Neck Dissection

DR. TIARA DESTAFIA

Fasia Servikal
Lapisan Superfisial

Platysma Otot-otot ekspresi wajah Superfisial Medial Profunda

Lapisan Profunda

Staging menurut American Joint Comittee on Cancer 2002

NX: Regional lymph nodes cannot be assessed. N0: No regional lymph node metastasis. N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest

dimension. N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension. N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension. N2c: Metastasis in bilateral or contralateral nodes no more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension

Staging Karsinoma Nasofaring

NX: Regional lymph nodes cannot be assessed.

N0: No regional lymph node metastasis.

N1: Unilateral metastasis in lymph node(s), 6 cm or less

in greatest dimension, above the supraclavicular fossa. N2: Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa. N3: Metastasis in a lymph node(s) > 6 cm and/or to supraclavicular fossa. N3a: Greater than 6 cm in dimension. N3b: Extension to the supraclavicular fossa.

Diseksi Leher Radikal

Indikasi : - Metastase kelenjar linfe yang multipel - Terutama bila metastase pada segitiga posterior leher dan berhubungan dengan nervus spinal asessesorius - Metastase tumor yang besar

Diseksi Leher Radikal Modifikasi Tipe I

Yang disisakan : nervus

spinal asessorius Indikasi :

Pada tumor yang tidak metastase ke nervus spinal assesorius

Diseksi Leher Radikal Modifikasi Tipe II

Yang disisakan : nervus spinal assesorius, vena

jugularis interna Indikasi : pada tumor yang hanya mengenai muskulus sternokleidomastoideus Jarang dilakukan, pada pasien tumor hipofaring atau laring dengan metastase pada 1/3 bawah dari muskulus sternokleidomastoideus

Diseksi Leher Radikal Modifikasi Tipe III

Yang disisakan : nervus

spinal asessorius dan vena jugularis interna dan musculus SCM Indikasi :

Pasien dengan tumor saluran nafas atas deg No Terutama bila primer tumor pada laring atau hipofaring Bisa untuk N1, bila nodul mobile dan tidak lebih besar dari 2,5 3 cm

Diseksi Leher Selektif

Diseksi leher selektif Level I-

III ( supraomohioid/anterolateral) Batas :

Post : cabang kutaneus plexus servikalis & atas posterior

muskulus sternokleidomastoideus

Inf : omohioid yang dilewati v. Jugularis interna

Pada tumor kavum oris yang

melewati midline -> diangkat bilateral

Diseksi Leher Selektif

Diseksi Leher Selektif

Level II-IV( lateral ) Pada tumor KSS pada laring, orofaring, hipofaring Pada tumor supraglotis dan dinding post faring > bilateral

Diseksi Leher Selektif

Diseksi Leher selektif Level VI ( anterior)

Pada tumor tiroid, glotis, subglotis, sinus piriformis,

esofagus bagian servikal dan tumor trakea

Diseksi Leher Selektif

Diseksi Leher selektif Level

II-V (posterolateral) Pada tumor kulit dari posterior skalp s/d latero superior aspek leher Untuk keganasan tumor kulit periaurikula dilakukan diseksi leher ( II,II,V) anterior skalp & temporal + parotis, fasial & nodul jugularis eksterna

Diseksi Leher Diperluas

Kulit , otot, nervus Perluasan otot ke tumor dibagi 3 kelompok; superfisial, prevertebral, paraspinal Otot superfisial ; sternohioid, sternotiroid, omohioid, milohioid, kompleks digastrik/stilohioid Untuk nervus yang banyak terkena adalah nervus hipoglossus karena metastase tebanyak pada level II Nervus lingual (7%), nervus vagus (4%), nervus laringeus superior (3%), nervus phrenikus (3%) dan nervus glossofaringeus (2%)

Diseksi Leher Diperluas

Diseksi Kelenjar Limfe Retrofaring Letaknya di belakang dinding faring posterior dan di depan lapisan prevertebra, trunkus simpatikus, ganglion Perluasan lemak nya tepat di bawah bifurkatio karotis sampai basis tengkorak Dibagi 2 ; medial dan lateral Pada pasien tumor orofaring dan hipofaring dg metastase leher

Diseksi Leher Diperluas

Diseksi kelenjar limfe mediastinum atas dam

paratrakeal

Banyak pada tumor laring laring yang mengenai regio subglotis dan untuk tumor servikal esofagus Pada pasien tumor transglotik, subglotik, ca cervikal esofagus, trakea dan tumor tiroid -> diseksi leher luas termasuk limfe pretrakeal dan paratrakeal Kegagalan untuk melakukan ini -> stoma rekuren

Diseksi Leher Diperluas

Reseksi Arteri Karotis Pengangkatan a. Karotis ->50% mengalami stroke berat atau kematian

Radioterapi Setelah Diseksi Leher

Diberikan pada mutipel nodul yang terlibat pada

multipel level pada leher & ditemukan nya perluasan ekstraskapular Waktu inisiasi <6 mg Dosis harian 1,8 Gy dengan total 57,6 Gy Untuk daerah ditemukannya perluasan ekstraskapular diberikan 63Gy

Komplikasi
Infeksi

Kebocoran udara
Perdarahan Fistula chylous

Edema cerebral atau fasial

Kebutaan Apnea

Trombosis vena jugular

Soal -Soal
1. Preservation of the blood supply to the skn flaps,

elevated to perform a neck dissection is best assured when a. The facial artery is not ligated b. The occipital artery is preserved c. The blood supply is based on predominantly vertical superficial plexus d. The blood supply is based on predominantly transverse superficial plexus e. The Y incision of Crile is performed

 Jawaban : E

 2. During an exploration of the neck for a chyle leak,

the vagus nerve is identified and the leak is arrested by placing a sutured ligature with 4-0 silk. Which of the following complications is the most likely to occur ? a. Pneumothorax b. Chylothorax c. Elevation of the hemidiaphragm d. Horners syndrome e. Crycopharingeal achalasia

 Jawaban : C

 3. CT dan MRI are superior to clinical exam in the

evaluation of one of the following lymph node groups of the neck : a. Upper posterior triangle b. Suboccipital c. Subdigastric (level II) d. Pretrakeal e. Retropharyngeal

 Jawaban : E

4. A patient with a nasopahryngeal carcinoma has a 7 cm matastasis in the right upper neck and a 2 cm one in the left jugulodigastric region. The clinical staging of the neck is a. N2a b. N2b c. N2c d. N3a e. N3b

 Jawaban : C

5. A 55 year old woman with a papillary carcinoma of the left lobe of the thyroid has an ipsilateral 2 cm metastasis in a node in a region II and multiple small enlarged from nodes in the supraclavicular and low posterior triangle of the neck. The operation necessary to eradicate the tumor in the neck nodes is most likely is a. Radical neck disecction b. Modified radikal tipe I c. Modified Radical tipe III d. Supraomohioid neck dissection e. Lateral Neck Dissection

 Jawaban : C

 6. Which of the following factors is the most

important predictors of tumor reccurences in the neck following radical neck dissection? a. The location of the primary tumor b. The number of histologically positive nodes c. The presence of multipel histologically positive nodes d. The presence of positive nodes at multipel levels in the neck e. The presence of ekstrascapular extension of tumor

 Jawaban : E

 7. A 39 year old patient has a tumor of the infrahyoid

epiglottis that extends to both false cords, more extensively on the right than on the left, but does not involve the anterior commisure. The motility of the vocal cords is normal. She has no palpable adenopathies in the neck. Pulmonary function is normal. Treatment will ideally consist of a. Supraglottic laryngectomy only b. Supraglottic laryngectomy and right modified radical neck dissection c. Supragolttic laryngectomy and bilateral supraomohioid neck dissection d. Supraglottic laryngectomy and bilateral lateral neck dissection e. Radiation therapy to the primary only

 Jawaban : D

 8. A 65 year old woman who used snuff over 50 years has a

squamous cell carsinoma of the anterior floor of the mouth. The tumor, which measured 2,5 cm in largest diameter and 0,5 cm in the thickness, was excised intraorally with apparently clear margins. Although the patient has no palpable adenopathy in the neck, she is reffered for consideration for definitive treatment of the neck. Your recommendation would be a. Observation only b. Radiation therapy to the primary and both sides of the neck c. Radiation therapy to the neck only d. Bilateral supraomohyoid neck dissection e. Bilateral modified radical neck dissection ( tipe III )

 Jawaban : A

 9. A patient with a deeply infiltrating squamous cell

carcinoma of the right side of the base of the tongue, which extends slightly beyond the midline, has a 3x4,5 cm nodal metastasis in right region II. There are no other palpable adenopathies in the neck. In addition to exicing the primary tumor, treatment would consist of a. Right radical neck dissection b. Right radical neck dissection and postoperative radiation c. Right radical and left supraomohyoid neck dissections d. Right radical and left modified radical neck dissection e. Chemotherapy, radiation therapy, and surgery salvage only

 Jawaban : B

 10. A patient with bilateral lymph node metastase

undergoing surgery. A right radical neck dissection been performed. In the course of doing the neck dissection, it becomes apparent that the internal jugular vein has to be resected. In addition to re...blood loss, intra and postoperative care of this patient should include a. Replacing fluids with blood and plasma only b. Incerasing blood volume with crystaloid c. Giving diuretics to maintain urine output d. Limiting fluid administration to 50 ml/hour e. Giving dexametasone 8-10 mg iv

 Jawaban : D