eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Modified Radical Neck Dissection: Multimedia

Author: John Werning, MD, DMD, FACS, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Florida
Contributor Information and Disclosures

Updated: Aug 7, 2008

Multimedia

Apron incision used by the author for unilateral ...
(Enlarge Image)
Media file 1: Apron incision used by the author for unilateral modified radical neck dissection.
[ CLOSE WINDOW ]
Apron incision used by the author for unilateral ...

Apron incision used by the author for unilateral modified radical neck dissection.

Incision typically performed for patients requiri...
(Enlarge Image)
Media file 2: Incision typically performed for patients requiring bilateral neck dissections. In this patient, who had a T4N2cM0 squamous cell carcinoma of the oropharynx, an apron flap was elevated that extended from 1 mastoid tip to the other. The blue line demonstrates the planned incision to perform a composite resection of the mandible and oropharynx.
[ CLOSE WINDOW ]
Incision typically performed for patients requiri...

Incision typically performed for patients requiring bilateral neck dissections. In this patient, who had a T4N2cM0 squamous cell carcinoma of the oropharynx, an apron flap was elevated that extended from 1 mastoid tip to the other. The blue line demonstrates the planned incision to perform a composite resection of the mandible and oropharynx.

Exposure of the neck following subplatysmal flap ...
(Enlarge Image)
Media file 3: Exposure of the neck following subplatysmal flap elevation, superficial to the greater auricular nerve and external jugular vein.
[ CLOSE WINDOW ]
Exposure of the neck following subplatysmal flap ...

Exposure of the neck following subplatysmal flap elevation, superficial to the greater auricular nerve and external jugular vein.

Modified radical neck dissection (MRND). Exposure...
(Enlarge Image)
Media file 4: Modified radical neck dissection (MRND). Exposure following subplatysmal flap elevation. The submental (IA) and submandibular contents (IB) have been dissected away from the underlying soft tissues (arrow).
[ CLOSE WINDOW ]
Modified radical neck dissection (MRND). Exposure...

Modified radical neck dissection (MRND). Exposure following subplatysmal flap elevation. The submental (IA) and submandibular contents (IB) have been dissected away from the underlying soft tissues (arrow).

Modified radical neck dissection (MRND). Elevatio...
(Enlarge Image)
Media file 5: Modified radical neck dissection (MRND). Elevation of the level I contents out of the submental and submandibular triangles, exposing the digastric and mylohyoid muscles. The level I contents are now lying along the anterior border of the sternocleidomastoid muscle.
[ CLOSE WINDOW ]
Modified radical neck dissection (MRND). Elevatio...

Modified radical neck dissection (MRND). Elevation of the level I contents out of the submental and submandibular triangles, exposing the digastric and mylohyoid muscles. The level I contents are now lying along the anterior border of the sternocleidomastoid muscle.

Modified radical neck dissection (MRND). Identifi...
(Enlarge Image)
Media file 6: Modified radical neck dissection (MRND). Identification of the spinal accessory nerve anterior to the sternocleidomastoid muscle in the contralateral neck of the same patient as it courses lateral to the internal jugular vein. A single nodal metastasis was clinically evident in this neck and an extended supraomohyoid neck dissection was performed.
[ CLOSE WINDOW ]
Modified radical neck dissection (MRND). Identifi...

Modified radical neck dissection (MRND). Identification of the spinal accessory nerve anterior to the sternocleidomastoid muscle in the contralateral neck of the same patient as it courses lateral to the internal jugular vein. A single nodal metastasis was clinically evident in this neck and an extended supraomohyoid neck dissection was performed.

Modified radical neck dissection (MRND). Identifi...
(Enlarge Image)
Media file 7: Modified radical neck dissection (MRND). Identification of the spinal accessory nerve (SAN; arrow) posterior to the sternocleidomastoid muscle (SCM) as it courses through the posterior triangle to the trapezius muscle. The SAN invariably exits from the posterior border of the SCM above the point where the greater auricular nerve courses around the SCM (arrowhead). The greater auricular nerve is coursing parallel and immediately superior to the external jugular vein. Intraoperative evaluation of the right jugulodigastric region demonstrated extensive metastatic fixation to the internal jugular vein. However, a plane of dissection was easily developed between the SAN and the nodal metastases. Therefore, an MRND with preservation of the SAN was performed.
[ CLOSE WINDOW ]
Modified radical neck dissection (MRND). Identifi...

Modified radical neck dissection (MRND). Identification of the spinal accessory nerve (SAN; arrow) posterior to the sternocleidomastoid muscle (SCM) as it courses through the posterior triangle to the trapezius muscle. The SAN invariably exits from the posterior border of the SCM above the point where the greater auricular nerve courses around the SCM (arrowhead). The greater auricular nerve is coursing parallel and immediately superior to the external jugular vein. Intraoperative evaluation of the right jugulodigastric region demonstrated extensive metastatic fixation to the internal jugular vein. However, a plane of dissection was easily developed between the SAN and the nodal metastases. Therefore, an MRND with preservation of the SAN was performed.

Modified radical neck dissection (MRND). The ster...
(Enlarge Image)
Media file 8: Modified radical neck dissection (MRND). The sternocleidomastoid muscle has been transected inferiorly and the external jugular vein has been ligated. The omohyoid muscle is now visualized superficial to the carotid sheath (arrow). The sternocleidomastoid muscle has been bisected to preserve the spinal accessory nerve as it courses towards the skull base.
[ CLOSE WINDOW ]
Modified radical neck dissection (MRND). The ster...

Modified radical neck dissection (MRND). The sternocleidomastoid muscle has been transected inferiorly and the external jugular vein has been ligated. The omohyoid muscle is now visualized superficial to the carotid sheath (arrow). The sternocleidomastoid muscle has been bisected to preserve the spinal accessory nerve as it courses towards the skull base.

Modified radical neck dissection (MRND). The omoh...
(Enlarge Image)
Media file 9: Modified radical neck dissection (MRND). The omohyoid muscle has been divided. The jugular vein has been divided and ligated.
[ CLOSE WINDOW ]
Modified radical neck dissection (MRND). The omoh...

Modified radical neck dissection (MRND). The omohyoid muscle has been divided. The jugular vein has been divided and ligated.

Modified radical neck dissection (MRND). The cont...
(Enlarge Image)
Media file 10: Modified radical neck dissection (MRND). The contents of the posterior triangle have been elevated in a posterior to anterior direction, preserving the fascia overlying the scalene muscles, the brachial plexus, and the phrenic nerve. The extensive nodal metastatic disease that was present around the carotid bifurcation (arrow) required reflection of the neck dissection specimen superiorly prior to internal jugular vein ligation.
[ CLOSE WINDOW ]
Modified radical neck dissection (MRND). The cont...

Modified radical neck dissection (MRND). The contents of the posterior triangle have been elevated in a posterior to anterior direction, preserving the fascia overlying the scalene muscles, the brachial plexus, and the phrenic nerve. The extensive nodal metastatic disease that was present around the carotid bifurcation (arrow) required reflection of the neck dissection specimen superiorly prior to internal jugular vein ligation.

Completed modified radical neck dissection (MRND)...
(Enlarge Image)
Media file 11: Completed modified radical neck dissection (MRND). The spinal accessory nerve is preserved and some protective fascia remains over the carotid artery. The borders of the neck dissection are now clearly seen: superior border, inferior border of the mandible; inferior border, clavicle; medial border, lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle; lateral border, anterior border of the trapezius muscle.
[ CLOSE WINDOW ]
Completed modified radical neck dissection (MRND)...

Completed modified radical neck dissection (MRND). The spinal accessory nerve is preserved and some protective fascia remains over the carotid artery. The borders of the neck dissection are now clearly seen: superior border, inferior border of the mandible; inferior border, clavicle; medial border, lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle; lateral border, anterior border of the trapezius muscle.

More on Modified Radical Neck Dissection

References
[ CLOSE WINDOW ]

References

  1. Crile G. Excision of cancer of the head and neck. JAMA. 1906;47:1780-1786.

  2. Martin H, Del Valle B, Ehrlich H, et al. Neck dissection. Cancer. May 1951;4(3):441-99. [Medline].

  3. Jesse RH, Ballantyne AJ, Larson D. Radical or modified neck dissection: a therapeutic dilemma. Am J Surg. Oct 1978;136(4):516-9. [Medline].

  4. Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. Arch Otolaryngol. Oct 1961;74:424-8. [Medline].

  5. Ewing M, Martin H. Disability following radical neck dissection; an assessment based on the postoperative evaluation of 100 patients. Cancer. Sep 1952;5(5):873-83. [Medline].

  6. Short SO, Kaplan JN, Laramore GE, et al. Shoulder pain and function after neck dissection with or without preservation of the spinal accessory nerve. Am J Surg. Oct 1984;148(4):478-82. [Medline].

  7. Terrell JE, Welsh DE, Bradford CR, et al. Pain, quality of life, and spinal accessory nerve status after neck dissection. Laryngoscope. Apr 2000;110(4):620-6. [Medline].

  8. Dulguerov P, Soulier C, Maurice J, et al. Bilateral radical neck dissection with unilateral internal jugular vein reconstruction. Laryngoscope. Nov 1998;108(11 Pt 1):1692-6. [Medline].

  9. Bocca E, Pignataro O. A conservation technique in radical neck dissection. Ann Otol Rhinol Laryngol. Dec 1967;76(5):975-87. [Medline].

  10. Byers RM. Modified neck dissection. A study of 967 cases from 1970 to 1980. Am J Surg. Oct 1985;150(4):414-21. [Medline].

  11. Shah JP, Candela FC, Poddar AK. The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity. Cancer. Jul 1 1990;66(1):109-13. [Medline].

  12. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg. Oct 1990;160(4):405-9. [Medline].

  13. Buckley JG, Feber T. Surgical treatment of cervical node metastases from squamous carcinoma of the upper aerodigestive tract: evaluation of the evidence for modifications of neck dissection. Head Neck. Oct 2001;23(10):907-15. [Medline].

  14. Bocca E, Pignataro O, Oldini C, et al. Functional neck dissection: an evaluation and review of 843 cases. Laryngoscope. Jul 1984;94(7):942-5. [Medline].

  15. Khafif RA, Gelbfish GA, Asase DK, et al. Modified radical neck dissection in cancer of the mouth, pharynx, and larynx. Head Neck. Nov-Dec 1990;12(6):476-82. [Medline].

  16. Strong EW. Preoperative radiation and radical neck dissection. Surg Clin North Am. Apr 1969;49(2):271-6. [Medline].

  17. Sobol S, Jensen C, Sawyer W 2nd, et al. Objective comparison of physical dysfunction after neck dissection. Am J Surg. Oct 1985;150(4):503-9. [Medline].

  18. Ahn C, Sindelar WF. Bilateral radical neck dissection: report of results in 55 patients. J Surg Oncol. Apr 1989;40(4):252-5. [Medline].

  19. Balm AJ, Brown DH, De Vries WA, et al. Blindness: a potential complication of bilateral neck dissection. J Laryngol Otol. Feb 1990;104(2):154-6. [Medline].

  20. Cotter CS, Stringer SP, Landau S, et al. Patency of the internal jugular vein following modified radical neck dissection. Laryngoscope. Jul 1994;104(7):841-5. [Medline].

  21. Gavilan J, Gavilan C, Herranz J. Functional neck dissection: three decades of controversy. Ann Otol Rhinol Laryngol. Apr 1992;101(4):339-41. [Medline].

  22. Hamoir M, Shah JP, Desuter G, et al. Prevalence of lymph nodes in the apex of level V: a plea against the necessity to dissect the apex of level V in mucosal head and neck cancer. Head Neck. Nov 2005;27(11):963-9; discussion 969. [Medline].

  23. Medina JE. A rational classification of neck dissections. Otolaryngol Head Neck Surg. Mar 1989;100(3):169-76. [Medline].

  24. Myers EN, Fagan JJ. Treatment of the N+ neck in squamous cell carcinoma of the upper aerodigestive tract. Otolaryngol Clin North Am. Aug 1998;31(4):671-86. [Medline].

  25. Robbins KT. Classification of neck dissection: current concepts and future considerations. Otolaryngol Clin North Am. Aug 1998;31(4):639-55. [Medline].

  26. Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. Jul 2002;128(7):751-8. [Medline].

  27. Schiff BA, Roberts DB, El-Naggar A, et al. Selective vs modified radical neck dissection and postoperative radiotherapy vs observation in the treatment of squamous cell carcinoma of the oral tongue. Arch Otolaryngol Head Neck Surg. Oct 2005;131(10):874-8. [Medline].

  28. Weiss KL, Wax MK, Haydon RC 3rd, et al. Intracranial pressure changes during bilateral radical neck dissections. Head Neck. Nov-Dec 1993;15(6):546-52. [Medline].

  29. Wiater JM, Bigliani LU. Spinal accessory nerve injury. Clin Orthop. Nov 1999;(368):5-16. [Medline].

  30. Zohar Y, Strauss M, Sabo R, et al. Internal jugular vein patency after functional neck dissection: venous duplex imaging. Ann Otol Rhinol Laryngol. Jul 1995;104(7):532-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

modified radical neck dissection, neck dissection, cervical lymph node metastasis, head and neck cancer, radical neck dissection, squamous cell carcinoma

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

John Werning, MD, DMD, FACS, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Florida
John Werning, MD, DMD, 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, and American Head and Neck Society
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, 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, Department of Otolaryngology-Head and Neck Surgery, 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 unstricted gift unknown

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.