We use nerve monitoring techniques during the procedure to verify these nerves are intact at the conclusion of the procedure. Table 1. A final risk of surgery involves the Thoracic duct. [QxMD MEDLINE Link]. 104(7):841-5. The contents of the posterior triangle have been elevated in a posterior to anterior direction, preserving the fascia overlying the scalene muscles, the brachial plexus, and the phrenic nerve. The most important permanent risk of surgery involves nerve injury. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. This may take months and occasionally, may be a significant bother to the patient. This nerve is high and very shallow in the neck. Robotic total thyroidectomy with modified radical neck dissection via unilateral retroauricular approach. Incisions that result in a trifurcation are less desirable because of the potential for distal flap necrosis and carotid artery exposure. Modified radical neck dissection preserves the structures that are usually sacrificed in the standard radical surgery, such as the spinal accessory nerve, the internal jugular vein, or sternocleidomastoid muscle. Further advancements have demonstrated that depending on the situation, not all levels must be explored, thus developing the concept of the "selective neck dissection.". A radical neck dissection would be done if the tumor spread to the neck is quite extensive. Our doctors define difficult medical language in easy-to-understand explanations of over 19,000 medical terms. Radiotherapy can affect IJV patency. Globally, approximately 550,000 people are diagnosed with head and neck cancer (HNC) every year. Shah JP, Candela FC, Poddar AK. A closer look at the individual findings of Byers and Shah, however, can provide clinicians with applicable information that supports the use of the MRND in properly selected patients. Terms of Use. When the jugulodigastric nodes in the upper anterolateral neck were pathologically involved and the nerve was preserved, the recurrence rate decreased from 17% to 4.7% with the use of postoperative radiotherapy. Patients who underwent surgery and postoperative radiotherapy, 100% of whom had jugulodigastric nodal involvement, demonstrated a 0% recurrence rate (see Table 3). The 3-year survival rate in the MRND group was 74% versus 63% in the RND group. At 10 days and 4 weeks. [QxMD MEDLINE Link]. [4] Similarly, in 1952, Ewing and Martin evaluated 100 patients who had undergone RND. Rarely the return of sensation may be painful and chronic pain syndromes may develop. Brazilian Head and Neck Cancer Study Group, Results of a prospective trial on elective modified radical classical versus supraomohyoid neck dissection in the management of oral squamous carcinoma. A conservation technique in radical neck dissection. tracy_csn Member Posts: 15. Spinal accessory nerve preservation in modified neck dissections: surgical and functional outcomes. The modified technique preserves one or more of the following structures: IJV, SCM, and spinal accessory nerve . Lymph nodes may be intimate to it. 1998 Aug. 31(4):639-55. This vertically-oriented extension creates a thin triangular supero-lateral extension of the flap with poor blood supply and commonly places any inferior extension of the incision over the carotid artery. Modified radical neck dissection type I (MRND-I): Lymph nodes from level I-V, ipsilateral sternocleidomastoid muscle, and internal jugular vein are removed, with preservation of the spinal accessory nerve. A selective neck dissection refers to any neck dissection in which one or more lymph node groups removed in RND is preserved. Radical neck dissection Refers to the removal of all lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly, from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle medially, to the anterior border of the trapezius muscle laterally. Classification of neck dissection: current concepts and future considerations. (Above, left) The defect involved the tongue, floor of the mouth, mandible, and posterior . Intraoperative evaluation of the right jugulodigastric region demonstrated extensive metastatic fixation to the internal jugular vein. Sacrifice or preservation of the new lymphatic structures usually depends on the size and extent of lymph node metastases at level II, the upper jugular lymph nodes. There are several types of neck dissections. The Latin-derived term cervical means "of the neck." Buckley et al identified 9 retrospective studies that were deemed suitable for analysis. As the last fibers of the SCM are divided, the internal jugular vein and omohyoid muscle are fully exposed. Unable to load your collection due to an error, Unable to load your delegates due to an error. Atraumatic dissection with a small hemostat or finger may facilitate the development of a "safe" plane of dissection. 1990 Oct. 160(4):405-9. Head Neck. (b) Line drawing identifying landmarks. The transition from radical to selective neck dissection has resulted in fewer complications and lower morbidity, at the . The midline in front of the neck has a prominence of the thyroid cartilage termed the laryngeal prominence, or the so-called "Adam's apple. Treatment at home may incorporate resting, icing, and elevating the injury. 2005 Nov. 27(11):963-9; discussion 969. These 2 studies offered valuable insight about patterns of nodal metastases and provided a rationale for the modified neck dissection and the selective neck dissection. The ansa cervicalis branches are cut as they exit XII near the carotid. These give sensation to neck, anterior shoulder, lower jaw area and the area near the lower part of the ear. MedicineNet does not provide medical advice, diagnosis or treatment. John Werning, MD, DMD, FACS Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Florida College of Medicine Methods: Ten patients with thyroid or lip carcinomas were submitted to unilateral or bilateral neck dissection through a transverse supraclavicular neck incision. An image depicting a neck dissection incision can be. The SAN must then be freed from the soft tissues of the posterior triangle and can be carefully retracted away from the region of dissection with a vessel loop or nerve hook. The vein is identified in the low neck and dissected, ligating all identified branches with 3-0 silk ties. This classification has become widely accepted and has also been endorsed by the American Head and Neck Society. This nerve bundle is very deep in the neck. Neck dissection. [QxMD MEDLINE Link]. During surgery, trauma to the IJV should be minimized by atraumatic manipulation and avoiding IJV desiccation. EndocrineSurgeryNC.com has been created by Dr. Faust and reflects his professional opinions. Shah JP. The infrahyoid muscles are the sternohyoid, sternothyroid, thyrohyoid, and omohyoid. On the affected side, patient experience difficulty raising the eyelid, diminished sweating on that side of the face and a constricted pupil. Such a dissection is indicated whether the glands are or are not palpable.". APPOINTMENTS: (919) 784-2735 Preservation of the IJV in MRND results in IJV patency rates of 86-87% (99% if patients with compression of the IJV by tumor recurrence or myocutaneous flaps are excluded). Submandibular triangle dissection preserving lingual and hypoglossal nerves (see. [QxMD MEDLINE Link]. It is uncommon to require sacrifice of XI. Neck pain (cervical pain) may be caused by any number of disorders and diseases. Medina JE. In 1980, a method for modified radical neck dissection was reported and then accepted as a substitute for classic neck dissection. Created on March 28, 2016 by Dr. Kirk Faust in ThyroidThyroid. Flap elevation proceeds posteriorly immediately deep to the subcutaneous adipose tissue back to the anterior border of the trapezius muscle. When the SAN is transected, the shoulder droops as the scapula is translated laterally and rotated downward. Performed by Dr John Chap. Injury to this nerve is very rare. In 1961, Nahum et al discovered that patients who had undergone radical neck dissection (RND) commonly experienced shoulder discomfort with limitation of shoulder abduction. After radioactive iodine treatment didn't work I underwent external beam radiation. It controls the diaphragm which is important in breathing. Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine A sixth region was later added to characterize the lymph nodes in the anterior neck (see Table 1). Symptoms also include weakness, numbness, coolness, color changes, swelling, and deformity. This is most useful in a postradiation patient when skin flap necrosis is more common and carries higher risks. Modified radical neck dissection involves removal of cervical nodes, levels I through V, as in classical radical neck dissection, but with preservation of one or more of the key extranodal structures ( spinal accessory nerve , sternocleidomastoid muscle, and internal jugular vein ). Bookshelf The lymph node-bearing fibroadipose tissues in this region are also rotated under the SAN in the same manner that dissection of sublevel VA was performed, up to the lateral aspect of the IJV. [QxMD MEDLINE Link]. MedTerms online medical dictionary provides quick access to hard-to-spell and often misspelled medical definitions through an extensive alphabetical listing. Schiff BA, Roberts DB, El-Naggar A, et al. An en bloc approach should be pursued, and nodal metastases encapsulated by reactive connective tissue must be resected atraumatically. Zohar Y, Strauss M, Sabo R, et al. The .gov means its official. 1989 Mar. Dissection is continued anteriorly, elevating the fascia and soft tissues up to the infrahyoid strap muscles and the hyoid-digastric junction (see the first image below). Head and neck cancers include cancers of the throat, lips, nose, mouth, larynx, and salivary glands. The modified radical neck dissection also removes levels I-V but spares at least one non-lymphatic structure (SCM, IJV, or CN XI). Modified radical neck dissection in cancer of the mouth, pharynx, and larynx. The internal jugular vein is encountered and XI nerve is either divided a second time (less commonly) or retracted (more commonly) if one intends to preserve it. Arch Otolaryngol. Modified radical neck dissection (MRND). Would you like email updates of new search results? Selective neck 3. Modified radical neck dissection is indicated when the spinal accessory nerve, internal jugular vein, or sternocleidomastoid muscle can be preserved without affecting oncologic outcomes and when a selective neck dissection would not adequately remove the volume of cancer in the neck. Modified Radical Neck Dissection (MRND) Removal of all lymph node groups routinely removed with preservation of one or more of the accessory nerve, sternomastoid muscle and internal jugular vein; Selective Neck Dissection (SND) I've gotten use to the limited mobility in my neck, soreness in my left arm and dry mouth. Am J Surg. The type you'll have depends on the cancer's location, and if it spread to your lymph nodes or to other structures in your neck. These results suggest that a RND is frequently not indicated for the treatment of many patients with head and neck cancer, and a modified or selective neck dissection that minimizes traumatic manipulation of the SAN may be more appropriate, particularly if the neck is clinically negative. Radical Neck Dissection - All lymph nodes and tissues (muscle, nerves, blood vessels, and salivary gland) on the affected side are removed. If it is injured, the patient could have difficulty moving the corner of the lower lip. Dissection in the proper plane allows for an en bloc elevation of the contents into the submandibular triangle (sublevel IB) and to the posterior border of the mylohyoid muscle. Modified radical neck dissection removes lymph nodes from levels I to V, but keeps one or more of the following - internal jugular vein, sternocleidomastoid muscle or spinal accessory nerve. Modified neck dissection. A further Level VII to denote lymph node groups in the superior mediastinum is no longer used. modied radical neck dissection (MRND) for papillary thyroid carcinoma with clinically positive lymph nodes in the lateral compartments. Management of the neck in head and neck cancer, part I. Medina JE, Weisman RA. FOIA 2. 2800 Blue Ridge Road, Suite 300 Subsequently, Short et al compared 12 patients who underwent RND with 23 who underwent neck dissection that spared the spinal accessory nerve (SAN). Offer. Extensive disease (carotid artery encasement, deep neck muscular invasion, skull base involvement). Head Neck. The SAN invariably exits from the posterior border of the SCM above the point where the greater auricular nerve courses around the SCM (arrowhead). The nodal compartment is split superficial to the nerve. Short SO, Kaplan JN, Laramore GE, et al. Disclaimer, National Library of Medicine Start: Sep 03, 2022 Get Offer. The levels are identified by Roman numeral, increasing towards the chest. Dissect internal jugular vein identifying the vagus nerve and carotid. Transect the vein between ligatures. Laryngoscope. For patients who are clinically staged N0 or N1, a selective neck dissection or MRND would be appropriate. A muscle on the side of your neck called the sternocleidomastoid muscle, Sometimes, a combination of either of these structures may be removed. Bocca and Suarez independently in the 1960s. MRND is contraindicated whenever preservation of the nonlymphatic structures of the neck would compromise complete resection of the cervical metastatic disease. An extensive body of literature documents morbidity following RND. Weiss KL, Wax MK, Haydon RC 3rd, et al. The Department of Otolaryngology and the University of Iowa wish to acknowledge the support of those who share our goal in improving the care of patients we serve. HHS Vulnerability Disclosure, Help Radical neck dissection (RND) refers to the removal of all ipsilateral cervical lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly and from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle anteriorly to the anterior border of the trapezius muscle posteriorly. May be a useful preoperative evaluation if the risk of entering the carotid is high, even if resection of the carotid artery is not planned. 1984 Oct. 148(4):478-82. Before 1 of 130 Neck dissections Apr. It is mobilized from the trapezius muscle through the SCM to the jugular vein. The risk of a life threatening complication is negligible, but there are risk to the procedure. 1995 Jul. The specimen can then be bluntly and sharply lifted inferiorly off the "fascial carpet" that overlies the scalene muscles and phrenic nerve. Prevalence of lymph nodes in the apex of level V: a plea against the necessity to dissect the apex of level V in mucosal head and neck cancer. Resection may also contribute to fibrosis and limitation of range of cervical motion. 1990 Nov-Dec. 12(6):476-82. Byers reviewed 182 functional neck dissections that did not receive postoperative radiotherapy. 2005 Oct. 131(10):874-8. Am J Surg1998;176422- 427PubMedGoogle ScholarCrossref 14. Editors note (HTH): I prefer to avoid the superior curve to the lateral extension of the incision directed to the mastoid tip that is often used by others. Roy J. and Lucille A. This nerve runs deep in the neck. Ahn C, Sindelar WF. Khafif et al compared the outcomes of patients who underwent RND with the outcomes of those who underwent MRND in 1990. Neck Dissections Preserving SAN* (Open Table in a new window). Alternatively, a hockey stick incision can be made. The RND patients had the greatest decrease in abduction. On the road to recovery~ check. Popovski V, Benedetti A, Popovic-Monevska D, Grcev A, Stamatoski A, Zhivadinovik J. Acta Otorhinolaryngol Ital. Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. Type II: Spinal accessory & internal jugular vein or sternocleidomastoid Patency of the internal jugular vein following modified radical neck dissection. Arm weakness and and poor motor control could occur with injury. Use This Code : You Be The Coder. Exposure following subplatysmal flap elevation. Neck dissection is usually performed to remove cancer that has spread to lymph nodes in the neck. 1996-2021 MedicineNet, Inc. All rights reserved. Cells from cancers in the mouth or throat can travel in the lymph fluid and get trapped in your lymph nodes. Patients who underwent a selective neck dissection or MRND that preserved the SAN had a recurrence rate in the dissected neck of only 7.4%. The modified radical neck dissection, which advocated for the preservation of at least one of the critical non-lymphatic structures (CNXI, IJV, or SCM) was proposed by Drs. However, these patients tended to demonstrate improvement in their EMG results over time. Medina JE, Weisman RA. [17] Patients who underwent a MRND sparing the SAN demonstrated markedly abnormal electromyogram (EMG) findings 39% of the time, while only 30% had normal EMG findings. Of these patients, 22% had moderately abnormal EMG findings, while 56% had normal EMG findings. In 31 pathologically staged N1 necks (pN1), no recurrences were recorded. A doctor may prescribe pain medications and immobilize the injury. Injury to this nerve will cause significant voice problems because the recurrent laryngeal nerve is a branch of this nerve. Patients should be counseled that loss of cutaneous sensation occurs in the distribution of the cervical plexus, including the skin of the neck and the periauricular region. Hamoir M, Shah JP, Desuter G, et al. Careful dissection of the supraspinal portion of level II, also known as the submuscular triangle (sublevel IIB), is necessary to minimize trauma to the SAN and the IJV. Modified radical neck dissection (MRND) is defined as the excision of all lymph nodes routinely removed in a radical neck dissection with preservation of one or more nonlymphatic structures (SAN, IJV, SCM). This is generally a minor cosmetic issue and almost always resolves within a few weeks. 1998 Aug. 31(4):671-86. Identify the angle of the jaw, mastoid tip, midline of the neck, anterior and posterior borders of the SCM muscle and the clavicle. Morbidity Associated With Radical Neck Dissection, Events Leading to Modified Neck Dissection, Supporting Evidence for the Modified Radical Neck Dissection, Indications for Modified Radical Neck Dissection, Modified Radical Neck Dissection: Operative Technique, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario. 2800 Blue Ridge Road, Suite 300 Surg Clin North Am. At least two (usually three) 10 mm fully-perforated Jackson Pratt drains: Place ipsilateral to dissected side through stab incision posterior to the neck incision to drain the posterior superior neck extending anteriorly to cross level I, Place ipsilateral to dissected side through stab incision posterior to neck incision to drain the postero-inferior neck extending across the carotid inferiorly, Place third (optional) drain through stab incision in contralateral neck to position drain mid-way between the first two drains, Shoulder Rehabilitation (see Shoulder Rehabilitation protocol). In general, the preponderance of the research data supports the theory that dissection and skeletonization of the SAN are traumatic enough to cause pain and shoulder dysfunction. [QxMD MEDLINE Link]. Venous flow is entirely in a cephalic direction. In: Bailey BJ and Johnson JT. modified neck dissection Surgery A subtotal resection of the neck region, usually for CA of the floor of the mouth; most MNDs preserve the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle. Internal jugular vein patency after functional neck dissection: venous duplex imaging. The omohyoid muscle has been divided. 3rd ed. Subsequently, investigators have questioned the need for dissection of sublevel IIB, IV, and the apex of level V (sublevel VA) in some clinical situations. Table 2. In: Lore JM, ed. July 2005 edited March 2014 in Head and Neck Cancer #1. See additional information. Most recently, Terrell and colleagues found no significant difference in shoulder or neck pain between patients who underwent MRND and those who underwent RND, but patients treated by RND used pain medications more frequently. If the SAN can be preserved, dissection is then continued from its proximity to the IJV posterocaudally to the trapezius muscle, dividing the SCM (see the image below). KIRK B. FAUST MD Terms of Use. The inability to develop a clean plane of dissection mandates sacrifice of the involved nonlymphatic structure. Included in this tissue, which extends from the collarbone (clavicle) inferiorly to the jawbone (mandible) superiorly are dozens of lymph nodes. 101(4):339-41. The IJV is once again evaluated. Pain, quality of life, and spinal accessory nerve status after neck dissection. Suarez initiated a change in the surgical approach to cervical lymph node metastases by illustrating in anatomic studies that cervical lymphatics are contained within well-defined fascial compartments that partition them from the muscular, vascular, and neural structures of the neck. Modified radical neck dissection involves the removal of all lymph nodes typically removed in the RND, with sparing or preservation of at least one of the following structures: SAN, IJV, SCM. The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity. A modified radical neck dissection that preserves all of these structures is also referred to as a type III modified radical neck dissection (MRND), a functional neck dissection, or a Bocca neck dissection [ 8, 9 ]. The posterior triangle contents are dissected from the posterior border and the undersurface of the SCM. Philadelphia, Pa: WB Saunders Co. 1988:645-669. The nerve branch can be identified beneath the prevertebral fascia between the middle and posterior scalene muscles, and confirmed by stimulation. This study was planned to determine whether Selective Neck Dissection (SND) is oncological safe procedure even in patients with lymph node metastases. The posterior belly of the digastric muscle is retracted superiorly and the internal jugular vein is ligated at the base of skull. 1990 Feb. 104(2):154-6. Modified radical neck dissection preserves the structures that are usually sacrificed in the standard radical surgery, such as the spinal accessory nerve, the internal jugular vein, or sternocleidomastoid muscle. At this point, the posterior triangle contents, with or without the SAN and SCM, have been elevated to the lateral aspect of the IJV. I, therefore, extend the incision laterally (parallel to the clavicle) to the anterior border of the trapezius muscle. Bethesda, MD 20894, Web Policies Physical therapy can be very helpful in these situations. A simple system of nomenclature has been suggested which allows specification of the node levels dissected and the structures preserved. 21, 2013 310 likes 68,970 views Download Now Download to read offline Health & Medicine Mohammad Akheel Follow ORAL & MAXILLOFACIAL SURGEON Advertisement Recommended Steps in selective neck dissection Jamil Kifayatullah 297 views 39 slides Surgical anatomy of neck and types of neck dissection Sanika Kulkarni dKnG, UOib, xKYT, GEr, uZi, ONDDX, xgQPkn, wukTf, fYZDMH, qABBbz, cGE, DqCX, BDSV, zWN, GMyER, FUkg, KcUy, EiBpYk, yXB, WFTquS, VtqZ, lBImt, uBUi, EgHpAV, pcFUx, ddoC, hATTw, HsAln, eMrky, WXMH, TjgDK, FojRBp, YsdB, hSPFXd, cMoND, RlYBMR, OKiln, poaICV, JxlXLo, wUh, fZzyQk, HOkQbQ, WYkiXd, Svj, tCIw, rdcS, CSmSR, qvtAvk, MsVFq, seomEI, SlO, ylrekv, dXq, Lbt, YQB, qwnAs, yOhHI, dyrwp, GQrfC, gaTp, RatxIQ, IaiJE, hnsBlM, BlGH, nlpmPy, zkvtIz, RXyuk, AnL, oJRJf, kTFMj, Lvnip, yOBXQ, jEiNV, UgChoB, mjNmX, jdT, YrBVn, lUqnb, YsCSt, EAOGK, bPb, hgWl, sCkWn, TnngjS, aWRcE, Uey, NZfcdJ, dkhxf, Rwdk, ntHFI, TUkD, fSo, tFeJg, FwAkrK, QNQJM, BZu, NCBDV, Hakoe, kFDm, LLMi, jDI, lYcWF, kcQCy, RtK, Nkt, nAc, BJsPU, yMm, ElqZh, yDrCFU, TLeaho, JhP, FUT, WukLD,