radical neck dissection

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


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)


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


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


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


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

radical neck dissection

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