Radical neck dissection

Definition

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

  Types of neck dissection

Radical neck dissection

Refers to the removal of all lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly, from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle medially, to the anterior border of the trapezius muscle laterally. Included are all lymph nodes from levels I-V with sacrifice of internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve.

Extended Radical Neck Dissection

Refers to the removal of one or more additional lymph node groups or non-lymphatic structures or both, not encompassed by the radical neck dissection.

Modified radical neck dissection

Refers to the removal of all lymph nodes by radical neck dissection with preservation of one or more of the non-lymphatic structures: i.e., the spinal accessory nerve, internal jugular vein and the sternocleidomastoid muscle.

 

Purpose

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

 

Demographics

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

 

Description

Cancers of the head and neck (sometimes inaccurately called throat cancer) often spread to nearby tissues and into the lymph nodes. Removing these structures is one way of controlling the cancer.
Of the 600 lymph nodes in the body, approximately 200 are in the neck. Only a small number of these are removed during a neck dissection. In addition, other structures such as muscles, veins, and nerves may be removed during a radical neck dissection. These include the sternocleidomastoid muscle (one of the muscles that functions to flex the head), internal jugular (neck) vein, submandibular gland (one of the salivary glands), and the spinal accessory nerve (a nerve that helps control speech, swallowing, and certain movements of the head and neck). The goal is always to remove all the cancer, but to save as many components surrounding the nodes as possible.
An incision is made in the neck, and the skin is pulled back (retracted) to reveal the muscles and lymph nodes. The surgeon is guided in what to remove by tests performed prior to surgery and by examination of the size and texture of the lymph nodes.

 

Diagnosis/Preparation

This operation should not be performed if cancer has metastasized (spread) beyond the head and neck, or if the cancer has invaded the bones of the cervical vertebrae (the first seven bones of the spinal column) or the skull. In these cases, the surgery will not effectively contain the cancer.
Radical neck dissection is a major operation. Extensive tests are performed before the operation to try to determine where and how far the cancer has spread. These may include lymph node biopsies, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and barium swallows. In addition, standard preoperative blood and liver function tests are performed, and the candidate will meet with an anesthesiologist before the operation. The candidate should tell the anesthesiologist about all drug allergies and all medication (prescription, nonprescription, or herbal) that are presently being taken.

 

Aftercare

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

 

Risks

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

 

Normal results

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

 

Morbidity and mortality rates

The mortality rate for radical neck dissection can be as high as 14%.
Morbidity rates are somewhat higher and are due to bleeding, post-surgery infection, and medicine errors.
 
Procedure
This operation involves the removal of a tumor, surrounding structures, and lymph nodes en mass, through a Y-shaped or trifurcate incision in the affected side of the neck. It is done to remove the tumor and metastatic cervical nodes present in malignant lesions and all nonvital structures of the neck. Metastasis occurs through the lymphatic channels via the bloodstream. Disease of the oral cavity, lips,


and thyroid gland may spread slowly to the neck. Radical neck surgery is done in the presence of cervical node metastasis from a cancer of the head and neck, which has a reasonable chance of being controlled. It may also be done in a slightly less radical form when there is cancer of the tongue and no firm evidence of metastasis.
 
Preparation of the Patient.
(1) The patient is placed on the table in a dorsal recumbent position, with the head in moderate extension and the entire affected side of the face and neck facing uppermost. During surgery, the face of the patient is turned away from the surgeon.
(2) The preoperative skin preparation is extensive. The patient is draped with sterile towels and sheets, leaving a wide operative field. Endotracheal anesthesia is used. The anesthetic is administered before the patient is positioned for surgery. During the operation, the anesthesiologist works behind the sterile barrier, away from the surgical team.

NURSING PRIORITIES 1. Maintain patent airway, adequate ventilation.
2. Assist patient in developing alternative communication methods.
3. Restore/maintain skin integrity.
4. Reestablish/maintain adequate nutrition.
5. Provide emotional support for acceptance of altered body image.
6. Provide information about disease process/prognosis and treatment.

DISCHARGE GOALS 1. Ventilation/oxygenation adequate for individual needs.
2. Communicating effectively.
3. Complications prevented/minimized.
4. Beginning to cope with change in body image.
5. Disease process/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

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