Post on 04-Jun-2018
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 1/45
Neck Dissections
• Vinod Narayanan
• MDS, FDSRCS(Eng), MOMSRCPS(Glasg)
• Saveetha University
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 2/45
Cervical node metastasis is the single
most important prognostic factor in
head and neck squamous carcinomas.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 3/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 4/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 5/45
Preoperative staging by palpation androutine magnetic resonance imaging
cannot be relied upon to detect early
cervical metastatic disease
FDG!PET /CT is a useful tool for preoperative evaluation of theneck because it accurately detected metastatic lymph nodes equal
and more than 5mm and less false positive cases than CT
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 6/45
Micrometastasis less than 2mm
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 7/45
30" risk of occult lymph node metatsasis # Level 1 to 3 $in clinically negative necks # N0 $
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 8/45
Gingivo buccal 80"No Neck ! 11" were positive
Tongue /FOM 70"No Neck ! 34" were positive
# Shah etal $
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 9/45
Distribution of nodal
metastasis in therapeuticneck dissections
Distribution of nodal
metastasis in elective neckdissections
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 10/45
Risk of nodal metastasis from oral cancer is related to
several factors:
• Location of the primary tumor,
• T-stage
• Degree of Differentiation
• Depth of invasion.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 11/45
• Excluding the hard palate and lip,
approximately 30% of patients with oralcavity cancer will present with cervical
metastases
• Depth of invasion greater than 8 mmwas associated with a 41% rate of occult
metastasis.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 12/45
• Tumour depth > 5mm --- Increased risk
on neck metastasis
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 13/45
Comprehensive Neck Dissection
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 14/45
Goals of neck dissection
• Remove gross disease in patients with
clinical evidence of nodal involvement
(therapeutic neck dissection)• Remove occult metastases in patients
whose tumor characteristics make one
suspicious of occult cervical metastases(elective neck dissection or END)
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 15/45
Radical Neck Dissection
Removal of all ipsilateral cervical lymph nodegroups extending from the inferior border of themandible to the clavicle, from the lateral borderof the sternohyoid muscle, hyoid bone, andcontralateral anterior belly of the digastricmuscle medially,to the anterior border of thetrapezius. Included are levels I through V.
Removal of three important
nonlymphatic structures
Internal jugular vein,
Sternocleidomastoid muscle,
Spinal accessory nerve.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 16/45
Extended Neck Dissection
Removal of one or more additional lymph
node groups - mediastinal nodes
or
Nonlymphatic structures such as the carotidartery or hypoglossal nerve.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 17/45
Schobinger
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 18/45
McFee
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 19/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 20/45
Utility / U Shaped
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 21/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 22/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 23/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 24/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 25/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 26/45
• No difference
• Worse outcomes in stage II cancer of thetongue with discontinuous neck dissection,-
local recurrence rates of 19.1% versus
5.3% and a 5-year survival of 63% versus80%.
In-continuity versus discontinuous neck
dissections
C li i
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 27/45
Complications• Excessive bleeding,• Chylous leak• Slipping of the
stump of theinternal jugular vein , middlethyroid vein, in thesupraclavicularfossa near the
internal jugular vein, slipping ofthe transversecervical vessels
• Air Embolism
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 28/45
• Frozen shoulder syndrome,• Winging of the scapula
• Massive facial edema with bilateral neck
dissections.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 29/45
Shoulder complaints
• Reduced range of motion (decreased
shoulder abduction), reduced strength inthe trapezius muscle
• Shoulder pain
• Disfigurement, and disability in dailyactivities
Even with preservation of the nerve, shoulder complaintsdeveloped in 18 % 77" after modi&ed radical neck dissection, and
in 29 to 39" after selective dissection.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 30/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 31/45
Slipping of the jugular vein in the inferior
portion may lead to air embolism
Nitrous oxide anesthesia should be stopped and
the patient ventilated with 100% oxygen.The patient should be positioned in the left
lateral decubitus position so that the air can be
trapped in the right atrium.
Aspiration of the air embolus can be performed
through cardiac puncture or aspirating through
the central venous catheter.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 32/45
Chyle leak
• External chylous fistula (in 1% to 2% of cases)
• Chylothorax is extremely rare
• The chyle leak should be suture ligated or
controlled with hemo clips.• Conservative management of postoperative
chyle fistula includes a medium-chain
triglyceride diet, low-fat diet, pressure
dressings, and suction of the drains.
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 33/45
Wound infections
Primary wound
infections - Rare
Secondary to oralcommunication
Gram -ve
(Klebsiella sp)
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 34/45
Selective Neck Dissection
Encompass those node groups most at risk # levels I to III $ and bereferred to as a selective neck dissection # levels I to III $
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 35/45
Suarez O: El problema de las meta ' stasis linfa ' ticas y
B E Pi O A i h i i di l k
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 36/45
Suarez O: El problema de las meta stasis linfa ticas yalejadas del ca ' ncer de laringe e hipofaringe. Revista deOtorinolaryngologia # Santiago de Chile $ 23:83!99, 1963
Bocca E, Pignataro O: A conservation technique in radical neckdissection. Ann Otol Rhinol Laryngol 76:975!987, 1967
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 37/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 38/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 39/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 40/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 41/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 42/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 43/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 44/45
8/13/2019 Hand Out- Neck Dissection -Vinod Narayanan
http://slidepdf.com/reader/full/hand-out-neck-dissection-vinod-narayanan 45/45