Crile and the Radical Neck Dissection

The grandfather of neck dissection in North America is George Crile, Sr., of the Cleveland Clinic. In 1906, Crile portrayed the field of head and neck surgery as being behind the times in terms of interest and progress. Many head and neck cases were regarded as hopeless. The belief, at that time, held that cancer of the upper aerodigestive system remained localized until regional metastases developed. Regional lymph nodes were regarded as vigorous barriers to distant dissemination. Crile cited...

Preserving The Submandibular Gland

As already mentioned, removal of the submandibular gland is not a routine surgical step of functional neck dissection. The gland must be included in the specimen when the location of the primary tumor dictates its removal or when metastatic disease is suspected in the submandibular triangle. In the remaining situations the submandibular gland may be preserved. This is the case with cancer of the larynx and hypopharynx, where the lymph nodes in the submandibular and submental region (area I) are...

The Marginal Mandibular Branch Of The Facial Nerve

It is cosmetically important to preserve the marginal mandibular branch of the facial nerve. The mandibular nerve courses just deep to the superficial layer of the cervical fascia but superficial to both the anterior facial vein and artery. Identification of the nerve is time consuming and may require nerve stimulation for the novice surgeon to confirm the exact location of this thin branch of the facial nerve. Figure 5-7 Lateral view of the dissection of the sternocleidomastoid muscle on the...

Dissection Of The Deep Cervical Muscles

If the previous steps have been properly performed, we will now have two main blocks of the dissection. The upper part includes the submandibular and submental triangles (area I), as well as the upper jugular and spinal accessory regions (upper part of areas II and V). The lower block includes the supraclavicular fossa (remaining part of area V). A small bridge of tissue still separates these two blocks and connects the specimen to the deep cervical muscles (Fig. 4-41). This bridge usually goes...

Evolution of Functional Neck Dissection

Osvaldo Sua rez did a fine job with functional neck dissection. He had a thorough knowledge of neck anatomy, was a great surgeon, and designed a new approach to the lymphatic system of the neck for patients with head and neck cancer. He was also able to teach the operation to those avid surgeons desiring to assist or observe him at surgery. However, he had an important weak point he did not dedicate enough time to promoting the diffusion of his technique within the scientific community. In...

Dissection Of The Carotid Sheath

Carotid Artery Dissection

The carotid sheath is a fascial envelope surrounding the internal jugular vein, common carotid artery, and vagus nerve (Fig. 2-3). It is interposed between the superficial and prevertebral layers of the cervical fascia. The carotid sheath must be included in the resection, preserving its neuro-vascular contents. Figure 4-42 The whole specimen is now anterior to the sternocleidomastoid muscle. Note the anterior (a) and posterior (p) branch of the cervical plexus. The anterior branches must be...

Management Of The External Jugular Vein

The external jugular vein begins in the substance of the parotid gland. It is most often formed by the union of the retromandibular (posterior facial) and the posterior auricular veins. It runs vertically downward across the superficial surface of the sternocleidomastoid muscle to pierce the fascia of the posterior triangle of the neck just above the clavicle. The external jugular vein terminates in the subclavian or in the internal jugular vein after receiving several tributaries throughout...

The Transverse Cervical Vessels

The transverse cervical artery and vein constitute important anatomical landmarks in the posterior triangle of the neck. The transverse cervical artery is one of the branches of the thyrocervical trunk. The variations in the branches and the exact manner of branching of the thyrocervical trunk are numerous (Fig. 4-39). However, the prevailing patterns usually show at least one branch that runs almost transversely across the neck, anterior to the anterior scalene muscle and the brachial plexus...

Incision And Flaps

The exact location and type of skin incision will depend on the site of the primary tumor and whether a unilateral or bilateral neck dissection is planned. The following are the main goals to be achieved by the skin incision Allow adequate exposure of the surgical field. Assure adequate vascularization of the skin flaps. Figure 4-6 Some popular skin incisions for functional and selective neck dissection. (A) Gluck incision for unilateral and bilateral neck dissection. (B) Double-Y incision of...

Dissection Of The Sternocleidomastoid Muscle

Usually, the first step of the operation is the dissection of the fascia that covers the sternocleido-mastoid muscle. The goal of this maneuver is to completely unwrap the muscle from its surrounding fascia. Prior to approaching the fascia of the sternocleidomastoid muscle, the external jugular vein must be ligated and divided. Usually, three sections of the external jugular vein are required in functional and selective neck dissection (Fig. 4-9) (1) at the tail of the parotid gland, where the...

Suggested Readings

J incision in neck dissections. J Laryngol Otol 1998 112 55-60. Al-Sarraf M, Pajak TF, Byhard RW, Beitler JJ, Salter MM, Cooper JS. Postoperative radiotherapy with concurrent cisplatinum appears to improve locoregional control of advanced resectable head and neck cancers. RTOG 88-24. Inter J Radiat Oncol Biol Phys 1997 37 777-782. Andersen P, Cambronero E, Spiro R, Shah JP. The role of comprehensive neck dissection with preservation of the spinal accessory...

Preoperative Preparation And Operating Room Setup

Operating Room Setup

The patient should be prepared as for any major operation. All routine laboratory tests must be performed, including electrocardiogram and chest radiographs. Preoperative evaluation is accomplished by the anesthesiologist prior to surgery. Premedication is used according to the anesthesiologist's choice. Prophylactic antibiotics are given according to the usual protocol. The patient's neck and upper chest are shaved and prepared for the operation. The patient is placed supine on the operating...

Cesar Gavilan MD

Chairman Department of Otolaryngology La Zarzuela Hospital Madrid, Spain Thieme Medical Publishers, Inc. 333 Seventh Ave. New York, NY 10001 Functional and Selective Neck Dissection Director, Production and Manufacturing Anne Vinnicombe Chief Financial Officer Peter van Woerden Illustrator Maria Angeles Cerdeira, M.D. Library of Congress Cataloging-in-Publication Data Functional and selective neck dissection Javier Gavilan et al. foreword by Jatin P. Shah drawings by Maria Angeles Cerdeira. p....

Dissection Of The Spinal Accessory Nerve

The dissection of the spinal accessory nerve is one of the few steps of the operation that we usually perform using scissors instead of scalpel. To approach this area the sternocleidomastoid muscle is retracted posteriorly, and the posterior belly of the digastric muscle is pulled superiorly with a smooth blade retractor (Fig. 4-26). The wet surgical sponges previously left over the nerve at the level of its entrance in the sternocleidomastoid muscle are removed and the nerve is dissected...

Incision Of The Fascia Over The Sternocleidomastoid Muscle

To facilitate the complete dissection of the fascia surrounding the sternocleidomastoid muscle the initial incision must be made as close to the posterior border of the muscle as possible (Fig. 5-7). The reason for this is that the fascia is more easily dissected off the sternocleidomastoid muscle in a forward direction. Making the incision close to the posterior border of the muscle leaves no remaining fascia to be dissected posteriorly and facilitates the complete isolation of the muscle from...

Surgical Anatomy

Goat External Jugular Vein

This section describes, in an orderly fashion, the anatomical structures found by the surgeon in the course of functional and selective neck dissection. The vascular supply of the skin of the neck is provided by descending branches of the facial, submental, and occipital arteries and by ascending branches of the transverse cervical and suprascapular arteries. The surgeon must take into consideration the blood supply of the skin when planning the incision. Access to the primary tumor and...

Dissection Of The Posterior Triangle Of The Neck

Erbs Point And Accessary Nerve

The supraclavicular fossa constitutes the lower part of area V. The need to include this area in the dissection has become one of the most controversial issues concerning functional and selective Figure 4-30 Spinal accessory maneuver on the right side of the neck. (A) The nerve is exposed between the sternocleidomastoid muscle and the internal jugular vein. (B) The fibrofatty tissue lying posterior and superior to the nerve is passed beneath the nerve. sa, spinal accessory nerve IJ, internal...

Danger Points In The Dissection Of The Internal Jugular Vein

Preservation of the internal jugular vein is one of the main advantages of functional neck dissection. Under normal conditions this is not a difficult step of the operation. However, some particular details may contribute to a successful dissection of this important structure. We prefer the scalpel for this part of the operation, which is usually striking given its apparent danger. However, it is our experience that, if properly performed, knife dissection of the carotid sheath is the most...

Identification Of The Spinal Accessory Nerve

The most common complaint after radical neck dissection is the discomfort of shoulder droop resulting from spinal accessory nerve transection. Functional neck dissection preserves the spinal accessory nerve. However, shoulder function after functional neck dissection is not always normal. The explanation to this apparently paradoxical fact must be sought in the variable innervation of the shoulder, especially with respect to the participation of the cervical plexus in shoulder motility. Injury...

Dissection Of The Submandibular Fossa

Removal of the submental and submandibular lymph nodes (area I) comes next. From a technical standpoint, this maneuver may be accomplished without removing the submandibular gland. In fact, preservation of the submandibular gland was originally described by Osvaldo Suarez as one of the advantages of the functional approach to the neck. However, the surgical treatment of most primary tumors that require the inclusion of level I as part of the dissection also requires the removal of the...

Lymph Node Distribution Lymphatic Chains

Lymph Node Distribution

The lymphatic system of the neck consists of a network of lymph nodes intimately connected by lymphatic channels. For teaching purposes, two major lymphatic networks may be considered in the neck, a superficial and a deep web. The superficial lymphatics of the head and neck drain the skin into the superficial lymph nodes located around the neck and along the external and anterior jugular veins. Superficial lymphatics include the submental, submandibular and facial, external jugular, anterior...

Topographic Anatomy

The topographic description of the neck intends to serve as a guide in which the external and readily accessible superficial features of the neck provide essential landmarks for deep structures. This is a critical element in the examination and description of clinical findings. From a topographic standpoint, the sternocleidomastoid muscle and the carotid sheath divide each side of the neck into two different spaces. Although pyramidal in shape, these spaces are known as the anterior and...

Preserving The Branches Of The Cervical Plexus

As already mentioned, the cervical plexus has important connections to the spinal accessory nerve. A branch from the second cervical nerve typically joins the spinal accessory nerve before it enters the sternocleidomastoid muscle. Also, branches from the second, third, and fourth cervical nerves join the spinal accessory nerve (Fig. 5-22). Although the branches connecting the cervical plexus with the spinal accessory nerve are believed to be sensory, surgical evidence suggests that their...

Fascial Anatomy of the Neck

The anatomical description of the fascial layers of the neck has suffered a number of different descriptions. For practical reasons we will consider two distinct fascial layers in the neck, the superficial cervical fascia and the deep cervical fascia. The superficial cervical fascia corresponds to the subcutaneous tissue. The deep cervical fascia is the key element for functional and selective neck dissection. The superficial cervical fascia extends from the zygoma down to the clavicle,...

The Origins of Functional Neck Dissection

''If you think you have discovered something new, it is because you do not read enough.'' This popular statement summarizes the philosophy of most innovations in the field of science. The great contributions to human knowledge are always the result of a combination of previous research and personal experience. However, almost every important scientific discovery is linked to a person's name. Functional neck dissection must be associated with the name and the person of Osvaldo Sua rez. It is...

Hayes Martin and the Concept of Head and Neck Surgery

Head and neck surgery made little progress in the ensuing decades in North America. The various surgical groups interested in head and neck cancer acknowledged a need for a more focused effort. To this goal, a head and neck service was established at the Memorial Hospital in New York City in 1914. Similar services were not developed at other centers for many years. The term head and neck surgery had very little meaning until Dr. Hayes Martin used it in the 1940s. Ward, Hendricks, and Martin...

Cervical Complications

Infection following functional and selective neck dissection is unusual, around 3 , and frequently related to hematoma. Infection is more frequent when the neck dissection is associated with surgical procedures that include opening of the aerodigestive tract. The majority of wound infections are related to pharyngocutaneous fistula after laryngectomy. Infection is best prevented by meticulous sterile surgical technique, gentle handling of the tissue, irrigation, and adequate placing of suction...

Management Of The Sternocleidomastoid Muscle

Including the posterior triangle of the neck in the field of dissection requires a combined approach, both posterior and anterior to the sternocleidomastoid muscle (Fig. 4-15). In the upper half of the neck the dissection is performed anterior to the sternocleidomastoid muscle, whereas in the lower half of the neck the supraclavicular fossa is approached posterior to the sternocleidomastoid muscle. To better understand this, imagine the surgical field divided horizontally in two halves by a...

Lymph Node Distribution Nodal Groups

Lymph Gland Distribution

For practical reasons, the neck may be artificially divided into different lymph node regions. This does not mean that there is a true anatomical or physiological separation within the lymphatic system of the neck. Not only is there no physical separation within the lymphatic system of the neck, but a widespread interconnection exists between the different nodal chains, as already described. Thus, the regional lymph node classification should be regarded only as a schematic representation of...