Evaluation of Four Incisions Used For Radical Neck Dissection- A Comparative Study

Objective: To evaluate the four commonly used incisions for Radical Neck Dissection on the basis of certain defined parameters. Patients and Methods: The investigators designed and implemented a prospective comparative study composed of patients with oral squamous cell carcinoma. The predictor variable was time taken to raise and close the flaps, accessibility to the neck lymph nodes, injury to vital structures and scar cosmesis followed up to a period of three months. Descriptive statistics were computed. Results: The sample was composed of 40 patients grouped as follows: Macfee Incision (=10 patients), Modified Macfee Incision (=10 patients), Modified Schobinger Incision (=10 patients) and Reverse Hockey Stick Incision (=10 patients). Group A, consisiting of the patients with Macfee Incision, took the least time to close among all the groups ( Mean= 32.60 minutes) while Group C (patients with Modified Schobinger Incision) required the most time for closure ( Mean= 51.90 minutes). The Modified Schobinger Incision provided best exposure to neck node levels. The Macfee Incision was found to have the best scar cosmesis among the four incisions. Conclusion: The results of this study suggest that Modified Schobinger Incision is the preferred incision for adequate access to neck lymphatics while Macfee Incision was found to provide the best scar cosmesis.

Classification of parotidectomy: a proposed modification to the European Salivary Gland Society classification system.

Parotidectomy remains the mainstay of treatment for both benign and malignant lesions of the parotid gland. There exists a wide range of possible surgical options in parotidectomy in terms of extent of parotid tissue removed. There is increasing need for uniformity of terminology resulting from growing interest in modifications of the conventional parotidectomy. It is, therefore, of paramount importance for a standardized classification system in describing extent of parotidectomy. Recently, the European Salivary Gland Society (ESGS) proposed a novel classification system for parotidectomy. The aim of this study is to evaluate this system. A classification system proposed by the ESGS was critically re-evaluated and modified to increase its accuracy and its acceptability. Modifications mainly focused on subdividing Levels I and II into IA, IB, IIA, and IIB. From June 2006 to June 2016, 126 patients underwent 130 parotidectomies at our hospital. The classification system was tested in that cohort of patient. While the ESGS classification system is comprehensive, it does not cover all possibilities. The addition of Sublevels IA, IB, IIA, and IIB may help to address some of the clinical situations seen and is clinically relevant. We aim to test the modified classification system for partial parotidectomy to address some of the challenges mentioned.

Do we need a new classification of parotid gland surgery?

BACKGROUND: In February 2016 the European Salivary Gland Society (ESGS) presented and recommended classification of parotidectomies based on the anatomical I-V level division of parotid gland. The main goal of this paper is to present the new classification, and to answer the question if it is more precise compared to classic one. MATERIAL AND METHOD: 607 patients (315 man, 292 women) operated on for parotid tumours in a tertiary referral centre, Department of Otolaryngology, Head and Neck Surgery, Medical University of Poznan (502 benign and 105 malignant tumours). Parotid surgery descriptions provided by retrospective analysis of all operating protocols covering the years 2006-2015 were "translated" into the new classification proposed by the ESGS. RESULTS: Analysis of operating protocols and fitting them into the new classification proposed by the ESGS show some discrepancies, in both benign and malignant tumours. Based on the re-evaluation of 607 cases, in 94 procedures for benign tumors the only information available was that "surgery was performed within the superficial lobe". Thus, the new classification forces the surgeon to be much more precise than previously. In 3 cases the whole superficial lobe was removed, together with the upper part of the deep lobe. Because the classification lacked parotidectomy I-II-IV, it indicated that the new classification was insufficient in the aforementioned three cases. In 6 cases of ECD more than one parotid gland tumour was removed. Among malignant tumours, total parotidectomy was the predominant procedure. In 3/13 cases of expanded parotidectomy the temporomandibular joint (TMJ) was additionally removed and it seems that the acronym TMJ should be included among the additional resected structures. It is also necessary to supplement the description of the treatment with casuistically resected anatomical structures for oncological purposes (RT planning) and follow-up imaging. Currently, since 2015 in Poland there has been the National Cancer Registry of benign salivary gland tumours (https://guzyslinianek.pcss.pl). New surgical anatomy and classification based on it will be very helpful in unequivocal, albeit brief and not laborious, reporting of procedures. To summarize, the classification is: easy to use, precise, and forced the surgeon to make a detailed description saving time at the same time. Although it is broad and accurate, it did not cover all clinically rare cases, multiple foci and it does not contain key information about the rupture of the tumour's capsule, so it is necessary to complement the type of surgery by this annotations. The simple, clear and comprehensive classification is especially valuable for centres that lead registration. Thus, we are personally grateful for this new classification, which facilitates multicentre communication.

Classification of parotidectomies: a proposal of the European Salivary Gland Society.

The objective of this study is to provide a comprehensive classification system for parotidectomy operations. Data sources include Medline publications, author's experience, and consensus round table at the Third European Salivary Gland Society (ESGS) Meeting. The Medline database was searched with the term "parotidectomy" and "definition". The various definitions of parotidectomy procedures and parotid gland subdivisions extracted. Previous classification systems re-examined and a new classification proposed by a consensus. The ESGS proposes to subdivide the parotid parenchyma in five levels: I (lateral superior), II (lateral inferior), III (deep inferior), IV (deep superior), V (accessory). A new classification is proposed where the type of resection is divided into formal parotidectomy with facial nerve dissection and extracapsular dissection. Parotidectomies are further classified according to the levels removed, as well as the extra-parotid structures ablated. A new classification of parotidectomy procedures is proposed.

Redefining classification of central neck dissection in differentiated thyroid cancer.

Therapeutic central neck dissection for differentiated thyroid cancer is recommended in the setting of clinically positive disease. The role of lymphadenectomy in patients with clinically negative disease is a matter of controversy and therefore extent of surgery varies. The boundaries of the central neck are variably described, as are the components of a central neck dissection. Patients with aggressive disease are managed with a comprehensive dissection, yet there is no classification system to distinguish this from a less rigorous operation. Therefore, there is variability in reporting and difficulty in the interpretation of results in the published literature. Here we propose a novel classification system for central neck dissection in thyroid cancer that allows accurate reporting of extent of surgery. The objectives are to reduce ambivalence and allow documentation of extent of lymphadenectomy, such that comparisons can be made between the varied strategies in the management of the central compartment.

Neck dissection with the harmonic scalpel in patients with squamous cell carcinoma of the oral cavity.

UNLABELLED: Our purpose was to evaluate the use of the Harmonic scalpel in neck dissections. MATERIAL AND METHODS: We conducted a randomized prospective intervention study to compare the Harmonic scalpel (32 patients) with the conventional technique (31 patients). RESULTS: Operative time was lowered by 64 min (p < 0.001) and 7.5 min (p = 0.367); blood lost during surgery was lowered by 80.5 ml (p < 0.001) and 76.6 ml (p < 0.001); the length of time the drains were kept in place was lowered by 1.3 days (p < 0.001) and 1.5 days (p < 0.01); and the volume of drainage was lower by 228.7 ml (p < 0.001) and 187.6 ml (p < 0.01) in selective and comprehensive neck dissections respectively in patients treated with the Harmonic scalpel. CONCLUSIONS: The Harmonic scalpel shortens operative time in selective dissections. It reduces blood loss during surgery; time drains are kept in place and the amount of drainage in comprehensive and selective neck dissections.

Early oral intake after reconstruction with a free flap for cancer of the oral cavity.

To allow healing of the surgical wound patients are traditionally given nothing by mouth for 6-12 days after resection and reconstruction of a cancer of the oral cavity. Our aim was to assess the impact of introducing oral intake within 6 days postoperatively. Consecutive patients who had resection and reconstruction of a cancer of the oral cavity with a free flap within an 8-year period were selected from the head and neck database. Personal and social data; type, stage, and site of the tumour; type of resection and free flap; postoperative complications; and duration of hospital stay were recorded, supplemented by review of casenotes for the time that oral intake was started, duration of nasogastric and tracheostomy intubation, and changes in body weight. Patients in the early oral intake group started oral intake within 5 days postoperatively, and those in the late group began feeding from postoperative day 6. The duration of hospital stay in the early group was significantly shorter than that in the late group. There was, however, no difference in the morbidity, including orocutaneous fistula, between the two groups. The duration of nasogastric and tracheostomy intubation was shorter, and weight loss was less, in the early group than in the late group, but not significantly so. Early oral feeding does not increase the morbidity for patients having resection and reconstruction with free flaps for cancers of the oral cavity. Early oral intake is associated with a shorter hospital stay, and this may have implications for improved postoperative outcome.

[Current advances in diagnosis and surgical treatment of lymph node metastasis in head and neck cancer]. / Aktuelle Fortschritte in der Diagnostik und chirurgischen Therapie der Halslymphknotenmetastasen bei Kopf-Hals-Karzinomen.

Still today, the status of the cervical lymph nodes is the most important prognostic factor for head and neck cancer. So the individual treatment concept of the lymphatic drainage depends on the treatment of the primary tumor as well as on the presence or absence of suspect lymph nodes in the imaging diagnosis. Neck dissection may have either a therapeutic objective or a diagnostic one. The selective neck dissection is currently the method of choice for the treatment of patients with advanced head and neck cancers and clinical N0 neck. For oncologic reasons, this procedure is generally recommended with acceptable functional and aesthetic results, especially under the aspect of the mentioned staging procedure. In this review article, current aspects on pre- and posttherapeutic staging of the cervical lymph nodes are described and the indication and the necessary extent of neck dissection for head and neck cancer is discussed. Additionally the critical question is discussed if the lymph node metastasis bears an intrinsic risk of metastatic development and thus its removal in a most possible early stage plays an important role.

[Neck dissection for Head and Neck cancers: state of the art and classification]. / Dissezioni linfonodali del collo per tumori del distretto cervico-facciale: note introduttive e classificazione.

The purposes of this article are to review the history and evolution of neck dissections, including an update on node levels and their anatomical landmark. A number of classification systems were proposed and subsequently established for neck dissection procedures. The system most often employed was published in 1991 by the American Head and Neck Society and American Academy of Otolaryngology- Head and Neck Surgery and revised in 2002 and 2008. According to this classification, neck dissections are grouped into four broad categories: radical neck dissection (RND), modified radical neck dissection (MRND), selective neck dissection (SND) and extended neck dissection (ERND). The choice between different surgeries depends on type and site of head and neck tumor as well nodal involvement.

Update on the classification and nomenclature system for neck dissection: revisions proposed by the Japan Neck Dissection Study Group.

BACKGROUND: Terminology for neck dissection is quite complicated because a large number of nonradical neck dissections were created by different surgeons, each of whom named their operational method in their own words in an attempt to preserve functions that were usually lost by radical neck dissection. This complication is still causing serious confusion among head and neck surgeons throughout the world, although there have been many proposals for standardization. METHODS: Japan Neck Dissection Study Group created in 2005 and updated in 2009 a new classification and nomenclature system that is easy to understand, compatible with Japanese classifications of other carcinomas, and easily interchangeable with other neck dissection terminology proposals. RESULTS: Based on the Classification of Regional Lymph Nodes in Japan, published by the Japan Society of Clinical Oncology, our new system divides cervical lymph nodes into four basic regions and other regions. Each of the four basic regions is further divided into several subregions. Each region, subregion, or principal nonlymphatic structure has its own symbol consisting of one alphabetical letter, two alphabetical letters, or one alphabetical letter plus one numeral. Each neck dissection operation is designated by a combination of these symbols. Neck dissections are classified into two groups, total neck dissection and selective neck dissection, according to the extent of resection of the cervical lymph nodes. CONCLUSION: We simply hope that this new system will contribute to resolving the confusion over the terminology used for neck dissection, not only in Japan but throughout the world.

Lymphadenectomy for melanoma in the clinically N1 neck: radical, modified radical, or selective?

The purpose of a neck dissection is to control the disease in the neck and has little influence on long-term survival. Radical neck dissection leads to significant morbidity; this morbidity is decreased in modified radical neck dissections and reduced even further in selective dissections. An analysis was made of 37 consecutive patients with melanoma for an 8-year period presenting with a clinically N1 neck (a single involved node based on clinical examination and radiologic investigation). Six patients underwent radical, 24 modified radical, and 7 selective neck dissections. There was a mean follow-up of 3 years 10 months after primary diagnosis. Minimum follow-up after lymphadenectomy was 18 months, and at this point, there were no cases of local recurrence (neck failure) in any of the survivors in the 3 groups. In our series, there was no difference in locoregional control for the 3 groups. We would recommend a modified radical neck dissection for the N1 neck in melanoma with an intraoperative decision being made on which structures to preserve based on position of involved lymph node and adjacent structures, particularly in younger patients. A selective neck dissection should be considered in those patients with significant comorbidity, distant metastatic disease, or primary sites on the back or posterior scalp.

Classification of neck dissections: an evolving system.

The authors review the evolving development of various types of neck dissections, and the resultant classification systems. The standard radical neck dissection, introduced at the turn of the 20th century, became the uniformly accepted treatment of cervical metastatic disease through the 1960s. The functional or modified radical neck dissection was developed in the 1950s and 1960s. This procedure became accepted treatment for suitable tumors by the 1970s. The concept of selective neck dissection, removal of only the node levels likely to be involved with tumor, gained acceptance by the late 1980s as definitive elective, and eventually, therapeutic neck dissection for suitable cases. In response to the increasing variations of neck dissection procedures, a number of classification systems were proposed and subsequently established. The system most often employed was published in 1991 by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. The system was revised in 2002 and 2008. These systems employ the American Joint Committee on Cancer staging system and traditionally established node levels. The neck dissections are grouped into four broad categories of radical neck dissection, modified radical neck dissection, selective neck dissection (this group is subclassified according to which node levels are removed) and extended neck dissection. Recently, the Japan Neck Dissection Study Group presented a new system for classification of neck dissections based on a system of letters and symbols. The system permits a comprehensive "shorthand" method of precise designation of the neck dissection procedure, but has the disadvantage of departing radically from previously employed systems by utilizing an entirely new terminology and designation of lymph node groups. This factor portends a lack of acceptance by surgeons long accustomed to conventional terminology. The abbreviated and tabular method of classifying neck dissections, however, is advantageous, and would be useful if integrated into the currently used terminology.

Neck dissection: nomenclature, classification, and technique.

Lymph node status is the single most important prognostic factor in head and neck cancer because lymph node involvement decreases overall survival by 50%. Appropriate management of the regional lymphatics, therefore, plays a central role in the treatment of the head and neck cancer patients. Performing an appropriate neck dissection results in minimal morbidity to the patient, provides invaluable data to accurately stage the patient, and guides the need for further therapy. The purposes of this article are to present the history and evolution of neck dissections, including an update on the current state of nomenclature and current neck dissection classification, describe the technique of the most common neck dissection applicable to oral cavity cancers, and discuss some of the complications associated with neck dissection. Finally, a brief review of sentinel lymph node biopsy will be presented.

Management of the node-positive neck in oral cancer.

Surgery continues to play a prominent role in the management of patients with loco-regionally advanced squamous cell carcinoma of the upper aerodigestive tract. Most evidence supports the use of comprehensive neck dissection for node-positive disease and suggests that planned neck dissection following definitive radiation therapy and chemoradiation therapy is unnecessary in the great majority of patients with node-positive neck disease who exhibit a complete response. Evidence for less aggressive therapy is much less compelling in patients with bulky adenopathy. For such patients, there is growing enthusiasm for selective or even super-selective neck dissection for surgical salvage. Finally, when cervical disease is so advanced as to involve the carotid artery, evidence continues to portend a dismal prognosis.

Consensus statement on the classification and terminology of neck dissection.

OBJECTIVE: To update the guidelines for neck dissection terminology, as previously recommended by the American Head and Neck Society. PARTICIPANTS: Committee for Neck Dissection Classification, American Head and Neck Society; representation from the Committee for Head and Neck Surgery and Oncology, American Academy of Otolaryngology-Head and Neck Surgery (T.A.D.). EVIDENCE: Review of current literature on neck dissection classification. CONSENSUS PROCESS: Semiannual face-to-face meetings of the Committee for Neck Dissection Terminology and e-mail correspondence. CONCLUSIONS: Standardization of terminology for neck dissection is important for communication among clinicians and researchers. New recommendations have been made regarding the following: boundaries between levels I and II and between levels III/IV and VI; terminology of the superior mediastinal nodes; and the method of submitting surgical specimens for pathologic analysis.

Rationale for modifying neck dissection.

Neck dissection is one the most commonly performed operations in head and neck surgery. Better understanding of the structure and patterns of lymphatic flow in the neck has transformed this operation into a more selective and less morbid treatment. Rationale for this operation and modifications of it in different clinical scenarios such as node negative, node positive and radiated neck are detailed in this article. Recommendations are made based on the available evidence.

An evaluation of the shoulder domain of the University of Washington quality of life scale.

UNLABELLED: The aim of this study was to compare the shoulder domain in the University of Washington quality of life (UW-QoL) scale with two shoulder-specific questionnaires. METHODS: We did a cross-sectional survey of 100 consecutive outpatients who had had operations on the head and neck for cancer using the UW-QoL, the neck dissection impairment index, and the shoulder disability questionnaire. RESULTS: The types of neck dissection were none (n=12), unilateral selective (n=63), bilateral selective (n=17), and radical or modified radical (n=8). There were significant correlations among the three questionnaires. The worst scores were found in the group who had modified radical or radical neck dissection. Although responses were similar between those who had no neck dissection and those who had unilateral level 3 neck dissection, a few patients reported considerable dysfunction after selective neck dissection. CONCLUSION: Although the UW-QoL shoulder domain is limited to one of four responses, our results support the conclusion that it is sufficiently sensitive to screen for dysfunction of the shoulder.