Neck
Neck - anatomy
Superior boundery – inferior edge of mandibula, mastoid
process and protuberatina occipitalis ext.
Inferior boundery – plain formed by the suprasternal
notch, clavicle and the spinous process of the seventh
cervical vertebra.
Osteomuscular system is adapted to the upright human
posture.
Visceral part of the neck contains upper aerodigestiv tract,
the carotic sheath and its contents on each side and
cervical lymphatic systém
There is on the neck cca 200 lymphnodes
Lymphnodes of the neck
Nodi cervicales superficiales
• Along v. jug. ext. Tributari zone: parotis, retruaurik. krajinu, intraparotické uzliny, okcipitální
uzliny.
Nodi lymphatici cervicales profundi
• They are in the carotid sheath.
Superior group (subdigastric)
• Lymph channels lead to this regional lymph nodes (group) from the tributary tissue area: soft
palate, tonsills, radix linguae, supraglotis, sinus piriformis.
• Nodus jugulodigastricus = Woodova uzlina= Küttnerova uzlina= Chassegnacova uzlina je v
Middle group
• Tributary tissue area: supraglotis, glandula thyreoidea, sinus piriformis. Boundary to the
crossing of m. omohyoideus and carotid sheath.
Inferior group
• Tributary tissue area: subglottis, trachea, cervikální jícen, glandula thyreoidea. „Great venous
angle“ = the left jugulosubclavian angle. In this area is Troisier-Wirchow lymph node. Ductus
thoracicus (thoracic duct) receive afferents from the lower half of the body, the cranial area.
Lymphatic chain at n. accessorius
• Tributary tissue area: nasopharynx, orofarynx, paranasal sinuses..
Lymphatic chain along vasa transversa colli
• nodi supraclaviculares - těsně nad klíční kostí.
Special groups of lymphnodes
• Nodi submentales, retropharyngei (největší z nich je Rouvierova uzlina), paratracheales,
nodus praelaryngicus (Poirierova uzlina).
Investigation
 aspection
 palpation
 ultrasound, Doppler technique - provide information
abokut vascular lesions, distinguish between cyst and
solid tumor
 computed tomography - allows greater differentiation :
vascular lesion, tumors, cysts - including their position
and extent
 biopsy
 cervical lymphography - is of little clinical value when
compared with other methods of investigation.
 MRI
 scintigraphy
Summary of
findings
 form and size in cm,
 site (lokalizaci),
topographic description
 consistency - soft,
elastic, fluctuant, firm or
hard
 mobility - vertically or
horizontally, fixed or
adherent
 pulsation, skin appearance
of the skin,
comparison to the
surrounding tissues
„Sentinell lymphnode“
 First lymphnode to which the lympha is comming
from primary tumor. If there are no metastasis,
the probability of metastatic spread is low.
 Identification –
– Through surgery - peritumoras application of
lymphotrop agent (koloidní roztoky označené
radioaktivním techneciem, barvivo).
– Before surgery – lymfoscintigraphy 1 day before surg.
 Palpation- až 1/3 of cases fals negative or fals
positive.
 UZ - senzitivita 94 % a specifita 91 % (závisí na
zkušenosti interpreta)
 FNAB fine needle aspiration cytology and biopsy
guided by ultrasound - až 76 % senzitivita a 100
% specifita
 Reliability od CT scan k průkazu metastatického
postižení krčních uzlin bývá udávána mezi 72 % -
93 %
 PET jeví vyšší senzitivitu, ale má nižší specifitu
než CT vyšetření.
 Combination of evaluation methods shows
presence of neck metastasis approx. v 70 %
případů, to znamená, že asi 30 % nemocných bez
klinických známek metastáz je ohroženo
lokoregionálním relapsem z mikrometastáz ve
spádových krčních uzlinách.
Metastasis of cancer
into neck lymphnode
Ca gl. thyreoidea
Differential diagnosis of tumors of
the neck
Lymphnodes X Extra lymphnodes
Inflammatory Cervical
Lymphadenopathy
Tumors
Congenital Anomalies
Inflammatory Cervical
Lymphadenopathy
acute - lymph nodes are painful
Chronic non specific lymphadenitis
shows on repeated infections in the region of pharynx in past. Persistent or recurrent lymph
node swellings are not compatible with a diagnosis of nonspecific lymphadenitis.
Chronic specific lymphadenitis tuberkulóza,
sarkoidóza.
Lymphadenitis retikulocullaris abscedens
Cat Scatch Fever the pustulous primary focus, which tends to ulcerate, occurs in the skin, .
This is followed 1 to 5 weeks later by a regional lymphadenopathy. In one third of cases a
fistula forms.Is caused by the cat scratch virus.
Tularemie.
Lymphadenitis with changes in blood account
mononucleosis infectiosa, rubeola, adenovirosis, hepatitis epidemica, viral pneumonia,
listeriosis, toxoplasmosis, lymphadenitisafter hydantoin
Rare lymphadenitis
kolagenózy, lues, mykózy.
Tumors
Benign
hemangiomas, lymphangioma (Cystic Hygroma), chemodectoma, lipomas (Morbus Madelungbenign
symetric lipomatosis of the neck)
Malignant lymph node tumors
Malignant lymphomas Hodgkin´s disease, Non - Hodgkin´s lymphoma. Treatment according to
oncologist.- actino- and chemotherapy.
Primar neck cancer
Thyroid gland , tzv. „branchiocarcinoma“ from lateral Branchial Fistulae and Cysts.
Lymph Node Metastases
treatment - surgery.
TNM classification:
N1 single homolateral less than < 3 cm;
N2 single homolateral > 3 cm < 6 cm
more homolateral lymph nodes< 6 cm
bilateral or contralateral < 6 cm
N3 > 6 cm
Congenital Anomalies
 lateral Branchial Fistulae and Cysts
 thyreoglossal Duct cysts and
fistulae (medial)
Inflammatory neck swelling - actinomycosis
Morbus
Madelung
benign symmetrical
lipomatosis
Morbus
Madelung
Metastasis
of
oropharyngeal
cancer
Karcinom orofaryngu s
metastázou na krku vlevo
Glomus tumor
left
Tumor
parotis
Mixtumor
parotis
Nádor parafaryngeálního
prostoru
Pokročilý
karcinom
slinné žlázy
Pokročilý karcinom hrtanu s metastázami na
krku – pacient před rokem odmítl léčbu
The methods of surgical treatment
of lymph node metastases
Surgery from external approach
Combinated with
Radiotherapy
The methods of treatment
Prescalene node biopsy (Daniels operation)
The radical curative neck dissection (Resectio venae jugularis
internae en bloc sec. Crile 1906) - the upper boundary of the
operation is the base of the skull and the lower boundary lies
at the level of the clavicle. The sternocledomastoid muscle, the
internal jugular vein are removed.
The goal of neck dissection is complete removal of lymph nodes
and vessels between the superficial and deep cervical fascia.
Functional deck dissection- the sternocleidomastoid muscle, the
internal jugular vein, the accessory nereve are preserved.
An elective neck dissection is a neck dissection carried out in the
absence of palpable lymph nodes for a primary tumor which
experience has shown to have a high metastatic rate oropharynx,
hypopharynx, supraglottic larynx, tghe bgase of
the tongue. The purpose of this operation is to deal with
micrometastases. In treatment for metastasis there is used a
combination with actinotherapy.
The Memorial Sloan Kettering
Cancer Center classification
 Oblast I - submentální a submandibulární
trojúhelník
 Oblast II - ohraničena ventrálně zadním
bříškem m. digastricus, kraniálně bazí leabní,
dorsálně zadní hranou kyvače a kaudálně
jazylkou a bifurkací a. car. communis.
 Oblast III - kraniálně ohraničena jazylkou a
bifurkací, ventrálně skeletem hrtanu, dosrálně
zadní hranou kyvače a kaudálně m.
omohyoideus, který ji odděluje od oblasti IV.
 Oblast IV - končí nad klíčkem.
 Oblast V - laterální krční trojhúhelník
ohraničený zadním okrajem kyvače, hranou m.
trapesius a klavikulou.
 Oblast VI – přední krční trojhúhelník
I submandibulární a
submentální uzliny
II horní jugulární uzliny
III střední jugulární
uzliny
IV dolní jugulární uzliny
V uzliny v zadním krčním
trojúhelníku a oblast
VI uzliny v předním
krčním trojúhelníku.
Classification of neck dissections
(Ferlito 2011)
• ND – symbol for neck dissection
• Letter L,R – description of side
• Removed regions of neck lymph nodes,
descripted by number I-VII (incl. A,B u obl. I,II a V)
• Removed non lymphatic structures n.XI, IJV, MSC)
Example:
ND R (I-V, SCM, IJV) = modified radical neck dissection right
with sparing of n. XI a m. sternocleidomastoideus
Modified radical neck dissection right with sparing of
n. XI
(ND L (I-V, SCM, IJV) )
Neck block dissection