journal article

Surgical education: neck dissection

Shaheel Chummuna,*, N.R. McLeanb, Maniram Ragbirb

aDepartment of Orthopaedics and Trauma, North Tyneside General Hospital, Rake Lane,North Shields, Newcastle Upon Tyne NE29 8HN, UKbDepartment of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Queen Victoria Road,Newcastle Upon Tyne NE1 4LP, UK

Received 4 July 2003; accepted 1 May 2004

KEYWORDSNeck dissection; Cervical

metastasis

Summary Neck dissection is a valuable procedure for treating metastatic cancers ofthe head and neck. Radical neck dissection remains the standard for cervicalmetastasis. Because of the morbidity associated with such a treatment, moreconservative approaches are being adopted. The authors describe how they do a neckdissection and review the issues that currently surround the choice of treatment.Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rightsreserved.

Neck dissection is a valuable procedure for treatingmetastatic cancers of the head and neck, andalthough Solis-Cohen (1901) hinted at the necessityof removing all of the neck lymphatics during totallaryngectomy,1 it was Crile in 1906,2 later popu-larised by Martin et al. in 1951,3 who gave the firstdescription of radical neck dissection (RND). Thisprocedure remains the standard for the manage-ment of cervical metastases from head and neckcancers, and is still the procedure by which othertechniques are judged. The morbidity associatedwith RND has led to the further development ofmore conservative techniques that are based onstaging of the disease at presentation.

Head and neck cancers rank as the 6th mostcommon cancer worldwide. It is estimated thatabout 60% of patients with oral cancers presentwith early disease (T1 or T2), with N0 necks.4,5

However, if these patients underwent elective neckdissection, about 30% would be found to have occultmetastatic disease.6,7 This finding is important asthe presence of cervical node metastases reducessurvival by 50%,8 emphasising the importance ofmanaging patients with N0 disease appropriately.The choice of treatment remains controversial.Some centres, adopt a wait-and-see policy whileothers favour an elective staging neck dissection todetermine the need for adjuvant therapy, (usuallyradiotherapy). The adverse prognostic implicationof occult metastasis in N0 necks has prompted theneed for an easier and more reliable stagingtechnique. Sentinel lymph node biopsy is currentlybeing evaluated as a technique in staging clinicallyN0 necks.9

Lymphatic drainage

A sound knowledge of the anatomy of the neck andthe pattern of nodal metastasis is central to the

The British Association of Plastic Surgeons (2004) 57, 610–623

S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2004.05.011

*Corresponding author. Present address. 75 Guelder Road,High Heaton, Newcastle Upon Tyne, NE7 7PP, UK.

E-mail address: [email protected]

surgical management of patients with head andneck cancers.

(1) The lymphatic system of the neck is dividedinto three systems:

† Waldeyer’s internal ring. This ring includes theadenoids, the tubal and lingual tonsils, thepalatine tonsils and aggregates of the lymphoidtissue on the posterior pharyngeal wall. Tumoursfrom this area have a high propensity forlymphatic spread.

† Waldeyer’s external ring. This set of nodesmainly drains the superficial tissues of the headand neck. In the head, the nodes are mainlylocated around the skull base and are theoccipital, post-auricular, parotid and buccalnodes. In the neck, the main nodes completingthe Waldeyer’s external ring are the superficialcervical, submandibular, submental and anteriorcervical nodes. These nodes drain tissues fromthe scalp, eyelids, face, nasal sinuses and oralcavity.

† The deep lymph node system. This consists of theupper, middle and lower cervical nodal groupsthat are situated along the internal jugular vein,the spinal accessory group that accompanies theXI nerve in the posterior triangle, and the nodesin the midline of the neck.

(2) Knowledge of the fascial spaces of the neck isimportant in neck dissection as the proceduresbecome easier, less bloody and better controlled ifdissection is along the fascial planes. Fascia encasesthe structures that are normally removed and bydissecting along a plane, several important struc-tures can be preserved.

In general, the lymphatic flow is from superficialto deeper, and from upper to the lower parts of theneck. Also, each anatomical subgroup of lymphnodes serve as the primary echelon lymph nodesdraining a specific site in the head and neck region,thus making it possible to identify the primarytumour based on the site of a specific group oflymph nodes (Fig. 1).

The Head and Neck Service at the MemorialSloan-Kettering Cancer Center has developed asimple and clear levelling system of cervicallymph nodes, dividing the neck into five differ-ent levels (Fig. 2). The different neck levelshave recently been divided into further sub-groups in an attempt to assess the prognosisassociated with the different groups of lymphnodes (Fig. 3).

Clinical staging of the cervical lymph nodes isbased on the criteria set by the American JointCommittee on Cancer and the International Union

against Cancer (1988) and reflects the volume ofthe tumour in the regional lymphatics, which isdirectly related to the prognosis (Fig. 4).

Pattern of metastasis

The dissemination of metastatic cancer toregional lymph nodes tends to follow a pre-dictible pattern. Fisch demonstrated the orderlypattern of lymphatic flow and based on thisknowledge, one can correctly predict thesequential spread of metastases from oraltumours.10 Shah reviewed 501 patients under-going RND for squamous cell carcinoma of theoral cavity.11 Most metastases were confined tolevels I – III, with only 20% of patients havingmetastases to level IV. Metastasis to level V wasvery rare (2%), and never occurred in theabsence of palpable metastasis in other levelsof the neck.11,12 Shoaib et al. looked at sentinellymph nodes (SLN) in 40 cases of squamous cellcarcinoma in the head and neck, and found thatmost SLN were found in levels I – IV.13 No SLNwas identified in level V.

Risk factors

The risk of nodal metastasis from tumours of theaerodigestive tract depends on the characteristicsof the primary tumour

W Site. The risk of lymphatic involvementincreases as one moves from the anterior tothe posterior aspect of the aerodigestive tract.The highest incidence of nodal metastasis isassociated with tumours of the tongue, fol-lowed by tumours of the floor of the mouth,lower gum, buccal mucosa, hard palate and thelips.14

Figure 1 The lymph node groups draining a specificprimary site as first echelon lymph nodes.

Surgical education: neck dissection 611

W T-Stage. Cancers of the oral cavity show apositive correlation between the T-stage ofthe tumour and the incidence of occult andclinically palpable neck metastasis.15

W Thickness. Depth of the tumour, independentof the T-stage, is related to the presence ofoccult metastasis. Spiro et al.5 found thattumours of the floor of the mouth less than

Figure 2 The Memorial Sloan-Kettering Cancer Centre levelling system of cervical lymph nodes.

S. Chummun et al.612

Figure 3 The neck divided into further sub-levels.


2 mm had the lowest risk of metastasis, whiletumours greater than 2 mm, especially thosegreater than 8 mm, were associated with thehighest rate of dissemination.

W Histology. The presence of perineural andperivascular invasion and the presence ofpoorly differentiated tumours are associatedwith an increased risk of nodal metastasis.16

Even microscopic extracapsular spread isassociated with a poorer prognosis.17

Terminology of neck dissection

Since its description by Crile in 1906, radical neck

dissection has been the standard treatment forcervical metastasis, providing a safe and reliablemethod for addressing the cervical lymph nodeswith recurrence rates ranging from less than 10% inN0 necks to greater than 70% in patients withmultiple node involvement.18 Moreover, theaddition of radiotherapy to RND reduces the riskof failure by 50% for all N stages.19

Although RND is an excellent technique for themanagement of cervical metastasis, it is none-theless associated with substantial morbidity. Thisconsequently led to the development of moreconservative approaches that might have lessmorbidity, while preserving oncologicaleffectiveness.

Figure 4 The American Joint Committee on Cancer and the International Union Against Cancer (AJCC/UICC) stagingsystem for cervical lymph nodes.


The Committee of Head and Neck Surgery andOncology and the American Academy of Otolaryn-gology/Head and Neck Surgery have recentlyrevised the terminology and classification of neckdissections.20 It is based on the rationale that:

1. radical neck dissection is the standard basicprocedure for cervical lymphadenectomy, andany other procedures are modifications of thisprocedure;

2. when modifications to a RND involve preser-vation of one or more nonlymphatic structures, itis termed a modified radical neck dissection(Table 1);

3. when modifications to a RND involve preser-vation of one or more lymph node groups that areusually removed in a RND, it is termed a selectiveneck dissection (Table 2);

4. when the modification involves the removal ofadditional lymph nodes (e.g. occipital andparotid nods) or nonlymphatic structures relativeto a RND, it is termed an extended radical neckdissection.

In a recent review by the Committee of Head and

Neck Surgery and Oncology and the AmericanAcademy of Otolaryngology/Head and Neck Surgeryon neck dissection,21 the committee noted thatthere was a worldwide desire to maintain theirprevious classification, but felt at the same timethat minor modifications, mainly in terms ofnomenclature, had to be amended to keep in linewith the current philosophy for the management ofcervical node metastasis.

As such, for modified radical neck dissections,instead of describing the procedure as types I– III, itis now described as a MRND with the structurepreserved specifically named. For e.g. a Type IMRND is now described as a MRND with preservationof the SAN.

Similarly, for selective neck dissections, theprocedures are described with respect to the levelsdissected. Therefore, a supraomohyoid neck dis-section is now described as a selective neckdissection (I– III).

Technique

Modified radical neck dissection

Several types of neck incisions have been devisedover the years (Fig. 4). It is our preference to use an‘apron’ flap and the incision is marked out as a‘champagne glass’ (Fig. 5). The ‘apron’ can beextended inferiorly with no vertical incision made,especially for level III neck dissection. The incisionshown can be used for all types of neck dissection,depending on the surgeon’s choice. The verticallimb of the incision runs from the midpoint of thetransverse limb, posterior to the SCM, to themidclavicular point, so that in the event of woundbreakdown, the trifurcation would not lie over thecarotid artery. From past experience, we feel thatthis flap is a safe flap, particularly when platysma israised with it. Since, the blood supply to these flapsis not disturbed, there is also a reduced risk ofmarginal necrosis at the trifurcation of the skinincision. This flap has also proved to be safe and

Table 1 Radical and modified radical neck dissection

Radical neck dissection Resection of SCM, IJV,SAN and all cervicallymph nodes from all5 levels

Modified radical neck dissectiontype I

Resection of SCM, IJVand all cervical lymphnodes from all 5 levels(Preservation of SAN)

Modified radical neck dissectiontype II

Resection of SCM andall cervical lymph nodesfrom all 5 levels(Preservation of SAN andIJV)

Modified radical neck dissectiontype III

Resection of all cervicallymph nodes from all5 levels, withpreservation of SCM,IJV and SAN

Table 2 Selective neck dissection

Selective neck dissection

Supraomohyoid neck dissection (SOHND) Resection of all lymph nodes from levels I– IIILateral neck dissection (LND) Resection of all lymph nodes from levels II– IVPostero-lateral neck dissection (PLND) Resection of all lymph nodes from levels II–V


reliable in patients who had received pre-operativeradiotherapy.

The skin is held under tension by the assistant andthe upper flap is elevated deep to the platysmamuscle. Once platysma has been divided, the flapcan be held under tension using rake retractors andthe dissection is completed to the level of themandible in the subplatysmal plane, preserving theexternal jugular vein and the mandibular branchesof the facial nerve. If there is any evidence of anyextra-capsular spread, platysma can be left on thespecimen and, if there is skin involvement, this mustbeexcised and reconstructedas appropriate (Fig. 6).

The upper flap is then sutured in position andthe lower flaps are then elevated, again withthe assistant keeping tension on the skin to allowease of dissection. The whole of the posteriortriangle is exposed, as is the sternocleidomastoidmuscle. One must be careful anteriorly not to causeany communication with the area of a potentialtracheostomy (Fig. 7).

Moist swabs are laid on the field to stop the areafrom drying out and it is usually easier to find anddoubly ligate the lower end of the external jugular

vein first, caution being taken with its posteriorbranches, which may inadvertently be damaged.

The dissection then proceeds along the lowerborder of the mandible, clearing level I, and lookingfor and preserving the mandibular branches of thefacial nerve, which can be easily found and

Figure 5 Different types of neck dissection. From McGregor and McGregor (1986) cancer of face and mouth: pathologyand management for surgeons. Churchill Livingstone, Edinburgh, p. 295, with permission.

Figure 6


dissected free where they cross the facial artery.The facial artery and vein are then doubly ligated.The complete submental triangle is usually dis-sected, i.e. on both sides, by skin retraction on thecontralateral side. A finger can be swept under themandible to release the submandibular salivarygland, and if the fibres of the mylohyoid are thendivided parallel to the mandible, the lingual nervecan be easily identified and the submandibularganglion and its parasympathetic nerve fibres seen,diathermied and cut (Fig. 8). The level I clearancecan then easily be completed and the surgeonshould remember that the proximal part of thefacial artery will be coming forward anteriorly, inclose proximity to the posterior belly of thedigastric muscle. This vessel can be doubly ligatedor held in a microvascular clamp if required forlater construction. The digastric muscle can be leftor resected as required.

A pack is then placed in level I and the assistant

pulls anteriorly on the sternocleidomastoid muscle,and the dissection proceeds along the anteriorborder of the trapezius muscle, locating theaccessory nerve, where it crosses the posteriortriangle (Fig. 9). A sling is placed around the nerveto ease dissection from the posterior triangle, andthe muscle fibres of the sternocleidomastoidmuscle are then divided, with any muscularbranches to the sternocleidomastoid muscle dia-thermied and cut. The nerve can then be tracedthrough the muscle and left intact.

The deep fascia of the posterior triangle isthen held with a pair of tissue forceps, and thedissection proceeds from posterior to anterior. Asone approaches the clavicle, the incision turnsanteriorly. Again, if the assistant puts tension onthe lower contents of level V, the fascia can beeasily divided with a knife, following diathermyof any vessels. The plane at level V is identifiedsuperiorly by cutting down onto splenius capitus

Figure 7

Figure 8

Figure 9

Figure 10


and inferiorly by the assistant putting traction onthe soft tissues. The only structures of note atthis site are the branches of the supraclavicularnerves and small adjoining veins and arteries. Ifthe transverse cervical artery and vein are low,they are kept in the neck; if they are in a higherposition, they are ligated and removed. Once thislevel has been cleared, attention should becentred on the lower border of the SCM. Theassistant pulls the muscle upwards, putting itunder tension, and the muscle can be cut using aknife or diathermy on spray coagulation (Fig. 10).When the muscle is cut, it retracts upwards andexposes the internal jugular vein (IJV) in thecarotid fascia. The fascia is then divided and afinger can be swept up from level 4 under theomohyoid muscle (Fig. 11). The omohyoid muscletendon is then divided and the dissection pro-ceeds superiorly (Fig. 12).

In the lower part of the posterior triangle, thebrachial plexus is exposed and dissection over thisarea is relatively simple, as there is a plane ofareolar tissue between the cervical lymph nodesand the supraclavicular fat pad contained withinthe deep cervical fascia (Fig. 13).

The surgeon must look carefully under magnifi-cation for either the thoracic duct or the jugularlymph chain and any branches inadvertentlydivided. These need to be oversewn with 8/0 or9/0 nylon. If there is a small leak at the site,Surgicele can be applied. The phrenic nerve is seenon the scalenus anterior muscle and preserved, andany branches of the cervical nerves are diathermiedand cut.

The dissection continues along the anteriorborder of the omohyoid muscle and the whole ofthe specimen is elevated superiorly. Level IIb isfully dissected as this is an area where recurrent

Figure 11

Figure 12

Figure 13

Figure 14


disease in the lymph nodes can be problematic rightup to the mastoid process and base of the skull. Asone approaches the carotid bifurcation, the anaes-thetist should be warned and one should thencarefully see and preserve the hypoglossal nerve. Atthis point, the accessory nerve will be encounteredand this can be removed from any remnants of theSCM and preserved in total (Fig. 14).

There are usually no major venous branchesentering the jugular vein posteriorly, but themiddle thyroid and the common facial veinsrequire double ligation. The latter can be heldin a microvascular clamp for future anastomosisif needed. The specimen now has some softtissue and veins around the hypoglossal nerveattaching it, the SCM should be divided and, asrequired, the digastric muscle can be removedat the same time.

Following completion of the dissection, the area iswashed out with warm water. Further haemostasis isachieved, three Redivace drains are placed: one atlevel I, a further one in the posterior triangle and thethird drain is placed in the supraclavicular fossa.These drains are secured in the skin with silk andVycril Rapidee, used as a loop, may be used to keepthe distal end of the drain in position. It is importantthat the drains to be on continuous suction while thearea is being closed, so as to reduce the incidence ofheamatoma formation.

The patient’s neck is then flexed and the chinbrought to the midline. The wound is closed inlayers with Vycril and nylon. Polyfaxe dressings canbe applied to the wounds.

The specimen is then placed on a foam boardand tagged for ease of pathological examination(Fig. 15).

What type of neck dissection to choose?

Radical neck dissection has long been the standardtreatment for the management of cervical metas-tasis. Bocca questioned the logic of performingen-bloc resections while structures, such as thevagus and hypoglossal nerves, which are equallyrelated anatomically to the lymphatics and lymphnodes, were left behind. He subsequently devel-oped the concept of modified radical neck dissec-tion (MRND),22 based on the finding that thestructures usually resected during RND are encasedin aponeurotic systems. Thus, by working along theplanes, one can perform en-bloc lymphadenectomywith preservation of nonlymphatic structures.Subsequent studies by Lingerman et al.23 andJesse et al.24 failed to show any significantdifferences in the rates of recurrences after MRNDwhen compared to RND. On the other hand, Andreet al.25 reported a recurrence rate of 4% after RNDand 26% after MRND, leading them to suggest that itmay be unwise to perform MRND in N-positivenecks.

In the last decade, emphasis has been placed onthe use of selective neck dissection (SND) in themanagement of N0 necks. This procedure, initiallydeveloped as a ‘staging operation’ to assess thepresence of occult metastasis, has evolved intoanother treatment modality for node negativenecks. A better understanding of the pattern ofmetastasis has been key in the development of thisnew approach to the management of N0 necks. Shahet al. looked at more than 1000 specimens fromcomprehensive neck dissections for head and necksquamous cell carcinomas and found a predomi-nance of cervical metastasis to certain levels foreach primary site.26 Oral cancers tend to metasta-sise to levels I– III, whereas oropharyngeal, hypo-pharyngeal and laryngeal tumours tend todisseminate mostly to levels II – IV. Therefore,patients with oral cancers who present withclinically N0 neck would benefit from a SOHND.Similarly, a lateral neck dissection (LND) wouldadequately address the necks of patients withoropharyngeal, hypopharyngeal and laryngealtumours.

The use of SND in clinically N0 patients with oralcancer has resulted in excellent control of diseasewith recurrence rates of less than 10%. Pitman et al.compared 282 clinically N0 patients undergoing RNDwith 92 clinically N0 patients undergoing a SND andfailed to find any statistically significant differencesbetween the recurrence rates.27 Although manyauthors are advocating the use of SND for manage-ment of the clinically N0 necks, further evaluation

Figure 15


of the technique needs to be done so as not tojeopardize any oncologic benefit. Byers et al.reviewed 277 cases of untreated oral tonguecancers and found that 15.8% of cases either hadmetastasis to level IV only or to level III, with nodisease noted in levels I and II.28 Similarly, Creanet al. found an extra 10% of occult metastasis tolevel IV that would have been missed had theypreformed a traditional SOHND in the clinically N0necks of the 49 cases of oral cancer that theyreviewed.29 Based on these findings, there may be apotential need to extend the SOHND to include levelIV in a SND for oral cancers.

In a critical review on selective neck dissection,Clayman and Frank found that, despite clearguidelines, the anatomical boundaries in a SND arenot as well defined as in a MRND, leading toincreased rate of out-of-field recurrences.30 Thisoutcome can also be affected by the operator’sexperience and judgement.

The role of SND in the therapeutic managementof the N-positive neck is slowly but graduallygrowing in stature. Medina et al.31 and Byerset al.6 treated N-positive patients with SND, whichproduced recurrence rates that were comparable tothat obtained with RND, and concluded that SNDhad a meaningful role in the management of N1patients. Ambrosch et al. recently reviewed the useof SND in the management of clinically positivenecks and found that the cases treated by SND withor without post-operative radiotherapy fared aswell as those cases managed with MRND or RND withor without post-operative radiotherapy.32 Andersenet al. reviewed 106 clinically and pathologicallynode positive patients undergoing SND for HNSCCand concluded that SND can be used in carefullyselected patients with clinically positive necks.33

At present, RND and MRND remain the mainstayfor the surgical management of advanced nodaldisease. However, there is still considerable debateregarding the use of SND in cases with advancednodal disease. Traynor et al.34 suggested that theuse of SND could be extended to N2B and N2Cdisease, in the absence of massive lymphadeno-pathy, nodal fixation, gross extracapsular spread(ECS) and a history of previous neck surgery. Similarresults were reported by Pellitteri et al. whoreviewed the use of SND in the surgical manage-ment of advanced nodal disease.35 It is possible thatin the future, SND, combined with adjuncts such asradiotherapy or chemotherapy, will become thestandard treatment for advanced nodal disease.

The use of radiotherapy in neck surgery

Radiotherapy used either pre or post-neck dissec-

tion has been to shown to reduce the incidence ofneck failure by at least 50% for all N-stages.36

Moreover, the fact that pre or post-radiotherapy(RTx) makes no difference in the outcome hasencouraged many surgeons to use RTx as a post-operative adjunct, as this consequently eases thedissection and reduces the rate of complications.The presence of large primary tumour and thepresence of positive margins normally dictate theuse of RTx. Usually patients with an N0 neck do norequire RTx.36 On the other hand, RTx has beenshown to be beneficial in the presence of multiplenode metastasis and ECS.37

Sentinel lymph node biopsy

The sentinel lymph node (SLN) concept states thatthe spread of a tumour is embolic in nature, and isvia the lymphatics to the first echelon lymph nodeencountered in the lymph node basin. Therefore,accurately diagnosing the absence of tumour from aSLN would imply a lymph node basin free of tumour,thus making the need for an elective staging neckdissection redundant. Shoaib et al. recently lookedat 40 patients with N0 disease and found that SLNbiopsy had a sensitivity of 94%.13 In a recentmulticentre trial, SLN biopsy was found to be assensitive as a supra-omohyoid dissection, and thatit has its place in staging N0 necks.9 It isrecommended that SLN biopsy be done in patientsin whom the lymphatics have not been disrupted.Although SLN biopsy has proved to be a valuabletool in the staging of N0 disease, it appears to havea lesser accuracy in the N-positive necks.

Complications related to neck dissection

As with any surgical procedure, neck dissection isassociated with several potential complicationsthat can be prevented by meticulous surgery andcareful follow-up. Although many of these compli-cations are rare in the hands of an experiencedsurgeon, some are nonetheless unavoidable.

Intra-operative bleeding can result from a seriesof small veins that are either present in theposterior triangle near the spinal accessory nerveor near the lower end of the trapezius muscle, oreven in the region of the mylohyoid muscle. Injuryto the transverse cervical artery with subsequentretraction of the artery behind the clavicle can leadto great difficulty in managing any haemorrhage.


Similarly, trauma to the internal jugular vein maylead to intra-operative bleeding that may bedifficult to control. As such, it is necessary thatone should carry out any dissection with extremecare, so as to prevent any uncontrollable intra-operative bleeding or the formation of a haema-toma. Should the latter be suspected, the patientshould be taken back to theatre as soon as possiblefor evacuation as it would compromise the take ofany flap.

Although rare, the possibility of an air embolusfollowing trauma to the IJV should be borne inmind. The IJV can sometimes be torn by theinappropriate use of artery forceps below the SCMin an attempt to mobilise the muscle prior todissection. In such a scenario, no attempt should bemade to clamp the hole with an artery forceps oruse diathermy, as this would only make the holebigger. If a tear occurs prior to the division of thevein, pressure is applied over the vein, theanaesthetist is asked to tilt the table head downand the area above and below the tear is securelyligated.

Cardiac arrhythmias can also occur during necksurgery. Manipulation of the carotid bulb duringdissection of the internal jugular vein can lead tothe arrhythmias that can be life threatening. Gentleand careful handling of the carotid bulb can reducethe incidence of such irregular rhythms. The use oflidocaine injected into the adventitia surroundingthe carotid bulb may reduce the risk of arrhythmias.

Carotid artery rupture is associated with 35–50%mortality. It is usually the culmination of severalfactors: improper incision used in an irradiatedneck, damage or stripping of the adventitial layer ofthe carotid sheath and the involvement of thecarotid artery by tumour itself. Rupture can beprevented in patients who have had previousirradiation to the neck by protecting the carotidarteries with a muscle flap (usually the levatorscapulae muscle), by not stripping the adventitia ofthe carotid sheath unless absolutely necessary andby keeping the vessels walls moist during operation.In case of rupture, local pressure is applied to thearea, the airway is protected with a cuffedtracheostomy tube and the blood pressure ismaintained with IV fluids. The patient should betaken to theatre, each end of the carotid arteryexposed, and tied off at healthy tissue using atransfixing stitch. Neurological sequelae due toligation include contralateral hemipleigia, hemi-anaesthesia, aphasia and optic nerve atrophy.

The marginal mandibular, spinal accessory,phrenic, vagus and hypoglossal nerves, the brachialplexus and the sympathetic chain are at risk ofbeing damaged during neck dissection. These

nerves may be transected or suffer a neuropraxiaduring surgery. Injury to the marginal mandibularnerve often occurs during dissection of either thesubmental triangle or the facial group of lymphnodes, resulting in altered function of the lipdepressors. The vagus nerve can be damaged duringligation of the internal jugular vein. Low vagusnerve injuries can lead to true vocal cord paralysis,whereas high vocal cord injuries will impair swal-lowing and airway protection. Injury to the phrenicnerve, although not common, may lead to subtlefindings such as atelectasis. Depending on thedegree of the injury, recovery may be spontaneous.As the SAN was removed during RND, this led to thedenervation of the trapezius muscle that conse-quently led to the ‘Shoulder Syndrome’, which wasassociated with impaired abduction of theshoulder, pain and stiffness, and abnormal scapularrotation. In some cases, shoulder dysfunction canalso be found in MRND and this is usually due tointra-operative damage to or ischaemia of the SAN.

Disruption of the sympathetic chain may alsoresult from neck dissection, following dissection ofthe carotid sheath, leading to Horner’s Syndrome.However, this should be avoided by careful dissec-tion and recognition of the sympathetic chain.

Chylous fistula occurs in 1–2% of neck dissections.If a chylous leak is detected intra-operatively, everyeffortmust bemade tofind the source and suture theopening. Accumulation of chyle affects flap survival,increases the risk of neck infections and leads toemaciation of the patient. Chyle in a fasting patientis a clear-yellowish fluid as compared to thetraditional milky white fluid. If a fistula is suspectedpost-operatively, the patient should begin IV feed-ing. The patient’s head is kept elevated and apressure dressing applied. Electrolytes and serumproteins should bemonitored daily. The use of total-parenteral nutrition (TPN) feeds has largelyobviated the need for re-exploration of the neck.

Fluid collection under the skin flaps can beprevented by using suction drainage. Seroma maybe drained using a wide-bore needle and applyingpressure dressing to the area.

Late complications following neck dissectiontend to be less severe, but may considerably affectthe quality of life of the patient. The formation of aneuroma may considerably affect the day to day lifeof the patient. In such cases, it is important toascertain that any lump in the neck is not a sign ofrecurrent disease. Similarly, chronic shoulder painmay impair the daily activities of the patient.Competent physiotherapy may help to improve thepatient’s condition.

Radical neck dissection for the management ofmetastatic neck disease is still regarded as the


standard treatment. The rationale for the develop-ment of modifications of the technique stems fromthe functional and cosmetic deficits associated withthis extensive procedure, and the realisation thatdisease can recur despite radical surgery. Thesubsequent improved knowledge of patterns oflymph node drainage, the appreciation of fascialcompartments encasing lymphatic structures and abetter understanding of the benefits of adjuvantradiotherapy and chemotherapy have fostered amovement away from the traditional RND. There isincreasing evidence that MRND and more conserva-tive approaches are as good as the radical neckdissection i.e. equal the current standard.

There is still an extensive debate regarding themanagement of the N0 neck: should the surgeonadopt a ‘wait and see’ policy, or opt for elective neckdissection. If so, which technique should he or sheadopt. It is hoped that the use of newer investigativetechniques, such as sentinel node lymphoscintogra-phy, the improved use of ultrasound-guided fineneedle aspiration and the use of positive emissiontomography, will improve the assessment andsubsequent management of N0 necks.

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