Neck dissection

Surgical approach

Indication: staging/clearance of cervical lymph nodes for head & neck malignancy (often with primary tumour resection ± free flap).
Incision and exposure: apron/modified MacFee incision; subplatysmal flaps raised; exposure of levels I–V nodal basins.
- Levels: I (submental/submandibular), II–IV (upper–lower jugular chain), V (posterior triangle).
Types: selective vs modified radical vs radical neck dissection.
- Radical: removes lymphatic tissue levels I–V + internal jugular vein (IJV) + sternocleidomastoid (SCM) + spinal accessory nerve (SAN).
- Modified radical: preserves one or more of IJV/SCM/SAN.
- Selective: removes selected nodal levels only (structures preserved).
Key structures at risk: carotid sheath (carotid artery, IJV, vagus), hypoglossal, marginal mandibular branch of facial nerve, SAN, phrenic nerve, sympathetic chain, thoracic duct (left), brachial plexus.
Haemostasis and drains: meticulous haemostasis; suction drains placed; layered closure; possible tracheostomy and/or free flap inset if combined surgery.

Anaesthetic management

Type of anaesthesia: general anaesthesia (often with controlled ventilation).
Airway device: cuffed ETT (RAE/oral or reinforced tube depending on access); consider nasal ETT if oral access required; tracheostomy may be performed intra-op or pre-op in selected cases.
- SGA: generally inappropriate (shared airway, long duration, aspiration/bleeding risk).
Duration: typically 2–4 h for isolated neck dissection; 6–12+ h if combined with primary resection and free flap.
Analgesia requirement: moderate–severe (incision, deep dissection, drains; worse if combined with major resection).
- Multimodal: paracetamol + NSAID (if appropriate) + opioid; consider regional blocks (superficial cervical plexus) and/or wound infiltration.
Monitoring/lines: standard + arterial line (common) for BP control and blood sampling; large-bore IV access; consider central access if major combined surgery (avoid ipsilateral IJV if surgical field).
Key intra-op aims: secure airway, smooth emergence (avoid coughing/straining), haemodynamic stability (carotid sinus manipulation), meticulous PONV prophylaxis, temperature management, fluid/blood strategy.

Pre-operative assessment

Cancer patient considerations: malnutrition, sarcopenia, anaemia, dehydration, sepsis/aspiration risk, alcohol dependence, smoking/COPD, chemotherapy/radiotherapy effects.
- Radiotherapy: reduced neck mobility, trismus, friable mucosa, oedema; difficult mask ventilation/intubation; carotid atherosclerosis and baroreceptor dysfunction possible.
Airway assessment: mouth opening, dentition, trismus, neck movement, previous surgery/RT, stridor/voice change, OSA; review imaging (CT/MRI) and ENT notes.
- Plan for failed intubation: awake fibreoptic/video-assisted technique if high risk; ensure ENT support and tracheostomy capability.
Cardiorespiratory: smoking-related disease; consider cardiology review if significant comorbidity; baseline ECG; CXR if indicated.
Bleeding risk: anticoagulants/antiplatelets; liver disease; check FBC/coagulation; group & save (crossmatch if combined major resection/free flap).
Consent/expectations: possible post-op HDU/ICU, tracheostomy, feeding tube, shoulder dysfunction (SAN), numbness, dysphagia; discuss analgesia and PONV plan.

Airway strategy

Shared airway: ensure tube secure and accessible; communicate with surgeon about access and need for tube repositioning.
Intubation approach: video laryngoscopy commonly; awake fibreoptic (oral/nasal) if predicted difficulty or post-RT airway; consider smaller ETT if oedema/RT changes.
Extubation planning: assess for airway oedema, bleeding risk, difficult reintubation, aspiration risk, reduced consciousness; consider delayed extubation/ICU if major combined surgery or significant swelling.
- If extubating: fully awake, head-up, suction carefully, consider lidocaine/opioid to blunt cough, ensure immediate access to reintubation equipment and ENT help.

Intra-operative considerations

Position: supine, head turned; protect eyes and pressure points; avoid excessive neck rotation (cervical spine disease, carotid flow).
Haemodynamic responses: carotid sinus/vagal stimulation can cause bradycardia/hypotension; infiltration with local anaesthetic by surgeon may help; treat with anticholinergic and pause manipulation.
- Differential: bleeding, anaesthetic depth, myocardial ischaemia, high vagal tone, drug effects.
Blood loss: usually modest in isolated selective dissections but can be significant in radical/combined resections; have blood available if high risk; maintain normothermia and correct coagulopathy.
Fluids: goal-directed where available; avoid excessive crystalloid (airway/flap oedema); consider vasopressors as needed (especially in free flap cases—use by local protocol).
Nerve injury implications: SAN injury → shoulder dysfunction; hypoglossal/vagus injury → dysphagia/aspiration/voice change; phrenic nerve injury → hemidiaphragm paralysis (respiratory compromise).
Thoracic duct injury (left): risk of chyle leak; may present post-op with milky drain output, fluid/electrolyte/protein loss; rarely chylothorax and respiratory compromise.
Venous air embolism: uncommon but possible with open neck veins (especially IJV); vigilance for sudden drop in ETCO2, hypoxia, hypotension; flood field, aspirate via central line if present, Durant position, supportive care.
PONV: high consequence (wound bleeding/haematoma, aspiration); use multimodal prophylaxis (e.g., dexamethasone + ondansetron ± droperidol) and opioid-sparing techniques.

Analgesia options

Baseline: paracetamol + NSAID/COX-2 (if safe) + opioid (titrated).
Regional: superficial cervical plexus block (SCPB) can reduce opioid requirement for neck incision pain; consider bilateral risk (phrenic nerve palsy) if deep block—avoid deep/bilateral in respiratory compromise.
- Technique note: SCPB is subcutaneous along posterior border of SCM; lower risk than deep cervical plexus block.
Adjuncts: low-dose ketamine, magnesium, clonidine/dexmedetomidine (selected patients), local infiltration by surgeon; consider PCA if significant pain expected.

Post-operative care

Location: PACU with low threshold for HDU/ICU if airway risk, major resection/free flap, significant comorbidity, or need for close flap monitoring.
Airway threats: neck haematoma, oedema, bleeding into airway, laryngospasm, aspiration; ensure head-up, humidified oxygen, suction, and clear escalation plan.
Neck haematoma: time-critical; signs include neck swelling, stridor, dysphonia, agitation, hypoxia; call for help, open wound/clips if necessary, secure airway early (may be difficult).
Cranial nerve deficits: assess voice/swallow; consider SLT review; aspiration precautions; NG feeding may be required.
Drain management: monitor output (blood/chyle); sudden increase may indicate bleeding; milky output suggests chyle leak.
VTE prophylaxis: mechanical + pharmacological as per bleeding risk and surgical plan.

Complications (anaesthetic relevance)

Early: airway obstruction (haematoma/oedema), bleeding, aspiration, PONV-related wound issues, hypocalcaemia if combined with thyroid/parathyroid surgery (not typical for isolated neck dissection).
Cardiovascular: bradycardia/hypotension from carotid sinus stimulation; arrhythmias; myocardial ischaemia in high-risk patients.
Respiratory: phrenic nerve injury (rare) → hemidiaphragm paralysis; chylothorax; pneumonia (aspiration).
Neurological: cranial nerve injury (X, XII, XI), sympathetic chain injury (Horner’s), brachial plexus injury from traction/position.

You are asked to anaesthetise a patient for neck dissection. What are your main concerns and plan?

Structure your answer: airway, bleeding, reflexes, positioning, analgesia, emergence, post-op destination.

Airway: assess for difficult mask/intubation (tumour, trismus, prior RT/surgery); plan primary technique (VL vs awake fibreoptic) and failed airway strategy with ENT support.
GA with cuffed ETT; secure tube well; shared airway communication; consider nasal/reinforced tube depending on access.
Monitoring: standard + arterial line (often); adequate IV access; blood availability depending on extent/combined surgery.
Intra-op risks: carotid sinus stimulation → bradycardia/hypotension; VAE (rare); nerve injuries; thoracic duct injury (left).
Analgesia: multimodal ± superficial cervical plexus block; PONV prophylaxis.
Emergence: smooth extubation strategy; avoid coughing/straining; consider delayed extubation/ICU if airway oedema/bleeding risk or difficult reintubation.

How does previous radiotherapy to the neck affect your anaesthetic?

Common FRCA viva theme: radiotherapy predicts difficulty and increases peri-operative airway risk.

Airway: reduced neck mobility, trismus, fibrosis; difficult mask ventilation and intubation; friable mucosa/bleeding; oedema and distorted anatomy.
Plan: consider awake intubation; have smaller tubes available; gentle technique; ENT backup for front-of-neck access/tracheostomy.
Vascular: accelerated carotid atherosclerosis; potential baroreceptor dysfunction; haemodynamic lability with carotid manipulation.
Post-op: higher risk of airway oedema and difficult reintubation → lower threshold for HDU/ICU and delayed extubation.

During dissection around the carotid sheath the patient becomes profoundly bradycardic and hypotensive. What is the likely cause and how do you manage it?

Carotid sinus reflex is classic in neck surgery.

Likely cause: carotid sinus stimulation (baroreceptor reflex) ± vagal stimulation.
Immediate actions: ask surgeon to stop manipulation; check ECG rhythm, depth of anaesthesia, ETCO2, pulse/arterial trace; exclude bleeding.
Treat: anticholinergic (atropine/glycopyrrolate) ± vasopressor (metaraminol/phenylephrine/ephedrine) as appropriate; consider local anaesthetic infiltration around carotid sinus by surgeon if recurrent.
If persistent/unstable: follow ALS/arrhythmia algorithm; consider external pacing if severe refractory bradycardia.

What are the causes of post-operative airway obstruction after neck dissection and how would you manage them?

Focus on time-critical haematoma and oedema; management prioritises oxygenation and early airway control.

Causes: neck haematoma, airway oedema, bleeding into airway, laryngospasm, aspiration, bilateral vocal cord dysfunction (if vagal/recurrent laryngeal involvement in combined surgery).
Initial management: call for help (ENT/anaesthetics), high-flow oxygen, sit up, suction, assess rapidly; prepare difficult airway equipment.
Haematoma: urgent decompression—open wound/remove clips if necessary while preparing definitive control; do not delay for imaging.
Secure airway early if deteriorating: RSI may be hazardous; consider awake approach if time; be ready for front-of-neck access/tracheostomy.

Discuss your extubation strategy after neck dissection.

FRCA often tests extubation as a planned procedure with risk stratification.

Assess: airway swelling, bleeding risk, surgical extent, drain output, duration, fluid balance, difficult intubation/reintubation risk, aspiration risk, level of consciousness.
If extubating: fully awake, head-up, ensure haemostasis, gentle suction, consider lidocaine/opioid to reduce coughing; ensure immediate access to reintubation kit and ENT help.
If high risk: plan delayed extubation in ICU/HDU; consider airway exchange catheter in selected difficult-airway patients (local practice).

What regional anaesthetic techniques can be used for analgesia in neck dissection and what are the risks?

Superficial cervical plexus block is most relevant; deep blocks carry higher risk.

Options: superficial cervical plexus block (unilateral); surgeon wound infiltration; less commonly deep cervical plexus block (specialist).
Benefits: opioid-sparing, improved comfort with drains and neck movement.
Risks: local anaesthetic systemic toxicity; inadvertent deep spread causing phrenic nerve palsy, recurrent laryngeal nerve block/hoarseness, Horner’s syndrome; vascular puncture (carotid/vertebral) especially with deep block.
Avoid: bilateral deep blocks; caution in severe COPD/limited respiratory reserve.

A patient develops sudden fall in ETCO2 and hypotension during neck dissection. What is your differential and immediate management?

Viva expects broad differential with prioritised actions; include VAE and haemorrhage.

Differential: venous air embolism, major haemorrhage, anaphylaxis, pulmonary embolism, severe bronchospasm, circuit/ventilation issue, myocardial event/arrhythmia.
Immediate actions: call for help; check patient/circuit; increase FiO2 to 1.0; confirm ventilation and capnography; assess pulse/BP/ECG; look at surgical field for bleeding/open veins.
If VAE suspected: inform surgeon to flood field and occlude veins; aspirate via central line if present; consider Durant position (left lateral head-down) if feasible; support with fluids/vasopressors; consider TEE/precordial Doppler if already in use (rare for this case).
If haemorrhage: activate major haemorrhage protocol as needed; transfuse; correct coagulopathy; maintain normothermia and calcium.

What post-operative complications are specific to neck dissection and how do they present?

Focus on complications with anaesthetic/critical care implications.

Neck haematoma: swelling, pain/pressure, stridor, hypoxia, agitation; can rapidly obstruct airway.
Chyle leak (left): milky drain output, fluid/electrolyte/protein loss; possible chylothorax with respiratory compromise.
Cranial nerve injury: SAN (shoulder droop), hypoglossal (tongue deviation/dysarthria), vagus (hoarseness, aspiration), sympathetic chain (Horner’s).
Phrenic nerve injury: dyspnoea, raised hemidiaphragm on CXR; worse in COPD/obesity.