118 Neck Dissection

Ohad Ronen, Sandeep Samant, K. Thomas Robbins

KEY POINTS pharynx, and larynx; cutaneous malignancies of the face and scalp
and cancers that arise in the nose and sinuses, as well as salivary
• Neck dissection is a surgical procedure designed to and thyroid glands, are also sources of metastatic nodal spread.
remove metastatic cancer that involves the cervical When cervical lymphadenectomy is performed for palpable or
lymph nodes. radiologically detectable metastatic disease in a patient with previ-
ously untreated cancer, it is referred to as a therapeutic neck dissection.
• The original standard procedure, the radical neck Frequently, a neck dissection may be electively performed even
dissection (RND), is seldom used now. in the absence of clinical or radiologic evidence of disease; this is
• Modifications of the RND procedure include the done when the likelihood of microscopic lymphatic metastasis is
modified RND, which has been designed to reduce significantly high on the one hand, and the likelihood for a proper
morbidity by sparing nonlymphatic structures, and the surveillance to detect neck recurrence and the ability to perform
selective neck dissection, which is used for treating early a curable salvage neck dissection in case of a regional recurrence
nodal disease by removing only the lymph node groups is low on the other hand. The propensity for spread to the regional
at greatest risk for harboring metastases. lymph nodes by carcinomas of the upper aerodigestive tract is
• The lymph nodes in the neck are grouped into six major variable and is associated with several factors such as histology,
levels, numbered I through VI, with additional divisions tumor (T stage) classification, and location of the primary tumor.
into two sublevels, A and B, for levels I, II, and V. For example, if the histology shows perineural invasion or invasion
of the tumor’s microcirculation, the risk is higher. In general, the
• Specific anatomic, radiologic, and surgical landmarks are more advanced the T stage, the higher the likelihood of nodal
used to define the borders between the different levels. spread. Certain subsites—such as the oral tongue, floor of the
• The term therapeutic neck dissection is used when mouth, piriform sinus, and supraglottic larynx—are associated
metastatic cervical lymphadenopathy is clinically evident. with higher rates of lymphatic metastasis compared with such
• The term elective neck dissection is used when the subsites as the buccal mucosa, lip, nasal cavity, paranasal sinuses,
procedure is performed to remove lymph node groups and glottic larynx. Although the anatomic distribution of the
among patients who have clinically node-negative surrounding lymphatic channels may explain some of this variation,
disease and who have an increased risk of harboring inherent differences in the biologic behavior among these cancers
occult disease in the neck. are also likely.
Other factors that are important when deciding whether cervical
• A planned neck dissection, performed whenever the risk
lymphadenectomy is indicated relate to the overall treatment plan.
of residual cancer is high, is typically done 6 to 8 weeks
For example, if the treatment of choice for the primary tumor is
after other treatment to the neck, such as radiotherapy
radiation, rather than surgery, it may be preferable to irradiate
or chemoradiotherapy, has been completed regardless of
the regional nodes when the clinical staging of the nodal disease
the clinical response to the initial treatment.
is N0 or N1. If surgical transgression of the regional lymphatics
• A salvage neck dissection is done when metastatic is required to resect the primary tumor, cervical lymphadenectomy
disease is clinically evident in the neck after previous should also be included. A discussion should be carried out in a
treatment. It can further be classified as early versus late multidisciplinary team setting with consideration given to all factors,
depending on whether neck metastases are persistent or and this should be followed by recommendations and counseling
recurrent. for the patient. In many instances, the treatment plan may include
• Complications of a neck dissection include air leaks, a neck dissection to be performed shortly after completion of
bleeding, chylous fistula, facial or cerebral edema, radiation therapy (RT) or chemoradiation therapy (CRT), typically
blindness, carotid artery rupture, and damage to nerves, following a 6- to 8-week interval, in which case the operation is
such as the phrenic, vagus, brachial plexus, and referred to as a planned neck dissection. The term salvage neck dissection
cutaneous nerves, as well as the mandibular branch of is reserved for treatment of recurrent cervical nodal disease.
the facial, hypoglossal, or lingual nerves.
• A neck dissection following chemoradiation therapy HISTORICAL PERSPECTIVE
poses special challenges, and the indications and the
extent of the procedure remain controversial. In publications prior to the 20th century, little attention was given
to the indications or techniques for treating cervical lymph node
metastases. The first conceptual approach for removing nodal
metastases was made in 1880 by Kocher,1 who described the removal
of the lymph nodes located within the contents of the subman-
dibular triangle to gain surgical access to a cancer of the tongue.
The terms neck dissection and cervical lymphadenectomy are synony- Kocher later recommended that nodal metastases should be
mous, and both refer to the systematic removal of lymph nodes, removed more widely through a Y-shaped incision, with the long
along with their surrounding fibrofatty tissue, from the various arm extending from the mastoid to the level of the omohyoid at
compartments of the neck. This procedure is used to eradicate its junction with the anterior border of the sternocleidomastoid
metastases to the regional lymph nodes of the neck. In most patients, muscle (SCM). Around the same time, Packard2 supported the
these metastases originate from primary lesions that involve mucosal concept of removing the surrounding lymph nodes for lingual
sites of the upper aerodigestive tract, particularly the oral cavity, cancer. The first description of the RND was by Jawdynski,3 a
1806
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 CHAPTER 118 Neck Dissection1806.e1

Abstract Keywords
118
Neck dissection is the most effective therapy to eradicate metastatic Neck dissection
cancer involving the cervical lymphatics. Since its early use, the cervical lymphadenectomy
procedure has evolved from one of radical extirpation to focused selective neck dissection
removal based on biologic risk and patterns of spread. Consequently, sentinel lymph node biopsy
the complications of its use have been reduced substantially. Specific limited access neck dissection
nuances of performing the procedures are associated with the site
of origin of the disease. Neck dissection is often used in combined
modality therapy in which case modifications are important.
Advances in detecting lymph node metastases allow for more
specific use of employing the procedure. Novel variations in
technique for neck dissection, such as super-selective procedures
and limited access approaches, purport further reduction in
morbidity without compromising efficacy.

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 CHAPTER 118 Neck Dissection 1807

Polish surgeon; however, the individual credited the most for documented by retrospective analyses of a large series of patients
developing and reporting the efficacy of this procedure is Crile,4 who have undergone neck dissection.12,16,22 The nodal groups at 118
who believed that distant (hematogenous) metastases were uncom- risk for involvement are widespread throughout the neck and
mon in head and neck cancer and that metastases more commonly extend from the mandible and skull base superiorly to the clavicle
occurred in the neck through the permeation of lymphatics. The inferiorly and from the posterior triangle of the neck laterally to
descriptions by both of these surgeons of a block resection to the midline viscera and to the contralateral side of the neck. It is
encompass all of the cervical nodal groups from the level of the now recommended that the lymph node groups in the neck be
mandible above to the clavicle below became the basis for the categorized according to the level system originally described by
RND we know today. Relevant to the modifications of RND that the Memorial Sloan Kettering Group (Fig. 118.1).18
were subsequently made, Crile recommended preservation of the Two important lymph node groups are found within level I;
internal jugular vein (IJV) and the SCM for patients in whom no these are the submental group and the submandibular group. The
palpable nodes could be detected. In addition, his technique was submental nodes are defined as those contained within the boundaries
to remove only the regional lymph nodes that were known to of the submental triangle (the anterior belly of the digastric muscles
drain the field of the original focus of disease, when metastases and the hyoid bone). The term submandibular nodes refers to the
could not be seen. Also, it is interesting to note that in the nodes that lie within the boundaries of the submandibular triangle
accompanying illustrations of the more radical en bloc resections, (the anterior and posterior bellies of the digastric muscle and the
the spinal accessory nerve (SAN) was preserved. body of the mandible). With many of these lymph node groups
This philosophy of radical en bloc resection based on Crile’s lying in close proximity to, but not within, the submandibular
descriptions remained popular with head and neck surgeons during gland (SG),23 this structure is removed to ensure thorough exentera-
the first half of the 20th century; this was owing, in part, to the tion of all of the lymph nodes within this triangle; thus the
works of Blair and Brown5 and Martin,6 who were strong proponents boundaries of level I lymph nodes include the body of the mandible,
of the radical en bloc technique of neck dissection in a manner the anterior belly of the contralateral digastric muscle, the posterior
similar to the radical surgery that had evolved for breast cancer. belly of the ipsilateral digastric muscle, and the stylohyoid muscle.
Martin, in particular, categorically insisted that the SAN, the IJV, It should be noted that the perifacial lymph nodes (Nodes of
and the SCM should be removed as part of all cervical lymphad- Stahr), including the buccinator nodes, are located outside this
enectomies. It may be useful to remember that, during this time, triangle superior to the mandibular body. These nodes may contain
RT had not yet been developed as an effective adjuvant modality, metastatic disease when the primary site involved is the lip, buccal
and radical surgery represented the only hope for cure. mucosa, anterior nasal cavity, or soft tissue of the cheek. Therefore
Associated with the procedure of the RND was the presence the neck dissection performed for nodal disease associated with
of significant postoperative morbidity related to shoulder dysfunc- primary lesions of these sites should be modified to encompass
tion; the operation also had limitations as a bilateral procedure.7 the perifacial nodes.
In the 1950s, Ward and Robben8 reported that the neck dissection
could be modified in some circumstances by sparing the SAN
and, hence, preventing postoperative shoulder drop. Later, Saunders
and colleagues9 compared the functional results of patients who
underwent RND with those in whom the SAN was spared; this
demonstrated that shoulder symptoms were only mild or moderate
in more than 80% of the patients who had the nerve preserved
or cable grafted. The concept of conservation neck surgery was
further popularized during the 1960s by Suárez10 in Argentina
and was promoted by Bocca and Pignataro,11 who independently
described an operation that removed all of the lymph node groups
while sparing the SAN, SCM, and IJV. They emphasized that
fascial compartments surrounding the lymphatic contents of the
neck could be removed without sacrificing the nonlymphatic
structures, as mentioned. I II
Other authors reported the sparsity of nodal disease within
the posterior triangle for carcinoma of the oral cavity, pharynx,
and larynx and thus set the stage for modifications directed toward
preserving lymph node groups.12–15 These observations paved the
way for another type of neck dissection modification, one in which III
one or more lymph node groups were selectively preserved.16–18
Some of the initial proponents of this concept were the surgeons V
at M.D. Anderson Cancer Center, who called the procedure a
“modified neck dissection.”19,20 Two of the variations of the modified
neck dissection were also called supraomohyoid and anterior neck VI
dissections16; however, the term selective neck dissection (SND) sub-
sequently became associated with the concept of preserving lymph IV
nodes in one or more of the neck levels, which was facilitated by
the American Academy of Otolaryngology’s classification.17,21 The
lymph node groups removed are based on the pattern of metastases,
which are predictable relative to the primary site of cancer
(Video 118.1).
Fig. 118.1 The six levels of the neck used to describe the location of
lymph nodes. Level I, submental and submandibular group; level II,
CERVICAL LYMPH NODE GROUPS upper jugular group; level III, middle jugular group; level IV, lower
The patterns of spread of cancer from various primary sites in jugular group; level V, posterior triangle group; and level VI, anterior
the head and neck to the cervical lymph nodes have been compartment group. (Courtesy Douglas Denys, MD.)

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1808 PART VI Head and Neck Surgery and Oncology

Level II is the region that contains the upper jugular lymph The superior mediastinal lymph nodes, sometimes referred to
nodes. These are located around the upper third of the IJV and as level VII, are bounded superiorly by the superior edge of the
adjacent to the SAN, extending from the level of the carotid manubrium, inferiorly by the superior border of the arch of the
bifurcation (surgical landmark) or hyoid bone (clinical landmark) aorta, and laterally by the CCA on the left side and the innominate
inferiorly to the skull base superiorly. The lateral boundary is the artery on the right.
posterior border of the SCM, and the medial boundary is the
stylohyoid muscle. Recently, the American Head and Neck Society
(AHNS) Neck Dissection Committee recommended that the
DIVISION OF NECK LEVELS BY SUBLEVELS
perpendicular plane defined by the posterior aspect of the SG The 2001 report of the AHNS committee recommended the use
could serve as the radiologic landmark for this boundary. of sublevels for defining selected lymph node groups within levels
Level III contains the middle jugular lymph node group. These I, II, and V on the basis of the biologic significance independent
nodes are located around the middle third of the IJV and extend of the larger zone in which they lie.21 These are outlined in Fig.
from the carotid bifurcation superiorly (surgical landmark) or the 118.2 as sublevels I, the submental nodes; IB, the submandibular
level of the inferior aspect of the body of the hyoid bone (clinical nodes; IIA and IIB, which together make up the upper jugular
and radiologic landmark) to the junction of the omohyoid muscle nodes; VA, the spinal accessory nodes; and VB, the transverse
with the IJV (surgical landmark) or the lower border of the cricoid cervical and supraclavicular nodes. The boundaries for each of
arch (clinical and radiologic landmark) inferiorly. The lateral these sublevels are defined in Table 118.1.
boundary is the posterior border of the SCM, and the medial The risk of nodal disease in sublevel IIB is greater for tumors
boundary is the lateral border of the sternohyoid muscle. Recently, that arise in the oropharynx compared with those of the oral cavity
the AHNS committee recommended that the lateral border of and larynx.24–31 Therefore in the absence of clinical nodal disease
the common carotid artery (CCA) could serve as the radiologic in sublevel IIA, it is likely not necessary to include sublevel IIB
landmark for the medial boundary. for tumors that arise in these latter sites. The dissection of the
Level IV contains the lower jugular lymph node group. These node-bearing tissue of sublevel IIB (submuscular recess) creates
nodes surround the lower third of the IJV and extend from the a risk of morbidity. Adequate exposure necessitates significant
omohyoid muscle (surgical landmark) or cricoid arch (clinical manipulation of the SAN and may account for trapezius muscle
landmark) superiorly to the clavicle inferiorly. The lateral boundary dysfunction observed in a significant minority of patients after a
is the posterior border of the SCM, and the medial or anterior SND. Sublevel IA is a zone from which many surgeons do not
boundary is the lateral border of the sternohyoid muscle. As with remove lymph nodes, unless the primary cancer involves the floor
level II, the lateral border of the CCA could serve as the radiologic of the mouth, the lip, or structures of the anterior midface, or
landmark for the medial boundary. when lymphadenopathy is obvious.
Level V encompasses all lymph nodes contained within the Level V is the third region that has been subdivided into levels
posterior triangle, and these are collectively referred to as the VA and VB. The superior component, level VA, primarily contains
posterior triangle group. The boundaries include the anterior border
of the trapezius muscle laterally, the posterior border of the SCM
medially, and the clavicle inferiorly. Using the horizontal plane
that corresponds to the inferior border of the cricoid cartilage,
level V is divided into two sublevels, VA and VB. The nodes in
level V comprise three predominant lymphatic pathways: nodes
located along the SAN as it traverses the posterior triangle (sublevel
VA); nodes located along the transverse cervical artery as it courses
along the lower third of the triangle (sublevel VB); and the
supraclavicular nodes located immediately above the clavicle
(sublevel VB). A supraclavicular node on the left side, located at
the terminus of the thoracic duct into the subclavian or IJV, can
IB IIA IIB
be enlarged in patients with abdominal (gastric, ovarian, testicular,
ovarian, or renal) cancer and is referred to as the (sentinel) node
of Virchow after Rudolf Virchow, a German pathologist, who first IA
described it in a case of gastric cancer; presence of such a node
is also called the Troisier sign.
Level VI encompasses the lymph nodes of the anterior compart- III
ment of the neck.18,21 This group comprises nodes that surround VA
the midline visceral structures of the neck, extending from the
level of the hyoid bone superiorly to the suprasternal notch
inferiorly. On each side, the lateral boundary is formed by the V
medial border of the carotid sheath. Located within this compart- VI
ment are the perithyroidal lymph nodes, the paratracheal lymph VB
nodes, and the precricoid (delphian) lymph node. These lymph
nodes and their connecting lymphatic channels represent pathways
of spread from primary cancers that originate in the thyroid gland, IV
at the apex of the piriform sinus, and in the subglottic larynx,
cervical esophagus, and cervical trachea. With the exception of
the lymph nodes that lie along the superior thyroid artery, the Fig. 118.2 The six sublevels of the neck used to describe the location
superior component of level VI does not routinely contain any of lymph nodes within levels I, II, and V. Level IA, submental group;
lymph node groups. It should be noted that level IA and level VI level IB, submandibular group; level IIA, upper jugular nodes along the
are midline compartments, unlike levels II through IV, which carotid sheath, including the subdigastric group; level IIB, upper
should be denoted as left versus right sided; however, dissection jugular nodes in the submuscular recess; level VA, spinal accessory
of level VI does imply removal of lymph nodes along both sides nodes; and level VB, the supraclavicular and transverse cervical
of the trachea and thyroid gland. nodes. (Courtesy Douglas Denys, MD.)

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 CHAPTER 118 Neck Dissection 1809

TABLE 118.1 Lymph Node Groups Found Within the Six Neck Levels and the Six Sublevels
118
Group Description
Submental (sublevel IA) Lymph nodes within the triangular boundary of the anterior belly of the digastric muscles and the hyoid bone; these nodes
are at the greatest risk of harboring metastases from cancers that arise from the floor of the mouth, anterior oral tongue,
anterior mandibular alveolar ridge, and lower lip (see Fig. 118.2)
Submandibular Lymph nodes within the boundaries of the anterior belly of the digastric muscle, stylohyoid muscle, and body of the
(sublevel IB) mandible, including the preglandular and postglandular and prevascular and postvascular nodes. The submandibular
gland is included in the specimen when the lymph nodes within this triangle are removed. These nodes are at greatest
risk for harboring metastases from cancers that arise from the oral cavity, anterior nasal cavity, and soft tissue structures
of the midface and the submandibular gland (see Fig. 118.3)
Upper jugular (sublevels Lymph nodes located around the upper third of the internal jugular vein and the adjacent spinal accessory nerve, extending
IIA and IIB) from the level of the skull base above to the level of the inferior border of the hyoid bone below. The anterior (medial)
boundary is the stylohyoid muscle (the radiologic correlate is the vertical plane defined by the posterior surface of the
submandibular gland); the posterior (lateral) boundary is the posterior border of the sternocleidomastoid muscle.
Sublevel IIA nodes are located anterior (medial) to the vertical plane defined by the spinal accessory nerve. Sublevel IIB
nodes are located posterior (lateral) to the vertical plane defined by the spinal accessory nerve. The upper jugular nodes
are at greatest risk for harboring metastases from cancers that arise from the oral cavity, nasal cavity, nasopharynx,
oropharynx, hypopharynx, larynx, and parotid gland (see Fig. 118.3)
Middle jugular (level III) Lymph nodes located around the middle third of the internal jugular vein, extending from the inferior border of the hyoid
bone above to the inferior border of the cricoid cartilage below. The anterior (medial) boundary is the lateral border of
the sternohyoid muscle, and the posterior (lateral) boundary is the posterior border of the sternocleidomastoid muscle.
These nodes are at greatest risk for harboring metastases from cancers that arise from the oral cavity, nasopharynx,
oropharynx, hypopharynx, and larynx (see Fig. 118.3)
Lower jugular (level IV) Lymph nodes located around the lower third of the internal jugular vein, extending from the inferior border of the cricoid
cartilage above to the clavicle below. The anterior (medial) boundary is the lateral border of the sternohyoid muscle, and
the posterior (lateral) boundary is the posterior border of the sternocleidomastoid muscle. These nodes are at greatest
risk of harboring metastases from cancers that arise from hypopharynx, thyroid, cervical esophagus, and larynx (see
Fig. 118.3)
Posterior triangle This group is composed predominantly of the lymph nodes located along the lower half of the spinal accessory nerve and
(sublevels VA and VB) the transverse cervical artery. The supraclavicular nodes are also included in the posterior triangle group. The superior
boundary is the apex formed by the convergence of the sternocleidomastoid and trapezius muscles; the inferior
boundary is the clavicle, the anterior (medial) boundary is the posterior border of the sternocleidomastoid muscle, and
the posterior (lateral) boundary is the anterior border of the trapezius muscle. Sublevel VA is separated from sublevel VB
by a horizontal plane that marks the inferior border of the anterior cricoid arch. Therefore sublevel VA includes the spinal
accessory nodes, whereas sublevel VB includes the nodes that follow the transverse cervical vessels and supraclavicular
nodes (with the exception of the Virchow node, which is located in level IV). The posterior triangle nodes are at greatest
risk for harboring metastases from cancers that arise from the nasopharynx, oropharynx, and cutaneous structures of
the posterior scalp and neck (see Fig. 118.3)
Anterior compartment Lymph nodes in this compartment include the pretracheal and paratracheal nodes, the precricoid (delphian) node, and the
(level VI) perithyroidal nodes, including the lymph nodes along the recurrent laryngeal nerves. The superior boundary is the hyoid
bone, the inferior boundary is the suprasternal notch, and the lateral boundaries are the common carotid arteries. These
nodes are at greatest risk for harboring metastases from cancers that arise from the thyroid gland, glottic and subglottic
larynx, apex of the piriform sinus, and cervical esophagus (see Fig. 118.2)
Superior mediastinum These nodes represent an extension of the paratracheal lymph node chain and extend inferiorly below the suprasternal
(level VII [optional]) notch along each side of the cervical trachea to the level of the innominate artery

the spinal accessory lymph nodes, whereas level VB contains the surface of the SG on each side of the neck; these are also referred
transverse cervical nodes and the supraclavicular nodes, which to as submandibular nodes. Level II extends from the skull base at
carry a more ominous prognosis when positive in cases with upper the lower level of the bony margin of the jugular fossa to the level
aerodigestive tract malignancies. of the lower border of the body of the hyoid bone. Level II nodes
lie anterior to a transverse line drawn on each axial image through
Correlation of Neck Level Boundaries With the posterior edge of the SCM, and they lie posterior to a transverse
line drawn on each axial scan through the posterior edge of the
Anatomic Markers Depicted Radiologically SG; however, any nodes that lie medial to the internal carotid
For radiologists to classify positive lymph node disease according artery (ICA) are retropharyngeal and thus are not level II nodes.
to the neck levels, it is necessary to use landmarks that are visible Level III nodes lie between the level of the lower border of
on image studies, which correspond to clinical and surgical the body of hyoid bone and the level of the lower border of the
landmarks (Table 118.2).32,33 Using such radiologic landmarks, cricoid cartilage. These nodes lie anterior to a transverse line
level I includes all of the nodes above the level of the lower border drawn on each axial image through the posterior edge of the
of the body of hyoid bone, below the mylohyoid muscles, and SCM. Level III nodes also lie lateral to the medial margin of
anterior to a transverse line drawn on each axial image through either the CCA or the ICA. On each side of the neck, the medial
the posterior edge of the SG. Level IA represents those nodes margin of these arteries separates level III nodes, which are lateral,
that lie between the medial margins of the anterior bellies of the from level VI nodes, which are medial.
digastric muscles, above the level of the lower body of the hyoid From a surgical perspective, it is important to note the sig-
bone, and below the mylohyoid muscle; these were previously nificance of the anatomic relationship between the omohyoid
classified as submental nodes. Level IB represents the nodes that muscle and the IJV because lymph nodes are usually located in
lie below the mylohyoid muscle, above the level of the lower body this region. These nodes should be included in level III, although
of the hyoid bone, posterior and lateral to the medial edge of the lymph nodes often lie under the omohyoid muscle that could
ipsilateral anterior belly of the digastric muscle, and anterior to actually be categorized as occupying the superior component
a transverse line drawn on each axial image tangent to the posterior of level IV.

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1810 PART VI Head and Neck Surgery and Oncology

TABLE 118.2 Imaging-Based Classification of Location of Lymph Nodes

Boundary Clinical Radiologic Surgical
LEVEL I
IA Superior Symphysis of mandible Geniohyoid muscle, plane tangent to Symphysis of mandible
inferior border of mandible
Submental Inferior Body of hyoid Body of hyoid Body of hyoid
Lateral (posterior) NA Anterior belly of ipsilateral digastric Anterior belly of ipsilateral
muscle digastric muscle
Medial NA Anterior belly of contralateral digastric Anterior belly of contralateral
muscle digastric muscle
IB Superior Body of mandible Mylohyoid muscle, body of mandible Body of mandible
Submandibular Inferior Plane through hyoid bone Inferior edge of the hyoid bone Digastric tendon attachment
to hyoid bone
Lateral (posterior) Anterior border of SCM Posterior edge of the submandibular Posterior edge of the
gland submandibular gland
Medial NA Anterior belly of digastric muscle Anterior belly of digastric
muscle
LEVEL II (UPPER JUGULAR)
IIA Superior Mastoid process Skull base, caudal edge of C1 lateral Skull base
process
Inferior Horizontal plane defined by the Horizontal plane defined by the inferior Carotid bifurcation
inferior border of the hyoid bone border of the hyoid bone
Lateral (posterior) NA Posterior border of the internal jugular Vertical plane defined by the
vein spinal accessory (XI) nerve
Medial Anterior border of SCM Posterior edge of the submandibular Posterior edge of the
gland submandibular gland
IIB (submuscular Superior Mastoid process Skull base, caudal edge of C1 lateral Skull base
recess) process
Inferior Horizontal plane defined by the Horizontal plane defined by the inferior Carotid bifurcation
inferior border of the hyoid bone border of the hyoid bone
Lateral (posterior) Lateral border of SCM Lateral border of SCM Lateral border of SCM
Medial NA Medial edge of internal carotid artery, Vertical plane defined by the
paraspinal (levator scapulae) muscle spinal accessory nerve
(cranial nerve XI)
LEVEL III (MIDJUGULAR)
Superior Horizontal plane defined by the Horizontal plane defined by the inferior Carotid bifurcation
inferior border of the hyoid bone border of the hyoid bone
Inferior Horizontal plane defined by the Horizontal plane defined by the inferior Omohyoid muscle
inferior border of the cricoid border of the cricoid cartilage
cartilage
Lateral (posterior) Lateral border of SCM Lateral border of SCM Sensory branches of the
cervical plexus
Medial Medial border of SCM Medial aspect of the common carotid Sternohyoid muscle
artery, paraspinal (scalenius) muscle
LEVEL IV
Superior Horizontal plane defined by the Horizontal plane defined by the inferior Omohyoid muscle
inferior border of the cricoid border of the cricoid cartilage
cartilage
Inferior Clavicle 2 cm cranial to sternoclavicular joint Clavicle
Lateral (posterior) Lateral border of SCM Lateral border of SCM Sensory branches of the
cervical plexus
Medial Medial border of SCM Medial aspect of the common carotid Sternohyoid muscle
artery, paraspinal (scalenus) muscle
LEVEL V (POSTERIOR TRIANGLE)
VA Superior Apex of the convergence of the Apex of the convergence of the SCM Apex of the convergence of
SCM and trapezius muscle and trapezius muscle the SCM and trapezius
muscle
Inferior Horizontal plane defined by the Horizontal plane defined by the inferior Horizontal plane defined by
inferior border of the cricoid border of the cricoid cartilage the inferior border of the
cartilage cricoid cartilage
Lateral (posterior) Anterior border of trapezius muscle Anterior border of trapezius muscle Anterior border of trapezius
muscle
Medial Lateral border of SCM Lateral border of SCM Sensory branches of the
cervical plexus
VB Superior Horizontal plane defined by the Horizontal plane defined by the inferior Horizontal plane defined by
inferior border of the cricoid border of the cricoid cartilage the inferior border of the
cartilage cricoid cartilage
Inferior Clavicle Clavicle Clavicle
Lateral (posterior) Anterior border of trapezius muscle Anterior border of trapezius muscle Anterior border of trapezius
muscle
Medial Lateral border of SCM Lateral border of SCM Sensory branches of the
cervical plexus

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 CHAPTER 118 Neck Dissection 1811

TABLE 118.2 Imaging-Based Classification of Location of Lymph Nodes—cont’d

118
Boundary Clinical Radiologic Surgical
Superior Hyoid bone Hyoid bone Hyoid bone
Inferior Superior edge of the manubrium Superior edge of the manubrium Superior edge of the
sternum bone sternum bone manubrium sternum bone
Lateral (posterior) Common carotid artery Medial aspect of the common carotid Common carotid artery
artery
Medial Common carotid artery Medial aspect of the common carotid Common carotid artery
artery
OPTIONAL: LEVEL VII (SUPERIOR MEDIASTINAL)
Superior Superior edge of the manubrium Superior edge of the manubrium Superior edge of the
sternum bone sternum bone manubrium sternum bone
Inferior NA Innominate artery Innominate artery
Lateral (posterior) NA Innominate artery and left common Innominate artery and left
carotid artery common carotid artery
Medial NA Innominate artery and left common Innominate artery and left
carotid artery common carotid artery
NA, Not applicable; SCM, sternocleidomastoid.

TABLE 118.3 American Head and Neck Society Classification of Neck Dissection
Terminology Definition
Radical Removal of lymph node levels I–V, sternocleidomastoid muscle, spinal accessory nerve, and internal jugular vein
Modified Removal of levels I–V of lymph node, as in RND, but with preservation of at least one of the nonlymphatic structures
(sternocleidomastoid muscle, spinal accessory nerve, internal jugular vein)
Selective Preservation of one or more lymph node levels relative to an RND
Extended Removal of an additional lymph node level or group or a nonlymphatic structure relative to an RND (muscle, blood vessel, nerve);
examples of other lymph node groups are superior mediastinal, parapharyngeal, retropharyngeal, periparotid, postauricular,
suboccipital, or buccinators; an example of other nonlymphatic structures can be external carotid artery or hypoglossal or
vagus nerves
RND, Radical neck dissection.

Neck Dissection Classification TABLE 118.4 Nomenclature Systems

The classification for neck dissection recommended by the AHNS is Proposed Neck Dissection AAO-HNS Revised Classification
based on the following rationale: (1) that RND is the standard basic Classification36 (2008)
procedure for cervical lymphadenectomy, and all other procedures I–V, SCM, IJV, CN XI Radical neck dissection
represent one or more modifications of this procedure; (2) when I–V, SCM, IJV, CN XI, and Extended neck dissection with
modification of the RND involves the preservation of one or more CN XII removal of the hypoglossal nerve
I–V, SCM, IJV Modified radical neck dissection
nonlymphatic structures, the procedure is called a modified radical
with preservation of the spinal
neck dissection; (3) when the modification involves the preservation accessory nerve
of one or more lymph node groups that are routinely removed in II–IV Selective neck dissection (II–IV)
the RND, the procedure is called a selective neck dissection; and (4) II–IV, V Selective neck dissection (II–IV, V)
when the modification involves the removal of additional lymph II–IV, SCM NA
node groups or nonlymphatic structures relative to the RND, the I–III Selective neck dissection (I–III)
procedure is called an extended radical neck dissection. This classifica- CN, Cranial nerve; IJV, internal jugular vein; NA, not applicable;
tion has been updated by the AHNS classification and is outlined in ND, neck dissection; SCM, sternocleidomastoid.
Table 118.3.9,34,35 This version includes modifications of the original
classification in an effort to remain contemporary and to follow
the current philosophy of lymph node metastases management.
In a 2010 editorial,36 a joint international effort was carried out IJV, hypoglossal nerve (CN XII), SAN (CN XI), SAN, external
to improve the classification even further to facilitate its use and, carotid artery (ECA), ICA, CCA, facial nerve (CN VII), vagus nerve
hence, to ease its incorporation into everyday practice worldwide. (CN X), sympathetic nerve chain (SN), phrenic nerve (PN), skin
It is based on the proposal by the Japanese Neck Dissection Study (SKN), parotid gland (PG), SG, and deep cervical muscles (DCM).36
Group.37,38 The main changes in the proposal by the international Although this latest classification has the advantage of being more
group include use of the symbol ND to represent the term neck precise in denoting the extent and nature of almost any cervical
dissection. A prefix is included to denote the side of the neck upon lymphadenectomy performed, it remains to be seen whether it
which the dissection has been performed using L for left and R for will gain widespread adoption and become the preferred method.
right. If bilateral, both sides must be classified independently. The One disadvantage of its use is the awkwardness in verbalizing the
second component of the description should be the neck levels various subsets. A comparison of the two nomenclature systems
and/or sublevels removed, each designated by the Roman numerals is outlined in Table 118.4.
I through VII, in ascending order. The third component of the Of note is the existence of other classifications for neck dis-
description is the nonlymphatic structures removed, and each is sections, such as the one for treating thyroid cancer. Different
identified through the use of specified acronyms for the SCM, authors and organizations have suggested classifications based on

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1812 PART VI Head and Neck Surgery and Oncology

anatomic and cancer distribution patterns typical for different

thyroid cancers.38a-c Since the classification is a crucial step in
cancer management including staging, surgery, nonsurgical treat-
ments, prognostication and for proper communication between
healthcare personal in different institutions and countries, there
is a need for either familiarization of the different classification
systems or adoption of a common system. We believe that the
AHNS classification system has the advantage of being modular
and can, therefore, be used to describe neck dissections done for
different tumors and throughout management course, thereby
avoiding confusion among healthcare providers and enabling
accurate reporting and discussion.
A planned neck dissection is typically performed 6 to 8 weeks
after the completion of RT or CRT when the probability of residual
disease in the neck is high. Some centers use 18F-fluorodeoxyglucose
positron emission tomography (PET) scan to further decide whether
to perform a neck dissection; however, because the reliability
of a PET scan is questionable before 3 months have passed fol-
lowing completion of RT or CRT, a planned neck dissection based
on the results of this investigation may have to be deferred until
this time.
As opposed to a planned neck dissection, a salvage neck dissection
is performed when metastatic disease in the neck occurs after it
has been previously treated. The salvage neck dissection can be
further classified as an early procedure, when it is done for persistent
disease after chemotherapy or radiation or a combination of both,
or late, when it is done for recurrent disease.

Radical Neck Dissection Fig. 118.3 Radical neck dissection; the boundaries of dissection are
depicted by the heavy line. (Courtesy Douglas Denys, MD.)
Definition. This procedure includes the removal of all ipsilateral
cervical lymph node groups that extend from the body of the
mandible superiorly to the clavicle inferiorly and from the contra-
lateral anterior belly of the digastric muscle and the lateral border less aesthetically pleasing, it is an excellent alternative to use in
of strap muscles anteriorly to the anterior border of the trapezius conjunction with oral cavity and oropharyngeal tumors, wherein
muscle posteriorly.34 Included are all lymph node groups from exposure of the primary site involves extending the incision through
levels I through V, the SAN, IJV, and SCM (Fig. 118.3). It does the lip for a mandibulotomy approach. If a cervical biopsy is done,
not include the removal of the postauricular and suboccipital nodes, as in a diagnostic procedure of sentinel lymph node sampling
periparotid nodes (except for a few nodes located in the tail of prior to neck dissection, an effort should be made to place the
the PG), perifacial and buccinator nodes, retropharyngeal nodes, biopsy incision along the line that would be used for a neck dis-
and paratracheal nodes. section procedure if one should be subsequently required.
Flap Elevation. The initial incision is carried through SKN
Indications. RND is indicated for patients with extensive lymph and platysma muscle, although the platysma is deficient in the
node metastases with extension beyond the capsule of the node midline and in the lateralmost parts of the incision. The flap is
or nodes that involve the SAN and the IJV. raised in the subplatysmal plane so that the external jugular vein
and the greater auricular nerves are not included in the flap (Fig.
Technique 118.5A). Although these structures will ultimately be sacrificed in
Positioning. The patient is positioned supine on the table with the RND, in SND procedures they are frequently preserved. When
a roll placed beneath the shoulders to optimally extend the neck. gross pathologic evidence of tumor extension through the platysma
The SKN is prepped and draped to allow for full exposure of muscle is apparent, with or without SKN involvement, the area
both sides of the neck with clear visualization of surrounding of disease involvement should also be removed, and modification
landmarks (e.g., the lower face, including the mentum, both mastoid of the SKN flap may be required. Identification of the marginal
processes, and earlobes) and the clavicles and suprasternal notch mandibular branch of the facial nerve is performed after complete
inferiorly. In this way, the incision may be mapped in an accurate elevation of the SKN flaps superiorly and inferiorly to expose all
fashion, and throughout the procedure, overall orientation may of the lymph node levels of the neck. It is recommended that the
be maintained. anterior facial vein be ligated and retracted superiorly along with
Incision Planning. The incision is planned for optimal exposure the submandibular fascia to protect this nerve only after the superior
of all lymph node levels to be dissected (levels I through V) and SKN flap is raised; this allows proper assessment of the prevascular
to preserve as much blood supply as possible. The neck flaps raised and postvascular lymph nodes in the submandibular triangle, and
should be broadly based, either superiorly or inferiorly, and should these nodes will need to be removed. Therefore it is best to incise
preferably avoid any trifurcations, particularly those that overlie the submandibular fascia at the lower border of the SG, extend
the carotid sheath. Incisions that best fit these criteria are the this incision anteriorly and posteriorly along the two bellies of
hockey stick and boomerang patterns; the McFee incision; and, the digastric muscle, and carefully raise this fascia off the SG
in patients undergoing bilateral neck dissection, the apron incision, superiorly, until the level of the lower border of the mandible
which is a bilateral hockey stick incision (Fig. 118.4). Other incisions appears as a separate flap; usually the mandibular branch of the
use trifurcations that overlie the carotid sheath, although modifica- facial nerve may be seen as this fascia is raised (see Fig. 118.5B).
tions of the Schobinger incision include placing the trifurcation Dissection of the Posterior Triangle. The subsequent order
more laterally. Although the boomerang incision may be somewhat of dissection is a matter of individual preference, although some

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 CHAPTER 118 Neck Dissection 1813

118

A B

C D
Fig. 118.4 Incisions for radical and modified radical neck dissections. (A) Hockey stick. (B) Boomerang.
(C) McFee. (D) Modified Schobinger. (E) Apron or bilateral hockey stick.

oncologic rationale exists for dissecting from below upward rather the operation to prevent injury to the PN and the brachial plexus.
than from above downward; thus the next step is to expose the As the fibrofatty tissue is swept in a lateral-to-medial direction,
anterior border of the trapezius muscle from its superior aspect, the sensory branches of the cervical plexus are encountered
where it converges with the posterior border of the SCM, to its and divided.
inferior aspect, where it approaches the clavicle (see Fig. 118.5C). Anterior Triangle Dissection. As the fibrofatty tissue is elevated
The fibrofatty tissue is then incised along its anterior border, medially toward the carotid sheath, it will be necessary to incise
beginning superiorly and working inferiorly to expose the muscular the mastoid and clavicular attachments of the SCM (see Fig.
floor of the posterior triangle. In so doing, the SAN will be severed 118.5D). The carotid sheath will be exposed, and identification
at the point at which it enters the trapezius muscle in the lower of the CCA and vagus nerve may be made. Attention should be
aspect of the posterior triangle. After this step has been completed, given to preserving the cervical sympathetic chain, which is closely
the floor of the posterior triangle at its inferior extent is next applied to the prevertebral fascia behind the carotid sheath. The
exposed by incising through the fibrofatty tissue immediately above plane of dissection will be carried between the vagus nerve and
the superior border of the clavicle; this requires incision through the carotid artery below and the IJV above; thus the IJV may be
the inferior belly of the omohyoid muscle and the fibrofatty tissue mobilized from the skull base superiorly to its inferior aspect near
that overlies the brachial plexus. In this region, the transverse the clavicle; ties may then be placed around the upper and lower
facial artery will be encountered immediately overlying the muscular ends of the IJV, thereby allowing ligation and complete mobilization.
floor of the triangle; this artery should be preserved, unless gross When incising the soft tissue contents of the lower medial aspect
disease involves this region. The fibrofatty contents of the posterior of the neck, lymphatic channels will be encountered, particularly
triangle are then mobilized anteriorly, lifting them away from the on the left side. It is imperative to precisely identify these and
floor of the neck, which, in this region, is formed by the splenius ligate them immediately as they are encountered. The thoracic
capitis, the levator scapulae, and the scalene muscles. It is important duct is located to the right of and behind the left CCA and the
to remain superficial to the prevertebral fascia during this step of vagus nerve. From here, the duct arches upward and laterally and

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1814 PART VI Head and Neck Surgery and Oncology

A B

C D E
Fig. 118.5 Steps of the radical neck dissection. (A) Raising the subplatysmal flap. (B) Ligation of the facial
vein, thereby preserving the mandibular branch of the facial nerve. (C) Dissection of the posterior triangle.
(D) Dissection of the lateral levels with the sternocleidomastoid and internal jugular vein. (E) En bloc resection
with level I lymph nodes.

passes behind the IJV and in front of the anterior scalene muscle lying superior to the muscle are divided, including the SCM as
and the PN; it then opens into the IJV, subclavian vein, or the it attaches to the mastoid process, vascular channels that extend
angle formed by the junction of these two vessels. The duct is into the postauricular region, the tail of the PG that extends
anterior to the thyrocervical trunk and the transverse cervical downward inferior to the level of the digastric muscle, and soft
artery. To prevent a chyle leak, the surgeon should also remember tissue attachments to the angle of the mandible. After completion
that the thoracic duct may be multiple in its upper end and that of this part of the dissection, all of the lower contents of the neck
at the base of the neck, it usually receives the jugular trunk, a dissection specimen should be freely mobile, and the only remaining
subclavian trunk, and occasionally other minor lymphatic trunks attachments are the upper end of the IJV and the undissected
that should be individually divided and ligated or clipped. contents of the submandibular triangle and the submental triangle
After ligation of the lower part of the IJV, the contents of (see Fig. 118.5E).
the mobilized specimen are retracted superiorly and medially. Dissection of the Upper Neck Compartments. Excision of level
Dissection is carried along the CCA and medially as far as the I lymph nodes commences by dividing the soft tissue that overlies
sternohyoid muscle. Further elevation of the contents exposes the body of the mandible, including the facial artery and vein as
the carotid bifurcation. As this is done, the branches of the IJV they emerge above the SG and extend lateral to the body of the
require identification and ligation. Specifically, these are the middle mandible. The anterior bellies of the ipsilateral and contralateral
and superior thyroid veins and the retromandibular vein. Further digastric muscles are skeletonized, thereby delineating the boundar-
superior elevation of the fibrofatty contents away from the upper ies of the submental triangle. After the fibrofatty tissue has been
part of the carotid sheath exposes the hypoglossal nerve, lying removed from this space, the fibrofatty contents of the anterior
lateral to the ECA, and the SAN, extending from above downward. portion of the submandibular triangle are removed from the
At this point, the posterior belly of the digastric muscle is underlying mylohyoid muscle until its lateral border can be
identified, and the soft tissue attachments of the neck contents identified. The lateral border of the muscle is then retracted

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 CHAPTER 118 Neck Dissection 1815

anteriorly to expose the deep contents of the submandibular triangle.

This allows for visualization of the lingual nerve, submandibular 118
duct, and hypoglossal nerve. The submandibular duct is isolated,
divided, and ligated. Next, the submandibular ganglion should be
divided, thereby allowing the lingual nerve to retract superiorly
away from the area of dissection. Care is taken to not injure the
hypoglossal nerve and its venae comitantes in the deep portion
of the triangle. The last attachment of the contents of the sub-
mandibular triangle is the proximal end of the facial artery as it
courses deep to the SG. It is important to remember that complete
excision is required of all contents of the submandibular triangle
within its muscular boundaries, not just the SG.
Variations in the approach to the RND should be made,
depending on the location of the disease and its degree of mobility.
For example, it is best to mobilize the areas that are least involved
with a tumor that is difficult to remove, which will enhance the
exposure of the anatomic structures that may be directly invaded
by the disease.
Neck drains are inserted and brought through separate stab
incisions through the most dependent areas of the dead space.
Closure of the incisions is usually performed in two layers
and includes approximation of the platysma anteriorly and the
subcutaneous tissue laterally and the second layer approximating
the SKN.

Modified Radical Neck Dissection

Definition. A modified radical neck dissection is defined as the en
bloc removal of lymph node–bearing tissue from one side of the Fig. 118.6 Boundaries of the modified radical neck dissection, in
neck (levels I through V). The dissection extends from the inferior which the spinal accessory nerve, sternocleidomastoid muscle, and
border of the mandible above to the clavicle below and from the internal jugular vein are preserved. (Courtesy Douglas Denys, MD.)
contralateral anterior belly of the digastric and lateral border of
the strap muscles medially to the anterior border of the trapezius
muscle laterally. Unlike the RND, one or more of the following
structures is preserved in the modified radical dissection: the SAN, The incisions and SKN flaps are raised for modified RND, as
IJV, and/or SCM (Fig. 118.6). The major purpose of these modifica- similarly described for the RND. The same procedure is followed
tions relates to the morbidity encountered when the SAN is to identify and protect the mandibular branch of the facial nerve
removed. Although the degree of morbidity is less for removal of in level I.
the SCM and the IJV, this issue becomes far more important if Unlike in the RND procedure, the next step is to identify the
bilateral neck dissections are required. Simultaneous sacrifice of SAN. This is initially done in the posterior triangle, from which
both IJVs may result in severe swelling of the face with increased the nerve exits at or around the Erb point (Fig. 118.7A). The
intracranial pressure. nerve lies superficially in the fibrofatty contents of the posterior
Indications. The major indication for a modified RND is to triangle and can usually be identified by careful spreading of the
remove grossly visible lymph node disease that is not directly fibrofatty tissue; the use of a nerve stimulator may facilitate this
infiltrating or fixed to the nonlymphatic structures, particularly process. Once located, the nerve is isolated and dissected away
if several levels are involved. It is difficult to justify sacrifice of from the underlying fibrofatty contents from the Erb’s point
the SAN if it is not directly involved with disease, when the medially to the point at which it enters the anterior border of the
hypoglossal nerve and the vagus nerve, which also lie in similar trapezius muscle laterally (see Fig. 118.7B). The nerve is next
proximity to nodal disease, are spared. isolated in its superior third, which is done by incising the anterior
border of the SCM from its attachment superiorly at the mastoid
Technique. Knowledge of the surgical anatomy of the SAN is to its lowermost attachment at the sternal head. The SCM is
essential to preserve this structure. Below the jugular foramen, retracted laterally as the fibrofatty soft tissue contents anterior to
the nerve is located deep to the digastric and stylohyoid muscles this muscle are dissected away from it, and the many arcades of
and lateral or immediately posterior to the IJV; it then runs small blood vessels that course between the muscle and the soft
obliquely downward inferiorly and posteriorly to reach the tissue are divided. This part of the procedure mobilizes the anterior
medial surface of the SCM near the junction of the superior aspect of the SCM along its full extent. As the muscle is retracted
and middle third. The SAN traverses this muscle, giving off a laterally in its upper portion, the SAN is seen entering its deep
major branch to it. The remaining part of the nerve then exits surface (see Fig. 118.7C). From this point, the nerve is traced
the posterior border of the SCM near the area known as the superiorly by dividing the overlying fibrofatty contents until the
Erb point, where the four superficial branches of the cervical posterior belly of the digastric muscle is identified. This muscle
plexus—the greater auricular, lesser occipital, transverse cervical, is retracted superiorly to gain exposure to the superior end of the
and supraclavicular nerves—emerge from behind the muscle. This IJV near the jugular foramen. The posterior border of the SCM
point is located approximately at the junction of the upper and may be freed completely from the underlying fibrofatty contents
middle thirds of this muscle. From here, the SAN courses through all the way from its mastoid attachment above to its clavicular
the posterior triangle of the neck to enter the anterior border attachment below. Except for its course through this muscle, the
of the trapezius muscle at a point located approximately at the SAN is now completely mobilized, from its entry into to the
junction of the middle and lower thirds of the anterior border anterior border of the trapezius muscle below to its superior extent
of this muscle. at the skull base above.

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1816 PART VI Head and Neck Surgery and Oncology

A B C

D F
E
Fig. 118.7 Steps of the modified radical neck dissection, in which the spinal accessory nerve, internal jugular
vein, and sternocleidomastoid (SCM) muscle are preserved. (A) Raising a subplatysmal flap. (B) The fascia
overlying the SCM is incorporated into the specimen. (C) Dissection of the fibrofatty tissue off the SCM.
(D) Dissection of the posterior triangle along the trapezius muscle and the deep cervical fascia. (E) Dissection
of the specimen off the internal jugular vein. (F) En bloc resection.

The fibrofatty tissue in the posterior triangle is separated from operation is still called a modified RND as long as at least one of
the entire anterior border of the trapezius muscle and is mobilized these structures is preserved (Fig. 118.8).
in a lateral to medial direction. Tissue that lies superficial to the
SAN as it courses across the posterior triangle should be divided
immediately above the SAN so that it may be passed along with
Selective Neck Dissection
its deep component beneath the nerve and the elevated SCM (see Definition. SND is performed for patients who are at risk for
Fig. 118.7D). After the fibrofatty contents have been dissected early lymph node metastases. The procedure consists of the en
and swept over the carotid artery, vagus nerve, and IJV, the SCM bloc removal of one or more lymph node groups at risk for harbor-
may be retracted laterally, and the contents are passed underneath ing metastatic cancer, an assessment that is based on the location
the muscle for subsequent dissection of the anterior triangle of of the primary tumor. Therefore the levels removed depend on
the neck (see Fig. 118.7E). Careful sharp dissection will allow for the location of the primary lesion and its known pattern of spread.
separation of these contents from the carotid artery and the jugular
vein. An electrocautery device can also be used on low setting, Rationale. Although the concept of SND dates back to procedures
with the tissue retracted on both sides. This dissection is continued used for treating lip cancer, its broader adoption to treat other
until the sternohyoid muscle, the medial boundary of the anterior cancers of the upper aerodigestive tract was popularized by surgeons
triangle contents in the lower neck, is reached. The branches of at the M.D. Anderson Cancer Center.20 It was based on removing
the IJV are usually ligated to allow a thorough clearance of the lymph node groups that were at highest risk in patients with
anterior triangle contents. Dissection is carried superiorly to remove node-negative disease. Studies have shown that this procedure
the fibrofatty tissue attachments that overlie the IJV at the level has the same therapeutic value as more extensive neck dissections16;
of the skull base. The retromandibular vein may be preserved, it is also intended to preserve functionally and cosmetically relevant
but the anterior facial vein must be ligated (see Fig. 118.7F). structures as a secondary goal.
Subsequent dissection is then performed to remove the contents The topographic distribution of lymph node metastases appears
of the submandibular and submental triangles. to be predictable in patients with previously untreated squamous
Sacrifice of one or two of the nonlymphatic structures of the cell carcinoma (SCC) of the head and neck, particularly in those
neck—the SAN, SCM, and IJV—may become necessary owing with early disease. The basic anatomic studies of Rouviere39 and
to gross involvement by cancer intraoperatively, although the Fisch and Sigel40 showed that lymphatic drainage of the mucosal

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 CHAPTER 118 Neck Dissection 1817

118

A B
Fig. 118.8 Modified radical neck dissection with preservation of the spinal accessory nerve only (A) and
preservation of the spinal accessory nerve and internal jugular vein (B). (Courtesy Douglas Denys, MD.)

surfaces of the head and neck follow relatively constant and predict-
able routes. The clinical study by Lindberg12 in 1972 showed that
Selective Neck Dissection for Oral Cavity Cancer
the lymph node groups most frequently involved in patients with Definition and Rationale. For oral cavity cancer, the procedure
carcinoma of the oral cavity are the jugulodigastric and midjugular of choice is SND (levels I through III), and this is often called
nodes. In addition, the nodes in the submandibular triangle are supraomohyoid neck dissection. The procedure involves removal of
frequently involved in patients with carcinoma of the floor of the the lymph nodes contained in the submental and submandibular
mouth, anterior oral tongue, and buccal mucosa. Lindberg also triangles (level I) in addition to those of the upper jugular (level
noted that tumors frequently metastasize to both sides of the neck II) and midjugular lymph nodes (level III). The cutaneous branches
and may skip the submandibular and jugulodigastric nodes, of the cervical plexus and the posterior border of the SCM mark
metastasizing first to the midjugular region. The Lindberg study the posterior limit of the dissection. The inferior limit is the
showed that in the absence of metastases to the first-echelon junction between the superior belly of the omohyoid muscle
nodes, tumors of the oral cavity and oropharynx rarely involve and the IJV.
the lower jugular and posterior triangle nodes. Similar findings SND is recommended for patients with oral cavity cancer who
were reported in 1976 by Skolnik et al.,14 who found no metastases are at risk of harboring occult nodal disease (Fig. 118.9). It can
in the nodes of the posterior triangle of the neck in RNDs, in a also be performed for patients with low-volume nodal disease
study of RND specimens, regardless of the site of the primary (N1) located in the upper neck provided that postoperative RT
tumor or the presence or absence of metastases in the jugular is part of the treatment plan. Tumors that originate in this region,
nodes. Further evidence was subsequently provided by Shah22 in particularly in the subsites of the oral tongue and the floor of the
a retrospective study of RND specimens taken from patients with mouth, have a high propensity to metastasize early regardless of
oral cavity and larynx or laryngopharyngeal metastases. Shah size and differentiation. Primary echelons for nodal spread include
demonstrated that tumors of the oral cavity metastasize most the submental, submandibular, upper jugular, and middle jugular
frequently to neck nodes in levels I, II, and III, whereas carcinomas groups. In patients with tongue cancer, the lower jugular lymph
of the pharynx, hypopharynx, and larynx involve mainly the nodes node groups (level IV) are also at risk.42 Even when no clinical
in levels II, III, and IV. Whenever positive nodes were found in evidence of nodal disease is apparent, a risk for occult disease of
other areas, disease was also found in the areas of highest risk. at least 20% is associated with these lesions. Unless the management
Some authorities believe that SND is, in essence, a procedure of choice for the primary lesion is RT, elective neck dissection
for staging the necks of patients whose tumors are amenable to with removal of the nodes in levels I through III—in addition to
treatment with surgery alone. In patients who have this procedure level IV for those with tongue cancer—is the minimal recommended
done in conjunction with excision of the primary tumor, further treatment for patients with SCC of the oral cavity associated with
information about the status of the nodal disease is provided. If N0 nodal disease; however, for patients with palpable nodal disease,
multiple lymph node metastases or extracapsular spread (ECS) in a modified RND is usually necessary, but a selective removal of
the neck dissection contents is evident, postoperative RT is levels I through IV is an appropriate alternative when the nodal
indicated. Byers and associates41 also reported a lower rate of disease is confined to levels I and II. With the possible exception
regional recurrence among patients with N1 disease if postoperative of a solitary metastatic node without extracapsular extension,
RT was administered. More intensive therapy may be used for postoperative RT is usually indicated for all patients who undergo
patients who have more aggressive tumors. SND who have positive pathologic nodes in the specimen.13 Elective

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1818 PART VI Head and Neck Surgery and Oncology

submandibular triangle for assessing tumor involvement of the

superficial layer of the deep cervical fascia. After this possibility
is excluded, the fascia that overlies the SG is carefully raised as a
separate flap to avoid injuring the mandibular branch of the facial
nerve. This branch is often seen within the superficial layer of
the deep cervical fascia, but with careful dissection of this layer
the nerve may be protected and preserved.
Next, an incision is made in the investing layer of the deep
fascia at the anterior border of the SCM. Care is taken to not
IIB
injure the external jugular vein and branches of the greater auricular
IB nerve that lie lateral to the SCM but posterior to the fascial incision
IIA being made. As lymph nodes associated with the external jugular
vein are almost never involved with aerodigestive tract carcinomas,
IA these structures are left undisturbed. The fibrofatty contents of
the anterior triangle are peeled away first from the anterior border
and then from the medial aspect of the SCM, all the way from a
III point close to the mastoid process above down to the level of the
omohyoid muscle below, stopping when the posterior border of
the muscle is reached. Although the upper third of the SCM is
being separated, the SAN comes into view as it enters the muscle
(see Fig. 118.11C). This nerve is dissected free of its surrounding
fibrofatty tissue from the level of the skull base adjacent to the
IJV to its point of entry into the SCM. It is necessary to dissect
along the inferior border of the posterior belly of the digastric
muscle and to retract it supralaterally to provide adequate exposure
of the upper carotid sheath near the skull base. Fibrofatty tissue
is also dissected away from the inferior border of the posterior
belly of the digastric muscle as far posteriorly as the attachment
Fig. 118.9 Boundaries of the selective neck dissection (SND) of levels of the mastoid process. This triangle, formed by the digastric
I through III (SND I–II), or the supraomohyoid type, for oral cavity muscle, SAN, and SCM, outlines the triangular packet of tissue-
cancer. (Courtesy Douglas Denys, MD.) bearing lymph nodes that belong to level II. It is important to
separate this triangular packet from the underlying paraspinal
muscles and to pass it under the SAN (see Fig. 118.11D). The
dissection is continued inferiorly by incising along the fibrofatty
cervical lymphadenectomy of the contralateral neck is indicated tissue that corresponds with the posterior border of the SCM to
for patients with primary lesions that involve the floor of the the level of the omohyoid muscle; care is taken to not cut across
mouth or the ventral surface or with midline involvement of the the sensory branches of the cervical plexus as the incision is carried
tongue, in whom ipsilateral neck dissection is planned, and in down to the muscular floor. When the sensory branches of the
whom no definite indications for postoperative RT exist. Contra- cervical plexus are encountered, the fibrofatty tissue is dissected
lateral therapeutic neck dissection is indicated for patients with in a plane that is superficial to these nerves (see Fig. 118.11E). At
clinically N2c disease. this point in the procedure, it is important to carefully inspect
and palpate the lower jugular chain and the posterior triangle for
Technique. When an ipsilateral supraomohyoid neck dissection evidence of nodal disease. If such is found, the dissection of the
is planned, a modified apron incision is made to provide adequate lymph node–bearing tissue would have to be extended to encompass
exposure of levels I through III (Fig. 118.10A). If bilateral neck level IV and the posterior triangle (level V), thereby converting
dissection is needed, the horizontal component of the apron incision the operation to a modified RND. For this purpose, a lower cervical
is carried across the midline to the other side of the neck (bilateral flap would then be raised for adequate exposure of the clavicle
incision; see Fig. 118.10B). The ipsilateral and bilateral apron and the anterior border of the trapezius.
incisions are also appropriate for exposure of the primary disease After completion of the lateral boundary of dissection, the
when a pull-through exposure is indicated. If bilateral neck dis- lymph node–bearing tissue is swept medially in a plane immediately
section is planned and a lip-splitting incision is also required, a above the fascia of the paraspinal muscles. The sensory branches
bilateral boomerang incision is substituted for the bilateral apron of the cervical plexus may be preserved only when a level V dis-
incision (see Fig. 118.10D). When the lip must be split for access section is not performed. This maneuver allows the lymph
to the primary tumor, the medial component of the ipsilateral node–bearing tissue to be swept over the carotid sheath and permits
apron incision may be extended for this purpose. This neck incision exposure of its structures from the level of the clavicle or omohyoid
pattern is also preferred for those with more advanced nodal disease muscle below to the skull base above. Sharp dissection is used to
associated with oral cavity primaries in whom it is necessary to remove the fascia that overlies the sheath, and this usually includes
dissect all five levels of the ipsilateral neck. The boomerang incision preservation of the IJV, if a tissue plane can be readily identified.
is also preferred for patients with stage N2c disease because it Next, the superior belly of the omohyoid muscle is skeletonized
may be extended across the midline for exposure of all levels of along its superior border to the level of the hyoid bone. The hyoid
the contralateral lymph nodes (see Fig. 118.10D). bone is also skeletonized medially, as is the anterior belly of the
For the removal of levels I through III, the modified apron contralateral digastric muscle; this completes the medial boundary
SKN flap is raised in the subplatysmal plane until the upper of dissection. The fibrofatty tissue is dissected from below, at the
two-thirds of the anterior border of the SCM, mastoid process, level of the omohyoid muscle, in a superior direction toward the
body of the mandible, and mandibular symphysis are exposed submandibular triangle. After the lymph node–bearing tissue in
(Fig. 118.11A and B). It is best not to raise the fascia off the SG the submental triangle has been cleared, the contents of the
until the subplatysmal flap is first elevated to the level of the body submandibular triangle are removed to complete the neck dissection
of the mandible, which permits a more accurate assessment of the (see Fig. 118.11). To ensure complete removal of all lymph nodes

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 CHAPTER 118 Neck Dissection 1819

118

A B

C D
Fig. 118.10 Incisions for a selective neck dissection (SND) of levels I through III (SND I–III). (A) Modified apron
incision. (B) Apron incision. (C) Boomerang incision. (D) Bilateral boomerang incision.

from this region, it is important to dissect along the fascial planes the incisions, a single drain is placed in the surgical bed to extend
of the muscles within this triangle, rather than enucleating the inferiorly from the digastric muscle above to a separate cutaneous
SG only, which includes dissection of the preglandular nodes puncture site made at the most dependent region below the SKN
beneath the anterior belly of the digastric muscle and the prevas- incision. The drain is placed on continuous suction, and a second
cular and postvascular nodes along the lower border of the body drain is placed in the contralateral neck for bilateral procedures.
of the mandible. It is usually not necessary to remove the perifacial Drains are usually removed 3 days after surgery if the fluid col-
nodes that lie lateral to the mandibular body unless the primary lection is less than 20 mL/24 hours.
cancer involves the buccal mucosa, upper gum, or upper lip.
Dissection of this latter nodal group increases the risk of injury Selective Neck Dissection for Oropharyngeal,
to the mandibular branch of the facial nerve.
After completion of the dissection, the excised tissue is separated Hypopharyngeal, and Laryngeal Cancer
according to the level of the lymph node groups, and each level Definition and Rationale. The procedure of choice for head
is submitted separately for pathologic evaluation. Before closing and neck anatomic sites is SND (levels II through IV), and its

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1820 PART VI Head and Neck Surgery and Oncology

A B C

D E
Fig. 118.11 Steps of the selective neck dissection (SND) of levels I through III (SND I–III) for oral cavity
cancer. (A) Modified apron incision. (B) Flap raised in the subplatysmal plane to expose the upper two thirds
of the carotid sheath and the submandibular and submental triangle; exposure of the upper third of the
spinal accessory nerve and dissection of the submuscular recess (level IIB). (C) Dissection of level III and
preservation of the cervical plexus. (D) Completion of the dissection of levels III and IIA. (E) Dissection
of level I.

boundaries are outlined in Fig. 118.12; it is also called a lateral that involve the pharyngeal wall, the designated procedure is an
neck dissection. The procedure refers to the removal of the upper SND of levels II through IV (retropharyngeal nodes). If the nodes
jugular (level II), midjugular (level III), and lower jugular lymph in level VI are removed, as in the case of laryngeal and hypopha-
nodes (level IV). The superior limit of dissection is the skull base ryngeal cancers that extend below the level of the glottis, the
and the inferior limit is the clavicle; the anterior (medial) limit is procedure designated is an SND of levels II through IV and VI.
the lateral border of the sternohyoid muscle and the stylohyoid It should be noted that some controversy exists over which
muscle; and the posterior (lateral) limit of the dissection is marked SND is indicated for an oropharyngeal cancer without known
by the cutaneous branches of the cervical plexus and the posterior metastasis to the neck (N0). Although the classic findings by Shah22
border of the SCM. When cancers involve the oropharynx and and others43–46 showed that the pattern of lymph nodes involved
the hypopharynx, evidence indicates that the lateral retropharyngeal are found in levels II through IV, other studies have suggested
nodes are also at risk. Level IIB is at greater risk for metastases that the levels at risk are I through III.47,48 One possible explanation
associated with oropharyngeal lesions relative to laryngeal and for this discrepancy could be the fact that it is very easy to confuse
hypopharyngeal cancers. Therefore, if level IIB is excluded, as is nodes located posterior and deep to the SG with level IB nodes,
sometimes done for N0 laryngeal and hypopharyngeal cancers, when in essence they are in level IIA. The same mistake could be
the procedure designated would be an SND of levels IIA, III, and made when dividing the specimen ex vivo into the different levels.
IV. When the risk for lymphatic metastases is bilateral, the pro- Another possible explanation would be that an original oropha-
cedure of choice is a bilateral SND of levels II through IV. If the ryngeal tongue-base cancer involves the oral tongue as well, thereby
retropharyngeal lymph nodes are included, as in the case of cancers putting level IB at higher risk.

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 CHAPTER 118 Neck Dissection 1821

Technique. The incision should allow for adequate exposure of minimally invasive surgery for oropharyngeal cancer, there is a
levels II through IV and, should occult disease be found, exposure trend toward minimizing incision length with many experienced 118
of level V as well. The hockey stick incision described for radical surgeons utilizing a limited horizontal SKN crease incision as a
and modified neck dissection is useful for this purpose; it may also port for clearance of contents in levels II through IV. After the
be extended across the midline and carried along the contralateral neck flaps have been raised, the fibrofatty contents of the anterior
neck as a broadly based apron flap or bilateral hockey stick inci- triangle are removed en bloc, including the lymph nodes that lie
sion (Fig. 118.13). However, it is worth noting that in the era of along the IJV from the skull base superiorly to the clavicle inferiorly.
The dissection proceeds by incising along the anterior border of
the SCM and by separating it from its underlying attachments
to the fibrofatty tissue. Care is taken to identify the SAN as it
enters the anterior aspect of the SCM. It then is skeletonized
from its entry point into the muscle inferiorly and into the skull
base superiorly, wherein it lies deep to the posterior belly of
the digastric muscle and lateral to the IJV. As described for the
supraomohyoid neck dissection, the fibrofatty tissue deep to the
SCM is incised and separated from the underlying splenius and
levator muscles. The sensory branches of the cervical plexus may
IIB
also be preserved by limiting the mobilization of fibrofatty tissue
to the region superficial to these nerve branches. The contents
are swept medially over the IJV, thereby exposing the full length
IIA of the vein, from the skull base above to the clavicle below. At
the lower end, care should be taken to meticulously identify and
ligate any lymphatic channels encountered. On the left side, the
thoracic duct will frequently be encountered; this structure must
be carefully separated away from the fibrofatty tissue to avoid any
III injury. If injury occurs, a repair must immediately be performed
with fine, nonabsorbable suture material (e.g., silk, monofilament
synthetic); occasionally this will necessitate ligation of the duct.
After the IJV has been completely skeletonized, the remainder
of the fibrofatty contents of the anterior triangle is mobilized by
skeletonizing the medial border of the sternohyoid muscle and the
IV stylohyoid muscle. The branches of the IJV in the neck may be
sacrificed to facilitate this process, although the communicating
branch to the anterior facial and retromandibular veins may be
easily preserved.

Fig. 118.12 Boundaries of the selective neck dissection (SND) of

Selective Neck Dissection for Cutaneous Malignancies
levels II through IV (SND II–IV), or the lateral type, for oropharyngeal, Definition and Rationale. The operation of choice depends on
laryngeal, and hypopharyngeal cancer. (Courtesy Douglas Denys, MD.) the location of the lesion and the adjacent lymph node groups,

A B
Fig. 118.13 Incisions for selective neck dissection (SND) of levels II through IV (SND II–IV). (A) Hockey stick.
(B) Bilateral hockey stick.

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1822 PART VI Head and Neck Surgery and Oncology

which are most likely to harbor metastatic disease. In the case of Technique. The optimal incision for posterolateral neck dissection
cancers that involve the posterior scalp and upper neck, the is one that allows exposure along the nuchal ridge to the occiput
procedure of choice is an SND of levels II through V (postauricular and posterior triangle and exposure of the upper, middle, and lower
and suboccipital; Fig. 118.14). This particular version is also called jugular lymph node groups; this can usually be accomplished with
the posterolateral neck dissection; it is primarily used to eradicate a lazy-S pattern or a combination of the hockey stick pattern with
nodal metastasis associated with cutaneous malignancies and soft a horizontal extension from its upper aspect along the nuchal ridge.
tissue sarcomas.9 The patient should be placed in the lateral decubitus position to
Posterolateral neck dissection involves the removal of the allow for adequate exposure of the posterior scalp and occiput.
suboccipital, retroauricular, upper jugular (level II), middle jugular In patients with midline posterior scalp lesions, the procedure
(level III), and lower jugular lymph nodes (level IV), along with should encompass the nodal groups on both sides of the neck.
the nodes of the posterior triangle of the neck (level V). The In this latter situation, the patient should be placed in the prone
superior limit of dissection is the skull base anteriorly and the position to allow access to both sides; SKN flaps are raised in the
nuchal ridge posteriorly; the inferior limit is the clavicle; the medial subplatysmal plane anteriorly and the subdermal plane posteriorly.
(anterior) limit is the lateral border of the sternohyoid muscle The posterior auricular and suboccipital nodes are removed after
and the stylohyoid muscle; and the lateral (posterior) limit is the incising the SKN along the nuchal ridge and raising the flap in
anterior border of the trapezius muscle inferiorly and the midline the dermal plane. Then the subcutaneous tissue that overlies the
of the neck superiorly. It is common to all sites that the lymphatic nuchal ridge and the upper trapezius muscle is removed; this
pathways for the seeding of tumor to the primary and secondary is important because lymph nodes in this region often lie very
echelon nodes involve the posterior auricular, occipital, posterior superficial in the soft tissue immediately below the SKN. Addi-
triangle, and jugular groups (see Fig. 118.14). Therefore the tionally, the dissection should be carried down to the underlying
dissection is designed to encompass the lymph node–bearing fascia of the upper neck muscles that attach to the nuchal ridge
fibrofatty tissue of the posterior and lateral compartments of the and occiput to ensure removal of lymph nodes along this plane.
neck. In addition, it is important to remove the intervening Next, the upper part of the trapezius muscle that attaches to the
subdermal fat and underlying fascia between the lymph node groups skull base should be divided to allow for exposure of suboccipital
and the primary disease, which ensures the removal of smaller nodes that lie in a deeper plane; these nodes typically lie along
nests of metastasizing tumor cells characteristic of malignancies the occipital artery as it courses laterally along the skull base.
that originate in cutaneous soft tissue. For cutaneous malignancies After completing this part of the dissection, the posterior triangle
that arise on the preauricular, anterior scalp, and temporal regions, is cleared in the fashion that has already been described for the
the elective neck dissection of choice is SND that includes the modified RND. The SAN is routinely identified and preserved,
parotid and facial nodes, levels IIA, IIB, III, and VA, and the unless there is direct tumor extension into the soft tissue that
external jugular nodes. For cutaneous malignancies that arise on surrounds it. The technique for locating and preserving the SAN
the anterior and lateral face, the elective neck dissection of choice has already been described. The remainder of the procedure
is SND of the parotid and facial nodes in levels IA, IB, II, and involves mobilizing the fibrofatty contents of the anterior triangle,
III. The development of techniques of lymphatic mapping may thereby removing the upper, middle, and lower jugular groups
have a future role in specifically defining nonpredictable lymphatic of lymph nodes. The technique for this procedure has already
echelons of risk for cutaneous malignancies. been described.

IIB

Sup. suboccipital
IIA
Deep suboccipital

Retroauricular
Semispinalis III
capitis VA

Sternocleidomastoid Splenius
capitis
VB
Spinal
Trapezius accessory IV
chain

A B
Fig. 118.14 (A) Localization of retroauricular and suboccipital lymph nodes. (B) Selective neck dissection
(SND) of levels II through V (SND II–V), also called a postauricular suboccipital or posterolateral neck
dissection, for posterior scalp and upper posterolateral cutaneous malignancies. (Courtesy Douglas
Denys, MD.)

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 CHAPTER 118 Neck Dissection 1823

Selective Neck Dissection for Cancer of the Midline the contralateral side is present. In this way the morbidity of
disrupting the blood supply to the parathyroid glands or reimplant- 118
Structures of the Anterior Lower Neck ing them can be avoided.
Definition and Rationale. The procedure of choice is the level
VI SND, often called an anterior neck dissection or central compartment Technique. If dissection of the lateral and posterior neck compart-
dissection (Fig. 118.15). The procedure is most often indicated, ments is indicated, this procedure is done first. Then, the strap
with or without dissection of other neck levels, for cancer of the muscles are either divided near the attachments at the sternum,
thyroid, advanced glottic and subglottic larynx cancer, advanced or they are mobilized and retracted laterally. The carotid artery
piriform sinus cancer, and cervical esophageal/tracheal cancer. is skeletonized along its medial border as far superiorly as the
This refers to the removal of the lymph nodes within the central superior thyroid artery (Fig. 118.16A). The ipsilateral lobe of the
compartment of the neck, including the paratracheal, precricoid thyroid gland is mobilized along its lateral border by dividing
(delphian), and perithyroid nodes, and the nodes located along the fascia and its arterial and venous supply (see Fig. 118.16B).
the recurrent laryngeal nerves. The superior limit of dissection The recurrent laryngeal nerve is identified inferiorly as it courses
is the body of the hyoid bone, and the inferior limit is the supra- along the tracheoesophageal groove. If the larynx is to be removed,
sternal notch; the lateral limits are defined by the medial border protection of the nerve is unnecessary. The fibrofatty contents of
of the carotid sheath (the CCA). This neck dissection does not each side of the anterior compartment may then be removed by
have a contralateral counterpart, and it assumes that the lymph excising all of the loose areolar tissue located between the carotid
nodes are removed on both sides of the trachea. In the case of artery laterally and the trachea medially (see Fig. 118.16C); the
metastases that extend below the level of the suprasternal notch, thyroid lobe is also removed as part of this en bloc resection (see
dissection of the superior mediastinal nodes may be indicated, in Fig. 118.16D). The parathyroid glands should be identified and
which case the procedure is designated an SND of level VI (superior reimplanted into the SCM. If it is necessary to completely remove
mediastinal nodes) or the optional level VII dissection. Exposure node-bearing tissue from the entire anterior compartment, the
of this latter region may require removal of the manubrium and procedure is completed on the contralateral side of the trachea.
possibly one or both sternal heads of the clavicles. Therefore a total thyroidectomy is performed and all of the
In the case of thyroid cancer in which there is evidence of parathyroid glands are reimplanted. The dissection is carried
nodal metastases into level V, the procedure of choice includes superiorly as far as the hyoid bone and inferiorly as far as the
the jugular nodes, as well as the posterior triangle nodes, and is suprasternal notch. If nodal disease is evident at the lower end of
designated an SND of levels II through V and VI. the trachea, a more thorough cleanout of the superior mediastinum
In patients with unilateral laryngeal and hypopharyngeal lesions, may be achieved by splitting the sternum or removing the manu-
the dissection of level VI may be confined to one side of the brium and one or more clavicular head.
compartment, provided no evidence of nodal metastases involving If the procedure is performed for a thyroid malignancy, the
strap muscles are preserved, unless their removal is indicated
because of direct invasion by the primary tumor. After the thy-
roidectomy has been completed and the recurrent laryngeal nerves,
as well as the parathyroid glands, have been identified, the fibrofatty
contents of the paratracheal gutter are peeled away from underlying
structures, along with the pretracheal soft tissues, up to the level
of the suprasternal notch. In addition, the delphian nodes located
above the upper border of the thyroid isthmus are removed sepa-
rately and included with the specimen.

Extended Neck Dissection

Any of the neck dissections described previously may be extended
to remove either lymph node groups or vascular, neural, or muscular
structures that are not routinely removed in a neck dissection. A
neck dissection may be extended to remove the retropharyngeal
lymph nodes on one or both sides when the primary tumor
originates in the pharyngeal walls. Ballantyne49 found a 44%
incidence of retropharyngeal node involvement in a group of
patients with carcinomas of the pharyngeal wall who were treated
surgically. Tumors of the tongue base, tonsil, soft palate, and
retromolar trigone may also spread to these lymph nodes, when
they involve the lateral or posterior walls of the oropharynx.
Adequate removal of a metastatic tumor in the neck may dictate
the need to extend a neck dissection to resect structures such as
VI
the hypoglossal nerve, levator scapulae muscle, or carotid artery.
Controversy still exists about the benefits of resecting the
common or ICA (Fig. 118.17). Some surgeons believe that resection
of these arteries is not justified in patients with SCC of the upper
aerodigestive tract, not only because of the associated morbidity,
but also because the prognosis of patients with disease in the neck
of sufficient extent to warrant such a resection is dismal.50 For
example, Moore and Baker51 observed a mortality rate of 30%
and a cerebral complication rate of 45% among patients who
Fig. 118.15 Boundaries of the selective neck dissection (SND) of level underwent carotid ligation; it should be noted that these figures
VI (SND VI), or anterior neck dissection, for thyroid cancer. (Courtesy included elective and emergency ligation. In a study of 28 patients
Douglas Denys, MD.) who had tumors grossly excised by “peeling” them off the carotid

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1824 PART VI Head and Neck Surgery and Oncology

Thyroid Ligation of
Strap muscles
gland inferior
divided
Thyroid gland thyroid
artery

Divided middle
thyroid vein

Sternocleidomastoid
muscle retracted Divided superior
B
A Ligation of superior thyroid artery Common carotid artery
thyroid vein
Internal jugular vein

Paratracheal
Thyroid gland lymph nodes
Dissection of paratracheal
lymph nodes
Trachea

Esophagus

C Cricothyroid D
Prevertebral fascia
muscle

Fig. 118.16 Steps of the selective neck dissection for level VI. (A) Ligation of the superior thyroid vessels.
(B) Ligation of the inferior thyroid vessels. (C) Resection of paratracheal lymph nodes. (D) En bloc resection of
the thyroid gland and level VI while preserving the recurrent laryngeal nerve.

artery, Kennedy and colleagues52 found that only 18% developed resection and reconstruction. Saphenous vein grafts are preferred
a recurrence in the neck without distant metastasis; this observation over prosthetic grafts for reconstruction, and if the SKN has
led the authors to state that only this small group of patients may been heavily irradiated, or if a portion of the SKN over the carotid
have benefited from carotid resection. Paryani, Goffinet, and Fee53 is resected, a myocutaneous flap should be used to cover the
reported encouraging results for patients with large cervical graft.59,60
metastases attached to the carotid artery who were treated by If carotid artery resection is considered preoperatively, endo-
resection of the tumor and by use of intraoperative iodine seed vascular balloon occlusion of the ICA with physiologic assessment
sutures as suture implants over the remaining carotid artery.54 will strongly predict the potential for stroke and the need for
Tumor control was obtained in the neck in 77% of the patients, revascularization.61,62 In this case, an angiogram is performed and
although only 15% of them were alive and free of disease after 1 an intravascular balloon is placed in the ICA. The patient is
year. Some surgeons advocate resecting the common artery or heparinized and the balloon is inflated to occlude the ICA. A
the ICA when the extent of disease dictates it; they believe that second catheter in the contralateral carotid artery is used for an
current methods of assessing the adequacy of cerebral circulation intracranial angiogram to assess the patency of collateral flow
on the basis of the contralateral carotid system allow for better through the circle of Willis to the hemisphere in jeopardy. The
preoperative patient selection.55–57 These beliefs, coupled with demonstration of an excellent crossover flow across a patent circle
improved techniques for vascular and soft tissue reconstruction, of Willis, along with symmetric venous filling bilaterally, is associ-
have made it possible to resect the carotid artery with acceptable ated with a lower risk of stroke, although this is not entirely predic-
morbidity. McCready and others58 reported their observations in tive. Therefore it is prudent to perform an occlusion test, which
16 patients who underwent carotid artery resection for the manage- involves the stoppage of blood flow for 30 minutes, induction of
ment of advanced carcinomas of the head and neck. Only two hypotension, and clinical observation of the patient. Alternatively,
patients (12%) developed postoperative cerebrovascular complica- a functional cerebral blood flow study—such as intraarterial xenon,
tions, and seven patients (45%) were free of disease at 1 year. xenon inhalation computed tomography (CT) scan, or single-photon
Others have reported similar results.55,57 Patients with frank emission CT (SPECT) scan—can be performed to assess functional
involvement of the carotid wall whose preoperative examination cerebral blood flow to the hemisphere in jeopardy. If studies suggest
indicates intolerance of carotid ligation should have carotid that the patient will not tolerate ICA sacrifice, consideration should

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 CHAPTER 118 Neck Dissection 1825

of results should, therefore, involve the consideration of several

factors related to the degree of extranodal involvement and whether 118
the primary tumor remains under control.
The presence of ECS is an important prognostic factor with
regard to recurrence in the neck after neck dissection.64,65 In
addition, the degree of extracapsular involvement is also important.
For example, Carter and colleagues50 reported a 44% recurrence
rate for macroscopic ECS versus a 25% rate for microscopic ECS.
In addition, the number of lymph nodes involved by tumor has
also been found to correlate with the rate of recurrence. Patients
with four or more involved nodes had a dramatically worse 4-year
survival than patients with only one involved node.66 Strong67 also
reported that the level of nodal involvement had prognostic
importance, observing a recurrence rate in the neck of 36.5% in
patients with positive nodes in one level versus 71% in patients
with positive nodes in multiple levels. Remember that the use of
adjuvant RT is considered by most to improve the rate of control
in the neck after neck dissection.63,68

Modified Radical Neck Dissection

The rate of recurrence in the neck after modified RND depends
on the amount of disease to which the procedure was applied.
When used as an elective procedure for patients with clinically
node-negative disease, which is no longer recommended, the
rate of recurrence varies between 4% and 7%; however, when
this procedure is used therapeutically for patients with clinically
node-positive disease, the recurrence rate in the dissected neck
Fig. 118.17 Extended radical neck dissection with resection of the varies between 0% and 20%. In some of these reports, preop-
common carotid artery. (Courtesy Douglas Denys, MD.) erative or postoperative radiation was also used. These results
indicate that in selected patients, modified RND is an attractive
alternative to RND.16,63

be given to surgery designed to salvage the ICA, or a revasculariza-

Selective Neck Dissection
tion procedure should be used. Numerous studies now support the effectiveness of SND for the
Revascularization procedures may be within the bed of the control of regional metastases related to upper aerodigestive tract
tumor resection if the proximal and distal ends of the carotid carcinoma. For supraomohyoid neck dissection (SND of levels I
artery and ICA remain. Artificial grafts can be used, as opposed through III), Byers16 reported a regional recurrence rate of 5.8%
to saphenous vein interposition grafts, depending on previous or for 154 patients with pathologic node-negative disease, 24 of whom
future RT and wound infection potential. ICA revascularization received postoperative RT. The rate of regional disease control
procedures continue to be practiced in select neurosurgical cases, for 80 patients with pathologic positive nodal disease was 15%;
particularly in those that involve extracranial to intracranial bypass 62 of these patients had multiple positive nodes, and 61% had
grafting, with good results seen at select centers.61,62 postoperative RT. In a later review of the M.D. Anderson experience,
Patients with significant atheromatous disease pose an interesting Medina and Byers56 found the recurrence rate to be 5% among
dilemma with regard to planned cervical dissections. A history of patients with pathologic node-negative disease, 10% when a single
any embolic symptoms will increase the risk of stroke with carotid nodal metastases without ECS was found, and 24% when multiple
vessel manipulation at surgery. If carotid salvage is planned as positive nodes or ECS was found. Postoperative RT decreased
part of the procedure, preoperative stenting should be considered the recurrence rate to 15% in the group with involvement of
before cervical dissection, or endarterectomy should be performed multiple nodes or ECS.
at the time of surgery, if anatomy allows. Asymptomatic carotid For patients who undergo lateral neck dissection (SND, levels
bifurcation disease should be managed by careful intraoperative II through IV), Byers16 reported a regional recurrence rate of
manipulation, with vessel preservation dictated by the surgical 3.9% among 256 patients with pathologic node-negative disease,
expectations. 126 of whom received postoperative RT. Among the 41 patients
with pathologic positive nodal disease, 37 of whom had postopera-
tive RT, 7.3% had regional recurrences.
RESULTS OF NECK DISSECTION Data that indicate relatively low regional recurrence rates
for patients with clinical node-negative neck disease support the
Radical Neck Dissection effectiveness of SND procedures for patients with upper aerodiges-
Obviously, the best results reported for patients who undergo RND tive tract carcinoma. What is more controversial is whether the
are those in whom the presence of histologically positive metastatic procedures are effective for patients with node-positive disease.
disease is not evident. In this scenario, 3% to 7% of patients will Pellitteri and colleagues69 found the regional recurrence rate for
have disease recurrence in the ipsilateral neck63; however, RND patients with pathologic positive nodal disease to be 11.1% among
is no longer indicated for patients with clinically node-negative 27 patients who underwent a supraomohyoid neck dissection and
(N0) disease. When RND is used as a therapeutic procedure, 4.8% among 21 patients who had a lateral neck dissection. These
regional control rates fall within a range. Again, RND is no longer results, along with those reported by Byers16 and Medina and
indicated for patients whose lymph node disease does not extend Byers,56 indicate that SND is feasible for a defined subset of patients
into surrounding nonlymphatic structures. An appropriate analysis with positive nodal disease. Postoperative RT is recommended

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1826 PART VI Head and Neck Surgery and Oncology

for patients with multiple nodal disease or ECS. More recently, Sentinel Lymph Node Biopsy–Guided
the efficacy of SND for clinically positive neck disease has been
demonstrated by others.70–72 In 2002, Andersen and colleagues73 Neck Dissection
reported on a 10-year, multi-institutional, retrospective review A potentially powerful adjunct to surgical treatment of the neck
of pooled data from 106 previously untreated clinically and is sentinel lymph node biopsy (SLNB). Pioneered by Morton
pathologically node-positive patients who underwent 129 SNDs and others89 for use in detecting the lymphatic spread of cutane-
and were followed for a minimum of 2 years or until the patient ous melanoma, this technique capitalizes on the principle that
died. Overall, nine patients experienced disease recurrence in lymphatic spread is orderly and occurs through first echelon lymph
the neck, for a regional control rate of 94.3%, and six of these node or nodes called the sentinel lymph nodes in a manner that
recurrences were in the areas of the neck that had been dissected absence of metastatic disease in these nodes predicts freedom
during the SND. The authors concluded that these results support from cancer in the remainder of the nodal basin. Both blue
the use of SND in selected patients with clinically positive nodal dye and radiolabeled colloid injected at the primary site have
metastasis from head and neck SCC. Regional control rates been used to identify sentinel nodes. With blue dye injection,
comparable with those achieved with the radical and modified the sentinel nodes are identified visually as blue nodes during
RNDs could be achieved in appropriately selected patients. The surgery. Radiolabelled colloid injection provides the additional
main advantages of the use of SND are that surgical time is benefit of preoperative mapping of the sentinel nodes using planar
shortened and morbidity is decreased, especially with regard to images from a gamma camera or 3D imaging by SPECT scan;
shoulder dysfunction. this allows optimal placement of the incision for sentinel node
Among patients previously treated with RT or other types of biopsy. This procedure is minimally invasive, and it possesses the
neck surgery, the initial trend was to perform neck dissections capacity to accurately stage the clinically occult neck in a number
that encompassed all five neck levels when salvage surgery was of different neoplasms.90
feasible; however, the data now support the use of SND as part Accuracy of sentinel node biopsy procedure in staging the neck
of the planned treatment for patients with bulky neck disease patients with early oral cavity cancer has been validated in many
whose primary tumor and regional nodes were initially treated single institution studies and in clinical trials in Europe and the
with definitive RT or chemoradiation.74,75 Nigauri and others76 United States.91–97 While in the American College of Surgeons
failed to find evidence of skip metastases outside levels II and III Oncology Group trial, the accuracy of sentinel node biopsy was
among 217 patients with SCC of the oropharynx who were treated assessed against neck dissection performed in the same operation
with RT. These authors recommended SND for patients with N1 after completion of sentinel node harvest. There is an abundance
disease, whereas modified RND or RND was recommended for of evidence from the European SENT trial as well as other single
patients with N2 or N3 disease. Boyd and colleagues77 analyzed institution studies to support the oncologic safety of sentinel node
25 patients with SCC of the oropharynx, nasopharynx, hypopharynx, biopsy being used as a stand-alone procedure to stage the neck;
and supraglottic larynx who had been treated with RT. Among here, only patients who are found to have metastasis in the sentinel
the 28 necks dissected (all but one patient had N2 or N3 disease), nodes undergo a neck dissection, while those with negative sentinel
only one had a tumor outside levels II through IV. On the basis nodes are able to avoid neck dissection. Advantages of sentinel
of this, SND was recommended for patients with disease in all node biopsy include reduced morbidity and greater ability to detect
pharyngeal sites who required salvage or planned neck surgery atypical or contralateral lymphatic drainage. Critics of this pro-
after RT. Efficacy of targeted chemoradiation and planned SND cedure have cited concern for somewhat reduced accuracy for
to control bulky nodal disease in advanced neck cancer has been floor of mouth compared to tongue cancers and a need for a
reported by Robbins and colleagues.78 In addition, Clayman and second procedure of completion neck dissection in patients with
associates79 used SND after chemoradiotherapy for oropharyngeal positive sentinel nodes because, typically, sentinel lymph nodes
cancer in patients with advanced nodal disease. Thus SND plays are best assessed by serial sectioning on permanent section his-
a more definitive role in the overall management of patients with topathology rather than intraoperative frozen section analysis.
initial bulky neck node disease with head and neck cancer that Although there are no studies directly comparing sentinel node
has been treated with nonsurgical modalities.80,81 biopsy–guided management to elective neck dissection for patients
with early oral cavity cancer with a clinically negative neck,
oncologic results in studies of sentinel node biopsy appear com-
Superselective Neck Dissection parable to those with elective neck dissection; hence the approach
Superselective neck dissection (SSND) is a procedure in which a of sentinel node biopsy is slowly gaining acceptance in the United
compartmental removal of lymph nodes limited to one or two States.
contiguous neck levels is performed.78 When SSND is used as
part of the primary treatment, it is important to point out that
the presence of positive nodal disease found within the neck
SEQUELAE OF NECK DISSECTION
dissection specimen at the time of surgery warrants extension of The most notable sequela observed in patients who have under-
the dissection, and if positive nodal disease is found after the gone RND is related to the removal of the SAN. The resulting
surgery, it is an indication for postoperative adjuvant RT. The denervation of the trapezius muscle, which is one of the most
most common use of the SSND is in the removal of lymph node important shoulder abductors, causes destabilization of the
disease associated with supraglottic cancer. In this setting, patients scapula, with progressive drooping and flaring of this bone at
who come to medical attention with clinically node-negative disease the vertebral border caused by lateral and anterior rotation. The
who, ultimately, are restaged pathologically rarely have positive loss of the trapezius function decreases the patient’s ability to
lymph nodes outside sublevel IIA and level III.70,82–84 Whereas abduct the shoulder above 30 degrees. These physical changes
SSND may have a role in other mucosal sites, a paucity of data result in the recognized shoulder syndrome of pain, weakness,
is available to support its use. In addition to its application as part and deformity of the shoulder girdle that is commonly associated
of the primary treatment, SSND may have a role in the treatment with RND.
of residual disease following chemoradiation that is confined to It has been debated whether a major difference is found in
a single level.85–88 Despite the absence of prospective studies to postoperative shoulder dysfunction after RND that preserves the
compare SSND with more extended neck dissection after organ- SAN. Using patient questionnaires, Schuller and others98 compared
preservation protocols, intuitively, reductions in fibrosis, shoulder symptomatology and the ability to return to preoperative employ-
dysfunction, and neck deformity might be expected. ment of patients who underwent either RND or modified RND.

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 CHAPTER 118 Neck Dissection 1827

Although they found no statistically significant difference between

the two groups, Stearns and Shaheen99 and others, using similar
COMPLICATIONS OF NECK DISSECTION 118
methods, found that the majority of patients who had a nerve- In addition to the various medical complications that may occur
sparing procedure did not have postoperative pain or shoulder after any surgical procedure in the head and neck region, a number
dysfunction.100,101 of surgical complications may be related solely or in part to the
Only recently have objective data about shoulder dysfunction neck dissection. In the follow-up of a patient who has undergone
after neck dissection been gathered prospectively. Using preopera- a neck dissection as part of the surgical treatment of cancer of
tive and postoperative observations of shoulder movement by the the head and neck region, several complications may arise. When
surgeons, who rated the degree of shoulder dysfunction, Leipzig a neck dissection is done after RT of more than 70 Gy, the risk
and others102 studied 109 patients who had undergone various of complications may be higher.52 The addition of chemotherapy
types of neck dissections. The researchers concluded that any type to RT may not increase the complication rate of neck dissection
of neck dissection may result in an impairment of function of the done as an isolated procedure without contamination from the
shoulder. They also noted that dysfunction occurred more fre- upper aerodigestive tract.105
quently among patients in whom the SAN was extensively dissected
or resected.
In 1985, Sobol and others60 performed a prospective study in
Air Leaks
which preoperative and postoperative measures of shoulder range Circulation of air through a wound drain is a common complication
of motion were compared. In addition, postoperative electromyo- that is usually encountered the day after surgery. The point of
grams (EMGs) were obtained in some patients. Shoulder range entrance of the air may be located somewhere along the SKN
of motion was better preserved in patients who underwent a incision, although if the drains are connected to suction in the
nerve-sparing procedure than in those who underwent RND. In operating room near the completion of the wound closure, such
addition, the type of nerve-sparing procedure was found to have an air leak usually becomes apparent then, and it can be corrected.
an influence on the degree of shoulder disability. Patients who Other points of entrance may not become apparent until after
had undergone a modified RND, in which the entire length of surgery, when the position of the neck changes, or when the patient
the nerve was dissected, had no dramatic difference in shoulder begins to move. A typical example of this situation is the improperly
range of motion compared with those patients who underwent secured suction drain that gets displaced and thereby exposes one
RND 16 weeks after surgery. Patients who underwent a supra­ or more of the drain vents. A similar situation occurs frequently
omohyoid neck dissection, in which dissection of the SAN was when a lateral trapezius flap is used in conjunction with a neck
less extensive, performed significantly better (P > .05) than either dissection; the slightest movement of the shoulder may produce
of the other groups in terms of shoulder range of motion and an air leak into the neck wound through the extensive donor
EMG findings for the trapezius muscle. Interestingly, 16 weeks defect, even after meticulous tacking of the SKN edges to the
after surgery, moderate to severe EMG abnormalities were noted underlying tissues and painstaking suturing of the SKN graft.
in as many as 65% of the patients in whom the SAN was dissected This problem may be prevented by using an adhesive vinyl drape
along its entire length (i.e., modified RND). Although no severe applied over the defect and surrounding SKN to seal any possible
abnormalities were noted in the group that underwent supra­ air leak, instead of using the traditional bolster of gauze to
omohyoid neck dissection, 22% of these patients showed moderate immobilize the SKN graft.
abnormalities. Several patients from each group had repeat studies Air leaks with potentially more serious consequences are those
approximately 1 year after surgery. Unlike patients who underwent that occur through a communication of the neck wound with the
RND, patients in whom the nerve was spared showed evidence tracheostomy site or through a mucosal suture line. In these patients
of improvement in all parameters studied. it is likely that, in addition to air, contaminated secretions are
A prospective study by Remmler and others103 revealed that circulated through the wound. Thus early identification of the
patients who had a nerve-sparing procedure had a serious but site of leakage is desirable, although it may not be a simple task,
temporary SAN dysfunction. In this study, preoperative strength, and correcting it may require revision of the wound closure in
range-of-motion measures, and EMG of the trapezius muscle the operating room.
were compared with postoperative measures obtained at 1, 3, 6,
and 12 months. The groups studied consisted of patients who
underwent nerve-sparing procedures and those who had the nerve
Bleeding
resected. Most of the patients in the nerve-sparing group had Postoperative hemorrhage usually occurs immediately after surgery.
supraomohyoid neck dissections. Patients who underwent RNDs External bleeding through the incision, without distortion of the
had a major decrease in trapezius muscle strength on EMG at 1 SKN flaps, often originates in a subcutaneous blood vessel. In
month, and these parameters did not improve with time. Interest- most patients, this may be readily controlled by ligation or infiltra-
ingly, patients in the nerve-sparing group had a small but significant tion of the surrounding tissues with an anesthetic solution that
reduction in trapezius muscle strength and evidence of trapezius contains epinephrine. Pronounced swelling or ballooning of the
muscle denervation at 1 and 3 months, which improved by 12 SKN flaps immediately after surgery, with or without external
months. More recently, Kuntz and Weymuller104 reported reduced bleeding, should be attributed to a hematoma in the wound. If a
quality-of-life scores among patients after neck dissection, with hematoma is detected early, “milking” the drains occasionally may
the worst scores being associated with RND and the best scores result in evacuation of the accumulated blood, and the problem
with SND. will resolve. If this is not accomplished immediately, or if blood
The evidence, therefore, indicates that even procedures that reaccumulates quickly, it is best to return the patient to the operat-
involve minimal dissection of the SAN may result in shoulder ing room, explore the wound under sterile conditions, evacuate
dysfunction.104 It is only appropriate, therefore, to make every the hematoma, and control the bleeding. Attempting to do this
effort to avoid undue stretch or trauma to the nerve when a in the recovery room or at the bedside is ill advised because lighting
nerve-sparing procedure is performed. In addition, it is imperative and surgical equipment may be inadequate, and sterile conditions
that every patient who undergoes a neck dissection be questioned may be precarious. Failure to recognize or manage a postoperative
about the function of the shoulder and be examined by a physical hematoma properly may predispose the patient to the development
therapist early during the postoperative period. If any deficit is of a wound infection. Although bulky pressure dressings may be
detected, the patient should be properly counseled and coached useful for curtailing postoperative edema, they do not prevent
to ensure proper rehabilitation of the shoulder. hematomas, and they may delay their recognition as well.

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1828 PART VI Head and Neck Surgery and Oncology

of extracellular fluids and dilutional hyponatremia aggravate the

Chylous Fistula cerebral edema and create a vicious cycle. In practice, these
In a review of 823 neck dissections performed by the surgeons at observations behoove the surgeon and the anesthesiologist to
Memorial Hospital in New York that included removal of the curtail the administration of fluids during and after bilateral
lymph nodes in level IV, Spiro, Spiro, and Strong68 found that 14 RNDs.110 In addition, perioperative management of fluid and
patients (1.9%) developed a chyle fistula. In this and other studies,106 electrolytes in these patients should not be guided solely by their
a chylous leak was identified and apparently controlled intraop- urine output but rather by the monitoring of central venous
eratively in the majority of patients who developed the complication. pressure, cardiac output, and serum and urine osmolarity.
These observations remind the surgeon to avoid injury to the
thoracic duct proper and to ligate or clip any visualized or potential
lymphatic tributaries in the area of the thoracic duct. This may
Blindness
be accomplished with relative ease if the operative field is kept Visual loss after bilateral neck dissection is a rare but catastrophic
bloodless when dissecting in this area of the neck. In addition, as complication. To date, five cases have been reported in the litera-
soon as the dissection of this area is completed, and again before ture.111 In one report, histologic examination revealed intraorbital
closing the wound, the area should be observed for 20 or 30 optic nerve infarction, which suggests intraoperative hypotension
seconds while the anesthesiologist increases the intrathoracic and severe venous distension as possible etiologic factors.66
pressure; even the smallest leak of chyle should be pursued until
it is completely controlled. Indiscriminate clamping and ligating
may be difficult and sometimes counterproductive because of the
Carotid Artery Rupture
fragility of the lymphatic vessels and the surrounding fatty tissue. The most feared and the most common lethal complication after
Hemoclips are ideal to control a source of leakage that is clearly surgery of the neck is the exposure and rupture of the carotid
visualized; otherwise it is preferable to use suture ligatures with artery, and every effort should be made to prevent this. If the
pliable material, such as 5-0 silk, tied over a piece of hemostatic SKN incisions have been designed properly, seldom does the
sponge to avoid tearing. carotid artery become exposed in the absence of a salivary fistula.
Despite the surgeon’s best efforts to avoid it, a postoperative Fistula formation and flap breakdown are more likely to occur in
chylous fistula occurs after 1% to 2% of neck dissections. Manage- the presence of malnutrition, diabetes, infection, and previous RT,
ment of this complication depends on the time of onset of the which impair healing capacity and compromise vascular supply.
leak, the amount of chyle drainage in a 24-hour period, and Faced with any of these risk factors, the surgeon should use flawless
the physician’s ability to prevent accumulation of chyle under the surgical techniques in the closure of oral and pharyngeal defects.
SKN flaps. When the daily output of chyle exceeds 600 mL, The use of free and pedicled vascularized flaps, which provide
especially when the chyle fistula becomes apparent immediately SKN for the closure of mucosal defects, has rendered nearly
after surgery, conservative closed-wound management is not likely obsolete the use of “protective” measures such as dermal grafts,
to succeed. In such patients, early surgical exploration is preferred levator scapulae muscle flaps, and controlled pharyngostomies.
before the tissues exposed to the chyle become markedly inflamed Management of the exposed carotid artery depends on the
and before the fibrinous material that coats these tissues becomes likelihood of rupture based on the length of the exposed segment,
adherent, thereby obscuring and jeopardizing important structures, the condition of the surrounding tissues, and the size of the
such as the phrenic and vagus nerves. oropharyngocutaneous fistula. Large cutaneous defects or large,
Chylous fistulae that become apparent only after enteral feedings high-output fistulae in previously irradiated patients are not likely
are resumed, and particularly those that drain less than 600 mL to heal by secondary intention in a timely manner. The likelihood
of chyle per day, are initially managed conservatively with closed- of rupture of the carotid artery in these patients is extremely high;
wound drainage, pressure dressings, and low-fat nutritional support. therefore an attempt should be made to repair the defect and to
Parenteral alimentation through a central line can further reduce cover the carotid artery using well-vascularized tissue before the
chylous output and may be considered for high-output or intractable vessel is irreversibly damaged. Whenever the carotid artery is
fistulae. exposed, it is advisable to take “carotid precautions,” which include
having compatible blood available, keeping appropriate surgical
instruments at the bedside, and warning and instructing nursing
Facial/Cerebral Edema personnel and house staff about the possibility of a carotid rupture,
Synchronous bilateral RNDs, in which both IJVs are ligated, may the site of potential rupture, and the steps to be taken in the event
result in the development of facial and/or cerebral edema. The of bleeding.
facial edema, which sometimes may be dramatically severe, appears When a carotid artery rupture occurs, it is usually possible to
to be caused by an inadequacy of venous drainage, which usually stop the bleeding with manual pressure, while blood and fluids
resolves to a variable extent with time as collateral circulation is are administered to restore and maintain the patient’s blood
established. Facial edema appears to be more common and more pressure; only then is the patient taken to surgery. Attempts to
severe in patients who have had previous irradiation to the head repair the area of rupture are futile. Introduction of Fogarty
and neck and in those patients in whom the resection included catheters through the area of rupture is helpful for controlling
large segments of the lateral and posterior pharyngeal walls. Massive the bleeding temporarily, while the artery is exposed and ligated
facial edema may be prevented by preserving at least one external proximally and distally to the area of rupture.
jugular vein whenever a bilateral RND is anticipated. The external
jugular is usually separated from the tumor in the neck by the NECK DISSECTION AFTER TREATMENT
SCM and may be dissected free between the tails of the parotid
and subclavian veins. WITH CHEMORADIATION
The development of cerebral edema may be at the root of the One of the treatment options for advanced local or regional SCC
impaired neurologic function and even coma that may occur after of the head and neck is CRT. This method of treatment may allow
bilateral RND. Ligation of the IJVs leads to increased intracranial for preservation of one or more upper aerodigestive organs with
pressure.107,108 It has been shown experimentally that the increased comparable or even better local and regional control rates compared
cerebral venous pressure that occurs as a result of ligating both with radiation alone.112–114 After treatment with CRT, the neck is
IJVs in dogs is associated with inappropriate secretion of antidiuretic hard to evaluate, both clinically and with the use of imaging
hormone.109 It may then be speculated that the resulting expansion techniques. As newer, more effective chemotherapy agents are

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 CHAPTER 118 Neck Dissection 1829

developed, and as diagnostic tools are improved and further extirpation surgery of the primary tumor should be followed based
innovations are made in the way RT is administered, constant on the pattern of lymphatic drainage of the primary tumor. The 118
assessment of the recommended approaches to evaluate and treat likelihood of occult metastasis in each neck level is also dependent
the neck after CRT is needed. The current assessment approach on histology, biologic markers, and genetic features of the primary
relies on the initial tumor stage and the clinical and imaging tumor. Although the retropharyngeal lymph nodes that drain
assessment before and after treatment. oropharyngeal cancer can be removed by TORS, dissection of
When control of disease at the primary site fails following CRT, levels II, III, and IV lymph nodes using a cervical incision is
without evidence of nodal involvement, a neck dissection should appropriate for most patients with cN0. Surgical clearance of the
be considered if the primary site is to be salvaged surgically. A lateral retropharyngeal lymph nodes can be performed through a
salvage neck dissection is necessary when nodal disease is evident cervical approach as well after completion of a level II through IV
after CRT. The salvage neck dissection can be further categorized neck dissection by approaching the region medial to the carotid
as an early salvage procedure, when disease persists after CRT, or sheath with retraction of the posterior belly of digastric muscle
late salvage neck dissection, when the neck recurrence is delayed. and hypoglossal nerve superiorly. Occasionally, the posterior
Delayed recurrent disease in the neck after CRT has a worse belly may have to be divided to facilitate access. The nodes lie
prognosis than a neck dissection done for persistent disease.115 The in a fat pad behind the posterior pharyngeal wall anterior to the
assessment of the regional response to CRT is done approximately prevertebral fascia.128
12 weeks after completion of treatment and is based on PET/CT
imaging techniques; however, if progressive disease is clinically
evident prior to this time, surgical intervention is indicated.78,116–118
MINIMALLY INVASIVE NECK DISSECTION
For patients with nodal disease of stage N0 or N1 who have With the widespread use of laser and robotic surgery, many tumors,
a complete response after irradiation alone or after CRT, a neck especially in early-stage (T1 to T2), of the oral cavity, larynx, and
dissection is indicated only if persistent regional disease is pharynx are approached transorally. Although a SND adds little
evident.78,117,119–122 Although it was initially controversial to perform to the nature, magnitude, and duration of an operation in which
a neck dissection for patients with stage N2 or N3 nodal disease the primary tumor is removed by a transcervical approach, in
who achieve complete response after CRT, a preponderance of cases in which a primary tumor has been removed transorally, the
literature now favors this strategy.123,124 If neck dissection is required, addition of neck dissection through unilateral or bilateral cervical
the selective type is often appropriate.77–79,85,119,125 The major incisions adds significantly to the operation; and in some centers
advantage of avoiding a neck dissection under such conditions is it is performed as a separate operation, requiring the patient to
the avoidance of the potential morbidity.104,126,127 undergo a second operation.
Another issue is the trend to minimize surgical morbidity and
NECK DISSECTION IN THE ERA OF pain and to improve cosmesis by avoiding a visible neck scar
through the use of a smaller scar than the traditional cervical
TRANSORAL SURGERY SKN incisions approach for a neck dissection, without compromis-
With the advancement of technology, there now exists an expanded ing the oncologic effectiveness.
indication for resecting upper aerodigestive carcinomas through a Recently, the transaxillary and retroauricular approach and the
minimal access approach. Transoral robotic surgery (TORS) and modified facelift and retroauricular approaches have been developed
transoral laser microsurgery (TLM) are integral parts of training for modified radical and SND using either endoscope or surgical
in many residency programs. These techniques and others enable robot. The robot has the advantages of 3D magnified view, scaled
surgeons to remove primary tumors without performing a neck and tremor-filtered movement, with multiarticulated wrist
incision. For this reason, the question of performing an elective movements.
neck dissection is more important. Nevertheless, the same principles The retroauricular approach allows a better surgical field for
that guide management of the neck in case of a transcervical the upper levels compared to the transaxillary approach; however,

Oral Oropharynx Laryngopharynx

cavity primary primary primary

No palpable Palpable nodes No palpable nodes Palpable nodes

nodes
High risk for
occult nodes*

SND (levels I to III) Ipsilateral/bilateral† Bilateral§ SND Ipsilateral MRND,

Bilateral SND for MRND‡ (levels I to V) (levels II to IV) contralateral
midline/floor of SND¶ (levels I to III) SND¶ (levels II to IV)
mouth primary
Fig. 118.18 Algorithm for cervical lymphadenectomy options in patients with carcinomas of the upper
aerodigestive tract, assuming that cervical lymphadenectomy is the treatment of choice for these regional lymph
nodes. *T1 to T4 oral tongue; T2 to T4 other sites; perineural/lymphatic invasion. †Bilateral neck dissection for
N2c disease. ‡RND if gross tumor invasion of nonlymphatic structures. ¶SND for nodes confined to one level.
§
Ipsilateral neck dissection for oropharyngeal primary tumors if postoperative radiotherapy is planned. MRND,
Modified radical neck dissection; RND, radical neck dissection; SND, selective neck dissection.

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1830 PART VI Head and Neck Surgery and Oncology

robotic surgery is much more difficult than a standard approach

and is more expensive. Retrospective studies on a small number
SUMMARY
of cases showed a comparable number of resected lymph nodes Neck dissection is an operative procedure designed to remove
and complication rate when done as an elective procedure.129 metastases that involve the regional cervical lymph nodes. The
Another prospective study showed similar results of a robotic- gold standard procedure is RND, which for most patients is too
assisted elective neck dissection.130 An endoscopically assisted neck extensive and results in excessive morbidity. Modifications of the
dissection might have an economic advantage in medical centers RND procedure have evolved, and these were designed to reduce
where a surgical robot is not available. In a randomized controlled morbidity by sparing nonlymphatic structures (modified RND)
trial, Fan et al. have proved the endoscopically assisted neck and to treat early nodal disease by removing only the lymph node
dissection feasibility, and although it was an hour longer on average groups at greatest risk for harboring metastases (SND). To help
there was no difference in the number of lymph nodes retrieved the reader determine which type of neck dissection is most
nor in complications.131 appropriate for the management of nodal disease associated with
As advances in technology allow for techniques that provide the three major sites of the upper aerodigestive tract, an algorithm
improved cosmesis and function with less morbidity, they should is provided (Fig. 118.18).
not be in lieu of the standard indications for a neck dissection
and without compromising the oncologic results. For a complete list of references, visit [Link].

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 CHAPTER 118 Neck Dissection1830.e1

REFERENCES 27. Lim YC, Lee JS, Koo BS, et al: Level IIb lymph node metastasis in
1. Kocher T: Ueber Radicalheilung des Krebes, Dtsch Z Chir 13:134–166, laryngeal squamous cell carcinoma, Laryngoscope 116:268–272, 2006. 118
1880. 28. Paleri V, Kumar SS, Oozeer N, et al: Dissection of the submuscular
2. Packard JH: A system of surgery, theoretical and practical in treatises by recess (sublevel IIb) in squamous cell cancer of the upper aerodigestive
various authors, Philadelphia, 1881, Lea’s Sons & Co. tract: prospective study and systematic review of the literature, Head
3. Jawdynski F: Przypadek raka pierwotnego szyi. t.z. raka skrzelowego Neck 30:194–200, 2008.
Volkmann’a. Wycieecie nowotworu wraz z rezekcyjea teetnicy 29. Rinaldo A, Elsheikh MN, Ferlito A, et al: Prospective studies of
szyjowej wspólnej i zyly szyjowej wewneetrznej, Wyzdrowienie Gaz neck dissection specimens support preservation of sublevel IIB for
Lek 8:530–537, 1888. laryngeal squamous carcinoma with clinically negative neck, J Am
4. Crile G: Excision of cancer of the head and neck. With special refer- Coll Surg 202:967–970, 2006.
ence to the plan of dissection based on one hundred and thirty-two 30. Sezen OS, Kubilay U, Haytoglu S, et al: Frequency of metastases at
operations, JAMA 47:1780–1786, 1906. the area of the supraretrospinal (level IIB) lymph node in laryngeal
5. Blair VP, Brown JB: The treatment of cancerous or potentially cancer, Head Neck 29:1111–1114, 2007.
cancerous cervical lymph-nodes, Ann Surg 98:650–661, 1933. 31. Talmi YP, Hoffman HT, Horowitz Z, et al: Patterns of metastases
6. Martin H: The treatment of cervical metastatic cancer, Ann Surg to the upper jugular lymph nodes (the “submuscular recess”), Head
114:972–985, 1941. Neck 20:682–686, 1998.
7. Nahum AM, Mullally W, Marmor L: A syndrome resulting from 32. Grégoire V, Eisbruch A, Hamoir M, et al: Proposal for the delineation
radical neck dissection, Arch Otolaryngol 74:424–428, 1961. of the nodal CTV in the node-positive and the post-operative neck,
8. Ward GE, Robben JO: A composite operation for radical neck Radiother Oncol 79(1):15–20, 2006.
dissection and removal of cancer of the mouth, Cancer 4:98–109, 33. Som PM, Curtin HD, Mancuso AA: The new imaging-based clas-
1951. sification for describing the location of lymph nodes in the neck
9. Saunders JR, Jr, Hirata RM, Jaques DA: Considering the spinal with particular regard to cervical lymph nodes in relation to cancer
accessory nerve in head and neck surgery, Am J Surg 150(4):491–494, of the larynx, ORL J Otorhinolaryngol Relat Spec 62:186–198, 2000.
1985. 34. Robbins KT, Clayman G, Levine PA, et al: Neck dissection classifica-
10. Suárez O: El problema de las metástasis linfáticas y alejadas del tion update: revisions proposed by the American Head and Neck
cáncer de laringe e hipofaringe, Rev Otorrinolaringol 23:83–89, 1963. Society and the American Academy of Otolaryngology–Head and
11. Bocca E, Pignataro O: A conservation technique in radical neck Neck Surgery, Arch Otolaryngol Head Neck Surg 128:751–758, 2002.
dissection, Ann Otol Rhinol Laryngol 76:975–987, 1967. 35. Robbins KT, Shaha AR, Medina HE, et al: Consensus statement on
12. Lindberg R: Distribution of cervical lymph node metastases from the classification and terminology of neck dissection, Arch Otolaryngol
squamous cell carcinoma of the upper respiratory and digestive tracts, Head Neck Surg 134:536–538, 2008.
Cancer 29:1446–1449, 1972. 36. Ferlito A, Robbins KT, Shah JP, et al: Proposal for a rational clas-
13. McGavran MH, Bauer WC, Ogura JH: The incidence of cervical sification of neck dissection, Head Neck 33(3):445–450, 2011.
lymph node metastases from epidermoid carcinoma of the larynx and 37. Hasegawa Y, Saikawa M, Hayasaki K, et al: A new classification and
their relationship to certain characteristics of the primary tumor. A nomenclature system for neck dissections: a proposal by the Japan
study based on the clinical and pathological findings for 96 patients Neck Dissection Study Group (JNDSG), Jpn J Head Neck Cancer
treated by primary en bloc laryngectomy and radical neck dissection, 31:71–78, 2005.
Cancer 14:55–66, 1961. 38. Hasegawa Y, Saikawa M: Update on the classification and nomenclature
14. Skolnik EM, Yee KF, Friedman M, et al: The posterior triangle in system for neck dissection: revisions proposed by the Japan Neck
radical neck surgery, Arch Otolaryngol 102:1–4, 1976. Dissection Study Group, Int J Clin Oncol 15(1):5–12, 2010.
15. Toker C: Some observations on the distribution of metastatic squamous 38a. Dralle H, Damm I, Scheumann GFW, et al: Compartment-oriented
carcinoma within cervical lymph nodes, Ann Surg 157:419–426, microdissection of regional lymph nodes in medullary thyroid
1963. carcinoma, Surg Today 24:112–121, 1994.
16. Byers RM: Modified neck dissection. A study of 967 cases from 1970 38b. Wittekind C, Greene FL, Henson DE, et al: TNM supplement,
to 1980, Am J Surg 150:414–421, 1985. ed 3, New York, 2003, Wiley-Liss, pp 25–33.
17. Robbins KT, Medina JE, Wolfe GT, et al: Standardizing neck dissection 38c. Qubain SW, Nakano S, Baba M, et al: Distribution of lymph node
terminology. Official report of the Academy’s Committee for Head micrometastasis in pN0 well-differentiated thyroid carcinoma, Surgery
and Neck Surgery and Oncology, Arch Otolaryngol Head Neck Surg 131:249–256, 2002.
117:601–605, 1991. 39. Rouviere H: Anatomie des Lymphatiaues de l’Homme, Paris, 1932,
18. Shah JP, Strong E, Spiro RH, et al: Surgical grand rounds. Neck Masson et Cie.
dissection: current status and future possibilities, Clin Bull 11:25–33, 40. Fisch UP, Sigel ME: Cervical lymphatic system as visualized by
1981. lymphography, Ann Otol Rhinol Laryngol 73:870–882, 1964.
19. Ariyan S, editor: Cancer of the Head and Neck, St. Louis, 1987, Mosby. 41. Byers RM, Clayman GL, McGill D, et al: Selective neck dissections
20. Jesse RH, Ballantyne AJ, Larson D: Radical or modified neck dissection: for squamous carcinoma of the upper aerodigestive tract: patterns
a therapeutic dilemma, Am J Surg 136:516–519, 1978. of regional failure, Head Neck 21:499–505, 1999.
21. Robbins KT, et al: Pocket guide to neck dissection classification 42. Byers RM, Weber RS, Andrews T, et al: Frequency and therapeutic
and TNM staging of head and neck cancer. Alexandria, VA, 2001, implications of “skip metastases” in the neck from squamous carcinoma
American Academy of Otolaryngology. of the oral tongue, Head Neck 19:14–19, 1997.
22. Shah JP: Patterns of cervical lymph node metastasis from squamous 43. Byers RM, Wolf PF, Ballantyne AJ: Rationale for elective modified
carcinomas of the upper aerodigestive tract, Am J Surg 160:405–409, neck dissection, Head Neck Surg 10:160–167, 1988.
1990. 44. Candela FC, Kothari K, Shah JP: Patterns of cervical node metastases
23. Dhiwakar M, Ronen O, Malone J, et al: Feasibility of submandibular from squamous carcinoma of the oropharynx and hypopharynx, Head
gland preservation in neck dissection: a prospective anatomic- Neck 12:197–203, 1990.
pathologic study, Head Neck 33(5):603–609, 2011. 45. Jose J, Coatesworth AP, Johnston C, et al: Cervical node metastases
24. Coskun HH, Erisen L, Basut O: Selective neck dissection for clinically in oropharyngeal squamous cell carcinoma: prospective analysis of
N0 neck in laryngeal cancer: is dissection of level IIb necessary?, prevalence and distribution, J Laryngol Otol 116:925–928, 2002.
Otolaryngol Head Neck Surg 131:655–659, 2004. 46. Lim YC, Koo BS, Lee JS, et al: Distributions of cervical lymph node
25. Elsheikh MN, Mahfouz ME, Salim EI, et al: Molecular assessment metastases in oropharyngeal carcinoma: therapeutic implications for
of neck dissections supports preserving level IIB lymph nodes in the N0 neck, Laryngoscope 116:1148–1152, 2006.
selective neck dissection for laryngeal squamous cell carcinoma with a 47. Spiro JD, Spiro RH, Shah JP, et al: Critical assessment of suprao-
clinically negative neck, ORL J Otorhinolaryngol Relat Spec 68:177–184, mohyoid neck dissection, Am J Surg 156:286–289, 1988.
2006. 48. Vartanian JG, Pontes E, Agra IM, et al: Distribution of metastatic
26. Ferlito A, Silver CE, Suarez C, et al: Preliminary multi-institutional lymph nodes in oropharyngeal carcinoma and its implications for
prospective pathologic and molecular studies support preservation the elective treatment of the neck, Arch Otolaryngol Head Neck Surg
of sublevel IIB and level IV for laryngeal squamous carcinoma with 129:729–732, 2003.
clinically negative neck, Eur Arch Otorhinolaryngol 264:111–114, 49. Ballantyne AJ: Significance of retropharyngeal nodes in cancer of
2007. the head and neck, Am J Surg 108:500–504, 1964.

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1830.e2PART VI Head and Neck Surgery and Oncology

50. Carter RL, Barr LC, O’Brien CJ, et al: Transcapsular spread of 77. Boyd TS, Harari PM, Tennehill SP, et al: Planned postradiotherapy
metastatic squamous cell carcinoma from cervical lymph nodes, Am neck dissection in patients with advanced head and neck cancer, Head
J Surg 150:495–499, 1985. Neck 20:132–137, 1998.
51. Moore O, Baker HW: Carotid-artery ligation in surgery of the head 78. Robbins KT, Wong FS, Kumar P, et al: Efficacy of targeted chemora-
and neck, Cancer 8:712–726, 1955. diation and planned selective neck dissection to control bulky nodal
52. Kennedy JT, Krause CJ, Loevy S: The importance of tumor attachment disease in advanced head and neck cancer, Arch Otolaryngol Head Neck
to the carotid artery, Arch Otolaryngol 103:70–73, 1977. Surg 125:670–675, 1999.
53. Paryani SB, Goffinet DR, Fee WE, Jr, et al: Iodine 125 suture implants 79. Clayman GL, Johnson CJ, Morrison W, et al: The role of neck
in the management of advanced tumors in the neck attached to the dissection after chemoradiotherapy for oropharyngeal cancer with
carotid artery, J Clin Oncol 3(6):809–812, 1985. advanced nodal disease, Arch Otolaryngol Head Neck Surg 127:135–139,
54. Chretien PB, editor: Head and neck cancer, Philadelphia, 1985, Mosby. 2001.
55. Biller HF, Urken M, Lawson W, et al: Carotid artery resection and 80. Hillel AT, Fakhry C, Pai SI, et al: Selective versus comprehensive
bypass for neck carcinoma, Laryngoscope 98:181–183, 1988. neck dissection after chemoradiation for advanced oropharyngeal
56. Medina JE, Byers RM: Supraomohyoid neck dissection: rationale, squamous cell carcinoma, Otolaryngol Head Neck Surg 141(6):737–742,
indications, and surgical technique, Head Neck 11:111–122, 1989. 2009.
57. Urken M, Biller HF, Lawson W, et al: Salvage surgery for recurrent 81. Robbins KT, Ferlito A, Shah JP, et al: The evolving role of selective
neck carcinoma after multimodality therapy, Head Neck Surg 8:332–342, neck dissection for head and neck squamous cell carcinoma, Eur Arch
1986. Otorhinolaryngol 270(4):1195–1202, 2013.
58. McCready RA, Miller SK, Hamaker RC, et al: What is the role of 82. Redaelli de Zinis LO, Nicolai P, Tomenzoli D, et al: The distribution
carotid arterial resection in the management of advanced cervical of lymph node metastases in supraglottic squamous cell carcinoma:
cancer?, J Vasc Surg 10:274–280, 1989. therapeutic implications, Head Neck 24:913–920, 2002.
59. Olcott C, Fee WE, Enzmann DR, et al: Planned approach to the 83. Khafif A, Fliss DM, Gil Z, et al: Routine inclusion of level IV in neck
management of malignant invasion of the carotid artery, Am J Surg dissection for squamous cell carcinoma of the larynx: is it justified?,
142:123–127, 1981. Head Neck 26:309–312, 2004.
60. Sobol S, Jensen C, Sawyer W, et al: Objective comparison of physical 84. Çagli S, Yüce I, Güney E: Is routine inclusion of level IV necessary in
dysfunction after neck dissection, Am J Surg 150:503–509, 1985. neck dissection for clinically N0 supraglottic carcinoma?, Otolaryngol
61. Grubb RL, Jr, Derdeyn CP, Fritsch SM, et al: Importance of hemo- Head Neck Surg 136:287–290, 2007.
dynamic factors in the prognosis of symptomatic carotid occlusion, 85. Robbins KT, Doweck I, Samant S, et al: Effectiveness of superselective
JAMA 280:1055–1060, 1998. and selective neck dissection for advanced nodal metastases after
62. Schmiedek P, Piepgras A, Leinsinger G, et al: Improvement of chemoradiation, Arch Otolaryngol Head Neck Surg 131:965–969, 2005.
cerebrovascular reserve capacity by EC-IC arterial bypass surgery 86. Robbins KT, Dhiwakar M, Vieira F, et al: Efficacy of super-selective
in patients with ICA occlusion and hemodynamic cerebral ischemia, neck dissection following chemoradiation for advanced head and
J Neurosurg 81:236–244, 1994. neck cancer, Oral Oncol 48(11):1185–1189, 2012.
63. Leemans CR, Tiwari R, van der Waal I, et al: The efficacy of compre- 87. Goguen LA, Chapuy CL, Sher DJ, et al: Utilizing computed
hensive neck dissection with or without postoperative radiotherapy in tomography as a road map for designing selective and superselective
nodal metastases of squamous cell carcinoma of the upper respiratory neck dissection after chemoradiotherapy, Otolaryngol Head Neck Surg
and digestive tracts, Laryngoscope 100:1194–1198, 1990. 143:367–374, 2010.
64. Johnson JT, Barnes EL, Myers EN, et al: The extracapsular spread 88. Suárez C, Rodrigo JP, Robbins KT, et al: Superselective neck dis-
of tumors in cervical node metastasis, Arch Otolaryngol 107:725–729, section: rationale, indications, and results, Eur Arch Otorhinolaryngol
1981. 270(11):2815–2821, 2013.
65. Snow GB, Larson DL, Guillamondegui OM, et al: Cancer of the neck, 89. Morton DL, Wen DR, Wong JH, et al: Technical details of
New York, 1986, MacMillin Publishing. intraoperative lymphatic mapping for early stage melanoma, Arch
66. O’Brien CJ, Smith JW, Soong SJ, et al: Neck dissection with and Surg 127:392–399, 1992.
without radiotherapy: prognostic factors, patterns of recurrence, and 90. Pan D, Narayan D, Ariyan S: Merkel cell carcinoma: five case reports
survival, Am J Surg 152:456–463, 1986. using sentinel lymph node biopsy and a review of 110 new cases,
67. Strong EW: Preoperative radiation and radical neck dissection, Surg Plast Reconstr Surg 110:1259–1265, 2002.
Clin North Am 49:271–276, 1969. 91. Civantos FJ, Zitsch RP, Schuller DE, et al: Sentinel lymph node
68. Spiro JD, Spiro RH, Strong EW: The management of chyle fistula, biopsy accurately stages the regional lymph nodes for T1-T2 oral
Laryngoscope 100:771–774, 1990. squamous cell carcinomas: results of a prospective multi-institutional
69. Pellitteri PK, Robbins KT, Neuman T: Expanded application of trial, J Clin Oncol 28:1395–1400, 2010.
selective neck dissection with regard to nodal status, Head Neck 92. Alkureishi LW, Ross GL, Shoaib T, et al: Sentinel node biopsy in
19:260–265, 1997. head and neck squamous cell cancer: 5-year follow-up of a European
70. Ambrosch P, Kron M, Pradier O, et al: Efficacy of selective neck multicenter trial, Ann Surg Oncol 17:2459–2464, 2010.
dissection: a review of 503 cases of elective and therapeutic treatment 93. Broglie MA, Haerle SK, Huber GF, et al: Occult metastases detected
of the neck in squamous cell carcinoma of the upper aerodigestive by sentinel node biopsy in patients with early oral and oropharyngeal
tract, Otolaryngol Head Neck Surg 124:180–187, 2001. squamous cell carcinomas: impact on survival, Head Neck 35:660–666,
71. Chepeha DB, Hoff PT, Taylor RJ, et al: Selective neck dissection 2013.
for the treatment of neck metastasis from squamous cell carcinoma 94. Samant S: Sentinel node biopsy as an alternative to elective neck
of the head and neck, Laryngoscope 112:434–438, 2002. dissection for staging of early oral carcinoma, Head Neck 36:241–246,
72. Konsulov SS, Yovchev IP, Doikov IY, et al: Selective neck dissection 2014.
in treatment of node-positive neck cases, Folia Med (Plovdiv) 43:27–29, 95. Govers TM, Hannink G, Merkx MA, et al: Sentinel node biopsy
2001. for squamous cell carcinoma of the oral cavity and oropharynx: a
73. Andersen PE, Warren F, Spiro J, et al: Results of selective neck dis- diagnostic meta-analysis, Oral Oncol 49:726–732, 2013.
section in management of the node-positive neck, Arch Otolaryngol 96. Chung MK, Lee GJ, Choi N, et al: Comparative study of sentinel
Head Neck Surg 128:1180–1184, 2002. lymph node biopsy in clinically N0 oral tongue squamous cell
74. Doweck I, Robbins KT, Mendenhall WM, et al: Neck level-specific carcinoma: Long-term oncologic outcomes between validation and
nodal metastases in oropharyngeal cancer: is there a role for selec- application phases, Oral Oncol 51:914–920, 2015.
tive neck dissection after definitive radiation therapy?, Head Neck 97. Schilling C, Stoeckli SJ, Haerle SK, et al: Sentinel European Node
25:960–967, 2003. Trial (SENT): 3-year results of sentinel node biopsy in oral cancer,
75. Hehr T, Classen J, Schreck U, et al: Selective lymph node dissection Eur J Cancer 51:2777–2784, 2015.
following hyperfractionated accelerated radio-(chemo-)therapy for 98. Schuller DE, Reiches NA, Hamaker RC, et al: Analysis of disability
advanced head and neck cancer, Strahlenther Onkol 178:363–368, resulting from treatment including radical neck dissection or modified
2002. neck dissection, Head Neck Surg 6:551–558, 1983.
76. Nigauri T, Kamata S, Kawabata K, et al: Treatment strategy for cervical 99. Stearns MP, Shaheen OH: Preservation of the accessory nerve
node metastasis from squamous cell carcinoma of the oropharynx, in block dissection of the neck, J Laryngol Otol 95:1141–1148,
Nippon Jibiinkoka Gakkai Kaiho 103:803–811, 2000, (in Japanese). 1981.

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 CHAPTER 118 Neck Dissection1830.e3

100. Short SO, Kaplan JN, Laramore GE, et al: Shoulder pain and func- 117. Grabenbauer GG, Rödel C, Ernst-Stecken A, et al: Neck dissection
tion after neck dissection with or without preservation of the spinal following radiochemotherapy of advanced head and neck cancer–for 118
accessory nerve, Am J Surg 148:478–482, 1984. selected cases only?, Radiother Oncol 66:57–63, 2003.
101. Weitz JW, Weitz SL, McElhinney AJ: A technique for preservation 118. Lavertu P, Adelstein DJ, Staxon JP, et al: Management of the neck
of spinal accessory nerve function in radical neck dissection, Head in a randomized trial comparing concurrent chemotherapy and
Neck Surg 5:75–78, 1982. radiotherapy with radiotherapy alone in resectable stage III and IV
102. Leipzig B, Suen JY, English JL, et al: Functional evaluation of the squamous cell head and neck cancer, Head Neck 19:559–566, 1997.
spinal accessory nerve after neck dissection, Am J Surg 146:526–530, 119. Stenson KM, Haraf DJ, Pelzer H, et al: The role of cervical lymph-
1983. adenectomy after aggressive concomitant chemoradiotherapy: the
103. Remmler D, Byers R, Scheetz J, et al: A prospective study of shoulder feasibility of selective neck dissection, Arch Otolaryngol Head Neck
disability resulting from radical and modified neck dissections, Head Surg 126:950–956, 2000.
Neck Surg 8:280–286, 1986. 120. Forest VI, Nguyen-Tan PF, Tabet JC, et al: Role of neck dissection
104. Kuntz AL, Weymuller EA, Jr: Impact of neck dissection on quality following concurrent chemoradiation for advanced head and neck
of life, Laryngoscope 109(8):1334–1338, 1999. carcinoma, Head Neck 28:1099–1105, 2006.
105. Proctor E, Robbins KT, Vieira F, et al: Postoperative complications 121. Frank DK, Hu KS, Culliney BE, et al: Planned neck dissection after
after chemoradiation for advanced head and neck cancer, Head Neck concomitant radiochemotherapy for advanced head and neck cancer,
26(3):272–277, 2004. Laryngoscope 115:1015–1020, 2005.
106. Crumley RL, Smith JD: Postoperative chylous fistula prevention 122. Pellitteri PK, Ferlito A, Rinaldo A, et al: Planned neck dissection
and management, Laryngoscope 86:804–813, 1976. following chemoradiotherapy for advanced head and neck cancer:
107. Royster HP: The relation between internal jugular vein pressure is it necessary for all?, Head Neck 28:166–175, 2006.
and cerebrospinal fluid pressure in the operation of radical neck 123. Hermann RM, Christiansen H, Rödel RM: Lymph node positive
dissection, Ann Surg 137:826–832, 1953. head and neck carcinoma after curative radiochemotherapy: a long
108. Sugarbaker ED, Wiley HM: Intracranial-pressure studies incident lasting debate on elective post-therapeutic neck dissections comes
to resection of the internal jugular veins, Cancer 4:242–250, 1951. to a conclusion, Cancer Radiother 17(4):323–331, 2013.
109. McQuarrie DG, Mayberg M, Ferguson M, et al: A physiologic 124. Hamoir M, Ferlito A, Schmitz S, et al: The role of neck dissection in
approach to the problems of simutaneous bilateral neck dissection, the setting of chemoradiation therapy for head and neck squamous
Am J Surg 134:455–460, 1977. cell carcinoma with advanced neck disease, Oral Oncol 48(3):203–210,
110. Wenig BL, Heller KS: The syndrome of inappropriate secretion of 2012.
antidiuretic hormone (SIADH) following neck dissection, Laryngoscope 125. Robbins KT, Shannon K, Vieira F: Superselective neck dissection
97:467–470, 1987. after chemoradiation: feasibility based on clinical and pathologic
111. Marks SC, Jaques DA, Hirata RM, et al: Blindness following bilateral comparisons, Arch Otolaryngol Head Neck Surg 133:486–489, 2007.
radical neck dissection, Head Neck 12:342–345, 1990. 126. Graner DE, Foote RL, Kasperbauer JL, et al: Swallow function in
112. El-Sayed S, Nelson N: Adjuvant and adjunctive chemotherapy in patients before and after intra-arterial chemoradiation, Laryngoscope
the management of squamous cell carcinoma of the head and neck 113:573–579, 2003.
region. A meta-analysis of prospective and randomized trials, J Clin 127. Morgan JE, Breau RL, Suen JY, et al: Surgical wound complica-
Oncol 14:838–847, 1996. tions after intensive chemoradiotherapy for advanced squamous cell
113. Forastiere AA, Goepfert H, Maor M, et al: Concurrent chemotherapy carcinoma of the head and neck, Arch Otolaryngol Head Neck Surg
and radiotherapy for organ preservation in advanced laryngeal cancer, 133:10–14, 2007.
N Engl J Med 349:2091–2098, 2003. 128. Moore EJ, Ebrahimi A, Price DL, Olsen KD: Retropharyngeal lymph
114. Pignon JP, Bourhis J, Domenge C, et al: Chemotherapy added to node dissection in oropharyngeal cancer treated with transoral robotic
locoregional treatment for head and neck squamous-cell carcinoma: surgery, Laryngoscope 123:1676–1681, 2013.
three meta-analyses of updated individual data. MACH-NC Col- 129. Tae K, Ji YB, Song CM, et al: Robotic selective neck dissection by a
laborative Group. Meta-Analysis of Chemotherapy on Head and postauricular facelift approach: comparison with conventional neck
Neck Cancer, Lancet 355:949–955, 2000. dissection, Otolaryngol Head Neck Surg 150(3):394–400, 2014.
115. Mendenhall WM, Parsons JT, Amdur RJ, et al: Squamous cell carci- 130. Lee HS, Kim WS, Hong HJ, et al: Robot-assisted Supraomohyoid
noma of the head and neck treated with radiotherapy: does planned neck dissection via a modified face-lift or retroauricular approach
neck dissection reduce the change for successful surgical manage- in early-stage cN0 squamous cell carcinoma of the oral cavity: a
ment of subsequent local recurrence?, Head Neck Surg 10:302–304, comparative study with conventional technique, Ann Surg Oncol
1988. 19(12):3871–3878, 2012.
116. Brizel DM, Prosnitz RG, Hunter S, et al: Necessity for adjuvant 131. Fan S, Liang FY, Chen WL, et al: Minimally invasive selective neck
neck dissection in setting of concurrent chemoradiation for advanced dissection: a prospective study of endoscopically assisted dissection
head-and-neck cancer, Int J Radiat Oncol Biol Phys 58:1418–1423, via a small submandibular approach in cT(1-2_N(0) oral squamous
2004. cell carcinoma, Ann Surg Oncol 21(12):3876–3881, 2014.

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