Radical Neck Dissection Overview

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Questions and Answers

What is the primary concern regarding the potential complications of a radical neck dissection?

Damage to nerves, muscles, and veins (correct)

Late recurrence of cancer in the neck

Difficulty in visualization during surgery

Infection in the surgical site

How does lymph node metastasis affect the survival rate of patients with squamous cell carcinoma?

It has no effect on survival rates

It reduces survival rate by half (correct)

It improves survival rates due to early detection

It doubles the survival rates with treatment

What measures can be taken to ensure adequate analgesia during a radical neck dissection?

Minimize the use of anesthesia

Use medications that blunt the physiological reaction to the ETT (correct)

Limit patient monitoring to basics

Avoid medication to heighten reflex responses

What does the outcome of neck dissection primarily depend on?

The stage of cancer, type of metastasis, and quality of the surgery Signup and view all the answers

Why is a meticulous airway examination critical before performing radical neck dissection?

To assess risk for difficult ventilation and intubation Signup and view all the answers

Which factor is the strongest predictor of overall prognosis in head and neck squamous cell carcinoma?

Extent of cervical lymphadenopathy Signup and view all the answers

What is the significance of deep cervical lymph nodes in squamous cell carcinoma?

They drain important areas that are high risk for oncologic spread. Signup and view all the answers

How does poorly differentiated tumors affect neck metastasis?

They are linked to a higher risk of neck involvement by metastasis. Signup and view all the answers

What impact does the involvement of multiple levels of neck lymph nodes have on prognosis?

Indicates a poor prognosis. Signup and view all the answers

Which of the following is NOT a factor affecting the risk of lymph node involvement in metastasis?

Degree of local inflammation around the tumor Signup and view all the answers

What structures are commonly resected during a radical neck dissection?

Sternocleidomastoid muscle, internal jugular vein Signup and view all the answers

Which of the following modifications may be made to the classic neck dissection technique?

Preservation of non-lymphatic structures Signup and view all the answers

What is the average surgical time for reconstruction following a radical neck dissection?

3 to 6 hours Signup and view all the answers

Which of the following complications is associated with simultaneous bilateral neck dissections?

Increased facial swelling Signup and view all the answers

What closure methods may be utilized following a radical neck dissection?

Split-thickness skin graft or chest flap Signup and view all the answers

What common comorbidities may present in elderly patients undergoing a radical neck dissection?

Coronary artery disease and chronic obstructive pulmonary disease Signup and view all the answers

Which laboratory test is essential for patients with a history of bleeding disorders prior to radical neck dissection?

Prothrombin time Signup and view all the answers

What is a significant consequence of tumor interference with eating in patients undergoing radical neck dissection?

Malnutrition and electrolyte imbalance Signup and view all the answers

In patients with squamous cell carcinoma, which paraneoplastic syndrome is most commonly observed?

Syndrome of inappropriate secretions of antidiuretic hormone (SIADH) Signup and view all the answers

Which preoperative evaluation is vital for optimizing functional status in patients presenting for radical neck dissection?

Comprehensive medical history assessment Signup and view all the answers

What is the primary purpose of utilizing a nerve integrity monitor during a radical neck dissection?

To help identify and preserve specific nerves Signup and view all the answers

What is the rationale for placing the patient's head in a 30-degree elevated position during the intraoperative period of a radical neck dissection?

To enhance venous return and decrease blood loss Signup and view all the answers

What are potential consequences of inadequate patient positioning during a radical neck dissection?

Postoperative neck discomfort and nerve damage Signup and view all the answers

Which of the following is NOT a standard monitor required during a radical neck dissection?

Electroencephalogram (EEG) monitoring Signup and view all the answers

What structures are most at risk of damage during a radical neck dissection due to the nature of the surgery?

Vasculature, nerves, and muscles in the neck Signup and view all the answers

What is the most critical factor the anesthetist must ensure before extubation after a radical neck dissection?

The patient has an intact airway and adequate respiratory function Signup and view all the answers

What is the recommended practice concerning airway reflexes during the extubation process post-RND?

They must be recovered to ensure safe, effective airway control Signup and view all the answers

What factors must be evaluated regarding the patient before tracheal extubation after a radical neck dissection?

Patient's preoperative physiologic status and existing comorbidities Signup and view all the answers

Which of the following is NOT a requirement for a safe extubation after a radical neck dissection?

Ability to identify the surgical procedure performed Signup and view all the answers

What is the primary reason for ensuring a patient is awake and able to follow commands before extubation?

To confirm recovery of spontaneous ventilation and airway reflexes Signup and view all the answers

What should be inspected before administering anesthesia in patients undergoing radical neck dissection?

The patient's vocal cords Signup and view all the answers

What complication risk must be monitored for postoperatively after a radical neck dissection?

Hematoma formation and cerebral ischemia Signup and view all the answers

Which of the following factors significantly increases the likelihood of postoperative complications after a radical neck dissection?

Chronic malnutrition and systemic illness Signup and view all the answers

What is the first indication of hematoma formation following a radical neck dissection?

Rapid accumulation of blood under the flap Signup and view all the answers

Which intervention can help prevent hematoma formation during a radical neck dissection procedure?

Employing meticulous hemostasis during surgery Signup and view all the answers

What is a potential serious consequence if a hematoma is not addressed promptly after surgery?

Airway compromise or flap necrosis Signup and view all the answers

Which postoperative complication might be influenced by factors such as diabetes mellitus and advanced age?

Wound infection and flap necrosis Signup and view all the answers

What complication results from simultaneous bilateral radical neck dissections with ligation or resection of both IJ veins?

Facial edema Signup and view all the answers

Which electrolyte disturbance is most commonly observed in patients undergoing radical neck dissection?

Hyponatremia Signup and view all the answers

What is a notable sign that may precede carotid artery rupture in patients who have undergone radical neck dissection?

Sentinel bleed Signup and view all the answers

Which intervention is critical to prevent complications related to facial edema post-radical neck dissection?

Maintaining head elevation Signup and view all the answers

What is the recommended initial treatment when a carotid artery rupture occurs post-radical neck dissection?

Direct pressure on the site Signup and view all the answers

Study Notes

Radical Neck Dissection Key Points

Lymph node metastasis significantly reduces survival rates for squamous cell carcinoma patients, halving the survival rate. Survival is under 5% for recurrent neck metastasis after prior surgery.
Radical neck dissection (RND) risks nerve, muscle, and vein damage. RND involves removal of the sternocleidomastoid muscle, internal jugular vein, spinal accessory nerve and submandibular gland. Additional structures like many local lymph nodes, some muscles, arteries, veins, and glands are resected to remove as much cancerous tissue as possible.
RND outcome depends on cancer stage, metastasis type, and surgical quality. Surgical time averages 1.5 to 3 hours for primary resection and 3 to 6 hours for reconstruction. Procedure duration can exceed 6-8 hours in some cases.
Patients may have difficult airway management issues. Preoperative airway exams are crucial, even with seemingly minor issues.
Adequate analgesia is vital due to the reflexogenic nature of the RND area. Opioid techniques may be favorable to maintain hemodynamic stability.
Stable intraoperative hemodynamics and minimizing ETT reaction are important. Maintaining relative hypotension (systolic blood pressure 80-100 mm Hg, mean arterial pressure ≥60 mm Hg) is a common technique to reduce blood loss.
Smooth, timely anesthetic emergence with hemodynamic stability ensures neurologic deficit assessment.
Antihypertensive medications might be used to prevent postoperative hemorrhage and manage hemodynamic variability.
Squamous cell carcinoma can invade the upper aerodigestive tract due to cellular proliferation and differentiation dysfunction. Most common primary sites are laryngeal, oropharyngeal, hypopharyngeal, and oral mucosal areas. Metastasis to regional lymph nodes, vascular channels, and other parenchymal sites (lungs, liver, bone, brain, and adjacent/other sites) can occur if lymphatic level invasion is not controlled.
The extent of cervical lymphadenopathy is the strongest predictor for overall prognosis, recurrence rate, and potential for metastasis in head and neck squamous cell carcinoma.
Risk of lymph node involvement depends on primary tumor site, size, histologic grade, perineural/perivascular invasion, and extracapsular spread. Poorly differentiated primary tumors are more aggressive and increase neck metastasis risk.
Multiple levels of neck lymph node involvement indicates poor prognosis. Superficial lymph nodes are involved late and have less oncologic importance. Deep cervical nodes are crucial, feeding from oral cavity, pharynx, larynx, salivary glands, thyroid, and head/neck skin; they accompany the internal jugular vein.
More than four involved lymph nodes correlate with a reduced survival rate. Posterior triangle involvement, contralateral spread, and node fixation to the carotid artery or a muscle indicate poor prognosis.
The degree and invasiveness of the disease require surgeon collaboration, as type, size, location, and impingement on structures influence anesthetic management.
Advances in surgical techniques, radiation therapy, and chemotherapy offer aggressive treatment for advanced head and neck cancers, aiming to preserve organ function using primary radiotherapy or concurrent chemo/radiotherapy. Surgery is often reserved for oncologic salvage.
Advanced deeply attached neck metastasis, recurrence after radiation or chemoradiation, and metastatic neck abscesses present significant challenges for head and neck surgeons during salvage operations.
No single standardized treatment for cervical metastasis exists; management varies significantly between physicians, institutions, and geographic regions, often without clear evidence of better outcomes.
RND is performed for surgical control of metastatic neck disease in patients with squamous cell carcinomas, salivary gland tumors, and skin cancer of the head and neck.
Surgical time averages 1.5 to 3 hours for primary resection and 3 to 6 hours for reconstruction.
Resection includes complete cervical lymphadenectomy and resection of the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve. Many local lymph nodes and some muscles, arteries, veins, and glands are resected to remove as much cancerous tissue as possible.
Neck dissections are often combined with resection of the primary lesion (tongue, pharynx, larynx).
Apron incision made along sternocleidomastoid, curving to the opposite side.
Sternocleidomastoid muscle, internal jugular vein are transected and tied.
Carotid arteries, vagus nerve, hypoglossal nerve, brachial plexus, and phrenic nerve are identified and preserved in the inferior portion of the dissection.
Cervical sensory branches are divided as the dissection specimen is swept superiorly.
Modifications to maintain non-lymphatic structures (spinal accessory nerve, internal jugular vein, sternocleidomastoid muscle, spinal accessory nerve, hypoglossal nerve, and lingual nerve) are done to maximize oncologic efficacy & minimize morbidity.
Defect closed with primary closure, split-thickness skin graft or chest flap (pectoralis major or deltopectoral). Free flaps (facial artery or superior thyroid artery) may be created for closure and revascularization.
Simultaneous bilateral neck dissections are rare due to complications (facial edema, laryngeal edema, blindness, cerebral edema).
Surgery should not be performed if cancer has spread beyond the head and neck, surgery won't control the primary tumor, or cancer has invaded cervical vertebrae or skull (especially invasive cancers like squamous cell carcinoma).

Preoperative Considerations

Patient Population: Elderly patients are common, often with tobacco/alcohol history, and may have pulmonary, hepatic, cardiac (coronary artery disease, hypertension), respiratory (bronchitis, pulmonary emphysema, COPD), and renal (chronic renal insufficiency) issues. Weight loss, malnutrition, anemia, dehydration, and electrolyte imbalances are possible due to difficulty eating. A careful history & physical is vital to ensure no preoperative exacerbations exist and patient functional status is optimized.
Laboratory Studies: Complete blood count with differential and coagulation studies (PT, PTT, INR) are critical, especially in patients with pre-existing anemia, bleeding disorders, hepatitis, or anticoagulant use. Electrolyte panels, liver function tests (LFTs), glucose tests, BUN, creatinine, blood type & screen (typing & cross-match for 2 units pRBCs if significant blood loss expected) are important. SIADH may occur in squamous cell carcinoma patients.
Imaging Techniques: CT, MRI, lymph node biopsies, barium swallows are crucial for staging. CT/MRI diagnose lymph node abnormalities, tumor necrosis, and extracapsular spread. MRI is better for non-metastatic enlarged nodes. Ultrasound and ultrasound-guided aspiration cytology are used; PET scanning is used as an adjunct to differentiate active tumors from fibrosis, and diagnose recurrent cancer/post-chemo/radiation status.
Histologic Examination: Histologic examination of all neck nodes is standard. Biopsies determine primary tumor type (e.g., squamous cell carcinoma, nasopharyngeal carcinoma, thyroid carcinomas, skin cancer) and characteristics. Fine needle aspiration cytology confirms primary tumor findings. Accurate staging is essential for prognosis and treatment.
Balloon Occlusion Test: Preoperative assessment of carotid vessel management may include a balloon occlusion test and four-vessel cerebral angiography to evaluate contralateral carotid, intracerebral circulation, and carotid back pressure. Carotid resection may be an option if tolerance of ipsilateral carotid occlusion is demonstrated without neurologic issues. If possible carotid involvement is suspected, complete preoperative evaluation of carotid patency is necessary.
Miscellaneous Tests: Chest radiograph rules out metastatic disease. A thorough physical exam (neurologic, cardiovascular, respiratory) is mandatory, along with an airway assessment, dentition evaluation, and ECG. Preoperative arterial blood gas analysis may be indicated in patients with advanced COPD, and pulmonary flow-volume loops may help patients with obstructive lung disease.
Physical Examination: Head and neck exam, detailed medical history, cardiac risk factors and functional status assessment, and neurovascular integrity check are critical. Carotid bruits and stenosis are assessed.

Airway Examination and Management

Patients undergoing RND frequently have difficult airways. A significant neck mass or tracheal abnormality is possible. Anesthetist must focus on evaluating the patient's ability to open their mouth for intubation. Airway edema or breathing difficulty, tracheal deviation, voice quality, history of hoarseness/stridor, signs of narrowing (especially post-surgery/radiation) are critical factors to examine. Radiation/surgery damages tissue flexibility, decreased tissue compliance, cervical spine range of motion limitation, and fibrosis are possible complications leading to difficult intubation/tracheal intubation.
Tumor location, size, and potential for bleeding, previous radiation or chemo effects on airway tissues, and careful surgeon collaboration to understand tumor characteristics, location, bleeding risk, and prior treatment are key factors.
Strategies to decrease airway complications such as orotracheal intubation (optimized head positioning, intubation aids, varied sized ETTs), fiber-optic intubation/tracheostomy under local anesthetic (difficult intubation is foreseen), and video laryngoscopy (better visualization) should be considered.
Laryngeal mask airway and other devices are important in difficult airway cases.
Cricothyrotomy and tracheostomy are part of the contingency plans.
Maintaining proper ETT position (avoiding supraglottic/endobronchial migration), especially during surgical procedures and securing the ETT and positioning are essential during surgery. Nasal intubation, if the patient's condition allows, may enhance surgical access. Good communication between the surgeon and anesthetist is crucial.

Previous RND Considerations

Potential for increased airway obstruction (immediate/during procedure) and significant postoperative laryngeal edema, neuronal imbalance, and possible tracheostomy needs in patients with previous bilateral RND procedures.
Altered lymphatic drainage patterns from previous dissections can potentiate postoperative edema in the larynx/neck, increasing the risk of airway complications.
Cephalic venous obstruction from significant facial edema/cyanosis, despite normal pulse oximetry, may be an issue. Cerebral venous congestion with central apnea and elevated intracranial pressure (ICP) may follow, necessitating ICP reduction measures and cerebral blood flow protection.

Additional Considerations (From the Second Text):

Intraoperative Monitoring: Standard monitors (ECG, pulse oximetry, end-tidal CO2, body temperature) should be used. An arterial line may be needed in specific high-risk patients (severe cardiopulmonary disease, chronic renal insufficiency, carotid proximity tumors, prolonged procedures) to provide more precise haemodynamic monitoring. A surgical nerve integrity monitor can help preserve specific nerves.
Patient Positioning: Patients are placed supine with the upper body elevated 30 degrees; head turned to the opposite side; a shoulder roll supports the neck to optimize the surgical field and improve venous return, decreasing blood loss and discomfort. Head elevation should continue postoperatively.
Non-lymphatic Structures: Surgeons and anesthetists must be aware of and protect various non-lymphatic structures (nerves, veins, arteries) during the procedure (vagus, facial, spinal accessory, hypoglossal nerves; carotid, jugular veins, superior/inferior thyroid arteries). Preserve all non-lymphatic structures as much as possible.
Intraoperative Nerve/Vascular Damage: RND carries nerve and vascular risks (facial, phrenic, vagus nerves, including spinal accessory and hypoglossal). Sacrificing or injuring any nerve (e.g., facial nerves, branches), may result in numbness, sensory loss, and impaired function (stooped shoulders). Severe nerve injury may cause chronic pain (neuroma formation) and specific syndromes (Horner).
Carotid Artery: Careful dissection around the carotid arteries to minimize plaque dislodgement and stroke risk is crucial.
Jugular Vein: The presence of tumor compression can alter venous flow; ligation or transfixation ligation is acceptable if alternative drainage routes are assured. The IJV's upper or lower ends may cause postoperative bleeding requiring surgical reintervention.
Venous Air Embolism: It's possible during large vein openings. Immediate surgeon action (compress open neck veins, irrigate with saline, pack/clamp) and anesthetist response (100% oxygen, left lateral decubitus position, circulatory support) are needed if suspected. Peripheral pulse loss may suggest cardiac arrest requiring aspiration via a central catheter, cardiac massage, and resuscitation.
Blood Loss: Estimated blood loss (EBL) is typically 150-200 mL; however, it's highly variable depending on factors like radiation therapy, primary tumor resection, or uncontrolled IJ vein bleeds which require digital control by the surgeon until the anaesthetist stabilizes the patient.
Anesthetic Technique: Individualized balanced techniques (inhaled and IV agents). Humidified inspired gases are essential. Opioid-based techniques (fentanyl or sufentanil) with continuous infusions may reduce total dose, enhance hemodynamic stability, and hasten recovery. Hypotensive anesthesia (80-100 mmHg systolic, MAP ≥60 mmHg) may decrease blood loss. Local anesthetic infiltration can reduce reflexogenic responses.
Smooth Emergence: Avoid or minimize patient reaction to ETT. Straining, bucking, coughing, or gagging during emergence increases venous pressure, potentially causing postoperative bleeding or suture line disruption. Prompt emergence and hemodynamic stability are imperative.
Hematoma Formation: Postoperative hematoma is possible, presenting in the first few hours. Inspect the area. Early management is crucial. Late recognition may lead to airway compromise, infection, or flap necrosis. Meticulous hemostasis and suction drains are vital for prevention. Prompt re-exploration, hemostasis, and evacuation are required for treatment. Postoperative drains are utilized to manage the situation.
Airway Edema: Fiber-optic examination can assess edema/tracheomalacia. Deflating ETT cuff to check for leaks during ventilation and using temporary pediatric ETT exchange device can help avoid post-extubation respiratory issues. Elective tracheostomy can be done before surgery.
Post-Op Ventilation: Postoperative sedation & prolonged mechanical ventilation are only warranted for physiologic/pathologic problems before recovery, contingent on surgery invasiveness, patient pre-op status, concurrent respiratory issues, & intraop edema degree.
Extubation Criteria: Preoperative physiologic state/airway assessment + comorbidities + prompt emergence + immediate neurologic exam for hematomas/cerebral ischemia/nerve injuries + verbal commands/neurologic function assessment + spontaneous respirations + normal ABG values are key. Residual anesthesia can mask neurologic deficits.
Post-op Nausea & Vomiting: 5-HT3 blocker and dexamethasone are routine.
Vocal Cord Inspection: Before anesthesia.
Delayed anesthetic recovery: considered to limit airway risks from awakening.
Elective postoperative ventilation: indicated for neurologic deficits, complications, respiratory/hemodynamic alterations, or swelling. Criteria for early extubation are needed.
Other Potential Complications: Wound infection, fistula, flap necrosis, osteoradionecrosis, and carotid artery rupture are increased by poor health, chronic malnutrition, alcoholism, diabetes mellitus, advanced age, systemic illness, and radiation therapy.

Postoperative Complications

Facial Edema: Unilateral RND: ipsilateral lower face/neck swelling. Bilateral simultaneous RND: facial/cerebral edema/both. This is likely due to lymph stasis as much as IJ vein removal. Mechanical obstruction and increased intracranial pressure can cause neurologic deficits and coma. Edema is more common in irradiated patients and can lead to chemosis and lid edema sufficient to prevent eye opening. Tracheostomy and head elevation prevention are needed.
Electrolyte Disturbances: Patients are hypovolemic with imbalances. Most common: dilutional hyponatremia; sometimes related to ADH secretion. Hypernatremia, hypokalemia, hypercalcemia, hypophosphatemia are also seen. Serum electrolyte values should be monitored and corrected.
Carotid Artery Rupture: Incidence 3-7%. Precipitation: radiation, infection, salivary fistula, suction catheters (erosion), suture line dehiscence. Most patients have initial bleeds within 48 hours post-op. Treatment includes direct pressure, 2 large-bore IVs for crystalloid, blood pressure/volume control pre-ligation, airway management, type & crossmatch for 4-6 units. Emergent clamping if bleeding continues. Definitive treatment is carotid artery ligation with reinforced sutures.

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Explore the critical aspects of radical neck dissection (RND) including its impact on survival rates for squamous cell carcinoma, potential complications, and the importance of airway management. This quiz covers essential considerations for preoperative assessments, analgesia, and anesthetic management during surgery. Gain insights into the factors affecting surgical outcomes and postoperative care.