Sensory changes associated with selective neck dissection

The notch of the mandible: what do different fields call it?

The bony notch on the inferior border of the mandible, anterior to the attachment of the masseter muscle, where the facial vessels commonly pass, has been called different names in the literature, e.g., premasseteric notch, antegonial notch, and notch for the facial vessels. Interestingly, various disciplines have leaned toward different names for this notch. Therefore, to aid in consistent communication among professionals, the present study aimed to analyze usage of these varied terms and make recommendations for the best terminology. Based on the adjacent anatomical structures used to name this notch, three groups were analyzed in this study, a group using masseter in the term, a group using gonion in the term, and a group using facial vessels in the term. A literature search found that the group using gonion in the term was found most in the literature. The orthodontics field used gonion in the term the most (29.0%: 31/107) followed by the oral and maxillofacial surgery field (14.0%: 15/107), the plastic surgery field (4.7%: 5/107), and the anatomy field (3.7%: 4/107). The dental field used gonion in this term the most (43.9%: 47/107) and the medical field used facial vessels in the term the most (33.3%: 6/18). Based on these results, the use of gonial terms for this notch seems to be preferred.

Complications after Functional Neck Dissection in Head and Neck Cancer Patients: An Observational, Retrospective, Single-Centre Study

INTRODUCTION

Functional neck dissection (FND) represents a surgical procedure usually associated with less morbidity.

METHODS

An observational, retrospective, analysis of patients diagnosed with any type of head and neck malignancy was designed to summarize and report the incidence of postoperative complications in patients undergoing FND including just those levels described for selective neck dissections in a tertiary university hospital between June 2016 and June 2019.

RESULTS

131 patients met the inclusion criteria. The total number of sides studied was 200. 40.5% of the patients suffer a complication in the postoperative period, being the spinal accessory nerve (SAN) injury the most common complication (10%). We did not find any statistical -correlation between the previous organ-preservation treatments and surgical complications (p = 0.207). An advanced T stage (p = 0.009) and the need of bilateral FND (p = 0.034) were significantly correlated with a higher risk of surgical complications.

CONCLUSION

FND represents a useful technique. In this study, 40.5% of the patients suffer a complication in the postoperative period, being the SAN injury the most common complication. However, these data contribute to increasing our knowledge about surgical complications related to FND.

Complaints of neuropathic pain, noxious cervical plexus neuropathy and neck tightness are reported by patients who undergo neck dissection: an institutional study and narrative review

There exists a subgroup of patients who undergo neck dissection (ND) who postoperatively complain of either neuropathic pain, dysaesthesia and/or discomfort that is located within the dermatomal distribution of the cervical plexus. The purpose of our study was to determine the prevalence, characteristic, and demographics of these symptoms in our patient cohort. We undertook a retrospective randomised observational cohort study of 105 patients who had undergone ND. The primary predictor variable was the undertaking of a ND. The secondary outcome variable was the complaint of either neuropathic pain or a noxious neuropathy, at a minimum of twelve months after surgery. A recognised symptom questionnaire and a visual analogue score was employed for the purpose of the study. A descriptive and statistical analysis was applied to the assembled data. Twenty patients (19%) complained of either spontaneous (n=9) or evoked (n=11) neuropathic pain that occurred within the surgical site. In addition, 71 patients (68%) described an altered sensation in the dermatomal distribution of the great auricular or tranverse cervical nerves while 70 patients (67%) described the feeling of 'neck tightness'. There were no characteristics of the study cohort that underpinned these results. Neuropathic pain can occur following ND. This can cause distress to a small but defined group of patients. Despite its importance, we found a paucity of studies in the literature that have investigated neuropathic pain following ND. We believe this condition requires more research attention and clinical awareness.

The effect of preservation of the supraclavicular nerve on sensation recovery in endoscopic thyroidectomy via a gasless anterior chest approach: A prospective study

BACKGROUND

Factors to sensory change on the neck and chest after endoscopic thyroidectomy were not well studied. The aim of this study was to assess whether preservation of the supraclavicular nerve (SCN) could make a difference.

METHODS

33 cases with the SCN preserved (Group A) and 32 cases with the SCN damaged (Group B) were recruited. Evaluation of tactile sensitivity and pain sensitivity as well as a questionnaire concerning subjective symptoms and quality of life was also administered preoperatively and postoperatively.

RESULTS

Sensation in the anterior chest of Group A had milder loss and reached preoperative level within the 1-year follow-up while that of Group B still showed deficit beneath the clavicle. Group A also had smaller proportion of numbness, symptomatic extension, psychological impact in early postoperative time.

CONCLUSION

Protection of the SCN can improve sensation recovery in the anterior chest and enhance the quality of life after surgery.

Sensory preservation in neck dissection: outcomes of a sub-sternocleidomastoid approach

OBJECTIVE

Cutaneous anesthesia in early postoperative period is common after neck dissection even if the cervical nerve (CN) rootlets are preserved. The aim of this study was to evaluate if the preservation of the terminal branches of CNs using sub-sternocleidomastoid (SCM) approach combined with medially placed skin incision can prevent early postoperative anesthesia.

MATERIAL AND METHODS

A retrospective chart review was performed on 129 neck dissections in 87 head and neck cancer patients.

RESULTS

The early postoperative sensory preservation rates for the ear tab, submandibular, lateral neck, and sub-clavicular areas of CN rootlet-preserved necks (n = 86) were 75.6%, 20.9%, 74.4%, and 86.0%, respectively, compared with 37.2%, 2.3%, 2.3%, and 4.7%, respectively, in CN rootlet-resected necks (n = 43). In CN rootlet-preserved necks, the sub-SCM approach (n = 54) showed 81.5%, 27.8%, 92.6%, and 94.4% preservation rates, respectively, compared with 65.6%, 9.4%, 43.8%, and 71.9%, respectively, using the conventional subplatysmal approach (n = 32). The rates were significantly better in the submandibular, lateral neck, and sub-clavicular areas after sub-SCM approach.

CONCLUSIONS

Preservation of CN rootlets is a required element for sensory preservation in neck dissection. The sub-SCM approach can effectively prevent early postoperative cutaneous anesthesia following CN-preserving neck dissection.

Neck Dissection Technique Commonality and Variance: A Survey on Neck Dissection Technique Preferences among Head and Neck Oncologic Surgeons in the American Head and Neck Society

Introduction Neck dissection (ND) technique preferences are not well reported. Objective The objective of this study is to educate practitioners and trainees about surgical technique commonality and variance used by head and neck oncologic surgeons when performing a ND. Methods Online survey of surgeon members of the American Head and Neck Society (AHNS). Survey investigated respondents' demographic information, degree of surgical experience, ND technique preferences. Results In our study, 283 out of 1,010 (28%) AHNS surgeon members with a mean age of 50.3 years (range 32-77 years) completed surveys from 41 states and 24 countries. We found that 205 (72.4%) had completed a fellowship in head and neck surgical oncology. Also, 225 (79.5%) respondents reported completing more than 25 NDs per year. ND technique commonalities (>66% respondents) included: preserving level 5 (unless with suspicious lymph nodes (LN)), only excising the portion of sternocleidomastoid muscle involved with tumor, resecting lymphatic tissue en bloc, preservation of cervical sensory rootlets, not performing submandibular gland (SMG) transfer, placing one drain for unilateral selective NDs, and performing a ND after parotidectomy and thyroidectomy and before transcervical approaches to upper aerodigestive tract primary site. Variability existed in the sequence of LN levels excised, instrument preferences, criteria for drain removal, the timing of a ND with transoral upper aerodigestive tract primary site resections, and submandibular gland preservation. Results showed that 122 (43.1%) surgeons reported that they preserve the submandibular gland during the level 1b portion of a ND. Conclusions The commonalities and variances reported for the ND technique may help put individual preferences into context.

Neck dissection for oral squamous cell carcinoma: our experience and a review of the literature

Objectives

This article describes our experience with neck dissection in 10 patients with oral squamous cell carcinoma.

Materials and Methods

Between January 2007 and October 2009, 10 patients underwent primary surgery for the treatment of squamous cell carcinoma of the oral cavity. For patients with N₀ disease on clinical exam, selective neck dissection (SND [I-III]) was performed. In patients with palpable cervical metastases (N+), modified radical neck dissections were performed, except in one patient in whom SND (I-III) was performed. The histopathologic reports were reviewed to assess the surgical margins, the presence of extra-capsular spread, perineural invasion, and lymphatic invasion.

Results

On histopathologic examination, positive soft tissue margins were found in three patients, and regional lymph node metastases were present in five of the ten patients. Perineural invasion was noted in five patients, and extra nodal spread was found in four patients. Regional recurrence was seen in two patients and loco-regional recurrence plus distant metastasis to the tibia was observed in one patient. During the study period, three patients died. Seven patients remain free of disease to date.

Conclusion

Histopathological evaluation provides important and reliable information for disease staging, treatment planning, and prognosis. The philosophy of neck dissection is evolving rapidly with regard to the selectivity with which at-risk lymph node groups are removed. The sample size in the present study is small, thus, caution should be employed when interpreting these results.

Neck dissection with cervical sensory preservation in thyroid cancer

Thyroid cancer is the most common endocrine malignancy. Recently, controversy has focused on the management of lymph node metastases, which represent approximately 90% of disease recurrences and may require considerable time, effort, and resources to diagnose and treat. Neck dissections play an essential role in the management of head and neck cancer. A modified radical neck dissection (MND) refers to resection of the lymph nodes in levels II through V and often including the central nodes in level VI. When performing modified neck dissection, we recommend to protect more reserved cervical plexus. The purpose is to better protect patient's neck skin feeling.

Surgical errors and risks - the head and neck cancer patient

Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. It can lead to functional impairment and has impact in future chances for disease related survival. There are many risks for head and neck surgeons that can cause errors and malpractice.

To avoid surgical mistakes, thorough preoperative management of patients is mandatory. As there are ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of the medical studies and data as well as qualification in modern surgical techniques and the surgeons ability for critical self assessment are basic and important prerequisites for head and neck surgeons in order to make out risks and to prevent from mistakes. Additionally it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and to be able to deal with complications, when they occur.

Despite all precaution and surgical care, errors and mistakes cannot always be avoided. For that it is important to be able to deal with mistakes and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery.

Anatomical variations of the spinal accessory nerve and its relevance to level IIb lymph nodes

Objective: This study was conducted to identify anatomical variations of the spinal accessory nerve (SAN) in the upper neck, the landmark of the anterior and inferior border of level IIb, and to evaluate the nerve's effect on the border and the number of lymph nodes (LNs) in level IIb.

Study Design and Setting: Case series with planned data collection.

Subjects and Methods: A total of 181 neck dissections (NDs) were prospectively enrolled in this study. The relation between the SAN and adjacent structures (internal jugular vein [IJV], sternocleidomastoid muscle [SCM], cervical plexus) and the number of LNs in level IIb was investigated.

Results: The SAN crossed the IJV ventrally in 72 cases (39.8%) and dorsally in 104 cases (57.4%), and passed through the IJV in five cases (2.8%). The SAN ran along the inner surface of the SCM and sent branches to the SCM without penetration of the muscle in 83 cases (45.9%), whereas in 98 cases (54.1%) the nerve sent branches to the SCM by penetration. Cervical plexus contribution to the SAN was seen from C2 in 96 cases (53.1%), C2 and C3 in 69 cases (38.1%), and C3 in 16 cases (8.8%). The mean number of LNs of level IIa and level IIb was 6.5 and 8.2 in cases in which the SAN crossed the IJV ventrally, and 6.8 and 5.4 in dorsally crossing cases. LNs included in the neck level IIb in ventrally crossing SAN cases were significantly larger than the dorsally crossing cases ( P < 0.05).

Conclusions: Our results may help to minimize the incidence of injuring the SAN in the upper neck during ND. Neck level IIb would contain more LNs if the course of the nerve leans toward the ventral side.

The relationship between shoulder pain and damage to the cervical plexus following neck dissection

The aim of our study was to evaluate the relationship between shoulder pain and damage to the cervical plexus after neck dissection. The study was performed prospectively on 34 neck sides of 17 patients with laryngeal cancer who underwent laryngectomy plus bilateral selective neck dissection (II, III, IV, +/- VI) at the Department of Otorhinolaryngology of Uludag University between December 2003 and October 2004. The cervical plexus was protected on one side of the neck and sacrificed on the other, while the accessory nerve was spared on both sides. The degree of sensorial innervation of the cervical plexus and shoulder pain were evaluated in the preoperative period and postoperatively at 2 weeks, 1 month, 3 months, and 6 months. Data obtained from both sides of the neck were compared. Sensory reception scores were statistically higher in the neck sides in which the cervical plexus was spared than in those where the plexus was sacrificed (P < 0.05). However, the degree of shoulder pain was similar on both sides of the neck (P > 0.05). Damage to the cervical plexus during neck dissection causes loss of sensorial innervation of the neck, but sacrificing the cervical plexus during selective neck dissection has no negative effect on shoulder pain.

Cervical sensory preservation during neck dissection

Although the practice of neck dissection has greatly advanced from radical to function-preserving surgery, the impact of the sensory nerve-preserving neck surgery on the pain and quality of life (QOL) of patients has received little study. We evaluated neck morbidity and its impact on QOL associated with selective or modified radical neck dissection with or without preservation of cervical root branches. We conducted a retrospective cohort study comparing 24 patients who had their cervical root branches preserved to 29 patients whose root branches were removed during neck dissection. The spinal accessory nerve was preserved and sex, age, pathologic status, side and extent of neck dissection, and radiotherapy were comparable between groups. The groups were compared based on sensory and motor functions of the neck and shoulder and questionnaires on depression and QOL at follow-up of mean 18.7 (range 12-34) months after surgery. The nerve-preserved patients showed a low incidence and severity of neck and shoulder pain compared to the nerve-removed subjects (p<.05). Loss of sensation was more frequently experienced in the nerve-removed group on the earlobe and the lateral neck of the operated side (p<.05). Depression and QOL scores were higher in the nerve-removed group and significantly correlated with pain intensity. Preservation of the cervical root branches reduces postoperative pain as well as permanent anesthetic areas of the neck. This may also improve the mental state and QOL of patients undergoing neck dissection.

Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer

There is a high prevalence of depression after cancer treatment. In the literature, several authors have raised questions about assessing somatic symptoms to explore depression after cancer treatment. These somatic sequelae are a consequence of cancer treatment and should cause higher depression rates in cancer patients. In this study, the Somatic domain on a depression questionnaire, the Center for Epidemiologic Studies-Depression scale (CES-D) was analyzed in different cancer patients after treatment, as compared with a control group. Data from 566 cancer patients (oral/oropharyngeal, gynecological, colorectal, and breast cancer) and 255 randomly chosen comparison patients were analyzed. The total score on the CES-D domain of Somatic Retarded Activity significantly differed between the cancer and comparison groups; but the cancer groups showed both less somatic morbidity (colorectal cancer) and more somatic morbidity (oral/oropharyngeal, breast) than the comparison group. In the analyses of the CES-D with and without the Somatic domain, the prevalence of depression symptoms with the Somatic domain is lower for the cancer groups. Authors conclude that cancer patients are not a homogenous group as regards somatic sequelae. Evidence for removing Somatic items from the CES-D for patients after cancer treatment was not confirmed.

Shoulder and neck morbidity in quality of life after surgery for head and neck cancer

BACKGROUND

Quality of life has become a major issue in determining the outcome of treatment in head and neck surgery with curative intent. The aim of our study was to determine which factors in the postoperative care, especially shoulder and neck morbidity, are related to quality of life and how these outcomes compared between patients who had undergone surgery and a control group.

METHODS

We analyzed physical symptoms, psychological symptoms, and social and functional well-being at least 1 year after surgery and evaluated the differences in quality of life between patients who had undergone head and neck surgery and a control group.

RESULTS

Depression scores contributed significantly to all domains of quality of life. Reduced shoulder abduction, shoulder pain, and neck pain are related to several domains of quality of life. The patient group scored significantly worse for social functioning and limitations from physical problems but scored significantly better for bodily pain and health changes.

CONCLUSION

Depression and shoulder and neck morbidity are important factors in quality of life for patients who have undergone surgery for head and neck cancer.

[Sentinel node in tumours of the lip and the oral cavity]

OBJECTIVES

This study shows the results obtained by the application of the sentinel node (SN) in oral and lip cancer and performs a lymphatic map of these tumours.

PATIENTS AND METHOD

We prospectively studied 14 patients with lip and oral tumours, all of them N0. We injected colloidal particles of serum albumin labeled with Tc-99 peritumoraly and we located the SN intraoperatively. The SN was then sent for anatomopathological study.

RESULTS

Sentinel node was identified in all of the patients. In 11 of them the sentinel node was negative for metastases and correctly predicted the status of the neck. In 3 patients the sentinel node was the only node that contained metastases. There were no false negatives. The sensibility of the technique was 100%.

CONCLUSIONS

The results showed that this technique is a feasible method for tumours in these locations and can avoid neck dissections in N0 patients.

Improved Staging of Cervical Metastases in Clinically Node-Negative Patients With Head and Neck Squamous Cell Carcinoma

BACKGROUND

The management of the N0 neck in oral and oropharyngeal cancer is often determined by the risk of metastases related to features of the primary tumor. Where the risk of metastases is >20%, elective neck dissection (END) has been advocated. This study reviewed clinical staging, surgical staging, pathologic staging, and histopathologic parameters to determine the prediction of nodal metastases and micrometastases in patients with head and neck squamous cell carcinoma.

METHODS

A prospective series of 61 clinically neck node-negative patients undergoing surgical resection of a T1/2 intraoral or oropharyngeal invasive squamous cell carcinoma and surgical staging of the neck, with sentinel node biopsy (SNB) alone or SNB-assisted END, between June 1998 and March 2002 were included in this study.

RESULTS

Pathologic upstaging of the clinically N0 neck occurred in 27 (44%) of 61 patients. Routine pathology with hematoxylin and eosin upstaged disease in 22 of 27 patients (sensitivity of 81%). Five patients with micrometastasis were staged pN1mi after stepped serial sectioning and immunohistochemistry. Tumor thickness, a noncohesive invasive front, and perineural and bone invasion were all histological predictors for cervical metastases. Five patients with micrometastases were staged pN1mi.

CONCLUSIONS

Both clinical staging and routine pathologic staging underestimate the presence of nodal metastases. Staging with either SNB alone or SNB-assisted END shows promise in the management of the N0 neck by identifying patients with micrometastases (pN1mi).

Vaciamientos selectivos en pacientes con metástasis ganglionares clínicas

OBJECTIVE

To evaluate the results obtained with selective neck dissection in patients with clinically positive neck nodes at diagnosis (N+).

PATIENTS AND METHODS

Retrospective study of N+ patients treated with a lateral or supromohyoid selective neck dissection with prophylactic purpose (sides of the neck N0) or therapeutic purpose (sides of the neck N+).

RESULTS

Forty nine selective neck dissections were carried out in 42 N+ patients. In 18 cases the neck dissection had a prophylactic purpose (sides of the neck N0), and in 31 of them a therapeutic purpose (sides of the neck N+). In 39 patients summary was followed by postoperative radiotherapy. There was no regional relapse in either side of the neck treated with a selective neck dissection.

CONCLUSIONS

Selective neck dissections in selected N+ patients are an adequate surgical technique. The main advantages of selective neck dissections are to shorten the surgical time, and to avoid the morbility associated with the dissection of the neck zones not included.

Morbidity of the neck after head and neck cancer therapy

BACKGROUND

Studies on morbidity of the neck after head and neck cancer therapy are scarcely described.

METHODS

Patients who underwent surgery, including neck dissection, with and without radiation therapy at least 1 year before the study were asked to participate. We assessed neck pain, loss of sensation, range of motion of the cervical spine, and shoulder pain.

RESULTS

Of the 220 patients who were invited, 153 (70%) participated in the study. Neck pain was present in 33% of the patients (n = 51), and shoulder pain was present in 37% of the patients (n = 57). Neuropathic pain of the neck was present in 32% (n = 49); myofascial pain, in 46% (n = 70); and joint pain, in 24% (n = 37). Loss of sensation of the neck was present in 65% (n = 99) and was related to type of neck dissection and radiation therapy. Range of motion of the neck was significantly decreased because of the neck dissection and/or radiation therapy in lateral flexion away from the operated side.

CONCLUSIONS

The occurrences of morbidity of the neck after cancer therapy were considerable and consisted of neck pain, loss of sensation, and decreased range of motion.

Selective dissection of levels II-III with intraoperative control of the upper and middle jugular nodes: A therapeutic option for the no neck

BACKGROUND

Selective neck dissections are accepted elective treatment in N0 patients. We present the results of a dissection of levels II to III and intraoperative pathologic control of a sample of subdigastric and supraomohyoid nodes in a group of patients with laryngeal carcinoma. When intraoperative analysis was positive, dissection of levels IV and V was completed.

METHODS

Between 1991 and 1997, 145 neck dissections with intraoperative control were carried out in 79 patients with laryngeal carcinomas. Postoperative radiotherapy was used in 49 patients.

RESULTS

There were occult metastases in 29 neck dissections (20%). In 22 cases (15%), tumor was found in the nodes sent to intraoperative pathologic study, and dissection of levels IV and V was completed. In 7 additional cases tumor was found in the postoperative study. The sensitivity of the use of frozen sections in the detection of occult metastases was 76%. In no case were positive nodes found at level V. There was no regional relapse in any of the 145 selective neck dissections.

CONCLUSIONS

The lateral selective neck dissection is an effective method in the elective treatment of the neck of N0 laryngeal carcinoma patients. Dissection of level IV can be spared when intraoperative biopsy specimens of a sample of the subdigastric and supraomohyoid nodes are negative. According to our results, at present we do not consider it necessary to dissect level V in selective neck dissections in patients with laryngeal carcinoma.