There are two major indications for radical neck dissection. The first is for the removal of palpable metastatic cervical lymph nodes, and the second is for the removal of presumed occult metastatic disease in the neck. The latter indication has been termed “prophylactic neck dissection.” “Elective neck dissection” better describes this operation, since it is not intended to prevent metastasis but to remove occult metastatic lymph nodes.
Before radical neck dissection is performed, the surgeon must have assurance that the primary lesion can be controlled either by simultaneous en bloc removal with the radical neck dissection or by radiation therapy. However, curative radiation for cervical metastases must be confined to a single node or small group of nodes, because patients cannot tolerate radical surgery plus radiation therapy to the entire neck. Node fixation, invasion of adjacent tissues, bilateral or contralateral, and distant metastases are relative contraindications to this procedure. In general, radical dissection of the cervical lymph nodes in a patient who is a reasonable surgical risk remains the preferred treatment for metastatic disease of the neck.
The usual patient with metastatic cancer in the neck from an unknown primary source should be treated as if the primary tumor were controlled. If surgical treatment of the cervical metastasis is deferred until the primary neoplasm becomes obvious, the opportunity to control the neck disease is sometimes lost.
The patient’s general medical status should be assessed and corrective measures instituted for any treatable abnormalities. Intraoral ulcerations represent a potential source of pathogenic material. The liberal preoperative use of nonirritating solutions (e.g., diluted hydrogen peroxide) can significantly reduce the danger of postoperative infection.
Only rarely will primary cancers of the hypopharynx, cervical esophagus, larynx, and so forth produce respiratory obstruction or interference with alimentation significantly enough to require preoperative tracheostomy or insertion of a feeding tube.
The major consideration is a free airway. The equipment should allow free movement of the head and easy access to the endotracheal tube.
The choice of anesthetic agents varies. Consideration must be given to the individual needs of the patient and to the need for cautery. General endotracheal anesthesia is preferred.
Complications at surgery are the carotid sinus syndrome, pneumothorax, and air embolus. The carotid sinus syndrome, consisting of hypotension, bradycardia, and cardiac irregularity, can usually be corrected by infiltrating the carotid sinus with a local anesthetic agent. Intravenous atropine sulfate will usually control the syndrome if the local anesthetic fails. Pneumothorax may result from injury of the apical pleura. It is treated with a closed-tube thoracostomy through the second intercostal space anteriorly.
The patient is placed in a dorsal recumbent position. The head of the table is somewhat elevated to lessen the blood pressure, particularly the venous pressure, ...