A seminar on various types of neck dissections.

1. NECK DISSECTION
Dr. Harmandeep Singh
Under the Guidance of
Dr. D.D. Wagh Sir

2. Contents
• Introduction
• History
• Surgical anatomy
• Levels of lymph nodes
• TNM staging
• Classifications
• Definitions of types of dissections
• Surgical procedure
• Complications
• Algorithm
• Conclusion
• References

3. Some simple
questions…..
• What is neck dissection??
• Why it is done??
• When it has to be done??
• Who developed it??
• Where it is done??
• How it is done??
• What are the structures involved??
• Any complications??

4. Introduction
• Cervical node metastasis is the single most important prognostic
factor in head and neck squamous carcinomas.
• Cure rates drop in half when there is regional lymph node
involvement

5. Definition
• The term neck dissection refers to a
surgical procedure in which the fibrofatty
contents of the triangles of the neck are
removed as a treatment for cervical
lymphatic metastases

6. Emil Theodor Kocher
Earned Nobel Prize in 1909 for his work
in thyroid and neck
surgery — the first ever awarded to a
surgeon.
1880 – Kocher proposed
removing nodal
metastases

7. 1906 – George Crile
described the classic radical
neck dissection (RND)

8. 1967 - Bocca and Pignataro
described the “Functional neck dissection” (FND)

9. EVOLUTION
• 1880 – Kocher proposed removing nodal metastases
• 1906 – George Crile described the classic radical neck
dissection (RND)
• 1933 and 1941 – Blair and Martin popularized the RND
• 1953 – Pietrantoni recommended sparing the spinal
accessory nerves
• 1967 - Bocca and Pignataro described the “functional
neck dissection” (FND)
• 1975 – Bocca established oncologic safety of the FND
compared to the RND
• 1989, 1991, and 1994 – Medina, Robbins, and Byers
respectively proposed classifications of neck dissections

10. ANATOMY
• Skin:
– Blood supply:
• Descending branches:
– The facial
– The submental
– Occipital
• Ascending branches
– Transverse cervical
– Suprascapular
– The branches perforate the platysma muscle,
anastomose to form superficial vertically-directed
network of vessels

11. • Platysma muscle:
– Wide, quadrangular
sheet-like muscle
– Run obliquely from the
upper part of the chest
to lower face
– Skin flap is raised
immediately deep to the
muscle
– The posterior border is
over or just anterior to
IJV and great auricular
nerve

12. • Sternocleidomastoid muscle:
– Differentiated from the
platysma by the direction
of its fibres
– Crossed by the EJV and
the great auricular nerve
from inferior to posterior
deep to platysma
– The posterior border
represent the posterior
boundary of nodes level II
- IV

13. Omohyoid Muscle
• Inferior belly passes behind the
sternocleidomastoid
• Superior belly lies close to the
lateral border of the
sternohyoid and inserted into
the lower border of the body of
the hyoid bone
• The central tendon of this
muscle is held in position by a
fascial sling derived from
investing layer of deep cervical
fascia and is prolonged down
to be attached to the clavicle
and first rib

14. • MARGINAL MANDIBULAR
NERVE:
– Located 1 cm in front of
and below the angle of
the mandible
– Deep to the superficial
layer of the deep cervical
fascia
– Superficial to adventitia
of the anterior facial vein

15. • Spinal Accessory nerve:
– Emerge from the jugular
foramen medial to the
digastric and stylohyoid
muscles and lateral and
posterior to IJV (30% medial
to the vein and in 3 -5% split
the vein)
– It passes obliquely
downward and backward to
reach the medial surface of
the SCM near the junction of
its superior and middle
thirds, Erb’s point

16. • Trapezius muscle:
– Its anterior border is the
posterior boundary of
level V
– Difficult to identify
because of its
superficial position
– Dissect superficial to the
fascia in order to
preserve the cervical
nerves

17. • Digastric Muscle: Posterior
belly:
– Originate from a groove
in the mastoid process,
digastric ridge
– The marginal
mandibular nerve lie
superficial
– The external and
internal carotid artery,
hypoglossal and 11th
cranial nerves and the
IJV lie medial

18. • Brachial Plexus & Phrenic
nerve:
– The plexus exit between
the anterior and middle
scalene muscles, pass
inferiorly deep to the
clavicle under the
posterior belly of the
omohyoid
– The phrenic nerve lie on
top of the anterior scalene
muscle and receive its
cervical supply from C3 –
C5

19. • Thoracic duct:
• Located in the lower left neck
posterior to the jugular vein
and anterior to phrenic nerve
and transverse cervical
artery.
• Has a very thin wall and
should be handled gently to
avoid avulsion or tear
leading to chyle leak

20. • Hypoglossal nerve:
• Exit via the hypoglossal canal
near the jugular foramen
• Passes deep to the IJV and over
the ICA and ECA and then deep
and inferior to the digastric
muscle and enveloped by a
venous plexus, the ranine veins
• Pass deep to the fascia of the
floor of the submandibular
triangle before entering the
tongue

21. Anatomy of the vascularization of neck skin
• Kambic and Sirca 1967 stated that arterial supply is in a
vertical direction.
• descending branches: facial and occipital artery
• ascending branches: transverse cervical and
supraclavicular arterial branches .

22. The vasculature can be summarized into
• Upper neck region - anterior to the angle of mandible -
branches of facial and submental arteries.
• Upper lateral neck - the area between ramus of mandible
and the sternocleidomastoid muscle-Occipital and
external auricular branches of external carotid .
• Lower half of neck - The transverse cervical artery and
suprascapular artery
• Large platysma - cutaneous branches and branches of
superior thyroid supplying the front middle portion of the
neck.

23. LYMPH NODES OF HEAD &
NECK
Conventionally divided into three systems
• Waldeyers internal ring
• Superficial lymph node system (Waldeyers external ring)
• Deep lymph node system (cervical lymph nodes proper)

24. Waldeyer’s ring
• Circular collection of
lymphoid tissue within
the pharynx at the
skull base.
• Ring includes the
adenoids, tubal and
lingual tonsils,
palatine tonsils,
aggregates on the
posterior pharyngeal
wall.

25. Superficial nodal system
• Drains the superficial tissues of
the head and neck.
• Two circles of nodes, one in the
head and the other in the neck.
• In the head – nodes are
situated around the skull base
• In the neck – submental,
submandibular and
anterior cervical nodes.

26. Deep lymph nodal system
Deeper fascial structures
of the head and neck
drain either directly into
the deep cervical nodes
or through the superficial
system.
• A. Junctional nodes
• B. Internal jugular nodes
• C. Spinal accessory
nodes
• D. Supraclavicular nodes
• E. Nuchal nodes
• F. Deep medial visceral

27. Classification of lymph node levels by
Memorial Sloan-Kettering Cancer Center
The boundaries of each
being defined by
surgically visible bones,
muscles, blood
vessels or nerves.
Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW.
Standardizing neck dissection terminology. Official report of the academy’s
committee for head and neck surgery and oncology. Arch Otolaryngol Head Neck

28. Levels of lymph nodes

29. Draining areas

30. Spread of cancer in
lymphatics
• Embolisation
• Permeation

31. Neck Dissection in Oral Malignancy

32. T Classification
• T – Primary tumour :
• T x primary tumour that cannot be assessed.
• T 0 No evidence of primary tumour.
• T is Carcinoma in situ.
• T 1 Tumour 2 cms or less in the greatest
diameter.
• T 2 Tumour 2cms but not more than 4cms in the
greatest diamension.
• T 3 Tumour more than 4 cms in the greatest
dimension.

33. T 4 a – Lip :
Tumour invades through the cortical bone, inferior
alvoelar nerve, floor of the mouth or skin.
T 4 a – oral cavity :
Tumour invades through the cortical bone into the
deep extrensic muscles of the tongue ( genioglossus,
hypoglossus, palatoglossus, styloglossus ) , maxillary
sinus or skin of the face.
T 4 b – lip and oral cavity :
Tumour invades the massetric space, pterygoid plates,
skull base or encases the internal carotid artery.

34. T staging

35. N staging
No regional lymph
node metastases
Single ipsilateral
lymph node, < 3 cm
Single ipsilateral lymph
node 3 to 6 cm
Multiple ipsilateral
lymph nodes < 6 cm
Bilateral or contralateral
nodes < 6cm
Metastases > 6 cm

36. • Distant metastases – M
• M x – distant metastases that cannot be assessed.
• M 0 – No distant metastases.
• M 1 – distant metastases.

37. Staging
N0 N1 N2 N3
T1 I
T2 II
T3 III
T4 IV

38. Impact of pattern of nodal metastasis
on neck dissection
Level of nodal involvement Site of primary tumour
Submental(IA) Floor of mouth, lips and anterior
part of tongue
Submandibular(IB) Retromolar trigone,
glossopalatine pillars,lateral floor
of mouth& anterior tongue
Jugulodigastric(II) Hypopharynx, base of tongue,
tonsil, nasopharynx & larynx
Mid jugular(III) Hypopharynx, base of tongue,
tonsil, nasopharynx & larynx
Lower jugular(IV) Thyroid, nasopharynx &
hypopharynx
Supraclavicular(V) Lung, thyroid, gastrointestinal &
genito urinary system
Posterior triangle(VI) Nasopharynx

39. Factors affecting nodal
metastasis
• Anterior portions < posterior
portions.
• Tumor size. (T)
• Perineural and perivascular
invasion are associated with
a high risk of nodal
metastasis.
• Poorly differentiated tumors >
well-differentiated tumors.
• Tumor thickness.
Ref - Jatin Shah’s Head & Neck Surgery & Oncology 4th Edition

40. •Excluding the hard palate and lip, approximately 30% of
patients with oral cavity cancer will present with cervical
metastases
• Depth of invasion greater than 8 mm was associated with
a 41% rate of occult metastasis.
•Tumour depth > 5mm --- Increased risk of neck metastasis

41. Assessment of cervical lymph nodes
• Clinical Examination
• Ultrasound
• Ultrasound guided fine
needle aspiration
cytology
• Computed tomography
• Magnetic resonance imaging
• PET
• Sentinel node biopsy

42. • PET scan - highest specificity (82%)
• Ultrasound - highest sensitivity (84%)
• Due to high number of small lymph node metastases from
oral cavity carcinoma, the non-invasive neck staging
methods are limited to a maximum accuracy of 76%
• Elective neck treatment should be mandatory for all
patients with squamous cell carcinoma of the oral cavity

43. • Sentinel lymph node is defined as a
lymph node to which a tumor first
metastasizes
• SLNB if negative for metastases, lymph
node dissection is not necessary.
• Use in oral cancer – controversial
• One of the main problem of SLNB of oral
cancer is skip metastasis in which the
disease bypasses level 1 and 2 nodes
and goes directly to level 3-4
Sentinel node biopsy
Ref - Jatin Shah’s Head & Neck Surgery & Oncology 4th Edition

44. When neck dissection has to be done?
• The incidence of metastatic disease for the upper
aerodigestive tract varies widely, from 1-85%,
depending on the site, size, and differentiation of the
tumor.
• The rate of ipsilateral metastatic disease in patients with
stage T3-T4 squamous cell carcinoma of the oral cavity,
oropharynx, hypopharynx, or supraglottis is
approximately 50%.
• The rate of bilateral or contralateral metastatic disease
in these patients varies from 2-35%.
• 20 – 30 % of the malignancies of tongue metastasize to
clinically undetectabe cervical nodes

45. Patterns of cervical lymph node metastasis from squamous carcinomas of the
upper aerodigestive tract.
Am J Surg. 1990 Oct;160(4):405-9
• A consecutive series of 1,081 previously untreated
patients undergoing 1,119 RNDs for squamous
carcinoma of the head and neck was reviewed to
study the patterns of nodal metastases.
• Predominance of certain levels was seen for each
primary site. Levels I, II, and III were at highest risk for
metastasis from cancer of the oral cavity.
• SOHND (clearing levels I, II, and III) for N0 patients
with primary squamous cell carcinomas is
recommended

46. • For patients with clinical cervical lymph node metastases
a therapeutic neck dissection is necessary and a
modified radical dissection is regarded as the safest
option.
Management of the neck in patients with T1 and T2 cancer in the
mouthBJOMS Vol 40, issue 6 .December 2004, Pages 494-500

47. Does N0 neck require
treatment??
• The metastases rate to the neck from oral cancer is 34%.
• Observation if probability is less than 20%
• Elective neck dissection - >20 %
• The lymph nodes at the highest risk of metastases from oral cavity
cancers are those at level I, II, III.
• Contralateral neck dissection: The primary oral cancer is midline
,bilateral along the tip of tongue or approaches /crosses midline.

48. • Most surgeons use an occult metastatic potential of 20% or greater
to determine need for elective treatment of the N0 neck. Based on
the paper by Mendenhall et aI., the occult metastatic rate for given
subsites is as follows:
• - 15-20%
T1 - glottis, retromolar trigone, gingiva, hard palate, buccal mucosa;
• - >20%
T1 - oral tongue, soft palate, pharyngeal wall, supraglottis, tonsil; T2 -
floor of the mouth, oral tongue, RMT, gingiva, hard palate, buccal
mucosa; T1-T4 - nasopharynx, piriform sinus, base of the tongue; T2-
T4 - soft palate, pharyngeal wall, supraglottis, tonsil; T3-T4 - floor of
the mouth, oral tongue, RMT, gingiva, hard palate, buccal mucosa.

49. • The following surgical outline was suggested:
– SCC oral cavity anterior to circumvalate papilla
• Supraomohyoid
– SCC Oropharynx, larynx and hypopharynx
• level I- IV or level II-V
– SCC with N+ nodes
• RND
– SCC with 2-4 positive nodes or extracapsular
spread
• RND and adjuvant therapy
Shah Cancer July 1;109-113: 1990

50. Aims of Neck Dissection
• Remove gross disease in patients with clinical
evidence of nodal involvement (therapeutic neck
dissection)
• Remove occult metastases in patients whose tumor
characteristics make one suspicious of occult cervical
metastases (elective neck dissection or END)

51. The definition of the different types of neck dissections
were outlined in the 1991 classification :
1) The radical neck dissection is considered to be a
standard basic procedure for cervical
lymphadenopathy.
2) When one or more of the non lymphatic structures
are preserved which otherwise are routinely removed
during radical neck dissection then it is termed as
modified radical neck dissection.

52. 3) When the alteration involves preserving the 1 or more
lymph node groups / levels routinely removed in
radical neck dissection the it is termed as selective
neck dissection.
4) When the alteration involves the removal of additional
lymph node groups or non lymphatic structures relative
to the radical neck dissection the procedure is called
as extended radical neck dissection.

53. Classification
 1991 classification
1. Radical neck dissection
2. Modified radical neck
dissection
3. Selective neck dissection
a ) supra omohyoid
b ) lateral
c ) posterolateral
d ) anterior
4. Extended neck dissection
 2001 classification
1. Radical neck dissection
2. Modified radical neck
dissection
3. Selective neck dissection
Here each variation is
depicted by the term “ SND
“ and the use of
parentheses to denote the
levels or sublevels removed
4. Extended neck dissection

54. Medina classification (1989)
– Comprehensive neck dissection
• Radical neck dissection
• Modified radical neck dissection
– Type I (XI preserved)
– Type II (XI, IJV preserved)
– Type III (XI, IJV, and SCM preserved)
– Selective neck dissection

55. Spiro’s three- tiered classification-1994
• Radical (4 or 5 levels resected)
• Conventional radical neck dissection
• Modified radical neck dissection
• Extended radical neck dissection
• Modified and extended radical neck dissection
• Selective (3 node levels resected)
• Supra-omohyoid neck dissection
• Jugular dissection (levels 11-1V)
• Any other 3-node levels resected
• Limited (no more than 2 nodes levels resected)
• Para tracheal node dissection
• mediastinal node dissection

56. Radical neck dissection
• Indications
– Extensive cervical involvement or matted lymph
nodes with gross extracapsular spread and
invasion into the X1, IJV, or SCM
– Significant operable neck disease (N2a,2b,2c)
– Access prior to pedicled flap reconstruction
– Occult primary
– Prescence of lymphangioma, haemlymphangioma,
residual branchial cyst, fistula along with the
malignancy.

57. Contraindications
– Untreatable primary tumor
– Patients unfit for tumor surgery
– Distant metastasis
– Unresectable neck disease
– Significant bilateral neck disease

58. Extent
 Removes
 Nodal groups I-V
 SCM, IJV, XI
 Submandibular gland, tail of
parotid
 Preserves
 Posterior auricular
 Suboccipital
 Retropharyngeal
 Periparotid
 Perifacial
 Paratracheal nodes

59. Preoperative Considerations
1. - Age and Sex of the patient
2. - Consent /any allergies/ lab reports/vital signs
3. - Location of the Primary
4. - Unilateral vs. Bilateral Neck Dissection
5. - Location of Adenopathy/ Type of Neck Dissection
6. - Likelihood of Postoperative Radiation
7. - Patterns of Skin Necrosis in different Skin flap
designs
8. - Potential for Wound healing problems
9. - Need for reconstructive flaps
10.- Tracheotomy may affect blood supply of some flap
designs

60. POSITION OF THE PATIENT
1. The patient is laid supine
2. The head turned opposite
side and hyperextended,
resting on head ring
3. Upper end of the operating
table elevated approximately
30 degree.
4. Mastoid tip., Ear lobule, Body
of the mandible, midline of
the chin, supra-sternal notch,
clavicle and region of
trapizius muscle insertion
should be visible

61. General Rules
General Rule of Placing the Incisions in Lines of
Relaxed Skin Tension Lines (RSTL)
1. Horizontal Curving Incisions placed at a level in the neck depending
on the site of the tumor
2. Facial incisions for parotid tumors can be combined with various
neck incisions depending on preoperative considerations
3. High submandibular incisions should be placed at least 2cm below
body of mandible
4. General Rule of placing vertical incisions so that weakest blood
supply areas and trifurcations are away from (usually posterior to)
carotid artery and at right angles for at least 2cm then with a "lazy"
S-shape to minimize potential for scar contracture

62. • 1.Good exposure of the neck and primary disease.
• 2. Ensure viability of the skin flaps. Avoid acute angles
• 3. Protect carotid artery even in the cases of wound
infection
• 4.Considered preoperative factor—previous radio or
chemotherapy.
• 5. Facilitate reconstruction Example, if pectoral muscle
is used a lower limb should be near the clavicle to
enable flap accommodation.
• 6. It should be cosmetically acceptable

63. Incisions
Y incision Mc fee incision
63
Schobinger Incision
Modified schobinger Conley’s Double Y

64. Apron incision Half apron incision
64
H incision

65. Steps Of Radical Neck Dissection

87. Incision

88. Dissection of the posterior triangle begins at the
anterior border of trapezius

89. Dissection of the posterior triangle medially leads to
exposure of brachial plexus, phrenic nerve and cutaneous
roots of the cervical plexus

90. Specimen reflected posteriorly and anterior flap
elevated to expose the sternal head of SCMM

91. Sternocleidomastoid muscle is detached from the sternum
and clavicle and retracted cephalad to expose the carotid
sheath

92. Internal jugular vein is ligated and divided after common
carotid and vagus nerve is exposed and retracted medially

93. Dissection proceeds cephalad along the carotid sheath up
the skull base

94. The upper skin flap is now elevated preseving the
mandibular branch of the facial nerve

95. Supraclavicular dissection 95

96. Dissection of the posterior
triangle 96

97. Retraction of the posterior belly of digastric show the upper end
of the IJV in level II
97

98. Division of the veins related to
hypoglossal nerve 98

99. Levels II-V
dissection
completed by
removing the
specimen and
dissecting the IJV
from carotid artery
and vagus nerve
99

100. Surgical field following RND

101. Shoulder syndrome
“Physical changes occuring in the shoulder joint due to
denervation of trapezius leading to destabilization of
scapula,pain and weakness and deformity of shoulder
girdle,restricting the patient’s ability to abduct shoulder
not above 90 ”
-Nahum MD

102. Modified radical neck
dissection(MRND)
– Excision of same lymph
node bearing regions as
RND with preservation
of one or more non-
lymphatic structures (XI,
SCM, IJV)
– MRND is analogous to
the “functional neck
dissection” described by
Bocca
102

104. Three types (Medina 1989) .
• Type I: Preservation of SAN
• Type II: Preservation of SAN and IJV
• Type III: Preservation of SAN, IJV, and SCM (
“Functional neck dissection”)
104

105. MRND TYPE I
MRND TYPE I
MRND TYPE II

106. MRND TYPE III
Advantages :
– Reduce postsurgical
shoulder pain and
shoulder dysfunction
– Improve cosmetic
outcome
– Reduce likelihood of
bilateral IJV resection in a
pt with bilateral lymph
node metastasis.

107. Selective Neck Dissection
– Cervical lymphadenectomy with preservation of
one or more lymph node groups
– Four common subtypes:
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection
Indication: primary lesion with 20% or greater
risk of occult metastasis

108. Lymphatic
Drainage

109. SND: Supraomohyoid type
• Most commonly performed
SND
• Definition
– En bloc removal of
cervical lymph node
groups I-III
– Posterior limit is the
cervical plexus and
posterior border of the
SCM
– Inferior limit is the
omohyoid muscle
overlying the IJV

110. Surgical procedure

111. SND: Lateral Type
• Definition
– En bloc removal of the
jugular lymph nodes
including Levels II-IV
• Indications
– N0 neck in carcinomas
of the oropharynx,
hypopharynx,
supraglottis, and larynx

112. SND: Posterolateral Type
• Definition
– En bloc excision of
lymph bearing tissues
in Levels II-IV and
additional node groups
– suboccipital and
postauricular
• Indications
– Cutaneous
malignancies
• Melanoma
• Squamous cell
carcinoma
• Merkel cell
carcinoma
– Soft tissue sarcomas
of the scalp and neck

113. SND: Anterior Compartment
• Definition
– En bloc removal of
lymph structures in
Level VI
• Perithyroidal nodes
• Pretracheal nodes
• Precricoid nodes
(Delphian)
• Paratracheal nodes
along recurrent
nerves
– Limits of the dissection
are the hyoid bone,
suprasternal notch and
carotid sheaths
• Indications
– Selected cases of
thyroid carcinoma
– Parathyroid
carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma
with subglottic
extension
– CA of the cervical
esophagus

114. Types of neck dissections

115. Extended Neck Dissection
• Definition
– Any previous dissection
which includes removal of
one or more additional
lymph node groups
and/or non-lymphatic
structures.
– Usually performed with
N+ necks in MRND or
RND when metastases
invade structures usually
preserved.
• Indications
– Carotid artery invasion
– Other examples:
• Resection of the hypoglossal
nerve resection or digastric
muscle,
• dissection of mediastinal
nodes and central
compartment for subglottic
involvement, and
• removal of retropharyngeal
lymph nodes for tumors
originating in the pharyngeal
walls.

117. Complications
INTRAOPERATIVE
• Hemorrhage
• Carotid sinus reflux
• Pneumothorax
• Air embolus
• Embolism
• Nerve damage
• Chylous fistula
POST OPERATIVE
• Hematoma
• Wound infection
• Skin flap loss
• Salivary fistula
• Chylous fistula
• Blindness
• Facial edema
• Electrolyte disturbances
• Carotid artery rupture

118. ALGORITHM FOR NECK DISSECTION

119. Important facts
• High incidence of occult mets in T1 & T2 leisons
involving floor of mouth ( 21% & 62%)
• Crossing the midline increases the incidence of
contra/ bilateral nodal mets
lesion 1cm away from midline …15%
lesion within 1 cms of midline… 15-30%
lesion crossing the midline……..>30 %
20 – 30 % of the malignancies of tongue metastasize
to clinically undetectabe cervical nodes
High incidence of skip metastasis- cancer of
tongue

120. Neck Dissection for Thyroid
Malignancy
• Regional lymph node
metastasis from primary
differentiated carcinomas
of the thyroid gland occurs
in a high proportion of
patients with a papillary
carcinoma.
• First Echeleon Lymph
nodes are Level V, VI.
• Sequentially progresses to
II,III,IV.

121. Neck Dissection in Thyroid Malignancy
• Central compartment node dissection is undertaken for
dissection of regional lymph nodes for metastases from
primary differentiated carcinomas of the thyroid gland
• When the primary tumor is extensive
• With invasion of the capsule of the thyroid gland
• With extension beyond the capsule of the thyroid gland
• If the primary tumor is of significant dimensions or involves
both sides of the thyroid gland, then bilateral
tracheoesophageal groove lymph node dissection is
undertaken.
• As long as findings of the lateral part of the neck are grossly
negative, a central compartment node dissection of the
neck is considered adequate

124. References
• Mastery of Surgery – J.E. Fischer, K.I. Bland
• Textbook of Head & Neck Surgery & Oncology 4th Edition.– Jatin
P. Shah
• Stell & Marans Textbook of Head & Neck Surgery & Oncology 5th
Edition.
• Robbins KT. Classification of neck dissection: current concepts
and future considerations. Otolaryngol Clin North Am. Aug
1998;31(4):639-55
• Shah JP: Patterns of lymph node metastasis from squamous
carcinomas of the upper aerodigestive tract. Am J Surg 1990,
160:405-409.
• Medina JE, Byers RM: Supraomohyoid neck dissection:
Rationale, indication and surgical technique.Head Neck 1989,
11:111-122
• Y. Ducic , L. Young , J. Mclntyre: Neck dissection: past and present.
Minerva Chir 2010;65:45-58

125. Thank You!