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PATTERNS OF CERVICAL LYMPH NODE METASTASIS IN HEAD AND NECK

CANCER: IMPLICATIONS TOWARDS PROGNOSIS AND TREATMENT

Article · July 2016

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 wjpmr, 2016,2(4), 216-223 SJIF Impact Factor: 3.535
Research Article
Badwal . WORLD JOURNAL OF PHARMACEUTICAL
World Journal of Pharmaceutical and Medical Research
ISSN 2455-3301
AND MEDICAL RESEARCH
[Link] WJPMR

PATTERNS OF CERVICAL LYMPH NODE METASTASIS IN HEAD AND NECK

CANCER: IMPLICATIONS TOWARDS PROGNOSIS AND TREATMENT.

Dr. Jaspreet Singh Badwal*

Phulkian Enclave, Jail Road, Patiala – 147001, Punjab.

*Corresponding Author: Dr. Jaspreet Singh Badwal

Phulkian Enclave, Jail Road, Patiala – 147001, Punjab.

Article Received on 16/06/2016 Article Revised on 04/07/2016 Article Accepted on 25/07/2016

ABSTRACT
The aim of this review is to identify the patterns of lymph node metastasis for different primary tumour locations in
head and neck cancer and highlight their effect on treatment and prognosis. Factors related to lymph node
metastasis in head and neck cancer form the basis for decision making in the treatment pathway, affecting the
guidelines for both primary treatment modality, as well as adjuvant therapy.

KEYWORDS: patterns of cervical lymph node metastasis head neck cancer, prognostic factors cervical lymph
node metastasis head neck cancer.

Purpose of the study: To identify the patterns of lymph terminology it is sometimes substituted by “Composite
node metastasis for different primary tumour locations in Resection”.[3] Hayes Martin,[4] in 1959, published the
head and neck cancer and highlight their effect on results of 665 radical neck dissections performed in 599
treatment and prognosis. patients. This defined a new era in treatment of head and
neck cancer. In further course of time, the concept of
INTRODUCTION modified radical neck dissection was developed by
Suarez,[5] who published his results in 1962.
Cancer of the head and neck demonstrates metastasis to
Subsequently, Byers[6] introduced the concept of
cervical lymph nodes via specific lymphatic drainage
selective neck dissection in 1988.
pathways. Each primary site of the upper aerodigestive
tract, the salivary glands, the thyroid gland and the skin
PATTERNS OF CERVICAL LYMPH NODE
of head and neck area are represented by specific sentinel
METASTASIS FROM CARCINOMAS OF UPPER
lymph node sites to which metastasis occurs. These
AERODIGESTIVE TRACT
sentinel lymph nodes constitute the only protective
Various primary sites of upper aerodigestive tract show
barrier, that for a time period, may confine the metastatic
metastasis to specific sentinel lymph node sites because
growth to an area accessible to treatment by surgery or
of the inherent anatomy of lymphatic drainage system.
radiotherapy. Once beyond this barrier, cancer of the
Patterns of cervical lymph node metastasis were first
head and neck is considered highly advanced.
studied in detail by Lindberg[7] in 1972. Later, Shah JP et
al.[8,9] published excellent studies on this topic.
It was Crile[1] (1906) who standardized the procedure of
Teymoortash [10] (2012) has reviewed the whole topic in
neck dissection, when he presented an account of 132
great detail. The following discussion will highlight the
surgeries in which he had performed radical neck
sites of sentinel lymph nodes for different primary
dissection for cancer of head and neck. The procedure
tumour locations.
came to be recognized as the standard protocol for neck
dissection. Grant Ward[2] in 1932, at the John Hopkins
a) Nasal cavity and sinuses
Hospital, performed an in-continuity resection of primary
Sinonasal squamous cell carcinomas have a metastatic
oral cancer with a neck dissection, a procedure which he
rate of about 10%.[10] This rate increases if there is an
named as “Composite Operation”. Hayes Martin, [3] in
infiltration of nasal floor, columella, upper lip or floor of
1938, at Memorial Hospital in New York, adopted the
maxillary sinus. The preferred metastatic areas include
same procedure at his department. By early 1940s,
lymph nodes of the levels I and II, the parotid nodes and
standard approach of midline bisection of lower lip,
the retropharyngeal nodes.[10.11]
segmental mandibulectomy and in-continuity radical
neck dissection had evolved. This procedure was termed
as “Commando Operation”, although in current

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Badwal . World Journal of Pharmaceutical and Medical Research

b) Lips and oral cavity retrospective evaluation of 4,768 patients with

The lymphatic drainage from upper lip is to level I, while nasopharyngeal cancer, enlarged cervical lymph nodes
buccal and parotid lymph nodes may also be affected. presented as the first symptom in 37% of cases, while
Cancers of lower lip demonstrate a low tendency for they were clinically detectable in 75% of patients.[21]
metastasis, mainly to level I. the metastatic rate
correlates with the size of the primary tumour, being d) Oropharynx
about 30% for T1-T2 cancer and 60% or more for T3-T4 The lymphatic drainage of oropharyngeal region is
cancers.[10] effectuated mainly into lymph nodes at levels II, III and
retropharyngeal lymph nodes. The cancers of posterior
The lymphatic drainage of anterior oral cavity is to level and lateral walls show a predilection for metastasis to
I while the posterior oral cavity may also drain to lymph retropharyngeal lymph nodes and level II. [10]
nodes of level II. Tongue cancers, which constitute about
25-40% of oral cavity cancers make an exception to this. e) Larynx
In a retrospective evaluation of 277 cases of tongue The lymphatic drainage of supraglottic and glottis areas
cancer, metastasis was present exclusively at levels III flows mainly to level II and III. The subglottic areas
and IV in 15.8% cases, without affecting levels I and II. drain to lymph nodes at level III and IV. The
The incidence of occult lymph node metastasis for T1 involvement of pre-laryngeal Delphian lymh node in
and T2 cancers of oral cavity is about 30-40%.[12] Level VI is associated with poor prognosis and higher
rate of local recurrences.[22]
Some of the cancers of anterior oral cavity may also
affect the lingual lymph nodes, which are located The metastatic frequency of laryngeal cancers varies
superior to mylohyoid muscle. As these lymph nodes are according to tumour location and its extent. About 40%
not removed during neck dissection, they may constitute of all supraglottic cancers show locoregional metastasis.
the origin of local recurrence. The exact significance of Glottis cancers show the lowest lymphatic rate due to the
these lymph nodes is not accurately known. However, if lower lymphatic density in glottic region. [10]
preoperative imaging leads to suspicion of involvement
of lingual lymph nodes, their dissection is indicated. [13] f) Hypopharynx
Lymphatic drainage of hypopharynx mainly involves
The metastatic rate of oral cancer is directly related to levels II and III, more rarely level IV. The posterior wall
tumour size and infiltration depth. A cut-off value of of hypopharynx drains first to retropharyngeal lymph
4mm. for tumour infiltration depth was defined as a nodes, followed by levels II and III.[10]
predictor for cervical metastasis in a meta-analysis of
metastasized cancers of oral cavity. [14] In relation to Incidence of lymph node metastasis from cancers of
tongue cancers, a multivariate analysis of clinical and hypopharynx is about 65-80%, while that of occult
histopathological tumour characteristics showed that metastasis is about 30-40%. Retropharyngeal metastasis
only the tumour infiltration depth has a predictive value occurs in about 13% of cases,[23] mainly from cancers
for cervical metastasis.[15] Preoperative MRI examination involving the retro-cricoid area and posterior wall of
can identify the tumour infiltration depth [16] with a high pharynx. Tumours of medial wall of pyriform sinus are
correlation with histopathological measurements. Values reported to have an increased risk of contralateral neck
of MRI measurements are about 10% higher than the metastasis.
histologically revealed values of infiltration depth. That
difference may be due to tissue shrinkage during tissue NECK DISSECTION IN CASES OF CLINICALLY
fixation.[16] N0 NECK
The relative need for elective neck dissection depends
c) Nasopharynx upon incidence of metastasis from cancers of head and
For nasopharyngeal cancers, retropharyngeal lymph neck. The incidence of metastasis in turn, depends upon
nodes constitute the first site of metastasis, which may be specific clinical and histological criteria such as – site of
affected in 94% cases of metastasized cancer.[17] primary tumour, T staging or size of tumour, infiltration
However, in an evaluation of 786 patients with depth of primary tumour, histology of primary lesion and
metastasized nasopharyngeal cancer, 13% of patients in many cases the grading of the lesion.[24]
showed metastasis in level II without any affection of
retropharyngeal lymph nodes.[18] Only a low percentage The risk of nodal metastasis, in relation to location of
of patients demonstrate metastasis in other cervical primary tumour, increases from anterior to posterior
regions without involvement of retropharyngeal and aspect of upper aerodigestive tract, i.e., from lips to
level II lymph nodes.[19, 20] Thus the lymphatic drainage backwards towards oral cavity, oropharynx and
of nasopharynx is believed to be into retropharyngeal hypopharynx. Similarly, for tumours of larynx and
and level II lymph nodes. pharynx, the risk of nodal metastasis increases as one
progresses from centre of upper aerodigestive tract
Nasopharyngeal cancers show a higher rate of metastasis (vocal cords) towards the periphery (lateral pharyngeal
compared to other head and neck cancers. In a wall).[24] From this account, an important inference to be

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Badwal . World Journal of Pharmaceutical and Medical Research

drawn is that elective neck dissection is not required in NECK DISSECTION FOR CLINICALLY
T1 cancers of low risk sites such as lower lip and vocal PALPABLE LYMPH NODES
cords. However, for primary sites with high risk of nodal When regional lymph node metastasis are clinically
metastasis, such as tongue, oropharynx and palpable, comprehensive clearance of all regional lymph
hypopharynx, elective neck dissection is justified in nodes at risk is mandatory. [24] Preservation of the
many cases. sternocleidomastoid muscle or internal jugular vein in
patients with palpable cervical lymph node metastasis
The above mentioned criteria can be used to make the from primary squamous cell carcinomas of upper
decision whether T1-T2 cancer of a specific site in head aerodigestive tract is not recommended. [24] However, if
and neck would require elective neck dissection. The the spinal accessory nerve is not involved by metastatic
decision is much less complicated in case of T3-T4 cancer, it should be routinely preserved even in patients
cancers, due to the higher rate of occult metastasis with clinically palpable metastatic lymph nodes. Such a
because of higher T staging. surgical approach has no adverse impact on long-term
survival.[24] On the other hand, the spinal accessory
Elective neck dissection of N0 neck is most commonly a nerve, sternocleidomastoid muscle and internal jugular
selective neck dissection, the extent of the latter being vein can all be preserved when a neck dissection is
based on the knowledge of patterns of lymph node undertaken for excision of cervical lymph node
metastasis from specific primary tumour sites. Cancers metastasis from differentiated carcinoma of thyroid
involving lips and oral cavity call for dissection of levels gland.[24]
I to III.[10] For upper and lower lips, the parotid nodes
must be examined, and if required, included in Though radical neck dissection is considered the gold
dissection. For cancers of tongue, infiltration depth of standard for surgical management of clinically apparent
tumour is a very important criteria and level IV must be metastatic lymph nodes, its indications[24] according to
included in neck dissection.[10] current literature are few and may be stated as.
a) N3 disease
For elective neck dissection in relation to cancers of b) Recurrent metastatic disease in previously irradiated
larynx, levels II to IV are generally included in neck.
dissection. In a prospective and randomized evaluation c) Grossly apparent extranodal spread with invasion of
of T2-T4 N0 supraglottic and transglottic cancers, no spinal accessory nerve and / or internal jugular vein
significant difference could be observed in prognosis, at the base of skull.
locoregional recurrence rate and complications with d) Involvement of skin by metastatic disease.
regard to modified radical neck dissection and selective
neck dissections of levels II to IV.[25] In more recent In all other instances, when appropriate indications exist,
prospective investigations, only selective neck dissection a function - preserving comprehensive neck dissection
of levels IIa and III is recommended for clinical N0 necks should be performed, sparing one or more vital anatomic
because of rarely affected lymph nodes at levels IIb and structures.[24]
IV, without the impairment of oncological result in any
manner.[26] PROGNOSTIC IMPLICATIONS OF CERVICAL
LYMPH NODE METASTASIS
Prospective studies for laryngeal cancers show a rare Specific factors have been identified pertaining to
affection of lymph nodes at level IIb (less than 1%) in characteristics of regional lymph node metastasis, which
cases of clinical N0 neck.[27,28] The metastatic spread in influence prognosis. While cancers in early stage (Stage I
level IV is similar. In a study of 58 patients with and II) have a 5-year survival rate of about 80% in total,
supraglottic cancers, no isolated metastasis were detected the 5-year survival of cancers of stage III, IVA and IVB
at level IV after elective neck dissection. [29] (locoregional metastasis) amounts to about 50% and in
patients staged IVC (distant metastasis) to about 25%. [33]
Ferlito (2007) summarized the data of 175 patients with Hence presence of lymph node metastasis is associated
laryngeal cancer and clinically N0 neck from three with dramatic reduction of survival rate. Various
prospective studies. Only in six patients (3.4%) pathologic characteristics of lymph node metastasis also
metastasis could be detected at level IV by pathologic have a prognostic relevance. These are the size, number
and molecular studies.[30] In hypopharyngeal cancer, the and location of lymph node metastasis. Lymph node
dissection of sublevel IIb is refused in order to avoid metastasis of levels IV and V usually implies an ominous
dysfunction of accessory nerve.[31,32] Thus, selective neck prognosis.[34,35] In this context, presence of extracapsular
dissection of levels IIa to IV is recommended for cancers spread of cervical metastasis represents the most
of hypopharynx. important prognostic factor and is associated with
significantly higher locoregional recurrence rate and
It must be emphasized that selective neck dissection distant metastasis.[36] Perivascular and perineural
should be followed by regular ultrasound examinations infiltration by tumour,[37] as well as presence of tumour
and adequate follow-up visits. emboli in regional lymphatics,[34] also have an adverse
impact on prognosis. Presence of above characteristics in

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a particular case would require adjuvant radiotherapy.[38] The decision for neck dissection is thus based mainly on
Positive finding of extracapsular spread demands tumour histology and T staging of tumour. While it is
adjuvant chemoradiotherapy.[38] justified to indicate selective neck dissection for high-
grade cancers, it may be indicated for low-grade cancers
Leemans and Tiwari[39] published a study on regional when the T staging is high (T3-T4). An elective neck
lymph node involvement and its significance in the dissection should include the levels I, II, III and Va. [46]
development of distant metastasis in head and neck
carcinoma. The authors stated that patients with three or The above discussion pertains mainly to the more
more positive nodes were at maximum risk for distant frequently occurring parotid gland cancers. Cancers of
metastasis (46.8%). The presence of extranodal spread submandibular gland represent only 5-10% of salivary
leads to threefold increase in the incidence of distant gland cancers. About half of all tumours of
metastasis, compared with patients without this feature submandibular gland are malignant. The most frequently
(19% versus 6.7%). occurring malignancies include adenoid cystic cancer
and mucoepidermoid cancer. In cases presenting with
NECK DISSECTION FOR CANCERS OF THE lymph node metastasis, the procedure is comparable to
MAJOR SALIVARY GLANDS that followed for parotid cancers. For high-grade cancers
The overall incidence of cervical lymph node metastasis and cases presenting with extraglandular growth (>T1),
in patients with salivary gland tumours is about 15-25% an elective neck dissection is mostly indicated for levels
at the time of first diagnosis.[10] The presence of lymph I to III.[47,48]
node metastasis in patients with salivary gland cancers
affects the prognosis in a decisive way. The 5-year NECK DISSECTION FOR CANCERS OF
survival rate of patients suffering from parotid cancers, THYROID GLAND
without any cervical lymph node metastasis, is reported Incidence of metastasis for different histologic types of
to be 74%.[40] The survival rate decreases to 17% when thyroid cancer is different for each type. Papillary
lymph node metastasis develops after initial treatment cancers are the most common with an incidence of 60-
and amounts to 9% with cervical lymph node metastasis 80%.[10] Papillary cancers metastasize preferably by
present at the time of diagnosis.[40] The treatment of lymphogenic pathway with metastatic rates of about
clinically positive neck mostly consists of modified 50%.[10] The follicular cancers exhibit haematogenous
radical neck dissection which may be followed by metastatic tendency with a lower lymphogenic metastatic
adjuvant radiotherapy in cases of multiple nodes or rate of about 5-15%.[10] In case of medullary cancers,
extranodal growth. The treatment for suspected occult lymph node metastasis are of decisive prognostic
lymph node metastasis is controversial. While some relevance and occur in about 50-80% of cases.[10] The
authors express reluctance concerning neck dissection in anaplastic thyroid cancers exhibit a rapid progression and
cases of N0 neck, others recommend neck dissection for aggressive growth accompanied by haematogenous
particular tumour types or after histological diagnosis of metastasis. They can have lymph node metastasis in
positive lymph nodes.[41] about 30% of cases.[10]

In regard to histology of salivary gland cancers, the high Regional lymph node metastasis from primary
grade cancers exhibit a frequency of about 50% for carcinomas of thyroid gland occurs in a high proportion
occult lymph node metastasis.[10,42] These high-grade of cases with differentiated carcinoma of thyroid gland.
cancers include – high grade mucoepidermoid cancer, The first echelon lymph nodes at highest risk for
squamous cell cancer, undifferentiated carcinoma, micrometastasis in clinically negative neck from primary
adenocarcinoma and malignant mixed tumours. The low differentiated carcinoma of thyroid gland are the
grade cancers show a frequency of maximal 10% for perithyroid nodes and those in the tracheoesophageal
occult lymph node metastasis. The low grade cancers groove and superior mediastinum.[24] Metastatic disease
include – low grade mucoepidermoid cancer, acinic cell shows a sequential progression from tracheoesophageal
cancer and adenoid cystic cancer.[10,42] Henceforth, based groove lymph nodes to lower deep jugular lymph nodes,
on high frequency of lymph node metastasis of high midjugular lymph nodes, lymph nodes of posterior
grade cancers, an elective neck dissection is triangle of neck and subsequently to upper jugular nodes.
recommended in this patient group.[43] Metastatic disease from primary thyroid to level I is
extremely rare.[24]
Apart from histology of tumours, tumour size correlates
well with incidence of lymph node metastasis. According Dissection for regional cervical lymph node metastasis is
to a study presenting multivariate analysis of risks for indicated in patients presenting with clinically palpable
occult lymph node metastasis, they amount to 20% for lymph nodes or in whom gross metastasis can be noticed
tumours larger than 4 cm., compared to 4% for smaller at the time of thyroid surgery.[49] The optimal surgical
tumours.[44] Presence of facial paralysis is another factor procedure providing comprehensive clearance of lymph
that can be correlated with occult lymph node metastasis. nodes from levels I to V is a comprehensive neck
Lymph node metastasis may be present in about 65-75% dissection type III, preserving the sternocleidomastoid
of patients with facial paresis.[45] muscle, accessory nerve and internal jugular vein.[49] In

[Link] 219
Badwal . World Journal of Pharmaceutical and Medical Research

addition to this, clearance of lymph nodes at the levels V 5-year survival rate of 60-70%. The 5-year survival rate
and VI (tracheoesophageal groove and superior of patients with multiple cervical metastasis or metastasis
mediastinum) is indicated in patients requiring surgical of more than 3cm. was shown to be 30%. [50] The
removal of lymph nodes from levels I to V.[49] Elective treatment of such metastasis includes a partial or total
dissection of lymph nodes from levels I to V is not parotidectomy in combination with neck dissection and
recommended. However, elective clearance of lymph subsequent radiotherapy. In cases of suspected positive
nodes from tracheoesophageal groove is advisable in cervical lymph nodes, modified radical neck dissection
those cases where primary tumours exhibit extrathyroid should be performed. In cases of clinical N0 neck and
extension, thus increasing the risk of metastatic disease presence of parotid metastasis, a selective neck
to the first echelon lymph nodes.[49] dissection of levels I, II, III and Va is indicated. [46]

The most common treatment for thyroid cancers includes b) Melanoma

total thyroidectomy with central compartment neck 20% of cutaneous malignant melanomas are located in
dissection in combination with radio-iodine therapy.[10] head and neck. Melanomas demonstrate metastasis via
lymphatic and haematogenous structures. About two-
NECK DISSECTION FOR CUTANEOUS thirds of the metastasis occur first in drainage region of
MALIGNANCIES OF THE HEAD AND NECK regional lymph nodes.[10] The 10-year survival rates for
Cutaneous malignancies of the scalp, such as squamous patients affected by cutaneous malignant melanomas
cell carcinoma and melanoma, exhibit metastasis to amount to 30-70% of patients with micrometastasis, 30-
regional lymph nodes in a predictable manner. A line 50% of patients with satellite or in-transit metastasis and
joining the helix of one year to the helix of opposite ear 20-40% of patients with clinically positive lymph node
in a coronal plane separates the water shed areas of the metastasis.[51]
scalp.[24] Tumours located anterior to this line show
metastasis to periparotid, preauricular and anterior In the case of locoregional lymph node metastasis
cervical lymph nodes (levels I to IV) and seldom detected clinically by means of imaging diagnosis, neck
metastasize to the posterior triangle of neck. Primary dissection sometimes accompanied by parotidectomy, is
tumours of scalp located posterior to the mentioned line recommended as standard therapy. For the clinical N0
show metastasis to suboccipital and postauricular lymph neck, sentinel lymph node biopsy is considered as
nodes, posterior triangle of neck and the deep jugular adequate procedure.[10]
chain (levels II to V).[24] The following discussion will
mainly focus on lymph node metastasis in relation to c) Merkel cell carcinoma
squamous cell carcinoma, melanoma and merkel cell Merkel cell carcinoma is a rare and highly aggressive
carcinoma. Basal cell carcinoma exhibits a very low rate cutaneous neuroendocrine cancer with a high rate of
of metastasis. local recurrences, regional lymph node metastasis and
distant metastasis occurring in the further course of
a) Squamous cell carcinoma disease. More than one third of patients show lymph
The periparotid lymph nodes mainly receive drainage node metastasis at the time of first presentation. With
from skin areas of ipsilateral front, temple, cheeks, further course of disease, 75% patients may develop
eyelids and auricle. About 40% of parotid metastases are regional metastasis. The 5-year survival rates of patients
caused by squamous cell cancer of skin. Cervical without regional metastasis are 75%, which decrease to
metastasis can be expected in more than 50% of cases 60% in patients with regional metastasis. The best
with parotid metastasis.[10] modality for local and regional control of disease
constitutes wide surgical excision of primary tumour
The 5-year survival rate of patients affected by squamous followed by neck dissection and adjuvant
cell carcinoma of skin with locoregional metastasis radiotherapy.[52]
amounts to about 50%. These patients are primarily
curable but a high risk of 20-25% local recurrence has The indication of elective neck dissection for merkel cell
been reported, despite aggressive multimodal therapy. carcinoma is controversial. Kokoska et al [53] state that the
Such local recurrences are usually incurable and are high incidence of lymph node metastasis and
associated with a high risk of distant metastasis, micrometastasis as most important prognostic factor
especially to the lungs.[10] justifies elective neck dissection and possibly
parotidectomy for clinically N0 neck in cases of merkel
The local tumour control rates as well as survival rates of cell carcinoma.
patients with parotid metastasis depend mainly on the
size of such metastasis, the infiltration of facial nerve METHODS
and the skull base. The extent of cervical metastasis with
Using Pubmed and GoogleTM Scholar, a literature search
co-existing parotid metastasis affects prognosis to a great
was performed up until May 2016, for articles published
amount.[10] O‟Brien et al[50] (2002) showed that patients
in English, using the search terms „cervical lymph node
with parotid metastasis without cervical metastasis or
metastasis head neck cancer‟ and „prognostic factors
with an isolated cervical metastasis of up to 3 cm., have a
lymph node metastasis head neck cancer‟. The abstracts

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of all the studies found in the search were analysed to 9. Shah JP, Candela FC, Poddar AK. The patterns of
judge their relevance and inclusion. Articles with cervical lymph node metastasis from squamous cell
insufficient data were excluded. References of the carcinoma of the oral cavity. Cancer., 1990; 66(1):
selected articles were searched to identify further related 109-113.
studies. 10. Teymoortash A, Werner JA. Current advances in
diagnosis and surgical treatment of lymph node
RESULTS metastasis in head and neck cancer. GMS Curr Top
Otorhinolaryngol Head Neck Surg., 2012; 11:
The study has helped to highlight the patterns of lymph
Doc04.
node metastasis from different primary tumour locations
11. Cantu G, Bimbi G, Miceli R, Mariani L, Colombo S,
in head and neck cancer and their implications towards
Riccio S, Squadrelli M, Battisti A, Pompilio M,
prognosis and treatment.
Rossi M. Lymph node metastasis in malignant
tumours of the paranasal sinuses: prognostic value
CONCLUSIONS
and treatment. Arch Otolaryngol Head Neck Surg.,
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neck cancer form the basis for decision making in the 12. Byers RM, Weber RS, Andrews T, McGill D, Kare
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CONFLICT OF INTERESTS 19(1): 14-19.
13. Zhang T, Ord RA, Wei WL, Zhao J. Sublingual
The author declares that there is no conflict of interests
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Maxillofac Surg., 2011; 40(6): 597-600.
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