The British Association of Plastic Surgeons (2004) 57, 610–623

Surgical education: neck dissection

Shaheel Chummuna,*, N.R. McLeanb, Maniram Ragbirb

a
Department of Orthopaedics and Trauma, North Tyneside General Hospital, Rake Lane,
North Shields, Newcastle Upon Tyne NE29 8HN, UK
b
Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Queen Victoria Road,
Newcastle Upon Tyne NE1 4LP, UK

Received 4 July 2003; accepted 1 May 2004

KEYWORDS Summary Neck dissection is a valuable procedure for treating metastatic cancers of
Neck dissection; Cervical the head and neck. Radical neck dissection remains the standard for cervical
metastasis metastasis. Because of the morbidity associated with such a treatment, more
conservative approaches are being adopted. The authors describe how they do a neck
dissection and review the issues that currently surround the choice of treatment.
Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights
reserved.

Neck dissection is a valuable procedure for treating
metastatic cancers of the head and neck, and
although Solis-Cohen (1901) hinted at the necessity
of removing all of the neck lymphatics during total
laryngectomy,1 it was Crile in 1906,2 later popu-
larised by Martin et al. in 1951,3 who gave the first
description of radical neck dissection (RND). This
procedure remains the standard for the manage-
ment of cervical metastases from head and neck
cancers, and is still the procedure by which other
techniques are judged. The morbidity associated
with RND has led to the further development of
more conservative techniques that are based on
staging of the disease at presentation.
Head and neck cancers rank as the 6th most
common cancer worldwide. It is estimated that
about 60% of patients with oral cancers present
with early disease (T1 or T2), with N0 necks.4,5
*Corresponding author. Present address. 75 Guelder Road,
High Heaton, Newcastle Upon Tyne, NE7 7PP, UK.
E-mail address: shaheelchummun@hotmail.com
However, if these patients underwent elective neck
dissection, about 30% would be found to have occult
metastatic disease.6,7 This finding is important as
the presence of cervical node metastases reduces
survival by 50%,8 emphasising the importance of
managing patients with N0 disease appropriately.
The choice of treatment remains controversial.
Some centres, adopt a wait-and-see policy while
others favour an elective staging neck dissection to
determine the need for adjuvant therapy, (usually
radiotherapy). The adverse prognostic implication
of occult metastasis in N0 necks has prompted the
need for an easier and more reliable staging
technique. Sentinel lymph node biopsy is currently
being evaluated as a technique in staging clinically
N0 necks.9
Lymphatic drainage
A sound knowledge of the anatomy of the neck and
the pattern of nodal metastasis is central to the

S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2004.05.011
Surgical education: neck dissection 611

surgical management of patients with head and

neck cancers.
(1) The lymphatic system of the neck is divided
into three systems:

† Waldeyer’s internal ring. This ring includes the

adenoids, the tubal and lingual tonsils, the
palatine tonsils and aggregates of the lymphoid
tissue on the posterior pharyngeal wall. Tumours
from this area have a high propensity for
lymphatic spread. Figure 1 The lymph node groups draining a specific
primary site as first echelon lymph nodes.
† Waldeyer’s external ring. This set of nodes
mainly drains the superficial tissues of the head
and neck. In the head, the nodes are mainly
located around the skull base and are the against Cancer (1988) and reflects the volume of
occipital, post-auricular, parotid and buccal the tumour in the regional lymphatics, which is
nodes. In the neck, the main nodes completing directly related to the prognosis (Fig. 4).
the Waldeyer’s external ring are the superficial
cervical, submandibular, submental and anterior
cervical nodes. These nodes drain tissues from Pattern of metastasis
the scalp, eyelids, face, nasal sinuses and oral
cavity. The dissemination of metastatic cancer to
† The deep lymph node system. This consists of the regional lymph nodes tends to follow a pre-
upper, middle and lower cervical nodal groups dictible pattern. Fisch demonstrated the orderly
that are situated along the internal jugular vein, pattern of lymphatic flow and based on this
the spinal accessory group that accompanies the knowledge, one can correctly predict the
XI nerve in the posterior triangle, and the nodes sequential spread of metastases from oral
in the midline of the neck. tumours.10 Shah reviewed 501 patients under-
going RND for squamous cell carcinoma of the
(2) Knowledge of the fascial spaces of the neck is
oral cavity.11 Most metastases were confined to
important in neck dissection as the procedures
levels I – III, with only 20% of patients having
become easier, less bloody and better controlled if
metastases to level IV. Metastasis to level V was
dissection is along the fascial planes. Fascia encases
very rare (2%), and never occurred in the
the structures that are normally removed and by
absence of palpable metastasis in other levels
dissecting along a plane, several important struc-
of the neck.11,12 Shoaib et al. looked at sentinel
tures can be preserved.
lymph nodes (SLN) in 40 cases of squamous cell
In general, the lymphatic flow is from superficial
carcinoma in the head and neck, and found that
to deeper, and from upper to the lower parts of the
most SLN were found in levels I – IV.13 No SLN
neck. Also, each anatomical subgroup of lymph
was identified in level V.
nodes serve as the primary echelon lymph nodes
draining a specific site in the head and neck region,
thus making it possible to identify the primary
tumour based on the site of a specific group of Risk factors
lymph nodes (Fig. 1).
The Head and Neck Service at the Memorial The risk of nodal metastasis from tumours of the
Sloan-Kettering Cancer Center has developed a aerodigestive tract depends on the characteristics
simple and clear levelling system of cervical of the primary tumour
lymph nodes, dividing the neck into five differ-
ent levels (Fig. 2). The different neck levels W Site. The risk of lymphatic involvement
have recently been divided into further sub- increases as one moves from the anterior to
groups in an attempt to assess the prognosis the posterior aspect of the aerodigestive tract.
associated with the different groups of lymph The highest incidence of nodal metastasis is
nodes (Fig. 3). associated with tumours of the tongue, fol-
Clinical staging of the cervical lymph nodes is lowed by tumours of the floor of the mouth,
based on the criteria set by the American Joint lower gum, buccal mucosa, hard palate and the
Committee on Cancer and the International Union lips.14
612 S. Chummun et al.

Figure 2 The Memorial Sloan-Kettering Cancer Centre levelling system of cervical lymph nodes.

W T-Stage. Cancers of the oral cavity show a W Thickness. Depth of the tumour, independent
positive correlation between the T-stage of of the T-stage, is related to the presence of
the tumour and the incidence of occult and occult metastasis. Spiro et al.5 found that
clinically palpable neck metastasis.15 tumours of the floor of the mouth less than
Surgical education: neck dissection 613

Figure 3 The neck divided into further sub-levels.

614
Figure 4 The American Joint Committee on Cancer and the International Union Against Cancer (AJCC/UICC) staging
system for cervical lymph nodes.
2 mm had the lowest risk of metastasis, while
tumours greater than 2 mm, especially those
greater than 8 mm, were associated with the
highest rate of dissemination.
W Histology. The presence of perineural and
perivascular invasion and the presence of
poorly differentiated tumours are associated
with an increased risk of nodal metastasis.16
Even microscopic extracapsular spread is
associated with a poorer prognosis.17
Terminology of neck dissection
Since its description by Crile in 1906, radical neck
S. Chummun et al.
dissection has been the standard treatment for
cervical metastasis, providing a safe and reliable
method for addressing the cervical lymph nodes
with recurrence rates ranging from less than 10% in
N0 necks to greater than 70% in patients with
multiple node involvement. 18 Moreover, the
addition of radiotherapy to RND reduces the risk
of failure by 50% for all N stages.19
Although RND is an excellent technique for the
management of cervical metastasis, it is none-
theless associated with substantial morbidity. This
consequently led to the development of more
conservative approaches that might have less
morbidity, while preserving oncological
effectiveness.
Surgical education: neck dissection
Table 1 Radical and modified radical neck dissection
Radical neck dissection Resection of SCM, IJV,
SAN and all cervical
lymph nodes from all
5 levels
Modified radical neck dissection Resection of SCM, IJV
type I and all cervical lymph
nodes from all 5 levels
(Preservation of SAN)
Modified radical neck dissection Resection of SCM and
type II all cervical lymph nodes
from all 5 levels
(Preservation of SAN and
IJV)
Modified radical neck dissection Resection of all cervical
type III lymph nodes from all
5 levels, with
preservation of SCM,
IJV and SAN
The Committee of Head and Neck Surgery and
Oncology and the American Academy of Otolaryn-
gology/Head and Neck Surgery have recently
revised the terminology and classification of neck
dissections.20 It is based on the rationale that:
1. radical neck dissection is the standard basic
procedure for cervical lymphadenectomy, and
any other procedures are modifications of this
procedure;
2. when modifications to a RND involve preser-
vation of one or more nonlymphatic structures, it
is termed a modified radical neck dissection
(Table 1);
3. when modifications to a RND involve preser-
vation of one or more lymph node groups that are
usually removed in a RND, it is termed a selective
neck dissection (Table 2);
4. when the modification involves the removal of
additional lymph nodes (e.g. occipital and
parotid nods) or nonlymphatic structures relative
to a RND, it is termed an extended radical neck
dissection.
In a recent review by the Committee of Head and
Table 2 Selective neck dissection
Selective neck dissection
Supraomohyoid neck dissection (SOHND)
Lateral neck dissection (LND)
Postero-lateral neck dissection (PLND)
615
Neck Surgery and Oncology and the American
Academy of Otolaryngology/Head and Neck Surgery
on neck dissection,21 the committee noted that
there was a worldwide desire to maintain their
previous classification, but felt at the same time
that minor modifications, mainly in terms of
nomenclature, had to be amended to keep in line
with the current philosophy for the management of
cervical node metastasis.
As such, for modified radical neck dissections,
instead of describing the procedure as types I – III, it
is now described as a MRND with the structure
preserved specifically named. For e.g. a Type I
MRND is now described as a MRND with preservation
of the SAN.
Similarly, for selective neck dissections, the
procedures are described with respect to the levels
dissected. Therefore, a supraomohyoid neck dis-
section is now described as a selective neck
dissection (I – III).
Technique
Modified radical neck dissection
Several types of neck incisions have been devised
over the years (Fig. 4). It is our preference to use an
‘apron’ flap and the incision is marked out as a
‘champagne glass’ (Fig. 5). The ‘apron’ can be
extended inferiorly with no vertical incision made,
especially for level III neck dissection. The incision
shown can be used for all types of neck dissection,
depending on the surgeon’s choice. The vertical
limb of the incision runs from the midpoint of the
transverse limb, posterior to the SCM, to the
midclavicular point, so that in the event of wound
breakdown, the trifurcation would not lie over the
carotid artery. From past experience, we feel that
this flap is a safe flap, particularly when platysma is
raised with it. Since, the blood supply to these flaps
is not disturbed, there is also a reduced risk of
marginal necrosis at the trifurcation of the skin
incision. This flap has also proved to be safe and
Resection of all lymph nodes from levels I– III
Resection of all lymph nodes from levels II–IV
Resection of all lymph nodes from levels II–V
616 S. Chummun et al.

Figure 5 Different types of neck dissection. From McGregor and McGregor (1986) cancer of face and mouth: pathology
and management for surgeons. Churchill Livingstone, Edinburgh, p. 295, with permission.

reliable in patients who had received pre-operative vein first, caution being taken with its posterior
radiotherapy. branches, which may inadvertently be damaged.
The skin is held under tension by the assistant and The dissection then proceeds along the lower
the upper flap is elevated deep to the platysma border of the mandible, clearing level I, and looking
muscle. Once platysma has been divided, the flap for and preserving the mandibular branches of the
can be held under tension using rake retractors and facial nerve, which can be easily found and
the dissection is completed to the level of the
mandible in the subplatysmal plane, preserving the
external jugular vein and the mandibular branches
of the facial nerve. If there is any evidence of any
extra-capsular spread, platysma can be left on the
specimen and, if there is skin involvement, this must
be excised and reconstructed as appropriate (Fig. 6).
The upper flap is then sutured in position and
the lower flaps are then elevated, again with
the assistant keeping tension on the skin to allow
ease of dissection. The whole of the posterior
triangle is exposed, as is the sternocleidomastoid
muscle. One must be careful anteriorly not to cause
any communication with the area of a potential
tracheostomy (Fig. 7).
Moist swabs are laid on the field to stop the area
from drying out and it is usually easier to find and
doubly ligate the lower end of the external jugular Figure 6
Surgical education: neck dissection
Figure 7
dissected free where they cross the facial artery.
The facial artery and vein are then doubly ligated.
The complete submental triangle is usually dis-
sected, i.e. on both sides, by skin retraction on the
contralateral side. A finger can be swept under the
mandible to release the submandibular salivary
gland, and if the fibres of the mylohyoid are then
divided parallel to the mandible, the lingual nerve
can be easily identified and the submandibular
ganglion and its parasympathetic nerve fibres seen,
diathermied and cut (Fig. 8). The level I clearance
can then easily be completed and the surgeon
should remember that the proximal part of the
facial artery will be coming forward anteriorly, in
close proximity to the posterior belly of the
digastric muscle. This vessel can be doubly ligated
or held in a microvascular clamp if required for
later construction. The digastric muscle can be left
or resected as required.
A pack is then placed in level I and the assistant
Figure 8
617
Figure 9
pulls anteriorly on the sternocleidomastoid muscle,
and the dissection proceeds along the anterior
border of the trapezius muscle, locating the
accessory nerve, where it crosses the posterior
triangle (Fig. 9). A sling is placed around the nerve
to ease dissection from the posterior triangle, and
the muscle fibres of the sternocleidomastoid
muscle are then divided, with any muscular
branches to the sternocleidomastoid muscle dia-
thermied and cut. The nerve can then be traced
through the muscle and left intact.
The deep fascia of the posterior triangle is
then held with a pair of tissue forceps, and the
dissection proceeds from posterior to anterior. As
one approaches the clavicle, the incision turns
anteriorly. Again, if the assistant puts tension on
the lower contents of level V, the fascia can be
easily divided with a knife, following diathermy
of any vessels. The plane at level V is identified
superiorly by cutting down onto splenius capitus
Figure 10
618
Figure 11
and inferiorly by the assistant putting traction on
the soft tissues. The only structures of note at
this site are the branches of the supraclavicular
nerves and small adjoining veins and arteries. If
the transverse cervical artery and vein are low,
they are kept in the neck; if they are in a higher
position, they are ligated and removed. Once this
level has been cleared, attention should be
centred on the lower border of the SCM. The
assistant pulls the muscle upwards, putting it
under tension, and the muscle can be cut using a
knife or diathermy on spray coagulation (Fig. 10).
When the muscle is cut, it retracts upwards and
exposes the internal jugular vein (IJV) in the
carotid fascia. The fascia is then divided and a
finger can be swept up from level 4 under the
omohyoid muscle (Fig. 11). The omohyoid muscle
tendon is then divided and the dissection pro-
ceeds superiorly (Fig. 12).
Figure 12
S. Chummun et al.
Figure 13
In the lower part of the posterior triangle, the
brachial plexus is exposed and dissection over this
area is relatively simple, as there is a plane of
areolar tissue between the cervical lymph nodes
and the supraclavicular fat pad contained within
the deep cervical fascia (Fig. 13).
The surgeon must look carefully under magnifi-
cation for either the thoracic duct or the jugular
lymph chain and any branches inadvertently
divided. These need to be oversewn with 8/0 or
9/0 nylon. If there is a small leak at the site,
Surgicele can be applied. The phrenic nerve is seen
on the scalenus anterior muscle and preserved, and
any branches of the cervical nerves are diathermied
and cut.
The dissection continues along the anterior
border of the omohyoid muscle and the whole of
the specimen is elevated superiorly. Level IIb is
fully dissected as this is an area where recurrent
Figure 14
Surgical education: neck dissection
Figure 15
disease in the lymph nodes can be problematic right
up to the mastoid process and base of the skull. As
one approaches the carotid bifurcation, the anaes-
thetist should be warned and one should then
carefully see and preserve the hypoglossal nerve. At
this point, the accessory nerve will be encountered
and this can be removed from any remnants of the
SCM and preserved in total (Fig. 14).
There are usually no major venous branches
entering the jugular vein posteriorly, but the
middle thyroid and the common facial veins
require double ligation. The latter can be held
in a microvascular clamp for future anastomosis
if needed. The specimen now has some soft
tissue and veins around the hypoglossal nerve
attaching it, the SCM should be divided and, as
required, the digastric muscle can be removed
at the same time.
Following completion of the dissection, the area is
washed out with warm water. Further haemostasis is
achieved, three Redivace drains are placed: one at
level I, a further one in the posterior triangle and the
third drain is placed in the supraclavicular fossa.
These drains are secured in the skin with silk and
Vycril Rapidee, used as a loop, may be used to keep
the distal end of the drain in position. It is important
that the drains to be on continuous suction while the
area is being closed, so as to reduce the incidence of
heamatoma formation.
The patient’s neck is then flexed and the chin
brought to the midline. The wound is closed in
layers with Vycril and nylon. Polyfaxe dressings can
be applied to the wounds.
The specimen is then placed on a foam board
and tagged for ease of pathological examination
(Fig. 15).
619
What type of neck dissection to choose?
Radical neck dissection has long been the standard
treatment for the management of cervical metas-
tasis. Bocca questioned the logic of performing
en-bloc resections while structures, such as the
vagus and hypoglossal nerves, which are equally
related anatomically to the lymphatics and lymph
nodes, were left behind. He subsequently devel-
oped the concept of modified radical neck dissec-
tion (MRND),22 based on the finding that the
structures usually resected during RND are encased
in aponeurotic systems. Thus, by working along the
planes, one can perform en-bloc lymphadenectomy
with preservation of nonlymphatic structures.
Subsequent studies by Lingerman et al.23 and
Jesse et al.24 failed to show any significant
differences in the rates of recurrences after MRND
when compared to RND. On the other hand, Andre
et al.25 reported a recurrence rate of 4% after RND
and 26% after MRND, leading them to suggest that it
may be unwise to perform MRND in N-positive
necks.
In the last decade, emphasis has been placed on
the use of selective neck dissection (SND) in the
management of N0 necks. This procedure, initially
developed as a ‘staging operation’ to assess the
presence of occult metastasis, has evolved into
another treatment modality for node negative
necks. A better understanding of the pattern of
metastasis has been key in the development of this
new approach to the management of N0 necks. Shah
et al. looked at more than 1000 specimens from
comprehensive neck dissections for head and neck
squamous cell carcinomas and found a predomi-
nance of cervical metastasis to certain levels for
each primary site.26 Oral cancers tend to metasta-
sise to levels I – III, whereas oropharyngeal, hypo-
pharyngeal and laryngeal tumours tend to
disseminate mostly to levels II – IV. Therefore,
patients with oral cancers who present with
clinically N0 neck would benefit from a SOHND.
Similarly, a lateral neck dissection (LND) would
adequately address the necks of patients with
oropharyngeal, hypopharyngeal and laryngeal
tumours.
The use of SND in clinically N0 patients with oral
cancer has resulted in excellent control of disease
with recurrence rates of less than 10%. Pitman et al.
compared 282 clinically N0 patients undergoing RND
with 92 clinically N0 patients undergoing a SND and
failed to find any statistically significant differences
between the recurrence rates.27 Although many
authors are advocating the use of SND for manage-
ment of the clinically N0 necks, further evaluation
620
of the technique needs to be done so as not to
jeopardize any oncologic benefit. Byers et al.
reviewed 277 cases of untreated oral tongue
cancers and found that 15.8% of cases either had
metastasis to level IV only or to level III, with no
disease noted in levels I and II.28 Similarly, Crean
et al. found an extra 10% of occult metastasis to
level IV that would have been missed had they
preformed a traditional SOHND in the clinically N0
necks of the 49 cases of oral cancer that they
reviewed.29 Based on these findings, there may be a
potential need to extend the SOHND to include level
IV in a SND for oral cancers.
In a critical review on selective neck dissection,
Clayman and Frank found that, despite clear
guidelines, the anatomical boundaries in a SND are
not as well defined as in a MRND, leading to
increased rate of out-of-field recurrences.30 This
outcome can also be affected by the operator’s
experience and judgement.
The role of SND in the therapeutic management
of the N-positive neck is slowly but gradually
growing in stature. Medina et al.31 and Byers
et al.6 treated N-positive patients with SND, which
produced recurrence rates that were comparable to
that obtained with RND, and concluded that SND
had a meaningful role in the management of N1
patients. Ambrosch et al. recently reviewed the use
of SND in the management of clinically positive
necks and found that the cases treated by SND with
or without post-operative radiotherapy fared as
well as those cases managed with MRND or RND with
or without post-operative radiotherapy.32 Andersen
et al. reviewed 106 clinically and pathologically
node positive patients undergoing SND for HNSCC
and concluded that SND can be used in carefully
selected patients with clinically positive necks.33
At present, RND and MRND remain the mainstay
for the surgical management of advanced nodal
disease. However, there is still considerable debate
regarding the use of SND in cases with advanced
nodal disease. Traynor et al.34 suggested that the
use of SND could be extended to N2B and N2C
disease, in the absence of massive lymphadeno-
pathy, nodal fixation, gross extracapsular spread
(ECS) and a history of previous neck surgery. Similar
results were reported by Pellitteri et al. who
reviewed the use of SND in the surgical manage-
ment of advanced nodal disease.35 It is possible that
in the future, SND, combined with adjuncts such as
radiotherapy or chemotherapy, will become the
standard treatment for advanced nodal disease.
The use of radiotherapy in neck surgery
Radiotherapy used either pre or post-neck dissec-
S. Chummun et al.
tion has been to shown to reduce the incidence of
neck failure by at least 50% for all N-stages.36
Moreover, the fact that pre or post-radiotherapy
(RTx) makes no difference in the outcome has
encouraged many surgeons to use RTx as a post-
operative adjunct, as this consequently eases the
dissection and reduces the rate of complications.
The presence of large primary tumour and the
presence of positive margins normally dictate the
use of RTx. Usually patients with an N0 neck do no
require RTx.36 On the other hand, RTx has been
shown to be beneficial in the presence of multiple
node metastasis and ECS.37
Sentinel lymph node biopsy
The sentinel lymph node (SLN) concept states that
the spread of a tumour is embolic in nature, and is
via the lymphatics to the first echelon lymph node
encountered in the lymph node basin. Therefore,
accurately diagnosing the absence of tumour from a
SLN would imply a lymph node basin free of tumour,
thus making the need for an elective staging neck
dissection redundant. Shoaib et al. recently looked
at 40 patients with N0 disease and found that SLN
biopsy had a sensitivity of 94%.13 In a recent
multicentre trial, SLN biopsy was found to be as
sensitive as a supra-omohyoid dissection, and that
it has its place in staging N0 necks.9 It is
recommended that SLN biopsy be done in patients
in whom the lymphatics have not been disrupted.
Although SLN biopsy has proved to be a valuable
tool in the staging of N0 disease, it appears to have
a lesser accuracy in the N-positive necks.
Complications related to neck dissection
As with any surgical procedure, neck dissection is
associated with several potential complications
that can be prevented by meticulous surgery and
careful follow-up. Although many of these compli-
cations are rare in the hands of an experienced
surgeon, some are nonetheless unavoidable.
Intra-operative bleeding can result from a series
of small veins that are either present in the
posterior triangle near the spinal accessory nerve
or near the lower end of the trapezius muscle, or
even in the region of the mylohyoid muscle. Injury
to the transverse cervical artery with subsequent
retraction of the artery behind the clavicle can lead
to great difficulty in managing any haemorrhage.
Surgical education: neck dissection
Similarly, trauma to the internal jugular vein may
lead to intra-operative bleeding that may be
difficult to control. As such, it is necessary that
one should carry out any dissection with extreme
care, so as to prevent any uncontrollable intra-
operative bleeding or the formation of a haema-
toma. Should the latter be suspected, the patient
should be taken back to theatre as soon as possible
for evacuation as it would compromise the take of
any flap.
Although rare, the possibility of an air embolus
following trauma to the IJV should be borne in
mind. The IJV can sometimes be torn by the
inappropriate use of artery forceps below the SCM
in an attempt to mobilise the muscle prior to
dissection. In such a scenario, no attempt should be
made to clamp the hole with an artery forceps or
use diathermy, as this would only make the hole
bigger. If a tear occurs prior to the division of the
vein, pressure is applied over the vein, the
anaesthetist is asked to tilt the table head down
and the area above and below the tear is securely
ligated.
Cardiac arrhythmias can also occur during neck
surgery. Manipulation of the carotid bulb during
dissection of the internal jugular vein can lead to
the arrhythmias that can be life threatening. Gentle
and careful handling of the carotid bulb can reduce
the incidence of such irregular rhythms. The use of
lidocaine injected into the adventitia surrounding
the carotid bulb may reduce the risk of arrhythmias.
Carotid artery rupture is associated with 35 – 50%
mortality. It is usually the culmination of several
factors: improper incision used in an irradiated
neck, damage or stripping of the adventitial layer of
the carotid sheath and the involvement of the
carotid artery by tumour itself. Rupture can be
prevented in patients who have had previous
irradiation to the neck by protecting the carotid
arteries with a muscle flap (usually the levator
scapulae muscle), by not stripping the adventitia of
the carotid sheath unless absolutely necessary and
by keeping the vessels walls moist during operation.
In case of rupture, local pressure is applied to the
area, the airway is protected with a cuffed
tracheostomy tube and the blood pressure is
maintained with IV fluids. The patient should be
taken to theatre, each end of the carotid artery
exposed, and tied off at healthy tissue using a
transfixing stitch. Neurological sequelae due to
ligation include contralateral hemipleigia, hemi-
anaesthesia, aphasia and optic nerve atrophy.
The marginal mandibular, spinal accessory,
phrenic, vagus and hypoglossal nerves, the brachial
plexus and the sympathetic chain are at risk of
being damaged during neck dissection. These
621
nerves may be transected or suffer a neuropraxia
during surgery. Injury to the marginal mandibular
nerve often occurs during dissection of either the
submental triangle or the facial group of lymph
nodes, resulting in altered function of the lip
depressors. The vagus nerve can be damaged during
ligation of the internal jugular vein. Low vagus
nerve injuries can lead to true vocal cord paralysis,
whereas high vocal cord injuries will impair swal-
lowing and airway protection. Injury to the phrenic
nerve, although not common, may lead to subtle
findings such as atelectasis. Depending on the
degree of the injury, recovery may be spontaneous.
As the SAN was removed during RND, this led to the
denervation of the trapezius muscle that conse-
quently led to the ‘Shoulder Syndrome’, which was
associated with impaired abduction of the
shoulder, pain and stiffness, and abnormal scapular
rotation. In some cases, shoulder dysfunction can
also be found in MRND and this is usually due to
intra-operative damage to or ischaemia of the SAN.
Disruption of the sympathetic chain may also
result from neck dissection, following dissection of
the carotid sheath, leading to Horner’s Syndrome.
However, this should be avoided by careful dissec-
tion and recognition of the sympathetic chain.
Chylous fistula occurs in 1 –2% of neck dissections.
If a chylous leak is detected intra-operatively, every
effort must be made to find the source and suture the
opening. Accumulation of chyle affects flap survival,
increases the risk of neck infections and leads to
emaciation of the patient. Chyle in a fasting patient
is a clear-yellowish fluid as compared to the
traditional milky white fluid. If a fistula is suspected
post-operatively, the patient should begin IV feed-
ing. The patient’s head is kept elevated and a
pressure dressing applied. Electrolytes and serum
proteins should be monitored daily. The use of total-
parenteral nutrition (TPN) feeds has largely
obviated the need for re-exploration of the neck.
Fluid collection under the skin flaps can be
prevented by using suction drainage. Seroma may
be drained using a wide-bore needle and applying
pressure dressing to the area.
Late complications following neck dissection
tend to be less severe, but may considerably affect
the quality of life of the patient. The formation of a
neuroma may considerably affect the day to day life
of the patient. In such cases, it is important to
ascertain that any lump in the neck is not a sign of
recurrent disease. Similarly, chronic shoulder pain
may impair the daily activities of the patient.
Competent physiotherapy may help to improve the
patient’s condition.
Radical neck dissection for the management of
metastatic neck disease is still regarded as the
622
standard treatment. The rationale for the develop-
ment of modifications of the technique stems from
the functional and cosmetic deficits associated with
this extensive procedure, and the realisation that
disease can recur despite radical surgery. The
subsequent improved knowledge of patterns of
lymph node drainage, the appreciation of fascial
compartments encasing lymphatic structures and a
better understanding of the benefits of adjuvant
radiotherapy and chemotherapy have fostered a
movement away from the traditional RND. There is
increasing evidence that MRND and more conserva-
tive approaches are as good as the radical neck
dissection i.e. equal the current standard.
There is still an extensive debate regarding the
management of the N0 neck: should the surgeon
adopt a ‘wait and see’ policy, or opt for elective neck
dissection. If so, which technique should he or she
adopt. It is hoped that the use of newer investigative
techniques, such as sentinel node lymphoscintogra-
phy, the improved use of ultrasound-guided fine
needle aspiration and the use of positive emission
tomography, will improve the assessment and
subsequent management of N0 necks.
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