Neck Dissection

A Comprehensive Overview of Surgical Technique, Indications, and Outcomes

Introduction

Neck dissection is a critical surgical procedure performed primarily for the management of metastatic lymph nodes in patients with head and neck cancer. Over the decades, the technique has evolved considerably, balancing efficacy with the preservation of function and quality of life. While it is most frequently employed in the context of squamous cell carcinomas, neck dissection also finds application in other malignancies, including thyroid, salivary gland, and skin cancers.

Historical Perspective

The evolution of neck dissection reflects advances in surgical science and oncology. The classical radical neck dissection, first described by George Crile in 1906, involved the removal of all lymphatic tissue from one side of the neck, along with the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. Over time, this approach was refined to minimize morbidity. Modified and selective neck dissections, which preserve one or more of these structures, were introduced as evidence emerged regarding patterns of lymphatic spread and the importance of functional preservation.

Anatomical Considerations

The neck comprises a complex web of lymphatic channels and nodal groups. For surgical purposes, the neck is divided into levels (I-VI), each containing specific nodal stations:

• Level I: Submental and submandibular nodes
• Level II: Upper jugular nodes
• Level III: Middle jugular nodes
• Level IV: Lower jugular nodes
• Level V: Posterior triangle nodes
• Level VI: Anterior compartment nodes (central compartment, often relevant for thyroid cancer)

Understanding these levels is vital for planning the extent of dissection and for prognostic assessment. Important neurovascular structures—such as the carotid artery, vagus nerve, hypoglossal nerve, and the previously mentioned spinal accessory nerve—are encountered during surgery and require meticulous handling.

Indications for Neck Dissection

Neck dissection is indicated primarily for the management of regional lymphatic metastases in head and neck cancers. The specific indications include:

• Clinically positive lymph nodes (N+ disease): Palpable or radiologically confirmed metastatic lymphadenopathy
• Elective neck dissection: In cases of high-risk primary tumors with no clinically evident nodal disease (N0), but a significant risk of occult metastases
• Staging: For accurate pathologic staging, which guides postoperative therapy
• Recurrent or persistent disease: Salvage neck dissection may be indicated after failed chemoradiotherapy

Types of Neck Dissection

Neck dissections are classified according to the structures removed and the nodal levels addressed.

Radical Neck Dissection

This original technique involves the removal of all ipsilateral cervical lymphatic tissue from levels I-V, along with the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. Though effective, it is associated with significant morbidity, including shoulder dysfunction and cosmetic deformity.

Modified Radical Neck Dissection

Here, all lymphatic tissue is removed as in the radical procedure, but one or more non-lymphatic structures (usually the spinal accessory nerve, sternocleidomastoid muscle, or internal jugular vein) are preserved. This approach maintains oncologic efficacy while reducing morbidity.

Selective Neck Dissection

Selective neck dissection removes only the lymph node groups most likely to harbor metastases based on the primary tumor’s location and biology. For example, in oral cavity cancer, levels I-III might be dissected, preserving levels IV and V. The spinal accessory nerve, sternocleidomastoid, and internal jugular vein are generally preserved unless directly involved by disease.

Extended Neck Dissection

This procedure goes beyond the boundaries of radical neck dissection to remove additional lymphatic or non-lymphatic structures when there is proven direct tumor involvement.

Preoperative Assessment

Thorough clinical and radiological evaluation is essential before neck dissection. Assessment includes:

• Detailed head and neck examination
• Palpation for lymphadenopathy
• Imaging studies (CT, MRI, PET-CT, or ultrasound) to define the extent of nodal disease
• Fine needle aspiration (FNA) or core biopsy of suspicious nodes
• Assessment of primary tumor site and its potential patterns of spread
• Evaluation of the patient’s comorbidities and functional status

Informed consent is crucial, with discussion of potential risks, benefits, alternatives, and postoperative expectations.

Surgical Technique

Neck dissection is performed under general anesthesia. Patient positioning, incision planning, and careful dissection are key to minimizing complications and maximizing oncologic yield.

• The standard incision is typically a transverse cervical incision, sometimes extended for better exposure.
• The platysma muscle is divided, and subplatysmal flaps are raised to expose the underlying structures.
• Identification and preservation of critical nerves, vessels, and muscles are prioritized unless directly involved by tumor.
• Lymphatic tissue is removed en bloc according to the planned levels and type of dissection.
• Hemostasis is secured, and the wound is closed with or without drainage, depending on intraoperative findings.

Meticulous technique is essential to avoid injury to the carotid artery, cranial nerves (especially the spinal accessory, hypoglossal, and vagus), and major veins.

Complications and Risks

Neck dissection carries inherent risks. Common complications include:

• Shoulder dysfunction: Due to injury or sacrifice of the spinal accessory nerve
• Hematoma or seroma: Accumulation of blood or serous fluid
• Wound infection: As with any surgical procedure
• Nerve injuries: Involving the marginal mandibular, hypoglossal, or vagus nerves, causing deficits in facial movement, speech, or swallowing
• Chyle leak: Especially in cases involving the lower neck (thoracic duct injury)
• Cosmetic deformity: Due to muscle and soft tissue removal
• Blood loss: Occasionally requiring transfusion

Prompt recognition and management of complications are essential to prevent long-term morbidity.

Postoperative Care and Rehabilitation

Recovery following neck dissection involves multidisciplinary input, including surgical, nursing, physiotherapy, and sometimes speech therapy. Key aspects include:

• Monitoring for bleeding, infection, and airway compromise
• Pain control and wound care
• Early mobilization to prevent shoulder stiffness and promote functional recovery
• Physical therapy focusing on shoulder and neck movements, especially if the spinal accessory nerve was sacrificed or manipulated
• Speech and swallowing therapy, especially in cases with cranial nerve deficits
• Psychological support to address body image issues and emotional adjustment

Discharge planning considers the patient’s ability to care for themselves, their support system, and arrangements for outpatient follow-up.

Outcomes and Prognosis

Neck dissection remains a cornerstone of regional disease control in head and neck cancers. When appropriately performed, it offers:

• Excellent regional control rates, particularly in N+ disease
• Improved staging accuracy, guiding adjuvant therapy
• Potential for long-term cure in combination with surgery and/or radiotherapy for the primary tumor

Functional outcomes are optimized with selective and modified techniques, reducing unnecessary morbidity. Quality of life is further enhanced by advances in reconstructive surgery and rehabilitation.

Nursing Care of Patients Undergoing Neck Dissection

Effective nursing care is integral in promoting optimal recovery, preventing complications, and supporting the patient through the physical and emotional challenges associated with the procedure.

Preoperative Nursing Care

• Education and Psychological Support: Patients and families require education regarding the procedure, anticipated outcomes, possible complications, and postoperative expectations. Addressing fears and anxieties is crucial.
• Assessment: Baseline assessment of vital signs, airway, swallowing function, and skin integrity should be documented. Evaluate nutritional status and pre-existing comorbidities.
• Preparation: Skin preparation, ensuring fasting as per surgical protocol, and administration of preoperative medications as ordered.
• Consent: Verify informed consent and ensure all preoperative investigations are complete.

Immediate Postoperative Care

• Airway Management: Airway patency is the foremost priority due to possible edema, bleeding, or nerve injury. Monitor for stridor, dyspnea, or altered breath sounds. Be prepared for emergency airway interventions if necessary.
• Pain Management: Administer analgesics as prescribed, assess pain regularly using appropriate scales, and employ non-pharmacological comfort measures.
• Vital Signs Monitoring: Closely monitor pulse, blood pressure, respiratory rate, and oxygen saturation. Observe for signs of hypovolemia, hemorrhage, or shock.
• Drain and Wound Care: Neck dissection often involves placement of surgical drains. Ensure patency and measure output regularly. Maintain a sterile dressing, and observe for excessive bleeding, hematoma, or infection.
• Neurological Assessment: Evaluate for nerve injuries—especially the spinal accessory, hypoglossal, and facial nerves—which may result in shoulder dysfunction, tongue deviation, or facial asymmetry.

Ongoing Nursing Responsibilities

Airway and Breathing

• Positioning: Maintain the patient in semi-Fowler’s position (head elevated 30-45 degrees) to reduce edema and facilitate breathing.
• Humidification: Use humidified oxygen if prescribed to prevent drying of mucous membranes.
• Chest Physiotherapy: Encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia, provided the surgical area is stable.

Pain and Comfort

• Pain Assessment: Frequently evaluate pain and adjust interventions as needed.
• Non-Pharmacological Methods: Use cold compresses, distraction techniques, and relaxation exercises.

Wound and Drain Management

• Drain Care: Monitor and record drain output. Notify surgeon if there is sudden increase or decrease in output or signs of blockage.
• Dressing Changes: Change dressings under aseptic technique as per protocol. Assess wound for redness, swelling, discharge, or signs of infection.
• Hematoma Prevention: Monitor for swelling and firmness under the skin, which may indicate hematoma formation. Early detection is vital to prevent airway compromise.

Nutrition and Hydration

• Oral Intake: Assess swallowing function before resuming oral intake. In cases of dysphagia, refer to speech and swallowing therapists.
• Enteral Feeding: If oral intake is compromised, initiate tube feeding as prescribed. Monitor for tube placement and tolerance.
• Hydration: Encourage adequate fluid intake and monitor electrolyte balance.

Mobility and Physical Rehabilitation

• Early Mobilization: Encourage movement as appropriate to prevent deep vein thrombosis and promote circulation.
• Physiotherapy: Refer to physiotherapist for shoulder exercises if the spinal accessory nerve is affected, to prevent stiffness and maintain mobility.

Psychosocial Support

• Body Image and Self-Esteem: Address concerns regarding scarring, altered appearance, and functional changes. Offer counseling services and support groups.
• Anxiety and Depression: Screen for emotional distress and provide appropriate referrals.

Complications and Prevention

• Hemorrhage: Immediate recognition and intervention is essential. Monitor for excessive bleeding at the site or drain.
• Infection: Maintain strict aseptic technique, monitor for fever, redness, or purulent discharge.
• Seroma and Hematoma Formation: Regularly assess neck contour and drain outputs.
• Nerve Injury: Assess for changes in mobility, sensation, and function in the neck, shoulder, and face.
• Chyle Leak: Monitor for milky drainage, especially in left-sided neck dissections. Report suspected chyle leak to the surgical team.

Patient and Family Education

• Wound Care: Teach proper care of surgical site and drain at home.
• Signs of Complication: Advise on symptoms requiring immediate medical attention, such as difficulty breathing, swelling, fever, or excessive drainage.
• Diet and Nutrition: Instruct on suitable foods and supplements to aid healing, and provide guidance on swallowing exercises if needed.
• Follow-Up Care: Schedule regular outpatient visits for wound assessment, suture removal, and ongoing rehabilitation.

Discharge Planning

• Home Care Instructions: Provide written and verbal instructions covering medication management, wound care, and physical exercises.
• Support Services: Refer to community resources, such as home nursing, physical and occupational therapy, and counseling as required.
• Activity Restrictions: Clarify limitations on strenuous activity, driving, and lifting, as appropriate for recovery stage.

Special Considerations

• Speech and Swallowing: Involve speech pathologists early if there are deficits in speech or swallowing.
• Tracheostomy Care: If performed, provide education and support for tracheostomy management.
• Long-Term Surveillance: Monitor for recurrence of disease, especially in patients with malignancy. Facilitate regular oncologic follow-up.

REFERENCE

1. Cracchiolo JR, Wong RJ. Neck Neoplasms and Neck Dissection. In: Lalwani AK, eds. Current Diagnosis & Treatment Otolaryngology–Head and Neck Surgery. 4th ed. New York: McGraw-Hill Education; 2020.
2. Wistermayer P, Anderson KG. Radical Neck Dissection. [Updated 2023 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563186/
3. Mechera R, Maréchal-Ross I, Sidhu SB, Campbell P, Sywak MS. A Nod to the Nodes: An Overview of the Role of Central Neck Dissection in the Management of Papillary Thyroid Carcinoma. https://pubmed.ncbi.nlm.nih.gov/36925192/. Surg Oncol Clin N Am. 2023 Apr;32(2):383-398.
4. Agrawal SM, Anehosur V. Incidence and Clinical Analysis of Complications of Neck Dissection. Indian J Otolaryngol Head Neck Surg. 2022 Dec;74(Suppl 3):5875-5880. doi: 10.1007/s12070-021-02489-w. Epub 2021 Mar 8. PMID: 36742775; PMCID: PMC9895549.
5. Ohad R, Samant S and Robbins KT. Neck Dissection. In: Flint PW, Francis HW, Haughey BH, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Philadelphia: Elsevier; 2021. 1806-1830. 
6. Gogna S, Kashyap S, Gupta N. Neck Cancer Resection and Dissection. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK536998/

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