College of Medicine of Mosul Surgery of the neck(4) بِسْمِ اللهِ الرَّحْمنِ الرَّحِيم Dr. Karam Kamal Sharif Assist. prof. of surgery College of Medicine of Mosul

Neoplastic cervical LAD 80% of neoplastic LN are malignant 80% of malignant LN are secondary 80% of primary tumors above the clavicle A- primary in head and neck (80%) =SCC from 1-Known primary: in oral cavity, nasopharynx Oropharynx, hypopharynx or thyroid 2- Occult hidden primary in base of tongue, hypophx., Pyriform sinuses, tonsils ,nasophx. & postcricoid area B- primary below the clavicle (20%) 1- bronchus 2- stomach, colon, pancreas. 3- testes, prostate. Character of LN involved by secondary malignant deposit are rapidly enlarged, big > 2 cm stony hard, irregular shape, fixed, painless with subsequent ulceration to skin secondary malignant LN 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda Primary cervical LN malignancy Represent 20% of malignant tumors mostly lymphomas /leukemias Hodgkins disease-lymphoma Usually involves children& young adults. More common in male. Clinically: Painless progressive enlargement of discrete mobile & rubbery LN May be very large LNs “bull neck +/-hepato/splenomegaly +/- B symptoms – fever, night sweats, pruritus& weight loss Management of neoplastic cervical LAD The primary should always searched and managed accordingly. Biopsy or FNAC for confirmation of diagnosis Surgery =excise LN with primary by neck dissection . Radiotherapy Can be used initially like in nasopharyngeal ca. Recurrent nodal disease. Residual tumour Hodgkins disease 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda Cervical LN metastasis decreases the 5-year survival rate in upper aero-digestive malignancies by 50%. . . NECK DISSECTION The gold standard for control of cervical metastasis is radical neck dissection (RND) with en-block removal of primary tumour if feasible Many incisions (Crile, Ward, Martin, Schechter, Macfee and Hockey stick) The aim is to fulfill 1-adequate exposure. 2-capable for extension. 3- cosmetically acceptable 4- not damage vital structure under the skin 5- avoid middle portion of the neck 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda Types of neck dissection & SM salivary gland. 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda Complications of RND A- Early: 1- Bleeding 2-Pneumothorax 3- Increase intracranial pressure due to ligation of IJV. 4-Chylus fistula due to injury to thoracic duct. 5- Carotid artery rapture. B-Late: 1- Scar formation and disfiguring 2-Frozen shoulder 3- Recurrence of tumour 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda NECK INJURIES Aetiology Blunt: mostly in car accidents fracture cervical spine Penetrating: (penetrate platysma) in stabs or missiles causing visceral or vascular injuries The neck is divided into 3 anatomical zones: to aid in decision making- diagnostic tests,-timing of surgery Zone I- thoracic outlet (clavicles to cricoid cartilage), Zone II- mid neck (cricoid to angle of the mandible). Zone III- upper neck (angle of mandible to base of skull). Why serious? Vital viscera/vessels Cx spine injuries have the highest mortality The most frequently involved region 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda Management steps 1-AcBCDE 2-Examination for: ” Hard signs” of significant neck damage: -Vascular injury -Shock/Expanding or pulsatile hematoma - Neurologic deficit -Venous air embolism due to IJV injury -Bruit or thrill in neck(AV fistula) -Thoracic duct injury - Chylous fistula up to 2 L/D -Neurologic deficit -Vagus / recurrent laryngeal/sympathetic chain -Laryngotracheal injury -Subcutaneous emphysema -Acute Airway obstruction -Sucking wound -Hemoptysis -Dyspnea -Stridor -Hoarseness or aphonia -Pharynx/esophagus injury Subcutaneous emphysema -Hematemesis - leakage ,cellulitis ? mediastinitis -Dysphagia or odynophagia 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

ZONE I INJURY-MANAGEMENT 3-Definitive treatment: according to NECK zones Penetrating injuries are potentially fatal. Arrange for Angiography or CT angio for suspected vascular injury to plan selective exploration Esophageal barium swallow to detect- missed esophageal injury- mediastinitis 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

ZONE II INJURY- MANAGEMENT Asymptomatic-stable pt with no penetrating wound So arrange for Selective exploration :. mandatory neck exploration or directed evaluation and serial examinations by Angio / duplex Doppler or CT A-gram, contrast study of esophagus, rigid endoscopy, and rigid bronchoscopy. Operation reserved for identified injuries Symptomatic- as Pt with refractory shock, uncontrollable bleed, expanding hematoma & wounds penetrating platysma all need (immediate) neck exploration & treat accordingly 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda Specific injuries zone II: Wounds above hyoid bone Rx as in tongue injuries Wounds of thyroid and cricoid cartilage Distal tracheostomy, larynx cartilages repositioned. + stent inserted for 5 days removed endoscopically later Division of the trachea (rare) Distal Tracheostomy (below wound) & repair of trachea. Neurovascular injury =exploration under GA with repair . Thoracic duct injury rare If recognised intraoperatively, the duct ligated. If undetected, chyle discharge from neck wound within 24 hours of surgery. Treatment= either by firm pressure, or wound reexplored and duct ligated. Esophageal injuries sutured & drained +antibiotics . 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

Electro surgery in Gynaecology - Prof.S.N.Panda CUT-THROAT Is due to attempted suicide Head extended- great vessels escape injury,while in homicidal cut throat there is a risk of great vessel injury Treatment proper neck exploration, debridement of ischemic tissue, the air passages are – repaired + tracheostomy Bleeding from thyroid artery- secured IJV- ligated above and below the injury site Pharyngeal injury- suture, with drainage NG tube for feeding 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

ZONE III INJURY- MANAGEMENT Potential for injury to major blood vessels and cranial nerves near the skull base Surgical exposure – difficult Arrange for Angiogram- interventional radiology to embolize bleeders 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda

الْحَمْدُ للّهِ رَبِّ الْعَالَمِينَ 12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda 14