RADICAL NECK DISSECTION

By dr.Lisa

Level I: Submental and submandibular nodes

Level Ia*: Submental triangle Boundaries
Anterior bellies of the digastric muscle Hyoid bone

Level Ib*: Submandibular triangle Boundaries

Body of the mandible Anterior and posterior belly of the digastric muscle

Primary drainage
Chin Lower lip Anterior floor of mouth Mandibular incisors Tip of tongue

Primary drainage
Oral Cavity Floor of mouth Oral tongue Nasal cavity (anterior) Face

Level II: Upper jugular nodes

Boundaries Anterior lateral border of the sternohyoid muscle, posterior digastric and stylohyoid Posterior posterior border of the sternocleidomastoid muscle Superior skull base Inferior level of the hyoid bone (clinical landmark) or carotid bifurcation (surgical landmark) Primary drainage Oral Cavity Nasal Cavity Nasopharynx Oropharynx Larynx Hypopharynx Parotid Level IIa anterior to XI Level IIb (Submuscular recess) - posterior to XI More likely to drain pharyngeal lesions than oral cavity or laryngeal lesions.

Level III: Middle jugular nodes

Boundaries Anterior lateral border of the sternohyoid muscle Posterior posterior border of the sternocleidomastoid muscles Superior hyoid bone (clinical landmark) or carotid bifurcation (surgical landmark) Inferior cricothyroid notch (clinical landmark) or omohyoid muscle (surgical landmark) Primary drainage Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx

Level IV: Lower jugular nodes

Boundaries Anterior lateral border of the sternohyoid muscle Posterior posterior border of the sternocleidomastoid muscles Superior cricothyroid notch (clinical landmark) or omohyoid muscle (surgical landmark) Inferior clavicle Primary drainage
Hypopharynx Larynx Thyroid Cervical esophagus

Level V: Posterior triangle

Boundaries Anterior posterior border of the sternocleidomastoid muscle Posterior anterior border of the trapezius muscle Inferior clavicle Primary drainage Nasopharynx Oropharynx Posterior neck and scalp Level Va - lymphatic structures that follow the spinal accessory nerve. Level Vb lymphatic structures that lie along the transverse cervical artery

Level VI: Anterior compartment (Prelaryngeal, pretracheal, paratracheal, and precricoid nodes)
Boundaries Lateral carotid sheath Superior hyoid bone Inferior suprasternal notch Primary drainage Thyroid Larynx (glottic and subglottic) Pyriform sinus apex Cervical esophagus

Face and Scalp

Facial, Ib Parotid Occipital, V Eyelids Ib Parotid, II Chin Ia, Ib, II External Ear Anterior Parotid, II Posterior Post auricular, II, V Middle Ear Parotid, II Floor of mouth Anterior Ia, Ib, IIa > IIb Lower incisors Ia, Ib, IIa > IIb Lateral Ib, IIa > IIb, III Teeth except incisors Ib, IIa > IIb, III Nasal Cavity Anterior Ib Posterior Retropharyngeal, II, V Nasopharynx Retropharyngeal, II, III, V Oropharynx IIb > IIa, III, IV, V Larynx Supraglottic IIa > IIb, III, IV Subglottic VI, IV Cervical esophagus IV, VI Thyroid VI, IV, V, Mediastinal Tongue Tip Ia, Ib, IIa > IIb, III, IV Lateral Ib, IIa > IIb, III, IV

Anterior Lateral Posterior Medial Lateral

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. Included are all lymph nodes from levels I-V with sacrifice of internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve. Loss of the spinal accessory nerve results in denervation of the trapezius muscle which causes shoulder drop, shoulder pain, and difficulty in abducting the arm more than 90. Transsection of the internal jugular vein predisposes to increased facial edema, although the contralateral vein eventually compensates. Sacrifice of both internal jugular veins greatly increases the risk of facial and cerebral swelling and can cause intracranial complications.

Extended Radical Neck Dissection

Refers to the removal of one or more additional lymph node groups or nonlymphatic structures or both, not encompassed by the radical neck dissection.

Modified radical neck dissection

Refers to the removal of all lymph nodes by radical neck dissection with preservation of one or more of the non-lymphatic structures: i.e., the spinal accessory nerve, internal jugular vein and the sternocleidomastoid muscle.

Modified radical neck dissection

include the following: Type I: The spinal accessory nerve is preserved. Type II: The spinal accessory nerve and the internal jugular vein are preserved. Type III: The spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle are preserved.

Selective neck dissection

Refers to any type of cervical lymphadenectomy where there is preservation of one or more of the lymph node groups removed by the radical neck dissection. Unlike the modified radical neck dissection in which all five lymphatic levels are removed, the selective neck dissection focuses on specific levels.

Selective neck dissection: Supraomohyoid Neck Dissection

Refers to the removal of lymph nodes contained in levels IIII. The posterior limit of the dissection is marked by the cutaneous branches of the cervical plexus and the posterior border of the sternocleidomastoid muscle. The inferior limit is the superior belly of the omohyoid muscle where it crosses the internal jugular vein.
For instance, since smaller N0 oral carcinomas tend to spread to levels I, II, and III, the surgeon can choose to excise only these three levels (termed a supraomohyoid neck dissection).

Extended Supraomohyoid Neck Dissection adds level IV nodes as well as the nodes in Level V superior to the inferior belly of the omohyoid.

Selective neck dissection: Posterolateral Neck Dissection

Refers to removal of the suboccipital lymph nodes, retroauricular lymph nodes and lymph nodes in levels II-V. may be utilized for posterior cutaneous lesions.

Selective neck dissection: Lateral Neck Dissection

Refers to the removal of lymph nodes in levels II-IV, along the internal jugular vein. A lateral neck dissection, which includes levels II-IV, might be more useful for a oropharyngeal, hypopharyngeal, or laryngeal carcinoma.

Selective neck dissection: Central Compartment Neck Dissection

Refers to the bilateral removal of lymph nodes surrounding the midline visceral structures of the anterior neck - level VI. The lymph nodes include the pre- and paratracheal, pre-cricoid (Delphian) and perithyroidal. The superior limit of the dissection is the hyoid bone; the inferior limit is the suprasternal notch; and the lateral limits are the carotid arteries. A central / anterior compartment neck dissection is used for thyroid, hypopharyngeal, tracheal, and laryngeal carcinomas.

Objective Respons of Chemotherapeutic

Complete response (CR) disappearance of all known dis, determined by 2 observations > 4 weeks apart Partial response (PR) > 50% decrease in total tumor load of the lesions that have been measured to determine the effect of tx by 2 observations > 4 weeks apart No change (NC) a 50% decrease in total tumor size cannot be established nor has a 25% increase in the size of >1 measurable lesions been demonstrated Progressive dis (PD) > 25% in the size of > 1 measurable lesions been demonstrated

THE END
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