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papilla on either side of the frenulum.
(a) Short frenulum. Congenital ankyloglossia (i.e. tongue
(b) Scar. Trauma or corrosive burn.
(c) Ulcer. Trauma, erosion of submandibular duct stone,
(d) Swelling. Ranula, sublingual dermoid, calculus of sub-
SECTION IX — Clinical Methods in ENT and Neck Masses
Figure 76.13. Palpation of the oral cavity.
Opening of the submandibular duct is seen as a raised
tie).
aphthous ulcer, malignancy.
mandibular duct, benign or malignant tumours, Ludwig’s angina.
7. Retromolar Trigone
Look for the inflammation due to impaction of last molar
tooth or a malignant lesion of this area.
PALPATION
All lesions of the oral cavity, particularly of the tongue,
floor of mouth, cheek, lip and palate, must be palpated.
A swelling in the floor of mouth should be examined by
bimanual palpation, to differentiate a swelling of submandibular (Figure 76.13) salivary gland from that of
submandibular lymph nodes.
V. EXAMINATION OF OROPHARYNX
Oropharynx lies opposite the oral cavity. It starts at the
level of anterior pillars and is bounded above by the junction of hard and soft palate and below by the V-shaped
row of circumvallate papillae.
Structures included in it are:
1. Tonsils and pillars
2. Soft palate
3. Base of tongue
4. Posterior pharyngeal wall
SYMPTOMATOLOGY
A disease of the oropharynx can disturb swallowing, phonation, respiration and hearing. A patient with disease of
oropharynx presents with one or more of the following
complaints:
1. Sore throat. Acute or chronic tonsillitis, pharyngitis,
ulcerative lesions of pharynx, etc.
2. Odynophagia (painful swallowing). Ulcers, peritonsillar or retropharyngeal abscess, lingual tonsillitis, etc.
3. Dysphagia (difficulty in swallowing). Tonsillar enlargements; parapharyngeal tumour; benign or malignant
disease of tonsils, base of tongue or posterior pharyngeal wall; paralysis of soft palate; globus hystericus.
4. Change in voice. Paralysis of palate causes hypernasality. Space-occupying lesions of the oropharynx
cause muffled or hot-potato voice.
5. Earache. Benign ulcers or malignant lesions of the
base of tongue, tonsil, pillars and palate cause referred
pain in the ipsilateral ear.
6. Snoring. Large tonsils and other oropharyngeal lesions may obstruct respiration and cause snoring or
sleep apnoea syndrome.
7. Halitosis (bad smell from the mouth). In the oropharynx, cause may be infected tonsils, postnasal discharge
or malignancy of oral cavity or oropharynx.
8. Hearing loss. A conductive hearing loss due to disturbance of eustachian tube function can result from enlarged tonsils (which interfere with movements of soft
palate), cleft palate, submucous palate, palatal paralysis, recurrent pharyngitis or tonsillitis.
9. Abnormal appearance. A patient may notice an abnormal finding while looking at his throat in the mirror and then consult the doctor. It is not unusual for
patient to be concerned about hypertrophic circumvallate papillae and have fear of cancer.
EXAMINATION
First, examine the oropharynx by asking the patient to
open the mouth widely. Tongue depressor is used when
this preliminary examination is unsatisfactory, or when it
is required to displace the tongue to one side to examine
tonsillolingual sulcus, or to press on the tonsils to look
for the contents of tonsillar crypts. The base of tongue
is examined by laryngeal mirror. Following structures of
oropharynx are carefully examined.
1. Tonsils and Pillars
(a) Tonsils
(i) Presence. Look for presence or absence of tonsils.
(ii) Size: Large and obstructive, small or embedded.
(iii) Symmetry. Unilateral or bilateral enlargement.
(iv) Crypts. White or yellow spots at the openings of
crypts (follicular tonsillitis), white excrescences
not easily wiped off (keratosis).
(v) Membrane. Diphtheria, Vincent’s angina, mem-
branous tonsillitis, etc.
(vi) Ulcer. Cancer, Vincent’s angina, tuberculosis, ul-
cerating tonsillolith.
(vii) Mass. Cystic (retention cyst), pedunculated or
sessile solid mass (papilloma, fibroma), proliferative growth (cancer).
(viii) Bulge. Peritonsillitis, parapharyngeal abscess,
parapharyngeal tumour.
Pressure on the anterior pillar with the edge of tongue
depressor may express cheesy material from the crypts
(normal) of frank fluid pus (septic tonsil).
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Palpation of the tonsil with a gloved finger is essential
to know the consistency of the mass (hard in malignancy
or tonsillolith), pulsation in tonsillar area (internal carotid artery aneurysm), palpation for an elongated styloid
process.
(b) Pillars. Uniform congestion of the pillars, tonsils
and pharyngeal mucosa is seen in acute tonsillitis. Congestion of only the pillars may be a sign of chronic tonsillitis. Ulceration or proliferative growth may be an extension of malignancy from the tonsil base of tongue or the
retromolar trigone.
2. Soft Palate
Look for redness (peritonsillitis), bulge or swelling. Normally, uvula is in the midline. It becomes oedematous
and displaced to the opposite side in peritonsillar abscess. Note movements of soft palate when the patient
says “Aa.” Deviation of the uvula and soft palate to the
healthy side is a sign of vagal paralysis. This may be associated with paralysis of posterior pharyngeal wall which
shows a “curtain effect” (the paralyzed side moves like a
sliding curtain to the healthy side).
A bifid uvula may be a sign of Nigeria and submucous
cleft palate. In such cases, a notch can be palpated in the
hard palate at its junction with soft palate in the midline.
In some African countries such as Nigeria and Ethiopia,
it is a custom to amputate the uvula in infancy or childhood (like circumcision) in the belief that the child would
never get a sore throat later in life, but it is a myth. It is
not unusual to see an absent uvula and a scar in the soft
palate in such patients.
3. Posterior Pharyngeal Wall
It can be seen directly. Look for lymphoid nodules (granular pharyngitis), purulent discharge trickling down the
posterior pharyngeal wall (sinusitis), hypertrophy of
lateral pharyngeal bands just behind the posterior pillars (chronic sinusitis), thin glazed mucosa and crusting
(atrophic pharyngitis).
4. Base of Tongue and Valleculae
Posterior one-third of tongue forms the base of tongue and
lies between the V-shaped row of circumvallate papillae
and the valleculae. Valleculae are two shallow depressions
which lie between the base of tongue and the epiglottis.
Base of tongue and valleculae are best examined by indirect laryngoscopy and finger palpation.
(a) indirect laryngoscopy. Look for the colour of
mucosa (normal or congested); prominent veins, varicosities at the base of tongue or lingual thyroid, ulceration
(malignancy, tuberculosis or syphilis), solid swelling (lingual tonsil, lingual thyroid, lymphoma, carcinoma base
of tongue), cystic swelling (vallecular cyst, dermoid or
thyroglossal cyst).
(b) palpation oF base oF tongue. It should never be
omitted. Extent of tumour which infiltrates deeper into
the tongue is better appreciated by palpation than by inspection. If the patient fails to relax sufficiently, palpation
should be done under general anaesthesia. When palpating any structure in the oropharynx in a child, the examiner should invaginate the patient’s cheek between his
teeth with finger of the opposite hand to prevent biting
on the examiner’s finger.
VI. EXAMINATION OF LARYNX
AND LARYNGOPHARYNX
SYMPTOMATOLOGY
A patient with disease of the larynx presents with one or
more of the following complaints:
1. Disorders of voice. e.g. hoarseness aphonia, puberphonia or easy fatiguability of voice.
2. Respiratory obstruction.
3. Cough and expectoration.
4. Repeated clearing of throat (chronic laryngitis, benign or malignant tumours of larynx).
5. Pain in throat (ulcerative lesions of larynx, perichondritis of laryngeal cartilages, arthritis of laryngeal
joints).
6. Dysphagia (epiglottitis, aspiration of secretions due to
laryngeal paralysis).
7. Mass in the neck (cervical nodes, direct extension of
growth, laryngocele).
EXAMINATION
Clinical examination of larynx includes:
1. External examination of larynx.
2. Indirect laryngoscopy.
3. Flexible or rigid fibreoptic endoscopy.
4. Assessment of voice.
5. Assessment of cervical lymph nodes.
1. External Examination of Larynx
Both inspection and palpation are employed. Look for:
(a) Redness of skin (abscess, perichondritis).
(b) Bulge or swelling (extension of growth or enlarged
lymph nodes).
(c) Widening of larynx (growth of pyriform fossa).
(d) Surgical emphysema (accidental or surgical trauma).
(e) Change in contour or displacement of laryngeal structures
(trauma or neoplasm). Palpate the hyoid bone, thy-
roid cartilage, thyroid notch, cricoid cartilage, and
the tracheal rings.
(f) Movements of larynx. Normally, larynx moves with de-
glutition. It can also be moved from side to side produc-
ing a characteristic grating sound (laryngeal crepitus).
Fixity of larynx indicates inflammation or infiltration
of growth into the surrounding structures. Loss of
laryngeal crepitus is due to postcricoid carcinoma.
2. Indirect Laryngoscopy
Technique. Patient is seated opposite the examiner. He
should sit erect with the head and chest leaning slightly
towards the examiner. He is asked to protrude his tongue
which is wrapped in gauze and held by the examiner
between the thumb and middle finger. Index finger is
used to keep the upper lip or moustache out of the way
(Figure 76.14). Gauze piece is used to get a firm grip of
the tongue and to protect it against injury by the lower
incisors.
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SECTION IX — Clinical Methods in ENT and Neck Masses
Figure 76.14. Indirect laryngoscopy.
gives a good view of the larynx, laryngopharynx, subglottis and even upper trachea. It is an outdoor procedure.
(b) Rigid endoscopy. For this purpose, a rigid fibreoptic
telescope is used. It gives a clear, wide-angle view of the larynx and laryngopharynx. It is also an outdoor procedure.
Local anaesthesia may be required for patients with an active gag reflex.
Stroboscopy. A stroboscope is a device which emits
light in pulses, the frequency of which can be set by the
examiner. If frequency of pulses is same at which vocal cords are moving, the latter appear stationary giving more time to study the cord. If frequency of pulses
is more or less than that of vocal cord movements, the
cords are seen in slow motion. Stroboscopes are synchronized with rigid or fibreoptic endoscopes and the vocal
cord movements can be recorded on video (video stroboscopy). Stroboscopy has been found very useful in
diagnosis of laryngeal paralysis, completeness of glottic
closure during phonation, very small early laryngeal cancer, vocal cord scarring, laryngeal cyst versus polyp and
sulcus vocalis.
4. Assessment of Voice
The examiner should make note of the quality of
voice of the patient when he is speaking, whether it is
hoarse, rough, breathy, bitonal, dysphonic, whispered
or feeble.
Figure 76.15. Structures seen upon indirect laryngoscopy.
Laryngeal mirror (size 4–6) which has been warmed
and tested on the back of hand is introduced into the
mouth and held firmly against the uvula and soft palate.
Light is focussed on the laryngeal mirror and patient is
asked to breathe quietly. To see movements of the cords,
patient is asked to take deep inspiration (abduction of
cords), say “Aa” (adduction of cords) and “Eee” (for adduction and tension). Movements of both the cords are
compared.
Structures seen on indirect laryngoscopy
( Figure 76.15). Indirect laryngoscopy permits examination of structures of the oropharynx, larynx and
laryngopharynx.
• Larynx. Epiglottis, aryepiglottic folds, arytenoids, cu-
neiform and corniculate cartilages, ventricular bands,
ventricles, true cords, anterior commissure, posterior
commissure, subglottis and rings of trachea.
• Laryngopharynx. Both pyriform fossae, postcricoid re-
gion, posterior wall of laryngopharynx.
• Oropharynx. Base of tongue, lingual tonsils, valleculae,
medial and lateral glossoepiglottic folds.
3. Flexible or Rigid Fibreoptic Endoscopy
(a) Flexible endoscopy. In difficult cases, where laryngeal examination cannot be performed with a mirror due
to anatomical abnormalities or intolerance of mirror by
the patient, a flexible rhinolaryngoscope can be used. It
is passed through the nose under local anaesthesia and
5. Assessment of Cervical Lymph Nodes
No examination of the larynx and hypopharynx is complete without thorough search for cervical lymph nodes.
VII. LYMPH NODES OF THE HEAD
AND NECK
CLASSIFICATION (FIGURE 76.16)
1. Upper horizontal chain of nodes
(a) Submental
(b) Submandibular
(c) Parotid
(d) Postauricular (mastoid)
(e) Occipital
(f) Facial
2. Lateral cervical nodes. They include nodes, superficial and deep to sternocleidomastoid muscle and in the
posterior triangle.
(a) Superficial external jugular group
(b) Deep group
(i) Internal jugular chain (upper, middle and lower
groups)
(ii) Spinal accessory chain
(iii) Transverse cervical chain
3. Anterior cervical nodes
(a) Anterior jugular chain
(b) Juxtavisceral chain
(i) Prelaryngeal
(ii) Pretracheal
(iii) Paratracheal
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1. Nodes of Upper Horizontal Chain
(a) Submental nodes. They lie on the mylohyoid muscle
in the submental triangle, 2–8 in number.
Afferents come from the chin, middle part of lower lip,
anterior gums, anterior floor of mouth and tip of tongue.
Efferents go to submandibular nodes and internal jug-
ular chain.
(b) Submandibular nodes. They lie in submandibular triangle in relation to submandibular gland and facial
artery.
Afferents come from lateral part of the lower lip, upper lip, cheek, nasal vestibule and anterior part of nasal
cavity, gums, teeth, medial canthus, soft palate, anterior
pillar, anterior part of tongue, submandibular and sublingual salivary glands and floor of mouth. Efferents go to
internal jugular chain.
(c) Parotid nodes. They lie in relation to the parotid
salivary gland and are extraglandular and intraglandular.
Preauricular and infraauricular nodes are part of the extraglandular group.
Afferents come from the scalp, pinna, external auditory canal, face, buccal mucosa.
Efferents go to internal jugular or external jugular chain.
(d) Postauricular nodes (mastoid nodes). They lie behind the pinna over the mastoid.
Afferents come from the scalp, posterior surface of pinna and skin of mastoid.
Efferents drain into infra-auricular nodes and into in-
ternal jugular chain.
(e) Occipital nodes. They lie both superficial and deep
to splenius capitus at the apex of the posterior triangle.
Afferents come from scalp, skin of upper neck. Effer-
ents drain into upper accessory chain of nodes.
(f) Facial nodes. They lie along facial vessels and are
grouped according to their location. They are midman-
dibular, buccinator, infraorbital and malar (near outer
canthus) nodes.
Afferents come from upper and lower lids, nose, lips
and cheek.
Efferents drain into submandibular nodes.
2. Lateral Cervical Nodes
They are divided into:
(a) Superficial group. It lies along external jugular
vein and drains into internal jugular and transverse cervical nodes.
(b) Deep group. It consists of three chains: internal
jugular, spinal accessory and transverse cervical.
(i) Internal jugular chain. Lymph nodes of internal jugu-
lar chain lie anterior, lateral and posterior to internal
jugular vein and extend from the digastric muscle to
the junction of internal jugular vein with the subclavian vein. They are arbitrarily divided into upper,
middle and lower groups.
Figure 76.16. Lymph nodes of the head and neck.
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(ii) Spinal accessory chain. It lies along the spinal acces-
(iii) Transverse cervical chain (supraclavicular nodes). It lies
SECTION IX — Clinical Methods in ENT and Neck Masses
Upper group (jugulodigastric node) drains oral cavity,
oropharynx, nasopharynx, hypopharynx, larynx
and parotid.
Middle group drains hypopharynx, larynx, thyroid,
oral cavity, oropharynx.
Lower jugular group drains larynx, thyroid and cervi-
cal oesophagus.
sory nerve. Upper nodes of this chain coalesce with
upper jugular nodes. Spinal accessory chain drains
the scalp, skin of the neck, the nasopharynx, occipital and postauricular nodes.
Efferents from this chain drain into transverse cervi-
cal chain.
horizontally, along the transverse cervical vessels, in
the lower part of the posterior triangle. The medial
nodes of the group are called scalene nodes. Afferents
to those nodes come from the accessory chain and
also infraclavicular structures, e.g. breast, lung, stomach, colon, ovary and testis.
3. Anterior Cervical Nodes
They lie between the two carotids and below the level of
hyoid bone and consist of two chains:
(a) Anterior jugular chain. It lies along anterior jugu-
lar vein and drains the skin of anterior neck.
(b) Juxtavisceral chain. It consists of prelaryngeal,
pretracheal, and paratracheal nodes.
Prelaryngeal node (Delphian node) lies on cricothyroid membrane and drains subglottic region of larynx
and pyriform sinuses.
Pretracheal nodes lie in front of the trachea, deep to
pretracheal fascia, and drain thyroid gland and the trachea. Efferents from these nodes go to paratracheal, lower
internal jugular and anterior mediastinal nodes.
Paratracheal nodes (recurrent nerve chain) lie along
recurrent laryngeal nerve and drain the thyroid lobes,
subglottic larynx, trachea and cervical oesophagus.
Figure 76.17. Medial and lateral groups of retropharyngeal lymph
nodes seen from behind. Node of Rouviere is the uppermost node of
the lateral group.
Lymph Nodes Not Clinically Palpable
(a) Retropharyngeal nodes. They lie behind the pharynx
and are divided into lateral and medial groups. Lateral
group lies at the level of atlas, close to the base of skull.
Most superior node of the lateral group is called node of
Rouviere (Figure 76.17).
Medial group lies near the midline but at a little lower
level.
Retropharyngeal nodes drain the nasal cavity, paranasal sinuses, hard and soft palate, nasopharynx, posterior
wall of the pharynx and send efferents to the upper internal jugular group.
(b) Sublingual nodes. They lie deep along the lingual
vessels and drain anterior part of the floor of mouth and
ventral surface of tongue. Lymphatics from these nodes
end in the submandibular or upper jugular nodes.
EXAMINATION OF NECK NODES
Examination of neck nodes is important, particularly in
head and neck malignancies and a systematic approach
should be followed.
Figure 76.18. Examination of the neck nodes.
Neck nodes are better palpated while standing at the
back of the patient. Neck is slightly flexed to achieve relaxation of muscles (Figure 76.18). The nodes are examined in the following manner so that none is missed.
1. Upper horizontal chain. Examine submental, subman-
dibular, parotid, facial, postauricular and occipital nodes.
2. External jugular chain. It lies superficial to sterno-
mastoid.
3. Internal jugular chain. Examine the upper, middle and
lower groups. Many of them lie deep to sternomastoid
muscle which may need to be displaced posteriorly.
4. Spinal accessory chain.
5. Transverse cervical chain.
6. Anterior jugular chain.
7. Juxtavisceral chain. Prelaryngeal, pretracheal and
paratracheal nodes.
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When a node or nodes are palpable, look for the fol-
lowing points:
1. Location of nodes.
2. Number of nodes.
3. Size.
4. Consistency. Metastatic nodes are hard; lymphoma
nodes are firm and rubbery; hyperplastic nodes are
soft. Nodes of metastatic melanoma are also soft.
5. Discrete or matted nodes.
6. Tenderness. Inflammatory nodes are tender.
7. Fixity to overlying skin or deeper structures. Mobility
should be checked both in the vertical and horizontal
planes.
CLASSIFICATION OF NECK NODES ACCORDING
TO LEVELS (SEE TABLE 76.1 AND FIGURE 76.19)
Level I: Submental (IA) and Submandibular
(IB) Nodes
IA Submental nodes, which lie in the submental trian-
gle, i.e. between right and left anterior bellies of digastric muscles and the hyoid bone.
TABLE 76.1 DIVISION OF NECK NODES
ACCORDING TO LEVELS
Level I • Submental(IA)
• Submandibular(IB)
Level II Upper jugular
• AnteriortoCNXI(IIA)
• PosteriortoCNXI(IIB)
Level III Mid jugular
Level IV Lower jugular
Level V Posterior triangle group (spinal accessory and
transverse cervical chains)
• Abovethelevelofintermediatetendon
of omohyoid (VA)
• Belowthelevelofintermediatetendon
of omohyoid (VB)
Level VI • Prelaryngeal
• Pretracheal
• Paratracheal
Level VII Nodes of upper mediastinum
IB Submandibular nodes, lying between anterior and
posterior bellies of digastric muscle and the lower
border of the body of mandible.
Level II: Upper Jugular Nodes
They are located along the upper third of jugular vein, i.e.
between the skull base above and the level of lower border of hyoid bone (or bifurcation of carotid artery) below.
Level III: Middle Jugular Nodes
They are located along the middle third jugular vein,
from the level of hyoid bone above, to the level of lower
border of cricoid cartilage (or where omohyoid muscle
crosses the jugular vein) below.
Level IV: Lower Jugular Nodes
They are located along the lower third of jugular vein;
from lower border of cricoid cartilage to the clavicle. Virchow’s node is included into this level.
Level V: Posterior Cervical Group
They are located in the posterior triangle, i.e. between posterior border of sternocleidomastoid (anteriorly), anterior
border of trapezius (posteriorly) and the clavicle below.
They include lymph nodes of spinal accessory chain, transverse cervical nodes and supraclavicular nodes. Level V
nodes are further subdivided into upper, middle and lower,
corresponding to planes that define levels II, III and IV.
Level VI: Anterior Compartment Nodes
They are located between the medial borders of sternocleidomastoid muscles (or carotid sheaths) on each side,
hyoid bone above and suprasternal notch below. They
include prelaryngeal, pretracheal and paratracheal nodes.
Level VII
They are located below the suprasternal notch and include nodes of the upper mediastinum.
Lymph nodes of supraclavicular zone or fossa (Ho’s
triangle) (Figure 76.20). Supraclavicular zone is situated
between (i) upper border of medial end of clavicle, (ii)
Figure 76.19. Classification of the neck nodes according to levels.
Levels are shown in Table 76.1.
Figure 76.20. Supraclavicular fossa (or Ho’s triangle) is bound by
medial and lateral ends of the clavicle and the point where the neck
meets the shoulder. Nodes in this zone include nodes of lower parts
of levels IV and V.
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upper border of lateral end of clavicle and (iii) point
where neck meets the shoulder. Nodes in this triangle
are important in carcinoma of the nasopharynx. Metastases in these nodes, irrespective of their size, would place
them in N3 category (AJCC, 1977). Nodes in this zone
include lower part of levels IV and V.
Other Groups
• Retropharyngeal
• Facial
• Preauricular
• Postauricular (mastoid)
• Intraparotid
• Suboccipital
NECK DISSECTION
It is a procedure to remove lymph nodes and the surrounding fibrofatty tissues from the neck, to eradicate
metastases to cervical lymph nodes from cancer of the
aerodigestive tract.
CLASSIFICATION OF NECK DISSECTION
1. Radical neck dissection.
2. Modified radical neck dissection.
(a) Type I—Preserves CN XI
(b) Type II—Preserves CN XI and internal jugular vein
(c) Type III—Preserves CN XI, internal jugular vein
and sternocleidomastoid muscle.
3. Selective neck dissection
(a) Supraomohyoid (or anterolateral) (removes level I
to III)
(b) Lateral (removes nodes in level II, III, IV)
(c) Posterolateral (removes level II to V suboccipital
and postauricular nodes)
(d) Anterior compartment (removes level VI nodes)
4. Extended neck dissection (vide infra).
Radical Neck Dissection
In this procedure, all lymph nodes, extending from the
mandible above to the clavicle below and from lateral
border of sternomastoid, hyoid bone and contralateral
anterior belly of digastric, medially, to the anterior border
of trapezius posteriorly, are removed. The dissection specimen would include:
1. Lymph nodes of submental, submandibular, upper, middle and lower jugular, and lateral (posterior)
triangle regions, i.e. level I to V along with its fibrofatty
tissue.
2. Sternomastoid muscle.
3. Internal jugular vein.
4. Spinal accessory nerve.
5. Submandibular salivary gland.
6. Tail of the parotid.
7. Omohyoid muscle.
It saves following structures:
• Carotid artery.
• Brachial plexus, phrenic nerve, vagus nerve, cervical
sympathetic chain, marginal mandibular branch of
facial, lingual and hypoglossal nerves.
Radical neck dissection does not remove nodes of postauricular, suboccipital, parotid (except those in the tail),
facial, retropharyngeal and paratracheal regions.
Incision used in radical neck dissection (Figure 76.21)
will depend on the incision being used to remove the
primary growth and whether patient received any
preoperative radiation.
Commonly, the incisions used are:
1. Schobinger
2. Mc Fee
3. Hockey stick
4. Extensions from Gluck–Sorenson’s incision, used for
laryngectomy with neck dissection (Figure 76.22).
Contraindications to radical neck dissection include:
1. Untreatable primary cancer.
2. Distant metastases.
3. Inoperable neck nodes when they are fixed to important
structures.
4. Medical illness which makes the patient unfit for major
surgery.
Modified Neck Dissection
It is similar to radical neck dissection but with preservation of one or more of the following structures:
1. Spinal accessory nerve
2. Internal jugular vein
3. Sternocleidomastoid muscle.
Selective Neck Dissection
It consists of preservation of one or more lymph node
groups and all the three nonlymphatic structures, i.e. spinal
Figure 76.21. Incisions commonly used in radical neck dissection. (A) Schobinger. (B) McFee. (C) Hockey stick.
Figure 76.22. Gluck–Sorenson’s incision used for laryngectomy. Dotted
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lines showing extensions of incisions for a radical neck dissection.
Chapter 76 — Clinical Methods in ENT
accessory, sternocleidomastoid muscle and internal jugular
vein.
• Supraomohyoid or anterolateral. Removes levels I to
III, usually done in cancer of oral cavity.
• Lateral. Removes levels II to IV.
• Posterolateral. Removes levels II to V with postauricu-
lar and occipital nodes.
• Anterior compartment. Removes nodes at level VI,
i.e. pretracheal, paratracheal and prelaryngeal.
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Extended Neck Dissection
It consists of any of the neck dissections as described
and further extended to include additional lymph node
groups or nonlymphatic structures or both. Additional
lymph node groups include retropharyngeal, parotid or
level VI nodes and nonlymphatic structures may include
external carotid artery, hypoglossal nerve, parotid gland
and levator scapulae, etc. that are not routinely included
in that dissection.
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Neck Masses
Clinically, neck masses can be divided into: (i) those in the
midline (Figure 77.1) and (ii) those in the lateral aspect of
neck (Figure 77.2). The latter can be grouped according to
triangles of neck. Only the clinically important ones are
described in this chapter.
THYROGLOSSAL DUCT CYST
It presents as a cystic midline swelling, usually affecting
young children but can occur at any age (Figure 77.3). It
is usually rounded with a diameter of 2–4 cm. It increases
in size with upper respiratory tract infection. Sometimes
it presents as a draining sinus if it has burst due to infection or has been surgically drained. Because of the attachment of thyroglossal duct to foramen caecum at the base
of tongue, it moves with tongue protrusion.
During development, thyroid anlage starts at foramen
caecum, passes through base of tongue and then descends
in front, behind or through the hyoid bone to form the
thyroid gland. Thyroglossal cyst can occur anywhere in
the course of thyroid duct (Figure 77.4). It may contain
the only functioning thyroid tissue in the body. Rarely
carcinoma develops in the cyst. CT/MRI neck should always be done to find orthotopic thyroid gland.
Treatment is complete surgical excision, including
with it the body of hyoid bone and core of tongue tissue
around the tract in the suprahyoid tongue base to the
foramen caecum (Sistrunk’s operation). Simple excision
of cyst without removal of its tract leads to recurrence.
SUBLINGUAL DERMOID CYST
It presents as a midline submental swelling but does not
move on protrusion of the tongue as it is not attached to
foramen caecum. Sometimes it arises from the floor of
mouth and needs differentiation from ranula. Treatment
is surgical excision. A midline dermoid is also seen just
above the suprasternal notch.
SUBMENTAL NODES
There are two to eight nodes situated in the submental
triangle between the platysma and mylohyoid muscle.
They drain chin, middle part of lower lip, incisor region of gingiva, anterior floor of mouth and the tip of
tongue.
When enlarged, the draining areas should be looked
for infections or malignancy.
PRELARYNGEAL AND PRETRACHEAL
NODES
They belong to juxtavisceral chain of nodes and lie in
front of the larynx and trachea. They drain the larynx
and trachea, thyroid isthmus and anteromedial aspect of
thyroid lobes. In case of enlargement of the above nodes,
draining areas should be examined.
Figure 77.1. Midline swellings of neck.
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