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L. Rodrigáñez et al.
Robbins KT, Shaha AR, Medina JE, Califano JA, Wolf GT, Ferlito
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Shah JP. Patterns of cervical lymph node metastasis from squa-
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de laringe e hipofaringe. Revista de Otorrinolaringologia (Santiago
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Arch Otolaryngol Head Neck Surg. 1994;120(7):703–6.
Sentinel Lymph Node Dissection
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ClareSchilling andRajaSawhney
14
14.1 Introduction
Sentinel node biopsy (SNB) is a surgical staging tool rst
described in the 1970s for penile cancer [1]. The technique
has evolved through several iterations, with renement in
lymphatic mapping imaging and lymphatic tracer
technology.
A sentinel node is any node on a direct lymphatic drainage pathway from the tumour. The basis for the procedure is
that a radiotracer injected peritumourally will drain initially
to the sentinel node(s); if these are found to be free of tumour,
the remaining nodes in the region can also be considered
disease-free. Differentiation between sentinel nodes and
lower-echelon nodes can be decided by the timing of appearance on dynamic imaging as well as by gamma counts
intraoperatively.
The radiotracer used varies internationally but generally
consists of a colloid base that is labelled with Technetium99m (Tc-99m). Tc-99m decays with gamma radiation at a
half-life of 6h, making it ideal for detection with a handheld
gamma probe up to 24h after injection, depending on the
dose injected. The radiotracer is passively accumulated in
the lymph node by virtue of the small colloid size, resulting
in detectable radiation hot spots. Lymphoseek (
tilmanocept) is a new-generation radiotracer that is actively
transported into lymph node macrophages via binding to
CD206 mannose receptor [2].
Radiotracers can be complemented by optical tracers to
aid in the intraoperative identication of sentinel nodes;
these are especially helpful when nodes are located close to
the tumour (shine-through effect) [3–5]. Traditional optical
99m
Tc-
tracers include blue dyes (patent blue, isosulfan blue, methylene blue), but these can stain the peritumoural injection site,
hampering margin assessment, and there is a documented
1% risk of allergic reaction [6]. The use of Indocyanine
green (ICG), a uorescent green dye, is gaining popularity as
an optical tracer for sentinel node localisation. ICG can only
be viewed with a near-infrared (NIR) camera, meaning the
injection site is not discoloured when viewed under white
light. The ICG uorescent signal can penetrate the overlying
tissue to about 1cm depth, potentially reducing dissection
and operating time [7]. Another advantage of ICG is that it
can non-covalently bind to the colloid component of traditional tracers (Nanocoll), resulting in a multimodal tracer
that is both hot (Tc-99m) and uorescent [8].
SNB in the head and neck should always be complemented by preoperative imaging. Static and dynamic lymphoscintigraphy (LSG) are useful techniques for
differentiating sentinel and second-echelon nodes, but these
planar images should be supplemented by SPECT/CT when
available. SPECT/CT fusion images give excellent anatomical localisation of nodes and are particularly useful for placing nodes in relation to the digastric and omohyoid muscles
and the internal jugular vein. Intraoperative imaging by
handheld gamma cameras and freehand SPECT (fhSPECT)
is possible, and such modalities have the advantage of updating the node location during anatomical changes caused during surgery.
14.2 Preoperative Checklist,
Considerations, andAnaesthesia
C. Schilling
Department of Head and Neck Surgery, University College London
Hospital, London, UK
e-mail: Clare.schilling@nhs.net
R. Sawhney (*)
Lotus Dermatology/Center for Aesthetic Plastic Surgery,
Brooksville, FL, USA
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_14
14.2.1 Patient Selection
SNB is a surgical staging procedure, not a denitive cancer
treatment. Excised sentinel nodes are examined by serial
sectioning, an intensive pathological procedure that can take
up to a week to complete. If the SNB is positive, then staged
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C. Schilling and R. Sawhney
completion nodal dissection is required, ideally within
3 weeks to minimise surgical complications. It is recommended that the patient’s overall medical status is considered
when offering SNB instead of elective nodal clearance.
Although SNB may be a less morbid procedure, patients
with WHO performance status >2 or multiple comorbidities
may be better offered elective nodal dissection owing to the
risk of missing complete cancer treatment if they are unable
to withstand two surgical procedures within a short period.
14.2.2 Tumour Selection
Tumours should be resectable with an oncological margin
without the need for free ap reconstruction. SNB is suitable
only for patients who have been clinically staged N0 by CT/
MRI and/or ultrasound scanning, ideally with ne needle
aspiration cytology of any suspicious nodes. SNB works
well for patients who have had previous tumours, radiotherapy, or surgery to the neck, although drainage may be
mapped to unexpected locations.
14.2.3 Scheduling
SNB can be done by a 1- or 2-day protocol (imaging and
surgery done on the same day or consecutive days), allowing
exibility of theatre and nuclear medicine scheduling.
Complications of completion lymphadenectomy increase in
the time between biopsy and denitive surgery. It is ideal to
pre-emptively schedule completion surgery within 3weeks
of the biopsy; the surgical slot can be cancelled if the SNB
yields a negative result.
14.2.4 Consent
Discussion should cover alternative strategies (watchful
wait, elective nodal dissection). The SNB positive rate is
20–40%, so patients should be informed of the potential for
further surgery. The complication rate for SNB is low (<5%).
General complications include haematoma, wound infection, nerve damage, and scar. Allergy to optical tracers is
reported as 1:100–10,000. SNB may be safe, but it is not
routinely offered for pregnant or breastfeeding women. The
false-negative rate of SNB in oral cancer (neck recurrence
after a negative result) is 5–14%, and the false omission rate
(incorrect result) is about 7% [9].
14.2.5 Radiotracer Injection
Radiotracer will normally be injected in the nuclear medicine department. Injections can be given by either a nuclear
medicine physician or a surgeon who has been adequately
trained, but the legal certication required to deliver a radioactive substance may vary from country to country. Four
submucosal or subdermal peritumoural injections (1–2mm
from the tumour edge) are given, followed by immediate
imaging. It is not advised to use local anaesthetic inltration
prior to injection of the radiotracer because of alteration
in local tissue pressure augmenting tracer drainage, but a
regional nerve block (such as lingual nerve) remote from the
tumour site can be used to good effect.
14.3 Indications
14.3.1 Standard Applications inHead
andNeck
• Malignant melanoma. The use of the Breslow thickness is
the most important determinant of the need for SNB in
melanoma. Guidelines suggest the use of SNB in cases of
tumours with intermediate Breslow thickness
(1.01–4mm), because occult metastases to lymph nodes
have been found in 20–40% of this population. SNB may
also be benecial in thin lesions with high-risk features.
These include biopsies where ulceration is present and a
mitotic rate of greater than 1/mm2 in patients with a
Breslow depth greater than 0.75mm. Sentinel node dis-
section is not recommended for lesions with thickness
>4mm, because of the high risk of metastatic disease.
• Squamous cell carcinoma of the skin. Numerous groups
have examined the use of SNB in patients with cutaneous
SCC, hoping to detect patients with early metastatic
spread. Unfortunately, there is little consensus about
which patients would benet from its use, and most
authors leave it up to surgeon discretion to decide whether
SNB would be benecial in particular cases.
• Merkel cell cancer. The use of SNB has become wide-
spread in the treatment of Merkel cell carcinoma. Sims
et al. [10] examined 150 patients treated at the Mayo
Clinic. They did not identify any characteristics identify-
ing which patients were more likely to have a positive
SNB, but they did nd that those patients with a positive
SNB who received additional treatment to the at-risk
nodal basin had similar disease-specic survival and
14 Sentinel Lymph Node Dissection
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overall survival compared with patients with a negative
SNB.
• Oral squamous cell carcinoma. SNB has been recommended for early oral cancer in numerous national guidelines. The SENT trial showed that elective nodal dissection
could be avoided in over 70% of T1–T2 patients staged by
SNB without affecting outcome (92% disease-free survival at 3years) [11]. The study also showed that >10% of
well-lateralised tumours drain to the contralateral neck,
and that 7% of positive nodes were in the contralateral
neck.
14.3.2 New Applications
Interest is developing in translating SNB to other malignancies in the head and neck. Feasibility studies and proof of
concept have been published in cancer of the thyroid [12],
salivary gland [13], oropharynx [14], and larynx [15]. The
relative benet of mapping lymphatic drainage and nodal
staging varies between tumour sites, but may well be supported by intraoperative gamma imaging allowing on-table
injection for difcult to access tumours.
SNB also may be useful in mapping the contralateral neck
in patients with large tumours approaching the midline, in
which there is uncertainty about whether bilateral neck dissection is required. SNB is also useful in second primary
tumours in patients who have had previous radiotherapy and/
or surgery, in whom the normal drainage pattern has been
disrupted [16].
14.4 Surgical Technique withTips
• Preoperative identication of sentinel nodes. It is recommended for the preoperative nuclear medicine imaging to
be reviewed jointly by the surgeon and nuclear medicine
physician prior to surgery. The position of the nodes can
be marked on the neck using a cobalt point source marker
pen, but this is a time-consuming procedure that can be
avoided by joint review of images. If an interspecialty
meeting is not possible, a radiology report should be
issued prior to surgery, stating the number and location of
identied nodes, with indication of whether these are sentinel or second-echelon nodes.
• Set-up in theatre. Required equipment includes a hand-
held gamma probe. This should be regularly calibrated
to ensure optimum performance. For the head and neck
region, a collimated probe with a narrow beam is ideal.
Contemporaneous recording of gamma counts should be
141
Fig. 14.1 Crosshatch technique to identify a sentinel node (red circle).
The white line illustrates the path of the gamma probe tip
noted per node. It is preferable to have a dedicated white
board ready in theatre with the required elds to facilitate documentation without interruption to the surgical
ow.
• Mapping nodes and incision placement. With the patient
positioned on the operating table, localisation of sentinel
nodes is undertaken using the handheld gamma probe. A
crosshatch technique (Fig. 14.1), moving the gamma
probe at a steady pace across the region of interest, is recommended to systematically search for sentinel nodes
seen on preoperative imaging. Once radiation hotspots
have been identied on the neck, the incisions can be
planned. It is advised to place incisions in the optimum
place to easily retrieve the sentinel node (Fig.14.2). There
is no need to excise the scar if subsequent completion
nodal dissection is required.
• Optical tracer injection. Optical tracer is injected under
general anaesthesia at four peritumoural sites as per the
radiotracer (0.5–1mL per site is sufcient). Blue dye or
free ICG both ow quickly to and through the sentinel
nodes, so there should be no delay to prep the patient and
proceed with the node retrieval. Gloves should be changed
after injection to avoid inadvertent contamination of the
surgical eld.
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a
b
c
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C. Schilling and R. Sawhney
Fig. 14.2 Suggested incision placement for retrieval of sentinel nodes.
Black marks indicate nodal position; a red line indicates the suggested
incision. (a) One incision, level IIa sentinel nodes. (b) Two incisions,
• Node localisation for oral cancer. Sentinel nodes can
often be located in high-frequency sites, depending
upon the location of the primary tumour (Fig. 14.3).
About 60% of midline tumours will drain bilaterally,
and >10% of lateralized tumours will drain to the contralateral neck [11]. Level II sentinel nodes are invariably located between the sternocleidomastoid muscle
(SCM) and the posterior belly of the digastric muscle.
Level III sentinel nodes can frequently be found where
the omohyoid muscle crosses the internal jugular vein
(IJV). These nodes are usually situated supercial to the
IJV, but they can also be located posterior to the vein,
either superior or deep to the omohyoid muscle.
Retrieval commences by subplatysmal dissection, with
a T-shaped incision to locate the anterior border of the
SCM (Fig.14.4). Retrieval of nodes deep to the SCM
can be facilitated by splitting the SCM along the direction of the bres.
• In vivo conrmation of sentinel node. The gamma probe
and optical tracer are used to conrm the sentinel node
prior to excision.
level IIa node and level III and IV nodes. (c) Three incisions, level Ia
and Ib accessed via submental incision. Bilateral level II and level III/
IV nodes accessed via lateral neck incisions
• Node removal. The sentinel node is removed with minimal handling, maintaining a small cuff of fat around the
node (Fig.14.5).
• Ex-vivo conrmation of radioactivity. Each excised node
should have an average gamma count taken over 5–10s.
To be considered a sentinel node, the excised node should
be 10 times greater than background radiation and at least
10% of the count of the hottest node. All nodes meeting
these criteria should be sent for serial sectioning. The bed
count should be checked on each occasion, to ensure that
further hot nodes are not left behind. The count, colour
(optical tracer), size, and location of each node should be
submitted with the pathology request. Nodes not meeting
the criteria should be sent for routine H&E examination.
• Careful haemostasis. There should be a low threshold for
insertion of a drain, avoiding haematoma formation and a
lump in the neck that can complicate follow-up. Wounds
should be closed in layers to aid completion surgery, if
required.
• Complete resection of primary tumour. The tumour should
be removed with an oncologically clear margin.
Posterior
Posterior
Posterior
manubrium
jugular vein
manubrium
jugular vein
a
b
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143
Jugular
fossa
IIA
IIB
III
VA
VB
Internal
jugular vein
boundary of
submandibular
gland
IB
IA
VI
IV
VII
Top of
manubrium
c
Lower border
of hyoid muscle
Lower margin
of cricoid cartilage
Right common
carotid artery
Jugular
fossa
submandibular
Posterior
boundary of
gland
Jugular
fossa
IIB
III
VA
VB
Internal
jugular vein
boundary of
submandibular
gland
IB
IIA
VI
IV
VII
manubrium
IA
Top of
submandibular
of hyoid muscle
of cricoid cartilage
Posterior
boundary of
gland
Lower border
Lower margin
Right common
carotid artery
Jugular
fossa
boundary of
submandibular
gland
IB
IA
VI
VII
Top of
manubrium
Jugular
fossa
IIA
IIB
III
VA
VB
IV
Internal
jugular vein
IIB
Internal
VB
IB
IIA
IA
III
VA
VI
IV
VII
Top of
Lower border
of hyoid muscle
Lower margin
of cricoid cartilage
Right common
carotid artery
IA
Top of
IB
IIA
IIB
III
VI
VII
VA
VB
IV
Internal
Fig. 14.3 Favoured drainage patterns. (a) Lateral tongue. (b) Floor of mouth, (c) Buccal mucosa, alveolus, maxilla, palate
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C. Schilling and R. Sawhney
a
b
Fig. 14.4 (a) Identication of the anterior border of sternocleidomastoid (SCM) muscle. (b) Retraction of the SCM to show the sentinel node
(stained blue)
Fig. 14.5 Removal of sentinel lymph node with a cuff of fat
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145
14.5 Postoperative Care
Postoperative care is similar to the care for general lymph
node biopsy. If a drain is inserted, inpatient care may be
required. Otherwise, patients can be managed by day surgery. Discharge may be led by recovery from resection of the
primary tumour, particularly in the case of oral cavity
tumours, as oral intake may be temporarily impaired. Clinic
review should be organised in 1week for results of the SNB.
A positive result (including isolated tumour cells [ITC])
mandates completion nodal dissection for most types of
tumours. The treatment of melanoma is slightly more controversial. A recent high-impact study [17] suggested that
immediate completion lymph-node dissection helped
increase regional disease control and provided prognostic
information. Unfortunately, it did not impact disease-specic
survival, so that the benet of the procedure must be weighed
against the associated surgical morbidity.
References
1. Cabanas RM.An approach for the treatment of penile carcinoma.
Cancer. 1977;39:456–66.
2. Surasi DS, O’Malley J, Bhambhvani P. 99mTc-Tilmanocept: a
novel molecular agent for lymphatic mapping and sentinel lymph
node localization. J Nucl Med Technol. 2015;43:87–91.
3. He PS, Li F, Li GH, Guo C, Chen TJ.The combination of blue dye
and radioisotope versus radioisotope alone during sentinel lymph
node biopsy for breast cancer: a systematic review. BMC Cancer.
2016;16:107.
4. van den Berg NS, Brouwer OR, Schaafsma BE, Mathéron HM,
Klop WM, Balm AJ, et al. Multimodal surgical guidance during
sentinel node biopsy for melanoma: combined gamma tracing
and uorescence imaging of the sentinel node through use of the
hybrid tracer indocyanine green-(99m)Tc-nanocolloid. Radiology.
2015;275:521–9.
5. Christensen A, Juhl K, Charabi B, Mortensen J, Kiss K, Kjær A,
von Buchwald C. Feasibility of real-time near-infrared uorescence tracer imaging in sentinel node biopsy for oral cavity cancer
patients. Ann Surg Oncol. 2016;23:565–72.
6. Barthelmes L, Goyal A, Newcombe RG, McNeill F, Mansel RE,
NEW START and ALMANAC Study Groups. Adverse reactions to
patent blue V dye—the NEW START and ALMANAC experience.
Eur J Surg Oncol. 2010;36:399–403.
7. Brouwer OR, Buckle T, Vermeeren L, Klop WM, Balm AJ, van der
Poel HG, etal. Comparing the hybrid uorescent-radioactive tracer
indocyanine green-99mTc-nanocolloid with 99mTc-nanocolloid
for sentinel node identication: a validation study using lymphoscintigraphy and SPECT/CT.J Nucl Med. 2012;53:1034–40.
8. Buckle T, van Leeuwen AC, Chin PT, Janssen H, Muller SH,
Jonkers J, van Leeuwen FW.A self-assembled multimodal complex
for combined pre- and intraoperative imaging of the sentinel lymph
node. Nanotechnology. 2010;21:355101.
9. Schilling C, Shaw R, Schache A, McMahon J, Chegini S, Kerawala
C, McGurk M. Sentinel lymph node biopsy for oral squamous
cell carcinoma. Where are we now? Br J Oral Maxillofac Surg.
2017;55:757–62.
10. Sims JR, Grotz TE, Pockaj BA, Joseph RW, Foote RL, Otley CC,
et al. Sentinel lymph node biopsy in Merkel cell carcinoma: the
Mayo Clinic experience of 150 patients. Surg Oncol. 2018;27:11–7.
11. Schilling C, Stoeckli SJ, Haerle SK, Broglie MA, Huber GF,
Sorensen JA, etal. Sentinel European Node Trial (SENT): 3-year
results of sentinel node biopsy in oral cancer. Eur J Cancer.
2015;51:2777–84.
12. Cabrera RN, Chone CT, Zantut-Wittmann DE, Matos PS, Ferreira
DM, Pereira PS, et al. The role of SPECT/CT lymphoscintigraphy and radioguided sentinel lymph node biopsy in managing
papillary thyroid cancer. JAMA Otolaryngol Head Neck Surg.
2016;142:834–41.
13. Schilling C, Gnanasegaran G, McGurk M. Three-dimensional
imaging and navigated sentinel node biopsy for primary parotid
malignancy: new application in parotid cancer management. Head
Neck. 2014;36(9):E91–3.
14. Hart RD, Nasser JG, Trites JR, Taylor SM, Bullock M, Barnes
D.Sentinel lymph node biopsy in N0 squamous cell carcinoma of
the oral cavity and oropharynx. Arch Otolaryngol Head Neck Surg.
2005;131:34–8.
15. Lawson G, Matar N, Nollevaux MC, Jamart J, Krug B, Delos M,
etal. Reliability of sentinel node technique in the treatment of N0
supraglottic laryngeal cancer. Laryngoscope. 2010;120:2213–7.
16. Flach GB, Broglie MA, van Schie A, Bloemena E, Leemans CR, de
Bree R, Stoeckli SJ.Sentinel node biopsy for oral and oropharyngeal squamous cell carcinoma in the previously treated neck. Oral
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Zager JS, etal. Completion dissection or observation for sentinelnode metastasis in melanoma. N Engl J Med. 2017;376:2211–22.
Part VI
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Salivary Gland Surgery: Parotid Gland Surgery
Transoral Removal ofSalivary Stones
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OskarEdkins andJohannesJ.Fagan
15
Sialolithiasis, or salivary stones, vary in size, shape, consistency, and position within the ductal system of the major salivary glands (the submandibular and parotid salivary glands).
The clinical presentation is generally that of obstructive sialadenitis, in which a person may experience painful swelling
of the affected gland when eating, or acute suppurative sialadenitis as a result of the ductal obstruction [1]. Delayed
treatment of suppurative sialadenitis may result in abscess
formation in the gland orwithin the fascial neck spaces.
Initial conservative management by means of massage,
hydration, heat application, sialagogues, and appropriate
antibiotics for acute infection will assist in management in
the acute setting [1]. Small calculi may pass spontaneously,
but the vast majority of calculi will require surgical removal
to relieve the obstruction of the ductal system and prevent
further symptoms and sequelae. The surgical approach for
removal of intra-canalicular stones depends on the expertise
of the surgeon, access to specialised equipment, the gland
affected, and the size and location of the stone. Glandsparing surgery, including diagnostic and interventional
sialendoscopy, open transoral sialolithotomy, or a combination of the two, is preferred, with sialadenectomy reserved
for a signicantly smaller portion of cases than previously
[2].
15.1 Preoperative Checklist,
Considerations, andAnaesthesia
15.1.1 Clinical Examination
Clinical assessment of patients presenting with obstructive
salivary gland pathology should include a comprehensive
examination of the oral cavity, oropharynx, oor of the
O. Edkins · J. J. Fagan (*)
Division of Otolaryngology, University of Cape Town, Groote
Schuur Hospital, Observatory, Cape Town, South Africa
e-mail: johannes.fagan@uct.ac.za
mouth, and the head and neck. Examination of the papilla of
the submandibular gland (Wharton’s) and the parotid gland
(Stensen’s) ducts may reveal asmall calculuslocated at the
ductal orice, inammation, stricture, or passage of either
clear or purulent saliva on massagingof the gland. Palpation
of the Wharton’s duct, in the oor of the mouth, and Stensen’s
duct, intraorally in the buccal region for the anterior third,
and externally over the masseter muscle for the middle third
of the duct, is essential to assess for palpable stones. Evidence
of acute infection and/or abscess formation should also be
assessed.
As always, a detailed medical history and a list of the
patient’s medications are required in preparation for surgery
to avoid unwanted complications. A history and symptoms
of autoimmune and Sjögren’s disease are also important to
elicit.
15.1.2 Imaging
Preoperative imaging is essential to diagnose obstructive
sialadenitis from stones, as well as toplan surgical removal.
The initial imaging modality of choice is high-denition
ultrasound (US) [3], where evidence of obstruction may be
seen as a dilated salivary duct, and the size and location of
the calculus may be assessed (Figs.15.1, 15.2, and 15.3). In
most cases, US may be sufcient, although its accuracy
isoperator dependent. CT images (Figs. 15.4 and 15.5) or
cone-beam CT (CBCT) may be required if US is inadequateor does not accurately delineate the size and location
of the stone and obstruction, as well asforcomplications of
sialolithiasis [3].
Plain X-rays may be of help, although a signicant proportion of stones are radiolucent. Sialography may assist in
imaging the morphology of the ductal system and may show
a lling defect with an intra-canalicular stone, but is not the
rst-line choice of imaging [1].
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_15
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