Head and Neck Surgery

What is a Neck Dissection and Why is it Performed?

Neck dissection is usually performed to remove cancer that has spread to lymph nodes in the neck.

Lymph nodes are small bean shaped glands scattered throughout the body that filter and process lymph fluid from other organs. The immune cells in the lymph nodes help the body fight infection. When cancer cells spread from another part of the body, they may get caught in a lymph node where they grow. An individual might feel a non-tender lump in the neck. The cancer in the lymph node is known as a metastasis. When someone undergoes surgery for cancer that has spread to lymph nodes, both the initial or primary cancer as well as the metastases must be removed.

Neck dissection refers to the removal of lymph nodes and surrounding tissue from the neck for the purpose of cancer treatment. The extent of tissue removal depends on many factors including, the stage of disease which reflects the extent of cancer as well as the type of cancer. The most common cancers removed from lymph nodes in the neck include head and neck squamous cell carcinomas, skin cancers including melanoma and thyroid cancers. In general, the goal of neck dissection is to remove all the lymph nodes within a predefined anatomic area. Many of the lymph nodes removed during surgery will not prove to have cancer in them.

Many patients wonder why so many non-cancerous lymph nodes must be removed; why can’t surgery be done to remove only the lymph nodes with cancer in them?

A cancer may shed any number of metastases that lodge in lymph nodes, grow and spread. There are over 150 lymph nodes on each side of the neck. During an operation, a surgeon will not be able to tell if a lymph node is clean, or if it has cancer that will later grow into a visible neck lump. The lymph nodes must be processed and tested; this takes time. For that reason, it is recommended that the lymph nodes in a predefined region are removed, not just lymph nodes that are obviously enlarged with cancer.

In addition, different cancers spread differently. Skin cancers first spread to lymph nodes in different parts of the neck than thyroid cancers or oral or larynx cancers. Squamous cell carcinomas that start in the lining or mucosa of the mouth, throat or larynx have a tendency to spread to lymph nodes early; cancer cells can often be detected in lymph nodes in the neck when examined under the microscope, even in the absence of visible or palpable neck lumps.

Lymph node metastasis reduces the survival of patients with squamous cell carcinoma by half. Therefore, the control of cancer that has spread to the neck is one of the most important aspects in the successful management of these particular cancers. The neck dissection is a standardized procedure that was developed to ensure the complete removal of cancer that has spread to the lymph nodes of the neck.

The Procedure

Neck dissections are done under general anesthesia through an incision that runs along a skin crease in the neck, extending vertically on the side of the neck. Incisions are usually designed to enhance the visualization and protection of important structures in the neck, and enable the safe removal of lymph nodes that harbor cancer.

Beneath the skin, underlying fat, and a thin layer of muscle (the platysma), the dissection proceeds to identify and remove the tissue containing the lymph nodes. If the sternocleidomastoid muscle is removed as part of the operation, there may be some flattening of the neck, but removal of this muscle rarely results in significant weakness.

What are the risks of neck dissection?

Neck dissections are subject to numerous potential operative complications that are common to all operative procedures, as well as complications specific to this procedure. Some of these are described below, but do not include all potential complications associated with neck dissection. The risk of specific complications may be best determined for an individual by the nature and extent of their cancer, prior treatment and other circumstances.

• Bleeding - patients may bleed after an operation. Bleeding under the skin after a neck dissection is rare. Sometimes an operative procedure to remove the blood is required. Rarely, a blood transfusion is also needed.

• Infection can occur after any surgical procedure including neck dissection (uncommon)

• Chyle leak, which results in fluid accumulation in the neck from disruption of the thoracic duct (this problem is more common after left sided neck dissections) (rare)

• Wound healing problems requiring additional surgery (rare)

Several important nerves are found in the neck around the lymph nodes and depending on the area of the neck to be operated, these nerves can be at risk for damage.   The primary nerves of concern are-

• The marginal nerve, a small branch of the facial nerve which controls lower lip movement

• The spinal accessory nerve which aids in shoulder mobility and raising the arm over head

• The hypoglossal nerve, which controls movement of the tongue (uncommon)

• The lingual nerve, which controls sensation on the side of the tongue (rare)

• The vagus nerve which controls movement of one vocal cord (rare)

Additional potential long-term problems include:

• Incision-Most incisions heal well, but some individuals develop scars.

• Numbness of the skin along the incision as well as over the cheek, ear and neck can be anticipated which improves with time; some long-term numbness can be anticipated

• Neck stiffness or pain

• Long-term swelling in the neck or lymphedema

• Shoulder weakness (uncommon)

• Changes in speech and swallowing (rare)

Some problems are attributable to nerve injury; more commonly, scarring under the skin from surgery and radiation contributes to disability. Some problems may be avoided with early and faithful adherence to a shoulder range of motion exercise program, lymphedema, or speech therapy rehabilitation programs.

When You're in the Hospital

You were likely to be in the hospital for 2 to 3 days. To help get ready for going home, you may have received help with:

• Drinking, eating, and perhaps talking

• Caring for your surgical wound and any drains

• Using your shoulder and neck muscles

• Breathing and handling secretions in your throat

• Managing your pain 

What to Expect at Home

Your health care provider will give you a prescription for pain medicines. Get it filled when you go home so you have the medicine when you need it. Take your pain medicine when you start having pain. Waiting too long to take it will allow your pain to get worse than it should.

You will have staples or sutures in the wound. You may also have mild redness and swelling for the first couple of weeks after surgery.

Diet and Nutrition

You can eat your regular foods unless your provider has given you a special diet.

If pain in your neck and throat is making it hard to eat:

• Take your pain medicine 30 minutes before meals.

• Choose soft foods, such as ripe bananas, hot cereal, and moist chopped meat and vegetables.

• Limit foods that are hard to chew, such as fruit skins, nuts, and tough meat.

• If one side of your face or mouth is weaker, chew food on the stronger side of your mouth.

Keep an eye out for swallowing problems, such as:

• Coughing or choking, during or after eating

• Gurgling sounds from your throat during or after eating

• Throat clearing after drinking or swallowing

• Slow chewing or eating

• Coughing food back up after eating

• Hiccups after swallowing

• Chest discomfort during or after swallowing

• Unexplained weight loss

Activity

• You may move your neck gently sideways, up and down. You may be given stretching exercises to do at home. Avoid straining your neck muscles or lifting objects weighing more than 2 kilograms for 4 to 6 weeks.

• Try to walk every day. You can return to sports (golf, tennis, and running) after 4 to 6 weeks.

• Most people are able to go back to work in 2 to 3 weeks. Ask your provider when it is OK for you to return to work.

• You will be able to drive when you can turn your shoulder far enough to see safely. Do not drive while you are taking narcotic pain medicine. Ask your provider when it is OK for you to start driving.

• Make sure your home is safe while you are recovering.

Other Self-care

You will need to learn to care for your wound.

• You may get a special antibiotic cream in the hospital to rub on your wound. Continue to do this 2 or 3 times a day after you go home.

• You can shower after you return home. Wash your wound gently with soap and water. Do not scrub or let the shower spray directly on your wound.

• Do not take a tub bath for the first few weeks after your surgery.

Follow-up

You will need to see your provider for a follow-up visit in 7 to 10 days. The sutures or staples will be removed at this time.

What is a Skin Graft?

A split skin graft is a surgical procedure where healthy skin is placed onto a prepared wound site. Skin grafts are normally used when a skin cancer has been cut from the body and the wound cannot be closed by using stitches.

What happens during the surgery?

The surgeon will make a small cut to remove the skin cancer and some normal skin from the surrounding area to ensure that the cancer has been completely removed. A very thin layer of skin (a graft) is taken from an area of your body normally covered by clothes, such as the thigh or buttock area. This area is known as the ‘donor site’.

What happens after the surgery?

You will wake up from the anaesthetic in the recovery room and be transferred to your ward shortly after. A nurse will monitor your blood pressure, pulse and temperature.  You may have an oxygen mask to help you breathe and an intravenous (IV) drip in your arm giving you fluid. This will be removed once you are able to eat and drink. Your pain may be treated in a number of ways. This will be decided by you, your doctors and nurses depending on the type of pain you have. You may be given tablets or an injection to help you feel better. You will have dressings over your skin graft and donor site wounds. The dressing to your skin graft will be removed on day seven and reviewed. The newly grafted area will require daily dressings until fully healed.