THE NECK

CONTENTS

Preface xi
Eric J. Dierks and R. Bryan Bell

Dedication xiii
Eric J. Dierks and R. Bryan Bell

GENERAL CONSIDERATIONS

Radiographic Correlation with Neck Anatomy 311

James C. Anderson and James A. Homan
The anatomy of the head and neck is an important set of knowledge for the oral and
maxillofacial surgeon. Current imaging techniques and the exquisite detail that they
provide are frequently the first glimpse at disease and important to surgical planning.
CT and MRI are the primary modes of neck imaging and are complimentary in the
information that they provide. This article reviews the current methods of anatomic
imaging and the current methods of analysis of the region by radiologists.

Neck Masses: Evaluation and Diagnostic Approach 321

Jason Lee and Rui Fernandes
Oral and maxillofacial surgeons frequently deal with patients who present with an
unknown neck mass. Formulation of a differential diagnosis is essential and requires that
the surgeon bring to bear a host of skills to systematically arrive at a definitive diagnosis
and ensure that the correct treatment is rendered. This article highlights some of the
skills needed in the workup of neck masses and reviews some of the available techniques
that aid in achieving the correct diagnosis.

NON-NEOPLASTIC DISORDERS

Congenital Neck Masses 339

Peter A. Rosa, David L. Hirsch, and Eric J. Dierks
Congenital neck lesions reflect abnormal embryogenesis in head and neck development.
A thorough knowledge of embryology and anatomy is critical in the diagnosis and
treatment of these lesions. The appropriate diagnosis of these lesions is necessary to
provide appropriate treatment and long-term follow up, because some of these lesions
may undergo malignant transformation or be harbingers of malignant disease.

VOLUME 20 Æ NUMBER 3 Æ AUGUST 2008 v

Deep Space Neck Infection: Principles of Surgical Management 353
Timothy M. Osborn, Leon A. Assael, and R. Bryan Bell
Knowledge of the management of infections of the deep spaces of the neck is essential to
the daily practice of oral and maxillofacial surgery. Timely decisions must be made
through the acute course of the disease. Interventions must be performed with the
appropriate surgical skill. The surgeon must decide on medical and surgical manage-
ment, including antibiotic selection, how to employ supportive resuscitative care, when
to operate, what procedures to perform, and how to secure the airway. To make these
decisions the surgeon must understand the anatomy of the region and the etiology of
infection, appropriate diagnostic workup, and medical and surgical management. This
article provides a review of these pertinent topics.

Deep Neck Infections: Clinical Considerations in Aggressive Disease 367

John F. Caccamese Jr. and Domenick P. Coletti
Deep neck infections are common and occur as a consequence of several etiologies.
Antibiotic therapy, interventional radiology, and patient support modalities have
become increasingly sophisticated, although surgery continues to be the mainstay of
treatment for most patients. Today, neck infections are rarely life threatening when
sound and timely management is applied.

Cervical Spine Injuries 381

Jeff W. Chen
This article describes the anatomy of the cervical spine and the most common types of
fractures associated with the cervical spine. Cervical spinal cord syndromes are also
reviewed because such syndromes discovered during neurologic examinations
frequently provide the first clue that there is an underlying spinal cord injury. Because
most associated maxillofacial and spinal injuries occur in the setting of motor vehicle
accidents, it is particularly important for the maxillofacial surgeon to be cognizant of the
injuries, particularly in the context of the need for facial/cranial surgery. Appropriate
measures are necessary to immobilize or fixate the spine before surgery to avoid
exacerbating the spinal injury.

Penetrating Neck Injuries 393

Shahrokh C. Bagheri, H. Ali Khan, and R. Bryan Bell
The modern approach to patients presenting with penetrating injuries to the neck
requires the cautious integration of clinical findings and appropriate imaging studies for
formulation of an effective, safe, and minimally invasive modality of treatment. The
optimal management of these injuries has undergone considerable debate regarding
surgical versus nonsurgical treatment approaches. More recent advances in imaging
technology continue to evolve, providing more accurate and timely information for the
management of these patients. In this article the authors review both historic and recent
articles that have formulated the current management of penetrating injuries to the neck.

Management of Laryngeal Trauma 415

R. Bryan Bell, David S. Verschueren, and Eric J. Dierks
Fractures of the larynx are uncommon injuries that may be associated with maxillofacial
trauma. Clinicians treating maxillofacial injuries should be familiar with the signs and
symptoms of laryngeal fractures and with proper airway management. A timely
evaluation of the larynx, rapid airway intervention, and proper surgical repair are
essential for a successful outcome.

vi CONTENTS
NON-SQUAMOUS NEOPLASMS

Thyroid Disorders: Evaluation and Management of Thyroid Nodules 431

James I. Cohen and Kelli D. Salter
Although thyroid nodules are a common clinical entity, few (5% to 10%) are malignant
and require surgical treatment. Most nodules are discovered incidentally in patients
undergoing surveillance for medical reasons unrelated to thyroid disorders. Therefore, a
systematic approach to their evaluation is important to avoid unnecessary surgery. High-
resolution ultrasonography and fine-needle aspiration have resulted in substantial
improvements in diagnostic accuracy, cost reductions, and higher malignancy yield at
the time of surgery. In this article, the authors present practical guidelines and a
suggested management strategy for the effective diagnosis and management of
incidentally discovered thyroid nodules.

Clinical Implications of the Neck in Salivary Gland Disease 445

Andrew R. Salama and Robert A. Ord
Neck manifestations from salivary gland tissue are most commonly related to
inflammation and obstruction of the glands. However, various benign and malignant
processes are also seen along a continuum of clinical presentation and behavior.
Preoperative diagnostics, including imaging and fine needle aspiration, are key elements
in treatment planning, even in the absence of absolute histologic confirmation of tumors.
Benign tumor implants in the neck can be managed with conservative surgery, whereas
aggressive surgical management, including neck dissection and adjuvant therapy, is
generally advocated for malignancy.

SQUAMOUS CELL CARCINOMA

Neck Dissection: Nomenclature, Classification, and Technique 459

Jon D. Holmes
Lymph node status is the single most important prognostic factor in head and neck
cancer because lymph node involvement decreases overall survival by 50%. Appropriate
management of the regional lymphatics, therefore, plays a central role in the treatment of
the head and neck cancer patients. Performing an appropriate neck dissection results in
minimal morbidity to the patient, provides invaluable data to accurately stage the
patient, and guides the need for further therapy. The purposes of this article are to
present the history and evolution of neck dissections, including an update on the current
state of nomenclature and current neck dissection classification, describe the technique of
the most common neck dissection applicable to oral cavity cancers, and discuss some of
the complications associated with neck dissection. Finally, a brief review of sentinel
lymph node biopsy will be presented.

Management of the N0 Neck in Oral Squamous Cell Carcinoma 477

Allen Cheng and Brian L. Schmidt
Oral squamous cell carcinoma (SCC) has an unpredictable capacity to metastasize to the
neck, an event that dramatically worsens prognosis. Metastasis occurs even in earlier
stages when no neck lymph node involvement is clinically detectable (N0). Management
of the N0 neck, namely when and how to electively treat, has been debated extensively.
This article presents the controversies surrounding management of the N0 neck, and the
benefits and pitfalls of different approaches used in evaluation and treatment. As current
methods of assessing the risk for occult metastasis are insufficiently accurate and prone
to underestimation of actual risk, and because selective neck dissection (SND) is an

CONTENTS vii
 effective treatment and has minimal long-term detriment to quality of life, the authors
believe that all patients who have oral SCC, excluding lip SCC, should be prescribed
elective treatment of the neck lymphatics. However, this opinion remains controversial.
Because of the morbidity of radiation therapy and because treatment of the primary
tumor is surgical, elective neck dissection is the preferred treatment. In deciding the
extent of the neck dissection, several retrospective studies and one randomized clinical
trial have shown SND of levels I through III to be highly efficacious.

Management of the Node-Positive Neck in Oral Cancer 499

Dimitrios Nikolarakos and R. Bryan Bell
Surgery continues to play a prominent role in the management of patients with loco-
regionally advanced squamous cell carcinoma of the upper aerodigestive tract. Most
evidence supports the use of comprehensive neck dissection for node-positive disease
and suggests that planned neck dissection following definitive radiation therapy and
chemoradiation therapy is unnecessary in the great majority of patients with node-
positive neck disease who exhibit a complete response. Evidence for less aggressive
therapy is much less compelling in patients with bulky adenopathy. For such patients,
there is growing enthusiasm for selective or even super-selective neck dissection for
surgical salvage. Finally, when cervical disease is so advanced as to involve the carotid
artery, evidence continues to portend a dismal prognosis.

SURGICAL TECHNIQUE

Tracheotomy: Elective and Emergent 513

Eric J. Dierks
Tracheotomy has been practiced since ancient times and continues to be a crucial
procedure. Contemporary elective adult tracheotomy is described in detail. Intra-
operative and postoperative complications can arise with elective tracheotomy. Pediatric
and obese patients require special consideration when undergoing a tracheotomy. The
emergency cricothryroidotomy and ‘‘slash’’ tracheotomy are discussed. Continuing
education regarding advances in tracheotomy procedures is advised.

Preparation of the Neck for Microvascular Reconstruction of the Head and Neck 521
Jason K. Potter and Timothy M. Osborn
Reconstruction of congenital, developmental, or acquired head and neck defects remains
a significant challenge for the oral and maxillofacial surgeon. Microvascular free tissue
transfer has several advantages over nonvascularized bone grafts and pedicled soft
tissue flaps that currently make it the modality of choice for the reconstruction of
extirpative defects of the head and neck. Preoperative planning must include detailed
attention to the technical aspects of the microvascular procedure. This includes a
thorough understanding of the vascular anatomy of the patient’s neck; vascular anatomy
of the various flaps including pedicle lengths; and a knowledge of how to facilitate
microvascular surgery in the neck and to manage complicating factors in the difficult
neck.

Index 527

viii CONTENTS
 FORTHCOMING ISSUES

November 2008
Head and Neck Manifestations of Systemic Disorders
Sidney L. Bourgeois, Jr, DDS, Guest Editor

February 2009
Complications of Cosmetic Facial Surgery
Joseph Niamtu III, DMD, Guest Editor

May 2009
Current Controversies in Maxillofacial Trauma
A. Omar Abubaker, DMD, PhD and
Daniel M. Laskin, DDS, MS, Guest Editors

PREVIOUS ISSUES

May 2008
Orofacial Pain and Dysfunction
Ramesh Balasubramaniam, BDSc, MS and
Gary D. Klasser, DMD, Guest Editors

February 2008
Practice Management
M. Todd Brandt, DDS, MD, Guest Editor

November 2007
Topics in Bone and Bone Related Disorders
Mark R. Stevens, DDS, Guest Editor

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 Oral Maxillofacial Surg Clin N Am 20 (2008) xi–xii

Preface

Eric J. Dierks, DMD, MD, FACS R. Bryan Bell, DDS, MD, FACS
Guest Editors

Learning is not attained by chance, it must be sought not proficient in, the management of a wide vari-
for with ardor and attended to with diligence. ety of cervical disorders.
Abigail Adams (1744–1818) The neck contains seven different organ sys-
The American Association of Oral and Max- tems and is one of the most complex anatomic
illofacial Surgeons defines oral and maxillofacial regions in the human body. Any or all of these
surgery as the specialty of dentistry that includes systems may be affected by a variety of congen-
the ‘‘diagnosis, surgical and related treatment of ital, developmental, and acquired abnormalities,
diseases, injuries and defects involving both the so an interdisciplinary approach to treatment
functional and esthetic aspects of the hard and often is necessary. Multiple surgical specialties
soft tissues of the head, mouth, teeth, gums, jaws overlap in this critical area; in addition to oral
and neck’’ [emphasis added]. In preparing this and maxillofacial surgery they include otolaryn-
issue of the Oral and Maxillofacial Clinics of gology, plastic surgery, neurosurgery, and tho-
North America, we recognize that the training of racic surgery, as well as general surgery and its
American oral and maxillofacial surgeons in the subspecialties of vascular, trauma, and endocrine
surgical and nonsurgical management of condi- surgery. To provide a contemporary and concise
tions affecting the neck is varied. We also recog- review of cervical disorders, we have invited
nize that our relatively young surgical specialty practitioners of a number of these allied disciplines
continues to mature as it advances the education whose areas of expertise complement those of the
of its members through formal fellowship training oral and maxillofacial surgeon to contribute their
in head and neck oncologic surgery, cranio-maxil- experience. We are deeply indebted to all the
lofacial trauma, pediatric cleft and craniofacial authors for their excellent and timely contributions
surgery, and esthetic surgery. As the profession and gratefully acknowledge the sacrifice of time and
matures, there is and will be a need for all oral energy that is necessary to generate a quality
and maxillofacial surgeons to be familiar with, if product.

1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.04.006 oralmaxsurgery.theclinics.com
xii PREFACE

‘‘To whom much is given, much is expected.’’ Eric J. Dierks, DMD, MD, FACS
Both of us have been fortunate in our personal and Oral and Maxillofacial Surgery Service
professional lives to be surrounded by individuals Legacy Emanuel Hospital and Health Center
who have made indelible impressions on us through Department of Oral and Maxillofacial Surgery
their confidence, industry, mentorship, friendship, Oregon Health & Science University
support, and love. We are each beholden to our Head and Neck Surgical Associates
professional fathers: Don A. Hay, Gene R. Hueb- 1849 NW Kearney, Suite 300
ner, Timothy A. Turvey, Raymond P. White, Bryce Portland, OR 97209
E. Potter, and Eric J. Dierks (RBB), and to Edwin
E-mail address: [email protected]
Granite, Brian Alpert, and William Meyerhoff
(EJD). We thank our colleagues, Leon Assael,
Robert Myall, Kevin Arce, William B. Long, for R. Bryan Bell, DDS, MD, FACS
their guidance and support; and our parents, Oral and Maxillofacial Surgery Service
William and Sherry Bell and Al and Harriett Legacy Emanuel Hospital and Health Center
Dierks, for their stimulation and inspiration. To Department of Oral and Maxillofacial Surgery
our wives, Heidi Bell and Barbara Dierks, we owe Oregon Health & Science University
everything. Head and Neck Surgical Associates
1849 NW Kearney, Suite 300
Portland, OR 97209
E-mail address: [email protected]
 Oral Maxillofacial Surg Clin N Am 20 (2008) xiii

Dedication

William H. Bell, DDS

We respectfully dedicate this edition of the books remain contemporary 40 years after their
Oral and Maxillofacial Surgery Clinics to Dr. Wil- publication. He has devoted his life to improving
liam H. Bell, who, in different ways and at differ- the human condition through patient care and
ent points in our careers, served as a continual to the advancement of surgery through research
source of inspiration. In the late 1960s, Dr. Bell and education. Now in his sixth decade as an oral
contributed to the transformation of our Ameri- and maxillofacial surgeon, at a time when our spe-
can specialty from that of oral surgery to one of cialty is again evolving, he continues to expand
oral and maxillofacial surgery through his land- our collective horizons through his teaching and
mark research on the biologic basis for the Le international outreach. It is our hope that the fire
Fort I osteotomy. His subsequent textbooks pro- that burns in him will ignite the spirits of genera-
vided a detailed description of the surgical correc- tions of surgeons to come for the betterment of
tion of dentofacial deformities and served as patients whom it is our privilege to serve.
a reference for thousands of surgeons in multiple
disciplines across the globe. It is a testament to Eric J. Dierks, DMD, MD, FACS
his meticulous attention to detail and passionate R. Bryan Bell, DDS, MD, FACS
pursuit of excellence that in many ways these

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 Oral Maxillofacial Surg Clin N Am 20 (2008) 311–319

Radiographic Correlation with Neck Anatomy

James C. Anderson, MD*, James A. Homan, MD
Division of Neuroradiology, Department of Radiology, Oregon Health & Science University,
3181 S.W. Sam Jackson Park Road, Mail Code L340, Portland, OR 97239–3098, USA

The anatomy of the head and neck is an anatomy in ways that can help visualize anatomy,
important set of knowledge for the oral maxillo- disease, and provide insight into surgical ap-
facial surgeon. Current imaging techniques and proaches [1]. Intravenous iodinated contrast en-
the exquisite detail that they provide are fre- hancement is generally used to help identify
quently the first glimpse at disease and important vascular structures and potentially contrast en-
to surgical planning. CT and MRI are the primary hancing pathology.
modes of neck imaging and are complimentary in Although contrast-enhanced CT provides ex-
the information that they provide. This article cellent detail of the vasculature of the neck, allow-
reviews the current methods of anatomic imaging ing one to evaluate both the venous and arterial
and the current methods of analysis of the region systems, CT angiography is performed to provide
by radiologists. additional resolution and detail to the vascula-
ture. Multidetector CT scanners allow for rapid
high-resolution acquisition of data timed to cor-
Imaging
respond to the contrast bolus passing through the
CT arterial system of the neck. This method has
developed to a point where CT angiography chal-
Although CT has long been one of the primary lenges catheter angiography as the initial method
methods of imaging the head and neck, current to evaluate the vasculature of the neck [2,3].
scanners have several advantages over the pre-
vious generations of scanners. Multidetector spi-
ral (helical) scanners now are composed of an MRI
array of detector elements mounted in a gantry MRI examinations of the neck are generally
that can continually rotate while the table and customized for the anatomic area of interest and
patient move through the scanner. This has the clinical history. Different techniques, coils,
largely replaced the ‘‘step-and-shoot’’ process of and sequences can be used for areas adjacent
earlier CT scanners. This configuration allows to the skull base versus the infrahyoid region.
extremely rapid acquisition of a volume data set. Because of the large number of variables that can
The practical advantage is less motion artifact be manipulated during scanning, customization
from the rapid scan and a data set that allows for and careful attention to scan quality are vital to
multiplanar manipulation after data acquisition. obtain information that is clinically useful.
Postprocessing in the coronal or sagittal planes Although there is no clear superiority of MRI
(and into any other nonstandard plane) and into or CT, MRI does have the advantage in the area
three-dimensional volume-rendered images and of soft tissue contrast. Depiction of normal soft
various slice thicknesses allows depiction of the tissue anatomy and pathologic process is excellent
with MRI. The relative lack of dental artifact on
MRI gives it the advantage when evaluating the
* Corresponding author. oral cavity and to some extent the oral pharynx and
E-mail address: [email protected] adjacent regions. CT data can be markedly de-
(J.C. Anderson) graded by the streak artifacts from dental
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.02.001 oralmaxsurgery.theclinics.com
312 ANDERSON & HOMAN

hardware. Although there are methods of scanning

off plane to reduce the area affected by the artifact,
this involves additional scanning and increased
radiation exposure. Previously stated advantages
of MRI to image in multiple planes has been
lessened somewhat by the advent of multidetector
spiral CT scanners, which allow manipulation of
the data into alternate planes to the usual trans-
verse plane [4].
Contrast use in MRI with gadolinium-based
compounds is generally safe, although awareness
of the possibility of contrast reactions and for
nephrogenic systemic fibrosis in patients with
impaired renal function, which is a relatively
new concern, should be considered [5].

Neck anatomy
The complexity of neck anatomy has led to
Fig. 1. Normal upper aerodigestive tract. This sagittal
various means of organizing the structures for upper aerodigestive tract illustrates its major subdivi-
analysis. One of the more entrenched methods is sions: the nasopharynx (N), oropharynx (OP), oral cav-
based on the location of and spread of squamous ity (OC), hypopharynx (HP), and larynx (L). Only the
cell cancer of the mucosa in the head and neck. most cephalad aspect of the larynx and hypopharynx
This uses the terms ‘‘nasopharynx,’’ ‘‘oral phar- is above the hyoid bone (arrow). This traditional method
ynx,’’ ‘‘hypopharynx,’’ and ‘‘larynx’’ to divide the of subdivision for the upper aerodigestive tract follows
neck into locations of the primary disease. This along the lines of the primary sites in the extracranial
method of division defines the areas by the head and neck where squamous cell carcinoma is found.
This traditional terminology remains central to the stag-
directly visualized mucosa and anatomic struc-
ing issued in squamous cell carcinoma of the upper aero-
tures. Radiographically, these areas can be de-
digestive tract.
fined and the extent of deep tissue invasion of
squamous cell cancer can be evaluated [6].
The nasopharynx is defined anteriorly by the
nasal choana and posteriorly by the prevertebral cell carcinoma, they do little to help with the
musculature, upper cervical spine, and inferior remainder of the anatomy deep to the mucosal
clivus. The lateral borders are the mucosal sur- surfaces when imaged in the traditional transverse
faces including the fossa of Rosenmüller and the plane of the cross-sectional imaging of CT and
eustachian tube. The inferior extent is the soft MRI.
palate and the imaginary line extending posteri-
orly from the hard and soft palate [6].
The oral pharynx is defined superiorly by the
Spaces
soft palate, and anteriorly by the ring of structures
composed of the posterior tongue (circumvallate Because of the transverse plane in which CT
papilla), the anterior tonsil pillars, and the soft imaging has long been viewed, radiologists have
palate. The inferior extent is the epiglottis and used various methods to describe the region in
glossoepiglottic fold and the phyngoepiglottic a manner that allows accurate communication of
fold. Posteriorly, the superior and middle con- both the anatomy and the disease processes of the
strictor muscles are the border [6]. head and neck. Unfortunately, there have been
The hypopharynx or laryngopharyx is the area debates about the terminology and definition of
inferior to the inferior margin of the oral pharynx, the fascia of the neck; it is difficult to define
and posterior to the larynx. It extends inferiorly to a single agreed on method for separating the
the lower border of the cricoid cartilage (Fig. 1) regions of the neck [6–10].
[6,7]. The method described next is primarily based
Although these definitions and divisions are on a system refined by Harnsberger. Although
useful in the staging and evaluation of squamous this may only be one of many methods, it has
 RADIOGRAPHIC CORRELATION WITH NECK ANATOMY 313

somewhat simplified the analysis of the neck when spaces. Each of these spaces contains a definable
imaged in the transverse plane. In this method the set of structures and is easily identified on cross-
fascial planes of the head and neck are used to sectional imaging and facilitates communication
divide the region into definable areas and as a between radiologists and clinicians [7].
means of systematically analyzing the complex
anatomy to help communicate the imaging find-
ings between colleagues. This spatial method of
Suprahyoid spaces
analysis has both an anatomic basis and is a
relatively systematic way to evaluate the neck in The sublingual space is located in the floor of
the transverse plane on CT and MRI. This the mouth with the mandible defining the antero-
method divides the neck into the suprahyoid and lateral border, the mylohyoid the inferiorly, hyoid
infrahyoid neck and then further divides regions posteriorly, and oral mucosa superiorly. The sub-
by the anatomic fascial planes. In this algorithm, lingual glands, deep lobes and ducts of the sub-
the facial structures are divided into the sinonasal mandibular glands, lingual arteries, nerves and
region, the orbit, and the oral cavity (Fig. 2). The veins, V3 branches from the trigeminal nerve,
remainder of the structures of the face and neck genioglossus, geniohyoid, styloglossus, palato-
are divided into spaces using the fascia as defining glossus, hyoglossus, and fat are contained within
structures. The spaces of the suprahyoid neck the sublingual space. Of pathologic importance,
are pharyngeal mucosal space, parapharyngeal the posterior margin of the sublingual space freely
space, masticator space, parotid space, carotid communicates with the submandibular and para-
space, retropharyngeal space, danger space, and pharyngeal spaces. A common description of the
perivertebral space. Additionally, there are the an- sublingual space is the ‘‘horizontal horseshoe.’’
atomic locations associated with the oral cavity The submandibular space lies superior to the
including the sublingual and submandibular hyoid and inferiolateral to the mylohyoid muscle
and freely communicates with the sublingual
space. This space contains the superficial lobes
of the submandibular glands, anterior bellies of
the diagastric muscles, and level 1A and 1B lymph
nodes. This space is also referred to as the
‘‘vertical horseshoe’’ [11].
The pharyngeal mucosal space is defined by the
mucosal surfaces of the nasopharynx, orophar-
ynx, and suprahyoid hypopharynx. The mucosal
surfaces of the oral cavity can be included, but
more commonly, the oral cavity is considered its
own space. The immediate submucosa is also
included; this space contains mucosa, lymphoid
tissue, minor salivary glands, and some muscular
tissue. MRI is considered the imaging modality of
choice for this space to evaluate for lesions that
cannot be directly visualized or for invasion deep
to the submucosa (Fig. 3) [12].
The parapharyngeal space is a primarily fat-
filled space extending from skull base to hyoid
bone. This space is defined in various ways by
Fig. 2. The ‘‘head and neck man.’’ In teaching and writ- various authors. Some authors divide this space
ing about the extracranial head and neck area the discus- into the prestyloid and poststyloid compartments;
sion is usually divided by the major anatomic regions others include portions of the deep parotid and
shown in this drawing. The suprahyoid neck (SHN) rep-
muscular tissue of the masticator. The primary
resents the deep core tissues posterior to the sinonasal
(S/N) and oral cavity (OC) areas. Below the level of area of debate on this space in the literature is
the hyoid bone (arrow) the infrahyoid neck (IHN) can whether the carotid sheath and its fascial layers
be seen. A distinct area within the infrahyoid neck is are the posterior border. For the purposes of this
the larynx (L). BOS, base of skull; CN, cranial nerves; article, however, the definition of this space is the
O, orbit; TB, temporal bone. one used by Harnsberger, which limits the
314 ANDERSON & HOMAN

Fig. 3. T1-wieghted transverse MRI at the level of the Fig. 4. Transverse CT image through the nasopharynx.
nasopharynx in the suprahyoid head and neck. The pha- Outlined in black is the parapharyngeal space as defined
ryngeal mucosa is well seen (arrows) as distinct from the by Harnsberger. This fat-filled structure is centrally lo-
fat and musculature deep to the mucosal surface. cated between the other spaces of the neck and is helpful
in determining location of origin of masses.

definition of the parapharyngeal space as the

primarily fatty-filled space that does not include the temporalis muscle. This more superior extent
parotid tissue, mucosa, muscle, bone, or nodes. (superior to the zygomatic arch) has been termed
The posterior border is the carotid space. The the ‘‘temporal fossa’’ or space; however, this is an
margins are limited medially by the middle layer anatomic designation only and no fascia separates
of the deep cervical fascia and laterally by a slip of these portions of the masticator space. Radiolo-
the superficial layer of the deep cervical fascia gists may refer to this area as the superior
separating it from the masticator and parotid. The masticator space or the suprazygomatic mastica-
contents of the parapharyngeal space defined in tor space; these are equivalent to the term ‘‘tem-
this manner are fat, vascular tissue, nerves, and poral fossa.’’ The common term ‘‘infratemporal
rare rests of salivary gland tissue (Fig. 4) [12,13]. fossa’’ is also part of the masticator space, being
The primary importance of the parapharyngeal the portion between the pterygopalatine fossa
space radiographically is that it serves as a marker medially and the zygomatic arch laterally. Also
to determine the location or origin of other path- of note, the parotid duct is superficial to the fascia
ology in the neck because it tends to be displaced and is not in the masticator space (Fig. 5) [14,15].
away from the site of origin of any mass. Dis- The parotid space is defined as the parotid
placement of the parapharyngeal space laterally gland and the structures that are within it, such as
implicates a lesion in the pharyngeal mucosa, post- the facial nerve, vessels, and the intraparotid
eriorly implicates the masticator space, anteriorly lymph nodes. CT is used to evaluate for stone
implicates the carotid space, anterolaterally impli- disease and some acute infections; however, MRI
cates the retropharyngeal space, and medial dis- is the modality of choice for imaging for masses,
placement implicates the lesion resides in the parotid perineural tumor spread, and autoimmune dis-
space. eases (Fig. 6) [16].
The masticator space is defined by the super- The carotid space is surrounded by the carotid
ficial layer of the deep cervical fascia (investing sheath, which has components of the investing
fascia). Medially, this extends from the deep edge and pretracheal layers of fascia. Within the
of the pterygoid muscles from the mandible to carotid sheath are the common and internal ca-
attach on the skull base medial to foramen ovale. rotid arteries, internal jugular vein, vagus nerve,
Laterally the fascia tracts along the superficial and other nervous tissue, and some deep cervical
masseter muscle to the zygomatic arch, then over lymph nodes. The carotid space extends from the
 RADIOGRAPHIC CORRELATION WITH NECK ANATOMY 315

Fig. 5. Transverse CT image through the nasopharynx. Fig. 7. Transverse CT image through the nasopharynx.
Outlined in white is the masticator space, which on this The carotid space is outlined in black and indicated by
image consists of the masseter muscle (M), mandibular the black arrowheads. The styloid process (white arrow)
ramus (R), and pterygoid muscules (Pt). Adjacent struc- lies anterior to the internal jugular vein (J). Masseter
tures include the parotid (P), styloid process (white ar- muscle (M) and parotid (P) are indicated.
row), internal carotid artery (C), internal jugular vein
(J), and vertebral artery (V). between the prevertebral layer of the deep cervical
fascia and the buccopharyngeal fascia. It is limited
skull base to the mediastinum and is in both the by the carotid sheaths lateral and also extends from
suprahyoid and infrahyoid neck (Fig. 7) [7,17]. skull base to mediastinum. It is primarily a potential
The retropharyngeal space and danger space space filled with loose connective tissue; however,
can be discussed together because they are situated in the suprahyoid portion there are lymph nodes
present, most notably the lateral retropharyngeal
nodes or nodes of Rouvière [18,19].
The perivertebral space is the area defined by
the prevertebral fascia, which encloses the bony
vertebra and surrounding muscles. This space is
divided into an anterior and posterior portion by
fascia that attaches to the transverse processes of
the vertebral bodies. This space extends both
suprahyoid and infrahyoid [20].

Infrahyoid
The infrahyoid neck can also be defined by
the anatomic facial planes and correlated with
the usual surgical approaches to these areas. The
traditional approach to these areas is the surgical
and gross dissection triangles. These triangles are
less easily defined and visualized using cross-
sectional imaging viewed in the transverse plane.
Fig. 6. Transverse CT image through the nasopharynx. Confusion often ensues when transverse images
The partotid spaces are outlined in white bilaterally. are viewed and attempted to be interpreted using
This space consists of the parotid gland, vessels, facial the anterior and posterior triangles as anatomic
nerve, and intraparotid lymph nodes. areas. An alternate method of analysis that is
316 ANDERSON & HOMAN

based on the cross-sectional images and fascially The visceral space is enclosed by the pretra-
defined spaces and can then be translated into the cheal layer of the deep cervical fascia, or to avoid
triangle vernacular has been devised. This con- confusion the visceral layer, because it surrounds
tinues the terminology and method developed for the tracheal, esophagus, and thyroid (Fig. 9). This
the suprahyoid neck [21]. extends from the hyoid into the thorax. Posteriorly
The anterior triangle is defined by the sternoclei- the visceral layer blends with the buccopharyngeal
domastoid muscle as the posterior and lateral fascia and laterally with the carotid sheath [21].
border, the midline is the medial border, and the The posterior cervical space is essentially the
inferior border is the clavicle. The triangle is further primarily fat-filled space, with some lymph nodes
divided by the hyoid bone into a suprahyoid and and the spinal accessory nerve, which lies between
infrahyoid components. The suprahyoid compo- the perivertebral space posteromedially, the ca-
nents of the submental and sublingual triangles are rotid space anteromedially, and the investing layer
not discussed here. The infrahyoid components are of the deep cervical fascia surrounding the ster-
further divided by the superior belly of the omo- nocleidomastoid muscle laterally. This space is
hyoid muscle into the muscular and carotid triangles. predominantly infrahyoid in location, although
The posterior triangle is defined anterorme- a small portion does extend superior to the hyoid.
dially by the sternocleidomastoid muscle, posteri- This space is essentially equivalent to the posterior
orly by the trapezius muscle, and inferiorly by the triangle [19,21].
clavicle. It is further divided by the inferior belly
of the omohyoid into the occipital and supra-
clavicular triangles [19].
Lymphatic system
The spatial analysis of the infrahyoid neck uses
the anatomic fascial planes to define five spaces, The use of imaging in the evaluation of the
two of which are unique to the infrahyoid anatomy cervical lymphadenopathy for neoplastic, inflam-
and the other three are continuations from the matory, and infectious processes is frequently
suprahyoid neck. These spaces are the visceral encountered in current medical practice. It is
space, carotid space, retropharyngeal space, peri- critical for the interpreting radiologist and con-
vertebral space, and posterior cervical space. The sulting surgeon to have a comprehensive knowl-
carotid, retropharyngeal, and perivertebral spaces edge base and understanding of the normal
have been discussed previously (Fig. 8). cervical lymphatic anatomy.

Fig. 8. (A) Transverse CT image through the infrahyoid neck. The investing fascia is highlighted and demonstrates it
splitting around the sternocleidomastoid muscule (SCM) and the trapezius muscle (T). (B) Transverse image through
the infrahyoid neck. The prevertebral fascia is highlighted. This fascia defines the perivertebral space, which is both
suprahyoid and infrahyoid in location, extending from skull base into the thoracic region.
 RADIOGRAPHIC CORRELATION WITH NECK ANATOMY 317

bounded by the skull base, hyoid bone, stylohyoid

muscle, and the posterior border of the sterno-
cleidomastoid muscle. This level is subclassifed
into IIA and IIB by a vertical plane created by the
spinal accessory nerve. Level IIA is anterior and
level IIB is posterior to the spinal accessory nerve.
The drainage received by this level includes oral
cavity, nasal cavity, nasopharynx, oropharynx,
hypopharynx, larynx, and parotid gland.
Level III is the middle jugular nodes and
delineated by the hyoid, cricoid cartilage, poste-
rior sternocleidomastoid muscle, lateral sterno-
hyoid muscle, common carotid, and internal
carotid. Lymph drainage into this level is from
the oral cavity, nasopharynx, oropharynx, hypo-
pharynx, larynx, and parotid gland.
Fig. 9. Transverse image through the infrahyoid neck at Level IV is the lower jugular nodes and located
the level of the cricoid cartilage (white arrow). The prever-
within the borders created by the cricoid cartilage,
tebral layer of the deep cervical fascia (or visceral fascia) is
highlighted in white. This fascia encircles the thyroid gland
clavicle, lateral sternohyoid, common carotid, and
(T), larynx, and esophagus. Posterior to the visceral space is posterior sternocleidomastoid muscle. Hypophar-
the retropharyngeal space (black arrowheads), which is seen ynx, thyroid, esophagus, and larynx all drain into
as a thin dark line of fat between the esophagus and the this nodal group.
vertebral body. C, carotid artery; J, internal jugular vein. Level V posterior triangle group are inferior to
the spinal accessory nerve and transverse cervical
artery and bounded by the trapiezus muscle,
The cervical lymphatic system demonstrates posterior sternocleidomastoid muscle, and clavi-
characteristic drainage patterns that involve nu- cle. This level is also separated into VA spinal
merous chains and clusters. These patterns of accessory nodes from VB transverse cervical-
drainage were categorized into zones for prognos- supraclaviclular nodes by a horizontal line ex-
tic importance and reproducible anatomic locali- tending from the cricoid. Drainage is from the
zation for neck dissection. The system currently in nasopharynx, oropharynx, and cutaneous struc-
place is the revised Neck Dissection Classification tures from the neck and posterior scalp.
by the American Head and Neck Society and The final group is the level VI anterior com-
American Academy of Otolarynogology-Head partment, which includes the prelaryngeal, pre-
and Neck Surgery that divides the cervical lym- thyroid, and pretracheal and paratracheal nodal
phatic system into separate levels [22]. groups. This compartment is bounded by the
Currently, the system organizes each side of hyoid, suprasternal notch, and lateral boundaries
the neck into six levels, with levels I, II, and V of the common carotid arteries. These nodes
further subclassified secondary to additional path- receive drainage from the thyroid gland, larynx,
ologic importance. Level I lymph nodes include piriform sinus, and esophagus.
the submental and submandibular groups. The Lymph nodes not located within these regions
submental nodal group (level IA) is bounded by are designated by their specific anatomic location.
the triangle formed by the anterior belly of the Examples include retropharyngeal, parotid, buc-
diagastric and hyoid bone and receives drainage cinator, postauricular, malar, mandibular, in-
from the floor of the mouth, anterior oral tongue, fraorbital, and suboccipital groups.
lower lip, and mandibular alveolar ridge. The
submandibular nodal group (level IB) is bounded
by the triangle formed by the anterior bellies of
Radiographic-based lymph node classification
the diagastric, stylohyoid, and body of the man-
dible. This level receives drainage from the oral Unfortunately, not all of the designated ana-
cavity, midface soft tissues, submandibular gland, tomic boundaries are radiographically apparent.
and anterior nasal cavity. Radiologists have devised substitutes that approxi-
Level II is the upper jugular lymph nodes mate the surgical landmarks (Box 1). The stylohyoid
including the jugulodigastric node, which are muscle and spinal accessory nerve are examples with
318 ANDERSON & HOMAN

Box 1. Radiographic-based lymph node posterior border of the

classification sternocleidomastoid muscle and
medial to the common and internal
Level I nodes are contained superiorly by carotid arteries.
the mylohyoid muscle, inferiorly by Level IV (lower jugular) nodes are
the lower body of the hyoid bone, and contained superiorly by the lower
anteriorly by an imaginary coronal line margin of the cricoid, inferiorly by the
at the posterior margin of the clavicle, anterolateral by an oblique
submandibular gland on axial line from the posterior margin of the
imaging. Level I nodes are further sternocleidomastoid, and medially by
subdivided into IA and IB. the common carotid artery.
Level IA (submental) nodes are those Level V nodes are contained posteriorly
level I nodes contained laterally by the by a coronal line on axial imaging from
medial aspects of the anterior the anterior margin of the trapezius
diagastric muscles, superiorly by the muscle and anteriorly by the posterior
mylohyoid, and inferiorly by the lower margin of the sternocleidomastoid
body of the hyoid. from the skull base to the clavicle.
Level IB (submandibular) nodes are level Level V nodes are also subdivided into
I nodes contained superiorly by the VA and VB nodes.
mylohyoid, inferiorly by the lower Level VA (spinal accessory) nodes are
body of the hyoid, medially by the level V nodes superior to a horizontal
medial aspects of the anterior line from the lower margin of the
diagastric muscles, and posteriorly by cricoid cartilage to the skull base.
a coronal line at the posterior aspects Level VA (transverse cervical/
of the submandibular gland. supraclavicular) nodes are those level
Level II (upper jugular) nodes are V nodes that lie inferior to the lower
contained superiorly by the skull base margin of the cricoid and clavicle.
from the margin of the jugular fossa and Level VI (anterior compartment) nodes
inferiorly to the lower body of the hyoid. are contained superiorly by the lower
The anterior border is the imaginary body of the hyoid and inferiorly by the
coronal line that extends from the sternal manubrium. These nodes also
posterior edge of the submandibular lie medial to an imaginary sagittal line
gland. The posterior border is an through the common and internal
imaginary coronal line at the posterior carotid arteries.
aspect of the sternocleidomastoid
muscle on axial imaging. Any lymph
nodes medial to an imaginary sagittal the posterior submandibular gland and fat plane
line through the carotid artery are posterior to the internal jugular vein being the ra-
referred to as ‘‘retropharyngeal’’ and not diographic correlates, respectively [23,24].
level II. Level II nodes are subclassified
into IIA and IIB.
Level IIA nodes are anterior, lateral, Summary
medial, and posterior but inseparable This article reviews the anatomy of the head
from the internal jugular vein. and neck with regards to its radiology. A brief
Level IIB nodes lie posterior to the discussion of the current imaging modalities is
internal jugular vein separated by provided. The various methods of visualizing,
a visible fat plane. analyzing, and communicating this complex re-
Level III (middle jugular) nodes are gion of anatomy are correlated.
contained superiorly by the lower
body of the hyoid and inferiorly by the
lower margin of the cricoid cartilage. References
These nodes also lie anterior to the
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ing with MDCT. Eur J Radiol 2003;45(Suppl 1):S23–31.
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[2] Brant-Zawadzki M, Heiserman JE. The roles of MR imaging. 3rd edition. St. Louis (MO): Mosby;
angiography, CT angiography, and sonography in 1996. p. 915–51.
vascular imaging of the head and neck. AJNR Am [14] Harnsberger HR. The masticator space. In:
J Neuroradiol 1997;18(10):1820–5. Harnsberger HR, editor. Handbook of head and
[3] Hollingworth W, Nathens AB, Kanne JP, et al. The neck imaging. 2nd edition. St Louis (MO): Mosby;
diagnostic accuracy of computed tomography angi- 1995. p. 46–59.
ography for traumatic or atherosclerotic lesions of [15] Moore KL, Dalley AF. Head. In: Moore KL,
the carotid and vertebral arteries: a systematic re- Dalley AF, editors. Clinically oriented anatomy.
view. Eur J Radiol 2003;48(1):88–102. 4th edition. Philadelphia: Lippincott Williams &
[4] Wippold FJ. Head and neck imaging: the role of CT Williams; 1999. p. 916–23.
and MRI. J Magn Res Imaging 2007;25:453–65. [16] Harnsberger HR. The parotid space. In:
[5] Grobner T, Prischl FC. Gadolinium and nephrogenic Harnsberger HR, editor. Handbook of head and
systemic fibrosis. Kidney Int 2007;72:260–4. neck imaging. 2nd edition. St Louis (MO): Mosby;
[6] Greene FL, Page DL, Fleming ID, et al, editors. 1995. p. 60–74.
AJCC cancer staging handbook. 6th edition. [17] Harnsberger HR. The carotid space. In:
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Springer: New York, Online access STAT!Ref neck imaging. 2nd edition. St Louis (MO): Mosby;
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neck. In: Harnsberger HR, editor. Handbook of Harnsberger HR, editor. Handbook of head and
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imaging. 3rd edition. St. Louis (MO): Mosby; 1996. 4th edition. Philadelphia: Lippincott Williams &
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[9] Accioli de Vasconcellos JJ, Britto JA, Henin D, [20] Harnsberger HR. The perivertebral space. In:
et al. The fascial planes of the temple and face: Harnsberger HR, editor. Handbook of head and
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2003;56:623–9. [21] Harnsberger HR. The infrahyoid neck: normal anat-
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1997;19:273–7. itor. Handbook of head and neck imaging. 2nd edi-
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aging. 3rd edition. St Louis (MO): Mosby; 1996. dissection classification update. Arch Otolaryngol
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[12] Harnsberger HR. The parapharyngeal space and [23] Som PM. Lymph nodes. In: Som PM, Curtin HD,
the pharyngeal mucosal space. In: Handbook of editors. Head and neck imaging. 3rd edition. St
head and neck imaging. 2nd edition. St Louis Louis (MO): Mosby; 1996. p. 772–93.
(MO): Mosby; 1995. p. 29–45. [24] Krestan C, Herneth AM, Formanek M, et al. Mod-
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 321–337

Neck Masses: Evaluation and Diagnostic Approach

Jason Lee, DDSa, Rui Fernandes, DMD, MD, FACSb,*
a
Division of Oral & Maxillofacial Surgery, Department of Surgery,
University of Florida College of Medicine, Jacksonville, FL, USA
b
Division of Oral & Maxillofacial Surgery, and Section of Surgical Oncology, Department of Surgery,
University of Florida College of Medicine, Jacksonville, FL, USA

Oral and maxillofacial surgeons frequently history and physical. In stressing the importance
deal with patients who present with an unknown of history-taking, Sir William Osler said: ‘‘If you
neck mass. Formulation of a differential diagnosis listen to your patient, they will tell you their
is essential and requires that the surgeon bring to diagnosis’’ [1].
bear a host of skills to systematically arrive at
a definitive diagnosis and ensure that the correct
History and review of systems
treatment is rendered. This article highlights some
of the skills needed in the workup of neck masses The chief complaint provides the foundation
and reviews some of the available techniques that for the evaluation of the patient and directs the
aid in achieving the correct diagnosis. examination. Once this data have been obtained,
the history of the present illness should be
examined further because it is valuable for the
Clinical evaluation
development of the initial diagnostic impressions.
The way you talk with a patient while taking Characteristics of the mass, such as the location,
a history lays the foundation for good care. By growth rate, and presence of pain, provide clues to
listening and responding skillfully and empathic- the nature of the problem. For example, a long-
ally, you learn what is bothering the patient and standing nonpainful mass with slow or insignifi-
what symptoms he or she has experienced. You cant changes points toward a benign process.
also may learn what the patient thinks the trouble Associated symptoms, such as referred pain,
may be, how or why it happened, and what
changes in voice quality, difficulty swallowing,
outcome is hoped for or feared. As you listen to
the story of an illness, moreover, you begin to
and epistaxis, should be discussed with the patient
formulate a range of possible diagnoses. By and can give clues to the origin of the mass. The
asking additional questions, you can fill in the surgeon should also question the patient regard-
gaps in the patient’s initial account and test some ing systemic symptoms. Although such symptoms
of your diagnostic hypotheses. [1]. may be uncommon, they can suggest metastatic
disease, especially if neurologic and pulmonary
The history and physical examination is the
complaints are present. The classic ‘‘B signs’’ of
cornerstone of medicine. The surgeon must
lymphoma are fever, night sweats, and weight
continually strive to improve on this skill through
loss.
deliberate and systematic manipulation of the
The clinician not only has to consider the
present illness, but the patient’s sex, age, social
history, occupational exposure, travel history, and
* Corresponding author. Department of Surgery,
past surgical and medical history. For example, it
University of Florida College of Medicine, 653-1 West is not too uncommon for patients to present to
8th Street, Jacksonville, FL 32246 a surgeon with a neck mass only a few months
E-mail address: [email protected]fl.edu after another physician removed a skin cancer
(R. Fernandes) from the patient’s face or neck.
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.04.001 oralmaxsurgery.theclinics.com
322 LEE & FERNANDES

Physical examination The lymphatic system of the neck is a network

of channels connecting both superficial and deep
The physical examination should be performed
lymph nodes. Although no physical or anatomic
in a systematic fashion. The temptation to focus
separation exists between lymph node groups,
on the problem area should be resisted. The
nodal groups have been subdivided into six to
clinician should carry out a standard, detailed
seven groups for practical reasons that mostly
head and neck examination with emphasis in this
relate to treatment. Suen and Goepfert [2] in 1987
case on the neck. A detailed skin examination
suggested this classification, which is based on the
should be done with attention directed to the
Memorial-Sloan Kettering classification [3]. It was
ipsilateral scalp in cases where parotid swelling is
then accepted by the Union International Contre
present. Cranial nerve examination is also impor-
le Cancer, the American Joint Committee on
tant because abnormal findings can indicate nerve
Cancer, and the American Academy of Otolaryn-
involvement by tumor and a poorer prognosis.
gology-Head and Neck Surgery for the standard-
These facts serve as guides in the differential
ization of clinical and surgical reports [4,5].
diagnosis. A thorough examination of the oral
cavity, nasopharynx, and the larynx is crucial. The
lateral pharyngeal walls can also be involved and
Endoscopy
ipsilateral bulging of the tonsilar area is com-
monly seen in dumbbell tumors of the parotid. Endoscopy should be part of the oral and
The detailed examination of these subsites is often maxillofacial surgeon’s armamentarium when
facilitated by the use of an endoscope or mirrors, evaluating patients with head and neck masses,
which is discussed later in this article. especially if malignancy is suspected. For
During the physical examination of a neck mass, example, supraglottic carcinomas can present as
the clinician should seek to determine the location, an unexplained mass in the neck and are often
size, and character of the lesion. One should missed on initial examination [6]. Endoscopy can
determine if the mass is tender to palpation, if the be divided into indirect and direct endoscopy,
mass is fixed, if there is pulsation, and if there is with the latter performed with a rigid or flexible
fixation to the overlying skin. Palpation of the scope. Indirect mirror laryngoscopy is one of the
thyroid should be done to assess for the presence of most useful techniques and has several advan-
thyroid nodules or enlargement. Some patients tages. It is inexpensive and, when properly
with large substernal goiters produce a positive performed on a cooperative patient, can bring
Pemberton’s sign (ie, elevated arms above the head into view all the necessary structures. The prob-
results in superior vena cava syndrome). Such lem with the indirect technique is that even with
findings as rubbery nodes may suggest a lymphoma, the aid of topical anesthesia, a strong gag reflex
whereas a large, firm, fixed node may point to can be observed. Areas that are difficult to visual-
a metastatic malignancy. Presence of a mass ize with indirect laryngoscopy include the anterior
isolated to the supraclavicular region should trigger commissure, portions of the epiglottis, the pyri-
thoughts of a primary abdominal malignancy or form sinus, the ventricle, and the lateral base of
malignancy at other sites beyond the head and neck. the tongue. Indirect mirror nasopharyngoscopy
When evaluating children, it is important to also offers good visualization, but is technique-
determine the timing of the appearance of the sensitive. Also, the soft palate can obstruct visual-
mass because this timing is critical in the formu- ization or biopsy. Direct flexible fiber-optic
lation of the differential diagnosis. The differential nasopharynscopy/laryngoscopy is the method
for a mass present at birth is different from those preferred by the authors. It is simple, relatively
that originated later, such as lymphangioma, well tolerated by patients, and can be easily and
vascular malformation, and hemangioma. comfortably performed in the office with topical
A thorough working knowledge of the anesthesia.
lymphatics of the head and neck is essential for the The classic ‘‘panendoscopy’’ of direct laryn-
practicing oral and maxillofacial surgeon. Regard- goscopy, rigid esophagoscopy, and bronchoscopy
less of the nature of the primary disease and the can also be performed, but has lost favor as
involvement of any nodal groups should be reported a routine means of evaluation of the unknown
using the accepted nomenclature. The patterns of primary patient. Several different scopes are avail-
drainage can give clues for finding a primary source able, but all use the same basic approach: a peroral
in a patient presenting with a neck mass. route, supine positioning, and general anesthesia
 NECK MASSES 323

in the operating room. The role of panendoscopy (FNAB) has become the gold standard for the
is controversial, especially with modern histologic evaluation of a patient with a neck
radiographic techniques, and might best be mass. FNAB is an inexpensive, rapid, and rela-
reserved for symptom-directed evaluation. tively accurate diagnostic tool for evaluating
neoplastic and nonneoplastic lesions, especially
Differential diagnosis in superficial or easily palpable masses. Imaging
techniques, such as ultrasound, CT, and MRI,
Formulating your diagnostic possibilities have also been described and proven safe in
should begin at the time of the first encounter deep-seated lesions [9]. In the head and neck,
and evolve through to the final diagnosis. The FNAB can be used in the thyroid, skull base,
formulation of a good differential diagnosis is salivary glands, paraspinal lesions, cervical
based on a thorough understanding of head and masses, and nodules. It also can aid in preopera-
neck pathology. However, a complete review of tive planning and patient counseling. This is espe-
possible lesions in the head and neck goes beyond cially true in patients with malignant versus
the scope of this article. The differential list is benign disease or patients who are poor surgical
arranged from the most probable diagnosis to the candidates. There has been some controversy in
least likely, usually including the five most likely the use of FNAB because of its potential pitfalls,
diagnoses. The differential serves as the ‘‘game such as tumor seeding, nerve damage, and salivary
plan’’ for the arriving at the final diagnosis. The fistulas. Experience has shown that these prob-
differential list is based on the clinical and imaging lems rarely occur when FNAB is properly per-
information gathered, which can later be ‘‘ruled formed and that complications are almost
in’’ or ‘‘ruled out’’ based on additional informa- nonexistent. For example, Smith [10] reported an
tion. The clinician also has to develop a priority incidence of 0.005% of tumor seeding, all of
list within each of the most likely categories. This which were abdominal, pelvic, or retroperitoneal
may ultimately reflect your treatment or next lesions.
diagnostic step (Fig. 1). Box 1 contains a list of If the clinician chooses to use FNAB in clinical
commonly occurring pathology in the head and practice, he or she must have an understanding of
neck subclassified based on congenital, infectious, its limitations. A variety of lesions in the neck are
benign, and malignant tumors. investigated by aspirates. These can range from
reactive changes, lymphomas, and malignancies to
Pathologic assessment congenital/developmental cysts. Each presents
with its own diagnostic challenges, which go
Histologic assessment of neck masses should
beyond the scope of this article. The diagnostic
rarely require open biopsies. The routine use of
accuracy is variable in the literature, with sensi-
open biopsies can lead to tumor seeding and can
tivities ranging from 77% to 95% and specificities
ultimately require a more extensive resection.
from 93% to 100% [11]. Squamous cell carcinoma
Currently, cytologic diagnoses of neck masses
(SCCA) represents the most common malignancy
are often obtained through the use of fine needle
in the cervical lymph chains. A common diagnos-
aspiration, while minimizing the stated negatives.
tic problem is to distinguish it from benign squa-
Hayes Martin recognized this during the infancy
mous lesions, including cysts [12–15]. The
of modern head and neck surgery:
clinician and patient must understand that the
Incisional biopsy for the removal of a portion or FNAB can be ‘‘positive’’ for SCCA or for other
of the whole of a cervical tumor should never be solid tumors, but a FNAB that does not show
made until other methods have been unsuccess- cancer cells is never ‘‘negative’’ and does not
ful. One of the most reprehensible surgical rule out cancer. Another area in which FNAB
practices is the immediate incision or excision of
has been questioned is in its inability to accurately
a cervical mass for diagnosis without preliminary
investigation for a possible primary growth.
diagnose primary lymphadenopathies and lym-
There can be no better example of ill-advised phomas [16]. The culmination of a cervical
and needless surgery [7]. lymphoma workup may still require open biopsy
for histopathology and flow cytometry.
The differential diagnosis of a neck mass in the
Fine needle aspiration biopsy
pediatric population is quite expansive, the most
Since Hayes Martin [8] first used the technique common being reactive lymphadenopathy. How-
in the 1930s, fine needle aspiration biopsy ever, the patient that fails to respond to an initial
324 LEE & FERNANDES

Patient with Neck Mass

Clinical History and ROS

- Determine characteristics of mass
- Symptoms of infection
- Symptoms of cancer

Physical Examination
- Examine skin, cervical nodes, thyroid,
oral and nasal cavity, larynx and pharynx
- endoscopy direct vs indirect
-ascultate for bruits, palpate for thrills

Formulate Diagnostic
Impression/Differential

Probable Diagnosis
-e.g. uncomplicated infection Diagnosis Unclear
- Inadequate information

Treat Accordingly
Fine needle Biopsy Imaging Studies
- CT, MRI, US,
Angiography, plain film,
PET

Non-diagnostic

Repeat 1-2 times Consider Open Biopsy

- consider CT, US -perform with oncologic
guided principles for prudence

Diagnostic

Treat Accordingly

Fig. 1. Algorithm for assessment of a neck mass. Abbreviations: PET, positron emission tomography; ROS, review of
system; US, ultrasound.

course of antibiotic therapy poses a treatment FNAB in the pediatric population [19,20]. The
dilemma to the clinician. The incidence of malig- psychologic trauma of an FNAB to the patient
nancy is lower in children than in adults, with and the parents has to be weighed against the risks
mesenchymal tumors representing 90% of the and benefits of traditional open biopsy under gen-
lesions found in children [17]. Torsiglieri and eral anesthesia.
colleagues [18] reviewed 455 pediatric FNABs FNAB is a valuable diagnostic tool in the
and found 55% congenital lesions, 27% inflam- evaluation of a neck mass in both the pediatric
matory, 5% noninflammatory benign lesions, and adult patient. Its low overall cost, low
3% benign neoplasms, and 11% malignancies, associated morbidity, and high accuracy put it at
the most common being lymphoma. Several the top of the diagnostic algorithm. However,
studies have reported the efficacy and safety of despite their positive attributes, FNABs are not
 NECK MASSES 325

CT and MRI studies can also complement one

Box 1. Limited differential for a neck another. An important consideration is context of
mass the study (eg, after-operation, following earlier
procedures).
Nonneoplastic The use of imaging in the determination of head
Congenital and neck malignancies is vital for determining the
Thyroglossal duct cyst origin, extent, and thus resectability of the mass.
Branchial cleft cyst Imaging of the cervical lymphatics alters the esti-
Hemangiomas mated clinical stage in 20% to 30% of patients [21].
Lymphangioma (cystic hygroma)
Layngoceole CT scan
Dermoid
Infectious CT is probably the most widely used imaging
Acute lymphadenitis study in the head and neck, outside the neuro-
Abscess cranium. It has the advantages of wide availabil-
Tuberculosis ity, speed, relatively low cost, and good spatial
Cat scratch disease resolution. It is excellent at separating fat from
muscle, and bone is well imaged. However, its
Neoplastic ability to separate muscle and tumor is not as
Benign good. Spiral (helical) CT is quickly becoming the
Lipoma mainstay in many medical centers [22]. The
Salivary advantages of spiral CT are a result of the contin-
Pleomorphic adenoma uous rotation of the x-ray tube and the detector as
Warthin’s tumor the patient moves through the gantry. This allows
Thyroid goiter rapid scanning of large volumes of tissue during
Paragangliomas (eg, carotid body quiet respiration; a reduction in the amount of in-
tumors) travenous contrast needed, as well as the amount
Malignant of motion artifact; and multiplanar and three-
Salivary dimensional reconstruction [23–25]. CT can be
Mucoepidermoid particularly valuable in the head and neck pathol-
Adenoid cystic ogy patient because many of these patients have
Thyroid carcinoma significant comorbidities, such as chronic
Metastatic carcinoma obstructive pulmonary disease, and cannot handle
Sarcoma their secretions. Therefore, breath-holding and
Lymphoma long scanning time are not well tolerated.

MRI
infallible and should never replace sound clinical
Although MRI has several favorable charac-
judgment.
teristics for the evaluation of the head and neck,
its superiority compared with CT has not been
Imaging studies
established [26,27]. There is, however, a distinct
Imaging is frequently employed to help advantage in its soft tissue capabilities and it is
determine the exact location and other character- useful when the distinction between the mass
istics of the disease process among patients who and surrounding soft tissue is poor. Metallic
present with a neck mass. The only exception may dental restorations do not significantly degrade
be someone with an obvious inflammatory or the MRI image. Many different techniques are
infective process where empiric treatment may be available for image enhancement on MRI. In gen-
started, followed by re-evaluation. CT and MRI eral, T1-weighed images relate to how quickly
have proven to be indispensable tools in evaluat- nuclei return to their base state. This type of
ing a patient with a neck mass and can be used to image takes less time to produce and fat appears
complement one another. In principle, imaging bright and cerebrospinal fluid dark. T2-weighted
complements the physical examination, and axial images relate to the loss of phase coherence and
and coronal sectional studies are based on anat- typically take longer to acquire. These images pro-
omy and the changes that occur with pathology. duce cerebrospinal fluid that is bright and fat that
326 LEE & FERNANDES

is darker. Gadolinium-enhanced images can also on the differential. PET is a functional study
improve the clarity of margins of many lesions based on the uptake of 18-fluorodeoxyglucose in
and, because gadolinium is a noniodinated cells proportional to their rate of glycolysis [37].
medium, it is considered safer in patients with PET scans have the ability to survey the whole
renal impairment and a history of allergic reac- body and detect primary tumors that would not
tions [28,29]. Additional techniques, such as fast- otherwise be visualized. It routinely is used to
spin echo and fat suppression, produce sharper detect an occult primary and in the evaluation
images in shorter times and allow for better delin- of recurrent disease after treatment [38,39]. Tradi-
eation of tissues. For example, in fast spin echo T2 tionally, the widespread use of PET has been
images, fat does not appear dark, and distinguish- limited because of its expense, its poor spatial res-
ing between fat and fluid (eg, hemorrhage) is olution, and its limited availability. Other limita-
difficult. Fat suppression techniques obliterate tions are its inability to detect lesions smaller
the signal from fat, producing an image where than 5 to 10 mm and the physiologic uptake of
fluid is bright and fat is dark. This technique laryngeal and oropharyngeal muscles, resulting
can also be applied to gadolinium-enhanced T1 in unwanted false positives [40,41]. Recently,
images where the lesion abuts fatty tissues and PET has been combined with other modalities,
the extent of the mass is obscured because both such as CT, providing anatomic and functional
are bright [30]. information. Several studies have reported
In patients with cancer of the head and neck, improved detection of primary and metastatic dis-
nodal involvement has significant prognostic ease when PET combined with CT was compared
value. Studies in the late 80s by Mancuso and with PET, CT, and MRI alone [42,43].
colleagues [31] and Som [32] illustrated the use of
CT in detection of nodal metastasis. Radio- Ultrasound
graphic abnormalities that may indicate a patho-
Ultrasound is another study that is readily
logic process include nodal enlargement beyond
available, inexpensive, noninvasive, and accurate.
maximal normal size, clusters of ill-defined nodes,
Conventional B-mode ultrasound has been used
and distinctive nodal shapes. Although shape and
with success as an examination tool in the
size are no longer considered reliable, round no-
evaluation of benign, inflammatory, vascular,
des tend to be neoplastic and elliptic nodes tend
and malignant lesions, as well as in the evaluation
to be normal or hyperplastic [33]. Contrast-
and surveillance of thyroid nodules [44–47]. It also
enhanced CT is thought to be superior to MRI
can be used in both the pre- and postoperative
in the detection of central nodal necrosis [27].
phases of treatment. Other techniques, such as
With the development of fat suppression tech-
contrast-enhanced color Doppler sonography,
niques, gadolinium enhancement, field strength,
have also been investigated to give information
high-resolution microimaging, and stylized sur-
about blood flow to lymph nodes. Moritz and col-
face coils, MRI has been reported to be compara-
leagues [48] showed that characterization of hilar
ble to CT in central nodal necrosis detection
vessels with branching indicated lymphadenitis
[26,34]. MRI is also preferred for targeted imag-
and predominately peripheral vessels indicated
ing of a primary site, such as base of tongue, sal-
malignancy with very high sensitivities and speci-
ivary glands, and the base of the skull, especially
ficities. The limitation of ultrasound is that it is
when perineural extension is a concern [35]. An-
highly operator-dependent and many radiologists
other recent advance is that of the use of MRI
inexperienced in ultrasound prefer CT or MRI.
imaging to identify pathologic nodes using super-
Ultrasound is commonly used to direct FNAB
magnetic iron oxide nanoparticles that accumu-
techniques to improve the diagnostic yield
late in normal functioning nodes, giving an
[49,50]. Ultrasound is widely used in Europe for
intense signal. The goal is to improve sensitivity
neck mass evaluation and many European oral-
in detecting smaller metastatic nodes from reac-
maxillofacial surgery clinics employ ultrasound
tive nodes [36].
as an adjunct to physical examination.

Positron emission tomography Angiography

Positron emission tomography (PET) is Vascular lesions should be considered when
another modality for evaluating the patient with dealing with a mass in the head and neck,
a neck mass, especially if metastatic disease is high especially in the pediatric population [51]. Clinical
 NECK MASSES 327

examination is often sufficient for diagnosis when Lymphangiomas (cystic hygromas)

all or a portion of the lesion is superficial. How- The old term for cervical lymphangioma is
ever, the extent of the lesion is often underesti- cystic hygroma. This entity results from a malfor-
mated [52,53]. Deeper lesions of the neck require mation of the lymphatic system in the cervical
imaging and sometimes the study itself can diag- region that leads to proliferation of the vessels in
nose the lesion. For example, angiography of the region and a subsequent mass. These masses
carotid body tumors demonstrates their patho- may encompass a large area of the neck without
gnomonic lyre signs (bowing of the external and true localization to a specific site. Lymphangio-
internal carotid arteries) [54]. Imaging can also mas may be subdivided into macrocystic versus
be essential for treatment feasibility, preoperative microcystic. This distinction is based on the pre-
planning, and sometimes diagnosis. The combined dominant size of the cystic spaces within the lesion
use of angiography, CT, and MRI has been and may impact on the treatment and resolution
described for evaluating hemangiomas, lymphan- of the lesion. Macrocystic lesions are more sus-
giomas, arteriovenous malformations, and para- ceptible to the sclerosing agent OK432 (picibanil).
gangliomas. In general, MRI is considered to
give the most diagnostic information regarding Branchial cleft cysts
tissue characterization and extension of vascular Branchial cleft cysts originate from entrapped
lesions [54,55]. CT and plain radiographic studies squamous epithelium and lymphoid tissues during
are valuable when intraosseous involvement is development of the branchial grooves. There are
suspected. However, care must be taken with multiple types of branchial cleft cysts ranging
lesions involving the mandible because on plain from type I to type IV. The most common
radiography vascular malformations are difficult branchial cleft cyst is the type II (second brachial
to distinguish from benign odontogenic tumors, cleft). The location of the second branchial cleft
such as ameloblastomas or myxomas [56]. Both cyst is in the upper neck deep to the sternocleido-
CT and magnetic resonance angiography can be mastoid muscle with its anterior sinus often
used for three-dimensional reconstruction. These exiting anterior to the muscle. These cysts often
can be helpful in preoperative planning and in present during the younger years of development
some situations can eliminate the need for angiog- with the majority presenting before 10 years of
raphy [57,58]. Catheter angiography is valuable age. One can occasionally see these cysts in adults,
when large vascular connections are suspected or often after an infection resulting in a rapid
when preoperative delineation of feeding and enlargement of the cyst and pain. These cysts
draining vessels for surgery and embolization is are often confused with large necrotic cystic nodes
needed. Catheter angiography does not, however, from tonsilar cancer.
demonstrate the involvement of the lesion with
the surrounding tissue [59,60]. Thyroglosal duct cysts
The most common developmental cyst found
in the neck is the thyroglossal duct cyst [61]. This
Common neck masses cyst originates from a lack of degeneration of the
cystic track from the migration of the thyroid
The following is a short list of common neck
gland in the neck during development. As such,
masses that may be encountered by the surgeon.
the track may be found anywhere from the fora-
men cecum up to the pyramidal lobe of the
Nonneoplastic masses
thyroid. During development, as the thyroid
Nonneoplastic masses in the neck may be descends in the neck, it is close to the developing
separated into two broad categories: congenital hyoid bone (Reichert’s cartilage). Given this
or infectious. The following is a brief description fact, the track of the cyst may be present in front,
of entities that may be placed in the differential of back, or through the central portion of the hyoid
neck masses. bone. The typical presentation of the thyroglossal
duct cyst is a large mass in the midline of the neck
Congenital that moves with swallowing or protrusion of the
Congenital masses are those that were present tongue. The lesion may also present as a lateral
since birth. They may have enlarged over a period or paramedian mass. A common clinical scenario
of time but the common thread is the presentation is that of a young person with a recent upper
at birth. respiratory track infection and a new neck mass.
328 LEE & FERNANDES

The resection of these cysts entails the complete 40% to 50% of these have residual telangectasias,
removal of the mass and its track along with the scarring, or atrophic skin that needs treatment.
central portion of the hyoid bone as described Immediate therapeutic intervention is necessary
by Sistrunk [62] (Fig. 2). in patients with lesions that compromise the air-
way, visual or auditory function, and feeding
Vascular lesions [67]. Many different treatment modalities have
Virchow [63] described the first anatomic path- been described, including steroids, cryotherapy,
ologic classification of vascular lesions. Our cur- embolization, sclerotherapy, laser, and surgery
rent understanding was greatly expanded by the [68]. Vascular lesions are classified by the type of
work of Mulliken and Glowacki [64], who classi- vessel involved and their intravascular flow (ie,
fied vascular lesions as hemangiomas and vascular high versus low). Capillary, lymphatic, and ve-
malformations. Hemangiomas are present at birth nous malformations are classified as ‘‘low flow.’’
and rapidly proliferate in the first years of life, fol- Arterial, arteriovenous malformations and arte-
lowed by a slow involution. Vascular malforma- riovenous fistulas are considered ‘‘high flow’’
tions are present at birth but may not be evident [64]. Generally, treatment consists of laser, or em-
and show proportionate growth. Hemangiomas bolization, or both, followed by surgery [68].
typically are classified as capillary, cavernous,
and capillary-cavernous. These lesions are more
Infectious
common in females (3:1) and 60% are located in
the head and neck [65,66]. A large majority of Infectious processes may also account for
these lesions are not treated because of their ten- enlargement/masses in the neck. These lesions
dency for spontaneously involution. However may appear as localized or diffuse. Other causes,

Fig. 2. (A) Adult male with enlarging neck mass. (B) CT scan of the central neck mass revealing the large cystic mass in
the central neck consistent with a thyroglossal duct cyst. (C) Surgical resection of the mass via a Sistrunk procedure. (D)
Surgical specimen.
 NECK MASSES 329

aside from the routine abscesses originating from may present in the neck as large isolated masses
odontogenic sources or folliculitis, include tuber- present for long periods of time without much
culosis and cat scratch disease (CSD). change over the years. The treatment of these
benign tumors is a simple excision. Recurrence
Tuberculosis of these tumors is rare (Figs. 3 and 4).
During the past 2 decades, tuberculosis was
a relatively rare disease. However, with the Carotid body tumors
continued progression of the HIV and AIDS, A carotid body tumor is a type of a para-
a rise in the number of cases has been noted in the ganglioma. Paragangliomas represent vascular
western hemisphere. Tuberculosis has and con- neoplastic tumors that arise from chemoreceptors
tinues to be a major health problem for the located in the walls of blood vessels or are
developing world. When present in the neck, this associated with specific nerves [73]. The tissue of
disease is referred to as scrofula. origin of these tumors denotes the name given to
the tumors. They range from carotid body tumors
Cat scratch disease
to jugular paragangliomas. The common presen-
The causative organism of CSD is the gram-
tation of a carotid body tumor is a neck mass
negative bacterium Bartonella henselae. CSD is
that does not move in a superior-inferior direction
one of the common reasons for infectious cervical
but does in the anterior-posterior direction. The
lymphadenopathy both in adults and children.
mass may be pulsatile or present with a bruit.
Usually 3 to 10 days after contact with an infected
Angiography used to be the primary imaging
cat, often a newly acquired kitten, a small papule
modality for carotid body tumors. This study
appears followed by a prolonged period of
would give a characteristic appearance referred
regional lymphadenopathy [69]. The workup for
to as the lyre sign. Today MR or CT scans may
CSD includes a thorough history and physical
be used to obtain this information. The treatment
examination and can be confirmed by serology
for these tumors is surgical resection whenever
(IgG or IgM antibodies against Bartonella) or
possible, depending on tumor size and patient
bartonella DNA. The treatment for CSD is sup-
comorbidities (Fig. 5).
portive care. A course of antibiotic, often a cepha-
losporin, may be employed for patients with
Thyroid nodules and goiters
painful or abscessed lymph nodes.
Goiter, the Latin term for throat, describes an
enlargement of the thyroid gland. The type of
Neoplastic masses goiter can be classified based on its epidemiologic,
Benign lesions etiologic, functional, or morphologic factors.
Tumors in the neck may originate from any Iodine deficiency is the most common factor
tissues present in the neck. As such, the tumors contributing to the development of goiter. How-
include salivary gland tumors (originating from the ever, other factors that can play a role include
submandibular gland or tail of the parotid gland), elevated thyrotropin, advanced age, pregnancy,
nerve sheath and nerve tumors, lipomas, vascular and exposure to lithium. Also, a variant of
tumors, and others. This simple but often forgotten Hashimoto’s thryoiditis is associated with goiters,
fact will aid in the formulation of a good differential as is Graves’ disease, and nutritional goitrogens
diagnosis for the surgical trainee. (eg, cassava) [74]. The World Health Organization
has also graded goiters from 0 to 2 or 3, based on
Lipomas palpation and size of the goiter. Treatment is
Benign lipomatous tumors have been subclas- based on functional disease or compressive symp-
sified according to their histologic features and toms (to surrounding nerves, vessels, or organs).
growth pattern into classic lipomas (solitary or Goiters also can be substernal, graded from I to
multiple), fibrolipoma, angiolipoma, infiltrating III, depending on the position in the mediastinum,
lipoma, intramuscular lipoma, hibernoma, pleo- necessitating the appropriate presurgical planning
morphic lipoma, lipoblastomatosis, and diffuse [75]. In the United States, surgery is the mainstay
lipoblastomatosis [70,71]. Further classification of treatment but radioactive iodine can be used
has also been done according to either size or instead [76,77] (Fig. 6).
weight. A tumor is classified as a giant lipoma if Thyroid nodules can also present a challenge
the size is greater than 10 cm in one dimension to the clinician. Although most thyroid nodules
or the weight greater than 1000 g [72]. Lipomas are benign, evaluation needs to be done to rule out
330 LEE & FERNANDES

Fig. 3. (A) Patient with a right neck mass in level V. (B) CT scan of the mass revealed a large mass consistent with
a lipoma. (C) Surgical exposure and delivery of the mass. (D) Surgical specimen.

cancer. The workup varies depending on the [79,80]. We present a short list of malignant neo-
surgeon and the patient’s presentation. Such plasms that can present in the neck.
factors as stability and size of nodule, age, sex,
Upper aerodigestive tract cancer
and history of irradiation all influence the risk of
Upper aerodigestive tract cancers include
malignancy [78]. The workup generally consists of
lesions arising from the oral cavity, nasopharynx,
fine needle aspiration (principal tool), ultrasound,
hypopharynx, and the larynx. These cancers
thyroid function tests, and scintigraphy.
represent about 3% of all cancers. It is predicted
that in 2008, 47,560 men and women will be
diagnosed with this disease. About 90% of these
Malignant neoplasms
will be epithelial in nature [81]. Alcohol and
Much like benign tumors of the neck, malig- tobacco are the common etiologic factors in the
nant neoplasms can originate from any tissues in development of this disease. Recent studies have
the region, or may present secondary to metastasis shown that there is also a link with the human
from distant sites. The possibilities range from papilloma virus. The oral cavity is the most com-
metastatic carcinomas (eg, lung, colon, breast) to mon site for primary tumors of the head and neck,
salivary gland malignancies (Fig. 7). An asymmet- with the tongue and floor of the mouth predomi-
ric, asymptomatic mass in the neck, especially in nating. Several factors influence the presence of
adults, is always considered a malignancy until regional metastasis, such as depth of invasion
proven otherwise. The occurrence of a malignant (O2 mm), site, and stage. As many as 30% of
process in these lesions is approximately 30% patients present with cervical involvement and
 NECK MASSES 331

Fig. 4. (A) A young woman with a long-standing, enlarging neck mass consistent with a lipoma. (B) Surgical delivery of
the mass. Note the superficial location of the mass. (C) Surgical mass.

up to 45% of patients harbor occult metastasis, hypopharynx extends from the hyoid to the post-
usually in levels I, II, or III [82,83]. Nasopharyn- cricoid area and is divided into three subsites: (1)
geal carcinoma is relatively rare in the United the pyriform sinus (the most common site), (2) the
States. However, because of the propensity of lateral/posterior pharyngeal walls, and (3), the
nasopharyngeal carcinoma for cervical metastasis, postcricoid area. Cervical involvement is high
which has been reported as high as 87%, it should and the prognosis is quite poor with these tumors.
not be overlooked [82,83]. Oropharyngeal carci- Laryngeal tumors are divided into (1) supraglot-
nomas most commonly arise at the tonsil and tic, (2) glottic, and (3) subglottic categories. Can-
base of tongue and, because of the abundant lym- cers of the glottis are most common and have the
phoid tissue in this subsite (Waldeyer’s ring), lym- best prognosis. Cervical involvement varies with
phomas often present here as well. Depending on the subsite and is highest with supraglottic carci-
the subsite, there is a 15% to 75% rate of cervical nomas. Supraglottic cancers tend to present later
node involvement and bilateral metastasis is com- because the area is difficult to examine and symp-
mon [82,83]. Large cystic metastasis from this sub- toms (eg, voice hoarseness) don’t arise as early
site is common and can be mistakenly diagnosed as with glottic cancers. Treatment of upper aero-
and treated as a branchial cleft cyst. As a result, digestive tract cancers depends on the subsite
high-risk ‘‘unknown primary’’ patients should un- and involves multimodality therapy consisting of
dergo tonsillectomy and blind biopsy. The surgery, radiation, and chemotherapy.
332 LEE & FERNANDES

Fig. 5. (A) Elderly patient with a symptomatic right neck mass that, on workup, was found to be a carotid body tumor.
(B) CT of the tumor showed the characteristic displacement of the tumor between the internal and external carotid
branch. (C) Exposure of the tumor taking care to have superior and inferior control of the vessels. (D) Near-complete
removal of the tumor without ligation of the vessels and preservation of the nerves.

Skin cancer multiple local recurrences. The risk of regional

Skin cancers are the most common malignancy nodal involvement for SCCA increases with mul-
in the United States, where basal cell carcinoma tiple recurrences, increased thickness, increased
(BCCA) and squamous cell carcinoma (SCCA) size (larger than 2 cm), more poorly differentiated
represent the majority of lesions treated. These tumors, perineural invasion, and tumor locations
malignancies are highly curable and rarely metas- in scars, burns, and certain sites (eg, temple, ear,
tasize: 0.1% for BCCA and 2% to 5% for SCCA lips) [84–87].
[84,85]. However, specific pathologic features Melanoma, although less common than the
represent an increased likelihood of cervical aforementioned skin cancers, has a mortality rate
spread that should be respected by the clinician. that far surpasses that of SCCA and BCCA. In
Like other head and neck malignancies, lymphatic 2008, 62,480 new cases will be diagnosed and 8420
spread is associated with decreased survival [85]. men and women will die of melanoma [81]. Sev-
For BCCA, most patients with metastatic disease eral staging factors, including depth of invasion,
have the morphea or basosquamous form, dem- site, ulceration, macrometastasis, and number of
onstrate perineural invasion, and are prone to positive nodes, should be considered when
 NECK MASSES 333

Fig. 6. (A) Patient with large anterior neck mass with greater extension to the right neck. (B) Coronal CT of the neck
reveals a large thyroid goiter with significant deviation of the great vessels and the airway. (C) Surgical specimen of the
goiter. Note the large lobulated mass. (D) Neck surgical bed after removal of the goiter.

Fig. 7. (A) Patient with multiple bilateral lower neck nodes. Workup consisting of fine needle aspiration and CT scan
revealed the neck nodes to be metastatic lung carcinoma. (B) Young man with known carcinoid tumor developed nu-
merous neck nodes, which were found to be metastatic nodes on open biopsy.
334 LEE & FERNANDES

choosing the appropriate therapy [88]. Mucosal the following interventions: total or subtotal
melanoma in the head and neck is rare but highly thyroidectomy, neck dissection, radioiodine
aggressive and lethal. The most common sites are ablation, chemotherapy, and radiation therapy.
the nose, paranasal sinuses, oral cavity, and naso- A detailed discussion thyroid nodule evaluation is
pharynx. These areas should be evaluated in pa- presented in another article of this volume.
tients with cervical lymphadenopathy and no
primary skin lesions. Lymphoma

Salivary gland tumors Cervical adenopathy is among the most com-

The clinician should be familiar with several mon presenting symptoms in lymphoma, occur-
malignant tumors that occur in the salivary ring in 75% of Hodgkin’s and 30% to 40% of
glands. The most common that present as a pri- non-Hodgkin’s patients. It is the most common
mary or metastatic lesion in the neck are mucoe- malignancy in childhood, representing 10% of all
pidermoid carcinoma (MEC) and adenoid cystic malignancies [90]. Hodgkin’s lymphomas are
carcinoma (ACC). MEC is the most common more frequent between 5 and 30 years of age,
salivary gland malignancy and the second most whereas the non-Hodgkin’s forms occur later in
common malignancy of the submandibular gland. life [91]. The nodes tend to be softer, more rub-
MEC is divided into low, intermediate, and high bery, and more mobile than those associated
grades, depending on the ratio of mucin, interme- with metastatic carcinoma. Extranodal involve-
diate, or epithelial cells. Compared to low-grade ment is seen in the head and neck most often in
MEC, high-grade lesions tend to present at a later Waldeyer’s ring and tends to be the non-Hodg-
stage; have higher incidence of nodal involvement, kin’s type. Diagnosis is usually achieved by fine
recurrence, and distant metastasis; and promise needle aspiration followed by open biopsy confir-
lower chances of survival [89]. ACC is the second mation. Therapy depends on the type and stage
most common salivary gland tumor and the most and consists of chemotherapy, or radiation, or
common in the submandibular gland. Most pa- both.
tients present between 30 and 70 years of age.
Three histologic subtypes exist: cribiform, tubu- Unknown primaries
lar, and solid. ACC has a tendency for perineural
Carcinomas from an unknown primary repre-
spread, most often affecting the facial nerve or V2
sent a small group of malignancies that pose
or V3 of the trigeminal nerve. Perineural spread
a significant challenge to the clinician. Patients
can be centripetal (toward brain) or centrifugal
with malignant cervical adenopathy with no
(peripheral), the former making resection difficult.
immediately apparent primary represent 3% to
Lymphatic spread is uncommon in ACC. There-
10% of all head and neck cancers [92]. Most of the
fore, a mass in the neck would likely represent
primary tumors occur in the upper aerodigestive
the primary lesion. Prognosis is time-dependent
tract, but primary sites in the lungs, abdomen,
and survival does not plateau at 5 years. Even
skin, and urinary tract are possible [93]. Gener-
after 20 years mortality continues to increase.
ally, if a patient presents with mid- to high-jugular
nodes, the clinician should suspect a head and
Thyroid cancer
neck origin versus an isolated supraclavicular
In general, thyroid cancer presenting as a neck node, which may be indicative of a primary below
mass is uncommon and the prognosis is good, the clavicles, such as in the lungs or gastrointesti-
with the notable exception of anaplastic carci- nal tract. The literature reports that the primary
noma. The typical cancers of the thyroid are the tumor is found in 10% to 40% of patients. The
well-differentiated carcinomas (WDTCs), medul- most common site for the origin of the primary tu-
lary carcinoma, anaplastic carcinoma, and lym- mor is the palatine tonsil (35%), base of tongue
phoma. The WDTCs are papillary and follicular (26%), lung (17%), and nasopharynx (9%). Other
carcinoma. Follicular carcinoma also includes sites, such as the esophagus, skin, and larynx, con-
Hurthle cell and insular carcinomas. Patients tribute between 1% and 4% [94–97]. However,
diagnosed with medullary carcinoma should be approximately 1% to 2% of primary tumors elude
screened for multiple endocrine neoplasia 2A, diagnosis despite repeated FNAB, imaging, and
multiple endocrine neoplasia 2B, and familial directed oropharyngeal biopsies [96]. Generally,
medullary carcinoma. Treatment depends on the the workup consists of physical examination; im-
cancer and the institution and involves some or all aging, including PET scan; biopsy of an affected
 NECK MASSES 335

node; directed biopsy of the upper aerodigestive [18] Torsiglieri AJ, Tom LW, Ross AJ 3rd, et al. Pediat-
tract; at least ipsilateral tonsillectomy; and ric neck masses: guidelines for evaluation. Int J
panendoscopy. Pediatr Otorhinolaryngol 1988;16(3):199–210.
[19] Ramadan HH, Wax MK, Boyd CB. Fine needle
aspiration of head and neck masses in children.
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 339–352

Congenital Neck Masses

Peter A. Rosa, DDS, MDa,b,
David L. Hirsch, DDS, MDa,b,*,
Eric J. Dierks, DMD, MD, FACSc,d
a
Department of Oral and Maxillofacial Surgery,
New York University College of Dentistry, New York, NY, USA
b
New York University School of Medicine, New York, NY, USA
c
Oregon Health & Science University, Portland, OR, USA
d
Legacy Emanuel Hospital, Portland, OR, USA

Congenital neck masses are subdivided based TDC is diagnosed in 40% of childhood neck
on their anatomic location in the neck. Midline masses and has no gender predilection [2]. There
neck masses include thyroglossal duct cyst (TDC), is less than a 1% incidence of thyroid carcinoma
dermoid cyst, epidermoid cyst, ranula, thymic or other malignancy within a TDC, 90% of which
cyst, and teratoma. Lateral neck masses include occur in adulthood [3].
branchial cleft cyst (BCC), laryngocele, lymphan- The etiology of TDC is reflected by the
gioma, hemangioma, and fibromatosis coli. Al- embryology and formation of the thyroid gland
though these lesions are congenital in nature, (Fig. 1). The thyroid gland is the first endocrine
manifestations of these lesions may not occur gland formed in embryogenesis [1]. It begins in
until later in life. This may lead to a mistaken the third embryonic week as an endodermal thick-
suspicion of acquired lesions of inflammatory or ening in the floor of the primitive pharynx-tuberc-
neoplastic origin. The appropriate diagnosis of ulum impar. A downgrowth develops called the
these lesions is necessary to provide appropriate thyroid diverticulum (median thyroid anlage) [4].
treatment and long-term follow up, because some This diverticulum opening, which is caudal to
of these lesions may undergo malignant trans- the median tongue bud, becomes the foramen ce-
formation or be harbingers of malignant disease. cum of the tongue. During elongation of the em-
bryo, the diverticulum descends into the neck
and becomes the thyroglossal duct [1]. The diver-
Midline congenital neck masses ticulum descends and fuses with components of
Thyroglossal duct cyst the fourth and fifth branchial pouches (lateral thy-
roid anlage). Because this occurs before the for-
Epidemiology and etiology mation of the hyoid bone, remnants of the duct
Seven percent of the population has remnants can become trapped within the hyoid bone during
of the thyroglossal duct. This lesion is the most its formation. The pyramidal lobe of the thyroid
common congenital anomaly of the neck. It gland, which is present in 30% of the population,
represents 70% of congenital neck masses [1] may represent distal remnants of the TGD [2].
and is the second most common neck mass after The proximal remnant becomes the foramen ce-
cervical adenopathy in the pediatric population. cum. The duct usually obliterates between the fifth
and eighth weeks. Failure of obliteration leads to
* Corresponding author. 366 5th Avenue, Suite 709, formation of the TDC. The cyst is usually lined by
New York, NY 10001 respiratory epithelium, which can undergo squa-
E-mail address: [email protected] mous metaplasia with repeated superinfection.
(D.L. Hirsch) Thyroid tissue can be seen within the cyst in
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.03.003 oralmaxsurgery.theclinics.com
340 ROSA et al

Fig. 2. TDC in a child. Note the midline position of the

neck mass.

Fig. 1. TDCs can form anywhere along the embryologic

path of descent of the thyroid gland. The dotted line in- in narrowing down the differential diagnosis for
dicates the path of thyroid descent. (Courtesy of Alexa this lesion. An imaging study, such as an ultra-
Lessow, MD, New York, NY.)
sound or CT scan, and a screening thyroid-
stimulating hormone (TSH) level should initially
45% of cases. Infection with Haemophilus influ- be performed. If TSH levels are elevated or a solid
enza, Staphylococcus aureus, and Staphylococcus mass is seen on ultrasound examination, a radio-
epidermidis can occur [5]. nucleotide scan may be indicated to rule out
median ectopic thyroid [4]. Some investigators ad-
Diagnosis vocate radionucleotide scans in all patients with
Most TDCs present in the first 5 years of life TDC because median ectopic thyroid may be
[6]. Two thirds are diagnosed within the first 3 de- present in 1% to 2% of TDCs [4]. If the cyst is ex-
cades. They are usually painless cystic masses in cised along with ectopic thyroid, replacement thy-
the midline of the neck, two thirds of which are roid hormone therapy may be necessary if all
adjacent to the hyoid (Fig. 2) [4]. They can, how- functioning thyroid tissue is present within the ec-
ever, be located anywhere from the tongue to the topic specimen [4].
pyramidal lobe of the thyroid. The cyst usually CT scans are not necessary for the diagnosis
moves with deglutination and with protrusion of but aid in planning surgical excision. A TDC is
the tongue, unlike dermoid cysts. This finding seen as a hypodense lesion with variable rim
can be helpful in the differential diagnosis. One enhancement with intravenous contrast. The lin-
third of these can present with concurrent or prior ing of the cyst may be thickened secondary to
infection, which is the most common way they are repeated infection, chronic inflammatory reaction,
diagnosed in the adult population [5]. Patients or malignancy.
rarely present with a chief complaint of foul taste
attributable to a draining fistula from the foramen Treatment
cecum. Most present with an asymptomatic mass The Sistrunk procedure is the classic procedure
or infection. TDCs at the base of the tongue and performed for the uncomplicated TDC. A trans-
large neck TDCs may lead to dyspnea because verse incision is made in the neck. The cyst and
of airway obstruction. the distal portion of the tract are identified, and
An appropriate physical examination, medical a wide-field dissection of the tract and adjacent
history, and history of presenting illness are vital tissues is continued from the thyroid gland,
 CONGENITAL NECK MASSES 341

including the pyramidal lobe, if present, superi-

orly toward the hyoid bone. The central compo-
nent of the hyoid bone associated with the TDC is
excised. Further en bloc removal of the proximal
tract contained within a cylinder of tongue
musculature is performed up to the foramen
cecum so that the entire tract is appropriately
removed. If the pharynx is entered, the opening is
suture ligated and the lesion is removed (Figs. 3
and 4) [6].
Surgical intervention during episodes of acute
inflammation leads to high recurrence rates (40%)
compared with treatment after inflammatory ep-
isodes have subsided (8%) [7]. It is preferable to
wait to excise a recently infected TDC until at
least 4 to 6 weeks after treatment with antibiotics.
A more recent review, however, has shown that
there may be no association between preoperative
infection and increased recurrence rates [8].
In approximately 1% of all TDCs, excised
carcinoma is detected incidentally. In such cases,
Fig. 4. Exposure and removal from a midline neck
94% are thyroid in nature (mostly papillary incision.
thyroid carcinoma) and 6% are of squamous cell
origin. If differentiated thyroid carcinoma within
the cyst is diagnosed, it is appropriately managed TSH suppression [9]. Portions of geniohyoid, my-
within the normal treatment for TDC [9] (Sistrunk lohyoid, genioglossus, and hyoid may be removed
procedure). If invasive or extensive carcinoma is with the TDC [10].
found, more extensive treatment is needed. This Recurrence of TDC can occur even with
may require a total thyroidectomy with or without a properly performed Sistrunk operation. One
neck dissection in addition to the Sistrunk proce- possibility is that the original Sistrunk procedure
dure, followed by radioactive iodine therapy and performed on the patient did not include laterally
directed or branching tracts [11]. Hewitt and col-
leagues [11] suggest dissecting a cuff of normal tis-
sue with the specimen and removing granulation
tissue because it may represent an inflammatory
reaction to adjacent retained epithelium. Close
dissection to the hypoglossal nerve (in some situa-
tions) may be necessary to prevent leaving resid-
ual TDC, in addition to taking intraoperative
frozen sections of nearby tissue. Close follow-up
is important because recurrences do occur, even
with the most comprehensive treatment.

Dermoid cyst
Epidemiology and etiology
Dermoid cysts are germ cell tumors that are
made up of ectodermal and mesodermal elements
but have no endodermal elements. Hair follicles,
smooth muscle, fibroadipose tissue, and sebaceous
glands may be found within them. Several theories
have been formulated as to their etiology. The first
is that they are derived from anatomically isolated
Fig. 3. Patient prepared for removal of a TDC. totipotential rests from the mesoderm and
342 ROSA et al

ectoderm that undergo disorganized growth. The transcervically (Fig. 5). Recurrence of these le-
acquired implantation theory postulates that the sions is unusual with appropriate excision, and
cysts come from germinal derivatives that were malignant transformation is rare [14].
implanted into deeper tissue by a traumatic event.
The third theory is congenital inclusion of germ Epidermoid cyst
layers into deeper tissues along embryonic fusion
lines that have failed to close completely, thereby Epidemiology and etiology
trapping epithelial debris [12]. Epidermoid cysts are usually seen after puberty
Twenty percent of all head and neck dermoids and are most common in the acne-prone areas of
are found in the cervical region, most often in the the face and neck. If seen before the onset of
submental region. Seven percent of all dermoids puberty, they may be associated with Gardner’s
occur in the head and neck [13]. Most often, der- syndrome. Younger people more commonly have
moids present in the periorbital region (especially these lesions on the face and neck, whereas older
in children [14]), nasal region, or scalp. They individuals are more prone to developing these
rarely manifest in infants and usually manifest in lesions on the back. They occur more commonly
childhood or later. They have no gender-related in men and boys than in women and girls.
predilection [15]. The epidermoid cyst is lined by stratified
squamous epithelium, and sometimes ciliated
Clinical presentation and evaluation epithelium, in addition to mucous-secreting cells.
These lesions present as mobile midline neck The epidermoid cysts in the submental region
masses that are soft, nontender, and filled with originate from epidermal cells that become trap-
sebaceous debris (cheesy keratinous material). ped during closure of the first and second bran-
Some may manifest in the lateral neck subman- chial arches during the third and fourth weeks of
dibular triangle between the mylohyoid and hyo- development [16]. They may arise after inflamma-
glossus. They usually do not move with tion or infection of the hair follicle, which may be
protrusion of the tongue or swallowing; however, attributable to a postinflammatory nonneoplastic
in some instances, they may have fibrous attach- proliferation of the follicular epithelium. They
ments to the hyoid, and thus may present similar may also sometimes arise from traumatic implan-
to TDC. The usual clinical presentation is a lump tation much like dermoid cysts.
or swelling under the tongue or submental region,
which can measure up to 10 to 12 cm in diameter Clinical presentation and evaluation
[15]. They are slow growing and become bother- Histologically, they are lined by stratified
some to the patient if they interfere with speech, squamous epithelium with orthokeratin that is
mastication, or tongue mobility, but they rarely sloughed into the cystic lumen. The cyst may or
obstruct the airway. Dermoids in this area can be- may not have a granulomatous inflammatory
come infected; in such cases, they become painful reaction surrounding it in reaction to exposed
and erythematous and could present with a drain-
ing sinus tract. They can usually be diagnosed by
CT or ultrasound imaging. A fine needle aspirate
(FNA) biopsy can be used but is not always diag-
nostic and may not be necessary. Ultrasound can
differentiate between simple cysts and dermoids
based on echogenicity, but dermoids may be sim-
ilar in echogenicity to lipomas [13].
Histologically, the presence of keratinizing
stratified squamous epithelium, hair follicles, and
sebaceous glands is characteristic of these cysts.

Treatment
Dermoid cysts are excised to prevent sub-
sequent infection, to establish a diagnosis, and Fig. 5. Large dermoid cyst of the submental region.
for cosmetic and functional purposes. Lesions Large dermoids of the submental region can be removed
located above the mylohyoid can be excised orally or through the neck depending on the amount of
orally, whereas large neck lesions are excised exposure needed.
 CONGENITAL NECK MASSES 343

orthokeratin. These cysts are mobile and fluctuant response that usually contains foamy histiocytes
to palpation. (Figs. 6–9).
Imaging studies Imaging studies
The same imaging modalities as those that aid A combination of a CT scan or MRI along
in the diagnosis of dermoid cysts can be imple- with FNA is effective in diagnosing the lesion. On
mented to diagnose epidermoid cysts. Dermoids FNA, saliva is aspirated from the lesion. The
and epidermoids are differentiated histologically absence of keratin or epithelial or glandular
by content. Epidermoids contain one germ cell elements further substantiates the diagnosis and
layer, whereas dermoids have derivatives of two differentiates between ranula and dermoid or
germ cell layers. epidermoid cyst.

Treatment Treatment
Simple excision is the treatment of choice. Surgical excision of the sublingual gland (the
Recurrence is uncommon if epidermoid cysts are etiology in most cases) is the surgical procedure of
properly excised, and malignant transformation is choice. Marsupialization involves the removal of
rare [17]. the roof of the lesion intraorally, thereby allowing
the sublingual gland to communicate with the oral
Plunging ranula cavity. This allows it to drain intraorally. Marsu-
Epidemiology and etiology pialization is noted to have a 67% recurrence rate,
A ranula is a mucocele in the floor of mouth and transoral excision of the sublingual gland has
that can ‘‘plunge’’ into the neck. Its course splits the lowest possibility of ranula recurrence [20].
the mylohyoid muscle, and the mass can be felt in OK-432 (picibanil), which is a lyophilized
the submental triangle. It is usually associated mixture of low-virulence strain Streptococcus pyo-
with the sublingual gland; however, it can be genes incubated with zylpenicillin, has been suc-
associated with the submandibular gland. Block- cessfully used as an intralesional sclerotherapy
age of the gland ducts leads to a build-up of agent. This may serve as a potential treatment
mucus material. This blockage can be attributable for plunging ranulas before considering surgery
to direct trauma to the sublingual gland or to [21]. The surgical excision of plunging ranulas
prior surgery to the floor of the mouth. The
ranula does not possess a true cystic lining and
forms a pseudocyst.
Simple ranulas do not penetrate through the
mylohyoid muscle. The plunging ranula presents
as a neck lesion by entering the fascial plane
between the hyoglossus and mylohyoid, where the
deep lobe of the submandibular gland is located.
A defect in the mylohyoid muscle (mylohyoid
boutonniere) that may be congenital in origin can
predispose a simple ranula to conversion into
a plunging ranula [18].
The presentation of a plunging ranula in the
pediatric population is rare. Sixty-two percent of
simple ranulas occur on the left side, and 58% of
plunging ranulas occur on the right side [19].
Clinical presentation and evaluation
Ranulas appear as blue dome-shaped lesions in
the floor of mouth, usually on either side of the
midline. The extraoral appearance of a plunging
ranula is seen as a submental mass extending
along the inferior border of one side of the Fig. 6. Early plunging ranulas resolve with sublingual
mandible, which may be quite large in size. They gland removal and decompression. Well-established or
are filled with mucinous material. The spilled previously infected plunging ranulas may also require
mucin from the ranula elicits a granulation tissue cervical exposure and excision.
344 ROSA et al

Fig. 9. Second BCC removed. Note that the tract of the

lesion must be removed with the cyst.

There are four subdivisions of teratomas: the

Fig. 7. Axial CT image of plunging ranula. dermoid cyst or epithelium-lined cyst, which
contains ectodermal and mesodermal elements
can be achieved orally; however, large plunging (most common); the teratoid cyst, which contains
ranulas may need cervical excision for adequate poorly differentiated tissues from all three germ
access. layers; the teratoma, which contains differentiated
tissues from all three germ layers, and epignathi,
Teratoma which contain highly developed malformations
resembling fetal organs [23].
Epidemiology and etiology The origin of teratomas is controversial. Some
A teratoma stems from all three germ cell believe that they are derived from pluripotent
layers (ectoderm, mesoderm, and endoderm). stem cells sequestered during embryogenesis,
Teratomas develop during the second trimester emerging from an ectopic primitive streak. An-
of pregnancy and are seen as midline or some- other theory is that they arise from embryonic
times lateral neck masses. They occur in 1 of 4000 tissue that escaped the regional influences of the
live births [22] with a slight female predominance primary organizer [23].
[23]. Ten percent of teratomas originate from the
head and neck. The most common site of develop- Clinical presentation and evaluation
ment is the neck, although they may also develop A teratoma may present in the neonatal period
in the nasopharynx, oropharynx, and oral cavity. with airway obstruction. If they arise in the neck,
these lesions can be fatal if untreated. They are
frequently associated with polyhydramnios sec-
ondary to inhibition or obstruction to swallowing
[23].
The diagnosis is usually made by prenatal
ultrasonography. If seen on ultrasound, an ultra-
fast MRI scan can be obtained prenatally to
determine the degree of tracheal compression
and to differentiate this lesion from other lesions
that it may mimic (ie, cystic hygroma) [24]. This
allows better evaluation of the lesion without the
use of radiation.

Treatment
Cesarean delivery can be considered for large
congenital teratomas, and preparation for imme-
Fig. 8. Second BCC in a child. diate surgical airway or intubation should be
 CONGENITAL NECK MASSES 345

implemented. Excision is the treatment of choice. multilobular and develop from degenerated Has-
Malignancy has not been reported in pediatric sall’s corpuscles (degenerated epithelial cells).
cervical teratomas; therefore, critical structures The cysts contain lymphocytes, along with
should be spared during excision [4]. Malignancy multinucleated giant cells; macrophages; choles-
has been documented among adults, and thus terol clefts; and an epithelial lining that may be
may require more aggressive management. cuboidal, columnar, or stratified squamous [25].
The size of the cyst wall can vary from a few mil-
limeters to as much as 1 cm [26].
Lateral congenital neck masses
Thymic cyst Imaging studies
The study of choice, ultrasound examination,
Epidemiology and etiology can demonstrate homogeneous and nonhomoge-
The thymus is important for cell-mediated neous masses and a solid or cystic mass [26]. CT
immunity during infancy. It grows to its maxi- scans can guide surgical resection by giving more
mum size at 2 to 4 years of age. It then involutes detail as to the location of the mass and its asso-
and becomes a fibrofatty remnant. ciation with adjacent structures. MRI is excellent
The thymus gland develops from the third and for soft tissue evaluation and can be a valuable
fourth pharyngeal pouches during the sixth week tool to determine the location of the cyst and its
of development. By the eighth week, paired mediastinal extension. FNA has little diagnostic
primordia fuse in the midline, attach to the value [25]. Chest radiography is important for
pericardium, and begin their descent into the the confirmation of normal thymic tissue in the
mediastinum [25]. As the superior attachment of mediastinum in children.
the thymic primordium fails to regress at 8 weeks,
solid or cystic ectopic tissue may be left behind
Treatment
along the path of migration [25].
The presence of a normal thymus is vital before
Sixty seven percent of thymic cysts occur in the
excision of this lesion in children, because the
first decade of life [26]. They are present on the left
thymus is important in their cell-mediated immu-
side in 68% of cases, on the right side in 25%, and
nity. Therefore, removal of a thymic cyst in a child
on the midline in 7% [26]. The gender distribution
with an abnormal thymus may compromise that
is reported to be equal or to have a 2:1 male pre-
child’s cell-mediated immunity. If normal thymic
dominance [27].
tissue is present, complete surgical excision that
spares the surrounding vital structures is the
Clinical presentation and evaluation treatment of choice [26].
Thymic cysts are usually located anterior or There is a 2% recurrence rate of thymic cysts
deep to the sternocleidomastoid muscle (SCM), in adults, and no recurrences have been noted in
and 50% extend into the mediastinum by direct children with complete excision [26]. In addition,
extension or by connection to a vestigial remnant there have been reports of rare malignant trans-
or as a solid cord [26]. They are exceedingly rare formation of these cysts [28].
and are not reported because of the fact that
they remain dormant, and thereby clinically insig-
Branchial cleft cyst
nificant. Eighty percent to 90% of cervical thymic
cysts are asymptomatic [27]. They may enlarge be- Epidemiology and etiology
cause of hemorrhage or infection and then be- Branchial cleft anomalies arise from the bran-
come symptomatic [27]. These can cause chial apparatus, which develops between the third
dysphagia, pain, dysphonia, and dyspnea based and seventh weeks of embryologic growth. There
on mass effect on the neck. Thymic cysts are are five branchial arches of mesodermal origin,
known to expand with the Valsalva maneuver. each of which gives rise to specific bony, cartilag-
These cysts can be congenital or acquired. The inous, muscular, and neurovascular structures in
congenital type is usually unilobular and origi- the head and neck (Table 1). Between each arch is
nates from persistent rudiments of the thymo- a groove, or cleft, arising from ectoderm. The for-
pharyngeal duct [27]. They sometimes have mation of a BCC is thought to be attributable to
epithelium from the thyroid and parathyroid incomplete obliteration of the branchial tracts
glands because of their close association during [29]. It is imperative that the surgeon be familiar
development. The acquired thymic cysts are with the structures associated with each arch,
346 ROSA et al

Table 1
Branchial arch derivatives
Nerve Artery Muscle Cartilage/Bone
First arch V3 None Tensor tympani, Malleus head and neck,
masticator mm incus body and short
Mylohyoid, anterior process, mandible,
belly of digastric, anterior malleal
tensor palatini ligament,
sphenomandibular
ligament
Second arch VII Stapedial artery Platysma, facial mm, Malleus manubrium,
(degenerates) stapedius, post incus long process, hyoid
belly of digastric, lesser cornu and part
buccinator, styloid of body, stapes, styloid
process, stylohyoid
ligament
Third arch IX Common carotid artery Stylopharyngeus, superior Greater cornu of hyoid,
and internal carotid and middle constrictors rest of body of hyoid
artery
Fourth arch X Superior Aorta on left, proximal Inferior pharyngeal Thyroid cartilage,
laryngeal subclavian artery constrictor, cuneiform cartilage
on right cricopharyngeus,
cricothyroid mm
Fifth arch X Recurrent Ductus arteriosis Intrinsic laryngeal mm Cricoid, trachea, arytenoid
laryngeal (except cricothyroid) cartilages, corniculate
cartilage
Abbreviation: mm, muscle.

because the tracts of the cysts follow a pathway gland [32] and can be confused with primary pa-
between the associated arch derivatives. rotid lesions.
Second branchial cleft cyst. Second branchial cleft
Clinical presentation anomalies are the most common, representing up
First branchial cleft cyst. Work [30] described first to 95% of all branchial anomalies [33]. Thirty-
branchial cleft anomalies by dividing them into seven percent present as cysts alone, and 63%
two types: type I, which arise from the cleft and are also associated with fistulas or sinuses [34].
are therefore ectodermal only, and type II, which A complete fistula, with internal and external
have contributions from the first and second bran- openings, is rare but has been reported [35]. The
chial arches as well, and therefore contain some tract of a second BCC courses superficial to cra-
mesodermal elements. Type I cysts typically nial nerves XII and IX; between the internal ca-
course parallel to the external auditory canal rotid artery and external carotid artery; and then
(EAC), superior and lateral to the facial nerve, pierces the middle constrictor, deep to the stylo-
and may terminate in the bony-cartilaginous junc- hyoid ligament, and opens into the tonsillar fossa.
tion of the EAC or in the middle ear space They The cysts typically present as a mass along the an-
are considered to be duplications of the membra- terior border of the SCM or near the angle of the
nous EAC; if infected, they can drain as a fistula mandible. They can present anywhere along the
inferior to the lobule or in the preauricular or course of the tract, however, from the anterior
postauricular area. Type II cysts can contain car- border of the SCM to the tonsillar fossa. Unusual
tilage and adnexal structures in addition to skin locations have been reported, including a cystic
and are considered to be a duplication of the car- mass in the parapharyngeal space [34]. Three per-
tilaginous and bony EAC. The tract can lie medial cent to 10% are bilateral [33] and can be associ-
or lateral to the facial nerve; if infected, it can ated with other congenital anomalies, such as
present with drainage at the angle of the mandible branchiootorenal syndrome, which is associated
[31] or internally, in the EAC, with otorrhea [32]. with conductive hearing loss and renal abnormal-
Type II cysts can present as cysts in the parotid ities. They can be asymptomatic, or they can
 CONGENITAL NECK MASSES 347

present with recurrent infection, sore throat, and

dysphagia. Patients with a second BCC often pres-
ent with a history of recurrent unilateral tonsillitis
(Figs. 10 and 11). Note that in an adult with a cys-
tic neck mass, it is imperative to rule out malig-
nancy; most commonly, tonsillar and papillary
thyroid carcinoma can present with a cystic meta-
static lymph node (Figs. 12 and 13).
Third branchial cleft cyst. Third branchial cleft
anomalies usually present anterior to the SCM
near the superior pole of the thyroid lobe. The
tract of the third branchial cleft anomaly courses
from anterior to the SCM superficial to cranial
nerve XII, deep to the carotid artery and cranial Fig. 11. Operative exposure of a right second BCC.
nerve IX, to pierce the thyrohyoid membrane
above the internal branch of the superior laryn-
geal nerve and open into the pyriform fossa. tract to the superior laryngeal nerve distinguishes
Patients may present with what seems to be acute a third from a fourth branchial anomaly because
thyroiditis [36]. they both open into the pyriform sinus. Because
a fourth BCC usually presents as a neck mass
Fourth branchial cleft cyst. Fourth BCCs are rare,
near the inferior lobe of the thyroid gland, it can
representing only 2% of all branchial anomalies
be confused with other entities, such as TDC, cys-
[36,37]. The tract of the fourth branchial cleft
tic hygroma, and thyroid cyst [36]. It should be
anomaly is different on each side of the neck.
high in the differential diagnosis when a patient
On the right side, the tract traces from anterior
presents with a neck mass that increases in size
to the SCM inferiorly to loop around the subcla-
with crying or the Valsalva maneuver or with re-
vian artery, deep to it and the carotid artery, lat-
current infections of the neck or thyroid gland.
eral to cranial nerve XII, and inferior to the
A neonate may present with a lateral neck mass
superior laryngeal nerve, to open into the pyri-
and airway compromise [36].
form fossa or the larynx. On the left side, which
is the more common presentation, the course is
lateral to cranial nerve XII, inferior to the supe-
rior laryngeal nerve, to open into the lower pyri-
form sinus or larynx. Only the relation of the

Fig. 10. Axial CT image of a left second BCC in an

adult. Fig. 12. Left second BCC in an adult.
348 ROSA et al

necessary to identify and dissect the facial nerve

branches if electrophysiologic facial nerve locali-
zation is used throughout the case [31]. A superfi-
cial parotidectomy is often necessary to preserve
the facial nerve. If a fistula ends in the EAC, a por-
tion of skin and cartilage surrounding the fistula
must be removed. There is a high rate of recur-
rence if the tract is not completely excised; in a re-
view of 39 patients presenting with first BCCs,
50% of the cases had had a previous resection
[32]. Injecting methylene blue dye into the fistula
or inserting a lacrimal probe to cannulate the tract
can aid in excision [33,36].
The second BCC is the most common brachial
cyst to require excision. If there is a fistula, an
ellipse of skin must be removed along with the
epithelial tract and cyst. An isolated level II lymph
node that contains a cystic metastasis from an
Fig. 13. CT appearance compatible with left second occult primary squamous cell carcinoma, fre-
BCC. Final pathologic examination revealed a cystic quently from the tonsil, can present in the adult
metastatic lymph node from an unknown primary, as a second BCC. Preoperative pharyngeal exam-
which later proved to be the ipsilateral tonsil. ination is appropriate for adult patients with an
apparent second BCC. Should the final pathologic
examination demonstrate a cystic metastasis
Imaging studies and diagnostic tests rather than a second BCC, the patient should
CT of the neck with contrast shows the location undergo an appropriate workup for an unknown
of the cyst and the relation of the tract to the primary. This can be done in one or two stages.
surrounding structures, aiding in the differential For third and fourth branchial cleft anomalies,
diagnosis. In the case of first branchial cleft direct laryngoscopy is used to explore the pyri-
anomalies, MRI shows the extent of the lesion in form sinus for a tract to cannulate [36]. After dis-
the parotid area and the location of the facial nerve section, the pharyngeal defect is closed with
in relation to the cyst tract. Injecting the tract with a purse-string suture. Endoscopic cauterization
oily or water-soluble contrast medium [35] and of fourth branchial cleft sinuses as an alternative
taking radiographs can be diagnostic but may to excision has been reported by Verret and col-
not show the whole extent of the tract if it is leagues [37] in a cohort of 10 patients.
blocked by inflammatory tissue or secretions.

Laryngocele
Treatment
If the cyst is infected, a course of antibiotics is Epidemiology and etiology
given and preliminary incision and drainage may Laryngoceles are abnormal saccular dilations
be unavoidable. Excision should be delayed for at of the appendix of the laryngeal ventricle of
least 4 to 6 weeks to allow resolution of in- Morgagni [38]. The sac is lined by pseudostratified
flammation and greater ease of dissection. Pre- columnar ciliated epithelium and communicates
vious incision and drainage can make later with the ventricle by a narrow stalk. Development
excision more difficult. of the congenital laryngocele is contingent on the
Surgical excision of type I first BCCs is presence of a congenital saccular dilatation of the
relatively straightforward; if there is a fistula, an ventricular appendage [38]. An increase in intralar-
ellipse of skin must be removed along with the yngeal pressure may cause the sac to distend and
epithelial tract and the opening into the EAC sometimes to extend into the aryepiglottic fold.
must be repaired. Excision of type II first BCCs There are three types of laryngoceles (internal,
can be more complicated, because the tract has an external, and combined type). Internal laryngo-
intimate although variable relation to the main celes may be small or extend beyond the upper
trunk of the facial nerve and its branches within border of the thyroid cartilage. The external type
the parotid gland. Some advocate that it is not forms when the dilated appendage penetrates the
 CONGENITAL NECK MASSES 349

thyrohyoid membrane and extends into the sub- 2. Cavernous lymphangioma: large dilated lym-
cutaneous tissues of the neck [38]. The combined phatic vessels; violates tissue planes
type has components of the first two types. Lar- 3. Cystic lymphangioma (or cystic hygroma):
yngoceles are reported to be less common in large macrocystic cystic spaces
women [38].
Smaller vessel lymphangiomas (capillary and
cavernous) are typically found above the mylo-
Clinical presentation and evaluation
hyoid muscle in the lip, tongue, or oral cavity. They
Most laryngoceles are asymptomatic. There
can be infiltrative and difficult to demarcate on CT.
can be symptoms of hoarseness or cough. Dysp-
Cystic hygromas, the most common type of lym-
nea can be a symptom in children and infants
phangioma in the neck, are more sharply demar-
because of obstruction. The laryngocele may be
cated on CT and tend not to be as infiltrative.
palpable as a soft reducible mass in the lateral
cervical region that may be more pronounced Clinical presentation and evaluation
during the Valsalva maneuver [38]. Laryngoceles Cystic hygromas are painless and compress-
are normally filled with air but may be filled ible, and they tend to enlarge gradually over time.
with mucus or pus to form laryngomucoceles or The posterior triangle of the neck is the most
mucopyoceles [39]. common location (Figs. 14 and 15), with approx-
Evaluation involves CT or MRI, along with imately 56% presenting in this location and ap-
laryngoscopy. Ultrasound can also be a useful proximately 44% presenting in the anterior
initial imaging modality. Localization of a mass triangle [43]. Occasionally, these lesions enlarge
dorsal to the hyoid bone and strap muscles and rapidly over days, which is thought to be attribut-
the depiction of a communication through the able to concurrent upper respiratory infection;
thyrohyoid membrane suggest the diagnosis of however, there have been reports of rapid enlarge-
a laryngocele on ultrasound [40]. ment, seemingly with no antecedent event [43]. Ul-
trasound, MRI, and CT are all useful adjuncts to
Treatment diagnosis and surgical planning.
Treatment is surgical. There are endoscopic
microsurgical techniques that may be used in the Treatment
removal of internal laryngoceles [41]. The external Surgical resection is definitive therapy; how-
approaches begin with following the external por- ever, the lesion can be difficult to resect depending
tion of the laryngocele sac through the thyrohyoid
membrane. The laryngocele is then transected
close to the orifice of the saccule. Endoscopic mar-
supialization is another option that may be at-
tempted instead of excision, but this technique
has variable recurrence rates. Because symptom-
atic laryngoceles have an occult cancer rate of
4% [42], histopathologic evaluation of the lesion
is vital.

Lymphangioma
Epidemiology and etiology
Approximately 50% to 65% of lymphangio-
mas are present at birth, with 90% presenting by
2 years of age [43] as compared with hemangi-
omas, which begin to involute at this age. The
head and neck are the most frequent sites of pre-
sentation. Lymphangiomas are considered to be
a subset of vascular malformations and are classi-
fied according to the size of the endothelially lined
sinuses they contain:
1. Capillary lymphangioma (or lymphangioma Fig. 14. Large supraclavicular lymphangioma in an
simplex): small capillary-sized vessels infant.
350 ROSA et al

to 1 year of life and slowly regress for the next 5 or

more years, which is known as the involuting
phase. The involuting phase is completed in 70%
of children by the age of 7 years [50]. During the
first year, the lesion appears bright red, and as it
involutes, it changes its color and begins to dull.
Historically, the terms capillary hemangioma
and cavernous hemangioma are used for superficial
and deep lesions, respectively. These terms are no
longer clinically relevant, however, because, histo-
logically, the endothelial pattern is similar
throughout the depth of the lesion.
Hemangiomas are classified based on their rate
of clinical regression: rapidly involuting congeni-
tal hemangiomas and noninvoluting congenital
hemangiomas.

Clinical presentation and evaluation

Most of these lesions appear as isolated lesions
that are firm to palpation and usually red in color.
Fig. 15. Transillumination of lymphangioma. A thrill can sometimes be palpable over the lesion.
Infants who present with these lesions in the lower
face are more likely to have tracheal and laryngeal
on its proximity to vital structures and its ten- hemangiomas [51].Glut-1 is an important histo-
dency not to follow natural anatomic tissue chemical marker (erythrocyte-type glucose trans-
planes. Recurrence rates can be high if the tumor porter protein) present in all stages of
is not excised completely. Alternative therapies hemangioma development and involution, and it
include systemic and intralesional steroids, intra- can help to differentiate hemangiomas from vas-
lesional injections of sclerosing agents [44], intra- cular malformations [47].
lesional injections of fibrin and bleomycin, and Ultrasound can be useful in differentiating
systemic cyclophosphamide [43]. The efficacy of these rapidly flowing vascular lesions from slower
these therapies is uncertain. Burezq and colleagues flowing venous malformations. Magnetic reso-
[45] recommend aspiration as conservative treat- nance angiography (MRA) can provide a great
ment, with excellent results in 14 cases of cystic deal of information in terms of the vascular flow
hygromas that were diagnosed over a 30-year characteristics, which may indicate which phase
period. the lesion is in. Three-dimensional CT angiogra-
phy has been shown to differentiate hemangiomas
Hemangioma from other vascular malformations [47].
Epidemiology and etiology
Hemangiomas account for 7% of all benign Treatment
neoplasms [46].Hemangiomas affect approxi- Intralesional and systemic steroids can reduce
mately 10% of infants in their first year of life the size of these lesions. Vincristine has been
[47]. Intramuscular hemangiomas can present in successfully used in lesions unresponsive to ste-
the masseter muscle (5% of all intramuscular roids and has now replaced interferon-a as a med-
hemangiomas) [48]. Most congenital hemangi- ical treatment because of interferon’s side effect of
omas of the head and neck region present during permanent spastic diplegia [47]. Becaplermin gel
the first 6 weeks of life. Head and neck hemangi- (recombinant human platelet-derived growth fac-
omas have a 3:1 female gender predilection and tor) is used to treat superficially ulcerated heman-
occur more commonly in whites [49]. There also giomas refractory to standard wound care [47].
seems to be a greater incidence in premature new- Surgical resection can be considered in any
borns weighing less than 1 kg. phase of the hemangioma. Ulceration, bleeding,
Hemangiomas enter into the proliferative airway compromise, and extent of cosmetic defect
phase of their development in the first 8 months must be accounted for as a risk for this decision.
 CONGENITAL NECK MASSES 351

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 Oral Maxillofacial Surg Clin N Am 20 (2008) 353–365

Deep Space Neck Infection: Principles

of Surgical Management
Timothy M. Osborn, DDS, MDa, Leon A. Assael, DMDa,*,
R. Bryan Bell, DDS, MD, FACSa,b
a
Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, 611 SW Campus Drive,
Mail Code SD 522, Portland, OR 97239, USA
b
Oral and Maxillofacial Surgery Service, Legacy Emanuel Hospital and Health Center,
2801 N. Gantenbein Avenue, Portland, OR 97227, USA

An intimate knowledge of the management of structures of the neck and creates potential spaces
infections of the deep spaces of the neck is essential (Fig. 1). The cervical fascia is divided into superfi-
to the daily practice of oral and maxillofacial cial and deep layers. The superficial fascia is
surgery. Decisions must be made in a timely fashion immediately deep to the dermis and it ensheathes
through the acute course of the disease. Interven- the platysma as well as the muscles of facial
tions must be performed with the appropriate expression, the superficial musculoaponuerotic
surgical and airway skill. The surgeon must decide system (SMAS). It extends from the cranium
on medical and surgical management, including down to the thorax and axilla. The deep layer is
divided into superficial, middle, and deep layers.
Antibiotic selection
The superficial layer of the deep cervical fascia
How to employ supportive rescusitative care
(SLDCF) is an essential structure in understand-
such as fluids and nutrition
ing deep space infections of the neck. The SLDCF
When to operate
generally forms the outer margin of odontogenic
What procedures to perform
deep space neck infections (DSNI). The tenacity
How to secure the airway
of this fascia prevents the egress of pus toward
To make these decisions the surgeon must the skin until neck infections are quite late. The
understand the anatomy of the region, the etiol- result is that because of the barrier of the SLDCF,
ogy of infection, appropriate diagnostic workup, infections will expand to the point of descending
and medical and surgical management. This toward the mediastinum, ascending to the lateral
article provides a review of these pertinent topics. pharynx and masticator spaces, or will expand
to the point of causing airway obstruction. Under-
Anatomy standing the SLDCF is essential to understanding
the pathway of infection.
Fascial layers The SLDCF begins posteriorly at the nuchal
An understanding of the anatomy of the ridge and spreads laterally and anteriorly, split-
cervical fascia is critical in understanding the loca- ting to envelop the trapezius and sternocleido-
tion of a deep neck infection, in predicting the ex- mastoid (SCM). It attaches to the hyoid bone
tent of infection, and in choosing an approach for anteriorly. It envelops both the parotid and sub-
surgical drainage. The cervical fascia is the fibrous mandibular glands. It fuses with the fascia,
connective tissue that envelops and divides the covering the anterior bellies of the digastric and
mylohyoid forming the inferior margin of the
submandibular space. At the mandible, the fascia
* Corresponding author. splits and the internal layer covers the medial
E-mail address: [email protected] (L.A. Assael) surface of the pterygoid muscles up to the skull
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.04.002 oralmaxsurgery.theclinics.com
354 OSBORN et al

Fig. 1. Fascial spaces of the neck. (Reprinted from Netter anatomy illustration collection. Elsevier. All rights reserved;
with permission.)

base. The external layer covers the masseter muscular division does not offer important path-
muscle and inserts into the zygomatic arch. ways for infection because the attachment is quite
Inferiorly, it inserts into the clavicles, sternum, rigid, and no potential space is typically present
and acromion of the scapula. except as it presents abutting the prevertebral
The middle layer of the deep cervical fascia fascia. Inferiorly this division also inserts into the
(MLDCF) is also known as the pretracheal fascia. clavicle and the sternum. Superiorly it inserts into
It often forms the base of deep space infections of the hyoid and thyroid cartilages. Posteriorly it
the neck, thus creating a barrier to the extension fuses with the alar division of the deep layer of the
of infection into the pulmonary, tracheobronchial deep cervical fascial at the level of T2 and forms
tree, esophagus, and prevertebral space. It is the anterior wall of the retropharyngeal space.
separated into muscular and the visceral divisions. The visceral layer of the MLDCF envelops the
The muscular division surrounds the sternothy- thyroid, trachea, and esophagus. It extends in-
roid, sternohyoid, and thyrohyoid muscles. The feriorly into the upper mediastinum and joins the
 DEEP SPACE NECK INFECTION 355

fibrous pericardium The middle layer also border is the pterygoid muscles and mandible.
encloses the pharyngeal constrictors and Overlying the buccopharyngeal fascia is the
the buccinator muscles. The visceral layer of the superior pharyngeal constrictor muscle, which
MLDCF is the pathway to mediastinitis in separates the peritonsillar ‘‘space’’ from the lateral
the deep space head and neck infection, forming pharyngeal space. The lateral pharyngeal space
the anterior barrier that must be traversed by communicates anteriorly with the submandibular
advancing infection.. To descend, the infection space and posteriorly with the retropharyngeal
will also disrupt the alar division of the DLDCF, space. The styloid process and its attached struc-
described below. tures divide the lateral pharyngeal space into two
The deep layer of the deep cervical fascia compartments; the anterior and posterior. The
(DLDCF) separates into a posterior prevertebral anterior compartment contains fat and connective
division and an anterior alar division. The tissue, whereas the posterior compartment con-
prevertebral division is adherent to the anterior tains cranial nerves IX, X, XII, the cervical
aspect of the vertebral bodies from the base of the sympathetic chain, the internal jugular vein, and
skull down the spine. It extends posteriorly the carotid artery. The retropharyngeal space lies
around the spine and the muscles of the deep between the middle and deep layers of cervical
neck, the vertebral muscles, muscles of the poste- fascia, and extends from the skull base to the
rior triangle, and the scalene muscles. It envelops bifurcation of the trachea. There is a midline
the brachial plexus and subclavian vessels, raphe that is formed by the attachment of the
extending laterally into the axillary sheath. The superior constrictor muscle to the alar layer of the
alar division is located between the visceral deep cervical fascia. This midline raphe separates
division of the middle layer and the prevertebral two chains of lymph nodes that lie within the
division of the deep layer. The deep layer corre- space. The pretracheal space is located below the
sponds to the posterior boundary of the retro- hyoid bone and extends inferiorly to the level of
pharyngeal space, extending down to the level of the fourth thoracic vertebrae along the arch of the
T2, where it fuses with the visceral fascia. Thus the aorta. The pretracheal space has the MLDCF as
DLDCF is important in providing the posterior its anterior border, and is bounded posteriorly by
boundary for extension of infection to the medi- the esophagus.
astinum. The DLDCF is rarely perforated by The infections in these spaces can be direct
infection, but when this occurs, it can result in extensions from other spaces of the head and
cervical spine osteomyelitis or epidural abscess neck, or from the primary site. Extensions of
following head and neck infection. infections can follow the fascial planes into the
mediastinum or the axilla. Of special mention are
the so-called ‘‘danger space’’ and the carotid
Spaces
sheath. The danger apace is the area between the
The spaces created by these fascial planes are alar and prevertebral fascia that extends from the
potential spaces that are useful to consider in skull base to the diaphragm. The carotid sheath
understanding the pathway of infection (Fig. 2). forms a potential space that allows for infection to
They include the lateral pharyngeal, retrophar- descend into the mediastinum, whereas infection
yngeal, submandibular, and pretracheal. that rests between the MLDCF and the DLDCF
The floor of the mouth and mandible, the in the retropharyngeal region will create a retro-
superficial layer of deep cervical fascia, and the pharyngeal abscess that will end at about the
lateral pharyngeal space bind the submandibular tracheoesophageal junction.
space. This space is divided by the mylohyoid
muscle into sublingual and submandibular por-
Microbiology
tions that are continuous posteriorly around the
free margin of the muscle. The sublingual portion The most common organism associated with
contains the submandibular duct, lingual nerve, deep neck infections was Staphylococcus aureus in
and hypoglossal nerve, whereas the submandibu- the pre-antibiotic era. Drug resistance has, how-
lar portion contains the anterior belly of the ever, contributed to a change in the microbial flora
digastric. The lateral pharyngeal space is an associated with these serious infections, which are
inverted, cone-shaped potential space that extends now most commonly associated with aerobic strep-
from the skull base to the hyoid. The medial tococcal species and nonstreptococcal anaerobes.
border is the buccopharyngeal fascia; the lateral [1,2]. The bacteria that commonly cause deep
356 OSBORN et al

CC - Cricoid cartilage
HB - Hyoid bone
SCM - Sternocleidomastoid muscle
T - Tongue
TC - Thyroid cartilage
U - Uvula

Medial
pterygoid Lateral
pterygoid Temporalis
Canine space

Coronoid process/
Temporalis insertion
Masseter
Lateral pterygoid Parotid space
Buccopharyngeal
Buccinator fascia
Buccal space Palatine tonsil
U
Lateral
Fascial cleft pharyngeal space
Sublingual space Medial pterygoid
T
Sublingual gland SLDF (Blue)
Superficial space
Submaxillary space/ Superficial fascia
HB
Submaxillary gland (Orange)
MLDF (Purple)
TC
Vascular space DLDF (Green)
Levator scapulae
Cleavage
SCM
CC

Trapezius
Scalene
Fascia fixing
omohyoid Subvaginal space
to clavicle

Omohyoid
Anterior
visceral
Sternohyoid
Space of Burns space

Fig. 2. Fascial spaces of the neck. (Modified from Janfaza P, Nadol JB, Galla RJ, et al. Surgical anatomy of the head and
neck. Philadelphia: Lippincott Williams & Wilkins, 2000. p. 684; with permission.)

neck infections represent the normal oral flora that more than half of severe odontogenic infections
becomes pathogenic when normal host defenses [6]. In diabetic patients, the microbial nature of
are ineffective. Commonly cultured organisms in- DSNI shows a higher infection rate of Klebsiella
clude Streptococcus viridans, Streptococcus milleri pneumoniae when compared with those who do
group species, B-hemolytic streptococci, Neisseria not have diabetes mellitus [4].
species, Peptostreptococcus, coagulase-negative
staphylococci and Bacteroides [2–4]. Other causes
Diagnosis
that should be considered but are uncommon are
Bartonella henselae and Mycobacterium tuberculo- When evaluating a patient in whom a deep
sis [5]. Anaerobic bacteria include Prevotella and neck infection is suspected, an orderly workup
Porphyromonas species, Actinomyces species, Bac- should be followed. As all evaluations should
teroides species, Propionobacterium, Hemophilus, begin, a history and physical examination should
and Eikenella. Anaerobic bacteria are found in be obtained, with focus on evaluation of the
 DEEP SPACE NECK INFECTION 357

airway. Information on the time from initiation of Infection of the lateral pharyngeal space is
symptoms to the present will give an understand- often caused by spread of tonsillar infection from
ing of the pace of advancement of the infection. the peritonsillar space through the superior
Potential initiating factors such as dental prob- pharyngeal constrictor muscle (Figs. 3 and 4).
lems, dental interventions, recent upper respira- Other causes include posterior extension of infec-
tory infection, recent surgery, or trauma need to tion from the submandibular space, anterior
be assessed. Any signs of impending airway extension from the retropharyngeal space, and
obstruction should prompt immediate and neces- medial extenstion from a deep lobe parotid
sary control of the airway. Patients who are abscess or masticator space abscess. Common
deemed to have a stable airway may have causes of retropharyngeal infection are from blunt
a more leisurely history and physical examination or penetrating trauma, instrumentation (esopha-
performed. Physical examination should include goscopy, feeding tube placement, intubation),
intraoral evaluation with focus on the floor and suppurative lymphadenitis (rare after age 5).
of mouth and dentition, oropharyngeal, and Spread of infection from the lateral pharyngeal
pharyngeal examination. Attention should also space or prevertebral space can result in retro-
be directed behind the palatopharyngeal fold. pharyngeal space involvement (Fig. 5).
Understanding the common and uncommon There are a number of imaging modalities that
presentation of DSNI is critical in the early can be used once a history and physical have been
recognition and management of these patients. performed. The potential for loss of airway during
Patients will often present with systemic signs and radiologic assessment should be considered in
symptoms of disease, such as fever, chills, malaise, every case. Any patient who has airway compro-
and loss of appetite. Because these are general mise should have control of the airway ensured
symptoms, more localizing symptoms such as via intubation or tracheotomy before any imaging
odynophagia, dysphagia, trismus, odontalgia, modalities are used. Clinicians can make use of
and dysphonia are often present. Mayor and plain radiographs (chest, lateral neck), ultraso-
colleagues [7] showed that the most common clin- nography, CT, MRI, and nuclear medicine scans.
ical presentation of DSNI was odynophagia in Inspiratory lateral cervical radiography has tradi-
84% of patients, followed by dysphagia (71%), tionally been used because it is simple, readily
fever (68%) neck pain (55%), neck swelling available, and applicable in cases of retrophar-
(45%), trismus (39%), and respiratory distress yngeal and prevertebral space involvement.
(10%). These symptoms have been shown to be Increased thickness of the distance from the
similar in other series as well [8–10]. Signs include anterior aspect of the vertebral body to the air
neck swelling, elevation of the floor of the mouth, column in the posterior pharyngeal wall (O7 mm
drooling, diaphoresis, elevated temperature, and at C-2), loss of cervical lordosis, and presence of
bulging of the pharyngeal wall or lingual aspect air in the soft tissues suggest space involvement
of the mandible. Classic description of pharyngeal [10,12]. In most institutions, this method is rarely
wall bulging is midline bulging for prevertebral used because of the 33% false-negative rate as well
infections and unilateral for retropharyngeal space as the wide availability of CT scans.
infections, because of the midline raphe formed by CT scanning is the most widely used modality
the superior constrictor muscle, which prevents for diagnosing DSNI because it is less expensive,
space involvement crossing the midline [2]. readily available, and can localize abscesses in the
There are a number of causes of deep neck head and neck, as well as other structural abnor-
infections. Determining the site of origin or cause malities. The results of CT scans are easily
of deep neck infections varies widely in the interpreted by surgeons and allow for precise
literature, ranging from 30% to 90% of cases surgical planning. CT is not as effective as
having an identified source of infection [1,7]. The ultrasound in determining abscess from cellulitis.
submandibular space is the most common site of On CT, cellulitis appears as soft-tissue swelling,
deep neck infections and they are caused by odon- increased density of surrounding fat, enhancement
togenic source in up to 85% of cases [11]. Other of involved muscles, and obliteration of fat
causes include laceration of the floor of the planes, whereas abscess is suspect when there is
mouth, mandibular fracture, tumor, lymph- a low density area with a peripheral enhancement.
adenitis, sialoadenitis, patient self-injection with With any radiologic evaluation, the findings must
intravenous drugs, systemic infection, and hema- be correlated with clinical findings. A study by
togenous spread of infection. Miller and colleagues [13] found combination of
358 OSBORN et al

Fig. 3. Fourteen-year-old patient who has peritonsillar abscess (PTA). Note lack of trismus, differentiating this from
a lateral pharyngeal space infection, which almost universally presents with trismus. PTAs can be safely managed by
needle aspiration combined with appropriate antibiotic therapy, again differentiating them from lateral pharyngeal space
infections, which generally require extraoral/transcervical drainage. (A) Clinical appearance. (B) CT scan of the same
patient demonstrating peritonsillar fluid collections bilaterally. (C) Needle aspiration.

clinical evaluation and CT findings led to accu- Use of MRI gives improved soft-tissue defini-
racy in identifying drainable collection of 89%, tion over CT without the use of radiation. MRI
sensitivity of 95%, and specificity of 80%. In and magnetic resonance angiography (MRA) may
a series reported in one paper [8], CT scans were also be more useful than CT technology in
not readily available, and the lack of CT with diagnosis of vascular complications of DSNId
contrast was an important contributing factor in internal jugular vein thrombosis (IJVT), carotid
all patient deaths. erosion or rupture [16,17]. MRI should also be
Use of ultrasound gives reliable determination used when central nervous system (CNS) involve-
of abscess versus cellulitis. The advantages of ment is suspected.
ultrasound is that it is transportable to the patient, Patients with DSNI should undergo incision
can be used to direct an aspirating needle, and and drainage that includes a culture and sensitiv-
involves no radiation [14]. Ultrasound is particu- ity as a guide antimicrobial therapy. There is
larly useful in children and in peritonsillar-upper varying susceptibility of organisms in head and
parapharyngeal infections, to avoid incision and neck infections, and culture and sensitivity allows
drainage in cellulitis and to support medical treat- identification of resistant organisms [18]. Gram’s
ment in those cases [15]. stain is a quick and useful tool to assist in initial
 DEEP SPACE NECK INFECTION 359

Fig. 4. Forty-five-year-old patient who has lateral pharyngeal space abscess with involvement of the masticator space.
Note external swelling caused by the masticator space infection and severe trismus. (A) Clinical appearance. (B) CT scan
demonstrating fluid collections involving the lateral pharyngeal space, submandibular space, and masticator space.

Fig. 5. Fifty-two-year-old patient who has retropharyngeal space abscess. (A) MRI demonstrating enhancing fluid col-
lection in retropharyngeal space. (B) Clinical photograph demonstrating surgical approach to open drainage. Dissection
begins at the anterior border of the sternocleidomastoid muscle; the internal jugular vein and carotid artery are identified
and protected, and the retropharyngeal space is entered high in the neck. Note retraction of the internal carotid artery.
360 OSBORN et al

antibiotic choice, such as when Gram’s stain may Comorbid medical conditions are found in
suggest staphylococcal infection versus strepto- many patients who have DSNI. Some of the
coccal infection. Although there are improved more common are diabetes mellitus, chronic
techniques for isolating anaerobic bacteria, there hepatitis, uremia or chronic renal failure, and
is little use for anaerobic culture in DSNI. The relative immune-suppressed states such as HIV/
majority of isolates in head and neck infections AIDS or in patients on chemotherapy [4]. These
are aerobic in nature, particularly with use of conditions require thorough workup and moni-
the swab technique of collection [19]. toring because they can be exacerbated by the
Routine sampling of blood cultures is not infection, and can also lead to more severe infec-
widely practiced for patients in the absence of signs tions. Diabetes in particular requires strict man-
of systemic symptoms such as fever, chills, night agement, and control of blood sugar below 200
sweats, or hypotension. Blood cultures are positive mg/dL is imperative for good control of infection
in 10% to 15% of patients who have systemic [26].
symptoms [4]. Patients who develop signs and
symptoms of septicemia despite adequate medical
Surgical treatment
or surgical treatment should have blood cultures.
An important consideration in people who have Many deep infections of the head and neck
DSNI is that in one series, the cause in 6% of require surgical intervention in the form of
patients was malignant tumor [20]. Therefore the incision and drainage. Many would argue that
use of panendoscopy following acute phase treat- when there is an abscess in the deep neck, surgical
ment should be considered in patients who have drainage is mandatory. Depending on the series,
no clear etiology of infection. One should also con- surgical drainage is required in 10% to 83% of
sider sampling of accessible lymph nodes if they are patients who present with deep neck space
found enlarged or abnormal. It may also be prudent infections [7,20]. When surgical drainage is neces-
to take a biopsy specimen of the abscess wall to es- sary, Topazian and Goldberg [27] recommend the
tablish or exclude the diagnosis of malignancy [20]. following principles in their text: incise in healthy
skin and mucosa when possible, not at the site of
maximum fluctuance, because these wounds tend
to heal with an unsightly scar; place the incision
Medical management
in a natural skin fold; place the incision in a depen-
Medical management of these patients should dent position; dissect bluntly; place a drain; and
begin promptly with intravenous access, fluid remove drains when drainage becomes minimal
resuscitation, and administration of IV antibi- [27].
otics. Antibiotic therapy should be administered Drainage of the submandibular space can be
empirically and tailored to culture and sensitivity by intraoral or extraoral incision. Intraoral drain-
results. Early intervention with a penicillin age is via incision in the anterior aspect of the
derivative and clindamycin is the key to successful floor of the mouth, and is indicated only in
therapy and avoidance of complications [21,22]. uncomplicated infections limited to the sublingual
Other regimens include the use of penicillins compartment; otherwise an external approach is
with -lactamase inhibitor, second, third, or fourth recommended [1]. The external approach is
generation cephalosporins, and metranidazole. through an incision approximately 3 to 4 cm
Ampicillin/sulbactam and clindamycin have each below the angle of the mandible and below the
been shown to be effective for anaerobic infections inferior extent of swelling. If the incision is placed
of the head and neck [18,23]. Pipercillin/tazobac- in the area of swelling and erythema, the wound
tam has shown efficacy in treating polymicrobial may heal with excessive scarring. The 2 to 3 cm
infections as a single agent [24]. Deep neck infec- incision should roughly parallel the inferior bor-
tions in the cellulitis stage can be successfully der of the mandible, but more importantly, should
treated with antibiotic therapy alone [4,25]. follow relaxed skin tension lines. The incision
Mayor and colleagues [7] showed that medical should be carried down through skin and subcuta-
treatment alone with antibiotics and steroids neous tissues to the platysma. The platysma can
could be as effective as open surgical treatment. then be divided with electrocautery or sharp
The traditional approach is for open surgical dissection. The superficial layer of deep cervical
drainage when the presence of purulence is fascia should then be incised parallel to the infe-
suspect. rior border of the mandible. Blunt or finger
 DEEP SPACE NECK INFECTION 361

dissection is then used in a superior-medial direc- confirmed, then a vertical incision can be made
tion to enter the submandibular space. Care over the mass. Blunt dissection with hemostats
should be taken to dissect toward the lingual as- should then be used to widely spread in the space.
pect of the mandible in the area of the posterior Copious irrigation should be used. The authors
molars so as to avoid the facial vessels. It is often use an intraoral approach to this space with
impossible to avoid penetration of the oral mu- a clearly defined area of loculation, especially in
cosa when teeth are extracted concomitantly, children. Drains are not routinely used with an
and in the authors’ experience this has not led to intraoral approach, but can be used if necessary,
orocutaneous fistula. Surgical drains should al- and sutured to the lateral pharyngeal wall and
ways be left in the space, or in multiple sites within buccal mucosa. In adults and in people who
the space. We often use red rubber catheters in ad- have large retropharyngeal space abscesses, an ex-
dition to Penrose drains to irrigate the space. ternal approach is used. The approach is through
Drainage of the lateral pharyngeal space is an anterior SCM approach as previously
approached mainly through an external ap- described. The carotid sheath is identified and mo-
proach. An intraoral approach to the lateral bilized medially. If there is sheath involvement, it
pharyngeal space is discouraged because of the can be opened. With the sheath and vessels mobi-
presence of the carotid sheath within the space lized medially, the prevertebral fascia will be
[1]. In cases where no access to the carotid artery, encountered. Blunt dissection with hemostat or
internal jugular vein, or mediastinum are antici- finger dissection is then used to enter the space.
pated, an approach similar to that of the sub- Drains are used, and again, the authors com-
mandibular space can be used. As the authors monly use multiple drains in the space. Adequate
have often seen, there is extension of submandib- drainage can be obtained without thoracotomy o
ular space infections into the lateral pharyngeal the level of T-4 [1].
space, and we approach both through the same Although it is a rare phenomenon, Ludwig’s
incision. The only difference is that the superome- angina deserves special mention (Fig. 6). It is
dial vector of dissection is carried through aiming defined as firm, acute, toxic cellulitis of the bilat-
for the angle of the mandible and into the lateral eral submandibular and sublingual spaces in addi-
pharyngeal space. Another approach is through tion to the submental space, most commonly
the anterior SCM approach, which should be secondary to dental infection. Ludwig’s requires
used if access to the carotid artery or internal jug- prompt diagnosis and surgical intervention. As
ular vein may be necessary. The incision is ori- with all infections if the head and neck, airway
ented vertically along the anterior border of the security is of prime concern. There is a higher in-
SCM beginning 3 to 4 fingerbreadths inferior to cidence of upper airway obstruction in cases of
the auricle. The incision is carried down to the Ludwig’s as well as greater need for tracheostomy.
superficial layer of deep cervical fascia, and the Parhiscar and Har-El [28] noted that 16 of 36
carotid sheath is identified and opened. Dissec- patients underwent elective tracheostomy under
tion is carried superiorly along the vessels as indi- local anesthesia without complication. In this
cated. Once near the angle of the mandible, blunt series, when intubation was attempted, it failed
dissection can be used in a superior-medial direc- in 55% of cases and emergent tracheostomy was
tion to enter the space, as described before. If necessary [28]. Therefore, with patients who
vascular complications are likely, proximal and have Ludwig’s angina, or anyone who has similar
distal closure should be achieved with loose liga- risk of upper airway obstruction, the authors
ture. In any case, drains should be left in the perform urgent elective tracheostomy under local
space. The authors routinely use two drains, anesthesia.
one in the anterior and one in the posterior
compartment.
Airway management
Drainage of the retropharyngeal space can be
accomplished through an intraoral or extraoral Airway compromise is the most immediate and
approach (see Fig. 5). When draining the space life-threatening of the complications encountered
intraorally, it is wise to first aspirate the area of in management of deep neck infections. Proper
induration or fluctuance to confirm the presence management of the airway can be a lifesaving
of pus and not blood. If there is blood, one should measure in certain patients and should be
suspect carotid artery erosion, which dictates an of primary focus. There are three options for
external approach. Once the presence of pus is airway management: close clinical observation,
362 OSBORN et al

Fig. 6. Nineteen-year-old patient who has Ludwig’s angina, one of the few surgical emergencies in oral and maxillofacial
surgery. (A) Clinical appearance. Note: patient upright to maintain airway in preparation for awake tracheostomy. (B)
CT scan demonstrating involvement of the submandibular and submental spaces bilaterally. (C) Incision and drainage
with instrumentation of all involved spaces bilaterally (sublingual, submental, submandibular, and lateral pharyngeal).
(D) Postoperative appearance 1 day following surgical drainage. Note: with early tracheostomy the patient requires no
short- or long-term ventilatory assistance and is transferred out of the intensive care unit on postoperative day 1.

endotracheal intubation (fiberoptic or direct), or requirement for mechanical ventilation, and sub-
surgical airway. There are different advantages glottic stenosis, and endotracheal tube (ETT)
and disadvantages to each. Observation of the displacement/unintentional extubation. Tracheot-
airway is adequate if initial evaluation reveals no omy, on the other hand, allows for the bypass of
impending airway compromise, but does require upper airway obstruction. It is a very secure
close evaluation. The main complications of airway, there is less need for sedation and
observation without mechanical intervention are mechanical ventilation, and it allows for earlier
unrecognized impending airway loss, risk of over- transfer out of critical care units [29]. Tracheot-
sedation with loss of airway, or extension of omy is a surgical procedure with inherent risks
infection and edema leading to asphyxiation. such as pneoumothorax, bleeding, subglottic ste-
The benefit is that there is no mechanical in- nosis, tracheoinnominate or tracheoesophageal
tervention, which carries inherent risk. The ad- fistula, as well as unsightly scar. Training and
vantages of endotracheal intubation include the comfort with airway management procedures, as
speed with which airway control can be achieved, well as available hospital resources such as anes-
and that it is a nonsurgical procedure. Disadvan- thesiology, fiberoptic equipment, and critical
tages include the potential for failed intubation, care resources, also have an impact [21,30]. The
inability to bypass upper airway obstruction, decision to observe the airway, perform
 DEEP SPACE NECK INFECTION 363

Fig. 7. Forty-nine-year-old patient who has cervical necrotizing fasciitis of odontogenic origin. Patient presented to
emergency department in sepsis with mediastinal extension following inadequate drainage of a submandibular abscess
at an outside office. (A) Intraoperative photograph at the time of initial neck exploration. Note necrotic tissue. (B)
CT of the neck at presentation, demonstrating free air and inflammatory changes within the deep fascial spaces of
the neck. (C) CT of the chest at presentation, demonstrating similar free air and inflammatory changes within the me-
diastinum in addition to pulmonary fluid collections. (D) Mediastinal exploration.

intubation, or tracheotomy must be made on an may be heralded by recurrent small hemorrhages,

individual basis, considering the advantages and hematoma, bleeding, ipsilateral Horner’s syn-
disadvantages of each. drome, unexplained cranial nerve IX to XII neu-
ropathy, persistence of peritonsillar swelling, and
blood clots on exploration or incision and drain-
Complications
age [34]. If carotid artery erosion is suspected,
Even in the advent of modern antibiotics, then aggressive treatment is warranted by gaining
severe complications can occur in DSNI. These proximal and distal control with repair or ligation
include airway compromise, jugular vein throm- [10].
bosis, mediastinal involvement, pericarditis, pneu- IJVT is the most common vascular complica-
monia, emphysema, arterial erosion, meningitis, tion. It is characterized by shaking chills, spiking
and extracranial or intracranial extension of fevers, tenderness, and swelling at the angle of the
infection if there is delay in diagnosis and treat- mandible or along the SCM [10]. IJVT may pro-
ment [8,31–33]. Carotid artery erosion is a devas- duce bacteremia, circulating septic thrombi with
tating complication that can involve the common, distant infection, or pulmonary embolism. Treat-
internal, or external carotid branches. A bleed ment is with medical management consisting of
364 OSBORN et al

anticoagulation, or surgical treatment with liga- [11] Patterson HC, Kelly JH, Stroone M. Ludwig’s
tion of the vein. angina: an update. Laryngoscope 1982;92:370.
Mediastinitis is a rare complication of DSNI, [12] Bank D, Krug S. New approaches to upper airway
and the descending necrotizing mediastinitis that disease. Emerg Med Clin North Am 1995;13:473.
[13] Miller WD, Furst IM, Sandor GKB, et al. A pro-
results is one of the most serious and lethal forms
spective blinded comparison of clinical examination
(Fig. 7) [35]. The diagnosis of mediastinitis is and computed tomography in deep neck infections.
based on clinical examination and cervicothoracic Laryngoscope 1999;109:1873.
CT, which will show tracking of infection down [14] Baatenburg de Jong RJ, Rongen RJ, Lameris JS,
the neck and signs of fluid collection or gas within et al. Ultrasound-guided percutaneous drainage
the mediastinum. These patients are treated surgi- of deep neck abscesses. Clin Otolaryngol 1990;
cally through a cervical approach when there is no 15:159.
infiltration above the tracheal bifurcation or T4, [15] Quraishi MS, O’Halpin DR, Blayney AW. Ultraso-
and a combined cervical and thoracic approach nography in the evaluation of neck abscesses in chil-
in all other cases [36,37]. dren. Clin Otolaryngol 1997;22:30.
[16] Braun TF, Hoffman JC, Malko JA, et al. Jugular
venous thrombosis: MRI imaging. Radiology 1985;
Summary 157:357.
[17] McArdle CB, Marfahraee M, Amparo EG, et al.
Management of deep infections of the neck is MR imaging of transverse/sigmoid dural sinus and
a critical skill of oral and maxillofacial surgery. It jugular vein thrombosis. J Comput Assist Tomogr
is a unique opportunity for the specialty to act as 1987;11:831.
[18] Rega AJ, Aziz SR, Ziccardi VB. Microbiology and
the primary managing team for these patients. A
antibiotic sensitivies of head and neck space infec-
fundamental skill set is required for the diagnosis
tions of odontogenic origin. J Oral Maxillofac Surg
and management of these potentially life-threat- 2006;64:1377.
ening illnesses. [19] Lewis MA, MacFarlane TW, McGowan DA.
A microbiological and clinical review of the acute
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1990;28:359.
[1] Bottin R, Marioni G, Rinaldi R, et al. Deep neck [20] Ridder JG, Eglinger CF, Technau-Ihlinge K, et al.
infection: a present day complication. A retrospec- Deep neck abscess masquerading hypopharyngeal
tive review of 83 cases (1998–2001). Eur Arch Oto- carcinoma. Otolaryngol Head Neck Surg 2000;
rhinolaryngol 2003;260:576. 123:659.
[2] Marra S, Hotaling AJ. Deep neck infections. Am [21] Har-El G, Aroesty JH, Shaha A, et al. Changing
J Otolaryngol 1996;17:287. trends in deep neck abscess: a retrospective study
[3] Brook I. Microbiology and management of periton- of 110 patients. Oral Surg Oral Med Oral Pathol
sillar, retropharyngeal, and parapharyngeal 1994;77:446.
abscesses. J Oral Maxillofac Surg 2004;62:1545. [22] Stiernberg CM. Deep-neck space infection: diagno-
[4] Huang TT, Lieu TC, Chen PR, et al. Deep neck infec- sis and management. Arch Otolaryngol Head Neck
tion: analysis of 185 cases. Head Neck 2004;26:854. Surg 1986;112:1274.
[5] Ridder GJ, Technau-Ihling K, Sander A, et al. Spec- [23] Retsema JA, English AR, Girard A, et al. Sulbac-
trum and management of deep neck space infections: tam/ampicillin: in vitro spectrum, potency, and ac-
an 8-year experience of 234 cases. Otolaryngol Head tivity in models of acute infection. Rev Infect Dis
Neck Surg 2005;133:709. 1986;8(Suppl 5):S528.
[6] Flynn TR, Shanti RM, Levi MH, et al. Severe odon- [24] Gorbach SL. Pipercillin/tazobactam in the treat-
togenic infections, part 1: prospective report. J Oral ment of polymicrobial infections. Intensive Care
Maxillofac Surg 2006;64:1093. Med 1994;20(Suppl 3):S27.
[7] Mayor GP, Milan JM, Martinez-Vidal A. Is conser- [25] Sakaguchi M, Sato S, Ishiyama T, et al. Character-
vative treatment of deep neck space infections ization and management of deep neck infections.
appropriate? Head Neck 2001;23:126. Int J Oral Maxillofac Surg 1997;26:131.
[8] Larawin V, Naipao J, Dubey SP. Head and neck pace [26] Chen MK, Wen YS, Chang CC, et al. Deep neck
infections. Otolaryngol Head Neck Surg 2006;135:889. infections in diabetic patients. Am J Otolaryngol
[9] Tom MB, Rice DH. Presentation and management 2000;105:169.
of neck abscess: a retrospective analysis. Laryngo- [27] Topazian RG, Goldberg MH. Odontogenic infec-
scope 1988;98:877. tions and deep fascial space infections of dental ori-
[10] Gidley PW, Ghorayeb BY, Stiernberg CM. Contem- gin. In: Topazian RG, editor. Oral and maxillofacial
porary management of deep neck space infections. infections. 4th edition. Philadelphia: WB Saunders
Otolaryngol Head Neck Surg 1997;116:16. Company; 2002.
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[28] Parhiscar A, Har-El G. Deep neck abscess: a retro- [33] Chen MK, Wen YS, Chang CC, et al. Predisposing
spective review of 210 cases. Ann Otol Rhinol Lar- factors of life-threatening deep neck infection: logis-
yngol 2001;110:1051. tic regression analysis of 214 cases. J Otolaryngol
[29] Potter JK, Herford AS, Ellis E. Tracheotomy versus 1998;27:141.
endotracheal intubation for airway management in [34] Blum DJ, McCaffrey TV. Septic necrosis of the in-
deep neck space infections. J Oral Maxillofac Surg ternal carotid artery: a complication of peritonsillar
2002;60:349. abscess. Otolaryngol Head Neck Surg 1983;91:114.
[30] Peterson LJ. Contemporary management of deep in- [35] Roccia F, Pecorari GC, Oliaro A, et al. Ten years of
fections of the neck. J Oral Maxillofac Surg 1993;51: descending necrotizing mediastinitis: management
226. of 23 cases. J Oral Maxillofac Surg 2007;65:1716.
[31] Ruiz CC, Labajo AD, Vilas IY, et al. Thoracic com- [36] Estrera AS, Lanay MJ, Grisham JM, et al. Descend-
plications of deeply situated serious neck infections. ing necrotizing mediastinitis. Surg Gynecol Obstet
J Craniomaxillofac Surg 1993;21:76. 1983;157:545.
[32] Beck HJ, Salassa JR, McCaffrey TV, et al. Life- [37] Wheatley MJ, Stirling MC, Kirsh MM, et al. Descend-
threatening soft tissue infections of the neck. Laryn- ing necrotizing mediastinitis: transcervical drainage is
goscope 1984;94:354. not enough. Ann Thorac Surg 1990;49:780.
 Oral Maxillofacial Surg Clin N Am 20 (2008) 367–380

Deep Neck Infections: Clinical Considerations

in Aggressive Disease
John F. Caccamese Jr., DMD, MD, FACSa,b,*,
Domenick P. Coletti, DDS, MDa
a
Department of Oral and Maxillofacial Surgery, University of Maryland Medical System,
650 West Baltimore Street, Suite 1401, Baltimore, MD 21204, USA
b
Department of Pediatrics, University of Maryland Medical System,
22 South Greene Street, Baltimore, MD 21204, USA

Deep neck infections (DNIs) are common and life threatening when sound and timely manage-
occur as a consequence of several etiologies. The ment is applied.
result is either an abscess or cellulitis in the
potential spaces of the neck. Countless reports
Etiology
exist in the literature detailing the management of
infections arising from odontogenic sources, con- DNI can arise from many sources. Dental
genital lesions, cervical adenitis, malignancies, sources are widely held to be the most common
surgical treatment, upper respiratory infection, in adults and give rise to some of the more
and penetrating trauma. Life-threatening compli- aggressive infections [1–5]. Aside from odonto-
cations that have been associated with DNI genic infections, the etiology varies significantly
include airway obstruction, sepsis, septic emboli, by report. In some of the larger series, upper respi-
Lemierre syndrome, descending mediastinitus, ratory tract infection, intravenous drug abuse,
and pericarditis. Additionally, extremely aggres- and penetrating neck trauma have all been major
sive forms of DNI exist, including necrotizing contributors to this disease process [1–5]; how-
fasciitis (Fig. 1A, B and Fig. 2A, B, C). ever, one should consider all possibilities when
Despite numerous reports, little information evaluating a patient for DNI. Branchial sinuses,
exists regarding the true incidence of these in- thyroglossal duct cysts, and malignancies can all
fections. As is true in many areas of medicine, masquerade as infections or present secondarily
limited prospective data are available to guide infected [5–11]. A careful history, examination,
therapy. Treatment over the years has been based and imaging will help to differentiate the causes
mostly on surgical principle, airway management, (Fig. 3).
and an understanding of the microbiologic flora DNI in the pediatric patient can present more
of these infections. Antibiotic therapy, interven- of a diagnostic dilemma. The origin of infection is
tional radiology, and patient support modalities more varied in the pediatric population, and the
have become more sophisticated, although sur- location and microbial flora can differ substan-
gery continues to be the mainstay of treatment for tially as well. Although sinusitis, pharyngitis, and
most patients. Today, neck infections are rarely tonsillitis can all have important roles in pediatric
DNI, patients and their families frequently pres-
ent with no history of a precipitating event or
* Corresponding author. Department of Oral and
Maxillofacial Surgery, University of Maryland Medical
illness. Even within the pediatric population, the
System, 650 West Baltimore Street, Suite 1401, Balti- age of the patient results in an altered distribution
more, MD 21204 of the site and etiology of infection [12]. Several
E-mail address: [email protected] studies have noted a higher incidence of staphylo-
(J.F. Caccamese) coccal species in pediatric DNI, as well as
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.03.001 oralmaxsurgery.theclinics.com
368 CACCAMESE & COLETTI

Fig. 1. (A) CT scan of an intraparenchymal abscess as a result of septic emboli from a dental source. (B) The patient
following craniotomy for incision and drainage of the abscess.

a propensity for peritonsillar, retropharyngeal, complement function; therefore, glycemic control

and parapharyngeal space involvement [13–16]. is crucial in the management of diabetic infec-
History and physical examination can also present tions. Additionally, diabetic infections might be
a challenge, making imaging more useful in the populated with different bacterial flora, making
determination of etiology in this patient group. culture and sensitivity data more important in
their global management.

The role of systemic disease

Microbiology
Systemic diseases, especially those that sup-
press the immune system, can make patients more Most DNIs are polymicrobial, with only 5%
susceptible to head and neck infections. Declining identified as purely aerobic and 25% with isolated
neutrophil function resulting in impaired phago- anaerobic species. Due to their fastidious nature,
cytosis and decreased bactericidal action have anaerobic organisms can be difficult to culture,
been demonstrated in the elderly, hemodialysis and their exact role in disease is difficult to assess
patients, and diabetic patients [17]. Other patients [20].
at risk are those who take immunosuppressive Neck infections commonly involve pathogens
medications to treat chronic disease, such as can- such as Streptococcus viridans, Streptococcus mill-
cer patients, patients with autoimmune disease, eri, Prevotella spp, Peptostreptococcus spp, and
and transplant recipients. Klebsiella pneumoniae [21–24]. Staphylococcal
Diabetic patients have long been known to species are infrequently found in adult neck infec-
have an increased susceptibility to infection, and tions, many of which are coagulase negative and
DNI is no different in that regard [3,18]. In fact, represent skin flora contamination. Streptococcus
studies suggest that diabetic patients not only viridans is the predominant organism is adult
become infected more frequency but also tend to neck infections (43.7%), but Klebsiella pneumo-
be older, have a higher rate of complications, an niae has been shown to be more common in
increased severity of infection, prolonged hospi- diabetic patients (56.1%) [19]. Due to the predict-
talization, and require more aggressive therapy able makeup of most polymicrobial head and
[18,19]. Systemic hyperglycemia results in neck infections, most patients can be treated em-
a derangement of the immune system involving pirically with regimens that include clindamycin
neutrophil function, cellular immunity, and or beta lactams alone or in combination with
 CLINICAL CONSIDERATIONS IN AGGRESSIVE DISEASE 369

Fig. 2. (A) Retropharyngeal abscess from a dental source in an otherwise healthy young patient. (B) Extension of this
abscess into the mediastinum and pericardium. The patient required thoracotomy. (C) An extended neck incision at the
time of drainage. All neck spaces were drained.

metronidazole [25,26]. In a recent study of odon- cohort of neck infections from 0% to 64% over
togenic infections by Flynn and colleagues [25], 6 years.
19% of isolated species were found to be penicillin The utility of cultures has been questioned,
resistant, with only 4% of species with clindamy- with some reports indicating that culture and
cin resistance. These resistant strains accounted sensitivity data do not lead to a change in
for 54% and 17% of cases with sensitivity data, antibiotic selection or treatment [26]. Others
respectively. have recommended cultures for extensive or
DNIs in children are also likely to be poly- rapidly spreading infections, necrotizing and
microbial, with beta-lactamase producing organ- gas-forming infections, nosocomial or recurrent
isms becoming more common. Group A infections, and those that occur in an immuno-
streptococci represent the major pathogen, with compromised host [30]. Given the ever increasing
Prevotella being the most common anaerobe; possibility of drug-resistant organisms, perhaps
however, many studies have demonstrated an in- this issue should be revisited.
creased incidence of Staphylococcus aureus in In necrotizing fasciitis, the causative organisms
pediatric neck infections [15,27–29]. This observa- are classically group A b-hemolytic streptococci
tion is most likely a result of fewer odontogenic and Staphylococcus aureus, alone or in synergism.
infections in children and a higher rate of upper Other aerobic and anaerobic pathogens can also
respiratory tract–related infections. Ever concern- be present, such as Bacteroides, Clostridium, Pep-
ing is the increasing rate of methicillin-resistant tostreptococcus, Proteus, Pseudomonas, and Kleb-
S aureus (MRSA), which according to Ossowski siella [31]. Triple antibiotic therapy is usually
and colleagues [29] has increased in their patient instituted empirically, with regimens including
370 CACCAMESE & COLETTI

Necrotizing fasciitis is associated with streptococ-

cal pyrogenic exotoxins, thought to be responsible
for toxic shock, and the enzyme cysteine protease
that is involved in tissue destruction. Typically,
the infection begins with an area of erythema that
quickly spreads over a course of hours to days; as
the skin’s blood supply is lost, it necroses. The
rate of necrosis is typically disproportionate to the
clinical signs and symptoms (Fig. 4). Without
prompt aggressive surgical drainage and debride-
ment, secondary involvement of deeper muscle
layers may occur, resulting in myositis or myonec-
rosis. The infection then progresses to systemic
shock, organ failure, and death.
From a purely anatomic standpoint, DNIs
usually follow the path of least resistance, pene-
trating the nearest and thinnest cortical bone and
tracking along the fascial planes in the neck and
face. Usually, infections spread from the primary
Fig. 3. CT scan of a neck ‘‘infection’’ referred for defin- fascial spaces (eg, sublingual, submandibular),
itive treatment after several attempts at incision and extending by confluence to the secondary spaces
drainage for presumed neck abscess at an outside institu- of the retropharynx and prevertebral space as well
tion. On further history, the patient described a recently as the carotid sheath, with eventual descent into
excised squamous cell carcinoma of the ear. The mass the mediastinum, a possibility via the ‘‘danger
was studied by biopsy rather than being re-drained space’’ or the anterior visceral space.
and was found to be metastatic squamous cell
carcinoma.

gentamicin, metronidazole, clindamycin and History

others to target these pathogens. The diagnosis of severe aggressive odontogenic
infection is initiated with a thorough history and
physical examination. Important components of
Pathogenesis of spread the history include the time course of the onset of
Three patterns of spread are seen in severe
head and neck infectionsdabscess formation,
cellulitis, and necrotizing fasciitis. A variety of
toxins, species, and strain-specific antigens are
responsible for the infection’s behavior. Classic
teaching links abscess formation to staphylococcal
species which produce coagulase, an enzyme that
converts fibrinogen to fibrin. Fibrin-coated staph-
ylococci resist phagocytosis, making the bacteria
more virulent, and the bound coagulase induces
the ‘‘clumping’’ of cells and the sequestration of
bacteria and leukocytes. Streptococcal species give
rise to cellulitis by producing invasins and protein
toxins such as streptokinase and hyaluronidase
that break down the ground substance and pro-
Fig. 4. Opening incision of necrotizing fasciitis infec-
mote the spread of infection.
tion. The infection developed in the patient after extrac-
In necrotizing fasciitis, there is a rapid pro- tion of third molars at an outside institution. An attempt
gressive liquefaction of subcutaneous fat and was made at conventional incision and drainage before
fascia, thrombosis of the subdermal veins, and transfer. Note the discoloration of the skin representing
decreased polymorphonuclear (PMN) leukocyte full-thickness necrosis as well as the necrotic appearance
function promoted by hypoxic wound conditions. of the subcutaneous fat.
 CLINICAL CONSIDERATIONS IN AGGRESSIVE DISEASE 371

symptoms, fever, a history of a recent toothache

or dental procedure, intravenous drug use, upper
respiratory tract infection or tonsillitis, sinusitis,
trauma, or skin abscess or infection. Exploring all
potential etiologies in the history is important,
and attention to specific symptoms suggestive of
airway compromise is paramount. These symp-
toms include dysphagia, odynophagia, a muffled
voice, inability to handle secretions, and, fre-
quently, trismus as a result of inflammation
adjacent to the muscles of mastication. Patients
with the latter symptoms represent true surgical
emergencies and can quickly progress to a life-
threatening loss of airway.
A careful review of systems should focus on the Fig. 5. This patient has an obvious right-sided neck
presence of comorbid disease that might contrib- swelling with erythema, ecchymosis, and a ‘‘pointing’’
ute to the infected state or complicate surgical infection.
management of the infection. Diabetes and other
immunosuppressive diseases have been shown to cavity, indicating an infection of dental, salivary,
contribute to infections in the head and neck and sinus, or tonsillar origin.
elsewhere. Additionally, immunosuppressive med- A patient sitting postured in a sniffing position,
ications might necessitate modification of the drooling, and using their accessory muscles of
surgical and anesthesia protocol as well as post- respiration is an ominous sign of impending
operative medical management. airway compromise (Fig. 6). Caution is advised
at any attempt to lay the patient flat to obtain im-
aging or even intubate, because this may precipi-
Examination tate complete airway obstruction. Many of these
patients have poor oral intake leading to dehydra-
A thorough head and neck examination must tion, which, in addition to fever, will contribute to
be performed efficiently following the basic prin- tachycardia. These acute infections can destabilize
ciples of visualization, palpation, and percussion.
A careful head and neck examination might
obviate the need for adjunctive imaging in the
acute setting, thereby decreasing the time until
surgical management is initiated. The neck exam-
ination begins with a visual survey of the patient
looking for swelling, erythema, pustules, or
‘‘pointing’’ of the infection (Fig. 5). Careful palpa-
tion of the anterior and posterior triangles should
be performed. All fascial spaces of the oral cavity,
face, and neck should be bimanually palpated to
determine if the swelling is firm or fluctuant in na-
ture. Draining sinus tracts and pits should be ex-
plored, and all carious teeth should be palpated
and percussed to further elucidate the source of
the infection. Crepitus can indicate gas-forming
organisms and might also be a sign of a necrotizing
infection. The palate, tonsils, and posterior phar-
ynx should be examined for patency and symme-
try. Nasal endoscopic examination is sometimes
useful when trismus is severe. If trismus is present, Fig. 6. A patient sitting upright in bed to maintain his
the maximal interincisal opening should be mea- airway. Note the appearance of distress and the fullness
sured because this can influence the anesthetic and erythema of the neck. This infection originated from
plan. A fetid odor is often detected in the oral an acute or chronic periodontal condition.
372 CACCAMESE & COLETTI

pre-existing diseases such as diabetes and cause

hyperglycemia and ketosis.
Necrotizing fasciitis presents with an area of
erythema that quickly spreads over a course of
hours to days (Fig. 7). The margins of infection
move out into normal skin without being raised
or sharply demarcated. As the infection prog-
resses, it gives way to a dusky or purplish discol-
oration of skin near the site of insult (Fig. 8).
The patient usually appears moderately to se-
verely toxic but, early on, may look deceptively
well. The rate of necrosis is disproportional to
the signs and symptoms of the infection, and the
patient will eventually succumb to shock, organ
failure, and death if early aggressive surgical man-
agement is not initiated. Fifty percent of patients
with necrotizing infections present with hypoten-
sion; 10% to 30% have signs of acute renal fail- Fig. 8. This patient was transferred from an outside in-
ure, coagulopathy, abnormal liver function, stitution after multiple attempts at incision and drainage
of the right side of the face. By history, the infection
acute respiratory distress syndrome, and hemo-
originated at the base of the nose. The infection pro-
lytic anemia [32]. gressed rapidly to a full-thickness necrosis, and the pa-
tient was diagnosed with necrotizing fasciitis at the
time of definitive drainage and debridement. The organ-
ism was MRSA.
Imaging
Plain radiographs such as a panoramic and have some centers abandoning their use [33,34].
periapical films are useful to identify an odonto- CT scanning is now the imaging modality most
genic source of infection. Soft tissue lateral views used to assess severe neck infections (Fig. 9). Al-
of the neck have been used to visualize increased though CT scanning has an important role in di-
prevertebral soft tissue thickening in retrophar- agnosing DNIs, it is not 100% predictive. Smith
yngeal abscesses, but in the era of contrast- and colleagues [35] evaluated the positive predic-
enhanced CT, sufficiently high false-negative rates tive value of CT in DNIs. Seventy-five percent
of the patients surgically drained had a discreet
collection of pus correlating with CT findings;
however, 25% did not. It was concluded that the
decision for surgical drainage should be made

Fig. 7. The same patient in Fig. 6. Note the erythema

and fullness of the submandibular region and the ante-
rior neck. At the time of drainage and debridement, nec- Fig. 9. CT scan of the neck demonstrating gas within
rotizing fasciitis and myositis were observed. the spaces of the neck indicating gas-forming organisms.
 CLINICAL CONSIDERATIONS IN AGGRESSIVE DISEASE 373

clinically, and that one should expect a 25% neg- stay when compared with those who were intubated.
ative exploration rate. Lazor and colleagues [36] They concluded that tracheotomy provided better
performed a 10-year retrospective review compar- use of critical care resources with reduced cost.
ing preoperative CT with intraoperative findings. In patients with a severe DNI, priority is given
Similar to Smith and coworkers, they reported to securing the airway. This goal is facilitated by
a positive correlation in 76.3% of patients. Both communication between the surgeon and anesthe-
clinical examination and contrast-enhanced CT siologist. Airway challenges specific to neck in-
have been shown to be critical components in di- fections include trismus, neck swelling, mass
agnosing DNIs. Miller and colleagues [37] per- effect, and edema of the tongue, pharynx, and
formed a blinded prospective trial of 35 patients larynx. If the vocal cords can be visualized with
comparing the ability of clinical examination direct laryngoscopy, standard oral endotracheal
and contrast-enhanced CT to predict the presence intubation is safe. Recently, video-assisted direct
of abscess formation in suspected DNIs. Twenty- laryngoscopy (GlideScope, Verathon, Bothell,
two patients had drainable collections. Clinical ex- Washington) has demonstrated value in manage-
amination was 63% accurate with 55% sensitivity ment of the challenging airway, and this modality
and 73% specificity. CT was 77% accurate with has been applied at the authors’ institution [40].
95% sensitivity and 53% specificity. If the two The anesthesiologist should be informed of lateral
modalities were combined, the accuracy increased pharyngeal, retropharyngeal, or peritonsillar col-
to 89%, with 95% sensitivity and 80% specificity. lections of pus. Injudicious use of the laryngo-
It was concluded that both clinical examination scope could rupture an abscess in this location,
and contrast-enhanced CT were critical compo- resulting in aspiration of purulent material with
nents in diagnosing these infections. subsequent pulmonary complications. If cord
Munoz and colleagues [38] compared CT with edema is present, excessive manipulation of the
MRI in the evaluation of head and neck infection. airway is ill advised, because this may cause fur-
Although MRI was found to be superior in detect- ther swelling, bleeding, or laryngospasm requiring
ing abscess and defining spaces as well as lesion an emergent surgical airway. In many severe
conspicuity and identification of source, CT de- DNIs, oral intubation is not possible. The recom-
picted gas and calcification more accurately and mended modality of airway management is an
was easier to interpret with regard to motion arti- awake fiberoptic intubation or an awake tracheot-
fact. Overall, MRI was found to be superior for omy. In emergent airway management, cricothyr-
the initial evaluation of DNI; however, its utility oidotomy is a quicker and safer choice, but
is limited at the authors’ center due primarily to swelling and edema may make palpation of the
the time involved in obtaining the study and the cricoid and thyroid cartilages difficult.
availability of MRI at all hours of the day. Potter and colleagues [39] reported that trache-
Although CT scanning offers an advantage for otomy was the treatment of choice when severe
the clinician by improving the identification of all DNIs were managed by otolaryngologists in
involved spaces of the face, neck, brain, and a comparison with fiberoptic intubation managed
mediastinum, patients with a compromised airway by oral and maxillofacial surgeons. Ovassapian
can be at risk for obstruction if placed supine for and colleagues [41] reported on 26 patients with
scanning. Despite the valuable information that deep DNI who underwent awake fiberoptic intu-
can be gained from imaging, the clinician must bation. Three patients were intubated in the sit-
weigh the risks and benefits of obtaining a scan. In ting position, two in Fowler’s position, and 21
situations in which airway loss is a real consider- in the 10-to 15-degree supine position. Twenty-
ation and imaging is believed to be mandatory, five of the intubations were successful; postopera-
the clinician should consider securing the airway tively seven patients were kept intubated and five
(fiberoptic intubation, awake tracheotomy) before underwent tracheotomy. Awake tracheotomy was
obtaining the study. recommended when fiberoptic intubation is not
feasible or when intubation attempts fail. Awake
fiberoptic intubation requires a skilled anesthesi-
ologist facile with the technique. Tracheotomy
Airway
also requires skill and experience in this patient
Potter and colleagues [39] reported that pa- population, because neck swelling may obscure
tients who had a neck infection and underwent the usual surgical landmarks and cause deviation
tracheotomy had a shorter hospital and ICU of the trachea. There are risks and benefits
374 CACCAMESE & COLETTI

associated with intubation and tracheotomy, and dehydration, fever, or shock, aggressive fluid
each case must be considered individually. The resuscitation is initiated. Employment of vaso-
choice of procedure should be based on multiple pressors might be necessary for patients in septic
issues, including the surgical plan, anticipated shock once volume has been restored. The main-
length of intubation, patient status at the time of stay of therapy for DNI is prompt surgical
drainage, and medical comorbidity. In Potter’s se- drainage and removal of the source of infection
ries, 34 patients underwent tracheotomy and 51 when relevant, even in cases of cellulitis involving
were endotracheally intubated. One patient in important fascial spaces. Aggressive incision and
the tracheotomy group had a cerebrovascular ac- drainage will lead to earlier resolution by chang-
cident secondary to a ruptured carotid aneurysm. ing the local environment to one more favorable
Two patients in the intubation group died, one for antibiotic delivery and for the activity of host
from an unplanned extubation and the other defense mechanisms. The authors’ preference
from laryngeal edema post extubation with an in- when dealing with infections that have progressed
ability to reintubate. According to their report, to the neck is to create an incision large enough to
tracheotomy patients had a shorter hospital and allow digital palpation of the involved drained
ICU stay in comparison with intubated patients. spaces and bimanual inspection when anatomi-
It was concluded that tracheotomy provided bet- cally possible. This inspection helps to ensure
ter use of critical care resources with reduced adequate drainage of all loculations and facilitates
cost [39]. In a review of retrospective data from irrigation of the wound (Fig. 10).
a similar cohort of patients at the University of Whether a role exists for nonsurgical manage-
Maryland, only 2% of patients required tracheot- ment or minimally invasive intervention (eg,
omy, and a similar length of stay was observed radiologically guided aspiration and drainage) is
[42]. the subject of debate in the literature. Medical
In the setting of DNI, it is often difficult to therapy alone seems to have a role in isolated
assess when the patient is suitable for extubation space infections in the pediatric patient [28,43,44];
despite the presence of inspiratory and expiratory however, it has also been suggested that paraphar-
cuff leaks and meeting appropriate ventilatory yngeal abscesses could be treated medically with
weaning parameters. Extubation of these patients intravenous antibiotics alone or with needle
has the potential of being disastrous, and it is aspiration. Oh and colleagues [45] performed an
recommended to err on the side of caution if any 8-year prospective study of 34 patients with
doubt exists, or to perform a tracheotomy. CT-proven parapharyngeal abscesses. Nineteen
of these patients were treated conservatively with
antibiotics only or needle aspiration, and 15
Laboratory investigations were treated surgically with incision and drainage.
A complete blood count can show leukocytosis
with an increased percentage of PMN leukocytes
and a left shift; however, in isolated space
abscesses, the white cell count might be normal.
Many patients, especially those with necrotizing
infections, have a metabolic acidosis as demon-
strated by their basic metabolic panel and arterial
blood gas. In cases of septic shock, lactate, blood
urea nitrogen, creatinine, potassium, and glucose
can all be elevated.

Surgical management
Medical therapy is primarily supportive in
nature, because DNIs are primarily a surgical
disease. For any patient demonstrating surgical
urgency, the ABCs of basic life support are Fig. 10. At a minimum, access to the neck should be ad-
initiated. In deep neck and necrotizing infections equate to allow digital exploration of the involved
in which patients are exhibiting signs of spaces.
 CLINICAL CONSIDERATIONS IN AGGRESSIVE DISEASE 375

Patients with airway compromise had tracheoto- anatomic structures (ie, facial nerve). Penrose
mies performed (n ¼ 5). The length of hospital drains are placed to keep the wound open for
stay was 8.2 days in the conservative group and drainage and to allow for daily bedside irrigation
11.6 days in the surgical group. One patient in as needed. Thorough digital exploration of these
the conservative group developed mediastinitis. spaces using known anatomic landmarks will
It was concluded localized parapharyngeal reduce the likelihood of missing loculations or
abscesses may in some cases respond to antibiotics involved spaces, thereby reducing the need for
alone. Sichel and colleagues [46] performed reoperation and decreasing hospital stays. Bross-
a nonrandomized prospective study of infections Soriano and colleagues [51] conducted a retrospec-
limited to the parapharyngeal space without tive review of 113 patients with Ludwig’s angina
airway compromise or signs of shock. Twelve treated with small incisions. Sixty-two patients
patients presented with this diagnosis; however, had extension into the parapharyngeal space,
five were excluded due to extension into other and 32 had retropharyngeal involvement. Forty-
spaces. Six of the seven cases were pediatric six were diabetic, and 34 required tracheotomy.
patients, and all were treated with a 9- to 14-day More than half of the patients were hospitalized
course of intravenous amoxicillin with clavulanic for 6 or fewer days. In this series, 33 patients
acid. All of the patients were cured without the had major complications such as mediastinitis,
need for drainage [46]. sepsis, or death. Nevertheless, it was concluded
In peritonsillar abscesses, catheter or needle that drainage using small incisions was safe and
drainage has been recommended with the addition effective in patients with Ludwig’s angina.
of ancillary steroids, and image-guided aspiration In necrotizing fasciitis, aggressive surgical de-
using either CT or ultrasound has been applied to bridement is crucial, and any delay in treatment
DNIs [47]. Poe and colleagues [48] reported the can result in mortality. When the skin is incised,
use of CT-guided aspiration in a small series of little to no bleeding is observed due to small vessel
four cases without complications. Yeow’s group thrombosis. The underlying fascia is necrotic, and
prospectively reviewed 15 cases of unilocular thin turbid ‘‘dish water’’ pus is classically seen.
neck abscesses that failed antibiotic therapy alone. The skin and underlying fascia must be radically
Thirteen patients were successfully treated with and aggressively excised until bleeding skin edges
needle or catheter aspiration and two required are achieved. In these circumstances, the authors
re-aspiration. Two patients failed this therapy have noted hesitation or avoidance by the in-
and required traditional surgical drainage [49]. experienced surgeon to perform such excision,
Chang and colleagues [50] performed a prospective because significant esthetic and functional defor-
controlled study of 14 patients with well-defined mities result from the debridement (Fig. 11A, B).
unilocular abscesses. All of the patients were suc- It must be understood that this wide excision of
cessfully treated by ultrasound-guided drainage, affected tissue is a life-saving procedure, and
and eight patients had an indwelling catheter that any hesitation to treat the disease aggressively
placed. It was concluded that ultrasound-guided will result in further tissue loss and possibly death.
percutaneous drainage was an effective treatment When underlying muscle is involved, it must also
for well-defined unilocular abscesses in the head be excised. The wound is then packed open and
and neck. irrigated with hydrogen peroxide and saline
Few trials have examined percutaneous solution with frequent dressing changes. Daily
methods for space infections from odontogenic washouts and wound inspections with further
sources. Additionally, many infections occupy debridement are performed until the extent of
more than one space or present with an indistinct the infection declares itself (Fig. 12A, B). Before
cellulitic process. In these situations, aggressive considering reconstruction, it is usually recom-
surgical drainage is recommended with the em- mended to wait at least 2 weeks or until a healthy
ployment of generous incisions. Adequate access bed of granulation tissue has developed and the
allows an exploration of all involved spaces with patient is systemically stable. If available, hyper-
digital palpation and manipulation to breakdown baric oxygen may be helpful in the treatment of
loculations, perform washout of necrotic debris, necrotizing fasciitis, although its role is contro-
and place drains, all of which alter the wound versial in the literature. Jallali and colleagues
environment to one more favorable for cure. [52] performed a review of the English literature
Incisions should be placed to allow dependant to review current practice and the evidence
drainage when possible and to avoid important for the use of hyperbaric oxygen as adjunctive
376 CACCAMESE & COLETTI

Fig. 11. (A) The patient shown in Fig. 8 with staphylococcal necrotizing fasciitis of the right side of the face. (B) The
same patient after first stage drainage and debridement. She was eventually reconstructed with a radial forearm free flap.

therapy in necrotizing fasciitis. They concluded Sequencing reconstructive strategies for patients
that the results are currently inconsistent, and with necrotizing fasciitis can be a monumental
that more robust evidence by way of prospective challenge. Extensive tissue loss following aggres-
randomized trials is necessary before routine use sive debridement may require composite (eg,
of hyperbaric oxygen for necrotizing fasciitis can skin, muscle, bone) tissue replacement. The chal-
be recommended. lenges of reconstruction for these destructive
Reconstruction is not considered until after the head and neck infections are similar to those in
wounds are stabilized with signs of a healthy oncologic head and neck surgery. They include
granulation tissue bed (Fig. 13A, B, C). Further- a compromised airway, impaired sensory and mo-
more, these patients are often profoundly cata- tor function, esthetic facial deformity, an inability
bolic as a result of sepsis and poor nutrition to control secretions, and impaired speech. The
and have a diminished immunologic response. goals of reconstruction are the restoration of

Fig. 12. (A) The patient shown in Fig. 4 after first stage debridement of necrotizing fasciitis resultant from third molar
extraction. (B) The same patient at the time of final debridement once the infection had declared itself completely. Rapid
spread along the relatively avascular fascial planes took this infection down onto the chest wall. The patient was even-
tually skin grafted and is alive and well.
 CLINICAL CONSIDERATIONS IN AGGRESSIVE DISEASE 377

Fig. 13. (A) This patient had a necrotizing infection of the neck requiring debridement of skin, muscle, nerve, vascular
structures, and the submandibular glands, leaving him with significant deficits and a soft tissue defect. He underwent
serial debridements and meticulous wound management. (B) The same patient after stabilization of the wound size dur-
ing a period of management that included frequent dressing changes and a vacuum-assisted closure device to facilitate
a clean wound and encourage granulation tissue. (C) The same patient before definitive reconstruction. Note the healthy
appearance of the wound.
378 CACCAMESE & COLETTI

function and form. To achieve these goals, the The advantage of a free tissue transfer is its
surgeon must understand the advantages and ability to simultaneously restore the multidimen-
disadvantages of each rung of the reconstructive sional tissue loss in a single operative visit. It is more
ladder. Local flaps have limited use with compos- reliable in hostile environments when compared
ite defects due to the limited volume of tissue, the with local or regional flaps with bone grafting.
limited versatility with composite defects, the Additionally, free tissue transfer is more versatile in
typically modest vascular supply, the inability reconstructing larger continuity defects, although
to transfer bone, and the possible need for a mul- necrotizing infections infrequently involve the
tistage approach (ie, walking tube flaps). Regional resection of bone. When osseous reconstruction is
flaps are more versatile with defects related required, there is greater success with placement of
to necrotizing fasciitis. Advantages include endosseous implants and decreased time to
(Fig. 14A–D) a reliable vascular supply and the complete the oral rehabilitation. One important
presence of adequate soft tissue volume. Disad- consideration in the use of free tissue is the recipient
vantages are the pedicle base, which limits the site vessels, especially in this environment of
arch of rotation; the many involved functional infection and inflammation. Frequently, target
muscle units, which make the donor site a concern; vessels have been debrided in the process of disease
and the negligible ability to transfer bone (a multi- control. Additional imaging may be required to
staged procedure with bone grafts). find suitable inflow and outflow for the flap.

Fig. 14. (A) This patient was transferred from an outside institution for further management of necrotizing fasciitis of
the right side of the neck. The exposed carotid sheath can clearly be visualized in the wound. The infection had entered
the superior mediastinum. (B) The wound was reconstructed with a pedicled latissimus dorsi muscle flap. Photograph
shows the flap at the time of elevation. (C) The flap at inset. (D) The flap after split-thickness skin grafting.
 CLINICAL CONSIDERATIONS IN AGGRESSIVE DISEASE 379

A true comprehension of the architectural hard [5] Lee JK, Kim HD, Lim SC. Predisposing factors of
and soft tissue defects facilitates a strategic complicated deep neck infection: an analysis of 158
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restoring oral lining, followed by soft tissue cover-
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age of the face and vital structures and then skeletal 1545–50.
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Summary incidence and alternative approaches for surgical
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 381–391

Cervical Spine Injuries

Jeff W. Chen, MD, PhD, FACS
Legacy Emanuel Hospital, Portland, OR, USA

Cervical spine injuries involve both fractures because such syndromes, discovered during the
and spinal cord injuries. The fractures may be neurologic examination, frequently provide the
detected radiographically whereas the detection of first clue that there is an underlying spinal cord
spinal cord injuries may require both clinical and injury. Because the majority of the associated
radiographic data. Spinal cord injuries may occur maxillofacial and spinal injuries occur in the
in the absence of a fracture if there is a herniated setting of motor vehicle accidents, it is particularly
disc, spinal cord contusion, or ligamentous injury. important for the maxillofacial surgeon to be
The social impact of a cervical spinal injury is cognizant of the injuries, particularly in the
tremendous and carries both emotional and eco- context of the need for facial/cranial surgery.
nomic implications for the patient and the pa- Appropriate measures are necessary to immobilize
tient’s family. Recognition of a cervical spine or fixate the spine before surgery to avoid
injury is important to avoid further neurologic exacerbating the spinal injury.
compromise.
Facial or skull fractures are frequently associ- Cervical spine anatomy
ated with cervical spine fractures or spinal cord
injury. The incidence of cervical spine injuries in The occipital condyles
trauma patients has been reported to range from
The occipital condyles are paired semilunar
0% to 8%. This depends upon the mechanism of
points of articulation that project off of the
injury and the age and gender of the patient [1–4].
inferior surface of the skull. These lie along the
In a postmortem study of trauma patients, it has
anterior and lateral parts of the foramen magnum.
been estimated that approximately 24% of the pa-
They extend medially. The occipital condyles
tients examined had spinal injuries [1]. In a recent
articulate with the superior concavities of the
study of 3356 patients with craniomaxillofacial
lateral masses of the atlas. The slope of the
fractures, Elahi and colleagues [4] identified 124
condyles matches the slope of the lateral masses
cases of cervical spine injury for an incidence of
of the atlas so that the condyle lies somewhat
3.69%. The vast majority of the injuries occurred
within the atlas (Fig. 1). This relationship is not as
with motor vehicle accidents. They found that
well developed in the pediatric population. This
there were two main clusterings for the injuries:
may explain the higher incidence of atlanto-
the C1 to C2 area and the C6 to C7 area. They
occipital injuries in these patients [5].
also found an increased incidence with decreasing
Glasgow Coma Score. This makes sense intui- Anatomy of the atlas (C1)
tively because more severe traumatic brain injuries
The term atlas is derived from Greek mythol-
are more likely to be associated with increased
ogy after the god whose task it was to bear the
forces of injury [4].
heavens on his shoulders. The atlas is a ringlike
This article briefly discusses the anatomy of the
structure with two lateral masses with smooth
cervical spine and the most common types of
articulating surfaces superiorly and inferiorly (see
fractures associated with the cervical spine. Cer-
Fig. 1). Above the atlas are the occipital condyles,
vical spinal cord syndromes are also reviewed
which are below the superior articulating surfaces
of the axis (C2). The anterior arch includes the an-
E-mail address: [email protected] terior tubercle in the midline, while the posterior
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.03.006 oralmaxsurgery.theclinics.com
382 CHEN

Fig. 1. The atlas (C1) from above. Note the lateral masses and the sites of articulation superiorly with the occipital
condyles. The vertebral arteries are depicted in red.

arch includes the posterior tubercle in the midline. magnum. Posteriorly, the tectorial membrane is
The anterior arch is about half the length of the a continuation of the posterior longitudinal liga-
posterior arch. The anterior tubercle is attached ment as it passes from the body of C2 to the ante-
to the anterior longitudinal ligament and the rior rim of the foramen magnum. This limits
longus coli muscles. The posterior tubercle is extension. The alar ligaments extend from the
attached to the ligamentum nuchae. The trans- tip of the dens to the medial aspects of the occip-
verse foramen are lateral to the lateral masses. ital condyles. These ligaments are primarily re-
The vertebral artery passes through the transverse sponsible for restraining lateral and rotational
foramen before turning medially and posteriorly motion at the occiput–C1 junction [8].
to go behind the superior articular process [6]. The transverse ligament lies posterior to the
A series of ligaments attach the atlas to the axis dens and goes between the lateral masses of C1.
and the skull. This restrains the dens and prevents anterior
translation. The apical ligament goes between
Anatomy of the axis (C2) the tip of the dens and the basion (anterior rim
The axis has a vertebral body from which the of the foramen magnum). This further restricts
toothlike dens or odontoid extends upward. The anterior translation. The anterior atlantodental
anterior articular surface of the dens articulates ligament is a small ligament between the anterior
with the posterior surface of C1 (the articular part of the dens and posterior aspect of the
facet for the dens). A series of ligaments connect anterior tubercle of C1. A great deal of rotation
the dens with the ring of C1 and the occiput. The occurs at the atlantoaxial joint. Studies have
lamina join posteriorly in a bifid spinous process. demonstrated normal values of unilateral rotation
The axis has well-defined pedicles (Fig. 2). The that range from 34 to 47 [9,10].
transverse processes extend laterally and have fo-
ramen to accommodate the vertebral artery [6]. Anatomy of the subaxial spine (C3–C7)
The C1–C2 junction is composed of the atlantoax- The lower cervical vertebrae have vertebral
ial joints on both sides with their lateral mass bodies that increase in size from a cranial to
biconvex articulations, which have loosely associ- caudal direction. They are broader in the trans-
ated joint capsules. verse dimension compared with the anteroposte-
rior direction. Each intervertebral disc has an
Occiput–C1–C2 relationships
external annulus fibrosus that surrounds the
The ligaments between the occiput, C1, and C2 nucleus pulposus. These discs act as cushions
are critical for the maintenance of stability in this between the vertebral bodies and give the spine
region (Fig. 3). The primary motion at the oc- the ability to flex and extend. The vertebral bodies
ciput–C1 junction is in the sagittal plane [7]. are joined anteriorly by the anterior longitudinal
Anteriorly, flexion is limited when the tip of the ligament, and posteriorly by the posterior longitu-
dens abuts the anterior margin of the foramen dinal ligament.
 CERVICAL SPINE INJURIES 383

Fig. 2. The axis (C2) in an anterior-posterior view. Note the odontoid process and foramen for the vertebral arteries.

The pedicles extend posterolaterally from the Spinal cord

vertebral body joining with the lamina that join
The spinal cord lies within the spinal or
posteriorly in the midline (Fig. 4). The processes
vertebral canal and extends from the foramen
of the articular pillars project laterally from the
magnum down to the conus (approximately T12–
junction of the pedicles and lamina and support
L1). There is variability in the width of the spinal
the superior and inferior articular facets. The
cord that corresponds to areas of increased in-
transverse processes project laterally off of the
nervation. The spinal cord demonstrates enla-
vertebral bodies and house the transverse fora-
rgement between C2 and C6 with a maximal
men, through which the vertebral artery passes.
transverse diameter of 13 to 14 mm [6]. The spinal
Vascular anatomy nerve roots exit the neural foramina laterally. The
cross-sectional anatomy of the spinal cord demon-
The paired vertebral arteries are the main strates topographic organization of the fiber
vessels associated with the cervical spine. Typi- tracts. The location of the fracture or compression
cally the vertebral arteries arise off of the left and relative to the different fiber tracts explains many
right subclavian arteries. They enter the transverse of the clinical spinal cord injury syndromes.
foramina between C6 and C7 and travel in
a cephalad direction through the transverse fora-
men of C6 up to the transverse foramen of C1, Cervical spine fractures and dislocations
where they exit and pass posteriorly behind the
Occiput–C1 articulation
articular process of C1 (Fig. 5). The vertebral ar-
teries join intracranially at the level of the pons to The occipital–cervical articulation is highly
form the basilar artery. Before this junction, mobile. The stability in this region is largely pro-
branches descend from the vertebral arteries and vided by the series of ligaments discussed earlier.
join, forming the anterior spinal artery, which The occipital condyles are well visualized by CT
courses along the length of the anterior spinal scanning at the base of the skull and are classified
cord. There are contributions throughout its according to CT scan findings. A type I fracture is
course from 6 to 10 anterior radicular arteries a comminuted fracture of the occipital condyle or
that arise from the vertebral arteries or the inter- condyles that occurs as a result of a direct impact to
costals arteries [6]. the top of the head (axial loading). Thus, the
384 CHEN

Fig. 3. Occipital–C1–C2 junction. The key ligaments holding this region together include the alar, the apical, and the
transverse ligaments. (A) Posterior view with the removal of posterior elements and spinal cord. This demonstrates
the alar and cruciform ligaments holding the odontoid process posteriorly. (B) Cross-sectional view from above showing
the Odontoid being held forward by the transverse ligament.

occipital condyles impact upon the lateral masses displacement are usually treated with a halo
of C1. A type II fracture involves a fracture of the vest. Type III fractures that demonstrate instabil-
occipital condyle with extension upwards to in- ity are treated with posterior cervical fusion
clude the skull base. A type III fracture involves between the occiput, C1, and C2.
medial displacement of the bone fragments off of Traditionally, occipitalcervical dislocation in-
the occipital condyle. There is disruption of the juries were fatal with few survivors. Forensic
attachment sites of the alar ligaments. These are studies have demonstrated an up to 10% incidence
frequently bilateral and occur in 30% to 50% of of occipitalcervical dislocation injuries in fatal
atlanto-occipital dislocations [11,12]. motor vehicle accidents [1,13]. Improved resuscita-
Type I and II fractures tend to be stable tion techniques and triaging have resulted in more
fractures and may be treated with cervical braces survivors with this dislocation. Many of these pa-
for 6 weeks. Type III fractures with minimal tients have a significant traumatic brain injury,

Fig. 4. Subaxial cervical spine (C3–C7).

 CERVICAL SPINE INJURIES 385

Fig. 5. Key arteries (red) of the cervical spine. The cervical spine’s relationship with the course of the paired vertebral
arteries is delineated. The vertebral arteries traverse the vertebral foramen before going medially at the level of C1.
(A) Lateral view of the cervical spine. (B) Posterior view from above focusing on the C1-2 junction.

and this dislocation may not be recognized initially. the Jefferson fracture. This typically occurs by
Some of the clinical findings include brainstem in- axial loading and is a burst fracture that results
jury with cardiopulmonary arrest; cranial nerve in three to four fractures that involve both the
findings (VI, XI, and XII most frequently); posterior and anterior arches of C1 (Fig. 6). For
Brown-Sequard syndrome, or central cord syn- this fracture to occur, the axial load needs to be
drome, or both; and subarachnoid hemorrhage. distributed fairly evenly [12]. The third type of
These occipitalcervical dislocations are highly un- C1 fracture is that which usually involves one lat-
stable. The goal is to stabilize the spine to prevent eral mass. This occurs if the head is deviated from
further injury to the underlying neural tissue. These the true saggital plane at the time of impact [11].
dislocations are treated with an occipital–C1–C2 These fractures are described in isolation, but
fusion using posterior rods and screws [5,12,13]. are frequently associated with fractures of the
second cervical vertebra.
These atlas fractures are generally treated
Atlas fractures
nonoperatively. This depends largely upon the
Fractures of the atlas make up about 10% of amount of lateral displacement of the lateral
all acute cervical spine injuries [11]. The most masses. For those with a larger amount of
common type of C1 fracture involves the posterior displacement, thus suggesting more disruption of
arch bilaterally at the junction of the posterior the ligaments, a halo brace with traction is used
arch and the lateral masses. The mechanism of for 6 to 12 weeks. For the patient with isolated
this injury is hyperextension of the cervical spine, posterior arch fractures or Jefferson fractures with
which leads to compression of the posterior arch less than 2 mm of lateral displacement of the
of C1 between the occiput and the spinous process lateral masses, treatment is with a rigid orthotic
of C2. The second most common atlas fracture is brace for 10 to 12 weeks [11,12].
386 CHEN

Fig. 6. C1 fractures. (A) Anterior ring fractures that may occur with axial loading with flexion. (B) Typical fracture
pattern seen with the Jefferson fracture, where there are fractures in the anterior and posterior rings.

Axis fractures Type II fractures are the most common type of

odontoid fracture and occur at the junction (or
Odontoid fractures
neck) of the odontoid process and vertebral body.
The prevalence of dens fractures in patients
These have the highest rates of nonunion, which
with cervical spine injuries that survive the initial
range from 5% to 63% [18]. It has long been pro-
injury ranges from 10% to 15% [14–16]. The clas-
posed that the reason for the poor healing rates at
sification scheme of Anderson and D’Alonzo [17]
this site was because of poor vascular supply.
is the most widely adopted for odontoid fractures
However, further studies have demonstrated
(Fig. 7). Type I fractures involve an oblique frac-
a rich vascular supply to the neck of the odontoid.
ture off of the tip of the dens. These are rare frac-
It is currently believed that the poor rate of union
tures and are usually treated nonoperatively using
is the result of the inability of the ligaments to sta-
a rigid brace.
bilize this region when a break exists [18,19].
Therefore, it is not surprising that several different
methods for stabilizing this fracture have evolved
over the years.
Odontoid fractures as a proportion of all
cervical fractures occur more frequently in the
pediatric population than in the adult population.
However, given that pediatric injuries are less
common than adult injuries, this overall number is
relatively low [18]. The adult population may be
divided into those less than and those greater
than 65 years of age. Odontoid fractures in those
less than 65 years usually occur as a result of sig-
nificant force, such as in a motor vehicle crash. In
those over 65, ground level falls account for the
majority of these fractures [20,21]. We have found
that the elderly patients frequently have osteopo-
rosis, which leads to a weakened neck of the
odontoid.
Clinically, many of the younger patients are
unconscious from concomitant traumatic brain
injury and are unable to be examined. Elderly
Fig. 7. Typical locations of the type I, II, and III odon- patients typically have severe pain at the base of
toid fractures in the anterior-posterior view, according the skull with increased pain upon movement. We
to the classification scheme of Anderson and D’Alonzo. have found that, in many of these patients, the
 CERVICAL SPINE INJURIES 387

odontoid fracture may not be recognized initially rate of fusion with an 88% nonunion rate
because the patient may not seek help right away. reported if there is more than 4 mm of odontoid
CT scanning through this region with coronal and displacement. Similarly, age over 40 has been as-
saggital reconstructions provides the best means sociated with a nonunion rate of 67% [18,22].
to visualize these fractures. Plain films with lateral Although the halo has the advantage of a non-
and open-mouth odontoid views have been the operative approach, it does impede mobility and
traditional way to view this area. However, it is respiratory function. It is best suited for young,
frequently difficult to visualize this region because mobile patients. Elderly patients do not fare as
of the osteopenia of the odontoid or obscuration well with halo immobilization [20,23]. Facial lac-
by the surrounding teeth. erations and facial fractures may also make it dif-
There are a several ways to treat these frac- ficult to fixate the halo ring to the head. Typically,
tures. As mentioned above, the type II odontoid patients are treated in a halo for approximately 12
fractures have a poor rate of union without some weeks. If there is still nonunion at 4 months, most
type of immobilization. External immobilization advocate an operative stabilization.
using a halo apparatus has been used for many Posterior cervical fusion of C1–C2 using
years. Nonunion rates in adults have been a Gallie-type wiring technique has achieved excel-
reported to range from 6% to 64% [22]. The lent results with fusion rates in excess of 90%.
alignment of the fracture is a key factor in the Wires are placed in a sublaminar fashion between

Fig. 8. CT scan demonstrating the lateral (A) and coronal reconstruction (B) views of a patient who suffered an odon-
toid fracture. This patient is an 18-year-old female who was in a high-speed rollover motor vehicle accident. She was
neurologically intact with severe neck pain. Postoperative plain lateral (C) and open-mouth odontoid views (D) demon-
strating the placement of two odontoid screws.
388 CHEN

C1 and C2 with interposed bone graft [5,18].

There are variations on this procedure, depending
on the location of the wires and the bone. Re-
cently, advances in the use of polyaxial pedicle
screws have allowed fixation using a rod and
screw construct [24]. While posterior fusion proce-
dures provide a firm fixation and a high rate of
union, they also result in the loss of mobility at
the C1–C2 junction [18].
Anterior odontoid screw fixation achieves
a high rate of union and preserves the mobility
of the patient at the C1–C2 level. One or two
screws are placed along the axis of the odontoid,
across the fracture line, and to the tip of the
odontoid. This allows ‘‘lagging’’ of the fracture
pieces together [25]. This technique is very depen-
dent upon an ability to align the fracture and tra-
jectory of the screw in the operating theater. We
typically use orthogonally placed C-arm fluoros-
copy to achieve fixation of the odontoid fracture.
Type III odontoid fractures extend into the
base (vertebral body) of C2 (see Fig. 7; Fig. 8).
These fractures typically have a large cancellous Fig. 9. Traumatic spondylolisthesis of C2 (hangman’s
surface area that allows good approximation of fracture). The fracture occurs bilaterally along the pars
the fragments. These have a high fusion rate using articularis of C2 as indicated. A ‘‘disconnect’’ occurs be-
tween the junction of C2 and C3 and the articulation of
rigid bracing [18].
C1 and C2. C2 may thus slip forward relative to C3.

Traumatic spondylolisthesis of C2
These fractures involve bilateral pedicles of the anterior plating system. These may also be fused
axis (Fig. 9) and have been given various names, posteriorly using pedicle screws into the C2
including hangman’s fracture, fractures of the body. This surgery is difficult because of the prox-
neural arch, fractures of the ring of the axis, and imity of the vertebral arteries to the course of the
traumatic spondylolisthesis of the axis [26]. This screws.
fracture received a great deal of attention and
notoriety in the last century as anatomic studies
Injuries of the subaxial spine (C3–C7)
were done on criminals who died from judicial
hanging. The submental placement of the knot The lower cervical spine from C3 to C7
was important in achieving the hyperextension accounts for most of the flexion and extension
that resulted in the posterior arch of C2 snapping of the neck. The anterior and posterior longitudi-
off and adhering to C3 while the ends and anterior nal ligaments span the length of the cervical spine.
arch of C1 remained fixed to the skull. This led The fact joint capsules, as well as the interspinous
to instantaneous severing of the spinal cord ligaments, give additional stability at each seg-
[26,27]. ment. The stability of the lower cervical spine
In current times, these types of fractures are depends on the integrity of the ligamentous
usually the result of motor vehicle accidents structures. The forces of injury may lead to
(Fig. 10). These fractures are subcategorized ac- abnormal movement from ligamentous damage.
cording to the amount of displacement of the This may occur in the absence of a fracture.
body of C2 relative to C3. Generally, patients Subaxial spine injuries may be broadly catego-
with traumatic spondylolisthesis of C2 have no rized according to the mechanism of injury.
neurologic findings but have neck pain. These Flexion injuries may occur in motor vehicle
fractures are effectively treated with immobiliza- accidents, falls from great heights, and dives into
tion in a halo brace for approximately 12 weeks. shallow water. Evaluation includes plain radio-
Surgically, these may be addressed with disc exci- graphs, cervical CT scans and MRI scans. The
sion at C2–C3 with placement of a bone graft and ‘‘teardrop’’ fracture is an example of a flexion
 CERVICAL SPINE INJURIES 389

Fig. 10. CT scans demonstrating a C7 burst fracture and subluxation in a 23-year-old female involved in a motor vehicle
accident. (A) Lateral reconstruction view. Note collapse and retropulsion of fragments (arrow). (B) Coronal reconstruc-
tion view. Black arrow indicates vertebral artery on the right. Blue arrow shows C7 vertebral body collapse. (C) MRI
demonstrating signal change in the spinal cord. Left arrow indicates C7 burst fracture. Right arrow notes areas of signal
change in the spinal cord. (D) T1 MRI demonstrating the fracture (arrow). (E, F) Stabilization after corpectomy is
achieved with an anterior plating system.

injury and is characterized by complete ligamen- with flexion forces, this may result in posterior
tous and disc disruption at the level of the injury disruption of the posterior elements and joints.
with disruption of the facet joints posteriorly. The This is a very unstable condition and is frequently
characteristic large triangular anterior bone frag- associated with neurologic deficits [25].
ment is the result of the superior vertebra being Extension injuries may result in disruption of
severely flexed on the inferior vertebra [28,29]. the anterior longitudinal ligament and disruption
Axial loading injuries may lead to burst of the lamina and spinous processes. Fractures of
fractures of the cervical vertebrae. In combination the facets may also occur leading to potential
390 CHEN

instability. Hyperextension injuries frequently Acknowledgment

occur without fractures. However, such injuries
All original art courtesy of Therese L. Chen,
often result in a central cord syndrome with
Portland, Oregon.
profound neurologic deficits. Central cord syn-
drome is characterized by weakness that is greater
distally than proximally. Patients frequently have References
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 393–414

Penetrating Neck Injuries

Shahrokh C. Bagheri, DMD, MDa,b,c, H. Ali Khan, DMD, MDc,
R. Bryan Bell, DDS, MD, FACSd,e,f,*
a
Oral and Maxillofacial Surgery, Northside Hospital, Atlanta, GA, USA
b
Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, Atlanta, GA, USA
c
Atlanta Oral and Facial Surgery, Atlanta, GA, USA
d
Oral and Maxillofacial Surgery Service, Legacy Emanuel Hospital and Health Center, Portland, OR, USA
e
Oregon Health & Science University, Portland, OR, USA
f
Head & Neck Surgical Associates, Portland, OR, USA

The modern approach to patients presenting It is clear that patients who present hemody-
with penetrating injuries to the neck requires the namically unstable, with severe hemorrhage, or
cautious integration of clinical findings and with an expanding hematoma should undergo
appropriate imaging studies for formulation of immediate surgical exploration. In patients who
an effective, safe, and minimally invasive modality have no hard signs of vascular injury, however, it
of treatment. The optimal management of these can be difficult to predict the presence of occult
injuries has undergone considerable debate re- injury based on clinical examination alone. Sur-
garding surgical versus nonsurgical treatment gical exploration of all penetrating neck injuries,
approaches. More recent advances in imaging although feasible, will result in a significant num-
technology continue to evolve, providing more ber of unnecessary operations. Monson and
accurate and timely information for the manage- colleagues [1] attempted to reduce the number of
ment of these patients. In this article the authors negative neck explorations by describing three
review both historic and recent articles that have zones of injury, based upon their anatomic loca-
formulated the current management of penetrat- tion and accessibility to surgical intervention.
ing injuries to the neck. Traditionally, zone I and zone III injuries were
The formidable anatomy of the neck demands managed selectively because of the difficulties as-
carefully designed treatment planning when af- sociated with surgical access, and zone II injuries
flicted with penetrating injuries. Seven major body were routinely explored. This resulted in over-
systems are confined within this relatively concen- treatment of a significant number of zone II
trated region of the body: (1) the vascular system, injuries (negative neck explorations) and under-
compromising the common, internal, and external treatment of zone I and III injuries (missed in-
carotid arteries, the highly variable jugular venous juries). Today, there has been a shift toward
system, and the vertebral vessels; (2) the gastroin- selective intervention for injuries involving all
testinal system, including the oropharynx and three zones when ‘‘hard signs’’ of vascular injury
esophagus; (3) the respiratory system, including are absent, and this has somewhat diminished
the laryngo-tracheal structures; (4) the endocrine the importance of the three zones of the neck.
system, including the thyroid and parathyroid The current indications for immediate surgical
glands; (5) the lymphatic system; (6) skeletal struc- intervention include an expanding hematoma,
tures, including the vertebral column, mandible, exsanguinating hemorrhage, shock, airway com-
and hyoid bone; and (7) the nervous system, which promise, and massive subcutaneous emphysema
includes several cranial nerves and the spinal cord. [2]. Injury from a single projectile, regardless of
velocity, may result in life-threatening penetration
* Corresponding author. of the trachea or larynx, the esophagus, major
E-mail address: [email protected] (R.B. Bell) blood vessels, or cervical nerve roots, cranial
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.04.003 oralmaxsurgery.theclinics.com
394 BAGHERI et al

nerves, or the spinal cord. Surgeons managing and left-sided hemiplegia. The first reported un-
these injuries must be familiar with the complex complicated surgical procedure was done by
anatomic structures of the head, neck, and maxil- Fleming [5] in 1803, in which he ligated the lacer-
lofacial region to provide safe, rapid, and predict- ated common carotid artery of a sailor. Several
able therapy. years later, in 1811, Abernathy reported a patient
who was gored by a bull and was managed in
Historical perspective similar fashion by ligation of the lacerated left
common and internal carotid arteries. The patient
Historic articles make reference to complica- developed a profound hemiplegia and subse-
tions related to penetrating neck injuries over quently died [6]. Since Abernathy, the outcome
5000 years ago [3]. According to Homer’s Iliad of patients who have penetrating neck injuries
(Chapter XXII, Verses 322–329), Hector, while has made modest improvement, based upon the
fighting his last duel, was almost entirely pro- concomitant refinement of the instruments of war-
tected by bronze armor except for a small area fare and the instruments of healing.
‘‘where the clavicle marks the boundary between Experience during wartime has significantly
the neck and the thorax.’’ The area above the contributed to the evolution of the current man-
suprasternal notch was described by Homer as agement protocols. During the period from the
‘‘the shorter way to death,’’ and it is in this area American Civil War to World War I, the reported
that Achilles delivered a fatal blow by thrusting mortality from penetrating neck injuries raged
his lance into Hector’s neck (Fig. 1). Long after from 11% to 18% [7,8]. In this time period, the
the collapse of the ancient civilizations of Greece, majority of the injuries where treated by expectant
literary reports of wounds of the neck continue to or nonsurgical management. In 1944, Bailey [9]
be derived from surgery of warfare. The first proposed early exploration of all cervical hemato-
documented case of the treatment of a cervical mas on the basis of his wartime experience. By the
vascular injury is attributed to the great French end of World War II, an unacceptably high rate of
surgeon Ambrose Pare (1510–1590), who ligated initially unrecognized neurovascular injuries re-
the carotid artery and jugular vein of a soldier sulting from expectant treatment prompted most
who had a bayonet wound [4]. The patient military surgeons to explore any injury that pene-
survived but developed profound aphasia trated the platysma [9–19]. This practice was
further popularized in the civilian sector by
Fogelman and Stewart [15] in 1956, who reported
a series of 100 patients treated at Parkland Memo-
rial Hospital in Dallas, Texas, where patients
underwent either early or delayed neck explora-
tion following penetrating injuries to the neck.
The study authors retrospectively reported a sig-
nificantly lower mortality rate for patients receiv-
ing immediate/early treatment (6% versus 35%).
Subsequently, mandatory early exploration of
any neck injury violating the platysma muscle
became the standard approach to diagnosis by
the majority of trauma surgeons the United
States.
The Korean War introduced two important
logistic innovations that made invaluable contri-
butions to decreasing overall mortalitydthe
Mobile Army Surgical Hospital (MASH) and
the concept of early evacuation by helicopter.
Rapid evacuation of the severely injured patients,
such as those who had penetrating neck injuries,
Fig. 1. ‘‘Achilles Kills Hector,’’ c. 1631. A painting by reduced the overall mortality rate from wounds
Peter Paul Rubens depicting the death of Hector as from 4.5% experienced during World War II to
Achilles thrusts his lance through Hector’s neckd‘‘the 2.5% in Korea [20]. Reports of mortality from
shorter way to death’’. penetrating neck injuries during the Korea
 PENETRATING NECK INJURIES 395

(2.5%) and Vietnam war (15%) demonstrate sig-

nificantly different survival rates [21,22]. The de-
velopment of high-velocity weapons (ballistic • Bronze and • Surgical
speeds of over 2000 m/second) used by the mili- iron technique and
tary in the Vietnam conflict contributed to the • Steel instrumentation
higher mortality of penetrating injuries. Table 1 il- • Gunpowder • Anesthesia
lustrates the mortality rates of military and civil- • Modern • Antibiotics
ian neck wounds reported during recent military ballistics • Imaging
conflicts, and also civilian experience [21,23].
Fig. 2 outlines the balance between mortality Fig. 2. Mortality and medical and surgical advances
and medical and surgical advances that have influ- that have influenced the outcome of neck trauma.
enced the outcome of neck trauma.
As conflicts in the Balkans, the Middle East,
and North Africa began during the later part of previous major conflicts [45]. A recent analysis
the twentieth century and the beginning of the of battlefield injuries from the second Gulf War
twenty-first century, mortality rates from civilian in Iraq and Afghanistan found that, excluding
penetrating neck injuries were generally accepted intracranial and ophthalmic injuries, 21% of all
to be from 2% to 11% [23–43]. It is difficult, how- patients will present with at least one injury
ever, to compare the civilian data to the military involving the head and neck region [46]. Data
experience: most civilian reports do not distin- from Operation Iraqi Freedom II suggests that
guish between gunshot wounds and stab wounds roughly 10% of all combat casualties will have
when reporting mortality. More importantly, neck injuries, and that mortality approaches
most civilian injuries are the result of low-velocity 12% [47].
weapons such as handguns, which is not the case The incidence and significance of head and
in a war zone. Prgomet and colleagues [44] re- neck injuries appears to be increasing with
ported a 2.1% mortality for 187 patients who changes in mechanisms of injury. A recent study
had war-related neck injuries occurring during evaluated 10 retrospective studies selected from
the war in Croatia from 1991 to 1992 that were the period 1982 to 2005 that reviewed war injuries
treated with selective neck exploration based in from Vietnam, Lebanon, Slovenia, Croatia, Iraq,
large part on physical examination. Although Somalia, and Afghanistan [48]. Injuries from frag-
the experience from the Gulf Wars is still being ac- ments (improvised explosive devices, IEDs) were
crued, there are data based on the Kosovo experi- more common during the 90s than during the
ence that the incidence of head and neck injuries Vietnam War, when shooting injuries predomi-
in modern warfare is more than twice that of nated. Injuries to the trunk were reduced in con-
flicts from 1991 onwards as military personal
armor systems including protective vests were
Table 1 used; however, the mortality of wounded soldiers
Mortality rates of military and civilian neck wounds in all conflicts was consistently between 10% and
No. of cases 14%. There was a high incidence of injuries to the
War reported Mortality head and neck (up to 40%), though they affected
American Civil War 4114 15 only 12% of the body surface area. Though the
Spanish-American War 188 18 data from the different military conflicts are not
World War I 594 11 always comparable, there are trends in the type
World War II 851 7 of injuries and mortality, which may lead to
Korea ? 2.5 changes in existing systems of medical care.
Vietnam ? 15
Croatia 187 2.1
Gulf War I & II ? 12 Anatomic considerations
Civilian experience 4193 3.7–5.9
Key to understanding the physical signs and
Data from Asensio JA, Valenziano CP, Falcone RE,
et al. Management of penetrating neck injuries. The con- symptoms of penetrating neck injuries is appreci-
troversy surrounding zone II injuries. Surg Clin North ating anatomy and the fascial envelope that
Am 1991;71(2):267–96, and Chipps JE, Canham RG, surrounds the various anatomic structures. The
Makel HP. Intermediate treatment of maxillofacial neck is invested by two fascial layers: the super-
injuries. U S Armed Forces Med J 1953;4:951. ficial fascia, which encompasses the platysma and
396 BAGHERI et al

is part of the superficial musculoaponeurotic head and neck anatomy is beyond the scope of
system (SMAS) in the face; and the deep cervical this article.
fascia, which comprises the investing, pretracheal, Monson and colleagues [1] described the most
and prevertebral layers. Injuries that are confined widely accepted anatomic classification with
to the superficial fascia, which means that the regard to penetrating neck injuries by dividing
platysma has not been penetrated, are not lethal the neck into three anatomic zones anterior to
because there are no vital structures superficial to the sternocleidomasoid muscle (Fig. 3). Zone I ex-
the platysma. Deep to the superficial fascia, tends from the level of the clavicles and sternal
however, lies a network of interconnected con- notch at the thoracic inlet to the cricoid cartilage.
nective tissue layers that split to surround muscles The important structures in zone I include the
and other vital structures and then unite on the arch of the aorta, proximal carotid arteries, verte-
other side. Below the hyoid bone the superficial bral arteries, subclavian vessels, innominate
layer of the deep cervical fascia encircles the entire vessels, apices of the lungs, esophagus, trachea,
neck deep to the superficial fascia. The preverte- brachial plexus, and thoracic duct (Fig. 4). Pa-
bral (deep) fascia encloses the vertebral column tients often present with exsanguinating hemor-
and its associated muscles, thus forming the rhage that may require transthoracic as well as
vertebral compartment. Condensations of con- transcervical approaches to affect repair. Zone II
nective tissue stretch anteriorly to surround the is the largest and most exposed area, and extends
great vessels and vagus nerve, forming the carotid from the level of the cricoid cartilage to the angle
sheath. It is this tight fascial compartmentaliza- of the mandible (Fig. 5). The important structures
tion of the vital neck structures that limits in zone II include the common, internal, and
external bleeding from vascular injuries, thus external carotid arteries, the jugular veins, various
minimizing the chance of exsanguination. The cranial nerves, the larynx, hypopharynx, and
pretracheal layer (middle) makes up the anterior proximal esophagus. Bleeding is often tampo-
compartment of the neck, is bounded by the naded by the fascial layers of the neck. Proximal
carotid sheaths laterally, and the prevertebral and distal control of the bleeding vessels is readily
fascia posteriorly, and forms the visceral com- achieved through various standard neck incisions
partment containing the trachea, esophagus, and (Fig. 6). Zone III extends from the level of the
associated structures. A comprehensive review of angle of the mandible to the base of the skull.

Zone III

Zone II

Zone I

Fig. 3. Anatomic zones of the neck. Zone 1 extends from the level of the clavicles and sternal notch at the thoracic inlet
to the cricoid cartilage. Zone II extends from the level of the cricoid cartilage to the angle of the mandible. Zone III
extends from the angle of the mandible to the base of the skull.
 PENETRATING NECK INJURIES 397

Fig. 4. Anatomic structures of zone I.

Important structures in this relatively inaccessible the projectile depends on the mass and velocity of
region include the distal cervical, petrous, and the projectile according to the following equation:
cavernous portions of the internal carotid artery,
1
the vertebral artery, the external carotid artery KE ¼ MV2
2
and its major branches, the jugular veins, the
prevertebral venous plexus, and the trunk of the Thus high-velocity injuries result in greater
facial nerve. Injuries involving zones I or III pres- damage because of the exponentially larger
ent difficult challenges with regard to diagnosis amounts of energy being transmitted to the tissue
and surgical approach because of the overlap be- (velocity is squared). In addition, the power of the
tween the chest cavity and the intracranial cavity. projectile is proportional to the conversion of
Although the management of zone II injuries has kinetic energy into mechanical disruption, which
been controversial, trauma to this relatively acces- in turn, causes indirect tissue damage. Low-
sible region is usually readily managed once the velocity projectiles travel less than 2000 feet per
diagnosis has been rendered. second, characteristically create a small entrance
and exit wound, and cause damage by lacerating
and crushing the tissue. There is little transmission
of energy, and therefore little damage is sustained
Pathophysiology of gunshot wounds and ballistics
beyond those structures that come in direct
The wounding power of a projectile depends contact with the projectile. High-velocity projec-
on several variables, including its size, shape, tiles are those that travel at speeds greater than
composition, stability, and most importantly, 2000 feet per second, have an unpredictable
velocity. The energy imparted to the tissue by course and exit wound, and create widespread
398 BAGHERI et al

Fig. 5. Anatomic structures of zone II.: 1. facial nerve; 2. internal carotid artery; 3. external carotid artery; 4. sSpinal
accessory nerve; 5. internal jugular vein; 6. vagus nerve; 7. cervical plexus; 8. mandible; 9. facial artery; 10. lingual nerve;
11. mylohyoid muscle; 12. hypoglossal nerve; 13. lingual artery; 14. superior thyroid artery; 15. common carotid artery.

damage from the production of shock waves and ranges from .17 to .460, with muzzle velocities
temporary cavitation (Fig. 7). ranging from 2000 to 4000 feet per second, and
The wounding power of a gun is generally kinetic energy up to 3000 ft-lb. Shotguns require
proportional to the caliber (diameter) of the special consideration because of the unique com-
weapon’s muzzle. Firearms are classified by their position of the projectile. Shotgun pellets have
caliber and muzzle velocity. Low-velocity a muzzle velocity of about 1200 feet per second
weapons are responsible for most civilian injuries and create tissue damage proportional to the
and include various handguns or pistols. The distance from the target, the number of pellets
caliber of handguns ranges from .22 to .45 caliber, that hit the target, and the size and pattern of the
with a muzzle velocity ranging from 700 to 1000 pellet strike. At close range, shotguns can inflict
feet per second. The kinetic energy delivered by massive tissue damage and large avulsive wounds;
these bullets ranges from 100 ft-lb to 1000 ft-lb. however, the velocity of the projectiles drops
High-velocity weapons include rifles inflict the considerably after approximately 20 to 40 yards,
type of injury generally seen in a war-zone or in which makes the weapons less effective at greater
civilian hunting accidents. The caliber of rifles distance. Low-velocity injuries consist of direct
 PENETRATING NECK INJURIES 399

Extension into origin of

sternocleidomastoid muscle
Mastoid process
Standard neck incision
Sternocleidomastoid Collar incision
muscle
Extension as a
supraclavicular incision
Clavicle
Extension as
“Book thoracotomy”

Sternum

Extension as
median sternotomy

Fig. 6. Incisions for operative exposure of penetrating neck injuries.

tissue injury by following tissue planes, and are caused by the production of shock waves and
generally associated with less morbidity than temporary cavitation, and are not easily deflected
high-velocity injuries. High-velocity injuries are by hard tissue structures (facial bones, skull, or
characterized by extensive regional damage vertebrae). The reader is referred to other, more
comprehensive texts on the pathophysiology of
gunshot wounds and ballistics [49].

Mechanism of injury
The mechanism of injury is an important
consideration in the evaluation and management
of a patient who has a penetrating injury to the
neck. Penetrating wounds typically occur from
either stab injuries or penetrating missiles. The
type of projectile often largely depends on the
situation in which it is used, and differs in civilian
populations compared with military combat. Ci-
vilian wounds typically result from low-velocity,
small caliber handguns, stab wounds, various
projectiles during motor vehicle collisions, or
more unusually, from shotguns or rifles during
hunting accidents [23–43]. Military wounds, on
the other hand, are caused by missiles moving at
a wide range of velocities with a high incidence
of injuries caused by booby traps, land-mines,
mortar, artillery, or rocket explosions. These
wounds are characterized by multiple, low-veloc-
ity fragment wounds involving the exposed neck
Fig. 7. Photograph of a patient who received a close-
or face. Additionally, gunshot wounds are typi-
range shotgun blast to the face. High-velocity projectiles
(those that travel at speeds greater than 2000 feet per cally from high-velocity rifles, cause significant
second) and shotgun pellets (traveling at 1200 feet per cavitational damage, and involve one or several
second), have an unpredictable course and exit wound, vital structures in the head and neck. Stab injuries,
and create widespread damage from the production of either civilian or military, can result from knives,
shock waves and temporary cavitation. ice picks, razor blades, glass shards, or other
400 BAGHERI et al

objects that are applied with sufficient force to

break through skin and into the subcutaneous tis-
sues of the neck (Fig. 8). The trajectory of these
stab wounds may be apparent from the history
of the incident, and can be predictive of underly-
ing neurovascular injury [50,51]. For example,
cervical stab wounds have a higher incidence of
subclavian vessel injury because the majority of
these wounds occur in a downward direction
and extend over the clavicle into the subclavian
vessels [52].
A review of the senior author’s institutional
experience of 120 consecutive patients who had Fig. 9. Etiology of penetrating neck injuries, LEHHC,
penetrating neck injuries, including a demographic 2000–2005.
analysis, was recently performed [2]. Typical of
most trauma victims, the patients were predomi-
nantly male (M ¼ 89, F ¼ 31), had a mean age the aerodigestive tract, musculoskeletal system,
of 33.8 years (range ¼ 4–92 years) and manifested cranial nerves, or thyroid gland. Of these, there
varying injury severity (mean Injury Severity Scale were 13 zone I injuries (16%), 50 zone II injuries
(ISS) ¼ 13.0; range ¼ 1–50). The majority of the (64%) and 16 zone III injuries (20%). Deep
injuries resulted from an assault with a deadly neck wounds and vascular trauma were the most
weapon (n ¼ 56); however, 36 injuries resulted common; however, virtually every vital structure
from accidents and 28 injuries were self-inflicted. in the neck was represented.
There were 31 patients who had gunshot wounds
(GSW), 63 patients who had stab wounds (SW),
13 who had flying glass injuries, and 13 who Diagnosis
were impaled with sharp objects (Fig. 9). Of the
Physical examination
120 patients, 55 presented with superficial injuries
that did not penetrate the platysma. These pa- The initial evaluation of a trauma patient
tients were generally managed in the emergency begins with the ‘‘ABCs’’ of trauma management
department with wound debridement and closure. as outlined by the Advanced Trauma Life Support
The primary study group consisted of 65 patients Manual (ATLS) advocated by the American Col-
who sustained more significant injuries that vio- lege of Surgeons: (1) establish a secure airway, (2)
lated the platysma, including deep, complex, or assure breathing/respiration, and (3) initiate
avulsive wounds, vascular injuries, or injuries to volume resuscitation [53]. Particular importance
should be placed on the airway because bleeding
within the tight compartmentalized spaces of the
neck may appear quiescent externally, but can
cause progressive airway compromise and even-
tual complete obstruction (Fig. 10). Orotracheal
intubation is recommended, and usually feasible;
however, once the neck swelling is advanced,
endotracheal intubation may be impossible.
Emergency cricothyrotomy or trachestomy may
be necessary to establish a patent airway.
In conjunction with the primary and second-
ary surveys, a thorough head and neck examina-
tion should be performed. The clinical evaluation
should focus on signs and symptoms suggestive
of injuries to major vessels, the aerodigestive
Fig. 8. Photograph of a patient who has a stab wound tract, spinal cord, or cranial nerves or nerve
to the neck. The trajectory of wounds may be apparent roots. The surgeon should look for signs of
from the history of the incident, and can be predictive of entrance and exit wounds and classify them
underlying neurovascular injury. according to the level of injury. Based on the
 PENETRATING NECK INJURIES 401

anatomic location of the entrance/exit wound, the Diagnostic evaluation

suspected trajectory of the penetrating object,
Angiography became the most reliable method
and the physical signs and symptoms, the surgeon
of evaluation vascular injuries in a hemodynami-
should be able to direct attention to certain organ
cally stable patient (Fig. 11). The patients would
systems or structures.
undergo direct contrast angiography. This tech-
Physical examination alone has been shown to
nique has limitations, however, including its inva-
be a reliable indicator of clinically significant
sive nature and potential complications. The
vascular injury [39–42,53]. Hematoma is the
reported incidence of complications related to
most common sign of vascular injury, followed
catheter angiography ranges between 0.2% to
by shock and external bleeding. Other ‘‘hard’’
2% [41,55–57]. Hematoma at the puncture site is
signs of vascular injury include absent carotid
the most common complication; however, vascu-
pulse, carotid bruit or thrill, shock not responsive
lar spasm, allergic reactions, embolization of
to fluid resuscitation, and diminished radial pulse.
atherosclerotic plaques, thrombosis, and arterial
Signs and symptoms of aerodigestive injuries
dissection can also be seen. The severity of the
include dysphagia, hoarseness, subcutaneous em-
cardiovascular and central nervous system
physema or crepitance, dyspnea, and air bubbling
complications related to this method allows for
from a wound. Focal neurologic defects such as
questioning, especially in the hemodynamically
altered sensation within the anatomic distribution
stable patient, given the reported high frequency
of known sensory nerves such as the greater auric-
(over 70%) of negative test results [58–61].
ular nerve, local motor defects such as tongue
The complications related to catheter angiog-
deviation indicative of hypoglossal nerve injury,
raphy have led to the search for other noninvasive
or peripheral sensorimotor defects indicating
diagnostic methods for detection of vascular
brachial plexus injury are common.
injuries. Color Doppler ultrasonography has
Absence of these signs or symptoms, however,
emerged as a fast, safe, noninvasive method for
does not mean absence of injury. In Fogelman
evaluation of vascular flow and wall integrity.
and Stewart’s [15] classic paper on penetrating
Several authors have compared this technique
neck injuries, 43% of their patients who had sig-
with catheter angiography, outlining the advan-
nificant vascular injury had no evidence of periph-
tages and disadvantages of this method [60–62]. In
eral vascular collapse, and 70% had no evidence
most centers its use has been limited for the eval-
of bleeding at the time of admission. In addition,
uation of penetrating neck injuries. The method is
of the 13 patients who had obvious injury and
highly operator-dependent, which may result in
penetration of the trachea and larynx, 4 failed to
a long examination time in the hands of the inex-
develop clinical signs or symptoms before surgical
perienced operator. Physical examination findings
exploration and repair. A more recent study, how-
related to the trauma such as hematoma, lacera-
ever, by Azuaje and colleagues [54], reported on
tions, or subcutaneous emphysema limit the reli-
a series of 216 patients who had penetrating
ability of the results. In addition, zones I and III
neck injuries, and demonstrated that physical
and the vertebral arteries are often difficult to
examination alone boasted a 93%sensitivity and
assess.
97% negative predictive value for predicting vas-
Despite the availability of advanced imaging
cular injuries. Based on the clinical evaluation,
modalities for the evaluation of penetrating neck
recommendations can be made regarding further
trauma, physical examination techniques continue
diagnostic evaluation, observation, or immediate
to be of significant value. In 1993 Demetriades and
surgical intervention. It is clear that emergent sur-
colleagues [39] looked at physical examination and
gical exploration is necessary for patients who
selective conservative management in patients who
have hard signs of vascular injury such as hemo-
had penetrating neck injuries. They prospectively
dynamic instability, exsanguinating hemorrhage,
evaluated 335 patients and examined the decision
or expanding hematoma. Those patients who are
whether to operate or observe according to a proto-
hemodynamically stable and have no respiratory
col based mainly on physical examination. In their
compromise should undergo further diagnostic
cohort of patients, 20% were subjected to emer-
evaluation. The indications for the various diag-
gency surgery, and angiography was used in only
nostic modalities remain controversial, however,
3 patients. They concluded that physical examina-
and the remainder of this article deals with a ratio-
tion is a reliable method for detecting significant
nale for management.
402 BAGHERI et al
 PENETRATING NECK INJURIES 403

injuries following penetrating neck trauma, and patients. Several factors have contribute to the
suggest that angiography is rarely needed. emergence of this modality in modern trauma
Magnetic resonance angiography (MRA) has care: (1) the use of helical and multislice CTA tech-
developed in the last 2 decades as a useful imaging nology to obtain reproducible and reliable images
modality for evaluation of vascular injuries, both is easy and not operator-dependent, (2) it requires
in the management of vascular trauma and also in minimal support of additional nonphysician staff
the diagnosis and management of stroke victims. (in contrast to angiography), (3) it is readily
For the management of stroke, the combined available, (4) It is highly accurate for detection
method of MRI/MRA has become the gold of vascular injuries, and (5) multiplanar and
standard because of the superior imaging resolu- three-dimensionally–generated images are easily
tion of the brain parenchyma that is critical for obtained, facilitating the traditionally more chal-
stroke evaluation, and the relatively accurate lenging interpretation of images in the axial plane.
diagnosis of vascular injuries and anatomy; how- Munera and colleagues evaluated the use of helical
ever, MR technology has not evolved as the gold and multislice CTA as an initial method for evalu-
standard in the evaluation of penetrating neck ating patients who had possible arterial injuries to
injuries because of several factors: (1) time-con- the neck, reporting a sensitivity of 100% and
suming scans limit it use in the acutely unstable a specificity of 98.6% [73,74].
patient, (2) the non-MR compatibility of much In 2005, Woo and colleagues [64] examined
trauma equipment limits its use, (3) relative higher how the management of penetrating neck trauma
cost, (4) decreased ability to detect cervical spine has changed with the advent of computed tomog-
fractures, and (5) decreased imaging resolution raphy angiography CTA. They retrospectively re-
compared with recently introduced helical and viewed their experience over 10 years for 130 cases
multislice computed tomography angiography of penetrating neck trauma, with 34 undergoing
(CTA). CTA and 96 with no CTA. The CTA group had
Helical and multislice CTA has emerged as only one neck exploration (3%), versus 32
a fast, minimally invasive, accurate study to (33%) in the non-CTA group. Negative neck ex-
evaluate penetrating neck injuries, with virtual plorations were significantly higher in the group
elimination of the need for mandatory neck that did not receive a CTA.
exploration [2,63–66]. Helical and multislice CTA In an effort to appreciate the affect that CTA
is used to assess patients suffering from both pen- has had on the management of penetrating neck
etrating and blunt trauma to the neck, extremities, injuries at the authors’ trauma center, a study of
mediastinum, and abdomen [63–72]. A significant 120 consecutive patients who had penetrating
advantage of helical and multislice CTA in trauma neck injuries presenting to Legacy Emanuel Hos-
patients is the ability to obtain high-quality images pital and Health Center (LEHHC) from 2000 to
in less than 1 minute. It has emerged as a important 2005 was performed, with the purpose of further
imaging modality in most hospital emergency elucidating the role of CTA in clinical decision-
rooms for diagnosis and management of trauma making and to assess patient outcome [2]. Of the
:

Fig. 10. Nineteen-year-old female who has a low-velocity, transpharyngeal gunshot wound. Low-velocity projectiles
travel less than 2000 feet per second, characteristically create small entrance and exit wounds, and cause damage by lac-
erating and crushing the tissue. There is little transmission of energy and therefore little damage is sustained beyond
those structures that come in direct contact with the projectile. (A) Frontal view demonstrating neck swelling, dyspnea,
and impending airway obstruction. Orotracheal intubation is recommended and usually feasible; however, once the neck
swelling is advanced, endotracheal intubation may be impossible. Emergency cricothyrotomy or trachestomy may be
necessary to establish a patent airway. (B) Lateral view of the same patient demonstrating entrance wound. (C) CTA
(axial image) of the same patient demonstrating the path of the bullet with transpharyngeal subcutaneous emphysema,
right mandibular fractures, and no evidence of vascular injury. A marker is placed at the exit wound on the left side. (D)
CTA (axial image) of the same patient, again demonstrating the transpharyngeal trajectory of the bullet, massive sub-
cutaneous emphysema, and bilateral mandibular fractures. Despite lack of evidence of vascular injury, the bullet trajec-
tory and findings of subcutaneous emphysema are highly suggestive of upper aerodigestive tract injury and mandate
further interrogation. (E) Rigid esophagoscopy is performed to evaluation the hypopharynx and cervical esophagus
to the level of the gastric introitus. Bilateral hypopharyngeal perforations were noted just above the pyriform recess.
(F) Postoperative appearance of the patient 6 months following operative repair of her mandibular fractures and non-
surgical management of her transpharyngeal gunshot wounds.
404 BAGHERI et al

Fig. 11. Imaging of a patient who sustained a low-velocity gunshot wound to the neck involving zone III. The patient
was neurologically intact and had no hard signs of vascular injury. (A) Carotid angiogram that demonstrates a 5 mm
aneurysm or pseudoaneurysm involving the internal carotid artery at about the level of the 2nd cervical vertebra. (B)
Post-endovascular repair arteriogram demonstrating coiling on the aneurysm.

120 patients, 55 were excluded from the study be- explored. This resulted in overtreatment of a sig-
cause either the patients’ injuries were superficial, nificant number of zone II injuries (negative
the patients died before operative intervention, or neck explorations) and undertreatment of zone I
the patients underwent emergent neck exploration and III injuries (missed injuries). Today, the shift
to control hemorrhage. CTA was used extensively toward selective intervention for injuries involving
at LEHHC beginning in 2003; therefore the 65 pa- all three zones when ‘‘hard signs’’ of vascular in-
tients who had injuries penetrating the platysma jury are absent has somewhat diminished the im-
and who met the inclusion criteria for the study portance of the three zones of the neck.
were divided into groups and compared based There is no universal agreement with regards
upon having received CTA as part of the diagnos- to selective versus mandatory exploration, the role
tic evaluation. The results showed that the use of of and type of preoperative diagnostic examina-
CTA in the study group resulted in significantly tions, the rationale for ligation, observation, and
fewer formal neck explorations when compared revascularization of the injured carotid artery, or
with patients who did not receive CTA (CTA ¼ the role of endovascular repair of arterial injuries.
6 explorations versus no CTA ¼ 27 explorations). Management should be based upon the surgeon’s
In addition, the rate of negative neck exploration experience and, most importantly, the resources
was significantly decreased from 48% in patients available at each particular center. As discussed
not receiving a CTA to 0% in those who did re- previously, the approach at LEHHC over the last
ceive a CTA. At the authors’ institutions, how- 5 years has generally been one of selective surgical
ever, we continue the judicious use of various management based upon physical examination
adjunctive studies to evaluate the upper aerodiges- and findings on CTA. All patients who have
tive tract (Fig. 12). active bleeding, expanding hematoma, shock,
massive subcutaneous emphysema, or significant
airway compromise are surgically explored,
Management regardless of the zone of injury. Indications for
immediate surgical intervention include
For practical purposes, neck injuries are clas-
sified according to the scheme proposed by Exsanguinating hemorrhage
Monson and colleagues [1] in 1969. Traditionally, Expanding hematoma
zone I and zone III injuries were managed selec- Shock
tively because of the difficulties associated with Airway compromise
surgical access, and zone II injuries were routinely Massive subcutaneous emphysema
 PENETRATING NECK INJURIES 405

Fig. 12. Forty-three-year-old male who has a self-inflicted gunshot wound to the neck and face presenting with massive
epistaxis. (A) CT scan demonstrating bullet trajectory through the maxillary sinus and multiple bullet fragments
throughout the temporal bone, internal and external auditory canal. (B) Angiogram was obtained because of the trajec-
tory and epistaxis to rule out vascular injury. Arrow points to a ‘‘blush’’ associated with the right internal maxillary
artery, consistent with a pseudoaneurysm. (C) Angiogram following endovascular coiling of the right internal maxillary
artery. Arrow points to the coil.

Patients who have injuries that penetrate the anatomic injuries varies somewhat from surgeon
platysma and are hemodynamically stable are to surgeon, but is generally based on the location
evaluated by CTA. Further diagnostic studies, and extent of the injury in addition to the neuro-
such as angiography, esophagography, direct logic status of the patient. Fig. 13 illustrates the
laryngoscopy, or rigid esophagoscopy, are used management algorithm used at LEHHC for pene-
based on the CT findings. The use of CTA at the trating neck injuries, and provides an outline for
authors’ institution has resulted in fewer formal the remainder of the article. Fig. 14 demonstrates
neck explorations and virtual elimination of nega- the general trend in the use of CTA, neck explora-
tive exploratory surgery. Thus far, however, it has tion, and negative neck exploration in the patients
not had a significant effect on the number of ad- treated at LEHHC between 2000 and 2005 [2].
junctive diagnostic modalities performed in the If surgical exploration is deemed necessary,
preoperative setting. The management of specific the neck may be approached by one of several
 406
Physical Examination
AP Chest X-ray
Lateral/AP neck film

Hard signs of vascular injury

Hemodynamic stability
Refractory shock
+/- signs/symptoms
Obvious neurovascular disruption

Immediate neck exploration CTA

Findings suggestive of vascular or neurovascular injury No evidence of vascular, neurologic or aerodigestive tract injury Suspicious for aerodigestive tract injury

BAGHERI
Zone I or III Zone II Observe Endoscopic evaluation

Hypopharyngeal injury
Angiography and consider endovascular repair Open surgical repair

et al
Observe or surgically repair
Open surgical repair depending upon extent
with extended approaches of injury
if endovascular repair not possible

Evidence of esophageal or laryngeal injury

Surgical repair

Fig. 13. LEHHC management guidelines for penetrating neck injuries.

 PENETRATING NECK INJURIES 407

80
70
60 CTA
50
neck exploration
40
30 negative neck
exploration
20
10
0
2000 2001 2002 2003 2004 2005

Fig. 14. Trends in the use of CTA, neck exploration, and the rate of negative neck exploration. The surgical manage-
ment of these injuries is extremely complicated because of their location in the posterior neck encased within the cervical
vertebral column.

incisions, based on the suspected injury and the or innominate vessels may require a median ster-
zone of entry (see Fig. 6). The standard approach notomy, disarticulation of the sternoclavicular
is a vertical incision along the anterior border of joint, or anterolateral thoracotomy. Appropriate
the sternocleidomastoid muscle extending from neurosurgical, vascular, and cardiothoracic surgi-
the angle of the mandible to the sternoclavicular cal assistance is advised when managing these
junction. This incision may be modified with hor- challenging injuries.
izontal limbs extending to the mastoid for further
exposure of zone III injuries or along the superior
Extracranial vascular trauma
aspect of the clavicle for zone I injuries. Alterna-
tively, horizontal incisions may be used, encom- Vascular injuries are the most common in-
passing skin flaps developed in a subplatysmal juries associated with penetrating neck trauma,
plane superiorly and inferiorly, to provide maxi- occurring in 40% of patients; 10% of these
mum access to multiple zones, anteriorly and pos- injuries involve the carotid artery. The mortality
teriorly. Once the skin flaps are developed, the rate associated with penetrating injury is 10% to
marginal mandibular branch of the facial nerve 30%. Physical findings may be characterized by
is identified and protected, and the great vessels neruologic defects, including an ipsilateral
are approached by identifying and skeletonizing Horner’s syndrome or cranial nerve dysfunction.
the anterior-medial aspect of the sternocleidomas- Penetrating injuries to the neck from gunshot
toid muscle. Proximal and distal control of the wounds, stab wounds, or other lacerations can
carotid artery can then be attained from the result in the formation of pseudoaneurysms,
base of the skull to the clavicle. This approach arteriovenous fistulae, vessel transections, intimal
also provides wide access for repairing cranial flaps, dissections, and occlusions to the carotid or
nerves, the esophagus, and other vital structures. vertebral arteries or jugular veins. Management
The horizontal incision can be carried to the paradigms are directed at rapidly identifying the
opposite side as an ‘‘apron flap’’ to provide max- injury and preventing cerebral ischemia. As
imum exposure to both sides of the neck. For stated previously, CTA has been shown to be
these reasons, a horizontal incision is the authors’ highly efficacious for identifying vascular injuries
preferred approach for most significant neck in- of the head and neck, and has the additional
juries when multiple structures or multiple zones advantage of simultaneously providing informa-
are involved (ie: carotid artery and esophagus). tion on cerebral ischema or infarct as well as
Special consideration is given to the operative other associated injuries. Once a vascular injury
management of high carotid injuries at or above is identified, the decision must made to repair,
the skull base (zone III) that may require a vertical bypass, ligate, or observe the lesion. Unilateral
ramus osteotomy to provide access to the distal carotid artery occlusion can be well-tolerated in
extracranial vessels [75]. Access may be improved patients who have adequate collateral circulation
by dividing the digastric and stylohyoid muscles to the brain; however, in patients who have an
or by disinserting the sternocleidomastoid muscle. incomplete circle of Willis, contralateral occlu-
Lower zone I injuries that involve the subclavian sions or stenoses, or athrosclerotic disease, strong
408 BAGHERI et al

consideration should be given to revasculariza- observed and followed with repeat imaging in
tion. In recent years, endovascular therapy has 1 to 2 weeks.
altered the management of many of these Exsanguinating hemorrhage at any level gen-
patients, and the approachdwhether medical, erally mandates rapid surgical exploration and
surgical or endovasculardis based upon hemo- repair, if possible. All injuries, regardless of
dynamic stability, the extent of hemorrhage, the location, are preferentially repaired surgically.
type and location of the injury, and the neuro- Injuries of the common and internal carotid
logic status of the patient. arteries are repaired by lateral arteriorrhaphy or
There is general agreement that carotid injuries resection of the injured vessel, with either primary
in neurologically intact patients should be re- re-anastomosis or replacement with an interposi-
paired. When possible, primary repair of carotid tional graft (Fig. 15). During repair, an interlumi-
artery injuries is preferred. Otherwise the use nal shunt may be used to maintain prograde
of saphenous vein or polytetrafluoroethylene cerebral blood flow. Distal internal carotid in-
(PTFE) can be considered. There are no conclu- juries that are actively bleeding and cannot readily
sive studies to suggest the superiority of one be exposed may be controlled with a balloon cath-
method over the other for repair of vascular eter (Fogarty) that is placed into the distal lumen
trauma from penetrating injuries of the neck. of the artery. Once the balloon is inflated and the
There appear to be no significantly increased rates bleeding controlled, the vessel can be repaired
of infection or thrombosis with the use of PTFE directly or ligated. As stated earlier, however, liga-
compared with saphenous vein grafts [76,77]. tion is indicated only in comatose patients.
Controversy exists, however, with regards to the Advances in endovascular therapy have altered
revascularization of carotid occlusion in patients the management of traumatic vascular injuries,
who have a depressed state of consciousness or and its role in the treatment of vascular lesions of
coma, and the management of an occlusive injury the head and neck is evolving. There is some
in an asymptomatic patient who would require evidence to suggest that traumatic occlusions of
a complex repair. The former controversy is based the carotid artery may be repaired by endovas-
on experience with carotid artery arthroscerotic cular revascularization, particularly in those
disease and the findings that some patients who patients in whom surgical repair is technically
have cerebral ischemia who are revascularized difficult or impossible [84–88]. No large series of
will develop hemorrhagic infarcts [78]. In 1974, long-term data are available regarding the safety
Thal and coworkers [79] published their experi- and efficacy of this technique, despite its rapidly
ence in the management of 60 patients who had expanded use. Caution must be exercised until
penetrating carotid injuries based upon pretreat- more data are available. A recent study by Coth-
ment neurologic status. Their findings suggested ren and coworkers [89] reported unfavorable
that patients who have no preoperative neurologic
symptoms and those who have mild neurologic
deficits should routinely undergo primary repair.
Those patients who have severe neurologic deficits
or coma should undergo repair only if distal ca-
rotid patency is demonstrated on angiography.
Liekweg and Greenfield [80] similarly recommen-
ded that ligation of the carotid artery be reserved
for the comatose patient who has no prograde
flow and for cases in which primary repair is tech-
nically impossible. More recent studies have con-
firmed the efficacy of routine repair of carotid
injuries in all but comatose patients [81–83]. In
the asymptomatic patient who has an occlusive in-
jury there is a small risk of thrombus propagation
into the middle cerebral artery. Most trauma
centers anticoagulate these patients if there is no Fig. 15. Repair of an injured common carotid artery
contraindication to anticoagulation. Relatively with an interpositional graft using polytetrafluoroethy-
minor injuries such as pseydoaneurysms less lene (PTFE) in a patient who sustained a zone II gun-
than 5 mm and small intimal defects may be shot wound.
 PENETRATING NECK INJURIES 409

results for blunt trauma patients who had persis- popularity for vertebral injuries and its use seems
tent carotid pseudoaneurysms that were treated promising.
with endovascular stenting. In this prospective
analysis, 46 patients sustained blunt carotid
Esophageal injury
pseuodoaneurysms; 23 of them underwent carotid
stent placement with anticoagulation, and 23 were Injury to the cervical esophagus is uncommon,
treated with anticoagulation alone. There were but should be suspected in cases in which there is
four complications in stented patients, including a penetrating injury in the proximity. It has been
three strokes and one subclavian dissection. estimated that most busy trauma centers encoun-
Carotid occlusion rates were significantly higher ter only about five patients per year with these
in the stented group (45% versus 5% in those injuries [91]. Delay in diagnosis has been cited as
who received antithrombotic agents alone). Until the most important contributor for significant
further data that support the routine use of endo- mortality of about 19% [92,93]. The American
vascular therapy are available, the authors reserve Association for the Surgery of Trauma supported
its use for patients who have stable, intimal, high the most significant multicenter study on penetrat-
zone III carotid injuries and most vertebral artery ing esophageal injuries [94], and concluded that
injuries. increased esophageal-related morbidity occurs
Vertebral artery injuries are much less common with the diagnostic workup and its inherent delay
than carotid injuries. The surgical management of in the operative repair of these injuries. The opti-
these injuries is extremely complicated because of mal safety period has not been established, but for
their location in the posterior neck, encased within centers practicing selective management of pene-
the cervical vertebral column (Fig. 16). Unilateral trating neck injuries, the highest priority should
vertebral artery occlusion rarely results in a neuro- be given to identification and repair. The use of
logic deficit if the contralateral vertebral artery is esophagoscopy and esophagography in combina-
normal and the posterior inferior cerebellar artery tion with physical examination is highly sensitive
is preserved. McConnell and Trunkey [90] recom- in diagnosis of any injuries. There has been
mend operative repair of the injured vertebral ar- some debate over the use of flexible versus rigid
tery instead of ligation if the contralateral esophagoscopy [95]; however, a recent retrospec-
vertebral is hypoplastic or stenosed. Endovascular tive study by Horwitz and colleagues [96] suggests
management of these injuries has gained that the flexible scope is highly sensitive, safe, and

Hypoglossal nerve

Greater occipital nerve

C2
Vertebral artery X Vagus nerve
Accessory nerve

Fig. 16. Anatomy of the vertebral arteries.

410 BAGHERI et al

accurate when used by an experienced operator. a combination of suturing of fractured segments,

The cervical esophagus should be repaired directly rigid internal fixation using miniplates, or place-
whenever possible in a one- or two-layered ment of stents [97]. Please see the article by Bell,
fashion, depending on the extent of the injury. Verschueren, and Dierks in this issue for a thor-
Adjunctive muscle flaps, such as a strap muscle ough review of laryngeal injuries.
or sternocleidomastoid muscle, can be used to
buttress the repair, which should be liberally Endocrine injury
drained. Avulsive injuries that result from high- Clinically significant injuries to the thyroid and
velocity weaponry occasionally require the use of parathyroid glands are not common. Penetrating
microvascular free tissue transfer or other re- injuries that lacerate the gland do not significantly
gional rotational flaps to effect adequate repair. alter gland function. Vascular injuries are easily
The majority of patients who die secondary to managed by cauterization or direct suturing of the
esophageal injury do so because of mediastinitis offending vessels. Ligation of the inferior thyroid
and sepsis; therefore all treatments are to prevent artery will control significant hemorrhage associ-
abscess formation. ated with the thyroid gland. Compromised thy-
roid hormone and calcium metabolism are rare;
Laryngotracheal injury however, surveillance of calcium and thyroid
Injury to the laryngotracheal structures in hormone function can be considered.
most commonly seen in the cervical trachea. The
Cervical spine injury
evidence of extensive subcutaneous emphysema
on clinical examination (crepitus) or CTA imag- Penetrating injuries to the cervical spine can
ing is highly suspicious of injury to the airway, cause severe irreversible injuries, and despite
although subcutaneous emphysema may also be prompt medical or surgical treatments, the out-
caused by dissection of air into the subcutaneous come is primarily related to the severity of the
tissue by the initial traumatic insult. The manage- initial traumatic insult (Fig. 17). Early interven-
ment of tracheal injuries is mainly dependent on tion can prevent further injury. The diagnosis of
the size of the injury. Small injuries may be patients presenting with cervical spine injury is
primarily repaired. Larger defects may require generally easy to confirm by physical examination
a combination of tracheotomy, along with the use findings, and can range from minor to severe neu-
of synthetic materials, or local and regional flaps. rologic deficits that compromise, cardiovascular
Laryngeal injuries may be repaired with (most commonly manifesting as hypotension), or

Fig. 17. Twenty-six-year-old male with a low-velocity gunshot wound to the neck. (A) Lateral cervical spine radiograph
demonstrating bullet fragments within the neck. These films are good screening films but lack multidimensional perspec-
tive. (B) CT scan of the same patient demonstrating bullet fragments lodged within the body of the 4th cervical vertebra.
 PENETRATING NECK INJURIES 411

motor and sensory deficits. Hypotension in the perforations, laryngeal fractures, and neurologic
presence of cervical spine injury may be caused injuries are still best treated with direct open
by the compromised systemic arterial and venous surgical repair. Endovascular techniques are help-
vascular innervation, causing vasodilatation and ful for small, stable, inaccessible (zone III) pseu-
subsequent hypotension; however, blood loss doaneurysms or intimal injuries, but currently
causing hypovolemic shock needs to be ruled out have little role for more significant injuries. At
before consideration of other etiologies of shock. the end of the day, the treatment of each patient
The use of steroids in spinal injury remains to should be individualized and based on the pa-
be fully elucidated. Currently, no studies have tients’ signs and symptoms, the experience of the
evaluated the use of steroids in penetrating neck surgeon, and the resources available at each
injuries that result in cervical spine injury. In 1991 institution.
Bracken and colleagues [98] published the Results
of the Second National Acute Spinal Cord Injury References
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 415–430

Management of Laryngeal Trauma

R. Bryan Bell, DDS, MD, FACSa,b,*,
David S. Verschueren, DMD, MDa,b,
Eric J. Dierks, DMD, MD, FACSa,b
a
Oral and Maxillofacial Surgery Service, Legacy Emanuel Hospital and Health Center, Portland, OR, USA
b
Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR, USA

Laryngeal trauma is uncommon, occurring in with increased risk for laryngeal injury [3]. In
approximately 1 patient per 14,000 to 30,000 blunt trauma, the larynx is compressed between
emergency room visits [1–4] and 1 patient per an intrusive object (eg, steering wheel or handle-
131,000 hospital admissions [5]. The incidence bars) and the cervical spine. Depending on the
can be as high as 1 in 445 in seriously injured pa- amount of compressive force and the degree of os-
tients presenting to major urban trauma centers sification of the larynx, this may result in a variety
[6]. Laryngeal injuries often present in association of injury patterns, ranging from simple isolated
with maxillofacial injuries and are potentially cartilaginous fractures of the thyroid cartilage
complicated by life threatening airway obstruc- requiring little or no treatment to a complex
tion, impaired vocal function, dysphagia, chronic composite tissue injury with massive cartilaginous
aspiration and death (Fig. 1). Surgeons managing displacement, endolaryngeal disruption, or lar-
patients who have maxillofacial injuries should be yngotracheal separation.
familiar with the diagnosis, airway management, The average age of patients who have laryngeal
complications, and treatment of patients who trauma has been reported to be approximately
have laryngeal trauma. Functionally and anatom- 37 years, although the distribution is wide and
ically complex, the larynx is partially protected by older patients (older than 70 years of age) tend to
the mandible, sternum, and cervical spine. Once have poorer outcomes (Fig. 3) [5]. If the injury is
violated, it can rapidly become a tight space for severe enough to warrant surgical treatment,
airway compromise and collapse, requiring laryngeal trauma is associated with a longer
emergency airway stabilization and extensive than 13-day hospital stay and carries with it a mor-
reconstruction. tality rate of approximately 1% [5].
The most common cause of laryngeal injury is
blunt trauma caused by motor vehicle collisions
or sporting accidents, followed by penetrating Classification of laryngeal injuries
neck injuries, such as gunshot wounds (Fig. 2)
[3,5,6]. Sporting injuries, such as those associated Injuries to the larynx can include the soft or
with all-terrain vehicles (ATVs) and jet skis, are hard tissues and may be described by the mode,
increasing in frequency and may be associated site, structure, and degree [7]. The mode is either
blunt or penetrating. The site of injury has been
classified as supraglottic, glottic, subglottic, or
a combination of all three. Additional description
* Corresponding author. Oral and Maxillofacial
is provided by identifying the structures injured,
Surgery Service, Legacy Emanuel Hospital and Health such as the hyoid bone, thyroid cartilage, cricoid
Center, 1849 NW Kearney, Suite 300, Portland, OR cartilage, and arytenoids. The degree of injury
97209 can also be appreciated by classifying the patient
E-mail address: [email protected] (R.B. Bell) into a known scheme based on various clinical
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.03.004 oralmaxsurgery.theclinics.com
416 BELL et al

Mandible that are seen in civilian trauma centers [6].

fracture Nasal
fracture Although penetrating injuries are seen less
Open neck 7 Other facial
2 frequently outside of a war zone, it has been the
injury fracture
18 9 authors’ experience that they are typically more
Open severe and result in greater endolaryngeal disrup-
pharyngeal
injury
tion and potentially poorer outcomes.
Other facial It is important to identify accurately the site of
4
injury
10
injury during assessment of the patient. Trauma
Chest injury to the supraglottic larynx may result in a variety
13 Skull fracture of injuries, including epiglottic hematoma or
7 avulsion, hyoid bone fracture, thyroid cartilage
fracture, arytenoid dislocation or degloving, en-
Intracranial Cervical dolaryngeal edema, and airway obstruction. Epi-
injury spine fracture
17 13 glottic hematoma may progress to inspiratory
stridor and voice changes (Fig. 5). Epiglottic avul-
Fig. 1. Primary diagnoses, excluding external laryngeal sion may occur in association with fractures of the
trauma. (Data from Jewett BS, Shockley WW, Rutledge hyoid and thyroid cartilage and results in epiglot-
R. External laryngeal trauma analysis of 392 patients.
tic displacement superiorly. The result is profound
Arch Otolaryngol Head Neck Surg 1999;125:
dysphagia and aspiration. Fiberoptic nasophar-
877.)
yngoscopy is generally diagnostic; however,
concomitant bleeding and edema may make
awake endoscopy challenging. Therefore, direct
and radiographic factors. Schaefer and his col-
laryngoscopy under anesthesia may be necessary
leagues [2] described the most well-known classifi-
to appreciate fully the extent of endolaryngeal in-
cation based on the severity of the injury and the
jury. Arytenoid subluxation is a common finding
level of management necessary, but they did so
in patients who has significant laryngeal injuries
largely in the pre-CT scan era. The authors have
and may result in vocal cord dysfunction. Frac-
subsequently modified this classification scheme
tures of the hyoid bone are relatively common in
slightly to incorporate technologic advances in
sporting injuries, such as baseball, jet skiing, and
imaging that serve to make a more contemporary
karate (Fig. 6). Severe painful dysphagia is the
management tool and a useful therapeutic guide
most common symptom. Isolated fractures of
(Fig. 4) [6].
the hyoid may provide little in the way of physical
Blunt trauma resulting from motor vehicle
findings, although the injury is readily identified
accidents accounts for most laryngeal injuries
on CT scan.
Patients who have glottic injuries often present
with hoarseness that is generally associated with
Hanging fractures of the thyroid cartilage (Fig. 7). Such
8 injuries may result in vocal cord edema, endolar-
Fall yngeal lacerations, or avulsion of the vocal cords
12 from the anterior commissure. Shortening of the
vocal cords is associated with seemingly minimal
displacement of the thyroid cartilage and has the
Assault potential for significant vocal changes unless accu-
MVA
8
49
rately reduced.
Subglottic injuries typically involve the cricoid
cartilage and cervical trachea and often result in
profound airway compromise immediately after
the injury. Complete cricotracheal disruption with
acute airway obstruction is associated with rapid
Sporting death unless prompt corrective measures are used
23
(Fig. 8). Immediate airway stabilization in the
Fig. 2. Cause of laryngeal fractures: Legacy Emanuel form of a tracheostomy is usually necessary and is
Hospital and Health Center, 1992 to 2004. MVA, motor often performed in the field. Among survivors, as-
vehicle accident. sociated findings may include recurrent laryngeal
 MANAGEMENT OF LARYNGEAL TRAUMA 417

Fig. 3. External laryngeal trauma: age versus mortality. (From Jewett BS, Shockley WW, Rutledge R. External laryngeal
trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg 1999;125:877; with permission.)

nerve injury, cricothyroid separation, and laryng- emphysema manifested as crepitus, or cervical
otracheal separation. ecchymosis (Fig. 9) [8]. Diagnosis of laryngeal in-
jury in a timely manner is important for treatment
and prognosis. Evaluation of laryngeal trauma
Evaluation
begins with ensuring a patent airway. The force
The clinician should have a high suspicion for of the injury can cause significant soft tissue and
laryngeal injury in any patient who has blunt or cartilaginous disruption with minimal external
penetrating neck trauma, particularly those signs of laryngeal trauma. As noted previously,
patients presenting with cervical subcutaneous common signs of laryngeal injury include stridor,

Fig. 4. Legacy Emanuel Hospital and Health Center laryngeal injury classification. fx, fracture.
418 BELL et al

Epiglottic hematoma

Tongue Vallecula

Epiglottis

Hematoma

Arytenoid

Airway

Fig. 5. Epiglottic hematoma causing airway obstruction.

Shortening
of vocal cords

Supraglottic
edema

Fig. 7. Fracture of the thyroid cartilage with associated

glottic injuries resulting in vocal cord edema, endo-
laryngeal lacerations, or avulsion from the anterior
Fig. 6. Fracture of the hyoid bone. Asymptomatic commissure. Shortening of the vocal cords is associated
patients require no specific treatment. Pain and ody- with seemingly minimal displacement of the thyroid
nophagia are treated by open reduction and internal cartilage and has the potential for significant vocal
fixation or partial hyoid resection. changes unless accurately reduced.
 MANAGEMENT OF LARYNGEAL TRAUMA 419

Cricoid separated
from trachea

Tracheal
retraction

Tracheal
retraction

Fig. 8. Laryngotracheal separation causes upward retraction of the larynx and downward retraction of the trachea and
commonly results in fatal airway obstruction.

vocal changes, subcutaneous emphysema, hemop- according to the American College of Surgeons
tysis, hematoma, ecchymosis, laryngeal tender- Advanced Trauma Life Support (ATLS) guide-
ness, vocal cord immobility, loss of anatomic lines. In stable patients, this may include flexible
landmarks, crepitus, and difficulty in swallowing. fiberoptic laryngoscopy to examine the extent of
The preferred artificial airway in patients who endolaryngeal injury and to provide valuable
have a laryngeal fracture is a tracheostomy, which information about vocal cord function and mo-
should be performed with the patient awake under bility (Fig. 10). Fiberoptic examination can also
local anesthesia if possible [9]. Although oral help to determine if the patient’s airway is ade-
endotracheal intubation is not contraindicated, quate before placing the patient in the CT
care must be taken to avoid further disruption scanner.
of the endolaryngeal structures, creation of CT is the single most important diagnostic tool
a ‘‘false passage’’ into a submucosal pocket, or currently available [10]. Fine-cut CT imaging
facilitation of potentially catastrophic laryngotra- allows rapid and precise anatomic evaluation of
cheal separation. Once the airway has been the cartilaginous framework, even in minimally
secured, associated cervical spine, esophageal, displaced cartilaginous fractures, and provides
and vascular injuries can then be evaluated. evidence of upper aerodigestive tract injury with
The workup of laryngeal trauma includes subcutaneous emphysema (Fig. 11). Angiography
physical examination, radiologic examination, can also be added when needed for penetrating
and panendoscopy. A thorough physical exami- injuries to help evaluate vascular injuries.
nation, particularly focused on neck tenderness, Formal endoscopic evaluation using direct
crepitus secondary to subcutaneous emphysema, laryngoscopy, esophagoscopy, and bronchoscopy
soft tissue edema, and loss of anatomic land- allows the treating surgeon to visualize the upper
marks, is part of the standard secondary survey aerodigestive tract and extent of mucosal injury
420 BELL et al

Fig. 11. CT scan of a patient who has a laryngeal

fracture involving the thyroid and cricoid cartilage
Fig. 9. Clinical photograph of a 19-year-old woman demonstrates subcutaneous emphysema.
with a significantly displaced laryngeal fracture present-
ing with cervical edema and crepitus, loss of anatomic
landmarks in the neck, and progressive dyspnea and stri- with laryngotracheal injuries at Legacy Emanuel
dor. Endotracheal intubation was performed in the field Hospital in Portland, Oregon, which incorporated
before the diagnosis. these advancements into a classification scheme
and a protocol for the management of patients
who have laryngeal fractures based on airway
fully. CT, direct laryngoscopy, and rigid esoph-
status, high-definition CT, and physical examina-
agoscopy are the most effective tools to define or tion (Fig. 12) [6]. The remainder of this article fur-
clarify the nature of the upper aerodigestive tract. ther defines this management protocol and
The authors recently published their experience
provides the reader with a rational therapeutic
approach.

Fore-shortened
vocal cords Management
Historical perspectives
Supraglottic
edema Management of laryngeal trauma may include
nonsurgical or surgical treatment depending on
the status of the airway, CT or CT angiography
(CTA) findings, and the amount of cartilaginous
Mucosal tears
displacement (Fig. 13). Advances in diagnostic
imaging and refinements in surgical technique
have altered the management of patients who
have laryngotracheal injuries. The goal of treat-
ment is to restore the three primary functions of
the larynxdairway, voice, and swallowingdand
Dislocated and exposed to prevent complications, such as airway embar-
arytenoid cartilage rassment, dysphonia, tracheal or laryngeal steno-
Fig. 10. Artist’s depiction of an endoscopic view of the sis, and dysphagia.
glottic larynx demonstrates distortion of normal anat- Because of the infrequency of laryngeal
omy, shortening of the vocal cords, mucosal disruption, trauma, few individuals have extensive experience
and dislocation of the arytenoid cartilage. with the management of complex laryngotracheal
 Suspected Laryngeal
Trauma

Physical Exam

Unstable Airway Stable Airway

MANAGEMENT OF LARYNGEAL TRAUMA

Tracheostomy CT Scan

Nondisplaced Displaced
CT Scan Cartllage fracture Cartilage Fracture

Displaced Nondisplaced Hoarse Normal Voice

Awake tracheostomy
Cartilage Fracture Cartllage fracture
Flexable Fiberoptic
Direct Laryngoscopy/ Direct Laryngoscopy/ Observe Direct Laryngoscopy/
Nasolaryngoscopy
Esophogoscopy Esophogoscopy Esophogoscopy
Endolarynx intact Mucosal Disruption Oral endotracheal
Endolarynx intact Mucosal Disruption Endolarynx intact Mucosal Disruption intubation for repair Endolarynx intact Mucosal Disruption
of maxillofacial injuires
Thyrotomy/ORIF Thyrotomy/ORIF Observe Awake tracheostomy Thyrotomy/ORIF
ORIF Observe ORIF
mucosal repair mucosal repair mucosal repair
Oral endotracheal Thyrotomy/ORIF
Repair maxillofacial Repair maxillofacial Repair maxillofacial Repair maxillofacial intubation for repair Repair maxillofacial Repair maxillofacial
mucosal repair
injuires injuries injuries injuries of maxillofacial injuires injuires injuries

Repair maxillofacial
injuires

Fig. 12. Legacy Emanuel Hospital and Health Center protocol for the management of laryngotracheal injuries. ORIF, open reduction and internal fixation.

421
422 BELL et al
 MANAGEMENT OF LARYNGEAL TRAUMA 423

injuries; therefore, most treatment recommenda- concluded that there was an increase in penetrat-
tions emanate from retrospective reviews of ing assault trauma and a decrease in motor vehicle
single-surgeon experience [1–6,11–25]. In 1983, collisions but found no difference in voice or air-
Leopold [3] reviewed more than 200 cases in the way outcome between blunt versus penetrating
literature and analyzed surgical versus medical trauma specifically. He noted, however, that
treatment, type and duration of stenting tech- patients who had penetrating trauma tended to
niques, and time interval between injury and have worse overall injuries. He recommended con-
surgery. He concluded that laryngeal trauma servation of all anatomy when possible and the
treated medically within 24 hours, without a stent, use of flexible fiberoptic laryngoscopy as a diag-
and without penetrating trauma resulted in better nostic tool. Although most of his experience
voice and airway function compared with patients occurred before the high-resolution CT scan era,
managed surgically after 48 hours with a stent and he questioned the use of CT when physical exam-
with blunt trauma. Leopold [3] also concluded ination obviously demonstrated the need for
that the best results were obtained when stents surgical intervention. Rigid esophagoscopy was
were used for only 2 to 4 weeks. considered more sensitive than flexible endoscopy
In 1986, Gussack and colleagues [4] reviewed for evaluating injuries in the pharyngoesophageal
12 case series with a combined total of 392 cases region. Oral intubation was considered hazardous
of laryngeal trauma and compared that with their because of the possibility of serious iatrogenic
own experience. These investigators concluded complications; therefore, tracheotomy under local
that laryngotracheal trauma is rare and that com- anesthesia for all patients suspected of having
plications like laryngeal stenosis and voice laryngeal trauma requiring airway support was
changes occur in as many as 40% of the cases. recommended. Patients in Schaefer groups 1 and
Decannulation and airway patency were assured 2 generally experienced full recovery without
without stenosis or significant granulation tissue surgical intervention. Surgical intervention in
in most patients. groups 3 and 4 within 24 hours was efficacious
In 1993, Bent and colleagues [23] reviewed with open reduction and internal fixation
their treatment of 77 patients who have laryngeal (ORIF) of cartilaginous fractures. Stents were
trauma. These authors concluded that conserva- avoided when possible.
tive treatment of Schaefer group 1 and 2 injuries Most recently, the authors reviewed their
is 100% effective and that surgical repair within single-institution experience at an urban, level 1
48 hours greatly reduced poor outcomes. The in- trauma center and specifically examined the
vestigators determined that based on the Schaefer incidence of concomitant maxillofacial injuries in
classification of degree of injury, one can roughly association with laryngeal trauma [6]. They also
predict patient outcome for voice and airway modified Schaefer’s classification scheme by incor-
function. In addition, they concluded that pene- porating a more contemporary view of CT imag-
trating trauma is neither more common nor less ing (see Fig. 4). Laryngeal injuries occurred in 1
serious than blunt trauma and that almost all per 445 severely injured patients presenting to
patients are decannulated with functional speech a level 1 trauma center with head, face, or neck
and normal deglutination. injuries (incidence ¼ 0.002). Ninety-six percent
To date, Schaefer and his colleagues [1,2,12] (26 of 27) of the patients who had laryngotracheal
have reported the most extensive experience in trauma also had maxillofacial injuries. These find-
the English literature, describing outcomes ings suggest that laryngeal injuries may be under-
in 139 patients treated at Parkland Memorial recognized at dedicated trauma care centers and
Hospital in Dallas, Texas from 1965 to 1991. He emphasize the importance of airway management
:

Fig. 13. A 42-year-old male assault victim with severe multisystem trauma, including panfacial fractures and highly dis-
rupted fractures of the thyroid and cricoid cartilage. (A) Clinical appearance after initial stabilization that included emer-
gent tracheostomy and nasal packing for severe epistaxis. (B) Clinical appearance 1 week before definitive management
of his laryngeal injuries and facial injuries. Treatment was delayed because of concomitant systemic injuries, systemic
inflammatory response, and disseminated intravascular coagulation. (C) CT scan of the same patient demonstrates frac-
tures involving the thyroid cartilage. (D) Intraoperative exposure for repair of laryngeal injuries. (E) ORIF of thyroid
cartilage and cricoid ring. There was no significant endolaryngeal injury. (F) Postoperative appearance of patient
6 months after injury.
424 BELL et al

Fig. 14. A 36-year-old man involved in a bicycle accident sustained a displaced mandibular fracture in addition to
laryngeal injuries. (A) Clinical appearance at presentation to the emergency room demonstrates cervical ecchymosis
and edema, stridor, and malocclusion. (B) CT scan of the same patient demonstrates displaced fracture of the thyroid
cartilage. (C) Postoperative appearance of the same patient immediately after awake tracheostomy, repair of the laryn-
geal injuries by ORIF of the thyroid cartilage, and ORIF of the mandibular fracture.

to all clinicians charged with caring for patients at facial esthetics or occlusal function. Because of
a trauma center. Most patients in this study the limited number of patients who presented to
required an advanced airway, generally a tracheos- follow-up, the authors were unable to draw statis-
tomy, which is similar to other published reports tically significant data from the study population.
[1–5]. Because of the fragile nature of the endolar- Nevertheless, there was a general trend among the
ynx, upper airway intervention takes precedence current patient population suggesting a positive
over repair of facial injuries. This study demon- correlation between complications, such as
strates that function and form can be restored to hoarseness, and the severity of injury as assessed
the larynx and the maxillofacial skeleton by by the Emanuel laryngeal injury classification.
adherence to a sound management protocol. All
patients in this series who returned for follow-up
Nonsurgical treatment
had a functional voice and were successfully
decannulated. Most patients (93%) thought that Nonsurgical management should be limited to
they had normal deglutition. Delayed treatment patients who have minor mucosal injuries and no
of all facial injuries did not result in unfavorable airway compromise. This generally involves head
 MANAGEMENT OF LARYNGEAL TRAUMA 425

of bed elevation to 30 to 45 , bed rest, voice rest, decision is one of surgeon comfort and experience.
humidified air, clear liquid diet, corticosteroids, Although flexible endoscopy allows the option of
antibiotics, and antireflux medications (eg, H2 photographic documentation of injuries, there is
antagonists, proton pump inhibitors) that help no convincing evidence that one option is better
to reduce granulation tissue formation. than the other [32]. A rigid or flexible bronchos-
copy may also be helpful to ascertain the full
Surgical technique extent of the injury, particularly in more complex
The rationale for surgery in patients who have laryngotracheal trauma. On completion of the
laryngotracheal trauma has been discussed endoscopic evaluation, a surgical plan may be
previously. Various treatment approaches have finalized before formal neck exploration.
been advocated, depending on the extent of the
Step 3: Neck exploration
endolaryngeal injury and the amount of cartilag-
A horizontal, middle, or low cervical incision is
inous displacement, which include nonoperative
made extending between the anterior borders of
management, open reduction with wire fixation,
the sternocleidomastoid muscles at a level midway
open reduction with rigid plate fixation, and the
between the sternal notch and the thyroid carti-
placement of endolaryngeal stents [1–31].
lage (see Fig. 14C). Superior and inferior skin
If surgery of any significance is indicated, the
flaps are developed in a subplatysmal plane, ex-
authors recommend a tracheostomy before repair
tending from the sternal notch to the hyoid
of the laryngeal structures. Repair should be
bone, and sutured to the adjacent skin. The strap
undertaken urgently, ideally within 24 hours of
muscles are separated in the midline and retracted
the injury. Significant delays, some of which
laterally. If esophageal injury is noted or sus-
cannot be avoided in patients who have severe
pected by clinical or radiographic examination,
multisystem injuries and coagulopathy, are likely
it is wise to skeletonize the anterior-medial aspect
to increase the chances of laryngeal stenosis,
of the sternocleidomastoid and identify, preserve,
scarring, and granulation formation.
and protect the carotid artery, jugular vein, and
Step 1: Tracheostomy vagus nerve. The thyroid cartilage is identified,
If the patient has not already had an emer- and the extent of cartilaginous injury is deter-
gency airway placed, and the airway is relatively mined (Fig. 15). Depending on the amount of dis-
stable, he or she is taken directly to the operating ruption, a midline thyrotomy may be necessary
room for an awake tracheostomy performed for endolaryngeal repair. A midline thyrotomy is
under local anesthesia and in the presence of an performed with an oscillating saw and carried to
anesthesiologist (Fig. 14). Using cervical spine the anterior commissure, which is divided with
precautions if indicated, or a shoulder roll if toler- a number 12 scalpel, thus facilitating lateral
ated, a standard horizontal tracheostomy incision
is made approximately half of the way between
the sternal notch and the cricothyroid membrane.
Injury permitting, the tracheotomy is made
between the second and third tracheal rings. A
single-lumen cuffed tracheostomy tube of appro-
priate diameter (generally size 6, 7, or 8 in adults)
or a reinforced flexible endotracheal tube is placed
and sutured to the skin.

Step 2: Endoscopic evaluation

Once the airway is stabilized, a direct laryn-
goscopy is performed using an anterior com-
missure scope to evaluate the oropharynx,
hypopharynx, supraglottic larynx, and larynx.
After this, an esophagoscopy is performed to
evaluate the cervical esophagus, which may be
concomitantly injured. The authors’ preference Fig. 15. Thyroid and cricoid cartilage is identified by
has been to use a rigid esophagoscope; however, careful dissection and retraction of the strap muscles,
other investigators prefer a flexible scope, and the and the extent of cartilaginous injury is determined.
426 BELL et al

Fig. 18. Anterior attachment of the vocal cord to the

thyroid cartilage (Broyle’s ligament) is resuspended to
the external perichondrium with 4-0 PDS suture.

Step 4: Laryngotracheal repair

As stated previously, a laryngofissure is occa-
Fig. 16. Midline thyrotomy is performed with an oscillat- sionally necessary to visualize the endolarynx
ing saw and carried to the anterior commissure, which is directly so as to repair mucosal lacerations or to
divided with a number 12 scalpel or scissors, thus facilitat- resuspend disrupted arytenoids. The authors have
ing lateral retraction of the thyroid or cricoid cartilage and found that a formal laryngofissure is not necessary
allowing visualization of the endolaryngeal structures.
in most significantly displaced laryngeal fractures,
because the exposure is already facilitated by the
retraction of the thyroid or cricoid cartilage and injury. Once identified, endolaryngeal mucosal
allowing visualization of the endolaryngeal struc- lacerations are closed with 4-0 chromic sutures
tures (Fig. 16). If exploration of the neck or endo- (Fig. 17). If the arytenoid has been dislocated, an
scopic evaluation demonstrates an esophageal attempt should be made to manipulate it into its
injury, the esophagus is repaired primarily, before normal anatomic position. If the anterior attach-
addressing the laryngeal injury. A nasogastric ment of the vocal cord to the thyroid cartilage
tube or appropriately sized Bougie tube is inserted (Broyle’s ligament) is disrupted, it should be
into the esophagus to facilitate repair.

Mucosal or
skin graft

Fig. 19. Laryngeal stent is secured in place by two

sutures placed through the skin, thyroid lamina, and
subglottic space and out through the opposite thyroid
Fig. 17. View of the endolarynx demonstrates mucosal lamina and skin. The sutures are tied loosely over
lacerations that are closed with 3-0 or 4-0 chromic sutures. silicone buttons.
 MANAGEMENT OF LARYNGEAL TRAUMA 427

resuspended to the external perichondrium with space and out through the opposite thyroid lam-
4-0 PDS suture (Fig. 18). If primary repair of ina and skin. The sutures are tied loosely over sil-
the mucosal or vocal cord injury is not possible, icone buttons. There is no universally accepted
consideration must be given to placing a stent, length of time that a laryngeal stent should be
with or without a skin graft (Fig. 19). The laryn- left in place [1,3–5]. The authors generally recom-
geal stent is secured in place by two sutures placed mend 2 weeks, which allows for adequate mucos-
through the skin, thyroid lamina, and subglottic alization and cartilaginous healing (Fig. 20).

Fig. 20. A 43-year-old longshoreman involved in a ‘‘clothesline-like’’ boating accident. (A) Preoperative appearance of
the patient on arrival to the emergency room. The patient was intubated in the field because of upper airway obstruction.
(B) CT scan of the same patient demonstrates massive subcutaneous emphysema suggestive of upper aerodigestive tract
injury. (C) Montgomery stent. (D) Laryngeal stent is secured in place by two sutures placed through the skin, thyroid
lamina, and subglottic space and out through the opposite thyroid lamina and skin. The sutures are tied loosely over
silicone buttons. (E) Postoperative appearance of the same patient 1 week after treatment.
428 BELL et al

Although rarely encountered, the most severe provide rigid internal fixation with titanium plates
injury is complete laryngotracheal separation. and screws. Once the external larynx is closed, the
Patients often die of airway obstruction before wound is closed in layers by first reapproximating
reaching a hospital. The tracheal stump may be the strap muscles in the midline. The superior and
mobilized cephalad into the neck using Babcock inferior skin flaps are then closed by reapproxi-
forceps. Anterior and posterior dissection of the mating the platysma layer and skin closure
trachea can be facilitated by flexing the neck achieved with nylon or staples. A Penrose drain
forward. An infrahyoid myotomy is rarely neces- is placed to drain fluids and to avoid subcutane-
sary. Caution must be exercised so as not to ous emphysema.
dissect the tracheoesophageal groove extensively
laterally, which contains the blood supply to the Postoperative care
trachea and the recurrent laryngeal nerves. Once The authors’ preference is to avoid oral intake
mobilized, a tension-free anastomosis of the with nasogastric tube feeding for approximately
tracheal stump to the cricoid ring is performed 2 weeks after significant laryngoesophageal dis-
using 2-0 Prolene or wire suture. Suspensory ruption. In isolated laryngeal injuries, however,
sutures to the prevertebral fascia are also helpful. a clear liquid diet is initiated whenever practical.
The tracheostomy tube is left in place for at least 5
Step 5: Cartilage stabilization
to 7 days. Decannulation is accomplished when-
After repair of the internal larynx, attention is
ever feasible, depending on the severity of the
turned to repair of the cartilaginous elements. The
injury, and often occurs after hospital discharge.
thyroid and cricoid cartilages are anatomically
Antibiotics are continued for 7 days after surgery.
reduced and stabilized with titanium or biode-
Removal of the stent occurs 2 to 3 weeks after
gradable miniplate and screw fixation (Fig. 21).
placement. Endoscopic laser excision of granula-
Particular emphasis is paid to reducing and stabi-
tion tissue is commonly needed after severe
lizing the cricoid cartilage anatomically, because
injuries. Referral to a laryngologist is optimal for
this is the only circumferential ring in the airway.
postoperative re-evaluation and subsequent care.
If the hyoid bone is fractured, this is repaired as
well. Some investigators have advocated removal
of a central portion of the bone to prevent the Complications
segments from rubbing together [7]. Although Complications for complex injuries are com-
treatment is not always required, the authors pre- mon and can be divided into acute and chronic.
fer to reduce displaced fractures anatomically and Acute complications include upper airway
obstruction and asphyxiation, recurrent laryngeal
nerve injury, postoperative hematoma, and in-
fection. Chronic complications include vocal cord
paralysis and hoarseness; recurrent granulation
tissue formation; supraglottic, glottic, subglottic
or tracheal stenosis; and chronic aspiration.

Summary
Several common conclusions can be drawn
Screws
from the existing literature, all of which are limited
by small sample size and retrospective nature. First,
early intervention within the first 24 to 48 hours
Plate
leads to the best results for the airway and voice.
These findings support early repair of mucosal and
cartilaginous anatomy that theoretically decreases
granulation and fibrous tissue formation. The
authors support this contention and recommend
early repair of all laryngeal injuries, preferably in
Fig. 21. Cartilaginous fragments are anatomically the first 24 hours of presentation.
reduced and stabilized with titanium or biodegradable Second, for patients who have Emanuel laryn-
plates and screws. geal injury stage 2 or greater, the preferred airway
 MANAGEMENT OF LARYNGEAL TRAUMA 429

is a tracheostomy. Of course, with acute airway [3] Leopold DA. Laryngeal trauma. A historical
obstruction and impending death, any airway is comparison of treatment methods. Arch Otolaryngol
a good airway and ventilation should be secured 1983;109(2):106–12.
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tracheal trauma: a protocol approach to a rare
present to the emergency department with pro-
injury. Laryngoscope 1986;96:660–5.
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laryngeal trauma and a currently stable airway. laryngeal trauma analysis of 392 patients. Arch
It is in these patients that an awake tracheostomy, Otolaryngol Head Neck Surg 1999;125:877–80.
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the potential iatrogenic sequelae of oral endotra- Management of laryngo-tracheal injuries associated
cheal intubation. with craniomaxillofacial trauma. J Oral Maxillofac
Third, patients managed conservatively have Surg 2006;64:203–14.
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been repeated in prior studies and should proba- Shockley WW, Pillsbury HC, editors. The neck:
diagnosis and surgery. St. Louis (MO): Mosby;
bly be considered inaccurate. It is important to
1994. p. 603–11.
recognize that patients who received nonoperative [8] Goudy SL, Miller FB, Bumpous JM. Neck crepi-
treatment usually had less severe injuries, and, tans: evaluation and management of suspected
subsequently, the rate of suboptimal outcomes upper aerodigestive tract injury. Laryngoscope
increased with the severity of laryngeal injuries. It 2002;112(5):791–5.
is more accurate to state that ‘‘less severe injuries [9] Granholm T, Farmer DL. The surgical airway.
have more favorable outcome, and surgical repair Respir Care Clin N Am 2001;7(1):13–23.
is rarely required for less severe injuries.’’ It is [10] Lupetin AR, Hollander M, Rao VM. CT evaluation
the authors’ opinion that laryngeal fractures, or of laryngotracheal trauma. Semin Musculoskelet
those with Emanuel laryngeal injury stage 2, 3, or Radiol 1998;2(1):105–16.
[11] Bent JP III, Porubsky ES. The management of blunt
4 injuries (or Schaefer group 2–4 injuries), should
fractures of the thyroid cartilage. Otolaryngol Head
be managed with aggressive surgery to prevent the Neck Surg 1994;110(2):195–202.
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and dysphagia. Although the authors prefer to geal injuries. ‘State of the art.’ Arch Otolaryngol
avoid the use of endolaryngeal stents, if the injury Head Neck Surg 1991;117(1):35–9.
involves complex endolaryngeal mucosal and [13] Fuhrman GM, Stieg FH, Buerk CA. Blunt laryngeal
arytenoid disruption, a stent may be required. trauma: classification and management protocol.
Fourth, successful decannulation, airway pa- J Trauma 1990;30:87–92.
tency, a functional voice, and normal deglutition [14] Hwang SY, Yeak SC. Management dilemmas in
can be expected in most patients who have laryngeal trauma. J Laryngol Otol 2004;118(5):
325–8.
laryngeal injuries and are managed with prompt
[15] de Mello-Filho FV, Carrau RL. The management of
airway stabilization and proper surgical repair laryngeal fractures using internal fixation. Laryngo-
when indicated [1,3–5]. scope 2000;110(12):2143–6.
Fractures of the larynx are uncommon injuries [16] Klotz PL, Fisher J. Evaluation of laryngeal trauma
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Clinicians treating maxillofacial injuries should be Toxicol 1952;32(1):62–75.
familiar with the signs and symptoms of laryngeal [17] Kuttenberger JJ, Hardt N, Schlegel C. Diagnosis
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intervention, and proper surgical repair are essen- Surg 2004;32(2):80–4.
[18] Merritt RM, Bent JP, Porubsky ES. Acute laryngeal
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References [19] Schild JA, Denneny EC. Evaluation and treatment
of acute laryngeal fractures. Head Neck 1989;
[1] Schaefer SD. The acute management of external 11(6):491–6.
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Otolaryngol Head Neck Surg 1992;118(6):598–604. ment of acute laryngeal trauma. Am Surg 1989;
[2] Trone TH, Schaefer SD, Carder HM. Blunt and 55(5):303–6.
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Otolaryngol Head Neck Surg 1980;88(3):257–61. laryngeal trauma. J Trauma 1987;4:448–52.
430 BELL et al

[22] Minard G, Kudsk KA, Croce MA, et al. Laryngo- [28] Lykins CL, Pinczower EF. The comparative
tracheal trauma. Am Surg 1992;59:181–7. strength of laryngeal fracture fixation. Am J Otolar-
[23] Bent JP, Silver JR, Porubsky ES. Acute laryngeal yngol 1998;19(3):158–62.
trauma: a review of 77 patients. Otolaryngol Head [29] LeJeune FE Jr, Weir DF. A laryngeal stent for repair
Neck Surg 1993;109:441–9. of laryngeal fractures. Laryngoscope 1983;93(10):
[24] Yen PT, Lee HY, Tsai MH, et al. Clinical analysis of 1359.
external laryngeal trauma. J Laryngol Otol 1994; [30] Woo P. Laryngeal framework reconstruction
108:221–5. with miniplates. Ann Otol Rhinol Laryngol 1990;
[25] Cherlan TA, Raman R. External laryngeal trauma: 99(10 Pt 1):772–7.
analysis of thirty cases. J Laryngol Otol 1993;107:920–3. [31] Sasaki CT, Marotta JC, Lowlicht RA, et al. Efficacy
[26] Bhanot S, Alex JC, Lowlicht RA, et al. The efficacy of resorbable plates for reduction and stabilization
of resorbable plates in head and neck reconstruction. of laryngeal fractures. Ann Otol Rhinol Laryngol
Laryngoscope 2002;112(5):890–8. 2003;112(9 Pt 1):745–50.
[27] Pou AM, Shoemaker DL, Carrau RL, et al. Repair [32] Weigelt JA, Thal ER, Snyder WH, et al. Diagnosis
of laryngeal fractures using adaptation plates. of penetrating cervical esophageal injuries. Am
Head Neck 1998;20(8):707–13. J Surg 1987;154:619–22.
 Oral Maxillofacial Surg Clin N Am 20 (2008) 431–443

Thyroid Disorders: Evaluation and Management

of Thyroid Nodules
James I. Cohen, MD, PhDa,*, Kelli D. Salter, MD, PhDb
a
Department of Otolaryngology/Head and Neck Surgery, Oregon Health & Science University,
3181 SW Sam Jackson Park Road, PV-01, Portland, OR 97239-3098, USA
b
Department of General Surgery, Oregon Health & Science University,
3181 SW Sam Jackson Park Road, L223, Portland, OR 97239-3098, USA

Although it is well documented that thyroid respectively [10]. These numbers have steadily
nodules are a common clinical disorder, signifi- increased from the reported 13,000 number of
cant controversy persists as to ideal management new cases and 1000 thyroid cancer–associated
strategies. Population studies suggest that approx- deaths in 1994 [10–12]. However, despite the nota-
imately 3% to 7% of adults have asymptomatic ble increase in the number of new cases, mortality
palpable thyroid nodules, and that the number of rates have remained constant [10–12]. Most ex-
nodules, including asymptomatic and symptom- perts in the field of cancer agree that the increas-
atic, increases with age [1–6]. However, the advent ing incidence of thyroid cancer likely reflects the
and implementation of high-resolution radio- implementation of technology with increased
graphic imaging has significantly impacted the sensitivity and specificity for detecting thyroid
discrepancy between clinically evident disease nodules. Such technology increases the need for
and incidentally discovered disease. High-resolu- physicians to improve their ability to differentiate
tion ultrasound (US) can detect thyroid nodules benign from malignant thyroid lesions, because
in 20% to 67% of randomly selected individuals, the clinical importance of thyroid nodules rests
with a higher frequency in women and the elderly on the need to exclude thyroid cancer.
[3–8]. Moreover, 20% to 48% of patients who Incidentally discovered nodules present the
have a single palpable nodule have additional same risk for malignancy (w10%) as palpable
nodules identified on US. This discrepancy is fur- nodules if they are equivalent in size [3–6,13].
ther supported by data from autopsies conducted Therefore, the physician who finds an incidental
for medical reasons unrelated to thyroid disor- thyroid nodule is faced with the challenge of
ders. Such data suggest that the prevalence of determining the clinical significance of the lesion.
thyroid nodules in clinically normal glands is Differentiating a benign nodule, which may re-
approximately 50% to 70% [3–6,9]. Therefore, quire observation only and no specific treatment,
the true prevalence of nodular thyroid disease in from a malignant nodule, which requires more ag-
the general population remains unknown. gressive treatment, presents a diagnostic dilemma.
As the incidence of thyroid nodules has ex- Because of the high prevalence of incidental dis-
hibited a steady rise over the past decade, so too ease, it is neither economically feasible nor neces-
has the incidence of thyroid cancer. The National sary to surgically excise all, or even most, thyroid
Cancer Institute estimates the number of new nodules. It is essential that the physician develop
cases and deaths from thyroid cancer in the and follow a reliable, cost-effective strategy for
United States in 2007 to be 33,550 and 1,530, diagnosis and treatment of incidentally found thy-
roid nodules. This article provides practical guide-
lines, algorithms, and current recommendations
* Corresponding author. for the effective diagnosis and management of thy-
E-mail address: [email protected] (J.I. Cohen) roid nodules incidentally discovered by physicians
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.02.003 oralmaxsurgery.theclinics.com
432 COHEN & SALTER

managing patients for other medical reasons. has a thyroid nodule. Unfortunately, neither the
Important elements of the history and physical history nor the physical examination is highly
examination, laboratory evaluation, and imaging sensitive or specific for detecting malignancy. How-
modalities are reviewed, and a suggested manage- ever, several well-documented factors are associ-
ment strategy is presented. This outline is not ated with an increased risk for malignancy and,
intended to be all inclusive, nor does it preclude therefore, warrant further discussion [3–6]. Factors
additional evaluation, according to the specific that present a high risk for thyroid cancer include:
clinical situation. Furthermore, the specific man- history of head and neck or total body radiation;
agement of hypothyroidism, hyperthyroidism, or family history; rapid growth; hard, fixed nodule;
thyroid malignancies is beyond the scope of this and/or regional, cervical lymphadenopathy. Fac-
article. These lesions should be specifically man- tors that present a moderate risk include: male gen-
aged by a multidisciplinary team, including, at der; age younger than 30 or older than 60 years;
a minimum, an endocrinologist and surgeon who and/or persistent local symptoms (hoarseness, dys-
specialize in the treatment of such disorders. phagia, dysphonia, dyspnea).
A history of head and neck or total body
irradiation is a well-known risk factor for
Diagnosis
subsequent development of thyroid cancer. The
No reliable noninvasive way exists to distin- incidence of thyroid malignancy in a patient who
guish a benign thyroid nodule from a thyroid has a nodule and a previous history of radiation
carcinoma. Multiple diagnostic methods must be has been reported to range from 20% to 50%
used to increase the accuracy of the diagnosis. [2–6,14–18]. Therefore, the incidental finding of
Fig. 1 provides a basic algorithm of diagnostic a thyroid nodule in a patient who has had prior
modalities typically used in the initial evaluation radiation exposure requires careful and complete
of a thyroid nodule. Generally, the inability to evaluation, although by itself it does not justify
accurately differentiate benign from malignant removal if the workup should prove negative.
nodules warrants operative removal of the lesion. Despite high levels of intraobserver and
interobserver variations, careful inspection and
palpation of the thyroid, the anterior neck com-
History and physical examination
partments, and the lateral neck compartments
The history and physical examination, including should always be performed. Texture and size of
that of adjacent cervical lymph nodes, remain the the nodule should be documented. A firm or hard,
diagnostic cornerstone in evaluating a patient who solitary or dominant nodule with an increased

Thyroid Nodule

History and Physical Examination TSH

High Normal Low

Free T3 + Free T4
TPOAb+ Free T4 Ultrasound

Scintigraphy

No Suspicious Suspicious
Features Features
Cold Hot

FNA
Endocrinology
Asymptomatic Symptomatic
Consult

Fig. 1. Diagnosis and management of thyroid nodules. FNA, fine-needle aspiration; T3, triiodothyronine; T4, thyroxine;
TPOAb, thyroid peroxidase antibody; TSH, thyroid-stimulating hormone (thyrotropin).
 EVALUATION AND MANAGEMENT OF THYROID NODULES 433

rate of growth that clearly differs from the rest of follicular (14%), and anaplastic (2%) forms have
the gland suggests an increased risk for malig- been observed in Japanese patients, only papillary
nancy [2,4,6]. The presence of multiple nodules appears to occur in Caucasian patients [25]. Fi-
(symptomatic or asymptomatic) does not decrease nally, papillary thyroid carcinoma can occur in
the likelihood that any one of them is a carcinoma, families independent of syndromes such as FAP,
as was once thought, although the overall inci- Cowden, or Werner [21,22,25]. This form of thy-
dence of malignancy in a multinodular gland is roid cancer is believed to be inherited as an auto-
the same as that for any given nodule (w10%) somal dominant condition. However, a specific
[3–6,19,20]. Each nodule should be evaluated on genetic mutation has not been identified. There-
its own merit regardless of the number of nodules fore, genetic testing is not currently available for
present. Finally, ipsilateral or contralateral cervi- these families.
cal lymphadenopathy is worrisome in the setting Extremes of age (!30 or O60) and male
of a thyroid nodule and significantly increases gender are associated with an increased risk for
the risk for malignancy. thyroid cancer if a nodule is present [2–6]. Thyroid
Thyroid cancer may present as a familial trait nodules during childhood and adolescence should
or syndrome [21–24]. Although medullary thyroid induce caution, because the rate of malignancy is
carcinoma (MTC) accounts for only approxi- twofold higher in children than in adult patients
mately 10% of all thyroid carcinomas, 25% of [2–6]. Furthermore, although thyroid nodules
MTCs occur secondary to an inherited cancer are four times more common in women and
risk, namely familial MTC (!2%) and multiple increase with age, men are at greater risk for
endocrine neoplasia (MEN 2A, w25% or MEN malignancy than women [2–6].
2B, !2%) [23–25]. Mutations in the RET proto- Most patients who have thyroid nodules have
oncogene are responsible for all three conditions few or no symptoms. When present, symptoms
[23–25]. Patients diagnosed with MTC should are generally nonspecific. No defined relationship
undergo genetic testing to determine if mutations exists between nodule histology or size and the
in the RET proto-oncogene are present. reported symptoms. However, persistent local
Papillary and follicular carcinomas, the two symptoms of hoarseness, dysphagia, dysphonia,
most common forms of thyroid cancer, may also dyspnea, or cough should raise the suspicion of
present as a family trait or syndrome [21,22,25]. malignancy and warrant further investigation,
Patients who have familial adenomatous po- including an evaluation for thyroid cancer [2–6].
lyposis (FAP) syndrome or Gardner syndrome Finally, iodine deficiency and socioeconomic
(a variant of FAP), Cowden syndrome, and status have been proposed as independent risk
Werner (adult progeroid) syndrome are at in- factors for thyroid carcinoma [6,26–29]. Popula-
creased risk for development of thyroid cancer tion-based studies conducted from the 1960s to
[21,22,25]. Families with adenomatous polyposis the 1990s on residents living in areas of endemic
(FAP or Gardner syndrome) show an increased goiter indicated that iodine deficiency was an as-
incidence (2%) of papillary thyroid cancers, which sociated risk factor for thyroid cancer, primarily
tend to be multicentric (65%), exhibit a higher fe- of the follicular and papillary subtypes [26–29].
male-to-male ratio (6:1), and develop at a younger Lower socioeconomic status additionally was
age (third decade) [21,22,25]. Patients who have identified as an independent risk factor for more
Cowden syndrome have up to a 10% lifetime advanced disease secondary to limited access to
risk for follicular or papillary thyroid cancer, appropriate health care [26–29].
with follicular being the most common
[21,22,25]. Approximately 70% to 85% of people
Laboratory evaluation
with Cowden syndrome will have benign thyroid
changes, including multinodular goiter, adenoma- Because clinical evaluation is not sensitive for
tous nodules, and follicular nodules [21,22,25]. thyroid gland disease, laboratory examination is
Thyroid cancer associated with Werner syndrome, necessary. Measurement of the serum thyrotropin
an autosomal connective tissue disorder, occurs or thyroid-stimulating hormone (TSH) concentra-
a decade earlier than in the general population, tion is the single most useful test, and may be the
with a mean age of 34 years. Variability in the only one warranted, in the initial evaluation of
type of non-MTC occurring in patients who thyroid nodules [2–6]. The TSH assay has a high
have Werner syndrome has been observed among sensitivity in detecting even subtle thyroid dys-
ethnic groups. Although papillary (84%), function [30]. If the serum TSH level is within
434 COHEN & SALTER

the normal range, the measurement of free thyroid in patients who have factors suspicious for spo-
hormones adds no further relevant information. radic MTC and is imperative in those patients
Abnormal serum TSH levels, however, generally who have a suspected familial MTC or a familial
warrant further laboratory testing (see Fig. 1). If MEN syndrome.
the serum TSH level is high, a free thyroxine
(T4) and thyroglobulin or thyroid peroxidase anti-
Imaging modalities
body (TPOAb) should be obtained to evaluate for
hypothyroidism or thyroiditis [2–6]. In both these High-resolution ultrasound
situations, the thyroid gland can be enlarged or High resolution ultrasonography (US) is the
nodular. By contrast, if the serum TSH level is cornerstone of imaging for assessment of thyroid
low, a free T4 and free triiodothyronine (T3) level nodules. To date, it is the most accurate test
should be obtained to evaluate for hyperthyroid- available to evaluate such lesions, measure their
ism, such as an autonomic functioning gland or dimensions, identify their structure, and evaluate
thyrotoxicosis [2–6]. diffuse changes in the thyroid gland [4–6]. How-
Serum thyroglobulin, a protein normally pro- ever, because of the high prevalence of clinically
duced by the thyroid gland, correlates with the inapparent, small thyroid nodules, routine US is
iodine status and the size of the thyroid gland not recommended as a screening test in the gen-
rather than the nature (malignant versus benign) eral population unless well-known risk factors
of a thyroid nodule. Many factors, including the are present.
degree of thyrotropin receptor stimulation, the Many studies have been published debating the
volume of the gland, inflammation, radiation, ability of US to distinguish between benign and
multinodular goiter, biopsy, or surgery, may cancerous lesions [13,32–38]. In 2005, the Society
falsely elevate or decrease levels of thyroglobulin of Radiologists in Ultrasound convened a panel
[4–6,31]. Furthermore, the presence of TPOAb, of specialists from a variety of medical disciplines
which attack the thyroglobulin protein, may de- to formulate a consensus regarding management
crease the reliability of the thyroglobulin assay of thyroid nodules identified by ultrasonography
[4–6,31,32]. Such antibodies may be present in in adult patients [39]. The likelihood of cancer in
10% of normal subjects, 15% to 30% of patients a thyroid nodule was shown to be the same
who have differentiated thyroid cancer, 89% to regardless of the size measured at US [13,32–39].
98% of patients who have Grave’s disease, and Furthermore, sonographic features suggestive of
100% of patients who have Hashimoto’s thyroid- malignancy were found to vary between types of
itis [4–6,31,32]. Additionally, autoimmune thyroid thyroid carcinomas [13,32–39]. Despite these
diseases are associated with several other organ- discrepancies, several sonographic features were
specific and systemic autoimmune disorders [32]. found to be suggestive of an increased risk for
Therefore, a preoperative assay cannot be used malignancy (Fig. 2, Table 1), including microcalci-
to diagnose or exclude cancerous lesions. Al- fications, hypoechogenicity, irregular margins,
though commonly implemented as a means of absence of nodule halo, predominant solid com-
monitoring for recurrence of thyroid cancer in pa- position, and intranodular vascularity [13,32–39].
tients following thyroidectomy, measurement of However, the sensitivities, specificities, positive
serum thyroglobulin should not be used in the predictive values and negative predictive values
routine assessment of thyroid nodules. for these criteria were variable between studies
Routine measurement of calcitonin, a useful [13,32–39]. No US feature was found to have
serum marker of MTC, in all patients is not cost- both a high sensitivity and positive predictive
effective [4–6]. However, the incidence of sporadic value but the combination of factors was shown
MTC in patients who have nodular thyroid to improve the positive predictive value of US to
glands can be as high as 1.5% [23,25]. Further- some degree. Therefore, patients who have palpa-
more, unlike familial MTC which often is diag- ble thyroid nodules or incidentally discovered
nosed early secondary to family history and nodules with concerning patient demographics or
genetic testing, sporadic MTC usually presents risk factors should undergo US to evaluate for
at a later stage with regional metastasis because sonographic features suggestive of malignancy,
of increased difficulty in diagnosis due to various baseline characteristics and volume of the nod-
morphologies [23,25]. Therefore, although not ule, coincidental thyroid nodules, and baseline
recommended in routine assessment of thyroid characteristics and volume of the remaining thy-
nodules, a calcitonin level should be considered roid gland. In addition the cervical lymph nodes
 EVALUATION AND MANAGEMENT OF THYROID NODULES 435

Fig. 2. Ultrasound images of thyroid nodules of varying parenchymal composition (cystic to solid) and vascularity. (A)
Gray-scale image of predominately cystic nodule (calipers) that proved to be benign at cytologic examination (fine-needle
aspiration [FNA]). (B) Gray-scale image of mixed solid and cystic nodule (calipers) with septate (arrow). (C) Addition of
color Doppler mode did not demonstrate marked internal vascularity. The lesion was benign at cytologic examination
(FNA). (D) Gray-scale image of predominately solid nodule (calipers) with surrounding halo (arrows) that proved to be
benign at cytologic examination (FNA) and surgery. (E) Gray-scale image of predominately solid nodule (calipers) with
irregular margins (arrows) and multiple fine echogenicities (arrowheads). (F) Addition of color Doppler mode demon-
strated marked internal vascularity indicating increased likelihood that nodule is malignant. FNA and surgery confirmed
papillary carcinoma.

beds should be evaluated by ultrasonography as factors and ultrasonographic characteristics con-

warranted. cerning for malignancy should undergo cytohisto-
Despite recommendations from the Society of logic analysis of a representative tissue sample
Radiologists in Ultrasound Consensus Conference obtained by way of either fine-needle aspiration
Statement, ultrasonography cannot reliably distin- (FNA) or coarse-needle biopsy (CNB) [39]. In gen-
guish between benign and cancerous lesions without eral, FNA is preferred over CNB because it is ex-
adjunct testing. Therefore, patients who have risk tremely accurate and less invasive and allows for

Table 1
Sonographic features associated with thyroid cancer
US feature Sensitivity (%) Specificity (%) PPV (%) NPV (%)
Microcalcifications 26–59 86–95 24–71 42–94
Hypoechogenecity 27–87 43–94 11–68 74–94
Irregular margins or halo absence 17–78 39–85 9–60 39–98
Solid composition 69–75 53–56 16–27 88–92
Intranodular vascularity 54–74 79–81 24–42 86–97
Abbreviations: NPV, negative predictive value; PPV, positive predictive value.
Modified from Frates MC, Benson CB, Charboneau JW, et al. Management of thyroid nodules detected at US: Society
of Radiologists in Ultrasound consensus conference statement. Radiology 2005;237:794–800.
436 COHEN & SALTER

Fig. 3. Methods for obtaining thyroid tissue for cytohistologic analysis. A CNB uses a larger needle (16 or 18 gauge) and
requires that the thyroid nodule be at least 2 cm in size. By contrast, an FNA uses a smaller needle (25 or 27 gauge) and
allows for more complete sampling of the nodule because of the multiple passes taken through the nodule.

more complete sampling of the nodule because of hyperfunctioning (‘‘hot’’) from hypofunctioning
the multiple passes taken through the nodule (‘‘cold’’) nodules (Fig. 4) [4–6,40,41]. Hyperfunc-
(Fig. 3) [4–6]. Additionally, US should be performed tioning nodules represent approximately 5% of
in all patients who have a history of familial thyroid thyroid nodules and present a low risk for malig-
cancer, MEN II, or childhood cervical irradiation, nancy (%1%) [4–6]. Hypofunctioning nodules
even if palpation yields normal findings [39]. Fur- have a reported malignant risk of 5% to 25%
thermore, the physical finding of adenopathy suspi- and represent approximately 75% to 95% of thy-
cious for malignant involvement in the anterior or roid nodules [4–6]. The remaining 10% to 15% of
lateral neck compartments warrants US examina- nodules are indeterminate, with a variable risk for
tion of the lymph nodes and thyroid gland because malignancy [4–6]. Because most thyroid lesions
of the risk for a lymph node metastatic lesion from are ‘‘cold’’ and few of these lesions are malignant,
an unrecognized thyroid carcinoma [39]. the predictive value of hypofunctioning nodules
for the presence of malignant involvement is
Radionuclide scintigraphy low. The diagnostic specificity is further reduced
Radionuclide scintigraphy (iodine 123 [123I] in small lesions (!1 cm), which may not be iden-
or technetium-99m pertechnetate), once the cor- tified by scintigraphy. For these reasons, thyroid
nerstone for thyroid imaging, has now been re- scintigraphy is not usually useful as a first-step
placed by high-resolution ultrasonography as the diagnostic study in the evaluation of thyroid
imaging modality of choice for evaluating thyroid nodules. Indications that may warrant use of
nodules [4–6]. Such scans, in the current status thyroid scintigraphy include identification of a
of thyroid imaging, are used primarily as ad- solitary thyroid nodule in the setting of decreased
juncts to ultrasonography for differentiating serum thyrotropin, an indeterminate FNA or
 EVALUATION AND MANAGEMENT OF THYROID NODULES 437

Fig. 4. Iodine 123 (123I) thyroid scintigraphy patterns in thyroid glands (dashed lines) with ‘‘cold’’ and ‘‘hot’’ nodules. (A)
Nonfunctioning ‘‘cold’’ nodule in the lower left thyroid lobe (solid line). (B) Hyperfunctioning ‘‘hot’’ right thyroid nodule
(solid line), with suppressed serum TSH level and suppressed uptake of 123I in the remainder of the thyroid gland.

CNB of a thyroid nodule, and for the detection discussed, including history and physical, labora-
of nonspecific neck masses or lymphadenopathy tory analysis, and associated known risk factors.
[4–6,40,41]. Although abnormalities of the thyroid gland can
be detected on CT and MRI, sonography provides
CT and MRI important additional information that may be
CT and MRI, like other imaging modalities, useful in guiding further clinical management.
cannot reliably differentiate between malignant Therefore, patients who have an incidentally
and benign nodules [4–6,42]. Therefore, these tests discovered thyroid nodule on CT or MRI and
are rarely indicated in the initial evaluation of
a thyroid nodule. However, such imaging mo-
dalities may be used as secondary adjuncts if
warranted. A CT scan can be used to evaluate
nodules in a difficult-to-palpate, diffusely enlarged
gland, to assist in detection of mediastinal thyroid
tissue, and to assess for extrathyroidal invasion
and cervical lymphadenopathy (Fig. 5). By con-
trast, MRI demonstrates exquisite soft tissue
details and vascular anatomy, and thus, allows
for identification of extraglandular invasion and
involvement of the great vessels, respectively.
Therefore, either of these imaging modalities
may be implemented in preoperative staging. CT
contrast medium contains iodine which reduces
subsequent uptake of iodine molecules and thus
may interfere with nuclear scintigraphy (123I) or
postoperative radioiodine ablation therapy (131I) Fig. 5. CT scan of the neck demonstrating a metastatic
for malignant nodules. MRI uses contrast me- right thyroid lobe carcinoma. The anterior aspect of the
dium (gadolinium) that does not interfere with right thyroid lobe has a nodular exophytic mass (long
arrow) near the junction with the isthmus. On the right
nuclear scintigraphy.
side is a heterogeneous low-density enlarged lymph
Incidental clinically silent thyroid nodules are node (short arrow) that contains septations and nodules
commonly discovered in patients undergoing CT of high density. Fine-needle aspiration and surgery of
or MRI for medical reasons unrelated to thyroid the mass demonstrated papillary carcinoma with metas-
disorders. The decision to pursue further workup tasis to the right paratracheal and lateral neck lymph
of such nodules depends on several factors already nodes.
438 COHEN & SALTER

concerning clinical features should undergo ultra- Table 2

sonography to determine the need for biopsy and Statistical features of thyroid fine-needle aspiration
further analysis. Statistical feature Mean (%) Range (%)
Sensitivity 83 65–98
Cytohistochemistry analysis Specificity 92 72–100
A cytohistochemistry analysis should be per- PPV 75 50–96
formed on thyroid nodules with associated fea- False-negative rate 5 1–11
tures concerning for malignancy. Tissue for such False-positive rate 5 0–7
analysis is obtained by way of either FNA or Abbreviation: PPV, positive predictive value.
CNB (see Fig. 3). Detailed reviews of aspiration Modified from AACE/AME Task Force on Thyroid
biopsy of thyroid nodules have been published Nodules. American Association of Clinical Endo-
previously [4–6,43–45]. In general, FNA is the re- crinologists and Associazione Medici Endocrinologi
moval of a few clusters of individual thyroid cells medical guidelines for clinical practice for the diagnosis
by means of a small needle (usually a 25- or and management of thyroid nodules. Endocr Prac
27-gauge 1.5-in needle). By contrast, CNB uses 2006;12(1):63–102; Gharib H, Papini E. Thyroid nodules:
a larger needle (usually a 16- or 18-gauge needle) clinical importance, assessment, and treatment. Endocri-
nol Metab Clin N Am 2007;36:707–35; with permission.
and is more difficult to perform, and fewer phy-
sicians have experience in this procedure. In
addition, the large size of the needle may cause
a small amount of bleeding (%1%), injury to [4–6,39]. As a general rule, a solitary thyroid nod-
the trachea, or injury to the recurrent laryngeal ule larger than 1 cm in diameter with microcalcifi-
nerves. Furthermore, unlike FNA, which can be cations should be biopsied [4–6,39]. A solitary
performed on all types of nodules, the nodule thyroid nodule that is at least 1.5 cm in diameter
must be at least 2 cm in size to perform a CNB and solid, or almost entirely solid, or with coarse
successfully. Finally, although CNB provides calcifications should be biopsied [4–6,39]. Man-
a larger tissue sample that retains it cellular archi- agement of mixed solid and cystic (or almost en-
tecture, it rarely provides a more precise histologic tirely cystic) nodules is more controversial than
diagnosis than FNA. Therefore, because of its that of solid nodules. FNA is likely unnecessary
minimal invasiveness, accuracy (w95%) and if the nodule is almost entirely cystic and
cost effectiveness, US-guided FNA has now without US features concerning for malignancy
become the diagnostic technique of choice for (see Table 1) [4–6,39]. However, it is generally
evaluating thyroid nodules [4–6]. For these rea- recommended that FNA be performed on a mixed
sons, only the role of FNA in the evaluation of
thyroid nodules will be discussed in this article.
The accuracy of FNA or CNB is only as good
Table 3
as the person performing the procedure and the
Recommendations for thyroid nodules greater than or
person who analyzes and reports the cytologic equal to 1 cm in maximum diameter
findings. However, when performed by experi-
enced personnel, the sensitivity and specificity Ultrasound features Recommendation [4–6,39]
(Table 2) of thyroid FNA are excellent [4–6]. Solitary nodule
Microcalcifications R1.0 cm: US-guided FNA
Fine-needle aspiration Solid (or mostly solid) R1.5 cm: US-guided FNA
Not every patient who has a thyroid nodule Mixed R2.0 cm: US-guided FNA
None of the above Consider US-guided FNA
should undergo FNA. Which thyroid nodule
but substantial
should be aspirated is a topic of intense current growth
debate among multiple medical specialties. As Mostly cystic and FNA probably
stated in the 2005 Society of Radiologists in none of the above not warranted
Ultrasound Consensus Conference Statement, Multiple nodules Consider US-guided FNA
the decision to perform or defer FNA in a given of one or more nodules
patient should be made according to the individ- based on above criteria;
ual circumstances [39]. Several recommendations sampling should be
(Table 3) based on current literature and common focused on lesions with
practice strategies were made by the committee to suspicious US features
rather than size
assist physicians in their decision-making process
 EVALUATION AND MANAGEMENT OF THYROID NODULES 439

or almost entirely cystic nodule with a solid mural patients who had multiple nodules (14.9%) [20].
component of at least 2 cm in size [4–6,39]. Sonographic characteristics were unable to distin-
Finally, any nodule that exhibits substantial guish benign from malignant disease accurately.
growth should be biopsied [4–6,39]. Consistent with previous evidence, solitary
Controversy remains regarding the optimal nodules were found to have a higher likelihood
management of patients who have multiple of malignancy than nonsolitary (cystic or mixed)
thyroid nodules. Some advocate routine FNA of nodules [20]. Cancer was multifocal in 46% of
all nodules larger than 10 mm, whereas others patients who had multiple nodules larger than
recommended FNA of only the largest nodule. 10 mm [20]. Seventy-two percent of cancers
The American Thyroid Association Guidelines occurred in the largest nodule [20]. However, as
Taskforce currently recommended that in the the number of nodules increased, the frequency
presence of two or more thyroid nodules larger of cancer in the largest nodule decreased, and
than 1 to 1.5 cm, those with suspicious sono- thus reduced the predictive value of FNA of the
graphic appearance should be aspirated preferen- largest nodule. A strategy of biopsying the largest
tially [5]. If none of the nodules exhibits suspicious nodule detected only 86% of patients who had
sonographic appearance and multiple sonograph- two nodules, one of which contained cancer, and
ically similar coalescent nodules are present, only only approximately 50% of patients who had
the largest nodule should be aspirated [5]. This three or more nodules, one of which contained
lack of a consistent recommendation stems in cancer [20]. Thus, for confident exclusion of thy-
part from the absence of studies investigating roid cancer in a gland with multiple nodules larger
the prevalence and location of thyroid cancer in than 10 mm, it was recommended that FNA be
patients who have multiple thyroid nodules. performed in up to three or four nodules larger
Recently, a retrospective observational cohort than 10 mm [20].
study conducted from 1995 to 2003 investigated Management of thyroid nodules following
the prevalence and distribution of carcinoma in biopsy depends on the cytohistologic diagnosis
patients who have solitary and multiple thyroid (Fig. 6). However, before making a cytohistologic
nodules on sonography [20]. A total of 1985 diagnosis, the FNA specimen first must be evalu-
patients underwent FNA of 3483 nodules. The ated for adequacy and classified as either adequate
prevalence of thyroid cancer was similar between or inadequate (or unsatisfactory) [46–48]. If the
patients who had a solitary nodule (14.8%) and specimen is considered inadequate or

FNA

Adequate Inadequate

Repeat
FNA

Benign Malignant Follicular Suspicious Indeterminate X1

Neoplasm
Inadequate

Endocrinology
Observe; and
Endocrinology Surgery Consult
Consult Surgery
Repeat FNA Consult
Surgery
Consult and/or
Surgery Consult

Fig. 6. Recommended management of thyroid nodules based on cytohistologic diagnosis. Tissue samples must first be
evaluated for adequacy. If the specimen is considered inadequate or unsatisfactory, the FNA should be repeated with
ultrasound guidance. A second indeterminate classification generally warrants surgical excision for accurate tissue
analysis if the nodule has any features that are worrisome for malignancy.
440 COHEN & SALTER

unsatisfactory, the FNA should be repeated with neoplasm, or (5) indeterminate. Approximately
US guidance, because the risk for malignancy in 70% of FNA specimens are classified as benign,
such samples reportedly ranges from 2% to 37%, 10% as suspicious, 5% as malignant, and 10% to
depending on patient demographics and preopera- 15% as indeterminate [4–6,46–48].
tive analysis [49–53]. A second inadequate classifi- Benign nodules, usually of macrofollicular
cation generally warrants surgical excision for pattern, are characterized by abundant colloid,
accurate tissue analysis if the nodule has any including watery colloid, which leads to red blood
features that are worrisome for malignancy. Once cell rouleau formation, and variably sized groups
the FNA specimen is considered adequate, it can of cytologically bland follicular epithelial cells.
be evaluated further by the pathologists and cate- They often have a cystic component, defined as
gorized into one of five cytohistologic diagnostic cyst fluid (absence of rouleau formation) with
categories (Fig. 7) [4–6,46–48]: (1) benign or conspicuous histiocytes. Cytopuncture of cyst
nonneoplastic, (2) malignant (usually papillary fluid is a source of scant biopsies, leading to
carcinoma), (3) suspicious for cancer, (4) follicular false-negative diagnosis. In general, benign

Fig. 7. Common thyroid cytology based on FNA analysis. (A) Benign thyroid nodule with abundant colloid, including
watery colloid (shown here), and variably sized groups of cytologically bland follicular epithelial cells. (B) Cystic
component of benign thyroid nodule with conspicuous histiocytes (arrow). (C) Papillary carcinoma with intranuclear
cytoplasmic pseudoinclusions (arrow) and dense squamoid cytoplasm. (D) Bizarre multinucleated giant cells (arrow)
of papillary carcinoma (compare with histiocyte in A). (E) Suspicious for papillary carcinoma lesion with many features
of papillary carcinoma, including enlarged follicular cells with enlarged and prominent nuclei, powdery chromatin,
nuclear grooves (arrow), and intranuclear cytoplasmic inclusions. (F) Follicular neoplasm with repetitive microfollicular
groups and minimal amount of colloid, as would be expected given the cellular neoplasm with scant colloid seen in the
accompanying histologic section of the follicular adenoma (G). (H) Indeterminate lesion exhibiting suboptimal
cellularity but with features suggestive of papillary carcinoma.
 EVALUATION AND MANAGEMENT OF THYROID NODULES 441

thyroid nodules can be followed by an endocrinol- and management of incidentally discovered

ogist with clinical examination and ultrasonogra- thyroid nodules.
phy [4–6]. Appendix 1 contains a summary of key aspects
Malignant lesions or those suspicious for for examination of thyroid nodules, as recommen-
cancer (usually papillary carcinomas or follicular ded by the American Thyroid Association [5], the
neoplasms) warrant surgical excision [4–6]. Papil- American Association of Clinical Endocrinolo-
lary thyroid carcinoma on cytohistologic exami- gists [6], the Associazione Medici Endocrinologi
nation may have moderate amounts of colloid [6], and the Society of Radiologists in Ultrasound
and a cystic component similar to benign nodules [39].
but it is characterized by the combination of
intranuclear cytoplasmic pseudoinclusions, dense Appendix 1
squamoid cytoplasm, and papillary architecture.
Other minor criteria that may support the Summary of key factors and recommendations
diagnosis of papillary carcinoma include bizarre, regarding thyroid nodule examination
multinucleated giant cells, psammoma bodies,
History and physical examination
thick ‘‘bubble-gum’’ colloid, nuclear membrane
irregularities (so-called nuclear grooves), and About 90% to 95% of thyroid nodules are
nuclear enlargement. By contrast, follicular benign.
neoplasms, including follicular adenoma, follicu- Risk for cancer is similar in solitary nodules
lar carcinoma, follicular variant of papillary and multinodular goiter.
carcinoma, and Hurthle cell neoplasm, are Absence of symptoms does not exclude
characterized by a cellular aspirate with repetitive malignancy.
microfollicular groups and minimal amount of Pertinent patient demographics and physical
colloid. Currently, no noninvasive methods examination factors should be assessed:
reliably differentiate between follicular adenoma History of head and neck or total body
and follicular carcinoma. irradiation
Indeterminate lesions exhibit cellularity Family history of thyroid carcinoma in first-
suboptimal for making a definitive diagnosis but degree relative
generally show features suggestive of one of the Rapid growth and hoarseness
above categories. Patients who have such lesions Ipsilateral cervical lymphadenopathy
may undergo a second FNA or be directly triaged Fixation of nodule to surrounding tissue
to surgery. The decision to repeat the FNA or Vocal cord paralysis
surgically excise the lesion must be based on
a combination of factors, including patient pref- TSH level should be obtained.
erence, physician recommendations, and clinical Diagnostic imaging
history of the lesion [4–6,46–48].
US of thyroid nodules should be performed in
high-risk patients who have pertinent patient
demographics or physical examination
Summary factors.
Thyroid nodules are a common clinical entity. Nodules should be identified for FNA biopsy.
Most nodules are discovered incidentally in pa- Cytohistochemistry analysis
tients undergoing surveillance for medical reasons
unrelated to thyroid disorders. The physician who Biopsy should be obtained from all solitary,
identifies an incidental thyroid nodule is faced firm, or hard nodules.
with the challenge of determining the clinical FNA should be performed:
significance of the lesion, with the primary objec- Nodules of any size in patients who have
tive being to evaluate the nodule for malignancy. concerning patient demographics or phys-
Using a reliable, cost-effective strategy for di- ical examination findings suggestive of
agnosis and treatment of incidentally discovered malignancy
thyroid nodules improves the ability to differenti- All hypoechoic nodules greater than or equal
ate benign from malignant nodules. This article to 1 cm with microcalcifications, irregular
provides practical guidelines and a suggested margins, intranodular vascularity, absence
management strategy for the effective diagnosis of halo, or predominately solid consistency
442 COHEN & SALTER

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nodular thyroid disease. Surgery 1998;124:656–61. diagnostic thyroid fine-needle aspiration cytology:
[41] Meller J, Becker W. The continuing importance of management dilemmas. Thyroid 2001;11(12):
thyroid scintigraphy in the era of high-resolution 1147–51.
 Oral Maxillofacial Surg Clin N Am 20 (2008) 445–458

Clinical Implications of the Neck

in Salivary Gland Disease
Andrew R. Salama, DDS, MD*,
Robert A. Ord, DDS, MD, FRCS, FACS
Department of Oral and Maxillofacial Surgery, University of Maryland Medical Center, Baltimore
College of Dental Surgery, 650 West Baltimore Street, Suite 1401, Baltimore, MD 21201, USA

Few regions of the human body are as ana- This temporal sequence gives rise to the unique
tomically and functionally complex as the neck. phenomenon of intraglandular lymph nodes and
The proximity of the salivary glands to the neck extracapsular salivary tissue. Heterotopic salivary
compels clinicians to comprehensively understand gland tissue (HSGT) is defined as salivary tissue
the multitude of disease processes in the neck that not contained in either major or minor salivary
relate to salivary tissue. Because the embryogen- glands. Although rare, this phenomenon has been
esis of the major salivary glands is intrinsically reported in a multitude of head and neck sites and
related to the development of the neck, it is not even distantly in the digestive tract [1]. Most
surprising that salivary tissue can occasionally be heterotopic implantations occur along lines of
found within the neck distinct from the major embryologic fusion, commonly along the sterno-
salivary glands. The submandibular gland and cleidomastoid muscle and the sternoclavicular
parotid tail are confined to the anatomic bound- joint and may even be bilateral [2].
aries of the neck and serve as the source of Daniel and McGuirt [3], however, found
neoplastic and nonneoplastic processes. The HSGT to be more common in the periparotid
neck also serves as a primary lymphatic drainage region. A slight right-sided predilection seems to
basin for the major and minor salivary glands. occur. The most commonly supported hypothesis
This article reviews the clinical spectrum of benign is that HSGT develops from vestigial portions or
and malignant processes related to salivary gland ectodermal heteroplasia of the precervical sinus of
tissues in the neck. His. Other proposed mechanisms are the develop-
mental entrapment of salivary gland tissue in cer-
vical lymph nodes, or embryologic migration of
Heterotopic salivary gland tissue salivary tissue.
The developmental complexity of the head and An underlying genetic basis is suggested by the
neck, particularly the propinquity to major sali- association of HSGT with branchio-oto-renal
vary glands, makes them common sites for syndrome [4]. Lesions typically appear in infancy
aberrant tissue growth. Among the major salivary and manifest as cervical cysts, masses, or produc-
glands, the parenchyma of the parotid gland, tive sinuses that drain serous and mucoid secre-
which is derived from oral epithelium, typically tions. Some disagreement exists regarding their
develops first. Encapsulation of glandular tissues, association with branchial cleft cysts. Although
however, is a late embryologic event and occurs salivary gland tissue may be found in branchial
last in the parotid gland. cleft cysts, HSGT lacks lining epithelium typically
found in branchial cleft cysts.
Clinical features that distinguish HSGT from
* Corresponding author. developmental cysts include absence of infection,
E-mail address: [email protected] drainage of clear fluid associated with eating, and
(A.R. Salama) absence of communication into the pharynx [5].
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.03.002 oralmaxsurgery.theclinics.com
446 SALAMA & ORD

Absolute distinction is only possible with histo- along the deep lobe of the submandibular gland
logic examination. between the mylohyoid and hyoglossus muscles.
Histologically, HSGT largely resembles nor- Alternatively, a dehiscence in the mylohyoid
mal salivary gland tissue, but has a marked muscle allows for unimpeded flow from the
absence of excretory ducts. HSGT without its sublingual to the submandibular space [12]. One
own duct system is called aberrant glands, and study showed fenestrations in the mylohyoid in
accessory glands when a duct system is present. 36% to 45% of cadaver dissections [13].
This distinction has treatment implications, The diagnosis is clinical and fairly straightfor-
because surgery for HSGT is simple compared ward when a cystic swelling in the lateral portion
with the potential complexity of branchial clefts of the neck is accompanied by the prototypical
cysts. The differential diagnosis should include swelling of the floor of the mouth. Diagnosis can
branchial cyst anomalies, accessory salivary be more difficult in the absence of an intraoral
glands, and neoplasia. component. Fine needle aspiration cytology
Neoplastic transformation in HSGT is uncom- (FNAC) may be helpful. Analysis of the fluid
mon, but the pathologic diversity is the same as shows high levels of amylase and may also show
that of orthotopic salivary glands [3,6]. Nearly histiocytes, which are common in the wall of the
80% of neoplasms arising in HSGT are benign; pseudocyst [14].
the most common is Warthin’s tumor, although The differential diagnosis should include
various benign and malignant tumors have been epidermoid cyst, dermoid cyst, cystic branchial
reported [7]. HSGT can be simply excised; anomalies, cervical lymphangiomas, and malig-
however, with neoplasia, the surgical treatment nancy. Cervical metastases, particularly from
depends on the histologic nature of the underlying oropharyngeal cancer, may present as a cystic
tissue. neck mass, which in patients older than 40 years
should be considered malignant until proven
otherwise.
The plunging ranula
CT is valuable diagnostic tool. Cystic swellings
A ranula is simply a mucocele in the floor of in the submandibular or parapharyngeal space
the mouth, notably in the lingual gutter. The that abut or extend into the sublingual space
term’s origin is Latin, ranula (frog), because the suggest a plunging ranula [10]. The ‘‘tail sign’’ is
clinical presentation resembles the bulging under- a radiographic description of a radiolucent duct-
belly of a frog [8]. like extension between the cervical component
Ranula commonly arise from the sublingual and sublingual gland, and is usually located at
gland and represent a mucus extravasation after the posterior margin or through the mylohyoid
trauma or obstruction of the sublingual duct. A (Fig. 1C, D) [15].
limited number of patients actually report a his- The most commonly advocated surgical
tory of surgery or trauma in the affected area. approach is excision of the sublingual gland.
The swelling or extravasation typically ex- Removing the source of the extravasation has
pands the surrounding tissue, which may be lower recurrence rates than other methods. In-
confined within the oral cavity, occur simulta- cision, drainage, and marsupialization generally
neously in the oral cavity and neck, and occasion- do not have high rates of success. Recurrence
ally be present in the neck without an intraoral rates reported by Crysdale and colleagues [16]
component [9]. Plunging or diving ranula describes were 61% with simple marsupialization, 100%
the extension of the swelling to involve the sub- with incision and drainage, and 0% with sublin-
mandibular or parapharyngeal spaces [10]. gual gland excision.
Clinically, ranula manifest as painless, fluctu- Treating the neck component of the plunging
ant lateral neck swellings that do not change ranula does not require a cervical approach in
shape or size with swallowing or eating (Fig. 1A, most cases, and remains somewhat controversial.
B). Average size is 4 to 10 cm, but they can extend Drainage rather than excision of the neck
to the skull base or the retropharyngeal space or component has yielded comparably low rates of
toward the supraclavicular region [11]. Approxi- recurrence when combined with excision of the
mately 80% are associated with an intraoral sublingual gland [17]. Intraoral sublingual gland
component. removal should be performed, followed by drain-
Extension into the neck occurs through two age of the neck pseudocyst, which may be
mechanisms. Extravasated secretions may dissect approached intraorally using suction catheters,
 SALIVARY GLAND DISEASE 447

Fig. 1. (A, B) A 23-year-old African American man who has a recurrent ranula after experiencing a low-velocity gunshot
wound 2 years prior. Progression of the ranula manifested as a fluctuant submental swelling. (C, D) Axial and coronal
CT showing an in-continuity cystic lesion extending from the floor of the mouth into the neck with a dehiscence of the
mylohyoid muscle. He underwent a right sublingual gland excision and transoral decompression of the neck component.

or transcervically with needle decompression. Extraparotid Warthin’s tumor

Compression dressings or surgical suction drains
Warthin’s tumor (papillary cystadenoma lym-
are helpful in preventing fluid reaccumulation in
phomatosum) is a slow-growing tumor arising
the neck. Closure of the mylohyoid dehiscence is
almost exclusively in the parotid, typically in the
not necessary, but may help eliminate neck recur-
tail [14]. It comprises 6% to 10% of all benign
rence [18].
salivary glands tumors and is most common in
Rho and colleagues [19] showed complete
white men in their 50s and 60s. The gender distri-
shrinkage and resolution of plunging ranulae in
bution has changed over time with a near-equal
33% of patients after one treatment with OK-
distribution among men and women [22].
432, a sclerosant used to treat cervical lymphan-
A strong statistical relationship exists between
giomas. The described technique required
Warthin’s tumor and tobacco smoke. Klussmann
multiple reinjections yielding a final recurrence
and colleagues [23] report that 89% of 185 pa-
rate of 14%. Fukase and colleagues [20] showed
tients in their series were smokers and that
disappearance or marked reduction in 97% of
smoking was a statistically significant factor in
patients treated with OK-432 injections. Another
the development of bilateral lesions. It has a broad
nonsurgical approach is to use Botulinum toxin,
spectrum of clinical presentation, including bilat-
which has shown some efficacy in treating floor
eralism, multicentricity, and extraparenchymal
of mouth ranulae [21].
448 SALAMA & ORD

tumor implantation [24]. Several etiopathogenic large cystic spaces are present, the value of techne-
theories have been suggested. tium 99m scintigraphy is diminished. Diffusion-
One explanation is that salivary gland tissue weighted and dynamic contrast-enhanced MRI
becomes entrapped in the periparotid or intra- have been shown to be more predictive of War-
parotid lymph nodes and develops into tumors. thin’s than technetium 99m scintigraphy [26].
Theoretically, this phenomenon stems from the EPWT should be included in the differential
late developmental encapsulation of the parotid diagnosis of a cystic neck mass, particularly
gland, which allows intermingling of lymphoid when found in conjunction with a synchronous
and salivary tissue. Another possible mechanism parotid mass. A fine-needle aspiration biopsy
purports that Warthin’s tumors arise as a reactive (FNAB) may help evaluate an EPWT, because
process to degenerated oncocytes. its sensitivity approaches 90% [27]. A review of
Extraparotid Warthin’s tumor (EPWT) is 97 cases reported the accuracy to be 74% because
a rare event and is commonly seen in the of confounding variables in the specimen
periparotid lymph nodes. Among 14 cases of (squamous metaplasia/atypia, mucoid/mucinous
EPWT, Snyderman and colleagues [25] reported background, spindle-shaped cells, and cystic/
that nearly half were incidental pathologic find- inflammatory debris) [28].
ings in neck dissection specimens performed for Warthin’s tumors and EPWT are slow-grow-
malignancy, and one third presented as solitary ing and typically treated surgically. An extracap-
neck masses. EPWTs not associated with synchro- sular dissection is recommended for surgical
nous lesions of the parotid appear as solitary management of EPWT. With multifocal intra-
cystic masses along the jugular lymph node chain parotid lesions, a superficial parotidectomy is
(levels II and III) [24]. A parotid tail mass may be advocated. Alternatively, an extracapsular dissec-
difficult to distinguish from one located in level II tion may be performed for a single tumor focus
of the neck through clinical examination alone. within the parotid gland. An evaluation of the role
CT or MRI may be used to localize a mass and of extracapsular dissection for parotid tumors
define tumor architecture (cystic versus solid) showed nearly equivalent 5- and 10-year survival
(Fig. 2). Technetium 99m pertechnetate scintigra- rates, with decreased morbidity, compared to
phy is particular sensitive in detecting Warthin’s superficial parotidectomy [29].
tumor and even distinguishing between benign Because most parotid lymph nodes are found
and malignant salivary gland neoplasms. The in the tail, Warthin’s tumors often occur in this
epithelial cells in Warthin’s have the ability to region and may be mistaken for a neck mass [30].
concentrate large anions (pertechnetate). When The preferred treatment for these tumors is partial

Fig. 2. (A, B) A CT and PET/CT showing a well-defined mass of the parotid tail. The standard uptake value of the mass
was 22. Fine needle aspiration showed atypia without overt malignancy. The final pathology after superficial parotidec-
tomy was Warthin’s tumor. (Courtesy of Steven Engroff, DDS, MD, State College, PA).
 SALIVARY GLAND DISEASE 449

parotidectomy with dissection of the cervical and

mandibular branches of the facial nerve. Malig-
nant transformation within Warthin’s tumors is
reported to be extremely rare; management
should be based on the nature of the underlying
malignancy.

Pleomorphic adenoma
Pleomorphic adenoma (PA), which is a benign
mixed tumor, is the most common salivary gland
tumor and accounts for approximately 80% of
parotid tumors. These occur over a wide age
range, although are most common in the 30s
and 40s [14]. PA has been reported in various
anatomic locations within the maxillofacial
region, including the neck. In a review from the Fig. 3. 44-year-old African American woman who has
archives of the Armed Forces Institute of Pathol- a parotid tail mass. The cervical and marginal mandibu-
ogy (AFIP) that included 6880 cases of PA, 89 lar branches of the facial nerve have been dissected to
(1.3%) were localized to the cervical lymph nodes. perform a partial superficial parotidectomy.
PA may be found in the neck in several clinical
scenarios. PAs of the parotid tail may encroach on
level II of the neck. The origin of a mass in this be performed with comparable rates of local
location may be difficult to clinically distinguish as recurrence. A meta-analysis by Witt [32] did not
a parotid tail mass, submandibular gland mass, or show a difference in rates of recurrence between
cervical lymph node. Pedunculated masses arising superficial parotidectomy and extracapsular
from the inferior pole of the parotid have been dissection.
referred to as ‘‘earring lesions.’’ No anatomic Although PA displays extracapsular tumor
divisions exist between the parotid tail and the extension, the value of margins has been ques-
main body of the parotid gland. tioned in relation to local recurrence. Natvig and
Hamilton and colleagues [31] consider the tail Soberg [33] did not find a difference in recurrence
to be the inferior 2.0 cm of the gland. Nearly three based on histologic margin status.
quarters of parotid tail tumors are benign, with
a near-equal distribution between PA and War-
Metastasizing pleomorphic adenoma
thin’s tumors. Localizing lesions to the parotid
gland in these instances is important to avoid Although benign, PAs have been reported to
a surgical approach that would injure the mar- metastasize regionally and distantly. Metastasiz-
ginal mandibular branch of the facial nerve. ing pleomorphic adenoma (MPA) displays iden-
A superficial parotidectomy is nearly univer- tical histologic features to their primary site
sally accepted in the surgical management of counterparts. El-Naggar and colleagues [34] ques-
benign parotid tumors. When used in the man- tion the true benign nature of MPA and draw
agement of small (!4 cm) mobile PAs confined to attention to the atypia found in reviewed cases.
the superficial lobe, recurrence rates range from They believe that the histologic diversity of PA
1% to 4% [32]. A more conservative surgical increases chances for sampling errors and misin-
approach is a subtotal resection of the superficial terpretation and suggest that MPA may represent
lobe, which does not dissect all branches of the an unclassified malignant neoplasm.
facial nerve and removes less nontumorous tissue. An overwhelming association exists between
The primary difference between a partial incomplete excision of the primary tumor and
superficial parotid resection and extracapsular repeated surgical procedures in the development
dissection is the identification and dissection of of MPA [35]. Local recurrence is notably associ-
the facial nerve and the removal of a margin ated with enucleation and capsular rupture during
of uninvolved glandular tissue (Fig. 3). Several surgery. Most reported cases occur after surgery
authors have shown that partial parotidectomy for a primary tumor, typically in the parotid,
and extracapsular dissection of a benign PA can minor salivary, or submandibular glands. Experts
450 SALAMA & ORD

have suggested that surgical manipulation of The incidence of transformation is nearly 10% in
tumors allows tumor cells to enter the blood- untreated tumors present for 15 or more years.
stream and spread hematogenously [36]. Among cases reviewed at the AFIP, CExPA
Up to 90% of patients who have MPA have occurred an average of 13 years later than their
concomitant local recurrence [37]. Metastases benign counterpart (60 versus 47 years) [41].
typically present several years after the primary Malignant transformation is also seen in with
is diagnosed. Nouraei and colleagues [38] reported recurrent PAs, with rates ranging from 5% to 7%.
the mean time of metastasis to be 16 years in Clinical behavior largely depends on the
patients who had a history of local recurrence. underlying nature of the malignant component
The median age of patients who have MPA is of the tumor; high-grade tumors (adenocarcinoma
approximately 60 years, and no sex predilection and ductal carcinoma) are associated with
is apparent. higher rates of regional metastasis. The presence
Hematogenous metastasis to distant sites is of regional metastasis portends a poor clinical
more common than regional cervical metastasis. outcome; 5-year survival decreased from 67% to
The most common sites of metastases are bone, 16% in one study [42]. In a review of 73 patients
head and neck, lungs, and abdomen. Metastatic who had CExPA, Olsen and Lewis [43] reported
sites within the head and neck are nearly equally that 33% had clinically evidence of cervical metas-
distributed among the cervical lymph nodes and tasis at presentation and 16% had occult metasta-
nonlymphatic sites. Metastases at multiple sites sis after neck dissection.
and those that occur within 10 years of the primary In a comprehensive review of malignant
tumor are associated with a poor prognosis. parotid tumors by Lima and colleagues [44], all
Despite the benignity of the tumor, patients cases of CExPA were high-grade tumors. More-
who have MPA have 5-year disease-specific sur- over, grade was a factor in development of metas-
vival rates of 58%. Surgical treatment of metas- tases and survival.
tases generally offers the most favorable degree of Cervical lymphadenopathy in the setting of
disease-free survival [35,39]. The value of a thera- a biopsy-proven CExPA should mandate a neck
peutic neck dissection in the presence of cervical dissection. Neck dissection confers a survival
metastasis is unclear. benefit when performed therapeutically. The value
of an elective neck dissection is still debated,
although it seems prudent for staging purposes
Malignant mixed tumors
and clearance of occult metastasis. The type of neck
Carcinoma ex pleomorphic adenoma (CExPA) dissection for Nþ disease (selective versus compre-
is a rare, epithelial malignancy of salivary gland hensive/radical) has not been determined because
origin that accounts for 3.6% of all salivary of the limited number of cases in the literature [45].
neoplasms, 6.2% of all mixed tumors, and Carcinosarcomas are biphasic tumors, with the
11.6% of malignant salivary neoplasms [40]. malignant component comprised of epithelial and
Unlike carcinosarcomas of the salivary glands, mesenchymal tissues. They are rarer than CExPA,
only the epithelial component is malignant. This representing less than 0.1% of salivary gland
malignant component is most commonly adeno- tumors. The limited number of cases (8) in the
carcinoma not otherwise specified, and is recog- AFIP files confirms their rarity [41].
nized as an aggressive clinical entity with The major salivary glands are the most com-
propensity for metastasis. mon site for carcinosarcomas (80%), although
Whether CExPA represents a de novo malig- they have been reported in minor salivary glands.
nancy or stems from transformation of a benign Whether they arise de novo or from a preexisting
PA is unclear. Diagnostic criteria include the PA, or whether the epithelial and mesenchymal
presence of some histologically benign tissue or components simultaneously transform is currently
history of an excised benign mixed tumor. debated. Approximately 30% occur in the setting
Diagnosis can be difficult because of the variable of an existing PA [46]; some experts believe they
size of the malignant component, which may represent variants of carcinomas.
result in biopsy sampling errors. CExPAs are The prognosis of patients who have salivary
most common in the parotid, followed by the carcinosarcomas is extremely poor. A correlation
submandibular gland and minor salivary glands. exists between the most abundant malignant
Malignant transformation is related to the histologic component and clinical behavior.
duration of the preexisting benign tumor (Fig. 4). The carcinomatous component is typically
 SALIVARY GLAND DISEASE 451

Fig. 4. (A, B) 57-year-old man who has a 10-year history of progressive preauricular swelling. He presented with a com-
plete ipsilateral facial nerve palsy and pain. (C, D) CT scan showing extensive tumor infiltration with a central cystic
space; the borders of the tumor are ill-defined.

adenocarcinoma, undifferentiated carcinoma, or pathology had either sialadenitis or sialolithiasis.

squamous cell carcinoma, whereas the sarcoma- The remainder of the cases were neoplasms; 12%
tous tissue is predominantly chondrosarcoma and benign and 11% malignant [47].
osteosarcoma [46]. An estimated 10% to 15% of salivary gland
Regional metastasis is uncommon and most tumors occur in the submandibular gland. The
metastases are hematogenous rather than lym- distribution of benign and malignant neoplasms is
phatic. The lung is the most common site of nearly equal. Most benign tumors are PAs and
metastasis [41]. Regional metastasis mandates Warthin’s tumors. Adenoid cystic carcinoma
a radical neck dissection. (ACC) is the most common malignant neoplasm
of the submandibular gland, followed by mucoe-
pidermoid carcinoma (MEC) and malignant
Submandibular gland tumors
mixed tumors. Several rarer tumors have been
The submandibular triangle of the neck (level reported, including acinic cell carcinoma, salivary
I) contains the submandibular gland and several duct carcinoma, epimyoepithelial carcinoma, car-
first-echelon lymph nodes that drain the oral cinosarcoma, oncocytic carcinoma, and primary
cavity. Any swelling in this region may indicate squamous cell carcinoma.
a possible neoplasm. Most pathologic processes in In the submandibular gland, PA accounts for
the submandibular triangle, however, are nonneo- 40% to 60% of all neoplasia, and 75% of all
plastic. Approximately three quarters of patients benign tumors. They occur over a broad age
in a survey review of submandibular triangle range, from the third to fifth decade [47,48].
452 SALAMA & ORD

Overall, benign tumors have a slight female analyze superficial salivary gland lesions with the
predilection; the male:female ratio is 2:3 [47]. same precision as CT and MRI [54].
Malignant submandibular tumors are common Using ultrasound tumor margin delineation as
later in life (sixth decade) and the gender ratio a decisive tool in distinguishing benign from
favors men [49]. malignant tumors, Gritzmann [55] showed 90%
Tumors clinically manifest as painless discrete, sensitivity. Ultrasound is a technique-sensitive
hard, mobile masses below the inferior border of tool that is underutilized in the United States,
the mandible. Little correlation is seen between where CT and MRI are first-line investigations.
tumor size and symptom duration. Pain is a clin- Although MRI is widely considered superior in
ical feature in a minority of patients whose tumors tumor margin determination, Koyuncu and
are benign, and is experienced by up to 30% of colleagues [56] showed the sensitivity and specific-
those whose tumors are malignant [50]. ity of CT and MRI were nearly the same for
Benign masses of the submandibular gland tumor location, tumor margin, and tumor infiltra-
are difficult to clinically distinguish from those tion. Furthermore, they concluded that both
that are malignant, although these tend to be modalities provide equivalent diagnostic informa-
larger and may have faster clinical doubling times tion for treatment planning purposes. CT may
[51]. Misdiagnosis and delays are not uncommon, have some benefit in detecting early cortical
because many patients are preliminary diagnosed erosion of the mandible and identifying regional
with inflammatory or obstructive salivary metastatic disease.
disorders. In determining the exact anatomic location of
Inflammatory disease is clinically characterized submandibular masses (intraglandular versus ex-
by pain and intermittent swelling, frequently traglandular) Chikui and colleagues [57] reported
exacerbated with eating. Fixation to the overlying slightly higher accuracy rates with MRI than with
skin and limited mobility are indicative of malig- contrast-enhanced CT (Fig. 5). Although CT,
nancy, present in only 3% of submandibular MRI, and ultrasound enable diagnosis of a sub-
tumors [52]. Ipsilateral weakness of the marginal mandibular mass, neither seems to safely predict
mandibular branch of the facial or hypoglossal the underlying histology [58]. PET and PET/CT
nerve, or lingual nerve hypesthesia indicate peri- scans have not been shown to predictably differen-
neural invasion; they are uncommon late clinical tiate between benign and malignant parotid
signs almost exclusive to malignancy. tumors [59]. In the preoperative evaluation of
Differential diagnosis of a submandibular high-grade salivary gland tumors, however,
mass that has no features of malignancy should PET/CT has shown superiority to CT alone in
include lymphadenopathy, vascular malforma- both diagnosis and staging [60].
tion, developmental cysts, and plunging ranula. Preoperative cytologic diagnosis may be
Hematologic malignancies, including Hodgkin obtained through an FNAB. Open biopsy is
and non-Hodgkin’s lymphoma, may manifest as
submandibular swellings. Infectious and nonin-
fectious granulomatous disease, such as sarcoido-
sis and tuberculosis, may also present with
swelling and mass in the submandibular region
[53]. Bimanual palpation of the gland helps distin-
guish it from lymphadenopathy. The indolent
growth of benign and malignant tumors may
lead to erroneous diagnosis and treatment.
Many cases are referred to tertiary care centers
for management after gland excision [49].
Radiologic evaluation of a submandibular
mass is indicated after a thorough history and
examination. CT, ultrasound, and MRI can be
used to evaluate neck masses. Ultrasound is
advocated as an initial noninvasive modality Fig. 5. Axial CT showing a level IB metastatic lymph
that can assist in determining benign from malig- node from a high-grade mucoepidermoid carcinoma.
nant pathology. It can also be used to guide The tissue plane between the submandibular gland and
diagnostic procedures such as FNAB and can help the level IB lymph node is ill-defined.
 SALIVARY GLAND DISEASE 453

generally contraindicated because of potential for transposition of the marginal mandibular branch
tumor seeding and increased risk for local of the facial nerve (Fig. 6B).
recurrence. Although recurrence is less well documented in
The diagnostic value of FNAB in salivary the submandibular gland, multicentric/multinod-
gland tumors is controversial. FNAB was shown ular tumors without a pseudocapsule are present
to have a sensitivity and specificity of 73% and in 75% to 98% of recurrent parotid tumors
91%, respectively, for distinguishing a benign [65,66]. Recurrence is complicated by detection
tumor from a malignancy [61]. Cohen and col- of finite tumor implants. Excising the scar with
leagues [62] concluded that an FNAB positive a margin of the surrounding skin is recommended
for malignancy was predictive of the final histo- as part of the en bloc excision [64].
logic diagnosis, whereas the predictive value of An en bloc resection of level I of the neck is
a negative FNAB was low. Misinterpretation advocated when the diagnosis cannot be confirmed
between benign and malignant tumors has been or the tumor is known to be a low-grade malig-
documented, emphasizing that final treatment nancy. Some authors have suggested that the
decisions should not be based on cytologic data initial procedure for all submandibular masses
alone [47]. should be a regional dissection. This approach
Surgery is the primary treatment modality for ensures safe removal of benign tumors and simul-
most if not all salivary gland tumors. Tumors that taneous staging of first-echelon nodes in the case
are preoperatively confirmed as benign can be of malignancy [67]. With this approach, low-grade
removed with extracapsular gland dissection. malignancies confined to the gland do not require
Some authors advocate a more generous resection further treatment after a level I dissection.
for PA to include a cuff of normal tissue, because A completion selective neck dissection (I–III/
the capsule may be thinner in the submandibular IV) is recommended for high-grade tumors. Sim-
gland [63]. ple gland excision is often inadequate to treat
Enucleation is not advocated, because higher malignant tumors, which is reflected in lower
rates of local recurrence are seen. PAs are found survival rates [67]. Extraglandular extension re-
in proximity to the gland surface in 20% of cases quires resection of adjacent tissue to achieve surgi-
(Fig. 6A) [64]. Extirpation of superficial tumors cal margins. Tumor clearance frequently involves
should involve a margin of connective tissue or excision of the mylohyoid and digastric muscles
platysma, which may mandate isolation and and the lingual and hypoglossal nerves [49].

Fig. 6. (A) Contrast-enhanced axial CT showing a distinct soft tissue mass in the superficial portion of the left subman-
dibular gland. The mass approximates the platysma. Fine needle aspiration biopsy suggested pleomorphic adenoma. (B)
Surgical resection of the entire gland with a cuff of platysma muscle as the superficial surgical margin. The final pathol-
ogy was pleomorphic adenoma. (From Carlson E, Ord R. Textbook and color atlas of salivary gland pathology. Oxford:
Wiley-Blackwell, 2008; with permission.)
454 SALAMA & ORD

The presence of cervical metastasis and knowl- The presence of regional metastases decreases
edge of a high-grade tumor dictate a systematic mean survival by greater than 50% [68]. Ad-
approach based on tumor behavior. The likeli- vanced age and male gender have also been shown
hood of regional metastasis is partly determined to confer a poor prognosis. Although ACC is the
by tumor histology. Patient age, histologic grade, most common malignancy, patients who have
facial nerve involvement, extraglandular exten- intermediate- and high-grade MEC have a worse
sion, and tumor size have been shown to be prognosis. Rinaldo and colleagues [75] reported
clinical predictors of nodal metastasis [68]. 10-year relative survival rates of 73%, 62%,
Tumors with higher rates of cervical metastasis and 53% for submandibular ACC, CExPA, and
include high-grade MEC, high-grade and anaplas- MEC, respectively.
tic adenocarcinoma, and salivary duct carcinoma. Distant metastases occurs in 5% to 50% of
Spiro [51] reported more frequent metastases with patients who have ACC, most commonly the
submandibular MEC than from other sites. A lung, and has been shown to occur years after
strong relationship exists between tumor grade treatment of the primary, even in the setting of
and metastasis. In a clinicopathologic study of pa- local and regional control [76]. Regional metasta-
tients who had MEC, 33% developed regional sis from submandibular ACC is more common
metastases, of which 85% had high-grade tumors than in the other major salivary glands, presum-
[69]. ACC infrequently metastasizes to the cervical ably because of the proximity of the draining
lymph nodes, and distant metastases are far more lymph nodes [75].
common. Traditionally, salivary gland carcinomas were
The reported rate for clinical lymph node considered radioresistant. Recent reports suggest
metastasis from malignant submandibular tumors that radiation may provide some degree of locore-
is 8% to 20% [49,70]. The overall rate of cervical gional control. Adjuvant therapy is reserved for
metastasis from submandibular tumors, including patients who have advanced-stage disease (III/
those harvested during neck dissection, is as high IV), inadequate surgical margins, high tumor
as 41% [71]. The most frequently involved nodes grade, and high-risk histologic features (perineu-
for submandibular malignancies are level II, I, ral/perivascular invasion) [51].
III, IV, and V (in descending order) [72]. Armstrong and colleagues [70] showed
An elective neck dissection in an N0 neck is improved local control in patients who had ad-
commonly performed when the risk for metastasis vanced-stage disease who underwent postoperative
is greater than 20%, although its benefit has not radiotherapy compared with those who did not
been established. This procedure is recommended (69% versus 40%). Storey and colleagues [77] re-
for high-grade tumors, extracapsular extension, ported 2-, 5-, and 10-year actuarial locoregional
and larger tumors (O4 cm) [73]. Intraoperative control rates of 90%, 88%, and 88%, respectively,
frozen section analysis has been used to determine in a cohort involving postoperative radiotherapy.
whether to perform an elective neck dissection. Mendenhall and colleagues [78] showed im-
Postoperative radiation has been suggested as proved 10-year locoregional control rates between
an alternative to elective neck dissection [74]. The radiation alone and adjuvant radiotherapy in
treatment of the N0 neck in salivary gland cancer early- and advanced-stage disease. The overall
has not been evaluated in a prospective controlled benefit in locoregional control was also remark-
manner. A radical neck dissection is indicated able (81% versus 40%). As a sole treatment mo-
with clinical evidence of regional metastasis; how- dality in patients who had stage I to III disease,
ever, limited data indicate that a comprehensive radiation provided 10-year overall survival and
neck dissection confers any benefit over a selective local control rates of 65% and 75%, respectively.
neck dissection (I–III or I–IV). The response rates in these patient may be dose-
Prognosis largely depends on the histologic related, because doses greater than 70 Gy resulted
grade and stage. Camilleri and colleagues [49] in improved outcomes, particularly with ACC.
reported that clinical stage at presentation was Radiation fields, including the tract of invaded
the most powerful prognosticator; the 5-year named nerves to the skull base, confer a greater
survival rates were 85% and 20% in stage I and degree of local control. Radiation alone is re-
IV disease, respectively. Hocwald and colleagues served for patients who have advanced-staged
[73] stated that the only predictor of clinical out- disease or those who have severe medical comor-
come on multivariate analysis was histologic bidities. Most patients undergoing radiation alone
evidence of cervical node involvement. for curative intent have advanced-stage disease
 SALIVARY GLAND DISEASE 455

and poor prognosis. Only an estimated 20% of Luukkaa and colleagues [83] reported 5-year
patients who have stage IV disease will be cured survival rates of 78%, 25%, 21%, and 23%,
with radiation alone [78]. respectively, according to stage (I–IV). The pres-
Treatment failures are caused by recurrent or ence of nodal metastasis has been shown to affect
residual primary disease and regional and distant overall survival [84]. The overall 5-year survival in
metastasis. Hocwald and colleagues [73] showed parotid cancer with and without nodal metastasis
that distant failure was more common than locore- is 10% and 75%, respectively [85].
gional failure (28% versus 19%). Locoregional Kaplan and Johns [86] stratified the treatment
control provides some survival benefit. Recurrence of parotid malignancies. Early-stage low-grade
is related to the number of positive lymph nodes, malignancies (T1 and T2) are addressed with a pa-
male gender, named nerve involvement, and extra- rotidectomy. Similarly staged high-grade tumors
glandular extension of tumor [78]. The impact of are treated with parotidectomy and selective
local recurrence on survival depends on stage neck dissection followed by radiotherapy. Recur-
and tumor grade. The 5- and 10-year determinate rent tumors and those with clinical evidence of
survival rates among patients who have recurrent nodal metastasis are addressed with a nerve-sacri-
high-grade tumors are 40% and 29% [75]; the ficing parotidectomy and radial neck dissection
10-year overall survival is 55% to 60% [77,78]. followed by postoperative radiotherapy.
Locally recurrent disease is managed with surgery Significant controversy surrounds the benefit
if possible, followed by radiation. of radiotherapy and neck dissection in managing
Conventional postoperative radiotherapy of- parotid malignancies. Nodal metastasis in parotid
fers limited benefit in the presence of gross cancer is variable; 16% to 20% of patients have
residual disease, with locoregional control rates evidence of pathologically involved nodes at pre-
ranging from 20% to 30%. Fast neutron radio- sentation [82,84], and the incidence of occult
therapy (FNRT) has proven benefit in patients metastasis is approximately 20% [82,87].
who have gross residual disease. Douglas and Risk for nodal involvement is related to tumor
colleagues [79] achieved a 6-year actuarial survival stage and histologic grade. Frankenthaler and col-
rate of 59% using FNRT. leagues [88] reported that tumor grade, patient age,
A smaller study comparing FNRT and con- lymphatic invasion, and extraparotid tumor exten-
ventional radiotherapy for inoperable or recurrent sion were predictive of occult cervical metastasis.
salivary gland carcinoma clearly showed the The indications for elective neck dissection have be-
advantages of FRNT, with a locoregional control come better defined. Medina [74] recommends elec-
at 10-years of 56% versus 17% with statistical tive neck dissection in the following circumstances:
significance. A modest, statistically insignificant high-grade tumor, T3/T4 tumors, facial nerve
benefit in survival was seen: 25% versus 15% [80]. paralysis, age older than 54 years, extraglandular
Severe and life-threatening complications from extension, and perilymphatic invasion.
FNRT are nearly double those of conventional An observational study of the value of elective
radiotherapy. neck dissection for parotid malignancies showed
a 5-year disease-free survival rate of 86% among
patients who underwent this procedure compared
Parotid carcinoma and the neck
with 69% for those who did not. The same study
Parotid carcinomas are uncommon, constitut- showed a 5-year survival rate of 80% for patients
ing 14% to 25% of all parotid tumors [51,81]. who had an N0 neck, and no difference in survival
Zbaren and colleagues [82] stratified patients based on treatment [87]. Armstrong and colleagues
into high- and low-grade malignancies with [70] suggested that patients at high risk undergo
near-equal distribution. The most common high- neck dissection involving at least levels I, II, and III.
grade tumors were adenocarcinoma, CExPA, In reviewing the use of postoperative radio-
squamous cell carcinoma, MEC, and ACC. therapy in managing the N0 neck, Chen and
Prognosis and management of parotid malig- colleagues [89] showed that the use of elective
nancies are related to the staging and histologic neck irradiation did not confer a statistically
grading of the tumor. Significant prognostic significant survival benefit. However, the 5- and
factors also include extraglandular extension, 10-year estimated rate of disease-free survival
nodal status, perineural invasion, and facial nerve was 81% and 63%, respectively. No patients who
dysfunction [44,68,73]. Advanced age is also con- underwent elective neck dissection experienced
sidered a poor prognosticator. nodal relapse, compared with 24 of 120 who did
456 SALAMA & ORD

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 Oral Maxillofacial Surg Clin N Am 20 (2008) 459–475

Neck Dissection: Nomenclature,

Classification, and Technique
Jon D. Holmes, DMD, MD, FACSa,b
a
Oral and Facial Surgery of Alabama, 1500 19th Street South, Birmingham, AL 35205, USA
b
University of Alabama at Birmingham, Birmingham, AL, USA

The ability of a cancer to metastasize most treatment of choice for the primary remains sur-
commonly manifests itself by growth in regional gery in most cases.
lymph nodes. Lymph node status is the single The purpose of this article is to present the
most important prognostic factor in head and history and evolution of neck dissections, includ-
neck cancer because lymph node involvement ing an update on the current state of nomencla-
basically decreases overall survival by 50%. Un- ture and current neck dissection classification,
fortunately, approximately 40% of patients with describe the technique of the most common neck
oral cancer will harbor cervical lymph node dissection applicable to oral cavity cancers, and
metastasis at presentation [1]. Appropriate man- discuss some of the complications associated with
agement of the regional lymphatics, therefore, neck dissection. Finally, a brief review of sentinel
plays a central role in the treatment of the head lymph node biopsy will be presented. Indications
and neck cancer patients. Removal of the at- for the various neck dissections are discussed in
risk lymphatic basins serves two important other articles in this issue and in other excellent
purposes. First, it allows the removal and identi- reviews [2].
fication of occult metastasis in patients in whom
cervical metastasis are a risk, which is referred Lymph node levels: anatomy and nomenclature
to as an elective neck dissection. Secondly, it al-
lows the removal of disease in patients in whom The head and neck are drained by a rich network
metastasis are highly suspected based on imaging, of interconnected lymphatics. Knowledge of re-
clinical examination or fine needle aspiration, gional lymph flow and cervical lymph node anat-
which is referred to as a therapeutic neck dissec- omy is necessary for staging and guiding therapy,
tion. (Note that the term ‘‘prophylactic neck dis- whether surgery for occult metastasis or designing
section’’ should be avoided and replaced with the an appropriate radiation treatment plan.
more accurate term ‘‘elective neck dissection,’’ Rouviere [3] demonstrated that the lymph
when discussing removal of at-risk lymphatic drainage from mucosal sites within the head and
basins in the absence of clinical evidence of me- neck occurred in a predictable pattern leading to
tastasis.) Performing an appropriate neck dissec- one or more of the approximately 300 lymph no-
tion results in minimal morbidity for the des located above the clavicle. Lindberg [4] subse-
patient, provides invaluable data to accurately quently found that cancers of the head and neck
stage the patient, and guides the need for further metastasize in a consistent manner to first echelon
therapy. It is especially indicated in almost all lymph nodes. In areas disturbed by previous
cases of oral cavity cancer, for which the surgery, radiation or bulky tumors, lymph flow
can completely bypass first echelon nodes because
of increased hydrostatic pressure within the node
[5]. Building upon the work of Rouviere and Lind-
berg, Shah and others demonstrated the efficacy
E-mail address: [email protected] of modifications of the standard neck dissection
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.02.005 oralmaxsurgery.theclinics.com
460 HOLMES

and selective removal of nodes at highest risk (see inferiorly, the stylohyoid muscle posteriorly,
discussion below on selective neck dissection). Im- and the anterior belly of the digastric anteri-
portant to communication among researchers and orly. It includes the pre- and postvascular
clinicians, a division of cervical lymph nodes into nodes that are related to the facial artery.
levels defined by clinical and radiographic land-
Lymph nodes contained within level I are at
marks was proposed by clinicians at Memorial
highest risk in oral cancers involving the skin of
Sloan-Kettering Cancer Center. Subsequent mod-
the chin, lower lip, tip of the tongue, and floor
ifications suggested by the Head and Neck Service
of the mouth [3,4].
at M.D. Anderson resulted in the generally ac-
cepted levels endorsed by the American Head Level II
and Neck Society and the American Academy of
Otolaryngology and defined below [6–8]. The Level II contains the upper jugular lymph
most important aspect of the current subdivisions nodes that surround the upper third of the
is the correlation between radiographic landmarks internal jugular vein and the spinal accessory
used by radiologists and radiation oncologists; nerve. It includes the jugulodigastric node (also
and surgical landmarks to describe accurately known as the principle node of Kuttner) which is
which lymph node basins are excised (Fig. 1). the most common node containing metastases in
oral cancer. It is also frequently subdivided based
Level I on the course of the spinal accessory nerve.
Level I includes the submandibular and sub- Level II a: Bounded superiorly by the skull
mental nodes. It extends from the inferior border base, inferiorly by the hyoid bone radio-
of the mandible superiorly to the hyoid inferiorly, graphically and the carotid bifurcation
and is bounded by the digastric muscle. It may be surgically, anteriorly by the stylohyoid mus-
subdivided: cle and posteriorly by a vertical plane de-
fined by the spinal accessory nerve.
Level I a: The submental group. Lies between Level II b: Bounded superiorly by the skull
the anterior bellies of the digastric muscles. base, inferiorly by the hyoid bone radio-
Bounded superiorly by the symphysis and graphically and the carotid bifurcation
inferiorly by the hyoid; surgically, anteriorly by a vertical plane
Level I b: The submandibular group. Bounded defined by the spinal accessory nerve and
by the body of the mandible superiorly, the posteriorly by the lateral aspect of the ster-
posterior belly of the digastric muscle nocleidomastoid muscle.
Nodal tissue within level II receives efferent
lymphatics the parotid, submandibular, submen-
tal, and retropharyngeal nodal groups. It also is at
risk for metastases from cancers arising in many
oral and extra-oral sites, including, the nasal
cavity, pharynx, middle ear, tongue, hard and
soft palate, and tonsils [3,4].
Level III
Level III encompasses node-bearing tissue
surrounding the middle third of the internal
jugular vein. It is bounded superiorly by the
inferior border of level II (hyoid radiographically
and carotid bifurcation surgically), inferiorly by
the omohyoid muscle surgically and the cricoid
cartilage radiographically, anteriorly by the ster-
nohyoid muscle and posteriorly by the lateral
border of the sternocleidomastoid muscle. Level
III contains the dominant omohyoid node and
receives lymphatic drainage from level II and level
Fig. 1. Current lymph node levels. V. In addition, it can receive efferent lymphatics
 NECK DISSECTION 461

from the retropharyngeal, pretracheal, tongue Evolution of neck dissection in the management
base, and tonsils. of head and neck cancer
Level IV While both Chelius and Kocher seperately
recommended removal of regional lymph nodes
Level IV contains the nodal tissue surrounding
in the treatment of head and neck cancer as early
the inferior third of the internal jugular vein. It
as the mid-nineteenth century, it is George Crile,
extends from the inferior border of level III to the
Sr., who receives credit for his systematic de-
clavicle. Anteriorly, it is bounded by the lateral
scription of management of cervical lymphatics in
border of the sternohyoid muscle; and posteriorly,
cancers of the head and neck [9]. His oft-quoted
by the lateral border of the sternocleidomastoid
1906 article, published in JAMA, recapitulated
muscle. It contains a variable number of nodes
and expanded upon his less well-known 1905 arti-
that receive efferent flow primarily from levels III
cle published in The Transactions of the Southern
and IV. The retropharyngeal, pretracheal, hypo-
Surgical and Gynecological Association. Both arti-
pharyngeal, laryngeal and thyroid lymphatics also
cles presented his justification of and technique
make a contribution. Only rarely is level IV
for addressing the cervical lymphatics in a system-
involved with metastatic cancer from the oral
atic fashion in cancers of the head and neck; he
cavity without involvement of one of the higher
championed their removal in surgical treatment
levels.
of head and neck cancer. Crile [10–12] was
Level V strongly influenced by Halsted’s work in breast
cancer, and he drew parallels to the management
Level V makes up the posterior triangle. of head and neck cancers recommending the en
Similar to levels I and II, level V may be bloc removal of non-lymphatic structures along
subdivided. with the regional lymphatics similar to the method
Level V a: Begins at the apex formed by the of mastectomy of the day (ie, the sternocleidomas-
intersection of the sternocleidomastoid and toid muscle was removed similar to the pectoralis
the trapezius. The inferior border is estab- muscle and the internal jugular vein was sacrificed
lished by a horizontal line defined by the similar to the axillary vein). It is interesting to
lower edge of the cricoid cartilage. Medially, note that although Crile suggested in these early
the posterior edge of the sternocleidomas- publications that the spinal accessory nerve could
toid forms the anterior edge and the anterior be preserved if not directly involved with cancer,
border of the trapezius forms the posterior later surgeons purporting to follow his example
(lateral) border. recommended its removal in all cases. Martin
Level V b: Begins at a line defined by the infe- and colleagues [13] stated that any attempt to pre-
rior edge of the cricoid cartilage and extends serve the spinal accessory nerve should be ‘‘con-
to the clavicle. It shares the same medial and demned unequivocally.’’ Other structures, such
lateral borders as level Va. as the submandibular gland were also preserved
in some cases presented by Crile. Careful study
Level V receives efferent flow from the occip- of Crile’s original article text and illustrations re-
ital and post auricular nodes. Its importance in veals that only a portion of the patients, primarily
primary oral cavity cancers is limited except when those with evidence of cervical metastasis, under-
lymph flow is redirected by metastases in the went what would come to be known as his great-
higher levels. Oropharyngeal cancers, however, est contribution to head and neck surgery: the
such as tongue base and tonsillar primaries can radical neck dissection.
spread to level V nodes. Crile’s contribution was further expanded
Level VI during the Hayes/Martin era at Memorial Hospi-
tal in New York City. Other authors had pub-
The anterior compartment lymph node group lished on the utility of neck dissection in the
is of minimal importance in primaries originating management of head and neck cancer, including
in the oral cavity. It is made up of the lymph node descriptions of composite resections combining
bearing tissue occupying the visceral space. It neck dissection with removal of the primary and
begins at the hyoid bone, extends inferior to the mandible in bloc; however, it was Martin’s
suprasternal notch, and laterally is bound by the comprehensive treatise published in 1951 that
common carotid arteries. summarized his indications, technique, and
462 HOLMES

outcomes with the radical neck dissection; and cervical structures, including the spinal accessory
cemented his place in head and neck surgical nerve, internal jugular vein, sternocleidomastoid
history [13,14]. In his treatise, Martin promoted muscle, and in cases without direct involvement,
a radical neck dissection with removal of the lym- the submandibular gland, thereby sparing mor-
phatic structures from the inferior border of the bidity without sacrificing loco-regional control.
mandible superiorly to the clavicle inferiorly, The dissection was based on the concept that the
and the midline of the neck anteriorly to the ante- fibro-adipose lymph node-bearing tissue could be
rior edge of the trapezius muscle posteriorly. In removed en bloc by careful dissection of the fascia
addition, the en bloc removal included the re- from non-lymphatic structures. It should be noted
moval of three defining, non-lymphatic structures: that the authors recommended preservation of
the sternocleidomastoid muscle; the internal jugu- these structures only when they were not in con-
lar vein; and the spinal accessory nerve. Martin tact with suspected involved lymph nodes
acknowledged some surgeons’ preference for [15–17]. Although properly considered one of
‘‘a more limited dissection’’ in some circum- the earliest proponents of functional neck dissec-
stances; he recommended these more limited oper- tion, Suarez’s [18] previous publications had not
ations be termed ‘‘partial neck dissection.’’ In been in English and therefore, they had escaped
general, however, he condemned these more the notice of many European and American sur-
limited removals, making special reference to the geons. Subsequent to the publications by Bocca,
‘‘supraomohyoid neck dissection.’’ Understanding Calearo, and Gavilian, there was an explosion in
the morbidity associated with the radical neck dis- interest in more limited neck dissections; publica-
section, Martin’s indications were precise and tions describing a variety of modifications to the
included: the presence of known cervical metasta- accepted technique of radical neck dissection be-
sis (ie, therapeutic neck dissection); plan for gan to appear. These numerous publications often
control of the primary; no evidence of distant used a variety of terms often describing the same
metastasis; reasonable chance of removal of the technique; the variation in terms led to an enor-
cervical metastasis; and finally, that the neck mous amount of confusion among clinicians and
dissection should offer a more certain chance of consternation among trainees who tried to deci-
cure than radiation therapy [13]. Martin’s pro- pher a variety of overlapping terms and the indi-
found influence on a generation of surgeons cations for each type of named dissection. The
trained in head and neck surgery led to the radical resultant, often misused, terminology of neck
neck dissection becoming the operation for man- dissection was standardized by the American
agement of the cervical lymph nodes in head Academy of Otolaryngology’s Committee for
and neck cancer. Despite an evolution and Head and Neck Surgery and Oncology in 1991
narrowing of the indications for the radical neck [19].
dissection, it remains, in the minds of most head The goals of the committee were: to develop
and neck surgeons, the standard operation upon a standardized system of neck dissection termi-
which all variations are compared both in tech- nology that preserved traditional terms (such as
nique and outcomes (see classifications below). radial neck dissection and modified neck dissec-
As the field of head and neck surgery evolved, tion), while avoiding eponyms and acronyms; to
surgeons began to question the dogma promul- define the lymph node levels and non-lymphatic
gated from Memorial Hospital. This questioning structures removed in each type of neck dissec-
was especially prevalent among surgeons from dif- tion; and, to standardize the clinical and surgical
ferent specialties and abroad. In many ways, frag- boundaries of the lymph node levels (see discus-
mentation among head and neck surgeons of sion above). An update, published in 2002,
different backgrounds and specialties led to differ- attempted to answer some of the criticisms of
ent opinions and ideas regarding the indications the original system and take into account ad-
and technique of neck dissection. Surgeons began vances in clinical practice. These revisions, pro-
to question the wisdom of limiting neck dissection posed in 2001, sought to improve communication
to those with proven cervical metastasis, and they with radiologists and other clinicians [8]. These
explored ways of limiting morbidity if one were to proposed changes were primarily in regard to
apply elective neck dissection more liberally. In the selective neck dissections and specific names,
1967, Bocca and Gavilian, following the lead of such as supraomohyoid neck dissection; such
Suarez, published the technique of ‘‘functional names were eliminated in favor of the phrase
neck dissection’’ which preserved non-lymphatic ‘‘selective neck dissection’’ followed in parentheses
 NECK DISSECTION 463

by the levels removed (see discussion of classifica- structures: the internal jugular vein, the ster-
tions below) (Table 1). Although not universally nocleidomastoid muscle, and the spinal
accepted initially (ie, other classifications exist), accessory nerve (Fig. 2).
the standard suggested by the committee has led Modified radical neck dissection (MRND):
to improved communication among clinicians Refers to removal of the same lymph node
across surgical and non-surgical specialties who levels (I–V) as the radical neck dissection,
treat head and neck patients [20]. but with preservation of the spinal accessory
nerve, the internal jugular vein, or the ster-
nocleidomastoid muscle. The structures pre-
Classification of neck dissections served should be named. Some authors
Neck dissections can be broadly classified as propose subdividing the modified neck dis-
comprehensive or selective. Comprehensive neck section into three types: type I preserves
dissections include all of the lymph node levels the spinal accessory nerve; type II preserves
removed in a standard radical neck dissection the spinal accessory nerve and the sternoclei-
(levels I–V), and include radical neck dissection and domastoid muscle; and type III preserves the
modified radical neck dissection. A dissection that spinal accessory nerve, the sternocleidomas-
leaves in place one or more of these levels is toid muscle, and the internal jugular vein;
considered a selective neck dissection. Likewise, but the standard is to name the preserved
any dissection that removes additional lymph structure following the MRND abbrevia-
node levels or non-lymphatic structure is termed tion, instead of using subtypes.
an extended neck dissection. Specific definitions Selective neck dissection (SND)
are outlined below: Refers to the preservation of one or more
lymph node groups normally removed in
Radical neck dissection (RND): a radical neck dissection. In the 1991 classi-
Refers to the removal of all ipsilateral cervi- fication scheme, there were several ‘‘named’’
cal lymph node groups extending from the selective neck dissections. For example, the
inferior border of the mandible to the supraomohyoid neck dissection removed
clavicle, from the lateral border of the ster- the lymph nodes from levels I–III. The sub-
nohyoid muscle, hyoid bone, and contralat- sequent proposed modification in 2001
eral anterior belly of the digastric muscle sought to eliminate these named dissections.
medially, to the anterior border of the trape- The committee proposed that selective neck
zius. Included are levels I– V. This entails the dissections be named for the cancer that
removal of three important, non-lymphatic

Table 1
Comparison of 1991 and 2002 neck dissection
classification
1991 classification 2001 classification
Radical neck dissection Radical neck dissection
Modified radical Modified radical neck
neck dissection dissection
Selective neck dissection Selective neck dissection:
a. Supraomohyoid avoid named neck
b. Lateral dissection. Instead each
c. Posterolateral variation should be
d. Anterior denoted SND followed
by parenthesis
containing designations
for the nodal levels or
sublevels removed
Extended neck dissection Extended neck dissection
From Robbins KT, Clayman G, et al. Neck dissec- Fig. 2. Intraoperative photo following radical neck
tion classification update. Arch Otolaryngol Head dissection with sacrifice of internal jugular vein, spinal
Neck Surg 2002;128:751–8; with permission. accessory nerve, and sternocleidomastoid muscle.
464 HOLMES

the surgeon was treating and to name the

node groups removed. For example, a selec-
tive neck dissection for most oral cavity
cancers would encompass those node groups
most at risk (levels I–III) and be referred to
as a SND (I–III) (Fig. 3).
Extended neck dissection
The term extended neck dissection refers to
the removal of one or more additional lymph
node groups, non-lymphatic structures or
both, not encompassed by a radical neck dis-
section, for example, mediastinal nodes or
non-lymphatic structures, such as the carotid
artery and hypoglossal nerve (Fig. 4).
It is important to remember that classification
schemes are continually changing; as science
evolves, the indications for different dissections
will certainly change. For example, in the case of Fig. 4. Extended neck dissection demonstrating sacrifice
an oral cavity primary without evidence of lymph of carotid artery and reconstruction using a vein graft.
node metastases, a selective neck dissection, re-
moving lymph nodes from levels I–III is the treated and avoidance of named dissections,
generally accepted procedure of choice. Shah which may not reflect differences in technique
and others demonstrated that a supraomohyoid amongst different surgeons.
neck dissection eradicates occult metastatic dis- Brief mention should also be made regarding
ease in 95% of patients [21]. Some surgeons, how- another controversy in the evolution of neck
ever, advocate including level IV (extended dissection: the concept of in-continuity versus
supraomohyoid neck dissection) to decrease the discontinuity neck dissections. In the past, it was
risk, however small, of missed occult metastases. considered mandatory to remove the primary
The strength of the current classification system tumor in direct continuity with the neck dissec-
lies in its specificity regarding lymph node basins tion, in one specimen [13,14]. Work by Spiro and
Strong [22] found no adverse impact on survival
when neck dissection was performed in a discon-
tinuous manner. Bias might have occurred, how-
ever, as smaller lesions were in the discontinuity
group. A study by Leeman and colleagues [23]
found worse outcome in stage II cancer of the
tongue with discontinuity neck dissection with
local recurrence rates (19.1% versus 5.3%) and
5-year survival (63% versus 80%). At this time
most surgeons prefer an in-continuity approach
if technically feasible, without the resection of
obviously uninvolved structures such as the
mandible.

Technique
Many excellent surgical atlases are available
that offer complete descriptions of the technique
of the various neck dissections [24]. The technique
Fig. 3. Intraoperative photo demonstrating selective of modified neck dissection (MRND) is described,
neck dissection of levels I–III, previously known as here, and it is easily adapted to performance of
supraomohyoid neck dissection, but described as SND selective neck dissection (SND) and radical neck
(I–III) in current nomenclature. dissection (RND), with exceptions noted.
 NECK DISSECTION 465

Positioning the patient with a shoulder roll or

on a Mayfield headholder with slight extension
makes dissection easier. A myriad of incisions
have been described for access to various neck
dissections, including very limited incisions, which
are combined with good retraction for selective
neck dissections [25]. The choice of incision design
in MRND is guided by the need for access to the
cervical lymphatic basins contained in levels I–V.
In addition, the need for access to the oral cavity
in combined approaches, ie, lip splitting, should
be considered. It should be noted here that there
are two approaches classically taught for the
MRND: the original anterior-posterior approach
of Suerez, which was popularized by Bocca, and
the Suen approach, which is an anterior approach
popular in the United States. The later requires
good retraction of the SCM laterally to access
the posterior neck, and yet access may still be lim- Fig. 5. Standard incision for modified neck dissection.
ited [26–28]. For an anterior approach to the Posterior extension (dotted) can be performed to allow
MRND, an oblique incision extending from the improved access to posterior triangle (level V).
mastoid inferiorly and crossing the sternocleido-
mastoid muscle then extending across the neck is an anterior approach in most cases: the nerve
in a natural neck crease at approximately the level will be identified early in the dissection and
of the cricoid cartilage allows adequate access in followed posterior and inferior through the poste-
most cases (the so-called ‘‘hockey stick’’ incision). rior triangle.
For access to level I, the incision must be carried At this point in the procedure, it is helpful to
across the midline enough to allow retraction think of the neck dissection as an exercise in
superiorly. Alternatively, an apron type flap with dissecting and preserving four nerves: the
the horizontal component placed higher combined marginal mandibularis; the spinal accessory;
with a releasing incision trailing posterior-inferior the hypoglossal; and the lingual nerve, all of
(Schobinger) [29] can be used. If needed, the au- which serve as landmarks along the pathway to
thor of this article prefers a modification with
the trifurcation placed lower in the neck (Lahey)
[30], which is more important in cases of RND
where the sternocleidomastoid muscle is sacrificed
and the carotid at increased risk (Fig. 5).
Elevation of superior and inferior flaps in
a subplatysmal plane above the superficial layer
of the deep cervical fascia is accomplished to the
level of the inferior border of the mandible and
clavicle respectively (Fig. 6). The platysma termi-
nates posteriorly, and in this area, the dissection
will be in a subcutaneous plane. The external jug-
ular vein serves as an excellent guide to keep this
dissection at the appropriate level because the dis-
section should be superficial to it. A good tip is to
keep the flaps under good tension perpendicular
to the neck to aid in their elevation. The spinal
accessory nerve courses in a subcutaneous plane
as it exits from the posterior aspect of the SCM,
and care must be taken to identify and protect
this nerve as flaps are developed here in the ante- Fig. 6. Elevation of subplatysmal flaps exposes the
rior-posterior approach. This author’s preference superficial layer of the deep cervical fascia.
466 HOLMES

completion of the neck dissection. First, the reporting less morbidity if it is preserved. This
marginal mandibular nerve is protected. Often it author’s preference in most cases is to incise the
can be identified along its course through the fascia approximately 1 cm posterior to the anterior
superficial layer of the deep cervical fascia follow- edge, and then elevate it around the edge and
ing elevation of the subplatysmal flaps. Otherwise, onto the medial surface. Alternatively, the entire
it can be preserved by dividing the superficial layer fascia can be elevated from the SCM. Dissection
of the deep cervical fascia two centimeters below then proceeds along a broad front along the
the inferior border of the mandible. The facial medial surface of the SCM. Attempting to dissect
vein can be divided and retracted superiorly to directly to the spinal accessory nerve at this time
protect the nerve as the fascia over the sub- should be avoided as there is a tendency to be
mandibular gland is dissected. The vein can be working within a hole, and injury to small vessels
sutured superiorly to retract and protect the nerve associated with the nerve can make visibility diffi-
during the remaining dissection (Figs. 7 and 8). cult. Instead, dissecting along a broad front allows
This author’s preference is to dissect the nodes improved visibility. The dissection is carried down
associated with the facial vessels (ie, prevascular to the level of the posterior belly of the digastric,
nodes) in most cases at this point. It is often diffi- which can be retracted superiorly with a right
cult to keep these nodes in continuity with the angle retractor. An assistant using right angle
remainder of the neck dissection while protecting retractors at right angles to each other can effec-
the marginal nerve, and if separated, the nerves tively retract the SCM laterally and the posterior
should be labeled and submitted separately so belly of the digastric superiorly, offering an excel-
that they are not lost. Dissection then frees the lent view of the operative field. The spinal acces-
attachments along the length of the inferior bor- sory nerve will become visible with careful
der of the mandible. Subsequently, attention is dissection, spreading in the direction of the nerve’s
directed to identifying the spinal accessory nerve, course anterior-superior to posterior-inferior.
the defining point of the modified neck dissection. Once identified, a decision must be made regard-
An incision is made through fascia along the ing level IIb (submuscular recess), which in
anterior edge of the SCM. The external jugular many cases can be left (see discussion of nerve
vein will be ligated at this point. Authors disagree injuries in complications below). If it is to be re-
on the need for removal of the fascia overlying the moved, the spinal accessory must be mobilized
lateral aspect of the SCM, with some authors by splitting the fibroadipose node-bearing tissue
above it and dissecting it free. The nerve should
be handled carefully since manipulation alone
can lead to long-term dysfunction. Using a vein
retractor to protect the nerve, cautery and blunt
dissection are used to dissect the node-bearing
tissue from level IIB. The deep cervical fascia
overlying the splenius capitus, levator scapulae,
and scalene muscles should be preserved. Also,
care must be taken not to injure the internal jug-
ular vein at this level as control of the subsequent
bleeding can be troublesome. The fibroadipose
node-bearing tissue is then passed under the spinal
accessory nerve and kept in continuity with the
remainder of the neck dissection. This maneuver,
which defines the modified neck dissection, was
the subject of the most vocal criticisms of the tech-
nique, as it appeared to break with the en bloc
concept of removal that was championed for so
many years.
Dissection then proceeds posteriorly while
Fig. 7. Division of facial vein with suture left long for keeping the spinal accessory nerve in view. The
retraction of the marginal branch of the facial nerve. posterior limit of the dissection is usually the
Note the fascia has been elevated off the submandibular cervical plexus rootlets coursing from the poste-
gland. rior edge of the SCM. Although they can be
 NECK DISSECTION 467

Fig. 8. (A) Incising node bearing tissue over spinal accessory nerve. (From Lore JM, Medina J. An atlas of head and
neck surgery. 4th edition. Philadelphia: Saunders; 2004. p. 809; with permission.) (B) passing node bearing tissue
from level IIb under nerve. (From Lore JM, Medina J. An atlas of head and neck surgery. 4th edition. Philadelphia:
Saunders; 2004. p. 809; with permission.) (C) Intraoperative photo demonstrating passing tissue under nerve following
dissection on submuscular recess (level IIb). Note right angle retraction of posterior belly of digastric and sternocleido-
mastoid muscle).

sacrificed without undue sequelae, they are pre- be used in the presence of bulky, clinical neck dis-
served unless there is known nodal disease in this ease. Again, dissection of the posterior triangle
area. The posterior limit of the dissection superi- should be kept superficial to the deep cervical fas-
orly usually corresponds to the posterior edge of cia. Often, blunt dissection with a finger covered
the SCM. Inferiorly, the spinal accessory nerve is with gauze can aid sweeping the node-bearing tis-
identified as it exits the posterior edge of the SCM. sue in this area.
Using an anterior approach, retraction for dissec- Subsequently, the nodal contents are brought
tion of the posterior triangle can be difficult. If an underneath the SCM while retracting it superiorly
anterior-posterior approach is used with a releas- (Fig. 10A, B) Retracting the contents anteriorly,
ing incision (Schobinger or Lahey) [30], the spinal the contents are then sharply dissected across
accessory nerve can be identified exiting the poste- the internal jugular vein. Blade dissection com-
rior edge of the SCM, and then the skin flaps can bined with good traction on the specimen and
be elevated keeping the nerve in view (Fig. 9). This counter-traction on the vein is helpful here.
approach allows a more comprehensive removal (Fig. 11A, B) Alternatively, blunt dissection with
of level V in most cases and it is more likely to a fine hemostat combined with cautery can be
468 HOLMES

the submental area following the anterior belly of

the omohyoid to the hyoid then clearing the nodal
tissue along the anterior belly of the digastric.
Level I is cleared by dissecting to the level of the
mylohyoid. This is best performed with cautery to
control troublesome bleeding from the arterial
branch to the mylohyoid muscle. Once the poste-
rior edge of the mylohyoid is identified, a right
angle retractor is placed and the muscle is
distracted anteriorly exposing the lingual nerve
as the contents of the submandibular triangle,
whose attachments were previously freed from the
inferior border of the mandible are distracted
inferiorly (Fig. 12). The submandibular duct is
Fig. 9. Nodal contents of posterior triangle brought ligated and transected. The attachments of the
underneath the spinal accessory nerve in the posterior lingual nerve to the submandibular gland are
triangle. (From Lore JM, Medina J. An atlas of head then divided. Finally, the facial artery is encoun-
and neck surgery. 4th edition. Philadelphia: Saunders; tered again and divided which allows the specimen
2004. p. 810; with permission.) to be delivered (Fig. 13A, B).
Variations to the technique described above
are numerous. In addition to surgeon preferences,
used. Tributaries to the internal jugular vein are the techniques are adapted to the oncologic goals
ligated and divided. Rarely, the internal jugular of the particular case. For example, the selective
vein will be entered accidentally during this part removal of levels I–III, which in the past was
of the operation. If so, the opening should be im- known as the supraomohyoid neck dissection, is
mediately occluded to prevent air entrainment the most commonly performed neck dissection for
into the vein. A helpful maneuver is to place one oral cavity cancer. Some authors [31,32], however,
finger above the rent and one below, and then encourage the removal of level IV in certain cases,
retract one superiorly and the other inferiorly such as tongue cancer, given the 9% rate of skip
expressing the blood from that portion of the metastasis to this level and the limited morbidity
vein and exposing the rent for suture repair. associated with it removal. The technique which
As the node bearing tissue is dissected from the is described above is easily adapted for these
inferior portion of the vein, the omohyoid muscle variations, and the principles remain the same. It
will typically be divided. Dissection continues is important in the current classification scheme
across the carotid artery. The hypoglossal nerve to note which levels were addressed in the dissec-
is identified typically 1–2 cm above the carotid tion, in addition to the type of dissection, so that
bifurcation. Once the hypoglossal nerve has been proper communication with other clinicians is
identified, dissection can proceed anteriorly up to possible.

Fig. 10. (A, B) Demonstrating dissection of posterior triangle passing underneath the SCM in the anterior-posterior
approach. (From Lore JM, Medina J. An atlas of head and neck surgery. 4th edition. Philadelphia: Saunders; 2004.
p. 810; with permission.)
 NECK DISSECTION 469

Fig. 11. (A, B) Blade dissection along the internal jugular vein. (From Lore JM, Medina J. An atlas of head and neck
surgery. 4th edition. Philadelphia: Saunders; 2004. p. 813; with permission.)

Sentinel node biopsy presented by Shellenberger [35]. Briefly, the tech-

nique involves injecting the area surrounding the
As surgeons pursue less invasive surgical mo-
primary site with a radioactive-labeled colloid:
dalities, dissection of the N0 neck (staging neck
99mTc-sulfur colloid. (Various molecular weights
dissection or elective neck dissection) is becoming
can be chosen depending on the transit time de-
increasingly limited through the use of selective
sired.) A radiograph can be taken to localize the
neck dissections; their goal, as noted above, is to
sentinel node, which is the first node that receives
remove those nodal basins at highest risk for
lymph flow from the area of the tumor. The pa-
harboring occult metastases based on the site
tient is then taken to the operating room where
of the primary. Perhaps the ultimate evolution
the surgeon may inject isosulfan blue, a dye,
of selective neck dissection is the sentinel node
around the tumor. This will also drain to the first
biopsy (SNB). The sentinel node technique, first
echelon node and stain it blue, assisting the
popularized for melanoma, has been investigated
surgeon in its identification during surgery. Also,
for use in head and neck cancer [33,34]. In theory,
the surgeon will use a gamma detection probe
it allows the identification and removal of the
counter probe to identify the node with the high-
lymph node (‘‘sentinel node’’) that would first
est concentration of radioactive colloid. The node
receive metastases from a given site. An excellent
is then removed and if it is histologically positive,
review of the indications and technique was
further treatment such as completion of neck
dissection and/or radiation may be indicated. In
melanoma, sentinel node biopsy has a reported
sensitivity of 82%–100%, and very few false
negatives [36,37]. It should be noted that the
lymph nodes removed via the sentinel node
technique are subjected to much closer pathologic
scrutiny, including analysis of more sections
through the node and immunohistochemical
analysis in some cases.
The technique of sentinel node biopsy has been
investigated in the head and neck with varying
results. Problems with applying the sentinel node
technique to the oral cavity relate to the rich
lymphatic drainage pattern with possible bilateral
Fig. 12. Retraction of the posterior edge of the mylo- drainage, and the complex anatomy in the cervical
hyoid muscle anteriorly and of the submandibular trian- region, which can lead to difficulty in dissecting
gle contents inferiorly brings the lingual nerve into view. a single node from the neck. In addition, close
470 HOLMES

did not contain cancer, but another cervical

node did. They also found that tumor in the
node can lead to obstruction and redirection of
lymphatic flow. Pitman and colleagues [39] further
demonstrated the utility of the SNB technique for
the N0 neck. Hyde and his collegues [40] reported
on 19 patients with clinically and radiolographi-
cally negative necks that underwent SNB and
PET scanning followed by conventional neck dis-
section. In 15 of 19 patients, the sentinel node as
well as the remaining nodes were negative. In
3 of 19 patients, the sentinel node was positive
along with other nodes. In one patient, the senti-
nel node was negative, but another node removed
in the neck dissection was positive. The node was
located close to the primary, which often leads to
difficulty discriminating activity due to the tumor
and that of adjacent nodes. Interestingly, PET
failed to reveal cancer in the four patients with
subsequently identified cervical metastasis (see
previous discussion on PET scanning). The true
contribution of the sentinel node concept may be
the information that has been gained from the
careful analysis of the lymph nodes, which are
subjected to more intense histopathologic evalua-
tion than lymph nodes removed in classic neck
dissections. Studies have demonstrated that
review of lymph nodes deemed negative by light
microscopy were subsequently found to be posi-
tive with more numerous node sectioning and/or
Fig. 13. Photo (A) and schematic (B) demonstrating immunohistochemical analysis. Because it can be
completed dissection. (From Thawley SE, Panje WR, assumed that patients with these previously unre-
Batsakis JG, et al. Comprehensive management of ported metastases were not irradiated in many
head and neck tumors, volume 2. 2nd edition. Philadel- cases, the traditional neck dissection may have
phia: Saunders; 1999. p. 1410; with permission.) been therapeutic more often than some believed.
In the future, the SNB as the ultimate evolution
of selective neck dissection may become the
proximity of the sentinel node to the primary, for operative procedure of choice for dealing with
example, a FOM primary and submental node, the N0 neck. In an excellent review, Pitman and
can lead to the accumulation of colloid around her colleagues concluded, however, that that
the primary which can obscure the sentinel node. SNB remains an experimental technique in head
The rich lymphovascular network can also lead and neck cancers and has not become a standard
to drainage to several nodes. Civantos and his col- of care [41].
leagues [38] used the sentinel node technique in
18 oral cavity cancers with N0 necks. They com-
Complications
pared sentinel node biopsy to CT scan and PET
scan by obtaining a CT and PET followed by Complications, which are unanticipated,
SNB and neck dissection. They found 10 true pos- should be separated from normal anticipated
itives: six identified on frozen, two on permanent, sequelae of neck dissection, such as swelling and
two on immunoperoxidase staining for cytokera- bruising. Complications associated with neck
tin. In six specimens, the sentinel node was the dissection are uncommon, and are more often
only positive node. They also found seven true related to patient factors rather than the surgeon’s
negatives and one false negative. In one case, the technique. For example, a history of chemo-
sentinel node identified by the radioactive colloid radiation therapy is associated with a 26%–35%
 NECK DISSECTION 471

complication rate in patients undergoing neck The facial nerve is at some risk during neck
dissections [42,43]. Given the increased (and often dissection. Specifically, injury to the marginal
questionable) use of neo-adjuvant therapy, sur- mandibular branch is not uncommon. Retraction
geons must be prepared for longer, more tedious can temporarily disrupt function, and patients
dissections, and increased complications. Other should be counseled that while most will recover,
patient factors, such as tobacco and alcohol some will not. Higher dissection in the area of the
abuse, malnutrition, and diabetes can directly tail of the parotid in an attempt to clear bulky
affect complication rates. Briefly discussed here disease can result in injury to the cervicofacial
are the more common complications: neurologic division of the facial nerve or even the main trunk,
injury, vascular injury, thoracic duct injury (chyle but this is rare. Injury recognized intraoperatively
leak), and wound infection. or in the early postoperative period should be
repaired.
Neurologic Injury to the hypoglossal nerve is possible
Most modifications of neck dissections have during neck dissection. The procedure is especially
been made in an attempt to prevent the morbidity problematic in the patient who has previously
of radical neck dissection. Specifically, the painful undergone radiation therapy leading to scarring
shoulder syndrome associated with sacrifice of the and fibrosis in the neck. A confluence of veins
spinal accessory nerve lead many (including Crile around the nerve just anterior to the carotid artery
himself) to preserve the nerve, and paved the way can lead to troublesome bleeding and inadvertent
for modified neck dissections (Fig. 14). Interest- injury to the nerve. In addition, bulky nodal
ingly, not all patients in whom the nerve is inten- disease in the area can lead to nerve transection
tionally sacrificed develop shoulder weakness, and while trying to obtain adequate margins. Imme-
while preservation of the spinal accessory nerve diate repair can be considered, although results
decreases the incidence of painful shoulder syn- are unsatisfying in most cases. Fortunately, uni-
drome, it does not eliminate it. Extensive skeleto- lateral injury to the hypoglossal nerve is fairly well
nization of the nerve performed during modified tolerated by most patients.
neck dissections including level IIB can result in Phrenic nerve injury in patients undergoing
significant dysfunction even if the nerve is pre- neck dissection has been reported to be as high as
served. Several studies have suggested that dissec- 8% by some authors [45]. Fortunately, the true
tion of level IIB (above the nerve) is unnecessary incidence is likely much lower in modified and
in the clinically node-negative neck because of selective neck dissections. The nerve lies under
the low incidence of metastases in this area the deep cervical fascia over the anterior scalene
(1.6%), and is recommended only if bulky disease muscles and this fascia should be preserved.
is present in level IIa [44]. It is this author’s prac- Again, difficulty may be encountered dissecting
tice to exclude extensive dissection of this area in in the postirradiated field or in cases of bulky dis-
most oral cavity cancers, and the clinically N0 ease. Injury is usually manifested by elevation of
neck. Patients with signs of shoulder dysfunction the hemi-diaphragm noted on postoperative chest
should be referred for physical therapy. radiographs; bilateral injury can lead to respira-
tory failure. Pulmonary complications are usually
limited unless the patient has pre-existing pulmo-
nary compromise, a not uncommon co-morbidity
among head and neck patients.
Injury to the brachial plexus can similarly
occur when dissection is inadvertently performed
deep to the prevertebral fascia low in the neck. It
is a devastating injury, and early recognition
should lead to appropriate consultation and
consideration of repair. Unfortunately, repairs
are associated with less than satisfactory results
in most cases.
Horner’s syndrome (ie, ptosis, miosis, and
Fig. 14. Shoulder syndrome associated with sacrifice of anhydrosis) results from injury to the cervical
spinal accessory nerve. (Courtesy of Eric Dierks, sympathetic trunk, which lies posterior to the
DMD, MD, FACS, Portland, OR.) carotid sheath. The cervical sympathetic trunk is
472 HOLMES

at risk when dissection is carried posterior to the Injury to the thoracic duct usually occurs
carotid, which is rarely indicated. during manipulation of the internal jugular vein
The vagus nerve is at greatest risk during deep in the left neck were it lies posterior to the
ligation of the internal jugular vein. Damage vein. Prevention is the best policy. When dividing
results in unilateral vocal cord paralysis, which the lymphatic tissue low in the left neck, especially
is manifested by a ‘‘breathy,’’ weak voice. If the in cases were the internal jugular vein is divided,
injury is high in the neck before the branch of the the tissue should be clamped and suture-ligated.
superior laryngeal nerve, then laryngeal sensation Injury is manifested by appearance of milky fluid
is impaired and aspiration becomes a risk. Vocal in the surgical field (Fig. 15). Outcomes are
cord augmentation or medialization procedures improved if the injury is recognized intraopera-
may be helpful. tively. If injury is suspected or to confirm the
Injury to the lingual nerve can occur during repair, the anesthesiologist can hold a positive
removal of the primary, but the lingual nerve is pressure breath to increase intrathoracic pressure.
also at risk when it is distracted along with the Injuries recognized intraoperatively should be
contents of the submandibular triangle. This is managed by oversewing the duct with multiple
especially true when the lingual nerve has been nonabsorbable sutures under loupe magnification,
mobilized aggressively during the extirpation if possible. Injury in usually heralded in the post-
of the primary. In addition, blind clamping of operative setting by unexpectedly high drain
lingual vessels can lead to its injury. The attach- output from the left neck or by the appearance
ments between the nerve and submandibular of milky fluid in the suction drains It can be con-
gland should be carefully transected while keeping firmed by testing the triglyceride content of the
the nerve in view. drainage and comparing them to serum values.
Many of these leaks can be controlled by conser-
vative measures: medium triglyceride diet (ques-
Vascular
tioned by some authors); pressure; and suction
Vascular injury can be classified as intraoper- drainage. Surgical exploration is indicated in leaks
ative or late. Intraoperative complications include greater than 300–400 mL/day or leaks persisting
carotid sinus sensitivity and vessel laceration, more than 4–5 days. Chylous leaks can lead to sig-
which in this discussion will include thoracic nificant electrolyte disturbances and malnutrition;
duct injury. Late injuries discussed here consideration should be given to total parenteral
include hemorrhagedspecifically, hemorrhage in nutrition (TPN) in the short-term. Surgical explo-
the postoperative setting. ration of leaks can be a frustrating exercise and
Carotid sinus sensitivity results from manipu- requires patience. The patient can be fed a rich
lation of the carotid body, and it typically milk or cream product preoperatively in an at-
manifests as acute bradycardia and decreased tempt to increase chyle production and aid intra-
cardiac output. Atropine can be given, but the operative identification of the leak. Discussions
best results are usually obtained by subadventitial with anesthesia staff should be held regarding
administration of a small amount (!1 cc) of plain timing of this as it relates to NPO status. Use of
1% lidocaine, although this practice has been
questioned [46].
Intraoperative hemorrhage is controlled with
pressure and appropriate ligature, either suture or
clips (see discussion above under technique). In
the postradiated setting hemorrhage can become
more of an issue as fibrotic tissue prevents the
collapse of veins as well as the normal retraction
and constriction of arteries. This can make the
dissection much more tedious, leading to injury
and ligation of unintended vessels, such as the
internal carotid artery. Laceration of the common
or internal carotid arteries should be promptly
repaired if a preoperative assessment to establish
the presence of collateral cerebral circulation Fig. 15. Intraoperative photo demonstrating chyle leak
(carotid occlusion test) has not been done. and suturing.
 NECK DISSECTION 473

sclerosing agents, such as doxycycline, or fibrin of cure with single modality therapy diminishes.
glue has been advocated. Oversewing the area In his presidential address to the New England
and consideration of importation of vascularized Surgical Society, Blake Cady MD, FACS referred
tissue, such as a myofascial free or pedicled flap, to ‘‘lymph node metastases as the speedometers of
probably offers the best chance at successful the oncologic vehicle, not the engine. Indicators,
resolution. not governors of survival’’[50]. Clearly, the role
Late vascular complications typically involve for the radical neck dissection has diminished
hemorrhage in the form of carotid blowout, and greatly as less invasive surgical techniques for
these are almost always a result of previously dealing with the cervical lymphatics have gained
irradiated tissue breakdown and/or infection. popularity. This trend will likely continue, as the
Loss of free tissue transfers with avulsion of the role of surgery in the control of metastatic disease
arterial pedicle can also result in late hemorrhage. is better defined [6,51,52]. As is true in most cases
While some authors have recommended leaving in surgery, what is thought to be new usually
failed flaps in place for a period of time, caution means history was not studied closely enough.
should be exercised as the vascular pedicle can The concepts of elective neck dissection, modified
break down resulting in significant hemorrhage neck dissection, and selective neck dissection were
[47]. Prevention strategies include: appropriate use described by the fathers of head and neck surgery.
of prophylactic antibiotics; importation of vascu- Indications for the various neck dissections, how-
larized tissue in compromised situations; and opti- ever, continue to evolve. A comprehensive discus-
mization of the patient’s ability to heal through sion of the management of cervical lymph nodes
careful handling of tissues, maximizing nutrition, in each subsite within the head and neck is beyond
and confirming adequate thyroid function in the the scope of this article. Excellent reviews are
previously irradiated patient. available and recommended [2,7,53].
Operations on the oral cavity are considered Most importantly, during this time of evolu-
‘‘clean-contaminated,’’ and therefore, perioperative tion, clinicians must be able to accurately commu-
antibiotics are indicated. Several well-controlled nicate amongst each other what surgery was
studies have demonstrated that antibiotics performed; what structures were sacrificed and
started before the incision and continued for no which were preserved; and specifically, what
more that 24 hours serve to minimize perioper- lymph node basins were addressed. Avoidance of
ative infections and the emergence of resistant nonstandard, named neck dissections and the use
strains. Continuation beyond 24 hours should be of more accurate descriptions are important in this
considered in patients at increased risk or those regard. Equally important is the need to educate
with ongoing contamination. First generation nonsurgeons in the nomenclature and in the use of
cephalosporins and clindamycin represent the more limited dissections. Caution is merited when
most commonly used prophylactic antibiotics in extrapolating previous research results in which
oral cancer surgery. Topical antimicrobials, such patients may have received more comprehensive
as chlorhexidine and clindamycin rinses, have also neck dissections to patients who may have received
been shown to successfully reduce the incidence of more limited dissections, especially in decisions
infections [48,49]. regarding the need for adjuvant therapy.
Coverage of major vessels with imported tissue
should be strongly considered in cases of RND in
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 477–497

Management of the N0 Neck

in Oral Squamous Cell Carcinoma
Allen Cheng, DDS, Brian L. Schmidt, DDS, MD, PhD, FACS*
Department of Oral & Maxillofacial Surgery, University of California, 521 Parnassus Avenue,
Room C-522, Box 0440, San Francisco, CA 94143-0440, USA

Squamous cell carcinoma (SCC) of the oral The decision regarding the N0 neck has been
cavity has a poor prognosis that has only mar- debated extensively [32,33,35]. Countless studies
ginally improved despite the medical, surgical, have been published associating various clinical
and biochemical advances of the past 50 years factors, biomarkers, and radiologic findings with
[1–3]. Local recurrence in the oral cavity and me- the likelihood of occult metastasis in an effort to
tastasis through the lymphatics to regional lymph elucidate the proper treatment algorithm. This
nodes are the most important causes of this poor plethora of data and variety of recommendations
prognosis, with regional metastasis halving 5-year may be why every oncologic surgeon is, as
survival rates [4–8]. O’Brien and colleagues [26] described, ‘‘guided
Treatment of primary oral SCC tumors follows as much by personal philosophy and local custom
clear oncologic principles: resection of tumors as by scientific evidence’’ on whether and how to
with a 1 to 1.5-cm margin of normal tissue treat the N0 neck.
[9–16]. Treatment of clinically evident neck metas- This article presents the controversies sur-
tasis is equally clear: dissection and extirpation of rounding management of the N0 neck, discusses
the neck fibroadipose and lymphatic tissues, and the benefits and pitfalls of different approaches
removal of associated structures [17–21]. toward its evaluation and management, and
However, management of the neck when me- attempts to achieve a consensus on the appropri-
tastasis is not clinically evident (N0) is where the ate algorithm for management.
greatest ambiguity lies, given the unpredictable
propensity of oral SCC for occult neck metastasis When to treat the N0 neck
and the grave prognosis it portends [22–24].
Reports show rates of occult metastasis for oral The decision to treat the N0 neck is easily
SCC ranging from 20% to 45% [22,25–30]. reached when patients have a deeply invasive T4
When neck metastasis is detected after initial tumor of the retromolar trigone or, in contrast,
surgery, a greater surgical resection is required a superficial T1 tumor of the lip. In the former
for salvage, with increased morbidity and poorer example, the neck is surgically accessed in the
outcomes; or the tumor is nonresectable [23,31]. approach to remove the primary tumor and the
However, elective treatment of the N0 neck may risk for occult metastasis is high, and therefore
prevent these recurrences and the need for more the indications for an elective neck dissection are
radical surgery, but may also subject a patient clear. In the latter example, the tumor behaves in
to an unnecessary major surgery and its associ- a more indolent fashion, similar to a cutaneous
ated risks, particularly the shoulder syndrome SCC. Because the surgical approach does not
described by Nahum and colleagues [5,9,32–34]. include the neck and the risk for regional in-
volvement is low, a neck dissection is not required
* Corresponding author. and close observation is appropriate.
E-mail address: [email protected] The lesions that lie between these two extremes
(B.L. Schmidt) pose a challenge, because the clinical behavior of
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.02.002 oralmaxsurgery.theclinics.com
478 CHENG & SCHMIDT

oral cavity SCC is capricious and unpredictable invasive front, as criteria for deciding on man-
based on current clinical, pathologic, or molecular agement of the neck.
characteristics. The T1 or T2 tumors that are 3 to
4 mm thick trouble surgeons. Every busy onco-
Quality of life and its role in decision making
logic surgeon who treats oral cancer can recall
a patient who had a superficial T1 lesion that was Analyses such as that of Weiss and colleagues
resected with widely clear margins, but ultimately [36] have limitations. Clinical outcomes are diffi-
returned in 1 year with multiple neck metastases cult to prioritize, and a critical piece of informa-
and then eventually died of the disease. This is the tion is missing from their analysis: the reported
patient who is most disturbing and spurs oncol- effects on quality of life and how quality of life
ogists toward more aggressive management. compares among types of treatments and between
Few rigorously designed studies are available treatment and observation. A patient’s perception
to guide surgeons in the management of the of quality of life is profoundly individual and
N0 neck. A commonly cited study is the Weiss often different from the surgeon’s perception of
and colleagues [36] decision tree analysis, which success.
proposes that a 20% risk for occult metastasis The issue in question is whether patients would
should be the threshold for treating the neck. prefer to undergo an elective neck dissection that
This seminal paper is so central to the decision may not be necessary or be at risk for developing
regarding elective treatment of the neck that revis- a recurrence, have a markedly worse prognosis,
iting this work is essential in any discussion about and face the possibility of a much more disfiguring
when to treat the N0 neck. and morbid surgery in the form of a radical neck
In their study, Weiss and colleagues [36] per- dissection (RND) and chemoradiation therapy.
formed a computer-assisted mathematical analysis To arbitrarily assign values to each of these
of the decisions and associated outcomes involved outcomes based on the opinions (although expe-
in managing the N0 neck, weighting the outcomes rienced) of a handful of surgical colleagues is an
with their likelihood of occurrence and relative inaccurate estimate of each outcome’s subjective
cost and benefit to patients. They created a deci- desirability from a patient’s perspective [43,44].
sion tree beginning with the decision to operate, Since that publication, the use of the selective
irradiate, or closely observe (Fig. 1). Each of these neck dissection (SND) has supplanted RND as
decisions branch out to different possible out- the preferred elective treatment for the neck
comes and further decisions. [18,19]. Quality of life studies using general well-
The most distal branches of the decision tree ness and shoulder function-specific assessments
were given probabilities for occurrence based on have shown that the SND, when restricted to
data from a review of seven clinical series pub- levels I to III, is not a significant detriment to
lished from 1971 to 1984 [21,37–42]. Each of the quality of life, with outcomes in patients who
outcomes, including cure, death, cure with sur- underwent neck dissection nearly equal to those
gery, cure with radiation, and cure with salvage, who did not [45–49]. In contrast, patients who
were weighted based on desirability. Desirability had undergone RND or modified RND
was determined by three head and neck surgeons (MRND), similar to those in the series of studies
using a ‘‘time tradeoff method,’’ which refers to referenced by Weiss and colleagues [36], had a sig-
how much time of life these surgeons would give nificant detriment to quality of life characterized
up to have better function. For example, if one by increased long-term dysfunction, disfigure-
were willing to trade 4 months of life for better ment, and shoulder pain [50].
function, and the life expectancy was 120 months Taylor and colleagues [46] used the Neck
with a particular treatment, then the usefulness Dissection Impairment Index (NDII) to show
rating is 97% (116/120). Using this methodology, that the greatest factors affecting quality of life,
Weiss and colleagues [36] concluded that the in descending order of significance, were age and
benefits outweigh the costs in prophylactically weight, radiation therapy, and the extent of neck
treating the N0 neck only when the risk for occult dissection. Similarly, Rogers and colleagues [45],
metastasis exceeds 20%. using the University of Washington Quality of
Their threshold of 20% has been used in Life (UW-QoL) scale coupled with the NDII
many studies attempting to identify clinical and shoulder disability questionnaire (SDQ),
factors, such as stage, thickness, depth of found that patients treated with MRND or
invasion, and histologic characteristics of the RND had the worst scores, whereas those who
 MANAGEMENT OF THE N0 NECK 479

Cure-Salvage
Cure-Salvage

Recur Salvage

No Cure-Salvage
Death
Neck Dissection Outcome
Cure-NR
Cure-NR
No Recur

No Cure-NR
Death

Cure-Salvage
Cure-Salvage
Recur Salvage

No Cure-Salvage
Radiation Therapy Death
Outcome
Cure-NR
Cure-NR
No Recur

No Cure-NR
Death

Cure-Salvage
Cure-Salvage
Recur Salvage

No Cure-Salvage
Observation Outcome Death
Cure-NR
Cure-NR
No Recur

No Cure-NR
Death

Fig. 1. Decision tree used by Weiss and colleagues [36] to perform a computer-assisted decision analysis. The figure de-
picts three alternative management strategies for the N0 neck. The filled box indicates the branching point between three
different management strategies. Filled circles indicate branching points between two possible outcomes. Outcomes in
boxes indicate the final outcome of that branch of the decision tree. Each of these outcomes was given a probability
of occurrence and a desirability rating as quantified by the time tradeoff method. NR, no recurrence. (Adapted from
Weiss MH, Harrison LB, Isaacs RS. Use of decision analysis in planning a management strategy for the stage
N0 neck. Arch Otolaryngol Head Neck Surg 1994;120(7):699–702; with permission.)
480 CHENG & SCHMIDT

had an SND of levels I through III had similar 58 patients underwent observation and 104 elec-
scores to those who underwent no neck dissection. tive therapy in the form of an SND, radiation
Therefore, with the relatively low morbidity of therapy, or these modalities combined. The deci-
SND compared with RND, the desirability values sion to perform elective treatment of the neck
in the decision tree would certainly be different. was based on the clinical factors mentioned ear-
Quality of life must also be considered for lier, using 20% risk as the threshold for treatment.
patients followed up using the ‘‘wait and see’’ Tumor stage was the strongest predictor in this
approach and later develop neck metastasis. study. In the elective treatment group, 30% of the
Salvageable patients will be obligated to undergo neck dissection specimens had evidence of meta-
a RND, possibly with chemoradiation therapy static disease, and 4% of the patients, all of whom
[20,51–53]. Given the findings of the studies men- had positive nodes on initial neck dissection,
tioned earlier, the quality of life in these patients developed unsalvageable neck recurrences.
would be much lower even if a cure were obtained. Among the observation group, 9% developed
Thus, when the ‘‘wait and see’’ approach is nodal metastasis, which were all N2 or greater,
used, failure results in decreased survival and and the salvage rate was 80% at 3 years from
quality of life. Of course, elective treatment is primary surgery.
only advisable if it effectively prevents recurrences The disease-specific survival was 89% for the
and decreases cancer-related mortality. Most elective neck dissection group, 67% for the
studies on SND show that it prevents neck elective radiation therapy group, and 94% for
recurrence and controls occult neck metastasis the observation group. This result seems to in-
[8,54]. Therefore, the negative impact on quality dicate that using clinical criteria and a 20% risk
of life and survival using the ‘‘wait and see’’ threshold would have favorable results. That is,
approach must be considered. most patients who have occult metastasis would
be treated electively, and the number of patients
who develop neck recurrences while undergoing
Few prospective trials evaluating
observation would be small and can be treated
treatment algorithms
effectively with salvage therapy.
Weiss and colleagues’ decision tree analysis is However, this study was purely a descriptive
an important component in any algorithm used to study, and did not include either a control group
decide on prescribing elective neck dissection. or randomization. Therefore, whether the high
However, to the authors’ knowledge, only one survival rates are related to use of the 20%
prospective series has attempted to evaluate the threshold or some other factor unique to the
clinical usefulness of the 20% risk for occult investigators’ practice, such as the clinical exper-
metastasis as a threshold for elective treatment tise of O’Brien and colleagues [26] in predicting
of the neck [26]. Most publications on elective risk for occult metastasis, is difficult to determine.
treatment of the neck are retrospective and do Furthermore, an 80% salvage rate for neck recur-
not describe how the decision is reached regarding rences is probably not transferable to most other
whether to operate and what diagnostic criteria oncology practices [23]. Even if the results are as-
exactly constitute a greater than 20% risk. Gener- sumed to validate the decision tree analysis model,
ally, the information on which the treatment deci- the surgeon and patient must still decide whether
sion is based is not provided and only the a 9% rate of neck recurrence and salvage surgery
outcomes associated with each approach are re- is an acceptable risk.
ported. The original decisions in these retrospec-
tive studies were likely clinically based on the
Elective neck dissection versus ‘‘wait and see’’
surgeon’s experience and each patient’s individual
values. This approach does not allow an examina- Although the series by O’Brien and colleagues
tion of the validity of the decision tree. seems to be the only one that evaluated the
O’Brien and colleagues [26] reported on the ap- decision tree, several studies advocate elective
plication of the decision tree model, using clinical neck dissection over the ‘‘wait and see’’ approach,
criteria, specifically tumor site, tumor stage, and although very few were randomized and pro-
the necessity of accessing the neck in resecting spective. Only three prospective randomized trials
the primary tumor, in deciding when to electively seem to have compared the ‘‘wait and see’’
treat the neck. In their series of 162 patients who approach to the elective neck dissection, and
had oral or oropharyngeal SCC and N0 necks, only one evaluated the use of the SND (Table 1)
 MANAGEMENT OF THE N0 NECK 481

Table 1
Summary of data from randomized controlled trials on elective treatment of the N0 neck in patients who have oral SCC
Occult Regional
Elective Total metastasis involvement
Study therapy patients on ENDa on observation Salvageb Rate of DFSc
Vandenbrouck RND 75 49% (9%) 47% Not reported 46% (58%)
et al [21] at 3 years
Fakih et ald [55] RND 70 33% (14%) 57% 22% (30%) 64% (53%)
at 12 months
Kligerman SND 67 33% (12%) 39% 25% (27%) 72% (49%)
et al [54] at 3 years
Abbreviations: DFS, disease-free survival; END, elective neck dissection; SCC, squamous cell carcinoma.
a
Numbers in parentheses indicates neck recurrences after END.
b
Salvage rates in neck recurrences only. Numbers in parentheses indicate salvage rates for neck recurrences in
observation group. Minimum follow-up time shown.
c
Numbers in parentheses indicate DFS in observation group.
d
Study is specific to oral tongue SCC.

[21,54,55]. Vandenbrouck and colleagues [21] SCC and no evidence of neck involvement, who
randomized 75 patients who had primary SCC were randomized to either resection of the
of the oral cavity and no evidence of nodal metas- primary tumor without elective neck dissections
tasis to undergo either resection of the primary or resection and an RND. They followed up their
tumor without neck dissection or resection with patients bimonthly for 1 year. This study found
a traditional RND. Patients in both groups that 57% of patients in the ‘‘wait and see’’ group
remained on a monthly follow-up schedule for developed neck metastasis and 47% of the pa-
3 years. tients in the RND group had histologic evidence
This series found that 49% of patients in the of occult metastasis.
elective neck dissection group had occult metas- At 1 year, the disease-free survival (DFS) of the
tasis and 47% in the ‘‘wait and see’’ group ‘‘wait and see’’ group was 52% compared with
ultimately developed neck involvement and sub- 63% in the RND group, although this was not
sequently required salvage RND and radiation statistically significant. In the RND group, 4 of the
therapy. Moreover, a higher incidence of extrac- 30 patients developed contralateral nodes, which
apsular spread was seen in the ‘‘wait and see’’ were included in the count for occult metastasis,
group. At 3 years, both groups had statistically compared with none in the ‘‘wait and see’’ group.
equivalent survival patterns. Because all patients in the surgery group
Despite being randomized, 21% of patients in underwent ipsilateral neck dissections only, and
the elective treatment group had T3 tumors without information on tumor location and
compared with only 6% in the ‘‘wait and see’’ whether the tumor violated the midline, some of
group. This difference in stage could be a potential those 4 patients may have been indicated for
confounder of the survival ratings. Furthermore, a contralateral SND, which might have affected
the reduced quality of life associated with RND the overall treatment outcome and the difference
and postoperative radiation therapy must be between the groups. In addition, the 1-year
considered. Based on these results, Vandenbrouck follow-up in this study is somewhat short, given
and colleagues [21] recommended that elective that 95% of recurrences occur in the first 2 years
neck dissection be offered to patients likely be [58]. This limited follow-up makes the effective-
lost to follow-up, but not necessarily to other ness of salvage treatment in the ‘‘wait and see’’
patients. However, considering current risk assess- group difficult to accurately evaluate.
ment models, patients in the ‘‘wait and see’’ group Another criticism is that 28% of patients
who had larger nodes and higher incidence of initially enrolled and who underwent initial ther-
extracapsular spread would be predicted to have apy were lost to follow-up and removed from
a poorer prognosis and may have benefited from analysis. No data were provided as to which
earlier treatment [24,53,56,57]. group these patients were lost, compromising the
In 1989, Fakih and colleagues [55] published randomization and introducing a potential selec-
a study of 70 patients, with T1 and T2 oral tongue tion bias.
482 CHENG & SCHMIDT

However, Fakih and colleagues did observe Many retrospective, nonrandomized studies
a significant difference in the presence of occult have also reported on the benefits of SND over
nodal metastasis among tumors with thickness the ‘‘wait and see’’ strategy in treating the neck
greater than 4 mm (see later discussion). [31,53,59–61]. These studies are summarized in
Kligerman and colleagues [54] published the Table 2. Keski-Santti and colleagues [60] found
only prospective, randomized, controlled trial a significant improvement in survival despite
comparing elective SND of levels I through III more advanced primary tumors in the elective
with the ‘‘wait and see’’ approach for the N0 treatment groups, with 35% of patients in the
neck. This series randomly assigned 67 patients observation group developing neck recurrences,
who had oral SCC and N0 necks to either and a 33% salvage rate.
resection alone of the primary tumor or in con- Similarly, Capote and colleagues [31] found an
junction with a SND of levels I through III. These 8% rate of neck recurrence in the elective neck
patients were followed up for at least 3 years dissection group versus a 26.8% rate in the obser-
postoperatively. vation group, with a 5-year survival rate of 91.7%
The investigators found a 21% rate of occult and 77%, respectively. Again, success of salvage
metastasis in the elective SND group and a 39% therapy was low at 32%.
rate of recurrence in the neck in the ‘‘wait and In another nonrandomized retrospective re-
see’’ group. Of significance, only 27% of patients view of 359 patients, Duvvuri and colleagues
who developed neck recurrences were salvageable. [59] found a 27% regional failure rate compared
This finding is in sharp contrast to the 80% with 8% in the elective neck dissection group,
salvage rates reported by O’Brien and colleagues although no difference in survival was seen at
and is more consistent with other reported studies 5 years. Elective radiation therapy has also been
[23,26]. shown to improve outcomes when used to manage
Kligerman and colleagues also reported that the N0 neck [41].
overall survival at 3 years was significantly A few studies have advised against elective
improved in the elective neck dissection group. In treatment of the neck in favor of the ‘‘wait and
contrast to the findings of Fakih and colleagues, no see’’ approach [62–65]. In a retrospective analysis
factors were found to be significantly associated of 590 patients, Khafif and colleagues [65] found
with occult metastasis that could be used for that patients who had occult metastasis who
prediction, including stage or depth of invasion. underwent an elective RND did not experience

Table 2
Summary of data from retrospective observational studies on elective treatment of the N0 neck
Occult Regional
Elective Total metastasis involvement
Study therapy patients on ENDa on observation Salvageb Rate of DFSc
Khafif RND 590 42% (13%) 19% 49% 68% (88%)
et ald [65] at 3 years
Nieuwenhuis N/A 161 N/A 21% (79%) (79%) at
et ald [63] 12 months
Duvvuri SND 359 23% (8%) 27% Not reported 66% (54%)
et ald [59] at 3 years
Keski-Santti SND, RT 80 34% (13%) 24% 11% (47%)e 82% (81%)
et al [60] or SNDþRT at 3 years
Capote END 154 Not reported (8%) 26.8% 32%f 92.5% (71.2%)
et al [31] at 5 years
Abbreviations: DFS, disease-free survival; END, elective neck dissection; RND, radical neck dissection; RT, radia-
tion therapy; SCC, squamous cell carcinoma; SND, selective neck dissection.
a
Numbers in parentheses indicates neck recurrences after END.
b
Salvage rates are in neck recurrences only, unless otherwise noted. Numbers in parentheses indicate salvage rates
for neck recurrences in observation group. Minimum follow-up time shown.
c
Numbers in parentheses indicate DFS in observation group.
d
Study not specific to oral cavity primaries; they may include oropharyngeal and laryngeal.
e
Overall salvage rate for local and regional recurrences is shown.
f
Overall neck salvage rate for both observation and END groups is shown.
 MANAGEMENT OF THE N0 NECK 483

a survival benefit compared with those who Limitations of imaging

underwent observation and subsequently devel-
Imaging using CT, MRI, positron emission
oped clinically apparent nodal involvement and
tomography (PET), ultrasound, and now PET/CT
required subsequent salvage RND.
has been used to assess primary tumors.
However, these investigators assumed that
Unfortunately, despite improved resolution and
pathologically N0 (pN0) necks did not have occult
software analysis, these techniques are still
disease, although this assumption is not entirely
insufficiently sensitive for detecting occult neck
accurate as evidenced by the 7% neck recurrence
metastases, with 20% to 45% of patients staged as
rate among patients who had pN0 necks in their
N0 using these techniques having occult nodal
study (see later discussion). When the elective
involvement on pathologic evaluation of the neck
RND group was analyzed, including patients
[22,28,29].
who were pathologically positive and negative
For imaging techniques to be useful in treat-
for nodal involvement, DFS was significantly
ment decisions, they must be able to detect
improved over the salvage rate in the observation
metastatic nodes found in patients who have
group (68% vs. 49%, respectively).
early-stage tumors, which are present only 20%
Khafif and colleagues [65] did not recommend
to 45% of the time. These nodes are commonly
elective treatment of the neck, based on the as-
small, with diameters as small as 3 to 10 mm.
sumption that RND or radiation therapy would
Also, the long axis of these nodes, which can be
be used, which are both associated with significant
visualized accurately on pathology, is often not
morbidity. However, they supported using a more
parallel to any of the planes used for anatomic
selective node sampling for staging purposes.
imaging, causing even greater foreshortening
In a retrospective study of 891 patients who
[29,69].
had oral SCC and N0/Nþ necks, Layland and
The presence of structural changes, such as
colleagues [62] showed that disease-specific sur-
cystic changes or necrosis, aids detection, but
vival was equivalent whether the neck was treated
these features are rarely present in occult disease
electively or after nodal disease became apparent.
[29]. In addition, these techniques must be not
One criticism of this study is that the observation
only sufficiently sensitive to detect microscopic
arm had a greater percentage of early T1 disease
disease but also specific enough such that frequent
than T2 through T4 disease, a discrepancy that
false-positive results do not cause universal
was not statistically addressed and could have
prescription of elective neck treatment.
confounded the outcome.
Anatomic imaging studies, such as MRI and
CT, have been shown to have similar accuracies,
Assessing risk for occult metastasis
with sensitivities ranging from 56% to 85% and
Elective treatment of the N0 neck is a complex specificities from 47% to 95% [70–73]. PET
decision because no accurate way exists to de- showed a sensitivity of 75% to 90% and specificity
termine the risk for occult metastasis. The sensi- of 90% to 100%. Patients in these studies, how-
tivity of clinical examination to detect metastasis, ever, did not have N0 necks exclusively. The sensi-
even by expert surgeons, has been inadequate, tivity and specificity is expected to be much lower
with a sensitivity of 51% reported by one major for detecting occult nodes in earlier-stage disease.
head and neck surgery group [22]. Other groups Multiple studies from one surgical oncology
have also reported on the low sensitivity of clinical group have reported success using ultrasound-
examination, ranging from 60% to 70% [66–68]. guided fine needle aspiration biopsy with a ‘‘wait
Cancer is a heterogeneous disease, with signif- and see’’ approach for patients who have N0
icant biologic variability even among patients who necks [63,66,74–76]. In one study using this strat-
have the same cancer. In this regard, SCC of the egy, Nieuwenhuis and colleagues [63] reported
oral cavity is no different and is notorious for that 21% of their patients developed nodal disease
displaying a wide spectrum of clinical behavior. during follow–up. These patients were then
Much work has been devoted to dissecting these treated with a therapeutic neck dissection of levels
differences to create a risk assessment model for I through V, with a salvage rate of 79% at 5 years.
occult metastasis in oral SCC. However, no single However, diagnosing occult metastasis with ultra-
parameter (or set) or adjunctive diagnostic tech- sound seems to be highly technique-sensitive and
nique has been sufficiently sensitive, and few have user-specific, because other studies have been un-
held up to further study. able to replicate this success [22,77].
484 CHENG & SCHMIDT

PET/CT is a recent imaging technology com- TNM staging protocol [79]. Tumor staging is an
bining the improved sensitivity of PET for meta- important step in determining prognosis. Higher
static disease with the higher resolution and stages have been correlated with higher rates of
accuracy of CT. In a cohort of patients with N0 positive margins on resection, higher rates of
necks, Schoder and colleagues [69] found that recurrence, and lower 5-year survival rates [1].
PET/CT had a sensitivity and specificity of 67% However, some debate exists on how accurate
and 85%, respectively. Using histopathology, the current staging system is in prognosticating,
they determined that nodes 3 mm or smaller could especially regarding predicting nodal metastasis.
not be reliably detected with PET/CT. They More specifically, the AJCC system has been
therefore concluded that, despite overall high criticized for emphasizing certain features of the
accuracy, PET/CT has limited clinical usefulness primary tumor, such as diameter, while excluding
in this application because of the inadequate other factors that some studies suggest may play
sensitivity for small nodes and high number of a larger role, such as perineural invasion, depth of
false-positives (13%). They also emphasize that tumor invasion, and the characteristics of the
the surgeons in their group had the PET/CT invasive front (discussed in more detail later).
results before planning treatment, and that the Although advanced stage is used to predict risk
information did not alter the decision to operate for occult metastasis, multivariate analyses have
in any of the patients. shown that stage is not an independent risk factor
Nahmias and colleagues [78] also recently pub- for neck involvement when tumor thickness has
lished a detailed study on the use of PET/CT in been factored out [8,80]. Despite this fact, the sim-
staging the neck. This study carefully mapped plicity of using the superficial diameter of a lesion
out each node from a neck dissection and then as a prognostic tool, especially considering that it
compared it with the corresponding node visual- is likely to have some relationship to tumor thick-
ized on the preoperative PET/CT. Using this ness, still makes staging a frequently used measure
methodology, they examined the staging capacity that is recommended by most practices [22].
of PET/CT on a node-by-node basis.
Their study included 70 patients who had oral Significance of micrometastases
cancer; 47 had N0 necks and 19 were clinically
In addition, histopathologic review of nodes is
node-positive. The sensitivity and specificity of
not infallible. On more careful examination,
PET/CT for detecting metastatic nodal involve-
several studies have found a high prevalence of
ment in the 47 patients who had N0 necks patients
micrometastases (ie, foci of tumor within lymph
were 79% and 82%, respectively, with positive
nodes smaller than 3 mm) when lymph nodes were
(PPV) and negative predictive values (NPV) of
serially sectioned, as opposed to the sampling
68% and 89%, respectively. Analysis on a node-
technique of bisectioning lymph nodes that is used
by-node basis in patients who have N0 necks
at most hospitals [81,82]. The rates of these micro-
showed a sensitivity and specificity of 26% and
metastases ranged from 16% to 25% in previously
99%, respectively, with a PPV of 63% and NPV
pathologically staged N0 necks. Although the
of 95%. The investigators concluded that, because
prognostic significance of these micrometastases
of a NPV of 89% and a false-negative rate of
is still unclear, at least some of these tumor cells
11%, PET/CT did not help rule out occult nodal
may be ultimately responsible for neck recur-
metastasis to a degree that would affect a surgeon’s
rences seen even in pathologically N0 necks.
decision to electively treat the neck.
The other implication is that previous studies
Therefore, although it is a critical adjunct to
on the prevalence of occult metastasis discovered
treatment planning and diagnosing nodal metas-
through elective neck dissections may be grossly
tasis, imaging is not sensitive enough to replace
underestimating the actual prevalence of nodal
histopathologic staging using an elective neck
involvement, and that many of these neck dissec-
dissection.
tions are actually therapeutic. This possibility may
explain the improved survival rates seen in elective
Tumor staging and risk of occult metastasis treatment groups in several studies [54,60].
Clinical factors, such as tumor staging and
Role of tumor location in occult metastasis
location, have long been associated with differ-
ential risk. Current convention is to use the The oral cavity has been divided into several
American Joint Commission on Cancer (AJCC) subsites: lips, oral tongue, mandibular alveolar
 MANAGEMENT OF THE N0 NECK 485

gingiva, maxillary alveolar gingiva, hard palate, on the proportion of well-differentiated cells
floor of mouth, retromolar trigone, and buccal within the tumor. Broders showed that degree of
mucosa [79]. Much variability has been observed differentiation was able to predict rates of metas-
and described for tumors of different subsites tasis in lip carcinomas [91].
regarding their effects on occult metastasis and Byers and colleagues [22] also found the
survival. Broders system of tumor differentiation correlated
SCC of the lip is generally considered to have with nodal metastasis in a mixed group of patients
a very favorable prognosis and low risk for who had N0 and Nþ necks, although whether it
regional metastasis if treated early. Tumors of would be as useful in evaluating the N0 neck inde-
the maxillary gingiva and hard palate have also pendently was unclear. Unfortunately, it has not
been considered to have low incidence of regional correlated well with patient prognosis or risk for
metastasis. However, tumors of the oral tongue, regional involvement when studied by other
floor of mouth, mandibular gingiva, and retro- groups, probably because of the ambiguity of
molar trigone are often reported to have high the definitions used in the Broders system and
rates of occult metastasis [83]. Buccal mucosa its oversimplicity [92,93]. To improve the predic-
tumors have also been shown to predict poor tive value of grading, several groups have tried
prognosis, with high rates of local and regional to create multifactorial malignancy grading sys-
failure [84,85]. tems that include several histopathologic criteria
Several recent studies have challenged some of [92–100]. The large number of these systems is a re-
the aforementioned ideas, particularly the sup- flection of the complexity of quantifying malig-
posed indolent nature of maxillary SCC. In a series nancy in oral SCC.
of 26 patients who had SCC of the maxilla, Modified versions of the grading system pub-
Simental and colleagues [86] found a 27% lished by Anneroth and colleagues [92,93,101] are
incidence of occult metastasis and a 34.6% rate probably the most widely used today. They
for overall nodal metastasis. Similarly, Fernandes include several factors, such as degree of keratini-
and colleagues [87] reported a 40% incidence of zation, nuclear polymorphism, number of mitoses
metastasis in a series of 15 patients. The senior au- per high power field, pattern of invasion, and
thor of this article also had this experience, with lymphoplasmacytic infiltration. Other factors
a 42.9% rate of cervical metastasis in 14 patients that have been studied include tumor shape (re-
who had maxillary SCC [88]. ductive or expansive), growth pattern (endophytic
Therefore, all intraoral tumors seem to possess or exophytic), perineural invasion, vascular inva-
some risk for regional metastasis, and therefore sion, muscular invasion, and depth of invasion.
a worse prognosis, despite conventional thinking. Using the Anneroth malignancy grading system
Using the purported characteristics of different with modifications by Woolgar and colleagues,
subsites within the oral cavity as a reason not to Kademani and colleagues [102], found it to be pre-
address the neck is not currently justified. How- dictive of DFS and neck metastasis in a series of
ever, SCC of the lip is still unlikely to have the 215 patients who had oral SCC.
same risk, and elective neck treatment can be In an exhaustive study of 71 patients with
deferred unless the tumor is advanced in stage or SCC of the oral tongue, Po Wing Yuen and
adjacent subsites are involved, or if nodal colleagues [80] evaluated the Anneroth, Bryne,
involvement is clinically detectable. and Martinez-Gimeno grading systems, and
stage, perineural invasion, vascular invasion, lym-
phovascular invasion, shape, stage, growth pat-
Limitations of histopathologic grading
tern, and thickness. After careful analysis, only
Histologic grading has been used for some time tumor thickness was an independent risk factor
to predict the behavior of benign and malignant for nodal metastasis. In a similarly thorough
tumors. However, although useful in some study of 29 patients, which also included immu-
tumors, its prognostic value in SCC is controver- nohistochemical analysis of tumors for vascular
sial. Broders’ [89,90] classification of the degree of endothelial growth factors (VEGF) and health-
malignancy has been used for many decades and related behaviors, Warburton and colleagues
was the first attempt to develop a grading system [103] also found tumor thickness to be the only
for head and neck SCC. It classifies tumors as well independent predictor of nodal metastasis. Clark
differentiated, moderately well differentiated, and colleagues [8] also reached the same conclu-
poorly differentiated, or undifferentiated based sion in 164 patients.
486 CHENG & SCHMIDT

Currently, tumor thickness seems to be the Another problem with using recommended
only factor that has consistently shown promise as cutoffs for tumor thickness is that most studies
an indicator of risk for occult nodal metastasis; addressing tumor thickness are based on the
however, the recommended cutoff for pres- argument that failure rates up to 20% are an
cribing elective neck treatment varies greatly in acceptable risk. Whether this risk is truly accept-
the literature, ranging from 1.5 to 8 mm able depends on the surgeon and, more impor-
[80,96,101,103–108]. This variability highlights tantly, the patient.
some of the pragmatic issues with the use of tumor Warburton and colleagues [103] approached
thickness as a risk index. their determination of a thickness cutoff differ-
The first practical problem is how tumor ently. They attempted to find a point where sensi-
thickness is measured. Some studies measured tivity and specificity were maximized. They settled
the entire tumor thickness from the surface, on a threshold of tumor thickness of 2.2 mm,
whereas others advocated a ‘‘reconstructed’’ which yielded a sensitivity and specificity of
thickness, measuring from a line that approxi- 87.5% and 78.9%, respectively. Although this
mates the boundary of where the normal mucosa method is probably one of the most objective
would be to the deepest extent of the tumor. Still ways to create a useful risk measurement tool,
others focused on depth of invasion, only the 2.2-mm cutoff is small enough to make its
measuring from the basement membrane to the use in clinical practice problematic. A thickness
deepest extent of tumor. The variability in of 2.2 mm would include all but the most superfi-
techniques is probably one of the key reasons cial T1 tumors [105]. Thickness in these T1 tumors
for the wide range of recommended cutoff values. would be difficult to measure accurately because
The second practical problem is how to best of the biopsy sampling error.
obtain the tumor thickness. All of the studies are Among the many histopathologic factors and
retrospective, with most using paraffin-fixed multifactorial malignancy grading systems, only
sections from the primary tumor specimen to tumor thickness has endured as being correlated
determine thickness. This technique allows pa- with nodal metastasis. However, despite being the
thologists to first grossly examine the entire tumor most important predictor of occult nodal metas-
ex vivo to determine the portion where the deepest tasis, tumor thickness is an imprecise instrument
extent of invasion is most likely found. However, because of technical issues in its application.
considering that the decision to treat the neck
electively is generally made before the primary
Future diagnostics using molecular biomarkers
tumor is treated, the information must be
acquired before surgery to offer much benefit. Oral SCC, like all cancers, is a disease of
Surgeons could conceivably resect the primary genetic etiology, and the capricious nature of the
tumor, determine the thickness, then have patients disease is likely a manifestation of the heteroge-
return for a second operation to address the neck neity within the genetic codes of cancer cells and
if it is indicated. However, this method is imprac- the many genetic changes involved in carcinogen-
tical because most surgeons (and patients) prefer esis [109]. Cancer is a consequence of genetic and
treating the two sites within the same operation, epigenetic alterations that lead to protein dysre-
especially if the neck will already be accessed, gulation affecting cell division, differentiation,
either in the surgical approach or with the immune recognition, tissue invasion, and metasta-
intention of exposing vessels for microvascular sis. Thus, using molecular techniques to discern
anastomosis. these tumor-specific characteristics and predict
In lieu of having the permanent tumor speci- their phenotypes and behavior would be highly
men, clinicians often depend on incisional biopsies beneficial in treating patients. Therefore, much
to determine thickness. This approach has its own energy has been devoted to trying to identify mo-
problems, because surgeons performing the lecular biomarkers that can assist in predicting
biopsy have no accurate method to predict where risk for occult nodal metastasis in oral SCC.
the deepest part of the tumor will be found. Several potential genetic biomarkers have been
Therefore, the measured thickness obtained from identified as being involved in oral carcinogenesis
the biopsy is often an underestimation of the true and possibly metastasis, including epidermal
maximal tumor thickness, and applying these growth factor receptor, cyclin D1/CCND1, TP53,
measurements to recommended thresholds leads E-cadherin, MMP-9, TIMP1, laminin-5, MMP-1,
to undertreatment of the neck. and uPA (Table 3) [110–120]. Unfortunately, the
 MANAGEMENT OF THE N0 NECK 487

Table 3
Potential molecular markers for predicting metastasis
Method of molecular
Molecular marker Role in carcinogenesis/metastasis evaluation
TP53 Most commonly mutated locus in human cancers Direct sequencing of exons
TP53 arrests cell cycle so DNA repair can occur or damaged 4–9 from genomic DNA
cells can be removed by inducing apoptosis [111,120] [153,154]
Cyclin D1 Overexpressed in 68% of oral SCCs [110] Immunohistochemistry [110]
Overexpression correlates with lymph node metastasis
and poor outcome [110,114]
EGFR Levels correlate with lymph node metastasis and poor Immunohistochemistry [116]
outcome [116,117]
E-cadherin Lower levels are associated with a metastatic phenotype in head Immunohistochemistry [119]
and neck SCC lines [115,119] and tumor specimens [118]
MMP-9 Increased levels have been associated with invasiveness Immunohistochemistry [157]
of oral SCC and metastasis [155,156]
uPA uPA expression correlates with invasion and metastasis [158] Immunohistochemistry [158]
Blockage of uPA abrogates SCC invasion [159]
VEGFR Binding of VEGF induces proangiogenesis and/or Immunohistochemistry [103]
prolymphangiogenesis pathways
Overexpression correlated to lymphatic spread in some tumors
Not an independent predictor of neck metastasis in oral cavity
SCC [103]

science in oral SCC is early and has not transi- comparative genomics hybridization (CGH) [122].
tioned to clinical application. It has the advantage of identifying gene ampli-
One critical problem that impedes the use of fications and deletions over the entire genome,
any of these biomarkers is the tremendous het- including nontranscribed elements, with high
erogeneity among tumor genetics. Although one resolution. These types of mutations and chromo-
of these biomarkers may be found in some oral somal alterations are typical of solid tumors such
cancers, it is unlikely to be found in all, or even as oral SCC [122].
most, oral cancers, thus reducing its sensitivity as The inclusion of nontranscribed elements using
a marker for metastasis. Scientists have had some array CGH is unlike cDNA microarrays, which
success in circumventing this problem using focus on transcribed amplicons. Snijders and
multigene assays in the form of microarrays to colleagues [123] analyzed a series of 89 oral SCC
create molecular profiles of tumors. Rather than tumors and identified several novel genetic ampli-
investigating a specific genetic marker, clinicians fications that may play a role in oral SCC carcino-
can take a ‘‘shotgun’’ approach to studying tumor genesis. However, studies are still assessing the
characteristics by hitting a large number of genes. usefulness of array CGH in predicting metastasis
Using cDNA microarrays, Chung and col- in oral SCC.
leagues [121] were able to create a multimarker as- The science of molecular biological techniques
say that can predict regional metastasis in head and in oral SCC diagnostics is in its infancy. However,
neck SCC with 83% sensitivity. However, they the potential to accurately characterize specific
were only able to achieve this when oral cancers tumor traits through identifying multiple genetic
were removed from the analysis, highlighting the markers is considerable.
distinctly mercurial nature of oral carcinogenesis
compared with oropharyngeal, hypopharyngeal,
Economic costs
and laryngeal SCC. A second problem is that
even with an 83% sensitivity, they had a false- Although not a primary consideration, the
negative rate of 17%, and therefore their assay economic burdens certain health care choices
was not sensitive enough to obviate the need for and interventions entail are important to appreci-
elective neck dissections. ate to maximize resources in the financially
Another molecular tool that has great poten- strained climate of the current American health
tial and is becoming more widely available is array care system. To this end, health economists have
488 CHENG & SCHMIDT

used cost-minimization and -effectiveness analy- dissection should be offered to all patients who
ses. Unfortunately, a dearth of research exists on have oral SCC at any intraoral site.
the economic ramifications of elective treatment
of the neck in oral SCC [124].
How to treat
In an extensive study published in 2006 by
Speight and colleagues [125] on data from two Surgery is not the only treatment option avail-
hospitals in the United Kingdom, patients who able for elective treatment of the neck. Radiation
had oral SCC of earlier stage had shorter hospital therapy is also efficacious in managing the N0 neck
stays and a smaller mean per-patient cost. Initial and is often used in head and neck cancer for this
diagnosis and treatment costs were $3443 for pre- application [41]. However, surgery remains the
cancer patients compared with $24,890 in patients preferred modality in elective treatment of the
who had stage IV cancer. The report concluded N0 neck in oral SCC, for various reasons.
that prevention and early intervention would be It is preferable to select the same treatment
the most cost-effective way to address the substan- modality for the neck that is being used to treat
tial costs of oral cancer. Similarly, in 2004 Lang the primary tumor, if possible. Although radia-
and colleagues [126] used Surveillance, Epidemiol- tion therapy has been shown to be effective in
ogy, and End Result–Medicare data to show that treating oropharyngeal, nasopharyngeal, hypo-
patients who had regional and distant metastasis pharyngeal, and laryngeal SCC, it has compared
had twice the hospital stay and related costs com- unfavorably with surgery as a primary therapy for
pared with patients who had localized cancer. oral SCC because of its considerable morbidity
Although these studies do not directly address and poor cancer control rates [128,129].
the question of elective treatment of the N0 neck, Toxicities include mucositis, xerostomia and its
it can be hypothesized that patients who have dental sequelae, erythematous skin changes, sub-
early cancer and undergo elective neck dissections cutaneous fibrosis, carotid artery stenosis, and
would probably generate lower costs, because osteoradionecrosis [130]. Furthermore, speech
they are clinically staged as I or II, than patients and ability to swallow are often more severely
who develop clinically apparent metastases after affected with radiation therapy. These adverse
treatment with the ‘‘wait and see’’ approach. The reactions lead to a protracted recovery that likely
latter would be stage IV and would require RND, contributes to the lower quality of life scores
longer intensive care unit admissions, and exceed- that are correlated with radiation therapy
ingly expensive chemoradiation therapy [127]. [46,131,132]. Because surgery is the preferred treat-
Considering that neck failure occurs 20% to ment for primary oral SCC tumors, and SND is
45% of the time in the ‘‘wait and see’’ approach, better tolerated by patients than radiation therapy,
one might expect the overall economic burden to it is sensible to prescribe SND rather than
be larger in this group. Further investigation is radiation therapy for the N0 neck in oral SCC.
needed to clarify this issue. Despite treatment with curative intent, oral
SCC has a relatively high recurrence rate [133].
The use of radiation therapy as a primary therapy
Summary
precludes its future use as adjunctive or salvage
In light of recent quality of life studies, SND is therapy. Surgery in an irradiated field is a consid-
much less morbid than RND. In long-term erable challenge, making the salvage surgery more
studies, quality of life in patients who undergo difficult and complicated. Reserving radiation
SND is equivalent to that of patients who did not therapy to the neck for oral SCC for adjunctive
undergo neck dissection. Therefore, the decision or second-line therapy makes sense.
tree analysis which analyzed the threshold for Probably the most important reason to choose
elective RND use, should be revisited to set a new surgery over radiation therapy to treat the
and likely lower threshold for elective treatment N0 neck is the staging information that histo-
with SND. In addition, given the inability to pathologic review of the neck specimen provides
accurately assess risk for neck metastasis using [134,135]. Although the accuracy of lymph node
clinical, histopathologic, radiologic, or molecular staging has limitations, the histopathologic review
techniques; the added morbidity of the ‘‘wait and of the neck is still invaluable. The presence of ex-
see’’ approach; and the effectiveness of SND in tracapsular spread and multiple occult nodes can
preventing neck failure in a randomized clinical significantly alter prognosis and signals the need
trial, the authors believe that elective neck for additional treatment [24,56].
 MANAGEMENT OF THE N0 NECK 489

Extent of neck dissection wherein metastatic tumors could ‘‘skip’’ the upper
echelon of nodes (ie, the jugulodigastric or
Since Crile’s [136] description of the RND in
submandibular nodes) and be found in the midju-
1905 and 1906, treatment of the neck has become
gular chain. These skip metastases were not found
less radical and more conservative, such as spar-
in the lower jugular chain (level IV) or in the
ing nonlymphatic structures (spinal accessory
posterior triangle of the neck (level V).
nerve, sternocleidomastoid muscle, and internal
Several subsequent studies have confirmed
jugular vein) and decreasing the number of levels
Lindberg’s observations. In a series of 1119
of neck lymphatics removed [18,38]. The clinical
RNDs for primary oral SCC tumors, Shah and
significance is a marked reduction in postopera-
colleagues [19] found that level V nodes were
tive morbidity, particularly with avoiding sacrifice
never involved when levels I through IV were neg-
of the spinal accessory nerve and preventing
ative. Similarly, in a cohort of 1123 patients who
trauma to this nerve by foregoing dissection of
had head and neck SCC, Davidson and colleagues
the posterior triangle [48]. Currently, SND of
[138] reported that only 1% of patients staged
levels I through III is the most frequently used
clinically as N0 had metastasis to level V. In
surgical option to treat the N0 neck in patients
2004, Dias and colleagues [139] published a series
who have oral SCC [19]. Fig. 2 illustrates the
of 339 patients in which only 1.5% who had
levels of neck as classified in 2002 by Robbins
N0 necks had skip metastasis to level IV, and
and colleagues [137].
none had skip metastases to level V.
This selectivity is based on the observation that
In addition to these findings on the patterns of
oral SCC follows predictable patterns of lym-
cervical metastasis, several groups have shown the
phatic metastasis [8,19,138–141]. Lindberg’s [140]
efficacy of SND in treating the N0 neck [8,54,59].
classic study in 1972 showed that in primary
This efficacy has been shown to be comparable to
SCC tumors of the oral cavity, neck metastases
RND [30,33,142,143].
could be found in the submandibular triangle,
submental triangle, upper jugular chain, and
midjugular chain of lymph nodes. Lindberg also Level IIB
described the prevalence of ‘‘skip metastases,’’
In an effort to further delineate the selectivity
of elective neck dissection, the inclusion of sub-
levels of the neck has been debated. In 2002,
a reclassification of the neck dissection was
published that divided level II into IIA and IIB
using the spinal accessory nerve as the dividing
line, and level V into VA and VB using a horizon-
tal plane that crosses the inferior border of the
anterior cricoid arch as a dividing line (see Fig. 2)
[137].
The purpose of this reclassification was to
distinguish sublevels IIB and VA for potential
preservation, based on the premise that IIB nodes
(also known as the supraretrospinal triangle,
supraspinal accessory lymph node pad, or submus-
cular recess) were rarely involved in occult metas-
tasis and that dissection of those nodes may lead
to traction of the spinal accessory nerve and
subsequent shoulder dysfunction [50].
Several studies have confirmed that occult
metastases to level IIB are rare. Silverman and
colleagues [144] only found 1.6% of 74 patients
Fig. 2. Illustration of the levels and sublevels of the who had IIB metastasis. Elsheikh and col-
neck. Notice that level II is divided into IIA and IIB leagues [145] found no positive IIB nodes using
by the spinal accessory nerve and level V is divided by reverse transcriptase polymerase chain reaction
a horizontal plane from the inferior border of the cricoid molecular techniques, except in SCC of the
arch into VA and VB. oral tongue. In this subsite, they found that
490 CHENG & SCHMIDT

10% of patients had molecular evidence of Sentinel node biopsy

tumor cells in IIB nodes. Lim and colleagues
Perhaps the best example of the shift toward
[146] also only found 5% of metastasis to this
ultra-selectivity in managing the N0 neck is the
level in 74 patients.
advent of the sentinel node biopsy. This technique
Contemporary practice at the University of
involves injection of radiolabeled tracer around
California, San Francisco (UCSF) is still to
the periphery of the tumor, allowing the tracer to
includes level IIB in the neck specimen. The
drain through the lymphatic system to the first
clinical reasoning behind this approach is that
echelon of nodes. The sentinel nodes are delin-
no significant amount of shoulder dysfunction has
eated with a gamma probe, followed by their
been seen from including this level, nor have any
surgical removal in a manner that preserves
quality of life studies evaluated the benefits of
oncologic safety. After excision, the nodes are
preservation of level IIB. However, dissection of
examined initially with frozen section. If micro-
level IIB in the setting of recurrence will certainly
metastases are identified, patients undergo SND.
be much more difficult than addressing this area at
Postoperatively, the nodes from the permanent
initial surgery. Therefore, the authors recommend
specimen are examined thoroughly with serial
that IIB nodes be included in SND.
sectioning, as opposed to bisectioning, which is
the technique typically used to sample lymph
Level IV
nodes for histopathologic review. If micrometa-
Some controversy also surrounds the inclusion stases are located in the permanent serial sections,
of level IV nodes in the SND. Although several patients return to the operating room for a con-
groups have shown that level IV nodes are rarely ventional SND, if not already performed [149].
involved in skip metastases [8,139], others have This technique, which has been used effectively
found the opposite [147]. Byers and colleagues to treat melanoma and breast cancer, shows great
[147] found that skip metastases to level IV promise for treating the neck in oral SCC
occurred at the alarming rate of 15.8%. Some of [150,151]. Preliminary results from a multicenter
these differences may be caused by the anatomic trial in 2004 were favorable [152]. In addition,
variability of the omohyoid muscle position, a recent clinical trial published by Stoeckli and
which is commonly used to determine the inferior colleagues [149] showed that the use of sentinel
border of level III and superior border of level IV node biopsy had very high sensitivity and specific-
[148]. ity for detecting occult metastases, with a false-
The current practice within the Department of negative rate of only 6%. Furthermore, in nine
Oral and Maxillofacial Surgery at UCSF is to not patients (13%) who had laterally located floor of
include level IV in SND. However, level IV is mouth and oral tongue SCC, use of sentinel
examined clinically in situ during surgery. If node biopsy identified drainage to contralateral
physical findings suggesting metastasis are noted, nodes and level IV nodes, regions that would
such as nodal induration or enlargement, level IV not have been addressed with a conventional
is included with the specimen. The rationale SND.
behind this approach is twofold. First, in this Despite this promise, some concerns have been
department’s experience, skip metastasis to level raised regarding the use of sentinel node biopsy.
IV has not been observed and dissection of these One criticism is that the radiolabeled tracer
nodes is of low yield. Second, dissection of level injected into an oral SCC tumor, especially
IV may damage the phrenic nerve and, when tumors of the floor of mouth and oral tongue,
operating on the left, the thoracic duct. would obscure gamma probe readings in the first
echelon nodes because of their proximity to the
primary tumor, negating any benefit from the
Bilateral neck dissection
exercise. Stoeckli and colleagues [149] circum-
Contralateral occult metastasis is also ob- vented this problem by going against conventional
served, particularly in tumors that encroach on practice and excising the primary tumor first,
the midline [140]. Prescribing a bilateral SND is before the sentinel nodes were marked out and
recommended for patients who have oral SCC addressed.
that violates the midline [137], including any Another criticism is that if micrometastasis is
SCC tumor requiring a wide resection that crosses detected later, only after serial sectioning of the
the midline to achieve a 1-cm margin. permanent specimen, patients would be subjected
 MANAGEMENT OF THE N0 NECK 491

to a second surgery. Knowing the high rates of squamous cell carcinoma. Int J Oral Maxillofac
occult metastasis, this would likely result in 20% Surg 2003;32(1):30–4.
to 45% of patients requiring second surgeries. [2] Shah JP, Johnson NW, Batsakis JG. Oral cancer.
Studies evaluating this technique are generally London New York: Martin Dunitz; Distributed
in the United States by Thieme New York; 2003.
small; more are needed before the efficacy of
[3] Parkin DM, Pisani P, Ferlay J. Global cancer
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It seems unlikely that removing level I and II prediction for patients with cancer. Cancer 1992;
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performing two separate operations instead of omohyoid neck dissection in the treatment of head
one. Although sentinel node biopsy is certainly and neck tumors. Survival results in 212 cases. Arch
very promising and warrants further investiga- Otolaryngol Head Neck Surg 1993;119(9):958–63.
[6] Leemans CR, Tiwari R, Nauta JJ, et al. Regional
tion, it is still too early to recommend it as
lymph node involvement and its significance in
a treatment for the N0 neck except in select cases. the development of distant metastases in head
Summary and neck carcinoma. Cancer 1993;71(2):452–6.
[7] Shah JP, Andersen PE. Evolving role of modi-
The, surgical management of the N0 neck is fications in neck dissection for oral squamous
ideally performed through SND of levels I carcinoma. Br J Oral Maxillofac Surg 1995;33(1):
through III. Level IIB should be included in this 3–8.
dissection, because it does not add significant [8] Clark JR, Naranjo N, Franklin JH, et al. Estab-
lished prognostic variables in N0 oral carcinoma.
morbidity to the surgery. Level IV should be
Otolaryngol Head Neck Surg 2006;135(5):748–53.
spared because removing this level is of low yield
[9] Lavertu P, Adelstein DJ, Saxton JP, et al. Manage-
and may damage the phrenic nerve and possibly ment of the neck in a randomized trial comparing
the thoracic duct if operating on the left neck. concurrent chemotherapy and radiotherapy with
radiotherapy alone in resectable stage III and IV
Conclusion squamous cell head and neck cancer. Head Neck
1997;19(7):559–66.
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[12] Partridge M, Brakenhoff R, Phillips E, et al. Detec-
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SCC, should undergo elective treatment of the Detection of minimal residual cancer to inves-
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radiation therapy and because the treatment of adequate treatment. Clin Cancer Res 2000;6(7):
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[14] Slootweg PJ, Hordijk GJ, Schade Y, et al. Treat-
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 499–511

Management of the Node-Positive Neck in Oral Cancer

Dimitrios Nikolarakos, BDSc, MBBS, FRACDS(OMS)a,
R. Bryan Bell, DDS, MD, FACSa,b,*
a
Oral and Maxillofacial Surgery Service, Legacy Emanuel Hospital and Health Center,
2801 N. Gantenbein Avenue, Portland, OR 97227, USA
b
Department of Oral and Maxillofacial Surgery, Oregon Health & Science University,
611 S.W. Campus Drive, Portland, OR 97201, USA

It has long been established that cancer of the removed in the RND, the procedure is termed
upper aerodigestive tract metastasizes to the re- modified RND (MRND). This remains a com-
gional lymphatics of the neck. The presence of prehensive form of neck dissection.
such lymphatic metastasis is one of the most  When the alteration involves preservation of
important negative prognostic indicators, confer- one or more lymph node levels routinely re-
ring approximately a 50% reduction in cure rates moved in the RND, the procedure is termed
compared with those obtainable if such metasta- selective neck dissection (SND). This is there-
ses are not present [1–5]. The treatment of patients fore a less than comprehensive form of neck
with clinical or radiographic evidence of cervical dissection.
metastasis has traditionally been surgical. More  When the alteration involves removal of addi-
recently, this has been extended to include roles tional lymph node groups or nonlymphatic
for adjuvant radiotherapy and chemoradiother- structures relative to the RND, the procedure
apy. In the treatment of some oropharyngeal tu- is termed extended neck dissection.
mors, chemoradiotherapy is used primarily with
surgery reserved for salvage of regional failure. Comprehensive neck dissections
If modern oncologic principles are to be
Surgical therapy followed, the safest surgical procedure for man-
agement of cervical lymph node metastasis from
Neck dissection classification
oral cancer is the removal of the diseased nodal
Robbins and colleagues [6] outlined the con- group and the comprehensive clearance of all
ceptual guidelines for neck dissection classification: remaining lymphatics on the affected side of the
neck (ie, levels I through V).
 The radical neck dissection (RND) is the stan-
dard procedure for the comprehensive re- Radical neck dissection
moval of at-risk lymph node groups (levels The first cervical lymphadinectomy procedure
I–V) and all other procedures represent alter- was described in Europe as early as 1888 [7]. The
ations to this procedure. procedure was popularized by Crile [8] in a 1906
 When the alteration involves preservation of publication, when it was first termed the RND.
one or more nonlymphatic structures routinely The RND involves the en bloc removal of all
five lateral lymph node levels along with the re-
moval of the sternocleidomastoid muscle (SCM),
Received from: Oral and Maxillofacial Surgery
Service, Legacy Emanuel Hospital and Health Center,
the internal jugular vein (IJV), and the spinal ac-
Portland, Oregon. cessory nerve (SAN). Bears and Martin helped
* Corresponding author. 1849 NW Kearney, Suite to further establish the procedure and widen its
300, Portland, OR 97209 use in the 1950s. The RND became the most ex-
E-mail address: [email protected] (R.B. Bell) tensively used surgical procedure through the
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.03.005 oralmaxsurgery.theclinics.com
500 NIKOLARAKOS & BELL

1950s and into the 1960s for cervical metastases, extensive studies of the lymphatic drainage
and was shown to confer a survival benefit. It is pathways and patterns of cervical metastatic
still considered the gold standard by which all spread, has given theoretic merit to the concept
other interventions are measured. of a more selective neck dissection, even in the
presence of clinically evident neck disease
Modified radical neck dissection [2,4,16–18]. It is now well appreciated that oral
The cosmetic deformity and significant shoul- cancer has a predilection for spread to levels I
der disability associated with the removal of through III and rarely to level IV and V, in
the SCM, IJV, and SAN [9] prompted Suárez the absence of concurrent involvement of levels
[10,11], Bocca and Pignataro [12] to introduce I through III [19–21]. Furthermore, in the pres-
modifications to the RND. The rationale for these ence of metastasis in levels I through III, the
modifications is that the fibrofatty lymph node– risk of disease in level IV increases from 3%
containing tissues lie within fascial layers that to 17%, but the risk of level V involvement
invest these structures. The dissection can be remains less than 3% [19]. It is logical, there-
maintained within these planes, essentially skele- fore, to conclude that it is safe to dissect only
tonizing the SCM, IJV, and SAN, thus not violat- levels I through III in oral cancer with clinically
ing the oncologic principal of comprehensive en N0 necks and levels I through IV if there is clin-
bloc lymphadenectomy. Each of these structures ically evident nodal disease in levels I through
can be preserved if they are not directly involved II.
by tumor. No prospective randomized controlled studies
The work of Bocca and colleagues [13] and have been performed to test the efficacy of the
Byers [14] established that the MRND is as effec- SND compared with comprehensive types of neck
tive as the RND in the treatment of cervical me- dissection in the clinically Nþ neck. All studies
tastasis and this has become the accepted currently available are small retrospective case
standard for the treatment of all but the bulkiest series with the expected lack of statistical power
neck disease that directly involves the SCM, IJV, and potential for selection bias. They are further
and SAN [15]. confounded by the range of protocols that exist
There are many classifications of modified for nodal levels to be dissected and administration
neck dissection. Each of the three simplest pre- of adjuvant radiotherapy. It is unlikely that an
serves one, two, or all three nonlymphatic struc- appropriately prospective randomized study will
tures. Type I MRND preserves the SAN; type II ever be undertaken given the large number of
MRND preserves the SAN and IJ; and type III patients that would be required to provide statis-
MRND preserves the SAN, IJV, and SCM. tical significance.
In 1985, Byers [14] reviewed 967 cases that
Selective neck dissection (less than comprehensive)
underwent modified neck dissection (including
To further ameliorate the morbidity of thera- supraomohyoid neck dissection). When radiation
peutic neck dissection, surgeons have introduced therapy was administered to patients with a patho-
an even more conservative approach, which is logically positive node larger than 3 cm, extracap-
aimed at removing only the affected lymph nodes sular disease or multiple involved nodes, the
along with the nodal groups at most risk of also overall recurrence rate for the modified proce-
containing micrometastsis. SND was discussed as dures were similar to that previously reported
early as the 1960s [15]. It has been extensively in- for RND. He concluded that supraomohyoid
vestigated for the management of the clinically neck dissection (SOHND levels I–III) is adequate
negative neck (N0) in oral cancer and has become for early stage disease if postoperative radiother-
the standard of care in this setting. The applica- apy is administered for ECS or if multiple levels
tion of this therapy in the management of clini- are involved. Kowalski and Carvalho [22] ana-
cally evident cervical metastasis (node-positive or lyzed 164 oral cavity cancer patients with clini-
Nþ neck) is far more controversial. The SND cally N1 and N2 necks who were submitted to
contravenes the oncologic principal of en bloc therapeutic RND. The investigators found that
lymphadenectomy with the division of lymphatic 42.1% of these necks turned out to be
channels and the retention of nodal groups that pathologically N0. Of those clinically N1, 57.4%
are potentially diseased by tumor cells. were actually pathologically N0. Only 1 patient
The current understanding of the embolic with multiple positive nodes had a metastatic
nature of tumor metastasis, along with the node in level IV while none had positive nodes
 MANAGEMENT OF NODE-POSITIVE NECK IN ORAL CANCER 501

in level V. These patients would therefore have postoperative radiotherapy was administered for
been candidates for SOHND. histologic evidence of multiple levels of nodal in-
A 1989 series by Medina and Byers [23] in- volvement or the presence of ECS. ECS was found
cluded 114 patients who were clinically Nþ. in 34% of patients and was correlated with recur-
Most were N1. Of these, only 79.8% actually rence in the neck (2.4% if no evidence of ECS
had pathologic evidence of metastasis. SND alone versus 21.9% if ECS was present) and 5-year dis-
had a neck recurrence rate of 10% in the patho- ease-specific survival (75.3% versus 55.8% respec-
logically N1 necks without ECS and 24% if mul- tively). The overall regional control rate was
tiple nodes or ECS was present. Postoperative 94.3%. All ipsilateral recurrences occurred within
radiotherapy reduced this to 15%. the field of dissection (none outside the expected
Chepeha and colleagues [24] analyzed a group drainage pathway and none in level V). The inves-
of 52 patients undergoing 58 SNDs. Twenty-six tigators recommended that SND was appropriate
were clinically N0 and 26 were clinically Nþ. in selected patients with N1 and N2 disease. They
Postoperative radiation was administered if more recommended comprehensive neck dissection in
than two nodes were found involved on patho- the presence of massive adenopathy, evidence of
logic examination, if ECS was present, or if the nodal fixation, or obvious ECS, a history of
primary was staged as T3/4. The neck recurrence neck surgery, and radiotherapy. In addition, the
rate was 6% and was considered comparable to surgeon should be prepared to alter the plan for
the recurrence rate reported in the literature for unexpected findings, such as involvement of IJV,
MRND with similar indications for radiotherapy. SCM, and SAN, and if suspicious nodes are en-
Two of the 6 patients with neck recurrences had countered in lower levels.
those recurrences outside the dissected field. In Controversy also exists over the appropriate
a similar study, Traynor and colleagues [25] re- extent of SND. Byers and colleagues [30] found
viewed 29 patients who had 36 SNDs for clinically that 15% of patients with oral tongue cancer pre-
and pathologically Nþ (N1 to N2c). Twenty pa- sented with only level III or IV disease. This was
tients underwent postoperative radiotherapy for confirmed by Woolgar [31], who found the inci-
similar indications. The 4-year regional failure dence of skip metastasis to level IV to be 10%.
rate was 4%. No recurrences occurred outside Shah [1] found a 15% incidence of positive nodes
the dissected field. in level IV in clinically positive necks treated with
In a 1996 study, Ambrosch and colleagues [26] MRND. As SND limited to levels I through III
reported on 167 patients who underwent SND. may not remove these nodes, leading to inade-
They found a neck recurrence rate of 6.6% for quate staging and perhaps undertreatment if the
patients with pathologically Nþ necks. More re- indications for radiotherapy are based on the
cently, the same group reported on SND for clin- number of nodes found to be diseased. Based on
ically N0 and pathologically Nþ in 503 patients. this data, dissection of levels I to IV would be
The 3-year neck recurrence rates were 4.7% path- most appropriate for management of the Nþ
ologically N0, 4.9% for pathologically N1, and neck in oral cancer.
12.1% for pathologically N2. Postoperative radio- Furthermore the role of postoperative radio-
therapy trended to improve the recurrence rate in therapy, especially when only one pathologic node
N1 and definitely improved the recurrence rate in is detected (N1), is unclear. There is no consistent
patients with multiple positive nodes or those with interinstitutional protocol for the use of radio-
ECS [27]. therapy in the pathologically N1 neck.
Pelliteri and colleagues [28] reported on a re- Byers and colleagues [32] analyzed 363 patients
view of 82 patients undergoing 94 SNDs for clin- who underwent SND for necks that were clinically
ically N0 to N3 disease using similar indications N0, N1, N2a, or N2b. The recurrence rate
for postoperative radiotherapy. The recurrence reported was 35.7% in the N1 necks not treated
rate for pathologically N2 and above was 11.5% with postoperative radiotherapy. This was re-
despite the presence of ECS. In addition, this re- duced to 5.6% when radiotherapy was under-
currence rate was not statistically different to taken. The recurrence rate for N2b necks
that found in the N1 cohort (12.5%). dropped from 14% to 8.3% with radiotherapy.
In a 2002 multi-institution study, Anderson They concluded than the SOHND in conjunction
and colleagues [29] reviewed 129 patients with with postoperative radiotherapy is highly effective
both clinically and pathologically positive necks in controlling neck metastasis in patients with
(N1 to N2c). All underwent SND and limited disease in the neck.
502 NIKOLARAKOS & BELL

In a retrospective study of 176 patients, Mu- comprehensive forms of neck dissection. While
zaffar [33] found no statistical difference in the MRND is definitely an improvement over RND,
incidence of recurrence and disease-free survival patients undergoing MRND have been shown to
between matched cohorts with pathologically have significantly worse shoulder function than
Nþ necks treated with SND, MRND, and those undergoing SND [39–41].
RND. All patients had postoperative radiother- The body of evidence now available supports
apy. Spiro and colleagues [34] reported on 296 the use of SND for the management of N1 and N2
SOHNDs performed for clinically N0 and N1 dis- neck disease from oral squamous cell carcinoma
ease. All underwent postoperative radiotherapy. and limited to one or two levels. Disease control is
Of the pathologically N0 necks, 5% failed in the comparable to that achieved with comprehensive
neck. Six percent of pathologically Nþ necks neck dissections with significantly reduced mor-
failed. Only 1 recurrence occurred outside the dis- bidity. The dissection should include levels I to IV
sected field. They also concluded that the to remove the most at-risk nodes. It is unnecessary
SOHND in conjunction with postoperative radio- to extend the dissection to level V because of the
therapy was highly effective in controlling neck very low risk of metastasis to these nodes. Post-
metastasis in patients with limited disease in the operative radiotherapy is strongly recommended
neck. for disease N2 and above if multiple levels are
In a 2005 study, Schiff and colleagues [35] in- involved or if there is evidence of ECS. There is
vestigated the effectiveness of SND versus some evidence to support the use of adjuvant
MRND in 220 patients with squamous cell carci- radiotherapy for isolated N1 disease, although
noma of the oral tongue. They found no signifi- more research is required to clarify this further.
cant difference in the neck recurrence rate SND is not recommended in the presence of
between the two procedures. There was, however, massive adenopathy. Relative contraindications
selection bias in that there was a much larger tu- include nodal fixation, gross ECS, and a history of
mor burden in the final pathology of those patients neck surgery and radiotherapy. The surgeon
selected for MRND (78.9% pathologically N2b or should be prepared to extend the neck dissection
greater) compared with those selected for SND to include resection of nonlymphatic structures
(40% N2b or greater). Of the cohort with N2 or found to be invaded by tumor intraoperatively.
greater disease, 4 of 16 SND had regional failure This would include tumor adhesion to the IJV,
while none of 14 MRND had recurrence. They SCM, or SAN.
were otherwise matched for ECS and radiother-
apy. The investigators suggest that while SND
Postoperative chemoradiotherapy
may be effective treatment for many Nþ necks,
for advanced-stage squamous cell carcinoma
more aggressive surgery and adjunctive therapies
may be required for significant tumor burden. In Until recently, primary surgery of locally
addition to this, they found that, of the N1 cohort advanced head and neck squamous cell carcinoma
(50 patients), 2 of 25 that did not have radiother- was traditionally followed by postoperative ra-
apy had regional failure while none of the 25 diotherapy alone. Despite such relatively aggres-
that did have radiotherapy failed. They concluded sive bimodality treatment, this approach yielded
that all Nþ necks should receive radiotherapy. loco-regional recurrence of 30%, distant metasta-
ECS is a significant negative prognostic in- sis of 25%, and 5-year survival rates of 40%. In
dicator associated with increased local recurrence 2004, the European Organization for Research
rate and decreased disease-free survival. The in- and Treatment of Cancer (EORTC) and Radia-
cidence of ECS increases to 75% in positive nodes tion Therapy Oncology Group (RTOG) published
larger than 3 cm [36–38]. With the paucity of data the results of two randomized trials (EORTC trial
available regarding the use of SND in nodes larger #22,931 and RTOG trial #9501) that evaluated
than 3 cm in mind, most investigators continue to the role of concomitant chemotherapy-enhanced
support the role of MRND over SND in the radiation therapy (CERT) in the postoperative
treatment of bulky nodal disease. setting for this group of patients [42,43]. Level I
Recent quality-of-life studies have confirmed evidence was reached with the publication of the
the improvement in shoulder function and post- results of these two studies, which, except for the
operative pain with the more conservative types of primary endpoints chosen and definition of high
neck dissection, which is ultimately the motivation risk, had been designed similarly. Both trials dem-
for the drive toward the use of SND over the onstrated that, compared with postoperative
 MANAGEMENT OF NODE-POSITIVE NECK IN ORAL CANCER 503

radiation alone, adjuvant CERT was more effica- to postoperative radiotherapy for patients with re-
cious in terms of loco-regional control and dis- sectable head and neck cancer considered at high
ease-free survival. However, there is some risk for cancer recurrence [47]. Sizeable differences
discordance between the trials in terms of overall in acute severe adverse events with chemor-
survival in that the EORTC study revealed adiotherapy compared with radiotherapy alone
a highly significant difference in overall survival, were observed in some studies (77% versus 34%,
whereas the RTOG trial showed only a marginal P ¼ .0001). The most common grade-adverse
improvement. Both studies compared the addition events were mucositis or dysphagia, followed by
of concomitant relatively high doses of cisplatin various hematologic events and nausea and vom-
(100 mg/m2 administered intravenously on days iting. Treatment-related deaths occurred in 1% to
1, 22, and 43) to radiotherapy versus radiotherapy 2% of the patients.
alone given after surgery in patients with high-risk With regards to the neck, the data support the
cancers of the oral cavity, oropharynx, larynx, or use of postoperative chemoradiotherapy for the
hypopharynx. purpose of achieving better local-regional control
To clarify the differences between the RTOG and improving survival when compared with
and EORTC trials, a comparative analysis of the adjuvant radiotherapy alone. However, the data
selection criteria, clinical and pathologic risk also suggest that patients with two or more
factors, and treatment outcomes was performed positive lymph nodes as a solitary risk factor
using data pooled from both studies [44]. Extrac- might benefit less from chemoradiotherapy, with
apsular extension (ECE) and/or microscopically the corollary that nodal burden as assessed by
involved surgical margins were the only risk fac- tumor-node-metastasis (TNM) stage might better
tors for which the impact of CERT was significant identify patients benefiting from combined-mo-
in both trials. There was also a trend in favor of dality therapy. Therefore, patients with solitary
CERT in the group of patients who had stage nodal disease (N1) may not benefit from the addi-
III or IV disease, perineural infiltration, vascular tion of chemotherapy, given the associated toxic-
embolisms, or clinically enlarged level IV or V ity, if no additional adverse histopathologic
lymph nodes secondary to tumors arising in the features are present (ECE, positive resection mar-
oral cavity or oropharynx. Patients who had two gins, or perineural invasion).
or more histopathologically involved lymph nodes Fig. 1 provides a treatment algorithm for the
without ECE as their only risk factor did not seem management of cervical metastasis from oral
to benefit from the addition of chemotherapy in squamous cell carcinoma.
this analysis. Subject to the usual caveats of retro-
spective subgroup analysis, the data suggested
Management of the node-positive neck in organ
that in locally advanced head and neck cancer, mi-
preservation treatment regimens
croscopically involved resection margins and ECS
of tumor from neck nodes are the most significant To preserve organ function (eg, base of tongue,
prognostic factors for poor outcome. The addi- oropharynx, and larynx), concurrent chemoradia-
tion of concomitant cisplatin to postoperative tion has become routine as the primary treatment
radiotherapy otherwise improved outcome in pa- of some advanced-stage head and neck cancers.
tients with one or both of these risk factors who When chemotherapy is combined with radiother-
were medically fit to receive chemotherapy. apy to avoid surgery, it achieves comparable local
It is clear that the addition of chemotherapy to control and overall survival compared with radical
radiotherapy exacts a cost of increased toxicity resection and postoperative radiotherapy without
and potential long-term effects that may make this the considerable loss of quality of life, diminished
approach unfeasible for many patients. As toxic oral function, and changes in facial appearance
deaths can occur, patients must be properly associated with this type of surgery [48–51].
selected for combined-modality treatment, be Additional surgical management of the posi-
monitored closely, receive appropriate drug-dose tive neck when chemoradiotherapy is used as the
reductions, and be provided with optimal sup- primary treatment modality is controversial.
portive care. An additional meta-analysis pub- Experience with conventional single-modality ra-
lished in 2007 pooled the evidence from four diotherapy yielded lower regional control rates of
existing randomized trials [42,43,45,46] studying N2 and N3 neck disease than those for combined
nearly 1000 patients. This meta-analysis also sup- surgery and radiotherapy. Surgical salvage of
ported the addition of concomitant chemotherapy recurrence was very difficult and rarely achieved.
504 NIKOLARAKOS & BELL

Monitor

pN1 T3/4 primary or

+ resection
margins
N1/N2 SND (I-IV)
or MRND Radiotherapy

pN2
Clinically Risk factors:
N+ + resection
Neck margins
and/or ECS

Chemo-
radiotherapy
N3 or
<N3 with:
Gross ECS MRND or RND
Fixation
Past neck surgery
or radiotherapy

Fig. 1. Management of the clinically positive neck. pN, pathologic N stage.

These results were influential when guidelines insignificant, rate of regional recurrence following
were being developed for the management of apparent complete clinical response to chemora-
advanced nodal disease when organ preservation diotherapy. Up to 65% of these patients are sub-
protocols were introduced. sequently deemed not to be candidates for salvage
Generally, patients with initial N1 necks do surgery because of comorbidities or the presence
not require neck dissection unless there is evidence of unresectable disease. Salvage surgery is also
of persistent disease after the chemoradiotherapy. more difficult to perform because of extensive ra-
Similarly, it is agreed that partial responders to diation-induced soft tissue changes and generally
the initial therapy based on clinical and radiolog- has a very poor prognosis [52–58].
ical evidence of residual disease should proceed to The many interinstitutional variations in treat-
neck dissection. ment protocols and limited numbers of patients
The options for N2 and N3 neck disease that treated in individual centers have resulted in
has had a complete response to chemoradiother- a paucity of studies of sufficient quality and power
apy are planned neck dissection (either pre- or to define the role of neck dissection in patients
postchemoradiotherapy) or a watch-and-wait pol- with bulky neck disease who have had a complete
icy with surgery reserved for salvage of recurrent clinical response to chemoradiotherapy. There
neck disease. appears, however, to be a trend in the available
Many cancer centers recommended neck dis- research supporting a more conservative ap-
section for all N2 and N3 disease post–organ- proach to this conundrum.
sparing therapy regardless of response. This was Whether neck dissection postchemoradiother-
in part due to the fear of higher recurrence rates, apy provides better regional control compared to
borne out of the data on the use of radiotherapy chemoradiotherapy alone is debatable. Overall
alone for neck disease mentioned previously. survival in these patients with N2 or N3 disease
Additionally, studies emerged that demonstrated is similar regardless of the addition of neck
a high rate of identifiable tumor cells in the lymph dissection and reflects the high incidence of
nodes removed during planned neck dissection in distant metastasis associated with such advanced
patients who had a complete clinical and radio- disease [59,60].
logical response to the initial therapy. No clinical Some patients who have undergone neck
parameters were identified that could reliably dissection following complete clinical response
predict which of the complete clinical responders have been found to have residual nodal disease,
would have pathologically evident residual disease but it is questionable whether the tumor detected
[7–13]. Furthermore, there is a small, but not an is viable [58]. Despite this, the regional control
 MANAGEMENT OF NODE-POSITIVE NECK IN ORAL CANCER 505

rates for chemoradiotherapy alone seem compara- disease-free survival benefit (P ¼ .08) for complete
ble to those achieved with the addition of surgery. responders who underwent neck dissection. These
Armstrong and colleagues [61] reported on a se- investigators recommended routine planned neck
ries of 54 patients with Nþ cancer treated with in- dissection for all patients undergoing primary
duction chemotherapy followed by radiotherapy. chemoradiotherapy.
Seventeen of 44 patients with complete clinical The reported complication rates from a neck
response did not proceed to planned neck dissec- dissection after concurrent chemoradiotherapy
tion. Only 1 patient had a neck recurrence and ranged from 26% to 61%. The rate is highest in
the neck control rate in this cohort was 94%. Gar- the first year postoperatively (77% compared with
den and colleagues [62] reported no neck recur- 20% after the first year) [66]. Mostly this reflects
rences in 27 patients who completely responded poor wound healing [53,66,67]. Such serious surgi-
to chemoradiotherapy. Similarly, Robbins and cal morbidity is difficult to justify given the un-
colleagues [63] reported that 33 of 56 (59%) necks proven benefits of neck dissection in patients who
had complete response to chemoradiotherapy. have had a complete response to chemoradiation.
There were no recurrences in the 17 of these that The current standard of care is to recommend
did not proceed to neck dissection. Interestingly, neck dissection for patients with N1 or N2 neck
of the 16 complete responders who had neck dis- disease with only partial or no response following
sections, none had residual disease, and, of the chemoradiotherapy. The literature presented
18 partial responders, only 14 (78%) had patho- above supports a watch-and-wait approach for
logically positive nodal disease [63]. Corry and those patients determined to have had a complete
colleagues [64] reported on 25 complete re- clinical response. Patients with N3 disease may
sponders who did not undergo neck dissection. have a survival benefit from planned neck
None of these responders developed recurrence, dissection regardless of complete response to
supporting the watch-and-wait approach in these chemoradiotherapy.
patients. Methods available to assess response include
Stenson and colleagues [58] reported on 69 pa- physical examination and diagnostic imaging.
tients who had neck dissections after chemoradio- Physical evaluation is often inaccurate because
therapy. Thirty-five percent had pathologically of the presence of soft tissue fibrosis and scarring
residual disease that did not correlate with the of the neck mass posttreatment. As discussed,
clinical or radiographic response. Clayman and neck dissections in patients with clinically com-
colleagues [65] found that 36% of 66 patients plete response have detected residual tumor.
had complete response to chemoradiotherapy. Conversely, 55% of partial clinical responders
These patients had better regional control than have had negative necks pathologically [68].
did partial responders. Of the partial responders, CT, MRI, and ultrasound imaging modalities
those who proceeded to neck dissection had im- also have significant error rates [68]. False-positive
proved regional control and overall survival rates for CT evaluation of nodal status have been
than those who did not. reported in up to 57% of cases. MRI does not
In 2004, Argiris and colleagues [59] reported seem to add further diagnostic accuracy in pre-
on 131 patients with N2 or N3 neck disease dicting the presence of residual tumor [68–79].
treated with chemoradiotherapy. Ninety-two Physiologic posttreatment imaging with positron
(70%) had a clinically complete response and 62 emission tomography may become the most use-
of these received a neck dissection. There was no ful modality to detect the presence of viable resid-
significant difference in the regional recurrence ual disease. Sensitivity in detecting recurrent
rate between those complete responders who had disease of 96% and negative predictive values of
a neck dissection and with those who did not. In 83% to 91% have been reported [71–74]. The op-
the N3 group, regardless of response, there was timal standardized uptake value threshold has not
a trend toward improved survival with neck dis- been established to take into account the inflam-
section. The investigators concluded that there matory changes caused by the chemoradiation.
was benefit in neck dissection for patients with Similarly, the optimal timing of such a scan to
N3 disease but that planned neck dissection for ensure resolution of the inflammation and still al-
patients achieving complete response to chemora- low for early detection of residual disease is yet to
diotherapy conferred no additional benefit. be determined. Currently, to assist in deciding
Brizel and colleagues [52] evaluated 108 pa- whether to recommend a follow-up neck dissec-
tients with N2 or N3 disease and found a 4-year tion, it is reasonable is to require a positron
506 NIKOLARAKOS & BELL

emission tomography scan for patients who have occasionally hinders the identification of tumor
had a clinically complete response to chemoradio- invasion radiographically.
therapy at 12 weeks posttreatment [75]. Untreated carcinoma with cervical metastasis
Fig. 2 provides a treatment algorithm for the and direct carotid involvement should be treated
management of cervical metastasis when organ with full-course radiation and chemotherapy.
preservation treatment is undertaken. Often, the response is sufficient to eliminate the
need to sacrifice the carotid artery and the vagus,
hypoglossal, and sympathetic nerves [77].
Carotid artery involvement
The treatment options available for the man-
Involvement of the carotid artery by cervical agement of persistent or recurrent neck disease
metastasis from head and neck cancer imparts an with direct involvement of the carotid artery
extremely poor prognosis. Without treatment, the include supportive/palliative care, surgery, and
tumor invades the arterial wall, which can result chemotherapy. The surgical options are resection
in carotid rupture and fatal exsanguination. The of the carotid artery with or without reconstruc-
patients often suffer from fistula formation and tion or a surgical peel. The decision to proceed
erosion into the pharynx or skin, all of which with carotid artery resection should be made
greatly impact on dignity and quality of life. Total during the treatment-planning phase to allow for
removal of the tumor, including the involved appropriate informed consent and coordination
carotid artery is likely to improve loco-regional of the surgical team.
control. Unfortunately, advanced tumors are Some investigators have argued that peeling
associated with a higher incidence of distant cancer off the carotid violates oncologic principles
metastasis, therefore limiting the impact of such because it leaves microscopic tumor adherent to
aggressive treatment on disease-free survival. the artery with 42% of resected arteries showing
Imaging criteria for carotid artery invasion invasion of the arterial wall [78]. It provides only
have been defined as greater than 25% effacement a very narrow margin of resection and is thought
of the circumference of the artery on CT or the to weaken the arterial wall, predisposing to post-
loss of the fascial plane around the artery on T2- operative rupture [79]. It may, however, be neces-
weighted MRI [76]. The cancer rarely invades the sary in the setting of unexpected involvement
lumen of the artery. Scaring surrounding the ar- without preoperative workup, inability to recon-
tery from previous surgical or radiation therapy struct the artery due to deficient collateral cerebral

Complete response Monitor

PET CT 12
Clinically CR
weeks postop

N1/N2 Disease Incomplete response

Organ Incomplete response Neck dissection

Preservation
Regimen

N3 Disease

Fig. 2. Management of neck metastasis during organ preservation regimens. CR, complete response; PET, positron
emission tomography.
 MANAGEMENT OF NODE-POSITIVE NECK IN ORAL CANCER 507

circulation, and management of unresectable stable may be safer than intraoperative ligation.
disease. The weakened artery should be covered The internal carotid artery is occluded with ra-
with well-vascularized, nonirradiated tissue to diologically guided placement of coils proximal
prevent carotid blowout. to the ophthalmic branch 2 weeks before sur-
Carotid resection remains a controversial gery, allowing for full heparinization, tight
treatment option because of the risk of neurologic blood-pressure control, and fixation of the coils
complications. Reports of the results of carotid to the artery wall. If there is inadequate collat-
resection were disappointing, with rates of neuro- eral cerebral circulation on preoperative assess-
logic complications (permanent hemiplegia, coma, ment and reconstruction is technically not
and death) of about 30% [80,81]. Advances in possible, then nonsurgical means of palliation
cerebral perfusion studies and surgical techniques should be chosen [72].
have resulted in a significant decrease in morbidity Carotid artery reconstruction with vein grafts
and mortality associated with the procedure. The following tumor resection was first reported by
preoperative assessment is aimed at predicting the Conley [85] in 1953. Stoney and Wylie [86] re-
patient’s tolerance of interruption of carotid ported on the use of arterial grafts for reconstruc-
arterial flow. tion in 1970. Lore and Boulos [87] described the
Intraoperative measurement of the internal currently used two-step procedure with bypass
carotid artery stump pressure following tempo- of the affected segment of carotid to allow tumor
rary occlusion of the vessel provides the most extirpation and limit the disruption to cerebral
accurate information on collateral cerebral blood flow, followed by immediate reconstruction of
flow. This can be combined with intraoperative the artery. When carcinoma involves the skull
measurement of somatosensory evoked potentials base, extracranial-intracranial carotid bypass sur-
to detect alteration in brain function during the gery can be undertaken. This can be staged over
occlusion. Patients with stump systolic pressures two separate procedures to minimize the risk of is-
below 50 mm Hg are at high risk of neurologic chemia caused by the temporary occlusion of the
injury if the carotid artery is ligated and carotid middle cerebral artery [88].
reconstruction is indicated [82]. Pressures over 70 In a meta-analysis of the literature reporting
mm Hg are sufficient to allow safe ligation of the outcomes of carotid reconstruction, Katsuno and
artery without adjunctive measures. Patients with colleagues [89] found that the rate of major neuro-
pressures ranging from 50 to 70 mm Hg who un- morbidity was 4.7% and of mortality was 6.8%.
dergo ligation benefit from postoperative heparin- The combined major morbidity and mortality
ization [83]. rate was 10.1%. The overall complication rate is
Carotid backpressure can now be measured 50% [77]. This, they felt, balanced favorably
preoperatively, at the time of angiography, by with the oncologic effectiveness of the procedure,
using a balloon catheter to temporarily occlude with 2-year survival rates reported up to 35%
the artery. This has been supplemented with cold [89]. Whether this translates to a long-term sur-
xenon CT techniques, single photon emission CT vival benefit is unclear, but advocates of this
(SPECT) studies, and positron emission tomo- approach report that carotid resection provides
graphic studies conducted during the balloon improved regional control [81,90].
occlusion test as quantitative measures of cerebral Carotid artery involvement by advanced cervi-
ischemia. deVries and colleagues [82] reported on cal metastasis is associated with a very poor
136 patients who underwent this evaluation, of prognosis. In select cases, resection of the tumor
which 22 had a favorable study and went on to along with the carotid artery is possible and may
have ligation of the carotid artery without provide improvements in local control rates and
complication. quality of life but has not been shown to impart
Chazono and colleagues [84] reported on the a survival benefit. The surgeon and patient must
occurrence of intraoperative cerebral infarctions choose a treatment plan that best balances the
in 2 of 12 patients despite favorable preoperative significant and potentially devastating complica-
studies. This has led some investigators to rec- tions associated with carotid resection surgery
ommend carotid artery reconstruction whenever against the natural progression of the disease if
possible, regardless of balloon occlusion test re- left untreated. When resection of the carotid
sults. When reconstruction is not possible, pre- artery is planned, interpositional grafting should
operative permanent occlusion of the carotid be undertaken whenever possible to minimize
artery while the patient is hemodynamically neuromorbidity.
508 NIKOLARAKOS & BELL

Summary [3] Kowalski LP, Medina JP. Nodal metastases: predic-

tive factors. Otolaryngol Clin North Am 1998;31(4):
With more than 100 years of clinical experi- 621–37.
ence, surgery continues to play a prominent role [4] Woolgar JA, Scott J, Vaughan ED, et al. Survival,
in the management of patients with loco-region- metastasis, and recurrence of oral cancer in relation
ally advanced squamous cell carcinoma of the to pathological features. Ann R Coll Surg Engl 1995;
upper aerodigestive tract. The preponderance of 77(5):325–31.
evidence supports the use of comprehensive neck [5] Layland MK, Sessions DG, Lenox J. The influence
of lymph node metastasis in the treatment of squa-
dissection for Nþ disease. The literature also
mous cell carcinoma of the oral cavity, oropharynx,
supports the use of modified radical neck dissec-
larynx, and hypopharynx: N0 versus Nþ. Laryngo-
tion for all but the most bulky adenopathy (N3 scope 2005;115(4):629–39.
disease) or in the radiated or operated neck. While [6] Robbins KT, Clayman G, Levine PA, et al. Ameri-
there may never be level 1 data specifically can Head and Neck Society; American Academy
comparing comprehensive versus selective neck of OtolaryngologydHead and Neck Surgery.
dissection in the face of cervical metastasis, there Neck dissection classification update: revisions pro-
is evolving evidence that SND clearing levels I posed by the American Head and Neck Society and
through IV results in similar failure rates to those the American Academy of OtolaryngologydHead
of modified RND in patients with N1 or N2 and Neck Surgery. Arch Otolaryngol Head Neck
Surg 2002;128(7):751–8.
disease. The evidence for performing a less than
[7] Ferlito A, Johnson JT, Rinaldo A, et al. European
comprehensive neck dissection in N3 patients is
surgeons were the first to perform neck dissection.
less compelling. Laryngoscope 2007;117(5):797–802.
There is also reasonable evidence to suggest [8] Crile G. Excision of cancer of the head and neckd
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response. Once again, however, the evidence for pain and function after neck dissection with or with-
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organ-preservation therapy) is much less compel-
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 513–520

Tracheotomy: Elective and Emergent

Eric J. Dierks, DMD, MD, FACSa,b,*
a
Department of Oral and Maxillofacial Surgery, Oregon Health & Science University,
611 S.W. Campus Drive, Portland, OR 97239, USA
b
Legacy Emanuel Hospital, 2801 N. Gantenbein Avenue, Portland, OR 97227, USA

History Contraindications
Tracheotomy has been practiced since ancient There are no absolute contraindications to
times [1]. As early as 3600 BC, the procedure was tracheotomy. The rarely encountered anatomic
depicted on Egyptian engravings from the Abydos variant of a high position of the innominate artery
and Sakkara regions of Egypt. Tracheotomy and that crosses the trachea above the sternal notch
cricothyroidotomy passed through an era of great would preclude standard tracheotomy technique.
controversy and Hippocrates condemned the
operation due to the risk of carotid damage.
Elective adult tracheotomy:
This period was followed by general acceptance
anatomy and technique
of the procedure’ life-saving potential. The name
of Chevalier Jackson [2] will always be associated Elective tracheotomy can be performed under
with tracheotomy. In 1921, he described the either local or general anesthesia, although gen-
indications and techniques for tracheostomy and eral anesthesia is preferred. The head and neck
also condemned what he referred to as ‘‘high are tilted backward, either with the aid of a shoul-
tracheostomy,’’ or cricothyroidotomy. der roll or by placing the head on a suitably
positioned Mayfield horseshoe headholder. The
purpose of this position is to distract the larynx
Indications
and trachea, increasing the distance from the
The indications for tracheotomy fall into four cricoid cartilage to the sternal notch.
general categories: Following administration of local anesthesia
with epinephrine, a transverse incision is made
1. To protect the larynx and trachea from the
between the medial borders of the sternocleido-
damage produced by prolonged translaryng-
mastoids, at a level approximately half the
eal intubation in patients who require pro-
distance between the cricoid and the sternal
longed ventilatory support.
notch. The subcutaneous fat is bluntly separated
2. To remove the airway from a surgical field in
with a gauze sponge to avoid damage to the
the maxillofacial region, pharynx, or larynx.
anterior jugular veins, which can often be identi-
3. To bypass upper airway obstruction, not
fied, but not injured, by this maneuver. The
manageable by simpler means.
median raphe between the paired, paramedian
4. To facilitate pulmonary toilet by the use of
sternohyoid and sternothyroid muscles is identi-
a tube within the trachea that is shorter
fied and entered with a Crile hemostat, thereby
than an endotracheal tube.
passing through the superficial layer of the deep
cervical fascia. The strap muscles are retracted
laterally with an Army-Navy retractor as the
operation proceeds in the midline toward the
* Head & Neck Surgical Associates, 1849 NW trachea.
Kearney #300, Portland, OR 97209 The trachea is mobile in the transverse plane and
E-mail address: [email protected] periodic reassessment of the midline is necessary.
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.02.004 oralmaxsurgery.theclinics.com
514 DIERKS

The thyroid isthmus is identified and is usually Complications and misadventures

retracted superiorly. If the isthmus is enlarged, or if in elective tracheotomy
it lies directly in the path of the planned tracheot-
Intraoperative
omy, it can be dissected off the trachea and divided
between suture-ligatures or with electrocautery. Paratracheal or pretracheal placement of the
The pretracheal fascia is swept off the trachea trach tube is occasionally encountered following
with a gauze sponge and the tracheal rings are what seemed to be accurate passage of the tube into
identified. the trachea. This problem is usually rapidly iden-
Once the trachea has been visualized, the tified by the lack of end-tidal CO2 registration on
surgeon will request the appropriate sized trache- the capnograph monitor or by the lack of appro-
otomy (or ‘‘trach’’) tube, usually a #8 for a man priate breath sounds upon chest auscultation. If
and a #6 for a woman. The scrub nurse will inflate there is doubt, a tracheal suction catheter can be
and deflate the tube’ cuff to test for leaks and will quickly passed and the tube’ malposition can be de-
lubricate the tube and cuff with water-soluble termined by the lack of a cough response in a lightly
lubricant to help avoid cuff tears upon insertion. anesthetized patient or by the lack of normal aspi-
The scrub nurse will also place the stylet within ration of sputum or bloody tracheal secretions.
the trach tube lumen. The cricoid is palpated Pneumothorax can occur following routine
through the wound and is hooked from beneath tracheotomy but it would logically be more likely
its inferior border with a cricoid hook to allow the following a difficult trach or one with excessive
assistant to provide anterior-superior traction. lateral dissection. A portable chest radiograph has
This serves to both elevate and transfix the traditionally been used to identify this potential
trachea within what would otherwise seem to be complication.
a deep hole. If the location of the thyroid isthmus Bleeding during or following tracheotomy is
interferes with hooking the cricoid ring, the first probably the most frequent complication of tra-
tracheal ring can be hooked. If desired, ‘‘stay cheotomy. Bleeding identified shortly after the
sutures’’ can be placed through the tracheal ring skin incision is most likely due to laceration of an
cartilage on either side of the planned tracheal anterior jugular vein. Bleeding deeper within the
opening. wound more likely arises from the highly vascular
After alerting the anesthesiologist, a scalpel is thyroid gland. If division of the thyroid isthmus
used to make the tracheal incision of choice, is needed, the isthmus should be carefully and
usually a midline vertical incision between rings completely elevated from the trachea with a right-
two, three and often four. T-shaped or transverse angle dissector such as a Mixter or Dietrich, and
incisions between the tracheal rings can also be the stumps suture-ligated. Alternatively, thorough
used, but care is taken to avoid laceration of the electrocautery can be used to divide the isthmus.
membranous posterior tracheal wall. Calcified Deeper bleeding arising lateral to the trachea can
rings may need to be cut with a heavy scissor occur from vessels of the lateral vascular arcade
such as a curved Mayo. The Army-Navy re- that nourish the trachea. Bipolar cautery is useful
tractors are removed, but the cricoid hook is left in this area due to the proximity of the underlying
in place until successful positioning of the trach recurrent laryngeal nerve which courses near the
tube has been confirmed. tracheo-esophageal groove.
A Trousseau or other tracheal dilator is placed
and deployed to aid passage of the tube into the
Postoperative
trachea. The trach tube is then inserted with
a curving motion. The stylet is removed and, if The appearance of buds of granulation tissue
a dual lumen trach tube is used, the inner cannula around the trach tube is common and is occa-
is placed and connected to the ventilator tubing. sionally problematic due to bleeding. Silver nitrate
Once end-tidal CO2 is confirmed and/or chest aus- application can be helpful.
cultation performed, the cricoid hook is removed Peri-tracheostomal wound infection can occur
and the flange of the trach tube is sutured to following tracheotomy and generally responds to
skin in four quadrants. A circumferential tie is wound hygiene and wet-to-dry packing around
then placed around the neck. A portable chest the trach tube. Such infections can produce
radiograph is obtained in the recovery room to necrosis of the adjacent tissues, however, healing
confirm proper positioning of the tube and to around the trach tube by granulation is to be
assess for pneumothorax. expected (Figs. 1 and 2).
 TRACHEOTOMY: ELECTIVE AND EMERGENT 515

where the innominate artery crosses [3]. TIF usu-

ally presents as an initial sentinel or herald bleed
that is followed hours to weeks later by a fatal,
ex-sanguinating hemorrhage. TIF is initially man-
aged by attempting to inflate the cuff of the trach
tube or an endotracheal tube at the site of the
fistula. If this fails, the Utley maneuver involves
opening the inferior aspect of the tracheotomy
site to allow blunt finger dissection into the ante-
rior mediastinum [4]. Anterior compression of the
innominate artery against the manubrium will
diminish the hemorrhage until an emergency tho-
racotomy can be performed.
Tracheal stenosis is often cited as a complica-
tion of tracheotomy but it may often be caused
by prolonged translaryngeal intubation before
tracheotomy. In a series of 1130 tracheotomies
of Goldenberg and colleagues [5] identified
21 cases of tracheal stenosis, all of which occurred
Fig. 1. Necrotizing peri-tracheal wound after cleaning
in patients who had been intubated for at least
with serial wet-to-dry dressings.
12 days before tracheotomy.
Slow displacement of the trach tube out of the
Tracheocutaneous fistula is much more com- trachea into the peri-tracheal soft tissues can
mon following tracheotomy in children than occur in two forms, one of which can be life-
adults, where it is generally a function of the threatening.
duration of the trach tube. Electrocautery of the Type I slow displacement results from a pro-
fistula walls may be all that is required to produce gressive increase in the distance from the anterior
fistula closure in children, whereas formal excision tracheal wall to the neck skin, usually due to
of the fistula with layered wound closure, in- postoperative edema occurring within the first few
cluding interposition of the adjacent strap postoperative days. It occurs primarily among
muscles, is often needed among adults. patients with thick or obese necks. As the trach
Tracheo-innominate fistula (TIF) can develop tube approaches complete distraction out of the
months after tracheotomy and is usually due to trachea, the edges of the adjacent tracheal rings
erosion of the anterior tracheal wall by the tube will provide mechanical interference with a suction
tip. This erosion extends anteriorly to involve the catheter as it is passed though the end of the trach
posterior wall of the innominate artery as it tube. Difficulty passing a suction catheter into the
crosses the trachea in the upper mediastinum. trachea is a danger sign. Visual inspection of the
Standard tracheal incisions in the second and trach site is unremarkable as the trach flange lies
third tracheal ring will invariably place a part of in normal contact with the skin, flange sutures are
the trach tube tip near the aspect of the trachea intact, and air is passing through the trach tube. A
portable lateral chest radiograph may help con-
firm type I slow displacement phenomenon, but
consideration should be given to immediate place-
ment of a longer trach tube under controlled
conditions. When the tip of the trach tube slips
completely out of the trachea into the neck soft
tissues, immediate and catastrophic airway ob-
struction can occur (Fig. 3).
Type II slow displacement occurs in the
absence of an increased distance from the anterior
tracheal wall to the neck skin. It is seen in patients
with normal neck size and occurs later than type I
displacement, often in patients ready for decan-
Fig. 2. Peritracheal wound healed by granulation. nulation. Like type I displacement, the hallmark is
516 DIERKS

absence of sutures in the trach tube flange, in

a patient whose airway is otherwise intact and is
ready to decannulate. The trach tube is then
simply removed, if no longer needed for other
purposes.

Special considerations
Pediatric tracheotomy
The technique of pediatric tracheotomy differs
somewhat from that of adult tracheotomy. The
mobility of the trachea within the neck is more
pronounced than that of adults and distances
between anatomic landmarks are smaller. As
a result, modestly exuberant retraction can direct
the dissection toward the common carotid artery,
which can easily be mistaken for the trachea. The
greater elasticity of the cartilaginous tracheal
Fig. 3. Type I displacement. Tip of trach tube has been rings allows effective placement and subsequent
drawn out of trachea into peritracheal tissue due to in- use of stay sutures to open the trachea. Children
crease in distance from the skin to tracheal anterior wall. that require long-term tracheostomy may benefit
from construction of a tracheal stoma with an
the report by the bedside nurse that passage of the inferiorly-based flap of the anterior tracheal wall
suction catheter is difficult. In type II displace- sutured to the inferior skin of the trach stoma
ment, it may be impossible to pass the catheter as (Bjork flap) (Fig. 5). The size of the trach tube
the trach tube may already be completely out of must be accurately matched to the trachea as stan-
the trachea. Visual inspection of the trach site dard pediatric trach tubes are cuffless, relying on
slows elevation the trach tube flange off the skin close fit of the tube to the tracheal lumen for
by 1 cm or more (Fig. 4). The patient is often seal. Following placement of the trach tube, an in-
breathing without difficulty and is able to pho- traoperative chest radiograph is usually obtained
nate. In this scenario, the trach tube has migrated to check position of the tube to avoid right main-
out of the trachea due to loose trach ties or the stem bronchus intubation.

Fig. 5. An inferiorly-based flap of the anterior tracheal

Fig. 4. Type II displacement with characteristic eleva- (Bjork flap) is elevated and will be sutured to the skin
tion of trach flange off the underlying skin surface. at the inferior border of the tracheal stoma.
 TRACHEOTOMY: ELECTIVE AND EMERGENT 517

Pediatric tracheotomy is associated with

a higher incidence of complications. Carr and
colleagues [6] noted a 43% incidence of serious
loss of airway due to accidental decannulation,
tube occlusion, or requirement of a separate surgi-
cal procedure. These authors also noted a 0.7%
mortality due to tracheotomy-related complica-
tions. Following tracheal decannulation, the
incidence of tracheocutaneous fistula is much
higher among children than adults.

Tracheotomy in the obese patient

The obese neck presents several problems when
the obese patient requires tracheotomy. Critical
assessment of the obese patient’ neck may reveal
that although the patient may be obese, the low,
anterior neck may not be obese and a standard Fig. 7. Shiley XLT tracheotomy tube with proximal
tracheotomy may be appropriate. The obese extension is very useful for obese patients.
patient with an obese neck is more the norm; the
increased distance from the skin of the anterior
neck to the anterior tracheal wall must be managed Percutaneous dilational tracheotomy
to avoid complications and potential catastrophe.
Percutaneous dilational tracheotomy (PDT) is
The excision of fat from the area of the tracheot-
a bedside technique based upon the Seldinger
omy is usually helpful; the construction of a tra-
dilational process that creates a track for trach
cheal stoma via an inferiorly based Bjork flap to
tube placement via serial dilation of the orifice
form the inferior wall of the stoma, combined with
over a guide wire placed by percutaneous puncture.
a superiorly based skin flap to form the superior
Ciaglia and colleagues [9] introduced this as a dila-
wall, will result in a tracheostomy that stands open
tional technique in 1985 and it has been widely used
upon removal (or dislodgement) of the trach tube
since. This technique is primarily applied to the
(Fig. 6). A 43% overall complication rate was
intubated patient who requires conversion to tra-
encountered in a series of defatting tracheotomies
cheotomy for prolonged ventilatory support.
among obese patients [7]. Specialized trach tubes
The advantages of PDT include the cost
with an increased length of the proximal part of
savings and scheduling convenience of the pro-
the trach tube are very helpful in the obese neck
cedure when performed at bedside in the ICU as
(Fig. 7). If such a tube is not available, a standard
compared with open tracheotomy in the operating
endotracheal tube can be split and tailored to
room. Although originally developed as a tech-
create an extended-length trach tube [8].
nique to be done blindly, many pulmonologists,
intensivists and others who use PDT do so with
bronchoscopic guidance. The guidance confirms
intra-tracheal placement of the guide wire and
tube, but diminishes some of the potential cost
savings. Specific training is the technique is
required. Kost [10] noted a 9.2% overall compli-
cation rate with complications increasing to 15%
when the BMI exceeded 30.

Emergency surgical airway: cricothyroidotomy

and emergency tracheotomy
Emergency cricothyroidotomy or ‘‘crike’’
Fig. 6. Tracheal stoma for an obese patient constructed
with a Bjork flap inferiorly and a skin flap sutured to the Cricothyroidotomy has also been termed ‘‘con-
superior aspect of the tracheal opening. iotomy’’ as it involves entry through the conus
518 DIERKS

elasticus, a fibro-elastic membrane extending from Once the emergency cricothyroidotomy patient
the cricoid cartilage superiorly and medially to the has been stabilized, consideration should be given
inferior edge of the anterior aspect of the thyroid to converting the cricothyroidotomy to a formal
cartilage. The median cricothyroid ligament is tracheotomy. This potentially minimizes the
a readily discernible anteromedial condensation trauma to the cricothyroid muscle and the artic-
of the conus elasticus. Cricothyroidotomy or ulation of the cricoid and thyroid cartilages. In
‘‘crike’’ has gained popularity as an emergency some situations, the tracheotomy can be per-
airway access technique due to its straightforward formed through the crike incision. If the crike
nature and the fact that it does not require formal incision is too high to allow this, it can be loosely
surgical training to either learn or perform. It is closed following conversion.
less dependent on optimal patient positioning and
can be performed with alacrity in most patients. ‘‘Slash’’ tracheotomy
Patients requiring emergency cricothyroidot-
The sailors’ adage ‘‘any port in a storm’’
omy fall into one of two general morphologic
applies to the rapid placement of a deep vertical
categories: those whose cricothyroid membranes
neck incision down to trachea without regard for
can be readily palpated and those who by virtue
hemostasis, in a desperate attempt to secure
of obesity, edema, subcutaneous air or blood,
a surgical airway. Although cricothyroidotomy
cannot. In the former category, cricothyroidot-
is clearly preferable, ‘‘slash’’ trachs are occasion-
omy can be readily executed by stabilizing the
ally appropriate and necessary. One such scenario
cricoid with the non-dominant hand while creat-
is that of the elective tracheotomy ‘‘gone bad’’
ing a transverse skin incision over the cricothyroid
with loss of control of the airway during an
membrane. The surgeon will repalpate the crico-
elective procedure in which the endotracheal tube
thyroid membrane through the skin incision,
has become dislodged and the patient falls
followed by a second transverse incision through
into the ‘‘cannot intubate/cannot ventilate’’
the membrane that enters the airway. Thin
predicament. Here, a ‘‘reverse slash’’ can be
patients may undergo this procedure with one
performed by placing the scalpel deep within
incision through skin and membrane, often
the wound and incising outward and upward in
necessitating a sawing motion. Finger dilation or
a vertical fashion, cutting through everything
dilation produced by twisting the scalpel handle
overlying the trachea and larynx including skin.
in the membrane opening is followed swiftly
This inverted T-shaped wound allows much
by placement of a small endotracheal or trache-
wider access for palpation of the cricoid and
otomy tube.
trachea, allowing entry into the airway. The
The latter category of patients poses a challenge
blood-filled wound may not allow visual inspec-
as the location of the cricothyroid membrane via
tion and the surgeon must proceed via palpation
external palpation is obscured. The surgeon may
alone. Any emergency surgical airway procedure
wisely opt for a large vertical incision that allows
that results in a living patient is a success,
a wider range of palpation to identify the location
regardless of collateral damage to the cricoid,
of the cricothyroid membrane. The membrane is
trachea, thyroid cartilage, lung, or other adjacent
then entered via transverse incision and the tube
structures.
of choice placed.
Bennett and colleagues [11] measured the cri-
Emergent re-opening of a trach site
cothyroid membrane in a series of fresh adult
cadavers and found a vertical midline measure- Following decannulation, airway obstruction
ment mean of 13.69 mm (range from 8–19 mm) can recur, necessitating re-establishment of the
and width between the cricothyroid muscles tracheotomy. Should this scenario present as an
mean of 12.39 (range of 9–19 mm). These authors airway emergency, the tracheotomy tract can be
point out that the diameter of an endotracheal or quickly reopened by forcing a Crile or other
tracheotomy tube placed through a cricothyroi- hemostat through the healing wound and into
dotomy should not exceed 8.5 mm in external the trachea, followed by opening the hemostat,
diameter, which corresponds to the external di- which will allow the insertion a trach tube or other
ameter of a size #4 Shiley tracheostomy tube. available endotracheal tube. In the adult patient,
In the heat of an emergency airway obstruction, this maneuver can be performed though a healed
it is obvious that any tube that can be passed incision at the prior tracheotomy site up to several
will suffice. months after decannulation.
 TRACHEOTOMY: ELECTIVE AND EMERGENT 519

Controversies Tracheal stay sutures

Elective cricothyroidotomy Stay sutures entail the placement of suture
through the tracheal rings on either side of the
In 1976, two cardiothoracic surgeons pub-
tracheal opening, draping these sutures through
lished a provocative paper regarding their experi-
the wound and taping them to the chest wall. In the
ence with 655 elective cricothyroidotomies among
event of tube dislodgement, traction can be applied
a population of elective thoracic surgery patients
to these sutures to spread the tracheal opening,
[12]. Their retrospective study cited the advan-
facilitating tube re-placement. Stay sutures work
tages of cricothyroidotomy as simplicity, absence
well in the pediatric patient as the cartilaginous
of cross-contamination among median sternot-
nature of the tracheal rings allows reasonably
omy patients, and safety, with a 6.1% complica-
secure suture placement as well as the flexibility to
tion rate. Their paper was widely referenced and
open upon traction of the sutures. Stay sutures are
also widely criticized. A wave of enthusiasm for
significantly less effective in the adult patient. The
elective cricothyroidotomy followed, but a subse-
progressive ossification of the tracheal rings allows
quent prospective study identified five cases of
the ring to crack and split upon suture placement.
subglottic stenosis in a series of 76 elective crico-
Suture traction on a calcified tracheal ring does not
thyroidotomies [13].
allow the wide dilation seen in the pediatric patient
and, in an emergency, the stay sutures in an adult
Skin incision can interfere with of tube replacement. This author
has abandoned their use in the adult patient.
The transverse incision has been generally
The establishment of a surgical airway via
accepted as the incision of choice for elective
tracheotomy or cricothyroidotomy represents
tracheotomy, due to its ease of execution and
a skill set shared by multiple surgical disciplines.
cosmetics. The vertical incision is associated with
Although the risk-to-benefit ratio of this group of
wider access as well as decreased bleeding; the
procedures is generally highly favorable, it
vertical incision is reserved for emergency appli-
behooves surgeons to periodically revisit this
cations and possibly for those situations in which
interdisciplinary topic to provide the highest level
hemostasis considerations are paramount.
of care to their patients.

Tracheal incision References

The type of incision into the trachea probably [1] Frost EA. Tracing the tracheostomy. Ann Otol
has less to do with subsequent tracheal stenosis Rhinol Laryngol 1976;85:618–24.
than it does with the duration of intubation [2] Jackson C. High tracheotomy and other errors. The
preceding the tracheotomy and other factors. A chief causes of chronic laryngeal stenosis. Surg
dog study comparing vertical, horizontal, and Gynecol Obstet 1921;32:392–8.
window excision tracheal entry failed to show [3] Oshinsky AE, Rubin JS, Gwozdz CS. The anatomi-
cal basis for post-tracheotomy innominate artery
a significant difference in reduction of tracheal
rupture. Laryngoscope 1988;98:1061–4.
lumen diameter, with all three techniques [4] Utley JR, Singer MM, Roe BB. Definitive manage-
resulting in an average of about 25% reduction ment of innominate artery hemorrhage complicating
[14]. tracheostomy. JAMA 1972;4:577–9.
[5] Goldenberg D, Ari EG, Golz A, et al. Tracheotomy
Timing of elective tracheotomy complications: a retrospective study of 1130 cases.
Otolaryngol Head Neck Surg 2000;123:495–500.
Optimal timing of elective tracheotomy in the [6] Carr MM, Poje CP, Kingston L, et al. Complica-
ventilator-dependent patient has been the subject tions in pediatric tracheostomies. Laryngoscope
of a controversy that is summarized well by 2001;111:1925–8.
McWhorter [15]. An initial Glasgow Coma Score [7] Gross ND, Cohen JI, Andersen PE, et al. ‘‘Defat-
ting’’ tracheotomy in morbidly obese patients.
of seven or less has been identified as an indicator
Laryngoscope 2002;112:1940–4.
for early tracheotomy among trauma patients [8] Bettez M, Maves MD. The endotracheal tube as
[16]. A survey of critical care nurses noted that a tracheotomy tube. Otolaryngol Head Neck Surg
92% would personally prefer a tracheotomy to 1991;105:480–2.
prolonged intubation if they personally required [9] Ciaglia P, Firsching R, Syniec C. Elective percuta-
intubation for greater than 10 days [17]. neous dilational tracheostomy, a new simple
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bedside procedure, preliminary report. Chest 1985; [14] Bryant LR, Mujia D, Greenberg S, et al. Evaluation
87:715–9. of tracheal incisions for tracheostomy. Am J Surg
[10] Kost KM. Endoscopic percutaneous dilatational 1978;135:675–9.
tracheotomy: a prospective evaluation of 500 con- [15] McWhorter AJ. Tracheotomy: timing and tech-
secutive cases. Laryngoscope 2005;115:1–30. niques. Curr Opin Otolaryngol Head Neck Surg
[11] Bennett JDC, Guha SC, Sankar AB. Cricothyroi- 2003;11:473–9.
dotomy: the anatomical basis. J R Coll Surg Edinb [16] Lanza DC, Koltai PJ, Parnes SM, et al. Predictive
1996;41:57–60. value of the Glasgow coma scale for tracheotomy
[12] Brantigan CO, Grow JB. Cricothyroidotomy: elec- in head-injured patients. Ann Otol Rhinol Laryngol
tive use in respiratory problems requiring tracheos- 1990;99:38–41.
tomy. J Thorac Cardiovasc Surg 1976;71:72–81. [17] Astrachan DI, Kirchner JC, Goodwin WJ.
[13] Sise MJ, Shacksord SR, Cruickshank JC, et al. Prolonged intubation vs. tracheotomy: complica-
Cricothyroidotomy for long term tracheal access. tions, practical and psychosocial considerations.
Ann Surg 1984;200:13–7. Laryngoscope 1988;98:1165–9.
 Oral Maxillofacial Surg Clin N Am 20 (2008) 521–526

Preparation of the Neck for Microvascular

Reconstruction of the Head and Neck
Jason K. Potter, MD, DDSa,b,*, Timothy M. Osborn, DDS, MDc
a
Plastic and Maxillofacial Surgery, Dallas, TX, USA
b
Department of Oral and Maxillofacial Surgery, Baylor College of Dentistry, Dallas, TX, USA
c
Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR, USA

Reconstruction of congenital, developmental, advantages over nonvascularized bone grafts

or acquired head and neck defects remains a sig- and pedicled soft tissue flaps that currently
nificant challenge for the oral and maxillofacial make it the modality of choice for the recon-
surgeon. Arguably, in no other anatomic location struction of extirpative defects of the head and
is the quality of both form and function of the neck. The advantages of microvascular free flaps
reconstructed part more critically appraised by include (1) predictable composite tissue transfer
the patient, surgeon, and society. from a variety of donor sites at a single stage
Reconstruction of head and neck defects was (immediate reconstruction); (2) radiation toler-
previously limited by the paucity of local tissues ance; and (3) minimal donor site morbidity.
available to reconstruct complex wounds. The Although there is little argument that microvascu-
development of pedicled flaps during the 1970s lar surgery increases the complexity of the re-
and 1980s (deltopectoral, pectoralis major, lat- constructive procedure, it has been shown to
issimus dorsi) revolutionized head and neck carry success rates of greater than 90% in experi-
surgery and quickly became the workhorse pro- enced hands [1–8].
cedures of the reconstructive surgeon. Critical Quality microvascular reconstruction begins,
review of these techniques, however, has illumi- as with any surgical procedure, with sound pre-
nated the shortcomings of pedicled flaps for operative planning. Preoperative planning focuses
routine use in the reconstruction of composite on the characteristics of the missing or anticipated
head and neck defects: (1) the pedicled transfer of missing tissues, but no matter how aesthetic the
bone-containing soft tissue flaps is unpredictable final result looks on the table it is as successful as
and limited because of extreme arcs of rotation; the microsurgical portion of the procedure. What
(2) large, axial pattern rotational flaps, such as separates a consistently successful microvascular
the pectoralis major myocutaneous flap, com- surgeon is the attention to details in the setup of
monly result in unsightly contours and an un- the microsurgery that facilitates a smooth and
favorable donor site defect; and (3) the use in timely procedure without unanticipated difficul-
midface and upper facial reconstruction is lim- ties. The preoperative planning must also include
ited. Pedicled flaps and nonvascularized bone detailed attention to the technical aspects of the
grafting techniques continue to play an important microvascular procedure. This includes a thorough
role in reconstructive oral and maxillofacial sur- understanding of the vascular anatomy of the
gery. It has become clear, however, that micro- patient’s neck, vascular anatomy of the various
vascular free tissue transfer has several flaps including pedicle lengths, anticipation of the
needed pedicle length given defect location and
probable inflow-outflow vessels, and knowledge
* Corresponding author. of how to facilitate microvascular surgery in the
E-mail address: [email protected] neck and to manage complicating factors in the
(J.K. Potter) difficult neck.
1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.04.004 oralmaxsurgery.theclinics.com
522 POTTER & OSBORN

General considerations Studies have shown that there is no increased

risk of flap failure in patients who smoke, where
There are several factors that have the poten-
one study has shown that there is increased risk
tial to influence the outcome of microvascular free
of venous anastomotic failure [9,17]. In general,
tissue transfer. These include patient age, tobacco
smoking is not considered an increased risk for
use, diabetes, prior radiation, and prior operative
microvascular failure but is a significant risk fac-
procedures.
tor for wound healing complications both at the
Patient age has not been demonstrated to be
reconstructed site and the donor site [18].
a contraindication for free tissue transfer in many
Inadequate length of pedicle can be an issue
studies. The success rates of free tissue transfer in
when there are no appropriate vessels in the area
patients over 65 has been shown to be similar to
of reconstruction. When this is not anticipated in
a younger cohort; however, perioperative medical
the preoperative planning it can significantly
morbidities are more common in the older pop-
compromise the outcome of the procedure. In
ulation [9,10].
the authors’ experience this is most common when
The type of anastomosis has long been con-
there is a history of prior surgery or radiation
troversial and each case must be individualized.
therapy to the neck compromising the status of
There is no significant difference in flap survival
the normal vasculature or in cases where the
with end-to-end versus end-to-side anastomosis
defect site is distant from the neck (scalp, orbit,
[11]. The authors most commonly use end-to-end
central face). Most commonly this is remedied
arterial anastomosis because of similarity in size
with interpositional vein grafting; however, arte-
of commonly used flap vessels in and the recipient
riovenous fistula in head and neck reconstruction
arteries in the head and neck. In most flaps the
can be used when there is limitation of the
authors use end-to-side venous anastomosis with
vascular pedicle, or in cases when appropriate
flap veins and the internal jugular vein. This al-
vessels are not available in the vicinity of the
lows for use of multiple venous outflows and
reconstructive site. Recent studies have shown no
accounts for size discrepancy.
increased rate of flap failure when interposition
The effect of radiation on arteries and veins has
vein grafting is used, although there may be
been well documented. These include perivascular
a higher requirement for flap revision [19]. Other
fibrosis, endothelial damage, and microvascular
studies have shown increased risk of flap failure
occlusion, which can impair the quality of re-
when both interposition vein grafts and arteriove-
cipient vessels [12,13]. Clinical studies have shown
nous loops are used [20]. The benefit of creation of
no significant difference in flap survival in radi-
an arteriovenous fistula is that flow is established
ated patients and nonradiated patients [9]. The au-
and checked in the fistula before free flap anasto-
thors commonly perform free tissue transfer in
mosis, and kinking of friable vein grafts is pre-
patients before they receive radiation and to treat
vented [21]. Free flap selection can be an
complications from radiation with no increase in
important factor in avoiding issues with inade-
flap failure.
quate pedicle length. Selection of flaps with reli-
Diabetes has well-known adverse macroangio-
able pedicle length can impact survival and use
pathic and microangiopathic effects. The effect of
of fewer but more reliable donor sites can contrib-
diabetes on the vasculature of the head and neck
ute to successful outcome of free tissue transfer
has not been determined. In microvascular tissue
[22]. Heavy reliance on radial forearm, fibula,
transfer, studies have demonstrated that patients
and rectus abdominis for head and neck recon-
with diabetes are not at increased risk for flap
struction has been associated with successful free
failure or abnormal healing of the anastomosis as
tissue transfer because these flaps contain long
long as normoglycemia is maintained [14,15]. Ag-
vascular pedicles and large-diameter vessels [1].
gressive management of blood glucose is neces-
sary throughout the healing period and is often
Preparation of the neck for microsurgery
difficult secondary to the major surgical proce-
dure, tube feeding, and patient noncompliance. Planning begins with the patient’s history and
The use of tobacco has been associated with physical examination. Specific details regarding
peripheral vascular disease; however, the effects in prior surgery, trauma, radiation, or disease pro-
the head and neck are not documented [16]. There cess must be elicited in the preoperative phase.
is conflicting evidence in the literature regarding Prior neck surgery or carotid vascular surgery can
the effects of smoking and free tissue transfer. significantly affect the feasibility of microsurgery
 PREPARATION OF THE NECK FOR MICROVASCULAR 523

in the affected neck. If any uncertainty exists for head and neck reconstruction vessels 2 to 3
regarding the availability of adequate vessels for mm in diameter are usually needed for suitable
microsurgery, the clinician should have a low size match. The vessels are analyzed to determine
threshold to obtain angiographic imaging defini- if end-to-end anastomosis of at least the artery is
tively to define the patient’s anatomy. feasible. If there is a greater than 2:1 size mis-
A second major consideration is the underlying match either an end-to-side anastomosis is per-
disease process requiring reconstruction. Patients formed or the larger vessel is narrowed by
being treated for head and neck malignancies various techniques.
frequently undergo lymphadenectomy (neck dis- Intimate knowledge of the vascular anatomy of
section) that provides excellent exposure to the the carotid system is critical in preparation for
major vascular structures of the neck. Patients microvascular surgery in the neck. Several
being treated for benign disease or trauma require branching patterns are recognized and should be
exposure of the vascular structures without that familiar to the surgeon. Vessels coming off the
afforded by neck dissection. In this situation the anterior surface of the external carotid include
surgeon must still perform wide exposure because the superior thyroid, facial, and lingual arteries.
it is critical for access to and preparation of the The superior thyroid tends toward a smaller
vessels for microsurgery. Microsurgery is ex- diameter compared with the facial and lingual
tremely difficult to perform deep in the neck and is frequently positioned low in the neck. The
without adequate access. facial and lingual arteries may share a common
Incision design is an important consideration takeoff from the external carotid. The facial vessel
in contemporary microvascular head and neck tends to be tortuous and may lead to a tendency
reconstruction. The surgeon has much greater for kinking at the anastomosis if not carefully
latitude in determining where to place the incision planned. If a larger-caliber vessel is needed the
if no lymphadenectomy is to be performed. In this external carotid may be divided distal to
case, the incision is placed within a prominent the takeoff of the facial and lingual arteries. The
neck crease several finger breadths below the vessel in this location lies deep to the hypoglossal
inferior border of the mandible. There is virtually nerve and frequently above the inferior border of
no reason to ‘‘split the lip’’ unless such extension the mandible. Resection of or division of the
was an oncologic requirement. The incision can be posterior digastric and stylohyoid muscles pro-
extending to the opposite neck if access to the vides improved visualization to the underlying
anterior mandible is required as part of the vessels (Figs. 1 and 2) [23]. Access can be further
procedure. The incision is carried through skin, facilitated by dividing the vessel, dissecting it
subcutaneous tissue, and platysma, and superior free, and flipping it from under the hypoglossal
and inferior skin flaps are developed in a sub- nerve (Figs. 3 and 4). This provides significant
platysmal plane. The anterior border of the flexibility in positioning the vessel and greatly in-
sternocleidomastoid muscle is identified and skel- creasing the access for microsurgery.
etonized on its medial extent. The internal jugular
vein is identified and circumferentially exposed
from the digastric muscle superiorly to the omo-
hyoid muscle inferiorly. Likewise, the common
carotid artery is identified and dissected superiorly
to expose circumferentially the external carotid
artery and its branches.
Once the recipient vessels in the neck are
exposed as part of an ablative procedure or
primarily for microvascular reconstruction atten-
tion should focus on selection of a suitably sized
vessel that also lies in good position to receive the
flap vessel. This is best accomplished using loupe
magnification. The recipient vessels are assessed Fig. 1. View of vascular structures of the right neck fol-
for caliber, quality, and compatibility with the lowing selective neck dissection. Note the superficial po-
flap vessels. In general, the minimum diameter for sition of the posterior digastric and stylohyoid muscles
arteries and veins for microvascular anastomosis relative to the branches of the external carotid artery in-
is 1 mm [9]; however, for most free tissue transfers terferes with access for microsurgery.
524 POTTER & OSBORN

Fig. 2. View of vascular structures of the right neck fol-

lowing removal of posterior digastric and stylohyoid
muscles. Note improved visualization of and access to
branches of external carotid artery.

The internal jugular vein is the authors’ pre-

ferred choice for venous outflow. It is prepared by Fig. 4. Significantly improved access and length of ves-
dissecting 360 degrees for several centimeters to sel is provided by dividing vessel, dissecting it free, and
free it from the surrounding structures (Fig. 5). flipping it from under to hypoglossal nerve. The vessel
This allows for unhindered manipulation of the now lies superficial to hyoglossal and is unimpeded for
vessel and placement of vascular clamps proxi- microsurgery.
mally and distally that does not interfere with
the microsurgical field. Care must be taken to surgeon should be cautioned to avoid using it in
protect the vagus nerve during these maneuvers. situations where size match is not ideal. An end-
Frequently, the stump of the common facial vein to-side anastomosis into the internal jugular is
may be preserved by the ablative surgeon. When technically more feasible and likely more reliable
it provides an excellent size match to the flap in this situation. Occasionally, the internal jugular
vein it may be used for venous outflow. The vein may be resected, fibrotic, or otherwise unsuit-
able. In these situations the external jugular may
be used. This vessel may be divided and trans-
posed for end-to-end anastomosis or used in an
end-to-side fashion.
Once vessels are selected and prepared, the
head is positioned to the contralateral side and
dura hooks or lone star hooks are used to provide

Fig. 3. Note position of distal external carotid artery

(left neck) in relation to hypoglossal nerve and inferior
border of mandible (behind retractor). Significant ten-
sion on vessel loop is needed to visualize adequate length Fig. 5. Internal jugular vein access following careful and
of vessel. meticulous dissection is now ready for microsurgery.
 PREPARATION OF THE NECK FOR MICROVASCULAR 525

wide exposure while using the surgical micro-

scope. This is best accomplished with retraction of
the sternocleidomastoid muscle posterolaterally
and the mandible superiorly (Fig. 6).
Proper vessel care is essential throughout
preparation of the neck and during time under
the microscope. Desiccation caused by inattention
can lead to sloughing of vessel endothelium and
vessel thrombosis. During flap elevation and
before flap division, 4% lidocaine or papaverine
is applied on moistened cottonoids as a topical
vasodilator. This technique also serves to protect
vessels from desiccation.

Microvascular anastomosis Fig. 6. Retraction hooks placed into the sternocleido-

mastoid muscle and at inferior border of mandible
The microvascular anastomosis is arguably the provide a stable, wide surgical field for successful
most important component of microvascular microsurgery.
tissue transfer and beyond the scope of this article.
The vessels must be prepared appropriately to is the most convenient conduit for vein graft or
facilitate appropriate coaptation of the vessels and arteriovenous loop creation. The arteriovenous
inset in such a way so that there is no tension on loop can be used as a one-stage or two-stage
the vessels. The sequence of anastomosis (ie, reconstruction, with the second stage division and
artery first, vein first, and so forth) is dictated by anastomosis of the arteriovenous loop and flap
the relation of vessels to each other so that the occurring approximately 1 week later. Another
first anastomosis does not sit on top of the next technique that can be used is cephalic transposi-
vessel to be sutured. The arterial and venous tion where the cephalic vein is divided distally and
anastomosis is performed using 8–0 or 9–0 suture transposed to the neck.
under the microscope. If available, the authors use In previously operated necks, it may also be
a dual venous outflow of the flap. After the necessary to use vasculature outside of the carotid
anastomosis is completed, the clamps are released system. The transverse cervical vessels have been
and the patency and seal of the site is verified. shown to be suitable as recipient vessels in more
than 90% of cases and should be used in difficult
head and neck reconstruction [24]. Patients who
The vessel-depleted neck
have had previous neck dissection should not be
In situations in which the primary recipient excluded from having microvascular free flap re-
vessels are no longer available because of previous construction. Free flaps in these patients have
ablation, prior free tissue transfer, or poor quality been shown to be highly effective despite a paucity
or caliber, selection of alternative vasculature is of potential cervical vessels with reliance on flaps
necessary. Alternative vessels are often at a greater with long vascular pedicles [25]. Patients who
distance from the recipient site, which makes have failed free flaps should not be excluded
pedicle length a limiting factor. The ideal flap from another free flap reconstruction because
for the reconstruction may not have sufficient they often are able to have a second free flap re-
pedicle length and the pedicle must be lengthened. construction [26].
Options to increase pedicle length include inter- Survival of free flaps depends on an adequate
position vein grafts, cephalic transposition, crea- venous drainage system. In free flap reconstruc-
tion of an arteriovenous loop, or selection of an tion of head and neck defects, the ablative pro-
alternative flap with a long pedicle. cedure or prior surgery may precipitate internal
The decision to use an interposition vein graft jugular vein thrombosis. Studies in which the
was based on the distance between flap and internal jugular vein was preserved with neck
recipient vessels. When the gap is less than 10 dissection demonstrated a 14% to 33% thrombo-
cm, a reversed interposition vein graft is used; sis rate [27,28]. Prevention of internal jugular vein
however, when the gap is greater than 10 cm, an thrombosis is partially under the control of the
arteriovenous loop is created. The saphenous vein surgeon and risk can be minimized by atraumatic
526 POTTER & OSBORN

manipulation of the vein, avoiding desiccation, [13] Drake DB, Oishi SN. Wound healing considerations
maintaining optimal flow characteristics by liga- in chemotherapy and radiation therapy. Clin Plast
tion of jugular side branches far enough away to Surg 1995;22:31.
prevent constriction, but close enough to prevent [14] Cooley BC, Hanel DP, Anderson RB, et al. The in-
fluence of diabetes on free flap transfer: I. Flap sur-
blind jugular side pouches, which may contribute
vival and microascular healing. Ann Plast Surg 1992;
to retrograde thrombosis [27]. Although there is 99:156.
a high incidence of internal jugular vein thrombo- [15] Cooley BC, Hanel DP, Lan M, et al. The influence of
sis, free flap success is still 90% to 95% and there diabetes on free flap transfer: II. The effect of ische-
does not seem to be an effect on ultimate free flap mia on flap survival. Ann Plast Surg 1992;29:58.
survival rates [29]. [16] Tapp RJ, Balkau B, Shaw JE, et al, The DESIR
Study Group. Association of glucose metabolism,
smoking and cardiovascular risk factors with inci-
dent peripheral arterial disease: the DESIR study.
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[1] Blackwell KE. Unsurpassed reliability of free flaps [17] Schusterman MA, Miller MJ, Reece GP, et al. A sin-
for head and neck reconstruction. Arch Otolaryngol gle center’s experience with 308 free flaps for repair
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[2] Pryor SG, Moore EJ, Kasperbauer JL. Implantable Surg 1994;93:472–80.
Doppler flow system: experience with 24 microvas- [18] Krueger JK, Rohrich RJ. Clearing the smoke: the
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measuring blood flow and oxygenation. Plast tive microsurgery. J Reconstr Microsurg 1993;125:
Reconstr Surg 2005;115:539. 869.
[5] Velanovich V, Smith DJ Jr, Robson MC, et al. The [21] Rand RP, Gruss JB. The saphenous arteriovenous
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[6] Qiao Q, Zhou G, Chen GY, et al. Application of he- [22] Kroll SS, Miller MJ, Reece GP, et al. Anticoagulants
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tion. Microsurgery 1996;17:487. Surg 1995;96:643.
[7] Chung TL, Pumplin DW, Hotlon LH, et al. Preven- [23] Webb RM, Baker NJ. Division of digastric tendon
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aspirin, heparin, and the glycoprotein IIb/IIIa inhib- the neck. J Oral Maxillofac Surg 2008;66(2):408–9.
itor Tirofiban. Plast Reconstr Surg 2007;120:1281. [24] Yu P. The transverse cervical vessels as recipient
[8] Chien W, Varvares MA, Hadlock T, et al. Effects of vessels for previously treated head and neck cancer
aspirin and low-dose heparin in head and neck patients. Plast Reconstr Surg 2005;115:1253.
reconstruction using microvascular free flaps. La- [25] Head C, Sercarz JA, Abemayor E, et al. Microvascu-
ryngoscope 2005;115:973. lar reconstruction after previous neck dissection.
[9] Nahabedian MY, Singh N, Deune EG, et al. Recip- Arch Otolaryngol Head Neck Surg 2002;128:328.
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of the head and neck. Ann Plast Surg 2004;52:148. crovascular free flaps in head and neck reconstruc-
[10] Serletti JM, Higgins JP, Moran S, et al. Factors af- tion. Arch Otolaryngol Head Neck Surg 1994;120:
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[11] Ueda K, Harii K, Nakasuka T, et al. Comparison of jugular vein thrombosis following modified neck
end-to-end and end-to-side venous anastomosis in dissection: implications for head and neck flap re-
free tissue transfer following resection of head and construction. Head Neck 1998;20:169.
neck tumors. Microsurgery 1996;17:146. [28] Leotonsins TG, Currie AR, Mannell A. Internal
[12] Beckman JA, Thakore A, Kalinowski BH, et al. Ra- jugular vein thrombosis. Laryngoscope 1995;95:169.
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 Oral Maxillofacial Surg Clin N Am 20 (2008) 527–533

Index
Note: Page numbers of article titles are in boldface type.

A Benign neoplastic masses, of neck, 329–330

Adenoma, pleomorphic, 449–450 carotid body tumors, 329
metastasizing, 449–450 lipomas, 329
thyroid nodules and goiters, 329–330
Aerodigestive tract, upper, cancer of, neck masses
in, 330–331 Biopsy, fine needle aspiration, in evaluation of
neck masses, 323–324
Anastomosis, microvascular, in head and neck
in evaluation of thyroid disorders, 438–441
reconstructive surgery, 525
Branchial cleft cysts, 327
Anatomy, neck, cervical spine, 381–383
congenital neck masses due to, 345–348
atlas (C1), 381–382
axis (C2), 382
occipital condyles, 381 C
occiput-C1-C2 relationship, 382 Cancer, oral. See Oral cancer.
spinal cord, 383
Carotid artery, involvement of, in node-positive
subaxial spine (C3-C7), 382–383
oral cancer, 506–509
vascular, 383
in deep space infection, 353–355 Carotid body tumors, benign neck masses due to,
of lymph nodes, levels and nomenclature, 329
459–463 Cat scratch disease, neck masses due to, 329
penetrating injuries of the neck and, 395–397
radiographic correlation with, 311–319 Cervical spine, injuries of, 381–391
anatomy, 312 anatomy, 381–383
imaging, 311–312 fractures and dislocations, 383–390
CT, 311 atlas, 385
MRI, 311–312 axis, 386–388
lymphatic system, 316–318 occiput C1 articulation, 383–385
spaces, 312–316 subaxial spine, 388–390
infrahyoid, 315–316 penetrating, 410–411
suprahyoid, 313–315 Chemoradiotherapy, postoperative, for advanced-
Angiography, in evaluation of neck masses, stage oral squamous cell carcinoma, 502–503
326–327 Computed tomography (CT), in evaluation of
Atlas (C1), anatomy of, 381–382 thyroid disorders, 437–438
fractures of, 385 of neck, 311
of neck masses, 325
Axis (C2), anatomy of, 382
fractures of, 386–388 Congenital neck masses, 327, 339–352
traumatic spondylolisthesis of, 388 lateral, 345–351
branchial cleft cyst, 345–348
hemangioma, 350–351
B laryngocele, 348–349
Ballistics, gunshot wounds to the neck, lymphangioma, 349–350
pathophysiology of, 397–399 thymic cyst, 345

1042-3699/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
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528 INDEX

Congenital (continued) axis, 386–388

midline, 339–345 odontoid, 386–388
dermoid cyst, 341–342 traumatic spondylolisthesis of C2, 388
epidermoid cyst, 342–343 occiput C1 articulation, 383–385
plunging ranula, 343–344 subaxial spine, 388–390
teratoma, 344–345
thyroglossal duct cyst, 339–341 G
Cricothyroidectomy, elective, 519 Goiter, thyroid, benign neck masses due to,
emergency, 517–518 329–330
Cystic hygroma, neck mass due to, 327 Gunshot wounds, to the neck, pathophysiology
of, 397–399
D
Deep spaces, of the neck, infections of, clinical H
considerations in aggressive disease, 367–380 Hemangioma, congenital neck masses due to,
surgical management of, 353–365 350–351
Dermoid cysts, of neck, congenital, 341–342 Heterotopic salivary gland disease, 445–446
Diagnosis, of deep space neck infections, 356–360 History, patient, in aggressive deep neck
of neck masses, 321–337 infections, 370–371
of penetrating injuries to the neck, 401–404 in evaluation of neck masses, 321
in thyroid disorders, 432–433
Dislocations, of cervical spine, 383–384
Hygroma, cystic, neck mass due to, 327
Dissection, of neck, 459–475
classification of, 463–464
complications, 470–473 I
lymph node levels, anatomy and nomenclature, Imaging, in deep neck infections, 372–373
459–463 in evaluation of neck masses, 325–327
sentinel node biopsy, 469–470 in evaluation of thyroid disorders, 434–438
technique, 464–468 radiographic correlation with neck anatomy,
311–319
E anatomy, 312
CT, 311
Emergency care, tracheotomy, 517–519
lymphatic system, 316–318
cricothyroidectomy, 517–518
MRI, 311–312
emergent re-opening of a trach site, 518
spaces, 312–316
slash tracheotomy, 518
infrahyoid, 315–316
Endocrine injuries, penetrating, 410 suprahyoid, 313–315
Endoscopy, in evaluation of neck masses, 322–323 Infections, neck masses due to, 328–329
cat scratch disease, 329
Epidermoid cysts, of neck, congenital, 342–343
tuberculosis, 329
Esophageal injuries, penetrating, 409–410 of deep space of neck, clinical considerations
Evaluation, of neck masses, 321–337 in aggressive disease, 367–380
airway, 373–374
Extended neck dissection, 464 etiology, 367–368
examination, 371–372
F history, 370–371
imaging, 372–373
Fine needle aspiration biopsy, in evaluation of
laboratory investigations, 374
neck masses, 323–324
microbiology, 368–370
in evaluation of thyroid disorders, 438–441
pathogenesis of spread, 370
Fractures, of cervical spine, 383–390 role of systemic disease, 368
atlas, 385 surgical management, 374–379
 INDEX 529

medical management, 360 Lymphangioma, congenital neck masses due to,

surgical management, 353–365 349–350
airway management, 361–363 neck mass due to, 327
anatomy, 353–355
Lymphatic system, cervical, imaging in evaluation
complications, 363–364
of, 316–318
diagnosis, 356–360
radiographic-based classification of,
microbiology, 355–356
317–318
Infrahyoid spaces, of neck, 315–316
Lymphoma, neck masses due to, 334
Injuries, of the neck, cervical spine, 381–391
anatomy, 381–383
fractures and dislocations, 383–390 M
penetrating, 393–414
Magnetic resonance imaging (MRI), in evaluation
anatomic considerations, 395–397
of thyroid disorders, 437–438
diagnosis, 400–404
of neck, 311–312
historical perspective, 394–395
of neck masses, 325–326
management, cervical spine, 410–411
endocrine, 410 Masses, neck, common types of, 327–335
esophageal injury, 409–410 benign neoplastic, 329–330
extracranial vascular trauma, 407–409 carotid body tumors, 329
laryngotracheal injury, 410 lipomas, 329
mechanism of, 399–400 thyroid nodules and goiters, 329–330
pathophysiology of gunshot wounds and infectious, 328–329
ballistics, 397–399 cat scratch disease, 329
tuberculosis, 329
malignant neoplastic, 330–335
L lymphoma, 334
Laryngeal trauma, 415–430 salivary gland tumors, 334
classification, 415–417 skin cancer, 332–334
evaluation, 417–420 thyroid cancer, 334
management, 420–428 unknown primaries, 334–335
complications, 428 upper aerodigestive tract cancers,
historical perspective, 420–424 330–332
nonsurgical treatment, 424–425 nonneoplastic, 327–328
surgical technique, 425–428 branchial cleft cysts, 327
congenital, 327
Laryngocele, congenital neck masses due to,
lymphangiomas, 327
348–349
thyroglossal duct cysts, 327–328
Laryngotracheal injuries, penetrating, 410 vascular lesions, 328
congenital, 327, 339–352
Lipoma, benign neck masses due to, 329
lateral, 345–351
Lymph nodes, levels of, anatomy, and branchial cleft cyst, 345–348
nomenclature, 459–463 hemangioma, 350–351
N0 neck in oral squamous cell carcinoma, laryngocele, 348–349
477–497 lymphangioma, 349–350
how to treat, 488–491 thymic cyst, 345
when to treat, 477–488 midline, 339–345
node-positive neck in oral cancer, dermoid cyst, 341–342
499–511 epidermoid cyst, 342–343
carotid artery treatment, 506–508 plunging ranula, 343–344
in organ-preservation treatment regimens, teratoma, 344–345
503–506 thyroglossal duct cyst, 339–341
postoperative chemoradiotherapy, 502 evaluation and diagnostic approach, 321–337
surgical therapy, 499–502 clinical evaluation, 321
530 INDEX

Masses (continued) postoperative chemoradiotherapy, 502

differential diagnosis, 323 surgical therapy, 499–502
endoscopy, 322–323 infections, deep space, clinical considerations
fine needle aspiration biopsy, 323–324 in aggressive disease, 367–380
history and review of systems, 321 airway, 373–374
imaging studies, 324–327 etiology, 367–368
pathologic assessment, 323 examination, 371–372
physical examination, 322 history, 370–371
Medical management, of deep space neck imaging, 372–373
infections, 360 laboratory investigations, 374
microbiology, 368–370
Metastases, of pleomorphic adenoma, 449–450 pathogenesis of spread, 370
Microbiology, in deep neck abscesses, 355–356 role of systemic disease, 368
in aggressive disease, 368–370 surgical management, 374–379
medical management, 360
Microvascular surgery, preparation of, for surgical management, 353–365
microvascular reconstruction of head and
airway management, 361–363
neck, 521–526
anatomy, 353–355
general considerations, 522
complications, 363–364
microvascular anastomosis, 525
diagnosis, 356–360
planning for microsurgery, 522–525
microbiology, 355–356
vessel-depleted neck, 525–526
injuries
Mixed tumors, of salivary gland, malignant, cervical spine, 381–391
450–451 anatomy, 381–383
Modified radical neck dissection, 463 fractures and dislocations, 383–390
of node-positive neck in oral cancer, 500 laryngeal trauma, 415–430
classification, 415–417
evaluation, 417–420
N management, 420–428
Neck, clinical implications of, in salivary gland penetrating, 393–414
disease, 445–458 anatomic considerations, 395–397
extraparotid Warthin’s tumor, 447–449 diagnosis, 400–404
heterotopic disease, 445–446 historical perspective, 394–395
malignant mixed tumors, 450–451 management, 404–411
parotid carcinoma, 455–456 mechanism of, 399–400
pleomorphic adenoma, metastasizing, pathophysiology of gunshot wounds and
449–450 ballistics, 397–399
plunging ranula, 446–447 masses, congenital, 339–352
submandibular gland tumors, 451–455 lateral, 345–351
dissection of, 459–475 midline, 339–345
classification of, 463–464 evaluation and diagnostic approach,
complications, 470–473 321–337
lymph node levels, anatomy and clinical evaluation, 321
nomenclature, 459–463 common types of, 327–335
sentinel node biopsy, 469–470 differential diagnosis, 323
technique, 464–468 endoscopy, 322–323
in N0 oral squamous cell carcinoma, 477–497 fine needle aspiration biopsy, 323–324
how to treat, 488–491 history and review of systems, 321
when to treat, 477–488 imaging studies, 324–327
in node-positive oral cancer, 499–511 pathologic assessment, 323
carotid artery treatment, 506–508 physical examination, 322
in organ-preservation treatment regimens, preparation of, for microvascular
503–506 reconstruction of head and neck, 521–526
 INDEX 531

general considerations, 522 O

microvascular anastomosis, 525 Obese patients, tracheotomy technique in, 517
planning for microsurgery, 522–525
vessel-depleted neck, 525–526 Occipital condyles, anatomy of, 381
radiographic correlation with anatomy, Occiput-C1 articulation, fractures and
311–319 dislocations of, 383–385
anatomy, 312
Oral cancers, management of N0 neck in
imaging, 311–312
squamous cell carcinoma, 477–499
CT, 311
how to treat, 488–491
MRI, 311–312
extent of neck dissection, 489–491
lymphatic system, 316–318
when to treat, 477–488
radiographic classification of, 317–318
assessing risk for occult metastases, 483
spaces, 312–316
economic costs, 487–488
infrahyoid, 315–316
elective neck dissection vs.‘‘wait and
suprahyoid, 313–315
see,’’ 480–483
thyroid disorders, 431–443
future diagnostics using molecular
diagnosis, 432–441
biomarkers, 486–487
fine-needle aspiration, 438–441
limitations of histopathologic grading,
history and physical examination,
485–486
432–433
limitations of imaging, 483–484
imaging modalities, 434–438
prospective trials evaluating treatment
laboratory evaluation, 433–434
algorithms, 480
tracheotomy, 513–520
quality of life and, 478–480
contraindications, 513
staging and risk of occult metastases,
controversies, 519
484
elective, in adults, 513–516
management of node-positive neck in,
complications, 514–516
499–511
emergency surgical airway, 517–519
carotid artery treatment, 506–508
cricothyroidectomy, 517–518
in organ-preservation treatment regimens,
emergent re-opening of a trach site,
503–506
518
postoperative chemoradiotherapy, 502
slash tracheotomy, 518
surgical therapy, 499–502
indications, 513
special considerations in elective, 516–517 Organ preservation, in management of neck in
in obese patients, 517 node-positive oral cancer, 503–506
pediatric, 516–517
percutaneous dilational tracheotomy,
P
517
Parotid carcinoma, and the neck, 455–456
Neoplastic masses, of neck, benign,
Pediatrics, tracheotomy technique in, 516–517
329–330
carotid body tumors, 329 Penetrating injuries, of the neck, 393–414
lipomas, 329 anatomic considerations, 395–397
thyroid nodules and goiters, 329–330 diagnosis, 400–404
malignant, 330–335 historical perspective, 394–395
lymphoma, 334 management, cervical spine, 410–411
salivary gland tumors, 334 endocrine, 410
skin cancer, 332–334 esophageal injury, 409–410
thyroid cancer, 334 extracranial vascular trauma, 407–409
unknown primaries, 334–335 laryngotracheal injury, 410
upper aerodigestive tract cancers, mechanism of, 399–400
330–332 pathophysiology of gunshot wounds and
ballistics, 397–399
Nodules, thyroid, benign neck masses due to,
329–330 Percutaneoius dilational tracheotomy, 517
532 INDEX

Physical examination, in evaluation of neck Selective neck dissection, of node-positive neck in

masses, 322 oral cancer, 500–502
in evaluation of penetrating injuries to the
Selective radical neck dissection, 463–464
neck, 400–401
in thyroid disorders, 432–433 Skin cancer, neck masses due to, 332–334
Pleomorphic adenoma, 449–450 Slash tracheotomy, 518
metastasizing, 449–450 Spaces, of neck, 312–316
Plunging ranula, 343–344, 446–447 deep, infection of, aggressive disease, clinical
considerations in, 367–380
Positron emission tomography (PET), in
surgical management, 353–365
evaluation of neck masses, 326
infrahyoid, 315–316
suprahyoid, 313–315
R
Spine, cervical. See Cervical spine.
Radical neck dissection, 463
of node-positive neck in oral cancer, 499–500 Squamous cell carcinoma, management of N0
neck in, 477–499
Radiology, radiographic correlation with neck
how to treat, 488–491
anatomy, 311–319
extent of neck dissection, 489–491
anatomy, 312
when to treat, 477–488
CT, 311
assessing risk for occult metastases, 483
imaging, 311–312
economic costs, 487–488
lymphatic system, 316–318
elective neck dissection vs.‘‘wait and
MRI, 311–312
see,’’ 480–483
spaces, 312–316
future diagnostics using molecular
infrahyoid, 315–316
biomarkers, 486–487
suprahyoid, 313–315
limitations of histopathologic grading,
Radionuclide scintigraphy, in evaluation of 485–486
thyroid disorders, 436–437 limitations of imaging, 483–484
prospective trials evaluating treatment
Ranula, plunging, 343–344, 446–447
algorithms, 480
Reconstructive surgery, preparation of, for quality of life and, 478–480
microvascular reconstruction of head and staging and risk of occult metastases,
neck, 521–526 484
general considerations, 522
Stay sutures, tracheal, in tracheotomy,
microvascular anastomosis, 525
controversies in, 519
planning for microsurgery, 522–525
vessel-depleted neck, 525–526 Subaxial spine (C3-C7), anatomy of, 382–383
injuries of, 388–390
S Submandibular gland tumors, 451–455
Salivary gland disease, clinical implications of
Suprahyoid spaces, of neck, 313–315
neck in, 445–458
extraparotid Warthin’s tumor, 447–449 Surgical management, neck dissection, 459–475
heterotopic disease, 445–446 classification of, 463–464
malignant mixed tumors, 450–451 complications, 470–473
parotid carcinoma, 455–456 lymph node levels, anatomy and
pleomorphic adenoma, metastasizing, nomenclature, 459–463
449–450 sentinel node biopsy, 469–470
plunging ranula, 446–447 technique, 464–468
submandibular gland tumors, 451–455 of deep space neck infections, 353–365
airway management, 361–363
Salivary gland tumors, neck masses due to, 334
anatomy, 353–355
Scintigraphy, radionuclide, in evaluation of complications, 363–364
thyroid disorders, 436–437 diagnosis, 356–360
 INDEX 533

in aggressive disease, 374–379 Tracheotomy, 513–520

microbiology, 355–356 contraindications, 513
of laryngeal trauma, 425–428 controversies, 519
of node-positive neck in oral cancer, 499–502 elective, in adults, 513–516
of penetrating injuries of the neck, cervical complications, 514–516
spine, 410–411 emergency surgical airway, 517–519
endocrine, 410 cricothyroidectomy, 517–518
esophageal injury, 409–410 emergent re-opening of a trach site, 518
extracranial vascular trauma, 407–409 slash tracheotomy, 518
laryngotracheal injury, 410 indications, 513
preparation of neck for for microvascular special considerations in elective, 516–517
reconstruction of head and neck, 521–526 in obese patients, 517
general considerations, 522 pediatric, 516–517
microvascular anastomosis, 525 percutaneous dilational tracheotomy, 517
planning for microsurgery, 522–525
Trauma. See Injuries.
vessel-depleted neck, 525–526
Tuberculosis, neck masses due to, 329
T
Teratoma, congenital neck masses due to, U
344–345 Ultrasound, high-resolution, in evaluation of
Thymic cysts, congenital neck masses due to 345, thyroid disorders, 434–436
345 in evaluation of neck masses, 326

Thyroglossal duct cysts, 327–328, 339–341 Upper aerodigestive tract, cancer of, neck masses
in, 330–331
Thyroid cancer, neck masses due to, 334
Thyroid disorders, evaluation and management
of, 431–443
V
fine-needle aspiration, 438–441 Vascular anatomy, of cervical spine, 383
history and physical examination, 432–433 Vascular surgery, preparation of neck for
imaging modalities, 434–438 microvascular reconstruction of head and
CT and MRI, 437–438 neck, 521–526
high-resolution ultrasound, 434–436
radionuclide scintigraphy, 436–437 Vascular trauma, extracranial, in penetrating
laboratory evaluation, 433–434 injuries to the neck, 407–409

Thyroid goiter, benign neck masses due to, Vesicular lesions, neck masses due to, 328
329–330
Thyroid nodules, benign neck masses due to, W
329–330 Warthin’s tumor, extraparotid, 447–449