Operative Technique for Lateral Neck Dissection
The operative technique for lateral neck dissection should be tailored to the nodal stage: perform selective neck dissection (levels II-IV, with level VI when appropriate) for N0 disease, selective or comprehensive dissection for N1-N2 disease, and comprehensive neck dissection for N3 disease. 1
Classification and Nomenclature
Modern neck dissections are classified as either comprehensive or selective rather than the historical radical/modified radical terminology 1:
- Comprehensive neck dissection removes all lymph node groups included in a classic radical neck dissection, regardless of whether the sternocleidomastoid muscle, jugular vein, or spinal accessory nerve is preserved 1
- Selective neck dissection targets specific nodal levels based on common pathways of metastatic spread 1
Technical Approach Based on Nodal Stage
N0 Disease (Clinically Negative Neck)
Perform selective neck dissection including levels II-IV, with level VI added for infraglottic laryngeal and hypopharyngeal cancers 1:
- For laryngeal primary tumors: dissect at least levels II-IV 1
- For hypopharyngeal primary tumors: dissect at least levels II-IV and level VI when appropriate 1
- Elective level VI dissections are particularly appropriate for infraglottic laryngeal cancers 1
- H&N squamous cell cancer with N0 disease rarely presents with nodal metastasis beyond selective neck dissection bounds (<10% of cases) 1
N1-N2 Disease
Either selective or comprehensive neck dissection may be performed, though comprehensive dissection is generally preferred for therapeutic intent 1:
- Selective neck dissection may prevent morbidity and is appropriate in certain N1-N2 patients with low tumor burden 1
- Patients with cervical node metastases undergoing therapeutic operations generally receive comprehensive neck dissections, as disease often extends beyond selective dissection bounds 1
N3 Disease
Perform comprehensive neck dissection 1
Laterality Considerations
Determine ipsilateral versus bilateral dissection based on tumor location, thickness, and extent 1:
- Bilateral neck dissection is indicated for tumors at or near the midline and/or tumor sites with bilateral drainage (e.g., base of tongue, palate, supraglottic larynx, deep space pre-epiglottic involvement) 1
- For advanced anterior tongue or floor of mouth lesions approximating or crossing midline, perform contralateral submandibular dissection as necessary for adequate tumor resection 1
Site-Specific Modifications for Salivary Gland Malignancies
For parotid malignancies requiring elective neck treatment, perform ipsilateral selective neck dissection of levels II-IV 1:
- Elective neck treatment should be offered over observation for T3-T4 tumors and high-grade malignancies 1
- For cN1 neck, perform ipsilateral neck dissection of involved and at-risk levels, potentially extending to adjacent levels up to levels I-V 1
Specimen Orientation and Pathologic Assessment
The neck dissection specimen should be oriented or sectioned to identify lymph node levels encompassed in the dissection 1:
- This allows accurate pathologic staging and determination of need for adjuvant therapy 1
- The chief role of selective neck dissections is determining candidacy for adjuvant chemotherapy/RT or RT 1
Critical Pitfalls to Avoid
- Do not perform selective neck dissection in patients with clinically evident nodal disease beyond N1-N2a - these patients require comprehensive dissection 1
- Do not omit level VI dissection for infraglottic laryngeal cancers - this level is frequently involved 1
- Do not perform unilateral dissection for midline tumors - bilateral drainage mandates bilateral treatment 1