1. Sarah Gregory Physiotherapy Principal Clinical Specialist Critical Care, RSCH January 2015

2. Background Malignant tumours of the upper aerodigestive tract are the 6th most common cancers. Histologically more than 90% of these tumours are squamous cell carcinomas (SCC). Squamous cell carcinomas of the upper aerodigestive tract tend to metastasise.

3. Lymphatic Drainage The lymph flow in the head and neck area is drained by 300 lymph nodes. This lymph flow follows certain predictable directions towards groups of lymph nodes..

4. Lymph Node Levels ISubmental and submandibular IIUpper jugulodigastric group draining naso pharynx IIIMiddle jugular nodes draining naso- and oropharynx, oral cavity, hypopharynx, larynx. IVInferior jugular nodes draining hypopharynx, subglottic larynx, thyroid, oesophagus. VPosterior triangle group VIAnterior compartment group

5. Neck Dissection Undertaken by Maxillo-facial and ENT surgeons As part of bigger surgical procedure As stand alone surgery

6. Types Radical Neck Dissection: Levels I to V dissected, including resection of the internal jugular vein,sternocleido- mastoid muscle and accessory nerve

7. Modified (Radical) Neck Dissection: Levels I to V dissected but preserving one or more of the accessory nerve, internal jugular vein or sternocleidomastoid muscle

8. Selective Neck Dissection: Denotes preservation of one or more lymph node groups (levels I to V) and preservation of the accessory nerve, internal jugular vein and the sternocleidomastoid muscle

9. Extended Neck Dissection Denotes the removal of 1 or more additional lymph node groups or non- lymphatic structure not encompassed by the RND. E.g. Carotid A, Vagus N, paratracheal LN

10. Spinal Accessory Nerve

11. Spinal Accessory Nerve CN XI Supplies Trapezius Scapular elevation Scapular retraction Scapular rotation Neck side flexion / extension Supplies Sterno-cleido- mastoid Head rotation Head side flexion Neck forwards flexion

12. Accessory Nerve Shoulder Dysfunction (ANSD) “ not uncommon for patients who have undergone ND to be referred to outpatient physiotherapy department for frozen shoulder” 195260% pts  shoulder mvt following RND 198060% pts  shoulder mvt despite trying to spare AN 1989% pts with  shoulder mvt under reported 199177% pts subjectively had difficulties 46% failed to return to work because of shoulder difficulties 2004 67% pts suffer AN injury despite SND/MRND 200739% pts report shoulder problems even with SND

13. ANSD – causes? RND Sacrifice of Spinal Accessory Nerve SND Neuropraxia – microtrauma through intra-operative manipulation and traction R/T Fibrosis of muscle fibres and neural sheath Nerve demyelination General  in physical activity

14. ANSD 1  muscle strength of upper and middle trapezius Depression, abduction and medial rotation of scapula  Lateral rotation and elevation of scapula  Active shoulder abduction and flexion shoulder pain and dysfunction Abnormal mechanics  shoulder pain and dysfunction

15. ANSD 2  muscle strength of upper trapezius muscles bilat. Tension in upper trapezius muscles Poor cervical posture Cervical spine dysfunction

16. Physiotherapy Postural awareness / scapular setting Active exercises Neck ROM exs Targeted exercises for scapular muscle deficit Bilateral upper trapezii Unilateral middle trapezius Unilateral serratus anterior GHJ ROM exs Shoulder flexion (including auto assisted as required) External rotation Advise / exercise leaflet, Home exercise programme +/- OPD sessions

17. References The impact of selective neck dissection on shoulder and cervical spine movements B. Scott, D. Loweb, S.N. Rogers Physiotherapy (2007) 93 102–109 An exploratory trial of preventative rehabilitation on shoulder disability and quality of life in patients following neck dissection surgery Lauchlan D.T., Mccaul J.A., Mccarron T., Patil S., Mcmanners J. & Mcgarva J. European Journal of Cancer Care (2011) 20, 113–122 Impact of Neck Dissection on Scapular Muscle Function: A Case-Controlled Electromyographic Study Aoife C. McGarvey, Peter G Osmotherly, Gary R. Hoffman, Pauline E. Chiarelli, Archives of Physical Medicine and Rehabilitation (2013); 94:113-9 Maximising shoulder function afer accessory nerve injury and neck dissection surgery: a multicentre randomised controlled trial Mcgarvey AC, Hoffman GR, Osmotherly PG, Chiarelli PE Head and Neck - DOI 10.1002 / HED MONTH 2014 Neck Dissection Classification Update Revisions Proposed by the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck Surgery K. Thomas Robbins, MD; Garry Clayman, MD; Paul A. Levine, MD; Jesus Medina, MD; Roy Sessions, MD; Ashok Shaha, MD; Peter Som, MD; Gregory T. Wolf, MD; and the Committee for Head and Neck Surgery and Oncology, American Academy of Otolaryngology–Head and Neck Surgery Arch Otolaryngol Head Neck Surg. 2002;128(7):751-758 http://archotol.jamanetwork.com/article.aspx?articleid=482968#CLASSIFICATIONOFNECKDISSECTION http://emedicine.medscape.com/article/849516-overview#aw2aab6b4