Radical neck dissection

Definition

Radical neck dissection is a surgical operation used to remove cancerous tissue in the head and neck.

Purpose

The purpose of radical neck dissection is to remove lymph nodes and other structures in the head and neck that are likely or known to be malignant. Variations on neck dissections exist, depending on the extent of the cancer. A radical neck dissection removes the most tissue. It is performed when the cancer has spread widely in the neck. A modified neck dissection removes less tissue, and a selective neck dissection even less.

Demographics

Experts estimate that there are approximately 5,000–10,000 radical neck dissections in the United States each year. Men and women undergo radical neck dissections at about the same rate.

Description

Cancers of the head and neck (sometimes inaccurately called throat cancer) often spread to nearby tissues and into the lymph nodes. Removing these structures is one way of controlling the cancer.

Of the 600 lymph nodes in the body, approximately 200 are in the neck. Only a small number of these are removed during a neck dissection. In addition, other structures such as muscles, veins, and nerves may be removed during a radical neck dissection. These include the sternocleidomastoid muscle (one of the muscles that functions to flex the head), internal jugular (neck) vein, submandibular gland (one of the salivary glands), and the spinal accessory nerve (a nerve that helps control speech, swallowing, and certain movements of the head and neck). The goal is always to remove all the cancer, but to save as many components surrounding the nodes as possible.

An incision is made in the neck, and the skin is pulled back (retracted) to reveal the muscles and lymph nodes. The surgeon is guided in what to remove by tests performed prior to surgery and by examination of the size and texture of the lymph nodes.

Diagnosis/Preparation

This operation should not be performed if cancer has metastasized (spread) beyond the head and neck, or if the cancer has invaded the bones of the cervical vertebrae (the first seven bones of the spinal column) or the skull. In these cases, the surgery will not effectively contain the cancer.

Radical neck dissection is a major operation. Extensive tests are performed before the operation to try to determine where and how far the cancer has spread. These may include lymph node biopsies, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and barium swallows. In addition, standard preoperative blood and liver function tests are performed, and the candidate will meet with an anesthesiologist before the operation. The candidate should tell the anesthesiologist about all drug allergies and all medication (prescription, nonprescription, or herbal) that are presently being taken.

Aftercare

A person who has had a radical neck dissection will stay in the hospital several days after the operation, and sometimes longer if surgery to remove the primary tumor was performed at the same time. Drains are inserted under the skin to remove the fluid that accumulates in the neck area. Once the drains are removed and the incision appears to be healing well, people are usually discharged from the hospital, but will require follow-up doctor visits. Depending on how many structures are removed, a person who has had a radical neck dissection may require physical therapy to regain use of the arm and shoulder.

Risks

The greatest risk in a radical neck dissection is damage to the nerves, muscles, and veins in the neck. Nerve damage can result in numbness (either temporary or permanent) to different regions on the neck and loss of function (temporary or permanent) to parts of the neck, throat, and shoulder. The more extensive the neck dissection, the more function a person is likely to lose. As a result, it is common following radical neck dissection for people to have stooped shoulders, limited ability to lift one or both arms, and limited head and neck rotation and flexion due to the removal of nerves and muscles. Other risks are the same as for all major surgery: potential bleeding, infection, and allergic reaction to anesthesia.

Normal results

Normal lymph nodes are small and show no cancerous cells under a microscope. Abnormal lymph nodes may be enlarged and show malignant cells when examined under a microscope.

Morbidity and mortality rates

The mortality rate for radical neck dissection can be as high as 14%.

Morbidity rates are somewhat higher and are due to bleeding, post-surgery infection, and medicine errors.

Alternatives

Alternatives to radical neck dissection depend on the reason for the proposed surgery. Most alternatives are far less acceptable. Radiation and chemotherapy may be used instead of a radical neck dissection in the case of cancer. Alternatives for some surgical procedures may reduce scarring, but are not as effective in the removal of all pathological tissue. Chemotherapy and radiation or altered fractionated radiotherapy are reasonable alternatives.

See also Carotid endarterectomy ; Parathyroidectomy ; Thyroidectomy .

Resources

BOOKS

Bland, K. I., W. G. Cioffi, and M. G. Sarr. Practice of General Surgery. Philadelphia: Saunders, 2001.

Braunwald, E., D. L. Longo, and J. L. Jameson. Harrison's Principles of Internal Medicine, 15th Edition. New York: McGraw-Hill, 2001.

Goldman, L., and J. C. Bennett. Cecil Textbook of Medicine, 21st Edition. Philadelphia: Saunders, 1999.

Schwartz, S. I., J. E. Fischer, F. C. Spencer, G. T. Shires, and J. M. Daly. Principles of Surgery, 7th edition. New York: McGraw Hill, 1998.

Townsend, C., K. L. Mattox, R. D. Beauchamp, B. M. Evers, and D. C. Sabiston. Sabiston's Review of Surgery, 3rd Edition. Philadelphia: Saunders, 2001.

PERIODICALS

Agrama, M. T., D. Reiter, M. F. Cunnane, A. Topham, and W. M. Keane. "Nodal Yield in Neck Dissection and the Likelihood of Metastases." Otolaryngology Head and Neck Surgery 128, no.2 (2003): 185–190.

Cmejrek, R. C., J. M. Coticchia, and J. E. Arnold. "Presentation, Diagnosis, and Management of Deep-neck Abscesses in Infants." Archives of Otolaryngology Head and Neck Surgery 128, no.12 (2002): 1361–1364.

Ferlito, A., et al. "Is the Standard Radical Neck Dissection No Longer Standard?" Acta Otolaryngolica 122, no.7 (2002): 792–795.

Kamasaki, N., H. Ikeda, Z. L. Wang, Y. Narimatsu, and T. Inokuchi. "Bilateral Chylothorax Following Radical Neck Dissection." International Journal of Oral and Maxillofacial Surgery 32, no.1 (2003): 91–93.

Myers, E. N., and B. R. Gastman. "Neck Dissection: An Operation in Evolution: Hayes Martin Lecture." Archives of Otolaryngology Head And Neck Surgery 129, no.1 (2003): 14–25.

Ohshima, A., et al. "Is a Bilateral Modified Radical Neck Dissection Beneficial for Patients with Papillary Thyroid Cancer?" Surgery Today 32, no.12 (2002): 1027–1030.

Wang, L. F., W. R. Kuo, C. S. Lin, K. W. Lee, and K. J. Huang. "Space Infection of the Head and Neck." Kaohsiung Journal of Medical Sciences 18, no.8 (2002): 386–392.

ORGANIZATIONS

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-32311. (312) 202-5000, Fax: (312) 202-5001. E-mail: http://postmaster@facs.org. http://www.facs.org .

American Academy of Otolaryngology—Head and Neck Surgery. One Prince St., Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org/index2.cfm .

American Cancer Society. 1599 Clifton Road NE, Atlanta, GA 30329. (800) 227-2345. http://www.cancer.org .

American Osteopathic College of Otolaryngology—Head and Neck Surgery. 405 W. Grand Avenue, Dayton, OH 45405. (937) 222-8820 or (800) 455-9404, Fax: (937) 222-8840. info@aocoohns.org

OTHER

Amersham Health. [cited April 7, 2003] <http://www.amershamhealth.com/medcyclopaedia/Volume%20VI%202/n ck%20dissection.asp> .

Baylor College of Medicine. [cited April 7, 2003] http://www.bcm.tmc.edu/oto/grand/120293.html .

Eastern Virginia Medical School. [cited April 7, 2003] http://www.voice-center.com .

Medical Algorithms Project. [cited April 7, 2003] http://www.medal.org/docs_ch37/doc_ch37.23.html .

ThyroidCancer.Net . [cited April 7, 2003] <http://www.thyroidcancer.net/topics/what+is+a+neck+dissection? MS_Session=4ebe4755df4793bda647c0bf21fd977f> .

University of Washington Department of Surgery. [cited April 7, 2003] http://depts.washington.edu/soar/abstract/ab16.htm .

L. Fleming Fallon, Jr. MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A radical neck dissection is usually performed by a surgeon with specialized training in otolaryngology, head and neck surgery. Occasionally, a general surgeon will perform a radical neck dissection. The procedure is performed in a hospital under general anesthesia.

QUESTIONS TO ASK THE DOCTOR

• What tests will be performed to determine if the cancer has spread?
• Which parts of the neck will be removed?
• How will a radical neck dissection affect daily activities after recovery?
• What is the likelihood that all of the cancer can be removed with a radical neck dissection?
• Are the involved lymph nodes on one or both sides of the neck?
• What will be the resulting appearance after surgery?
• How will my speech and breathing be affected?
• Is the surgeon board certified in otolaryngology head and neck surgery?
• How many radical neck procedures has the surgeon performed?
• What is the surgeon's complication rate?