Neck Dissection Katie Fedder - PowerPoint Presentation

1. Neck DissectionKatie Fedder MD

2. Why do we do it? Prognostic and therapeutic treatment of the cervical region in various types of head and neck cancerHN cancer grows at primary site and next stop is….Lymphatic channels  lymph nodes!Spread of cancer to cervical node cuts cure rate by…50% !!!!!

3. How I describe it‘Remove all the lymph nodes from jaw bone to collar bone’ (can adjust depending on levels needed)Find all the ‘important’ structures, get them out of the way, and remove everything elseNo discrete lymph node excision or ‘plucking’ in complete oncologic surgeryRemoval of all ‘fibrofatty’ contents of the neck = includes lymph nodes AND lymphatic channels

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5. Fascial Planes of the NeckSuperficial cervical fascia(platysma)Deep cervical fasciaSuperficial layer(SCM, straps, trap)Middle layersCarotid sheath (carotid, IJV, X)Visceral fascia (trachea, esoph, thyroid)Alar fascia (connects carotid sheaths)Deep layer(paravertebral)

6. Clinical RelevanceFascial layers can serve as a barrier to infectionRetropharyngeal spaceRoute of spread from oropharyngeal infectionDanger spaceSpace extends inferiorly to mediastinum; potential route for rapid development of mediastinitis

7. Triangles of the Neck

8. “Anterior Cervical Triangle”Boundaries:Superior: MandibleAnterior: Strap musclesPosterior: Anterior border of SCMContentsSubmandibular triangleNerves, fat, lymph nodes Carotid sheath

9. “Posterior Cervical Triangle”Boundaries:Anterior: Posterior border of SCMPosterior: Trapezius Inferior: ClavicleContentsCN XIOmohyoid

10. Classification of Neck DissectionTONS of terminologyIn general, have become more limited over the years (based on equivalent survival outcomes w less surgery)Timing terminologyElective TherapeuticSalvage

11. Other terminologyRadical: I-V + SCM + IJV + CN XIModified Radical: I-V with preservation of 1-3 of additional structuresSelective: preservation of some lymphatic level(s)Extended: resection of major structure not listed here

12. Levels of Lymphatic Drainage

13. PIBIAIIIIIIVVAVB

14. Level 1Submental triangle 1aBoundaries: ABD, hyoid, mylohoidNot much to mess up here!Submandibular triangle 1bABD and PBD, mandibleProbably most difficult anatomy- highest concentration of important stuff

15. Marginal mandibular nerveDeep to: platysma, superficial layer of deep cervical fasciaSuperficial to: facial vein

16. Hypoglossal NervePasses between ICA and ECA and makes a big turnDeep to mylohyoidSuperficial to hyoglossus

17. Level IIIncludes upper nodes along deep jugular chainBoundaries: lateral border of strap muscles, PBD, SCM, hyoid [carotid bifurcation]Split into two compartments by CN XIIIa anterior to nerveIIb posterior to nerve

18. Spinal Accessory Nerve

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20. What will you encounter in the procedure?Platysma Absent in the MIDLINE and at MOST LATERAL ASPECT of neck dissection incisionFibers run OPPOSITE those of the SCMEverything DEEP to this muscle should be removed for the pertinent lymphatic levels of your neck dissection(Down to what fascial layer??)

21. SternocleidomastoidBulky, reliable landmarkExtends from mastoid tip to clavicle/ manubriumDissection along the medial border of this muscle while retracting it laterally is ESSENTIAL to exposure of lymphatic levelsTry to avoid cutting into/ too close to the muscle itself- ideally leave fascial layer over fibers

22. Be Careful!External jugular veinGreat auricular nerveReliable landmarks seen during incisionEJV more variable of the two but can easily be identified on skin surface and/or CT neckAlways try to preserve GAN (exception = difficult parotidectomy)EJV often cut- but do it in a controlled way

23. OmohyoidRuns from hyoid, tethered to clavicle, attaches to scapula!!separates level III and IVIJV lies DIRECTLY beneath this

24. Omohyoid

25. PBDResident’s friendSuperficial to: ECACN XIIICAIJV