permanently gastrostomy-dependent.

NECK DISSECTION

Head and neck SCC has a propensity to travel to the cervical lymphatics, the risk of which increases

with T-stage. Pharyngeal tumors, especially those of the nasopharynx and hypopharynx, may present

with a cervical neck mass. In cases when a patient presents with a neck mass for more than 2 weeks, the

clinician should have a high suspicion for metastatic SCC, rather than an infectious or congenital

etiology, and workup should entail imaging, fine-needle aspiration, and endoscopy.

In any patient presenting with SCC, consideration of therapeutic or elective treatment of the neck is

imperative. In general, the cervical lymph nodes are treated with the same modality as the primary

tumor; if surgery is undertaken for an oral cavity primary, for example, simultaneous neck dissection is

performed. Similarly, the radiation oncologist will contour the treatment field to incorporate the

relevant nodal basins in patients treated nonsurgically. Elective neck dissection or elective neck

irradiation in the absence of clinically positive nodes is performed when the risk of occult nodal

metastasis is greater than 15% (Table 41-11).

MANAGEMENT

Table 41-11 Indications for Elective Treatment of the Neck Based on Anatomic

Locale and T Stage

The techniques for neck dissections have evolved with time, initially being developed in the late 19th

century as an en bloc procedure for removal of cervical lymphatics. Crile and Martin subsequently

popularized the radical neck dissection, removal of the cervical lymphatics with sacrifice of the

sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. The modified radical neck

dissection, removal of levels I to V with preservation of one or more of the three structures, then gave

way to the idea of oncologic lymphadenectomy with decreased morbidity.62 Currently, selective neck

dissection, the removal of the at-risk nodal basins with preservation of the SCM, internal jugular, and

accessory nerve, is most commonly as the standard of care, as it preserves oncologic principles and

minimizes morbidity.63 The patterns of lymphatic drainage from each subsite are well described based

on the publications of Lindberg and Shah.64,65 In general, dissection of levels II to IV is performed for

cancers of the larynx, oropharynx, and hypopharynx, while levels I to III and possibly IV are addressed

for oral cavity cancer (Fig. 41-13). Level V is rarely involved except in NPC and skin cancer.

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Figure 41-13. Intraoperative photograph demonstrating the left neck after performance of a selective (supraomohyoid) neck

dissection. Selective neck dissection is generally a low morbidity procedure. Vital structures such as the internal jugular vein (IJV),

common carotid artery (CCA), and spinal accessory nerve (large arrow) are carefully preserved. In the context of an N0 neck, other

nonvital structures such as the sternocleidomastoid muscle (SCM), external jugular vein (EJV) greater auricular nerve (GAN),

cervical sensory rootlets (small arrows) and ansa cervicalis (asterisks) may also be spared.

Table 41-12 Complications of Common Head and Neck Surgeries

As in central neck dissection for thyroid cancer, a systematic, comprehensive approach should be used

to perform neck dissection, rather than “node-plucking.” The boundaries for the common “lateral neck

dissection,” encompassing levels II to IV, should extend from the digastric muscle’s insertion on the

mastoid with the SCM superiorly to the plane of the clavicle inferiorly, and from the posterior edge of

the SCM to the strap muscles anteriorly. The floor of dissection is the cervical sensory rootlets in level

III and the fascia overlying the deep musculature in level II (levator scapulae) and in level IV (anterior

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and middle scalenes). Care should be taken in level IV to avoid the phrenic nerve and brachial plexus, as

well as the thoracic duct and right lymphatic duct. When level IB is included in the specimen, the

marginal mandibular nerve must be elevated off the submandibular gland and protected to allow for

safe resection of the gland and nodes along the facial vessels. Level V dissection requires identification

of the spinal accessory nerve just below Erb point; it is then traced to its entry into the trapezius to

protect it along its course.

COMPLICATIONS OF HEAD AND NECK SURGERY

Due to the intricate, complex anatomy of the region, surgery of the head and neck may be fraught with

complications and morbidity. Although better understanding of anatomy and refined surgical techniques

have fostered “functional” and “minimally invasive” approaches, complications occur, even in

experienced hands. Salvage surgery after radiation or chemoradiation may be particularly difficult due

to the extensive fibrosis that occurs. Table 41-12 lists common and serious, rare complications of

common head and neck procedures. When performing these procedures, the surgeon should be aware of

critical structures in the area, and thorough discussion with the patient should be a part of the informed

consent process.

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