Surgery to remove the lymph nodes in your neck

Cancers of the mouth and oropharynx can spread to lymph nodes in your neck. Your surgeon might remove some or all of the lymph nodes in your neck.

Surgery to remove the lymph nodes in the neck is called a neck dissection. Surgeons don't routinely do a neck dissection on everyone because it can have long term side effects.

You might have a sentinel lymph node biopsy (SLNB), This is a test to find the first lymph node or nodes that a cancer may spread to. The doctor then checks to see if this lymph node contains cancer cells.

Why do you need surgery to remove the lymph nodes?

Lymph nodes are small bean shaped glands found throughout the body, including the head and neck area. They are part of the lymphatic system that filters body fluid and fights infection. They also trap damaged or harmful cells such as cancer cells.  

They are often the first place cancer cells spread to when they break away from a primary cancer.

Your doctor needs to find out if lymph nodes in the neck contain cancer. It is important to know this to work out the stage of the cancer and plan treatment.

Before your operation, your surgeon might know that there is cancer in your lymph nodes. In this case, the surgeon removes your lymph nodes during your surgery to remove the cancer. 

Sometimes your surgeon doesn't know if there are cancer cells in your lymph nodes before you have surgery. In this case, your surgeon might remove the lymph nodes closest to the cancer. They send the nodes to the laboratory to check them for cancer cells.

For an early stage cancer your doctor might suggest a sentinel lymph node biopsy.

Checking your lymph nodes (sentinel lymph node biopsy)

A sentinel lymph node biopsy (SLNB) is a test to find the first lymph node or nodes that the cancer may spread to. The doctor then checks to see if this lymph nodes contains cancer cells. 

This is usually for people with early stage mouth cancer. 

You might have a sentinel node biopsy at the same time as your operation to remove the cancer.

How you have a sentinel lymph node biopsy

Before your sentinel lymph node biopsy

The day before or morning of your operation you have a scan to show where the sentinel nodes are. You usually have this in the nuclear medicine department in the hospital. This scan shows the surgeon which lymph nodes to remove but doesn’t tell them whether the nodes contain cancer.  

You have an injection of a small amount of mildly radioactive liquid into the area close to the cancer. The radioactive liquid is called a tracer.

Then you have a scan. This picks up the radioactive liquid and traces it as it moves through the lymphatic vessels and into the lymph nodes. The first nodes that the tracer drains into are the sentinel nodes. The radiographer might mark where these nodes are on your skin.

The scan can take around 90 minutes, but this time may vary. Afterwards you might go straight to the ward to prepare for surgery. Or you may go home and return the following day for your surgery. 

What happens?

Your surgeon removes the sentinel lymph nodes during your operation to remove the mouth cancer. During the operation, your surgeon also injects a small amount of blue dye around the cancer. The dye and the tracer help the surgeon identify the sentinel node.  

Your surgeon usually removes between 1 to 3 nodes. They send the lymph nodes to the laboratory to check for cancer cells. 

After the sentinel lymph node biopsy

Depending on the type of surgery you have for your cancer, you may go home the same day or the following day.

As you have had a general anaesthetic, you will need someone to take you home and stay with you for 24 hours after the operation.

You usually get the results about 1 to 2 weeks after your surgery.

Possible problems

Pain

You may have pain around the site of the sentinel lymph node biopsy in your neck. This might last up to 2 weeks. Taking mild painkillers can help. You might also have a stiff or sore neck. This usually gets better in a few weeks.

Swelling

Fluid collecting near the wound can cause swelling and pain. It also increases the risk of infection. This usually starts to settle soon after your surgery but can take longer.

If you have some or all of the lymph nodes in your neck removed, the swelling might be due to lymphoedema. Lymphoedema means a build up of lymph fluid that causes swelling in a part of the body. It's pronounced limf-o-dee-ma. 

The lymph nodes are part of your body's drainage system. Removing them can affect the natural circulation and drainage of tissue fluid.

You should let your doctor or nurse know of any swelling you have. 

Blue or green urine

The blue dye is removed by the kidneys and can make your wee look blue or green. This usually lasts for a couple of days.

Rarely some people are allergic to the blue due, it is important to let your surgeon know if you have any allergies beforehand.

What happens next?

A positive result means there are cancer cells in the sentinel nodes. This means the cancer has started to spread. Your doctor will talk to you about further treatment. They might recommend that you have:

• surgery to remove all the lymph nodes in your neck (a neck dissection)
• radiotherapy to the neck area

A negative result means there are no cancer cells in the sentinel nodes. This means that it is unlikely the cancer has spread to the other lymph nodes.

Having a neck dissection

Surgery to remove the lymph nodes in the neck is called a neck dissection.  

You might need to have lymph nodes removed from just one side of your neck or you might need to have them removed from both sides.

There are different types of neck dissection:  

• selective neck dissection
• modified radical neck dissection
• radical neck dissection

Selective neck dissection

Your surgeon removes some lymph nodes from your neck. They usually remove the nodes close to the cancer that are most likely affected by the cancer  

You might have a selective neck dissection if the doctors know or suspect that only a small number of lymph nodes contain cancer. 

Modified radical neck dissection

There are 3 types of modified radical neck dissection.

With one type your surgeon removes most of the lymph nodes between your jawbone and collarbone on one side of your neck.

With the other 2 types your surgeon also needs to remove one or more of the following structures:

• a muscle on the side of your neck called the sternocleidomastoid muscle
• a nerve called the accessory nerve
• a vein called the internal jugular vein

Radical neck dissection

You have nearly all the nodes on one side of your neck removed. Your surgeon will also remove:

• the sternocleidomastoid muscle on the side of your neck
• a nerve called the accessory nerve
• the internal jugular vein

You usually have surgery to remove the cancer at the same time as your neck surgery.

Possible side effects after a neck dissection

This surgery has some side effects. These depend on which nerves or muscles the surgeon removes.

Blood clot

During your operation, your surgeon puts a drain into your neck. Any fluid around your neck goes from the drain into a bottle attached to the drain. This helps prevent clots from forming. But sometimes blood may collect under the skin and form a clot (haematoma). You may have to go back to the operating theatre to remove the clot if this happens.  

Nerve damage

Shoulder stiffness and arm weakness

The accessory nerve controls shoulder movement. So if the surgeon removes it, your shoulder will become stiffer and more difficult to move. Raising your arm over your head on that side can also become more difficult.

After a selective neck dissection, the weakness in your arm usually lasts only for a few months. But if the surgeon completely removes your accessory nerve, the damage is permanent. Usually, you see a physiotherapist, who teaches you exercises to help improve the movement in your neck and shoulder. It is important to do these exercises regularly.

Some people still have problems with pain and movement a year after surgery, despite doing their exercises. If this happens, your surgeon may refer you to a shoulder surgery specialist.

Other possible effects of nerve damage 

The cranial and spinal nerves supply the head and neck area. A neck dissection can damage some of these nerves. If this happens you might have:

• numbness in the ear on the same side as the operation
• loss of movement in the lower lip
• loss of movement on one side of the tongue
• loss of feeling on one side of the tongue

Pain

You may also have some pain. Taking painkillers can help. Physiotherapy exercises can also reduce pain. Your doctor can refer you to a pain clinic if the pain continues or is not controlled with painkillers.

Stiff neck

You may have a stiff neck after surgery. Your physiotherapist will show you some exercises that will help improve this. It can take a few weeks or longer for your neck to be less stiff. You may need to continue the exercises after you go home.

Feeling numb around the scar line

This will improve in time, but for some people, this may not completely go away.

Chyle leak 

Chyle is milky fluid carried around the body by the lymphatic system. Rarely one of the lymph channels (called the thoracic duct) leaks after this operation. This may cause chyle to collect under the skin. You are usually on bed rest in hospital until it stops.

Some people may have to go back to the operating theatre if the leak continues. 

Removing the muscle at the side of your neck (Sternocleidomastoid muscle)

Removing the muscle at the side of your neck doesn't usually cause a problem. But it does make your neck look thinner and sunken on that side.

You might have a neck dissection on both sides, this means removing both muscles. Afterwards you are likely to have some difficulty bending your head forward. Physiotherapy can help to improve movement and prevent stiffness. 

Swelling (lymphoedema)

After surgery to remove some or all of the lymph nodes in your neck, the area can be swollen. This can be due to general swelling around the surgical wound. This usually goes down within a couple of weeks. But it can also be a sign of lymphoedema, this swelling doesn’t go away.

Lymphoedema in the head or neck can also cause symptoms inside your mouth and throat. For example, swelling of your tongue and other parts of your mouth.

Tell your doctor or nurse straight away if you:

• have any swelling or a feeling of fullness or pressure
• find it difficult to swallow
• have changes in your voice

They will refer you to a lymphoedema specialist if they think you might have lymphoedema. It’s important to start treatment early to stop the swelling from getting worse.

Exercises for lymphoedema

If you have lymphoedema, your physiotherapist or specialist nurse will usually go through these exercises with you. Using your head, neck and shoulder muscles may help to reduce swelling. 

Below are 2 videos that can help you with these exercises. Both are by a physiotherapist called Carla from the lymphoedema team at University College Hospital London. Speak to your doctor or lymphoedema specialist if you are unsure about doing any of them.

The first video shows you how to do breathing exercises. The second video shows you how to do head and neck exercises. It is important to do the breathing exercises before and after the head and neck exercises. 

These exercises should not be painful, so you must stop them if you have any pain. If the pain doesn't get better contact your doctor. Do each exercise slowly and gently, and it may help to rest in between.

The video about deep breathing exercises is 1 minute long.

The video about head and neck exercises is just under 3 minutes long.