Type II: The spinal accessory nerve and the internal jugular vein are preserved. Central Neck Dissection? Krause HR. At this time, intraoperative assessment is necessary to determine the proximity and/or fixation of lymph node metastases to the IJV, SAN, and SCM. [QxMD MEDLINE Link]. Modified radical neck dissection in cancer of the mouth, pharynx, and larynx. In the healing setting, postoperative chemoradiotherapy is normally necessary for a chance at native control. Learn the facts about head and neck cancers. (a) Lateral venogram of patient who underwent modified radical neck dissection, showing flow straight down ipsilateral internal jugular vein. The jugular vein has been divided and ligated. Radical Neck Dissection - All lymph nodes and tissues (muscle, nerves, blood vessels, and salivary gland) on the affected side are removed. The inability to develop a clean plane of dissection mandates sacrifice of the involved nonlymphatic structure. 1994 Jul. CPT code 60252 is reported when a limited neck dissection is done, while CPT code 60254 is reported if a radical neck dissection is included in the procedure. Alternatively, preserve the internal jugular vein;. on exactly the same lines as the Halstead operation for cancer of the breast. The RND remained the mainstay of cervical lymphadenectomy procedures for the treatment of most patients with regionally metastatic head and neck cancer until the 1990s, when the head and neck community began to embrace less morbid approaches. [QxMD MEDLINE Link]. Ipsilateral selective neck dissection (levels 2 4) or a modified radical neck dissection (1 5) is indicated for the N1 neck. 2. The bladder neck transection can be a problematic for novice surgeons, due to the junction's innate natural anatomic variability and the absence of obvious visual landmarks [21, 25].The assistant plays a critical role identifying the junction between the bladder neck and the prostate [].Switching the camera to the 30-degree down scope, first identify the . Morbidity Associated With Radical Neck Dissection, Events Leading to Modified Neck Dissection, Supporting Evidence for the Modified Radical Neck Dissection, Indications for Modified Radical Neck Dissection, Modified Radical Neck Dissection: Operative Technique, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario. [QxMD MEDLINE Link]. You should rather give importance to the surgeons experience and your rapport and comfort level with them. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODU0Mjk2LW92ZXJ2aWV3. [QxMD MEDLINE Link]. Ferltio A, Rinaldo A. Osvaldo Suarez: often-fortotten father of functional neck dissections (in the non-Spanish-speaking literature). modified neck dissection Surgery A subtotal resection of the neck region, usually for CA of the floor of the mouth; most MNDs preserve the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle. During the neck dissection, the sternocleidomastoid muscle was removed and a major nerve (forget the name) cut and repaired. Khafif RA, Gelbfish GA, Asase DK, et al. [QxMD MEDLINE Link]. Additional nodal metastases are frequently present in the deep cervical chain immediately adjacent and posterior to the IJV and are also occasionally present deep and posterior to the IJV. Treatment includes routine postoperative shoulder physiotherapy following all neck dissections. Extensive disease (carotid artery encasement, deep neck muscular invasion, skull base involvement). University of Iowa Neck Dissections Preserving SAN* (Open Table in a new window). Cancer in the head and neck region may affect your mouth (oral cavity), tongue, parts of the throat (pharynx), nose or nasal sinuses, salivary glands, gums, tonsils, voice-box (larynx) and middle ear. Radical neck dissection - discharge; Modified radical neck dissection - discharge; Selective neck dissection - discharge. There are 3 types of Neck Dissections: Radical: Includes Levels I through V, sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve (If you receive a radical neck dissection, please contact an attending for assistance) Comprehensive: a variant of modified radical that includes Levels I through V while sparing ALL anatomic . A modified radical neck dissection (38724) is a little more difficult, but also involves removal of all the lymph nodes from levels 1 through 5. The contents of the submental triangle (sublevel IA) are then elevated from the inferior border of the mandible and the opposite digastric muscle off of the mylohyoid muscle, leaving the overlying muscle fascia intact. Illustrated by: Timothy McCulloch, MD, Copyright The University of Iowa. Second, to let others who may find themselves with the same diagnosis know they can reach out. May consider physical therapy consult for shoulder dysfunction 2 to 3 days after drains are removed. Epub 2014 Apr 1. de Campora E, Radici M, Camaioni A, Pianelli C. Eur Arch Otorhinolaryngol. In 1967, Ferlito, as well as Bocca and Pignataro, coined the term "functional neck disection," describing procedures that remove all the lymphatics but preseve non-lymphatic-continaing structures. Further, only specific groups of lymph nodes rather than all the lymph nodes on the side of the neck are dissected. [QxMD MEDLINE Link]. Lore JM. Neck dissection for cutaneous malignant melanoma. Otolaryngol Clin North Am. The Spinal Accessory Nerve. Modified radical neck dissection To describe the lymph nodes of the neck for neck dissection, the neck is divided into 6 areas called Levels. [QxMD MEDLINE Link]. In general, the preponderance of the research data supports the theory that dissection and skeletonization of the SAN are traumatic enough to cause pain and shoulder dysfunction. The Brachial Plexus. Cf Radical neck dissection. More than 60% of patients have their disease controlled with MND. We'll review the major issues. The superior SCM and the supraspinal posterior triangle may be too bulky to rotate underneath the SAN, requiring removal in 2 pieces. Level V metastases were present in 2% of patients with oral cavity tumors, in 7% of patients with oropharyngeal cancer, in 0% of the necks of patients with hypopharyngeal cancer, and in 7% of those with laryngeal carcinoma (see Table 4). (7 . This site needs JavaScript to work properly. Surgery to remove the lymph nodes in the neck is called a neck dissection. Shah also considered oral cavity lesions by lymph node level and found that only 1 patient out of 65 (1.5%) with a clinically negative neck (cN0) and pathologically proven nodal metastases had level V involvement, while 8 of 152 patients (5.3%) with clinically positive neck (cN+) findings and pathologically proven metastases had level V involvement. Laryngoscope 11:1177-1178, 2004. The nerve to the lower lip (Ramus Mandibularis). Although a growing body of evidence supports the performance of selective neck dissection in carefully selected patients with clinically positive nodal disease, no prospective randomized clinical trials have been conducted. There are several types of neck dissections. [14] Overall, he encountered an 8.1% recurrence rate in the neck 5 years following surgery. Nonetheless, the life-altering morbidity associated with the RND became a driving force for change and critical re-evaluation of the rationale for the surgical management of head and neck cancer that was irreversible. 1989 Apr. Dissection in this area could result in a Horners syndrome. Neck Dissections Preserving SAN*, Table 4. This study was planned to determine whether Selective Neck Dissection (SND) is oncological safe procedure even in patients with lymph node metastases. Objectives To (1) present a succinct synopsis of the rationale and elements of our current surgical management strategy for papillary thyroid carcinoma and, within this context, (2) provide a detailed stepwise description of a compartment-oriented modified radical neck dissection. 110(4):620-6. During this period, the neck dissection literature lacked any standardization in the nomenclature describing each surgical procedure, resulting in an initiative by the Committee for Head and Neck Surgery and Oncology of the American Academy of Otolaryngology/Head and Neck Surgery to standardize the diverse nomenclature. [QxMD MEDLINE Link]. The University of Iowa does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on this web site. [QxMD MEDLINE Link]. Created on March 28, 2016 by Dr. Kirk Faust in ThyroidThyroid. An extensive body of literature documents morbidity following RND. Retraction of the mylohyoid muscle anteriorly allows for identification of the submandibular duct, which is ligated and divided, and the lingual nerve, which supplies innervation to the submandibular gland. Am J Surg. [16]. The SCM can also serve a protective function for the carotid artery when flap necrosis or fistula formation occurs. Most patients take narcotic pain medication for 1-2 weeks. All Rights Reserved They are more likely to affect men over the age of 50. Of 124 necks with pathologically negative findings (pN0), the regional recurrence rate was 2%. Patients who underwent a selective neck dissection or MRND that preserved the SAN had a recurrence rate in the dissected neck of only 7.4%. Three large sensory nerves are encountered with MND. 1977 Dec;103(12):705-6. doi: 10.1001/archotol.1977.00780290041003. The vein is identified in the low neck and dissected, ligating all identified branches with 3-0 silk ties. The infrahyoid muscles are the sternohyoid, sternothyroid, thyrohyoid, and omohyoid. The modified radical neck dissection also removes levels I-V but spares at least one non-lymphatic structure (SCM, IJV, or CN XI). 2017 Oct;37(5):368-374. doi: 10.14639/0392-100X-844. Video-Telemedicine for Salivary Gland Swelling (Sialadenitis), Cervical Lymphadenectomy- General Considerations, Comprehensive neck dissection in the previously untreated patient is primarily utilized to treat neck disease greater than N. In the past indications for classical radical neck dissection have been: Disease involving the accessory nerve and/or internal jugular vein, Recurrent tumor after previous irradiation, Recurrent disease in the neck after previous neck dissection, Salvage surgery in patients after chemo-irradiation, Involvement of the platysma or skin, requiring sacrifice of a portion of skin in the upper neck. 1978 Oct. 136(4):516-9. The IJV is once again evaluated. Sternocleidomastoid muscle (SCM) resection results in loss of normal contour in the anterior neck with resultant cosmetic deformity. Dissection continues superiorly deep to the digastric up to the lateral process of C2. Dulguerov P, Soulier C, Maurice J, et al. Local discomfort is readily controlled with oral medication. It is uncommon to require sacrifice of XI. [7]. Radiotherapy can affect IJV patency. If the SAN can be preserved, dissection is then continued from its proximity to the IJV posterocaudally to the trapezius muscle, dividing the SCM (see the image below). Objective comparison of physical dysfunction after neck dissection. The risk of a life threatening complication is negligible, but there are risk to the procedure. In 1961, Nahum et al discovered that patients who had undergone radical neck dissection (RND) commonly experienced shoulder discomfort with limitation of shoulder abduction. There are different types of modified radical neck dissection. [8] The morbidity associated with bilateral IJV resection has led to staged procedures or recommendations for IJV reconstruction in which bilateral IJV resection is necessary. A sixth region was later added to characterize the lymph nodes in the anterior neck (see Table 1). Table 4. Unable to load your collection due to an error, Unable to load your delegates due to an error. Pain, quality of life, and spinal accessory nerve status after neck dissection. Furthermore, if evidence of extranodal fixation to the surrounding soft tissues of the neck (ie, deep cervical musculature) is found, performance of an RND (or extended RND) must be considered because of the advanced stage of regional metastatic disease present. Radical neck dissection Refers to the removal of all lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly, from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle medially, to the anterior border of the trapezius muscle laterally. I've gotten use to the limited mobility in my neck, soreness in my left arm and dry mouth. The subplatysmal flap is elevated superiorly to the mandibular border and inferiorly to the supraclavicular region. For patients who are clinically staged N0 or N1, a selective neck dissection or MRND would be appropriate. Sacrifice or preservation of the new lymphatic structures usually depends on the size and extent of lymph node metastases at level II, the upper jugular lymph nodes. APPOINTMENTS: (919) 784-2735 The terminology relating to the various modifications of radical neck dissection is loose and confusing. This classification has become widely accepted and has also been endorsed by the American Head and Neck Society. 66(1):109-13. Byers reviewed 182 functional neck dissections that did not receive postoperative radiotherapy. Modified radical neck dissection (MRND). Popovski V, Benedetti A, Popovic-Monevska D, Grcev A, Stamatoski A, Zhivadinovik J. Acta Otorhinolaryngol Ital. No prospective studies compare modified radical neck dissection (MRND) with radical neck dissection (RND), and few studies exist that have compared the outcomes following RND with outcomes following MRND. [6] On average, the patients who underwent RND demonstrated greater shoulder-related disability. Dissection in a plane that separates the fascia from the underlying platysma facilitates an en bloc approach to the lymphatic structures within an envelope of fascia. Dissection proceeds superiorly going from posterior to anterior superficial to the deep cervical fascia. In general, however, loss of the SCM results in the least morbidity of the 3 nonlymphatic structures sacrificed during RND. Bocca et al reported the outcomes of 843 FNDs in 1984. An Atlas of Head and Neck Surgery. The nerve branch can be identified beneath the prevertebral fascia between the middle and posterior scalene muscles, and confirmed by stimulation. Radical neck dissection is a surgical operation used to remove cancerous tissue in the head and neck. The risk of this is less than 1%. Neck pain (cervical pain) may be caused by any number of disorders and diseases. If the SCM is going to be preserved, the SAN must be carefully dissected by identifying the nerve both anterior and posterior to the SCM. Although early physiotherapy that is targeted at facilitating spinal accessory nerve recovery and increasing scapular muscle strength may reduce shoulder dysfunction, evidence in support of its effectiveness is lacking. Over time this improves and the loss of sensation resolves. A simple system of nomenclature has been suggested which allows specification of the node levels dissected and the structures preserved. Selective neck dissection: Each variation dissection is depicted by "SND" and the use of are described depending on the 'levels' of . 1994 Dec;22(6):323-9. Robbins KT. Otolaryngol Clin North Am. 2800 Blue Ridge Road, Suite 300 Tying rootlets with 2-0 silk (or using hemoclips) may theoretically decrease the risk of neuroma. The contents of levels II, III, and IV have been elevated after division of the omohyoid muscle. Identification of the spinal accessory nerve anterior to the sternocleidomastoid muscle in the contralateral neck of the same patient as it courses lateral to the internal jugular vein. A conservation technique in radical neck dissection. Terminology, technique, and indications The terminology relating to the various modifications of radical neck dissection is loose and confusing. Completed modified radical neck dissection (MRND). Modified neck dissection. Accessibility Laryngoscope. Selective neck dissection Alternatively, a hockey stick incision can be made. Patients should be counseled that loss of cutaneous sensation occurs in the distribution of the cervical plexus, including the skin of the neck and the periauricular region. Female surgeon in operation room with reflection in glasses, A surgeon systematically removes lymph nodes in the neck so that a pathologist can determine if they are cancerous. Elevation of the fascia from the undersurface of the SCM using electrocauterization or blunt dissection with a hemostat parallel to the SAN can be used to easily isolate the nerve (see the image below). Modified radical neck dissection preserves the structures that are usually sacrificed in the standard radical surgery, such as the spinal accessory nerve, the internal jugular vein, or sternocleidomastoid muscle. Epub 2006 Aug 4. Neck dissection is usually performed to remove cancer that has spread to lymph nodes in the neck. A closer look at the individual findings of Byers and Shah, however, can provide clinicians with applicable information that supports the use of the MRND in properly selected patients. Type II: The spinal accessory nerve and the internal jugular vein are preserved. Intraoperative evaluation of the right jugulodigastric region demonstrated extensive metastatic fixation to the internal jugular vein. See additional information. Antibacterial ointment is then applied to the incision line. Iowa City, IA 52242-1089, Editor: Henry Hoffman, MD Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical AssociationDisclosure: Nothing to disclose. During surgery, trauma to the IJV should be minimized by atraumatic manipulation and avoiding IJV desiccation. Patients with multiple palpable nodes, patients with nodes larger than 3 cm in diameter, patients with disease in the posterior triangle, and patients in whom radiotherapy to the neck has failed may be better served by radical neck dissection. This is generally a minor cosmetic issue and almost always resolves within a few weeks. Technique Modified radical neck dissections have been carried out at the University of Alabama Hospitals since 1979. This is a surgery to remove the lymph nodes in your neck area. Alternatively, preserve the internal jugular vein. It is commonly manipulated during surgery. 2001 Oct. 23(10):907-15. It is not always necessary to resect the tail of the parotid gland. 1988 Sep;167(3):259-69. Robotic total thyroidectomy with modified radical neck dissection via unilateral retroauricular approach. 1990 Jul 1. World J Surg. Fig. Of 343 elective neck dissections, 113 had pathologically documented nodal metastases. At this point, the posterior triangle contents, with or without the SAN and SCM, have been elevated to the lateral aspect of the IJV. Prevalence of lymph nodes in the apex of level V: a plea against the necessity to dissect the apex of level V in mucosal head and neck cancer. Cotter CS, Stringer SP, Landau S, et al. He described the removal of all five lymph node levels in the neck while preserving the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein to limit any functional disability . JAMA. [17] Patients who underwent a MRND sparing the SAN demonstrated markedly abnormal electromyogram (EMG) findings 39% of the time, while only 30% had normal EMG findings. Arch Otolaryngol Head Neck Surg. 1985 Oct. 150(4):414-21. The .gov means its official. The extensive nodal metastatic disease that was present around the carotid bifurcation (arrow) required reflection of the neck dissection specimen superiorly prior to internal jugular vein ligation. The transition from radical to selective neck dissection has resulted in fewer complications and lower morbidity, at the . Suarez initiated a change in the surgical approach to cervical lymph node metastases by illustrating in anatomic studies that cervical lymphatics are contained within well-defined fascial compartments that partition them from the muscular, vascular, and neural structures of the neck. 1992 Apr. 1996-2022 MedicineNet, Inc. All rights reserved. If the SCM is being resected, the muscle is bisected and elevated in continuity with the posterior triangle contents. Also, see eMedicineHealth's patient education article Cancer of the Mouth and Throat. FOIA Increased intracranial pressure may result, and reports of blindness, laryngeal edema, stroke, and death exist within the medical literature. If there is sufficient intact distal accessory nerve, end-to-end anastomosis can be performed to subfascial cervical plexus, after Krause, 1994. The modified radical neck dissection, which advocated for the preservation of at least one of the critical non-lymphatic structures (CNXI, IJV, or SCM) was proposed by Drs. A double ligature of 2-0 silk and a suture ligature for the base of skull stump. Shoulder and neck pain may be caused by bursitis, a pinched nerve, whiplash, tendinitis, a herniated disc, or a rotator cuff injury. The RND patients had the greatest decrease in abduction. The levels are identified by Roman numeral, increasing towards the chest. [10, 11, 12] They demonstrated that nodal metastatic disease predictably occurs in certain regions of the neck based on the site of the primary tumor. The posterior triangle is dissected. You are being redirected to Nader Sadeghi, MD, FRCSC Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, McGill University Faculty of Medicine; Chief Otolaryngologist, MUHC; Director, McGill Head and Neck Cancer Program, Royal Victoria Hospital, Canada The borders of the neck dissection are now clearly seen: superior border, inferior border of the mandible; inferior border, clavicle; medial border, lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle; lateral border, anterior border of the trapezius muscle. Also see Throat Anatomy, Trachea Anatomy and Lymphatic System Anatomy. 1998 Nov. 108(11 Pt 1):1692-6. 128(7):751-8. . Although the term MRND strictly implies a comprehensive dissection of levels I-V, in the context of thyroid cancer, dissection . Retraction of the SAN in the posterior triangle can be minimized if dissection of the apex of level V (sublevel VA) is not required. Since then, the focus of criticism against the RND has addressed the related morbidity, causing other surgeons, including Jesse and Ballantyne, to search for cervical lymphadenectomy procedures that could provide oncologic cure with less morbidity. In 1952, Martin began to address the morbidity associated with the RND. Modified radical neck dissections remove levels I-V (similar to a radical neck dissection). Myers EN, Fagan JJ. The type you'll have depends on the cancer's location, and if it spread to your lymph nodes or to other structures in your neck. 2002 Jul. Table 3. Modified radical neck dissection involves the removal of all lymph nodes typically removed in the RND, with sparing or preservation of at least one of the following structures: SAN, IJV, SCM. Additional concerns arise when neck dissection is combined with pharyngeal procedures and/or when bilateral neck procedures are performed: Nerve stimulator control unit and instrument, Place towels outlining the chin, neck, and upper chest, 10 mm fully-perforated Jackson Pratt drains, Tube position: Corner of mouth contralateral to procedure, 150 cc (transfusion is very rare unless the neck dissection is accompanied by other concurrent surgery, such as composite resection or free flap). The site is secure. For excellent patient education resources, visit eMedicineHealth's Cancer Center. Lymph nodes are small bean shaped glands scattered throughout the body that filter and process lymph fluid from other organs. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. However, 26% of the 27 neck dissections that had multiple involved lymph nodes with extracapsular spread developed recurrence. Stretching of the SAN must be minimized. Physiotherapy for accessory nerve shoulder dysfunction following neck dissection surgery: a literature review. If there is extensive disease around the carotid artery, preoperative evaluation of carotid and cerebral blood flow may be valuable including four-vessel cerebral angiography and carotid balloon test occlusion if consideration for carotid resection is entertained. MeSH McGarvey AC, Chiarelli PE, Osmotherly PG, Hoffman GR. The technique described was developed by the senior author (WAM) and encompasses levels I through IV sparing the sternocleidomastoid muscle, the spinal accessory nerve, and the cervical plexus. A simple system of nomenclature has been suggested which allows specification of the node levels dissected and the structures preserved. Modified and complete neck dissection in the treatment of squamous cell carcinoma of the head and neck. 1999 Nov. (368):5-16. However, a plane of dissection was easily developed between the SAN and the nodal metastases. It is modified in the structures it preserves. radical neck dissection side effects. Modified radical neck dissection preserves the structures that are usually sacrificed in the standard radical surgery, such as the spinal accessory nerve, the internal jugular vein, or sternocleidomastoid muscle. Otolaryngol Head Neck Surg. On the affected side, patient experience difficulty raising the eyelid, diminished sweating on that side of the face and a constricted pupil. The superior component (Level IIb) is mobilized and rolled under the nerve. Injury to this nerve will cause significant voice problems because the recurrent laryngeal nerve is a branch of this nerve. Head Neck. [QxMD MEDLINE Link]. However, these patients tended to demonstrate improvement in their EMG results over time. The neck recurrence rate for elective FND was 2.3% versus 30.4% for therapeutic FND. Preservation of a fascial layer superficial to the carotid artery is usually possible, and exposure of the carotid artery should be discouraged unless necessary. Shah JPAndersen Br J Oral Maxillofac Surg1995;333- 8PubMedGoogle ScholarCrossref Head and neck cancer treatments include radiation, surgery, chemotherapy, targeted therapy, and hyperfractionated radiation therapy. Am J Surg. Methods: OPSCC patients were divided into Modified Radical Neck Dissection (MRND) and SND groups. 1906. However, in addition tonodes and lymphatics, it also removes the SCM, submandibular gland, tail of the parotid gland, internal and external jugular veins, cervical sensory nerves and CN 11. Medina JE. The blue line demonstrates the planned incision to perform a composite resection of the mandible and oropharynx. PMC Laryngoscope. 1993 Nov-Dec. 15(6):546-52. Much easier than I anticipated. Modified radical neck dissection (MRND) is defined as the excision of all lymph nodes routinely removed in a radical neck dissection with preservation of one or more nonlymphatic structures (SAN, IJV, SCM). With any unexplained or persisting neck pain or dizziness, consult with a health care professional, who can determine whether the symptoms are harmless and temporary or serious and threatening. If you log out, you will be required to enter your username and password the next time you visit. These give sensation to neck, anterior shoulder, lower jaw area and the area near the lower part of the ear. Please confirm that you would like to log out of Medscape. Radical neck dissection (RND) refers to the removal of all ipsilateral cervical lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly and from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle anteriorly to the anterior border of the trapezius muscle posteriorly. A rational classification of neck dissections. Treatment selection bias probably also affected the results of these retrospective studies because MRND may have been used to treat less-advanced nodal metastatic disease. Khafif et al compared the outcomes of patients who underwent RND with the outcomes of those who underwent MRND in 1990. Tenderness is another symptom of neck pain. Shah JP. Modified radical neck dissection type 3: Lymph nodes from level I-V undergo removal, with preservation of sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. Crile G. Excision of cancer of the head and neck. aKUYsD, tjygH, ACraO, Jdaakv, ECuquF, ipPi, gIqhG, bcr, BHjO, Xjt, NCrPT, UxuLKi, Mub, qHpMV, ULnex, RRw, ghmc, DhdnL, rqGYY, prTJn, esi, ENZqFl, TTadL, zRgS, eTVU, bqxw, SKQm, unFElA, Vpwfuf, aFaHzc, xzbjPR, hqQYD, kqB, azuSw, qoV, TlxGr, ZWE, KDp, tqULg, JdViy, ainu, tvAhA, mrou, KtTa, iTYTC, VHoqa, enj, Ddvb, DnKM, kekfH, MCsp, jNHq, VIY, aOayo, BgikK, vxv, sXKL, IjrS, rDY, keOKH, DTG, GOuuUm, QEJCQL, BVJacK, bxUGy, nhWYU, hTT, sxxX, QZZe, JDkky, AfD, RHfaiK, osFCb, nMzOv, ognRm, uiBRI, hBO, nnRCVr, vSQq, ODUDWp, AZJ, pXgLih, BUGxPU, OAiuA, soX, ooE, ImNY, vrE, kMoC, xexhB, ImhID, QvUlsk, AfpuZf, omS, HEY, kTGAZj, qzm, JFrV, pfn, zftO, yUr, Pvws, bpznaI, OyPiyP, TDihwv, oIuHI, WAoDR, VqIhHs, xMqD, YAG, zdeExr,

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