Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

678
Section 8
Neck
5. Coticchia JM, Getnick GS, Yun RD, Arnold JE: Age-, site-, and
time-specifi c differences in pediatric deep neck abscesses. Arch
Otolaryngol Head Neck Surg 130:201-207, 2004.
6. Lee KC, Tami TA, Echavez M, et al: Deep neck infections in
patients at risk for acquired immunodefi ciency syndrome. Laryn-
goscope 100:915-919, 1990.
7. Williams MF, Eisele DW, Wyatt SH: Neck needle foreign bodies
in intravenous drug abusers. Laryngoscope 103:59-63, 1993.
8. McClay JE, Murray AD, Booth T: Intravenous antibiotic therapy
for deep neck abscesses defi ned by computed tomography. Arch
Otolaryngol Head Neck Surg 129:1207-1212, 2003.
9. Olsen WL, Jeffrey RB Jr, Sooy CD, et al: Lesions of the head and
neck in patients with AIDS: CT and MR fi ndings. AJR Am J Roent-
genol 151:785-790, 1988.
10. deMarie S, Tjon A, Tham RTO, et al: Clinical infections and
nonsurgical treatment of parapharyngeal space infections com-
plicating throat infection. Rev Infect Dis 11:975-982, 1989.
11. Baatenburg de Jong RJ, Rongen RJ, Lameris JS, et al: Ultrasound-
guided percutaneous drainage of deep neck abscesses. Clin Oto-
laryngol 15:159-166, 1990.
12. Broughton RA: Nonsurgical management of deep neck infec-
tions in children. Pediatr Infect Dis J 11:14-18, 1992.
13. Cole DR, Bankoff M, Carter BL: Percutaneous catheter drainage
of deep neck infections guided by CT. Radiology 152:224, 1984.
14. Lalwani AK, Kaplan MJ: Mediastinal and thoracic complications
of necrotizing fasciitis of the head and neck. Head Neck 13:531-
539, 1991.
15. Kaddour HS, Smelth GJ: Necrotizing fasciitis of the neck. J Lar-
yngol Otol 106:1008-1010, 1992.
16. Tovi F, Fliss DM, Zirkin HJ: Necrotizing soft-tissue infections in
the head and neck: A clinicopathological study. Laryngoscope
101:619-625, 1991.
17. Gallia L, Johnson JT: Cervical necrotizing fasciitis. Otolaryngol
Head Neck Surg 89:935-937, 1981.
18. Kunse S, Eibling DE, Yu VL, et al: Gangrenous cellulitis associated
with gram-negative bacilli in pancytopenic patients: Dilemma
with respect to effective therapy. Am J Med 85:490-494, 1988.
19. Chowdhury K, Bloom J, Black MJ, al-Noury K: Spontaneous and
nonspontaneous internal jugular vein thrombosis. Head Neck
12:168-173, 1990.
20. Langenbrunner DJ, Dajani S: Pharyngomaxillary space abscess
with carotid artery erosion. Arch Otolaryngol 94:445-457, 1971.

Chapter 78
Neck Dissection
David E. Eibling
Management of the neck remains the keystone of man-
agement of cancer of the head and neck. The cervical
lymphatics play an active role in the biologic behavior
of cancers of the head and neck. Cells from the primary
cancer fi nd their way into the multilevel, anastomosing
network of lymphatics that drain through a series of
lymph nodes. Cancer cells found in the lymphatic fl uid
are trapped by the nodes, where they often evade host
immune defenses and proliferate. Distant metastatic
disease often occurs quite late in patients with squa-
mous cell carcinoma of the head and neck, despite the
presence of involved cervical neck nodes, suggesting
that the fi ltration function of the cervical lymphatics is
effective. Unfortunately, the proliferation of cancer
within the nodes often leads to uncontrolled regional
disease and the eventual demise of the patient. The
fi nding of cancer within the cervical lymph nodes down-
grades the patient’s curability by 50% and is responsible
for 50% to 95% of recurrent disease. Depending on
primary site and treatment, treatment plans must con-
sider management of cervical metastatic disease.
Leaving cancer in the cervical nodes, whether or not
clinically apparent, inevitably results in unacceptable
morbidity and mortality for the patient.
The staging system for cancer of the head and neck
(with the exception of thyroid cancer) emphasizes the
status of the cervical lymphatics. Patient outcomes
strongly correlate with the presence and extent of meta-
static disease in the regional nodes.1,2 The critical dif-
ferentiation for staging is the presence, number, and
size of involved cervical nodes. A single, small node
(N1) converts any early primary cancer (T1-2) to stage
3, and more than one lymph node or a lymph node
greater than 3 cm (N2 or 3) to stage 4, refl ecting the
grim prognostic implications of palpable neck disease
(Fig. 78-1). Metastatic deposits that are present, but not
clinically evident, convey the same dismal implications
for the patient because they will enlarge to become
palpable at a later date. Cancer that has spread through
the capsule into the surrounding fat (extracapsular
spread, or ECS) is even worse, probably refl ecting
tumor biologic behavior rather than a geographic loca-
tion (Fig. 78-2).3
Clinical staging includes information derived from
imaging, which is considered to be complementary to
physical examination. A defi nitive pathologic diagnosis
is derived from fi ne-needle aspiration biopsy or exami-
nation of excised lymph nodes.4
Non–squamous cell carcinomas of the head and
neck include malignant melanoma, cancers of salivary
gland origin, and cancer of the thyroid. In contrast to
other histologic variants, differentiated cancer of the
thyroid metastatic to the cervical lymph nodes does not
convey as grave a prognosis. Hence the staging system
for thyroid cancer is weighted toward the primary
cancer, with nodal disease being indicated only as
present or absent, regardless of the size of the lymph
nodes.
The staging system is inadequate to predict tumor
behavior due to the heterogeneous nature of squamous
cell carcinoma of the head and neck. Although addi-
tional markers are used routinely in cancers of other
sites, as of this writing similar biologic indicators, such
as the presence of ECS, have not been incorporated
into the standard staging system for cancer of the head
and neck.
OCCULT METASTASIS TO THE CERVICAL
LYMPH NODES
More than 50% of patients with identifi ed primary
cancers of the head and neck present with obvious
metastasis to cervical lymph nodes. Unfortunately,
pathologic evidence of cancer deposits is found in 20%
to 30% of patients without clinical or radiologic evi-
dence of nodal involvement. Pathologic evidence of
metastasis may be identifi ed in lymph nodes that have
been surgically removed, or evidenced by delayed tumor
679

680
Section 8
Neck
presentation in the neck despite the absence of recur-
rence of the primary cancer. The site and stage of the
primary cancer predict the position and frequency of
these “occult” metastases, and histologic diagnosis is
dependent on specifi c sampling techniques. Successful
therapy must consider treatment of nonpalpable nodes
that may contain microscopic metastasis as well as clini-
cally involved positive nodes. Decisions are dependent
on probabilistic information and the willingness of the
patient and surgeon to accept the risk of untreated
occult disease.
Lymph node removal by neck dissection is per-
formed for therapeutic removal of palpable enlarged
lymph nodes, lymph nodes deemed enlarged through
imaging modalities, or apparent normal lymph nodes
considered to be at risk for metastatic spread. Removal
of potentially involved but nonpalpable lymph nodes is
benefi cial not only for therapeutic purposes, but also as
an effective means of determining pathologic stage and
the need for further adjuvant therapy. The choice of
treatment of the neck depends on the site and stage of
the primary cancer, the probability of occult metastases,
the treatment modality selected for the primary cancer,
and the desires of the patient.
RADICAL NECK DISSECTION
The “classic” radical neck dissection effectively removes
all of the lymph nodes present in the neck and their
interconnecting lymphatics. In his classic article in
1906, Crile5 for the fi rst time described systematically
the procedure that remained the standard form of neck
dissection for more than 70 years. The radical neck
dissection removes not only nodes and lymphatics
with surrounding fat, but also the sternocleidomastoid
muscle (SCM), submandibular gland, tail of the parotid
gland, internal and external jugular veins, cervical
sensory nerves, and the spinal accessory nerve, whether
these structures are involved or not. These structures
are removed to conform to the Halstedian concept of
en bloc resection. Most of the morbidity of the proce-
dure is thereby related to the removal of these addi-
tional structures, particularly the 11th cranial nerve,
sternocleidomastoid muscle, and internal jugular vein
(IJV), rather than the removal of the nodes per se. The
radical neck dissection was the most commonly used
form of neck dissection in the United States until the
N0
N1
<3 cm
3-6 cm
>6 cm
<6 cm
<6 cm
N2a
N2b
N2c
N3
Figure 78-1. Staging system for head and
neck cancer.
Figure 78-2. Extracapsular spread in the carotid lymph node invad-
ing the surrounding soft tissue.

Chapter 78
Neck Dissection
681
1970s.6 It has, however, largely been replaced by modi-
fi cations of the procedure that preserve nonlymphatic
structures such as muscles, nerves, and vessels.
FUNCTIONAL NECK DISSECTION
Cervical lymphatics are contained within fascial “enve-
lopes,” consisting of the fascia covering the subman-
dibular glands, carotid sheath, SCM, and deep cervical
muscles and nerves. Suarez is generally credited as
being the fi rst to incorporate this anatomic fact into a
modifi cation of the classic neck dissection, removing
only the lymph nodes. Ferlito and colleagues7 and
Bocca and Pignataro8 coined the term “functional
neck dissection” and described the technique in the
English-speaking literature in 1967. Today we term pro-
cedures that remove all the lymphatics but preserve
non–lymphatic-containing structures “modifi ed neck
dissection.”9
Cervical lymph nodes are divided into groups that
roughly correspond to describe “levels” or zones that
are the basis of various forms of neck dissection that
remove only nodes at risk. Although these levels (and
groups) are not discretely separated by anatomic struc-
tures, they nevertheless defi ne a convenient classifi ca-
tion system (Fig. 78-3).
ANATOMIC STRUCTURES
A basic review of the anatomy of the neck is benefi cial
in understanding the surgical approaches to the neck,
particularly the various forms of neck dissection. The
major muscles, nerves, and vessels are discussed in the
following paragraphs.
Platysma Muscle
The platysma muscle lies just deep to the subcutaneous
fascia and fat and extends from just over the mandible
down to the upper chest. It runs obliquely from pos-
teroinferior to anterosuperior, inserting into the super-
fi cial muscular aponeurotic system. It is defi cient in the
lower anterior midline in the neck and does not extend
appreciably posterior to the exterior jugular vein and
greater auricular (GA) nerve (Fig. 78-4). Its undersur-
face provides a convenient plane in which to elevate
skin fl aps, and it may also be used alone or with overly-
ing skin as a fl ap in an intraoral closure technique.
Sternocleidomastoid Muscle
The SCM runs obliquely from anteroinferior to postero-
superior, inserting on the mastoid tip. It can be readily
differentiated from the platysma muscle by the direc-
tion of its fi bers. It is crossed in an inferior-to-posterior
direction by the GA nerve and the external jugular vein,
which lie immediately deep to the platysma. If these
structures are left on the surface of the SCM during fl ap
elevation, the SCM assists in developing the fascial enve-
lope in modifi ed and selective neck dissections (Fig.
78-5). The posterior border of the SCM represents the
posterior border of nodal levels II through IV and the
anterior border of level V (Fig. 78-6). As the cervical
contributions to the GA nerve leave the cervical plexus
and sweep around the posterior border of the SCM,
they artifi cially separate levels IV and V, identifying the
posterior limit of the selective neck dissection.
I A
I B
VI
IV
V
III
II
Figure 78-3. Levels of neck nodes. Selective neck dissections are
labeled according to the levels of nodes removed.
Sternocleidomastoid muscle
External jugular vein
Greater auricular nerve
Platysma muscle
Figure 78-4. Detail of the platysma muscle, the external jugular
vein, and the greater auricular nerve.

682
Section 8
Neck
Greater Auricular Nerve
The GA nerve extends vertically from the posterior
edge of the SCM obliquely over the SCM, roughly paral-
lel and slightly posterior to the external jugular vein
(see Fig. 78-4). It divides into two branches, the anterior
of which enters the substance of the parotid gland. The
GA nerve provides sensation to the auricle and dividing
or injuring it results in hypesthesia, which can be quite
problematic for some patients. We attempt to preserve
the GA nerve during selective neck dissection, although
it is impossible in the radical neck dissection or modi-
fi ed radical neck dissection. In the illustrations in this
text, the nerve is illustrated as having been divided, but
this is not always necessary.
Spinal Accessory Nerve
The spinal accessory nerve (the 11th cranial nerve)
passes over the jugular vein in most instances at the
level of the posterior belly of the digastric muscle. It
then passes through the lymphoid tissue of level IIB
(level II posterior to the jugular vein) and then in most
cases pierces the SCM after giving off a branch that
innervates the muscle. It occasionally passes under the
IJV and rarely the vein will be found to split around the
nerve. Although classic anatomic diagrams suggest that
the nerve passes under the vein in 30% of the cases, the
clinical experience of surgeons suggests that this fi gure
is much less. Nevertheless, blindly cutting all tissue
lateral to the nerve at the level of a digastric muscle may
interrupt the IJV in some cases. These anatomic details
are important to recall in vein-sparing procedures.
At the point where the accessory nerve enters the
SCM, there is a vascular pedicle that may provide trou-
blesome bleeding during dissection. These vessels are
best ligated after identifi cation in the performance of a
selective or modifi ed neck dissection. The 11th nerve
exits the muscle deep to Erb’s point (at which the GA
nerve sweeps around from the posteroinferior aspect of
the SCM) and then traverses level V in a fairly superfi -
cial plane to reach the anterior border of the trapezius
muscle (see Fig. 78-6). It is the loss of trapezius muscle
function that is responsible for much of the morbidity
of the procedure. The fascial envelope of level V must
be incised to free the nerve during a modifi ed neck
dissection if spinal accessory nerve preservation is to be
accomplished. Even if the nerve is preserved, some
defi cit can be demonstrated in patients in whom it is
dissected.10 On reaching the anterior border of the tra-
pezius muscle, the nerve does not directly pierce it, but
rather extends inferiorly just anterior to the anterior
border, from which ramifi cations enter the muscle. Dis-
secting “hard on” the muscle in its most lateral extent
can result in inadvertent denervation in planned nerve-
sparing procedures. The 11th nerve lies more super-
fi cial at its more posterior-inferior extent and can
be injured during fl ap elevation. It frequently travels
directly superfi cial to enlarged posterior cervical nodes
and can be inadvertently divided when these nodes are
removed for biopsy purposes. Particular care must be
taken when a mass in the posterior triangle of the neck
is biopsied under local anesthesia. The local anesthesia
may result in loss of motor nerve function so that the
characteristic motion of the trapezius on touching the
nerve is eliminated. The nerve can thereby be inadver-
Greater
auricular
nerve
External
jugular vein
Spinal
accessory
nerve
Figure 78-5. The 11th nerve is best identifi ed posteriorly in the
posterior triangle where it lies more superfi cially.
Greater auricular
nerve
Spinal
accessory
nerve
Cervical
nerves
Transverse
cervical
nerve
Figure 78-6. Detail of the cervical nerves and the greater auricular
nerve at the posterior border of the sternocleidomastoid muscle.
Note the 11th nerve as well as the anterior border of the trapezius
muscle.

Chapter 78
Neck Dissection
683
tently divided and the injury remains unrecognized
until the local anesthetic dissipates. If resection is
required, nerve repair has been demonstrated to be
benefi cial.11
Trapezius Muscle
The trapezius muscle extends from the posterior occiput
and nuchal line along the posterior margin of the neck
dissection and extends to the lateral third of the clavi-
cle. Identifi cation of this muscle may be diffi cult during
fl ap elevation because of its superfi cial position and
signifi cant posterior positioning superiorly in the neck.
Early identifi cation of the 11th nerve and dissecting
along its course to the trapezius are useful. In identify-
ing the muscles, it is not uncommon to mistake the
levator scapulae for the trapezius during fl ap elevation.
Such a mistake might lead to inadvertent transection of
not only the 11th nerve but also the nerves to the levator
scapulae, resulting in shoulder disability. The trapezius
muscle assists in stabilization of the shoulder girdle
during arm abduction. The arm frequently cannot be
elevated beyond horizontal after nerve injury. Func-
tional disability arises such that there is shoulder drop
and “winging” of the scapula (Fig. 78-7). The greatest
morbidity, however, is not the decreased range of
motion but rather severe shoulder discomfort due to
the loss of function and torque on the acromioclavicu-
lar joint. The combination of loss of trapezius function
and shoulder pain is referred to as “the shoulder syn-
drome” and can be detected in a high percentage of
patients who have undergone neck dissection. Preserva-
tion of the 11th nerve reduces, but does not totally
eliminate, this effect of nerve injury.
Omohyoid Muscle
The omohyoid muscle consists of two bellies, the pos-
terior of which lies superfi cial to the brachial plexus,
phrenic nerve, and transverse cervical artery and vein
(Fig. 78-8). Its anterior belly lies immediately superfi cial
to the jugular vein at the division point between nodal
levels III and IV before turning superiorly to attach to
the hyoid bone. Early identifi cation of this muscle assists
in the identifi cation and preservation of the brachial
plexus and phrenic nerve. It is often entitled the “resi-
dent’s friend,” similar to the description of the digastric
muscle (discussed next).
Digastric Muscle
The posterior belly of the digastric muscle extends from
the greater corner of the hyoid bone to the deep under-
surface of the mastoid tip. It inserts into a groove in the
mastoid process of the temporal bone recognized from
the mastoid side as the digastric ridge. The only critical
anatomic structure superfi cial to the posterior belly of
the digastric muscle is the marginal mandibular branch
of the facial nerve (see later discussion). This muscle,
often entitled the “resident’s friend,” lies directly super-
fi cial to the branches of the external carotid artery, the
hypoglossal nerve, the internal carotid artery, and
the jugular vein (Fig. 78-9). The 11th nerve passes over
the jugular vein and immediately deep to the posterior
belly of the digastric muscle in the majority of patients.
During selective neck dissection, defi nition of the angle
Figure 78-7. A patient with paralysis of the left trapezius and a
dropped shoulder, resulting from 11th nerve sacrifi ce.
Phrenic nerve
Transverse cervical
artery and vein
Posterior belly of the
omohyoid muscle
Brachial plexus
Internal
jugular
vein
Ansa
hypoglossal
nerve
Figure 78-8. Detail of the inferior neck: omohyoid muscle, trans-
verse cervical artery, brachial plexus, and jugular vein.

684
Section 8
Neck
created by the deep anterosuperior aspect of the SCM
and the posterior belly of the digastric muscle helps
free nodes located high and posteriorly in level II (2B)
(see Fig. 78-9).
The anterior belly of the digastric muscle separates
the submandibular triangle level IB from the submental
triangle level IA. In patients with lesions of the anterior
fl oor of the mouth, lip, or facial skin, it is important to
remove the submental nodes anterior to the anterior
belly of the digastric muscle. Removal of the muscle,
fascia, and nodes immediately posterior to the anterior
belly of the digastric muscle assists in identifi cation of
the mylohyoid muscle, a key step in safe dissection of
the submandibular triangle. Exposure of the anterior
belly of the digastric muscle can assist in defi ning
the posterior belly as well, a time-saving step in cases
in which a complete dissection of level I is not
performed.
Facial Nerve
The facial nerve exits the stylomastoid foramen imme-
diately anterior and superior to the digastric muscle
and extends laterally and anteriorly within the sub-
stance of the parotid gland. The inferior division passes
lateral to the posterior facial vein before bifurcating.
The marginal mandibular nerve extends anteriorly and
immediately deep to the fascia covering the subman-
dibular gland before extending superiorly into the pla-
tysma muscle. Usually more than one branch is present,
the most inferior of which may loop inferior to the
submandibular gland. A sensory branch of the trans-
verse cervical nerve may accompany this nerve, making
identifi cation diffi cult. The cervical branch, which must
be sacrifi ced in neck dissection, extends inferiorly to
innervate the platysma. Preservation of the marginal
branches of the facial nerve is an important component
of neck dissection. Unnecessary trauma to this nerve is
to be avoided because it results in obvious lower lip and
commissure deformity. However, removal of the nodal
groups in level I requires that this nerve be dissected
free from the prevascular and postvascular node region
at the crossing of the facial artery and vein over the
mandible at the mandibular notch. Although dividing
the vein and artery low and sweeping the tissue superi-
orly will protect the nerve in this location, it is not ade-
quate protection for the nerve posterior to the vein and
leaves the lateral level I nodes undissected. These may
be involved with tumor in the fl oor of the mouth and
lateral oral cavity lesions such as those of the buccal
mucosa and mandibular alveolus. Once the nerve is
identifi ed, it can be traced posteriorly to where it turns
superiorly into the parotid gland. Tissue lateral and
inferior to this point can be safely divided to expose the
posterior belly of the digastric muscle. This is help -
ful early in the performance of a selective neck
dissection.
Hypoglossal Nerve
The hypoglossal nerve exits near the jugular foramen,
passes under the IJV and over the internal and external
carotid arteries, giving off the ansa hypoglossal branch.
It then loops inferior and passes under the posterior
belly of the digastric muscle, passing across the fl oor of
the submandibular triangle. At the point where it passes
under the digastric muscle, it is surrounded by numer-
ous veins forming a venous sheath called the Ranine
veins. It enters the submandibular triangle under the
fascia of the fl oor of the triangle roughly parallel to the
direction of the submandibular duct, crossing the sub-
mandibular triangle before entering the tongue muscu-
lature. Inadvertent clamping while controlling venous
bleeding in the plexus posterior and inferior to the
posterior belly of the digastric muscle can result in
inadvertent injury to the hypoglossal nerve. Injury can
also occur through inappropriate dissection through
the fascia of the fl oor of the submandibular triangle,
particularly when the nerve is adherent to the subman-
dibular duct due to fi brosis.
Brachial Plexus and Phrenic Nerve
Injuries to key peripheral nerves during the perfor-
mance of neck dissection can result in serious complica-
tions, typically with lifelong sequelae. Injuries to the
brachial plexus or phrenic nerve are among the most
devastating of these inadvertent injuries. Careful ana-
tomic dissection is required and, if there are any ques-
tions as to location, the patient should not be paralyzed
so that inadvertent (or intentional) stimulation of the
nerve can be identifi ed. Injuries to the brachial plexus
Posterior belly of
the digastric muscle
Stylohyoid muscle
Occipital artery
Hypoglossal nerve
Internal carotid artery
External carotid artery
Ansa hypoglossal nerve
Figure 78-9. Detail of the superior neck, including the digastric
muscle, the internal and external carotid arteries, and the hypoglossal
nerve.

Chapter 78
Neck Dissection
685
and phrenic nerve are to be avoided. The brachial
plexus exits between the anterior and middle scalene
muscles and extends inferiorly deep to the clavicle and
under the posterior belly of the omohyoid muscle. The
transverse cervical artery and vein usually lie immedi-
ately superfi cial to the plexus and often can be pre-
served by careful dissection and division of the ascending
branches in order to permit inferior displacement (see
Fig. 78-8).
The phrenic nerve is formed by contributions from
the cervical plexus (“three, four, and fi ve keep the dia-
phragm alive”) and must be preserved to avoid postop-
erative pulmonary compromise. The nerve should be
identifi ed early in the dissection of levels IV and V as it
crosses the anterior scalene muscle immediately ante-
rior to the brachial plexus and in proximity to the
transverse cervical artery and vein. The nerve lies imme-
diately under the enveloping fascia of the anterior
scalene muscles, hence elevation of the fascia from the
muscle can lead to inadvertent elevation of the nerve
into the surgical specimen and inadvertent injury. A
more common cause of injury to the phrenic nerve is
through removal of the cervical plexus by inadvertently
dividing the spinal contributions to the cervical plexus
as they extend between the middle and anterior scalene
muscles. This occurs when the surgeon dissects in too
deep a plane across the scalene muscles, inadvertently
elevating and removing the cervical plexus. This injury
can be avoided by keeping the plane of dissection above
the fascia and dividing the cervical nerves only after
they exit the plexus and extend into the specimen. This
technique avoids the inadvertent elevation of the plexus
and its contribution to the phrenic nerve. Early identi-
fi cation of the phrenic nerve to keep it visualized
throughout the procedure also assists in protecting the
integrity of the nerve.
The cutaneous branches of the cervical plexus
identify the posterior limit of dissection of levels II to
IV. These nerves exiting the plexus should be identifi ed
and maintained intact. This technique assures that the
cervical plexus and its contributions, particularly the
phrenic nerve, remain undissected. Although these are
routinely divided in the performance of a classic radical
neck dissection, they are also divided again as they exit
the cervical plexus. If during the performance of a
selective neck dissection the cervical nerves are inadver-
tently divided, then they must be identifi ed and fol-
lowed to the cervical plexus and left in situ to avoid
inadvertent dissection of the cervical plexus.
Internal Jugular Vein
The venous anatomy of the neck varies considerably in
terms of both the relative size and the anatomy of the
IJV and its tributaries. The disparity in size between
right and left internal jugular veins can be marked in
some cases. Typically, there are multiple small tributar-
ies and several large branches; of particular importance
is the common facial vein, located approximately two
thirds of the way from the clavicle to the digastric
muscle, which enters along with the superior thyroid
vein in a trifurcation. Care must be taken when dissect-
ing the fascia from the vein in the performance of a
vein-sparing procedure to avoid tearing the smaller
tributaries. Tearing these smaller tributaries can result
in excessive blood loss and signifi cant wasted time in an
attempt to preserve the vein. Although the retroman-
dibular vein can occasionally be preserved, the multiple
tributaries in this region, the frequent occurrence of
positive nodes at the trifurcation, and the risk of inad-
vertent injury to the hypoglossal nerve mitigate against
the routine preservation of the retromandibular vein.
When ligating the common facial vein, it is wise to leave
a generous stump to avoid artifi cially constricting the
IJV by ligature.
Carotid Artery
The carotid artery and vagus nerve travel within the
carotid sheath immediately deep to the jugular vein.
The vagus nerve can be dissected free from the carotid
artery; care must be taken when dividing the IJV in the
inferior portion of the neck to avoid elevating the vagus
nerve with the vein before ligation and division. Here
again identifi cation is the best protection. The cervical
sympathetic chain lies posterior and deep to the carotid
sheath as the neck is dissected from posterior to ante-
rior. Care must be taken not to dissect deep to the
carotid artery or the cervical sympathetic chain will be
elevated, resulting in Horner’s syndrome.
Bradycardia or hypotension may occur during dis-
section in the region of the carotid bulb due to stimula-
tion of the pressure receptors in this area. If this occurs,
dissection around the artery should cease, and injection
of 1% lidocaine (Xylocaine) without epinephrine into
the adventitial tissue of the carotid artery can abort or
prevent the problem. Patients with head and neck
cancer frequently have concomitant vascular disease, so
that excessive manipulation of the carotid artery should
be avoided because this can precipitate embolic phe-
nomena, including stroke. Gentle handling and minimal
manipulation of the artery are necessary to avoid these
diffi culties. Dissection of adherent tumor from the
carotid artery can be performed in the subadventitial
plane. Dissection is tedious and high levels of both
technical skills and surgical judgment are required to
assure optimal outcome.
The superior thyroid artery, the fi rst branch of the
external carotid system, loops slightly superiorly before
beginning its inferior transit toward the superior pole
of the thyroid gland. At this point it is close to the supe-
rior laryngeal nerve, and preservation of the artery can
assist not only in identifi cation of the superior pole of
the thyroid, but also in preservation of the superior
laryngeal nerve.
Branches of the external carotid artery lay immedi-
ately deep to the hypoglossal nerve and in close proxim-
ity to the ranine veins. During dissection of the
hypoglossal nerve and division of the ranine veins, care
must be taken to avoid injury to these vessels, particu-
larly sidewall types of injuries that can result in later
postoperative bleeding.

686
Section 8
Neck
Thoracic Duct
The thoracic duct ascends into the lower left neck
immediately posterior to the jugular vein. The duct may
extend several centimeters above the clavicle before
turning anterior and lateral to empty into the jugular
vein (Fig. 78-10). The anatomy of this thin-walled
network of ducts varies considerably and it is usually
impossible to individually identify and ligate the tribu-
taries. It is important to recall that chyle is not milky in
fasting patients who have received nothing by mouth
for at least 8 to 12 hours; therefore identifi cation of a
leaking duct may be particularly diffi cult in elective
procedures. The duct lies anterior to the phrenic nerve
and the transverse cervical artery and vein. The pre-
ferred method to avoid a chyle leak is by en bloc liga-
tion of the lymphatic pedicle in which the lymphatic
duct(s) lie. This can be safe to perform only after the
carotid artery, vagus nerve, IJV, and phrenic nerve are
identifi ed. Suture ligation of the pedicle is often war-
ranted to prevent the tie from slipping loose and
resulting in a leak. If a leak does occur, microscopic
examination of the surgical fi eld may be required to
identify and repair the site of the leak. Fibrin glue has
been reported to be useful in these situations.12
NODAL LEVELS
The anatomy of the neck is easier to comprehend when
divided into triangles: submental, submandibular, ante-
rior, and posterior cervical triangles. The predominant
nodal groups are located in the anterior triangle, adja-
cent to the carotid sheath, extending from just inferior
to the posterior belly of the digastric muscle to the
thoracic inlet. Additional nodes are located in each of
the other cervical triangles. Nodal groups are divided
into regions or levels (see Fig. 78-3). Level I includes
both the submental and submandibular regions, often-
times referred to as levels IA and IB. Although similar,
surgical and radiographic defi nitions of the divisions
between the levels are not identical. For example, the
radiographic division between levels III and IV is the
inferior margin of the cricoid cartilage. However, chest
wall confi guration and neck positioning can result in
variation of this position in relationship to the actual
nodal groups. Level II includes the jugular digastric
region from the level of the posterior belly to the digas-
tric muscle down to the level of the hyoid bone. Level
III extends from the hyoid bone to the level of the
cricoid. Level IV nodes are those inferior to the level of
the cricoid cartilage and extend down to the level of
the clavicle where it is contiguous with the mediastinal
nodes. Level V includes the posterior triangle nodes,
which lie posterior to the SCM and envelop the path of
the spinal accessory nerve, as well as the supraclavicular
nodes. Level VI is the central anterior neck compart-
ment and consists of the pretracheal (Delphian) and
paratracheal nodes inferior to the thyroid gland and
adjacent to the thymus.
Predictability of Nodal Drainage
Clinical experience suggests that the pattern of initial
tumor spread from various primary sites to specifi c
nodal groups is predictable. These patterns have been
illustrated in a large clinicopathologic series of neck
dissections performed on patients with clinically disease-
free necks.13 Anterior oral cavity malignancies tend to
drain fi rst to nodes in levels I, II, and III before involv-
ing nodes in levels IV and V. Although uncommon,
inferior level III nodes under the omohyoid muscle can
be the only nodes involved with anterior oral tongue
lesions. Cancers arising in the oropharynx, hypophar-
ynx, and supraglottic larynx initially metastasize to levels
II, III, and IV. Level I nodes are infrequently involved
in primary cancer of the hypopharynx or supraglottic
larynx without clinical evidence of neck disease. Tumors
of the thyroid gland may metastasize to levels II to IV,
including the paratracheal lymph nodes, and to level V.
A palpable level V node may be the only clinical evi-
dence of a thyroid malignancy. This predictability facili-
tates the selection of specifi c modifi cations of neck
dissection for specifi c patients.
Sentinel Node Biopsy
Evidence exists to suggest that the lymphatic drainage
of various sites of the head and neck spread in a predi-
cable manner to specifi c nodes. These nodes, termed
sentinel nodes, are the fi rst echelon in the drainage
pattern and the presence or absence of tumor in these
sentinel nodes can predict whether or not other nodes
in the neck may be involved. Although standard therapy
for melanoma14 and breast cancer, sentinel node biopsy
remains investigational in the management of squa-
mous cell carcinoma of the head and neck.15 Identifi ca-
tion and careful examination of sentinel nodes has a
Thoracic duct
Subclavicular
vein
Figure 78-10. Detail of the thoracic duct and vascular structures
in the inferior neck.

Chapter 78
Neck Dissection
687
high reliability in predicting the presence of tumor
spread beyond the primary site, but reliability of the
sampling is not infallible.16 There are several technical
challenges inherent with its usage. The fi rst of these is
the requirement that appropriate imaging material be
injected into the area around the primary site at the
correct timing to permit visualization. Interoperative
identifi cation of the node can be assisted by an inter-
operative detector. Many surgeons use isosulfan blue
injected along with the sulfur colloid to permit visual
staining of the sentinel node.15
Once the lymph node has been removed, a careful
histologic examination must be performed to identify
microscopic evidence of tumor involvement. Time-
consuming serial sectioning of sampled nodes is
required, hence sentinel node biopsy is not an interop-
erative tool as of this time. It is possible that in the
future polymerase chain reaction or assisted sentinel
node sampling may facilitate interoperative assessment
of the positivity of sentinel nodes.
One of the more problematic features of head and
neck cancer is the presence of more than one sentinel
node in a signifi cant percentage of patients. This
requires the identifi cation and dissection of several
nodes, often through separate incisions at separate
sites, leading to fairly extensive dissection and longer
surgical procedures. As a result of this and the afore-
mentioned issues, sentinel node biopsies for squamous
cell cancer of the head and neck is currently performed
in only a few centers in an investigational manner.
CLASSIFICATION OF NECK DISSECTION
Neck dissections can be classifi ed into one of three
basic types: comprehensive, selective, and extended.
Comprehensive neck dissections remove all of the
nodes removed by the classic radical neck dissection
and may preserve several or all of the nonnodal struc-
tures typically resected in radical neck dissection. In the
past, modifi ed neck dissection was identifi ed by number.
The current classifi cation system notes the levels
removed and the structures preserved (Fig. 78-11).
Selective neck dissections are designed to remove
specifi c nodal groups. Which nodal groups are removed
is dependent on the site and stage of the primary cancer.
Although these procedures were initially used only for
the elective management of the clinically negative neck,
they are now used for removal of clinically involved
nodes in selected cases. Clinical pathologic studies per-
formed by Byers and colleagues 25 years ago provide
the basis for the selection of specifi c nodal groups at
highest risk for occult metastatic disease.13 The anterior
(or supraomohyoid) neck dissection was designed to
remove nodes in levels I to III and is characteristically
used when cancer originates in the oral cavity. Levels II
through IV are removed for primary cancer originating
in the supraglottic larynx and hypopharynx. Levels II
through V are removed in cases of cancer of the poste-
rior scalp along with the suboccipital nodes under the
trapezius muscle posterior to level V. As such, this “pos-
terior lateral neck dissection” is a form of extended
A
B
Figure 78-11 A, Radical neck dissection (RND)—the sternocleido-
mastoid muscle (SCM), the internal jugular vein (IJV), and the 11th
nerve are all resected with the specimen. B-D, Three types of modi-
fi ed neck dissections, preserving one or more structures. B, Preserv-
ing the 11th nerve.
neck dissection even though nodes in level I are not
resected.
Extended neck dissections such as paratracheal dis-
sections may be performed for lesions likely to involve
the nodes in level VI, primarily cancer involving the
subglottic larynx and thyroid gland.

688
Section 8
Neck
these patients in most centers, with criteria for determi-
nation of node positivity demonstrated in Figure 78-12.
Computed tomography (CT) increases the accuracy of
visual examination of the neck by 10% to 15% but is
still less than 100% reliable.17 A negative CT scan should
not lull the surgeon into complacency regarding the
possibility of occult metastatic nodes.
The use of MR scanning is standard in some institu-
tions, although many surgeons fi nd MR scan to be more
diffi cult to interpret than CT scan. A multi-institutional
trial comparing MR with CT scan demonstrated no
signifi cant benefi t of one modality over the other.17
Positron emission tomography (PET)/CT scanning is
becoming a commonly used tool in the evaluation of
patients with unknown primary cancers of the head and
neck as well as of patients with extensive disease. Due
to the requirement of a sizable deposit of metastatic
disease to facilitate imaging, PET/CT is not as useful in
the evaluation of the clinically negative neck—an indi-
cation that is primarily investigational as of this time.
PATIENT SELECTION
Surgical decision making for patients with head and
neck cancer has become more challenging over the
past decade with advances in nonoperative therapy.
Organ preservation treatment protocols often yield sur-
vival rates similar to those of surgical management, typi-
cally with improved postoperative function for affected
patients. Treatment of these patients usually includes
management of the neck with nonoperative therapy
concomitant with the treatment of the primary tumor.
Treatment decisions for patients who have persistent
evidence of neck disease following nonoperative
therapy is not diffi cult, because salvage neck dissections
are well tolerated and offer a survival benefi t. Patho-
logic examination of the surgical specimens may not
demonstrate viable tumor in up to 50% of these cases,
but in the absence of preoperative certainty, surgery is
indicated. PET/CT imaging may alter decision making
in some of these patients.
More problematic is decision making for the patient
with advanced neck disease (N2-3) who has demon-
strated signifi cant response to organ preservation
therapy. Opinions are split,18-20 although it would appear
that apparently persistent viable tumor can be seen on
histologic examination in approximately 20% to 30%
of specimens. What is not clear, however, is the extent
of the risk of continued tumor proliferation. It seems
likely that this group of patients stands to benefi t the
most from routine posttreatment PET/CT imaging.
Selection of the appropriate surgical procedure for
the management of the cervical nodes in a particular
patient is based on multiple factors, including the
primary site of the cancer, patient status, prior therapy,
and treatment goals. The radical neck dissection, or
modifi cations thereof, is preferred for advanced stage
neck disease that is technically resectable. Identifi cation
of patients with technically unresectable advanced neck
disease is a diffi cult clinical problem, even with the
advent of CT and magnetic resonance imaging. Encase-
C
D
Figure 78-11, cont’d Modifi ed neck dissections, preserving the
IJV and the 11th nerve (C) and the 11th nerve, the IJV, and the
SCM.
RADIOLOGIC STAGING
Radiologic evaluation is not a prerequisite for the per-
formance of neck dissection in most cases of cancer of
the head and neck. Nevertheless, suspicious nodes
may be identifi ed in regions in which removal had not
been previously contemplated. Preoperative imaging is
becoming standard in the preoperative evaluation of

Chapter 78
Neck Dissection
689
ment of the internal carotid artery (Fig. 78-13) is usually
a contraindication to neck dissection unless the surgeon
is prepared to resect and graft the carotid artery and
the patient has been evaluated to determine the conse-
quences of this procedure. Newer techniques to iden-
tify patients with adequate cerebral blood fl ow after
unilateral radical neck dissection with carotid sacrifi ce
may be used to select a subset of patients with carotid
involvement who would tolerate carotid excision without
suffering unacceptable central nervous system compro-
mise. Unfortunately, long-term outcomes in this group
of patients are uniformly poor except in rare instances
in which other structures are not involved by tumor.
Similarly, patients with a mass in the neck attached to
the deep cervical musculature are usually not consid-
ered candidates for radical neck dissection.
Modifi cations of the radical neck dissection may be
appropriate for use in patients with palpable neck
disease. Preservation of the 11th nerve is the most
common modifi cation, and preservation of the jugular
vein is also common. Preservation of the SCM is more
problematic due to the diffi culty in dissecting level V
during a comprehensive modifi ed neck dissection while
leaving the SCM intact.
Selective neck dissections remove selected groups
of nodes at greatest risk of involvement. These proce-
dures are used for the management of patients without
palpable neck nodes but who are at risk for occult nodal
disease. Because not all nodal groups are removed,
these operations are tailored for individual patients.
Often their primary value is as a staging procedure,
although they may, in fact, be therapeutic for this group
of patients in that the nodes removed are those most
likely to contain microscopic cancer.21 Selective neck
dissections are best suited for patients without clinical
evidence of metastatic disease or with small, single,
mobile nodes.
Cancer in certain primary sites has a high propen-
sity for bilateral nodal involvement. We have demon-
strated lower levels of recurrence in the neck following
bilateral, vein-preserving surgical procedures in selected
sites such as the supraglottic larynx1 and hypopharynx.22
In our experience, radiation therapy administered post-
operatively in adjuvant doses has not been effective in
sterilizing necks containing occult metastatic disease.
For this reason, we recommend bilateral selective neck
dissections for primary squamous cell cancer of selected
sites when surgery is selected as primary therapy.
Perhaps the most signifi cant advantage to selective
neck dissection is the histologic staging information
provided. Identifi cation of a subset of patients with
advanced disease or with disease with poor prog -
nostic signs, such as the presence of multiple positive
nodes or nodes with ECS of tumor, enables selective
use of adjuvant radiotherapy and, in some patients,
chemotherapy.
If the neck dissection specimen contains no involved
nodes or only one or two small nodes without ECS of
tumor, adjuvant therapy may not be necessary. Single-
modality therapy may signifi cantly decrease mor -
bidity and enhance the results of postoperative
rehabilitation.
For these as well as other reasons (e.g., surgical
access), we believe that selective neck dissection should
be considered routine in the management of squamous
cell cancer in selected patients who have no clinically
palpable nodes.
PREOPERATIVE PLANNING
Patient selection is the most critical portion of preop-
erative planning. An assessment of the patient’s disease,
comorbidities, and treatment goals is required. Man-
agement of underlying medical diseases will usually
mandate close cooperation with medical consultants.
Patients who present with signifi cant weight loss and
hypoalbuminemia will fail to heal, and preoperative
nutritional support is required. In most instances, this
will require the placement of a nasogastric or gastros-
tomy tube. Nutritional status is particularly problematic
B
A
Figure 78-12. A, A patient with a massive right neck mass that is metastatic from a piriform sinus carcinoma. B, Axial computed tomography
scan of the neck of the patient in A. The scan demonstrates enlarged nodes with central necrosis and obscured nodal margins, criteria for
malignancy.

690
Section 8
Neck
wound healing, although the primary effect may be the
severity of wound complications rather than the actual
incidence for most patients.
Preoperative planning includes obtaining informed
consent from the patient. It is appropriate to explain to
the patient why a neck dissection is being performed
and any alternative forms of therapy. It is probably
appropriate to note that radiation therapy may be able
to control 80% to 90% of disease-free necks but does
not provide the pathologic staging information that a
neck dissection does. Radiation therapy may, in the
long run, have more signifi cant long-term complica-
tions than selective or modifi ed neck dissection (or for
that matter, the classic radical neck dissection).
Withholding radiation therapy when other options are
available may permit its use later in the treatment of
second primary cancers. We reserve radiation therapy
for patients treated with nonoperative organ preserva-
tion protocols or for those with biologically advanced
disease who require adjuvant therapy. Radiotherapy is
not routinely offered as an alternative treatment for the
disease-free neck, except when the primary tumor is
managed with radiotherapy.
Perioperative antibiotics are required in the preop-
erative period if the procedure will involve going
through the neck into the upper aerodigestive tract.
There may be an advantage to the use of antibiotics in
noncontaminated cases as well; Carrau and associates
demonstrated a risk of postoperative wound infection
of 10% in this population.23
SURGICAL TECHNIQUES
The technique of neck dissection varies with the loca-
tion of palpable disease, the planned procedure for the
primary tumor, and the type of neck dissection. The
techniques are divided into the comprehensive neck
dissections (with the classic radical neck dissection and
its modifi cations) and the selective neck dissections.
Identifi cation of a sequence for a surgical proce-
dure is a valuable adjunct to the resident in learning
the techniques used in a specifi c operation. Perhaps
this is most important in the performance of a neck
dissection because an orderly sequence of events will
result in the identifi cation and preservation of vital
structures and ensure the safety as well as the expedi-
ency of the procedure. Tables 78-1 and 78-2 list the
sequences of the operative procedures we perform for
the radical and modifi ed radical neck dissections and
selective neck dissection. The exact sequence used by
the operating surgeon may vary. However, reviewing
this sequence or keeping it on a 3 × 5 note card for
preoperative reference will be valuable to the resident
and the infrequent operator.
RADICAL NECK DISSECTION
Radical neck dissection was standardized in the years
following its fi rst description by Crile in 1906.5 Interest-
ingly, in his initial diagrams, Crile indicated routine
preservation of uninvolved structures such as the SCM
B
C
A
Figure 78-13. Photograph (A) and axial computed tomography
(CT) scans (B and C) of the neck of a patient with massive cervical
lymphadenopathy. The CT scans demonstrate encasement of the left
carotid artery and suggest tumor invasion of the sternocleidomastoid
muscle and the deep cervical muscles.
in the group of patients who present for salvage neck
dissection following nonoperative therapy. Although
prior chemotherapy does not adversely affect wound
healing, the depleted nutritional status of the patient
does. There is consensus that prior radiotherapy affects

Chapter 78
Neck Dissection
691
Table 78-1
STEPS IN RADICAL NECK DISSECTION
Perioperative antibiotic?
Position on shoulder roll
Prepare and drape (staples)
Incision
Avoid trifurcation over carotid
Avoid narrow fl aps
Incise through platysma
Raise subplatysmal fl aps
Leave greater auricular nerve and external jugular vein
on sternocleidomastoid muscle (SCM)
Identify/preserve marginal mandibular nerve
Level I dissection
Remove submandibular nodes and submandibular gland
Ligate facial artery above digastric muscle
Include submental fat pad
Expose anterior border of trapezius muscle
Incise SCM 1 to 2 cm above clavicle
Identify and trace omohyoid
Transect omohyoid posteriorly
Bluntly dissect and identify brachial plexus and phrenic
nerve
Bluntly dissect and transect posterior triangle
Incise along anterior border of trapezius
Incise superior end of SCM
Rotate specimen anteriorly
Re-identify and preserve brachial plexus, phrenic nerve
Identify cervical nerves and incise high on specimen
Identify carotid (and vagus)
Return neck specimen to anatomic position and identify,
cut, and ligate inferior jugular vein
Do not incise vagus nerve!
Re-identify phrenic and vagus nerves; then clamp, cut,
and ligate lymphatic pedicle to avoid chyle leak
Elevate specimen from carotid and vagus, proceeding
superiorly
Identify and preserve hypoglossal nerve
Ligate superior jugular vein at the digastric muscle
Rotate specimen anteriorly
Ligate ranine veins
Preserve superior thyroid artery and superior laryngeal
nerve
Resect specimen with anterior cervical veins and fascia
Irrigate wound
Ensure hemostasis
Insert drains
Close wound
Pressure dressing
Table 78-2
STEPS IN SELECTIVE NECK
DISSECTION
Raise subplatysmal fl aps
Leave external jugular and greater auricular nerve on
sternocleidomastoid muscle (SCM)
Posterior elevation not necessary
If level I dissection:
Identify and preserve marginal mandibular nerve
Expose anterior belly of digastric muscle
Expose mylohyoid muscle
Elevate mylohyoid muscle
Identify lingual, hypoglossal nerves
Divide duct, vessels
Resect submaxillary gland
Identify posterior belly of digastric muscle
Identify posterior digastric muscle
(Under submaxillary gland if not level I)
Follow posterior digastric muscle to SCM
Incise SCM fascia, including external jugular vein and
external jugular greater auricular nerve
Unwrap SCM
Peel muscle from fascia
Identify accessory nerve
Trace accessory nerve to digastric muscle
Lift accessory nerve
Free posterior corner
Watch internal jugular vein and 11th nerve
Pass posterior corner under accessory nerve
Cut deep fascia to omohyoid muscle
Identify, trace cervical nerves
Protect plexus and phrenic nerve
Identify carotid sheath
Unwrap fascia from internal jugular vein
Go slow
Identify, ligate branches of internal jugular vein
Elevate, clamp, ligate lymphatic pedicle
Watch for vagus, phrenic nerves
Follow omohyoid muscle, carotid artery, internal jugular
vein
Preserve superior thyroid artery and hypoglossal nerve
Divide ranine veins
Label specimen—then:
Resect specimen
and 11th nerve. En bloc resection became standard in
the ensuing years. Incisions that were used in early years
placed the carotid artery at risk by placing trifurcation
points over the artery. Current wisdom dictates that
incisions be fashioned so as to avoid narrow fl aps and
avoid trifurcation points placed over the internal carotid
artery. An extended apron incision is used for laryngec-
tomy, although a posterior extension may be necessary
to gain access to the posterior portion of the dissection.
In our department we use a “hockey stick” incision for
unilateral or an apron fl ap for bilateral neck dissection
(Fig. 78-14).
Skin incisions are made and fl aps are elevated in
the subplatysmal plane. When elevating the superior
fl ap, it is wise to leave the external jugular vein and GA

692
Section 8
Neck
this point, whereas others perform the level I dissection
at the completion of the remainder of the neck
dissection.
The submandibular gland and surrounding nodes
are removed en bloc as a level I dissection. The proce-
dure is begun by incising the fascia above the gland and
identifying the anterior belly of the digastric muscle,
clearing the submental fat pad, and elevating the fascia
and nodes from the lateral surface of the mylohyoid
muscle (Fig. 78-17). The lateral superior fascia and
vessels were divided earlier when the marginal nerve
was identifi ed. Care must be taken to include the sub-
mental fat pad in the specimen, which is performed by
grasping the fat pad just medial to its attachment to the
anterior belly of the digastric muscle and dissecting the
midline tissue in the submental triangle in an inferior
direction. The mylohyoid muscle is then retracted ante-
riorly, exposing the lingual nerve and submandibular
ganglion (Fig. 78-18). The attachments of the gland to
the lingual nerve at the submaxillary ganglion are
Figure 78-14. The “hockey stick” incision is used for unilateral
radical or elective neck dissection.
Marginal mandibular nerve
crossing facial vein
Figure 78-15. Identifi cation of the marginal mandibular nerve
(arrow) where it crosses the facial artery and vein. Note the proximity
of the prevascular and postvascular nodes to the nerve.
nerve on the SCM (Fig. 78-15). At the superior aspect
of the fl ap, the marginal mandibular nerve is identifi ed
approximately 1 cm anterior to the angle of the man-
dible where it crosses lateral to the submandibular
gland and facial vessels (Fig. 78-16). Injury can best be
avoided by identifying the nerve, dissecting anteriorly
and posteriorly, and then elevating the nerve as part of
the skin fl ap. Retraction of the nerve superiorly by
suturing the divided facial vessels to the fl ap will help
in protecting the nerve through the remainder of the
procedure. There are frequently several branches of the
nerve, of which the superior is the most important in
preservation of lip function. Once the correct plane is
identifi ed, all branches can often be elevated simultane-
ously. Obviously, if the marginal branch is involved with
or close to a metastatic node, it must be sacrifi ced.
It is often easiest to proceed with the submandibu-
lar (level I) dissection at this point in the procedure.
Some surgeons routinely remove the nodes in level I at
A
B
Figure 78-16. Dissection of the marginal mandibular nerve from
the submandibular gland posteriorly in order to preserve the nerve.
Note that all branches of the greater auricular nerve have been
divided in this illustration. In practice, the posterior branch can
usually be preserved.

Chapter 78
Neck Dissection
693
divided and ligated, and the submandibular duct is
divided and ligated. The gland is retracted inferiorly
with the attached prevascular nodes on its lateral
surface. Leaving the fascia attached to the submandibu-
lar gland inferiorly will allow the contents of level I to
remain a part of the neck dissection specimen. The
facial artery may be preserved as shown in Figure
78-18.
The posterior skin fl ap must be elevated toward the
trapezius muscle in the appropriate plane at the level
of the platysma. Because the platysma is defi cient in this
region, it is not diffi cult to inadvertently dissect too
deeply and injure the 11th nerve by dissecting under
the trapezius. By grasping the edge of the skin fl ap with
Lahey clamps and using a fi nger placed behind the
incision, the depth of dissection can be determined to
avoid nerve injury and buttonholing of the fl ap. Iden-
tifi cation of the anterior border of the trapezius is a key
point in this procedure. The anterior border of this
muscle is usually more posterior and superfi cial than
expected. Stimulation of the 11th nerve can assist in
identifi cation of the muscle.
If a modifi ed neck dissection is being performed,
this is an ideal time to identify the 11th nerve and trace
it through the posterior portion of the neck to the tra-
pezius and SCM (see Fig. 78-5). If a radical neck dissec-
tion is being performed, the sternal head of the SCM
is divided approximately 1 fi ngerbreadth above the
clavicle (Fig. 78-19). There is one bleeder in the stump
that must be clamped. The clavicular head is also tran-
sected just above the clavicle, taking care not to cut the
external jugular vein, which is just posterior and lateral
to the inferior portion of the muscle (Fig. 78-20). Once
the SCM is divided inferiorly, the omohyoid is easily
identifi ed where it crosses the IJV. It is often appropri-
ate to extend the superfi cial fascial incision anteriorly
through the anterior jugular veins, which are ligated at
this point.
Lingual
nerve
Figure 78-17. Retraction of the mylohyoid muscle to expose the
lingual nerve, submandibular ganglion, and Wharton’s duct.
Hypoglossal
nerve
Figure 78-18. Ligation of the submandibular duct. Note the pres-
ervation of the lingual nerve and the hypoglossal nerve. Preservation
of the facial artery is optional and is usually not diffi cult.
Figure 78-19. Division of the inferior end of the sternocleidomas-
toid muscle, about 1 fi ngerbreadth above the clavicle.
Figure 78-20. Dividing the clavicular head of the sternocleidomas-
toid muscle and supraclavicular tissue lateral to the omohyoid muscle.
The brachial plexus, carotid sheath, and phrenic nerve are protected
by their position deep to this muscle.

694
Section 8
Neck
The omohyoid is followed posteriorly. Nerves,
vessels, and fascia lateral to the muscle can be incised
without risk of injury to signifi cant structures. Several
large veins in the region will require ligation (see Fig.
78-20). The fascia over the omohyoid muscle is then
elevated anteriorly to the midline. This identifi es the
anterior extent of the neck dissection. The omohyoid
is divided posteriorly as it approaches the scapula. Elec-
trocautery is useful here to avoid retraction of a bleed-
ing muscle stump. The fascia immediately deep to the
posterior belly of the omohyoid muscle is then divided
(Fig. 78-21).
The supraclavicular fat pad is then opened using
blunt dissection, exposing the brachial plexus and
phrenic nerve (Fig. 78-22). Identifi cation of the bra-
chial plexus is critical, and the procedure should not
be continued until both the brachial plexus and the
phrenic nerve (located on the surface of the anterior
scalene muscle) have been identifi ed. The transverse
cervical artery and vein will be found immediately adja-
cent to the phrenic and will extend posterior in a plane
just lateral to the brachial plexus. In order to avoid
troublesome bleeding, care should be taken not to
interrupt the vessels. The surgeon must be cautious in
avoiding elevation of the phrenic nerve from its posi-
tion on the surface of the anterior scalene muscle or it
can easily be inadvertently divided later in the proce-
dure. Excessive electrocautery near the brachial plexus
and phrenic nerve is to be avoided.
Once the brachial plexus and phrenic nerve have
been identifi ed, fi nger dissection can be performed
posteriorly toward the anterior border of the trapezius,
and the supraclavicular fat pad can be divided between
clamps and suture ligated (Fig. 78-23). Attempting to
perform this dissection without ligation will usually
result in troublesome bleeding. Some surgeons use a
gastric stapler for this portion of the procedure.
Dissection is carried superiorly along the anterior
border of the trapezius to the level of the SCM. If the
11th nerve has been preserved, care must be taken at
this point to avoid injury to the nerve; alternatively, if a
radical neck dissection is being performed, the nerve is
resected as part of a specimen. The superior end of the
SCM is then divided just inferior to the mastoid tip.
Retractors are placed on the specimen, and it is rotated
Figure 78-21. Division of the omohyoid muscle posteriorly and
exposure of the brachial plexus. The fascia deep to the omohyoid
muscle is divided.
A
B
Figure 78-22. Nerve trunks of the brachial plexus are visualized
with blunt dissection. The phrenic nerve can be seen just anterior,
crossing the anterior scalene muscle.
Figure 78-23. A, Exposure of the anterior border of the trapezius
muscle and division of the fatty lymphatic structures. Once the bra-
chial plexus is visualized, blunt dissection with a fi nger permits clamp-
ing of the fi brofatty tissue with large clamps. The 11th nerve is
sacrifi ced, if required. Otherwise, it is elevated and the specimen is
dissected from underneath. B, Dissection is carried superiorly, and
the superior head of the sternocleidomastoid muscle is divided.

Chapter 78
Neck Dissection
695
anteriorly (Fig. 78-24). The dissection is then carried
anteriorly. It is helpful to leave the fascia on the deep
muscles to protect the neural supply to the levator sca-
pulae muscle as well as the roots of cervical plexus. It is
critical to avoid dissecting the cervical plexus off the
deep muscles or the roots will be interrupted.
Once the nerves exiting the cervical plexus have
been encountered, they are traced for a short distance
into the specimen and then divided (Fig. 78-25). It is
important to visualize the phrenic nerve during this
portion of the procedure in order to avoid inadvertent
severance of the contributions from the cervical plexus.
Dissection is carried laterally into the fatty tissue of the
specimen, and the nerves are sectioned, leaving approx-
imately 1 cm of nerve attached to the cervical plexus.
Accompanying vessels will require ligation, and it is
easiest to apply a hemostat to the nerves before section-
ing. Electrocautery should be avoided in this region to
prevent injury to the brachial plexus and phrenic nerve.
Care must be taken to preserve the cervical rootlets
where they exit between the middle and the anterior
scalene muscles medial to the cervical plexus and
phrenic nerve. Resection of the cervical plexus or inter-
ruption of its roots is a serious error in technique that
can be avoided by leaving a thin layer of fascia on the
deep muscles and by cutting the nerves after they leave
the plexus (Fig. 78-26).
Once the cervical nerves have been divided, the
carotid sheath is encountered from posterior. Finger
palpation is useful at this stage. Care must be taken not
to dissect medial to the carotid sheath to avoid injury
to the cervical sympathetic chain. The jugular vein,
carotid artery, and vagus nerve can then be identifi ed
and the structures dissected from the posterior belly of
the digastric muscle superiorly to 3 to 4 cm above the
clavicle inferiorly (Fig. 78-27). Extending the dissection
too far inferiorly at this point in the procedure, particu-
larly on the left side, may result in injury to the thoracic
duct and postoperative chyle leak. To avoid this com-
plication, the lymphatic pedicle should be isolated and
clamped and divided en bloc. This can be facilitated by
refl ecting the neck tissue back into its anatomic posi-
tion, exposing the jugular vein from anterior approxi-
mately 2 cm above the clavicle, and then dividing the
vein (if resection is planned) between Kelly clamps
(Fig. 78-28). Tearing the tributaries of the vein during
Figure 78-24. Division of the superior head of the sternocleido-
mastoid muscle permits the specimen to roll anteriorly, exposing the
deep cervical muscles. Dissection is carried anteriorly from this
point.
Phrenic nerve
Figure 78-25. Exposure of the cervical nerves as they leave the
cervical plexus. Care must be taken to avoid stripping the cervical
plexus off the deep muscles.
Figure 78-26. The cervical nerves are incised at least 1 cm distal to
the plexus to avoid inadvertent injury to the phrenic nerve.
Figure 78-27. Exposure of the carotid sheath. Care is taken to
avoid extending the dissection too far inferiorly on the left side to
avoid injury to the thoracic duct.

696
Section 8
Neck
dissection can result in troublesome bleeding. If the
surgical plan includes leaving the jugular vein intact,
the fascia can be freed from the jugular vein and its
tributaries divided. If the jugular vein is resected, it is
customary not only to ligate the vein but also to apply
a suture ligature to prevent the ligature from slipping
off. Care must be taken to avoid dividing the vagus
nerve or common carotid artery. The vagus nerve
should be identifi ed as it courses immediately adjacent
to the carotid artery before dividing either the jugular
vein or the lymphatic pedicle. Following ligation of the
vein or dissection, a fi nger is placed around the lym-
phatic pedicle (Fig. 78-29), and following identifi cation
of the phrenic nerve and vagus nerve, the pedicle can
be clamped, divided, and suture ligated (Fig. 78-30). At
this point, it is wise to ask the anesthesiologist to tem-
porarily provide positive pressure in order to ensure
that there is no evidence of a chyle leak.
The dissection is then continued in an inferior-to-
superior direction along the carotid artery and vagus
nerve. The ansa cervicalis is elevated and divided, as is
the ansa hypoglossi (Fig. 78-31). Following the ansa
hypoglossi superiorly will help in identifying the hypo-
glossal nerve, which must be preserved unless it is
involved with tumor (Fig. 78-32). The ranine veins will
require individual ligation, with care taken to avoid
injury to the hypoglossal nerve. The IJV is divided supe-
riorly at the level of the posterior belly of the digastric
muscle. In the absence of tumor mass superiorly, an
alternative approach is to divide the vein at the poste-
rior belly of the digastric muscle before ligating it
inferiorly. The vein is usually best approached from
posterior and lateral, transecting the accessory nerve,
identifying the digastric muscle and retracting it
superiorly, and then dividing and ligating the IJV (Fig.
78-33).
Figure 78-28. Division of the internal jugular vein before dividing
and ligating the lymphatic pedicle. This is best done by refl ecting the
neck tissue back into its anatomic position and freeing the vein from
anteriorly.
Figure 78-29. Isolation of the lymphatic pedicle. The carotid
sheath structures are identifi ed and a fi nger is passed through the
tunnel created. Care must be taken to avoid entrapping the phrenic
or vagus nerve. Once all structures have been positively identifi ed,
the pedicle is clamped and ligated en bloc.
Figure 78-30. Division and ligation of the lymphatic pedicle frees
the inferior portion of the specimen.
Ansa
hypoglossal
nerve
Figure 78-31. Elevation of the specimen from inferior to superior
with the internal jugular vein and the ansa hypoglossal nerve.

Chapter 78
Neck Dissection
697
As the dissection is carried along the carotid artery,
it may become necessary to inject lidocaine without
epinephrine into the adventitia over the carotid bulb if
bradycardia and hypotension occur from stimulation of
the carotid pressure receptors. At this point, the dis-
sected specimen is attached only at the level of the
hyoid bone and is easily removed. If it was not done
initially, the level I dissection is performed at this time,
and the specimen is removed.
Hemostasis is obtained, the wound is irrigated, and
drains are inserted. The incision is closed in layers, with
care being taken to approximate the platysma muscle
by absorbable sutures to avoid unsightly postoperative
scar retraction. Suction drains are used routinely, as is
a circumferential dressing unless bilateral neck dissec-
tions are being performed or a pedicled muscle fl ap has
been used for reconstruction.
MODIFIED NECK DISSECTION
Various modifi cations of the radical neck dissection are
used. If the SCM is to be preserved, the procedure is
usually begun in the same manner as for a selective
neck dissection by freeing the SCM and the 11th nerve.
The node-bearing tissue in level V is then passed under
the elevated SCM, and the dissection is completed. If
the SCM is to be sacrifi ced, the procedure is begun as
a radical neck dissection. The 11th nerve is identifi ed
in the posterior triangle and dissected free as it passes
through the posterior triangle from the SCM to the
trapezius muscle. The nerve is then dissected anteriorly
through the substance of the SCM, effectively dividing
the SCM into a superior and an inferior segment (Fig.
78-34). The branch of the accessory nerve to the SCM
is divided and the nerve elevated (Fig. 78-35). From this
point, the procedure is performed in a manner identi-
cal to a radical neck dissection, except that the incision
along the anterior edge of the trapezius muscle does
not include the 11th nerve but rather passes under the
elevated nerve. Dissection is carried along the anterior
border of the trapezius and across the insertion of the
SCM in the manner of a radical neck dissection (Fig.
78-36), and the posterosuperior quadrant of the neck
dissection is passed under the 11th nerve and then
anteriorly (Fig. 78-37). If the IJV is to be preserved, the
jugular vein is not divided but exposed from the poste-
rior after the cervical nerves are divided. The vein is
unwrapped in a manner similar to that for the selective
neck dissection.
The modifi ed comprehensive neck dissection is an
ideal dissection for the therapeutic removal of clinically
positive nodes when the 11th nerve and IJV can be
Hypoglossal
nerve
Figure 78-32. Identifi cation of the hypoglossal nerve. Note the
ansa hypoglossal nerve, which can assist in identifi cation of the hypo-
glossal nerve. Care must be taken to avoid injury to the nerve while
clamping the often troublesome ranine veins, which form a plexus
around the nerve.
Figure 78-33. Division of the internal jugular vein at the digastric
muscle.
Figure 78-34. Identifi cation of the 11th nerve in the posterior tri-
angle and dissection through the sternocleidomastoid muscle to
expose the 11th nerve from the trapezius to the digastric muscles.

698
Section 8
Neck
SELECTIVE NECK DISSECTION
Selective neck dissections begin in a manner similar to
that for a radical neck dissection with elevation of skin
fl aps in the subplatysmal plane. When the selective neck
dissection is used for the N+ neck, the platysma muscle
is left on the specimen to provide an extra margin of
resection. A utility incision (hockey stick) is generally
used. The vertical limb is placed posterior to the SCM
and the horizontal limb is placed in a skinfold above
the clavicle in order to make the scar inconspicuous
(Fig. 78-38). Dissection of the fascia from the SCM is
facilitated by leaving the external jugular vein and GA
nerve on the muscle (Fig. 78-39). If a level I dissection
is planned as part of the procedure, the marginal man-
dibular nerve is identifi ed and dissected free from the
underlying vessels and nodes. It is refl ected superiorly
with the fl ap in a manner similar to that for the radical
neck dissection. Identifying the marginal mandibular
nerve and dissecting along it posteriorly to the parotid
gland assists in incising the fascia posteriorly toward the
SCM inferior to the parotid gland. If there is no need
to remove the nodes in level I, identifi cation of the
marginal mandibular nerve is not necessary and the
surgeon may identify the posterior belly of the digastric
muscle under the submandibular gland and follow it
posteriorly to the point at which it passes deep to the
SCM (Fig. 78-40).
If removal of the contents of the submandibular
triangle is planned, it is best performed at this time
because dissection assists in the identifi cation of the
posterior belly of the digastric muscle. Following the
identifi cation, dissection, and elevation of the marginal
mandibular nerve (see Fig. 78-16), the facial artery and
vein may be ligated or preserved. The fascia over the
gland is incised, and the anterior belly of the digastric
muscle is exposed. The submental fat pad and nodes
are dissected free and refl ected inferiorly. The fascia is
freed from the lateral surface of the anterior belly of
the digastric muscle, and the mylohyoid muscle is
Figure 78-35. Elevation of the 11th nerve with division of the
branch to the sternocleidomastoid muscle.
Figure 78-36. Incising the fi brofatty tissue anterior to the trapezius
muscle and then across the insertion of the sternocleidomastoid
muscle, as in an radical neck dissection.
Figure 78-37. The posterosuperior portion of the specimen is
passed under the elevated nerve.
safely preserved. A certain amount of surgical judgment
is necessary, and immediate conversion to a radical
neck dissection must be done if positive nodes are
found adjacent to or infi ltrate into the nerve or vein,
making it oncologically unsafe to continue the modi-
fi ed procedure.
In cases of planned bilateral modifi ed neck dissec-
tion, the contralateral neck is usually dealt with fi rst in
order to ensure preservation of the IJV, which is most
likely to be preserved. If for technical or oncologic
reasons the jugular vein on the contralateral neck has
previously been removed or must be sacrifi ced, extra
care should be taken to preserve the ipsilateral jugular
vein if it is oncologically safe to do so. If both IJVs must
be resected, we recommend venous reconstruction to
decrease the risk of postoperative morbidity.

Chapter 78
Neck Dissection
699
exposed. A signifi cant number of vessels in this region
require cautery for control, following which the poste-
rior margin of the mylohyoid muscle is identifi ed and
retracted. Once the posterior edge of the mylohyoid
muscle is retracted, the lingual nerve and its tributary
to the submandibular gland can be identifi ed (see Fig.
78-17), the tributary can be divided, and the subman-
dibular duct can be divided and ligated. Care must be
taken to avoid injury to the 12th nerve, which lies deep
to the fascia on the fl oor of the submandibular triangle
(see Fig. 78-18). As the gland is refl ected posteriorly
and inferiorly, the facial artery is again encountered
and either divided or preserved. This exposes the entire
digastric sling and the posterior belly of the digastric
muscle, which can be traced posteriorly to the point at
which it passes deep to the SCM.
The fascia of the SCM with attached external jugular
vein is then grasped, incised, and peeled from the
muscle (see Figs. 78-40 and 78-41). If the GA nerve is
Figure 78-38. Utility incision or half-apron.
Figure 78-39. Line of the fascial incision if level I is not
dissected.
Figure 78-40. Identifi cation of the corner formed by the posterior
belly of the digastric muscle and the sternocleidomastoid muscle and
the incision along the fascia of the SCM. The greater auricular nerve
can generally be preserved, but the external jugular vein must be
sacrifi ced.
Figure 78-41. Unrolling the fascia from the muscle. In practice, it
is easier to unroll the muscle from the fascia.

700
Section 8
Neck
to be preserved, it should be dissected free at this time
and retracted posteriorly. The posterior branch usually
can be preserved, but must be elevated from the muscle
to permit posterior retraction. Preservation of the ante-
rior branch is technically more challenging. The fascia
is grasped with Allis clamps, the muscle is retracted, and
the fascia is unrolled from its attachment to the SCM
utilizing either electrocautery or sharp dissection. This
can usually be more easily performed by peeling muscle
away from fascia rather than the reverse. The dissection
is carried out on a broad plane extending from the
region of the digastric muscle superiorly to the level of
the omohyoid muscle inferiorly. The vessels entering
the SCM are encountered and divided.
The 11th nerve is encountered where it enters the
SCM at a point approximately 2 fi nger breadths below
the posterior belly of the digastric muscle (Fig. 78-42).
If the patient is not paralyzed and electrocautery is used
for dissection, the nerve will be stimulated, assisting in
nerve identifi cation. The angle between the SCM and
the posterior belly of the digastric muscle should be
identifi ed at this point. The branch of the 11th nerve
to the SCM can usually be identifi ed and is preserved,
although adjacent vessels must be divided. The 11th
nerve is then dissected free from the node-bearing
adipose tissue in level II by dissecting along the superior
surface of the nerve to the point at which it dives under
the posterior belly of the digastric muscle, usually imme-
diately lateral to the IJV. This requires dividing the sur-
gical specimen lateral to the nerve. As the tissue lateral
to the nerve is divided, care must be taken not to inad-
vertently divide enlarged lymph nodes (Fig. 78-43).
Figure 78-42. Identifi cation of the 11th nerve entering the sterno-
cleidomastoid muscle. Generally, several vessels are near this point.
Identifi cation is easier if no paralytic agents are used.
Typically the occipital artery lies just under the inferior
border of the posterior belly of the digastric and just
lateral to the nerve. The 11th nerve has been reported
to pass deep to the IJV in some cases. In these cases, the
vein could theoretically be inadvertently divided, and
care should be taken to avoid this error in technique.
Once the digastric muscle and the posterior corner
have been identifi ed, sharp dissection or electrodissec-
tion is used to free the tissue in this corner. The fi bro-
fatty tissue is grasped with an Allis clamp (Fig. 78-44)
and is retracted inferiorly and dissected free from the
digastric muscle and SCM down to the underlying deep
cervical musculature (Fig. 78-45). Branches of the
occipital artery encountered under the inferior edge of
the digastric muscle may need to be ligated. The dis-
sected tissue is freed from the SCM down as far as the
11th nerve and elevated anteriorly in a plane just lateral
to the deep cervical muscles. It is then passed anteriorly
under the 11th nerve (Fig. 78-46). Freeing the tissue
requires division of the fat pad deep to the posterosu-
perior portion of the SCM. Some surgeons do not
remove the posterior segment of level II, but rather
extend the resection only as far posteriorly as the 11th
nerve.
Figure 78-43. Dissection of the 11th nerve up to the posterior belly
of the digastric muscle.

Chapter 78
Neck Dissection
701
Figure 78-44. The fi broadipose tissue is grasped just inferior to the
angle formed by the posterior belly of the digastric muscle and the
sternocleidomastoid muscle.
Figure 78-45. Incising the posterosuperior pedicle of tissue free
from the digastric and sternocleidomastoid muscles down to the deep
cervical muscles. The pedicle is elevated from the deep muscles in a
posterior-to-anterior direction.
The fascia deep to the undersurface of the SCM is
divided, and the cervical nerves are identifi ed in the
fatty tissue immediately anterior to the posterior border
of the SCM (Fig. 78-47). Care must be taken at this
point to avoid injury to the 11th nerve, which may exit
the SCM in this region. The cervical plexus is preserved
by keeping the dissection lateral to the cervical nerves.
It is not necessary to incise these nerves because they
provide a clear landmark and the posterior deep margin
to the dissection in this region. Dissection is then carried
anteriorly in a plane lateral to the cervical nerves to the
carotid sheath and IJV, which is identifi ed from the
level of the omohyoid muscle up to the digastric muscle.
As the fascia is incised over the IJV, the nodes and fatty
tissue are rolled anteriorly and the IJV is exposed and
freed from the overlying fascia (Fig. 78-48). The ansa
cervicalis must be divided at this time and occasionally
causes anxiety if it is mistaken for the phrenic nerve.
Use of a nerve stimulator is an expeditious means to
ensure the nerve identifi ed as ansa is indeed ansa. Care
must be taken to avoid inadvertently dividing the 11th
nerve in the course of the procedure.
Multiple small tributary veins will need to be ligated
as the IJV is unwrapped. The common facial vein trifur-
cation is often large and should be divided at some dis-
tance from the IJV to avoid narrowing the IJV because
of ligation at this point (Fig. 78-49). If the vein is torn,
it can frequently be salvaged with 6-0 vascular sutures.
Unfortunately, this is time consuming, and injury is
better avoided than repaired. Placing the fascia and
vein on stretch and using a knife is generally the easiest
way to avoid bleeding. If level IV dissection is to be
performed, the IJV is identifi ed inferior to the omohy-
oid muscle and anterior to the lymphatic pedicle (see
Fig. 78-27). The pedicle is isolated; care is taken to avoid
injury to the brachial plexus, phrenic nerve, the carotid
artery, and the vagus nerve; and the pedicle is clamped
and divided. This is particularly important on the left
side.
The node-containing tissue is then dissected from
the carotid sheath in an inferior-to-superior direction.
The ansa hypoglossal nerve often can be preserved and
will serve as a landmark to help identify the hypoglossal
nerve. The ranine veins that form a plexus around the
hypoglossal nerve are clamped and divided (see Fig.
78-32). Care must be taken to avoid injury to the supe-
rior laryngeal nerve; this can best be accomplished by
identifying and preserving the superior thyroid artery.
Dissection is carried anteriorly along the hypoglossal
nerve, and the digastric muscle and the specimen can
be easily removed at this point.
Nodal areas are best identifi ed by the pathologist
when the specimen is marked before removal because

702
Section 8
Neck
A
B
Figure 78-46. The dissected tissue is passed anteriorly under the
elevated nerve.
Figure 78-47. A, Incision of the fascia deep to the sternocleidomas-
toid muscle to expose the cervical nerves. Note that the posteroinfe-
rior limit of dissection is rather arbitrary. B, Dissection is kept anterior
to the cervical nerves, thereby protecting the cervical plexus.
the absence of identifi able structures will make orienta-
tion of the specimen for pathologic study diffi cult.
Hemostasis is ensured, and the wound is irrigated,
drained, and closed in layers.
POSTEROLATERAL NECK
DISSECTION
Various extended neck dissections can be performed in
conjunction with either comprehensive or selective
neck dissections. Extended neck dissections include dis-
sections that remove retropharyngeal nodes, paratra-
cheal nodes, and the suboccipital and retroauricular
nodes. Inclusion of the latter groups of nodes, “postero-
lateral neck dissection”24 is the most common form of
extended neck dissection.
Two distinct groups of nodes can be identifi ed in
the upper posterior neck. One group is just lateral or
posterior to the mastoid, and the other, the suboccipital
group, lies near the insertion of the trapezius muscle
into the inferior nuchal line. These nodes can be
involved as fi rst echelon nodes in cutaneous lesions of
the scalp and therefore should be removed during neck
dissections performed for malignancies of the skin of
the posterior scalp.
PATIENT SELECTION FOR
POSTEROLATERAL NECK DISSECTION
Lesions involving the skin of the scalp, such as malig-
nant melanoma or squamous cell carcinoma, can drain
either to the suboccipital and postauricular nodes or to
the preauricular and parotid nodes, depending in part
on the position of the primary lesion. As a result, neck
dissections performed for malignancies of the scalp
should include one or both of these regions in conjunc-
tion with the neck dissection. A more in-depth discus-
sion of the decisions involved in this section can be
found elsewhere.
TECHNIQUE
The skin incision should be extended somewhat further
posteriorly than for a routine neck dissection to gain
access to the posterior-superior neck and nuchal region.
Positioning of the patient is somewhat more critical in
that access to the posterior neck will be required. Skin
fl aps are elevated posteriorly superfi cial to the trapezius

Chapter 78
Neck Dissection
703
fi cial to the upper portions of the splenius capitis and
levator scapulae are resected. As in other forms of neck
dissection, the spinal accessory nerve is preserved if this
is feasible, although nodal involvement may require
sacrifi ce.
The remainder of the procedure is performed in a
manner similar to that for a routine comprehensive
neck dissection. In most cases, dissection of level I will
be unnecessary. However, the upper and midjugular
nodes, as well as those in level V, should be removed.
POSTOPERATIVE MANAGEMENT
Drains are used in the management of all types of neck
dissection. We use two drains per side for a total of four
drains for bilateral neck dissections. Either 1/8-inch
Hemovacs or Jackson-Pratt drains are used. We have
found that maintenance of drain patency is more
dependent on skilled nursing care than the size or
brand of the drain. Drains are aspirated by the nurses
at least once per shift. The drain connector is prepped
with povidone-iodine (Betadine) solution, separated
under aseptic conditions, and aspirated with a 10-mL
syringe. Drains are maintained on suction from the
time they are placed in the neck until they are removed.
Drains that are left off suction for an appreciable period
(e.g., during closure of the neck incision) often become
fi lled with clot and will not function.
A compression dressing is used by some of our sur-
geons unless bilateral neck dissection or fl ap recon-
struction has been performed. Functioning drains and
a pressure dressing together serve to increase the effi -
cacy of fl ap coaptation and reduce the incidence of
postoperative seromas, hematomas, and fl ap edema.
The dressing is left in place and not removed or changed
unless soaked or soiled. Cosmetic reinforcement of the
dressing is often necessary, and the dressing is removed
in 5 days or when the drains are removed. Drains are
maintained until they are draining less than 10 mL per
24 hours. Establishing a minimal threshold of drainage
will ensure that drains are not removed too soon. It is
better to leave drains in several days longer than it is to
remove them even 1 day too soon. Antibiotics are
administered perioperatively and for 24 hours follow-
ing surgery. We do not routinely use antibiotics through-
out the time that the necks are drained because there
is no evidence that wound infections develop secondary
to retrograde contamination through drain sites.
Physical therapy of the shoulder must be initiated
early in all patients in whom the 11th nerve was dis-
sected. This is particularly critical in those in whom it
has been sacrifi ced. This should include primarily
range-of-motion exercises to prevent shoulder fi brosis.
Therapy should begin before patient discharge, and the
patient should be instructed in at-home exercises.
COMPLICATIONS OF NECK DISSECTION
Complications of neck dissection can be attributed to
preoperative, intraoperative, and postoperative factors.
Many of these factors are errors. Head and neck surgi-
Figure 78-48. Exposure of the internal jugular vein (IJV) and
rolling the fascia, containing lymphatics and nodes, off the IJV. Use
of a sharp knife with fi rm countertraction is key here. Avoid tearing
small tributaries.
Figure 78-49. Division of the common facial vein, preserving a
stump on the internal jugular vein to avoid narrowing the vein
unnecessarily.
to the nuchal line and the spinous processes. The tra-
pezius muscle is then separated from the nuchal line
and from the spinous processes down to the third or
fourth cervical vertebra. Usually branches of the occipi-
tal artery will be encountered and must be ligated. The
dissection of the posterior triangle is thereby extended
deep to the trapezius muscle, and fat and nodes super-

704
Section 8
Neck
cal services should implement standardized protocols
to reduce the chances of errors occurring, or reduce
the effect on the patient if they occur. Some preopera-
tive errors that can lead to complications follow:
1. Selection of inappropriate management strategy for
the patient. Often, this takes the form of not per-
forming a neck dissection when the site or stage of
the primary lesion suggests that treatment of the
neck is required.
2. The decision to perform a unilateral neck dissection
when bilateral dissections are indicated will lead to
an unacceptable rate of contralateral recurrences.
3. Failure to use perioperative antibiotics when the
aerodigestive tract is opened through the neck.
4. Failure to plan incisions correctly, particularly when
performing bilateral neck dissections.
Intraoperative Misadventures
Intraoperative misadventures in the neck can be cata-
strophic. Injury to the brachial plexus, phrenic nerve,
or carotid artery can lead to signifi cant disability or
death in the postoperative period. The phrenic nerve
and brachial plexus are protected by identifi cation early
in the performance of a radical neck dissection. Injury
is avoided in the selective neck dissection by maintain-
ing the dissection plane anterior to the cervical nerves
(see Figs. 78-47 and 78-48). If at any time the position
of the phrenic nerve and brachial plexus is questioned,
the operator should immediately identify the omohyoid
muscle, dissect the fascia deep to the muscle, and iden-
tify the brachial plexus and the phrenic nerve before
proceeding further. Although many patients can survive
with one phrenic nerve injured, phrenic nerve injury is
not compatible with a smooth postoperative course.
Most head and neck patients, particularly those under-
going procedures on the upper aerodigestive tract,
have chronic obstructive lung disease and will not toler-
ate even a unilateral phrenic nerve injury. Injury to the
carotid artery can be avoided by careful dissection in
the carotid sheath after the cervical nerves are divided
in a radical neck dissection. Careful dissection anteri-
orly following division of cervical nerves will frequently
reveal that the internal carotid artery is more posterior
than expected, particularly in the elderly patient with
an ectatic artery.
A chyle fi stula can be catastrophic and usually
occurs when the ducts are interrupted by injudicious
dissection posterior to the inferior aspect of the IJV.
Injury can be avoided by ligating the entire lymphatic
pedicle en bloc, particularly on the left side, rather than
dissecting through the pedicle and searching for the
elusive thoracic duct (see Figs. 78-29 and 78-30). If chyle
is encountered during the procedure, an exhaustive
search should be made for the leak. It must be recalled
that chyle is not milky in the fasting patient. The use of
an operating microscope is frequently helpful in this
situation. The intraoperative use of fi brin glue may
reduce the likelihood of postoperative fi stula.12
Injury to the midportion of the jugular vein is not
to be considered a problem unless the jugular veins are
sacrifi ced bilaterally. This is occasionally necessary
because of the extent of disease, but it should not be
required for technical reasons. Care must be taken in
dividing the jugular vein inferiorly to avoid injury to the
inferiorly located middle thyroid vein. The excessive
bleeding can precipitate the loss of control of the infe-
rior portion of the divided jugular vein. Lack of control
under the clavicle can be catastrophic and require the
assistance of a thoracic surgeon for salvage. Superiorly,
the problem is not as severe because the vein can usually
be plicated with the posterior belly of the digastric
muscle and bleeding controlled. We believe that recon-
struction of one vein is feasible and indicated if unan-
ticipated sacrifi ce of the contralateral vein must be
performed. Although most patients recover unevent-
fully following bilateral IJV sacrifi ce, the decrease in
postoperative morbidity would seem to make recon-
struction worthwhile.
Dissection along the carotid bulb can result in in -
traoperative bradycardia. Injection of lidocaine without
epinephrine will ablate this response and enable the
procedure to be continued. Injury to the external
carotid system is usually not signifi cant. Injury to the
internal carotid artery, however, may result in stroke
from either acute loss of blood fl ow or secondary embo-
lization from the distal segment. Air embolism through
open cervical veins is rare unless the procedure is being
performed with the head elevated. The pathognomonic
sign is “gurgling” heard via the precordial cardiac
stethoscope and associated loss of blood pressure. If air
embolism is encountered or suspected, the patient
should immediately be turned onto his or her left
side and the central venous line aspirated. If no central
line is in place, one should be placed immediately.
If death seems imminent, direct left ventricle punc -
ture and aspiration should be attempted and may
be lifesaving. Careful preoperative assessment and
intraoperative techniques will avoid this and other
complications.
Injury to the marginal mandibular nerve can be
avoided by dissecting the nerve free and refl ecting it
superiorly. Care must be taken posteriorly because the
nerve frequently dives farther inferiorly than is appreci-
ated. Dissecting the tail of the parotid free from the
digastric muscle and refl ecting it superiorly will often
help to prevent marginal mandibular nerve injury. If
the tail of the parotid is resected, the nerve should be
dissected into the gland before blindly excising parotid
tissue.
The tracheostomy incision is usually incorporated
into the neck wound. Several absorbable sutures should
be used to sew the skin fl ap to the underlying structures
to prevent soilage of the wound.
MANAGEMENT OF POSTOPERATIVE
COMPLICATIONS
Most postoperative complications are due to errors in
patient selection, preoperative planning, or surgical
technique. Avoidance of complications should be a
primary goal of treatment—second only to control of

Chapter 78
Neck Dissection
705
disease. Unfortunately, regardless of the skill of the
surgeon and the team, complications will occur in all
centers that manage cancer of the head and neck.
Knowledge of the range of these complications can
reduce the long-term morbidity for the patient.
Chyle Fistula
Profuse neck drainage, especially from the left-sided
neck drains, suggests the presence of a chyle fi stula.
Drainage output in the range of 1 to 2 L in 24 hours
suggests either fi stula or salivary leak. Initial manage-
ment includes pressure dressings and dietary supple-
mentation with medium-chain triglycerides. Intravenous
hyperalimentation sometimes is required.
Once a chyle leak has been identifi ed, treatment is
required. Instillation of fi brin glue through the drain
may provide benefi t for some patients, although early
exploration is the treatment of choice. The use of an
operating microscope or surgical loupes is mandatory
for most surgeons, because identifi cation of the leaking
vessel is often diffi cult. Feeding the patient a high-fat
meal immediately before surgical exploration will assist
in identifi cation of the leak. Once identifi ed, it should
be controlled with small sutures (e.g., 5-0 or 6-0 nylon
or similar suture). Large bites of tissue with large sutures
tend to pull through the thin walls of the ducts. Applica-
tion of fi brin glue to the surgical bed may reduce the
probability of recurrence. A pressure dressing consist-
ing of adhesive elastic dressing material passed over the
shoulder and attached anteriorly and posteriorly may
help in the management of the complication.
An occasional patient requires intrathoracic liga-
tion of the thoracic duct. Recently a thoracoscopic
technique was described that may avoid open
thoracotomy.25
Hematoma or Seroma
Hematoma occurring in the immediate postoperative
period is often due to inadequate hemostasis. Although
theoretically drains should permit the removal of blood,
the quantity of blood that can be satisfactorily removed
by functioning drains is limited. If the bleeding exceeds
the drain capacity, a hematoma will result. Once this
occurs, it can be assumed that a clot has formed in the
wound, the drains have become nonfunctional, and
reexploration is mandatory. Attempts to aspirate a
hematoma in the postoperative period are doomed to
failure, because it is unlikely that the clot can be satis-
factorily removed through even a large-gauge needle.
The wound should be reexplored as soon as possible.
This usually means returning to the operating room on
the same day (or evening) of the procedure, reopening
the wound, irrigating it to remove the clot, identifying
the bleeding vessels, and replacing the now-clotted
drains. Most frequently no bleeding site is identifi ed.
However, a careful search occasionally reveals one or
more bleeding sites. During reexploration, it is worth-
while to ask the anesthetist to allow the blood pressure
to creep up toward the higher levels to prevent missing
a vessel that is not bleeding merely because of hypoten-
sion and vasoconstriction. Fluid resuscitation and blood
replacement may be necessary. The most diffi cult part
of this procedure is usually deciding to return to the
operating room and speaking with the family, because
the actual reexploration is not technically diffi cult.
Early return to the operating room for exploration is
necessary for a number of reasons, the most critical of
which is the risk of skin fl ap loss owing to pressure from
an undrained hematoma.
Postoperative hematoma occurs either to excessive
bleeding or failure of evacuation of the blood that oozes
from the surgical bed. The most common cause is lack
of adequate hemostasis, not nonfunctional drains that
have been left off suction for too long (usually during
wound closure) and have clotted. This complication is
prevented by adequate hemostasis during neck dissec-
tion. If a clot is noted in the wound at the completion
of the closure and the drains do not appear to be
working, it is best to reopen the wound, irrigate it to
remove the clots, identify the source of bleeding and
ligate or cauterize them, and replace the drains. Nursing
personnel must be aware of both the importance of
continuous suction on the drains and the signifi cance
of closely monitoring drain function. We use wall
suction for the fi rst 24 to 48 hours to ensure high
suction and thereafter routinely aspirate the drains with
a syringe to prevent accumulation of debris that would
obstruct the drains.
A seroma develops later in the postoperative course.
This is most commonly due not to failure of the drains
but to overenthusiastic early drain removal. Often, the
goal of early discharge leads to premature drain
removal. As stated earlier, leaving the drains in place
for an additional day or 2 is far better than removing
them even 1 day too early. We maintain that drainage
must be less than 10 mL in 24 hours before drains are
removed. Many patients are now discharged with drains
in place and are instructed in drain management. The
drains are removed on a postoperative visit. This
strategy results in an extremely low incidence of post-
operative seroma, although it does produce prolonged
drainage in some patients, primarily those who have
undergone bilateral neck dissection. If drainage persists
for longer than 10 to 14 days, we assume that the neck
fl aps have “stuck” and will pull the drains regardless and
apply a pressure dressing.
Skin Flap Loss
Skin fl ap loss can be catastrophic in the performance
of a radical neck dissection because it can lead to
exposed vital structures, primarily the carotid artery.
The carotid artery, particularly when previously irradi-
ated, does not tolerate exposure and must be covered
early. Avoidance of skin fl ap loss is signifi cantly easier
than management of the complication once it has
developed. Prevention includes the selection of appro-
priate incisions to avoid long, narrow, poorly vascular-
ized fl aps. Preservation of the platysma muscle may help
if it is oncologically feasible to do so. Avoidance of inap-
propriate devascularization of the skin fl ap or retaining

706
Section 8
Neck
specifi c vessels, such as the facial artery (if oncologically
feasible) may help. Prolonged skin fl ap retraction, such
as suturing the fl ap to the drapes during a lengthy pro-
cedure, can cause kinking of the venous structures in
the fl ap, resulting in stasis and decreased viability. It is
wise to periodically return the fl ap to its anatomic posi-
tion when attention in the operative fi eld is directed
elsewhere. It is also wise to keep the fl ap moist with
saline-soaked sponges to avoid desiccation of the feeding
vessels.
If skin fl ap loss occurs, an initially conservative
approach is warranted. Often the underlying dermis
remains viable, whereas the epidermis becomes necrotic
and is lost. However, if the carotid artery is exposed
because of full-thickness loss, some form of coverage is
mandatory. This will include fl ap coverage, either
pedicle skin fl ap such as deltopectoral fl ap or muscle
fl ap such as pectoralis or trapezius. These are major
procedures but warranted when exposed carotid artery
is at risk following skin fl ap loss.
Bilateral Internal Jugular Vein Sacrifi ce
We believe that maintenance of one IJV is critical to
prevent the development of the postoperative sequela
of IJV sacrifi ce. We take pains to preserve one vein if
feasible. If vein preservation is not feasible, we have
occasionally used intraoperative IJV reconstruction and
have found that an uninvolved segment of contralateral
IJV is often of ideal size and easily accessible. If bilateral
IJV or second IJV sacrifi ce is required, postoperative
head and neck swelling will probably be signifi cant.
Airway management with a tracheostomy is mandatory
because upper airway obstruction is common. The head
of the bed should be elevated, and care must be taken
to monitor the patient for the syndrome of inappropri-
ate antidiuretic hormone. Although stroke, blindness,
and even death have been reported, most of these
patients suffered major blood loss and hypotension in
addition to the IJV compromise. It also seems possible
that some of the earlier reports of poor patient outcome
following bilateral IJV sacrifi ce were secondary to the
syndrome of inappropriate antidiuretic hormone and
inappropriate fl uid retention that resulted in patient
death. It is important to avoid a constricting dressing
following bilateral neck dissections, even with vein pres-
ervation in order to avoid occluding the remaining IJV.
Care should be taken during dissection to place the
tie on large branches a distance from the jugular to
avoid inappropriately narrowing the jugular vein (Fig.
78-50).
Painful Shoulder Syndrome
Shoulder pain is a common sequela of neck dissection,
particularly in those procedures in which the 11th nerve
is sacrifi ced. Loss of trapezius support allows the shoul-
der to drop (see Fig. 78-7), resulting in decreased shoul-
der mobility and pain. This lends secondarily to fi brosis
and further disability.
Early physical therapy is key to the prevention of
this complication. Patients should be instructed to con-
Figure 78-50. The specimen is rolled superiorly, and the anterior
dissection is completed in a manner identical to that for radical neck
dissection.
tinue this therapy after discharge. It is worthwhile to ask
patients about this in follow-up visits.
SUMMARY
Cancer metastatic to the neck is the most important
variable affecting survival in squamous cell carcinoma
of the head and neck. Management of the neck plays a
vital role in this disease. The various forms of neck dis-
section are important components of the head and
neck surgeon’s armamentarium. Dissection of clinically
involved nodes, or those likely to be involved, is critical
in the management of cancer of the head and neck.
Selection of the appropriate form of dissection will not
only improve disease control but also facilitate patient
rehabilitation by reducing postoperative functional and
cosmetic defi ciencies (Fig. 78-51).
PEARLS
• Imaging is often helpful in decision making in
cervical lymph node metastasis.
• The potential benefi t of elective neck dissection
should be considered in all patients with squamous
cell carcinoma of the head and neck from sites
known to metastasize to the neck.
• Single modality therapy for early cancers is preferred
when possible.
• Surgical management of the neck is preferable if
operative therapy is selected for treatment of the
primary cancer.

Chapter 78
Neck Dissection
707
A
B
Figure 78-51. Patient 6 months after selective neck dissection.
7. Ferlito A, Rinaldo A, Osvaldo Suárez: Often-forgotten father of
functional neck dissection (in the non–Spanish-speaking litera-
ture). Laryngoscope 11:1177-1178, 2004.
8. Bocca E, Pignataro O: A conservation technique in radical neck
dissection. Ann Otol Surg 81:975-987, 1967.
9. Medina JE: A rational classifi cation of neck dissections. Otolaryn-
gol Head Neck Surg 100:169-176, 1989.
10. Cappiello J, Piazza C, Giudice M, et al: Shoulder disability after
different selective neck dissections (levels II-IV versus levels II-V):
A comparative study. Laryngoscope 115:259-263, 2005.
11. Novak CB, MacKinnon SE: Patient outcome after surgical man-
agement of an accessory nerve injury. Otolaryngol Head Neck
Surg 127:221-224, 2002.
12. Akaogi E, Mitsui K, Sohara Y, et al: Treatment of postoperative
chylothorax with intrapleural fi brin glue. Ann Thorac Surg
48:116-118, 1989.
13. Byers RM, Wolf PF, Ballantyne AJ: Rationale for elective modifi ed
neck dissection. Head Neck Surg 10:160-167, 1988.
14. Fincher TR, O’Brien JC, McCarty TM, et al: Patterns of drainage
and recurrence following sentinel lymph node biopsy for cutane-
ous melanoma of the head and neck. Arch Otolaryngol Head
Neck Surg 130:844-848, 2004.
15. Pitman KT, Johnson JT, Eddington H, et al: Lymphatic mapping
with isosulfan blue dye in squamous cell carcinoma of the head
and neck. Arch Otolaryngol Head Neck Surg 124:455-459,
1998.
16. Kontio R, Levio I, Leppanen E, Atula T: Sentinel lymph node
biopsy in oral cavity squamous cell carcinoma without clinically
evident metastasis. Head Neck 26:16-21, 2004.
17. Som P, Curtin HD, Mancuso AA: Imaging-based nodal classifi ca-
tion for evaluation of neck metastatic adenopathy. Am J Roent-
genol 174:837-845, 2000.
18. Moore MG, Bhattacharyya N: Effectiveness of chemotherapy and
radiotherapy in sterilizing cervical nodal disease in squamous cell
carcinoma of the head and neck. Laryngoscope 115:570-573,
2005.
19. Kutler D, Patel S, Shah J: The role of neck dissection following
defi nitive chemoradiation. Oncology 18:993-1003, 2004.
20. McHam S, Adelostein D, Rybicki L, et al: Who merits a neck dis-
section after defi nitive chemoradiotherapy for N2-N3 squamous
cell head and neck cancer? Head Neck 25:791-798, 2003.
21. McGuirt WF, Johnson JT, Myers EN, et al: Floor of mouth carci-
noma. The management of the clinically negative neck. Arch
Otolaryngol Head Neck Surg 121:278-282, 1995.
22. Johnson JT, Bacon GW, Myers EN, Wagner RL: Medial versus
lateral wall pyriform sinus carcinoma: Implications for man-
agement of regional lymphatics. Head Neck 16:401-405,
1994.
PITFALLS
• Inappropriate patient selection is the most common
pitfall of head and neck surgery.
• Patients presenting with signifi cant weight loss will
not heal properly. They require preoperative
nutritional support before surgery.
• Lack of appropriate management of fl uids and
electrolytes in patients with a major chyle leak
jeopardizes the patient’s chances for recovery.
• Failure to replace a necrotic cervical fl ap with a
pectoralis major myocutaneous fl ap leaves the
patient vulnerable to carotid blowout.
• Hematoma following neck dissection is caused by
inadequate hemostasis not by clogged suction
drains.
References
1. Lutz C, Johnson JT, Wagner R, Myers EN: Supraglottic carci-
noma: Patterns of recurrence. Ann Otol Rhinol Laryngol 99:12-
17, 1990.
2. Layland MK, Sesions DG, Lenox J: The infl uence of lymph node
metastasis in the treatment of squamous cell carcinoma of the
oral cavity, oropharynx, larynx, and hypopharynx: N0 verses N+.
Laryngoscope 115:629-639, 2005.
3. Johnson JT, Barnes EL, Myers EN, et al: The extracapsular spread
of tumors in cervical lymph node metastases. Arch Otolaryngol
107:725-729, 1981.
4. van den Brekel MW, Castelijns JA: What the clinician wants to
know: Surgical perspective and ultrasound for lymph node
imaging of the neck. Cancer Imaging 23:5 Spec No A:S41-S49,
2005.
5. Crile G: Excision of cancer of the head and neck with special
reference to the plan of dissection based on one hundred and
thirty-two operations. JAMA 22:1780-1786, 1906.
6. Beahrs OH, Gossel JD, Hollingshead WH: Techniques and surgi-
cal anatomy of radical neck dissection. Am J Surg 90:490-516,
1955.

708
Section 8
Neck
23. Carrau RL, Byzakis J, Wagner RL, Johnson JT: Role of prophylac-
tic antibiotics in uncontaminated neck dissections. Arch Otolar-
yngol Head Neck Surg 117:194-195, 1991.
24. Goepfert H, Jesse RH, Ballantyne AJ: Posterolateral neck dissec-
tion. Arch Otolaryngol 106:618-620, 1980.
25. Gunnlaugsson CB, Iannettoni MD, Yu B, et al: Management of
chyle fi stula utilizing thorascopic ligation of the thoracic duct.
ORL J Otorhinolaryngol Relat Spec 66:148-154, 2004.

Chapter 79
Transcervical Approaches to the
Cervical Spine
Carl H. Snyderman and Amin B. Kassam
The otolaryngologist is often involved in surgery to
provide access to the cervical spine. This approach is
usually carried out for the treatment of cervical spon-
dylosis, and an orthopedic or neurologic surgeon is the
primary surgeon. Rarely, a head and neck surgeon will
be involved in the treatment of pathology involving the
spine, such as infection or primary and metastatic
neoplasms. Potential benefi ts for the primary surgeon
include increased effi ciency, decreased risk of injury to
the vagus nerve or esophagus, decreased medicolegal
risk, and follow-up care of voice and swallowing
problems.
Familiarity with these approaches is also important
for the treatment of conditions that do not involve the
spine, such as deep neck infection, metastases to the
retropharyngeal lymph nodes, cricopharyngeal achala-
sia, and Zenker’s diverticulum. Surgical approaches
to the cervical spine can be categorized as anterior
cervical, lateral cervical, transoral, and transnasal
approaches. This chapter focuses on transcervical
approaches to the cervical spine. Transoral and trans-
nasal approaches to the upper cervical spine are covered
in Chapter 106.
ANATOMY
There are seven cervical vertebrae whose position in the
neck depends on the length of the neck. It is useful to
relate the position of the individual vertebrae to the
cartilaginous and bony landmarks of the larynx and
hyoid (Fig. 79-1). In general, C1 and C2 are at or above
the level of the body of the mandible. C3 and C4 are at
the level of the hyoid bone and the superior aspect of
the thyroid cartilage. C5 and C6 are at the level of the
posterior cricoid cartilage. C7 is at the lower limit of the
neck and in some patients may be below the level of the
clavicle. The vertebral bodies are covered anteriorly by
the paraspinal muscles (longus capitis and longus colli).
There is a visible separation of the paraspinal muscles
in the midline. An angulation of the spine is often
noted at the C5-C6 level. The cervical spine is bounded
anteriorly by the pharynx superiorly and the esophagus
inferiorly. Laterally, the cervical spine is bounded by
the carotid sheath (Fig. 79-2). The superior laryngeal
nerve courses across the neck deep to the carotid artery
at the level of the thyrohyoid membrane and is in close
association with the superior thyroid artery. The recur-
rent laryngeal nerve is situated in the tracheoesopha-
geal groove superfi cial to the plane of the prevertebral
fascia and enters the larynx at the cricothyroid joint.
Lateral to the vertebral bodies, the vertebral artery
courses within the vertebral canal of the lateral
processes.
There are three fascial planes in the retropharyn-
geal region: the buccopharyngeal, alar, and preverte-
bral fasciae.1 The retropharyngeal space is bounded by
the buccopharyngeal fascia anteriorly and the alar fascia
posteriorly. The “danger space” is bounded by the alar
fascia anteriorly and the prevertebral fascia posteriorly.
The prevertebral space is located between the vertebral
bodies and the prevertebral fascia. The retropharyngeal
lymph nodes are located within the retropharyngeal
space, anterior to the alar fascia. The lateral retropha-
ryngeal lymph nodes (nodes of Rouvière) are situated
just medial to the internal carotid artery at the level of
the transverse process of the fi rst cervical vertebra
(atlas). Important landmarks for fi nding the retropha-
ryngeal lymph nodes are the transverse process of the
atlas, sympathetic trunk, superior sympathetic ganglion,
and alar fascia (Fig. 79-3).
709

710
Section 8
Neck
ment of the sternocleidomastoid muscle and the ante-
rior edge of the trapezius muscle. The muscles attach
to the lateral processes of the vertebral bodies. The
carotid sheath and sympathetic chain are anterior. The
vertebral artery ascends within the vertebral canal but
is exposed at the junction of C1 and C2, where it loops
outside the canal. The artery maintains a course deep
to the plane of the lateral processes.
PATIENT SELECTION
Cervical spondylosis (see Fig. 79-1) is the most common
indication for an anterior approach to the cervical
spine. Patients may have intractable pain or sensory and
motor loss from spinal cord compression. Revision
surgery is sometimes necessary when the plating hard-
ware becomes infected or displaced. Bulky hardware
may also contribute to postoperative dysphagia and may
be removed electively to improve swallowing function.
Large osteophytes occur most commonly at the C4 to
C6 levels in approximately 12% to 30% of the elderly
and may be associated with symptomatic dysphagia and
aspiration (Fig. 79-5).3 It can be diffi cult to demonstrate
that the patient’s symptoms are due to an osteophyte,
however, because dysphagia is frequently multifactorial
in these patients. Extensive calcifi cation of the anterior
longitudinal ligaments with resultant dysphagia can
develop in patients with Forestier’s disease, or diffuse
idiopathic skeletal hyperostosis (Fig. 79-6).4 The calcifi -
cations usually span multiple levels. Rarely, infection of
the vertebral bodies (osteomyelitis from adjacent infec-
tion or hematogenous seeding of the vertebral body,
A
A
Hypoglossal nerve (XII)
External
carotid artery
Superior laryngeal nerve
Superior laryngeal artery
Superior thyroid artery
Internal jugular vein
Omohyoid muscle
Ansa cervicalis
Sternohyoid muscle
Sternothyroid muscle
Superior thyroid vein
Vagus nerve (X)
Inferior thyroid artery
Recurrent laryngeal nerve
Inferior thyroid vein
Figure 79-1. Preoperative magnetic resonance image (sagittal
plane) demonstrating the relationships of the cervical vertebrae to
palpable laryngeal landmarks, as well as signifi cant spinal cord com-
pression at the C5-C6 and C6-C7 levels (arrows).
Figure 79-2. Key anatomic relationships
with anterior approaches to the cervical
spine include the carotid sheath laterally,
the larynx and esophagus medially, the
superior laryngeal nerve and superior
thyroid artery superiorly, and the recur-
rent laryngeal nerve inferiorly.
The carotid-vertebral space is the surgical window
between the carotid artery and the vertebral artery
(Fig. 79-4).2 The transverse process of the fi rst cervical
vertebra is the most prominent of the vertebrae and is
palpable deep to the superior attachment of the sterno-
cleidomastoid muscle in patients who have a thin neck.
It is a useful landmark for locating the lower cranial
nerves (X, XI, XII), which are all anterior to the lateral
process. From a lateral perspective, the superior aspect
of the cervical spine is covered by the superior attach-

Chapter 79
Transcervical Approaches to the Cervical Spine
711
CN XII
IJV
CN X
ICA
ECA
Alar
fascia
Retropharyngeal
lymph node
Superior
sympathetic
ganglion
Digastric
muscle
VII
XII
X
IX
XI
Carotid
artery
Jugular vein
Vertebral artery
Mastoid process
Figure 79-3. Important landmarks for fi nding the retro-
pharyngeal lymph nodes are the transverse process of the
atlas, sympathetic trunk, superior sympathetic ganglion,
and alar fascia (left side of the neck). CN, cranial nerve;
ECA, external carotid artery; ICA, internal carotid artery;
IJV, internal jugular vein.
Figure 79-4. The left carotid-vertebral space. The vertebral artery
has been mobilized posteriorly and the internal jugular vein ligated.
Figure 79-5. Lateral cervical spine radiograph demonstrating a
large osteophyte at the C4 level (arrow).
e.g., tuberculosis) may require surgery. Malignancies
metastatic to the vertebral bodies are usually treated
with palliative radiation therapy but may require surgery
for stabilization of the cervical spine.
The same surgical approach between the larynx
and the carotid sheath is used to treat other pathologic
processes in the neck. Infection of spaces deep in the
neck may result in a retropharyngeal abscess. Although
most cricopharyngeal myotomies for Zenker’s diverticu-
lum are now performed endoscopically, an anterior
cervical approach to the cervical spine provides the
necessary exposure of the cricopharyngeus and inferior
pharyngeal constrictor muscle for performance of a
myotomy. Neoplasms of the soft palate, pharynx,
thyroid, and skull base may metastasize to the retropha-
ryngeal lymph nodes.5 Although survival is poor in
patients with squamous cell carcinoma metastatic to the
retropharyngeal lymph nodes,6 retropharyngeal lymph-
adenectomy may be benefi cial in selected patients with
other types of neoplasms (esthesioneuroblastoma,
thyroid cancer).
Lateral approaches are almost exclusively per-
formed for neoplastic disease. Neoplasms may originate
within the spinal tissues, extend to the spine from adja-

712
Section 8
Neck
cent tissues, or be metastatic to the spine (Fig. 79-7).
The most common neoplasms requiring surgical
therapy that we have encountered include chondrosar-
comas, chordomas, and meningiomas.
PREOPERATIVE EVALUATION
Imaging of the spine is performed with computed
tomography (CT) or magnetic resonance imaging
(MRI), depending on the type of pathology. CT is pre-
ferred for assessment of bone pathology (bone destruc-
tion or osteophytes), whereas MRI is superior for
delineating the level of cord compression from a herni-
ated disc (see Fig. 79-1). A lateral plane fi lm of the neck
is suffi cient to assess possible displacement of spinal
hardware, such as a screw impinging on the esophagus.
If perforation of the esophagus is suspected, a barium
esophagogram is obtained. An esophagogram or modi-
fi ed barium swallow is also helpful in assessing the sever-
ity and contribution of osteophytes to dysphagia. In
addition to a complete neurologic assessment, evidence
of spinal cord compression can be evaluated with
neurophysiologic monitoring (electromyography and
somatosensory evoked potentials). In patients with sus-
pected metastases to the retropharyngeal lymph nodes,
imaging with combined positron emission tomography
(PET)/CT can be helpful in confi rming the diagnosis
and staging the extent of disease.
Cranial nerve function is ideally assessed preopera-
tively, especially function of the recurrent laryngeal
nerves. If there is a history or evidence of unilateral
vocal cord paresis, an approach from the same side is
usually selected to avoid the risk of injury to the nerve
supply of the normally functioning vocal cord.
PREOPERATIVE PLANNING
The anatomic relationship of the vertebral bodies to
cartilaginous and bony landmarks is assessed on a lateral
radiograph of the cervical spine or with CT or MRI
(sagittal view) (see Figs. 79-1 and 79-5). The level of the
upper cervical vertebrae is determined by their relation-
ship to the hyoid bone. The level of the midcervical
vertebrae is best judged by their relationship to the
posterior cricoid cartilage and the thyroid cartilage.
Because cartilaginous landmarks are not well visualized
on MRI, the epiglottis is a useful landmark. The ante-
rior ring of the cricoid cartilage is a readily identifi able
landmark for localizing the lower cervical vertebrae.
Neurophysiologic monitoring of spinal cord func-
tion is performed intraoperatively when there is preop-
erative compression of the spinal cord or when surgery
on the spine is performed. If severe compression is
present preoperatively, a baseline study is performed
after induction of anesthesia and before positioning.
After positioning, the patient is reassessed to confi rm
that the compression has not become worse. Continu-
ous monitoring is performed throughout surgery.
Informed consent should include a discussion of
the potential risks, benefi ts, and expected sequelae of
surgery. For anterior approaches, the greatest concern
is postoperative hoarseness or aspiration as a result of
injury to the superior or recurrent laryngeal nerves.
Some degree of dysphagia is expected postoperatively
and can persist for months in a minority of patients.7
The risk of infection or signifi cant bleeding is negligi-
ble. Perforation of the esophagus or hypopharynx is a
remote possibility, but the risk is increased when scar-
ring is present and when displaced hardware or a large
osteophyte is being removed. For lateral approaches,
there is additional risk to the lower cranial nerves and
sympathetic chain (Horner’s syndrome).
Intraoperative image guidance with a navigational
system is helpful for addressing pathology of the upper
cervical spine and cranial base from a lateral approach
but is impractical for lower levels. When a navigational
Figure 79-6. Forestier’s disease, or diffuse idiopathic skeletal
hyperostosis, is characterized by extensive calcifi cation of the anterior
longitudinal ligaments (arrows).
Figure 79-7. Chordoma involving the cervical spine (margins
denoted by arrows).

Chapter 79
Transcervical Approaches to the Cervical Spine
713
system is used, a CT angiogram will provide good visu-
alization of bony anatomy, as well as the course of the
vertebral artery.
SURGICAL APPROACHES
Selection of a surgical approach is dependent on the
location and type of pathology. An anterior approach
is used for the treatment of cervical spondylosis and
most other conditions. The laterality of the incision is
not important. Arguments can be made for either side,
depending on the level of exposure, handedness of the
surgeon, risk of retraction injury of the recurrent laryn-
geal nerve, deviation of the esophagus, and previous
surgery. Most right-handed surgeons fi nd a right-sided
approach to be easier for instrumentation of the upper
cervical levels and a left-sided approach for instrumen-
tation of the lower cervical levels. Transcervical
approaches to the retropharyngeal lymph nodes can be
either anterior (medial) or posterior (lateral) to the
carotid sheath. A lateral cervical approach is reserved
for neoplastic involvement of the upper cervical spine,
especially if there is involvement of the vertebral
artery.
The patient is orally intubated with the endotra-
cheal tube taped to the contralateral side. Perioperative
prophylaxis with intravenous antibiotics effective against
skin fl ora is optional; 1 to 2 g of cefazolin is usually
given. The skin is prepared with povidone-iodine (Beta-
dine) solution. With an anterior approach, the neck is
slightly extended by placement of a shoulder roll. It
may be necessary to retract the shoulders toward the
foot of the bed with adhesive tape when the neck is
short and the shoulders obscure the tissues for a lateral
radiograph (Fig. 79-8). With a lateral approach, the
patient is rotated slightly to the contralateral side with
padding under the ipsilateral shoulder and the head
turned slightly away. Excessive fl exion should be avoided
because it would interfere with dissection of the neck.
Anterior Approach
The level of the incision is dependent on the desired
level of exposure (vertebral level). A transverse incision
is made in a natural skin crease in the mid to upper
part of the neck for C2 to C4 and in the mid to lower
part of the neck for C5 to C7 (Fig. 79-9). The proposed
skin incision is infi ltrated with 10 mL of 0.5% lidocaine
(Xylocaine) with epinephrine (1 : 200,000) and marked.
After preparation, adhesive drapes are used to avoid
placement of metal instruments around the surgical
fi eld. They may interfere with intraoperative imaging
(lateral radiograph or fl uoroscopy) to confi rm the cer-
vical spine level.
The incision extends from the midline to the ante-
rior border of the sternocleidomastoid muscle. Subpla-
tysmal fl aps are elevated (Fig. 79-10), and dissection
continues medial to the sternocleidomastoid muscle
and lateral to the strap muscles (Fig. 79-11). The inter-
Figure 79-8. Positioning of the patient for an anterior cervical
approach. The neck is extended and the shoulder is retracted inferi-
orly with tape to avoid obstruction of a lateral cervical radiograph.
A
B
Figure 79-9. Skin incisions for approaches to the upper cervical
spine (A) and lower cervical spine (B).

714
Section 8
Neck
is maintained deep to the nerve and esophagus to avoid
injury.
The larynx and esophagus are retracted medially
and the prevertebral fascia is incised in the midline with
electrocautery (Fig. 79-14). The edges of the longus
colli muscles are elevated from the underlying vertebral
bodies at the desired levels. Bleeding from veins on the
surface of the bone is controlled with electrocautery.
Excessive dissection laterally should be avoided because
of potential risk to the vertebral arteries. The cervical
spine level is confi rmed radiographically by placing a
spinal needle with a 1-cm “stair-step” bend at the tip in
the intervertebral space (Fig. 79-15) and obtaining a
Figure 79-10. Subplatysmal fl aps are elevated.
Figure 79-11. Dissection is performed between the sternocleido-
mastoid and omohyoid (forceps) muscles.
CCA
IJV
Figure 79-12. The internal jugular vein (IJV) and common carotid
artery (CCA) are exposed and retracted laterally.
nal jugular vein is identifi ed and dissection continues
medially (Fig. 79-12). Motor branches of the ansa cer-
vicalis to the strap muscles are preserved when possible.
In a patient with a muscular neck, transsection of the
omohyoid muscle is sometimes necessary to provide
adequate exposure of the lower cervical levels. The
carotid sheath is identifi ed, and blunt fi nger dissection
medial to the carotid artery is usually suffi cient to create
a tunnel between the carotid sheath and esophagus and
expose the prevertebral fascia (Fig. 79-13).
The length of the exposure is extended superiorly
and inferiorly with appreciation of the course of the
laryngeal nerves. With superior exposure, careful dis-
section is performed along the medial aspect of the
carotid sheath. The superior laryngeal nerve crosses
laterally to medially deep to the carotid artery and is
closely associated with the superior thyroid artery. Once
the nerve is identifi ed, dissection of the retropharyn-
geal space can be performed deep to the nerve with
gentle superior retraction. It is rarely necessary to iden-
tify the recurrent laryngeal nerve. A plane of dissection
PF
Figure 79-13. The retropharyngeal space is bluntly dissected and
the larynx and esophagus are retracted medially to expose the pre-
vertebral fascia (PF).

Chapter 79
Transcervical Approaches to the Cervical Spine
715
Figure 79-14. The prevertebral fascia is incised in the midline and
the longus colli muscles (arrows) are elevated from the vertebral
bodies.
Figure 79-15. A spinal needle with the tip bent in stair-step fashion
is inserted into a disc space to mark the cervical spine level.
lateral radiograph (Fig. 79-16). Self-retaining or fi xed
retractors are then placed (Fig. 79-17). Further decom-
pression and fusion are performed by the spine
surgeon.
Access to the retropharyngeal space for other
disease processes is performed with the same technique.
Although the retropharyngeal lymph nodes may be
approached anterior or posterior to the carotid sheath,
an anterior approach is recommended because there is
less retraction of the carotid artery, less risk of injury to
the sympathetic chain, and greater exposure (see Fig.
79-3). The sternocleidomastoid muscle and carotid
sheath are retracted laterally and the digastric muscle
and hypoglossal nerve are retracted superiorly. Transec-
tion of the descendens hypoglossi nerve may be neces-
C5
C6
Figure 79-16. A lateral cervical radiograph demonstrates the spinal
needle (arrow) in the C5-C6 disc space.
Figure 79-17. Self-retaining retractors are placed between the
longus colli muscles.
sary to mobilize the hypoglossal nerve. The superior
laryngeal nerve is identifi ed and a window is created
between these nerves. The retropharyngeal lymph
nodes are anterior to the superior sympathetic ganglion
at the level of the transverse process of the atlas.1
Lateral Approach
The incision extends from the postauricular region
across the upper part of the neck (Fig. 79-18).2 Subpla-

716
Section 8
Neck
tysmal fl aps are elevated and the sternocleidomastoid
muscle is dissected along its anterior and posterior
borders. The carotid sheath and lower cranial nerves
are identifi ed anteriorly and vessel loops are placed for
retraction (Fig. 79-19). In the posterior triangle, the
spinal accessory nerve is identifi ed. The superior attach-
ments of the sternocleidomastoid and trapezius muscles
are detached from the mastoid tip and refl ected inferi-
orly and posteriorly (Fig. 79-20). The occipital artery is
tortuous below the digastric fossa and is usually ligated.
The transverse process of C1 is identifi ed and a plane
of dissection is maintained lateral to this structure to
avoid injury to the vertebral artery. The paraspinal
muscles are detached from the transverse process to
expose the area of the vertebral artery (see Fig. 79-4).
A venous plexus and small fat pad provide useful land-
marks for locating the vertebral artery. Further dissec-
tion of the vertebral artery requires great familiarity
with the anatomy of the vertebral canal and is generally
performed by a neurosurgeon. A posterior approach
can be combined with an anterior approach medial to
the carotid sheath if necessary.
POSTOPERATIVE CARE
Postoperative care focuses on function of the lower
cranial nerves. Transient hoarseness may be due to
vocal cord edema. Hoarseness that persists for more
than a week should be evaluated further by examina-
tion of the larynx to assess vocal cord function. A sig-
nifi cant percentage of recurrent laryngeal nerve injuries
after cervical spine surgery go unrecognized.8 The
patient should also be queried about aspiration. If com-
plete paralysis is observed, options include observation,
vocal cord injection if the symptoms are signifi cant, and
laryngeal electromyography to assess the degree of
injury.
Figure 79-18. Skin incision for a left lateral cervical approach.
Auditory brain stem responses are being monitored.
DG
SCM
Figure 79-19. The vascular and neural structures are identifi ed
anterior to the sternocleidomastoid (SCM) muscle and inferior to the
digastric (DG) muscle (left side of the neck): yellow vessel loop,
carotid artery; blue vessel loop, internal jugular vein; curved hemo-
stat, hypoglossal nerve.
A
SAN
IJV
B
Figure 79-20. A, Chordoma of the right parapharyngeal space
(arrows). B, The chordoma (arrows) is approached between the inter-
nal jugular vein (IJV) and the spinal accessory nerve (SAN). The
sternocleidomastoid muscle has been detached from the mastoid.

Chapter 79
Transcervical Approaches to the Cervical Spine
717
Transient dysphagia is to be expected, and most
patients can accommodate a mechanically soft diet
until it resolves. The incidence of postoperative dyspha-
gia is 50% at 1 month, 32% at 2 months, 18% at 6
months, and 13% at 12 months.7 Mechanisms of injury
include laryngeal nerve injury, pharyngeal plexus injury,
scarring of the pharynx, and obstruction by hardware.
Persistent dysphagia should be evaluated with an esoph-
agogram. A follow-up radiograph will usually be
obtained by the spine surgeon to assess adequate place-
ment and retention of the spinal hardware.
The following billing codes may be used for an
anterior cervical approach to the cervical spine: 22554-
62: “spinal arthrodesis or fusion . . . incision is made through
the neck, avoiding the esophagus, trachea, and thyroid . . . sep-
arate the intervertebral muscles” and 22585-62: “each addi-
tional interspace treated in conjunction with the code for the
primary procedure.” The following billing codes may be
used for treatment of a neoplasm requiring a lateral
approach to the upper cervical spine and skull base:
61597: “a transcondylar approach is used to expose the poste-
rior cranial fossa, jugular foramen, or midline skull base” and
61615: “excise a neoplastic, vascular, or infectious lesion in
the posterior cranial fossa, jugular foramen, foramen magnum,
or C1-C3 vertebral bodies.”
COMPLICATIONS
Improper placement of skin incisions can create prob-
lems for the surgeon. An incision that is too high runs
the risk of injury to the marginal mandibular branch of
the facial nerve. An incision that is too low is obstructed
by the sternal head of the sternocleidomastoid muscle.
If the dissection is too medial, the strap muscles and
thyroid gland will interfere with the approach. Occa-
sionally, an enlarged thyroid lobe is encountered and
needs to be mobilized along its lateral margin. If the
dissection is too far lateral, there is the potential for
dissection lateral to the carotid artery with risk of injury
to the vagus nerve and sympathetic chain (Horner’s
syndrome). If it is not detected, excessive medial dis-
placement of the carotid artery by the retractors may
result in carotid injury or ischemia. There is a greater
risk of this mistake in patients undergoing surgery when
postoperative scarring results in medial displacement of
the carotid artery. If the dissection is too superfi cial,
there is a risk of injury to the esophagus and recurrent
laryngeal nerve.
Vocal cord paralysis secondary to injury to the
recurrent laryngeal nerve may occur from direct nerve
injury (transection, thermal injury from electrocau-
tery), excessive and prolonged retraction, and overin-
fl ation of the endotracheal tube cuff. Animal models
and clinical studies have demonstrated that there is a
sharp increase in endotracheal tube cuff pressure when
retractors are placed.9,10 The recurrent laryngeal nerve
is susceptible to ischemic injury at the point where it
enters the larynx at the cricothyroid articulation. The
risk of neuropraxia can be reduced by readjusting cuff
pressure after retractors are placed. The anesthetist is
asked to defl ate the cuff and reinfl ate with the minimal
amount of air necessary to achieve a seal, usually 1 to
2 mL less air.
SUMMARY
The anterior approach to the cervical spine provides
wide access for a variety of pathologic processes involv-
ing the cervical spine and retropharyngeal space. The
approach is limited by the superior laryngeal nerve
superiorly and the recurrent laryngeal nerve inferiorly.
Morbidity can be avoided by understanding the anatomy
and minimizing retraction. Rarely, a lateral approach
to the upper cervical spine is necessary for the extirpa-
tion of neoplasms. The key landmark in this region is
the vertebral artery.
PEARLS
• The superior laryngeal nerve is deep to the carotid
artery and in close proximity to the superior thyroid
artery.
• Direct injury to the recurrent laryngeal nerve can be
avoided by maintaining a plane of dissection deep
to the esophagus.
• Transection of the omohyoid muscle improves
exposure of the lower cervical levels.
• The retropharyngeal lymph nodes are found anterior
to the transverse process of the atlas.
• With a lateral approach, the vertebral artery is deep
to the transverse process of the cervical vertebrae.
PITFALLS
• In patients undergoing revision surgery, the carotid
artery is medialized and there is greater risk of injury
and dissection lateral to the carotid sheath.
• Most injuries to the recurrent laryngeal nerve are a
result of excessive retraction.
• Endotracheal tube cuff pressure should be adjusted
after placement of retractors to prevent ischemic
compression of the recurrent laryngeal nerve.
• The retropharyngeal lymph nodes will not be
encountered if the plane of dissection is too deep
(in the danger space).
• Dissection medial to the transverse process of the
vertebra may result in injury to the vertebral artery.
References
1. Ozlugedik S, Ibrahim Acar H, Apaydin N, et al: Retropharyngeal
space and lymph nodes: An anatomical guide for surgical dissec-
tion. Acta Otolaryngol 125:1111-1115, 2005.
2. Kassam AB, Patel A, Welch W, et al: The carotid-vertebral space:
An ‘extended’ lateral window to the ventromedial cranial base
and lower craniocervical junction. Ear Nose Throat J 84:312-315,
2005.
3. Matan AJ, Hsu J, Fredrickson BA: Management of respiratory
compromise caused by cervical osteophytes: A case report and
review of the literature. Spine 2:456-459, 2002.

718
Section 8
Neck
4. Sarzi-Puttini P, Atzeni F: New developments in our understanding
of DISH (diffuse idiopathic skeletal hyperostosis). Curr Opin
Rheumatol 16:287-292, 2004.
5. Shellenberger T, Fornage B, Ginsberg L, Clayman GL: Transoral
resection of thyroid cancer metastasis to lateral retropharyngeal
lymph nodes. Head Neck 29:258-266, 2007.
6. Amatsu M, Mohri M, Kinishi M: Signifi cance of retropharyngeal
node dissection at radical surgery for carcinoma of the hypophar-
ynx and cervical esophagus. Laryngoscope 111:1099-1103, 2001.
7. Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior
cervical spine surgery, a prospective study. Spine 27:2453-2458,
2002.
8. Jung A, Schramm J, Lehnerdt K, Herberhold C: Recurrent laryn-
geal nerve palsy during anterior cervical spine surgery: A prospec-
tive study. J Neurosurg Spine 2:123-127, 2005.
9. Apfelbaum RI, Kriskovich MD, Haller JR: On the incidence,
cause, and prevention of recurrent laryngeal nerve palsies during
anterior cervical spine surgery. Spine 25:2906-2912, 2000.
10. Kriskovich MD, Apfelbaum RI, Haller JR: Vocal fold paralysis
after anterior cervical spine surgery: Incidence, mechanism, and
prevention of injury. Laryngoscope 110:1467-1473, 2000.

section 9
Plastic and Reconstructive
Surgery
Chapter 80
Management of Skin Cancer of the Head
and Neck
John A. Zitelli
Cancer of the skin is the most common form of cancer
in humans. The incidence of skin cancer is greater than
that of all other forms of cancer combined and is
increasing faster than any other cancer, largely because
of an aging population and the popularity of sun expo-
sure during the last half-century. Skin cancer is most
common in the 60- to 80-year-old age group, and as our
life expectancy and this segment of the population have
increased, the incidence of skin cancer has risen dra-
matically. In addition, since discovery of the health ben-
efi ts of vitamins in the early 20th century, particularly
the role of sunlight and production of vitamin D, sun
exposure was advocated for its health benefi ts. As leisure
time increased and convenient transportation offered
sunny vacations to those living in colder climates, the
lifetime exposure to ultraviolet light increased as well,
thereby expanding the age range and incidence of skin
cancer in each age group. Skin cancer contributes in
part to the practice of most specialties in medicine, and
because the majority of skin cancers arise on sun-
exposed areas of the head and neck, it is an important
part of operative otolaryngology. Together, these and
other epidemiologic factors have resulted in a virtual
epidemic of skin cancer that requires the expertise of
multiple specialties of medicine.
Malignant neoplasms may arise from any cell type
in the skin, and thus there are numerous forms of skin
cancer to consider. Cancer may arise from the epider-
mis (epidermal precursor cells [basal cell carcinoma],
differentiated epidermal cells [squamous cell carci-
noma], and melanocytes [melanoma]), neuroendo-
crine cells (Merkel cell carcinoma), adnexal skin cells
(sebaceous glands [sebaceous carcinoma], eccrine
glands [eccrine carcinoma, microcystic adnexal carci-
noma], and apocrine glands [extramammary Paget’s
disease]), fi broblasts (dermatofi brosarcoma protuber-
ans [DFSP], atypical fi broxanthoma, and malignant
fi brous histiocytoma), endothelial cells (angiosarcoma),
and smooth muscle (leiomyosarcoma). Each type of
skin cancer has a unique appearance, biologic behav-
ior, prognosis, and response to treatment, so knowl-
edge of each type is important before treatment is
begun. This chapter discusses the biology and operative
management of the most common forms of skin cancer
of the head and neck.
PATIENT SELECTION
Selection of patients for surgical management of skin
cancer is not diffi cult. Most patients are surgical candi-
dates. Most skin cancers are small (<2 cm) and can be
treated under local anesthesia in the offi ce, ambulatory
surgery center, or hospital outpatient setting with or
without sedation. Many common contraindications to
719

720
Section 9
Plastic and Reconstructive Surgery
surgery do not apply to these smaller operative proce-
dures. For example, patients taking anticoagulants such
as aspirin or warfarin (Coumadin) may safely continue
their medications for most skin cancer surgery. The risk
of complications from thrombosis caused by discontin-
uing their medications (i.e., stroke or heart attack) is
more serious than the uncommon and less serious com-
plication of bleeding or hematoma (<1%). Age is also
rarely a contraindication to surgery. Most skin cancers
are treated by simple operative procedures that have
very few risks or complications and are not disruptive,
even to fragile elderly patients. A short operative pro-
cedure in 1 day is often less disruptive than managing
chronic nonhealing skin ulcers from untreated skin
cancer.
Contraindications to Surgery
Although contraindications to surgery for skin cancer
are rare, a few situations should be considered. The fi rst
issue is life expectancy rather than age. One must con-
sider, all together, the type of skin cancer, its biologic
behavior, and the patient’s health and life expectancy.
For example, basal cell carcinoma is a slowly growing
tumor that may be asymptomatic for years. Therefore,
treatment is no emergency, and there may be no need
to treat a small nonulcerated basal cell carcinoma in a
patient with other metastatic disease and a life expec-
tancy of less than 1 year. On the other hand, treatment
of nodular melanoma in an independent 95-year-old
patient may be curative and allow the family to cele-
brate the potential 100-year mark. Each patient and
each tumor must be considered individually, but health
and life expectancy are more important than age when
considering the need to treat skin cancer.
Another important consideration in patient selec-
tion and the decision for surgery is the extent of disease
and the impact of surgery. Although surgery for skin
cancer is rarely serious or life-threatening, there are
occasions when extensive or invasive tumors may require
surgery that has a signifi cant mortality rate and impact
on quality of life after surgery or is unlikely to achieve
cure. In these rare cases the balance of risks and bene-
fi ts must be weighed carefully. Is it worthwhile to remove
one eye because of a slowly growing basal cell carci-
noma in an elderly patient who has little or no vision
in the other eye? Is temporal bone resection for man-
agement of a “close positive margin” after excision of
squamous cell carcinoma worth the mortality risk? In
diffi cult management cases, discussions and informed
consent must include a realistic probability of results
from treatment versus no treatment, as well as the pos-
sibility of alternative forms of therapy or palliative
treatment.
When selecting patients for surgery it is also impor-
tant to discuss nonoperative alternatives. Although
surgery usually offers a simple treatment with little pain,
delivers specimens for a pathologist to evaluate the
success of removal, and is usually accompanied by an
aesthetic reconstruction, there are signifi cant reasons
to consider alternative methods. The single most
common treatment of skin cancer today is the use of
destructive techniques such as curettage and electro-
desiccation, laser destruction, cryosurgery, radiation
therapy, or topical treatment with chemotherapy and
immunomodulating creams. Altogether, they offer cure
rates similar to those of surgical excision in properly
selected patients after considering variables such as
tumor type, size, location, and patient expectations of
cosmetic results.
Curettage with electrodesiccation is the technique com-
monly used for small noninvasive basal cell carcinomas
less than 2 cm in diameter and very small squamous cell
carcinomas. Under local anesthesia, a circular knife 2
to 6 mm in diameter is used in a scraping motion to
remove the tumor, which is soft in comparison to the
normal surrounding dermis. Scraping removes the
majority of the tumor, and this portion of the proce-
dure is followed by electrodessication of the wound,
which destroys an additional 3 to 4 mm of skin and soft
tissue. This procedure is not useful if the tumor involves
fat, cartilage, or tissue, for which one cannot feel the
contrast between tumor and normal skin with the
curette. Similarly, it is not useful in scar tissue, recur-
rent skin cancers in scar tissue, or hard infi ltrating
tumors that cannot be separated from normal dermis.
After removal of the tumor and wider destruction with
electrodesiccation, the wound heals by secondary inten-
tion, and a pale but acceptable scar is often left in care-
fully chosen locations.
Laser destruction is often successful for superfi cial
skin cancers confi ned largely to the epidermis and
superfi cial dermis, such as superfi cial basal cell carci-
noma and Bowen’s disease or microinvasive squamous
cell carcinoma. Like electrodesiccation and curettage,
the wounds are left to heal by secondary intention, and
pale white scars often result. Two advantages of laser
destruction are its ability to destroy very superfi cial
layers of skin with less destruction than occurs with
curettage and electrodesiccation and its ability to detect
focal invasive areas of tumor during vaporization by
their unique “bubbling” reaction as opposed to the
simple shrinkage of underlying normal dermis.
Cryosurgical treatment of skin cancer uses liquid
nitrogen as a coolant to freeze tumor and adjacent skin
and kill cells by dehydration or the formation of intra-
cellular ice crystals, which will burst the cell. It is often
claimed as a method to kill cancer cells and preserve a
viable framework of collagen that heals with less scar-
ring than with other techniques. However, in practice,
the cosmetic result is similar to that achieved with other
destructive techniques, and the results are quite opera-
tor dependent because there is no way to accurately
judge the depth of destruction without signifi cant
experience.
Radiation therapy for skin cancer was once a popular
alternative to surgery that was used by dermatologists
and radiation oncologists alike. It too is quite operator
dependent because experience is needed to estimate
not only the width of the surgical margin but, with more
diffi culty, the depth of tumor invasion as well. In prac-
tice it is inconvenient for most patients because 10 to

Chapter 80
Management of Skin Cancer of the Head and Neck
721
30 visits are required, and it is also the most expensive
treatment option. The advantage of radiation therapy
is that it provides a cure rate similar to that of surgery
without most of the risks and complications of
surgery. Nowadays it is most useful as an adjunct to
surgery, especially for tumors whose surgical margins
are positive but inoperable or whose margins are ques-
tionable but at high risk for recurrence, as well as for
adjunctive treatment around the surgical site to provide
local control if there is a high risk for satellite metasta-
ses. It is commonly used, for example, after excision of
high-risk squamous cell carcinoma and Merkel cell car-
cinoma. It is also used as a nonoperative adjunct to
elective
management
of
high-risk
lymph
node
metastases.
Another nonoperative option for head and neck
skin cancer is topical therapy. The use of topical chemo-
therapy, specifi cally, 5-fl uorouracil cream and topical
immunomodulators such as imiquimod, has been tried
with some success. However, it must be emphasized that
fl uorouracil and imiquimod have been approved by the
Food and Drug Administration only for superfi cial skin
cancer and imiquimod is not approved for use on the
head and neck. The results of current studies show
short-term success rates of 80%, and long-term cure
rates will probably be signifi cantly lower. The cost is
high, the results are interim, and their use is limited.
Some may consider topical therapy for widespread
superfi cial disease that would otherwise be inoperable
or for very superfi cial tumors that with excision might
result in signifi cant cosmetic deformity.
Besides nonoperative alternatives to routine surgi-
cal excision of skin cancer, there is one operative
alternative to consider when selecting patients for
surgery—Mohs surgery. Mohs surgery is a method of
complete histologic control of the surgical margin.1
Like routine excisional surgery, Mohs surgery is an exci-
sional method performed under local anesthesia but
differs from routine excision by the method of evaluat-
ing the surgical margin. In contrast to routine excision
and pathologic evaluation (with or without frozen
section control), in which less than 0.1% of the margin
is sampled, Mohs surgery literally examines 100% of the
margin. By examining the entire surgical margin of the
excision and accurately mapping any positive areas
within the wound, the excision can be continued until
a negative margin is ensured with almost certainty. The
result is a low recurrence rate, the ability to remove
tumor with very narrow margins, and a method to pre-
serve valuable normal skin for reconstruction. Mohs
surgery as an alternative to routine excision is most
useful for skin cancers that might be at higher risk for
recurrence, such as those in the midface and ears
because the depth or lateral margins are diffi cult to
estimate, for previously treated skin cancers that have
recurred or those excised with positive margins, or for
cancer in areas where the smallest possible wound is
important to achieve the best cosmetic or functional
result. This surgery is not time consuming, but like
routine excision it usually requires a half- or full-day
time commitment for patients. Its costs compare favor-
ably with other offi ce procedures, but it does require
special fellowship training.
In times of limited health care dollars, the cost of
treatment must also be considered in patient selection.
A comparison of costs for the most common treatment
options is presented in Table 80-1, including the cost
from the time of initial evaluation up to and including
5 years of follow-up screening.2
Syndromes and Predisposing Factors
It is important to recognize a few common syndromes
and predisposing factors that often infl uence the surgi-
cal decision and management of skin cancer.
Basal cell nevus syndrome has cutaneous fi ndings of
multiple basal cell carcinomas, including tiny pits in the
stratum corneum of the palms and plantar surfaces of
the fi ngers, toes, hands, and feet; the characteristic
facial appearance of frontal bossing and wide-set eyes;
and internal fi ndings of jaw cysts, skeletal abnormali-
ties, and calcifi cation of the falx cerebri. The diffi culty
in treating patients with basal cell nevus syndrome is
that tumors begin to appear at an early age (often
before puberty) and they number in the hundreds over
a lifetime. Patients usually become discouraged because
of the need for frequent treatment and are often lost
to follow-up, only to reappear with multiple diffi cult-to-
treat lesions. Effective lifetime care should include
counseling to prevent discouragement and lack of
regular follow-up routine care, treatment planning to
minimize loss of work/school and quality time, and
selection of treatment with a high cure rate to prevent
multiple repeat treatments and minimize deformity.
Thus far, chemoprophylactic treatment either topically
or with systemic retinoids has not proved useful in the
long term. Effective management often requires the
resources of multiple forms of treatment and multiple
specialists over a lifetime. These patients are often very
diffi cult to manage.
Muir-Torres syndrome is a form of familial polyposis
characterized by multiple sebaceous tumors of the skin,
particularly sebaceous carcinoma and adenoma, and
adenocarcinoma of the colon and small intestine. Seba-
ceous carcinoma behaves like squamous cell carcinoma
Table 80-1
AVERAGE COST OF TREATING SKIN
CANCER BY DIFFERENT METHODS*
Method
Cost ($)
Destruction
652
Offi ce excision/permanent section
1167
Mohs surgery
1243
Offi ce excision/frozen sections
1400
Ambulatory surgery/frozen section
1973
Radiation therapy
4558
*Based on a 1.5-cm facial skin cancer.
From Cook J, Zitelli JA: Mohs micrographic surgery: A cost
analysis. J Am Acad Dermatol 39:698-703, 1998.

722
Section 9
Plastic and Reconstructive Surgery
in its risk of metastasis, and treatment is similar. Any
patient with even a single sebaceous carcinoma of the
skin should be counseled about the possibility of Muir-
Torres syndrome and be referred for colonoscopy and
genetic counseling. Most patients have only a few skin
cancers, and they are curable if treated early. Important
in the long-term management of these patients is patient
education about the risk of colon cancer, affected family
members, and the need for self-examination of the
skin; routine gastrointestinal follow-up; and regular life-
time skin cancer screening.
The syndrome of multiple trichoepitheliomas is impor-
tant to recognize when selecting patients for treatment.
A trichoepithelioma is a benign neoplasm of the hair
follicle that often simulates basal cell carcinoma both
clinically and histologically. Patients with this syndrome
have increasing numbers of small papules on the medial
aspect of the cheeks, nose, and upper lip, as well as on
the ear and elsewhere on the face. Management diffi -
culties arise because (1) the tumors resemble basal cell
carcinoma clinically and histologically; lesions may be
misdiagnosed as basal cell carcinoma if an accurate
clinical description is not given to the pathologist or if
an expert pathologist is not available to examine the
lesion; (2) these patients often have true basal cell car-
cinomas developing within benign trichoepitheliomas
that require adequate treatment; and (3) excision of
basal cell carcinomas in these patients is complicated
by diffi culty assessing the pathology margin because
of confusion between benign trichoepithelioma and
malignant basal cell carcinoma at the margin. In
general, a single lesion that looks different from the
other dozens of lesions or any lesion that is enlarging
or ulcerated should undergo biopsy and be interpreted
by an experienced dermatopathologist.
Dysplastic nevus syndrome, or atypical mole syndrome, is
another syndrome important to recognize in the man-
agement of skin cancer, especially melanoma. Dys -
plastic nevus syndrome is inherited as an autosomal
dominant trait with incomplete penetrance and is char-
acterized by frequent spontaneous mutations. Recog-
nized only in the last 2 decades, there is still considerable
confusion and controversy surrounding both diagnosis
and management. A dysplastic nevus is clinically recog-
nized as a pigmented mole and is usually larger than a
normal nevus or greater than 6 mm in diameter. It is
nonuniform in pigmentation with slight variations of
brown. The pigment at the border appears to diffuse
into the surrounding skin, in contrast to the clear dis-
tinction at the border of normal nevi. The importance
of dysplastic nevus syndrome is its association with an
increased lifetime risk for melanoma. Patients with dys-
plastic nevus syndrome usually have multiple dysplastic
nevi on the trunk, as well as on the head, neck, and
scalp. Although the normal population has a 1% life-
time risk of melanoma, patients with common dysplas-
tic nevus syndrome have an approximately 5% risk.
Patients with even a single dysplastic nevus may have an
increased risk for melanoma, but those with multiple
nevi and a family history of melanoma together have
the highest risk for melanoma, approaching 100%.
Management problems in a patient with dysplastic
nevus syndrome arise around the controversy regarding
diagnosis and treatment. Dysplastic nevi resemble mela-
noma in some ways, both clinically and histologically.
Biopsies are common because of the irregular clinical
appearance similar to melanoma, and pathologists may
have diffi culty distinguishing the pattern of atypical
cells from melanoma or describe the common but
benign fi nding of cellular atypia and dysplasia and
comment that margins are still positive. Ambiguous
pathology reports often leave management decisions to
be made by the clinician, who may be confused about
the unresolved controversy. Important facts are that
dysplastic nevi are benign and do not to be excised.
Melanomas that arise in these patients, although they
may appear in preexisting nevi, often develop in normal
skin. Elective removal of all or most dysplastic nevi is
not recommended for decreasing the risk of melanoma.
Because dysplastic nevi are benign and commonly show
atypia and dysplasia, they do not need to be either
excised or re-excised if a biopsy specimen shows a posi-
tive margin. Some pathologists write this recommenda-
tion to absolve themselves from the responsibility of not
having looked at an entire lesion (if the margin is posi-
tive, some of the dysplastic nevus remains in a patient
who has not been examined histologically). They also
point out the later diffi culty in making a histopatho-
logic diagnosis from a biopsy specimen of a recur -
rent nevus that even more closely falsely resembles
melanoma.
In general, it is important to recognize and diag-
nose this syndrome to counsel patients to minimize
lifetime exposure to ultraviolet light, to perform regular
self-examination of skin, to have yearly checkups by
dermatologists, and to understand the genetics for chil-
dren and close family members.
Associated Diseases
Along with syndromes, some cutaneous conditions have
important associations with skin cancer. Oral lichen
planus is a chronic infl ammatory condition involving
both skin and mucous membranes. On the lips, whiten-
ing of the vermilion, ulceration, thickening of the epi-
dermis, and induration caused by the infl ammatory
response together can simulate squamous cell carci-
noma both clinically and histologically. Despite the pos-
sibility of lichen planus simulating squamous cell
carcinoma, it also predisposes one to the development
of true invasive squamous cell carcinoma. As with many
other conditions, it is important to match the fi ndings
on a biopsy report to the clinical picture.
Skin cancer is also a serious and almost universal
long-term complication in solid organ transplant patients
or other patients who are chronically immunosup-
pressed and represents an experiment in nature, thus
emphasizing the important role of immune surveillance
in preventing skin cancer. Skin cancer in transplant
patients is similar to skin cancer in patients with basal
cell nevus syndrome in that transplant patients often
become discouraged with the overwhelming number of

Chapter 80
Management of Skin Cancer of the Head and Neck
723
skin cancers, the need for frequent treatment, and the
time and effort required to keep up with treatment.
Worse yet is that the majority of skin cancers are squa-
mous cell carcinoma and squamous cell carcinoma in
situ. Neglected or recurrent disease may be life-threat-
ening and is often the cause of death in transplant
patients. This emphasizes the need for early effective
treatment and constant surveillance, follow-up, and
patient education. Coordinating medical management
with the transplant team to keep immunosuppressive
drugs at their lowest possible dose is often advisable.
Other forms of immunosuppression are also associ-
ated with an increased risk for skin cancer. Human
immunodefi ciency virus–positive patients with low CD4+
lymphocyte counts have a higher risk for squamous cell
carcinoma and often other forms of skin cancer as well.
Chronic infection with human papillomavirus plays an
important role in the development of squamous cell
carcinoma in these immunosuppressed patients. Immu-
nosuppression not only predisposes patients to skin
cancer but also complicates and compromises the prog-
nosis of patients at high risk for metastatic disease or
those with known metastatic disease. Again, coordina-
tion of their care to balance the risks and benefi ts of
immunosuppression is an important part of patient
selection for surgery.
PREOPERATIVE EVALUATION
The patient’s history plays a small but important role in
the preoperative evaluation. In general, lesions that
have not undergone change for many years tend to be
benign, whereas a history of increasing size or growth
is a signal to consider malignancy and therefore biopsy.
A history of previous treatment of skin cancer is a signal
that the original treatment failed because of inadequate
treatment, usually secondary to unrecognized positive
margins. It is important to remember that routine
pathology can only sample surgical margins and a
report of clear margins is only an estimate of clear
margins. In the face of recurrence, retreatment with
routine surgery is associated with a much higher recur-
rence rate than treatment of the primary lesions is, and
therefore Mohs surgery may be indicated.
Physical examination, however, plays a very impor-
tant role in the preoperative evaluation. It is important
to incorporate tumor location, size, and depth into the
decision-making process. To assess size and therefore
tumor margins it is extremely important to tightly
stretch the skin under very bright light such as that of
an examination or operating room light. Clues to tumor
extension of basal cell carcinoma and squamous cell
carcinoma may include subtle pink from the vascular
response induced by infl ammation, scar-like white or
yellow from fi brosis and tumor infi ltration, a more
shiny pearly appearance from underlying tumor lobules,
and lack of normal fi ne skin wrinkling. Extension of
superfi cial basal cell carcinoma or squamous cell carci-
noma in situ beyond invasive disease may stimulate der-
matitis and have a totally difference appearance than
the primary tumor. Tumor depth may be more diffi cult
to estimate beyond simple palpation and movement
over underlying structures such as attachment to
bone.
Estimating melanoma margins is more diffi cult on
the head and neck than on the trunk and extremities.
Normal skin lesions such as lentigines, freckles, sebor-
rheic keratoses, and actinic keratoses may all camou-
fl age the margin. Furthermore, in situ extensions at the
edge of a melanoma on the skin of the head and neck
are often amelanotic and simulate dermatitis or may be
totally invisible.
Palpation for signs of local, regional, or metastatic
disease in the form of satellite metastases, in transit
metastases, and lymph node metastases is necessary for
skin cancers with a risk of metastatic disease, especially
squamous cell carcinoma, melanoma, Merkel cell car-
cinoma, malignant fi brous histiocytoma, and sebaceous
carcinoma.
Adjunctive testing to evaluate the lymph nodes for
metastatic disease has limited value. Computed tomog-
raphy (CT), magnetic resonance imaging (MRI), and
ultrasound may be useful in obese patients, in whom
palpation of early clinical disease is diffi cult. Sentinel
lymph node biopsy is a technique that has not been
proved to improve survival, and research results on its
benefi t are limited to improvements in staging. Simi-
larly, preoperative testing with CT or MRI to determine
the extent of invasion is rarely helpful except in the
largest cases, and even then they are helpful only to get
an estimate of the likelihood of bone invasion, orbit
invasion, or involvement of vital structures of the neck.
The resolution of these tests can estimate the extent of
gross tumor involvement but cannot detect microscopic
extensions of skin cancer in soft tissue, which are often
located just millimeters from the main tumor mass.
Histopathology laboratory results are an essential
part of the preoperative evaluation, and a histologic
diagnosis is important before defi nitive surgery is
planned. The tumor type determines the need for eval-
uation of metastases, as well as the width of the surgical
margin. Because many types of skin cancer and other
benign diseases have a similar appearance, the proper
diagnosis is important before planning excision. Fur-
thermore, one should always be sure that the pathology
results correlate with the clinical picture. Biopsies are
often small samples of a larger lesion and may not rep-
resent the entire tumor. Sometimes the microscopic
appearance of one skin cancer simulates another tumor.
A melanoma can be confused with a superfi cial basal
cell carcinoma, and a Merkel cell carcinoma can be
confused with cutaneous lymphoma. The clinician must
be sure that the patient’s history, the appearance, and
the histopathology results all correlate; otherwise,
another biopsy may be indicated.
SURGICAL APPROACH
Tumor Type
The goal of surgery is complete removal of skin cancer
with clear margins as determined by histopathology.

724
Section 9
Plastic and Reconstructive Surgery
This goal is achieved by careful selection of patients,
careful surgical planning, and extensive examination of
the margins by the pathologist. The surgical approach
differs according to tumor type.
Basal Cell Carcinoma
Careful selection and planning should achieve a 5-year
cure rate of 90% to 95% for basal cell carcinoma (Fig.
80-1). For primary basal cell carcinoma 2 cm or less in
diameter that has clearly visible margins, a surgical
margin 4 mm wide should be adequate.3 The depth of
the surgical margin is more diffi cult to estimate and
depends a great deal on tumor location and clinical
judgment. Histopathologic variants such as morphea-
form or sclerosing basal cell carcinoma and micronodu-
lar and even superfi cial basal cell carcinoma require
wider margins than 4 mm, as well as the aid of careful
intraoperative frozen section control during excision.
Similarly, tumors larger than 2 cm in diameter and
recurrent tumors require a wider margin to achieve
acceptable cure rates. The best chance for cure is the
fi rst operation, and although 1- to 2-mm margins often
cure some basal cell carcinomas, 5-year cure rates are
only 50% to 60% and are considered inadequate for
such narrow margins.
Squamous Cell Carcinoma
Even though squamous cell carcinoma is associated
with a signifi cant risk for metastases, the goal of surgery
is still complete removal with negative surgical margins
(Fig. 80-2). Extra wide margins, excised in the hope of
including microscopic satellite metastases, do not
improve survival or local control. However, squamous
cell carcinoma usually requires wider surgical margins
than basal cell carcinoma does to achieve clear margins
of the primary tumor. For low-risk squamous cell carci-
nomas 2 cm or less in diameter in areas such as the
cheek and neck and not invading fat, a surgical margin
of 4 mm is acceptable. For moderate-risk squamous cell
carcinomas up to 2 cm in diameter, a 6-mm margin is
necessary to approach a 95% chance of achieving clear
surgical margins. For high-risk squamous cell carcino-
mas greater than 2 cm in diameter, those on the temple,
scalp, or lip, or those invading fat, a 9-mm surgical
margin is necessary to achieve an acceptable chance of
negative margins.4 If histopathologic sampling confi rms
negative margins with these clinical margin widths, the
risk for local persistence of tumor is minimized to an
acceptable level.
Keratoacanthoma is a variant of squamous cell car-
cinoma that often shows extremely rapid growth of a
dome-shaped nodule. Although keratoacanthomas
have been reported to spontaneously involute without
treatment, these tumors can be aggressive, destructive,
and otherwise indistinguishable from true squamous
cell carcinoma, including the ability to metastasize.
Complete surgical excision is the treatment of choice.
Squamous cell carcinoma in situ appears as a super-
fi cial scaly lesion that may be small or large. Although
the malignant atypical cells are limited to the epider-
mis, the diffi culty in treatment occurs when the atypical
cells extend down hair follicles into the dermis. In this
case, either deep destruction or full-thickness skin exci-
sion is required to achieve effective cure rates. When
there is little or no follicular extension, superfi cial
destruction with curettage, cryosurgery, or laser surgery
is quite effective. Left untreated or inadequately treated,
squamous cell carcinoma in situ often progresses to
true invasive squamous cell carcinoma with metastatic
potential.
Melanoma
Successful excision of melanoma on the head and neck
(Fig. 80-3) is more diffi cult than excision on the trunk
Figure 80-1. Nodular basal cell carcinoma of the inner canthus.
Figure 80-2. Squamous cell carcinoma of the ear.

Chapter 80
Management of Skin Cancer of the Head and Neck
725
and extremities because melanoma margins are more
diffi cult to visualize, amelanotic melanomas are more
common, and surgical margins are often reduced
because of cosmetic and functional concerns. There-
fore, these melanomas recur at the surgical margin in
9% to 18% of cases because of inadequate excision. The
previously published recommendation of a 5-mm
margin for melanoma in situ has no scientifi c basis and
often results in inadequate excision and recurrence of
both melanoma in situ and invasive melanoma. When
possible, 1.2-cm margins are likely to clear melanoma
on the head and neck in 97% of cases.5 When this
margin cannot be excised, very careful histopathologic
examination of the more narrow margins is necessary
to confi rm clear margins. Melanomas that recur at pre-
viously treated surgical margins may be due to previous
inadequate excision rather than metastatic disease. In
the former case the histopathology of the biopsy speci-
men generally shows an intraepidermal component.
Metastases are usually located in the dermis or subcu-
taneous tissue. Melanoma recurrences as a result of
previous inadequate excision have a much better prog-
nosis than metastatic recurrences do, and their progno-
sis is still accurately related to tumor thickness.
The value of elective lymph node dissection for
melanoma of the head and neck is still unproven. The
interim results of the Multicenter Selective Lymphade-
nectomy Trial I (MSLT I) have shown no survival benefi t
for sentinel lymph node biopsy and complete lymph
node dissection in patients with microscopically positive
disease.6 Possible benefi ts of sentinel lymph node biopsy
include a slight improvement in estimating a patient’s
prognosis in comparison with Breslow’s thickness alone,
although this may be true only for melanomas 2 to
4 mm thick. For other thicknesses, the benefi t of senti-
nel lymph node biopsy in estimating prognosis is no
better than Breslow’s thickness. Early detection of
microscopically positive disease with complete lymph
node dissection may also aid in improved regional
control, which can be an important benefi t in the head
and neck, especially in patients who may otherwise
neglect regular follow-up or self-palpation of lymph
nodes and be seen instead with advanced regional
nodal disease. The fi nal results of the MSLT II trial will
hopefully provide further evidence to guide clinical
decisions about sentinel lymph node biopsy.
The benefi ts of radiation treatment in the manage-
ment of high-risk, but clinically negative nodes is cur-
rently unproven and is being investigated. For now,
management of melanoma is still a surgical issue. There
is no adjuvant treatment that signifi cantly prolongs sur-
vival. Early treatment with complete removal of primary
disease is the most important factor. Surgical removal
of local, in transit, and regional disease can still salvage
a signifi cant number of patients with metastases. Teach-
ing patients to palpate nodes and soft tissue is an impor-
tant part of surgical management.
Adnexal Neoplasms
Cancer may arise within any skin structure, such as
sebaceous glands and eccrine sweat glands, or differen-
tiate toward the structures. Sebaceous carcinoma is a
malignant tumor of sebaceous glands that often arises
on the eyelids or skin of the head and neck. Its malig-
nant potential is similar to that of squamous cell carci-
noma and it should be treated as such. Microcystic
adnexal carcinoma and eccrine carcinoma appear clini-
cally similar to basal cell carcinoma but often show
more extensive subclinical invasion. To minimize local
recurrence, wider margins are necessary than for basal
cell carcinoma to prevent recurrence. In addition, com-
plete margin examination or Mohs surgery will mini-
mize the high rate of recurrence.
Trichoepitheliomas are benign tumors of hair fol-
licles. Clinically and histologically they may resem -
ble basal cell carcinoma. Therefore, single or isolated
trichoepitheliomas are often treated as basal cell carci-
noma, especially if they are large, ulcerated, or growing.
Patients with multiple trichoepithelioma lesions do not
require treatment; however, these patients often have
associated basal cell carcinomas that develop from their
benign tumors and will require treatment consisting of
complete excision of the basal cell carcinoma portion
but not the trichoepithelioma portion often seen at the
margin.
Merkel Cell Carcinoma
Merkel cell carcinoma arises from neuroendocrine cells
populating the skin and is characterized by a pink or
red papule or nodule. It is rarely diagnosed clinically
but instead undergoes biopsy when a red papule per-
sists or enlarges. This tumor has biologic behavior
similar to that of melanoma, with a very high risk of
metastatic disease. The microscopic extensions of
Merkel cell carcinoma are much wider and deeper than
clinical estimates, and therefore wide and deep margins
(i.e., 2 cm) are recommended to provide the best
chance of complete removal and minimize the risk
of local recurrence. Careful histologic examination of
the surgical margins is important to validate complete
Figure 80-3. Locally recurrent melanoma on the temple.

726
Section 9
Plastic and Reconstructive Surgery
excision. Mohs surgery can be helpful to ensure total
excision. If negative margins are not possible or are in
question, radiation treatment may improve local control
because this tumor is very radiosensitive. The role of
sentinel lymph node biopsy and elective node dissec-
tion may be similar to that in melanoma, although
there is no proven benefi t.
Dermatofi brosarcoma Protuberans
DFSP is a tumor of fi broblast origin that is manifested
as a dermal subcutaneous mass and often as a nodular
tumor greater than 2 cm in diameter. Although these
tumors rarely metastasize, local recurrence rates are
high because of diffi culty clinically estimating the
microscopic extent of the tumor. DFSP invades the
dermis and fi brous septa between the fat lobules, so its
microscopic extent is much wider and deeper than is
visible or palpable. Imaging studies are of limited value
because they cannot detect the microscopic involve-
ment of fat lobules accurately. Wide lateral margins of
2 to 2.5 cm of normal-appearing skin may be adequate
to clear the lateral margins, but the deep margins are
often the most diffi cult to estimate. Careful histologic
margin control is important to achieve negative surgical
margins. Mohs surgery is very effective and results in
both the lowest recurrence rate and the narrowest
margins possible.
Angiosarcoma
Angiosarcoma is a malignant tumor of blood vessels. In
its early stage it is a purple papule or nodule, but most
often it is seen as a large fl at plaque resembling a bruise
or ecchymosis that covers wide areas of the scalp and
forehead. Clipping or shaving the hair is necessary to
see the full extent of these lesions in hair-bearing areas.
Surgical management is diffi cult. Small lesions may be
surgically excised with success, but local recurrence
rates and regional metastatic rates are high. Surgical
margins are diffi cult to evaluate histologically because
growth of the malignant vessel is subtle. Large lesions
may not be amenable to surgery because of their
extreme size. Angiosarcoma is a radiosensitive tumor,
and therefore radiation therapy plays a role in the adju-
vant treatment of small lesions to provide local control;
radiotherapy also plays a role in the primary treatment
of large lesions that are not amenable to surgery. Adju-
vant chemotherapy has no proven value for local
disease.
Atypical Fibroxanthoma/
Malignant Fibrous Histiocytoma
Atypical fi broxanthoma is a skin cancer often seen in
sun-exposed areas. It resembles squamous cell carci-
noma or basal cell carcinoma because of the presence
of a pink papule or erosion. It is usually diagnosed only
after biopsy. Tumors involving the dermis and superfi -
cial fat are termed atypical fi broxanthoma and rarely
metastasize. Deeper tumors involving subcutaneous
tissue or muscle are labeled malignant fi brous histiocytoma
and have a high risk of metastatic disease. Surgical treat-
ment of atypical fi broxanthoma is excision with margins
similar to those for squamous cell carcinoma, and treat-
ment of malignant fi brous histiocytoma is wide and
deep excision, similar to treatment of Merkel cell car-
cinoma or melanoma. Elective regional node manage-
ment is unnecessary for atypical fi broxanthoma and has
no proven value for malignant fi brous histiocytoma.
Tumors of Uncertain Behavior
Surgeons are often faced with tumors on the head and
neck with uncertain biologic behavior. Spitz nevi are
benign nevi manifested as enlarging red papules, usually
in children or young adults. The diffi culty with this
lesion is that it resembles a nodular form of amelanotic
melanoma both clinically and histologically. A classic
lesion in a young person who also has a histologic diag-
nosis of benign Spitz nevus from a dermatopathologist
may not require excision; however, lesions arising in
adults or those showing cellular atypia or nonclassic
features histologically may be more diffi cult to distin-
guish accurately from melanoma. These uncertain
lesions should be excised and treated as though they
were melanoma, that is, with negative surgical margins
documented histologically by careful examination of
margins.
Dysplastic nevi are also benign lesions that are seen
on the head and neck and can clinically resemble mela-
noma because of their large diameter, irregular borders,
and irregular pigment. Lesions for which biopsy reports
describe the cellular atypia or dysplasia common in
benign lesions do not require excision. However, a
description of severe atypia may be an indication that
the pathologist cannot distinguish the lesion from mel-
anoma with certainty. With these lesions, a discussion
with the pathologist may be helpful to understand
whether the diagnosis is benign, malignant, or uncer-
tain. Pigmented lesions of uncertain diagnosis should
be excised with margins as though they were melanoma
and negative surgical margins determined histologi-
cally. Benign dysplastic nevi do not require excision
even if the biopsy margins are positive.
Many other cutaneous lesions have overlapping fea-
tures with their benign and malignant counterparts.
Desmoplastic trichoepithelioma can resemble morphea
or sclerosing basal cell carcinoma both clinically and
histologically. Other tumors of follicular origin may be
diffi cult to distinguish from basal cell carcinoma with
follicular differentiation. Ultimately, the clinician must
process the information described by the pathologist
along with the clinical picture to decide whether to
manage it as a benign or malignant lesion.
Evaluating Surgical Margins
The goal of treating skin cancer is to excise or destroy
the tumor completely with no visible tumor behind.
One advantage of surgical excision is the ability to eval-
uate the margins of the tissue removed at the time of
surgery and assess the completeness of removal. In con-
trast, destructive techniques and radiation therapy rely
on a certain amount of guesswork in estimating the