頸部郭清術における頸神経温存

Considering the spinal accessory nerve in head and neck surgery.

Objective comparison of physical dysfunction after neck dissection.

Objective: Cutaneous anesthesia in early postoperative period is common after neck dissection even if the cervical nerve (CN) rootlets are preserved. The aim of this study was to evaluate if the preservation of the terminal branches of CNs using sub-sternocleidomastoid (SCM) approach combined with medially placed skin incision can prevent early postoperative anesthesia.Material and methods: A retrospective chart review was performed on 129 neck dissections in 87 head and neck cancer patients.Results: The early postoperative sensory preservation rates for the ear tab, submandibular, lateral neck, and sub-clavicular areas of CN rootlet-preserved necks (n = 86) were 75.6%, 20.9%, 74.4%, and 86.0%, respectively, compared with 37.2%, 2.3%, 2.3%, and 4.7%, respectively, in CN rootlet-resected necks (n = 43). In CN rootlet-preserved necks, the sub-SCM approach (n = 54) showed 81.5%, 27.8%, 92.6%, and 94.4% preservation rates, respectively, compared with 65.6%, 9.4%, 43.8%, and 71.9%, respectively, using the conventional subplatysmal approach (n = 32). The rates were significantly better in the submandibular, lateral neck, and sub-clavicular areas after sub-SCM approach.Conclusions: Preservation of CN rootlets is a required element for sensory preservation in neck dissection. The sub-SCM approach can effectively prevent early postoperative cutaneous anesthesia following CN-preserving neck dissection.

Neck dissection remains the standard method of treating cervical metastasis from head and neck squamous cell carcinoma. In light of recent trends to modify the classic radical neck dissection (RND) for early neck disease, we reviewed our experience with radical and modified RND (MRND) plus radiotherapy as treatment for N2/N3 neck disease in head and neck squamous cell carcinoma. We retrospectively reviewed our clinical records from July 1989 to June 1996 to identify 43 neck dissections in 39 patients who were found to have pathologically N2 or N3 neck disease treated primarily by neck dissection and postoperative radiotherapy. All patients had head and neck squamous cell carcinoma with a minimum follow-up of 24 months. Nine percent (4/43) of the dissected necks were pathologically N2a, 72% (31/43) were N2b, 7% (3/43) were N2c, and 12% (5/43) were N3. Of these, 28% (12/43) underwent a RND and 72% (31/43) underwent a MRND. The most common modification of RND was preservation of the spinal accessory nerve. All patients underwent postoperative radiotherapy with a mean dose of 55 Gy. Only 4 of 43 dissected necks had isolated treatment failure, for a regional control rate of 91%. The combination of RND or MRND and radiotherapy is highly effective in controlling neck disease in the absence of persistent or recurrent local disease. Also, in our experience, MRND appears to be as effective as RND in controlling even advanced neck disease, which supports preservation of the spinal accessory nerve whenever oncologically feasible.

Background/Objectives: We investigated whether cervical sensitive nerves (CSN) provide motor input to the trapezius muscle and how this relates to short-term functional outcomes after neck dissection. Methods: A total of 22 neck dissections were performed in 17 patients; the SAN was preserved. CSN roots (C2–C4) were stimulated intraoperatively using IONM. Shoulder and neck function were evaluated preoperatively and at 3 months in 15 operated necks using goniometry, an IMU-based motion analysis system (iSen), trapezius isometric strength, the Modified Constant–Murley Score (MCMS), and the Shoulder Pain and Disability Index (SPADI). Results: CSN-evoked trapezius responses were detected in 10/22 (45.5%) dissections (C2: 6/22, 27.2%; C3: 4/22, 18.2%; C4: 0/22). Postoperatively, neck extension/rotation and shoulder abduction/external rotation decreased significantly within groups; upper and middle trapezius strength and MCMS also declined. Shoulder flexion loss was smaller when CSN motor participation was present. Median shoulder flexion (goniometry) changed from 162°→140° in CSN(+) vs. 170°→131° in CSN(−) (between-group p = 0.024). With iSen, shoulder flexion changed 120°→116° in CSN(+) vs. 122°→97° in CSN(−) (p = 0.033). Conclusions: Approximately half of the neck dissections exhibited CSN-related motor responses. Short-term shoulder flexion was better preserved when CSN motor participation was present, suggesting that documenting CSN motor input intraoperatively may inform early rehabilitation planning.

Preservation of the spinal accessory nerve during neck dissection should be the rule rather than the exception. Despite the presence of many described techniques to locate the nerve, a tedious dissection is often required; as a consequence, it remains vulnerable to damage. We describe a novel method, not previously reported, based on identifying a constant vein which crosses the nerve. This aids in the nerve's early identification. Our method enables the surgeon to locate the nerve precisely and to avoid damage to it, thereby maximizing post-operative function.

The X-pointer: A forgotten anatomical relationship of spinal accessory nerve and great auricular nerve

Surgical treatment of malignant tumors of the parotid gland

Lateral neck dissection (LND) leads to a significant morbidity involving accessory nerve injury. Modified radical neck dissection (MRND) aims at preservation of the accessory nerve, but patients often present with negative functional outcomes after surgery. The role of neuromonitoring (IONM) in the prevention of shoulder syndrome has not yet been defined in comparison to nerve visualization only. We retrospectively analyzed 56 thyroid cancer patients who underwent MRND over a period of six years (2015–2020) in a high-volume institution. Demographic variables, type of surgical procedure, removed lymph nodes and the metastatic node ratio, pathology, adoption of IONM and shoulder functional outcome were investigated. The mean number of lymph nodes removed was 15.61, with a metastatic node ratio of 0.2745. IONM was used in 41.07% of patients, with a prevalence of 68% in the period 2017–2020. IONM adoption showed an effect on post-operative shoulder function. There were no effects in 89.29% of cases, and temporary and permanent effects in 8.93% and 1.79%, respectively. Confidence intervals and two-sample tests for equality of proportions were used when applicable. Expertise in high-volume centres and IONM during MRND seem to be correlated with a reduced prevalence of accessory nerve lesions and limited functional impairments. These results need to be confirmed by larger prospective randomized controlled trials.

Modified radical neck dissection with preservation of the accessory nerve is often used for elective neck dissection or early-stage neck metastasis.Dissection of the upper neck, requires confirmation of several anatomical landmarks, such as the internal jugular vein, occipital artery, hypoglossal nerve, accessory nerve, vagus nerve, and digastric muscle. During the dissection, surgeons should be aware that the anatomical relations of these landmarks can vary.After the accessory nerve leaves the jugular foramen, it crosses the internal jugular vein and descends obliquely to the trapezius muscle.Variations in the relation of the accessory nerve to the internal jugular vein should be taken in account to perform the dissection correctly.We encountered a patient in whom the accessory nerve passed through the internal jugular vein.

The recurrent laryngeal nerve is a critical structure that must be carefully preserved during thyroid surgery. Any injury to this nerve can result in severe complications, including hoarseness, aspiration, and respiratory difficulty. Therefore, preserving the recurrent laryngeal nerve during surgery is crucial. In patients with a history of previous thyroid surgery, identification and preservation of the recurrent laryngeal nerve can be more challenging. We report a case of 43-year-old man diagnosed with recurrent papillary thyroid cancer who had previously total thyroidectomy with bilateral central neck dissection and right modified radical neck dissection due to papillary thyroid cancer. Re-do operation was successfully done without nerve injury using laryngeal nerve monitoring with electromyogram tube.

Laryngeal nerve morbidity in 1.273 central node dissections for thyroid cancer

Introduction: Minilaparoscopy-assisted thyroidectomy using the bilateral breast approach is a technique for thyroidectomy in patients with thyroid disease. This technique can promote the effect of cosmetology in thyroid surgery. In this video, we outline the instrument, operating room setup, and trocar position, present a minilaparoscopy-assisted hemithyroidectomy and central neck dissection (level VI), and demonstrate recurrent laryngeal nerve and two parathyroids in operation. Materials and Methods: In August 2014, we operated on a 35-year-old female patient. The patient underwent fine-needle aspiration cytology, diagnosed as left papillary thyroid carcinoma. After CT scan and ultrasonic inspection preoperation, the clinical staging is cT1aN0M0 staging I. According to the Chinese thyroid nodule and thyroid cancer guideline,1 we decided to perform left hemithyroidectomy and central neck dissection (level VI) using a bilateral areolar approach. 0.2 mL carbon nanoparticle suspension was injected to the thyroid gland with ultrasonic guidance 2 weeks before operation. The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the superior pole vessels are divided. The superior pole is then mobilized laterally and the recurrent laryngeal nerve is searched for at the inferior pole. The dissection continues between the nerve and the posterior part of the thyroid progressively, from bottom to top. After the recurrent nerve dissection, the gland can usually be extracted without difficulty, dividing the last vessels in berry ligament holding the gland. While in central neck dissection, first, we confirmed the lateral boundaries of central compartment and identified the recurrent laryngeal nerve. Then completed the central neck dissection. Finally, we present the superior thyroid artery, recurrent laryngeal nerve, and parathyroids after dissection, cleaning up, and closure. Results: The patient who was operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Carbon nanoparticle suspension is an ideal lymphatic tracer for endoscopic thyroidectomy and central neck dissection, although there is some leakage of carbon nanoparticle suspension in this patient. It does not affect the identification and preservation of recurrent laryngeal nerve and parathyroids. Conclusions: We prefer to operate cN0 thyroid cancer using this technique because it allows us to better identify and preserve the recurrent laryngeal nerve and parathyroids and same boundaries in central neck dissection. Moreover, it brings better cosmetic results for young patients. No competing financial interests exist. Runtime of video: 9 mins 57 secs

Preservation of spinal accessory nerve in modified neck dissections.

Vagal schwannoma is a benign tumor that can occasionally develop into malignant degeneration from the Schwann cells surrounding the cranial, peripheral, and autonomic nerves. The schwannomas arising in the head and neck region are rare, and rarer is their origin from the cervical vagus nerve. Despite being challenging, multiple treatment options are available, including observation, complete tumor excision with nerve transaction, and nerve preservation, depending on clinicoradiological factors. The cervical vagal schwannoma is a rare entity. We report a rare case of a 50-year-old female with painless swelling on the right side of the neck associated with mild discomfort during swallowing, diagnosed as cervical vagal schwannoma.