1992 Mar-Apr;16(2):222-6. doi: 10.1007/BF02071524. University of Iowa Treatment includes routine postoperative shoulder physiotherapy following all neck dissections. Roy J. and Lucille A. 2.5.2. Variations on neck dissections exist, depending on the extent of the cancer. In general, however, loss of the SCM results in the least morbidity of the 3 nonlymphatic structures sacrificed during RND. Flap elevation proceeds posteriorly immediately deep to the subcutaneous adipose tissue back to the anterior border of the trapezius muscle. Further, only specific groups of lymph nodes rather than all the lymphnodes on the side of the neck are dissected. Byeon HK, Holsinger FC, Tufano RP, Chung HJ, Kim WS, Koh YW, Choi EC. 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. HHS Vulnerability Disclosure, Help Postoperatively, compression of the IJV should be minimized by avoiding tight dressings and tracheostomy tube ties. Neck dissection is surgery to remove the lymph nodes in your neck. Radical neck dissection is an operation that was created in 1906 to solve the problem of metastatic neck disease. A more important risk involves the motor nerves in the area. Shah retrospectively reviewed 1081 patients who underwent 1119 RND procedures with an average harvest of 39 lymph nodes. Inspection and palpation are used to assess for IJV thrombosis, encasement of the IJV or SAN, and extracapsular involvement of the SCM. Type III: The spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle are preserved. Elevation of the fascia from the undersurface of the SCM using electrocauterization or blunt dissection with a hemostat parallel to the SAN can be used to easily isolate the nerve (see the image below). Though these factors decide the cost of the surgery, your choice should not be based on the financial aspects alone. Ann Surg Oncol. FAX: (919) 784-2708 Injury to this nerve is very rare. Table 3. However, 26% of the 27 neck dissections that had multiple involved lymph nodes with extracapsular spread developed recurrence. This nerve runs deep in the neck. [QxMD MEDLINE Link]. 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. Modified radical neck dissection (MRND). 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. It is a well-designed operation that is relatively easy for the trained head. Lymph nodes are small, bean shaped glands scattered throughout the body that filter and process lymph fluid from other organs. (Radical Neck Dissection and Modifications - Sparing Cranial Nerve XI, Sternocleidomastoid Muscle and/or Internal Jugular Vein), return to: Cervical Lymphadenectomy- General Considerations. If it is injured, the patient could have difficulty moving the corner of the lower lip. 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. 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. I've gotten use to the limited mobility in my neck, soreness in my left arm and dry mouth. CPT code 60252 is reported when a limited neck dissection is done, while CPT code 60254 is reported if a radical neck dissection is included in the procedure. You may have a neck dissection if there is a high risk of the cancer spreading to the lymph nodes in your neck. Preoperative radiation and radical neck dissection. 2800 Blue Ridge Road, Suite 300 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. Treatment selection bias probably also affected the results of these retrospective studies because MRND may have been used to treat less-advanced nodal metastatic disease. [QxMD MEDLINE Link]. Well review the major issues. Head Neck. Of 124 necks with pathologically negative findings (pN0), the regional recurrence rate was 2%. On the road to recovery~ check. A sixth region was later added to characterize the lymph nodes in the anterior neck (see Table 1). Modified radical neck dissection preserves the structures that are usually sacrificed in the standard radical surgery, such as the spinal accessory nerve, the internal jugular vein, or sternocleidomastoid muscle. The https:// ensures that you are connecting to the Arm weakness and and poor motor control could occur with injury. Furthermore, if evidence of extranodal fixation to the surrounding soft tissues of the neck (ie, deep cervical musculature) is found, performance of an RND (or extended RND) must be considered because of the advanced stage of regional metastatic disease present. At this point, the posterior triangle contents, with or without the SAN and SCM, have been elevated to the lateral aspect of the IJV. The plane of dissection should be just superficial to the adventia of the vein. The RND patients had the greatest decrease in abduction. 21, 2013 310 likes 68,970 views Download Now Download to read offline Health & Medicine Mohammad Akheel Follow ORAL & MAXILLOFACIAL SURGEON Advertisement Recommended Steps in selective neck dissection Jamil Kifayatullah 297 views 39 slides Surgical anatomy of neck and types of neck dissection Sanika Kulkarni 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. Before Injury to this nerve will cause significant voice problems because the recurrent laryngeal nerve is a branch of this nerve. Patients who underwent a selective neck dissection or MRND that preserved the SAN had a recurrence rate in the dissected neck of only 7.4%. Radical neck dissection - discharge; Modified radical neck dissection - discharge; Selective neck dissection - discharge. Subsequently, Short et al compared 12 patients who underwent RND with 23 who underwent neck dissection that spared the spinal accessory nerve (SAN). 101(4):339-41. Radiotherapy can affect IJV patency. 1984 Jul. Suarez initiated a change in the surgical approach to cervical lymph node metastases by illustrating in anatomic studies that cervical lymphatics are contained within well-defined fascial compartments that partition them from the muscular, vascular, and neural structures of the neck. Patency of the internal jugular vein following modified radical neck dissection. This is generally a minor cosmetic issue and almost always resolves within a few weeks. [9] The FND was a comprehensive neck dissection, removing all cervical lymph node levels included in the RND but preserving the internal jugular vein (IJV), sternocleidomastoid muscle (SCM), and spinal accessory nerve (SAN). Modified Radical Masectomy Warujpong Boonkum Vestibular schwanoma 03342729593 NASOPHARYNGEAL CARCINOMA Mamoon Ameen Tumors of the Lung and Surgery of Mediastinum Muhammad Eimaduddin Occult primary mangmnt Md Roohia NECK DISSECTION- A COMPREHENSIVE STUDY Priyanko Chakraborty carcinoma breast RADIOTHERAPY TECHNIQUES Nabeel Yahiya Dissection is continued anteriorly, elevating the fascia and soft tissues up to the infrahyoid strap muscles and the hyoid-digastric junction (see the first image below). A single ligature is adequate for the inferior limb. [4] Similarly, in 1952, Ewing and Martin evaluated 100 patients who had undergone RND. Rarely, this plexus may be important if cancer penetrates deeply (inferiorly) down the neck through the thoracic inlet into the upper chest. Selective neck 3. Epub 2014 Apr 1. de Campora E, Radici M, Camaioni A, Pianelli C. Eur Arch Otorhinolaryngol. Sobol et al performed electromyography 16 weeks following surgery. In: Lore JM, ed. Ann Otol Rhinol Laryngol. Ann Otol Rhinol Laryngol. The omohyoid muscle has been divided. This may take months and occasionally, may be a significant bother to the patient. We now refer to this as a "modified neck dissection." Accessibility More than 60% of patients have their disease controlled with MND. Surgeons don't routinely do a neck dissection on everyone because it can have long-term side effects. Modified radical neck dissection (MND) is a complicated operation. Byers reviewed 182 functional neck dissections that did not receive postoperative radiotherapy. Shah JP. McGarvey AC, Chiarelli PE, Osmotherly PG, Hoffman GR. Bethesda, MD 20894, Web Policies Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. The transition from radical to selective neck dissection has resulted in fewer complications and lower morbidity, at the . Preservation of the IJV may also facilitate microvascular surgical reconstruction. 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. The neck is the part of the body that separates the head from the torso. It was the standard of care for the next 70 years. Upfront chemoradiotherapy can also be a valid therapy technique however, as with N2 illness, patients requiring salvage surgery endure . Modifications to the radical neck dissection include the following: Type I: The spinal accessory nerve is preserved. [QxMD MEDLINE Link]. Small branches may be controlled with bipolar electrocautery. This is most useful in a postradiation patient when skin flap necrosis is more common and carries higher risks. Unable to load your collection due to an error, Unable to load your delegates due to an error. A rational classification of neck dissections. This is actually a nerve bundle which controls the muscles of the shoulder arm and hand. FOIA There are different types of modified radical neck dissection. may be radical, modified, selective and extended and either unilateral or bilateral. An en bloc approach should be pursued, and nodal metastases encapsulated by reactive connective tissue must be resected atraumatically. Bookshelf The posterior triangle is dissected. 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. tracy_csn Member Posts: 15. Intraoperative evaluation of the right jugulodigastric region demonstrated extensive metastatic fixation to the internal jugular vein. If simultaneous IJV ligation is performed, IJV reconstruction with a greater saphenous vein graft should be considered. https://emedicine.medscape.com/article/849834-overview#a3. Cells from cancers in the mouth or throat can travel in the lymph fluid and get trapped in your lymph nodes. Bilateral radical neck dissection: report of results in 55 patients. Alternatively, a hockey stick incision can be made. Consequently, the indications for MRND and selective neck dissection in these patients also remains poorly defined. Modified and complete neck dissection in the treatment of squamous cell carcinoma of the head and neck. July 2005 edited March 2014 in Head and Neck Cancer #1. 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. Table 2. Type II: The spinal accessory nerve and the internal jugular vein are preserved. 21151 Pomerantz Family Pavilion A study of 967 cases from 1970 to 1980. 200 Hawkins Drive A skin incision is made that optimizes exposure of the neck. Bladder Neck Transection. 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. A model has been prepared, simulating. [13] The mean combined recurrence rate following RND was 13.6% (95% confidence interval, 12.0-15.2%), whereas the mean combined recurrence rate following MRND was 6.9% (95% confidence interval, 5.4-8.4%). The most important permanent risk of surgery involves nerve injury. (a) Lateral venogram of patient who underwent modified radical neck dissection, showing flow straight down ipsilateral internal jugular vein. Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck SocietyDisclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan, Ryte, Neosoma, MI10
Received income in an amount equal to or greater than $250 from: , Cliexa;;Neosoma
Received ownership interest from Cerescan for consulting; for: Neosoma, eMedevents, MI10. 2005 Oct. 131(10):874-8. To the best of their knowledge, the authors report the rst case of TOETVA for MRND. The immune cells in the lymph nodes help the body fight infection. 1998 Aug. 31(4):639-55. Modified radical neck dissection (MRND). Web Privacy Policy | Nondiscrimination Statement. Posterior to anterior identification also bisects the SCM, preventing an en bloc dissection if RND is necessary. The inability to develop a clean plane of dissection mandates sacrifice of the involved nonlymphatic structure. 2000 Apr. There are 3 types of Neck Dissections: Radical: Includes Levels I through V, sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve (If you receive a radical neck dissection, please contact an attending for assistance) Comprehensive: a variant of modified radical that includes Levels I through V while sparing ALL anatomic . Although early physiotherapy that is targeted at facilitating spinal accessory nerve recovery and increasing scapular muscle strength may reduce shoulder dysfunction, evidence in support of its effectiveness is lacking. The IJV is once again evaluated. Of 343 elective neck dissections, 113 had pathologically documented nodal metastases. John Werning, MD, DMD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck SocietyDisclosure: Nothing to disclose. Terrell JE, Welsh DE, Bradford CR, et al. Dissection proceeds superiorly going from posterior to anterior superficial to the deep cervical fascia. government site. The Phrenic Nerve. Atraumatic dissection with a small hemostat or finger may facilitate the development of a "safe" plane of dissection. Although the term MRND strictly implies a comprehensive dissection of levels I-V, in the context of thyroid cancer, dissection . Modified radical neck dissection (MRND). Postoperative shoulder dysfunction is significant after accessory nerve resection. As it is classically described, the dissection is carried across the inferior portion of the parotid tail including it in the specimen. APPOINTMENTS: (919) 784-2735 The different types of neck dissection are classified based on the site (zones I-V) from where nodes are being removed and whether the following three important surrounding structures are removed: Apart from modified radical dissection, the other types include: The goal of neck dissection is to remove all cancer while preserving as much healthy tissue as possible. Therefore, an MRND with preservation of the SAN was performed. [QxMD MEDLINE Link]. 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. MedTerms medical dictionary is the medical terminology for MedicineNet.com. Bocca E, Pignataro O, Oldini C, et al. 1977 Dec;103(12):705-6. doi: 10.1001/archotol.1977.00780290041003. [3] This article reviews the rationale for and technique of the modified radical neck dissection (MRND) that developed from these efforts. It is mobilized from the trapezius muscle through the SCM to the jugular vein. Female surgeon in operation room with reflection in glasses, A surgeon systematically removes lymph nodes in the neck so that a pathologist can determine if they are cancerous. Further advancements have demonstrated that depending on the situation, not all levels must be explored, thus developing the concept of the "selective neck dissection.". Alternatively, preserve the internal jugular vein. The sternocleidomastoid muscle has been transected inferiorly and the external jugular vein has been ligated. Modified radical neck dissection type 3: Lymph nodes from level I-V undergo removal, with preservation of sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. In 1961, Nahum et al discovered that patients who had undergone radical neck dissection (RND) commonly experienced shoulder discomfort with limitation of shoulder abduction. The suprahyoid muscles are the digastrics, stylohyoid, mylohyoid, and geniohyoid. The width and scope of this surgery mandate a polished surgical technique and thorough knowledge of the anatomy. He wants to see me back in a month. A modified neck dissection removes less tissue than a radical procedure, and a selective neck dissection removes the least amount of tissue of all these types of surgeries. A muscle on the side of your neck called the sternocleidomastoid muscle, Sometimes, a combination of either of these structures may be removed. 1952 Sep. 5(5):873-83. Dissection is continued to the posterior border of the SCM. Three large sensory nerves are encountered with MND. I, therefore, extend the incision laterally (parallel to the clavicle) to the anterior border of the trapezius muscle. These give sensation to neck, anterior shoulder, lower jaw area and the area near the lower part of the ear. To me these are small things. A conservation technique in radical neck dissection. A conservation technique in radical neck dissection. Classification of neck dissection: current concepts and future considerations. [QxMD MEDLINE Link]. Patients should be counseled that loss of cutaneous sensation occurs in the distribution of the cervical plexus, including the skin of the neck and the periauricular region. 1967 Dec. 76(5):975-87. Most recently, Terrell and colleagues found no significant difference in shoulder or neck pain between patients who underwent MRND and those who underwent RND, but patients treated by RND used pain medications more frequently. Surg Gynecol Obstet. Modified radical or a radical neck dissection has a job in each the healing and palliative setting. MedicineNet does not provide medical advice, diagnosis or treatment. Objectives To (1) present a succinct synopsis of the rationale and elements of our current surgical management strategy for papillary thyroid carcinoma and, within this context, (2) provide a detailed stepwise description of a compartment-oriented modified radical neck dissection. This nerve controls the side of the tongue. Some degree of swelling is very common. Crile G. Excision of cancer of the head and neck. These modifications are described in relation to which structures are preserved: Type I: Spinal accessory nerve is preserved. 1994 Dec;22(6):323-9. Ahn C, Sindelar WF. Khafif et al compared the outcomes of patients who underwent RND with the outcomes of those who underwent MRND in 1990. The nerve to the lower lip (Ramus Mandibularis). Level V Metastasis in RND Patients*. The lymph nodes are removed and injury to the listed structures is possible. Philadelphia, Pa: WB Saunders Co. 1988:645-669. The level I contents are now lying along the anterior border of the sternocleidomastoid muscle. 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. Hamoir M, Shah JP, Desuter G, et al. The .gov means its official. The author prefers to use an apron flap design that extends from the mastoid tip to the mandibular symphysis (see the first image below). The greater auricular nerve is coursing parallel and immediately superior to the external jugular vein. 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 . However, in addition tonodes 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. All of the patients with level V involvement had nodal involvement at other levels. 1990 Oct. 160(4):405-9. KIRK B. FAUST MD The purpose was to effectvely remove all of the lymph nodes present in the neck and their interconnecting lymphatics. Depending on the tumor invasion, the doctor may either remove most of the lymph nodes between jawbone and collarbone on oneside of the neck and may or may not remove oneor more of the following: Modified radical neck dissection is usually considered for: This type of neck dissection is performed when there is evidence of more extensive involvement of lymph node metastasis. This description is combined with intraoperative photographs and . 2002 Jul. 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. Modified radical neck dissection (MRND). As the last fibers of the SCM are divided, the internal jugular vein and omohyoid muscle are fully exposed. Lymph Node Groups of the Neck (Open Table in a new window). Small vertical extensions along the border of the trapezius (superior most commonly, inferior occassionally) offer excellent exposure. Submandibular triangle dissection preserving lingual and hypoglossal nerves (see. Modified radical neck dissection To describe the lymph nodes of the neck for neck dissection, the neck is divided into 6 areas called Levels. Balm AJ, Brown DH, De Vries WA, et al. The preserved nonlymphatic structures should be specifically mentioned (eg, modified radical neck dissection with preservation of the IJV and SCM). Terms of Use. However, these patients tended to demonstrate improvement in their EMG results over time. It controls the diaphragm which is important in breathing. Although complications are rare for experienced head and neck surgeons, they naturally occur also after elective neck dissection (END). Performed by Dr John Chap. A: mandible, B: ligated internal jugular vein, C: cervical spine, D: injection cannula, E: shoulder. Epub 2014 Sep 17. 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. However, if the possibility of spinal accessory preservation is in question, anterior identification will more quickly determine whether to sacrifice or preserve the nerve. 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. Table 3. Shah also considered oral cavity lesions by lymph node level and found that only 1 patient out of 65 (1.5%) with a clinically negative neck (cN0) and pathologically proven nodal metastases had level V involvement, while 8 of 152 patients (5.3%) with clinically positive neck (cN+) findings and pathologically proven metastases had level V involvement. The Brachial Plexus. 47:1780-1786. Radical neck dissection Refers to the removal of all lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly, from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle medially, to the anterior border of the trapezius muscle laterally. Injury to this nerve will compromise shoulder function especially raising the shoulder. Many patients with N3 disease (nodal metastases > 6 cm) require RND, but MRND can be considered when dissection is feasible. Modified Radical Neck Dissection (MRND) Removal of all lymph node groups routinely removed with preservation of one or more of the accessory nerve, sternomastoid muscle and internal jugular vein; Selective Neck Dissection (SND) Am J Surg. 66(1):109-13. The marginal mandibular nerve can be preserved by elevating the submandibular gland fascia as part of the flap or by elevating the flap deep to the common facial vein after dividing it. This problem occurs in about 3% of patients and is an issue only with left MND. Injury to the SAN results in dysfunction of the trapezius muscle. The approach is more useful when the surgeon chooses to resect the SCM from the onset of surgery. Identification of the SAN can be performed anterior or posterior to the SCM. Neck dissection for cutaneous malignant melanoma. Symptoms also include weakness, numbness, coolness, color changes, swelling, and deformity. Ipsilateral selective neck dissection (levels 2 4) or a modified radical neck dissection (1 5) is indicated for the N1 neck. If you log out, you will be required to enter your username and password the next time you visit. Head Neck. Neck pain (cervical pain) may be caused by any number of disorders and diseases. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Level V Metastasis in RND Patients* (Open Table in a new window). 1999 Nov. (368):5-16. The subplatysmal flap is elevated superiorly to the mandibular border and inferiorly to the supraclavicular region. In 1952, Martin began to address the morbidity associated with the RND. Dissection in this area could result in a Horners syndrome. Modified radical neck dissection (MRND). Injury to this nerve is quite rare as it is easily seen and few lymph nodes are near it. [QxMD MEDLINE Link]. Shah JPAndersen Br J Oral Maxillofac Surg1995;333- 8PubMedGoogle ScholarCrossref 1985 Oct. 150(4):414-21. It is commonly manipulated during surgery. Raleigh, NC 27607, TELEPHONE: (919) 784-7874 Resection may also contribute to fibrosis and limitation of range of cervical motion. When the SAN is transected, the shoulder droops as the scapula is translated laterally and rotated downward. [QxMD MEDLINE Link]. The submental (IA) and submandibular contents (IB) have been dissected away from the underlying soft tissues (arrow). Medscape. Modified radical neck dissection in cancer of the mouth, pharynx, and larynx. 1989 Apr. 1993 Nov-Dec. 15(6):546-52. (after 15 days of antibiotics and about 400 bandage and gauze changes). 94(7):942-5. Incision typically performed for patients requiring bilateral neck dissections. [QxMD MEDLINE Link]. Head Neck. [QxMD MEDLINE Link]. Cervical lymph nodes. 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. Terms of Use. J Laryngol Otol. Modified radical neck dissection (MRND). The contents of this web site are for information purposes only, and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. The cervical sympathetic plexus. Federal government websites often end in .gov or .mil. Selective vs modified radical neck dissection and postoperative radiotherapy vs observation in the treatment of squamous cell carcinoma of the oral tongue. The neck dissection is then removed and oriented for lymph node level-specific histopathologic evaluation for pathologic staging purposes (see the second image below). Modified radical neck dissection removes lymph nodes from levels I to V, but keeps one or more of the following - internal jugular vein, sternocleidomastoid muscle or spinal accessory nerve. 2800 Blue Ridge Road, Suite 300 Neck Dissections Preserving SAN*, Table 4. Identification of the spinal accessory nerve anterior to the sternocleidomastoid muscle in the contralateral neck of the same patient as it courses lateral to the internal jugular vein. Exposure of the neck following subplatysmal flap elevation, superficial to the greater auricular nerve and external jugular vein. Central Neck Dissection? In addition to radiation and chemo for my tonsil cancer, I had a radical neck dissection. Int J Clin Oncol. If the SCM is being resected, transection is performed below the mastoid tip and above the clavicle as in a RND. You should rather give importance to the surgeons experience and your rapport and comfort level with them. Post-op patients experience variable loss of sensation or blunted sensation around the wound and in the areas described. E-MAIL: kirk.faust@unchealth.unc.edu, Minimally Invasive Thyroidectomy Techniques, Postoperative Care Following Thyroid Surgery, Monitoring Thyroid Cancer Patients and Diagnosis of Recurrence, Surgery for Locally Recurrent Thyroid Cancer, Surgery for Regional Recurrence of Thyroid Cancer, Risk & Post-Op Issues (Modified Radical neck Dissection). 40(4):252-5. Patients with multiple palpable nodes, patients with nodes larger than 3 cm in diameter, patients with disease in the posterior triangle, and patients in whom radiotherapy to the neck has failed may be better served by radical neck dissection. Because outcome data are limited, the precise role of MRND remains undefined, especially in N2 and N3 nodal disease. Radical neck dissection removes nearly all lymph nodes on one side of the neck as well as the internal jugular vein, sternocleidomastoid muscle and . The neck supports the weight of the head and is highly flexible, allowing the head to turn and flex in different directions. The University of Iowa does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on this web site. Wiater JM, Bigliani LU. JAMA 22:1780-1786, 1906. Medina JE, Weisman RA. The radical neck disecton was first described in 1906 by Crile, based on the Halstedian concept of en bloc resection. Causes of neck pain and dizziness vary, and treatment depends on the cause. 1996-2022 MedicineNet, Inc. All rights reserved. MacFee incision consists of two parallel horizontal incisions, one high and one low. Bocca E, Pignataro A. This large nerve runs the length of the neck along the major blood vessels. Robotic total thyroidectomy with modified radical neck dissection via unilateral retroauricular approach. Spinal accessory nerve injury. Such dissection should preserve the thick reactive fibrous tissue encapsulating most nodal metastases. Surg Clin North Am. It was the standard of care for the next 70 years. Ipsilateral radical neck dissection or selective neck dissection (levels 2 5) is indicated for the N2/3 neck. The infrahyoid muscles are the sternohyoid, sternothyroid, thyrohyoid, and omohyoid. [QxMD MEDLINE Link]. For more information about the relevant anatomy, see Neck Anatomy. 2006 Dec;33(4):365-74. doi: 10.1016/j.anl.2006.06.001. [QxMD MEDLINE Link]. The jugular vein has been divided and ligated. 3rd ed. Lore JM. Complications of neck dissection affect every surgeon regardless of experience and technical skill. Sternocleidomastoid muscle (SCM) resection results in loss of normal contour in the anterior neck with resultant cosmetic deformity. Most patients take narcotic pain medication for 1-2 weeks. The posterior triangle contents are dissected from the posterior border and the undersurface of the SCM. Further, only specific groups of lymph nodes rather than all the lymph nodes on the side of the neck are dissected. These results suggest that a RND is frequently not indicated for the treatment of many patients with head and neck cancer, and a modified or selective neck dissection that minimizes traumatic manipulation of the SAN may be more appropriate, particularly if the neck is clinically negative. Modified radical neck dissection (MRND). 110(4):620-6. Our doctors define difficult medical language in easy-to-understand explanations of over 19,000 medical terms. Reinnervation of the trapezius muscle after radical neck dissection. See Commando operation. This nerve is high and very shallow in the neck. These nerves are commonly stretched or divided during the operation. Injury to large blood vessels is very rare and generally easily dealt with, but significant bleeding or stroke have been reported. 1951 May. Included in this tissue, which extends from the collarbone (clavicle) inferiorly to the jawbone (mandible) superiorly are dozens of lymph nodes. The levels are identified by Roman numeral, increasing towards the chest. [QxMD MEDLINE Link]. Short SO, Kaplan JN, Laramore GE, et al. Elevation of the level I contents out of the submental and submandibular triangles, exposing the digastric and mylohyoid muscles. Use This Code : You Be The Coder. [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. Shoulder immobility or spinal accessory nerve palsy is reported as the most common complication occurring in 10% of patients after selective or modified radical neck dissection [ 9 ], but with preservation of . Oswaldo Suarez from Argentina was the first to describe functional neck dissection in 1963, now called modified radical neck dissection (MRND). Tenderness is another symptom of neck pain. Current status of oral cancer treatment strategies: surgical treatments for oral squamous cell carcinoma. Am J Surg. Chapter 113: Neck Dissection. Type II: Spinal accessory & internal jugular vein or sternocleidomastoid [QxMD MEDLINE Link]. 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. There are several types of neck dissections. Ann Otol Surg 81:975-987, 1967. This surgical incision location is ideal to minimize scarring, while also enabling the surgeon to safely remove any cancerous lymph nodes. These result in a better postoperative quality of life. Injury to muscles is not a significant issue. J Surg Oncol. [7]. Radical neck dissection is a surgical operation used to remove cancerous tissue in the head and neck. Much easier than I anticipated. This article reviews the rationale for and technique of the modified radical neck dissection (MRND) that developed from these efforts. Medina JE. Martin H, Del Valle B, Ehrlich H, et al. In general, the preponderance of the research data supports the theory that dissection and skeletonization of the SAN are traumatic enough to cause pain and shoulder dysfunction. Robbins KT. 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. 1995 Jul. At MD Anderson, Byers reviewed 1372 neck dissections, and at Memorial Sloan-Kettering, Shah reviewed 1119 RNDs for squamous carcinoma of the upper aerodigestive tract. However, 7 of these studies were published before the development of a standardized classification for neck dissections, and modified neck dissections at that time included both the MRND and the selective neck dissection. A further Level VII to denote lymph node groups in the superior mediastinum is no longer used. Injury may results in a paralyzed vocal cord. We use nerve monitoring techniques during the procedure to verify these nerves are intact at the conclusion of the procedure. Patients who underwent surgery and postoperative radiotherapy, 100% of whom had jugulodigastric nodal involvement, demonstrated a 0% recurrence rate (see Table 3). MRND is contraindicated whenever preservation of the nonlymphatic structures of the neck would compromise complete resection of the cervical metastatic disease. Patients with persistent pain and dysfunction after 1 year of conservative treatment may be candidates for surgical reconstruction with the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major are transferred. A radical neck dissection would be done if the tumor spread to the neck is quite extensive. . Dizziness is characterized as either vertigo with disequilibrium or lightheadedness associated with feeling faint or the potential to lose consciousness. A technique of modified neck dissection, which excludes dissection of the posterior triangle and spares the sternocleidomastoid muscle and spinal accessory nerve, has been described. Auris Nasus Larynx. When MND is performed the major blood vessels, nerves and muscles are exposed on the side of the dissection. The lymph node-bearing fibroadipose tissues in this region are also rotated under the SAN in the same manner that dissection of sublevel VA was performed, up to the lateral aspect of the IJV. [8] The morbidity associated with bilateral IJV resection has led to staged procedures or recommendations for IJV reconstruction in which bilateral IJV resection is necessary. These contributions are divided inferior to the submandibular ganglion. Also, see eMedicineHealth's patient education article Cancer of the Mouth and Throat. He proposed that these nonlymphatic structures could be preserved during neck dissection for limited disease without adversely affecting regional control. The submandibular triangle in radical neck dissection. Injury is very rare. At this time, intraoperative assessment is necessary to determine the proximity and/or fixation of lymph node metastases to the IJV, SAN, and SCM. [QxMD MEDLINE Link]. A simple system of nomenclature has been suggested which allows specification of the node levels dissected and the structures preserved. Am J Surg. [1] Hayes Martin further popularized use of the RND in the 1950s. Tying rootlets with 2-0 silk (or using hemoclips) may theoretically decrease the risk of neuroma. 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. Over time, the procedure has been modified to reduce morbidity while maintaining oncologic efficacy. The skin with surgical clips, 4-0 or 5-0 nylon. 1906. [QxMD MEDLINE Link]. No prior radiation postoperative day 6 or 7, Prior radiation postoperative day 10 to14. 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. Ferltio A, Rinaldo A. Osvaldo Suarez: often-fortotten father of functional neck dissections (in the non-Spanish-speaking literature). The risk of this is less than 1%. Background & Aims: To describe unilateral and bilateral modified radical neck dissections with access to the thyroid gland and all neck lymph node levels through a single supraclavicular transverse incision. These can usually be removed en bloc with the remainder of the dissection in a posteroanterior fashion, sharply incising the fascia of the jugular vein with a scalpel blade using a feather-light touch. Radical Neck Dissection - All lymph nodes and tissues (muscle, nerves, blood vessels, and salivary gland) on the affected side are removed. On the affected side, patient experience difficulty raising the eyelid, diminished sweating on that side of the face and a constricted pupil. These cancers account for 3% to 5% of cancers in the U.S. Tobacco and alcohol use are important risk factors. Bocca and Suarez independently in the 1960s. 104(7):841-5. Strong EW. 1996-2021 MedicineNet, Inc. All rights reserved. Rarely the return of sensation may be painful and chronic pain syndromes may develop. [14] Overall, he encountered an 8.1% recurrence rate in the neck 5 years following surgery. Arch Otolaryngol Head Neck Surg. 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. Modified radical neck dissection is indicated when the spinal accessory nerve, internal jugular vein, or sternocleidomastoid muscle can be preserved without affecting oncologic outcomes and when a selective neck dissection would not adequately remove the volume of cancer in the neck. Exposure following subplatysmal flap elevation. Raleigh, NC 27607, PAUL PARK MD The risk of permanent injury to one of these nerves is less than 3%. After discussions with an onologist and my surgeon a Modified Radical Neck Dissection was performed on Jan 6th. If bilateral neck dissections are planned, the incision extends from one mastoid tip to the other to create a single apron flap (see the second image below). The nerve branch can be identified beneath the prevertebral fascia between the middle and posterior scalene muscles, and confirmed by stimulation. Video-Telemedicine for Salivary Gland Swelling (Sialadenitis), Cervical Lymphadenectomy- General Considerations, Comprehensive neck dissection in the previously untreated patient is primarily utilized to treat neck disease greater than N. In the past indications for classical radical neck dissection have been: Disease involving the accessory nerve and/or internal jugular vein, Recurrent tumor after previous irradiation, Recurrent disease in the neck after previous neck dissection, Salvage surgery in patients after chemo-irradiation, Involvement of the platysma or skin, requiring sacrifice of a portion of skin in the upper neck. Blunt dissection above the carotid artery and vagus nerve. Related Resources - What Is Removed in a Modified Radical Neck Dissection? Functional neck dissection: an evaluation and review of 843 cases. 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. The risk of a life threatening complication is negligible, but there are risk to the procedure. Methods: OPSCC patients were divided into Modified Radical Neck Dissection (MRND) and SND groups. The 3-year survival rate in the MRND group was 74% versus 63% in the RND group. This nerve is not really in the area of dissection, but it can be compressed by retractors during the procedure. Weiss KL, Wax MK, Haydon RC 3rd, et al. Head Neck. The posterior belly of the digastric muscle is retracted superiorly and the internal jugular vein is ligated at the base of skull. Robbins KT, Clayman G, Levine PA, et al. 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. Modified radical neck dissection type I (MRND-I): Lymph nodes from level I-V, ipsilateral sternocleidomastoid muscle, and internal jugular vein are removed, with preservation of the spinal accessory nerve. Increased intracranial pressure may result, and reports of blindness, laryngeal edema, stroke, and death exist within the medical literature. Increasing awareness of the morbidity associated with radical neck dissection (RND) led head and neck surgeons to explore modifications of the classic procedure. [QxMD MEDLINE Link]. If the SAN can be preserved, dissection is then continued from its proximity to the IJV posterocaudally to the trapezius muscle, dividing the SCM (see the image below). Dissection in a plane that separates the fascia from the underlying platysma facilitates an en bloc approach to the lymphatic structures within an envelope of fascia. Of these patients, 22% had moderately abnormal EMG findings, while 56% had normal EMG findings. The Latin-derived term cervical means "of the neck." Over time this improves and the loss of sensation resolves. A posterior to anterior dissection is then performed beginning at the anterior border of the trapezius muscle. Seven nerve groups are considered. Laryngoscope. Physiotherapy for accessory nerve shoulder dysfunction following neck dissection surgery: a literature review. When it occurs it it rarely an issue for the patient. This problem has been reported after extensive dissection around the carotid artery as well. I'm a thankful 5 year survivor of thyroid cancer (papillary carcinoma). Indications for MRND-I is in bulky nodal disease with extracapsular spread involving the SCM and IJ, where the accessory nerve is free of . Management of the neck in head and neck cancer, part II. So, a question for other head and neck survivors who had radical neck dissections: - did/do you have much physical discomfort? However, patients receiving radiotherapy combined with surgery were not evaluated separately from patients who underwent surgery, and patients who underwent delayed neck dissections were also grouped with patients treated with immediate neck dissections. Krause HR. [5] Of these patients, 42 experienced shoulder discomfort, and 60 demonstrated shoulder stiffness and decreased range of motion. Epub 2006 Aug 4. Care is taken during flap elevation to remain superficial, preserving the greater auricular nerve and the SAN (see the image below). Posterior to the SCM, the nerve invariably can be found approximately 1 cm cephalad to the greater auricular nerve as it wraps around the SCM (see the image below). Table 1. Risk & Post-Op Issues (Modified Radical neck Dissection) Created on March 28, 2016 by Dr. Kirk Faust in Thyroid Thyroid Modified radical neck dissection (MND) is a complicated operation. JAMA. Use cautery to separate the SCM attachments posteriorly from the skin and mastoid tip. Neck Dissections Preserving SAN* (Open Table in a new window). Patients present with an asymmetric neckline, a drooping shoulder, winging of the scapula, and weakness of forward elevation. [QxMD MEDLINE Link]. [16]. The Department of Otolaryngology and the University of Iowa wish to acknowledge the support of those who share our goal in improving the care of patients we serve. Type II: The spinal accessory nerve and the internal jugular vein are preserved. 1978 Oct. 136(4):516-9. Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center Between the cricoid cartilage and the suprasternal notch, the trachea and isthmus of the thyroid gland can be felt. official website and that any information you provide is encrypted [2] The procedure uses, in Crile's words, "a 'block dissection' of the regional lymphatic system . Pain, quality of life, and spinal accessory nerve status after neck dissection. MedTerms online medical dictionary provides quick access to hard-to-spell and often misspelled medical definitions through an extensive alphabetical listing. Otolaryngol Clin North Am. Spinal accessory nerve preservation in modified neck dissections: surgical and functional outcomes. Purpose The purpose of radical neck dissection is to remove lymph nodes and other structures in the head and neck that are likely or known to be malignant. Head and neck cancers include cancers of the throat, lips, nose, mouth, larynx, and salivary glands. 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. 2. Extensive disease (carotid artery encasement, deep neck muscular invasion, skull base involvement). Such a dissection is indicated whether the glands are or are not palpable.". Arch Otolaryngol. We believe this operation is appropriate when local disease is advanced and clinically uninvolved neck nodes are likely to harbor occult metastatic disease, when resection of the primary tumor is through the neck, or when clinical disease in the neck is minimal. The contributions from the cervical nerve roots from C2, C3 and C4 and scar branch are ligated. Neck dissection is usually performed to remove cancer that has spread to lymph nodes in the neck. Stay 2 cm above the clavicle to avoid the thoracic duct. Shoulder and neck pain may be caused by bursitis, a pinched nerve, whiplash, tendinitis, a herniated disc, or a rotator cuff injury. Am J Surg. 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. 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. Disclaimer, National Library of Medicine Department of Otolaryngology Physical therapy can be very helpful in these situations. The quadrangular area is on the side of the neck and is bounded superiorly by the lower border of the body of the mandible and the mastoid process, inferiorly by the clavicle, anteriorly by a midline in front of the neck, and posteriorly by the trapezius muscle. [QxMD MEDLINE Link]. Levels I, II, and V have also been divided into sublevels, and the anatomic and radiographic boundaries of each level and sublevel have been clarified. Suction drains are strategically placed and a layered closure is performed. 1994;251(6):335-41. doi: 10.1007/BF00171540. 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. The neck recurrence rate for elective FND was 2.3% versus 30.4% for therapeutic FND. Retraction of the posterior belly of the digastric with a vein retractor may facilitate exposure. A neck dissection is a type of surgery in which groups of lymph nodes in the neck are removed to determine if they contain cancer cells. Stretching of the SAN must be minimized. You are being redirected to Muscles in the front of the neck are the suprahyoid and infrahyoid muscles and the anterior vertebral muscles. The posterior triangle contents posterosuperior to the nerve (sublevel VB) are rotated under the nerve inferiorly. [15] They were unable to demonstrate a statistical difference in the neck recurrence rate overall or in patients with N2 or N3 disease. Laryngoscope. In addition, these studies differed in their indications for neck dissection, use of preoperative or postoperative radiotherapy, and follow-up interval. Blindness: a potential complication of bilateral neck dissection. 8600 Rockville Pike Suarez, therefore, defined the anatomic basis and surgical criteria for the functional neck dissection (FND). As the cervical rootlets are encountered, they are transected high (adjacent to the specimen) to prevent injury to the phrenic nerve. If the SCM is being resected, the muscle is bisected and elevated in continuity with the posterior triangle contents. It is not always necessary to resect the tail of the parotid gland. Fig. No formalized indications have been created for modified radical neck dissection (MRND), and indications vary widely from one clinician to another. A simple system of nomenclature has been suggested which allows specification of the node levels dissected and the structures preserved. This study was planned to determine whether Selective Neck Dissection (SND) is oncological safe procedure even in patients with lymph node metastases. 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