Cervical lymph nodes
INTRODUCTION
The single most important factor affecting prognosis for patients
with squamous cell carcinoma of the upper aerodigestive tract is
the stage of the disease at the time of initial diagnosis and treat-
ment. Patients who present with tumors localized at the primary
site without dissemination to regional lymph nodes enjoy an
excellent prognosis. On the other hand, once dissemination to
regional lymph nodes takes place, the probability of five-year
survival, regardless of the treatment rendered, reduces to nearly
one-half of that seen in early staged patients (Fig. 9.1). Clearly,
therefore, the single most important prognostic factor in the treat-
ment of patients with squamous cell carcinoma of the head and
Fig. 9.1 Five-year survival rates in patients with squamous cell carcinoma
of the upper aerodigestive tract in relation to the extent of disease.
9
neck is the status of cervical lymph nodes. In spite of the progress
made in the field of early diagnosis by public education and
physician awareness in the past few years, a significant number of
patients still present with disease at an advanced stage at the time
of diagnosis. Reports from the American Cancer Society indicate
that over 40% of the patients with squamous carcinomas of the
oral cavity and pharynx present with regional dissemination of
disease at the time of initial diagnosis (Fig. 9.2). In other parts of
the world, such as Asia and Latin America, a majority of patients
with cancer of the upper aerodigestive tract present with advanced
stage disease. Thus, management of cervical lymph nodes becomes
a vitally important component of the overall treatment strategy
for patients with cancers of the head and neck.
Fig. 9.2 Distribution of patients with squamous carcinomas of the oral
cavity and pharynx in relation to the extent of disease at the time of
initial diagnosis.
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ANATOMY OF REGIONAL LYMPHATICS
Regional lymphatic drainage from the scalp and skin of the head
and neck region, the mucosa of the upper aerodigestive tract,
salivary glands, and the thyroid gland occurs to specific regional
lymph node groups. In addition to this, tumor dissemination via
regional lymphatics to these lymph node groups occurs in a pre-
dictable and sequential fashion. Therefore, specific regional lymph
node groups should he appropriately addressed in treatment
planning lor a given primary site. These include those regional
lymph nodes which are accessible for surgical resection and those
which are relatively inaccessible for adequate surgical resection.
The major lymph node groups of the head and neck region are
shown in Fig. 9.3. The preauricular, periparotid and intraparotid
lymph nodes are the first echelon lymph nodes for the anterior
half of the scalp, the skin of the forehead and the upper part of the
face. The periauricular and suboccipital group of lymph nodes
provide initial drainage to the posterior half of the scalp and the
posterior aspect of the external ear. Cervical lymph nodes in the
lateral aspect of the neck primarily drain the mucosa of the upper
aerodigestive tract. These include the submental, prevascular facial,
and submandibular group of lymph nodes located in the sub-
mental and submandibular triangles of the neck. Deep jugular
354
lymph nodes include the jugulodigastric, jugulo-omohyoid, and
supraclavicular group of lymph nodes adjacent to the internal
jugular vein. I.ymph nodes in the posterior triangle of the neck
include the accessory chain of lymph nodes located along the
spinal accessory nerve and the transverse cervical chain of lymph
nodes in the floor of the posterior triangle of the neck. Para-
pharyngeal and retropharyngeal lymph nodes are at risk of
metastatic dissemination from tumors of the pharynx.
'The central compartment of the neck includes the delphian
lymph node overlying the thyroid cartilage in the midline draining
the larynx and pcrithyroid lymph nodes adjacent to the thyroid
gland. Lymph nodes in the tracheoesophageal groove provide
primary drainage to the thyroid gland as well as the hypopharynx,
subglottic larynx, and cervical esophagus. I.ymph nodes in the
anterior superior mediastinum provide drainage to the thyroid gland
and the cervical esophagus, and serve as a secondary lymphatic
basin for anatomic structures in the central compartment of the
neck. Each anatomic subgroup of lymph nodes described above
specifically serve as primary echelon lymph nodes draining a specific
site in the head and neck region. Thus, location of a palpable
metastatic lymph node may often indicate the potential source of
a primary tumor. In Fig. 9.4 the regional lymph node groups
draining a specific primary site as first echelon lymph nodes are
depicted.
Fig. 9.3 The regional lymph nodes of the head
and neck region.
Fig. 9.4 The regional lymph node groups
draining a specific primary site as first echelon
lymph nodes.
 In order to establish a consistent a n d easily reproducible, user-
friendly m e t h o d for d e s c r i p t i o n o f regional cervical l y m p h nodes
w h i c h establishes a c o m m o n language between the c l i n i c i a n a n d
the pathologist, the Head a n d Neck Service at M e m o r i a l Sloan-
Kettering Cancer Center has described a leveling system of cervical
l y m p h nodes (I-'ig. 9.5). This system divides the l y m p h nodes in
the lateral aspect of the neck i n t o five nodal groups or levels. In
a d d i t i o n , l y m p h nodes in (he central c o m p a r t m e n t of the neck are
assigned Levels VI a n d V I I ( F i g . 9.6).
Level I : S u b m e n t a l g r o u p . T h e l y m p h nodes between the
anterior belly o f t h e digastric muscles a n d c e p h a l a d t o t h e h y o i d
bone. S u b m a n d i b u l a r g r o u p . L y m p h nodes i n the triangular
area bounded by the anterior a n d posterior bellies of the digastric
muscle and the i n f e r i o r border of the b o d y of the m a n d i b l e . T h e
l y m p h nodes adjacent to the s u b m a n d i b u l a r salivary g l a n d a m i
along the facial artery are i n c l u d e d in t h i s g r o u p .
Level I I : U p p e r j u g u l a r g r o u p . L y m p h nodes a r o u n d the
upper p o r t i o n of the i n t e r n a l jugular v e i n a n d the upper part of
the spinal accessory nerve, e x t e n d i n g f r o m the base of the skull
Fig. 9.5 a. Memorial Sloan Kettering Cancer Center leveling system of
cervical lymph nodes, b. Current modification of leveling system.
Fig. 9.6 Anatomic boundaries of nodal Levels VI (central compartment
group) and VII (superior mediastinal group).
u p t o the b i f u r c a t i o n o f the carotid artery o r the h y o i d bone
(clinical l a n d m a r k ) . The posterior l i m i t f o r this level is the
posterior border of the sternocleidomastoid muscle a n d the
a n t e r i o r border is the lateral l i m i t of the .sternohyoid muscle.
L e v e l I I I : M i d - j u g u l a r g r o u p . L y m p h nodes a r o u n d the
m i d d l e t h i r d o f the i n t e r n a l jugular v e i n f r o m the inferior border
of Level II up to t h e o m o h y o i d muscle or the i n f e r i o r border of
c r i c o i d cartilage (clinical l a n d m a r k ) . The anterior and posterior
borders are t h e same as those for Level I I .
L e v e l I V : L o w e r j u g u l a r g r o u p , l y m p h nodes a r o u n d the
lower t h i r d of (he i n t e r n a l jugular vein f r o m the inferior border
of Level III up to t h e clavicle. The anterior a n d posterior borders
are the same as those for Levels II a n d I I I .
L e v e l V : P o s t e r i o r t r i a n g l e g r o u p , l y m p h nodes around the
lower p o r t i o n of the spinal accessory nerve a n d along the
transverse cervical vessels. It is b o u n d e d by the triangle formed
by (he clavicle, posterior border of the sternocleidomastoid
muscle, a n d the a n t e r i o r border of the trapezius muscle.
L e v e l V I : C e n t r a l c o m p a r t m e n t g r o u p , l y m p h nodes i n the
prelaryngeal, pretracheal, ( D e l p h i a n ) , paratracheal a n d tracheo-
esophageal groove. T h e boundaries are: h y o i d bone to
.suprasternal n o t c h a n d between the medial borders of the
carotid sheaths.
Level V I I : S u p e r i o r m e d i a s t i n a l g r o u p , l y m p h nodes i n the
anterior superior m e d i a s t i n u m and tracheoesophageal grooves,
e x t e n d i n g f r o m t h e suprasternal n o t c h t o t h e i n n o m i n a t e artery.
CLINICAL STAGING OF CERVICAL LYMPH NODES
(N STAGING)
T h e A m e r i c a n Joint C o m m i t t e e o n Cancer a n d the International
U n i o n Against Cancer has agreed u p o n a u n i f o r m staging system
for cervical l y m p h nodes. T h i s nodal staging system is depicted in
F i g . 9 . 7 . The exact description of each N stage of l y m p h node
metastasis f r o m s q u a m o u s carcinomas of t h e head a n d neck is
described in F i g . 9 . 8 . Squamous carcinomas of the nasopharynx
and well-differentiated thyroid carcinomas have a different
biology a n d cervical metastases f r o m these t u m o r s are assigned
different staging systems.
Ipsilateral multiple Bilateral/contralateral >6 cm
<6cm <6cm
Fig. 9.7 The American Joint Committee on Cancer and the International
Union Against Cancer (A|CC/UICC) staging system for cervical lymph
nodes.
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Fig. 9.8 N staging of lymph node metastasis from squamous cell
carcinoma of the head and neck except nasopharynx (AJCC/UICC, 2002).

Nx Regional lymph nodes cannot be assessed

NO No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, <3 cm in
greatest dimension
N2a Metastasis in single ipsilateral lymph node >3 cm but
<6 cm in greatest dimension
N2b Metastases in multiple ipsilateral lymph nodes, none
>6 cms in greatest dimension
N2c Metastases in bilateral or contralateral lymph nodes, none
>6 cm in greatest dimension
N3 Metastasis in a lymph node >6 cm in greatest dimension

Fig. 9.9 The risk of nodal metastasis increases in relation to location of

The N Staging system simply reflects the volume of tumor bur-
den in regional lymphatics which is directly linked to prognosis of
the patient. The prognosis worsens with increasing N slage. How-
ever, there are other prognostic factors pertaining lo the lymph
nodes which are not included in the current N staging system.
NODAL FACTORS AFFECTING PROGNOSIS
There are several factors pertaining to the characteristics of regional
lymph node metastasis which directly influence prognosis. These
include the presence or absence of clinically palpable cervical
lymph node metastasis, the Size of the metastatic lymph node, t h e
number of lymph nodes involved, and the location of lymph
nodes involved by metastatic cancer. Involvement of lower cervical
lymph nodes (Level IV) and lower posterior triangle lymph nodes
(Level V) by metastatic cancer usually implies ominous prognosis.
Thus, involvement of lymph nodes in the lateral neck below the
level of the cricoid is of serious prognostic significance. In addition
to this, the presence of extranodal spread of metastatic disease by
capsular rupture of the lymph node with invasion of the soft tissues
adversly impacts upon prognosis. Perivascular and perineural
infiltration by tumor, as well as the presence of tumor emboli in
regional lymphatics, also have an adverse impact on prognosis.
Therefore, these factors must be considered in developing a
treatment strategy for patients in whom regional lymph nodes are
involved by metastatic disease, particularly for planning adjuvant
therapy and for assessment of prognosis.
primary squamous cell carcinomas of the upper aerodigestive tract.
metastasis from carcinoma of t h e true vocal cord is exceedingly
small. The risk, however, increases as one progresses from the
vocal cords lo the false vocal cords, aryepiglottic fold, pyriform
sinus, and pharyngeal wall. Nearly two-thirds of patients with
primary carcinomas of the hypopharynx present with clinically
palpable regional lymph node metastasis.
Certain primary sites have a significantly increased risk of nodal
metastases compared to the other sites in t h e same region. For
example, floor of mouth versus hard palate in the oral cavity and
glottic versus supraglottic sites in t h e larynx. In general, T-stage
usually reflects tumor burden or invasiveness and therefore the
risk of nodal metastases increases with increasing T-stage of the
primary tumor at any site. Similarly tumor size (large versus small)
increases the risk of dissemination to regional lymph nodes.
Certain histomorphologic features of the primary tumor also
increase the risk of nodal metastasis. Endophytic tumors in that
regard are more inclined to metastasize compared to exophytic
tumors. It has been well documented that for tongue and floor of
mouth cancers, tumor thickness is related to the risk of nodal
metastases. Poorly differentiated carcinomas have a higher risk of
nodal metastases compared to well-differentiated lesions. In
general, if the risk of occult metastases exceeds 15-20%, then
elective treatment of regional lymph nodes is recommended due
to its Significantly adverse impact on prognosis.

RISK OF NODAL METASTASIS

Involvement of regional lymphatics by primary squamous cell

carcinomas of the upper aercxligeslive tract is dependent on
various factors related to the primary tumor. These include the
site, size, T-stage and location of the primary tumor. In addition to
this, histomorphologic features of t h e primary t u m o r also
influence the risk of nodal metastases. The risk of nodal metastasis
increases in relation to location of the primary tumor, as o n e
progresses from the anterior to posterior aspect of t h e upper aero-
digestive tract, i.e. the lips, oral cavity, oropharynx, and hypo-
pharynx (Fig. 9.9). For tumors of the larynx and pharynx, the risk
of nodal metastasis increases as o n e progresses from the center of
the upper aerodigestive tract (vocal cords) to the periphery (lateral Fig. 9.10 Risk of occult nodal metastasis in cutaneous melanomas
pharyngeal wall). For example, the risk of regional lymph node relative to the depth of the primary lesion.

356
 Risk of nodal metastases f r o m cutaneous malignancies is h i g h l y
variable. Generally, small (<2 cm), squamous cell carcinomas of
the skin of t h e face a n d neck have a very low risk of nodal
metastases. Similarly, small cancers of the sweat glands or adnexal
origin also have a low risk of metastases to regional l y m p h nodes.
Therefore, elective treatment of regional l y m p h nodes is generally
not recommended except for patients w i t h massive t u m o r s .
On the o t h e r h a n d , cutaneous melanomas have a predictably
high risk of nodal metastases w i t h increasing thickness a n d size of
the primary t u m o r ( F i g . 9 . 1 0 ) . Therefore, one can justify elective
treatment of regional l y m p h nodes for thicker p r i m a r y mela-
nomas a l t h o u g h increasing p o p u l a r i t y of sentinel node m a p p i n g
techniques negate the c o n s i d e r a t i o n of 'elective l y m p h
dissections'.
Metastatic spread f r o m p r i m a r y carcinomas of salivary o r i g i n is
generally low ( - 2 0 % ) . Therefore, elective dissection of cervical
lymph nodes is r e c o m m e n d e d for h i g h stage (T3-T4) a n d h i g h
grade (poorly d i f f e r e n t i a t e d ! carcinomas.
Although dissemination t o regional l y m p h nodes f r o m d i f l r e n -
tialed carcinomas of the t h y r o i d ( p a p i l l a r y / f o l l i c u l a r ) is q u i t e
c o m m o n (-50%), elective dissection of regional l y m p h nodes is
not recommended since it does not have a significantly adverse
impact on prognosis.
PATTERNS OF NECK METASTASIS
Dissemination of metastatic cancer to regional l y m p h nodes f r o m
primary sites in t h e u p p e r aerodigestive tract occurs
predictable a n d sequential f a s h i o n . Thus, all regional l y m p h node
groups are usually not at risk of nodal metastases i n i t i a l l y f r o m
any primary site, in the absence of grossly palpable metastatic
lymph nodes. O n the o t h e r h a n d , w h e n c l i n i c a l l y palpable l y m p h
nodes are present at the t i m e of i n i t i a l diagnosis, comprehensive
clearance of all regional l y m p h node groups at risk is warranted.
Several w e l l - d o c u m e n t e d studies in the literature have c o n f i r m e d
that select groups of regional l y m p h nodes are i n i t i a l l y at risk for
each primary site in the head a n d neck region. U n d e r s t a n d i n g the
sequential patterns of neck metastasis therefore greatly facilitates
surgical management of regional l y m p h nodes in the c l i n i c a l l y
negative neck where the l y m p h nodes are at risk of h a r b o r i n g
micrometastasis.
Fig. 9.11 The first echelon lymph nodes at highest risk for early
dissemination by metastatic cancer from primary tumors in the oral
cavity.
Tor p r i m a r y t u m o r s in the oral cavity the regional l y m p h nodes
at highest risk for early d i s s e m i n a t i o n by metastatic cancer are
l i m i t e d to Levels I, I I , a n d 111 ( F i g . 9 . 1 1 ) . A n a t o m i c a l l y this tran-
slates i n t o regional l y m p h node groups c o n t a i n e d w i t h i n the
s u p r a o m o h y o i d triangle of the neck. The l y m p h node groups
c o n t a i n e d in the s u p r a o m o h y o i d triangle are: submental, sub-
mandibular, prevascular facial, jugulodigastric, upper deep
jugular, superior spinal accessory c h a i n of l y m p h nodes, and
m i d j u g u l a r l y m p h nodes. Skip metastasis to Levels IV and V in the
absence of metastatic disease at Levels I, I I , or III is exceedingly
rare. Therefore, if the neck is c l i n i c a l l y negative, Level IV and V
lymph nodes arc generally n o t at risk of h a r b o r i n g micro-
node metastasis f r o m p r i m a r y squamous carcinomas of the oral cavity.
O n e exception to this observation is p r i m a r y squamous cell
carcinomas of the m i d d l e t h i r d of the lateral border of the tongue
where skip metastases to Level IV have been reported.
Tor t u m o r s on the lateral aspect of the o r o p h a r y n x , hypo-
p h a r y n x , a n d larynx the first echelon l y m p h nodes at highest risk
of h a r b o r i n g micrometastasis in the c l i n i c a l l y negative neck are
the deep jugular l y m p h nodes at Levels I I , III and IV on the
ipsilaleral side ( F i g . 9 . 1 2 ) . The l y m p h node groups in the deep
jugular c h a i n are the jugulodigastric, highest spinal accessory
chain of lymph nodes, midjugular lymph nodes, jugulo-
o m o h y o i d l y m p h nodes, a n d supraclavicular l y m p h nodes deep to
the sternocleidomastoid muscle. C o n t i g u o u s l y m p h nodes lateral
to the i n t e r n a l jugular vein o v e r l y i n g the cutaneous roots of the
cervical plexus are usually considered a c o m p o n e n t of Levels I I , III
a n d IV. In patients w i t h p r i m a r y carcinomas of the oropharynx,
in a h y p o p h a r y n x a n d l a r y n x w i t h a c l i n i c a l l y negative neck the risk
of micrometastasis to Levels I a n d V is exceedingly small. Skip
metastasis to Levels I a n d V in the absence of disease at Levels I I ,
I I I , or IV is usually not seen. Primary t u m o r s w h i c h involve both
sides of the m i d l i n e have a p o t e n t i a l of microscopic dissemination
of metastatic disease to jugular l y m p h nodes on b o t h sides of the
neck. Similarly, t u m o r s of the medial w a l l of the p y r i f o r m sinus
are reported to have an increased risk of contralateral neck
metastases.
Regional l y m p h node metastasis f r o m p r i m a r y carcinomas of
the t h y r o i d g l a n d occurs in a h i g h p r o p o r t i o n of patients w i t h
differentiated c a r c i n o m a of the t h y r o i d g l a n d . The first echelon
l y m p h nodes at highest risk for micrometastasis in the clinically
negative neck f r o m primary differentiated carcinoma of the thyroid
Fig. 9.12 The first echelon lymph nodes at highest risk for
micrometastasis in the clinically negative neck from primary tumors of
the hypopharnyx and larynx.
357
 Fig. 9.13 The first echelon lymph nodes at highest risk for
micrometastasis in the clinically negative neck from primary carcinoma
of the thyroid gland.

Fig. 9.14 The first echelon lymph nodes at highest risk for dissemination
of metastatic cancer from carcinoma of the parotid gland are in the
periparotid and upper cervical region.

Fig. 9.15 Initial dissemination of metastatic cancer from primary

malignant tumors of the submandibular and sublingual salivary glands
occurs at lymph nodes in the supraomohyoid triangle.

gland arc adjacent to the thyroid gland, the so-called perithyroid
lymph nodes, and those in the tracheoesophageal groove and
superior mediastinum (Fig. 9.13). Sequential progression of
metastatic disease from the tracheoesophageal groove lymph
nodes progresses to lower deep jugular lymph nodes, mid jugular
lymph nodes, lymph nodes in the posterior triangle of the neck,
and subsequently to the upper jugular lymph nodes. Metastatic
disease from primary carcinoma of the thyroid to Level I is
exceedingly rare and seldom seen.
Only 20-25% of patients with carcinoma of the parotid gland
develop regional lymph node metastasis. The lymph node groups
at highest risk for early dissemination of metastatic cancer from
primary carcinoma of the parotid gland are those in the
preauricular, periparotid, and intraparotid region as well as lymph
nodes in the upper deep jugular chain and those in the'uppei
spinal accessory chain in the posterior triangle of the neck (Fig.
9.14|. Initial dissemination of metastatic cancer from primary
malignant tumors of Ihe submandibular salivary gland occurs at
lymph nodes in the supraomohyoid triangle (Fig. 9.15). Thus,
lymph nodes in the submandibular triangle and upper and

358
midjugular c h a i n of l y m p h nodes arc at risk of micrometastasis
from malignant t u m o r s of the s u b m a n d i b u l a r salivary g l a n d in
the clinically negative neck.
Cutaneous m a l i g n a n t t u m o r s of the scalp, such as squamous
carcinoma a n d m e l a n o m a , also spread to regional l y m p h nodes in
a predictable f a s h i o n . A l i n e j o i n i n g the helix of one ear to the
helix of the opposite ear in a coronal plane separates the water-
shed areas of the scalp. Tumors located anterior to this l i n e
metastasize to preauricular, periparotid and anterior cervical
l y m p h nodes (Levels I—IV) a n d seldom metastasize to the posterior
triangle of the neck. On the o t h e r h a n d , p r i m a r y t u m o r s of the
scalp posterior to this l i n e metastasize to the suboccipital a n d
postauricular group of l y m p h nodes as well as those in the
posterior triangle of the neck a n d the deep jugular c h a i n ( l e v e l s
II-V).

Fig. 9.16 Increasing accuracy of identifying occult metastasis by various

pathologic techniques.
SENTINEL NODE MAPPING

Over the course of the past 10 years the t e c h n i q u e of sentinel

node m a p p i n g , particularly for cutaneous melanomas has gained
increasing popularity. N u m e r o u s studies have reported the
accuracy a n d the p r e d i c t a b i l i t y of sentinel node biopsy to i d e n t i f y
occult metastasis. T h e accuracy has been reported to be in excess
of 98%. Thus, for cutaneous melanomas of the head a n d neck,
sentinal node m a p p i n g for the c l i n i c a l l y negative neck has
become the standard of care. On the o t h e r h a n d , the t e c h n i q u e of
sentinel node m a p p i n g for primary mucosal squamous cell
carcinomas of the oral c a v i t y a n d p h a r y n x still remains u n d e r
investigation. W h e t h e r the sentinel node m a p p i n g t e c h n i q u e w i l l
turn out to be useful for mucosal cancers of the upper aero-
digestive tract and will be practical in all situations is
questionable.
Another i m p o r t a n t issue in the procedure of sentinel node
mapping is accurate h i s t o p a t h o l o g i c assessment of the excised
'sentinel l y m p h n o d e ' to i d e n t i f y t r u l y occult a n d microscopic foci
of metastatic cancer. Routine processing by frozen seclion c a n
miss some patients w i t h t r u l y occult metastasis. However, the
accuracy of f i n d i n g occult metastasis increases w i t h m o r e sophis- Fig. 9.17 Preoperative 99mTC labeled sulfur colloid scan showing
sentinel node in the left lower neck.
ticated techniques as s h o w n in F i g . 9 . 1 6 .
While sophisticated p a t h o l o g i c techniques can i d e n t i f y the
most m i n u t e foci of microscopic cancer, even at the molecular
Fig. 9.18 Injection of
level, its c l i n i c a l significance still remains uncertain and is isosulfan blue dye
currently u n d e r study. around the primary
The procedure of sentinel node m a p p i n g is also e v o l v i n g a n d lesion.
employs one o r all o f the f o l l o w i n g three techniques: ( l | radio-
isotope scan i m a g i n g ; (2) i n j e c t i o n of blue dye; a n d (3) use of a
hand-held isotope tracer probe for l o c a l i z a t i o n . It has been s h o w n
that the c o m b i n a t i o n of all three techniques increases the accuracy
and the yield of sentinel l y m p h node i d e n t i f i c a t i o n .
A preoperative t e c h n e t i u m scan is o b t a i n e d first. This requires
injection of radioactive t e c h n e t i u m (99mTc) labeled sulfur c o l l o i d .
Generally, 0.05 m C i of the isotope is injected in four quadrants
around the p r i m a r y lesion a n d a g a m m a camera is used for
obtaining visual images at 3 m i n u t e s , 15 m i n u t e s , a n d a delayed
image at one h o u r ( F i g . 9 . 1 7 ) . Usually the first l y m p h node
identified by the t e c h n e t i u m scan is considered the sentinel
l y m p h node. I n some patients, more t h a n o n e sentinel l y m p h
node is i d e n t i f i e d .
Immediately p r i o r to the surgical procedure, isosulfan blue dye
1% (Lymphazurin ) is injected similarly in four quadrants around
the primary t u m o r ( F i g . 9 . 1 8 1 . No m o r e t h a n 0.5 ml of the dye is

359
Fig. 9.19 The hand-held gamma probe Fig. 9.20 The blue colored sentinel node which also had a high
radioactive count.
injected in the subdermal plane a r o u n d the t u m o r . The operative
procedure then is carried out w i t h i n 30 m i n u t e s of the i n j e c t i o n . CLINICAL FEATURES AND DIAGNOSIS
A hand-held g a m m a probe is used prior to p l a c i n g the i n c i s i o n
to localize the l y m p h node seen on the preoperative scan (i"ig.
9.19). The background a c t i v i t y is averaged f r o m measurements in The presence of a c l i n i c a l l y palpable, u n i l a t e r a l , firm, enlarged
four quadrants of the neck a n d a n y n o d e that has an in v i v o 10- l y m p h node in the adult s h o u l d he considered metastatic u n t i l
second count more t h a n three times t h a t of the b a c k g r o u n d is p r o v e n otherwise. The c l i n i c a l l y enlarged l y m p h node may be
considered ' h o t ' . C o r r e l a t i o n is made w i t h the preoperative scan present at a n y of t h e previously described a n a t o m i c locations in
and this area is marked out w i t h a m a r k i n g pen on the s k i n . the head a n d neck region. T h e l o c a t i o n of a palpable l y m p h node
m a y p o i n t to the p o t e n t i a l site of a p r i m a r y t u m o r . T h e important
An incision is placed d i r e c t l y o v e r l y i n g the localized sentinel
features to note d u r i n g e x a m i n a t i o n of the neck for cervical
l y m p h node a n d by careful alternate b l u n t a n d sharp dissection,
l y m p h nodes are the l o c a t i o n , size, consistency, a n d n u m b e r of
the 'blue n o d e ' is localized ( F i g . 9 . 2 0 ) . T h e h a n d - h e l d probe is
palpable l y m p h nodes as well as signs of extracapsular spread such
again used to measure the c o u n t of highest radiotracer a c t i v i t y . If
as i n v a s i o n of the o v e r l y i n g s k i n , f i x a t i o n to deeper soft tissues, or
the blue node corresponds to the area of highest radiotracer
paralysis of cranial nerves. Histologic diagnosis ol metastatic
activity, then the l y m p h n o d e is excised a n d sent for p a t h o l o g i c
c a r c i n o m a is usually established by a needle aspiration biopsy and
analysis. The surgical bed after excision of t h e l y m p h node is
c y t o l o g i c e x a m i n a t i o n of the smears. An enlarged metastatic
tested w i t h the h a n d - h e l d probe to s h o w that the radiotracer
cervical l y m p h node m a y b e the o n l y physical f i n d i n g present i n
activity is n o w reduced to that observed in the adjacent back-
some patients w h o s e p r i m a r y t u m o r s are either microscopic or
ground area, c o n f i r m i n g that the true 'sentinel l y m p h n o d e ' has
occult at the t i m e of presentation. A systematic search for a
been excised a n d sent for p a t h o l o g i c analysis. If the residual radio-
p r i m a r y t u m o r s h o u l d be u n d e r t a k e n in these patients prior to
activity in the basin is m o r e t h a n 10% of the ex Vivo c o u n t of
e m b a r k i n g u p o n therapy for the metastatic nodes. It a thorough
the hottest node in the basin, f u r t h e r e x p l o r a t i o n to f i n d m o r e
head a n d neck e x a m i n a t i o n , i n c l u d i n g fiberoptic nasolaryngo-
sentinel nodes is w a r r a n t e d . Similarly, after the node is excised,
scopy, fails to s h o w a p r i m a r y t u m o r , t h e n the diagnosis of
the radiotracer a c t i v i t y is measured w i t h a h a n d - h e l d probe f r o m
metastatic c a r c i n o m a to a cervical l y m p h n o d e f r o m an u n k n o w n
the l y m p h node ex v i v o to d e m o n s t r a t e that the l y m p h node ilsclt
p r i m a r y is established.
has a count al least 10 limes that of an adjacent n o n - s e n t i n e l
node. This ensures that t h e excised l y m p h n o d e is i n d e e d a true
sentinel l y m p h node. At present, o p i n i o n s regarding the value of
frozen section lor a sentinel n o d e vary. Because of the special THE UNKNOWN PRIMARY
processing required by sub-serial sectioning of the l y m p h n o d e to
identify occult metastasis, some investigators prefer n o t to send
A p p r o x i m a t e l y 10% of patients w i t h cancers of the head a n d neck
the l y m p h node for frozen section a n d wait for 'rush paraffin
present w i t h a c l i n i c a l l y palpable metastatic l y m p h n o d e w i t h o u t
sections' w i t h i n 24 hours lo get a more detailed analysis of the
a n y evidence of an o b v i o u s p r i m a r y t u m o r . A systematic workup
sentinel l y m p h node. Further surgical m a n a g e m e n t of regional
tor these patients is essential to establish accurate tissue diagnosis.
l y m p h nodes t h e n depends on the p a t h o l o g i c analysis of the
embark upon a systematic search for identifying the occult
excised sentinel l y m p h node.
p r i m a r y t u m o r , so as to facilitate an a p p r o p r i a t e therapeutic plan.

B60

Fig. 9.21 Technique of fine needle aspiration biopsy.
A thorough c l i n i c a l e x a m i n a t i o n of the head a n d neck area is
undertaken i n c l u d i n g careful s c r u t i n y of t h e scalp, e x a m i n a t i o n of
the external a u d i t o r y canals, a n d the skin of the head a n d neck
area. This is f o l l o w e d by careful c l i n i c a l e v a l u a t i o n of the oral
cavity, o r o p h a r y n x , h y p o p h a r y n x a n d l a r y n x i n c l u d i n g d i g i t a l
palpation o f t h e t o n s i l l a r fossae a n d t h e base o f t h e t o n g u e .
Following this, u n d e r topical anesthesia, endoscopic e x a m i n a t i o n
of the nasal cavity, n a s o p h a r y n x , h y p o p h a r y n x a n d larynx is
undertaken w i t h a flexible fiberoptic endoscope. If no p r i m a r y
tumor is readily visible, t h e n the t e n t a t i v e diagnosis of metastatic
carcinoma to a cervical l y m p h node f r o m an u n k n o w n p r i m a r y is
established.
The next step in the diagnostic w o r k u p is c o n f i r m a t i o n of tissue
diagnosis w h i c h is easily accomplished by a l i n e needle aspiration
biopsy. T h i s is usually p e r f o r m e d w i t h a 10 ml syringe a n d a n o .
22 gauge needle. A p p r o x i m a t e l y 1 ml of air is w i t h d r a w n in the
syringe and the needle is i n t r o d u c e d i n t o the palpable mass. The
plunger is w i t h d r a w n to create negative pressure w i t h i n the needle
and the syringe a n d m u l t i p l e passes are made in the t u m o r mass
to harvest tissue. F o l l o w i n g this, the negative pressure is released
and the needle is w i t h d r a w n . A core of tissue harvested in t h e
needle is n o w expressed on a glass slide by p u s h i n g o u t the air in
the syringe (Fig. 9 . 2 1 ) . A n o t h e r glass slide is used a n d smears are
made f r o m the harveted tissue. The glass slides are i m m e d i a t e l y
placed in 9 5 % a l c o h o l . T h e smears are sent for appropriate
cytologic e v a l u a t i o n .
The accuracy of t i n e needle aspiration biopsy depends u p o n :
(1) the experience of the i n d i v i d u a l p e r f o r m i n g the fine needle
aspiration procedure in securing adequate representative tissue from
the l y m p h n o d e ; a n d (2) the experience of the c y t o p a t h o l o g i s t in
Interpretation of the harvested cells. The c y t o p a t h o l o g i c inter-
pretation w i l l y i e l d o n e o f t h e several diagnostic possibilities
mentioned i n F i g . 9 . 2 2 .
The next course of a c t i o n in the w o r k u p a n d treatment for
patients w i t h metastatic c a r c i n o m a t o cervical l y m p h node f r o m
an u n k n o w n p r i m a r y is dependent on the cytopathologic report.
If indeed an accurate c y t o p a t h o l o g i c diagnosis is established, t h e n
the w o r k u p depends on f u r t h e r search for the occult p r i m a r y site.
If the tissue harvested is insufficient or n o n - d i a g n o s t i c , t h e n a
Fig. 9-22 Cytopathologic diagnostic possilbilities from a fine needle
aspriation biopsy.
• Squamous carcinoma (keratinizing or non-keratinizing).
• Poorly differentiated squamous cell <:arcinoma.
• Undifferentiated carcinoma.
• Melanoma.
• Adenocarcinoma.
• Lymphoid cells, rule out lymphoma.
• Non-diagnostic/insufficient material.
• Benign — no malignant cells seen.
repeat needle biopsy is p e r f o r m e d . An a l g o r i t h m for workup and
t r e a t m e n t at this stage is s h o w n in F i g . 9 . 2 3 .
If the c y t o p a t h o l o g y report indicates squamous cell carcinoma,
p o o r l y differentiated c a r c i n o m a , or undifferentiated carcinoma,
t h e n the p r i m a r y source is likely to be in the mucosa of the upper
aerodigestive tract. In this clinical setting, the value of a PET scan
( p o s i t r o n emission t o m o g r a p h y ) is s h o w i n g increasing promise. A
positive PET scan in the n a s o p h a r y n x , o r o p h a r y n x , or hypo-
p h a r y n x is likely to direct one's a t t e n t i o n to a potential primary
source a n d a directed biopsy is p e r f o r m e d at that site. If, however,
a PET scan is also negative, t h e n the patient undergoes systematic
evaluation of the upper aerodigestive tract under general
anesthesia w i t h m u l t i p l e endoscopies to i n c l u d e nasopharyngo-
scopy, laryngoscopy, esophagoscopy a n d bronchoscopy. Directed
biopsies are taken f r o m areas w h i c h look suspicious for a potential
p r i m a r y site. Suspicion of a p r i m a r y site is raised by firm nodu-
larity, submucosal i n d u r a t i o n o r surface b l e e d i n g o n palpation. I f
a p r i m a r y source is i d e n t i f i e d , t h e n clearly the management of the
patient w i l l depend on the identified p r i m a r y site and its treat-
m e n t a l g o r i t h m . If, however, no p r i m a r y site is identified, then
the t r e a t m e n t decisions are based on the extent of nodal disease
in the neck.
Patients w i t h metastatic disease c o n f i n e d to a single small
l y m p h n o d e w i t h o u t any c l i n i c a l or radiologic evidence of extra-
nodal spread can be managed equally w e l l w i t h radiotherapy or
surgery. O n the o t h e r h a n d , patients w i t h m u l t i p l e positive l y m p h
nodes, a large metastatic l y m p h node, or clinical or radiologic
evidence of e x t r a n o d a l spread require a comprehensive neck
dissection f o l l o w e d by postoperative radiation therapy. The extent
of neck dissection is dictated by the extent of nodal disease.
W h e n e v e r feasible, the spinal accessory nerve is preserved as long
as it is n o t d i r e c t l y i n v o l v e d by cancer a n d its preservation does
not c o m p r o m i s e adequate resection of metastatic l y m p h nodes.
C o n t i n u e d surveillance a n d f o l l o w u p o f patients f o l l o w i n g
d e f i n i t i v e t r e a t m e n t of metastatic cervical l y m p h nodes from an
u n k n o w n p r i m a r y is essential. A p p r o x i m a t e l y 1 2 - 1 5 % of patients
w i l l d e m o n s t r a t e the occult p r i m a r y source d u r i n g follow up. The
most frequent sites of occult p r i m a r y t u m o r s in that setting are the
o r o p h a r y n x , n a s o p h a r y n x , a n d h y p o p h a r y n x in that order.
RADIOGRAPHIC EVALUATION
Most patients w i t h palpable cervical lymph node metastasis
seldom require radiographic e v a l u a t i o n of the nodes for diagnosis.
However, w h e n massive metastatic disease is present, radiographic
e v a l u a t i o n by means of a CY scan w i t h intravenous contrast or an
VIKI scan w i t h g a d o l i n i u m contrast is desirable to assess the extent
of the nodal disease, particularly as it relates to the carotid artery,
the skull base, a n d the parapharyngeal space on the ipsilateral side
561
Fig. 9.2J Algorithm for investigation of a suspected unknown primary lesion. (FNAC—Fine needle aspiration cytology; MND—Modified neck
dissection; RND—Radical neck dissection; RT—Radiation therapy, TCB—Thyroglobulin).
as well as to evaluate the clinically negative contralateral .side.
Several lymph node groups which are not accessible to clinical
examination, such as those in t h e parapharyngeal and retro-
pharyngeal areas, are hest assessed by a CT scan or an MR1 scan.
Similarly, evaluation of lymph nodes in the superior mediastinum
is best accomplished with radiographic studies. The radiographic
features for diagnosis of a metastatic node are: size, rim enhance-
ment, central necrosis and cxtranodal invasion (Figs 9.24, 9.25).
Ultrasound-guided or CT scan guided fine needle aspiration
biopsy of a small lymph node often helps in establishing accurate
tissue diagnosis.
With increasing application of multidisciplinary treatment pro-
grams of chemotherapy and radiotherapy in a variety of com-
binations, the need for surgical management of cervical lymph
nodes has been questioned. Complete regression of clinically
palpable lymph nodes is often seen and many times these lymph
nodes are reported to be pathologically negative for metastases
following neck dissection. Radiologic evaluation by a CT or MRI
scan is inaccurate since it will often show a residual nidus of a
librotic node al the site of a previously palpable nodal metastasis.
362
In this setting, a PET scan appears to be of increasing value in
predicting the presence of viable tumor in t h e residue of a lymph
node which has shown a complete response (CR) (Fig. 9.26). It is
therefore recommended that all patients who show a CR or a
major response in neck nodes following chemo/radiotherapy
undergo a PET scan to facilitate the decision regarding the need
for a neck dissection.
COALS OF TREATMENT
Clearly the goal of treatmenl for cervical lymph node metastasis is
regional control of disease. Vlicromefastases and minimal gross
metastases may be controlled by radiotherapy alone. However,
surgery remains the mainstay of treatment of cervical lymph node
metastases since it provides comprehensive clearance of all grossly
enlarged lymph nodes and offers accurate histologic information
on lymph nodes at risk of having micrometastasis in the clinically
negative neck.
While the indications for comprehensive surgical clearance of
Fig. 9.24 The radiographic features for Fig. 9.2S Axial view of the CT scan of a patient Fig. 9.26 PET scan demonstrating viable
diagnosis of a metastatic node, on a contrast with N) metastasis showing soft tissue residual tumor in a patient with a radiologic
enhanced CT scan of the neck. extension with carotid artery invasion. CR in the neck following chemoradiation
therapy.

Fig. 9.27 All patients who are at risk of having micrometastasis in the N 0 Fig. 9.28 Clinical findings in a consecutive series of patients whose N 0
neck do not present for therapeutic neck dissection w i t h N, disease. neck was observed initially and who subsequently underwent
therapeutic neck dissection.

regional lymph nodes in the neck for clinically palpable

metastatic lymph nodes are obvious, the indications for elective
treatment of the N„ neck are less clear. Statistically, one is unable
to document differences in regional control rates or survival
between patients undergoing elective neck dissection for micro-
metastasis or those undergoing therapeutic neck dissection for N,
disease. Unfortunately, however, all patients who are at risk of
having micrometastasis do not present for subsequent therapeutic
neck dissection with N( disease (Fig. 9.27). Review of a con-
secutive series of patients whose N„ neck was observed initially
and who subsequently underwent therapeutic neck dissection shows
that a significant number of patients had clinically apparent meta-
static disease greater than N, (I-'ig. 9.28). Indeed, on pathologic
analysis, a majority of the patients had metastatic disease greater
than N, (Fig. 9.29). It is well known that the prognosis of a
patient with metastatic squamous carcinoma to regional cervical
lymph nodes is dependent on the extent of nodal disease in the
neck. Thus when a significant risk of micrometastasis to regional Fig. 9.29 Pathologic findings in a consecutive series of patients who
underwent subsequent therapeutic neck dissection, whose N0 neck was
lymph nodes is present based on the characteristics of the primary
observed initially.

363
Fig. 9.30 Indications lor postoperative radiotherapy to the neck.
Gross residual disease following neck dissection
Multiple positive lymph nodes in the neck
Extracapsular extension by metastatic disease
Perivascular or perineural invasion by tumor
Other ominous findings such as tumor emboli in lymphatics,
cranial nerve invasion, or extension of disease to the base of the
skull
tumor, an elective dissection of regional lymph nodes at risk
Should he considered.
Regional recurrence of metastatic disease in t h e dissected neck
is dependent on the volume of neck metastasis at the time of neck
dissection. Regional recurrence following neck dissection alone
for multiple metastatic lymph nodes is prohibitively high. There-
fore, to enhance the regional control rate, postoperative radiation
therapy is recommended. The need for adjuvant postoperative
radiation therapy, however, depends on t h e extent of disease in
the neck. Regional control of metastatic disease in the neck is sig-
nificantly enhanced with postoperative radiotherapy. Indications
for postoperative radiotherapy are listed in K g . 9.30.
SELECTION OF INITIAL TREATMENT
The surgical treatment of regional lymph nodes for carcinoma of
the head and neck region is based on t h e understanding of t h e
anatomy of the regional lymphatics, t h e patterns of regional
lymph node metastasis, and the risk of nodal metastasis depend-
ing on the characteristics of the primary tumor. When regional
metastases are clinically palpable, comprehensive clearance of all
regional lymph nodes at risk is mandatory. Classic radical neck
dissection remains the gold standard of surgical management of
clinically apparent metastatic lymph nodes. However, the mor-
bidity of the operation is significant and therefore it is recom-
mended only under select circumstances. The current indications
for classic radical neck dissection are:
• N, disease.
• Recurrent metastatic disease in a previously Irradiated neck.
• Grossly apparent extranodal spread with invasion of the spinal
accessory nerve and/or internal jugular vein at t h e base of the
skull.
• Skin involvement by metastatic disease.
On the other hand, when appropriate indications exist, a
function-preserving comprehensive neck dissection sparing o n e
or more vital anatomic structures should be considered as long as
it does not compromise satisfactory clearance of metastatic disease.
Preservation of the spinal accessory nerve alone significantly
reduces the morbidity of neck dissection. Thus if the spinal
accessory nerve is not involved by metastatic cancer, it should be
routinely preserved even in patients with clinically palpable
metastatic lymph nodes. Such a surgical approach docs not
adversely impact on local control or long-term survival, as long as
comprehensive clearance of all five cervical lymph node levels
is done, limited neck dissection for palpable nodal metastasis is
considered risky and is not recommended. Preservation of t h e
sternocleidomastoid muscle or internal jugular vein in patients
with palpable cervical lymph node metastasis from primary
squamous carcinomas of the upper aerodigeslive tract is not
364
recommended. On the other hand, the spinal accessory nerve, the
sternocleidomastoid muscle, and the internal jugular vein can all
be preserved when a neck dissection is undertaken for excision of
cervical lymph node metastasis from differentiated carcinoma of
the thyroid gland.
When an elective neck dissection is undertaken to excise
cervical lymph nodes at risk of harboring micrometaslasis (occult
metastasis), it is seldom necessary to excise all five levels of lymph
nodes. As mentioned earlier, the patterns of cervical lymph node
metastasis are predictable and sequential with involvement of the
first echelon lymph nodes initially before dissemination occurs to
other lymph node levels. Thus, an elective neck dissection is
usually of a limited extent addressing only the lymph node groups
at highest risk for a given primary site. Such a limited dissection
of lymph nodes is usually considered a 'staging procedure'. The
histologic information derived from the study of the excised
lymph nodes facilitates selection of adjuvant therapy in patients
who are at increased risk of neck failure and spares the need for a
morbid operation or adjuvant radiotherapy in others who are at
reduced risk. Thus, an elective operation for primary tumors of the
oral cavity with an N„ neck requires dissection of lymph nodes at
Levels I, II, and III. For primary tumors of the pharynx and larynx,
dissection of lymph nodes at Levels II, III, and IV is recommended.
If the primary tumor crosses the midline, bilateral clearance of
Levels II, III, and IV should be undertaken. lor large primary
tumors of the thyroid gland with a clinically negative neck,
dissection of lymph nodes in the central compartment of the neck
and the tracheoesophageal groove is t h e most o n e may consider
as an elective operation.
CLASSIFICATION OF NECK DISSECTIONS
The understanding of t h e biological progression of metastatic
disease from primary sites in t h e head and neck region to cervical
lymph nodes has allowed the development of several modifica-
tions of the classic radical neck dissection to reduce morbidity
and maintain therapeutic efficacy. In order to standardize the
terminology of various types of neck dissections, the following
classification scheme is recommended.
COMPREHENSIVE NECK DISSECTION
The term comprehensive neck dissection is applied to all surgical
procedures on the lateral neck which comprehensively remove
cervical lymph nodes from Level I through Level V. Under this
broad category are included the following operative procedures:
• Classic radical neck dissection.
• Extended radical neck dissection (resection of additional
regional lymph nodes or sacrifice of other structures such as
cranial nerves, muscles, skin, etc.)
• Modified radical neck dissection Type I (MRNT)-I). This
procedure selectively preserves the spinal accessory nerve.
• Modified radical neck dissection Type II (MRND-II). This
procedure preserves t h e spinal accessory nerve and the
sternocleidomastoid muscle but sacrifices the internal jugular
vein.
• Modified radical neck dissection Type III (MRND-llll. This
procedure requires preservation of the spinal accessory nerve,
internal jugular vein, and sternocleidomastoid muscle.
SELECTIVE NECK DISSECTION SUPRAOMOHYOID NECK DISSECTION (SOHND)

These operations selectively remove lymph n o d e g r o u p s at This o p e r a t i o n m a y he p e r f o r m e d in c o n j u n c t i o n w i t h excision

designated levels in the N 0 neck at risk of micromelastasis. ITiese
operations i n c l u d e :
• S u p r a o m o h y o i d n e c k d i s s e c t i o n . This procedure
encompasses dissection of l y m p h nodes at levels I, I I , a n d I I I .
(For p r i m a r y t u m o r s of the oral cavity.) An e x t e n d e d
s u p r a o m o h y o i d neck dissection encompassing Levels 1, I I , III
and IV is r e c o m m e n d e d for p r i m a r y cancers of the lateral
border of the oral t o n g u e .
• Jugular neck dissection ( a n t e r o l a t e r a l neck
d i s s e c t i o n ) . This procedure encompasses dissection of l y m p h
nodes at Levels I I , III a n d IV. (Lor p r i m a r y t u m o r s of the
h y p o p h a r y n x a n d larynx.)
• C e n t r a l c o m p a r t m e n t n e c k d i s s e c t i o n . I his procedure
encompasses clearance of l y m p h nodes at Level VI in t h e
central c o m p a r t m e n t of the neck adjacent to the t h y r o i d g l a n d
and in the tracheoesophageal groove. (For t h y r o i d cancer.)
• Posterolateral n e c k dissection. This operation
encompasses l y m p h nodes in the suboccipital triangle,
posterior t r i a n g l e of the neck, Level V a n d the deep jugular
chain of l y m p h nodes at Levels I I , III a n d IV. (For m e l a n o m a s
and squamous carcinomas of the posterior scalp.)
o f the p r i m a r y t u m o r f r o m the oral cavity either i n c o n t i n u i t y
where the p r i m a r y t u m o r a n d l y m p h nodes at Levels I, II and III
are removed in a monobloc fashion or as a discontinuous
procedure w h e r e the p r i m a r y t u m o r in the oral cavity may be
excised t h r o u g h a per oral approach a n d the s u p r a o m o h y o i d neck
dissection is d o n e t h r o u g h a separate transverse incision in the
upper part of the neck ( F i g . 9.32). T h e incision is placed in an
upper neck s k i n crease e x t e n d i n g f r o m the posterior border of the
s t e r n o c l e i d o m a s t o i d muscle towards the h y o i d bone up to the
m i d l i n e . T h e i n c i s i o n s h o u l d be at least t w o linger breadths below
t h e angle of the m a n d i b l e . If the p r i m a r y t u m o r is to be resected
perorally, this i n c i s i o n s h o u l d be satisfactory. On the other hand,
if t h e p r i m a r y t u m o r is n o t accessible t h r o u g h the open m o u t h or
if the p r i m a r y t u m o r of the oral c a v i t y is to be excised en bloc w i t h
the c o n t e n t s of the s u p r a o m o h y o i d triangle of the neck, then a
lower check flap approach w i l l be required. T h e skin incision
therefore is e x t e n d e d cephalad in the m i d l i n e to divide the lower
l i p i n the m i d l i n e .
T h e s k i n i n c i s i o n is o u t l i n e d in F i g . 9 . 3 3 w i t h an alternate
e x t e n s i o n i n the m i d l i n e s h o w n b y the d o i t e d line. T h e patient's
neck is extended a n d rotated to the opposite side to put the skin
at the site of surgery u n d e r t e n s i o n .

PREOPERATIVE PREPARATION

No specific preoperative preparation is required for patients

undergoing neck dissection o t h e r t h a n p l a n n i n g of the incisions
for neck dissection, particularly if the p r i m a r y t u m o r is to be
resected simultaneously. In a d d i t i o n to this, p l a n n i n g of the neck
dissection incisions must take i n t o c o n s i d e r a t i o n a n y reconstruc-
tive effort required to repair the surgical defect created f o l l o w i n g
excision o f the p r i m a r y t u m o r . T h e most c o m m o n l y e m p l o y e d
incisions for various types of neck dissections are s h o w n in
Fig. 9.31.

Fig. 9.12 The supraomohyoid neck dissection.

Fig. 9.31 The most commonly employed incisions for various types of
Fig. 9.33 The outlined skin incision

365
Dissection now continues anteriorly along the lower border of the clearly identify the Wharton's duct, and the lingual and hypo-
body of the mandible up to the attachment of the anterior belly glossal nerves in the floor of the mouth as they enter the tongue.
of the digastric muscle. Soft tissues between the mandible and The lingual and the hypoglossal nerves are shown in l ; ig. 9.42
anterior belly of digastric are separated. At this point, brisk hemor- with the Wharton's duct in the middle showing small amounts of
rhage is likely to be encountered from several vessels which
provide blood supply to the anterior belly of the digastric muscle
and the mylohyoid muscle. The nerve and vessels to the mylohyoid
muscle, however, enter parallel to each other in a fascial envelope
which is identified, clamped, divided and ligaled (Fig. 9.391.
Once all the nerve filaments and vessels along the free border of
the mylohyoid muscle are divided, the muscle will come into lull
view.
Gentle traction on the submandibular salivary gland with
several hemostats allows mobilization and delivery of the sub-
mandibular gland from its bed (Fig. 9.40|. A loop retractor is now-
placed along the lateral border of the mylohyoid muscle which is
retracted medially towards the chin of the patient (Fig. 9.41).
This gives exposure of the undersurface of the floor of the mouth
and brings into view the secreloniotor fibers to the submandibular
salivary gland as they come off the lingual nerve as well as the
Wharton's duct with accessory salivary tissue along the duct. At
this juncture, alternate blunt and sharp dissection is necessary to
Fig. 9.40 The lateral border of the mylohyoid muscle is exposed.

Fig. 9.38 Mobilization of soft tissues along the lower border of the body Fig. 9.41 The mylohyoid muscle is retracted medially towards the chin
of the mandible exposes the prevascular facial lymph nodes. of the patient.

Fig. 9.39 The neurovascular bundle to the mylohyoid muscle is Fig. 9.42 The lingual and the hypoglossal nerves are shown, with the
identified, clamped, divided and ligated. Wharton's duct in the middle.

367
salivary gland (issue along its length. Once the lingual nerve is
clearly identified, the secretomotor fillers to the submandibular
gland are d i v i d e d . The latter are s h o w n in l ; ig. 9 . 4 3 as they c o m e
off the lingual nerve. There is usually a small b l o o d vessel accom-
panying this nerve so it is d i v i d e d between clamps a n d ligated.
Similarly, the W h a r t o n ' s duct is d i v i d e d between clamps a n d its
distal s t u m p ligated. T h e entire submandibular g l a n d is n o w
retracted posteroinferiorly, a n d loose areolar tissue between the
salivary g l a n d a n d the digastric muscle is d i v i d e d . As o n e
approaches the posterior belly of the digastric muscle, the
proximal part of the facial artery as it enters the s u b m a n d i b u l a r
salivary gland is exposed ( F i g . 9 . 4 4 ) . It is d i v i d e d between clamps
and ligated. The entire contents of the submandibular triangle are
now dissected off a n d retracted interiorly.
A t t e n t i o n is n o w focused on the region of t h e tail of the parotid
gland and the anterior border of the upper part of the sterno-
mastoid muscle. T h e fascia along the anterior border of the
sternomastoid muscle is grasped w i t h several hemostats a n d
retracted medially to p r o v i d e traction a l o n g its anterior bonier
(Fig. 9.4S). Using electrocautery, the anterior border of the
sternomastoid muscle is cleared off its facial attachments. Several
t i n y vessels e n t e r i n g the upper pari of the sternomastoid muscle
Fig. 9.4J The secretomotor fibers to the submandibular gland shown
here are divided.
Fig. 9.44 The proximal part of the facial artery cephalad to the digastric
tendon is divided.
368
(branches f r o m the occipital a n d superior t h y r o i d arteries) are
d i v i d e d w i t h the electrocautery, f u r t h e r medial retraction of the
specimen exposes the carotid sheath as s h o w n in F i g . 9 . 4 6 . The
latter is incised a n d dissection n o w proceeds cephalad towards
the base of the s k u l l .
A hemoslat is used to separate the fascia of the carotid sheath
w h i c h is d i v i d e d a n d retracted medially ( F i g . 9.471. This dissec-
t i o n c o n t i n u e s cephalad up to the posterior belly of (he digastric
muscle w h i c h is retracted cephalad to expose (he upper end of the
jugular v e i n e n t e r i n g the jugular f o r a m e n . Several pharyngeal
veins as w e l l as tributaries to the c o m m o n facial vein may have to
be d i v i d e d in order to m o b i l i z e the specimen.
One of the pharyngeal veins is s h o w n in Fig. 9 . 4 8 w h i c h will
be d i v i d e d to facilitate m o b i l i z a t i o n of the specimen. The sterno-
mastoid muscle is n o w retracted f u r t h e r posteriorly exposing the
jugular vein in its entirety. The latter is still covered by a fascial
envelope containing upper deep jugular and jugulodigastric
l y m p h nodes ( F i g . 9 . 4 9 ) . The sternomastoid muscle is retracted
posteriorly to expose l y m p h nodes in the accessory chain at the
apex of the posterior triangle; these are m e t i c u l o u s l y dissected out
a n d retracted a n t e r i o r l y w i t h the rest of the surgical specimen.
W h i l e dissecting the l y m p h nodes at the apex of the posterior
Fig. 9.45 The fascia along the anterior border of the sternomastoid
muscle is retracted medially to provide traction along its anterior border.
Fig. 9.46 The carotid sheath is exposed.
triangle of the neck, extreme care s h o u l d be exercised to i d e n t i f y
and carefully preserve the spinal accessory nerve as w e l l as
cutaneous a n d muscular branches of the cervical plexus ( F i g .
9.50). Once the spinal accessory nerve is i d e n t i f i e d , the l y m p h
nodes posterolateral to it are dissected a n d passed beneath the
nerve anteriorly t o r e m a i n i n c o n t i n u i t y w i t h the rest o f the
specimen. The upper e n d of the jugular vein is n o w nearly f u l l y
cleared of deep jugular, jugulodigastric, a n d upper accessory c h a i n
lymph nodes.
Dissection of the apex of the posterior triangle clearly shows the
upper end of the i n t e r n a l jugular v e i n a n d the o v e r l y i n g o c c i p i t a l
artery crossing it at right angles.
The highest root of t h e cervical plexus is exposed w i t h f u r t h e r
dissection of the e l e v e n t h nerve a n d r e m o v a l of l y m p h nodes in
the jugulodigastric region. The posterior limit of the s u p r a o m o h y o i d
neck dissection in this area is rather arbitrary, since no specific
anatomic landmarks exist to d e f i n e t h e extent of posterior t r i a n g l e Fig. 9.49 The jugular vein is still covered by a fascial envelope
l y m p h node dissection, so c l i n i c a l j u d g m e n t must be exercised to containing upper deep jugular and jugulodigastric lymph nodes.
decide on the extent of t h e i r r e m o v a l .
Dissection of the accessory c h a i n l y m p h nodes posterior to the
internal jugular v e i n at the apex of the posterior t r i a n g l e is n o w
complete ( F i g . 9 . 5 1 ) . T h e entire jugular v e i n is exposed w i t h the
posterior belly of the digastric muscle retracted cephalad. T h e

Fig. 9.S0 The accessory nerve and the cutaneous and muscular branches
of the cervical plexus should be identified and carefully preserved.

Fig. 9.47 The fascia of the carotid sheath is divided and retracted
medially.

Fig. 9.48 One or more of the pharyngeal veins are divided to facilitate Fig. 9.51 Completed dissection of the accessory chain lymph nodes
mobilization of the specimen. posterior to the internal jugular vein at the apex of the posterior
triangle, exposes the occipital artery.

369
specimen is n o w reflected a n t e r i o r l y a n d the c o m m o n facial v e i n
is divided as it enters the i n t e r n a l jugular vein a n d is ligatcd ( F i g .
9.S2). Dissection c o n t i n u e s a n t e r i o r l y , carefully i d e n t i f y i n g a n d
preserving the hypoglossal nerve as w e l l as t h e descendens
hypoglossi, the nerve s u p p l y to the strap muscles.
The descendens hypoglossi is s h o w n in F i g . 9 . 5 3 as it comes o f f
the hypoglossal nerve a n d runs a n t e r o i n f c r i o r l y . Dissection also
continues along the medial aspect of t h e carotid sheath e x p o s i n g
the carotid hull). The surgical specimen m o b i l i z e d so far consists
of the contents of the s u b m a n d i b u l a r triangle, l y m p h nodes f r o m
the jugulodigastric region a n d t h e apex of the posterior t r i a n g l e of
the neck, as w e l l as the upper deep jugular l y m p h nodes.
Fig. 9.52 The specimen is reflected anteriorly and the common facial
vein is divided and ligated.
Fig. 9.S3 The descendens hypoglossi.
B70
Dissection is n o w c o n t i n u e d caudad towards the apex of the
s u p r a o m o h y o i d triangle, the j u n c t i o n where the superior belly of
t h e o m o h y o i d muscle crosses the sternomastoid muscle. A l o o p
retractor is placed to expose the lower pari of the carotid sheath
f r o m where rnidjugular l y m p h nodes are dissected out a n d reflected
cephalad. Dissection continues further medially exposing the origin
of the superior t h y r o i d artery w h i c h is preserved, but the superior
t h y r o i d v e i n w i l l have to be .sacrificed since this was previously
d i v i d e d f r o m the i n t e r n a l jugular v e i n ( F i g . 9 . 5 4 ) . The final
a t t a c h m e n t s of t h e specimen in the region of the t h y r o h y o i d
m e m b r a n e a n d the i n s e r t i o n of the strap muscles over the h y o i d
b o n e are d i v i d e d w i t h electrocautery.
Fig. 9.S4 Dissection is continued caudad towards the apex of the
supraomohyoid triangle.
Fig. 9.55 The surgical field following removal of the specimen.
 The surgical field f o l l o w i n g removal of the specimen shows
complete clearance of the s u p r a o m o h y o i d triangle ( F i g . 9 . 5 5 ) .
The a n a t o m i c structures d e m o n s t r a t e d here are the a n t e r i o r a n d
posterior bellies of digastric a n d m y l o h y o i d muscles. The l i n g u a l
and hypoglossal nerves as w e l l as the m a r g i n a l b r a n c h of the
facial nerve are also seen in t h e s u b m a n d i b u l a r triangle. T h e
superior belly o f the o m o h y o i d , s t e r n o h y o i d a n d the s t y l o h y o i d
muscles as w e l l as the b i f u r c a t i o n of the carotid artery are also in
clear view. Note that the l y m p h nodes f r o m Levels II a n d III along
the internal jugular v e i n are all dissected o f f w i t h the specimen.
The posterior a n d i n f e r i o r views of the surgical field d e m o n s t r a t e
the spinal accessory nerve as w e l l as branches of the cervical
plexus, and the lower e n d of the s u p r a o m o h y o i d t r i a n g l e where
Fig. 9.56 Posterior and
inferior views of the
S surgical field.
Fig. 9.57 A single
suction drain is
inserted through a
separate stab incision.
the sternomastoid a n d the o m o h y o i d muscles cross each other
(Tig. 9.56).
T h e w o u n d is n o w irrigated w i t h Bacitracin s o l u t i o n . A single
s u c t i o n d r a i n is inserted t h r o u g h a separate stab incision a n d is
placed parallel to the anterior border of t h e sternomastoid muscle
up to the s u b m a n d i b u l a r triangle ( F i g . 9 . 5 7 ) . The d r a i n is secured
in place w i t h a silk suture to the s k i n at t h e site of entry, and the
i n c i s i o n closed in t w o layers using 3-0 c h r o m i c catgut interrupted
sutures for platysma a n d 5-0 n y l o n i n t e r r u p t e d sutures for skin
( F i g . 9 . 5 8 ) . Blood loss d u r i n g this operative procedure should be
m i n i m a l . T h e postoperative appearance o f the patient d e m o n -
strates that there is essentially no esthetic or f u n c t i o n a l deformity
f o l l o w i n g this o p e r a t i o n ( F i g . 9 . 5 9 ) .
Fig. 9.58 The drain is secured in place, and the incision is closed in
layers.
Fig. 9.59 The postoperative appearance of the patient.
371
Fig. 9.60 The extended supraomohyoid neck dissection. Fig. 9.61 Outline of skin incision for jugular neck dissection

EXTENDED SUPRAOMOHYOID NECK DISSECTION

Patients w i t h p r i m a r y c a r c i n o m a of t h e lateral border of t h e oral

tongue have a small risk of h a v i n g skip metastasis to Level IV of
the ipsilateral neck. Therefore, an elective o p e r a t i o n being u n d e r -
taken for p r i m a r y carcinomas of the oral t o n g u e s h o u l d i n c l u d e
Level IV in a d d i t i o n to the standard s u p r a o m o h y o i d neck dissec-
t i o n . This extended s u p r a o m o h y o i d neck dissection is an operative
procedure very similar to the standard s u p r a o m o h y o i d neck dis-
section I F i g . 9 . 6 0 ) .
D u r i n g the course of dissection of Level III l y m p h nodes, the
lower skin flap is retracted caudad a n d (he t e n d o n of the o m o h y o i d
muscle crossing the lower h a l f of the i n t e r n a l jugular v e i n is
d i v i d e d . This p e r m i t s f u r t h e r r e t r a c t i o n o f t h e l o w e r s k i n f l a p
towards the clavicle. Dissection is n o w c o n t i n u e d a l o n g the lower
half of the i n t e r n a l jugular v e i n to i n c l u d e the l y m p h nodes at
Level IV. M e t i c u l o u s a t t e n t i o n s h o u l d he paid in this part of the Fig. 9.62 jugular (anterolateral) neck dissection.
dissection to carefully i d e n t i f y t h e l y m p h a t i c channels at the root
of the neck. These s h o u l d he i n d i v i d u a l l y c l a m p e d , d i v i d e d , a n d
ligated. In the left side of the neck, the t h o r a c i c duct s h o u l d be b o t h sides of the l a r y n g o p h a r y n g e a l mucosa. The operative pro-
carefully looked for, i d e n t i f i e d a n d ligated. Dissection of l y m p h cedure is p e r f o r m e d usually t h r o u g h the same i n c i s i o n employed
nodes at Level IV therefore includes the l y m p h nodes medial a n d for resection of the p r i m a r y t u m o r w h i c h is usually a transverse
anterior to the i n t e r n a l jugular v e i n as w e l l as lateral to the i n c i s i o n a l o n g an upper neck s k i n crease in the region of the
internal jugular vein in the region of the lymphatic t h y r o h y o i d m e m b r a n e e x t e n d i n g f r o m the posterior border of
channels/thoracic d u c t , a n d the o r i g i n of the transverse cervical .sternocleidomastoid muscle on o n e side of the neck to that on the
artery. These l y m p h nodes s h o u l d t h e n be b r o u g h t over to r e m a i n o t h e r side of the neck ( F i g . 9 . 6 1 ) .
i n c o n t i n u i t y w i t h the specimen o f o t h e r deep jugular l y m p h
F o l l o w i n g s k i n i n c i s i o n , the platysma is d i v i d e d t h r o u g h o u t the
nodes f r o m Levels II a n d 111. The e x t e n d e d s u p r a o m o h y o i d neck
e n t i r e l e n g t h of the i n c i s i o n a n d upper a n d lower skin flaps are
dissection w i l l therefore i n c l u d e a l l t h e l y m p h nodes i n the
elevated in the usual fashion exposing the anterior border of the
anterolateral triangle of the neck i n c l u d i n g Levels I, I I , 111 a n d IV.
s t e r n o c l e i d o m a s t o i d muscle in its e n t i r e t y f r o m the region of
The o n l y l y m p h nodes w h i c h are n o t resected w i t h this o p e r a t i o n
the posterior belly of the digastric muscle cephalad to the
are the ones a l o n g the lower spinal accessory c h a i n l y m p h nodes
i n s e r t i o n of the sternal head caudad. There is no particular virtue
and transverse cervical c h a i n of l y m p h nodes in the posterior
i n d o i n g jugular n o d e dissection i n c o n t i n u i t y w i t h resection o f
triangle of the neck.
the p r i m a r y t u m o r unless a t o t a l p h a r y n g o l a r y n g e c t o m y is being
p e r f o r m e d . I n a s m u c h as all i n t e r n a l jugular chains of l y m p h
nodes at Levels I I , I I I , a n d IV are excised in a m o n o b l o c fashion,
JUGULAR (ANTEROLATERAL) NECK DISSECTION t h e o n c o l o g i c purpose of this o p e r a t i o n is served. The extent of
the nodal tissue to be cleared is s h o w n in F i g . 9 . 6 2 . The internal
This operation is usually p e r f o r m e d in c o n j u n c t i o n w i t h resection jugular g r o u p of l y m p h nodes w h i c h lie anteriorly, laterally and
o f the p r i m a r y t u m o r o f t h e l a r y n x o r h y p o p h a r y n x . Jugular node posterior lo the i n t e r n a l jugular v e i n are excised in a monobloc
dissection m a y be p e r f o r m e d on the ipsilateral side for lesions f a s h i o n . This by necessity w i l l require clearance of l y m p h nodes of
w h i c h are u n i l a t e r a l in its mucosal extent or it m a y he p e r f o r m e d the i n t e r n a l jugular c h a i n at least up to the posterior border of the
bilaterally for those lesions w h i c h cross t h e m i d l i n e t o i n v o l v e s t e r n o c l e i d o m a s t o i d muscle.

y/2
 The operative procedure begins with incising the fascia along
the anterior border of the sternocleidomastoid muscle which is
grasped with hemostats to permit retraction of the sternomastoid
muscle posteriorly. This dissection continues on the undersurface
of the sternocleidomastoid muscle all the way up to its posterior
border. During the course of this pari of the operation, the blood
supply to the sternocleidomastoid muscle from branches of the
occipital artery and superior thyroid artery will be encountered.
These vessels are carefully divided and ligated. Once this is accom-
plished, the entire sternocleidomastoid muscle can be retracted
with Richardson retractors posteriorly, totally exposing the internal
jugular lymph nodes from the jugulodigastric region cephalad to
the supraclavicular region caudad.
Dissection begins at the upper end clearing the lymph nodes
which are posterior to the spinal accessory nerve as it exits from
the jugular foramen. These lymph nodes are covered by the upper
end of the sternocleidomastoid muscle and lie over the Splenitis
capitus and levator scapulae muscles in the floor of the posterior
triangle of the neck. Meticulous dissection of these lymph nodes
allows delivery from beneath the accessory nerve anteriorly to
remain in continuity with the jugulodigastric group of lymph
nodes. Similarly dissection of lymph nodes overlying the sensory Fig. 9.6S The surgical specimen
roots of the cervical plexus is undertaken, exposing the sensory
roots, and carefully continuing the dissection up to the lateral
border of the internal jugular vein to keep these lymph nodes in
continuity with the deep jugular lymph nodes. Clearance of the
accessory chain of lymph nodes and exposure of all the cervical
roots is essential to provide satisfactory clearance of contiguous
lymph nodes in the posterior triangle.

At this juncture, dissection continues anterolateral to the

internal jugular vein clearing off all the lymph nodes and freeing
up the internal jugular vein in its entirety from the jugular
foramen cephalad and to the supraclavicular region caudad. In so
doing, the tendon of the omohyoid muscle is divided. No attempt
is made to continue the dissection of lymph nodes in the
submandibular triangle, leaving the submandibular salivary gland
intact. Several pharyngeal branches of the internal jugular vein
and the common facial vein, however, will have to be divided and
ligated to facilitate dissection of the upper jugular lymph nodes.
By meticulous alternate blunt and sharp dissection, the hypo-
Fig. 9.64 The surgical field following bilateral jugular node dissections.
glossal nerve, the descendens hypoglossi, and the branches of the
superior thyroid artery are identified and carefully preserved,
delivering the specimen. specimen allow.s accurate pathologic staging of the primary tumor
The specimen shown in Fij>. 9.63 demonstrates monobloc to select patients who would require adjuvant postoperative radiation
excision of bilateral internal jugular group of lymph nodes from therapy.
levels II, III and IV. To facilitate accurate description of the excised
lymph nodes, it is important to apply numerical tags to the lymph
nodes depicting Levels II, III and IV. This would facilitate proper CENTRAL COMPARTMENT NECK DISSECTION
analysis of the surgical specimen to render an accurate histo-
pathologic report. If bilateral jugular node dissections are under- This operative procedure is undertaken for dissection of regional
taken, then the surgical specimen should also indicate whether it lymph nodes for metastases from primary differentiated carci-
is from the left- or right-hand side. noma of the thyroid gland when the primary tumor is extensive
The surgical field following bilateral jugular lymph node dissec- with invasion of the capsule of the thyroid gland or with exten-
tions performed in this patient with carcinoma of the posterior sion beyond the capsule of the thyroid gland to secure satisfactory
pharyngeal wall is shown in Fig. 9.64. Note complete clearance of clearance of local and regional disease from the central compart-
the internal jugular lymph nodes exposing the internal jugular ment of the neck. If the primary tumor is of significant dimen-
vein in its entirety. The roots of the cervical plexus in the posterior sions or involves both sides of the thyroid gland then bilateral
triangle are exposed. The submandibular salivary glands are seen tracheoesophageal groove lymph node dissection is undertaken..
cephalad. Suction drains are placed appropriately and the incision When minimal enlargement of the central compartment lymph
is closed in layers in the usual manner. The functional and esthetic nodes is observed during the course of the thyroidectomy, as long
impact of this surgical procedure is essentially none. However, as the lateral neck is grossly negative, a central compartment node
the histologic information derived from analysis of the surgical dissection of the neck is considered adequate (Fig. 9.65).

373
 Fig. 9.66 The surgical
field following total
thyroidectomy and
tracheoesophageal
groove lymph node
dissection.

Fig. 9.6S Central compartment node dissection.

The operative procedure usually begins w i t h a t h y r o i d e c t o m y . POSTEROLATERAL NECK DISSECTION

Following e x p l o r a t i o n of the t h y r o i d g l a n d , a decision is made
regarding the need for p e r f o r m a n c e of a central c o m p a r t m e n t
l y m p h node dissection. The first step in the operative procedure is This o p e r a t i v e procedure is r e c o m m e n d e d for clearance of
careful i d e n t i f i c a t i o n a n d preservation of the p a r a t h y r o i d glands regional l y m p h nodes f r o m the suboccipital triangle a n d the
w i t h their b l o o d s u p p l y i n t a c t . T h i s is usually a c c o m p l i s h e d by posterior t r i a n g l e of the neck at Level V in c o n j u n c t i o n w i t h deep
incising the fascia over the lateral border of the t h y r o i d g l a n d . jugular l y m p h nodes at Levels I I , III a n d IV ( F i g . 9.67). The
This fascia is carefully elevated f r o m t h e posterior b o r d e r of t h e operative procedure may be performed in continuity with
thyroid gland. In so d o i n g , several t e r m i n a l branches of the superior excision of the p r i m a r y s k i n c a r c i n o m a or m e l a n o m a of the
and inferior t h y r o i d arteries d i s t a l to the p a r a t h y r o i d glands are posterior scalp or it m a y be p e r f o r m e d d i s c o n t i n u o u s l y using a
encountered. These arc i n d i v i d u a l l y d a m p e d , d i v i d e d a n d ligated. h o c k e y stick t y p e of an i n c i s i o n w i t h posterior extension at the
Once the p a r a t h y r o i d glands are safely dissected off the t h y r o i d upper e n d to expose the o c c i p i t a l region ( F i g . 9 . 6 8 1 . The skin
g l a n d , the recurrent laryngeal nerve is i d e n t i f i e d a n d exposed flaps are elevated in the usual f a s h i o n . In order to accomplish
t h r o u g h o u t its course in the central c o m p a r t m e n t of the neck to dissection of the suboccipital l y m p h nodes, the trapezius muscle
facilitate clearance of t h e tracheoesophageal g r o o v e l y m p h nodes. is detached f r o m the o c c i p i t a l b o n e a n d reflected posteriorly to
Following i d e n t i f i c a t i o n a n d dissection of the recurrent laryngeal expose the suboccipital triangle. Suboccipital l y m p h nodes and
nerve, all the fibro-fatty tissue a n d l y m p h nodes in the central the l y m p h nodes deep to the trapezius muscle are then dissected
compartment of the neck are excised, e x t e n d i n g f r o m the carotid o f f f r o m t h e u n d e r l y i n g muscles a n d reflected a n t e r i o r l y t o remain
sheath laterally to the tracheoesophageal groove m e d i a l l y a n d
extending f r o m the level of the h y o i d b o n e superiorly to the
superior m e d i a s t i n u m i n t e r i o r l y . The l o w e r l i m i t of t h e tracheo-
esophageal groove n o d e dissection is somewhat arbitrary a n d ends
at the level of the i n n o m i n a t e artery in the superior m e d i a s t i n u m .
Often the tracheoesophageal groove node dissection is not able to
be accomplished in a m o n o b l o c f a s h i o n . T h i s is particularly true if
the parathyroid glands are to be dissected a n d preserved w i t h t h e i r
blood s u p p l y intact. Sacrifice of t h e strap muscles often facilitates
exposure and s m o o t h c o n d u c t of dissection of the central c o m -
partment l y m p h nodes.

The surgical field following clearance of bilateral tracheo-

esophageal groove l y m p h nodes a n d the central c o m p a r t m e n t o f
the neck is s h o w n in a patient w h o underwent total t h y r o i d e c t o m y
for papillary c a r c i n o m a o f the t h y r o i d g l a n d diffusely i n v o l v i n g
both lobes ( F i g . 9 . 6 6 ) . If the p a r a t h y r o i d glands are i n a d v e r t e n t l y
injured or dissected off d u r i n g the course of tracheoesophageal
groove node dissection, t h e n they s h o u l d b e i m p l a n t e d i n one o f
the muscles of t h e lateral neck. Fig. 9.67 Posterolateral neck dissection.

374

Fig. 9.68 Wide excision of melanoma of postauricular region in
continuity with posterolateral neck dissection.
Fig. 9.69 Suboccipital lymph nodes and the lymph nodes deep to the
trapezius muscle are dissected off from the underlying muscles, with
clearance of Levels II—V in the lateral neck.
i n c o n t i n u i t y w i t h l y m p h nodes o f the posterior t r i a n g l e o f t h e
neck ( F i g . 9.69). D u r i n g dissection o f the l y m p h nodes i n t h e
posterior t r i a n g l e of t h e neck, the accessory nerve is preserved if it
is not grossly i n v o l v e d by metastatic disease or if it does n o t
compromise satisfactory clearance of grossly enlarged metastatic
l y m p h nodes. Dissection of the deep jugular l y m p h nodes is under-
taken by retracting the s t e r n o c l e i d o m a s t o i d muscle a n t e r i o r l y ,
exposing the i n t e r n a l jugular v e i n a n d p e r m i t t i n g clearance Ol
l y m p h nodes a t Levels I I , III a n d I V i n c o n t i n u i t y w i t h l y m p h
nodes in the posterior t r i a n g l e of t h e neck. The postoperative
appearance of the patient shows a well-healed, csthetically accept-
able scar ( F i g . 9 . 7 0 ) . T h e surgical defect at the p r i m a r y site is s k i n
grafted.
Fig. 9.70 The
postoperative
appearance of the
patient.
MODIFIED RADICAL NECK DISSECTION TYPE I (MRND-I)
This operative procedure c o m p r e h e n s i v e l y provides clearance of
cervical l y m p h nodes at all live levels in the neck but selectively
preserves o n l y o n e a n a t o m i c structure w h i c h is the spinal accessory
nerve ( F i g . 9 . 7 1 ) . T h e patient s h o w n here had a p r i m a r y carci-
n o m a of the t o n g u e treated previously a n d he n o w presents w i t h
a c l i n i c a l l y apparent metastatic l y m p h n o d e at level II in the right
side of the neck. T h e l o c a t i o n of t h e l y m p h node is shown in
r e l a t i o n to t h e s k i n i n c i s i o n for this o p e r a t i o n w h i c h is exactly
similar to that e m p l o y e d for a classic radical neck dissection ( F i g .
9.72). The transverse i n c i s i o n is at least t w o linger breadths below
the angle of the m a n d i b l e . A curvaceous vertical l i m b begins at a
p o i n t posterior to the carotid artery.
T h e o p e r a t i o n begins w i t h e l e v a t i o n o f t h e posterior skin flap
first, r e m a i n i n g just on the undersurface of the platysma ( F i g .
9 . 7 3 ) . M e t i c u l o u s a t t e n t i o n s h o u l d he paid as elevation of the
lateral aspect of the skin flap approaches the anterior border of the
trapezius muscle in the lower part of the neck since the accessory
nerve enters the muscle in this r e g i o n . The posterior flap is
elevated w e l l over t h e a n t e r i o r border of the trapezius muscle to
expose at least 1 cm of its anterolateral surface ( F i g . 9.74). At this
p o i n t , the spinal accessory nerve is identified as ii enters the
trapezius muscle m e d i a l to its anterior border. A tissue spreading
t e c h n i q u e using an Adson's c l a m p ( l o n g hemostat) is used to
dissect the fascia a n d soft tissue over the nerve to prevent any
i n j u r y to it ( F i g . 9 . 7 5 ) . The nerve is traced up to its exit from the
posterior border of t h e s t e r n o c l e i d o m a s t o i d muscle, f u r t h e r dis-
section of the accessory nerve is h e l d at this p o i n t .
Dissection of the soft tissue a n d l y m p h nodes of the posterior
t r i a n g l e of the neck in the upper part n o w proceeds, remaining
superficial to the posterior c o m p a r t m e n t muscles, i.e. splenius
capitis a n d levator scapulae ( F i g . 9.76). The upper end of the
s t e r n o c l e i d o m a s t o i d muscle is n o w detached f r o m the mastoid
process. T h e s p i n a l accessory nerve in its lower part is dissected
free of the rest of the specimen using a M a r t i n ' s forceps and sharp
scissors to skeletonize the nerve ( F i g . 9 . 7 7 ) . Further dissection of
the nerve requires s p l i t t i n g of t h e sternocleidomastoid muscle in
its upper half, keeping the nerve u n d e r constant view at all times.
The s t e r n o c l e i d o m a s t o i d muscle is d i v i d e d up to the posterior
belly of digastric muscle to expose the spinal accessory nerve in its
entirety, f r o m the jugular f o r a m e n cephalad u n t i l its entry i n t o
the trapezius muscle caudad (Fig. 9.78). The nerve is now
375
Fig. 9.71 Modified radical neck dissection Type I.
Fig. 9.74 Elevation of the posterior skin flap is done until the anterior
border of the trapezius muscle is exposed.

Fig. 9.72 The location of the palpable lymph node and the skin incision Fig. 9.75 The spinal accessory nerve is identified at its point of entry in
is outlined on the patient. the trapezius muscle.

Fig. 9.7J The posterior skin flap is elevated first, keeping the platysma Fig. 9.76 Dissection of the upper part of the posterior triangle lymph
on the skin flap. nodes is carefully completed preserving the spinal accessory nerve.

376
completely dissected free circumferentially throughout its length.
The dissected portion of the specimen of the contents of the pos-
terior triangle is now passed underneath the nerve and retracted
medially. Dissection now proceeds along the medial border of the
levator scapulae and scalene muscles, exposing the roots of the
cervical plexus (Fig. 9.79). The cervical roots have three com-
ponents. Nerve supply to the posterior compartment muscles is
carefully preserved as shown in Fig. 9.79. The descending fibers
contributing to the phrenic nerve are also carefully preserved,
however, the cutaneous branches of the cervical plexus are
divided. The stumps of the cutaneous roots are ligatcd since small
blood vessels accompany these nerve roots. Further mobilization
of the specimen provides exposure of the internal jugular vein
from the posterior belly of the digastric muscle cephalad, up to the
root of the neck caudad (Fig. 9.80).
The surgical specimen is now flipped laterally and the medial
skin flap is elevated to expose the lower insertion of the sternocleido-
mastoid muscle. The skin flap is elevated to provide exposure of
the entire medial border of the sternomastoid muscle (as shown in
Fig. 9.81). With the use of the electrocautery, the sternal as well
Fig. 9.77 The spinal accessory nerve is lifted off the specimen and
meticulously dissected from the lymph nodes in the lower part of the
posterior triangle of the neck.
Fig, 9.78 Dissection of the posterior triangle of the neck is complete
with preservation of the accessory nerve.
as the clavicular heads of the sternocleidomastoid muscle are
divided just near their insertion. A layer of fibro-fatty tissue is present
between the undersurface of the sternocleidomastoid muscle and
the carotid sheath. At this juncture, the lymphatic ducts between
the deep jugular lymph nodes at the lateral aspect of the lower end
of the internal jugular vein are carefully identified, divided, and
ligated (Fig. 9.82). the transverse cervical artery and its accom-
panying vein are also divided and ligated. By alternate blunt and
sharp dissection, the lower end of the jugular vein is circum-
ferentially dissected free, carefully protecting the common carotid
artery, the vagus nerve, the sympathetic chain, and the phrenic
nerve (Fig. 9.83). The vein is doubly ligated, divided, and its
stump is suture ligated.
Dissection now proceeds along the carotid sheath cephalad all
the way up to the lower border of the digastric muscle where the
hypoglossal nerve with its descendens hypoglossi branch is visible
(Fig. 9.84). Medially the dissection proceeds along the superior
belly of the omohyoid muscle up to the hyoid hone from where it
is detached. The superior thyroid artery is carefully preserved but
the superior thyroid vein is divided and ligated. Several minor
Fig. 9.79 Cutaneous roots of the <ervical plexus are divided but
contributions to the phrenic nerve and nerve supply to the scalene
muscles are preserved.
Fig. 9.80 Medial retraction of the specimen exposes the internal jugular
vein.
377

Fig. 9.81 The medial skin flap is elevated to expose the lower end of the
sternocleidomastoid muscle.
Fig. 9.82 The lymphatic ducts at the root of
the neck are carefully divided and ligated.
Fig. 9.85 The upper skin flap is elevated,
carefully preserving the mandibular branch of
the facial nerve,
378
bleeding points along the branches of the descendens hypoglossi
are divided and elect rocoagulated. At this juncture, the dissection
of the lower part of the neck is completed.
The surgical specimen is now allowed to rest over the lower part
of the neck and the upper skin flap is elevated carefully,
identifying and preserving the mandibular branch of the facial
nerve (Fig. 9.85). The skin flap is elevated up to the lower border
of the body of the mandible to permit dissection of the pre-
vascular facial group of lymph nodes. The anterior belly of the
digastric muscle is identified next and the submental group of
lymph nodes are dissected from the midline and brought towards
the right-hand side. The nerve and blood supply to the mylohyoid
muscle is divided and ligated. This permits retraction of the sub-
mandibular salivary gland which is freed up by dividing the facial
artery and vein at the lower border of the body of the mandible
(Fig. 9.86). A large loop retractor is now used to retract the
mylohyoid muscle cephalad to expose the Wharton's duct, the
lingual nerve, and the secretomotor fibers to the submandibular
salivary gland. The secretomotor fibers are divided and ligated
(Fig. 9.87). Division of the Wharton's duct between clamps permits
Fig. 9.8J The lower end of the internal jugular Fig. 9.84 Further dissection cephalad along the
vein is divided and ligated. carotid sheath exposes the hypoglossal nerve
and descendens hypoglossi.
Fig. 9.86 The facial artery and vein are divided Fig. 9.87 The secretomotor fibers to the
and ligated near the lower border of the submandibular salivary gland are divided,
mandible.
 Fig. 9.88 The facial Fig. 9.90 Two suction
artery entering the drains are introduced
submandibular salivary in the surgical field.
gland as well as the
upper end of the
internal jugular vein
are exposed.

Fig. 9.89 The surgical field following removal of the specimen.

the dissection a n d d e l i v e r y of the s u b m a n d i b u l a r salivary g l a n d

from tlie s u b m a n d i b u l a r triangle. T h e r e m a i n i n g a t t a c h m e n t o f Fig. 9.91 The skin incision is closed in layers.
the submandibular g l a n d i s n o w t h r o u g h the p r o x i m a l s t u m p o f
the facial artery s h o w n in F i g . 9 . 8 8 . The facial artery is d i v i d e d
and ligated. Finally, the o n l y r e m a i n i n g a t t a c h m e n t of the speci-
men to the patient is at t h e upper e n d of the i n t e r n a l jugular v e i n
w h i c h is d o u b l y ligated, d i v i d e d , a n d its s t u m p is suture ligated
( F i g . 9 . 8 8 1 . T h e surgical held f o l l o w i n g removal of the specimen
Fig. 9.92 The
is shown in F i g . 9 . 8 9 . Absolute hemostasis is secured. Two suction
appearance of the
drains are introduced t h r o u g h separate stab incisions. T h e posterior patient six months
drain is allowed to rest a l o n g t h e anterior border of t h e trapezius following surgery.
muscle and the anterior d r a i n is placed parallel to the strap muscles
( F i g . 9.90). The d r a i n s are secured in p o s i t i o n w i t h loose loops of
chromic catgut sutures t h r o u g h the u n d e r l y i n g muscles to prevent
their displacement. The s k i n i n c i s i o n is thereafter closed in t w o
layers using 3-0 c h r o m i c catgut i n t e r r u p t e d sutures for platysma
and 5-0 n y l o n sutures or staples for skin ( F i g . 9.91).

The postoperative appearance of the p a t i e n t a p p r o x i m a t e l y six

months f o l l o w i n g M R N D - I i s s h o w n in F i g . 9 . 9 2 . Note t h e
absence of d r o p p e d shoulder. The c o n t o u r of the trapezius muscle
is preserved, d e m o n s t r a t i n g that the nerve s u p p l y to the muscle is
maintained i n t a c t , preserving the shoulder f u n c t i o n . T h e patient
is able to raise his s h o u l d e r all the w a y u p . T h e o n l y esthetic
debility is due to loss of the s t e r n o m a s t o i d muscle a n d soft tissues.

379
MODIFIED RADICAL NECK DISSECTION TYPE II
(MRND-II)
This operative procedure is similar to the modified radical neck
dissection Type III, preserving the sternocleidomastoid muscle and
the spinal accessory nerve but selectively sacrificing the internal
jugular vein (Fig. 9.93). The indications for this operation are
massive metastatic disease from differentiated carcinoma of the
thyroid gland grossly involving the internal jugular vein or meta-
static squamous cell carcinoma selectively invading the internal
jugular vein in the mid-cervical or lower cervical region. All the
steps of the operative procedure are otherwise essentially similar
to those described for MRND-III.
Massive metastatic lymph nodes from differentiated carcinoma
of the thyroid gland often involve the strap muscles al the lower
part of the neck requiring their sacrifice. Under those circum-
stances, a thyroidectomy and MRND-II are performed in a
monobloc fashion. In order to accomplish such an operative
procedure with technical ease the sternocleidomastoid muscle is
detached from its sternal as well as clavicular insertion, following
this, the sternocleidomastoid muscle is dissected off the carotid
sheath and retracted cephalad, keeping, however, the accessory
nerve protected well within its substance all the way up to the
posterior belly of the digastric muscle. In so doing, the transverse
cervical artery as well as the superior thyroid artery is divided,
however, its blood supply in the upper third coming from the
occipital artery is preserved, following reflection of the detached
sternocleidomastoid muscle, the remaining operation can be very
easily accomplished in a comprehensive monobloc fashion
permitting dissection of the posterior triangle lymph nodes and
deep jugular chain lymph nodes, in continuity with the primary
lesion in the thyroid gland, file internal jugular vein in these
situations is often adherent to, invaded by, or occluded by meta-
static lymph nodes. The sternocleidomastoid muscle is resutured
to the stumps of its insertion on the clavicle as well as the sternum
with non-absorbable suture material.
Fig, 9.9J Modified radical neck dissection - Type II.
380
M O D I F I E D RADICAL NECK DISSECTION TYPE III
(MRND-III)
Ibis operation comprehensively clears lymph nodes from all five
levels in the lateral neck preserving the sternocleidomastoid
muscle, spinal accessory nerve, and the internal jugular vein (Fig.
9.94). It is usually indicated in patients with metastatic lymph
nodes from differentiated carcinomas of the thyroid gland. It is
not a satisfactory operation lor metastatic squamous cell carci-
noma or metastatic adenocarcinoma of salivary gland origin. The
operation, usually done in conjunction with thyroidectomy for
clinically palpable neck metastases, is done through a single trans-
verse incision of the level of the cricoid cartilage. The incision
extends from the anterior border of the trapezius muscle on one
side to dial on the oilier. The upper skin flap is elevated all die
way up lo the mastoid process, laterally and above (he hyoid bone
in (he midline. The neck dissection specimen may be removed in
two segments: (1) the primary tumor of the thyroid gland with
central compartment lymph nodes and lymph nodes from the
anterior triangle of the neck on the ipsilaleral side; and (2) the
lymph nodes from the posterior triangle of the neck on the ipsilaleral
side. If bilateral neck dissections are done simultaneously, then
die specimen of posterior triangle lymph nodes from the contra-
lateral neck is removed separately.
The surgical field of a patient who has undergone total
thyroidectomy and a comprehensive MRND-III for metastatic
papillary carcinoma of thyroid is shown in Fig. 9.9S. The tech-
nical details of the steps of the operation are similar to those
described for other neck dissections. The anterior view of the sur-
gical field shows clearance of the central compartment of (he neck
following a radical, total thyroidectomy. Complete dissection
of die tracheoesophageal groove lymph nodes on both sides is
accomplished in this patient, preserving the right lower para-
thyroid gland wiih its vascular pedicle. Both carotid sheaths are
opened and the deep jugular nodes in the central compartment
of die neck on the right-hand side are also cleared. The
Fig. 9.94 Modified radical neck dissection - Type III.
sternomastoid muscle on the left side is retracted laterally
s h o w i n g clearance of the cervical l y m p h nodes at Level IV in the
supraclavicular region.
The lateral view of t h e surgical field f r o m the patient's l e f t - h a n d
side, w i t h the s t e r n o m a s t o i d muscle retracted posteriorly, shows
complete clearance of the tracheoesophageal g r o o v e l y m p h nodes.
The recurrent laryngeal nerve is preserved. L y m p h nodes in the
central c o m p a r t m e n t a n d jugular c h a i n are excised en bloc w i t h
the p r i m a r y lesion. I he laterally retracted s t e r n o m a s t o i d muscle
exposes the c o n t e n t s of t h e c a r o t i d s h e a t h , d e m o n s t r a t i n g total
clearance of l y m p h nodes f r o m the a n t e r i o r t r i a n g l e of t h e neck
d i g . 9.96).
The lateral v i e w of t h e surgical field w i t h the s t e r n o m a s t o i d
muscle n o w retracted a n t e r i o r l y demonstrates the c a r o t i d sheath
w i t h its c o n t e n t s clearly dissected ( F i g . 9 . 9 7 ) . All the l y m p h
nodes lateral to the carotid sheath a n d f r o m the posterior t r i a n g l e
Fig. 9.95 Anterior view of the surgical field after total thyroidectomy,
central compartment node dissection and left MRND-III.
Fig. 9.96 Lateral view of the surgical field with the sternomastoid
retracted laterally, shows clearance of the tracheoesophageal groove
and the deep jugular chain of lymph nodes.
of the neck are c o m p l e t e l y r e m o v e d . Note that the vagus, phrenic
a n d accessory nerves in the lower part of the surgical field over-
Is i n g the trapezius muscle are carefully preserved.
Since t h i s o p e r a t i o n has to be p e r f o r m e d w i t h the sternomastoid
muscle i n t a c t , it is o f t e n d i f f i c u l t to keep the surgical specimen in
c o n t i n u i t y as a m o n o b l o c resection. T h e c o n t e n t s of the anterior
t r i a n g l e of t h e neck a n d the p r i m a r y t u m o r m a y he resected en
bloc, w h i l e l y m p h nodes f r o m t h e posterior triangle may be
r e m o v e d as a separate s p e c i m e n . W o u n d closure w i t h suction
d r a i n s is s i m i l a r to previous surgical procedures on the neck.
The postoperative appearance of the patient a p p r o x i m a t e l y six
m o n t h s after bilateral M R N D - I I I w i t h t o t a l t h y r o i d e c t o m y for
papillary c a r c i n o m a of the t h y r o i d w i t h bilateral neck node meta-
stasis is s h o w n in F i g . 9 . 9 8 . A l t h o u g h there is loss of soft tissue,
the c o n t o u r of the neck a n d shoulder f u n c t i o n are preserved giving
an excellent esthetic result.
Fig. 9.97 Lateral view of the surgical field with the sternomastoid
retracted medially shows clearance of the deep jugular chain of lymph
nodes and posterior triangle of the neck.
Fig. 9.98 The appearance of the patient six months after surgery.
381
CLASSIC RADICAL NECK DISSECTION (RND)
The classic radical neck dissection has been the gold standard for
surgical treatment of clinically apparent, metastatic cervical
lymph nodes. It comprehensively clears lymph nodes from Levels
I, II, III, IV and V, but also requires sacrifice of sternocleidomastoid
muscle, spinal accessory nerve, internal jugular vein, and the sub-
mandibular salivary gland (Fig. 9.99). However, due to significant
postoperative esthetic deformity and functional disability, the
operation is currently recommended only when appropriate indi-
cations are present as discussed before. The specific indications are
patients with N t disease (Fig. 9.1001, extensive soft tissue disease
cither appreciated clinically or demonstrated radiologically (Fig.
9.101) or recurrent disease in the upper neck following previous
radiotherapy.
A variety of incisions have been described for completing a
radical neck dissection. However, a single trifurcate T-shaped
incision is preferable (Fig. 9.102). The transverse limb of the T
begins at the mastoid process and follows an upper neck skin
Fig. 9.99 Classic radical neck dissection.
Fig. 9.100 Patient with
a fungating N, nodal
metastasis from a
supraglottic primary.
382
crease remaining at least two finger breadths below the angle of
the mandible. The incision extends across the midline up to the
anterior border of the opposite sternomastoid muscle. At about
the midpoint of the transverse incision near the posterior border
of the sternomastoid muscle, the vertical limb of the T incision is
begun. This vertical limb is curvaceous and ends at the mid-
clavicular point. The incision provides adequate exposure for
completion of a radical neck dissection. It is suitable both for
bilateral radical neck dissections with a similar incision on the
opposite side of the neck and for a pectoralis major myocutaneous
flap reconstruction since the vertical limb can be safely extended
down on the anterior chest wall for elevation of the myo-
cutaneous flap. Since the blood supply to the three skin flaps
resulting from this incision is not disturbed, marginal necrosis at
the trifurcation of the skin incision is rarely seen. The bifurcation
of the incision is shown marked out on the skin here in relation
to the carotid artery. The trifurcation point should be kept pos-
terior to the carotid artery when feasible. This incision provides
the necessary exposure by elevation of the posterior, anterior and
superior skin flaps.
Fig. 9.101 Axial view
of the CT scan of a
patient with N, nodal
metastasis from a
squamous carcinoma
of the tonsil.
Fig. 9.102 Single trifurcate T-shaped incision.
 The dissection begins with elevation of the posterior skin flap
first. The incision begins with the posterior half of the transverse
incision at the mastoid process and continues with the vertical
incision at the trifurcation point (Fig. 9.1031. Hie anterior and
superior skin flaps are not elevated at this time. The skin incision
is made with a scalpel, but the rest of the dissection is carried out
with electrocautery. The skin incision is deepened through the
platysma, but if grossly enlarged lymph nodes arc present, and
there is suspicion of extension of disease beyond the capsule of
the lymph nodes, then the flap is elevated superficial to the platysma
muscle which is sacrificed. Electrocautery aids rapid elevation of
the posterior skin flap. Several skin hooks are employed to retract
the posterior skin flap, while countertraclion is provided by the
second assistant over the soft tissues in the neck. The plane of
dissection is along the undersurface of the platysma muscle. The
posterior skin flap is elevated until the anterior border of the
trapezius muscle is identified, and exposed all the way from die
mastoid process down to the clavicle. It is important to remember
that platysma is not present all the way up to the trapezius muscle
and therefore meticulous attention should be paid to remain in
the proper subcutaneous plane beyond the platysma to maintain
uniform thickness of the skin flap.
Fig. 9.103 The incision begins w i t h the posterior half of the transverse
incision at the mastoid process and continues with the vertical incision
up to the clavicle.
border of the trapezius muscle
Sharp rake retractors are now employed to retract the posterior
skin flap (Fig. 9.104). Soft tissues anterior to the trapezius muscle
are now grasped with several hemostats which are used to provide
traction on the surgical specimen. Dissection proceeds along
the floor of the posterior triangle of the neck, exposing each
succeeding muscle with anterior elevation of the specimen. The
superior attachment of the sternomastoid muscle is detached from
the mastoid process and retracted anteriorly. The plane of dis-
section continues just anterior to the anterior border of each
succeeding muscle in the posterior triangle of the neck. The
splenitis capitis and levator scapulae muscles are then exposed.
Several small veins have to be divided and ligated as this dissec-
tion proceeds anteriorly. In the lower part of the neck, the trans-
verse cervical artery and its accompanying vein are identified,
divided between clamps and ligated. Likewise, the inferior belly of
the omohyoid muscle is divided in the floor of the posterior
triangle of the neck and its anterior stump is retracted medially.
Dissection continues medially exposing the posterior scalene
muscle. The lower end of the external jugular vein is divided
between clamps near the clavicle and its stump is ligated.
As the scalene muscles are exposed, roots of the cervical plexus
come into view (Fig. 9.105). However, these are left intact until
the phrenic nerve is identified lying on the anterior aspect of the
scalenus amicus muscle. Similarly, motor branches of the cervical
plexus providing nerve supply to the posterior compartment
muscles should he carefully preserved. The cutaneous branches of
the cervical plexus, however, are transected, leaving short stumps
to prevent injury to the phrenic nerve. The cutaneous branches of
the cervical roots carry with them small blood vessels and
therefore these stumps should be ligated. In the lower part of the
posterior triangle of the neck, the brachial plexus comes into view.
Dissection over this is easy because there is a plane of loose areolar
tissue between the cervical lymph nodes and the supraclavicular
fat pad contained within the deep cervical fascia. Dissection of the
posterior triangle of the neck is now complete. The specimen
mobilized so far is now allowed to rest over the posterior triangle
I Fig. 9.106). A dry gauze pad is placed on the musculature of the
posterior triangle of the neck over which the surgical specimen is
allowed to rest.
Attention is now focused on the anterior skin flap. The transverse
skin incision is completed by extending it from the trifurcation
Fig. 9.105 Dissection of the posterior triangle medially leads to
exposure of the brachial plexus, phrenic nerve and the cutaneous roots
of the cervical plexus.
383
point up to the medial end, deepening it through the platysma. The small loop retractor placed on the strap muscles is now
The anterior skin flap is retracted medially using skin hooks and pulled to expose the common carotid artery and the vagus nerve
rake retractors. The use ol electrocautery permits rapid elevation (Fig. 9.108). The internal jugular vein should not be ligated until
of this skin flap through the loose plane of areolar tissue lying after both the carotid artery and the vagus nerve are identified and
deep to the platysma muscle. Several cutaneous vessels are retracted medially. The vein is doubly ligated, divided in between
encountered during elevation and these are electrocoagulated. and its proximal stump is sulure ligated.
The skin flap is elevated up to the medial border of the omohyoid The middle thyroid vein usually seen at this point entering the
muscle superiorly and up to the medial border of the medial aspect of the internal jugular vein is divided and ligated.
sternocleidomastoid muscle at its attachment to (he manubrium Dissection now proceeds along the lateral border of the carotid
sterni interiorly. A large loop retractor is now used to expose the sheath remaining posterior to the vein but anterolateral to the
sternal head of the sternomastoid muscle which facilitates vagus nerve. This is a relatively avascular plane and one can safely
complete elevation of the anterior skin flap. Using electrocautery divide (he carotid sheath along it all the way up to the base of the
with the cutting current, the tendon of the sternomastoid muscle skull. As dissection proceeds cephalad, minor vessels in the carotid
is divided from the sternal end, and the rest of the muscular sheath may cause bleeding which is easily controlled with electro-
attachment on the manubrium and the clavicle is divided using coagulation ( K g . 9.109).
coagulating current with the electrocautery. There is a plane of
Dissection of the lateral aspect of the carotid sheath in the
loose areolar tissue containing fat between the carotid sheath and
upper part of the neck brings the hypoglossal nerve into view. Dn
the posterior aspect of the sternomastoid muscle, so the latter can
the medial aspect of the carotid sheath, the dissection is carried
be safely divided with electrocautery.
cephalad along the medial border of the superior belly of the
Several small vessels enter the anterior skin flap as it is elevated omohyoid muscle up to the hyoicl bone Irom which it is detached.
near the clavicle. These are branches from the first perforating Small blood vessels running along (be descendens hypoglossi are
branch of the internal mammary artery, which provide blood divided and ligated. The superior thyroid artery is preserved but
supply to the lower skin flap. They are carefully preserved. Once
the sternomastoid muscle is detached from both its sternal and
clavicular heads, it is grasped with hemostats and retracted
cephalad. Using a scalpel the fascia between the carotid sheath
and the strap muscles is incised. A small loop retractor is used to
retract the strap muscles medially to expose the common carotid
artery and the vagus nerve. By alternate blunt and sharp dissec-
tion, the areolar tissue of the carotid sheath is divided circum-
ferentially around the internal jugular vein (Fig. 9.107). At this
juncture, the proximal end of the transverse cervical artery and
vein are identified, divided and ligated. Lymphatic vessels present
in the vicinity of the jugular vein are carefully identified, divided
and ligated. On the left-hand side of the neck, the thoracic duct
requires special attention. It should be meticulously identified,
carefully dissected, divided and ligated in order to prevent chyle
leak and fistula, l y m p h nodes contained in loose areolar tissue
behind the internal jugular vein are dissected and pulled out at
this lime to remain in continuity with the rest of the specimen.
During this dissection, the phrenic nerve should be carefully
protected and kept out ol harm's way. Fig. 9.107 The sternomastoid muscle is detached from the sternum and
clavicle and retracted cephalad to expose the carotid sheath.

Fig. 9.108 The internal jugular vein is ligated and divided after the
fig. 9.106 The specimen is reflected posteriorly, and the anterior (lap is common carotid artery and the vagus nerve are exposed, and retracted
elevated to expose the sternal head of the sternocleidomastoid muscle. medially.

384
the superior thyroid vein will have to be divided and ligated. A dry
gauze pad is now placed on the surgical field and the entire
specimen is allowed to rest over the gauze pad.
The superior skin flap is now elevated in the usual fashion,
remaining close to the platysma. The mandibular branch of the
facial nerve is located in the fascia over the submandibular salivary
gland approximately two finger breadths below and two finger
breadths anterior to the angle of the mandible. The nerve is care-
fully identified, dissected off the fascia, and retracted cephalad
with the skin flap. The facial vessels are divided and ligated (Fig.
9.110). The contents of the submandibular triangle are dissected
off by dividing the secretomotor fillers to the submandibular
salivary gland and the Wharton's duct but preserving the lingual
and hypoglossal nerves. The submandibular gland and level 1 lymph
nodes are thus reflected caudad to remain in continuity with the
rest of the specimen. Several pharyngeal veins along the digastric
tendon and posterior belly of the digastric muscle are divided and
ligated. At this juncture the hypoglossal nerve should be carefully
dissected, protected and preserved, finally, the tail of the parotid
gland is separated or transected along the superior border of the
posterior belly of the digastric muscle. In dividing the tail of the
parotid gland, the posterior facial vein and several arterial
branches of the occipital artery have to be divided and ligated.
The posterior belly of the digastric muscle is now retracted
cephalad with a deep, right-angled retractor, bringing into view
the occipital artery which runs across the internal jugular vein
anteriorly at right angles to it. If the occipital artery is high behind
the digastric muscle, it may be left alone, but if it is quite low it
will have to be divided and ligated. The adipose tissue and lymph
nodes lateral to the internal jugular vein under the sternomastoid
muscle are dissected out. This is easily accomplished once the
tendon of the sternomastoid muscle is detached from the mastoid
process.
The accessory nerve is divided near the jugular foramen and its
proximal stump is ligated as there is a small vessel running with
the nerve, finally, the upper end of the internal jugular vein is
skeletonized and the vein is doubly ligated and divided. I he
surgical specimen is now delivered.
Fig. 9.109 Dissection proceeds cephalad along the carotid sheath up to
the base of the skull.
Ihe surgical field following radical neck dissection shows
clearance of all five levels of lymph nodes as previously described,
along with loss of the sternomastoid muscle, internal jugular vein,
spinal accessory nerve and the submandibular salivary gland (Fig.
9.111). The wound is now irrigated with Bacitracin solution.
Meticulous hemostasis must be ensured prior to closure of the
wound. Two suction drains are inserted through separate stab
incisions (Fig. 9.112). One drain overlies the anterior border of
the trapezius muscle in the posterior triangle, and is retained there
through a loop of chromic catgut suture between the skin flap and
the trapezius muscle; another is maintained over the strap muscles,
anteriorly, and is retained by a loop of catgut suture. The rest of
the wound is closed in two layers using 3-0 chromic catgut
interrupted sutures for platysma and 5-0 nylon sutures for skin
(Fig. 9.113). It is vital for the suction drains to be on continuous
suction while the wound is being closed.
As soon as the last skin sutures are applied, the wound should
be made airtight allowing the skin flaps to remain completely
down and snug to the deeper tissues by suction through the
drains. If suction in this manner is not maintained, minor venous
oozing will allow the flaps to lilt, causing a collection of
hematoma and clotting of blood in drainage tubes which will, in
turn, initiate new venous oozing leading to a larger hematoma.
The suction drains are retained until the volume of serous drain-
age is minimal.
The postoperative appearance of the patient approximately six
months after surgery shows a well-healed scar with the esthetic
deformity due to loss of sternomastoid muscle (Fig. 9.114). Ihe
functional disability due to sacrifice of the spinal accessory nerve
causes inability to abduct the shoulder beyond 90° cephalad. This
is due to loss of function of the trapezius muscle. In addition to
this, the imbalance of shoulder musculature due to the paralyzed
trapezius muscle causes drooping of the shoulder and winging ot
the scapula (Fig. 9.115). When bilateral radical neck dissections
are performed with sacrifice of the internal jugular vein on both
sides for tumor of the oral cavity or oropharynx, chronic lymph-
edema of the face and swelling takes place. Although venous
drainage is initially compromised within a few weeks, collateral
Fig. 9.110 The upper skin flap is now elevated preserving the
mandibular branch ot the facial nerve.
385
Fig. 9.111 The surgical field following radical neck dissectior
Fig. 9.114 The appearance of the patient six months after surgery.

Fig. 9.112 Two suction drains are inserted through separate stab
incisions. Fig. 9.115 Esthetic deformity and functional disability due to paralyzed
trapezius muscle causes drooping of the shoulder, following radical neck
dissection.

Fig. 9.116 Chronic

lymphedema of the
face with thickening of
the subdermal plane
and cutaneous
telangiectasia,
following bilateral
radical neck
dissections.

Fig. 9.113 The skin wound is closed in two layers.

386
venous drainage through the pharyngeal veins restores venous
drainage as long as the anatomy of the central compartment is not
disturbed. However, chronic lymphedema of the face with
thickening of the subdermal plane and cutaneous telangiectasia
remains (Fig. 9.116). On the other hand, when simultaneous
bilateral radical neck dissections are performed in conjunction
with laryngectomy, acute obstruction to intracranial and extra-
cranial venous drainage takes place. This leads to the development
of massive venous and lymphatic edema of the face in the post-
operative period (Fig. 9.117) but with the passage of time,
collateral venous drainage is established through Batson's pre-
vertebral venous plexus, and the extent of venous and lymphatic
edema diminishes (Fig. 9.118). In addition, operative mortality
of such a massive resection is significant and therefore, when
feasible, bilateral radical neck dissections in conjunction with
pharyngolaryngectomy as a single stage procedure should be
avoided. Patients undergoing classic radical neck dissection
require an intensive program of postoperative physiotherapy for
rehabilitation of shoulder function and to avoid a painful and stiff
shoulder syndrome.
Fig. 9.117 Massive
venous and lymphatic
edema ot the face
following simultaneous
bilateral radial neck
dissections and
laryngectomy.
Fig. 9.118 Resolution
of facial edema
through prevertebral
venous collaterals, at
three months
postoperatively.
EXTENDED RADICAL NECK DISSECTION (RND WITH
MEDIASTINAL LYMPH NODE DISSECTION)
An extended radical neck dissection is an operation where
resection of tissues and structures in addition lo a classic radical
neck dissection is performed (Fig. 9.119). Thus, an extended
radical neck dissection may include removal of additional lymph
nodes from the parapharyngeal and retropharyngeal areas, from
the superior mediastinum, and from the apex of the axilla or there
may be non-lymphatic structures resected such as cranial nerves,
carotid artery, musculature of the floor of the posterior triangle of
the neck, or skin of the neck.
The clinical presence of lymph node metastases in the lower
part of the neck with contiguous involvement of superior media-
stinal lymph nodes often requires combined cervical and mediastinal
lymph node dissection. Such operative procedures may be necessary
in patients presenting either with thyroid carcinoma or occasion-
ally with melanoma. The patient shown here had a primary
melanoma of the skin of the lower part of the neck with clinically
apparent cervical lymph node metastasis in the supraclavicular
region, and extension of metastatic disease to the superior
mediastinal lymph nodes.
Ihe CT scan of the patient through the superior mediastinum at
the level of the arch of aorta shows a large centrally necrotic meta-
static mass on the right-hand side of the superior mediastinum
(Fig. 9.120).
Fig. 9.119 Extended radical neck dissection.
Fig. 9.120 CT scan through the superior mediastinum.
387
 The surgical procedure includes a right neck dissection with
sacrifice of a large area of skin at the site of the primary tumor in
continuity with superior mediastinal node dissection. The skin
incision for neck dissection begins at the mastoid process and
descends along the trapezius muscle lo connect with the outline
of an area of wide excision of the skin in the supraclavicular
region. The skin incision then continues medially to the supra-
sternal notch where a straight vertical limb is extended caudad
over the manubrium up to the xyphoid process (Fig. 9.1211.
Median sternotomy for mediastinal node dissection is per-
formed first (Fig. 9.122|. The skin incision from the suprasternal
notch lo the xyphoid process is deepened through the sub-
cutaneous tissue up to the anterior surface of the sternum. Using
digital blunt dissection in the suprasternal notch, a space is
created in the superior mediastinum behind the manubrium
sterni by detaching the strap muscles from the posterior aspect of
the manubrium ( H g . 9.1231. Digital dissection posterior to the
manubrium creates a space for insertion of the sternal saw, which
is used to divide the sternum ( H g . 9.1241. the median sternotomy
extends from the suprasternal notch to the xyphoid process. The
sternum is lifted up with the distal lip of the sternal saw during its
division to prevent injury to the mediastinal structures beneath.
Brisk hemorrhage occurs from the cut ends of the sternum hut this
Fig. 9.121 The skin incision for radical neck dissection and median
sternotomy incorporates wide excision o( the primary site.
Fig. 9.122 The operation begins with median sternotomy for
mediastinal node dissection.
388
is easily controlled with bone wax applied to the cut edges of the
sternum (Fig. 9.125).
A self-retaining sternal retractor is now used to expose the
mediastinum (Fig. 9.126). Careful and meticulous dissection of
the mediastinal fat and lymph nodes is undertaken, denuding the
innominate veins and the superior vena cava. The complete mass
of fibro-fatty tissue and lymph nodes is dissected and swept
towards the right-hand side. Dissection of the mediastinal lymph
nodes begins with identification of the left innominate vein (Fig.
9.127). l y m p h nodes from the region of the superior vena cava
are mobilized and dissected towards the right-hand side. This dis-
section is tedious and should be carefully undertaken to prevent
inadvertent injury to the innominate veins. Both innominate
veins and the superior vena cava are cleared of the lymph nodes.
Note that all the tissues are dissected and reflected superiorly
towards the right-hand side (Fig. 9.128).
At this point, dissection continues to mobilize the large mass
of lymph node metastases present between the innominate
artery and right innominate vein (Fig. 9.129). A cuff of the
parietal pleura of the right-hand side is removed since the mass
is adherent to the pleura. Once this is accomplished, superior
mobilization of the metastatic nodes is possible along the
innominate artery.
Fig. 9.123 The strap muscles are detached from the posterior aspect of
the manubrium, and digital dissection is done to free up the posterior
surface of the sternum.
Fig. 9.124 A sternal saw is used to divide the sternum from the
suprasternal notch up to the xyphoid process.
 The view of the surgical field from the opposite side (left-hand pleted in continuity with right radical neck dissection. However,
side of the patient) shows the mass of metastatic lymph nodes the specimen remains attached at the root of the neck to the
overlying the innominate artery in the superior mediastinum mediastinal nodes, near the origin of Ihe common carotid artery
(Fig. 9.130). At this point, excision of the primary site is com- from ihe innominate artery.

Fig. 9.125 Hemorrhage is easily controlled with bone wax applied to Fig. 9.128 All tissues over the innominate veins are dissected and
the cut edges of the sternum. reflected superiorly towards the right-hand side.

Fig. 9.126 The mediastinum is exposed with a self-retaining retractor. Fig. 9.129 Dissection continues to mobilize the large mass of lymph
node metastases present between the innominate artery and right
innominate vein.

Fig. 9.127 Dissection begins from the left-hand side with identification Fig. 9.130 The view of the surgical field from the left-hand side of the
of the left innominate vein. patient.

389
 Further dissection along the innominate artery at its bifurcation
shows the take-off of the common carotid artery and the sub-
clavian artery (Fig. 9.131). Note the defect in the parietal pleura
on the right-hand side showing the lung in the right pleural
cavity. The big mass of metastatic nodes lying inferior to the
innominate artery and posterior to the right innominate vein is
now dissected out and reflected cephalad towards the neck. As
dissection proceeds towards the root of the neck, the vagus nerve
comes into view with its recurrent laryngeal branch as it winds
around the subclavian artery to return into the neck (Fig. 9.132).
Remaining attachments of the surgical specimen in this area are
divided carefully avoiding any injury to the vagus or recurrent
laryngeal nerves.
The surgical field following radical neck dissection in continuity
with superior mediastinal lymph node dissection is shown in Fig.
9.133. Note the intact great vessels of the mediastinum which
include the left and right innominate veins and superior vena
cava, and the innominate artery with its common carotid and
subclavian branches. A close-up view of the surgical field shows
that the mass of metastatic lymph nodes was located inferior to
both the innominate and subclavian arteries, and superior and
posterior to the right innominate vein and superior vena cava
(Fig. 9.134). Retraction of the subclavian artery clearly shows the
recurrent laryngeal branch of the right vagus nerve turning
cephalad behind the artery (Fig. 9.135). The surgical specimen
shows a large area of skin at the site of the primary melanoma
resected in continuity with right radical neck dissection and
superior mediastinal lymph node dissection (Fig. 9.136).
The surgical defect is irrigated with Bacitracin solution. A right
thoracostomy tube drainage with underwater seal is established.
The pleural defect is repaired with primary closure. The median
sternotomy is repaired with peristernal heavy, silver wires. The
skin incision in the chest is closed in layers. The surgical defect in
the neck requires coverage with a rotation advancement flap
obtained from the anterior chest wall. The incision for the flap
begins at the lateral aspect of the skin defect in the neck and is
taken down along the dcltopectoral groove. The flap is elevated
superficial to the pectoralis major muscle, and is advanced
cephalad and rotated medially to cover the surgical defect. The
postoperative appearance of the patient approximately one
week after surgery shows primary healing of the incisions
(Fig. 9.137)

Fig. 9.131 The take-off of the common carotid artery and the subclavian
artery, at the root of the neck.

Fig. 9.132 The recurrent laryngeal branch of the right vagus nerve
winds around the subclavian artery to return into the neck.

390
Fig. 9.133 The surgical field following removal of the specimen.

Fig. 9.136 The surgical specimen of melanoma of the skin of the neck in
continuity with radical neck dissection and mediastinal node dissection.

Fig. 9.134 Close-up view of the surgical field, showing the location of
the metastatic mass.

Fig. 9.135 The recurrent laryngeal branch of the right vagus nerve Fig. 9.137 The appearance of the patient approximately one week after
turning cephalad behind the subclavian artery. surgery.

391
RESULTS OF TREATMENT with single level involvement. Adjuvant postoperative radiation
therapy, however, significantly improves regional control in the
dissected neck. This improvement in regional control is seen in
As mentioned earlier, the single most important factor in patients with limited neck disease (Ni) as well as in patients with
prognosis for squamous cell carcinoma of the head and neck is the extensive nodal disease (N2|,) (Fig. 9.138).
presence or absence of cervical lymph node metastasis. Cure rates
Significant functional and esthetic morbidity following classic
for patients with cervical lymph node metastasis are nearly one-
radical neck dissection warranted the need for modifying the
half of those achieved in patients who present with tumors
operation to reduce morbidity without compromising regional
localized at the primary site. The extent of nodal metastasis in the
control rates or survival. Modified radical neck dissection Type I
neck clearly has an impact on prognosis. Patients with N, disease
(MRND-I) achieves that goal without an adverse impact on
in the neck have a better prognosis compared with those with N^
prognosis. l'ive-year survival rates, regional failure rates, and the
and N( disease. In addition, the presence of capsular rupture and
location of recurrence are comparable for classic radical neck
extianodal spread also has an adverse impact on prognosis. Thus,
dissection and modified radical neck dissection Type I (MRND-I)
regional failure in the dissected neck depends on the extent of
(Fig. 9.139). Regional recurrence and survival following classic
nodal disease. Patients undergoing neck dissection for K„ neck
radical neck dissection and MKND-I are comparable (Figs
have the lowest risk of local recurrence compared to those with
9.140-9.142). Modified radical neck dissection Type I is generally
N,, Nj and N, disease. Patients with multiple level involvement
not recommended for N, disease. Clearly, regional recurrence rate
develop recurrence in the dissected neck twice as often as those

Fig. 9.138 Impact of postoperative adjuvant radiotherapy on regional

control in patients undergoing neck dissection.

• n = 186 (1975-1987)
• Oral cavity, pharynx, larynx primary tumors
• 92% Stage lll/IV
• 10-year regional recurrence free survival 77%
• Risk factors for regional failure:
>2 pathologically positive nodes
RT dose <60 Cy

Fig. 9.140 Survival and regional recurrence following radical neck

dissection and MRND-I for palpable metastases.

Fig. 9.141 Survival and regional failure rates following radical neck
dissection and MRND I for N, disease.

Fig. 9.139 Five-year survival rates in patients undergoing classic radical

neck dissection and modified radical neck dissection preserving the
spinal accessory nerve.

392
Fig. 9.142 Survival and regional failure rates following radical neck Fig. 9.144 Regional failure rates following supraomohyoid neck
dissection and MRND I for N> disease. dissection.

Fig. 9.143 Survival and regional failure rates following radical neck Fig. 9.145 Regional failure rates following jugular node dissection.
dissection for N, disease.

for patients undergoing classic radical neck dissection for Nt

disease is the highest in spite of postoperative radiotherapy (Fig.
9.143).
Selective neck dissections in patients with N„ neck provide
accurate pathologic staging of the regional lymph nodes at risk
of having micrometastasis and offer regional control rates
comparable to those obtained with more radical operative
procedures, with the use of postoperative radiation therapy when
appropriate indications are present. Regional control rates
following supraomohyoid neck dissection for cancers of the oral
cavity and jugular node dissection for cancers of the larynx and
pharynx are shown in Figs 9.144 and 9.145.
The current philosophy in the management of cervical lymph
nodes in squamous carcinomas of the head and neck region is to
perform a comprehensive modified radical neck dissection Type I, Fig. 9.146 The distribution of various types of neck dissections
preserving the spinal accessory nerve in patients with grossly performed at Memorial Sloan-Kettering Cancer Center between 1984
and 2000.
enlarged lymph nodes as long as the nerve is not involved by
metastatic disease. A selective neck dissection is recommended in
patients who have at least a 10-15% risk of having micro-
metastasis in the N„ neck based upon the characteristics of the
primary tumor. Postoperative radiation therapy is recommended
in all patients with multiple metastatic lymph nodes, extranodal
spread of tumor, or where other ominous histopathologic features
are present.

393
 Fig. 9.147 The changing incidence of radical
neck dissection at Memorial Sloan-Kettering
Cancer Center between 1984 and 2000.

The distribution of various types of neck dissections performed metastasis (Fig. 9.147). However, with increasing use of chemo-
on the Head and Neck Service at Memorial Sloan-Kettering Cancer radiotherapy as initial treatment for organ preserving approaches,
Center from 1984 to 2(MH) is shown in Fig. 9.146. Over the past there has been a modest rise in radical neck dissections since the
fifteen years, the number of patients undergoing a classic radical mid 1990s.
neck dissection as initial treatment of neck metastasis has declined
and an increasing number of patients are undergoing modifi-
cations in neck dissection for management of cervical lymph node

394