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Radical Neck Dissection and Minor Modifications

last modified on: Wed, 01/24/2024 - 07:04

Comprehensive Neck Dissection (Levels I - V)

(Radical Neck Dissection and Modifications - Sparing Cranial Nerve XI, Sternocleidomastoid Muscle and/or Internal Jugular Vein)

return to: Cervical Lymphadenectomy- General Considerations

GENERAL CONSIDERATIONS

  1. Indications
    1. Comprehensive neck dissection in the previously untreated patient is primarily utilized to treat neck disease greater than N 0; favorable N 1 disease may be treated with selective neck dissection. Expanding indications for selective neck dissection may warrant less than a comprehensive neck dissection for favorable N 2 disease when postoperative irradiation is planned.
    2. In the past indications for classical radical neck dissection have been:
      1. N 3 neck disease
      2. Disease involving the accessory nerve and/or internal jugular vein
      3. Recurrent tumor after previous irradiation
      4. Recurrent disease in the neck after previous neck dissection
      5. Salvage surgery in patients after chemo-irradiation
      6. Gross extra-nodal spread (fixation)
      7. Involvement of the platysma or skin, requiring sacrifice of a portion of skin in the upper neck
    3. In the past, patients with neck cancer persistence or recurrence after irradiation or chemo-radiation were generally treated with a comprehensive neck dissection.
  2. Contraindications
    1. N 0 (see Selective Neck Dissection protocol)
    2. Extensive disease (carotid artery encasement, deep neck muscular invasion, skull base involvement)
  3. Modifications to the radical neck dissection include the following:
    1. Type I: The spinal accessory nerve is preserved.
    2. Type II: The spinal accessory nerve and the internal jugular vein are preserved.
    3. Type III: The spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle are preserved.
    4. Extended radical neck dissection: Resection of lymph node groups and/or additional structures not included in the classic neck dissection is performed.
  4. Historic Perspective:
    1. The radical neck disecton was first described in 1906 by Crile, based on the Halstedian concept of en bloc resection. The purpose was to effectvely remove all of the lymph nodes present in the neck and their interconnecting lymphatics. It was the standard of care for the next 70 years. However, in addition to nodes and lymphatics, it also removes the SCM, submandibular gland, tail of the parotid gland, internal and external jugular veins, cervical sensory nerves and CN 11. Suarez later realized that cervical lymphatics are contained within fascial spaces, consisting of the fascia covering the submandibular glands, carotid sheath, SCM and deep cervical muscles and nerves, and he incorporated this fact ino his neck disections. In 1967, Ferlito, as well as Bocca and Pignataro, coined the term "functional neck disection," describing procedures that remove all the lymphatics but preseve non-lymphatic-continaing structures. We now refer to this as a "modified neck dissection." Further advancements have demonstrated that depending on the situation, not all levels must be explored, thus developing the concept of the "selective neck dissection."

PREOPERATIVE PREPARATION

  1. Additional Preoperative Evaluations
    1. CT scan of neck
    2. If there is extensive disease around the carotid artery, preoperative evaluation of carotid and cerebral blood flow may be valuable including four-vessel cerebral angiography and carotid balloon test occlusion if consideration for carotid resection is entertained. May be a useful preoperative evaluation if the risk of entering the carotid is high, even if resection of the carotid artery is not planned.
  2. Consent Inclusions
    1. General anesthesia
    2. Stroke and/or death (rare)
    3. Neck skin incision with secondary scar
    4. Bleeding, infection, swelling
    5. Removal of sternocleidomastoid (SCM) muscle with secondary asymmetry
    6. Removal of spinal accessory nerve with secondary shoulder weakness and pain (see Shoulder Rehab)
    7. Possible injury to hypoglossal nerve with secondary tongue weakness affecting speech and swallow
    8. Possible injury to vagus nerve with secondary weakness in voice and swallow
    9. Possible injury to facial nerve with secondary weakness of lower lip and/or face
    10. Possible injury to sympathetic trunk with secondary Horner's syndrome
    11. Possible injury to thoracic duct with secondary chyle leak
    12. Risk of significant facial or cerebral edema (primarily if both jugular veins are removed or injured)
    13. Possible skin flap loss
    14. Possible second surgery
    15. Additional concerns arise when neck dissection is combined with pharyngeal procedures and/or when bilateral neck procedures are performed:
      1. Risk of salivary fistula
      2. Late carotid bleeding

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Basic Soft Tissue Room Setup
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
    2. Special
      1. Nerve stimulator control unit and instrument
      2. Cummings retractor, large and medium
  3. Medications (specific to nursing)
    1. Antibiotic ointment
    2. 1% lidocaine with 1:100,000 epinephrine
  4. Prep and Drape
    1. Standard prep, 10% providone iodine
    2. Drape
      1. Head drape
      2. Place towels outlining the chin, neck, and upper chest
      3. Split sheet
  5. Drains and Dressings
    1. 10 mm fully-perforated Jackson Pratt drains
    2. Antibiotic ointment to suture lines

ANESTHESIA CONSIDERATIONS

  1. General Anesthesia
    1. Tube position: Corner of mouth contralateral to procedure
    2. Paralysis: None
  2. Systemic Medication
    1. Antibiotics (see Antibiotic protocol)
    2. Steroids
  3. Positioning
    1. Supine
    2. Head turned away
    3. Bed turned 180 degrees from anesthesia
  4. Estimated Blood Loss
    1. 150 cc (transfusion is very rare unless the neck dissection is accompanied by other concurrent surgery, such as composite resection or free flap)

OPERATIVE PROCEDURE

  1. Pertinent Anatomy
    1. Identify the angle of the jaw, mastoid tip, midline of the neck, anterior and posterior borders of the SCM muscle and the clavicle.
  2. Incisions
    1. Three common incisions are used:
      1. Utility or Lahey incision made in the skin creases of the neck beginning in the low neck and extending to the mastoid tip; occasionally a posterior limb is added
      2. Schobinger incision, which has a high horizontal limb (hyoid to mastoid tip) and long curving descending limb; this may be most useful in treating oral primary lesions
      3. MacFee incision consists of two parallel horizontal incisions, one high and one low. This is most useful in a postradiation patient when skin flap necrosis is more common and carries higher risks.
    2. Editors note (HTH): I prefer to avoid the superior curve to the lateral extension of the incision directed to the mastoid tip that is often used by others. This vertically-oriented extension creates a thin triangular supero-lateral extension of the flap with poor blood supply and commonly places any inferior extension of the incision over the carotid artery. I, therefore, extend the incision laterally (parallel to the clavicle) to the anterior border of the trapezius muscle. Small vertical extensions along the border of the trapezius (superior most commonly, inferior occassionally) offer excellent exposure.
  3. Skin Flap Elevation
    1. Subplatysmal plane leaving cervical plexus nerves and external jugular veins down
    2. If tumor is close to the platysma, elevate the skin above the platysma in that region (elevate subcutaneously)
    3. If the tumor invades platysma, consider resecting overlying skin:
      1. Superior limit of flap elevation is mandible, mastoid tip, and parotid
      2. Posterior limit is anterior edge of trapezius muscle
      3. Antero-medial limit is anterior border of sternohyoid muscle
      4. Inferior limit is clavicle
  4. Dissection With and Without Preservation of Internal Jugular Vein and Spinal Accessory Nerve
    1. Sternocleidomastoid is transected 2 cm above the clavicle with a #15 scalpel or electrocautery aided by traction through the surgeon's rostral pull employing a 4 x 4 gauze, counter-balanced by an assistant's inferior counter-traction. As the last fibers of the SCM are divided, the internal jugular vein and omohyoid muscle are fully exposed.
    2. Dissect internal jugular vein identifying the vagus nerve and carotid. Stay 2 cm above the clavicle to avoid the thoracic duct. Ligate internal jugular vein with 2-0 silk ties, two inferiorly and two superiorly. Transect the vein between ligatures.
    3. Alternatively, preserve the internal jugular vein. The vein is identified in the low neck and dissected, ligating all identified branches with 3-0 silk ties. Small branches may be controlled with bipolar electrocautery. Dissection continues superiorly deep to the digastric up to the lateral process of C2. The plane of dissection should be just superficial to the adventia of the vein.
    4. The specimen can then be bluntly and sharply lifted inferiorly off the "fascial carpet" that overlies the scalene muscles and phrenic nerve.
    5. Dissection proceeds superiorly going from posterior to anterior superficial to the deep cervical fascia. The posterior triangle is dissected. Transverse cervical vessels may be preserved if no tumor is present low in Level V. Cranial nerve XI is sacrificed if needed to completely clear the posterior triangle. It is uncommon to require sacrifice of XI.
    6. Alternatively, preserve the spinal accessory nerve and cranial nerve XI. Identify the nerve as it exits posteriorly to the SCM, 1 cm superior to Erbs point, or infero-laterally as it courses superficially to the lower one-third of the trapezius muscle. It is mobilized from the trapezius muscle through the SCM to the jugular vein. The contributions from the cervical nerve roots from C2, C3 and C4 and scar branch are ligated. The nodal compartment is split superficial to the nerve. The superior component (Level IIb) is mobilized and rolled under the nerve.
    7. Blunt dissection above the carotid artery and vagus nerve. As the cervical rootlets are encountered, they are transected high (adjacent to the specimen) to prevent injury to the phrenic nerve. Tying rootlets with 2-0 silk (or using hemoclips) may theoretically decrease the risk of neuroma.
    8. Identify and preserve XII nerve crossing the carotid bifurcation coursing deep to the digastric. The ansa cervicalis branches are cut as they exit XII near the carotid.
    9. Use cautery to separate the SCM attachments posteriorly from the skin and mastoid tip. As it is classically described, the dissection is carried across the inferior portion of the parotid tail including it in the specimen. It is not always necessary to resect the tail of the parotid gland.
    10. The internal jugular vein is encountered and XI nerve is either divided a second time (less commonly) or retracted (more commonly) if one intends to preserve it. The posterior belly of the digastric muscle is retracted superiorly and the internal jugular vein is ligated at the base of skull. A double ligature of 2-0 silk and a suture ligature for the base of skull stump. A single ligature is adequate for the inferior limb.
    11. Alternatively, preserve the internal jugular vein;. The specimen is dissected free of the internal jugular vein, and brought over or under it to join the medial portion of the dissection.
    12. Submandibular triangle dissection preserving lingual and hypoglossal nerves (see Selective Neck Dissection protocol, Level I)
  5. Trapezius reinnervation (optional)
    1. Postoperative shoulder dysfunction is significant after accessory nerve resection. If there is sufficient intact distal accessory nerve, end-to-end anastomosis can be performed to subfascial cervical plexus, after Krause, 1994. The nerve branch can be identified beneath the prevertebral fascia between the middle and posterior scalene muscles, and confirmed by stimulation.
  6. Closure
    1. Skin flaps are closed in two layers:
      1. The platysma with interrupted 3-0 vicryl
      2. The skin with surgical clips, 4-0 or 5-0 nylon
  7. Drains
    1. At least two (usually three) 10 mm fully-perforated Jackson Pratt drains:
      1. Place ipsilateral to dissected side through stab incision posterior to the neck incision to drain the posterior superior neck extending anteriorly to cross level I
      2. Place ipsilateral to dissected side through stab incision posterior to neck incision to drain the postero-inferior neck extending across the carotid inferiorly
      3. Place third (optional) drain through stab incision in contralateral neck to position drain mid-way between the first two drains
  8. Wound dressing
    1. Ointment to skin wounds

POSTOPERATIVE CARE

  1. Dressing
    1. None
  2. Monitoring
    1. Drain failure
    2. Hematoma, chyle accumulation
    3. Skin flap failure
    4. Fistula
    5. Stroke symptoms
  3. Shoulder Rehabilitation (see Shoulder Rehabilitation protocol)
    1. May consider physical therapy consult for shoulder dysfunction 2 to 3 days after drains are removed.
  4. Suture Removal
    1. No prior radiation postoperative day 6 or 7
    2. Prior radiation postoperative day 10 to14

REFERENCES

Lore JM. Cervical lymph nodes. In: Lore JM, ed. An Atlas of Head and Neck Surgery. 3rd ed. Philadelphia, Pa: WB Saunders Co. 1988:645-669.

Krause HR. Reinnervation of the trapezius muscle after radical neck dissection. J Craniomaxillofac Surg. 1994 Dec;22(6):323-9.

Medina JE, Weisman RA. Management of the neck in head and neck cancer, part I. Otolaryngol Clin North Am. August 1998;585-686.

Medina JE, Weisman RA. Management of the neck in head and neck cancer, part II. Otolaryngol Clin North Am. October 1998;759-856.

Myers EN. Operative Otolaryngology Head and Neck Surgery, Chapter 78, Neck Dissection. Vol 1. 2nd Edition. Elsevier; 2008:679-708.

Medina JE. Chapter 113: Neck Dissection. In: Bailey BJ and Johnson JT. Head & Neck Surgery-Otolaryngology. 2. 4th ed. Lippincoott Williams & Wilkins; 2006:1585-1609.

Crile G.  Excision of cancer of the head and neck with special reference to the plan of dissection based on one hundred and thirty-two operations. JAMA 22:1780-1786, 1906.

Ferltio A, Rinaldo A.  Osvaldo Suarez: often-fortotten father of functional neck dissections (in the non-Spanish-speaking literature). Laryngoscope 11:1177-1178, 2004

Bocca E, Pignataro A.  A conservation technique in radical neck dissection. Ann Otol Surg 81:975-987, 1967.

Medina JE. A rational classification of neck dissections.  Otolaryngol Head Neck Surg 100:169-176, 1989