Supraomohyoid Neck Dissection Workup

  • Author: Antonio Riera March, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Mar 2, 2012
 

Laboratory Studies

  • 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.
  • Perform chest radiography to exclude metastatic disease.
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Other Tests

  • 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

  • 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.
  • 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  Associate 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, American Cleft Palate/Craniofacial Association, American College of Surgeons, and Society for Ear, Nose and Throat Advances in Children

Disclosure: Nothing to disclose.

Coauthor(s)

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.

Specialty Editor Board

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 Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, 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, North American Skull Base Society, and Ontario Medical Association

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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 Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American 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, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

Additional Contributors

The authors and editors of Medscape Reference 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.
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 StepSurgical Steps and Pearls
Supraomohyoid neck dissection/definitionIt 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 designTry 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 elevationElevate 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 dissectionIdentify 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 SCMLigate 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 SCMContinue 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 veinIdentify 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 specimenFollow 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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