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Neck Dissection

A neck dissection is a systematic approach to removing entire groups of lymph nodes from the neck. This is very different than plucking out a few nodes from the neck (which should only be done in rare cases when all other modalities have failed to reach a diagnosis or to get more tissue to help with treatment decisions in diseases such as lymphoma). Removing lymph nodes from the neck does not alter your body’s ability to fight infection—so the patient should not be worried about that.

A neck dissection can be done as an elective neck dissection, which is the removal of the lymph nodes without any evidence that there is obvious cancer in the neck, or as a therapeutic neck dissection, which is the removal of lymph nodes in the neck with known cancerous lymph nodes in the region based on a biopsy or a high level of suspicion based on their appearance on imaging studies. An elective neck dissection will be considered if there is a high risk that there is microscopic (hidden or not clinically apparent) cancer in the lymph nodes (more than 20%).

The different lymph node groups of the neck are shown below:

07_neck_levels

The extent on the neck dissection will depend on a number of factors. Perhaps most important is the site of the primary cancer. Interestingly, there is a pattern to which level certain cancers spread when they enter the lymphatic system. For example, cancers of the oral cavity are known to spread to Levels I, II and III; therefore, an elective neck dissection for a cancer of the oral cavity should include these lymph node groups on the side of the primary cancer. The general patterns include:

  • Level I, II, III: oral cavity
  • Level II, III, IV: oropharynx, hypopharynx, larynx
  • Level V: scalp, facial skin
  • Level VI: thyroid, larynx
  • Level VII: thyroid

Another important factor contributing to the extent of the neck dissection required is whether there is clinical evidence of spread into the lymph nodes. If there is clinical evidence of cancer in the neck, your surgeon will probably be more comprehensive in cleaning out more of the neck.

Surgeons use different terms to describe neck dissections. You need not be concerned with the exact name given to different types of neck dissection, but you might be interested to know some nomenclature:

  • Radical neck dissection: This refers to the removal of lymph node groups I to V, as well as the sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. This used to be the standard neck dissection years ago but has been replaced with neck dissections that spare some or all of these structures. An extended radical neck dissection includes all of these, plus removal of additional lymph node groups or non-lymphatic structures not accounted for in the radical neck dissection definition.
  • Modified radical neck dissection: This is the removal of lymph node groups I to V, while sparing one or more of the three structures taken in the radical neck dissection (sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve). In old nomenclature, depending on what structure was removed, surgeons would call them Type I, Type II or Type III modified radical neck dissections. These days, they should be described as a modified radical neck dissection with sacrifice of the internal jugular vein and sternocleidomastoid muscle (this implies that the spinal accessory nerve was preserved). A modified radical neck dissection that preserves all three structures is also called a comprehensive neck dissection, indicative of the removal of lymph nodes from Levels 1 though 5.
  • Selective neck dissection: This is the removal of a select group of lymph nodes in the neck, with or without sacrifice of additional non-lymphatic structures. Most neck dissections in current times are really selective neck dissections. Some common selective neck dissections are given names such as the following:
    • Supraomohyoid neck dissection: This is the removal of lymph node Groups I, II and III.
    • Lateral neck dissection: This is the removal of lymph node Groups II, III and IV.
    • Posterolateral neck dissection: This is the removal of lymph node Groups II, III, IV and V.

If a major neck structure is removed as part of a selective neck dissection, it should be indicated. For example, a lateral neck dissection with sacrifice of the internal jugular vein is still a selective neck dissection.

  • Central compartment lymph node dissection: The central compartment (Level VI) is not included in the typical “neck dissection.” Level VI is systematically removed in cases of thyroid cancer and larynx cancer.
  • Salvage neck dissection: This is a neck dissection in a previously treated neck, whether previously treated by radiation, chemotherapy or surgery. This is performed for a persistent tumor in the neck lymph nodes despite treatment. A salvage neck dissection is typically more difficult than a primary neck dissection because of previous treatment scarring and effects. Also, it usually indicates that the cancer cells are more aggressive and resistant to treatment than they typically are.
  • Removal of skin, carotid artery: In some cases of very advanced tumors, your surgeon might require removing skin as part of the neck dissection. Even more rarely, the common carotid artery (or internal carotid artery) might be involved by tumor. This is the artery that supplies blood to your brain. If the carotid artery is almost completely surrounded by tumor, this is usually considered unresectable as there are major risks to attempted removal of the tumor with a low chance of getting it all out. If your cancer team does anticipate partial or total resection of the common carotid artery as a reasonable option for your treatment plan, and you understand the risks, you will likely have some pre-operative tests to see if the opposite carotid artery is strong enough to supply oxygen to both sides of the brain. Then, in most cases, a vascular surgeon will be available to help with the resection and subsequent reconstruction of the carotid artery if that is deemed necessary.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you have a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

You will be put completely to sleep with general anesthesia for this procedure. There are a number of different types of incisions your surgeon might make. Most important is that the incision allows the systematic removal of all the lymph nodes at risk of harboring cancer. This will be done by identifying and preserving all the major structures in the neck and by removing all the fat and lymph nodes that fill up the rest of the neck contents.

In some cases, some major structures might need to be removed because of invasion of cancer. Such structures could include the sternocleidomastoid muscle, the internal jugular vein and the spinal accessory nerve.

At the end of the procedure, your surgeon will probably place a small drain coming out of your skin. This is to drain any blood and/or fluid that might accumulate in the space that is created by removing the fat and lymph nodes. When the time is right (from one day to a few days), the drain will be removed by your surgical team. This takes only a few seconds, and you can think of it as removing a bandage. There will be a little discomfort, but it will go by quickly.

You should be up and out of bed by the next day. You should be slowly drinking liquids and eating by the next day as well.

Recovery and aftercare

The recovery course will depend on the extent of additional surgery and the reconstruction performed along with the neck dissection. Some surgery might require staying in the hospital for one to two weeks. A stay longer than two weeks is usually due to some sort of post-operative complication that your doctors are working to improve. With a neck dissection alone, you should be ready to go home after two to three days—and that’s only to allow the drain output to decrease.

If you do stay in the hospital for recovery, the recovery course can happen in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

As with any procedure, there are risks in undergoing a neck dissection that you need to be aware of:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Seroma: This is a collection of normal body fluid in the neck after removal of the drain. This can be treated with observation, as the body will eventually resorb it, or repeated needle aspirations. The risk of leaving seroma is that it could become infected.
  • Infection: Neck dissections are done under completely sterile conditions. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Damage to cranial and/or cervical nerves, including those that are responsible for:
    • Raising your arm way up into the air (CN XI, spinal accessory nerve)
    • Moving your tongue on one side (CN XII)
    • Moving the lower part of your face (Mandibular branch of CN VII)
    • Moving your diaphragm when you breath (phrenic nerve)
    • Sensation to various parts of the neck, ear and ear lobe (cervical roots and greater auricular nerve)
    • Moving your vocal cords on one side and controlling other bodily functions (CN X, vagus nerve)
    • Moving your arm (brachial plexus)
  • Chyle leak: This is a leak of fat containing lymphatic fluid from the thoracic duct, accessory thoracic duct or their branches. It will show up as a milky-appearing fluid coming into the drain in your neck (after you start eating). This complication occurs when the neck dissection extends down to Level IV (just above the clavicles), because this is where the lymphatic channels that carry this fatty fluid empty into the jugular vein. The main thoracic duct is on the left side, but an accessory duct can also be found on the right side. Therefore, though the higher risk for a chyle leak is on the left, your surgeon will be careful of this complication on both sides. This is treated by keeping you on a non-fat diet, with or without a drain and pressure placed over the area. If there is a really high output of chyle leaking or if it persists for weeks, you might need to go to the operating room for exploration and clipping of the duct.
  • Recurrent or chronic facial swelling: This can happen in two situations: when both internal jugular veins need to be sacrificed (which limits blood drainage from the face resulting in severe facial swelling) or in lymphedema (which is severe lymphatic obstruction from removal of all lymphatic drainage pathways. These are extremely rare complications of neck dissection and are seen in very advanced disease in patients who have received other forms of treatment.
  • Blood clots: Patients who undergo major surgeries, especially patients who have cancer, are at an increased risk of developing blood clots in their legs (deep venous thrombosis). Sometimes these blood clots can travel through the veins and into the lungs, causing a pulmonary embolus. This can be a serious complication, causing problems with oxygenation of your blood. If such a problem occurs, you will likely require anticoagulation (blood-thinning medication) to prevent more clots from forming and ending up in your lungs. This blood-thinning medicine, though necessary to prevent more clots, might itself cause another complication, such as bleeding, especially in the time immediately after surgery. This is why it is important for you to get out of bed early and move your legs. If you are not up and moving about, dynamic compression stockings should be used (these are like massage boots for your calves to keep the blood flowing). Also, you will probably be given a low dose of blood-thinning medication immediately after surgery to help prevent clots.