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Radical Neck Dissection Workup

  • Author: Antonio Riera March, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Aug 20, 2015
 

Laboratory Studies

See the list below:

  • CBC count and differential: The CBC count is important because it gives the clinician a baseline regarding the patient's preoperative hematologic status. Patients with advanced cancers of the head and neck may present with preexisting anemia, which may require further characterization.
  • Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) measurements: These studies are especially important in patients with preexisting bleeding diathesis, with hepatitis, or who are taking anticoagulants. Prolonged study results may need to be reversed preoperatively.
  • Electrolyte tests
    • Preoperative evaluation is important in patients with head and neck cancers. Many present with other medical problems or take medications that affect their electrolyte status.
    • A subgroup of squamous cell cancers may result in paraneoplastic syndromes; the most common is the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Management may necessitate consultation with an internist or an endocrinologist.
  • Liver enzyme profile is useful.
  • Glucose test: This study is useful preoperatively in patients with a history of diabetes.
  • BUN and creatinine testing is useful.
  • Blood type and screen: Because of refinements in the surgical techniques, blood loss has been significantly reduced in these procedures. In situations in which blood loss is expected to be significant, either typing and screening or typing and cross-matching are necessary.
  • Urinalysis is useful.
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Imaging Studies

See the list below:

  • An esophagogram may be helpful in evaluating an occult esophageal primary tumor.
  • CT scan and MRI may be used if they would help to define node status and treatment planning further. They may be crucial in delineating the extent of bony structures, deep cervical musculature, and carotid artery circumferential involvement.
    • CT scanning with contrast can depict excellent anatomic details.
    • In general, CT is the radiologic technique most commonly used to evaluate the staging of the primary lesion; therefore, also include the neck in the examination.
    • Criteria for assessing nodal metastases with CT include increased size, a rounder shape, presence of central necrosis, and nodal grouping. The most accurate CT criterion for the presence of metastatic adenopathy is central necrosis. The node periphery is usually thick and enhances with contrast. CT scanning also reveals extracapsular spread by enhancement of the nodal capsule.
    • Some radiologists feel that CT demonstrates paratracheal node involvement better than MRI.
    • MRI reveals tumor necrosis and extracapsular spread with less precision than CT scan, but MRI is better for assessing enlarged lymph nodes that are not necessarily metastatic.
    • MRI may also be used in patients who are allergic to iodinated contrast.
    • According to some radiologists, MRI also appears to reveal retropharyngeal node involvement better than CT.
  • Some institutions use ultrasonography and ultrasound-guided aspiration cytology to determine cervical neck metastasis. Ultrasound-guided aspiration cytology has a specificity of nearly 100%.
  • PET and PET/CT have recently emerged as an adjunct in the diagnosis of lymph node metastasis.
    • In recent studies, PET has shown positive findings for lymph node metastasis when CT scan and MRI findings were negative. An FDG-PET scan provides physiologic and biochemical data. Glucose metabolism in neoplastic cells produces increased uptake on FDG-PET scanning, which correlates strongly with viable tumor cells. Therefore, FDG-PET may be helpful in the assessment of neck metastasis and even distant metastasis.
    • Additionally, PET scanning has shown the ability to differentiate active tumors from chronic fibrotic changes. Therefore, PET may become more useful than CT and MRI in the detection of recurrent head and neck cancer. Furthermore, the dual use of the PET and CT scanners produces fused PET and CT images, which can further enhance the results of the PET scan. The definitive role of PET and PET/CT scans is evolving and showing great potential in the assessment of metastatic neck disease, the early diagnosis of recurrent head and neck cancer, and the status of the neck after chemoradiotherapy.
    • The most recent diagnostic guidelines for the use of PET/CT in head and neck oncology are (1) detection of occult primary tumors, particularly in patients in which the conventional imaging tests are negative; (2) initial staging for detection of neck metastasis in the negative neck after evaluation with CT or MRI; (3) detection of distant metastasis in patients with advanced metastatic neck disease; and (4) detection of residual or recurrent disease.
  • If tumor involvement of the carotid artery is possible, a complete preoperative evaluation of the carotid system is indicated. This includes a balloon occlusion test and a 4-vessel cerebral angiography to evaluate the status of the contralateral carotid, intracerebral circulation, and carotid back pressure.
  • Perform chest radiography to exclude metastatic disease.
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Other Tests

See the list below:

  • A complete physical examination is mandatory and includes evaluation of neurologic, cardiovascular, and respiratory status.
    • Palpate the patient's neck to define size, location, mobility, and degree of softness or hardness of any mass.
    • Evaluate the patient's weight and nutritional status.
  • Perform an ECG as indicated.
  • Evaluation by medical service personnel and further medical consultations may be indicated.
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Diagnostic Procedures

See the list below:

  • Use mirror laryngoscopy, flexible nasopharyngolaryngoscopy, or both to supplement the examination.
  • When the primary tumor is known, perform a panendoscopy to exclude a second primary tumor. Performing biopsy of the primary lesion is necessary. When the primary tumor is not known, perform a panendoscopy to look for the primary tumor and to perform random biopsies of the pyriform sinus, base of tongue, and nasopharynx to exclude occult tumors. An ipsilateral tonsillectomy is also advocated; however, this has been the subject of controversy for many surgeons.
  • Transnasal esophagoscopy for screening has emerged in the last decade as safe and well tolerated by patients as an office procedure with topical anesthesia alone. The transnasal esophagoscopy instrumentation set has a suction port, a biopsy port and an insufflator. Therefore, transnasal esophagoscopy can be used for assessment of the esophagus and also for biopsy of suspicious lesions in the supraglottic area. Its role is expanding for use in outpatient "panendoscopy" and biopsy.
  • When the patient has a neck mass, a fine-needle aspiration biopsy for cytology evaluation may be useful in helping the clinician determine management.
  • An open biopsy of a neck node is indicated only when the previous measures of physical examination, needle aspiration biopsy, random biopsies, and endoscopy are inconclusive. To circumvent this situation, patients are asked to sign a consent form for a possible neck dissection when a frozen section diagnosis confirms the presence of malignancy in the open node biopsy specimen.
  • Sentinel lymph node biopsy[5, 6, 7, 8] : A sentinel node is the first node of a particular group of nodes to receive the regional lymphatic flow from the primary site. The concept and the procedure for the sentinel lymph node biopsy in the evaluation of metastatic neck nodes in patients with head and neck squamous cell carcinoma is similar to the one used in the evaluation of nodal disease in skin melanoma. If the sentinel lymph node biopsy is negative, no further lymphadenectomy surgery is necessary. However, the sentinel lymph node biopsy applied to the mucosal cancer of the upper aerodigestive tract is still in the process of evaluation in research trials. Results in this regard are encouraging. Nevertheless, its application in the assessment of neck metastasis is still not established and standardized in the clinical setting.
  • Biotumor markers and molecular methods[9, 10] : New research techniques have been developed to detect micrometastasis of squamous cell carcinoma by using highly specific biotumor markers and molecular methods. The research is this regard is very active, with goals to impact diagnosis, prognosis, and therapy. However, the practical application, prognosis, and management significance is unknown until further studies are completed in prospective clinical trials.
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Histologic Findings

Biopsies of the primary site reveal the etiology of the initial mass and the characteristics of the tumor involved, such as squamous cell carcinoma of the upper aerodigestive tract, nasopharyngeal carcinoma, thyroid carcinomas, and skin cancer of the head and neck.

Fine-needle aspiration cytology of the neck confirms the pathology findings of the primary tumor. It also helps to determine the etiology of the cervical adenopathy when the patient has a neck metastasis from an occult primary tumor.

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Contributor Information and Disclosures
Author

Antonio Riera March, MD, FACS Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico School of Medicine

Antonio Riera March, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, Society for Ear, Nose and Throat Advances in Children, American Cleft Palate-Craniofacial Association, American College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Juan Trinidad Pinedo, MD, FACS Ad-Honorem Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico Medical School

Juan Trinidad Pinedo, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Puerto Rico Medical Association

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Drugs & Diseases wish to acknowledge Joan Flaherty, RN, for her editorial assistance and Gustavo Díaz, MD, for taking the digital surgical photos.

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The skin incision is made through the platysma, and the flap is elevated in the subplatysmal plane. In the superior lateral aspect of the flap, leaving the greater auricular nerve and the external jugular vein on the sternocleidomastoid muscle is important. The posterior flap is elevated toward the trapezius muscle.
The sternocleidomastoid muscle is exposed and incised above the clavicle with Bovie electrocautery.
The anterior and posterior belly of the omohyoid is identified. Note that the omohyoid crosses the internal jugular vein laterally.
The internal jugular vein is identified in the lower aspect of the neck, and a 2-0 silk suture is then passed around the vein and tied.
2-0 silk sutures and suture ligatures are placed as shown.
The supraclavicular fatty tissue is opened using blunt dissection with identification of the phrenic nerve. The phrenic nerve appears as a white cord down the midline of the anterior scalenus muscle. The internal jugular vein has been ligated and transected. The carotid artery is seen on the top of the image. The transverse cervical artery is seen at the bottom of the image.
The submental fatty tissue, the submandibular nodes, and the submandibular gland have been removed and displaced inferiorly together with the specimen.
The internal jugular vein is identified superiorly, medial to the posterior belly of the digastric muscle. The ligation of the internal jugular vein at this point is performed with a 2-0 silk suture and a distal suture ligature.
Final aspect of the surgical wound after removal of the operative specimen.
Axial contrast-enhanced neck CT showing an extensive mass of the left side of the neck.
Patient in supine position and head turned to the right side. Radical Left Neck Dissection completed: The classical radical neck dissection encompasses the lymphatic nodes in levels I-V. View of the surgical wound after removal of the operative monoblock specimen. S = Superior. I = Inferior. M = Medial. L = Lateral. (1) Anterior and posterior bellies of the digastric muscle. (2) Carotid artery and vagus nerve. (3) Anterior cervical nerve root. (4) Phrenic nerve. (5) Brachial plexus. (6) Internal jugular vein, inferior aspect, cut and ligated. (7) Anterior scalene muscle. (8) External jugular vein, inferior aspect, cut and ligated. (9) Hypoglossal nerve. (10) Sternocleidomastoid muscle, superior aspect, cut.
Selective Radical Neck Dissection 2-5 Part 1. Video courtesy of Dr. Nader Sadeghi.
Selective Radical Neck Dissection 2-5 Part 2. Video courtesy of Dr. Nader Sadeghi.
Selective Radical Neck Dissection 2-5 Part 3. Video courtesy of Dr. Nader Sadeghi.
Selective Radical Neck Dissection 2-5 Part 4. Video courtesy of Dr. Nader Sadeghi.
Selective Radical Neck Dissection 2-5 Part 5. Video courtesy of Dr. Nader Sadeghi.
 
 
 
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