Lateral neck dissections include radical, modified radical, and selective neck dissections. Indications for a radical neck dissection have largely been replaced by a modified radical or selective neck dissection. Modified radical and selective neck dissections are distinguished from a radical neck dissection by preservation of one or more nonlymphatic structures (spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle), thereby sparing associated morbidity.
There are two major indications for a lateral neck dissection for a variety of malignancies, including head and neck squamous cell, thyroid, and melanoma. The first is for removal of palpable or radiographically detected metastatic cervical lymph nodes, and the second is for 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 because it is not intended to prevent metastasis but to remove occult metastatic lymph nodes. The indications for a lateral neck dissection for head and neck squamous cell carcinoma are evolving because some of these primary tumors and associated lymph nodes are being treated with definitive radiation plus chemotherapy, thus avoiding surgery. In certain circumstances, salvage neck dissection is performed after chemoradiation. All these patients, including those with melanoma and thyroid cancer, generally benefit from a multidiscipline approach incorporating surgeons, medical oncologists, radiation oncologists, and endocrinologists for thyroid cancer.
The typical 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 occasionally 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, usually can be corrected by infiltrating the carotid sinus with a local anesthetic agent. Intravenous atropine sulfate usually will control the syndrome if the local anesthetic fails. Pneumothorax may result from injury of the apical pleura. ...