NECK

DISSECTION
 CASE
GEN.DATA
 EM
 41y/o
 female
 EDW
 Villereal, Samar
CHIEF COMPLAINT

LATERAL NECK
MASS, RIGHT
 History of Present Illness
(+) mass on anterior neck asso. w/
10 yrs PTA foreign body sensation
(-) dysphagia, odynophagia, DOB,
easy fatigability, palpitations

Private
MD

Thyroid UTZ and FNAB

Dx: Nodular Nontoxic goiter

Loss to follow-up
 Condition now associated w/ 2
3 years PTA cervical lymphadenopathy, 1x1cm
and 0.5x0.5cm respectively, lateral
neck, right

No consult
No meds

Condition
persisted AFPMC ADMITTED
PAST MEDICAL HISTORY
(+) Nodular nontoxic goiter
(-)PTB
(-) HPN
(-) DM
(-) BA
(-) CA
FAMILY HISTORY
(-)PTB
(-) HPN
(-) DM
(-) BA
(-) CA
ROS
(+) cervical (-) dysphagia
lymphadenopathy (-) odynophagia
(-) fever (-) colds
(-) wt loss (-)cough
(-) excessive sweating (-) hemoptysis
(-) resting tremors (-) DOB
(-) excessive thirst (-)palpitations
(-)change in bowel habits
Physical Examination
 Conscious, coherent, afebrile, not in distress
 BP 120/80 CR 88 RR 20 T 37

 AS, PPC, (-)TPWC, (-) nasoaural discharge

(+) CLAD at level II=3x2cms and at level III=2x1cms,
firm, nonmovable, nontender

 Symmetrical chest expansion, no retractions, CBS

 Adynamic precordium, NRRR, (-) murmurs, PMI at 5th
ICS LMCL

 Flat, NABS, soft, nontender, no organomegaly

 Full and equal pulses, no gross deformities

ADMITING DIAGNOSIS
Multinodular nontoxic goiter, bilateral T/C malignacy,
Cervical LAD r/o metastasis
DIFFERENTIAL DIAGNOSIS
1. LYMPHADENOPATHY
2. LYMPHOMA
3. GOITER/THYROID TUMORS
4. BRANCHIAL CLEFT CYST
5. THYROGLOSSAL DUCT CYST
6. METASTATIC TUMORS
LABORATORY AND ANCILLARY
PROCEDURES
Thyroid UTZ
Unenlarged TG w/ scattered calcifications
Multiple bilateral CLN and complex nodule in the right
Malignant process is considered.

CXR- normal
FNAB (31July09)
Upper Cervical LN= no malignant cells seen
Lower Cervical LN= Atypical cells suspicious for
malignant cells
FNAB (10Aug09)
Atypical cells suspicious for malignancy
FNAB (19Sept09)
No malignant cells seen
FBS 4.47
FT3 3.97
BUN 3.6
CREA 70.82 FT4 13.82
CHOL 5.10 TSH 5.97
URIC 214.89
 CBC
Hgb 138
Hct 0.38
RBC 4.37
WBC 4.2
Plt 213
Seg 0.36
Lymph 0.59
Eos 0.05
PT 11.6
INR 1.05
% act 98.6
CT 2’30’’
BT 1’15’’
 NECK
DISSECTION
Lymph nodes in the neck
level I = submandibular and submental nodes

levels II, III, IV = upper, middle, and lower jugular nodes

level V = posterior triangle nodes

Level VI = lymph nodes of the anterior, or central,

compartment of the neck

Level VI = paratracheal nodes

LEVEL OF LYMPH NODES IN THE NECK
 level I

Superiorly -body of the

mandible
Posteriorly- stylohyoid
muscle
Anteriorly- anterior belly
of the digastric muscle
 level Ia
Nodes in the submental
triangle (bound by the
anterior bellies of the
digastric muscles and the
hyoid bone
metastasis from cancers that
arise from the floor of mouth,
anterior tongue, anterior
mandibular alveolar ridge,
and lower lip
 level Ib
submandibular triangle
nodes

metastasis from cancers of

the oral cavity, anterior nasal
cavity, soft tissue structures
of the mid face, and
submandibular gland.
 Level II
anterior border = stylohyoid
muscle
posterior border = posterior
border of the
sternocleidomastoid muscle
IIa= part that lies
anteroinferiorly and closer to
the internal jugular vein
IIb= the portion above and
behind spinal accessory nerve
 Level II
metastasis from cancers that arise from the oral
cavity, nasal cavity, nasopharynx, oropharynx,
hypopharynx, larynx, and parotid gland
 Level III
nodes are located between
the hyoid superiorly and a
horizontal plane defined by
the inferior border of the
cricoid cartilage
anterior ly = sternohyoid
muscle posterior
posterior ly = posterior border
of the sternocleidomastoid
muscle is the border.
 Level III
metastasis from cancers that originate in the oral
cavity, nasopharynx, oropharynx, hypopharynx, and
larynx
 Level  IV
group of nodes related to the
lower third of the JV
these nodes are located
between the inferior border of
the cricoid cartilage and the
clavicle
anteriorly = sternohyoid
muscle, and the
posteriorly = posterior border of
the sternocleidomastoid
muscle.
 Level IV
metastasis from cancer that originates in the larynx,
hypopharynx, thyroid, and cervical esophagus
 Level V

these include the spinal

accessory, transverse
cervical, and
supraclavicular group of
nodes
anteriorly = posterior border
of the sternocleidomastoid
muscle
posteriorly = anterior border
of the trapezius muscle
 Level V
metastasis from cancers that arise in the
nasopharynx, oropharynx, and skin of the posterior
scalp and neck.
 Level  VI
refers to lymph nodes of
the anterior, or central,
compartment of the
neck
Laterally = carotid arteries
Superiorly = hyoid bone
Inferiorly = suprasternal
notch
 Level VI
Lymph nodes in the central compartment are not
routinely excised in radical neck dissection; most
commonly, they are removed during surgery for
thyroid, laryngeal, and hypopharyngeal cancer
 Level VII
Paratracheal nodes
Inferior to the suprasternal notch in the upper
mediastinum
 NECK DISSECTION
A. RADICAL NECK DISSECTION
B. MODIFIED RADICAL NECK
DISECTION
C. SELECTIVE NECK DISECTION
D. EXTENDED RADICAL NECK
DISECTION
Radical Neck Dissection

Clearance of all fibrofatty tissue from one side of the

neck
 Includes the ff:
 lymph nodes from levels I-V
 lymph nodes that surround the tail of the parotid
gland, the spinal accessory nerve, the internal jugular
vein, and the sternocleidomastoid muscle
Modified Radical Neck Dissection

Removal of the same lymph node groups as those

involved in the radical neck dissection (levels I-V) but
requires preservation of 1 or more of the following 3
nonlymphatic structures:
 the spinal accessory nerve
 the internal jugular vein
 the sternomastoid muscle.
Selective Neck Dissection

Refers to a type of neck dissection in which one or

more lymph node groups normally removed in a
radical neck dissection are preserved
 Selective Neck Dissection
a. supraomohyoid neck dissection (levels I, II, III),
b. lateral neck dissection (levels II, III, IV)
c. anterior compartment neck dissection (VI)
d. posterolateral neck dissection (levels II, III, IV, V).
Extended radical neck dissection
modification involves removal of additional lymph
node groups or nonlymphatic structures relative to
the radical neck dissection
THANK YOU