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Current Concepts in Surgical Management of Neck Metastases from Head and Neck CancerPublished on Patient Care Online (http://www.patientcareonline.com)

Current Concepts in Surgical Management of Neck Metastasesfrom Head and Neck CancerReview Article [1] | May 31, 1995By Scott P. Stringer, MD [2]

This article will address modified, selective, and radical neck dissection as well as other surgicalconsiderations, and will review the surgical techniques currently available for neck treatment.

Introduction

Radical neck dissection, first described by Crile in 1906 [1], is the standard against which all surgicalapproaches to neck metastases is compared. Consideration was subsequently given to moreconservative surgical techniques, but they did not gain widespread acceptance and were condemnedby Martin et al in the 1950s [2].

Surgical management of the neck has continued to evolve toward more conservative approaches,however. Even selective neck dissection techniques are now widely accepted. Current controversiescenter around the appropriate use of modified and selective neck dissections, indications for electiveneck treatment, and selection of the best therapeutic modality for elective neck treatment. Thisarticle will address these as well as other surgical considerations, and will review the surgicaltechniques currently available for neck treatment.

Anatomic Considerations

A neck dissection is, in fact, an anatomic dissection of the neck. Therefore, a clear grasp of theanatomy of the cervical lymph node groups and cervical aponeurotic system is essential for proper

understanding of neck dissection.FIGURE 1

Lymph node groups are most commonly referred to by the names in this illustration.

FIGURE 2

Lymph node groups are subdivided for ease of communication into levels as demonstrated by thisfigure.

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Cervical Lymph Node Groups

There are approximately 150 to 350 lymph nodes above the clavicles. Since the lymphatic system isembryologically related to the venous system, the lymph nodes are closely related to veins. Thecervical lymph nodes have commonly been divided into surgical levels to facilitate discussions ofpatterns of metastases and types of neck dissection (Figures 1 and 2).The submandibular and submental nodes constitute the level I group. The submental lymph nodesare located in the midline within the triangle defined by the anterior bellies of the digastric musclesand the hyoid bone. The submandibular nodes are situated within a triangle bounded by the anteriorand posterior bellies of the digastric muscle and the mandibular body. These nodes are in closerelationship to the submandibular gland and the posterior facial vein. Notably, the gland itself doesnot include any lymph nodes.The internal jugular vein lymph nodes are limited anteriorly by the lateral margin of the sternohyoidmuscle and posteriorly by the posterior border of the sternocleidomastoid muscle, and aresubdivided into three groups. The level II group, or upper internal jugular nodes, extend from theskull base superiorly to the hyoid bone or carotid bifurcation inferiorly. These nodes , also commonlyreferred to as jugulodigastric nodes, are closely related to the superior portion of the spinalaccessory nerve as well. The middle jugular group (level III group) continues inferiorly to theomohyoid muscle. The lower jugular group (level IV) nodes extend from the omohyoid muscle to thelevel of the clavicle.The level V group, or posterior triangle lymph nodes, are bounded by the posterior edge of thesternocleidomastoid muscle, anterior border of the trapezius muscle, and clavicle. Superiorly, thesenodes closely approximate the spinal accessory nerve, and are often referred to as the spinalaccessory chain. The nodes that are located near the confluence of the posterior triangle and upperjugular groups are sometimes termed junctional nodes. The supraclavicular nodes are part of theposterior triangle group.The anterior compartment group (level VI) is bounded superiorly by the hyoid bone, inferiorly by thesternum, and laterally by the common carotid arteries. Included in this group are the paratracheal,pretracheal, precricoid (Delphian), and tracheoesophageal groove nodes.Additional groups that are sometimes dissected outside the normally described boundaries of theneck include the facial, parotid, preauricular, retroauricular, suboccipital, and retropharyngeal

nodes.FIGURE 3

The contents of the neck are divided into several spaces by a variety of fascial interconnections.These spaces and fascial layers are demonstrated in this figure.

Cervical Aponeurotic System

The cervical aponeurotic system divides the neck into compartments, including the lateral andparavisceral spaces, that are removed with a neck dissection (Figure 3). The superficial cervicalfascia is a thin layer that invests the platysma muscle. The deep cervical fascia is subdivided intothree layers: investing (superficial), pretracheal (middle), and prevertebral (deep).The investing layer completely encircles the neck, splitting to enclose the sternocleidomastoid,omohyoid, and trapezius muscles. Superiorly, the investing fascia splits to enclose the subman-dibular and parotid glands, and attaches to the lower border of the mandible. The pretracheal layerencompasses the trachea, thyroid gland, and esophagus.The prevertebral layer covers the prevertebral, scalene, levator scapulae, splenius, and semispinaliscapitis muscles, and constitutes the floor of the lateral neck. The phrenic nerve, brachial plexus,sympathetic trunk, and dorsal scapular nerve all lie deep to the prevertebral fascia.The carotid sheath consists of all three layers of deep cervical fascia and contains the carotid artery

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and vagus nerve. The jugular vein is located within an extension of the carotid sheath as well.Critical to an understanding of modified and selective neck dissections is the concept that the lymphnodes lie within the lateral and paravisceral spaces, not within the fascial wrappings of the musclesor the carotid artery. The lymph nodes may, however, be in very close association with these fasciallayers. The spinal accessory nerve must be uniquely considered in neck dissection, as it actuallytravels through the lateral space of the neck just deep to the investing fascia and superficial to theprevertebral fascia.

Tumor Biology

Squamous cell carcinoma of the upper aerodigestive tract is the most common tumor to metastasizeto the cervical nodes. Less commonly, neck dissection is performed for malignant neoplasms of thethyroid gland, parotid gland, or skin. Distant metastases from below the clavicle occur, but neckdissection is generally of no benefit in the management of these neoplasms.Once a metastasis reaches a lymph node, tumor growth results in an indurated and more roundednode. Increasing size of the lymph node is directly associated with increased risk of tumor invasionthrough the capsule, and eventually, fixation to adjacent structures.The risk of cervical metastases from different primary sites and stages has been estimated byexamining the percentage of patients with similar stage tumors who present with clinically positivenode [3], the distribution of pathologically positive nodes in an electively dissected, clinicallynegative neck, and failure rates in untreated necks. In this fashion, the relative risk of cervicalmetastases may be approximated for specific sites. For example, the glottis has a low risk ofmetastasizing to the neck(< 20%), whereas the nasopharynx has a high risk (> 30%). Finally, lesionssuch as early supraglottic laryngeal tumors are considered to be of intermediate risk (20% to 30%)[4].In many cases, these fairly consistent patterns of metastases allow for the application of selectiveremoval of nodal groups for specified lesions. There are, however, situations in which the normalpattern of nodal metastases do not hold. For example, the right and left sides of the cervicallymphatic system normally do not shunt. However, previous neck surgery, prior irradiation, ormultiple positive nodes obstructing the lymphatic system may alter the patterns of cervicalmetastases such that shunting across the submental region occurs, or unusual nodal groups areinvolved for a given primary. Furthermore, recurrent lesions are associated with a higher risk ofcervical metastasis.

Diagnosis

Palpation of the neck for metastases, by itself, may be associated with significant error rates.Therefore, CT is used extensively to image both the primary site and neck, and may increase theaccuracy of neck staging from 70% to 93% [5]. Computed tomography is especially useful indetecting occult nodal disease, determining the presence or absence of extranodal disease,demonstrating the resectability of extensive nodal disease, and evaluating inaccessible areas, suchas the parapharyngeal space, retropharyngeal space, and tracheoesophageal groove (Figure 4).Although MRI can detect nodal disease as well [6], we currently limit its use to selected primarysites, such as the nasopharynx, or to those cases in which a specific issue, such as perineuralinfiltration, needs to be addressed. Ultrasound is used more extensively in Europe than in the UnitedStates to evaluate nodal disease. Magnetic resonance imaging and ultrasound may be helpful indetermining nodal fixation to the carotid artery, but no imaging method is definitive in this regard.

Selection of Treatment

The choice between irradiation or dissection for treatment of the neck is based on the treatmentmodality planned for the primary site and the clinical status of the neck. More advanced neckdisease is usually managed with combined therapy.

Management of the Clinically Negative Neck

Traditionally, elective neck treatment has been utilized to manage tumors with a high risk (> 20% to30%) of occult metastatic disease because of the improved neck control associated with thisstrategy [7]. The alternative is to adopt a "wait and see" approach, which may be associated with anincreased rate of distant metastases and a worse prognosis, even if the neck failure is successfullysalvaged [8,9]. However, it has been recently suggested that elective neck treatment may no longer

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be justified, since the use of CT and MRI to assess the neck should decrease the risk of occultdisease to approximately 12% [10].Because the morbidity of a modified radical neck dissection or elective neck irradiation is minimal,follow-up is simplified, and the cost of delivering the treatment in one instance is lower than that ofan additional treatment period for a neck failure, we continue to advocate elective neck treatment inpatients with a high risk of occult cervical metastases. An interesting use of decision analysis toolsby Weiss et al further supported the elective management of the neck with either dissection orirradiation for those tumors at high risk for occult metastases [11].TABLE 1

AJCC Staging System for Regional Lymph Node Metastases in Head and Neck Cancer, 1992

Radiation and surgery can achieve similar regional control rates for N0 neck (Table 1) disease [9],and it is desirable to use only one therapeutic modality when possible to save the other for eitherrecurrence or a second primary tumor. Therefore, when the primary tumor is to be treated withsurgery, an elective neck dissection is indicated for primary sites with a greater than 20% risk ofcervical metastasis. If, on the other hand, the primary site is to be treated with radiation, electiveneck irradiation is indicated when the risk of cervical metastasis exceeds 20%.

Management of the Clinically Positive Neck

If the primary tumor is to be managed surgically, dissection is indicated for clinically positive necks.Preoperative irradiation is rarely used, except when a node is fixed to the carotid artery or deepcervical fascia. The node will usually become resectable, and in many instances, no viable tumor isfound in the neck dissection pathologic specimen. When the primary site is to be irradiated, radiationalone is typically adequate for small N1 (1 to 2 cm) disease, especially for nasopharyngeal tumors.More advanced neck disease, particularly when regression is incomplete, requires a neck dissection4 to 6 weeks after the completion of radiation therapy in order to improve regional control

[12].FIGURE 5

The outlined area demonstrates the extent of the section and the structures removed in a radicalneck dissection. The structures removed include the stemocleidomastoid muscle, the spinalaccessory nerve, and the internal jugular vein.

Selection of Dissection Technique

The terminology for describing neck dissections has become quite confusing since the initialdescription of the "classic" radical neck dissection in 1906 [1]. An understanding of the classificationof neck dissections is essential for selecting the appropriate type of neck dissection and forcomparing treatment results. The description of neck dissections that follows is useful for such

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purposes [13].FIGURE 6

The outlined area demonstrates the extent of dissection in a modified radical neck dissection. Theextent of dissection is simiar to that of a radical neck dissection, but the stemocleidomastoid muscle,the spinal accessory nerve, and the internal jugular vein are preserved.

FIGURE 7

The outlined area demonstrates the extent of a supraomohyoid neck dissection. This is a form of aselective neck dissection, which would most commonly be used for tunors of the tongue and floor ofmouth. The outlined area is included in a lateral neck dissection, which would most commonly beused for tumors of the larynx.

FIGURE 8

The outlined area is that included in a lateral neck dissection, which would most commonly be usedfor tunors of the larynx.

Radical neck dissection entails the removal of lymph node levels I to V in continuity with the spinalaccessory nerve, sternocleidomastoid muscle, and internal jugular vein (Figure 5). A modified radicalneck dissection involves the removal of the same lymph node groups with preservation of one ormore of the nonlymphatic structures (Figure 6). A selective neck dissection describes a cervicallymphadenectomy, in which one or more of the lymph node groups is not removed. Supraomohyoidand lateral neck dissections are selective neck dissections that remove nodal levels I to III and II toIV, respectively (Figures 7 and 8). Finally, an extended neck dissection includes the removal of lymphnode groups or nonlymphatic structures not encompassed by a radical neck dissection.The choice of a neck dissection is based on the primary site as well as the number, size, and locationof positive lymph nodes. In addition, the results and morbidity associated with each type of neckdissection must be considered.

Radical vs Modified Radical Dissection

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We prefer a modified radical neck dissection over a radical neck dissection in any situation in whichequal regional control rates may be obtained. The removal of the spinal accessory nerve,sternocleidomastoid muscle, and internal jugular vein in a radical neck dissection is associated withtrapezius muscle dysfunction, alteration of the neck contour, and venous engorgement. Furthermore,bilateral modified neck dissection may be performed simultaneously rather than in a staged fashion,as with a radical neck dissection.Multiple authors advocate a modified radical neck dissection for N1 disease [14-16]. Since no lymphnodes are contained within the fascial wrappings of the sternocleidomastoid muscle or carotidsheath, all lymph nodes may be removed with a modified neck dissection, unless extensiveextranodal spread and/or fixation are present. These are, in fact, our only indications for a radicalneck dissection, as suggested by Bocca and Pignaturo [17].

Selective Neck Dissection

The advantage of a selective neck dissection is that it provides the same therapeutic benefit as acomprehensive neck dissection, with potentially less morbidity and decreased operative time. Casesmust be carefully evaluated to ensure that they are appropriate for a selective dissection, however.Use of selective neck dissection is based on the concept that metastases from a specific primary siteoccur in a predictable fashion. It is indicated for N0 or N1 neck disease associated with the primarysites described below. In the setting of more advanced neck disease or after previous treatment,lymphatic drainage is no longer predictable, and a comprehensive neck dissection is indicated.The most commonly employed selective neck dissection is the supraomohyoid dissection forclinically negative necks associated with oral cavity primaries. Lateral neck dissection is best suitedfor laryngeal, oropharyngeal, and hypopharyngeal primaries [18]. If significant unexpected lymphnode metastases are encountered during a selective neck dissection, the dissection should beconverted to a comprehensive neck dissection due to the unpredictable pattern of metastases inthat event.

Extended Neck Dissection

Extended neck dissection is indicated for removal of the following specific nodal groups associatedwith selected primary sites: (1) anterior compartment nodes (level VI) with thyroid gland,esophageal, and subglottic laryngeal primaries; (2) facial nodes for lip and mid-face skin primaries;(3) periparotid and preauricular nodes for skin lesions of the temple, cheek, and anterior auricle; and(4) retroauricular and suboccipital nodes for posterior scalp and posterior auricular lesions.A variation of an extended neck dissection is the inclusion of a retropharyngeal node dissection forpharyngeal tumors that have a particularly high incidence of nodal metastases to that area. Thesurvival benefit of this dissection, however, has not been proven [19,20].

Indications for Postoperative Irradiation

The decision to use postoperative irradiation in head and neck cancer is based on the initial tumorstage and pathologic findings. Both the primary site and neck must be considered in this regard.Specific to the neck, postoperative irradiation is indicated for extranodal tumor spread or multiplepositive nodes, especially at multiple levels. In addition, irradiation is useful for controlling theopposite, undissected neck when it is at risk and the primary site will need postoperative irradiation.

Management of Neck Metastases From an Unknown Primary

Cervical metastases arise overwhelmingly from upper aerodigestive tract squamous cell carcinomaprimary sites, although metastases that appear first in the lower portion of the neck may be ofinfraclavicular origin. When upper- or middle-third cervical metastases are present without anobvious primary site, we recommend a thorough search for that site, including imaging andendoscopy of the upper aerodigestive tract. If no primary is found, histopathology of the lymph nodeis almost always obtainable by means of fine-needle aspiration cytology.It is rarely necessary to perform a cervical node excision for diagnostic purposes. If a node excisionis required, or is inadvisably performed, radiation must be the next modality utilized in order toachieve a reasonable rate of regional control [21]. This approach may, however, unduly complicatethe management of the patient.

Results of Treatment

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Survival rates in head and neck cancer vary widely, due to the large number of primary sites anddifferent primary tumor sizes. However, various factors have been examined relative to theirinfluence on the control of regional metastases by neck dissection. Extranodal spread of tumor,which increases in proportion to lymph node size, has been identified as a very important factoraffecting regional control and survival [22-24]. An increased risk of distant metastases and adecrease in survival have been demonstrated with an increasing number of positive lymph nodes,particularly when located in the lower neck [22,25,26].Regional control rates may also be examined with regard to treatment selection. Regional controlrates for negative necks or necks with a single, positive node less than 3 cm managed with any typeof neck dissection should be 90% or greater [12]. Several retrospective studies have demonstratedno difference in nodal recurrence rates between modified and radical neck dissections forappropriately selected patients [15,27,28].Similar control rates (90% or greater) may be obtained with irradiation for N0 or early N1 neckdisease [29]. For more advanced nodal disease, control rates are improved with a combination ofneck dissection and radiation, as compared with either modality alone [12,30].The salvage rate for recurrence in a previously dissected or previously irradiated neck is low, rangingfrom 5% to 40%, and salvage appears to be more likely if irradiation has not been previouslyemployed [30,31].

Surgical Considerations

Prevention of Carotid Artery Rupture

Major vascular complications of neck dissection, especially carotid artery rupture, are oftencatastrophic. In an isolated neck dissection, carotid rupture is an extremely rare event. Carotidartery exposure occurs almost exclusively after the development of a pharyngocutaneous ororocutaneous fistula. Carotid exposure appears to be much less common after modified radical neckdissection, due to the protection provided by the sternocleidomastoid muscle.Proper skin flap thickness and the placement of skin incisions away from the carotid bifurcation arehelpful in preventing carotid exposure. In addition, the adventitia should be left on the carotid,unless there is a positive node partially fixed to the artery.Once the outer layer of the carotid is exposed, it desiccates and weakens, most commonly at thelevel of the carotid bifurcation. Full-thickness destruction occurs within approximately 1 to 2 weeks.The first sign of an impending carotid rupture may be a sentinel bleed, which is then usually followedby an actual rupture 24 to 48 hours later. If rupture occurs, the common, internal, and externalcarotid arteries are ligated, and the bifurcation is resected.Ligation and resection of the carotid artery for rupture have been associated with death rates of 33%to 50% and neurologic sequelae rates of 15% to 25% among survivors [32]. Elective resection forimpending rupture is associated with decreased morbidity and mortality when compared withemergent resection. In highly selected cases, balloon occlusion of the carotid may be useful as atemporizing measure and for the prediction of neurologic outcome. However, despite the results ofsuch a test, the artery most often will still require ligation.Various methods of tissue coverage have been suggested for the prevention of carotid exposureafter radical neck dissection; however, the effectiveness of such attempts is not clear [32]. Althoughdermal grafts are employed most commonly, the use of levator scapulae muscle flaps, omentum,and prevertebral fascia has been described. Dermal grafting is most likely to be of benefit in cases ofradical neck dissection that have a possibility of a pharyngocutaneous or orocutaneous fistula and ahistory of prior irradiation, especially if the carotid adventitia was removed.

Sacrifice of the Internal Carotid Artery

If irradiation has not been successful in freeing a fixed node from the carotid artery, a decision mustbe made relative to carotid artery resection. Even though carotid artery resection with bypass mayresult in acceptable perioperative morbidity and mortality [33], we generally do not perform thismaneuver, as survival is not improved with carotid artery resection [34,35].Reference GuideTherapeutic Agents

Mentioned in This ArticleBleomycin

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Carboplatin

Carmustine

Cisplatin

Cetuximab (Erbitux)

Docetaxel (Taxotere)

Erlotinib (Tarceva)

Fluorouracil

Gefitinib (Iressa)

Hydroxyurea

Lomustine

Methotrexate

Mitomycin

Paclitaxel

Procarbazine

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Brand names are listed in parentheses only if a drug is not available generically and is marketed as no more than two trademarked or registered products. More familiar alternative generic designations may also be included parenthetically.

Benefit of Saving the Spinal Accessory Nerve

A variety of neural injuries may be evident after neck dissection, but injuries to the spinal accessorynerve predominate. The spinal accessory nerve passes through the lymph node-bearing tissue of theneck, requiring that it either be sacrificed or dissected for preservation.The majority of permanent spinal accessory nerve injuries are associated with the purposefulsacrifice of the nerve in conjunction with a radical neck dissection. This results in denervation of thetrapezius muscle. The associated "shoulder syndrome" consists of shoulder pain, weakness, impairedmobility in abduction of the arm over 90°, shoulder droop, and scapular winging. The shoulder painis due to the increased demands for support of the scapula on the levator scapulae and rhomboidmuscles, and is worse if the dorsal scapular nerve is also injured. An adhesive capsulitis of theshoulder joint may develop as well, and predominate symptomatically [36].Because loss of the spinal accessory nerve is generally the most debilitating part of a radical neckdissection, various methods of preserving trapezius function have been utilized. Given that the spinalaccessory nerve receives contributions from the second, third, and fourth cervical nerves,preservation of these branches was proposed as a method of preserving some trapezius function.However, it now seems clear that these branches are mostly proprioceptive in nature, and anyresidual shoulder function was more likely due to preservation of the nerve to the levator scapulaemuscle.Resection of the spinal accessory nerve and cable grafting achieves some diminution of the shouldersyndrome. A "save XI" neck dissection still results in significant atrophy of the trapezius in up to 50%of patients, due to the extensive trauma to the nerve and devascularization associated with thisprocedure.Modified radical neck dissection with preservation of the sternocleidomastoid muscle and spinalaccessory nerve is associated with the least trauma to and devascularization of the spinal accessorynerve. This ultimately results in the best trapezius function, although there is still a temporary phaseof dysfunction, which recovers significantly by 6 months after neck dissection, as documented byelectrodiagnostic testing [37]. Since modified radical neck dissection is associated with acceptablenodal recurrence rates, this has become the nerve-sparing procedure of choice.

Benefit of Saving the Internal Jugular Vein

The internal jugular vein is typically conserved in modified radical and selective neck dissections.This allows the performance of simultaneous bilateral neck dissections with a diminished risk ofincreased intracranial pressure, the syndrome of inappropriate antidiuretic hormone secretion, facialedema, blindness, stroke, and airway obstruction.The benefit of saving the internal jugular vein during a unilateral neck dissection is not as clear, butlogically would seem to be of benefit, to a lesser degree. The internal jugular vein has beendemonstrated to be reliably patent following conservation procedures. Factors that are associatedwith the rare instance of internal jugular vein thrombosis include prior irradiation, nodal recurrence,and compression by a musculocutaneous flap [38-40].

Conclusion

The surgical management of cervical metastases from head and neck cancer has undergone asignificant change to more conservative techniques for appropriately selected individuals. Improvedimaging modalities facilitate the staging of cervical metastases. The selection of the appropriatetreatment for the neck is best done by a multidisciplinary group of surgeons, radiation oncologists,medical oncologists, path- ologists, and radiologists due to the complex relationship between themanagement of the primary site and the neck. References: 1. Crile G: Excision of cancer of the head and neck with special reference to the plan of dissectionbased upon one hundred thirty-two operations. JAMA 47:1780-1786, 1906.

2. Martin HE, De Valle B, Ehrlich H, et al: Neck dissection. Cancer 4:441-449, 1951.

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3. Lindberg RD: Distribution of cervical lymph node metastases from squamous cell carcinoma ofupper respiratory and digestive tracts. Cancer 29:1446-1449, 1972.

4. Mendenhall WM, Million RR: Elective neck irradiation for squamous cell carcinoma of the head andneck: Analysis of time-dose factors and causes of failure. Int J Radiat Oncol Biol Phys 12:741-746,1986.

5. Stevens MH, Harnsberger HR, Mancuso AA, et al: Computed tomography of cervical lymph nodes.Arch Otolaryngol Head Neck Surg 111:735-739, 1985.

6. van den Brekel MW, Castelijns JA, Croll GA, et al: Magnetic resonance imaging vs palpation ofcervical lymph node metastasis. Arch Otolaryngol Head Neck Surg 117:663-673, 1991.

7. Hughes CJ, Gallo O, Spiro RH, et al: Management of occult neck metastases in oral cavitysquamous ca. Am J Surg 166:380-383, 1993.

8. Jesse RH, Barkley HT, Lindberg RD, et al: Cancer of the oral cavity: Is elective neck dissectionbeneficial? Am J Surg 120:505-508, 1970.

9. Mendenhall WM, Million RR, Cassisi NJ: Elective neck irradiation in squamous cell ca of the headand neck. Head Neck 3:15-20, 1980.

10. Friedman M, Mafee MF, Pacella BL: Rationale for elective neck dissection in 1990. Laryngoscope100:54-59, 1990.

11. Weiss MH, Harrison LB, Isaacs RS: Use of decision analysis in planning a management strategyfor the stage N0 neck. Arch Otolaryngol Head Neck Surg 120:699-702, 1994.

12. Byers RM: Modified neck dissection: A study of 967 cases from 1970 to 1980. Am J Surg150:414-421, 1985.

13. Medina JE: A rational classification of neck dissections. Otolaryngol Head Neck Surg 100:169-176,1989.

14. Molinari R, Chiesa F, Cantu G, et al: Retrospective comparison of conservative and radical neckdissection in laryngeal cancer. Ann Otol 89:578-581, 1980.

15. Lingeman RE, Stephens R, Helmus C, et al: Neck dissection: Radical or conservative. Ann Otol86:737-744, 1977.

16. Gavilan C, Gavilan J: Five-year results of functional neck dissection for cancer of the larynx. ArchOtolaryngol Head Neck Surg 115:1193-1196, 1989.

17. Bocca E, Pignataro O: A conservation technique in radical neck dissection. Ann Otol RhinolLaryngol 76:975-987, 1967.

18. Wenig BL, Applebaum EL: The submandibular triangle in squamous cell ca of the larynx andhypopharynx. Laryngoscope 101:516, 1991.

19. Ballantyne AJ: Significance of retropharyngeal nodes in cancer of the head and neck. Am J Surg108:500-504, 1964.

20. Hasegawa Y, Matsuura H: Retropharyngeal node dissection in cancer of the oropharynx andhypopharynx. Head Neck 16:173-180, 1994.

21. Parsons JT, Million RR, Cassisi NJ: The influence of excisional or incisional biopsy of metastaticneck nodes on the management of head and neck cancer. Int J Radiat Oncol Biol Phys 11:1447-1454,1985.

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22. Snow GB, Annyas AA, van Slooten EA, et al: Prognostic factors of neck node metastasis. ClinOtolaryngol 7:185-192, 1982.

23. Johnson JT, Barnes EL, Myers EN, et al: The extracapsular spread of tumor in cervical nodemetastasis. Arch Otolaryngol Head Neck Surg 107:725-729, 1981.

24. Hirabayashi H, Koshii K, Uno K, et al: Extracapsular spread of squamous cell carcinoma in necklymph nodes: Prognostic factor of laryngeal cancer. Laryngoscope 101:502-506, 1991.

25. Ellis ER, Mendenhall WM, Rao PV, et al: Does node location affect the incidence of distantmetastases in head and neck squamous cell ca? Int J Radiat Oncol Biol Phys 17:293-297, 1989.

26. Strong EW: Preoperative radiation and neck dissection. Surg Clin North Am 49:271-276, 1969.

27. Skolnik EM, Deutsch EC: Conservative neck dissection. Laryngoscope 95:561-565, 1985.

28. Jesse RM, Ballantyne AJ, Larson D: Radical or modified neck dissection: A therapeutic dilemma.Am J Surg 136:516-519, 1978.

29. Barkley HT, Fletcher GH, Jesse RH, et al: Management of cervical lymph node metastases insquamous cell carcinoma of the tonsillar fossa, base of tongue, supraglottic larynx, andhypopharynx. Am J Surg 124:462-467, 1972.

30. Mendenhall WM, Million RR, Cassisi NJ: Squamous cell carcinoma of the head and neck treatedwith radiation therapy: The role of neck dissection for clinically positive neck nodes. Int J RadiatOncol Biol Phys 12:733-740, 1986.

31. Grandi C, Mingardo M, Guzzo M, et al: Salvage surgery of cervical recurrences after neckdissection or radiotherapy. Head Neck 15:292-295, 1993.

32. Hillerman BL, Kennedy TL: Carotid rupture and tissue coverage. Laryngoscope 92:985-988, 1982.

33. Biller HF, Urken M, Lawson W, et al: Carotid artery resection and bypass for neck carcinoma.Laryngoscope 98:181-183, 1988.

34. Brennan JA, Jafek BW: Elective carotid artery resection for advanced squamous cell ca of theneck. Laryngoscope 104:259-263, 1994.

35. Meleca RJ, Marks SC: Carotid artery resection for cancer of the head and neck. Arch OtolaryngolHead Neck Surg 120:974-978, 1994.

36. Patten C, Hillel AD: The 11th nerve syndrome: Accessory nerve palsy or adhesive capsulitis? ArchOtolaryngol Head Neck Surg 119:215-220, 1993.

37. Remmler D, Byers R, Scheetz J, et al: A prospective study of shoulder disability resulting fromradical and modified neck dissections. Head Neck 8:280-286, 1986.

38. Cotter CS, Stringer SP, Landau S, et al: Patency of the internal jugular vein following modifiedradical neck dissection. Laryngoscope 104:841-845, 1994.

39. Lake GM, Dinardo LJ, Demeo JH: Performance of the internal jugular vein after functional neckdissection. Otolaryngol Head Neck Surg 111:201-204, 1994.

40. Docherty JG, Carter R, Sheldon CD, et al: Relative effect of surgery and radiotherapy on theinternal jugular vein following functional neck dissection. Head Neck 15:553-556, 1993. Source URL: http://www.patientcareonline.com/oncology-journal/current-concepts-surgical-management-neck-me

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