Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Neck dissection
1. NECK
DISSECTION
By Prof. Muhammad Iqbal Butt
F.R.C.S. (Canada)
Chairman Department of E.N.T.
Lahore Medical & Dental College,
Dean Faculty of E.N.T.
College of Physicians and Surgeons, Pakistan
2. BENIGN AND MALIGNANT
LESIONS
Benign lesions are discrete, movable, nontender (20%)
Submandibular 25% are malignant
Malignant lesions metastasizing to the regional lymph
nodes:
• Lip 31%
• Cheek 40%
• Alveolus 35%
• Tongue and floor of mouth 63%
• Nasopharynx 80%
3. 80% of lateral neck masses are malignant
85% of these are from lesions of head and neck
Most common sites:
1. Nasopharynx
2. Tonsils
3. Base of tongue
4. Supraglottis
5. Thyroid
6. Pharynx
7. Mouth
8. Palate
4. PRIMARY LESIONS
Of the primary lesions of head and neck
Laryngopharynx 40%
Orophayrynx 40%
Thyroid 10%
Others 10%
Squamous cell carcinoma is present in 50%
45% of them are:
Undifferentiated carcinoma
Lymphoepithlioma
Lymphosarcoma
Adenocarcinoma
5% occult primary
5. DIAGNOSIS
1. History
2. Examination of ear, nose, throat, oral cavity should
give you diagnosis in 95% cases
3. Examination of nasopharynx
4. Waldeyer’s ring especially tonsils if lymphoma is
suspected
5. Squamous cell carcinoma progresses slowly,
adenocarcinoma much more rapidly
6. DIAGNOSIS
Mass superior jugular group and for tonsil, oropharynx,
supraglottis
Mass in middle and inferior group usually arises from
larynx
Mass in supraclavicular region arises below the clavicle:
Stomach
Intestine
Lung
Mass in posterior neck arises from nasopharynx and
paranasal sinuses or are primary lymphomas
7. IMPORTANT CONSIDERATIONS
Before embarking on treating locally, distant
metastases may be considered
FNAC
Incisional biopsy is to be done only as a last
resort for making diagnosis
MRI & CT scan
9. PAROTID
a) Superficial part
b) Superficial subglandular lying beneath the parotid
sheath (Fascia parotidomasseter)
b1) Preauricular
b2) Intraauricular
c) Deep intraglandular
d) The lower pole of the parotid
These are removed in radical neck dissection
10. SUBMANDIBULAR
a) Preglandular
b) Prevascular: Usually one large prevascular
node is lying in front of the anterior facial vein
and on the external maxillary artery
c) Retrovascular: Usually two retrovascular
nodes are situated behind the anterior facial
vein
12. RETROPHARYNGEAL
a) Medial: These are intercalated
b) Lateral: These are one to two lying between
prevertebral fascia and lateral pharyngeal wall
at the level of the atlas, near the carotid as it
enters the carotid canal
13. LATERAL CERVICAL
a) Superficial: There are one to four superficial nodes
over the upper half of sternocleidomastoid. These are
in close relation to the lower pole of the parotid.
b) Deep: The deep cervical nodes consist of three
chains:
i. Internal jugular
ii. Spinal accessory
iii. Transverse cervical
14. i. Internal jugular chain
The internal jugular chain lies along the anterolateral aspect
of the internal jugular vein and spinal laterally to the
posterior aspect of the vein in the lower neck
SUBDIGASTRIC: These are in relation to the posterior
belly of the digastric
CAROTID NODES: These are in relation to the carotid
bifurcation
OMHYOID: These are in relation to the superior belly of
the omhyoid
SUPRACLAVICULAR: These are in relation to the
clavicle
KUTTNER’S NODE: Also called the principle node of
Kuttner located anteriorly near the posterior belly of the
digastric
15. ii. Spinal accessory chain
These are five to ten nodes that extend along the
accessory nerve
16. iii. Transverse cervical chain
These are one to ten lymph nodes at the
jugulosubclavian junction. They accompany the
transverse cervical artery and vein. The most
medial of these is the Troissier’s node which may
be the site of metastasis of carcinoma of
stomach. These drain into the right lymphatic
duct.
17. ANTERIOR CERVICAL
NODES
These lie between the two carotid sheaths
below the level of the hyoid bone
1. Superficial anterior jugular
2. Deep anterior cervical
Lymph nodes groups:
a) Prelaryngeal
b) Paratracheal
c) Recurrent nerve chain
20. GENERAL
CONSIDERATIONS
If adenocarcinoma occult primary is high in the neck,
block dissection is performed with inspection of the
parotid gland
If biopsy shows undifferentiated carcinoma, radiate
especially for 4cm lymph nodes and then clean residual
disease
As a general rule, incurable lesions of the neck should
be first treated with radiation
Block dissection is used to relieve intractible pain
If adenocarcinoma is present in a supraclavicular LN,
look for primary in the thyroid
21. Functional neck dissection is indicated:
i. When bilateral neck dissection is indicated
ii. Preserves muscle function and protects the
carotids
BLOCK DISSECTION
22. LEVELS OF LYMPH NODES
I. Submental and submandibular
II. Upper deep cervical group of
lymph nodes around internal
jugular vein. Skull base to
carotid bifurcation or hyoid
III. Middle third of internal
jugular vein to the carotid
bifurcation up to omhyoid
muscle or cricothyroid notch
IV. Lymph nodes from omhyoid
to the clavicle
V. Lymph nodes along the spinal
accesory and transverse
cervical artery
VI. Lymph nodes in anterior
compartment around midline
visual structures
27. ELECTIVE THERAPEUTICS
No palpable nodes
Out of seventy operated cases only eight require
surgery
THERAPEUTICS (also called definitive)
If nodes are palpable surgery is definite
treatment
29. 1- Radical Neck Dissection
Removal of:
a) Sternocleidomastoid muscle
b) All lymph node groups (level 1-5)
c) Spinal accessory nerve
d) Internal jugular vein
30. 2- Modified Radical Neck Dissection
Remove all lymph nodes (level 1-5), preservation
of one or more non-lymphatic structures
i. Type I Modified Radical Neck Dissection preserves
the spinal accessory nerve
ii. Type II Modified Radical Neck Dissection saves
spinal accessory nerve, internal jugular vein
iii. Type III Modified Radical Neck Dissection
preserves spinal accessory nerve, internal jugular
vein, sternocleidomastoid muscle. Known as
Functional Neck Dissection (Berry picking)
31. 3- Selective Neck Dissection
a) Preservation of one or more lymph node groups and
b) All non-lymphatic structures (accessory nerve,
internal jugular vein, sternocleidomastoid muscle)
i. Supra omhyoid LN removed (level 1-3)
ii. Posterolateral LN removed (level 2-5)
1. Post-auricular and
2. Suboccipital lymph node groups
iii. Lateral (level 2-4) removed
iv. Anterior (level 6) removed
32. 4- Extended Radical Neck
Dissection
All structures in radical neck dissection and one
or more additional lymph node groups or non-
lymphatic structures or both
33. CONTRA-INDICATIONS OF
NECK DISSECTION
1. Mass in subclavian triangle
2. A large fixed mass
3. Mass extending to the mastoid
4. Undifferentiated carcinoma
5. Primary lesion that cannot be controlled
6. Distant metastases
7. Uncontrollable tumour will remain in neck after surgery
8. Papillary carcinoma of thyroid without extracapsular
invasion
9. Occult primary adenocarcinoma – sample nodal excision
with inspection of neck
34. INDICATIONS OF NECK
DISSECTION
The tumour has extended to lymph nodes
There is reasonable expectation of controlling
the PRIMARY TUMOUR
Emphasis is on preservation of function
Radiation failure
Lymph nodes larger than 3cm
36. SRUCTURES AT TIP OF
HYOID BONE
Carotid bulb, External & Internal carotid artery
Internal jugular vein
Vagus nerve, Hypoglossal nerve passing lateral
to carotids
Lingual vein, superior thyroid & facial vein
entering internal jugular vein
Superior thyroid artery, Superior laryngeal nerve
& artery
37. TRANSVERSE PROCESS OF
VI CERVICAL VERTEBRA
Also called carotid tubercle
It lies at the level of cricoids cartilage
Vertebral artery entering the foramen at this
level
38.
39.
40.
41.
42.
43.
44.
45.
46.
47. PREOPERATIVE
1. Type cross match 2-3
units of whole blood
2. Patient anaesthetized using
various tubes
3. Pillow placed under the
shoulder, raise the head
30°
4. Scrub to prepare:
i. Lower face
ii. Ears
iii. Neck
iv. Shoulders
v. Upper chest
52. DRAPING
Keep the ear outside
First sheet from chin to ear
Second sheet across upper chest
Third sheet mastoid to shoulder
Stitch the sheets
56. MARTIN INCISION
Upper incision -
submental area to tip of
mastoid
Lower incision -
suprasternal notch to
4cm above clavicle
Vertical arm – posterior
to carotid vessels
57. CONLEY INCISION
Incision is away from
carotid
Difficult area of the
trapezius can be easily
approached
66. INCISION
Protect the carotid with levator muscles, fascia
lata graft
Incision should be carried out through
i. Skin
ii. Subcutaneus tissue
iii. Platysma muscle
External jugular vein is not included with the
skin incision
67. INCISION
Include the platysma muscle in skin flaps
Use superior belly of omohyoid as medial guide
Use scalenus fascia as guide for depth
Critical areas and structures:
Internal jugular vein superiorly and inferiorly
Subclavian vein
Posterior facial vein hidden in tail of parotid gland
Superior laryngeal nerve deep to external and internal carotid arteries
Thoracic duct on left side
Apical pleura
Place incision so that trifurcation does not overlie the carotid
vessels
68. SURGERY 1
Skin flaps elevated:
i. Superiorly to ramus of
mandible
ii. Lift the deep cervical
fascia at level of hyoid
iii. Midline to strap
muscles
iv. Inferiorly to clavicle
69. SURGERY 2
Find the notch made on the
inferior border of mandible
by the external maxillary
vessels, anterior facial vein
and superficial layer of deep
cervical fascia as reflected
Sternocleidomastoid:
Upper and lower ends are cut
lose to the bone and up to
the deep fascia. The vein is
exposed and a 2cm strap is
left below
Tied in continuity
Two suture ligatures are put
in place
70.
71.
72. PROBLEM
The lower end slips or tears
DO NOT PANIC
Remedy!
JUGULAR VEINS: Always tie the lower end first
OTHER VEINS:
1. Transverse cervical vein
2. Transverse scapular vein
3. Anterior jugular vein
Fascia of carotid sheath is stripped and vagus nerve and internal
carotid artery saved
73. LEFT SIDE
THORACIC DUCT:
If you are 2cm above,
you should be alright. Still if
it is opened then white fluid
or blood will come out.
Try to
Repair it, or
Tie it off
74. THYROID
If involved with disease,
lobectomy on that side is
performed
After cutting the
sternohyoid and
sternothyroid, return to
deep layer of deep
cervical fascia
1. Phrenic nerve
2. Brachial plexus
3. Nerve to serratus anterior
4. Subclavian artery and vein
76. SAVING THE ACCESSORY
NERVE
Identify XIth CRANIAL
NERVE - save it if not
involved
If not possible, graft the
posterior auricular nerve
It is identified ⅓rd from
clavicle, ⅔rd from
mastoid tip
77. ANTERIOR DISSECTION
Separate the vein and thyroid from
carotid artery and vagus nerve
CAROTID MASSAGE
Vagus nerve may have to be
sacrificed
Adherent lymph nodes to carotid
Identify the phrenic nerve’s
cervical branches
Insertions of anterior belly of
omhyoid, sternothyroid are
transected
Identify the hypoglossal nerve
1.5cm above the carotid
bifurcation and lateral to it
Superior laryngeal nerve passes
deep to the internal and external
carotid artery. Their section will
lead to problems in deglutition
78. SUBMAXILLARY TRIANGLE
Digastric muscle is identified,
separated from hyoid bone
Anterior border is transected just
below insertion
The omhyoid muscle is transected
anteriorly
Lower end transected ahead
Upper end of external jugular vein
transected
Dissection across lower pole of
parotid gland
The stylomandibular ligament is
divided
The superior aspect of
submandibular gland is dissected
Facial vessels ligated
Posterior belly of digastric is cut
79. SUBMANDIBULAR GLAND
The submandibular gland is pulled
down exposing the lingual nerve
Whartin’s duct: This is resected
Facial artery is transected and ligated
just below the mandible
The posterior belly of digastric and
thyrohyoid are transected exposing
the internal jugular vein
Internal maxillary and occipital
arteries are identified and ligated
If it cannot be tied, oxycyll / surgicell
pack is left in place
Protect carotid artery with levator
scapulae
Wash the wound floor
Hemovac drain
80. CAUSES OF CAROTID
BLOWOUT
Infection
Incision line is on the carotid
Flaps are lifted by blood or serum
Injury during surgery
Suction tip close to the carotid
Radiated patient
81. WHEN TO TREAT CAROTID
BLOWOUT
Do it as an elective procedure
Elective Ligation Emergency Ligation
Number of patients 64 (100 per cent) 87 (100 per cent)
Stroke 15 (23 per cent) 44 (50 per cent)
Deaths 11 (17 per cent) 33 (38 per cent)
84. DERMAL GRAFT
1/12th of an inch
epidermis is elevated
Graft should be 7cm
wide
20 cm long
1/20 to 1/24th of an inch
thick
Use non-absorbable
sutures
94. COMPLICATIONS
1. Delayed bleeding
2. Shock
3. Air embolism
i. Hissing sound
ii. Blood pressure falls
iii. Regurgitation in heart
iv. Fundoscopy
4. Airway obstruction
5. Carotid sinus syndrome
6. Pneumothorax
95. 7. Nerve damage
i. Superior laryngeal nerve
ii. Facial nerve
iii. Vagus nerve
iv. Recurrent laryngeal nerve
v. Phrenic nerve
vi. Hypoglossal nerve
vii. Cervical sympathetic chain (Horner’s syndrome)
viii. Spinal accesory nerve
ix. Lingual nerve
x. Brachial plexus
96. 8. Chylous fistula
9. Subcutaneous emphysema
10. Wound infection
11. Gangrene of flap tissue – prevent base to tip
ratio
12. Carotid artery rupture
13. Fluid electrolyte imbalance