It is commonly manipulated during surgery. A study of 967 cases from 1970 to 1980. Further, only specific groups of lymph nodes rather than all the lymphnodes on the side of the neck are dissected. Am J Surg. Classification of neck dissection: current concepts and future considerations. Radical Neck Dissection This operation has been used for almost 100 years and describes the removal of lateral neck nodes and tissues to surgically remove cancer in the neck. A closer look at the individual findings of Byers and Shah, however, can provide clinicians with applicable information that supports the use of the MRND in properly selected patients. Level V Metastasis in RND Patients* (Open Table in a new window). [14] Overall, he encountered an 8.1% recurrence rate in the neck 5 years following surgery. Dissection proceeds superiorly going from posterior to anterior superficial to the deep cervical fascia. Suction drains are strategically placed and a layered closure is performed. 1996-2021 MedicineNet, Inc. All rights reserved. [QxMD MEDLINE Link]. The type you'll have depends on the cancer's location, and if it spread to your lymph nodes or to other structures in your neck. MacFee incision consists of two parallel horizontal incisions, one high and one low. Managing Editors: Sarah Elliott, Kay Klein, Claire Davis [QxMD MEDLINE Link]. Alternatively, preserve the internal jugular vein;. And if the operation does not involve all five zones, it is called a selective neck dissection. Although complications are rare for experienced head and neck surgeons, they naturally occur also after elective neck dissection (END). The contents of the posterior triangle have been elevated in a posterior to anterior direction, preserving the fascia overlying the scalene muscles, the brachial plexus, and the phrenic nerve. Globally, approximately 550,000 people are diagnosed with head and neck cancer (HNC) every year. Modified Radical Neck Dissection - step by step - By Prof Chintamani - YouTube This is a teaching video on Neck Dissection for Head and Neck cancers. Injury to this nerve is quite rare as it is easily seen and few lymph nodes are near it. The contents dissected from level I are elevated caudally to visualize the superior internal jugular vein. See additional information. Unable to load your collection due to an error, Unable to load your delegates due to an error. Carver College of Medicine This article reviews the rationale for and technique of the modified radical neck dissection (MRND) that developed from these efforts. I, therefore, extend the incision laterally (parallel to the clavicle) to the anterior border of the trapezius muscle. Federal government websites often end in .gov or .mil. [16]. Oswaldo Suarez from Argentina was the first to describe functional neck dissection in 1963, now called modified radical neck dissection (MRND). No prospective studies compare modified radical neck dissection (MRND) with radical neck dissection (RND), and few studies exist that have compared the outcomes following RND with outcomes following MRND. Ferltio A, Rinaldo A. Osvaldo Suarez: often-fortotten father of functional neck dissections (in the non-Spanish-speaking literature). Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine The immune cells in the lymph nodes help the body fight infection. Modified radical neck dissection type 3 is indicated in metastatic differentiated thyroid carcinoma 10. Much easier than I anticipated. The posterior triangle is dissected. The dissected contents of sublevels IA and IB are then elevated over the digastric muscle in continuity with the nondissected portion of the neck (see the images below). Mitzner R. Neck Dissection Classification. This philosophical shift in the treatment paradigm occurred in the absence of substantive prospective investigational research evidence that demonstrated equivalent oncologic efficacy to the RND. This is a small bundle of nerves on either side of the back bone that are responsible for a variety of unconscious neurologic function. JAMA 22:1780-1786, 1906. Ipsilateral selective neck dissection (levels 2 4) or a modified radical neck dissection (1 5) is indicated for the N1 neck. Flap elevation proceeds posteriorly immediately deep to the subcutaneous adipose tissue back to the anterior border of the trapezius muscle. The submental (IA) and submandibular contents (IB) have been dissected away from the underlying soft tissues (arrow). Over time this improves and the loss of sensation resolves. Modified radical neck dissection involves the removal of all lymph nodes typically removed in the RND, with sparing or preservation of at least one of the following structures: SAN, IJV, SCM. The modified radical neck dissection, which advocated for the preservation of at least one of the critical non-lymphatic structures (CNXI, IJV, or SCM) was proposed by Drs. Radical neck dissection (RND) refers to the removal of all ipsilateral cervical lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly and from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle anteriorly to the anterior border of the trapezius muscle posteriorly. Dissection continues superiorly deep to the digastric up to the lateral process of C2. Khafif RA, Gelbfish GA, Asase DK, et al. The technique described was developed by the senior author (WAM) and encompasses levels I through IV sparing the sternocleidomastoid muscle, the spinal accessory nerve, and the cervical plexus. (7 . For more information about the relevant anatomy, see Neck Anatomy. Ewing M, Martin H. Disability following radical neck dissection; an assessment based on the postoperative evaluation of 100 patients. Neck Dissections Preserving SAN*, Table 4. [QxMD MEDLINE Link]. Modified neck dissection. Lymph nodes are small, bean shaped glands scattered throughout the body that filter and process lymph fluid from other organs. Hamoir M, Shah JP, Desuter G, et al. 2006 Dec;33(4):365-74. doi: 10.1016/j.anl.2006.06.001. The standardization of terminology is important to communicate to other practitioners which levels were dissected and which structures were resected for postoperative management. This site needs JavaScript to work properly. 1984 Oct. 148(4):478-82. 2017 Oct;37(5):368-374. doi: 10.14639/0392-100X-844. [QxMD MEDLINE Link]. 40(4):252-5. (Their findings are reviewed in the section Supporting Evidence.). Roy J. and Lucille A. Ferlito A, Rinaldo A, Silver CE, Shah JP, Surez C, Medina JE, Kowalski LP, Johnson JT, Strome M, Rodrigo JP, Werner JA, Takes RP, Towpik E, Robbins KT, Leemans CR, Herranz J, Gaviln J, Shaha AR, Wei WI. A final risk of surgery involves the Thoracic duct. 2800 Blue Ridge Road, Suite 300 Laryngoscope. A conservation technique in radical neck dissection. Dissection in the proper plane allows for an en bloc elevation of the contents into the submandibular triangle (sublevel IB) and to the posterior border of the mylohyoid muscle. Lymph Node Groups of the Neck (Open Table in a new window). Since then, the focus of criticism against the RND has addressed the related morbidity, causing other surgeons, including Jesse and Ballantyne, to search for cervical lymphadenectomy procedures that could provide oncologic cure with less morbidity. Removal of sternocleidomastoid (SCM) muscle with secondary asymmetry, Removal of spinal accessory nerve with secondary shoulder weakness and pain (see Shoulder Rehab), Possible injury to hypoglossal nerve with secondary tongue weakness affecting speech and swallow, Possible injury to vagus nerve with secondary weakness in voice and swallow, Possible injury to facial nerve with secondary weakness of lower lip and/or face, Possible injury to sympathetic trunk with secondary Horner's syndrome, Possible injury to thoracic duct with secondary chyle leak, Risk of significant facial or cerebral edema (primarily if both jugular veins are removed or injured). Management of the neck in head and neck cancer, part I. Medina JE, Weisman RA. As the last fibers of the SCM are divided, the internal jugular vein and omohyoid muscle are fully exposed. A second surgery is usually required to take care of this problem. The University of Iowa appreciates that supporting benefactors recognize the University of Iowa's need for autonomy in the development of the content of the Iowa Head and Neck Protocols. Spinal accessory nerve injury. Laryngoscope. The IJV is once again evaluated. Table 3. The extensive nodal metastatic disease that was present around the carotid bifurcation (arrow) required reflection of the neck dissection specimen superiorly prior to internal jugular vein ligation. Modified radical neck dissection (MRND). (Above, left) The defect involved the tongue, floor of the mouth, mandible, and posterior . You are being redirected to This classification has become widely accepted and has also been endorsed by the American Head and Neck Society. Injury to this nerve will compromise shoulder function especially raising the shoulder. A skin incision is made that optimizes exposure of the neck. Balm AJ, Brown DH, De Vries WA, et al. Tenderness is another symptom of neck pain. The neck recurrence rate for elective FND was 2.3% versus 30.4% for therapeutic FND. Level V Metastasis in RND Patients*. Consequently, the indications for MRND and selective neck dissection in these patients also remains poorly defined. With any unexplained or persisting neck pain or dizziness, consult with a health care professional, who can determine whether the symptoms are harmless and temporary or serious and threatening. Incisions that result in a trifurcation are less desirable because of the potential for distal flap necrosis and carotid artery exposure. The nerve branch can be identified beneath the prevertebral fascia between the middle and posterior scalene muscles, and confirmed by stimulation. EndocrineSurgeryNC.com has been created by Dr. Faust and reflects his professional opinions. 1994 Jul. MND is very effective treatment for regional node disease. 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. Use This Code : You Be The Coder. As the cervical rootlets are encountered, they are transected high (adjacent to the specimen) to prevent injury to the phrenic nerve. [QxMD MEDLINE Link]. When the jugulodigastric nodes in the upper anterolateral neck were pathologically involved and the nerve was preserved, the recurrence rate decreased from 17% to 4.7% with the use of postoperative radiotherapy. Exposure following subplatysmal flap elevation. A posterior to anterior dissection is then performed beginning at the anterior border of the trapezius muscle. Most patients take narcotic pain medication for 1-2 weeks. [10, 11, 12] They demonstrated that nodal metastatic disease predictably occurs in certain regions of the neck based on the site of the primary tumor. If the tumor invades platysma, consider resecting overlying skin: Superior limit of flap elevation is mandible, mastoid tip, and parotid, Posterior limit is anterior edge of trapezius muscle, Antero-medial limit is anterior border of sternohyoid muscle, Dissection With and Without Preservation of Internal Jugular Vein and Spinal Accessory Nerve. Postoperative shoulder dysfunction is significant after accessory nerve resection. [1] Hayes Martin further popularized use of the RND in the 1950s. Subplatysmal plane leaving cervical plexus nerves and external jugular veins down, If tumor is close to the platysma, elevate the skin above the platysma in that region (elevate subcutaneously). Ann Surg Oncol. The contents of levels II, III, and IV have been elevated after division of the omohyoid muscle. This nerve bundle is very deep in the neck. When it occurs it it rarely an issue for the patient. The midline in front of the neck has a prominence of the thyroid cartilage termed the laryngeal prominence, or the so-called "Adam's apple. The posterior triangle contents are elevated in an en bloc fashion off the fascia of the deep cervical musculature, preserving the phrenic nerve and the brachial plexus, located deep to this fascia. In 31 pathologically staged N1 necks (pN1), no recurrences were recorded. Complications of neck dissection affect every surgeon regardless of experience and technical skill. At this point, the posterior triangle contents, with or without the SAN and SCM, have been elevated to the lateral aspect of the IJV. 1994 Dec;22(6):323-9. The specimen is dissected free of the internal jugular vein, and brought over or under it to join the medial portion of the dissection. Injury to this nerve will cause significant voice problems because the recurrent laryngeal nerve is a branch of this nerve. If the IJV requires sacrifice due to metastatic nodal involvement or tumor thrombosis, the vein is ligated and divided superiorly and inferiorly following identification and preservation of the vagus nerve (see the image below). MND preserves SCM and/or XIn and/or IJV. Ann Otol Rhinol Laryngol. The radical neck disecton was first described in 1906 by Crile, based on the Halstedian concept of en bloc resection. The greater auricular nerve is coursing parallel and immediately superior to the external jugular vein. Gavilan J, Gavilan C, Herranz J. Functional neck dissection: three decades of controversy. The 3-year survival rate in the MRND group was 74% versus 63% in the RND group. Functional Neck Dissection* (Open Table in a new window). Type II: The spinal accessory nerve and the internal jugular vein are preserved. Though treatment for neck pain really depends upon the cause, treatment typically may involve heat/ice application, traction, physical therapy, cortisone injection, topical anesthetic creams, and muscle relaxants. In 1980, a method for modified radical neck dissection was reported and then accepted as a substitute for classic neck dissection. Modified radical neck dissection involves removal of cervical nodes, levels I through V, as in classical radical neck dissection, but with preservation of one or more of the key extranodal structures ( spinal accessory nerve , sternocleidomastoid muscle, and internal jugular vein ). Medina JE. Head and neck cancer is cancer of the oral cavity, salivary glands, paranasal sinuses and nasal cavity, pharynx, larynx, or lymph nodes in the upper part of the neck. These 2 studies offered valuable insight about patterns of nodal metastases and provided a rationale for the modified neck dissection and the selective neck dissection. Arch Otolaryngol. Some degree of swelling is very common. A modified radical neck dissection (38724) is a little more difficult, but also involves removal of all the lymph nodes from levels 1 through 5. J Surg Oncol. Radical neck dissection removes nearly all lymph nodes on one side of the neck as well as the internal jugular vein, sternocleidomastoid muscle and . 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. J Craniomaxillofac Surg. Modified radical neck dissections remove levels I-V (similar to a radical neck dissection). These modifications are described in relation to which structures are preserved: Type I: Spinal accessory nerve is preserved. The neck dissection is then removed and oriented for lymph node level-specific histopathologic evaluation for pathologic staging purposes (see the second image below). In: Lore JM, ed. Type II: Spinal accessory & internal jugular vein or sternocleidomastoid The transition from radical to selective neck dissection has resulted in fewer complications and lower morbidity, at the . [QxMD MEDLINE Link]. Extensive disease (carotid artery encasement, deep neck muscular invasion, skull base involvement). 21151 Pomerantz Family Pavilion Rarely, this plexus may be important if cancer penetrates deeply (inferiorly) down the neck through the thoracic inlet into the upper chest. 1998 Aug. 31(4):639-55. 1992 Apr. After discussions with an onologist and my surgeon a Modified Radical Neck Dissection was performed on Jan 6th. The risk of a life threatening complication is negligible, but there are risk to the procedure. Strong EW. It controls a large muscle of the shoulder called the trapezius. Neck dissection is usually performed to remove cancer that has spread to lymph nodes in the neck. modified neck dissection Surgery A subtotal resection of the neck region, usually for CA of the floor of the mouth; most MNDs preserve the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle. [5] Of these patients, 42 experienced shoulder discomfort, and 60 demonstrated shoulder stiffness and decreased range of motion. The site is secure. Neck dissection is usually performed to remove cancer that has spread to lymph nodes in the neck. Therefore, an MRND with preservation of the SAN was performed. Neck Dissections Preserving SAN* (Open Table in a new window). Auris Nasus Larynx. 200 Hawkins Drive The plane of dissection should be just superficial to the adventia of the vein. 2014;19(3):423-30. doi: 10.1007/s10147-014-0689-z. Although a growing body of evidence supports the performance of selective neck dissection in carefully selected patients with clinically positive nodal disease, no prospective randomized clinical trials have been conducted. The author prefers to use an apron flap design that extends from the mastoid tip to the mandibular symphysis (see the first image below). In general, MRND is indicated whenever preservation of the spinal accessory nerve (SAN), internal jugular vein (IJV), or sternocleidomastoid muscle (SCM) is possible without compromising oncologic efficacy, and when a selective neck dissection would not be considered an adequate oncologic procedure. He described the removal of all five lymph node levels in the neck while preserving the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein to limit any functional disability . MedTerms online medical dictionary provides quick access to hard-to-spell and often misspelled medical definitions through an extensive alphabetical listing. This is a large thin-walled lymphatic vessel that is present at the base of the neck and empties lymphatic fluid from the body into the blood stream at the jugular vein on the left side of the neck. Preservation of the IJV in MRND results in IJV patency rates of 86-87% (99% if patients with compression of the IJV by tumor recurrence or myocutaneous flaps are excluded). This nerve controls the side of the tongue. and transmitted securely. There are different types of modified radical neck dissection. I've gotten use to the limited mobility in my neck, soreness in my left arm and dry mouth. Careful dissection of the supraspinal portion of level II, also known as the submuscular triangle (sublevel IIB), is necessary to minimize trauma to the SAN and the IJV. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Lore JM. A rational classification of neck dissections. These results compare favorably with the experience with RND reported by Strong, who found a 6.7% recurrence rate in necks with pathologically negative findings, a 36.5% recurrence rate when nodal metastases were present within one level, and a 71.3% recurrence rate when multiple lymph node levels were involved. Selective Neck Dissection - Only some of the lymph nodes and tissues are removed. [QxMD MEDLINE Link]. Alternatively, preserve the spinal accessory nerve and cranial nerve XI. As it is classically described, the dissection is carried across the inferior portion of the parotid tail including it in the specimen. 1906. Modified radical neck dissection (MND) is a complicated operation. 2001 Oct. 23(10):907-15. Crile G. Excision of cancer of the head and neck. Resection may also contribute to fibrosis and limitation of range of cervical motion. Between the Adams apple and the chin, the hyoid bone can be felt; below the thyroid cartilage, a further ring that can be felt in the midline is the cricoid cartilage. Since Crile's landmark publication in 1906, the radical neck dissection (RND) has remained the criterion standard for excision of cervical nodal metastases resulting from head and neck cancer. An extensive body of literature documents morbidity following RND. [QxMD MEDLINE Link]. Shoulder pain and function after neck dissection with or without preservation of the spinal accessory nerve. Buckley JG, Feber T. Surgical treatment of cervical node metastases from squamous carcinoma of the upper aerodigestive tract: evaluation of the evidence for modifications of neck dissection. 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. You should rather give importance to the surgeons experience and your rapport and comfort level with them. Although some clinicians believe that simultaneous bilateral internal jugular vein (IJV) ligation is of minimal risk if the operative time is less than 5-6 hours, the literature is filled with reports of serious complications secondary to bilateral RND. Treatment may involve surgery, radiation therapy, and/or chemotherapy. Type III: The spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle are preserved. [QxMD MEDLINE Link]. The lymph nodes are removed and injury to the listed structures is possible. Chapter 113: Neck Dissection. Retraction of the mylohyoid muscle anteriorly allows for identification of the submandibular duct, which is ligated and divided, and the lingual nerve, which supplies innervation to the submandibular gland. An official website of the United States government. [QxMD MEDLINE Link]. A modified radical neck dissection, which is the most comprehensive form of functional neck dissection, entails the resection of the nodal groups I through V, and is still considered the standard of care for management of the cN + neck. Symptoms also include weakness, numbness, coolness, color changes, swelling, and deformity. The neck supports the weight of the head and is highly flexible, allowing the head to turn and flex in different directions. A more important risk involves the motor nerves in the area. Modified radical neck dissection (MRND). Laryngoscope 11:1177-1178, 2004. 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. Treatment includes routine postoperative shoulder physiotherapy following all neck dissections. Physical therapy can be very helpful in these situations. 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