The classical radical neck dissection is too much for the patient with no clinical evidence of neck metastases. Moreover, it is not always successful with advanced metastatic disease (N2 and N3). Modifications recognize that what we do to patients may be less important than what patients bring to treatment with their immune systems. The human immune system plays a role in who gets well, the likelihood of recurrences in the neck, and the probability of a cure. Neck recurrences happen regardless of how radical or conservative the operation.
Radical neck dissection removes all the lymph node groups from the mandible to the clavicle, and from the midline of the neck to the anterior border of the trapezius muscle. Also removed are the nodes in the tail of the parotid, the internal jugular vein, the spinal accessory nerve, and the sternomastoid muscle. The postauricular, suboccipital, buccinator, perifacial, and retropharyngeal nodes are not removed. The radical operation is recommended for extensive lymph node metastases, gross extranodal spread from nodal metastases, and lymph node metastases around the accessory nerve and internal jugular vein. It is the operation often used for surgical salvage
TABLE 1-3. Medina's Modification of the American Academy Classification of Neck Dissection
Selective Lateral Anterolateral
Subtype A Subtype B
Type IA Type IB Type IIA Type IIB Type IIIA Type IIIB
Extended after chemotherapy or radiation failure, for the short fat neck and for the previously violated neck and other difficult or indeterminate situations.
According to the classification of the American Academy of Otolaryngology — Head and Neck Surgery, modified radical neck dissection is the ''en bloc'' removal of the same lymph nodes and lymphatics as the radical operation (levels I to V) but with the preservation of one or more nonlymphatic structures routinely taken with the radical operation. The goal of modification is to lessen the morbidity resulting from the sacrifice of the accessory nerve. The morbidity of the removal of the internal jugular vein becomes an issue only when bilateral operations are performed. Preservation of the sternomastoid muscle is said to provide a cosmetic benefit.
The modified radical operation is indicated when an operation is needed to remove all gross nodal metastases while preserving the accessory nerve. This is possible when the metastatic disease is in no greater proximity to that nerve than it is to the vagus or hypoglossal nerves. These nerves were ritualistically preserved with the radical operation, whereas the accessory nerve was sacrificed.
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