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Supraomohyoid Neck Dissection Workup

  • Author: Antonio Riera March, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 07, 2016
 

Laboratory Studies

See the list below:

  • CBC count and differential
  • 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.
  • Platelet count
  • Electrolyte tests
  • Liver enzyme profile
  • Glucose test
  • BUN and creatinine tests
  • 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
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Imaging Studies

An esophagogram can be helpful in evaluating an occult primary tumor.

Perform CT scan and MRI accordingly if they would help to define node status and treatment planning further.

  • CT scanning with contrast can depict excellent anatomic details.
  • In general, CT scan is the radiologic technique most commonly used to stage the primary lesion; therefore, also include the neck in the examination.
  • Criteria for assessing nodal metastases with CT are (1) increased size (>1.5-cm diameter), (2) poorly defined irregular borders or a rounder shape, (3) presence of central necrosis, (4) nodal grouping, and (5) central hypolucency.
  • The most accurate CT scan 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 scanning 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 LNs 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 scan.

Some institutions use ultrasonography and ultrasound-guided aspiration cytology to determine cervical neck metastasis. Ultrasound-guided aspiration cytology has a specificity of nearly 100%.

Positron emission tomography (PET) has recently emerged as an adjunct in the diagnosis of LN 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 scan 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 scan 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) detection and staging 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.

Sentinel lymph node biopsy:[13, 14, 15, 16] 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 used 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:[17, 18] 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.

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 ECG as indicated.
  • Perform other evaluations, with further medical consultations and recommendations, as indicated.
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Diagnostic Procedures

See the list below:

  • Supplement the examination with mirror laryngoscopy, flexible nasopharyngolaryngoscopy, or both.
  • 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 panendoscopy to look for the primary tumor. Obtain random biopsy samples of the pyriform sinus, base of tongue, tonsillar area, and nasopharynx to exclude occult malignancies.
  • Transnasal esophagoscopy (TNE) can be used in the office to look for primary tumor or tumors and, if found, to take the necessary biopsy or biopsies. TNE can be used to biopsy suspicious lesions in the nasopharynx, glottis, supraglottis, and the esophagus. TNE is done with topical anesthesia in the same fashion as with flexible laryngoscopy. The endoscope used in TNE is fitted with suction and biopsy port to accomplish the same goals as the classic panendoscopy.
  • When the patient has a neck mass, a fine-needle aspiration biopsy (FNAB) for pathology evaluation is indicated.
  • Open biopsy of the neck is indicated only when results of previous physical examination measures (eg, FNAB, random biopsies, endoscopy) are inconclusive.
  • Frozen section can be used intraoperatively to assess neck metastasis of suggestive nodes.
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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 (eg, SCC of the upper aerodigestive tract, nasopharyngeal carcinoma, thyroid carcinomas, head and neck skin cancer). FNAB findings of the neck metastasis confirms the pathology findings of the primary tumor. FNAB findings also help determine the etiology of the cervical adenopathy when the patient has a neck metastasis from an occult primary tumor. Frozen section can be used intraoperatively for suggestive nodes to confirm cervical metastasis.

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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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Bilateral inverted hockey stick incision. This skin incision is ideal for a wide exposure of all levels of nodes in both sides of the neck. The skin incision is made through the platysma, and the flap is elevated in the subplatysmal plane, leaving the external jugular vein (EJV) and the greater auricular nerve on the sternocleidomastoid (SCM) muscle. Elevation posterior to the SCM muscle is unnecessary. The subplatysmal flap is elevated to the level of the body of the mandible. The marginal mandibular nerve is identified (circle).
The submental fatty tissue, submandibular nodes, and submandibular gland are dissected and displaced inferiorly. The mylohyoid muscle is retracted and elevated anteriorly. The anterior belly of the digastric muscle is exposed.
The fascia over the sternocleidomastoid (SCM) muscle, along with the ligated external jugular vein (EJV), is grasped and peeled from the muscle. The accessory nerve is localized in the upper portion of the SCM muscle during the peeling maneuver.
View of the upper portion of the sternocleidomastoid (SCM) muscle and the accessory nerve during dissection.
A close view of the relationship between the accessory nerve and the upper portion of the internal jugular vein (IJV). In one third of patients, the accessory nerve passes medial to the IJV.
The carotid sheath and vagus are identified. The node-containing tissue is peeled over the carotid axis in an inferior-to-superior direction. Rolling over the fascia of the internal jugular vein (IJV) is best performed using a sharp knife with a No. 10 surgical blade. Traction and countertraction are crucial.
View of the upper and midportion of the sternocleidomastoid (SCM) and the accessory nerve (rectangle) during dissection. The carotid sheath (C) and the internal jugular vein (IJV) are seen in the picture.
The sternocleidomastoid muscle (SCM) is retracted. The carotid sheath (C), the vagus (V), and the accessory nerve (rectangle) are identified. The node-containing tissue is peeled over the carotid axis in an inferior-to-superior direction. The peeling of the nodal tissue over the internal jugular vein (IJV) has been partially done in the picture. Traction and countertraction are crucial during the peeling maneuver.
The final aspect of the surgical wound after removal of the operative specimen.
Surgical technique modification. The level I dissection is completed first and displaced inferiorly. The carotid triangle is then dissected. The ranine veins are carefully ligated. The superior thyroid artery and the superior laryngeal nerve are preserved. The exposure and identification of the carotid-internal jugular axis help in understanding the depth perception in the different planes (arrow 1). The dissection then proceeds as described previously from lateral to medial (arrow 2).
Surgical technique modification. Exposure and identification of the carotid-internal jugular axis has been accomplished. Finally, the dissection proceeds in the usual fashion, from lateral to medial, until the entire specimen is removed.
Table 1. Surgical Steps in Supraomohyoid Neck Dissection
Procedure Step Surgical Steps and Pearls
Supraomohyoid neck dissection/definition It is also called anterolateral neck dissection.



It consists of removal of cervical lymphatic nodes contained in neck levels I, II and III.



It is generally used as a selective neck dissection in patients with squamous cell carcinoma of the oral cavity, T1-T4 and N0, if the primary lesion is not to be treated with radiation therapy. In this manner, the supraomohyoid neck dissection is both diagnostic and therapeutic.



In the N+ neck, standardization is lacking; see text for a detailed description of indications and contraindications.



Incision design Try not to use trifurcation incisions.



The recommended incisions for unilateral neck dissection are the modified apron incision or the inverted hockey stick incision.



The recommended incisions for bilateral neck dissection are the apron incision or the bilateral inverted hockey stick incision.



Skin incision and skin and subplatysmal flap elevation Elevate the skin and subplatysmal flap to the level of the body of the mandible.



Expose the anatomy of the submandibular, submental, and carotid triangles.



Leave the external jugular vein and the greater auricular nerve on the SCM muscle.



Elevation posterior to the SCM muscles is unnecessary.



level I dissection Identify the mandibular nerve and elevate it, along with the surrounding tissue, in its own plane.



Remove the submental fatty tissue and identify the anterior belly of the digastric muscle.



Follow the anterior belly of the digastric muscle and identify the mylohyoid muscle.



Retract anteriorly the mylohyoid and expose the submandibular ganglion, lingual nerve, and submandibular duct. Divide and ligate the submandibular duct.



Clamp, divide, and ligate the facial artery.



Remove the submandibular gland and the submandibular lymph nodes.



Identify the hypoglossal nerve deep into the fascia of the submandibular triangle.



Identify and expose completely the posterior belly of the digastric muscle up to the mastoid tip.



If the facial artery is reencountered at this point, tie it and ligate it.



After completion of all of the above, dissect and displace inferiorly the submental fatty tissue, submandibular nodes, and submandibular gland.



Fascial peeling of SCM Ligate the external jugular vein.



Grasp the fascia over the SCM and peel it from the muscle.



The accessory nerve is encountered in the upper portion of the SCM during the peeling maneuver. Identify the accessory nerve directly by sight or indirectly with nerve stimulation.



Dissection posterior and inferior to the SCM Continue inferiorly the dissection of fibroadipose tissue along the posterior border of the SCM muscle to the level of the omohyoid muscle.



Identify and follow the sensory branches of the cervical plexus and continue the dissection lateral to these nerves.



Follow the sensory branches of the cervical plexus from posterior to anterior in order to reach the carotid sheath.



Identify and protect the cervical plexus and the phrenic and vagus nerves.



Carotid sheath, vagus nerve, internal jugular vein Identify the carotid sheath, the vagus nerve, and the internal jugular vein.



Unwrap the carotid sheath, freeing it of tissue containing nodes, working in an inferior to superior direction.



Identify the vagus nerve and preserve it.



Do the same with the internal jugular vein.



Identify, clamp, and ligate the branches of the internal jugular vein.



Completion and removal of specimen Follow the superior belly of the omohyoid muscle to the hyoid bone.



Divide and ligate the ranine veins.



Identify and preserve the superior thyroid artery and the hypoglossal nerve.



Complete the dissection at this point by removing the specimen.



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