Neck dissection

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The English term neck dissection ( dt. "Neck preparation") describes in medicine a surgical procedure with evacuation of all lymph nodes of the neck as part of a malignant tumor in the head and neck area . The aim is to remove metastases from the tumor and prevent further spread of tumor cells in the body.

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According to the therapeutic goal, one differentiates between the following forms:

Prophylactic neck dissection

The lymph nodes are removed even without a proven metastasis . This ensures that any invisible micrometastases that may be present are also removed.

Therapeutic neck dissection

One speaks of therapeutic neck dissection when metastases have already been detected in the lymph nodes .

Anatomical classification

The individual lymph node groups of the neck are divided into six (after Robbins 1991; modified after Robbins 2001) different levels with 6 sublevels. The classification is now widespread, as it determines the surgical effort and the prognosis for tumor removal:

Level I: Submental / submandibular lymph node group

Sublevel Ia: Submental:

Includes all lymph nodes within the triangular zone between the anterior margin of the digastric muscle, the hyoid bone, and the median cervical plane. The hyoid bone forms the lower limit. Existing metastases originate from tumors of the floor of the mouth, the anterior third of the tongue, the anterior lower jaw sections and the lower lip.

Sublevel Ib: Submandibular:

All lymph nodes that lie behind the anterior abdomen of the digastric muscle, in front of the stylohyoid muscle, and under the body of the mandible. The lower limit is formed by the posterior abdomen of the digastric muscle. When this level is cleared, the submandibular gland is also removed. The most common metastases come from tumors of the oral cavity, anterior nasal cavity, submandibular gland, and other soft tissue tumors of the midface.

Level II: craniojugular lymph node group

Sublevel IIa: medial craniojugular lymph node group:

Includes all lymph nodes located between the posterior border of the stylohyoid muscle (radiologically: posterior border of the submandibular gland) and the accessory nerve as well as the base of the skull and the lower border of the hyoid bone. The level corresponds roughly to the top third of the jugular vein. Tumors of the oral and nasal cavities as well as the nasopharynx, oropharynx and hypopharynx, the larynx and the gl. parotid metastasize preferentially to the entire level II.

Sublevel IIb: lateral craniojugular lymph node group:

Contains all lymph nodes in the area between the accessory nerve and the posterior border of the sternocleidomastoid muscle as well as the base of the skull and the lower border of the hyoid bone. Metastases: see level IIa.

Level III: mediojugular lymph node group:

Lymph nodes of the middle third of the jugular vein. The level extends from the lower edge of the hyoid bone to the lower end of the cricoid cartilage and medially from the lateral edge of the sternohyoideus to the posterior edge of the sternocleidomastoid muscle. Metastases are mainly found from tumors from the oral cavity, the larynx and from the nasopharynx, oropharynx and hypopharynx.

Level IV: caudojugular lymph node group:

Level IV includes all lymph nodes surrounding the lower third of the jugular vein. The level extends from the lower edge of the cricoid cartilage to the upper edge of the collarbone and from the sternohyoideus to the posterior edge of the sternocleidomastoid muscle. In particular, tumors from the hypopharynx, thyroid, larynx and cervical section of the esophagus metastasize preferentially to this level.

Level V: the accessory group of the posterior neck triangle:

Sublevel Va: cranial posterior neck triangle:

Level Va includes the lymph nodes around the posterior course of the accessory nerve. The triangular shape of the level is determined by the posterior border of the sternocleidomastoid muscle and the anterior border of the trapezius muscle. Basally, the triangle is blurredly separated from level Vb by the extension of the lower edge of the cricoid cartilage. There are mainly metastases from tumors of the nasopharynx and oropharynx as well as the posterior skin of the head and neck.

Sublevel Vb: caudal posterior neck triangle:

The level includes all lymph nodes of the transverse neck vessels and the supraclavicular lymph nodes. The sagittal boundaries correspond to those of level Va, in the caudal direction the level is bounded by the clavicle, in the cranial direction it changes to level Va. Metastases: see level Va.

Level VI: anterior compartment, parapharyngeal and retropharyngeal lymph node group:

Includes all pre- and paratracheal lymph nodes and the perithyroid lymph nodes, including the lymph nodes surrounding the recurrent laryngeal nerve. The level is in the median plane of the neck and is therefore lateral to the Aa. carotis communis (dexter et sinister) limited. Cranial reached the level to the hyoid bone inferiorly limits the jugular fossa ( " jugular notch ") the level. Metastases usually originate from tumors of the glottis, the cervical esophagus and the thyroid gland.

Surgical techniques

Radical neck dissection

The lymph nodes are removed together with the following anatomical structures:

• Internal jugular vein
• Sternocleidomastoid muscle
• Sternohyoideus muscle
• Sternothyroid muscle
• Omohyoideus muscle
• Submandibular gland
• Accessory nerve

The loss of lymph nodes, adipose and connective tissue, blood vessels, salivary glands and muscle parts is associated with a large loss of tissue and thus also functional restrictions for the patient.

Modified Radical Neck Dissection

How radical neck dissection while maintaining at least one non-lymphatic structure, e.g. B. the accessory nerve and thus less restriction of movement in the head / shoulder area.

The modified radical neck dissection is divided into:

• Type I: clearance level I – V, preserved structure: accessory nerve
• Type II: Level I – V clearance, preserved structures: accessory nerve, internal jugular vein
• Type III: Level I – V clearance, preserved structures: accessory nerve, internal jugular vein, sternocleidomastoid muscle

Functional neck dissection

The functional neck dissection has a better cosmetic and functional result and has e.g. For example, thyroid cancer does not have a worse life expectancy than classic neck dissection. The functional neck dissection preserves muscles, the accessory nerve and the internal jugular vein. If lymph nodes are caked with the jugular vein, this is removed, otherwise “only” the lymph nodes are resected.

Selective neck dissection

The regions of one side of the neck in which lymph node metastases of a primary tumor are detected or suspected are selectively removed . The selective neck dissection is divided into:

• Supraomohyoidal: Levels I-III;
• Lateral: Level II-IV;
• Posterolateral: Level II-V;
• Anterior: Level VI
• Anterolateral: Levels I-IV.

Sentinel Node

The first lymph station after an organ is called the sentinel lymph node ( sentinel lymph node ). This lymph node is usually removed during tumor operations. If this first lymph node is free of metastases, a further distant metastasis via the lymphatic system is unlikely. The removal of the sentinel lymph node is not a form of neck dissection; it is of prophylactic and diagnostic importance.

Individual evidence

1. ↑ Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW: Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology. Arch Otolaryngol Head Neck Surg. 1991 Jun; 117 (6): 601-5 PMID 2036180
2. ↑ Robbins KT, Clayman G, Levine PA, Medina J, Sessions RB, Shaha A, Som P, Wolf GT: 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. 2002 Jul; 128 (7): 751-8, doi: 10.1001 / archotol.128.7.751 , PMID 12117328

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