Radical Neck Dissection

History of presenting illness: Patients will often present with a sizable mass in the neck. Important questions include:

• a.

  Duration and rate of growth of the mass? Rapidly growing masses or a sudden increase in the size of the neck mass may indicate an aggressive cancer that requires expedited management.

• b.

  Are there any other associated factors? Patients may also complain of dysphagia, dysphonia, otalgia, epistaxis, hemoptysis, rapid weight loss, or other symptoms that may help in identifying the site of the primary cancer.

Past medical history

• a.

  The medical history should seek to identify significant medical comorbidities that may influence or, in some cases, preclude operative management.

• b.

  Recognition of comorbid disease helps to identify patients who will require close observation or specialized intervention during the perioperative course. For example, those with history of deep venous thromboembolism or atrial fibrillation will require a coordinated effort to ensure appropriate perioperative management of their coagulation status.

Past surgical history

• a.

  It is important to consider whether there has been any prior operative management including fine-needle aspiration (FNA), open biopsy, or previous neck dissection. Such prior interventions may influence incision planning and the extent of resection.

• b.

  Any previous operative and/or pathology reports should be reviewed. When possible, discussion with the previous operating surgeon can be of tremendous value in reoperative situations.

• c.

  Prior history of radiation is important. Surgical incision planning to avoid three-point closures over the carotid system and carotid coverage with vascularized tissue may be considerations in radiated patients due to the high incidence of wound infection and breakdown, increasing the risk of carotid blowout.

Social history

• a.

  Alcohol and tobacco are known to be risk factors for cancer of the head and neck; addiction history (including use of illicit drugs) also helps in preparation for postoperative management. For example, chronic alcohol abuse requires very close observation and frequently involves medical management for prevention of delirium tremens and other associated sequelae of alcohol withdrawal syndrome.

A complete examination of the head and neck including the cranial nerves and flexible fiberoptic laryngoscopy is critical in evaluating the primary cancer, residual disease, or recurrence.

A general examination of the patient may reveal signs of temporal wasting (indicating malnutrition), previous surgical incisions, or post-radiation skin changes.

All patients considered for RND should have clinically apparent lymph node metastasis. There is no indication for RND in the N0 neck. Questions to consider during examination of a neck mass should include:

• a.

  Is the mass in the neck mobile? If the mass appears firm, ill-defined, and partially fixed to underlying structures, RND is likely indicated. If the mass is well defined and mobile, the patient may be a candidate for a modified radical neck dissection (MRND) instead.

• b.

  Where is the mass in the neck located ? Large, fixed, and matted nodes high in level II or low in level V may portend the need for RND, as these tend to be overlapping locations for the critical nonlymphatic structures (SCM, IJV, CN XI).

• c.

  Is there involvement of the overlying dermis or skin ? If the skin is inseparable from the underlying neck mass, this may be a sign that an extended neck dissection with resection of the skin is warranted. This is important when considering design of the incision, as the resulting defect will likely require consideration of different reconstructive options.

Examination of the cranial nerves: Examination of the cranial nerves, particularly the lower cranial nerves (VII and IX to XII), will give an indication of the extent of the cancer, help to anticipate postoperative morbidity, and allow estimation of prognosis; the latter may impact the treatment plan.

Contrasted computed tomography (CT) scan of the neck with and without contrast (1 mm sections)

• a.

  A contrasted CT scan is complementary to the physical examination and allows preoperative assessment of lymph node metastasis, levels involved, and critical information regarding proximity/involvement of major vessels, skin, and deep muscles of the neck.

• b.

  In these situations of advanced cancer of the head and neck, CT imaging may assist in determining the resectability of the cancer. Invasion of the prevertebral/paraspinal musculature or encasement of the carotid artery may guide the surgeon away from operative management.

Positron emission tomography (PET)-CT

• a.

  Those patients being considered for RND have advanced stage cancer. A preoperative PET-CT assists in ruling out distant metastases, as the latter would preclude operative management of the neck, unless planned only for palliation.

CT angiography or formal angiography

• a.

  Some patients who have bulky lymph node metastasis will be found to have involvement of the carotid artery. In select patients, evaluation of the carotid artery with angiography and balloon occlusion testing may assist in the preoperative evaluation if extended RND with carotid resection is being considered (see Discussion).

MRND and selective neck dissections (SNDs) have been validated to show similar oncologic outcomes to RND but with much less morbidity. As such, the RND is not as frequently performed as it has been in the past.

RND is still indicated when there is bulky lymph node metastasis involving the SCM, IJV, and CN XI. These are often found in close proximity high up in level II ( Fig. 66.2 ) or lower in the posterior triangle of the neck.

Rather than attempting dissection of these structures away from the cancer, it is more oncologically sound to include these nonlymphatic structures in the specimen, generally speaking.

Invasion of the prevertebral or paraspinal musculature

Involvement of the brachial plexus

Complete encasement of the carotid artery is a relative contraindication.

• a.

  Studies have shown that carotid artery resection and grafting are feasible and can be considered, provided adequate collateral cerebral circulation can be gauged with preoperative balloon occlusion studies.

Involvement of the cranial base

Inability to completely control the primary cancer

Distant metastasis

Medical comorbidities should be appropriately addressed prior to consideration for surgery. Those patients with significant cardiopulmonary issues should be evaluated by the anesthesiologist and undergo a comprehensive medical evaluation for clearance.

Patients may also be severely malnourished, and when possible, the nutritional status should be optimized prior to surgery.

Informed consent and patient understanding are critical. Specifically, patients should comprehend the morbidity of facial lymphedema as well as shoulder dysfunction and associated pain ( Fig. 66.3 ), which may require intensive postoperative physical therapy.