale, indications, and surgical technique. However, in cases with extracapsular spread, the resection of adjacent structures such as SCM, IJV, and SAN may be required to get a “margin” around the disease, justifying the RND. Expected contour changes to the neck, numbness, the expected incision line, and possible deficits of the particular CNs at risk should be reviewed. Historically, neck dissection performed for presumed residual disease after (chemo) radiotherapy was performed as a comprehensive radical neck dissection to encompass all levels of disease (Fig.
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