Neck Dissections:

Classifications, Indications, and

Techniques
Christopher D. Muller, M.D.
Shawn D. Newlands, M.D., Ph.D.
January 16, 2002

Introduction
Status of the cervical lymph nodes
important prognostic factor in SCCA of the
upper aerodigestive tract

Introduction
Cure rates drop in half when there is
regional lymph node involvement

Evolution of the neck dissection

1880 Kocher proposed removing nodal
metastases
1906 George Crile described the classic
radical neck dissection (RND)
1933 and 1941 Blair and Martin
popularized the RND
1953 Pietrantoni recommended sparing
the spinal accessory nerves

Evolution of the neck dissection

1967 - Bocca and Pignataro described the
functional neck dissection (FND)
1975 Bocca established oncologic safety
of the FND compared to the RND
1989, 1991, and 1994 Medina, Robbins,
and Byers respectively proposed
classifications of neck dissections

Evolution of the neck dissection

1991 Official Report of the Academys
Committee for Head and Neck Surgery and
Oncology standardizing neck dissection
terminology

Surgical Anatomy

Fascial layers of the neck

Superficial cervical fascia
Deep cervical fascia
Superficial layer
SCM, strap muscles, trapezius
Middle or Visceral Layer
Thyroid
Trachea
esophagus
Deep layer (also prevertebral fascia)
Vertebral muscles
Phrenic nerve

Platysma
Origin fascia overlying the pectoralis
major and deltoid muscle
Insertion 1) depression muscles of the
corner of the mouth,
2) the mandible, and
3) the SMAS layer of the face
Function 1) wrinkles the the neck
2) depresses the corner of the mouth
3) increases the diameter of the neck
4) assists in venous return

10

11

Platysma
Surgical considerations
Increases blood supply to skin flaps
Absent in the midline of the neck
Fibers run in an opposite direction to the SCM

12

13

Sternocleidomastoid Muscle
(SCM)
Origin 1) medial third of the clavicle
(clavicular head)
2) manubrium (sternal head)
Insertion mastoid process
Nerve supply spinal accessory nerve (CN
XI)
Blood supply 1) occipital a. or direct from
ECA
2) superior thyroid a.
3) transverse cervical a.

14

SCM
Function turns head toward opposite side
and tilts head toward the ipsilateral
shoulder
Surgical considerations
Leave overlying fascia (superficial layer of
deep cervical fascia down)
Lateral retraction exposes the submuscular
recess

15

 External
Jugular v.
Greater
auricular n.
Spinal
accessory n.

16

Omohyoid muscle
Origin upper border of the scapula
Insertion 1) via the intermediate tendon
onto the clavicle and first rib
2) hyoid bone lateral to the
sternohyoid muscle
Blood supply Inferior thyroid a.
Function 1) depress the hyoid
2) tense the deep cervical fascia

17

18

Omohyoid
Surgical considerations
Absent in 10% of individuals
Landmark demarcating level III from IV
Inferior belly lies superficial to
The brachial plexus
Phrenic nerve
Transverse cervical vessels
Superior belly lies superficial to
IJV

19

20

Trapezius muscle
Origin 1) medial 1/3 of the sup. Nuchal
line
2) external occipital protuberance
3) ligamentum nuchae
4) spinous process of C7 and T1-T12
Insertion 1) lateral 1/3 of the clavicle
2) acromion process
3) spine of the scapula
Function elevate and rotate the scapula and
stabilize the shoulder

21

Trapezius

22

Trapezius
Surgical considerations
Posterior limit of Level V neck dissection
Denervation results in shoulder drop and
winged scapula

23

Digastric muscle
Origin digastric fossa of the mandible (at
the symphyseal border
Insertion 1) hyoid bone via the
intermediate tendon
2) mastoid process
Function 1) elevate the hyoid bone
2) depress the mandible (assists
lateral pterygoid)

24

25

Digastric
Surgical considerations
Residents friend
Posterior belly is superficial to:
ECA
Hypoglossal nerve
ICA
IJV
Anterior belly
Landmark for identification of mylohyoid for
dissection of the submandibular triangle

26

27

Marginal Mandibular Nerve

Should be preserved in neck dissections
Most commonly injury dissection level Ib
Can be found:
1cm anterior and inferior to angle of mandible
At the mandibular notch

Deep to fascia of the submandibular gland

(superficial layer of deep cervical fascia)
Superficial to adventitia of the facial vein
More than one branch often present
Travels with sensory branches that are sacrificed

28

29

30

Marginal Mandibular Nerve

31

Spinal Accessory Nerve

Originates in the spinal nucleus may
extend to the fifth cervical segment
Union of motor neurons
Passes through two foramen
Foramen Magnum enters the skull posterior
to the vertebral artery
Jugular Foramen exits the skull with CN IX,
X and the IJV

32

Spinal Accessory Nerve

CN XI Relationship with the IJV

33

Spinal Accessory Nerve

Crosses the IJV
Crosses lateral to the transverse process of
the atlas
Occipital artery crosses the nerve
Descends obliquely in level II (forms Level
IIa and IIb

34

Spinal Accessory Nerve

Penetrates the deep surface of the SCM
Exits posterior surface of SCM deep to
Erbs point
Traverses the posterior triangle ensheathed
by the superficial cervical fascia and lies on
the levator scapulae
Enters the trapezius approx. 5 cm above the
clavicle

35

36

Phrenic Nerve
Sole nerve supply to the diaphragm
Supplied by nerve roots C3-5
Runs obliquely toward midline on the
anterior surface of anterior scalene
Covered by prevertebral fascia
Lies posterior and lateral to the carotid
sheath

37

38

39

 Lateral neck
Phrenic n.
Brachial
plexus
Lateral neck
musculature

40

Phrenic Nerve

41

Hypoglossal nerve
Motor nerve to the tongue
Cell bodies are in the Hypoglossal nucleus of the
Medulla oblongata
Exits the skull via the hypoglossal canal
Lies deep to the IJV, ICA, CN IX, X, and XI
Curves 90 degrees and passes between the IJV and
ICA
Surrounded by venous plexus (ranine veins)

Extends upward along hyoglossus muscle and into

the genioglossus to the tip of the tongue

42

Hypoglossal Nerve
Iatrogenic injury
Most common site - floor of the submandibular
triangle, just deep to the duct
Ranine veins

43

Hypoglossal Nerve

44

45

Thoracic duct
Conveys lymph from the entire body back to the
blood
Exceptions:
Right side of head and neck, RUE, right lung right heart and
portion of the liver

Begins at the cisterna chyli

Enters posterior mediastinum between the azygous vein
and thoracic aorta
Courses to the left into the neck anterior to the vertebral
artery and vein
Enters the junction of the left subclavian and the IJV

46

Thoracic duct

47

Thoracic Duct

48

Staging of the Neck

49

Staging of the neck

N classification AJCC (1997)
Consistent for all mucosal sites except the
nasopharynx
Thyroid and nasopharynx have different
staging based on tumor behavior and
prognosis
Based on extent of disease prior to first
treatment

50

51

Staging of the neck

NX: Regional lymph nodes cannot be
assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph
node, < 3
N2a: Metastasis in a single ipsilateral
lymph node 3 to 6 cm

52

Staging of the Neck

N2b: Metastasis in multiple ipsilateral
lymph nodes, none more than 6 cm
N2c: Metastasis in bilateral or contralateral
nodes < 6cm
N3: Metastasis in a lymph node more than
6 cm in greatest dimension

53

Lymph Node Levels/Nodal

Regions

54

Lymph node levels/Nodal regions

Developed by Memorial Sloan-Kettering
Cancer Center
Ease and uniformity in describing regional
nodal involvement in cancer of the head and
neck

55

56

 Level I: Submental and submandibular

triangles

57

Lymph node levels/Nodal regions

Levels II, III, IV: nodes associated with IJV
within fibroadipose tissue (posterior border
of SCM and lateral border of sternohyoid)

58

Lymph node levels/Nodal regions

Level II: Upper third jugular chain,
jugulodigastric, and upper
posterior cervical nodes
Boundaries - hyoid bone (clinical landmark) or
carotid bifurcation (surgical
landmark)

59

Lymph node levels/Nodal regions

Level III: Middle jugular nodes
Boundaries - Inferior border of level II to
cricothyroid notch (clinical landmark)
or omohyoid muscle (surgical
landmark)

Level IV: Lower jugular nodes

Boundaries inferior border of level III to
clavicle.

60

Lymph node levels/Nodal regions

Level V: Posterior triangle of neck
Boundaries - posterior border of SCM, clavicle,
and anterior border of trapezius

61

Lymph node levels/Nodal regions

Level VI: Anterior compartment structures
(hyoid, suprasternal notch, medial border of
carotid sheath)

62

Lymph Node Subzones

63

Subzones of Levels I-V

64

Rationale for subzones

Suggested by Suen and Goepfert (1997)
Biologic significance for lymphatic
drainage depending on site of tumor
Level I subzones
Lower lip, FOM, ventral tongue Ia
Other oral cavity subsites Ib, II, and III

65

Rationale for Subzones

Level II subzones
Oropharynx and nasopharynx IIb
XI should be mobilized

Oral cavity, larynx and hypopharynx may not be

necessary to dissect IIb if level IIa is not involved

Level IV subzones
Level IVa nodes increased risk in Level VI
Level IVb nodes increased risk in Level V

66

Rationale for Subzones

Level V subzones
Oropharynx, nasopharynx, and cutaneous Va
Thyroid - Vb

67

Classification of Neck
Dissections

68

Classification of Neck
Dissections
Standardized until 1991
Academys Committee for Head and Neck
Surgery and Oncology publicized standard
classification system

69

Classification of Neck
Dissections
Academys classification
Based on 4 concepts
1) RND is the standard basic procedure for cervical
lymphadenectomy against which all other
modifications are compared

2) Modifications of the RND which include

preservation of any non-lymphatic structures are
referred to as modified radical neck dissection
(MRND)

70

Classification of Neck
Dissections
Academys classification
3) Any neck dissection that preserves one or more
groups or levels of lymph nodes is referred to as a
selective neck dissection (SND)

4) An extended neck dissection refers to the removal

of additional lymph node groups or non-lymphatic
structures relative to the RND

71

Classification of Neck
Dissections
Academys classification
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
3) Selective neck dissection (SND)
Supra-omohyoid type
Lateral type
Posterolateral type
Anterior compartment type
4) Extended radical neck dissection

72

Classification of Neck
Dissections
Medina classification (1989)
Comprehensive neck dissection
Radical neck dissection
Modified radical neck dissection
Type I (XI preserved)
Type II (XI, IJV preserved)
Type III (XI, IJV, and SCM preserved)

Selective neck dissection (previously

described)

73

Classification of Neck
Dissections
Spiros classification

74

Radical (4 or 5 node levels resected)

Conventional radical neck dissection
Modified radical neck dissection
Extended radical neck dissection
Modified and extended radical neck dissection
Selective (3 node levels resected)
SOHND
Jugular dissection (Levels II-IV)
Any other 3 node levels resected
Limited (no more than 2 node levels resected)
Paratracheal node dissection
Mediastinal node dissection
Any other 1 or 2 node levels resected

Radical Neck Dissection

Definition
All lymph nodes in Levels I-V including spinal
accessory nerve (SAN), SCM, and IJV

75

76

Radical Neck Dissection

Indications
Extensive cervical involvement or matted
lymph nodes with gross extracapsular spread
and invasion into the SAN, IJV, or SCM

77

Modified Radical Neck

Dissection (MRND)
Definition
Excision of same lymph node bearing regions
as RND with preservation of one or more nonlymphatic structures (SAN, SCM, IJV)
Spared structure specifically named
MRND is analogous to the functional neck
dissection described by Bocca

78

79

Modified Radical Neck

Dissection
Three types (Medina 1989) commonly
referred to not specifically named by
committee.
Type I: Preservation of SAN
Type II: Preservation of SAN and IJV
Type III: Preservation of SAN, IJV, and
SCM ( Functional neck
dissection)

80

MRND Type I

81

MRND Type II

82

MRND Type III

83

MRND Type I
Indications
Clinically obvious lymph node metastases
SAN not involved by tumor
Intraoperative decision

84

MRND Type I
Rationale
RND vs MRND Type I:
Actuarial 5-year survival and neck failure rates
for RND (63% and 12%) not statistically
different compared to MRND I (71% and 12%)
(Andersen)
No difference in pattern of neck failure

85

MRND Type II
Indications
Rarely planned
Intraoperative tumor found adherent to the
SCM, but not IJV and SAN

86

MRND TYPE III

Rationale
Suarez (1963) necropsy and surgery specimens of
larynx and hypopharynx lymph nodes do not share
the same adventitia as adjacent BVs
Nodes not within muscular aponeurosis or glandular
capsule (submandibular gland)
Sharpe (1981) showed ) 0% involvement of the SCM in
98 RND specimens despite 73 have nodal metastases
Survival approximates MRND Type I assuming IJV,
and SCM not involved

87

MRND Type III

Widely accepted in Europe
Neck dissection of choice for N0 neck

88

Modified Radical Neck

Dissection
Rationale
Reduce postsurgical shoulder pain and shoulder
dysfunction
Improve cosmetic outcome
Reduce likelihood of bilateral IJV resection
Contralateral neck involvement

89

Selective Neck Dissections

Definition
Cervical lymphadenectomy with preservation
of one or more lymph node groups
Four common subtypes:
Supraomohyoid neck dissection
Posterolateral neck dissection
Lateral neck dissection
Anterior neck dissection

90

SELECTIVE NECK
DISSECTION
Also known as an elective neck dissection
Rate of occult metastasis in clinically negative

91

neck 20-30%
Indication: primary lesion with 20% or greater risk
of occult metastasis
Studies by Fisch and Sigel (1964) demonstrated
predictable routes of lymphatic spread from
mucosal surfaces of the H&N
May elect to upgrade neck intraoperatively
Frozen section needed to confirm SCCA in
suspicious node (Rassekh)
Need for post-op XRT

SND: Supraomohyoid type

Most commonly performed SND
Definition
En bloc removal of cervical lymph node groups
I-III
Posterior limit is the cervical plexus and
posterior border of the SCM
Inferior limit is the omohyoid muscle overlying
the IJV

92

93

SND: Supraomohyoid type

Indications
Oral cavity carcinoma with N0 neck
Boundaries Vermillion border of lips to junction
of hard and soft palate, circumvallate papillae
Subsites - Lips, buccal mucosa, upper and lower
alveolar ridges, retromolar trigone, hard palate, and
anterior 2/3s of the tongue and FOM

Medina recommends SOHND with T2-T4NO

or TXN1 (palpable node is <3cm, mobile, and
in levels I or II)

94

SND: Supraomohyoid type

Bilateral SOHND
Anterior tongue
Oral tongue and FOM that approach the midline
SOHND + parotidectomy
Cutaneous SCCA of the cheek
Melanoma (Stage I 1.5 to 3.99mm) of the cheek
Exceptions
inferior alveolar ridge carcinoma
Byers does not advocate elective neck dissection for buccal
carcinoma

Adjuvant XRT given to patients with > 2- 4 positive

nodes +/- ECS.

95

SND: Supraomohyoid type

Rationale
Expectant management of the N0 neck is not
advocated
Based on Linbergs study (1972)
Distribution of lymph node mets in H&N SCCA
Subdigastric and midjugular nodes mostly affected
in oral cavity carcinomas
Rarely involved Level IV and V

96

SND: Supraomohyoid type

Hoffman (2001) oral cavity combination of 5
reviews
Level I 30.1%
Level II 35.7%
Level III 22.8%
Level IV 9.1%
Level V - 2.2%

97

SND: Lateral Type

Definition
En bloc removal of the jugular lymph nodes
including Levels II-IV

98

99

SND: Lateral Type

Indications
N0 neck in carcinomas of the oropharynx,
hypopharynx, supraglottis, and larynx

100

 Oropharynx
Tonsils
Tonsillar pillars
Tonsillar fossa
Tongue base
Pharyngeal wall
Hypopharynx
Pyriform sinus
Postcricoid
Pharyngeal wall

Supraglottis

Epiglottis
Aryepiglottic folds
FVC
Sup. Ventricle

Larynx
Apex of ventricle
to 1cm below

101

SND: Lateral Type

Rationale oropharynx
Overall risk of occult mets is 30-35%
Hoffman (2001)
Level I 10.3%
Level V 7%
<5% for both Levels I and V if only N0 necks
considered

102

SND: Lateral Type

Rationale Hypopharynx
Occult metastases in 30-35%
Johnson (1994)
Medial pyriform (MP) vs. lateral pyriform carcinomas (LP)
MP 15% failed in the contralateral neck
LP 5% failed in the contralateral neck
Johnson advocates bilateral SNDs for N0 MP carcinomas and
ipsilateral SND for N0 LP carcinomas

Bilateral SND is often indicated in the majority of

hypopharyngeal tumors because of extensive
submucosal spread and involvement of multiple
subsites

103

SND: Lateral Type

Rationale supraglottic
Highest incidence of occult nodal metastasis or
any other subsite in the larynx
Occult nodal disease in 30%
>20% with contralateral occult disease
Shah (1990)
Level I 6% involvement
Level V 1% involvement
Bilateral SND recommended by most authors

104

SND: Lateral Type

Rationale glottic larynx

Sparse lymphatics late spread

T1 5% occult metastases
T2 2% to 6% occult metastases
Byers (1988) and Candela (1990)
Recurrent T1 and T2 had higher rate of metastases
20% to 22%

Recommend unilateral SND for these lesions

105

SND: Lateral Type

106

T3 10% to 20% occult metastases

T4 up to 40% occult metastases
30% salvage rate for
Ipsilateral SND advocated for T3 and T4 glottic
carcinomas

SND: Posterolateral Type

Definition
En bloc excision of lymph bearing tissues in
Levels II-IV and additional node groups
suboccipital and postauricular

107

SND: Posterolateral Type

Indications
Cutaneous malignancies
Melanoma
Squamous cell carcinoma
Merkel cell carcinoma
Soft tissue sarcomas of the scalp and neck

108

SND: Anterior Compartment

Definition
En bloc removal of lymph structures in Level
VI
Perithyroidal nodes
Pretracheal nodes
Precricoid nodes (Delphian)
Paratracheal nodes along recurrent nerves
Limits of the dissection are the hyoid bone,
suprasternal notch and carotid sheaths

109

SND: Anterior Compartment

Indications

110

Selected cases of thyroid carcinoma

Parathyroid carcinoma
Subglottic carcinoma
Laryngeal carcinoma with subglottic extension
CA of the cervical esophagus

Extended Neck Dissection

Definition
Any previous dissection which includes
removal of one or more additional lymph node
groups and/or non-lymphatic structures.
Usually performed with N+ necks in MRND or
RND when metastases invade structures usually
preserved

111

Extended Neck Dissection

Indications
Carotid artery invasion
Other examples:
Resection of the hypoglossal nerve resection or
digastric muscle,
dissection of mediastinal nodes and central
compartment for subglottic involvement, and
removal of retropharyngeal lymph nodes for tumors
originating in the pharyngeal walls.

112

SUMMARY
Cervical metastasis in SCCA of the upper
aerodigestive tract continues to portend a poor
prognosis
Staging will help determine what type neck
dissection should be performed
Unified classification of neck nodal levels and
classification of neck dissection is relatively new
Indications for neck dissection and type of neck
dissection, especially in the N0 neck, is a
controversial topic

113

 Case 1
55 y/o WM
Right T2 supraglottis

Name the indicated neck

dissection.

114

 Case 2
40 y/o man
R T2 larynx
Name appropriate neck
dissection.
What if the cord is fixed?

115

116

117

118

119

Apron Incision

120

Half Apron Incision

121

Conley Incision

122

Double-Y Incision

123

H Incision

124

MacFee Incision

125

Y Incision

126

Modified Schobinger Incision

127

Schobinger Incision

128

129

130

131

132

133

134

135

136

137

138

139