Neck Dissection Surgery

The lymph nodes of the neck decide much of a head and neck cancer plan. Removing the right ones, and keeping the right nerves, matters for life afterward.

In a trial of 500 patients with early mouth cancer, removing normal-looking neck nodes at the first operation raised three-year survival to 80.0 percent, against 67.5 percent when surgeons waited for nodes to appear.

What a neck dissection removes

The neck holds around 300 lymph nodes, and cancers of the head and neck drain to them in predictable patterns. A tumor of the front of the mouth sends cells first to the nodes under the jaw, a tumor of the tonsil or tongue base to the nodes along the upper jugular vein, and a thyroid cancer to the nodes in the center of the neck beside the windpipe. Surgeons therefore map the neck into six levels on each side and remove the levels that a given cancer is most likely to reach, keeping the muscles, nerves and vessels that run through them wherever the cancer allows. The specimen goes to the pathologist level by level, so the report can say how many nodes contained cancer, where they were, and whether the cancer had broken out through the wall of a node, a finding called extranodal extension that changes the treatment that follows.

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Selective, modified radical or radical

The name of the operation tells you how much comes out.

Keeping the spinal accessory nerve is the single biggest factor in how the shoulder works afterward.

When the neck is operated on

Three situations bring a patient to neck dissection, and the evidence behind each differs.

Nodes that already contain cancer. Proven nodes come out. Enlarged on a scan and confirmed by a needle biopsy, they leave either with the main tumor or after radiotherapy and chemotherapy when they have not fully responded.

A neck that looks normal on scans. Small mouth cancers spread to the neck more often than scans can show. The question of whether to remove normal-looking nodes at the first operation or to wait and operate only if they grow was settled by a large trial in Mumbai, India, published in the New England Journal of Medicine in 2015. In 500 patients with early mouth cancer and a normal-looking neck, three-year overall survival reached 80.0 percent after an elective neck dissection at the time of the main operation, against 67.5 percent with watchful waiting followed by surgery if nodes appeared. Adverse events were 6.6 percent against 3.6 percent.

Sentinel node biopsy instead. French surgeons tested the alternative in 307 patients with small mouth and oropharyngeal cancers, published in the Journal of Clinical Oncology in 2020, comparing a full neck dissection with sentinel node biopsy, in which a tracer injected beside the tumor shows the first one to three nodes, and only those are removed unless they contain cancer. Two-year freedom from neck recurrence came out the same, 89.6 percent against 90.7 percent, the hospital stay was a day shorter, and shoulder and neck function was better for the first six months with the smaller operation.

After chemoradiotherapy. Patients treated with chemoradiotherapy for advanced throat cancer used to have a planned neck dissection afterward. The British PET-NECK trial, published in the New England Journal of Medicine in 2016, replaced that with a PET-CT scan twelve weeks after treatment and surgery only for nodes that had not responded, and two-year survival came out at 84.9 percent with scan-guided surveillance against 81.5 percent with planned surgery. Only 54 neck dissections were needed instead of 221.

The operation

Four things make the review before surgery faster.

1. The biopsy report, and the slides or blocks where available.
2. The scans on disc, CT, MRI or PET-CT, rather than printed images.
3. Any operation notes from earlier surgery on the mouth, throat or neck.
4. Your medicine list, especially blood thinners.

Risks, with what is done about each

Most of what follows is uncommon, and each has a standard answer.

• Shoulder pain and weakness. Stretching or handling of the spinal accessory nerve weakens the trapezius muscle that lifts the shoulder. A 2017 systematic review in the European Journal of Surgical Oncology found shoulder pain in 9 to 25 percent of patients after selective dissection, higher after radical surgery, and nerve preservation lowers but does not remove the risk. Exercises start in the first days and run for months.
• Chyle leak. Milky lymph fluid from the thoracic duct low in the left neck, seen in 52 of 6,482 neck dissections in one Indian cancer center. A low-fat diet, pressure dressing and drainage settled most within nine to twelve days, and a few need a second operation.
• Lower lip weakness. A small nerve branch under the jaw can be stretched, giving an uneven smile for weeks or months. Most recover.
• Numbness of the neck and earlobe. The small skin nerves are cut in most dissections. Feeling returns partly over a year.
• Swelling under the chin. Lymph fluid collects for some months, especially after radiotherapy, and lymphatic massage helps.
• Bleeding and infection. A collection of blood under the skin needs a return to theater in a small number of patients, and antibiotics treat wound infection.

When the pathology changes the plan

Pathology results arrive within about a week. Two findings change what happens next. More than one node with cancer adds radiotherapy to the neck. Cancer that has broken through the wall of a node, or cancer at the edge of the removed tissue, adds chemotherapy to that radiotherapy. Radiotherapy and chemotherapy are both delivered at Biruni Hospital, on the same site as the surgery, and radiotherapy normally starts within six weeks of the operation, so a patient whose plan grows can continue with the same team without a gap. Patients who prefer to have radiotherapy at home leave with a written handover, the pathology report level by level and the scans on disc. Before that decision, the tumor board, with surgeons, radiation and medical oncologists, pathologists and radiologists around one table, reviews the full report, and the plan is explained to you in a consultation with an interpreter if you want one.

Recovery and the shoulder

Two to five days in hospital for a selective neck dissection alone, until the drains come out. Pain is moderate and controlled with tablets. The neck feels tight and numb. Eating and talking are normal unless the main tumor was removed from the mouth or throat at the same time, which sets its own recovery.

Daily life in the first weeks

Lifting heavy weights and sleeping on the operated side wait for the wound to heal, and driving waits until you can turn your head fully. The shoulder program described with the risks above continues at home for at least three months, and the tight feeling in the neck eases over the same period as the scar softens.

How long to stay in Istanbul

Eight to ten days in Istanbul covers most selective and modified radical neck dissections.

Liv Hospital's page for international patients lists stays in Istanbul by type of operation.

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Neck dissection combined with removal of a mouth or throat cancer and a free flap reconstruction keeps patients longer. Flying waits for four things.

What decides the cost

Selective or comprehensive dissection, one side or both, and whether the main tumor and a reconstruction come out in the same operation set most of the figure, while scans before surgery including a PET-CT, nerve monitoring, the hospital nights, and the need for radiotherapy or chemotherapy afterward all move the total.

Published packages in Istanbul bundle the surgery, anesthesia, monitoring after the operation, a private room with meals, follow-up visits, airport transfers and, in some, hotel nights. Flights and visa fees sit outside them. A quote you can compare names the levels and sides to be removed and says whether scans, monitoring and follow-up sit inside it. That figure comes only from a head and neck surgeon reading your scans and biopsy report. The review costs nothing.

Arranging the trip

A coordinator answers the first WhatsApp message and stays with you to discharge, and the number keeps working after you fly home. The team speaks English, Arabic, French, Russian, Serbian, Romanian and Spanish, and an interpreter joins for any other language. One companion stays in your room on a companion bed for the whole admission, while the international patients office books the hotel for the nights either side and sends the invitation letter for a medical visa about ten days before travel. Transfers are arranged. Halal, vegetarian and diabetic meals come from the hospital kitchen, a prayer room sits on site, and a request for a female physician goes to the department with your first message.

Bring the biopsy slides or blocks as well as the report.

Once you are back home

Head and neck cancer returns most often in the first two years, so follow-up visits come every one to three months in the first year and space out to every six months by the third. Three months after treatment, a PET-CT or neck scan sets the baseline. Your local surgeon or oncologist can do the examinations while the coordinator passes the reports back to the team in Istanbul, and shoulder exercises carry on at home with a physiotherapist's help if the shoulder stays stiff.

Any new lump in the neck, a wound that swells or leaks milky fluid, fever, or bleeding from the wound. Each needs a doctor the same day.

Neck dissection surgery FAQ