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– MRND Type I:
1. Clinically obvious neck lymph nodes
metastasis and SAN not involved by
tumor
2. Intraoperative decision just like
preservation of the facial nerve in
parotid surgery
Indications
• MRND Type II:
1. Rarely planned
2. Intra-operative decision for tumor found
adherent to SCM but away from SAN &
IJV
• MRND Type III:
– Depend on the autopsy reports
1. Lymph nodes were in the fibrofatty and do not
share the same adventitia with blood vessels
2. They are not found within the aponeurosis or
glandular capsule of the submandibular
“Functional neck dissection”
Indications
• MRND Type III:
– For treatment of N0 neck nodes
– Indicated for N1 mobile nodes and not
greater than 2.5 – 3.0 cm
• Contra-indicated in the presence of node
fixation
• Result is difficult to interpret because of
the use of radiation therapy
Indications
• Selective/elective neck dissection:
– For treatment of N0 neck nodes
– For N+ nodes when combined with
radiotherapy
• Adjuvant radiotherapy for patient with 2 – 4 positive
nodes or extra-capsular spread
– Supraomohyoid is indicated for SCC of oral
cavity with N0 and N1 with palpable mobile
nodes less than 3 cm and located in level I and
II
– Upgrade intra-operatively following positive
frozen section
Treatment option for N0 nodes
• Observe
• Radiation therapy
• Elective neck dissection
– Low morbidity
– Staging neck for possible extended
surgery
– Need for post-operative radiotherapy
Rationale for S/END
• Rate of occult metastasis in clinically
negative nodes is 20 – 30% using
clinical and radiographic findings
– Ct scan combined with physical exam
decreased the rate of occult metastasis to
12%
– This suggested lowering of the criteria
for elective neck dissection
Friedman et al Laryngoscope 100; 54 – 59: 1990
Rationale for S/END
• Anatomic studies showed that
lymphatic drainage from the
mucosal surfaces follow a constant
and predictable route
• Lymph flow from SA chain to the
jugular chain is unilateral
Shah. Ann Surg Oncol 1(6); 521-532: 1994
Rationale for S/END
• Shah, in his study produced a compelling
evidence of predictable nodal metastasis
from SCC from upper aerodigastive tract
– He found a specific pattern for nodal spread
by location of primary
• NO in patients with oral cavity SCC:
– 7/1119 (3.5%) had nodal involvement outside
supraomohyoid dissection
– 3 (1.5%) had isolated involvement outside
level I - III
Friedman Laryngoscope 100; 54-59: 1990
Rationale for S/END
– N+ nodes in patients with oral SCC:
• 50/246 had nodal metastasis outside level IV
• 10/246 had metastasis in level V
– He examined nodal involvement in patients
with nasopharynx and other upper parts of the
aerodigastive tract
• Conclusion:
– SCC of the oral cavity:
• Level I, II and III are at risk
– SCC nasopharynx and larynx
• Level II, III and IV are at risk
Shah Amer J Surg 160; 405-409: 1990
Shah Cancer July 1 ; 109-113: 1990
Rationale for S/END
• Byers stated that SND combined with
postoperative radiotherapy in selected
patients with oral cavity SCC was adequate
treatment with similar recurrence rate as
those treated with MRND III
• Spiro reported 12% with supraomohyoid
dissection in N1 nodes but not all of them
received radiotherapy
Byers Head Neck Surg; Jan-Feb; 160-167: 1988
Selective/Elective Neck
Dissection
• A good option for N0 neck
• Not a suitable option for N+ neck
• Is used N+ neck when combined
with radiotherapy
• Intra-operative frozen section
evaluation is needed to confirm in
cases of intraoperative palpable
nodes
The anatomy
• Skin:
– Blood supply:
• Descending branches:
– The facial
– The submental
– Occipital
• Ascending branches
– Transverse cervical
– Suprascapular
– The branches perforate the platysma muscle, anastomose
to form superficial vertically-directed network of vessels