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334
Manipal Manual of Surgery
• It is a non-involuting capillary haemangioma
(dilatation due to defective maturation of
cutaneous innervations during embryogenesis).
• Area supplied by sensory branches of the fifth
cranial nerve is involved.
• Starts with light red colour and progresses to deep
colour.
• Pulsed dye laser using light with specific wave-
length of 585 or 595 nanometres is one of the best
treatments available. This process is called
‘photothermolysis’.
• It may be associated with Sturge-Weber syndrome
(page 335).
Fig. 34.65: Cavernous haemangioma of the cheek
Flat, patchy lesion on the face in the area of fifth cranial nerve
that does not fade is port-wine stain.
3. Strawberry angiomas produce swelling which
protrude from the skin surface. The child is normal
at birth. After a month, a bright red swelling appears
over the head and neck region, which exhibits sign
of compressibility. The lesion consists of immature
vascular tissue. Even though the lesion grows initially,
by 5–7 years of age, swelling regresses and colour
fades. Hence, no specific treatment is necessary. The
treatment is indicated only when the swelling
persists. 70% resolve by 7 years of age.
VENOUS (CAVERNOUS) HAEMANGIOMA
This occurs in place where venous space is abundant,
e.g. lip, cheek, tongue, and posterior triangle of the neck
(Key Box 34.29 and Fig. 34.65).
Key Box 34.29
Cavernous Haemangioma
Compressible swelling
Bluish warm, nontender swelling
Associated with arteriovenous communication
Associated with lipoma: Naevolipoma
Clinical Features
• History of a swelling in the neck of long duration.
History of bleeding is present when it occurs in the
oral cavity.
• The swelling is warm and bluish in colour but not
pulsatile.
• Soft, fluctuant, transillumination is negative.
• Compressibility is present. This sign is also called
‘sign of emptying’ or ‘sign of refilling’. When the
swelling is compressed between the fingers, blood
diffuses under the vascular spaces and when pressure
is released, it slowly fills up. Compressibility is a
diagnostic sign of haemangioma (Fig. 34.66).
Differential Diagnosis
1. Lymphangioma is brilliantly transilluminant. If a
lymphangioma is infected or has been treated with
preliminary injections, it may not show transillumination.
. Lipoma is not compressible.
2
3. Cold abscess
4. Branchial cyst when it is in anterior triangle.
Gluteal region is one of the sites of haemangioma, AV
fistula, aneurysm and neurilemmoma. A patient presented
with this swelling which was firm with a few cystic areas.
It was excised in toto. Remember to check whether it is a
low pressure (venous) or a high pressure arterial lesion
before excising a haemangioma. Massive bleeding can
occur, if it is a high pressure lesion.
Section II • General Surgery
Fig. 34.66: Sign of compressibility was positive in this case. It
was initially diagnosed as post-auricular dermoid
Note: Importance of complete clinical examination
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
335
Treatment of Cavernous Haemangioma
Principles
1. Injection is the first line of treatment of cavernous
haemangioma. It makes the swelling fibrotic, less
vascular and small. Thus, excision can be done at a
later date (Key Boxes 34.30 and 34.31).
2. Excision of haemangioma in the oral cavity is more
difficult than in the neck.
. It is better to have a control of external carotid artery
3
in the neck, while excising haemangioma in the oral
cavity. If necessary, external carotid artery should be
ligated in order to control the bleeding.
4. Adequate blood to be arranged.
5. Previous embolisation into the feeding artery
decreases the size of the haemangioma (therapeutic
embolisation).
6. Large haemangiomas in the oral cavity should be
excised only after preliminary sclerotherapy and
taking all the precautions mentioned above.
Key Box 34.30
Injection Line of Treatment
Boiling water, hypertonic saline or sodium tetradecyl
sulphate (STD solution) can be used
In multiple spaces, in multiple sittings
Obliteration occurs due to aseptic thrombosis and fibrosis
Lesion becomes flat
Complications of Haemangioma (Key Box 34.32)
Key Box 34.32
Complications of Haemangioma
Ulceration and bleeding: Commonly occurs with
capillary haemangioma
Infection: Septicaemia usually precipitated by a small
ulcer
High output cardiac failure
CONGENITAL ARTERIOVENOUS (AV) FISTULA
(Arterial Haemangioma)
• An abnormal communication between artery and
vein, results in AV fistula (Key Box 34.33).
• AV fistula can be congenital or acquired (Figs 34.67
and 34.68).
• Such AV fistula has got structural and functional
effects (Figs 34.69A and B).
Key Box 34.33
Arteriovenous Fistula: Types
Congenital
Traumatic
Iatrogenic: Created in cases of renal failure
Key Box 34.31
Swellings: Treated with Sclerosants
Haemangioma
Haemorrhoids
Prolapse rectum
Oesophageal varices
Varicose veins
Syndromes Associated with Haemangioma
(Table 34.6)
Table 34.6 Syndromes associated with haemangioma
and their findings
Syndromes associated Findings
with haemangioma
1. Klippel-Trénaunay- 1. Naevus flammeus, osteohyperWeber syndrome trophy of extremities, AV fistula
and varicose veins
2. Osler-Rendu-Weber 2. Haemangioma of lip associated
syndrome with haemangioma of GIT
3. Sturge-Weber syndrome 3. Haemangioma of brain, mental
retardation, Jacksonian epilepsy,
glaucoma
Fig. 34.67: Most common type of AV fistula you see today is in
the nephrology ward—created to facilitate haemodialysis
Fig. 34.68: X-ray of the hand— traumatic AV fistula
Section II • General Surgery
336
Manipal Manual of Surgery
Fig. 34.69A: Traumatic
AV fistula. See the arterialisation of the vein
Fig. 34.69B: DSA picture
Structural Effect
Since high pressure blood from an artery flows into the
vein, the veins get dilated, tortuous and elongated. This
arterialisation of the vein results in secondary varicose
veins.
Physiological Effect
Increased pulse rate, increased cardiac output, increased
pulse pressure result due to increased venous pressure
and arteriovenous shunt.
Functional Effect
• Soft, cystic, fluctuant,
transillumination negative, pulsatile swelling.
• A continuous bruit/
murmur is characteristic
(Fig. 34.70).
• Nicoladoni’s sign or
Branham’s sign
On compressing the
–
feeding artery, the
venous return to the
Fig. 34.70: Traumatic AV
fistula affecting wrist and
. Kindly observe promi-
hand
nent veins and swollen fingers
heart diminishes, resulting in fall in pulse rate and pulse pressure.
– On compressing feeding artery, pulsation or conti-
nuous murmur may also disappear and swelling
will diminish in size.
• If the AV fistula is big, a high output cardiac failure
can occur.
• The affected part is swollen (because of high pressure)
than—local gigantism (Figs 34.71 and 34.72). Thus,
overgrowth of the limb or toe can occur.
• Distal to the AV fistula, there are ischaemic ulcers,
due to comparative reduction in the blood
Section II • General Surgery
supply.
Fig. 34.71: Local gigantism due to haemangioma involving
gluteal region
Fig. 34.72: Haemangioma tongue causing macroglossia. She
also had haemangioma of the cheek and skin
This lady visited many general practitioners for a swelling
near the coccyx region (adjacent to natal cleft). The
diagnosis which was made in this case was subcutaneous
neurofibroma, pilonidal sinus abscess, boil and haemangioma. Careful examinations revealed pulsations. History
dates back to 20 years duration. It was a case of congenital
AV fistula. Wide excision was done. She has been asymptomatic for 2 years now.
A 30-year-old patient who had an injury to the dorsum of
hand, had pain and swelling in dorsum of hand for
60 days duration. Many had missed the diagnosis.
However, swelling had local rise of temperature,
pulsations and reducibility (Fig. 34.70).
Investigations
Angiography with DSA (digital subtraction angiography) pictures are essential before treating these
patients (Fig. 34.69B).
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
Figs 34.73 and 34.74: Congenital AV fistula of 25 years duration.
After therapeautic embolisation, it has regressed by over 70%.
Patient is waiting for another course of embolisation. (Courtesy:
Dr Umesh Bhat, Surgeon, Kundapur and Dr Subhaschandra, Interventional Cardiologist, Manipal Hospital, Bangalore)
Treatment
• Therapeutic embolisation is the treatment of choice
for arteriovenous fistula, in congenital cases (Figs 3
4.73
and 34.74).
• Acquired lesion needs to be observed or treated by
quadruple ligation, if needed.
CIRSOID ANEURYSM
• Not an aneurysm
• It is an AV fistula occurring in older people affecting
the temporal region.
• The arteries and the veins are dilated and tortuous
and are compared to pulsating bag of worms.
COLD ABSCESS IN THE POSTERIOR TRIANGLE (Fig. 34.75)
Causes
1. Posterior cervical lymph nodes primarily involved—
route of infection from adenoids
or other lymph nodes
in the anterior triangle.
2. Lower posterior lymph nodes or Scalene node—route
of infection from lungs.
3. From tuberculous cervical spine: Caries spine
• Clinically, it presents as pain in the back, cold
abscess and neurological presentation.
337
• Rust’s sign: Child with caries spine will support
the head by holding the chin.
• Cold abscess from caries spine can rupture
anteriorly or posteriorly.
A. Anterior rupture: It ruptures deep to pre-
vertebral layer of deep cervical fascia. From here,
it can take the following routes:
• Upper cervical region: Presents as deep seated
abscess in the posterior wall of the pharynx
in the midline.
• Lower cervical region: Pus will press on
oesophagus and trachea forwards.
• Laterally pus passes deep to prevertebral
fascia behind carotid sheath in the posterior
triangle (Fig. 34.76).
B. Posterior rupture: Pus may enter spinal canal and
then can travel along anterior primary division
of the cervical spinal nerves.
Diagnosis
• Cervical spine X-ray to rule out spinal tuberculosis.
• Chest X-ray to rule out pulmonary tuberculosis.
• Nondependent aspiration of the cold abscess
followed by AFB staining.
Treatment
• Antituberculous treatment
• Nondependent aspiration, if cold abscess is present.
• Please refer orthopaedic books for specific treatment
of TB spine.
Differential Diagnosis
• Haemangioma—compressible
• Lymphangioma—transilluminant
• Schwannoma (Fig. 34.76)
Fig. 34.75: Cold abscess in the posterior triangle
Fig. 34.76: Schwannoma in the posterior triangle. Soft tissue
sarcoma is another diagnosis. (Undergraduate clinics at JNMC,
Belgaum, Karnataka). (Courtesy: Dr Aditya Patil, Prof. Ashok Godhi,
Head, Department of Surgery)
Section II • General Surgery
338
Manipal Manual of Surgery
LYMPH NODES SECONDARIES (METASTASIS)
IN THE HEAD AND NECK
Introduction
Very often, the patients present to the surgeon with
lymph node swelling in the neck with or without any
complaints. If there is an obvious lesion in the oral
cavity, the diagnosis is easy. On the other hand,
difficulty arises in locating the primary malignancy,
which is hidden or occult. It is important to know
the anatomical location of the lymph nodes in the
neck and drainage area, so that drainage areas can be
investigated.
Before understanding the various lymph nodes,
drainage area and block dissection, it is advisable to
know surgical anatomy of the neck and lymphatic
drainage.
SURGICAL ANATOMY OF NECK
Neck is that region of the body that lies between the
lower border of the mandible and the suprasternal notch
and the upper border of the clavicle. Its boundaries
include mandible, zygomatic process of temporal bone,
external auditory canal, mastoid process, superior
nuchal line, external occipital protuberance, manubrium
sterni, clavicle, acromioclavicular joint and spinous
process of 7th cervical vertebra.
Fascial Layers of Neck
• Two fascial layers in the neck: Superficial cervical
fascia and deep cervical fascia.
• Superficial cervical fascia corresponds to subcuta-
neous tissue.
• Deep cervical fascia (fascia colli) is the important layer
for functional and selective neck dissection. It is this
layer that divides neck into various compartments.
Deep Cervical Fascia
It has superficial and deep components.
A. Superficial layer (investing or anterior fascia): It
is attached to following structures—occipital
protuberance, mastoid process, capsule of parotid
gland, angle of jaw, and body of the mandible to
the symphysis. And here, it proceeds around
contralateral side in a similar manner. It then goes
posteriorly across the spinal process of the cervical
vertebrae. Anteriorly, it passes from the mandible
to hyoid bone. Inferiorly, it attaches to sternum,
upper edge of clavicle, acromion, and spine of
scapula. At the inferior border, in the midline,
superficial layer splits in two different layers just
Section II • General Surgery
superior to the manubrium of sternum. The space
between these two layers is known as the supra-
sternal space of Burns.
From posterior to anterior, the superficial layer
splits to enclose the trapezius, the portion of the
omohyoid muscle that crosses the posterior triangle
of the neck, and the sternocleidomastoid muscle.
In a similar way, it envelops the strap muscles,
before ending in the midline. The superficial veins
of the neck lie on or within this superficial layer of
the deep cervical fascia.
B. Deep layer (prevertebral fascia): The deep or
prevertebral layer, like the superficial layer,
attaches posteriorly to the spinous process of the
cervical vertebrae. Above, it reaches the skull base
at the jugular foramen and carotid canal, then
passes across the basilar process to the opposite
side. It covers the muscles of the back that enter
into the neck immediately deep to the trapezius
muscle. At the upper limit of the posterior triangle,
the spinal accessory nerve crosses the posterior
triangle at this level, along with some lymph nodes.
At the lower end, both fascial layers further
separate, the deep layer covers the scalene muscles,
whereas superficial layer remains attached to the
trapezius muscle and the clavicle.
Lymphatic Drainage of Neck
• The cervical lymphatics are divided into superficial
and deep. The superficial lymphatics perforate the
cervical fascia and drain into the deep lymphatics.
The deep vessels and nodes are most commonly
found along blood vessels, nerves and muscles. For
example: Along the internal jugular vein classically
described as jugular chain of lymph nodes. Look for
this finding in ultrasound examination of neck.
• Lymph nodes have been given numbers according
to their levels and drainage sites which are given
below (Fig. 34.77).
Fig. 34.77: Lymph nodes stations
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
339
Memorial Sloan-Kettering Cancer Centre: Lateral
Lymph Node Classification
Level I : Lymph nodes in the submental triangle and
submandibular triangle.
Level II
: Upper jugular nodes. Deep to the sterno-
cleidomastoid muscle, anterior to posterior
border of sternocleidomastoid, posterior to
posterior aspect of the posterior belly of
diagastric, superior to level of hyoid.
Level II is further divided into (IIa) which
is inferior and in front of the line of spinal
accessory nerve, (IIb) is above and posterior
to line of spinal accessory nerve.
Level III : Middle jugular nodes from hyoid
superiorly to cricothyroid membrane
inferiorly.
Level IV : Lower jugular nodes from cricothyroid
membrane superiorly to clavicle inferiorly.
Level V : Posterior cervical region from anterior
border of trapezius posteriorly to posterior
border of sternocleidomastoid anteriorly
and clavicle inferiorly.
a. Above the line of spinal accessory
nerve.
b. Below the level of spinal accessory
nerve.
Level VI : Anterior compartment nodes from hyoid
bone superiorly to suprasternal notch
inferiorly and laterally by medial border of
carotid sheath.
Level VII : Upper mediastinal nodes inferior to supra-
sternal notch (no longer used).
Drainage Area
• Level Ia lymph nodes: Floor of mouth, anterior
oral tongue, anterior mandibular alveolar ridge,
lower lip.
• Level Ib lymph nodes: Oral cavity, anterior nasal
cavity, soft tissue of midface, submandibular
gland.
• Level IIa and IIb nodes: Oral cavity, nasal cavity,
nasopharynx, oropharynx, hypopharynx, larynx,
parotid gland.
• Level III lymph nodes: Oral cavity, nasopharynx,
oropharynx, hypopharynx, larynx.
• Level IV lymph nodes: Hypopharynx, thyroid,
cervical oesophagus, larynx.
• Level V lymph nodes: Scalp, parotid gland, naso-
pharynx, thyroid gland, etc.
• Level VI lymph nodes: Thyroid gland, glottic and
subglottic larynx, apex of pyriform sinus, cervical
oesophagus (Figs 34.78 and 34.79).
Rational for Subzones (Fig. 34.80)
Level II subzones
• Oropharynx and nasopharynx—IIb
–
XI should be mobilised
• Oral cavity, larynx and hypopharynx—may not be
necessary to dissect IIb, if level IIa is not involved.
Level IV subzones
• Level IVa nodes—increased risk in level VI
• Level IVb nodes—increased risk in level V
Level V subzones
• Oropharynx, nasopharynx, and cutaneous—Va
• Thyroid—Vb.
Fig. 34.78 Fig. 34.79
Figs 34.78 and 34.79: Levels of various lymph nodes, nodal-N position and relation to various triangles
Section II • General Surgery
340
Manipal Manual of Surgery
Level Lymph Node Group
Ia Submental nodes
Ib Submandibular nodes
IIa Upper jugular, anterior to IX
IIb Upper jugular, posterior to IX (submuscular recess)
III Middle jugular nodes
IVa Lower jugular nodes (behind clavicular head of sternocleidomastoid
muscle)
IVb Lower jugular nodes (behind sternal head of sternocleidomastoid muscle)
Va Posterior triangle nodes (spinal accessory group)
Vb Posterior triangle nodes (transverse cervical artery group, supraclavicular
group)
VI Anterior (central) compartment lymph nodes (paratracheal, perithyroidal,
Delphian)
Fig. 34.80: Subzones of neck lymph node metastasis—level 4b are supraclavicular lymph nodes
Reason why lymphatic spread occurs widely is given in
Key Box 34.34
Key Box 34.34
Factors which Accelerate Local
and Regional Spread of Malignant Tumour
Angiogenesis
Lymphangiogenesis
Lack of basement membrane on lymphatic vessels
Extracapsular breakout
Clinical Presentation of Metastatic Deposits in the
Lymph Nodes
1. Majority of patients are elderly males (>50 years),
present with painless swelling in the neck of a few
months duration.
. The symptoms with which a patient presents to the
2
hospital gives the clue to the site of origin of the
primary. A few examples are given below:
• Difficulty in swallowing: Carcinoma posterior
1/3rd of tongue, oropharyngeal carcinoma or
carcinoma oesophagus.
• Difficulty in breathing: Laryngeal cancer
• Hoarseness of voice: Larynx or thyroid
• Obvious growth in oral cavity: Carcinoma cheek,
alveolus, tongue, etc.
• Haemoptysis, difficulty in breathing: Bronchogenic
carcinoma
• Epistaxis, ear pain or deafness: Nasopharyngeal
carcinoma
Section II • General Surgery
Refer to Key Box 34.35 also
Key Box 34.35
Nasopharyngeal Carcinoma1: Trotter’s Triad
Conductive deafness
Homolateral immobility of soft palate
Pain in the side of the head due to involvement of 5th
cranial nerve.
1
More details about nasopharyngeal carcinoma are given in page 366 in
the chapter on oral cavity.
Clinical Signs
• Lymph nodal metastasis appears as a hard, nodular
or irregular mass in the anatomical location of the
lymph nodes (Figs 34.81 to 34.89).
• Early cases may have some mobility. However, in
majority of cases, nodes get fixed and they attain a
huge size. Very often, what appears as one lymph
node, is a complex mass of multiple lymph nodes.
• On sternomastoid contraction test or chin test, these
nodal swellings become less prominent.
• Skin ulceration is a late feature. A prominent skin
fold is due to infiltration into the platysma—
platysma sign.
• The primary malignancy may be evident in the
anterior third of tongue, cheek, alveolus, etc.
• Posterior one-third of tongue should be palpated with
gloved finger (Key Box 34.36).
Key Box 34.36
Occult Primary Sites
Posterior 1/3rd of tongue, oropharynx
Nasopharynx, sinuses
Upper oesophagus, bronchus, thyroid
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
341
• Secondaries in the lymph nodes can cause pressure
effects or may cause paralysis of nerves. Upper
anterior deep cervical lymph nodes can cause
hypoglossal nerve paralysis (Key Box 34.37) where
in the tongue points towards the side of lesion. When
there is no evidence of the primary lesion clinically,
the situation is described as occult primary with
secondaries in the neck.
• Pain in the distribution of trigeminal nerve (face)
suggests nasopharyngeal malignancy infiltrating
skull base (foramen lacerum).
Key Box 34.37
Clinical Examination in a Case of
Lymph Nodes in the Neck
Lymph nodes: All groups
Drainage areas
Pressure effect on
Hypoglossal nerve
Accessory nerve
Cervical sympathetic chain
TYPES OF SECONDARIES IN THE NECK
1. Secondaries in the neck with known primary
• In this case, secondaries in the neck are present and
the site of primary tumour is clinically identified
either in oral cavity, pharynx, thyroid, etc.
• Primary may be treated by surgery or radiotherapy
as the case may be.
• Secondaries may need radical neck dissection.
2. Secondaries in the neck with clinically unidentified
primary
• Here the hard neck nodes are present but primary
is not identified clinically. However, it is detected
after investigations. Example: Oropharyngeal
carcinoma.
• FNAC is done to confirm the diagnosis.
• Various investigations like panendoscopy, blind
biopsies, CT may be done to establish the
primary.
3. Secondaries in the neck with an occult primary:
It is biopsy proven cancer of neck nodes which
even after complete clinical and radiological
workup reveals or yields no demonstrable primary
lesion.
How do you Suspect Metastasis in the Neck?
Any elderly patient presenting to the hospital with firm
to hard lymph node in the neck of short duration with
or without fixity. He has no signs and symptoms of
inflammation such as fever or pain to begin with.
Having suspected a metastatic deposit, remember the
following facts:
• 80% of them are metastatic deposits.
• Majority of malignant neoplasms are epithelial in origin.
• Nodes in the upper half (level I and II) can be due to primary
in the oral cavity, tongue, oropharynx, larynx.
• Nodes in the lower half (level III and IV) can be due to
primary in the thyroid, tongue.
• Nodes in the supraclavicular region (level V): Carcinoma
in the GIT, genitourinary tract, lungs and nasopharynx.
• Nodes in the pretracheal, suprasternal region (level VI):
Papillary carcinoma thyroid
Rule of 80 in Neck Masses
80% of neck masses are neoplastic
80% of neoplastic masses occur in males
80% of neck masses are malignant
80% of malignant neck masses are metastatic
80% of metastatic neck masses are from primary sites
above clavicle
NECK DISSECTIONS
Introduction
• Crile in 1906, first described a standardised dissection
of cervical nodes by applying anatomical and
oncological principles including removal of
surrounding fibrofatty tissue from various compartments of the neck.
• Radical neck dissection (RND) causes significant
functional and cosmetic morbidity.
• Today adjuvant chemoradiotherapy is an important
modality of treatment.
• Thus with better understanding of tumour biology,
natural history of disease and availability of adjuvant
radiotherapy, radical neck dissection is not frequently
done but its modifications are done.
Classification of Concepts
1. RND is the standard basic procedure for cervical
lymphadenectomy against which all other modifications are compared.
. Modifications of the RND which include preservation
2
of any non-lymphatic structures are referred to as
modified radical neck dissection (MRND).
3. Any neck dissection that preserves one or more
groups or levels of lymph nodes is referred to as a
selective neck dissection (SND).
4. An extended neck dissection refers to the removal of
additional lymph node groups or non-lymphatic
structures relative to the RND.
Section II • General Surgery
342
Manipal Manual of Surgery
METASTASIS IN CERVICAL LYMPH NODES—VARIOUS LEVELS (Figs 34.81 to 34.89)
Fig. 34.81: Level I and II nodes.
Carcinoma floor of the mouth
Fig. 34.84: Level V nodes: Post-
cricoid carcinoma
Fig. 34.82: Level II and III nodes:
Carcinoma alveolus
Fig. 34.85: Predominantly level II, III
and V nodes: From nasopharyngeal
carcinoma
Fig. 34.83: Level III, IV and V nodes:
Carcinoma posterior 1/3rd of tongue
Fig. 34.86: Predominantly level II, III
and V nodes: From nasopharyngeal
carcinoma
Fig. 34.87: Level I, II, III and V nodes:
Primary could not be identified—a
Section II • General Surgery
case of occult primary
Fig. 34.88: Scalene node: In between
the two heads of sternomastoid—a
case of bronchogenic carcinoma
Fig. 34.89: Hugely enlarged lymph nodes which are
bluish in colour, pushing the carotid arteries
anteriorly—papillary carcinoma thyroid
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
343
Classification
1. Radical neck dissection (RND)
2
. Modified radical neck dissection (MRND)
Type I (XI preserved)
Type II (XI, IJV preserved)
Type III (XI, IJV, and SCM preserved) “Functional
neck dissection”
3. Selective neck dissection (SND)
• Supraomohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type
. Extended radical neck dissection
4
• Rule of 80 in neck masses
Indications
• Carcinoma tongue, carcinoma floor of mouth
• Malignant melanoma
• Metastatic lymph nodes from pharynx and upper
oesophagus.
Contraindications
• Fixed nodes, evidence of distant metastasis
• Untreatable primary cancer
Types (Details of the Neck Dissections)
I. Classical R
(Crile’s Operation) (Figs 34.90 to 34.97)
Removal of levels I to V nodes + IJV, sternocleidomastoid + spinal accessory and submandibular
salivary gland + Tail of parotid.
Incision
1. MacFee: Two incisions are given (Fig. 34.90)
• Upper incision extends from mastoid process to
hyoid bone up to the point of chin across intermediate tendon of digastric muscle.
• Lower incision is given 2 cm above clavicle—from
anterior border of trapezius to midline.
• Gives a very good exposure and vascularity of flaps
are good. No corners and hence, no necrosis.
2. Crile’s incision
• Upper incision is similar to MacFee. The other
incision is oblique along the length of sternocleidomastoid inclining more in the posterior triangle
(Fig. 34.91).
adical Neck Dissection
• When sternocleidomastoid has to be removed as a
part of neck dissection or to clear the lymph nodes
which are badly stuck to jugular vein or to
accommodate PMMC flap, Crile’s incision is
better (Fig. 34.92).
• Here all the cervical lymph nodes from level I to
level VI are removed along with nonlymphatic
structures such as sternocleidomastoid muscle,
internal jugular vein, accessory nerve (XI), submandibular salivary gland and cervical sympathetic plexus. A few examples wherein radical
neck dissection is done are carcinoma tongue,
oropharyngeal carcinoma, etc.
II. Modified R
(Fig. 34.93)
Type I
• Preserve one structure: Spinal accessory nerve
• Classically done for squamous cell carcinoma of
upper aerodigestive tract with clinically positive
neck dissection.
Type II MRND
Preserve two structures: Spinal accessory and IJV.
Type III MRND or Bocca’s functional neck
dissection (Fig. 34.94)
• Preserve three structures: Spinal accessory, sterno-
cleidomastoid and internal jugular vein.
• Done for metastatic well-differentiated carci-
noma thyroid.
In this, all the lymph nodes from level I to
level V are removed but nonlymphatic struc-
tures are preserved.
• Dissection is from lower border of mandible to
clavicle and from anterior border of trapezius
to midline.
III. Selective Neck Dissection
• Here any of the lymphatic compartments is pre-
served (which should have been removed as part
of classic RND). A few examples are given below.
a. Supraomohyoid dissection (Fig. 34.92):
b. Lateral neck dissection: Levels II, III, IV are
c. Posterolateral neck dissection: Levels II to V
adical Neck Dissection (MRND)
Removal of nodes in levels I, II and III is done
for carcinoma oropharynx, carcinoma cheek.
Usually done for carcinoma floor, lateral
tongue, etc.
removed as in carcinoma larynx and cervical
oesophagus.
are removed as in cutaneous malignancy of
Section II • General Surgery