Head and Neck Lecture for
Junior Medical Students
Shawn D. Newlands, M.D., Ph.D.
Probably the most important thing for you to
take away from this lecture is that a neck mass in an adult that is present for
longer than a week, is cancer until proven otherwise. About 90% of all adult neck masses are malignant, whereas the
pediatric population neck masses are much more rarely malignant.
Like most things in medicine, they can be
categorized based on their origin as being congenital, inflammatory, acquired
or neoplastic. This list is by no means
comprehensive, but is just a taste of some of the etiologies that you might run
across. Congenital neck masses,
although they are primarily first noticed in the pediatric population, are
often not diagnosed or do not become apparent until the patient is in
adulthood.
Patients with brachial cleft cysts may not present until
they’re in their fourth or fifth decade of life, so these lesions are in the
differential diagnosis in both pediatric and adult population. Branchial cleft cysts originate from the
failure of pharyngobranchial ducts to become obliterated during early
development. They usually present when
they become swollen after the patient suffers from a cold or other upper
respiratory infection. They’re
characteristically fluctuant in nature and have a cystic feel which helps to
differentiate them from more solid lesions.
The most common source is the second branchial cleft. These cysts tend to be just anterior to the
sternocleidomastoid muscle. Treatment
is excision. ((Slide 10)
Thyroglossal
duct cysts arise from a remnant left as the thyroid gland that descends from
the floor of the pharynx, which becomes the base of the tongue, between 4 ½ and
6 weeks of development. This tract
travels either superficial to, through or just deep to the hyoid and reaches
the foramen caecum. These cysts also
often present after an upper respiratory infection and may not present until
the patient is in young adulthood.
Treatment is excision with the tract.
The operation for thyroglossal duct cysts includes removal of the center
portion of the hyoid bone to reduce the likelihood that the entire cyst is
excised which reduces the likelihood of recurrence. This operation is the Sistrunk procedure and is best performed
after any acute infection has resolved.
(Slide 11)
A cystic
hygroma is also known as a lymphangioma.
It’s an abnormality in development of regional lymphatics. Ninety-percent of these tumors occur before
the end of the second decade of life and they seldom regress. They often enlarge after upper respiratory
tract infection. Treatment is surgical
excision. Like the neck dissections,
this operation involves removing the lymphatic bearing tissue and leaving
non-lymphatic structures, such as nerves and large blood vessels, intact. (Slides 6-9)
Hemangioma
is the single most common head and neck neoplasm in children. Hemangiomas often regress and are best
treated conservatively but sometimes need resection. (Slide 12)
In
children, most cervical lymphadenopathy is inflammatory in nature. This is often in response to a viral
infection. The viruses such as HIV and
Epstein Barr virus can also cause cervical adenopathy.
Suppurative
infections of the cervical lymph nodes following upper respiratory tract
infection are very common in young children and often need to be drained. Mycobacterial infection is suspected when
suppurative lymph nodes in the neck do not resolve rapidly with
antibiotics. You can also acquire neck
masses such as ranula, which is from an obstructed sublingual duct. This can present in the neck as a cystic
mass.
A
laryngocele is caused by blockage of the ventricle and the larynx, which can
balloon out of the laryngeal framework and into the neck. This is seen in trumpet players and glass
blowers and is rarely seen in children.
The
neoplastic neck masses include benign masses such as lipomas and carotid body
tumors, which are also called chemodectomas.
In adults the most common source of neck masses is neoplasm. These are generally metastatic from the
aerodigestive tract. We will talk about
this at length later in this lecture.
Metastatic
neoplasms to the neck are almost always in the lymph nodes. Squamous cell or basal cell carcinoma from
the face and scalp can metastasize to neck lymph nodes. Occasionally you will see metastasis from a
distant site to a cervical lymph node, particularly GI and lung primaries to
supraclavicular nodes.
Parotid
tumors and melanomas of the head and neck also metastasize to neck lymph
nodes.
Primary
tumors in the neck include lymphomas, sarcomas and thyroid cancer.
One item
on the history, which is extremely helpful in trying to develop a differential
diagnosis for neck mass, is the duration
during which the neck mass is present.
Something is present for less than 7 days, then it’s likely to be
inflammatory; if it’s present from 7 days to 7 years, it’s likely neoplastic;
and for 7 years or longer, it’s likely a congenital. Obviously, there’s a lot of overlap in these categorizations, but
again, especially in adults, if you have a neck mass which has been present for
more than a week that really needs to be worked up aggressively. Too often we see delays, the patient is
treated with antibiotics, etc., and during that time, if they do have head and
neck cancer, this could significantly affect their prognosis. When you are interviewing a patient with a neck
mass, obviously there are a number of questions you ask besides just about the
duration of the mass. One is whether it
hurts. Sometimes people will complain
of pain that is actually where the mass is.
Other people will complain of ear pain; that’s a very important sign in
head and neck oncology. Because the
vagus nerve has some cutaneous intervention in the ear as well as in the
pharynx, cancer pain from the lateral pharyngeal wall and tonsillar region
perceived as otalgia. Pain on
swallowing obviously is a sign for throat cancer as well. Other things we ask about are how the size
of the lesion has changed over time. A
neck mass that increases steadily over time in an adult is very likely to be
cancer whereas a lymph node that fluctuates is more likely to be infectious or
perhaps an inflamed branchial cleft cyst or something of that sort.
Hoarseness
is an indication of a laryngeal or supraglottic lesion. Most patients with head and neck cancer
suffer from weight loss. This is often
a result of mechanical difficulty in eating, pain on eating and cachexia from
having a tumor. Sometimes these lesions
will bleed, and the patient will complain of hemoptysis. Difficulty swallowing due to obstruction is
often present, especially in cervical esophageal tumors. Respiratory stress, both by patient report
and just by listening to the patient for stridor, will give you an indication
if the patient might have a laryngeal lesion.
And lastly, a number of these cancer patients, you’ll notice if you’re
in the cancer clinic for any time at all, have a characteristic “tumor smell,”
which is basically the smell of necrotic tumor in their mouth, which is a
tip-off also to a head and neck cancer.
Do not be fooled by the patient’s history. They often “just noticed” a mass which we know has been there
longer than they claim it has.
Likewise, a history of hoarseness from yelling may be do to cancer and
the yelling just brought it to the patient’s attention.
Like with
all aspects of medicine that you learn about, past medical and surgical
histories are important. You should ask
about a family history for cancer. A
patient with a medullary carcinoma may have a M.E.N. or multiple endocrine
neoplasm syndrome. People who have
recently emigrated from China, particularly the region of Canton, would be at
much higher risk for nasopharyngeal carcinoma.
Nasopharyngeal carcinoma accounts for about 18% of cancer in these
areas, whereas in the United States it’s well less than .5%. There are people who, in the 1950s and ‘60s
received radiation therapy for acne treatment.
These people have increased risk for papillary carcinoma of the thyroid.
One of
the first things we always ask about is tobacco and ethanol use. The incidents of head and neck cancer in
people who smoke is in the neighborhood of 20 to 30 times greater than in
nonsmokers, and the combined use of smoking and ethanol increases your risk a
hundred-fold for these lesions. Certainly people who have had head and neck
cancer in the past which has been treated, are at increased risk for either a
recurrence of that same cancer or development of another cancer. This is attributed to a concept coined field
cancerization. Basically, patients with
mucosal carcinomas from smoking and ethanol use have damage to the surrounding
mucosa. This mutagenic damage
predisposes them to second and even third or fourth primary tumors.
Occupational
exposures can also be very important.
Woodworkers, especially with softwood, who do not use filtration masks,
have a very high incidence of adenocarcinoma of the sinuses. In the past, those glow-in-the-dark watch
dials were painted with radium and the people who painted those watch dials and
watch hands would lick the paint brush on their tongue and they had a high
incidence of tongue carcinoma. Nickel
is also correlated with carcinoma of the sinuses, and Epstein Barr virus is
correlated with one type of nasopharyngeal carcinoma. At least twice a year, I
make a new diagnosis of HIV in a patient who previously did not know that they
had this disease. These patients
present with either a bilateral swelling of the parotid glands or bilateral
cervical adenopathy.
The
physical exam starts with the head and neck exam. It’s important that you perform a thorough exam on every
patient. This is particularly true in
patients that have neck masses. We
start the head and neck exam with an external view of the head and neck. General appearance, of course, is
important. Does the face have any
lesions or does the patient have facial paralysis? Are the eyes present and
moving normally and not bulging? Look
at the skin and often times it’s obvious what the patient is in there for. Neurological status is important in head and
neck exam. Cranial nerve dysfunction is
often a sign of some pathology along the course of the nerve and is often
tip-off to lesions at the patient’s base of skull.
We then
exam the head and neck area internally with a number of different tools that
are outlined on the slide. Go in an
order, such as the ears first, then the nose and then the throat, and in the
throat we look in the oral cavity, the oropharynx, nasopharynx, the hypopharynx
and larynx. For all aspects of this
exam, other than looking in the ears, a head mirror is required. We use a nasal speculum to look inside the
nasal cavity. Oftentimes, if there is a
high index of suspicion or we want to get a better look, we can use a rigid
fiberoptic endoscope, which will give us an excellent view of the entire nasal
cavity. We can also look at the
nasopharynx this way; alternatively, you can look at the nasopharynx by looking
through the mouth and using a mirror to look upwards behind the soft palate
into the nasopharynx. We exam the oral
cavity by moving things around using tongue blades.
The
bi-manual exam is an often forgotten part of this exam, where your finger is
inside the mouth to palpate the floor of the mouth with the other hand in the
submandibular area. This will help you
feel lymph nodes in the floor of the mouth as well as abnormalities in the
submandibular gland. A laryngeal mirror
is used to look at the hypopharynx and larynx.
Again, this requires a head mirror and some practice to master. Alternatively, we can use a fiberoptic
laryngoscope, which is abbreviated as F.O.L. on the slide. This tool gives us an excellent view of the
patient’s pharynx and larynx.
-
Thyroid Gland
The neck
can also be examined using the various senses, including palpation,
auscultation and observation.
Examination of the neck includes examination of the parotid glands and
examination of the thyroid gland. One
very important concept in working up the neck mass, and head and neck oncology
in general, is the concept of different levels in the neck. Different levels of the neck contain
different lymph nodes groups, and these lymph node groups drain different parts
of the head and neck. Therefore, the
location of an enlarged lymph node in the head and neck will give you a clue as
to where the pathology might be that is causing this. Alternatively, if you discover a patient has head and neck
cancer, these are the lymph nodes that you would pay the most attention to in
trying to discern if they might have some metastatic disease. Level one is the submandibular triangle, to
correlate it with the triangles that you learned in gross anatomy. The predominant lymphatic drainage from the
head and neck occurs along the jugular vein.
The lymphatics along the jugular vein are divided into the upper, middle
and lower jugular groups. These
correspond to Levels Two, Three and Four.
Depending on whether you’re at surgery or doing a physical exam
externally, the borders of the different levels are slightly changed. The juncture between the upper jugular and
the middle jugular group (Levels II and III) is the hyoid bone and the cutoff
between the middle jugular and the lower jugular groups (Levels III and IV) is
either the cricoid ring, if you palpate externally, or the omohyoid muscle if
you have the neck open. The posterior
triangle from the posterior border of the sternocleidomastoid muscle to the
trapezius muscle down to the clavicle contains the spinal accessory lymphatic
chain; this is Level Five. Level Six
includes the peritracheal lymph nodes.
There are
other lymph node groups in the head and neck which are not in the levels
discussed. These are listed on this slide. Actually, the submental lymph nodes, which
are in the submental triangle, are considered part of the Level One lymph node
group. Preauricular and postauricular
lymph nodes and suboccipital lymph nodes drain the scalp. Lymph nodes both around and in the parotid
gland, as well as lymph nodes surrounding the pharynx can all be involved in
head and neck cancer, and need to be addressed or considered during treatment
for head and neck cancer.
This list
of drainage patterns seen in the head and neck is not comprehensive or
exclusionary, and certain structures that are in the midline, including the
nasopharynx, the soft palate and supraglottic larynx, tend to have bilateral
lymph node drainage. Starting with the lower lip, that often drains to the
submental triangle. Lower lip cancers
are often caused by pipe smoking or sun exposure. Scalp lesions typically drain to the parotid and suboccipital
nodes. These are also commonly caused
by sun exposure. Primary tumors of the
parotid gland drain to periparotid nodes as well as nodes in Levels One and
Two. Oral cavity tumors includes tumors
of the tongue, floor of mouth, the gingiva, the retromolar trigone and the
buccal mucosa tend to drain to Levels One, Two and Three. The oral pharynx includes the soft palate,
tonsil and the pharyngeal walls. These
areas drain to Levels Two and Three as well as to retro- and peri-pharyngeal
lymph nodes. The nasopharynx drains
bilaterally, and it drains to Levels Two, Three and Five. The hypopharynx, which is the pharynx below
the level of the epiglottis and includes the pyriform sinuses, drains to Levels
Two, Three and Four and also can drain to peripharyngeal and retropharyngeal
lymph nodes. The supraglottic larynx,
which includes the epiglottis, aryepiglottic folds and arytenoids, drains to
Levels Two and Three. True glottic
tumors, which are those of the true vocal cords, drain to Levels Three, Four
and Six. Thyroid tumors drain to Levels
Three, Four, Five and Six. And lastly,
cervical esophageal cancers also drain to Levels Three, Four, Five and
Six. The most important thing to come
away from this with is the concept of the specificity of the lymph node
drainage to different areas of the aerodigestive tract.
Now, let’s suppose we have a patient who has
presented to us with a neck mass. This
is an adult. We’re suspicious of
cancer, as we should be. It’s slowly
growing. He complains of dysphagia and
otalgia. What are the things we need to
do at this point? Obviously, what we
strive to do is to make a diagnosis and to help develop a treatment plan, and a
number of things can be done at the initial visit. One of the things we emphasize here, and most people who do head
and neck cancer emphasize, is going ahead and trying to move expeditiously
through the work-up. The reason for
this is, obviously, that the cancer is growing and has an increased chance to
spread. It’s difficult to get the
patients into treatment very quickly with head and neck cancer, and that’s
because there’s a number of tests that need to be ordered. So, for these reasons, we like to a lot of
this stuff done as soon as possible, so that we can move expeditiously through
the work-up and get the person treated.
The easiest way to make diagnosis is to biopsy any lesions that are seen
on physical exam. So, if this patient
with the lymph node has a necrotic ulcerative suspicious lesion on their
tongue, you would go ahead and biopsy the tongue lesion and that would give you
the diagnosis. If you have a diagnosis
of squamous cell carcinoma from the biopsy of the primary site, then there is
no need to biopsy the lymph node.
Now if,
on your physical exam, you’re unable to find an obvious primary tumor, then of
course you’ll want to know whether this really is a squamous cell carcinoma or
is it some other lesion, either benign or malignant that requires a different
work-up. The best way to do this is to
do a fine needle aspiration of the lymph node.
Fine needle aspiration, as it implies, involves placing a fine needle
into the mass to get a number of cells for cytohistologic analysis. Using a fine needle, there is virtually no
risk of a cancer spread along the biopsy tract. With cooperation from the pathologist, you can get a pretty good
idea what the patient has immediately, which expedites treatment planning. Any patient that we see in the clinic with a
new head and neck cancer, with some exceptions, will get imaging; generally
speaking a CT scan is the gold standard.
CT scan of the neck covers from the maxillary sinuses down to the
thoracic inlet, and this is the standard CT scan that we order. Occasionally we want to get a better view of
the sinuses or the regions of the orbits, in which case, we would order a sinus
CT. CT scans are the gold standard for
this purpose because, with contrast, it’s very easy to tell enlarged lymph
nodes from blood vessels and it’s very good for detecting bone invasion. Bone invasion is a particular concern with
tumors of the oral cavity, which may involve the mandible or maxilla. For certain applications including tongue tumors,
the MRI may have some advantages, but generally speaking, the CT is the gold
standard.
Unless
you have reason to suspect a lymphoma, based on fine needle aspiration and an
ability to see a primary lesion, open excisional biopsy of neck nodes is generally
frowned upon. We would excise benign
masses such as branchial cleft cysts or lipomas. But in a squamous cell carcinoma or suspected malignancy of that
sort, where the fine needle aspiration doesn’t provide enough data for a
diagnosis, then open biopsy may be a diagnostic procedure of last resort. You would send the lymph node for pathology
from the operating room, and if the pathology is consistent with squamous cell
carcinoma, you need to be prepared to complete a neck dissection. The danger with an excisional biopsy of a
lymph node with metastatic carcinoma in it is that you will spread the tumor
through the incisions, and this is the reason why it’s recommended that you do
a complete neck dissection at that time.
At the
time of the first visit, we will order a chest x-ray; we’re looking for
metastatic disease from any squamous cell carcinoma as well as a primary lung
tumor. Although this section says neck
mass diagnostic work-up, this diagnostic work-up is universal, really, for
patients with suspected aerodigestive carcinoma, even if they do not have
palpable lymphadenopathy. We obtain
blood labs, both for anticipated surgery as well as to assess the patient’s
nutrition. Most people will require
liver function tests to look for evidence of metastasis. Calcium levels and thyroid levels are
checked if we are concerned about tumors from the thyroid/parathyroid
gland. Occasionally other tests are
indicated. A chest CT would be ordered
if there was an abnormal chest x-ray or if there was a lot of lymphadenopathy
low in the neck and you really wanted to look carefully to see if this has
spread to the mediastinum. A barium
swallow is a good way to evaluate the esophagus, although oftentimes we’ll
evaluate that by directly visualizing it, as we’ll talk about a couple of
slides further on, when we talk about endoscopy. It’s not infrequent that we evaluate someone with a
supraclavicular node and the suspicion really is that they would have a
carcinoma from below the clavicles, and upper GI or an abdominal CT may show
the source of this tumor. Renal cell
carcinomas are also notorious for metastasizing to the head and neck. We rarely get a bone scan; these sorts of
tests for advanced metastases would be used only on patients with very advanced
disease. Panoramic x-rays of the
mandible are often used to evaluate for bony erosion in patients with oral
cavity cancer.
A unique situation
arises when you have a patient that has a lymph node in the neck, you’ve done a
needle aspiration and you find it’s squamous cell carcinoma. But you just can’t find the primary on
physical exam. Now, this happens about
5 – 10% of the time, and it’s what we call an unknown primary or TxN
positive patient, somebody who has a tumor which is unknown and has a positive
neck disease. These people are
evaluated with imaging after a thorough exam.
As we discussed a minute ago, a CT scan is usually used. The next that’s done is a panendoscopy, or
triple endoscopy. This procedure
involves a laryngoscopy, esophagoscopy and bronchoscopy to exam the larynx, the
pharynx (including the nasopharynx), the esophagus and the bronchial tree. Oftentimes, despite careful examination, you
do not see the source of the cancer. If
you do see anything suspicious, that’s immediately biopsied, and if you can’t
see anything on direct examination then removal of the tonsils, biopsy of the
nasopharynx on both sides and the base of the tongue on both sides are
indicated. These structures are part of
Waldeyer’s Ring, or the lymphatics of the aerodigestive tract, and they’re
notorious for hiding small tumors in the crypts. These tumors can metastasize while they’re still quite small at
the primary location, but grow to be quite large in the regional
lymphatics. Now if the patient is truly
Tx, meaning that even after this procedure you don’t find the source
of the cancer, then you need to proceed with radiotherapy from nasopharynx to
the clavicles to cover the whole aerodigestive tract. The goal is to eliminate any small tumor that you couldn’t find. In addition, you need to treat the neck
disease; this will often involve a neck dissection, although often the neck can
also be treated with radiotherapy.
What
is the treatment for head and neck cancer?
Well, first thing that we generally do is a panendoscopy. (Slide 29) This is a procedure whereby we look at the entire
aerodigestive tract. We do this for two
reasons. The first is for staging. Oftentimes, you can get a much better look
at a lesion with the patient under anesthesia.
This is particularly true if it’s a hypopharyngeal, laryngeal or
supraglottic lesion. The second reason
is that you’re looking for a second primary tumor. Synchronous primary tumors, which are present at the diagnosis of
the first cancer, are present 10% of the time in these patients. This is a consequence of their risk factors
and the concept of field cancerization I mentioned earlier. They basically have failed the biological
test for propensity to cancer in the sense that they’ve developed one cancer
and therefore, they’re prone to develop others. Oftentimes these second primary tumors are the lung, and that’s
why a chest x-ray is so important. On
occasion, however, you find an unsuspected esophageal second primary, although
we don’t find those all that often.
Sometime the panendoscopy is combined with the main surgery if it’s
clear that surgery is the best initial treatment for the disease.
Head and
neck oncology is an area that encompasses multiple medical specialties. These include head and neck surgery,
radiation therapy and medical oncology.
Especially for advanced tumors, multi-modality therapy is generally
used. Multi-modality therapy means that
for one tumor you use two or more of the modalities mentioned: surgery,
radiation therapy and/or chemotherapy.
At UTMB and a lot of other institutions, there is a head and neck tumor
board. This includes surgeons,
radiation therapists, medical oncologists, head and neck radiologists and
pathologists. We meet and discuss all
the head and neck cancer cases, and the group comes to a decision as to what
the best treatment is. This helps
ensure the patient that they are getting the benefit of everybody’s
expertise. We don’t always use the same
modality for both the primary and the neck disease. For instance, the patient may have a very small tumor of the base
of their tongue and significant disease in the neck. This patient might undergo radiation only to their tongue base,
but have radiation and a neck dissection to treat the neck disease.
For many
early lesions, surgery alone is an effective treatment modality. For other early lesions, radiation alone is
often used. Chemotherapy alone is not
an effective treatment modality and is only used as part of multimodality
treatment for advanced lesions.
Another
important consideration in head and neck oncologic treatment is difference
between a cure and locoregional control.
Locoregional control is elimination of the tumor at the primary site and
in the neck lymphatics. While it’s
always our goal to cure people who have head and neck cancer, this is a very
deadly disease, and patients often present in advanced stages. Generally speaking, therapy is better at
controlling local and neck disease and a large number of these patients will
eventually develop distant metastasis.
Thus, despite control of the cancer in their head and neck, they will
not be cured. This does not mean that
these patients are not benefited by their treatment. Death due to uncontrolled head and neck cancer is very
unpleasant; it can be very disfiguring and require the patient to have a
tracheotomy and a feeding tube. Even if
the patients eventually succumb to the disease, local regional control is a
benefit in the patient’s quality of life.
STAGE GROUPING (TNM) (Slide 31)
|
STAGE 0 |
Tis |
N0 |
M0 |
|
STAGE I |
T1 |
N0 |
M0 |
|
STAGE II |
T2 |
N0 |
M0 |
|
STAGE III |
T3 |
N0 |
M0 |
|
|
T1 |
N1 |
M0 |
|
|
T2 |
N1 |
M0 |
|
|
T3 |
N1 |
M0 |
|
STAGE IV-A |
T4 |
N0 |
M0 |
|
|
T4 |
N1 |
M0 |
|
|
Any T |
N2 |
M0 |
|
STAGE IV-B |
Any T |
N3 |
M0 |
|
STAGE IV-C |
Any T |
Any N |
M1 |
Staging
of head and neck cancer. All cancer
treatment really is subject to staging systems, and head and neck cancer is no
exception. The staging system varies
from site to site, so the T staging for oral cavity is different from that in
the oral pharynx and the hypopharynx.
The neck
lymph node staging system is universal with the exception of nasopharyngeal
cancers, and therefore is easier to remember.
What I’d like you to remember is the diagram above. Based on the local T stage and the N stage,
the overall staging correlates with survival.
Survival rates in head and neck cancer are measured at five years. Properly treated, patients with Stage I disease
have about a 90% 5-year survival rate.
Stage II disease generally corresponds with a 75% survival rate. Stage III is 50%, and Stage IV is 25%. As you can see, anybody has N2
neck disease, meaning either two or more lymph nodes, or a lymph node, more
than 3 cm in size, is automatically a Stage IV. So, the majority of patients who are presenting with a neck lymph
node as a primary presenting symptom are either at least a Stage III, and
usually Stage IV, disease.
The
surgical treatment of head and neck cancer has a number of different
aspects. The first is the stage
endoscopy that we talked about earlier.
The second is treatment of the primary disease. This may require any of a very broad range
of procedures; I’ll talk about some of them later in the lecture. Suffice it to say that these operations are
tailored to the location and size of the tumor.
An area
that requires a lot of thought is handling of the cervical lymphatics. Not every tumor requires neck dissection,
but certainly the possibility of lymphatic spread to the neck, either or not
adenopathy is present needs to be considered.
Now,
anytime we do head and neck oncologic surgery, we’re concerned also about
reconstructing the area to try to preserve function as much as possible, and
generally speaking, function means speech and swallowing.
We always
go through a process of considering the airway management whenever we do head
and neck cancer treatment. This often
involves tracheotomy, but not always, and sometimes this can be among the more
difficult parts of the treatment regimen.
We also have to consider management of the patient’s nutrition. Many of these patients are malnourished
preoperatively because of the disease or possibly because of alcoholism. And certainly the stress of surgery, as well
as the inability to swallow because of surgery, needs to be taken into
consideration. The majority of these
patients have working GI tracts, and so some way to bypass the upper digestive
system is utilized generally to aliment the patient peri- and postoperatively. And lastly, wound care is an issue in all
surgery, and certainly head and neck surgery, where most of the time we operate
in a surgical field full of spit, is no exception to this rule.
- Selective
There are
two different conceptual types of neck dissections that we do. These are staging neck dissections, where
basically there are no enlarged lymph nodes, but we’re taking out lymph nodes
to see if there’s any microscopic disease.
If a patient has no neck disease, they’re staging is lower and therefore
the prognosis is much better. The
second type of neck dissection is the therapeutic neck dissection. This is one where you’re actually treating lymphatic
spread with the neck dissection.
There are
a number of different types of neck dissections that you’ll hear about, and
I’ve listed the general types here, from the most radical to the most
conservative. In the early part of this
century, Crile described the radical neck dissection. This neck dissection was used for many years, regardless of the
extent or location of lymph node disease being treated. This original operation, which is a very
good one, has been refined since that time.
A radical neck dissection is neck dissection whereby the contents of the
neck Levels I – V are removed. (Slide 34) The internal jugular vein, spinal accessory nerve, and
sternocleidomastoid muscle are removed.
The vagus nerve, carotid artery, hypoglossal nerve, digastric muscle,
and sympathetic truck are preserved. (Slide 34) Now, if, in addition, if any of these five “preserved”
structures are removed, that would make this an extended radical neck
dissection. A neck dissection is a
modified neck dissection if you save the 11th cranial nerve,
the internal jugular vein and/or the sternoclidomastoid muscle. In a traditional modified radical, only the
11th nerve is saved, but there’s numbers for the different
types of modified radical neck dissections.
(Slide 35)
Functional
neck dissection is basically another way of categorizing modified radical neck
dissections. And lastly, we come to
selective neck dissections. Selective
neck dissections mean that the lymph nodes from levels one through five are not
removed, but that you have removed, say, just levels one, two and three, or
two, three and four. Selective neck
dissections are used when you are operating on a neck that has no
lymphadenopathy, and you’re doing it for staging purposes. (Slide 36)